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UNIVERSITY  OF  ILLINOIS 
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1919 


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Tint  Lancet,  July  5, 1919. 


THE  LANCET. 

J{  journal  or  British  and  Foreign  tftedicine,  Surgerp,  Obstetrics,  Phpsiologp, 
Chemistrp,  Pharmacologp,  Public  health,  and  Pews. 


IN  TWO  VOLUMES  ANNUALLY. 


Vol.  CXCYI. 


Vol.  I.  FOR  1919. 


N I N ET  Y - S E V E N T H YEA  R. 


SAMUEL  SQUIEE  SPEIGGE,  M.A.,  M.D.  Cantab., 

EDITOR. 


LONDON 

PRINTED  AND  PUBLISHED  BY  THE  PROPRIETORS,  AT  THE  OFFICES  OF  “THE  LANCET,”  No.  423,  STRAND,  AND 

Nog  1 & 2,  BEDFORD  STREET,  STRAND 


MCMXIX. 


/ 


Tni!  Lancet,  July  5,  1919. 


(3  13- 

T7~ 


INDEX  TO  VOLUME  I,  1919. 

Headers  in  search  of  a given  subjeot  mill  find  it  useful  to  bear  in  mind  that  the  references  are  in  several  cases 
distributed  under  two  or  more  separate  but  nearly  synonymous  headings — such,  for  instance,  as  Brain  and  Cerebral, 
Heart  and  Cardiac,  Liver  and  Hepatic,  Bicycle  and  Cycle,  Child  and  Infant,  Broncliocele,  Goitre,  and  Thyroid, 
Diabetes,  Glycosuria  and  Sugar,  Eye,  Ophthalmic,  and  Vision,  Sfo.,  Sfc.  ( Py  Q)  ~ Parliamentary  Question. 


Pages. 

Date  of  issue. 

No. 

1-50  ... 

. ...  Jan.  4th  ... 

...  4975 

51-90  ... 

....  ,,  11th  ... 

...  4976 

91-128  ... 

...  ,,  18th  ... 

...  4977 

129-164  ... 

25th  ... 

...  4978 

165-202  ... 

...  Fell.  1st  ... 

...  4979 

203-242  ... 

,,  8th  ... 

...  4980 

243-284  ... 

,,  15th  ... 

...  4981 

285-324  ... 

,,  22nd  ... 

...  4982 

325-364  ... 

...  4983 

A 

Abderhaiden’s  pregnancy  reaction,  111 
Abdominal  operation,  haematemesis  after,  529 ; 
reflexes,  significance  and  surgical  value  of 
(Mr.  D.  Ligat),729;  tuberculosis,  940 
Aberdeen  Royal  Infirmary,  meeting,  414 
Aberdeen  University,  pass  lists,  87.584  ; spring 
graduation,  584 ; Prof.  C.  E.  Marshall 
appointed  to  the  Regius  chair  of  materia 
mediea  and  therapeutics,  854  : club  dinner, 
862 

Abiotrophy  of  the  retinal  neuro  epithelium  or 
“ retinitis  pigmentosa,”  893 
Abortifacient,  quinine  as  (Prof.  W.  C.  Swayne 
and  Mr.  E.  Russell),  841 
Abrahams,  Dr.  A.,  Dr.  N.  Hallows,  and  Dr.  H. 

French,  influenzal  septicaemia,  1 
Abrahams,  Maj.  A.,  epidemic  perinephric  sup- 
puration, 1044 

Abscess  in  fibromyoma,  22  ; pyosalpinx  and 
ovarian,  265 

Abscess,  peritonsillar  (Dr.  A.  Wylie),  178 
Abscesses,  fixation  in  influenza,  895 
Absentee,  practice  of  the,  45,  80 
Accommodation  for  hospital  nurses  (Py  Q),  770 
Acetone,  alcohol,  and  benzene  in  the  air  of 
certain  factories,  772 

Achard,  Prof.  C.,  Review  of  Studies  on  Renal 
Function  in  Chronic  Nephritis  (thesis  by 
Pasteur-Vallery-Radot),  752 
Acidosis  and  its  significance,  30 
Aekerley,  Dr.  R.,  “ hot  liquids  and  cancer,” 
635 

Adami,  Prof.  J.  G.,  prevention  and  arrest  of 
venereal  disease  in  the  Army,  109;  War  Story 
of  the  Canadian  Army  Medical  Corps 
(review),  111 

Adams,  Dr.  D.  K.,  acute  ascending  myelitis, 

Adams,  Mr.  J.,  new  pattern  gland  dissector, 

868 

Adams,  Mr.  J.  E.,  maldevelopment  of  the 
liver,  744 ; carcinoma  of  appendix,  845 
Adamson,  Dr.  Rhoda,  effect  of  industrial 
employment  upon  women,  465 
Adenoids,  treatment  of,  284,  323 
Advanctd  Suggestion  (Neuro-induction)  (Mr. 

H.  Brown)  (review),  302 
After-care  of  tuberculous  ex-service  men,  767 
Agglutination  test,  standard,  permanent 
criterion  for  (Mr.  A.  D.  Gardner),  21 
Agglutinins,  other,  formation  of,  in  cases  of 
Malta  fever  (Dr.  L.  T.  Burra),  64 
Aids  to  Medical  Diagnosis  (Dr.  A.  Whiting), 
second  edition,  1918  (review),  112 ; to  Sur- 
gery'(Dr.  J.  Cunning  and  Mr.  C.  A Joil), 
fourth  edition,  1919  (review),  659;  to  the 
Analysis  of  Foods  and  Drugs  (Mr.  C.  G 
Moor  and  Mr.  W.  Partridge),  fourth  edition, 
1918  (review),  848;  to  Histology  (Dr.  A. 
Goodall),  second  edition  (review),  848 
Air  for  oxygen  in  anaesthesia  (Dr.  J.  H.  Fryer), 
216 

Aitken,  Capt.  R , R. \.M.C.  (see  Obituary  of 
the  war) 


INDEX  TO  PAGES. 


Pages. 

Date  of  issue. 

No. 

365-406  .. 

. ...  March  8th  ... 

...  4984 

407-448  ... 

,,  15th  ... 

...  4985 

449-488  ... 

,,  22nd  ... 

...  4986 

489-540  ... 

,,  29th  ... 

...  4987 

541-592  ... 

...  April  5th  ... 

...  4988 

593-644  ... 

,,  12th  ... 

...  4989 

645-688  ... 

,,  19th  .... 

...  4990 

689-728  ... 

,,  26th  ... 

...  4991 

729-772  ... 

...  4992 

Pages. 

Date  of  issue. 

No. 

773-826  .. 

...  4993 

827-868  . 

,,  17th  .... 

...  4994 

869-922  .. 

,-....  ,,  24th  .... 

..  4995 

923-964  .. 

,,  31st  .... 

..  4996 

965-1012  .. 

June  7th  .... 

..  4997 

1013-1054  .. 

....  ,,  14th  .... 

..  4998 

1055-1098  .. 

,,  21st  .... 

..  4999 

1099-1140  .. 

....  ,,  28th  .... 

..  5000 

Aitken,  Dr.  C J.  H.,  invalidism  for  15  years 
through  nasal  blockage,  156 
Albert  medal,  award,  915 
Alberta  Health  Department,  232 

I Aldridge,  Dr.  C.,  death  of,  843 
Alexander,  Dr.  W.,  obituary,  530 
Allahabad,  new  medical  school,  760 
Allbutt,  Sir  C.,  portrait  of,  814,  910 
Allen,  Capt.  W.  R.,  R.A.M.C.  (see  Obituary  of 
the  war) 

Allotments  and  health,  284 
Alport,  Capt.  A.  C.,  Malaria  and  its  Treatment, 
in  the  Line  and  at  the  Base  (review),  616 
Amar,  Prof.  J.,  Physiology  of  Industrial 
Organisation  (review),  265 
Amibiasine,  898 

Ambulances,  Red  Cross,  utilisation  of,  187 
America,  visit  of  foreign  medical  men,  1091 
American  Journal  of  Care  for  Cripples  (review), 

American  Journal  of  Ophthalmology  (review), 

American  Journal  of  Public  Health  (review), 
660 

American  Medical  Corps,  work  of,  431 
American  Public  Health  Association  and 
influenza,  230;  gifts,  318;  post-graduates  in 
London,  943 

American  Review  of  Tuberculosis  (review),  265, 
468,  566,  747,  1029 

Amoebic  and  bacillary  dysentery,  diagnosis  of 
(Dr.  G.  M.  Findlay),  135;  dysentery  carriers, 
a correction,  157  ; dysentery,  treatment,  429  ; 
dysentery,  674 

Anaemia,  severe,  700 ; aplastic,  744  ; jaundice 
in  (Dr.  W.  H.  Willeox),  932 
Anaerobic  tube,  Buchner's,  modified,  226 
Anaesthesia,  spinal  (Dr.  F.  S Rood),  14  ; air  for 
oxygen  in  (Dr.  J.  H.  Fryer),  216;  safe,  231  ; 
surgical,  lacrymal  gland  in  (Dr.  L.T.  Ruther- 
ford), 792 ;.  rectal  ether  (Mr.  J.  C.  Clayton), 
793 ; for  ophthalmic  operations  (Mr.  C.  T.  W 
Hirsch),  1068 

Anaesthetics,  a nasal  air- way,  1030 ; Dr.  J. 
Regnault  on,  1037 

Analytical  Records  from  “The  Lancet” 
Laboratory— 

Amibiasine,  898 
Aniodol,  384 

“ Cofectant  "lozenges,  24 
Digalen,  384 
Ethyl  chloride  films,  24 
Feroxal,  24 
Genasprin,  24 

Influenza  vaccine  (mixed),  24 
Italian  ichthyol,  24 
Omnopon,  384 

Petroleum  jellies  (“  Semprolia  ” brand),  898 
Sedobrol,  384 

Solution  pot.  iodide  (Souffron),  384 
Stropbanthus  and  strophanthine  (cris- 
tallisee),  384 *  1 

Thiocol,  384 
Valenda  spray,  898 
Veronidia,  24 


Anaphylaxis  (Dr.  J.  K.  Gaunt),  889 
Anatomical  films,  1125 

Anatomy,  chair  of,  University  College,  London, 

Anderson,  Dr.  H.  G.,  Medical  and  Surgical 
Aspects  of  Aviation  (review),  982 
Anderson,  Mr.  W.  H.,  dislocation  of  teeth,  441 
Andrews,  Dr.  H.  R. , four  cases  of  full-time 
ectopic  pregnancy,  611;  removal  of  sub- 
mucous fibroid  with  Hegar’s  dilators,  1073 
Aneurysm,  traumatic,  of  external  carotid 
70o'  I aortic,  700;  cirsoid, 

Angeioid  streak  in  retina,  613 
Angioma  of  retina,  300  ; of  the  choroid,  895 
Animal  ailments  in  1918, 1088 
Animal  Life  and  Human  Progress  (Prof  A 
Dendy)  (review),  1120 
Animals  (Anaesthetics)  BUI,  821 
. Aniodol,  384 

Ankylostomiasis,  oil  of  chenopodium  in,  90- 
in  Australia,  476 

Annals  of  Medical  History  (review),  566 
Anthrax,  appointmentof  Advisory  Committee 
200  ; prevention  of,  821 
Anthrax  Bill,  Prevention  of,  685,  865,  959 
Anti-hookworm  campaign  in  tea  districts  998 
Antimony  in  bilharziasis,  79;  tartrate  for 
bhharziasis  (Dr.  J.  B.  Christopherson), 

Antiplague  serum  in  influenza,  663 
Antipyrin,  persistent  pigmentation  due  to, 
1036 

Ant-rabic  treatment  (Py  Q),  918;  centres, 
1138 

Aortic  aneurysm,  700 
Aplasticanaemia,  744 

Apothecaries’  assistants,  qualificitions  of 

Apothecaries  Society  of  London,  pass-lists 
48,  584 

Apparatus,  new  “606,”  618 
Appendicitis,  acute,  and  acute  appendicular 
obstruction  (Mr.  S.  T.  Irwin),  98,  197; 
accurate  diagnosis  in  (leading  arlicle),  114’ 
197 ; X rays  in  diagnosis,  279  ; coexistence  of 
small  gut  reflex  in  cases  of  (Mr.  D.  Ligat) 
731 ; acute  (Dr.  R.  A.  Barlow), 844 
Appendix,  vermiform,  examination  by  X rays 
(Dr.  E I.  Spriggs),  91 ; carcinoma  of,  845 
Apperly,  Mr.  R.  E.,  heart  failure.  658 
Appointments,  weekly  lists  of,  49,  89,  127  162 
200,  240,  321,  362,  403,  445,  487,  537,  589  642’ 
726,  824,  865,  919, 961,  1009,  1051, 1096, 1138  ’ 

Apyrexial  symptoms  of  malaria,  222 
“ Arellano  ” influenza  mask,  90 
Armour,  Col.  D.,  cirsoid  aneurysm,  700 
Army  huts  for  tuberculous  patients  (Py  Q), 
641 ; medical  equipment,  surplus  (Py  Q),  864 
Arthritis  and  rheumatism,  meningococcal  (Dr. 

P.  Sainton),  1080 
Artificial  limbs  (Py  Q),  320,  321 
Ascending  paralysis,  acute  (Dr.  H.  Sutherland). 
841 

Ashe,  Dr.  J.  S.,  endothelioma  of  the  ovary,  264 
Aspirin,  intolerance  of  (Dr.  E.  J.  Tyrrell),  1118 
Aspirin  poisoning  (Dr.  F.  W.  Lewis),  64 


446752 


iv  The  Lancet  ] 


INDEX  TO  VOLUME  I.,  1919. 


[July  5,  1919> 


Assessments,  disability,  and  medical  boards 
<Pv  Q),  918 

Association  of  Factory  Doctors  and  Managers, 
768 

Association  of  Panel  Committees  and  notifica- 
tion fees,  439 

Association  of  Public  Vaccinators,  meeting, 
413 

Astley  Cooper  prize,  282 

Astragalus,  fracture-dislocation  of  (Mr.  H.  C. 

' Orrln).  20 

Asylum  Workers'  Association,  meeting,  955 

Atmospheric  pollution,  monthly  record,  81; 
Meteorological  Office  Advisory  Committee 
on,  report  on  observations  in  the  year 
1917-1918  (see  Supplement,  June  14th); 
investigation  of,  1035 

Australia,  Correspondence  from— In- 
fluenza pandemic;  Influenza  vaccines: 
Nationalisation  of  medicine ; Anky- 
lostomiasis ; Australian  Army  Medical 
Corps,  476— Influenza  epidemic;  Inoculation 
and  masks;  Unseemly  disputes,  681- 
Influenza  ; Federal  aud  State  quarantine, 
760 

Australian  Army  Medical  Corps  in  Egypt  in 
1914-15  (Sir  J.  W.  Barrett  and  Lieut.  P.  E. 
Deane)  (review),  66 

Autonomic  nervous  system,  arrangement  of, 
951 

Autotherapy  or  bleeding,  124 

Autumn  influenza  epidemic  (1918)  (Dr.  J.W.  H. 
Eyre  and  Dr.  E.  C.  Lowe),  553 

Aviation  candidates,  medical  examination  of, 
46  Insurance  Association,  035 

Aviation,  medical  aspects  of  (Dr.  L.  E.  Stamm) 
206;  Medical  and  Surgical  Aspects  of  (Dr. 
H.  G.  Anderson)  (review),  982 

Aviators,  nasal  obstruction  in  (Dr.  D.  Guthrie), 
136 ; visual  requirements  of,  894 


B 

Babies  in  Peril,  or  Mother  and  Infant  Wel- 
fare Centres  (Miss  E.  M.  Bennett)  (review), 
618 

Bacillary  dysentery:  are  relapses  frequent, 
529;  dysentery,  673;  dysentery,  mild  (Dr.  J. 
Kyle),  937  * 

Bacilli,  tubercle,  human,  bovine,  and  avian, 
attenuation  of  (Dr.  N.  Raw),  376 
Bacillus  influenzas,  simply  prepared  culture- 
nifdia  for(Mr.  A.  Fleming),  138 
Bacillus  multifermentans  tenalbus  .(Dr.  J.  L. 
Stoddard),  13 

B.  paratyphosus  B,  an  atypical  strain  of  (Dr. 

W Brougliton-Alcock),  1023 
Bacteriology,  Manual  of  (Prof.  R.  Muir  and 
Prof.  J.  Ritchie),  seventh  edition,  1919  (re- 
view), 467  ; endowed  chair.  988 
Bacteriology  of  influenza,  760;  epidemic  in 
Lower  Egypt.  (Dr.  G.  M.  Findlay),  1113 
Bailey,  Capt.  J.  C.  M.,  R.A.M.C.,  O.B.E.  (see 
Obituary  of  the  war) 

Baillie.  Dr.  D M.,  use  of  intravenous  iodine 
in  influenzal  broncho-pneumonia,  423;  and 
Mr.  E.  G.  D.  Pineo,  treatment  of  gonorrhcea 
by  pus  vaccines,  508 

Baines,  Mr.  A.  E.,  Studies  in  Electro-physio- 
logy i Animal  and  Vegetable)  (review),  701 
Baldwin,  Mr.  A.,  plastic  operation  on  face  for 
deep  scarring,  3C0 

Balfour,  Dr.  A.,  sanitary  and  insanitary  make- 
shifts in  the  Eastern  war  areas,  604 
Balgarnie,  Dr.  W.,  ruptured  rectus  abdominis, 
influenzal, 843 

Ballance,  Sir  C.,  and  Dr.  H.  Campbell,  general 
paralysis  of  the  insane,  treatment,  6C8 
Barber,  Dr.  H.,  Dr.  C.  F.  White,  and  Dr.  A.  T. 
McWhirter,  Wassermann  reaction,  a criticism 
of  its  reliability,  502 

Bardswell,  Dr.  N.  D.,  Y.M.C.A.  Agricultural 
Training  Colony,  Kinson,  Dorset,  456 ; public 
health  aspect  of  tuberculosis,  464 
Barium  salts  administered  for  radiological 
examination,  death  from,  943 
Barlow,  Dr.  R.  A.,  acute  appendicitis,  844 
Baron,  Sir  B.  J.,  death  of,  10?5 
Barrett,  Lady,  deficiency  of  the  pituitary  body 
in  a girl.  465 

Barrett,  Sir  J.  W.,  and  LieuL  P.  E.  Deane, 
Australian  Army  Medical  Corps  in  Egypt  in 
1914-15  (review),  66;  management  of  vene- 
real diseases  in  Egypt  during  the  war,  140, 
193 

Barton,  Mr.  E.  A.,  quality  of  commercial 
vaccine  lymph,  313 

Bnshford,  Capt.  K.  F.,  Cspt.  J.  A.  Wilson,  and 
Maj.-Gen.  Sir  J.  R.  Bradford,  filter-passing 
virus  in  certain  diseases,  169 ; acute  infective 
polyneuritis,  348 

Bassett,  Lieut  R J.,  R.A.M.C.  (see  Obituary 
of  the  war) 

Bassett-Smith,  Surg.  Capt.  P.  W.,  sprue 
associated  with  tetany,  178 


Bastian,  Surg. -Com.  W.,  origin  of  life,  work  of 
the  late  Charlton  Bastian,  951 
Basu,  Maj.  B.  D.,  Diabetes  and  its  Dietetic 
Treatment,  ninth  edition,  1918  (review), 
383 

Bateman,  Dr.  A.  G.,  death  of,  679 
Bath,  the  new,  1037 

Batten,  Mr.  II.,  disease  of  both  maculae, 
613 

Baufle,  Dr.  P.,  Dr.  R.  Coope,  and  Dr.  E. 

Joltrain,  chronic  colopatbies,  933 
Baylis,  Mr.  H.  A.,  incidence  of  Enlanueba 
hi-tolytica,  Ac,  in  naval  entrants,  54; 
amoebic  dysentery  carriers,  a correction,  157; 
Bayliss,  Prof.  W.  M.,  wound  shock,  668; 
and  Dr.  H.  H.  Dale,  shock,  discussion, 
256 

Bayly,  Mr.  H.  W.,  laboratory  methods  and 
diagnosis  of  venereal  diseases.  817 
Beattie,  Prof.  J.  M.,  diagnostic  value  of  the 
Wassermann  reaction  in  syphilis,  466 
Bed  for  faetures  and  general  hospital  pur- 
poses, 266 

Bedside  and  Wheel-chair  Occupations  (Dr. 

H J.  Hall)  (review),  800 
Begg,  Col.  C.  M.,  C.B.,  C.M.G.,  New  Zealand 
M.C.  (see  Obituary  of  the  war) 

Belfast,  health  of,  121 ; strike  in,  193;  Hospital 
for  Skin  Diseases,  meeting,  193  ; Royal  Vic- 
toria Hospital,  resignation  of  Sir  W.  Wbitla, 
M.P.,  as  senior  physician.  274  ; Queen's  Uni- 
versity, Col.  T.  Sinclair  elected  registrar, 
358;  doctors  and  Ministry  of  Health.  577; 
Ophthalmic  Hospital,  meeting,  997 ; Dental 
Clinic,  1040 

Belgian  Doctors’  and  Pharmacists’  Relief 
Fund,  37,  125,  384,  618;  (leading  article), 
228  ; close  of  the  fund,  235;  decorations,  915 
Bell,  Dr.  B.,  abscess  in  fibromvoma,  22 
Bell,  Mr.  A.  S.  G.,  cerebro-spinal  meningitis, 
887 

Benaroya,  Dr.  M.,  lung  puncture  in  treatment 
of  influenzal  pneumonia,  742 
Benn  Ulster  Eye,  Ear,  and  Throat  Hospital, 
Belfast,  meeting,  722 

Bennett,  Miss  E.  M.,  Babies  in  Peril,  or  Mother 
and  Infant  Welfare  Centres  (review), 
618 

Bennett,  Mr.  L.  H.,  obituary,  125 
Bennett,  Dr.  R.  A , intestinal  obstruction  by 
Meckel's  diverticulum,  1117 
Benson,  Mr.  C M.,  obituary,  358 
Berkeley,  Dr.  C , Gynecology  for  Nurses  and 
Gynecological  Nursing,  third  edition.  1918 
(review),  848 

Bertrand,  Mile.  T.,  and  M.  Emile  Sergent, 
meningeal  hemorrhage  in  typhoid  fever,  519 
Bilharziasis  (Dr.  N.  H.  Fairley),  1016  ; its  pre- 
vention and  treatment  (leading  article),  1032 
Bilharziasis,  antimony  in,  79 ; antimony 
tartrate  for  (Dr.  J.  B.  Christopherson),  1021 
“ Billie  Carleton,”  inquest  on,  236 
Bing,  Prof.  K.,  and  Dr.  A.  L.  Vischer,  psycho- 
logy of  internment,  697 
Bingham,  Capt.  J.  W.,  R.A.M.C.  (see  Obituary 
of  the  war) 

Biochemistry  and  Physiology  in  Modern  Medi- 
cine (Prof.  J.  J.  R.  Macleod  and  Dr.  R.  G. 
Pearce)  (review),  513 

Biological  Chemistry.  Study  of  (Dr.  S.  B. 
Schryver)  (review),  659 

Biology  and  the  medical  curriculum  (Mr.  T.  G. 
Hill), .273,  312 

Biology,  Experimental,  Monographs  on,  the 
Elementary  Nervous  System  (Prof.  A.  H. 
Parker)  (review),  702 
Bird’s  brain,  the,  616 

Birmingham  University,  post-graduate  study, 
725 

Births,  marriages,  and  deat  hs,  weekly  lists  of, 
49.  69,  127,  162.  200,  240,  283  , 322  . 362,  404, 
445,  487,  537,  590.  642.  686,  726,  771,  825.  866, 
919,  962.  1009,  1062,  1097.  1138 
“ Birthplace  of  gynaecology,"  189 
Bismuth  Order,  the,  128 
Black,  Dr.  Guy,  the  late,  1003 
Blackwater  fever  (Mr.  J.  P.  Williams).  886 
Blake.  Lieut. -Col.  J.  A.,  Gunshot  Fractures 
of  Extremities  (review),  184 ; Fractures 
(Gunshot  Fractures  of  Extremities) (review), 
702 

Blakeway,  Mr.  H.,  obituary,  35S 
Blanchard,  Prof.  R.,  obituary,  315 
Bland-Sutton,  Sir  J.,  gizzards  and  counterfeit 
gizzards,  203  ; missiles  as  emboli,  773 
Bleeding  or  autotherapy,  124 
Blind  men  on  committees,  868;  subject,  the 
ease  of,  964  ; in  Ireland,  treatment  of  (Py  Q), 
1051 

Blood,  diseases  of,  transfusion  in,  379;  volume 
and  related  blood  ebangrs  in  ha-morrhage, 
852 ; transfusion  by  the  citrate  method  (Mr. 
A.  Fleming  and  Dr.  A.  B.  Porteous),  973, 
988  ; transfusion  (Dr.  E.  L.  Hunt  and  Dr. 
Helen  I nglety),  975,  988;  transfusion,  Pepys 
on,  1098 

Blood-supply  of  muscles  (Dr.  J.  Campbell  and 
Dr.  C.  M.  Pennefather),  294 


Board  of  Customs,  medical  Uffiee.*  to  (Pv  Q.). 
1009 

Boards  of  guardians,  powers  of  (Py  Q),  918 
Bock,  Airlie  V..  and  O.  H.  Robertson,  blood 
volume  and  related  blood  changes  after 
hemorrhage,  852 

Bodily  Deformities  (Mr.  E.  J.  Chance)  (review',. 

8C0 

Body  temperature,  electrical  methods  of 
n easuring,  564 
Boerhaave,  Hermann,  576 
Boisseau,  J.,  G.  Roussy,  and  M.  D’Oelsnitz, 
Traitement  des  Psychonevroses  de  Guerre 
(review),  1119 

Bolduan,  Dr.  C.  F.,  and  Dr.  J.  Koopman, 
Immune  Sera,  fifth  edition,  1917  (review), 
746 

Bone  grafts,  mandibular,  181 ; sinuses,  treat- 
ment by  solid  metal  drains  (Mr.  C.  J, 
Symonds),  971 

Bone-grafting  operations  (Mr.  W.  M.  Munby 
and  Mr.  A.  D.  E.  Shefford),  1070 
Bonney,  Mr.  V.,  continued  high  maternal 
mortality  of  childbearing.  775,  796 
Bonus  to  nurses  in  South  Africa,  1026 
Books,  Ac.,  received,  87.  162,  241,  324,  406, 
486.  540,  771,  825,  866,  920,  962,  1010, 
1096 

Books  of  reference,  324;  for  Serbia,  398,  643 1 
in  large  libraries,  care  of,  826 
Booth,  Dr.  J.  M.,  obituary,  860 
Borland,  Dr.  V.,  prophylactic  treatment  o 
constipation  in  children,  459 
Bottles,  medicine,  shortage  (Py  Q),  957 
Boulenger,  Dr.  M.  F.,  phthisis  in  factory  ancf 
workshop,  156 

Boulogne  as  a military  medical  base, 
664 

Boulogne,  Dr.  P.,  lymphadenitis  in  right  iliac 
fossa  simulating  appendicitis,  988 
Bowel,  double  resection  (Mr.  G.  Taylor).  461 
Bowlby,  Sir  A.,  Hunterian  oration  on  Britishr 
military  surgery  in  the  time  of  Hunter  and 
in  the  great  war,  285 

Bowman  lecture  on  plastic  operations  on  the 
orbital  region  (Prof.  Morax),  894 
Boycott,  Prof.  A.  E.,  biology  and  the  medical 
curriculum,  312 

Boyd,  Dr.  W.  R.,  heroin  poisoning,  755 
Boyden,  Dr.  P.  H.,and  Sir  A.  Reid,  treatment 
of  venereal  disease,  212,  314 
Boyes,  Q.M.-Sergt.  J.  T..  and  the  late  Dr.  A.  H. 

Carter,  cerebro-spinal  fever,  1C66 
Boyle,  Mr.  H.  E.  G.,  a warning.  164;  nltrous- 
oxide-oxygen-ether  outfit,  226,  231 ; laryngo- 
fissure  with  removal  of  inlra-laryngeal 
growth,  659 

Bradford,  Maj.-Gen.  Sir  J.  R..  Capt.  E.  F. 
Bashford,  and  Capt  J.  A.  Wilson,  filter- 
passing virus  in  certain  diseases,  169;  acute 
infective  polyneuritis,  348 
Brain  and  the  vaso  motor  system  (Dr.  L. 
Brown),  967 

Brain-worker’s  diet  (leading  article),  901 
Brandy  and  whisky,  medical  supplies  of  (Py  Q), 
1050 

Branson,  Dr.  W.  P.  S.,  hemorrhagic  spinal 
effusions,  883 

Breati  ing,  Deep,  Science  and  Art  of  (Dr.  S. 
Otabe)  (review),  467 

Brentnall,  Mr.  E.  S..and  Mr.  H.  Platt,  faradic 
stimulation,  884,  989 

Brewerton,  Mr.  E.,  angioma  of  retina,  300  j 
angeioid  streak  in  retina,  613 
Brierley.  Mr.  W.  B.,  origin  of  life,  work  of  the 
late  Charlton  Bastian,  1001 
Briggs,  Dr.,  radical  cure  of  complete  pro- 
cidentia, 22 

Brighton  Hospital  Sunday  Fund,  24;  and 
wounded  soldiers,  400  ; 2nd  Eastern  General 
Hospital  closed  down,  950 ; hospital  for 
women  and  children,  1140 
Brigstocke,  Mr.  R.  W.,  obituary,  437 
Briscoe,  Mr.  J.  F.,  meatless  dietary  in  epilepsy, 
1093 

Bristol  Royal  Iafirmary,  annual  meeting, 
972 

Bristol  University,  pass  lists,  318;  post- 
graduate study,  724 

Bristow.  Maj.  W.  R . physical  treatment  in 
relation  to  orthopedic  surgery,  671 
British  and  German  psychology^  1002 
British  East  Africa,  lack  of  medical  facilities, 
725 

British  Guiana,  influenza  epidemic  in  (Dr. 
F.  G.  Rose).  421 

British  Journal  of  Children’s  Diseases  (review), 
225,  660 

British  Journal  of  Ophthalmology  (review), 

1029 

British-made  morphia  (Py  Q),  864 
British  Medical  Association,  special  clinical 
meeting.  146,  272 ; (leading  article),  518, 
526,  662,  665;  war  neuroses  (leading  article). 
619;  exhibits.  625;  conference  ot  medical 
bodies,  £08,855;  scholarships  and  grants  in 
»id  of  scientific  research,  915;  Ulster  branch, 
1040 


The  Lancet,] 


British  Medical  Association  (Special 
Clinical  Meeting).— Reception  at  the 
Guildhall ; The  fellowship  of  man  and  the 
felljwshlp  of  medicine,  665— Tin-:  Lancet 
luncheon  at  Ilyde  Park  Hotel,  666— Popular 
-lecture ; Reception  at  the  Royal  Socioty  of 
Medielno  Exhibition.  666,  718 
Section  of  Medicine.  — I)r.  F.  W. 
Mott,  war  nouroses,  709— Maj. -Gen.  Sir  W. 
Herrlngham,  clinical  aspects  of  influenza, 
711 — Brevet  Col.  L.  W.  Harrison,  venereal 
disease,  713— Sir  J.  Mackenzie,  prognosis  in 
cardio  vascular  affections,  715— Demonstra- 
tions, 716 

Section  of  Surgery.— Col.  T.  R.  Elliott, 
gunshot  wounds  of  the  chest,  666  - Col.  G.  E. 
Gask,  surgical  aspects,  667— Prof.  W.  M. 
Bayliss,  wound  shock,  668 — Maj.  R.  C. 
Elmslie,  surgical  treatment,  670— Maj. 
W.  R.  Bristow,  physical  treatment  in  rela- 
tion to  orthopedic  surgery,  671— Demonstra- 
tions by  Col.  J.  G.  Adami,  Sir  G.  Makins, 
Col.  Sir  J.  Lynn-Thomas,  Maj.  M.  G.  Pearson, 
Lieut. -Col.  F.  S.  Brereton,  672,  673 
Section  of  Preventive  Medicine  and  Patho- 
logy.— Col.  L.  S.  Dudgeon,  bacillary 
dysentery,  673— Prof.  W.  Yorke,  amoebic 
dysentery  in  England,  674— Lieut. -Col. 
S.  P.  James,  risk  of  the  spread  of  malaria  in 
England,  677— Demonstrations,  Col.  L.  S. 
Dudgeon.  679 

Exhibition.— Surgical  instruments  and 
hospital  appliances,  718 — Drugs,  719 

British  Psychological  Society,  391  (see  also 
Medical  Societies) 

British  Science  Guild  Exhibition,  625;  annual 
meeting,  1138 

Broca,  Prof.  A.,  Disabilities  of  the  Locomotor 
Apparatus  the  Result  of  War  Wounds 
(review),  799 

Broderick,  Mr.  F.  W.,  a public  dental  service, 
440 

Brodie,  Dr.  G.  B.,  obituary,  1042 
■Brompton  Hospital  for  Consumption,  report, 
581 

Broncho-pneumonia,  purulent,  associated 
with  the  meningococcus,  81 ; meningo- 
coccus, in  influenza  (Dr.  W.  Fletcher), 
104,  124 ; pneumonia  in  the  Army 

<Py  Q),  402  ; pneumonia,  influenzal,  use  of 
intravenous  iodine  in  (Dr.  D.  M.  Baillie), 
423 

Broncho  spirochetosis,  116 
Broughton- Alcock,  Dr.  W.,  atypical  strains  of 
B.  paratyphosus  B,  1023 
Browdy,  Dr.  M.  W.,  simple  aid  In  reducing 
paraphimosis,  448 

Brown,  Capt.  W.  S.,  R.A.M.C.  (see  Obituary 
of  the  war) 

Brown,  Dr.  L.,  role  of  the  sympathetic  nervous 
system  in  disease,  827,  873,  923,  965 
Brown,  Dr.  T.  G.,  and  Dr.  R.  M.  Stewart, 
-v*  •*  heterestbesia,”  79 
Brown,  Dr.  W.,  war  neurosis,  833 
Brown,  Mr.  H.,  Advanced  Suggestion  (Neuro- 
induction) (review),  302 
Browne,  Capt.  W.  S.,  R.A.M.C.  (see  Obituary 
of  the  war) 

Browning,  Dr.  C.  H.,and  Dr.  E.L.  Ivennaway, 
Wassermann  tests,  785 

Bruce,  Dr.  J.  M.,  and  Dr.  W.  J.  Dilling, 
Materia  Medica  and  Therapeutics,  an  Intro- 
duction to  the  Rational  Treatment  of 
Disease,  eleventh  edition,  1918  (review), 
112 

Bruce,  Maj.-GeD.  Sir  D.,  tetanus  treated  in 
home  military  hospitals,  331 
Brussels  University,  resumption  of  medical 
courses,  353 

Bubonic  plague  at  home  (leading  article), 
986 

Buchner’s  anserobic  tube,  modified,  226 
Buckley,  Dr.  Winifred  F.,  comminuted  fracture 
of  humerus,  981 

Buntine,  Dr.  R.  A.,  memorial  service  in 
memory  of,  190 

Burial  certificates  and  midwives  (Py  Q), 
959 

Burland,  Dr.  C.,  Ship  Captain’s  Medical  Guide 
(review),  23 

Burma  Medical  Council,  760 
Burnell,  Dr.  G.  H.,  primary  pneumococcic 
meningitis,  623 

Burnett,  Sir  E.  N.,  address  on  hospital  accom- 
modation, 362 

Burnford,  Dr.  J.,  the  epidemic,  with  reference 
to  pneumonia  in  Macedonia,  794 
Burra,  Dr.  L.  T.,  formation  of  other  agglutinins 
in  cases  of  Malta  fever,  64 
Burtchaell,  Sir  C.,  honoured,  432 
Butcher,  Mr.  H.  H.,  and  Dr.  A.  J.  Eagleton, 
treatment  of  complicated  influenza,  560 
Buttar,  Dr.  C.,  and  Dr.  A.  Latham,  Medical 
Parliamentary  Committee,  arrangement  of 
conference,  634,  817 
Butter  for  invalids  (Py  Q),  641 
Buzzard,  Dr.  T.,  obituary,  82 


INDEX  TO  VOLUME  I.,  1919. 


0 

Cabot,  Dr.  II.,  Modern  Urology  (review),  467 
Cabot,  Dr.  it.  O.,  Differential  Diagnosis, 
second  edition,  1918  (review),  112  ; Training 
and  Rewards  of  the  Physician  (review),  224 
Cadham,  Dr.  F.  T.,  vaccine  in  influenza,  885 
Ctecum,  cancer  of  (Dr.  J.  K.  Haworth),  140 
Cairo,  Public  Health  Laboratories,  reports  and 
notes,  682 

Calcutta  mortality  in,  760,  997  ; vital  statistics 
of,  233,  857,  913 

Calmette,  Prof.  A.,  health  of  Lille  during 
German  occupation,  430 
Calves  reared  on  whey  and  meals,  interesting 
experiment,  964 

Cambridge  University,  pass-lists,  724  ; vacation 
course  in  advanced  pathology,  862;  diploma 
of  psychological  medicine,  955 
Cammidge,  Dr.  P.  J.,  prevention  and  treat- 
ment of  diabetic  coma,  60  ; improved  method 
for  estimation  of  sugar  in  urine  and  blood, 
939 

Campbell,  Capt.  J.,  R.A.M.C.  (see  Obituary  of 
the  war) 

Campbell,  Dr.  H.,  causes  and  incidence  of 
dental  caries,  46,  123,  198 ; and  Sir  C. 
Bal  lance,  treatment  of  general  paralysis  of 
the  insane,  608 

Campbell,  Dr.  J.,  and  Dr.  C.  M.  Pennefather, 
blood-supply  of  muscles,  294 
Camus,  Dr.  J.,  and  others,  Physical  and 
Occupational  Re-education  of  tlie  Maimed 
(review),  183 

Canada,  Correspondence  from.— Influenza 
scourge,  38— Some  mental  statistics  in 
Canada ; Canadian  Association  for  the  pre- 
vention of  tuberculosis,  report ; National 
Sanatorium  Association ; Tuberculosis  toll 
in  Canada  ; New  Military  College,  39 — Lepers 
in  Canada  ; Pensions  to  Canadian  soldiers ; 
Health  Department,  Province  of  Alberta ; 
Improving  the  health  of  Canada,  232 — 
Military  medical  officers  and  civilian  practice, 
233— Medical  gatherings ; Osteopathy  ; Free 
hospital  movement  in  Western  Canada ; 
Federal  Department  of  Public  Health  for 
Canada ; Menace  of  venereal  disease  in 
Ontario;  Prescribing  of  liquor  in  Ontario, 
949 — Canadian  Public  Health  Association, 
annual  meeting;  Ontario  Medical  Associa- 
tion, address  in  medicine ; University  of 
Montreal ; Public  health  campaigns,  1132 

Canada,  Department  of  Health  for,  767 
Canadian  Association  for  the  Prevention  of 
Tuberculosis,  report,  39;  Army  Medical 
Service,  work  of,  946 
Cancer  and  hot  liquids,  583,  635,  683 
Cancer,  lingual,  etiology,  75,  123;  of  caecum 
(Dr.  J.  K.  Haworth),  140;  intrinsic,  of 
larynx,  263,  271 ; of  the  stomach,  perforation 
in,  272  ; absenceof,  in  the  Arctic  regions, 528, 
1045  ; district  in  France,  853 
Candidates,  medical,  for  Parliament,  35 
Candy,  Dr.  G.  S , National  Medical  Service, 
what  is  it  worth  ? 279 
Cannabalism  in  Sind,  allegations  of,  311 
Capo  Medical  Council,  election,  395 
Carcinoma  of  appendix,  845 
Carcinoma,  primary,  of  duodenum.  1128 
Cardiac  valves,  ruptureof,  due  to  explosion,  231 
Cardiogiam,  first  lead  of,  inverted  “T”  in, 
significance  of  (Dr.  I.  Harris),  168 
Cardio- vascular  affections,  prognosis  in  (Sir  J. 
Mackenzie),  715 

Cargill,  Mr.  L.  V.,  pituitary  tumour,  613; 
injuries  and  diseases  of  the  orbit  and 
accessory  sinuses,  614;  pigmented  connec- 
tive tissue,  1072 

Caries,  dental,  causes  and  incidence,  40,  80, 123, 
155,  198,  238 

Carnwath,  Capt.  T., lessons  of  a great'epidemic, 
242 

Carotid,  external,  traumatic  aneurysm  of  (Dr 
S.  C.  Dyke),  21 

Carr,  Dr.  J.  W.,  polycythaemia,  700 ; congenital 
morbus  cordis  with  polycythaemia,  700 
Carr,  Mr.  J.  C.,  unregistered  dental 
practitioners,  724 

Carrel,  Anne,  and  J.  Dumas,  Technic  of  the 
Irrigation  Treatment  of  Wounds  by  the 
Carrel  Method  (review),  617 
Carruthers,  Maj.,  intra-ocular  growth,  613 
Carry  On  (review),  566 

Carson,  Mr.  H.  W.,  ruptured  rectus  abdominis, 
912 

Carter,  Mr.  H.,  Control  of  Drink  Trade  in 
Great  Britain:  A Contribution  to  National 
Efficiency,  1915-18,  second  edition,  1919 
(review),  1119 

Carter,  the  late  Dr.  A.  H.,  and  Q.M.-Serg.  J.T. 

Boyes,  cerebro-spinal  fever,  1066 
Carter,  Dr.  H.  R.,  medical  examination  of 
aviation  candidates,  46 


[July  5,  1919  v 


Case-taking.  Clinical  (Dr.  R.  D.  Keith) 
(review),  112 

Casserole,  lead  in  the,  905,  1002 
Castellaln,  Dr.  H.  G.  It.,  Association  of  Factory 
Doctors  and  Managers,  768 
Casualties  among  the  sons  of  medical  men 
(see  Casualties  under  War  and  After) 
Casualty  list  (see  Casualty  list  under  War  and 
Alter) 

Catalyst,  the  rdle  of  (leading  article),  141 
Catarrhal  jaundice,  epidemic  (Dr.  W.  H. 

Willcox),  930 
Cause  or  coincidence,  539 
Caussade,  Dr.,  and  others,  action  of  hypo- 
chlorites on  pleural  false  membranes,  895 
Cautley,  Dr.  E.,  aortic  aneurysm,  700;  severe 
anaimia,  700  ; cccliac  disease  700 
Cavendish  lecture  on  the  rblo  of  consulting 
surgeon  in  war  (Sir  G.  H.  Makins),  1099 
Centenarians,  198,  584,  860,  998,  1098 
Centipede  bite,  Mr.'S.  W.  Coffin,  1117 
Central  Health  Department,  proposal  for,  273 
Central  Medical  War  Committee,  scheme  for 
demobilisation,  84,  193;  interests  of  those 
who  have  been  on  service,  357  ; its  work  in 
demobilisation  ended,  527 
Central  Midwives  Board,  meeting,  48,  199,  361, 
585,  956 

Cerebral  cortex,  the,  and  sensation,  389 
Cerebro-spinal  Fever  (Dr.  C.  Worster-Drought 
and  Dr.  A.  M.  Kennedy)  (review),  1073 
Cerebro-spinal  fever,  outbreak  of  (Py  Q),  485; 
Lumleian  lecture  on  (Sir  H.  Rolleston),  641, 
593,  645;  fever  cases  as  carriers  (Dr.  D. 
Embleton  and  Dr.  G.  H.  Steven).  783;  fever 
(the  late  Dr.  A.  H.  Carter  and  Q.M.-Serg. 
J.  T.  Boyes),  1066;  fever  (Prof.  C.  Dopter), 
1075 

Cerebro-spinal  fever  regulations,  1126 
Cerebro-spinal  meningitis  (Mr.  A.  S.  G.  Bell), 
887 

Cervical  nerve  roots,  gunshot  injuries  of  (Dr. 

J.  S.  B.  Stopford),  336 
Cervix,  sarcoma  of,  110 

Chaikin,  Mr.  G.,  Medical  Officers  of  Schools 
Association,  47 

Challamel,  Dr.  A.,  hypodermic  injections  of 
eucalyptus  oil  in  influenza,  424 
Chambers,  Dr.  Helen,  Dr.  Gladwys  M.  Scott, 
Dr.  J.  C.  Mottram,  and  Dr.  S.  Russ,  experi- 
mental studies  with  small  doses  of  X rays, 
692 

Chance,  Mr.  E.  J.,  Bodily  Deformities  (review), 
800 

Chantemesse,  Prof.  A.,  death  of,  433 
Chapman,  Dr.  C.  W.,  artificial  cyanosis  of  lips, 
529 

Chappie,  Dr.  W.  A.,  stretching  tables  for  flexed 
thigh  stumps  after  amputation,  984 
Charing  Cross  Hospital  Medical  School,  post- 
graduate study,  481 

Charter  of  Science  for  the  Army  Medical 
Department  (leading  article),  753 
Chemical  work  in  India,  organisation  of,  434 
Chemistry  at  Cambridge,  852 
Chemistry  of  Synthetic  Drugs  (Dr.  P.  May), 
second  edition,  1918  (review),  224 ; Inorganic, 
Introduction  to  (Prof.  A.  Smith),  third 
edition,  1918  (review),  225  ; in  1918,  progress 
of  (leading  article),  470;  Organic,  Recent 
Advances  in  (Mr.  A.  W.  Stewart),  third 
edition,  1918  (review),  617;  Physical  and 
Inorganic,  Recent  Advances  in  (Mr.  A.  W. 
Stewart),  third  edition,  1919  (review),  617 ; 
Biological,  Study  of  (Dr.  S.  B.  Schryver) 
(review),  659 ; Physiological,  Practical  (Prof. 
P.  B.  Hawk),  sixth  edition,  1919  (review), 
983 

Chemists,  professional,  and  the  Scottish  Board 
of  Health,  910 

Chemotherapy  in  cutaneous  tuberculosis  (Mr. 
H.  J.  Gauvain),  412 

Chenoy,  Capt.  F.  B.,  I. M.S.(see  Obituary  of  the 
war) 

Chepmell.  Dr.  I.  D.,  death  of,  31,  157 
Cherrett,  Dr.  B.  W.,  death  of,  200 
Chesser,  Dr.  Elizabeth  S.,  (?)  congenital  synos- 
tosis, 298 

Chest,  opening  up  of,  663  ; gunshot  wounds  of 
666,  667 ; gunshot  wounds  and  other  affec- 
tions of  (Mr.  C.  MacMahon),  697 
Chicken  pox,  contact  infection,  397 
Chief  Secretary  for  Ireland  and  the  medical 
profession,  812 

Child-hearing,  continued  high  maternal  mor- 
tality (Mr.  V.  Bonney),  775,  796 ; (leading 
article),  802 

Child  Study  Society  (see  Medical  Societies) 
Child,  the,  as  an  impediment,  592;  as  an 
inducement,  644 

Child  welfare  and  maternity,  191,  192,  435,  436, 
811,  995  (Py  Q),  321 
Child  welfare  in  India,  857 
Children  of  devastated  Serbia,  963 
Children’s  Convalescent  Home,  Weston-super- 
Mare,  meeting,  922 

Children’s  Hospital  for  Bermondsey,  682 
Children’s  teeth,  905 


vi  The  Lancet,] 


INDEX  TO  VOLUME  I.,  1919. 


[July  5,  1919 


Chloroform  apparatus,  dangerous,  473 
Cholera  in  India, 434  ; and  influenzain  Bombay 
(PyQ),442 

Choruido-retinitis,  bilateral,  895 
Chowdhury,  Capt.  H.  C.  If.,  I.M.S.  (6ee 
Obituary  of  the  war) 

Christie,  Mai.  A.  C.,  X Bay  Technic  (review), 
184 

Christopherson,  Dr.  J.  B.,  antimony  in 
bilharziasis,  79 ; antimony  tartrate  for 
bilharziasie,  1C21 

Chronicity  of  dysentery  infection,  1038 
Chylothorax,  recurrent,  following  trauma  (Dr. 
A.  E.  Malone  and  Dr.  J.  G.  Wardrop), 
1116 

Chyme  infection  and  disease,  766 
Cirsoid  aneurysm,  700 

Civil  medical  practitioners’  war  service,  list, 
438 

Clarke,  Dr.  H.  C.,  medical  men  and  share 
holding,  1015 

Clarke,  Mr.  E.,  Crookes’s  lenses,  237 ; presby- 
opia, 895 

Clarke,  the  late  Dr.  J.  M.,  memorial  to,  20 
Claude,  Henri,  and  Jean  Lhermitte,  gunshot 
concussion  of  spinal  cord,  67 
Claxton  ear-cap,  868 

Clayton-Greene,  Mr.  W.  H.,  Pye's  Surgical 
Handicraft,  eighth  edition,  1919  (review), 
383 

Clifford,  Dr.  H.,  “ cyclops  foetus,”  301 
Clinical  Medicine,  System  of  (Dr.  T.  D.  Savill), 
fifth  edition,  1918  (review),  66;  Case  taking 
(Dr.  K.  D.  Keith)  (review),  111 ; Medicine, 
Treatise  on  (Dr.  W.  H.  Thomson),  second 
edition,  1918  (review),  383  ; Microscopy  and 
Chemistry  (Prof.  F.  A.  McJunkin)  (review), 
1028 

Clinical  research,  coordination  by  the  State 
(Dr.  D.  C.  Watson),  992;  position  ot 
psychiatry,  1092 ; pathology  en  detail, 
1088 

Clinical  thermometer  tests  (Py  Q),  587 
Coal-getting,  hygienic  conscience  in  relation 
to  (leading  article),  900 

Cobb,  Dr.  I.  G.,  Organs  of  Internal  Secretion, 
their  Diseases  and  Therapeutic  Application, 
second  edition,  1918  (review),  111 
Cocaine,  prescribing  of,  910 ; the  possession  of, 
948 

Cockayne,  Dr.  E.  A.,  congenital  absence  of 
lower  portion  of  left  pectoralis  major  muscle 
and  left  mammary  gland,  565;  a case  for 
diagnosis,  940 

Cockin,  Dr.  If.  P.,  obituary.  83 
Cocks,  Capt.  J.  S.,  If  A. M.C.  (see  Obituary  of 
the  war) 

Codrington,  Lieut.-Col.  Sir  A.  E.,  and  Judge 
Parry,  War  Pensions,  Past  and  Present 
(review),  799 
Cceliac  disease,  7C0 
“ Cofectant”  lozenges,  24 
Coffin,  Mr.  S.  W.,  centipede  bite,  1117 
Cohen,  Dr.  M.  W.,  case  of,  680 
Coldstream,  Dr.  A.  K.,  obituary,  530 
Cole,  Mr.  P.  P.,  fistula  of  the  parotid,  971 
Coles,  Dr.  A.  C.,  spirochretes  in  the  blood  in 
trench  fever.  375,  388 
Colitis,  secondary,  chronic,  1045 
Collegeof  Ambulaneeatid  future  of  the  V.A.D., 
271 

Collins,  Dr.  J.,  Neurologi.al  Clinics  (review), 
302 

Collins,  Mr,  E.  T.,  abiotrophy  of  the  retinal 
neuro-epithelium  or  “ retinitis  pigmentosa,” 
893 ; and  Mr.  L.  Paton,  angioma  ot  the 
choroid,  895 

Collis,  Dr.  E.  L.,  appointed  Talbot  professor  of 
preventive  medicine  at  Cardiff,  854 
Colloid  antimony  sulphide  intravenously  in 
kala-azar  (Sir  L.  Kogers),  505 
Colloid  metals  and  phenol  in  the  treatment  of 
influenza,  472 

Colloidal  silver  in  trench  fever,  583 
Colloids  (n  medicine  and  in  industry,  906 
Colopathies,  chronic  (Dr.  E.  Joltrain,  Dr.  P. 

Baufle,  and  Dr.  R Coope),  933 
Colonial  health  reports,  50.89,202,  242,324  488, 
591,644.772, 825, 1011,1054 
Coma,  diabetic,  prevention  and  treatment 
(Dr.  P.  J.  Camrnidge),  60 
Comber,  Mr.  A.  W.,  place  aux  embusquds, 

Commin  uted  f ract  ure  of  burner  us  ( Dr.  Winifred 
F.  Buckley),  981 

Complement-fixation  tests  in  gonococcal  in- 
fec'.icns  (Dr.  A.  H.  Priestley),  787 
Composite  neurosis,  analysis  of  (Dr.  F.  Dillon), 

Concussion,  gunshot,  of  spinal  cord  (Henri 
Claude  and  Jean  Lhermitte),  67 
Conference  of  representatives  of  various 
medical  bodies,  808— Representatives,  855- 
Common  action ; Medical  Consultative 
Council  to  Ministry  of  Health ; National 
Insurance  Defence  Trust.,  856 
Constable,  Dr.  Evelyn  A.,  Influenza  and  diph- 
theria, 563 


Constipation  in  children,  prophylactic  treat- 
ment (Dr.  V.  Borland),  459 
Consumptive,  the  advanced,  care  of,  706 
Consumptives  in  the  Army  (Py  Q),  641 
Contact  infection  of  chicken  pox,  397 
Convalescence,  fitness,  and  unfitness  in  (Dr. 

B.  Parsons-Smith),  509 
Cooke,  Dr.  W.  E.,  polyorrhomenitis,  562 
Coope,  Dr.  R.,  Dr.  E.  Joltrain,  anl  Dr.  P. 

Baufle,  chronic  colopathies,  933 
Copper  treatment  of  lupus,  528 
Cord,  vocal,  a plastic  (Dr.  F.  N.  Smith),  108 
Core,  Dr.  D.  B.,  dreams  of  the  terror-neurosis, 

155 

Cornea,  congenital  pigmentation,  613 
Corner,  Mr.  E.  M.,  infective  scar  tissue, 
840 

Corns  on  babies’  noses,  583 
,l  Corps,  esprit  de,”  1124 

Corpus  striatum,  the,  and  paralysis  agitans, 
77 

Correction,  1012 

Correspondents.  Answers  to.— Enquirer.  50 
— D.  B.  H.,  164— Croix  de  Guerre,  202— 
H.  W.  C.,  324  - F.  II.  M. , 448— Viperus,  540— 
A.  B.  C.,  592— Enquirer,  728— R.  K.  H.,  868— 
X.  Y.  Z.,  Ex-Medico,  964-F.  C„  1012- 
E.  T.  B.,  1054 

Cotterill,  Capt.  D.,  R.A.M.C.  (see  Obituary  of 
the  war) 

Cottle,  Dr.  W.,  death  of,  991 
Coussieu,  Dr.  H.,  migration  of  a round  worm 
into  the  ear,  28 

Cowper,  Temp.  Surg.  W.  P.,  R.N.  (see  Obituary 
of  the  war) 

Craik,  Dr.  R.,  leucocyte  count  in  influenza, 

156 

Crawford,  Dr.  Barbara  G.  R , and  Dr.  W.  J. 
Rutherford,  hereditary  malformation  of  the 
extremities,  979 

Cream,  supply  of,  new  regulations,  48 
Cremation  Society  of  England,  report,  883 
Creosote  in  influenza,  use  of,  128 
Cretan  library,  488 
Crewe,  Lord,  books  for  Se'bia,  398 
Crime  and  Criminals  (Dr.  C.  Mercier) (review), 
382 

Crime,  detection  of,  and  medical  practitioners, 
120,  198 

Crime  and  responsibility  (leading  article), 
1121 

Criminal  or  moral  imbecile,  1Q41 
Criminal,  the  psychopathic  (leading  article), 
143,  432 

Criminology  (Mr.  M.  Parmelee)  (review),  982 
Cripples,  a survey  of,  27 ; motor  mechanics 
for,  76 

Crocker,  Dr.  W.,  Veterinary  Post-mortem 
Technic  (review),  225 

Crofton,  Dr.  W.  M.,  Abderhalden’s  pregnancy 
reaction.  111 

Crombie,  Lieut.  W.  M.,  I.M.S.  (see  Obituary 
of  the  war) 

Crookes,  Sir  W.,  death  of,  624 
Crookes’s  lenses,  124,  237 

Crookshank,  Dr.  F.  G.,  epidemic  encephalo- 
myelitis and  influenza,  79;  presence  of  a 
filter-passing  virus  in  influenza,  313  ; import- 
ance of  symptoms,  480 

Croonian  lectures  on  the  role  of  the  sym- 
pathetic nervous  system  in  disease  (Dr.  L. 
Brown),  827,  873,  923,  965 
Cruise,  Mr.  R.  R.,  contracted  sockets,  893 
Culture  media  for  B.  influenzx,  simply  pre- 
pared (Mr.  A.  Fleming),  138 
Cumberbatch,  Dr.  E.  P , Essentials  of  Medical 
Electricity,  fourth  edition,  1919  (review).  514 
Cummins,  Col.  S.  L.,  and  Maj.  H.  G.  Gibson, 
analysis  of  cases  of  tetanus,  325  ; cultivation 
of  a filter-passing  organism  in  influenza, 
528 

Cunliffe,  Maj.  E.  N.,  R.A.M.C.  (see  Obituary  of 
the  war) ; obituary,  634 

Cunning,  Mr.  J.,  and  Mr.  C.  A.  Joll,  Aids  to 
Surgery,  fourth  edition,  1919  (review),  659 
Cunning,  Mr.  J.,  epidemic  perinephric 
suppuration,  1001,  1135 

Cunningham,  Mr.  J.  F.,  cartilaginous  tumours 
of  roof  of  the  orbit,  300 
Cures,  war,  116 

Curl,  Dr.  S.  W.,  and  Dr.  H.  B.  Roderick,  re- 
curring effusion  into  the  pericardial  sac, 
980 

Curtis,  Mr.  H.,  .etiology  of  lingual  cancer,  123  ; 
saccharose  injections  in  pulmonary  phthisis. 
636 

CushnyJDr.  A.  R.,  Text-bcok  of  Pharmacology 
and  Therapeutics,  seventh  edition,  1918  (re- 
view), 22 

Cutaneous  tuberculosis,  chemotherapy  in  (Mr. 

H.  J.  Gauvaio),412 
Cyanosis,  artificial,  of  lips,  529 
“ Cyclops  foetus, ”300 

Cyst,  ovarian,  spontaneous  rupture  (Mr.  D.  N. 

Ivalyanvala),  423 
Cystic  tumours  of  the  vulvn,22 


D 

Dalby,  Sir  W.  B.,  obituary,  83 
Da'e,  Dr.  H.  II.,  and  Prof.  W.  M.  Bayliss, 
shock,  discussion,  256 

Daly,  Mr.  A.,  direct  massage  of  the  heart, 

658 

Darre,  Dr.  II.,  haemoglobinurie  bilious  fever, 
treatment,  940 

Davidson.  Sir  J.  M.,  obituary,  633 
Davies,  Dr.  S.,  causes  and  incidence  of  dental 
caries,  124  ; hot  liquids  and  cancer.  683 
Daw,  Dr.  S.  W.,  Orthopedic  Effects  of  Gunshot 
Wounds  and  their  After  Treatment  (review), 
847 

Deacon,  Mr.  J.  F.  W.,  Mr.  J.  B.  Lane,  and  Lord 
Kinnaird,  residential  treatment  for  pregnant 
women  suffering  from  venereal  diseases, 
80 

Deafnefs,  war,  157,  198,  238;  associated  with 
the  stigmata  of  degeneration,  182 
Deane,  Lieut.  P.  E.,  and  Sir  J.  W.  Barrett, 
Australian  Army  Medical  Corps  in  Egypt  in 
1914-15  (review),  66 

Death  from  barium  salts  administered  for 
radiological  examination,  943 
Death-rate  of  mental  defectives  in  institu- 
tions, 78 

Deaths,  total,  from  wounls  in  the  Great  War, 
406 

Decentralisation  at  the  Ministry  of  Pensions, 
663 

Decorations,  foreign  (see  Decorations  under 
War  and  After) 

Deformities,  Bodily  (Mr.  E.  J.  Chance) 
(review),  800 

Delusions,  genesis  of,  1028 
Demobilisation,  medical  appointments  in 
Ireland  during,  18;  medical,  in  France,  38, 
477 ; of  the  British  Red  Cross,  41 ; medical, 
84;  scheme  of  Central  Medical  War  Com- 
mittee, 84.  193;  of  medical  men  (Py  Q).  321, 
360,535,  631;  of  panel  practitioners  ( Py  Q), 
359;  of  doctors  and  nurses  (Py  Q),  443;  of 
medical  officers  (Py  Q),  485,  641 ; men, 
medical  treatment  of  (Py  Q),  640  ; of  field 
ambulance  officers  (Py  Q , 918 ; and  Territorial 
medical  officers  (Py  Q),  918,  960 
Demobilised  practitioner,  the  position  <_f,  439; 
(leading  article),  515 

Dendy,  Prof.  A.,  Animal  Life  and  Human 
Progress  (review),  1120 

Dental  caries,  causes  and  incidence,  46,  80,  123, 
155,  198,  238;  practice,  qualified  and  un- 
qualified (leading  article),  385;  practice,  un- 
qualified, evils  of,  359 ; practitioners,  unregis- 
tered, 724;  surgeons  and  the  army  gratuity 
(Py  Q),  4C2  ; service,  a public,  440 
Denial  Congress,  Sixth  International,  Trans- 
actions of  (review),  24 
Department  of  health  for  Canada,  767 
Despatches,  mentioned  in  (see  Despatches 
under  War  and  After) 

Destroyers  and  Other  Verses  (Dr.  H.  Head 
(review),  1120 

Detoxicated  vaccines  (Dr.  D.  Thomson),  374  ;v 
with  special  reference  to  gonorrheea.  nasal 
and  bronchial  catarrh,  and  influenza.  11C2  ; 
in  treatment  of  gonorrhoea  (Dr.  D.  Lees), 
1107 

Devaux,  A.,  nervous  complications  of 
exanthematic  typhus,  567 
Devon  and  Exeter  Royal  Hospital,  meeting, 
441  ; and  Cornwall  Sanatorium  for  Con- 
sumptives, Didworthy,  meeting,  1007 
Devota,  Mr.  F.  J.,  intravenous  injection  of 
potassium  iodide  in  tabes  dorsalis,  239 
Dewey.  Lieut.  E.  W.,  need  for  physical  educa- 
tion, 867 

Diabetes  and  its  Dietetic  Treatment  (Map 
B.  D.  Basu),  ninth  edition,  1918  (review), 
383  ; indications  for  operation,  945 
Diabetes  innocens  and  renal  glycosuria  (Dr. 
L.  Brown),  923;  insipidus  and  circulatory 
diseases  in  relation  to  the  sympathetic.  965 
Diabetic  coma,  prevention  and  treatment 
(Dr.  P.  J.  Camrnidge),  £0 
Diagnosis,  accurate,  in  appendicitis  (leading 
Article),  114;  a case  for,  940 
Diagnosis,  Differential  (Dr.  R.  C.  Cabot), 
second  edition,  1918  (review),  112 ; Medical, 
Aids  to  (Dr.  A.  Whiting),  second  edition. 
1918  (review),  112;  Surgical,  Elements  of 
(Sir  A.  P.  Gould  and  Mr.  E.  P.  Gould),  fifth 
edition.  1919  (review),  659 
Diagnostic  Clinique  (Examens  et  Symptomes) 
(Dr.  A.  Martinet)  (review),  984 
Diagnostic  Hospital,  New  York,  950 
Diaphragm,  disease  below,  unilateral  hydro- 
thorax  due  to  (Mr.  W.  G.  Nashl.  378  _ ____ 

Diaphragmatic  hernia  (Mr.  R.  Warren),  1069, 
1089 

Diarrhceal  outbreak  in  Aberdeen,  560 
D.ckinson.  Mr.  W.  H.,  influenza  and  chronic 
lung  disease,  314 

Diet  and  influenza,  memorial  on,  436 


INDEX  TO  VOLUME  I.,  1919. 


[July  5,  1919  vii 


The  Lancet,] 


Diot  kitchens  fur  military  hospitals,  37 
Differential  Diagnosis  (Dr.  It.  C.  Cabot), second 
edition.  1918  (review),  112 
Dlgaleu,  384 

Digestive  juices,  secretion  of  (Dr.  L.  Brown), 
873 

Dill,  Dr.  J.  F.  G.,  Medical  Parliamentary 
Committee,  858 

Dilling,  Dr.  W.  J , and  Dr.  J.  M.  Bruce, 
Materia  Modica  and  Therapeutics,  an  Intro- 
duction to  the  national  Treatment  of 
Disease,  eleventh  edition,  1918  (review), 
112 

Dillon,  Dr.  F.,  analysis  of  a composite  neurosis, 
57 

Dinner  fork  in  the  stomach  and  duodenum 
(Mr.  K.  A.  Lees).  298 

Dinniok,  Dr.  O.  T.,  treatment  of  syphilis,  1055 
Diphtheria  and  influenza  (Dr.  15.  A.  Constable), 
563 

Diphtheria  bacillus,  staining  (Dr.  P.  L. 
Sutherland),  218 

Diphtheria  in  New  York  City,  524 
Directory  of  Distriot  Nursing  and  Streets  List 
for  London  (review),  660 
Disability,  medical  assessment  of  (Py  Q).  1137 
Disabled!  Rehabilitation  of,  International  Con- 
ference on, 761 

Disablement,  problem  of,  851 
Disease  and  tlemady  of  Sin  (Mr.  W.  M.  Maokay) 
(review),  302  ; and  chyme  infeotion,  766 
Disease,  organic,  hysterioal  element  in,  and 
injury  of  central  nervous  system  (Dr.  A.  F. 
Hu.  st  and  Dr.  J.  L.  M.  Symns),  359 
Disease,  sympathetic  nervous  system  in,  role 
of  (Dr.  L.  Brown),  827,  873,  923 
Diseases,  Epidemic.  0,-der,  new,  and  its  effeot 
(leading  article),  303,  309 
Diseases  of  the  Skin  (Dr.  J.  M.  Sequeira),  third 
edition,  1919  (review),  798 
Diseases,  physiology  and  the  study  of,  447  ; 
epidemic,  observed  in  Rumania  during  the 
campaign  of  1916-17  (Dr.  Henri  Vuillet), 
569 

Disinfectant,  electrolytic,  in  influenza, 
90 

Disinfectants,  germicidal  valuation  of, 
576 

Disinterested  prescriptions,  1036 
Dislocation  of  teeth  (Mr.  II.  M.fSavery),  339, 
441 

Dispensary  doctors,  salaries  of,  121 
Dispersal  b ards,  medical  men  on  (Py  Q),  820 
Disposal  of  dysentery  oarriers , 626 
District  nursing  associations  and  public 
health  (Py  Q),  686 

Dixon,  Prof.  F. , special  supports  of  the  uterus, 
904 

Dockyard  workmen,  medical  examination  of 
(Py  Q),  917 

Doctor,  woman,  sued  by  member  of  the 
Q.M.A.A.C.,  1040 
Doctor’s  welcome  in  Uganda,  218 
Doctors,  French,  and  the  excess  profits  tax,  38 ; 
dispensary,  salaries  of.  121  ; demobilisation 
of,  631 ; need  for  more,  997 
Doctors’  fees,  rise  in.  997 

D’Oelsnitz,  M.,  G.  Roussy,  and  J.  Boisseau, 
Traitement  des  Psychonevroses  de  Guerre 
(review),  1119 

Dog  as  test  object,  625,  864,  945 
Dogs'  Protection  Bill,  763,  957 ; resoluti  n from 
the  Royal  Society  of  Medicine,  764  ; resolu- 
tion passed  by  the  Royal  Faculty  of  Phy- 
sicians and  Surgeons  of  Glasgow,  915  ; resolu- 
tion passed  by  the  Royal  College  of  Surgeons 
of  Edinburgh,  939;  memorandum  by  the 
Medical  Research  Committee,  947 
Donaldson,  Dr.  R , presence  of  a filter-passing 
virus  in  influenza,  280 

Donations  and  bequests,  47,  88,  102,  282,  311 
368,  400,  504,  527,  769,  879,  910,  1023,  1095, 
1138 

Dopter,  Prof.  C.,  cerebro  - spinal  fever, 
1075 

•Dore,  Dr.  S.  E.,  treatment  of  lupus  vulgaris 
with  picric-brass,  635 
Drage,  Dr.  L. ..Ministry  of  Health,  281 
Drake- Brockman,  Lieut. -Col.  E.  F.,  obituary, 
860 

Dreams  of  the  terror-neurosis,  155 
Dr6w,  Dr.  C.  L.,  obituary,  998 
“ Droppei-foot  ” appliance,  142.  284,  468 
Dr.  John  Fothergill  and  His  Friends  (Dr.  R.  H. 
Fox)  (review),  1118 

Drink  Trade  (Control  of)  in  Great  Britain  -. 
Contribution  to  National  Efficiency,  1915-18, 
second  edition,  1919  (H.  Carter)  (review), 
1119 

Drug  law,  new  narcotic,  for  New  York  State, 
353;  situation  in  New  York,  813;  habit, 
national  investigation,  950;  addiction  in 
the  United  States,  1090 

Drugs,  illicit  traffic  in,  36 ; indigenous,  of 
India,  307;  a la  mode,  945;  supply  of, 
934 

Drugs,  Synthetic,  Chemistry  of  (Dr.  P.  May), 
second  edition,  19.8  (review),  244 


Drummond,  Mr.  J.  C.,  fat  - soluble  A, 

990 

Dry  sweeping  in  railway  carriages,  644 

Dublin  housing,  report,  154;  meeting  of 
delegates,  1040 

Dublin  University,  Trinity  College,  School  of 
Physic,  pass-lists,  48,  639 

Ducroquet,  Dr.,  Prothdse  Fonetlonelle  dos 
Blesses  de  Guerre  (review),  848 

Dudgeou,  Col.  L.  S.,  bacillary  dysentery, 
673 

Dudley,  Dr.  S.  F.,  dlagnoris  of  primary 
syphilis,  737 

Duffy,  Capt.  J.  V.  B.A.M.C.  (see  Obituary  of 
the  war) 

Dumas,  .T.,  and  Anne  Carrel,  Teohnic  of  the 
Irrigation  Treatment  of  Wounds  by  the 
Carrel  Method  (review).  617 

Duncan,  Mr.  D.,  osteo-arthrltia,  488 

Duodenum,  primary  carcinoma  of,  1128 

Durham  University,  Faculty  of  Medicine,  pass- 
lists,  584,  639 

Dwyer,  Capt.  J.  J.,  D.S.O.,  R.A.M.C.  (see 
Obituary  of  the  war) 

Dyke,  Dr.  S.  C.,  traumatic  aneurysm  of 
external  carol  id,  21 

Dysentery,  arcccbic  and  bacillary,  diagnoses  of 
(Dr.  G.  M.  Findlay),  135 ; amoebic,  carriers, 
a correction,  167  ; amoebic,  treatment,  429; 
bacillary,  are  relapses  frequent,  529 ; in 
Germany  in  1918,  622 ; bacillary,  673 ; 
amoebic,  674  ; notification  of,  723;  bacillary, 
mild  (Dr.  J.  Ryle),  937 

Dysentery  carriers,  disposal  of,  626;  infection, 
ohronicity  of,  1033 

Dyspepsia,  reflex  (Dr.  L.  Brown),  875 


E 

Eagleton,  Dr.  A.  J.,  and  Mr.  H.  n. 
Butcher,  treatment  of  complicated  in- 
fluenza, 560 

Ear,  Diseases  of,  in  Children,  Essay  on  Preven- 
tion of  Deafness  (Dr.  J.  K.  Love)  (review), 
896 

East  Sussex  Hospital,  meeting,  1095 
Eaton,  Mr.  E.  M.,  visual  perception  of  solid 
forms,  1072 

Echo  Personalities  (Mr.  F.  Watts)  (review), 
983 

Eclampsism,  accidental  hemorrhage  in  con- 
nexion with  (Sir  S.  Smyly),  133 
Ectopic  gestation,  22;  gestation,  with  an 
apparently  imperforate  hymen  (Dr.  S.  G. 
Papadopoulos),  140;  gestation  (Dr.  B.  T. 
Rose  and  Mr.  E.  H.  Shaw),  175;  pregnancy, 
full-time,  four  cases,  611 
Edible  Oils  and  Fats  (Mr.  C.  A.  Mitchell) 
(review),  848 

Edinburgh,  meeting  of  the  medical  profession 
in,  1040 

Edinburgh  University,  report,  87 ; Dr.  D. 
Turner  appointed  additional  examiner  in 
medical  physics,  141 ; chair  of  therapeutics, 
433  ; affairs  of,  910 ; prospective  vacant 
chair,  1040 

Edmond,  Mr.  W.  S.,  and  Dr.  J.  Taylor, 
advances  in  the  treatment  of  fractures, 
46 

Education  in  ophthalmology,  report,  578 
Education,  scientific,  and  its  cost  (leading 
article),  428;  medical,  reform  of  (leading 
article),  571  ; Experimental  (Dr.  R.  R.  Rusk) 
(review),  618  ; medical,  post-graduate 
(leadiug  article),  703  ; physical,  need  for,  8t>7 
Edwards,  Dr.  P.  W.,  “mass  meetings”  and 
their  representative  character,  314 
Effusion,  recurring,  into  the  pericardial  sac 
(Dr.  H.  B.  Roderick  and  Dr.  S.  W.  Curl),  980 
Effusions,  spinal,  htemorrhagic  (Dr.  W.  P.  S. 
Branson),  888 

Egypt,  public  health  work,  146 ; Public 
Health  Department,  annual  report  for  1916, 
681 

Egyptian  Fellaheen  Medical  Service  (Py  Q), 
641 

Electrical  methods  of  measuring  body 
temperature,  564  ; training  for  disabled  men, 
728 

Electricity,  Medical,  Essentials  of  (Dr.  E.  P. 
Cumberbatch),  fourth  edition,  1919  (review), 
514 

Electro-cardiograph,  the,  564 
Electro-Diagnosis  in  War  (Prof.  A.  Ziramern 
and  M.  Pierre  Perol)  (review),  468 ; Pathology, 
Studies  in  (Dr.  A.  W.  Robertson)  (review), 
701 ; Physiology  (Animal  and  Vegetable) 
(Mr.  A.  E.  Baines)  (review),  701 
Electrolytic  disinfectant  in  influenza.  90 
Elements  of  Surgical  Diagnosis  (Sir  A.  P. 
Gould  and  Mr.  B.  P.  Gould),  fifth  edition, 
1919  (review),  659 

Elias,  Dr.  H..  and  Dr.  Richard  Singer,  war 
cures,  116 

Elizabeth  Girrett  Anderson  Hospital  appeal, 
1026 


Elliott,  Col.  T.  It.,  gunshot  wounds  of  the 
chest,  666  ; and  Capt.  I).  S.  Lewis,  Maj.  J.  H. 
Thurslield,  Maj.  A.  J.  Jex-Blake,  and  Maj. 
M.  Foster,  invalidism  caused  by  P.U.O.  and 
trench  fever,  1060 

Elliott,  Dr.  Q.,  radium  treatment  of  epithe- 
lioma of  the  lip,  388 

Ellis,  Dr.  H.  A , picric-brans  preparations  in 
treatment,  of  lupus,  415.  430 
Ellis.  Mr.  W.  A.,  obituary,  125 
Elliston,  Mr.  G.  S.,  after-care  of  tuberculous 
ex-sorvioo  men.  767 ; After-Treatment  of 
Wounds  and  Injuries  (review),  896 
Elmslie,  Maj  R.  C.,  surgical  treatment,  670 
Embleton,  Dr.  1).,  and  Dr.  G.  H.  Steven, 
cerebro-spinal  fever  cases  as  carriers,  788 
Emboli,  missiles  as  (Sir  J.  Bland  Sutton),  773, 
913 

Emergency  hospital,  private,  977 
Emigration  of  tuberculous  soldiers  (Py  Q), 
821 

Emotional  shock  on  the  battlefield  (Cl. 
Vincent),  69 

Emphysema,  diffuse,  of  wall  of  small  intestine, 
263  ' 

Employment  Opportunities  for  Handicapped 
Men  in  the  Opi  ieal  Goods  Industry  (Mr.  B.  J. 
Morris)  (review),  982 

Empyema,  “ medical  treatment”  of,  1127 
Encephalitis  lethargica  and  typhus,  156 
Encephalitis  and  poliomyelitis,  notification  of, 
76 

Encephalo  myelitis,  epidemic,  and  influenza, 
79 

Endothelioma  of  the  ovary,  264  ; of  the  tonsil, 
300 

Enham  Village  Centre,  vocational  training, 
1053 

Entamoeba  histolytica,  &c.,  in  naval  entrants 
(Mr.  H.  A.  Baylis),  54 ; a correction,  157 
Enteralgia,  pancreatitis  a cause  (Dr.  L.  Brown), 
876 

Entczoa,  intestinal,  among  the  native  labourers 
of  Johannesburg,  521 
Environment,  susceptibility  to,  519 
Epidemic  diseases  observed  in  Rumania  during 
the  campaign  of  1916-17  (Dr.  Henri  Vuillet), 
569 

Epidemic  Diseases  Order,  new,  and  its  effect 
(leading  article),  303,  309 
Epidemic  perinephric  suppuration  (Mr.  J. 
Cunning).  1134 

Epididymitis  and  orchitis  (Sir  H.  Rolleston), 
601  * 

Epilepsy,  meatless  dietary  in,  1046,  1093 
Epilepsy,  the  “spectrum”  of,  157 
Episcopal  Hospital,  Medical  and  Surgical 
Reports  (review),  23 

Epistaxis  and  hEemoptysis  in  influenza,  481 
Epithelial  cell,  malignant,  polymorphism  of, 
743 

Epithelioma  of  the  lip,  radium  treatment, 
388 

Epstein,  Prof.  A.,  death  of,  30 
Epulides,  multiple,  744 

Erythema,  acute,  resembling  measles  (Dr. 
F.  H.  Kelly),  255 ; nodosum,  reactivation  by 
tuberculin,  7C5 

Erythrajmia,  case  of  (Dr.  Margaret  H.  Fraser), 
338 

“ Esprit  de  corps,”  1124 

Essentials  of  Medical  Electricity  (Dr.  E.  P. 
Cumberbatch),  fourth  edition,  1919  (review), 
. 514 

Ether  anesthesia,  rectal  (Mr.  J.  C.  Clayton), 
793 

Ethyl  chloride  films,  24 
European  food  situation,  148,  306,  387 
Euthanasia  (leading  article),  803 
Evatt,  Capt.  J.  M.,  R.A.M.C.  (see  Obituary  of 
the  war) 

Evulsion  of  optic  nerve,  895 
Examioing  Board  in  Eogland  by  the  Royal 
Colleges  of  Physicians  of  London  and 
Surgeons  of  England,  pass-lists,  239,  639, 
724 

Exanthematic  typhus,  nervous  complications 
(A.  Devaux),  567 

Exeter  City  Asylum,  meeting,  183 
Experimental  Education  (Dr.  R.  R.  Rusk) 
(review),  618 

Extra  uterine  pregnancy,  22,  611;  advanced, 
301 ; continuing  to  terra,  611 
Extremities,  Gun-Shot  Fractures  of  (Lieut.- 
Col.  J.  A.  Blake)  (review),  184,  702;  mal- 
formation of,  hereditary  (Dr.  W.  J. 
Rutherford  and  Dr.  Barbara  G.  R.  Crawford), 
979 

Eye,  Hygiene  of  (Dr.  W.  C.  Pos?y)  (review), 
184;  Refraction  of.  Manual  for  Students 
(Mr.  G.  Hartridge),  sixteenth  edition,  1919, 
(review),  984 

Eyes  Right,  Papers  for  Teachers  and  Parents 
on  the  Hygiene  and  Treatment  of  the  Eye 
(Dr.  J.  M.  Maephail)  (review),  984 
Eyesight  and  education,  894 
Eyre,  Dr.  J.  W.  H.,  and  Dr,  E.  C.  Lowe, 
autumn  influenza  epidemic  (19 18),  553 


viii  The  Lancet,] 


INDEX  TO  VOLUME  I.,  1919. 


[July  5, 1919 


F 

Factories,  medical  inspection  in  (Py  Q),  402 
Factory  surgeons  and  the  Ministry  of  Health, 
432  ; medical  officer  in  war  an  i peace,  447 
Fairley,  Ur.  N.  H.,  bilharziasis,  1016 
Faradic  stimulation  (Mr.  II.  Platt  and  Mr.  E.  S. 

Brentnall),  884, 989 
Fat-soluble  A,  990 

Fazakerley  Hospital,  release  of  ( Py  Q),  821 
Feat  of  endurance  (leading  article),  1085 
Fedorb,  Surg.-Cmdr.  F.,  11. N.  (see  Obituary  of 
the  war) 

Feeble  mindedness  from  two  standpoints,  520 
Feeding,  Physiological,  of  Children  (Ur.  E. 

Pritchard)  (review),  1028 
Fees  for  notification  of  infectious  diseases,  577 
Fellowship  of  medicine  (leading  article),  26 ; of 
medicine,  emergency,  post-graduate  facili- 
ties, 189,  400,  477 

Femoral  hernia,  strangulated  (Dr.  S.  M. 
* Lawrence),  64 

Fergus,  Dr.  A.  F.,  panel  ophthalmic  practice, 
758 

Ferguson,  Maj.  A.  I!.,  Capt.  T.  J.  Mackie,  Capt. 
L.  F.  Hirst,  and  Col.  A.  H.  Tubby,  action  of 
flavine,  838 
Feroxal,  24 

Fever,  pseudo-paratyphoid  (Dr,  E.  Paton), 

Fibroid,  sessile  red,  22 ; submucous,  removal 
with  Ilegar's  dilators.  1073 
Field  Service  Book,  Medical  (Mr.  C.  M.  Page) 
(review),  383 

Fielding-Ould,  Dr.  R.,  medical  profession  and 
the  trade-union  question,  397 
Fiessinger,  M.  Ch.,  treatment  of  paroxysmal 
tachycardia  by  respiratory  effort,  853 
Filarial  infection  in  Macedonia  (Dr.  J.  G. 
Forbes),  654 

Elides,  Lieut.-Cradr.  P.,  and  Lieut.-Cmdr. 

R.  J.  G.  Parnell,  Wassermann  reaction,  807 
Films,  anatomical,  1125 
Films,  ethyl  chloride,  24 

Filter-passing  virus  in  certain  diseases  (Maj.- 
Gen.  Sir  J.  R.  Bradford,  Capt.  E.  F.  Bashford, 
and  Capt.  J.  A.  Wilson),  169;  in  influenza, 
280, 313, 528 

Findlay,  Dr.  G.  M.,  differential  diagnosis  of 
amcebic  and  bacillary  dysentery  from  the 
blood,  135 ; bacteriology  of  influenza  epidemic 
in  Lower  Egypt,  1113 
Finger-printB  as  signatures,  1132 
Fisher,  Dr,  T.,  hilus  tuberculosis  in  children 
and  adults,  814 

Fisher,  Mr.  J.  H.,  migraine,  613;  exhibition  of 
case,  1072 

Fisher,  Surg. -Lieut.  E.  G.,  R.N.  (see  Obituary 
of  the  war) 

Fistula  of  the  parotid  ( Mr.  P.  P.  Cole),  971 
Fitness  and  unfitness  in  convalescence  (Dr.  B. 
Parsons-Smith),  509 

Flack,  Dr.  M.,  simple  tests  of  physical 
efficiency,  210 

Flavine,  action  of  (Col.  A.  H.  Tubby,  Maj. 
A.  R.  Ferguson,  Capt.  T.  J.  Mackie,  and 
Capt.  L.  F.  Hirst),  838;  in  ophthalmic 
surgery,  895;  (Mr.  A.  Lawson),  1112 
Fleming,  Mr.  A.,  simply  prepared  culture 
media  for  B.  influenza:,  138;  and  Dr.  A.  B. 
Porteous,  blood  transfusion  by  the  citrate 
method,  973,  988 

Flemming,  Dr.  C.  E.  S.,  general  practitioners’ 
hospital,  1042 

Flemming,  Mrs.  E.  E.,  medical  inspection  of 
secondary  schools,  616 

Fletcher,  Dr.  W.,  meningococcus  broncho- 
pneumonia in  influenza,  104  ; and  Dr.  Doris 
Mackinnon,  chronicity  of  dysentery  infec- 
tion, 1038 

Flint,  Dr.  H.  L.,  advances  in  polygraphic 
technique,  176;  and  Dr.  M.  J.  Stewart, 
ulcerative  endocarditis,  1114 
Flint,  Mr.  E R.,  intussusception  treated  by 
resection,  938 

Florence,  Mr.  P.  S.,  Use  of  Factory  Statistics 
in  the  Investigation  of  Industrial  Fatigue 
(review),  301 

Florence  Nightingale  Hospital  for  Gentle- 
women, report,  584 

Fluids,  puncture,  thoracic  (Dr.  S.  R.  Gloyne), 
935 

Flying,  medical  aspects  of  (leading  article), 
227 

Foetus  during  spontaneous  evolution,  610 
Folley,  Dr.  E.,  “Spanish  influenza,” 656,  663 
“ Food  poisoning,”  epidemic,  348 
Food  situation,  European,  148,  306,  387 ; 
inspection,  Local  Government  Board,  189 ; 
problem  and  physiology,  283 ; material, 
accessory,  large  waste,  474;  minimum  re- 
quirements, 518  ; Board,  the  need  for,  591 ; 
in  relation  to  health,  591 
Foods  and  Drugs,  Aids  to  Analysis  of  (Mr. 
C.  G.  Moor  and  Mr.  W.  Partridge),  fourth 
edition,  1918  (review),  848 


Foods,  perishable,  carriage  of,  592 
Foramen  lacerum  posterius,  syndrome  of,  188 
Forbes,  Dr.  J.  G.,  filarial  infection  in 
Macedonia,  654 

Forced  Movements,  Tropisms,  and  Animal 
Conduct  (Monographs  on  Experimental 
Biology)  (Dr.  J.  Loeb)  (review),  745 
Ford,  Miss  Rosa,  congenital  pigmentation  of 
cornea,  613  ; pituitary  tumour.  613 
Formalin  spray  in  checking  influenza  (Dr.  A. 
Wylie).  256 

Foster,  Maj.  M.,  Col.  T.  R.  Elliott,  Capt.  D.  S. 
Lewis,  Maj.  J.  H.  Thursfield,  and  Maj.  A.  J. 
Jex-Blake,  invalidism  caused  byP.U.O.  and 
trench  fever,  1060 
Foster,  Prof  G.  C.,  death  of,  282 
Fothergill,  Dr.  W.  E , institution  of  maternity 
hospitals,  912 

Fothergill  (Dr.  John)  and  His  Friends  (Dr. 

R.  II.  Fox)  (review),  1118 
Fracture-dislocation  of  astragalus  (Mr.  H.  C. 
Orrin),  20 

Fracture,  “propeller”  (Lieut.-Col.  A.  L. 
Johnson),  293;  of  humerus,  comminuted 
(Dr.  Winifred  F.  Buckley),  980 
Fractures,  advances  in  treatment,  46,  80 ; of 
thigh,  suspension  treatment  (Dr.  W.  H. 
Johnston),  170;  occupational,  349;  com- 
pound, of  the  upper  limb  (Mr.  E.  G. 
Slesinger),  365  ; retrogressions  in  treatment 
of  (Maj.  M.  Sinclair),  507 
Fractures,  Gunshot,  of  the  Extremities  (Lieut.- 
Col.  J.  A.  Blake)  (review),  184,702 
Fractures  treated  in  Germany,  results,  760 
Fraser,  Dr.  Margaret  H.,  erythremia,  338 
Fraser,  Mr.  J.  S.,  and  Mr.  W.  T.  Garretson, 
radical  and  modified  radical  mastoid  opera- 
tions, 339 

Fraser,  Sir  T.,  retirement  of,  631 
Freak  of  nature,  575,  723,  963 
Free  hospital  movement  in  Western  Canada, 
949 

French,  Dr.  H.,  Dr.  A.  Abrahams,  and  Dr.  N. 
Hallows,  influenzal  septicaemia,  1 ; appointed 
Physician  to  His  Majesty’s  Household,  854 
French  doctors  and  the  exceis  profits  tax,  38  ; 
Orthopaedic  Society,  477  ; Auxiliary  Army 
Medical  Corps,  mortality  in,  540  ; anti- 
small-pox campaign  during  the  war,  759 
French  Supplement  to  The  Lancet  (leading 
article),  347 


French  Supplement  to  “ The  Lancet 
Achard,  Prof.  C.,  Review  of  Studies  on  Renal 
Function  in  Chronic  Nephritis  (thesis  by 
Pasteur- Vallery-Radot),  752 
Claude,  Henri,  and  Jean  Lhermitte,  gunshot 
concussion  of  spinal  cord.  67 
Devaux,  A.,  nervous  complications  of  exan- 
thematic  typhus,  567 

Dopter,  Prof.  0.,  cerebro-spinal  fever,  1075 
Jeanselme,  Prof.  E.,  distribution  of  soldiers, 
temporarily  unfit  through  malaria,  in 
agricultural  colonies,  751 
Lhermitte,  Jean,  and  Henri  Claude,  gun- 
shot concussion  of  spinal  cord,  67 
Moure,  Dr.  P.,  and  Dr.  E.  Sorrel,  surgical 
complications  following  exanthematic 
typhus,  341 

Paisseau,  G.,  malaria  during  the  war,  749 
Sainton,  Dr.  P.,  meningococcal  rheumatism 
and  arthritis,  1080 

, Sorrel,  Dr.  E.,  and  Dr.  P.  Moure,  surgical 
complies'  ions  following  exanthematic 
typhus,  341 

Vincent,  Cl.,  contribution  to  the  study  of 
manifestations  of  emotional  shock  on  the 
battlefield,  69 

Vaillet  , Dr.  Henri,  epidemic  diseases  observed 
in  Roumania  during  the  campaign  of  1916- 
1917,  569 

Fremantle,  Dr.  F.  E.,  medicine,  Parliament, 
and  public,  312 

Fresh  Air  Fund,  1054 

Freud,  Prof.  S.,  Psychopathology  of  Everyday 
Life  (review),  234 

Frey-Bolli,  Dr.  E.,  the  retained  placenta, 
806 

Friedenwald,  Dr.  J.,and  Dr.  A.  McGlennan, 
perforation  in  cancer  of  the  stomaoh. 
272 

Friend,  Mr.  G.  E.,  apparent  immunity  from 
influenza,  105,  119 

Friends  for  sick  children,  946 

Frost  v.  King  Edward  VII.  National  Memorial 
Association  for  the  Prevention,  Treatment, 
and  Abolition  of  Tuberculosis,  37 

Fry,  Dr.  H.  J.  B.,  Buchner’s  anaerobic  tube, 
modified,  226 

Fry,  Mr.  W.  E.,  endothelioma  of  tonsil,  300 

Fryer,  Dr.  J.  H.,  air  for  oxygen  in  anaesthesia, 
216 

Fryer,  Mr.  P.  J.,  and  Mr.  F.  E.  Weston, 
Technical  Handbook  of  Oils,  Fats  and  Waxes 
(review),  897 

Fullerton,  Dr.  A.,  missiles  as  emboli,  913 


G 

Gallighan,  Mr.  W.  M.,  Text-book  of  Sex 
Education  for  Parents  and  Teachers  (re- 
view), 617 

Gangrene,  gas  (Dr.  W.  J.  Wilson),  657  ; lung, 
collapse  therapy  of,  902  A 

Gardner,  Mr.  A.  D.,  permanent  criterion  for 
the  standard  agglutination  test,  21 
Garretson,  Mr.  W.  T.,  and  Mr.  J.  S.  Fraser, 
radical  and  modified  radical  mastoid  opera- 
tions, 339 

Gas,  mustard,  nystagmus  caused  by  (Mr. 
R.  P.  Ratnakar),  423  ; gangrene  (Dr.  W.  J. 
Wilson),  657 

Gask,  Col.  G.  E.,  gunshot  wounds  of  the 
chest,  surgical  aspects.  667 
Gassing,  late  results  of,  433 
Gastroptosis  (Dr.  L.  Brown),  878 
Gaunt,  Dr.  J.  K.,  anaphylaxis,  889 
Gauvain,  Mr.  H.  J.,  chemotherapy  in 
cutaneous  tuberculosis,  412 
Gedge,  Mr.  A.  J.,  “ourselves  only,”858 
Gemmell,  Dr.  W.,  death  of,  823 
Genasprin,  24 

General  Council  of  Medical  Education 
and  Registration  (Summer  Session). — 
President’s  address,  954— Yearly  tables  and 
appointment  of  committees,  955— Case  of 

I.  B.  Birelay  ; Case  of  N.  O.  McConnell  ; 
Case  of  H.  Mowat;  Case  of  R.  R.  Coyle, 
1004 — Case  of  W.  H.  Fawcett ; Report  by  the 
Dental  Education  and  Examination  Com- 
mittee, 1005 -Report  from  the  Education 
Committee ; Report  from  the  Examination 
Committee ; Report  from  the  Examination 
Committee,  analysis  of  tables,  1006— Report 
of  Public  Health  Committee ; Report  of  the 
Pharmacopceia  Committee ; Report  of 
Dental  and  Examination  Committee  on 
applications  for  exceptional  registration; 
Reappointment  of  General  Registrar,  1907 

General  paralysis  of  the  insane  (Dr.  H. 

Campbell  and  Sir  C.  Ballance),  608 
General  practice,  a personal  retrospect  (Dr. 

J.  Pearse),  129,  197  ; practice,  some  pitfalls 
of  (Dr.  H.  M.  McCrea),  1010,  1053;  practice, 
how  to  start  and  how  to  succeed  (Dr.  G. 
Steele-Perkins),  1097, 1140 

General  practitioner’s  hospital,  1042 
Genito  urinary  passages,  gonorrhoea  of.  219 
Germicidal  valuation  of  disinfectants,  576 
Gestation,  ectopic,  82  ; ectopic,  with  an  appa- 
rently imperforate  hymen  (Dr.  S.  G.  Papa- 
dopoulos),  140 ; ectopic  (Dr.  B.  T.  Rose  and 
Mr.  E.  H.  Shaw).  175 

Gibbon,  Dr.  J.  G„  acquired  immunity  in 
influenza,  583 

Gibson,  Dr.  H.  E.,  early  treatment  of  gonor- 
rhoea, 739 ; laboratory  methods  and  the 
diagnosis  of  venereal  diseases,  859 
Gibsou,  Maj.  H.  G.,  and  Col.  S.  L.  Cummins, 
analysis  of  cases  of  tetanus.  325 
Gibson,  Maj.  H.  G.,  R.A.M.C.  (see  Obituary  of 
the  war) ; obituary,  395 
Gibson,  William,  research  scholarship,  1130 
Gizzards  and  counterfeit  gizzards  (Sir  J.  Bland- 
Sutton),  203 

Glaister,  Mr.  J.  N.,  case  of  a blind  subject,  964 
Gland,  lacrymal,  in  surgical  anaesthesia  (Dr. 
L.  T.  Rutherford),  792 ; dissector,  new 
pattern,  868 

Glands,  tuberculous,  treatment,  424 
Glasgow  University,  pass-lists,  639,  725; 

appointments,  1094 

Glaucoma,  double  sclerectomy  operation,  893 
Glen  Lomond  Sanatorium  (Py  Q),  359,  402 
Glossitis  and  stomatitis,  lemon  as  a soecific, 
760 

Glover,  Dr.  J.  A.,  purulent  broncho-pneumonia 
associated  with  the  meningococcus,  124 
Glovne,  Dr.  S.  R.,  thoracic  puncture  fluids, 
935 

Glycerine  and  other  media,  restoration  to  the 
Pharmacopceia,  350 

Glycosuria,  sympithetic  nervous  system  in 
relation  to  (Dr.  L.  Brown),  923 
Goadby,  Sir  K.,  latent  infection  of  healed 
wounds,  879 

Goat  as  a milk  supplier,  1053 
Gonococcal  infections,  complement-fixation 
test  in  (Dr.  A.  H.  Priestley)  787 
Gonorrhoea  complicated  by  acute  gonorrhoeal 
arthritis  aud  keratosis  Dr.  N.  P.  Laing).  377 ; 
early  treatment  of  (Dr.  "H.  E.  Gibson),  739 
Gonorrhoea  of  genito-urinary  passages,  219 
Gonorrhoea,  treatment  by  pus  vaccines  (Dr. 
E.  G.  D.  Pineo  and  Dr.  D.  M.  Baillie),  508; 
urethra-  haemorrhagica,  756 
Goodall,  Dr.  A.,  Aids  to  Histology,  second 
edition  (review),  848 

Goodall,  Dr.  E , coordination  of  clinical 
research,  position  of  psychiatry,  1092 
Goodall,  Dr.  E.  W.,  the  Nursing  Keg'ster,  528 


[.July  5,  1919  ix 


The  Lancet,] 


G ooilall- Copes' ake.  Beatrice  M.,  Massage  as  a 
Career  for  Women  (review),  617 
Goodwin,  Lieut.- Gen.  Sir  .1  , war  memorial  to 
officers  and  men  of  tlio  It  766 

Gordon,  Dr.  W.,  essential  prlncip’es  of  suc- 
cessful medical  administration,  356 
Goring,  Dr.  C.  B.,  obituary,  911 
Gotto,  Mrs.  S.,  medical  practitioners  and  the 
detection  of  crime,  198 

Gould,  Sir  A.  1*.,  and  Mr.  E.  P.  Gould, 
Elements  of  Surgical  Diagnosis,  fifth  edition, 
1919  (review),  659 

Graham,  Mr.  J.  H.  P.,  primitive  agents  in 
treatment,  45;  State  Medical  Service,  312 
Grain  pests  and  scientific  accuracy,  539 
Grant,  Dr.  1).,  tuberculosis  in  relation  to 
upper  air  and  food  passages,  223 
Grant,  Dr.  L.,  life  and  health  in  the  Highlands, 
488 

Grant,  Dr.  W.  J.,  essential  principles  of  suc- 
cessful medical  administration,  441 
Grants  to  panel  practitioners  (Py  Q),  401,  403; 

for  medical  referees  (Py  Q),  442 
Gratuities  to  temporary  naval  medical  officers 
(Py  Q),  485  ; war,  to  nurses  (Py  Q),  1008 
Gray,  Col.  H.  M.  W.,  Early  Treatment  of  War 
Wounds  (review),  513 

Gray,  Dr.  Elizabeth,  and  Dr.  J.  A.  B.  Hicks, 
investigation  of  influenza  cases,  419 
Great  Britain  and  Denmark,  187 
Gre$t  Northern  Hospital,  cinema,  955 
Greek,  a smattering  of,  991  ; compulsory,  at 
Oxford,  1000,  1045,  1089 

Griffith,  Dr.  W.  S.  A.,  reconstruction  in  the 
teaching  of  obstetrics  and  gynaecology  to 
medical  students,  discussion,  258;  retro- 
peritoneal lipoma,  1072 

Griffith,  Maj.  H.  11.,  Austr.  A.M.C.  (see 
Obituary  of  the  war) 

Grimsdale,  Mr.  H.  B.,  pulsating  tumour  of 
orbit,  613 

Grocers’  uift  to  the  blind,  955 
Grove,  Dr.  W.  R.,  metrorrhagia  in  influenza, 
156 

Gruner,  Dr.  O.  C.,  origin  of  life,  work  of  the 
late  Charlton  Bastian,  1044 
Guardianship  Society,  1012 
Gunshot  concussion  of  spinal  cord  (Henri 
Claude  and  Jean  Lhermitte),  67 ; wounds, 
treatment  (Mr.  A.  H.  Tubby,  Dr.  G.  R. 
Livingston,  and  Dr.  J.  W.  Mackie),  251; 
injuries  of  the  cervical  nerve  roots  (Dr. 
J.  S.  B.  Stopford),  336 ; wounds  of  the  chest, 
666  ; wounds  of  the  chest,  surgical  aspects, 
667 ; wounds  and  other  affections  of  the 
chest  (Mr.  C.  MacMahon),  697 
Gunshot  Injuries,  Orthopaedic  Treatment  (Dr. 
L.  Mayer  (review),  23  ; Fractures  of  Ex- 
tremities (Lieut. -Col.  J.  A.  Blake)  (review), 
184,  702 

Guthrie,  Dr.  D.,  nasal  obstruction  in  aviators, 
136 

Guthrie,  Dr.  L.  G.,  obituary,  44 
Gynsecology  for  Nurses  and  Gymecological 
Nursing  (Dr.  C.  Berkeley),  third  edition, 
1918  (review),  848 

Gynaecology,  the  birthplace  of,”  189 


H 


Hsematemesis  after  abdominal  operation,  529 
Haematology,  literature  of,  817 
Haemoglobinuric  bilious  fever,  treatment,  940 
Haemoptysis,  post-influenzal  (Dr.  H.  Wilson), 
137  ; and  epistaxis  in  influenza,  481 
Haemorrhage,  accidental,  in  connexion  with 
eclamp-dsm  (Sir  W.  Smyly),  133 ; meningeal, 

I in  typhoid  fever,  519;  blood  volume  and 
related  blood  changes  after,  852 
Haemorrhagic  spinal  effusions  (Dr.  W.  P.  S. 
Branson),  888 

Hains,  Capt.  C.  C.,  Austr.  A.M.C.  (see  Obituary 
of  the  w«r) 

Hall,  Dr.  H.  G.,  Bedside  and  Wheel-chair 
Occupations  (review).  808 
| Halliburton,  Prof.  W.  D.,  physiology  and  the 
I food  problem,  283  ; origin  of  life,  work  of 
(i  the  late  Charlton  Bastian,  10C0 
| Hallows,  Dr.  N.,  Dr.  H.  French,  and  Dr.  A. 

! Abrahams,  influenzal  septicaemia.  1 
i Harden,  Prof.  A , Mr.  S.  S.  Zilva,  and  Dr.  G.  F 
Still,  infantile  scurvy,  17 
Harris,  Dr.  I.,  significance  of  inverted  “T”  in 
first  lead  of  the  cardiogram,  168;  correction, 
218  ; some  forms  of  irritable  heart,  787 
Harris,  Mr.  J.  N.,  parasitic  mange  in  horses, 
280 

Harrison,  Brevet-Col.  L.  W.,  gonorrhoea  of 
genito-urinary  passages,  219 ; venereal 
disease,  713 

Hart,  Mr.  J.  H.,  pelvic  sarcoma,  378 
Hartley,  Col.  E.  B.,  V.C.,  obituary,  633 
Hartley,  Dr.  A.  C.,  obituary,  437 
Hartridge,  Mr.  G.,  Refraction  of  the  Eye, 
Manual  for  Students,  sixteenth  edition,  1919 
(review),  984 


INDEX  TO  VOLUME  I.,  1919. 


Harvard  medical  unit  (leading  article),  115 
Ilawf  s,  Mr  C.  S.,  obituary,  45 
Hawk,  Prof.  P.  B.,  Practical  Physiological 
Chemistry,  sixth  edition,  1919  (review),  983 
Hawkins,  Mr.  W.  It.  T.,  death  of,  972 
Haworth,  Dr.  J.  K.,  cancer  of  cjccum  with 
pelvic  abscess  and  gangrene  of  rectum,  140 
Hay,  Mr.  W.  A.  E.,  death  of,  199 
H yes,  Mr.  K.,  Intensive  Treatment  of 
Syphilis  and  Locomotor  Ataxia  by  Aachen 
Methods,  third  edition,  1919  (review),  46S 
Head,  Diseases  of,  Roentgen  Diagnosis  ot  (Dr. 

A.  Schuller)  (review),  466 
Head,  Dr.  H. , sensation  and  the  cerebral  cortex, 
389  ; Dostroyers  and  Other  Verses  (review), 
1120 

Headaches,  pituitary,  and  their  cure,  6S4 
Healed  wounds,  latent  infection  of  (Sir  K. 
Goad  by),  879 

Health  Conference  of  Insurance  Organisa- 
tions: Presidential  address;  Ministrv  of 

Pensions ; Sanatorium  treatment,  629— 
Niggardly  grant  for  medical  research; 
Medical  research  and  the  State ; Medical 
research  and  the  lessons  of  the  war,  630- 
National  Health  Insurance,  631 
Health,  medicine,  and  sanitation  in  India, 
127,  163 ; and  life  in  the  tropics,  644 ; 
Department  of,  for  Canada,  767 ; report  of 
New  York,  950 

Health,  public,  campaigns  in  Canada,  1132 
Health  Reader  for  Girls  (Agnes  L.  and  E. 

Stenhouse)  (review),  142 
Health  reports,  colonial,  50,  89,  202.  242,  324, 
488,  591,  644,772,  825,  1054;  Malav  States, 
1011;  teaching,  90;  of  Belfast,  121;  and 
radiant  heat,  164;  of  Canada,  improving  the, 
232;  and  allotments,  284;  of  Lille  during 
German  occupation,  430 ; in  South  Africa, 
524  ; visitors,  salaries  of  (Py  Q),  685;  Council 
for  Wales  (Py  Q\  865;  of  the  Navy  and 
Marine  Corps  of  the  U.S.,  950 
Healthy,  disadvar  tage  of  being,  307 
Hearing,  new  theory  of,  510 
Heart  disease  and  distress,  left  scapular  pain 
and  tenderness  in  (Dr.  J.  Parkinson),  550,  575 ; 
direct  massage  of,  658 ; failure,  658;  irritable, 
some  forms  of  (Dr.  I.  Harris),  787  ; in  hyper- 
tension (Dr.  L.  Brown),  968;  perforating 
wound  of  (Maj.  F.  C.  P.vbus),  1026 
Heart.  Soldier's,  and  the  Effort  Syndrome  (Dr. 
T.  Lewis)  (review),  142 ; and  Aorta,  Diseases 
of  (Dr.  A.  D.  Hirschfelder),  third  edition, 
1918  (review),  383 

Hearts  of  Man  (Dr.  R.  M.  Wilson)  (review),  701 
Hellier,  Prof.  J.  B.,  retirement  of,  282 
Hemianopia,  transient,  574 
Henderson,  Mr.  E.  E.,  bilateral  choroido- 
retinitis.  895 

Henley,  Capt.  E.  A.  W.,  N.Z  M.C.  (see  Obituary 
of  the  war) 

Henry,  Dr.  A.  K.,  destruction  of  mosquito 
larvae  in  streams,  908 
Herb  growing,  medicinal,  1053 
Hermann  Boerhaave,  576 

Hernaman-Johnson  Dr.  F.,  X rays  in  diagnosis 
of  appendicitis,  279 

Hernia,  femoral,  strangulated  (Dr.  S.  M. 
Lawrence),  64 ; diaphragmatic  (Mr.  R. 
Warren).  1069,  1089 
Heroin  poisoning,  '/55 

Herringbam,  Maj. -Gen.  Sir  W.,  clinical  aspects 
of  influenza,  711 
“ Heteraesthesia,”  78 
Hibbert,  Mr  C.  H.,  death  of,  977 
Hicks,  Dr.  J.  A.  B.,  and  Dr.  Elizabeth  Gray, 
investigation  of  cises  of  influenza,  419 
Hill,  Mr.  T.  G.,  biology  and  the  medical 
curriculum,  273 

Hilus  tuberculosis  in  the  adult  (Dr.  C.  Riviere), 
213  682,  814 

Hine,  Capt,  M.  L , and  Col.  W.  T.  [Lister, 
evulsion  of  optic  nerve,  895 
Hirsch,  Mr.  C.  T.  W.,  anaesthesia  for  oph- 
thalmic operations,  1068 
Hirschfeld,  Dr.  L , new  germ  of  paratyphoid, 
296 

Hirschfelder,  Dr.  A.  D , Diseases  of  the  Heart 
and  Aorta,  third  edition,  1918  (review),  383 
Hirst,  Capt.  L.  F.,  Capt.  A.  H.  Tubbv,  Maj. 
A.  R.  Ferguson,  and  Capt.  T.  J.  Mackie, 
action  of  flavine,  838 

Histology,  Aids  to  (Dr.  A.  Goodall),  second 
edition  (review),  £48 

Hobbs,  Surg. -Lieut.  R.  A , R.N.  (see  Obituary 
of  the  war) 

Hobhouse,  Dr.  E , lysorophus,  1093 
Hodgetts,  I)r.  C.  A.,  Department  of  Health  for 
Canada,  769 

Hojel,  Lieut. -Col.  J.  G.,  C.I.E.,  I.M.S.  (see 
Obituary  of  the  war) 

Holland,  Dr.  E.,  syphilitic  placentae,  1073 
Home,  at,  in  the  War  (Mr.  G.  S.  Street) 
(review),  142 

Home,  Fleet-Surg.  W.  E.,  lemon  juice  or  lime 
juice,  128 

Home  for  men  disabled  by  the  war,  45 
Home  Office,  medical  inspectors  of  (Py  Q),  402 


Horne  v.  institutional  training  of  young 
children.  615 

Honours,  88,  200;  New  Year,  31,  78;  New 
Year,  deferred,  765;  Order  of  the  Indian 
Empire,  47;  Belgian,  915;  birthdav,  999„ 
1039,  1046  ; war  (see  Honours  under  War  and 
After) 

Hookworm  disease  in  Bengal,  318 
Ilopewell-Smith,  Mr.  A.,  Normal  and  Patho- 
logieal  Histology  of  the  Mouth  (review),  897 
Hopkins,  Prof.  F.  G.,  vitamines.  unknown  but 
essential  accessory  factors  of  diet,  363 
Horder,  Sir  T.,  epidemic  perinephric  suppura- 
tion, 1044 

Horses,  parasitic  mango  in,  280 
Hospital  for  Bognor,  242;  accommodation  at 
West  Ham  (Py  Q).  820;  accommodation  for 
civil  needs  (Py  Q),  865;  treatment  for 
soldiers,  sailors,  and  pensioners  (Py  Q),  865; 
for  tropical  diseases,  new,  946;  general  prac- 
titioner’s, 1042 ; nurses,  accommodation  for 
(Py  Q),  770 

Hospital  officers,  pecuniary  position  of  (leading 
article),  573 

Hospital  stoppages  in  India,  998 
Hospital  Sunday  Fund,  Metropolitan  (leading 
article),  1032,  1C93;  Brighton,  24 
Hospital  wards  as  hotels,  998 
Hospitals  and  dispensaries  in  India,  1917-18,  50 
Hospitals,  military,  closing  the  smaller  (Py  Q), 
640;  Government  control  of  (Py  Q),  641; 
civilian,  pressure  on  (Py  Q),  641 ; for  disabled 
men,  813  ; voluntary,  and  the  work  of  the 
almoner  (leading  article),  849 
Hot  liquids  and  cancer,  583,  635,  683 
Household  refuse,  526 

Housing  problem,  28 ; in  Mesopotamia,  301  ; 
Bill,  4S4;  and  infant  mortality,  643;  rural., 
987  ; conference  in  Belfast,  1138 
Howell,  Mr.  B.  W.,  lymphangeioma  of  tor  gue, 
940 

Howell,  Prof.  W.  H.,  Text-book  of  Physiology 
for  Medical  Students  and  Physicians,  seventh 
edition,  1918  (review),  984 
Hudson.  Mr.  A.  C.,  retinal  degeneration 
following  intra-ocular  foreign  body.  299 
Huerre,  Dr.  R.,  chemical  composition  of  lemon 
juice,  895 

Huet,  Lieut.  F.  P.  Y.,  Austr.A.M.C.  (see  Obit- 
uary of  the  war) 

Human,  bovine,  and  avian  tubercle  bacilii,. 

attenuation  of  (I)r.  N.  Raw),  376 
Human  Machine  and  Industrial  Efliciencj 
(Prof.  F.  S.  Lee)  (review),  847 
Humerus,  comminuted  fracture  of  (Dr. 

Winifred  F.  Buckley),  980 
Hunger  and  disease  in  Central  Europe, 
903 

Hunt,  Dr.  E.  L.,  and  Dr.  Helen  Ingleby,. 

transfusion  of  blood,  975.  988 
Hunt,  Dr.  J.  R.,  paralysis  agitans  and  the 
corpus  striatum.  77 

“ Hunter,  John,  Phases  in  the  Life  and  Work 
of ’’(Prof.  A.  Keith),  269 
Hunterian  oration  on  British  military  surgery 
in  the  time  of  Hunter  and  in  the  great  war 
(Sir  A.  Bowlby),  285;  lecture  on  compound 
fractures  of  upper  limb  (Mr.  E.  G.  Slesinger), 
365 

Hurst,  Dr.  A.  F.,  war  deafness,  238  ; and  Dr. 
J.  L.  M.  Symns,  hysterical  element  in 
organic  disease  and  injury  of  central  nervous 
system,  369 

Huts,  army,  for  tuberculous  patients  (Py  Q)*. 
641 

Hydrology,  instruction  in,  635 
Hydrops  articulorum,  intermittent  (Dr.  R. 
MacLelland),  463 

Hydrothorax,  unilateral,  due  to  disease  below 
the  diaphragm  (Mr.  W.  G.  Nash),  378 
Hygiene  and  the  Fiench man’s  house  as  his 
castle,  274 

Hygiene  for  school  teachers,  8C4 
Hygiene  of  the  Eye  (Dr.  W.  C.  Poseyr> 
(review),  184 

Hygienic  conscience  in  relation  to  coal-gettiDg 
(leading  article),  9C0 

Hvgienic  reconstruction  of  war  devastation,. 

Inter-Allied  Conference  i i Paris,  856 
Hygienic  repair  of  the  roads,  202 
Hyperchlorhydria,  causation  ol  (Dr.  L.  Brown)r 
877 

Hypertrophic  stenosis  of  pylorus,  389 
Hy  pochlorites.  action  of,  on  pleural  false 
membranes,  895 

Hypnotic  Suggestion  and  P.-ycho-therapeutics 
(Mr  B.  Taplin)  (review),  302 
Hypothermia  in  iifluenza,  398 
Hypothermic,  or  depression,  stage  of  influenza,. 
196 

Hysterical  element  in  organic  disease  and 
injury  of  central  ue/vout  system  (Dr.  A.  F. 
Hurst  and  Dr.  J.  L.  M.  Symns),  369 
Hysterical  perpetuation  of  symptoms'  (Mr. 
C.  H.  L.  Rixon),  417  ; disabilities,  rapid  cure 
(leading  article),  427 

Hysterical  vomiting  in  soldiers  (Dr.  W.  IL 
Reynell),  18,  118 


x The  Lancet,] 


INDEX  TO  VOLUME  I.,  1919. 


[July  5,  1919 


I 

Ichtbyol,  Italian,  24  , . ,, 

Ilium  nation,  standard,  of  Snellen  a types.  34 
Imhotep  (Asclepios),  new  records  concerning, 
128 

Immune  Sera  'Dr.  C F.  Bolduan  and  Dr.  J. 

Koopman),  fifth  edition,  1917  (review),  746 
Immunity,  a further  advance  (leading  article), 

516  • oil 

Immuno  transfusion,  814 
Imperial  Antarctic  Expedition,  868 
Impersonator,  an  ingenious,  38 
Incision  of  tympanic  membrane,  new  method 
(Mr.  R.  Lake),  977 

Income  limit  under  the  Insurance  Act  (Py  Q>. 
1050 

Income-tax  and  medical  men  (Py  Q),  360; 
(Consolidation)  Act,  1918  (review),  566 

India,  Correspondence  from  Indian 
system  of  medicine ; Medical  research  in 
India;  Sick  pay  for  Indian  nursing  sisters; 
New  honorary ' surgeon  to  the  Viceroy; 
Allegations  of  Cannibalism  in  Sind;  Simla 
and  De'hi  health  officers,  311  — Indian 
Science  Congress ; Supply  of  subassistant 
surgeons ; Next  war,  man  v.  Insects) ; 
Plague;  Organisation  of  chemical  w jrk  in 
India  ; Cholera,  434— New  medical  school  at 
Allahabad  ; Burma  Medical  Council ; Plague 
inoculation  statistics  ; Mortality  in  Calcutta  ; 
Mission  to  lepers;  Smallpox  epidemic 
expected  in  Bengal,  760— Juvenile  smoking 
in  India,  761— Medical  Services  Committee, 
813,  857 -Sanitation  in  Lahore;  Small-pox  at 
Decca;  Possible  recrudescence  of  influenza; 
Lady  Hardinge  Medical  College,  813 -Child 
welfarein  India  ; Infant  mortality  in  Bengal ; 
Vital  statistics  of  Calcutta,  857-Mortality  in 
Calcutta;  Need  for  more  doctors,  997 — Hos- 
pital stoppages  in  India  ; Hospital  wards  as 
hotels  ; Indian  Defence  Force  Medical  Corps; 
Anti-hookworm  campaign  in  tea  districts ; 
Indian  Ministry  of  Health,  998 

India,  health,  medicine,  and  sanitation  in,  127, 
163 

Indian  Medical  Service,  pay  in,  278,  444,  589, 
638  765,  823,  861,  916,  969,  1008  ; committee, 
813,857 

Indian  systems  of  medicine,  311 ; nursing 
sisters,  sick  pay  for,  311,  764;  Science  Con- 
gress, 434  ; Defence  Force  Medical  Corps, 
998 ; Ministry  of  Health,  998  ; future  of,  1087  ; 
India  and,  1135 

Industrial  accidents,  causation  and  preven- 
tion (Dr.  H M.  Vernon),  549 
Industrial  efficiency  and  preventive  medicine 
(leading  article),  113;  unrest  and  the  new 
public  health,  202;  Fatigue  Research 
Board  (Py  Q),  401;  emp'oyment,  effect 
upon  w men,  465  ; disputes  in  asylums, 
473  ; medical  service  (leading  article).  1084 
Industrial  Organisation.  Physiology  of  (Prof. 
J.  Ararat)  (revieav),  265;  Fatigue.  Use  of 
Statistics  in  the  Investigation  of  (Mr.  P.  S. 
Florence)  (review),  301 ; Situation  after  the 
War,  Memorandum  on,  the  Garton  Founda- 
tion (review),  617 ; Efficiency  and  the 
Human  Machine  (Prof.  F.  S.  L e)  (review). 
847 

Infant  mortality  and  housing,  643;  mor- 
tality in  Bengal,  857  _ „ 

Infantile  scurvy  (Prof.  A.  Harden,  Mr.  S.  b. 

Zilva,  and  Dr.  G.  F.  Still),  17 
Infant’s  tenacity  of  life,  324,  364 
Infection,  contact,  of  chicken-pox,  397  ; latent, 
of  healed  wounds  (Sir  K.  Goadby),  879  ; 
mixed,  inhilus  phthisis.  1128 
Infectious  diseases,  notification  of,  fees  for, 
575 

Infective  scar  tissue  (Mr.  E.  M.  Corner),  840 
Influenza  and  chronic  lung  disease,  281,  314 ; 
combating  (Py  Q'.  321.  359,330;  prevention 
of  (leading  article),  346;  the  toll  of,  350 ; 
preventive  inoculation  against,  357 ; patients 
in  the  Army  (Py  Q),  401 ; and  infectious 
diseasfs,  treatment  hy  lymphotherapy  and 
hfematotherapv,  424 ; treatment  by  hypo- 
dermic injections  of  eucalyptus  oil,  424; 
prophylactic  inoculation  of  (leading  article), 
572 

Influenza,  comparative  pat  ho’ ogy  of  (Dr.  G.  R. 
Murray),  12  ; pathology  of,  lessons  of  a great 
epidemic  (leading  article),  25,  242  ; its  epi- 
demiology and  clinical  asp  cts  (leading 
article)  72 ; and  encephalo  myelitis,  79 ; 
meningococcus  broncho  pneumonia  in  (Dr. 
W.  Fletcher),  104  ; apparent,  immunity  from 
t VIr.  G.  E.  Friend),  105,  119,  529,  5S3; 
staphiitococcus  aureus  septicaemia  in  (Dr.  A. 
Patrick),  137  ; metrorrhagia  in,  156  ; hypo- 
thermic, or  depression  stage,  196  ; the  return 
of,  305  ; pandemic  (leading  article',  3S6  ; pro- 
phylaxis in  (Mr.  F.  T.  Merchant),  393; 


hypothermia  in.  398 ; and  its  prevention,  con- 
ference on,  406;  investigation  of  cases  (Dr. 
J.  A.  B Hicks  and  Dr.  Elizabeth  Gray),  419; 
and  diet,  memorial  on,  436;  and  oatmeal 
(Py  Q).  443  ; treitment  byeolloid  metals  and 
phenol,  472;  vaccines,  476;  epistaxis  and 
haemoptysis  in,  481 ; epidemic,  does  it  affect 
the  lower  animals  ? 520  ; musk  in,  529  ; 
autumn  epidemic  (1918)  (Dr.  J.  W.  H.  Eyre 
and  Dr.  E.  C.  Lowe),  553;  complicated,  treat- 
ment (Dr.  A.  J.  Eagleton  and  Mr.  H.  H. 
Butcher),  560 ; present  epidemic  (Dr.  M.  J. 
Rowland*),  563;  and  diphtheria  (Dr.  E.  A. 
Constable),  553  ; “ Spanish,”  635  ; “ Spanish  ” 
(Dr.  E.  Foiley),  656,  663 
Influenza,  electrolytic  disinfectant  in,  90; 
mask,  the  “ Arellano,”  90 ; use  of  creosote  in, 
128  ; leucocyte  count,  in,  156  ; formalin  spray 
in  checking  (Dr.  A.  Wylie), 256;  filter-passing 
virus  in,  280,  313,  528;  trimethenal-allyl- 
carbide  in,  140;  intrapulmonary  injection  of 
serum  in,  1087 

Influenza  epidemic  (Dr  V/.  Russell),  689; 
preventive  vaccines  fo-,  707  ; clinical  aspects 
of  (Maj.-Geu.  Sir  W.  Herringham),  711; 
bacteriology  of,  760;  with  reference  to  pneu- 
monia in  Macedonia,  794  ; possible  recrudes- 
cence, 813  ; national  campaign  against,  813; 
vaccine  in  (Dr.  F.  T Cadham),  855;  iixa-ion 
abscesses  in,  895;  infecting  agent  in  (Prof. 
T.  Yamanouchi,  Dr.  K.  Sakakami,  and  Dr. 
S.  Iwashima),  971 

Influenza  in  France,  38  ; s purge  in  Canada, 
39 ; victims,  medical,  in  South  Africa,  78 ; 
and  American  Public  Health  Association, 
230;  recrudescence  in  New  York,  353;  mor- 
tality in  South  Africa,  395.  720;  epidemic  in 
Edinburgh  and  district,  433;  and  cholera  in 
Bombay  (Py  Q , 442;  in  Australia,  476,  681, 
760;  in  Cape  Town,  524;  in  British  Guiana 
(Dr.  F.  G.  Rose),  421;  epidemic  in  Lower 
Egypt,  bacteriology  of  (Dr.  G.  M.  Findlay), 
1113 

Influenza  vaccine  (mixed),  24 
Influenza!,  B.,  simply  prepared  culture  media 
for  (Mr.  A.  Fletniug),  138 
Influenzal  septicaemia  (Dr.  A.  Abrahams,  Dr. 
N.  Hallows  and  Dr.  H.  French),  1 ; epidemic, 
lessons  of,  242 ; intra  abdominal  catastrophes 
(Dr.  R E.  Smith),  421;  broncho-pneumonia, 
use  of  intravenous  iodine  in  (Dr.  D.  M. 
Baillie).  423;  pneumonia  (Sir  W.  Osier),  501 ; 
pneumonia,  lung-puncture  in  (Dr.  M. 
Benaroya),  742,  816 

Ingestion  of  adrenalin  and  intravenous  injec- 
tion of  colloidal  quinine.  760 
Ingleby.Jlr.  Helen,  and  Dr.  E.  L.  Hunt,  trans- 
fusion of  blood,  975,  988 
Inoculation  and  masks,  631 
Inorganic  and  Physical  Chemistry,  Recent 
Advance*  in  (Mr.  A.  W.  Stewart),  third 
edition,  1919  (review),  617 
Inorganic  Chemistry,  Introducti  n to  (Prof. 

A.  Smith),  third  edition,  1918  (review),  225 
Insane,  general  paralysis  of,  treatment  (Dr.  H. 

Campbell  and  Sir  C.  Ballince),  608 
Insurance  Act.  medical  benefit  (Py  Q),  820; 

practitioners’  terms  (Py  Q),  821 
Insurance  Acts  Memorandum,  discussion  on, 
at  Norwich,  1138 

Insurance  Bill,  Hr alth,  and  the  medical  pro- 
fession of  New  York,  524 
Insurance,  health,  compulsory,  opposition  to, 
1090 

Insurance  Medical  Service,  propose!  exten- 
sions, 351;  practice  (Py  Q>.  403 
Insurance  Organisations,  Health  Conference 
of,  629 

Insurance  practitioners,  pool  for  (Py  Q),  1008 ; 

increased  war  bonus  to,  1129 
Inter-Allied  Fellowship  of  Medicine,  152 
Internal  Secretion,  Organs  of,  their  Diseases 
and  Therapeutic  Application  (Dr.  I.  G.  Cobb), 
second  edition  1918  (review).  111 
Intei  national  Conference  on  Rehabilitation  of 
the  Disabled,  761 

International  Opium  Convention  (Py  Q).  443, 

Internment,  psychology  oE  (Prof.  R.  Bing  and 
Dr.  A.  L.  Viseher),  696 

Intestinal  enfozoi  among  the  native  labourers 
in  Johannesburg,  521 

Intestinal  obstruction  by  Meckel’s  diverticulum 
(Dr.  R.  A.  Bennett),  1117 
Intestinal  Stasis,  Chronic,  Operative  Treat- 
men1  (Sir  3V.  A.  Lane),  fourth  edition.  1918 
(review),  65;  stasis,  chronic  (Sir  W.  A. 
Lane).  333;  stasis  (Dr.  L.  Brown)  873 
Intestine,  small,  diffuse  emphysema  of,  263 
Intra-abdominal  catastrophes,  influenzal  tDr. 

K.  E.  Smith),  421 
Intraoardial  injection,  1035 
Intra  ocular  growth,  613 

Intrapulmonary  injection  of  serum  in  in- 
fluenza, 1087 

Intrinsic  cancer  of  larynx,  263,  271 
Intussusception  treaed  by  resection  (Mr.  is.  If. 
Flint),  93S  ; mortality  from,  944 


Invalid  Children’s  Ail  Association,  946 

Invalidism  caused  by  P.U.O.  and  trench  fever 
(Col.  T.  R.  Elliott,  Capt.  D.  S.  Lewis,  Maj. 

J.  H.  Thursfield,  Maj.  A.  J.  Jex-Blake,  and 
Maj.  M.  Foster),  1060 

Invalidism  for  15  years  through  nasal  blockage, 

156 

In  ertel  11  T”  in  first  lead  of  the  cardiogram, 
significance  of  (Dr.  I.  Harris),  168 ; correc- 
tion, 218 

Iodine,  intravenous  use  of,  in  influenzal 
broncho-pneumonia  (Dr.  D.  M.  Baillie),  423 

Ireland,  Correspondence  from.  — Irish 
Medical  Committee  ; Ministries  of  Health 
Bill ; Salaries  of  dispensary  doctors  ; Health 
of  Belfast,  121— Milk-supply  of  Dublin,  192 — 
Strike  in  Belfast;  Belfast  Hospital  for  Skin 
Diseases,  193— Medical  reform  for  Ireland ; 
Sir  W.  Whitla,  I P.;  Royal  Victoria  Hos- 
pital, Belfast,  274— Ministry  of  Health  for 
Ireland  ; Irish  vital  statistics,  condition  of 
medical  service  in  Ireland ; Proposed 
establishment  of  Irish  Public  Health 
Council,  475— Separate  Health  Bill  for 
Ireland,  476,  909— Medical  inspection  of 
schools  in  Ireland,  577,  997— Ireland  and  the 
Ministry  of  Health  Bill ; Belfast  doctors  and 
the  Ministry  of  Health,  577— Ireland  and 
the  Ministry  of  Health  Bill,  631  -Ireland 
and  public  health  reconstruction ; Chief 
Secretary  for  Ireland  and  the  medical  pro- 
fession, 812— Rainfall  in  the  North  of 
Ireland,  910— Belfast  Ophthalmic  Hospital,- 
997— Ulster  branch  of  British  Medical 
Association ; Ministry  of  Health  Bill ; 
Belfast  Dentil  Clinic;  Meetings  of  delegates 
in  Dublin,  1040 

Ireland,  medical  appointments  during  de- 
mobilisation, 18;  and  the  Ministry  of 
Health,  (Py  Q)  321,  359,  400,  442.  475.  577, 
5S2,  1040 ; medical  inspection  of  school 

children  (Py  Ql,  641,  997;  medical  treatment 
of  children,  819 

Irish  Medical  Committee,  121;  dispensary 
doctors’  agitation,  160  ; housing  (Py  Q),  320 ; 
Poor  law  medical  officers  (Py  Q),  442;  vital 
statistics,  conditions  of  medical  service , 
in  Ireland,  475  ; Public  Health  Council,  pro- 
posed, 475  ; children,  medical  inspection  and 
treitment,  685 ; Medical  Association,  annual 
meeting.  1091 

Irrigation  Tieatment  of  Wounds  by  the  Carrel 
Method,  Technic  of  (J.  Dumas  and  Anne  \ 
Carrel)  (review),  6L7 

I-ritable  heart,  some  forms  of  (Dr.  I.  Harris), 
787 

Irwin,  Mr.  S.  T.,  acute  appendicitis  and  acute- 
appendicular  obstruction,  98  , 

Italian  ichthyol,  24 

Ivory  Cross,  the.  1011 

Iwashima,  Dr.  S.,  Prof.  T.  Yamanoucbi,  and 
Dr.  K.  Sakakami,  infecting  agent  in 
influenza,  971  • 


j 

Jaffrey,  Mr.  F.,  obituary,  953 
James,  Lieut  -Col.  S.  P..  risk  of  the  spread  of<‘ 
malaria  in  England,  677 
James,  Mr.  W..  multiple  epulides.  744 
Jameson,  Maj.  D.  D.,  M.C.,  Austr.A.M.C.  (see 
Obituary  of  the  war)  ■ 

Jaundice  (Dr.  W.  H.  Willcox),  869  ; toxic  (Dr. 
W.  H . Willcox',  871, 929 ; catarrhal,  epidemic 
(Dr.  W.  H.  Willcox),  930;  (leading  article), 
942 

Jeanselme,  Prof.  E.,  distribution  of  soldiers, 
temporarily  unfit  through  malaria,  in  agri- 
cultural colonies,  751 

Jellett,  Dr.  H.,  pyosalpinx  and  ovarian  abscess, 
265 

Jessel,  Dr.  G.,  North-Western  Tuberculosis 
Society,  859 

Jex-Blake,  Maj.  A.  J.,  Maj  M.  Foster,  Col.  T.  R. 
Elliott,  Capt.  D.  S.  Lewis,  and  Maj  J.  H. 
Thuisfield,  invalidism  caused  by  P.U.O.  and 
trench  fever,  1060 

‘•John  Hunter,  Phases  in  the  Life  and  Work 
of”  *Prof.  A.  Keith),  269 
Johnson,  Lieut.-Coi.  A.  L.,  “propeller 
fracture,  293 

Johnston,  Dr.  W.  H.,  suspension  treatment  of 
fractures  of  thigh,  170  . 

Johnston,  Maj  T.  R.  St.,  appointed  Colonial 
Secretary  of  Falkland  Islands,  282 
Johnston.  Mr.  R.  McK..  and  Sir  R.  W.  Philip, 
position  of  the  demobilised  practitioner, 
439 

Johnstone,  Dr.  R.  W.,  Text-book  of  Midwifery 
for  Studen's  and  Practitioners,  second 
edition,  1918  (review),  982 
Joints,  swelling  of,  940 

Jo'.l,  Mr.  C.  A . and  Dr.  J.  Cunning,  Aids  to 
Surgery,  fourth  edition,  1919  (review), 

659 


The  Lancet,] 


INDEX  TO  VOLUME  I,,  1919. 


Joltrain,  Dr.  E.,  Dr.  P.  Banfle,  and  Dr.  li. 

Coope,  chronic  colopathios,  933 
Jones,  Dr.  A.  B.,  and  Dr  E.  J.  Llewellyn, 
Ponaiona  and  tho  Principles  of  their  Evalua- 
tion (roview),  799 

Jones,  Dr.  E.,  Papers  on  Psycho  Analysis, 
second  edition,  1918  (review),  234 
Jones,  Dr.  G.,  medical  men  and  shareholding, 
1093 

Jones,  Mr.  H.  15.,  deafness  associated  with  the 
stigmata  of  degeneration,  182 
Jonos,  Surg.-Lieut.  M/TJ.,  It  N.  (see  Obitmry 
of  the  war) 

Journal  of  General  Physiology,  807 
Journal  of  Physiology  (review),  746 
Journal  of  the  East  African  and  Uganda 
Natural  History  Society  (review),  225 
Journal  of  the  Royal  Army  Medical  Corps, 
916 

Juler,  Mr.  F.  A.,  obstruction  of  retinal  vessels, 
1072 

Jung,  Dr.  C.  G.,  Studies  in  Word  Association 
(review),  234 ; Theory  of  Psycho-Analysis 
(review),  234 


K 

Kala-fizar,  its  Diagnosis  and  Treatment  (Dr. 
E Muir)  (review).  142;  colloid  antimony 
sulphide  intravenously  in  (Sir  L.  Rogers), 
505 

Kalyanvala,  Mr.  D N.,  spontaneous  rupture  of 
ovarian  cyst,  423 

Keith,  Capt.  G.  E.,  R.A.M  C.  (see  Obituary  of 
the  war) 

Keith,  Dr.  It.  D.,  Clinical  Case-taking  (review), 
112 

Keith,  Prof.  A.,  “ Phases  in  the  Life  and  Work 
of  John  Hunter,”  269  ; and  Sir  T.  Wrightson, 
new  theory  of  hearing,  510 
Kelly,  Dr.  F.  H.,  acute  erythema  resembling 
measles,  255 

Kellv,  Mr.  W.  P.,  epistaxis  and  haemoptysis  in 
influenza,  481 

Kemp,  Dr.  W.  G. , death  of,  239 
Kemp  Prossor  colour  scheme  (Dr.  E,  N 
Snowden),  522 

Kennaway,  Dr.  E.  L.,  and  Dr.  C.  II.  Browning, 
Wassermann  tests,  785 

Kennedy,  Dr.  A.  M.,  and  Dr.  C.  Worster- 
Drought.  Cerebro-spinal  Fever  (review),  1073 
Kennedy,  Lieut. -Col.  J.  C.,  mucoid  forms  of 
parafy  phoid , 237 

Keogh,  Surg.-Com.  J.  A.,  R.N.  (see  Obituary  of 
the  war) 

Kettle,  Dr.  E.  H..  polymorphism  of  malignant 
epithelial  cell,  743 
Khaki  monotony,  90 

Kidd,  Dr.  W.,  the  word  “ psychology,”  1093 
Kidderminster  Infirmary,  proposed  war 
memorial,  4 5 

King,  Dr.  Chari  >tte  A.,  swelling  of  joints,  940 
King,  Dr.  W.  W.,  two  cystic  tumours  of  the 
vulva,  22 ; recurrent  sarcoma  after  removal 
of  apparently  simple  myomata,  301 
King  Edward's  Hospital  Fund  for  London, 
meeting,  87,  475, 862 

King  Edward  VII.  Sanatorium,  Midhurst, 
report,  688 

King  George's  Fund  for  Sailors,  meeting,  87 
Kinnaird,  Lord.  Mr.  J.  F.  W.  Deacon,  and  Mr. 
J.  E.  Lane,  residential  treatment  for  preg- 
nant women  suffering  from  venereal  diseases 
80 

Knapp,  Dr.  A.,  Medical  Ophtha’mology  (Inter- 
national System  of  Ophthalmic  Practice) 
(review),  23 

Koopman,  Dr.  J.,  and  Dr.  C.  F.  Bolduan, 
Immune  Sera,  fifth  edition,  1917(review),  746 


L 

Laboratory  methods  and  diagnosis  of  venereal 
diseases,  817,  859 
Labyrinthitis,  circumscribed,  893 
Lacrymal  gland  in  surgical  aufesthesia  (Dr. 
L.'T.  Rutherford),  792 

Lady  Chichester  Hospital  for  Women  and 
Children,  Brighton,  1140 
Lady  Hardinge  Medical  College,  813 
Laing,  Dr.  N.  P.,  gonorrhcea  complicated  by 
acute  gonorrhoeal  arthritis  and  keratosis,  377 
Lake,  Mr.  It.,  new  method  of  incision  of 
tympanic  membrane,  977 
La  Medicina  Ibera  (review),  226 
Lancet,  The,  luncheon  at  Hyde  Park  Hotel, 
666 

Lane,  Mr.  J.  E.,  Lord  Kinnaird,  and  Mr. 
J.  F.  W.  Deacon,  residential  treatment  for 
pregnant  women  suffering  from  venereal 
diserses,  80 

Lane,  Sir  W.  A.,  Operative  Treatment  of 
Chronic  Intestinal  Stasis  fourth  edition, 
1918  (review),  65;  chronic  intestinal  stasis, 
333  ; disease  and  chyme  infection,  766 


Langley,  Prof.  J.  N.,  arrangement  of  the 
autonomic  nervous  system,  95 
Language,  universal,  of  quantity,  539 
Langworthy,  Mr.  O.  V.,  death  of,  200 
La  Perdita  Sanitaria,  1054 
Larrey  and  war  surgery  (Dr.  W.  G.  Spencer), 
867,  920.  962 

Laryngo-flssure  and  cancer  of  the  larynx,  271 ; 

with  removal  of  Intra-laryngea!  growth,  659 
Larynx,  intrinsic  cancer  of,  2113,  27i 
Latent  sepsis,  eradication  of  (Mr.  H.  Platt), 
175 

Latham,  Dr.  A.,  and  Dr.  C.  Buttar,  Medical 
Parliamentary  Committee,  arrangement  of 
conference,  634,  817 

Laumonier,  Dr.  J,,  typhoid  fever  treated  by 
colloidal  iron,  424 

Lawrence,  Capt.  II.  K.,  M C.,  South  African 
M.C.  (see  Obituary  of  the  war) 

Lawrence,  Dr.  S.  M.,  strangulated  femoral 
hernia,  f 4 
Laws  of  life,  32^ 

LawEon,  Mr.  A.,  (1)  new  method  of  applying 
radium  in  diseases  of  the  eye  ; (2)  flavine  In 
ophthalmic  surgery.  895,  1112 
Lay  members  of  mixed  committees  and 
medical  questions,  1041 
Lea,  Dr.  C.  E.,  obituary,  953 
Lead  in  the  casserole,  9 ‘5,  1002 


LEADING  ARTICLES 

Appendicitis,  accurate  diagnosis  in,  114 
Belgian  Doctors' and  Pharmacists’  Relief  Fund, 
228 

Bilharziasis,  its  prevention  and  treatment, 
1032 

Brain-worker's  diet,  901 

British  Medical  Association,  clinical  meeting, 
518,  662  ; war  neuroses,  619 
Bubonic  plague  at  home,  986 
Catalyst,  the  role  of,  144 

Charter  of  Science  for  the  Army  Medical 
Department,  753 

Chemistry  in  1918,  progress  of,  470 
Childbirth,  maternal  mortality  of,  and  the 
teaching  of  midwifery,  802 
Coal-getting,  hygienic  conscience  in  relation 
to,  900 

Criminal,  the  psychopathic,  143 
Demobilised  practitioner,  position  of,  515 
Dental  practice,  qualified  and  unqualified. 
385 

Detoxicated  vaccines,  1123 

Diagnosis,  accurate,  in  appendicitis.  114 

Education,  scientific,  and  its  cost,  428  , medical. 

reform  of,  571 ; medical,  post-graduate,  703 
Epidemic  Diseases  Order,  new,  and  its  effect, 
303 

Euthanasia,  803 
Feat  of  endurance,  10S5 
Fellowship  of  Medicine,  26 
Flying,  medical  aspects  of,  227 
French  Supplement  to  The  Lancet,  347 
Harvard  Medical  Unit,  115 
Hospital  officers,  pecuniary  position  of,  573 
Hcspital  Sunday  Fund,  Metropolitan,  1032 
Hospitals,  voluntary,  and  the  work  of  the 
almoner,  849 

Hygienic  conscience  in  relation  to  coal-gettiog, 
900 

Hysterical  disabilities,  rapid  cure  of,  427 
Immunity,  a further  advance,  516 
Industrial  efficiency  and  preventive  medicine, 
113 

Industrial  medical  service,  1084 
Influenza,  pathology  of,  lessons  of  a great  epi- 
demic, 25;  epidemiology  and  clinical  aspects, 
72  ; the  prevention  of,  346  ; pandemic.  386 
Influenza,  prophylactic  inoculation  in,  572 
Jaundice,  Lettsomian  lectures  on,  942 
Lessons  of  a great  epidemic,  the  pathology  of 
influenza,  25;  epidemiology  and  clinical 
aspects,  72 

Lettsomian  lectures  on  jaundice,  942 
Maternal  mortality  of  childbirth  and  the 
teaching  of  midwifery,  802 
Medical  aspects  of  flying,  227 
Medical  education,  reform  of,  571  ; evidence 
and  trials  in  camera,  620 
Medical  ParlismeL  tary  Commit  tee,  pi  ogress 
of,  801 

Medical  practitioner,  outlook  of.  145 
Medical  profession  and  the  trade-union  ques- 
tion, 345 

Medical  research  and  its  place  in  the  State, 
517 

Medical  Services  Bill,  941 
Medicine  and  the  State,  185;  Parliament,  and 
public,  267 

Medicine,  teaching  of,  227 
Meningococcus,  the,  a recent  chapter,  1C83 
Metropolitan  Hospital  Sunday  Fund,  1032 
Ministry  of  Health  Bill,  inspection  of  school 
children,  471 ; the  nextstage,  1031 
Neuroses  of  the  war,  71 
New  houses  for  old,  753 
New  Year’s  wish,  25 


[July  5,  1919  xi 


Outlook  of  tho  medical  practitioner,  115 
Outlook,  the,  1121 

Pari  henogcncsis  in  vertebrates,  1033 
Pecuniary  position  of  hospital  officers,  673 
Pensioners,  war,  in  civil  hospitals,  186 
Pneumonia,  recent  advances  in  treatment, 
701 

Post-graduate  medical  education,  703 
Practitioner,  the  demobidsed,  position  of,  515 
Preventive  medicine  aud  industrial  efficiency, 

113 

Prophylactic  inoculation  in  influenza,  572 
Psychopathic  criminal,  the,  143 
Rabies  and  its  treatment  in  this  country,  74 
Radium  Institute,  850 
Red  Cross,  past,  future,  and  present,  661 
Refoim  of  medical  education.  571 
Research,  medical,  and  its  place  in  the  State, 
517 

Sanitation  in  the  Near  East,  621 
Scientilic  education  and  i»s  cost,  428 
Services  Bill,  medical,  941 
State  subsidy  of  tuberculous  labour,  469 
Sugar  control  in  the  body,  935 
Tuberculosis  service,  304 

Voluntary  hospitals  and  the  work  of  the 
almoner,  849 

War  pensioners  in  civil  hospitals,  186 
Women  iu  industry,  899 

Lead  line  on  tailors’  gums,  a dangerous  prac- 
tice, 644 

Leber’s  atrophy,  changes  in  the  sella  turcica, 
300 

Lee,  Dr.  J.  R.,  pelvic-femur  splint  and  arm 
splint,  103 

Lee,  Prof.  F.  S.,  The  Human  Machine  and 
Industrial  Efficiency  (review)  847 
Leeds  Workpeople's  Hospital  Fund,  618 
Lees,  Dr.  D.,  detoxicated  vaccines  in  treatment 
of  gonorrhcea,  1107 

Lees,  Mr.  1C.  A.,  dinner  fork  in  the  stomach 
and  duodenum,  298 
Leeson,  Mr.  C , prison  rerorm,1002 
Leete,  Dr.  II.  M.,  experiments  on  masks,  392 
Leftwich,  Dr.  R.  W.,  obituary,  580 
Legal  profession  and  woman,  680  ; definition  of 
“ rag6,”  991 

Le^gh,  Mr.  T.,  death  of,  634 
Leighton,  Dr.  P.  A.,  and  Dr.  S.  A.  Owen, 
medullary  symptom-ccmplex,  1024,  1087 
Lelean,  Prof.  P.  S.,  Sanitation  in  War,  third 
edition,  1919  (review),  514 
Lemarchand,  Surg  Sub  -Lieut.  F.  W.,  R.N.V.R. 

(see  Obituary  of  the  war) 

Lemon  as  a specific  for  glossitis  and  stomatitis, 
760 

Lemon  juice  or  lime  juice,  128,  164;  juice, 
chemical  competition,  895 
Lenzmann’s  Manual  of  Emergencies,  Medical, 
Surgical,  and  Obstetric  (Dr.  J.  Snowman) 
(review),  513 

Lepers  in  Canada,  232;  in  India,  240,  760 
Lepine,  Prof.  J , Mental  Disorders  of  War 
(review),  1074 

Leprat,  Dr.  L.,  bacteriology  of  influenza,  760 
Lessons  of  a great  epidemic,  the  pathology  of 
influenza  (leading  article),  25,  242;  epidemio- 
logy and  clinical  aspects  (leading  article),  72 
Lessons  of  the  War  (Sir  A.  E.  Wright),  489 
Lettsomian  lectures  on  jaundice  (Dr.  W.  H. 

Willcox),  869,  929 ; (leading  article),  942 
Leucocyte  count  in  influenza,  156 
Leven,  Dr.  G..  lemon  as  a specific  for  glossitis 
and  stomatitis,  760 ; increase  of  weight 
effected  by  diet  of  1 >w  calorific  value,  940 
Levithin  and  Allied  Substances,  the  Lipins 
(Dr.  H.  Maclean)  (review),  745 
Lewin,  Dr.  Octavia,  treatment  of  adenoids, 
323 

Lewis,  Capt.  D.  S.,  Maj.  H.  J.  Thursfield,  Ma,j. 
A J.  Jex-Blake,  Capt.  M.  Foster,  and  Col. 
T.  R.  Elliott,  invalidism  caused  by  P.U.O. 
and  trench  fever,  1060 
Lewis,  Dr.  F.  W..  aspirin  poisoning,  64 
Lewis,  Dr.  T.,  Soldier’s  Heart  and  the  Effort 
Syndrome  (review^  142 

Ley,  Mr  G.,  extra-uterine  pregnancy  con- 
tinuing to  term,  611 

Leyton,  Dr.  O.,  transfusion  in  diseases  of  the 
blood,  379 

Lhermitte,  Jean,  and  Henri  Claude,  gunshot 
concu  sion  of  spinal  cord,  67 
Library,  a Cretan,  488 
Life  and  health  in  the  Highlands,  488 
Life,  origin  of,  work  of  the  late  Charlton 
Bastian,  951,  952,  1000,  1001,  1044,  1092, 
1133 

Ligat,  Mr.  D.,  significance  of  surgical  value  of 
certain  abdominal  reflexes,  729 
Lille,  health  of,  during  German  occupation, 
430 

Lillingston,  Dr.  C.,  women  chiefs,  636 
Limb,  lower,  prosthesis  of,  149 ; upper,  com- 
pound fractures  of  (Mr.  E.  G.  Slesinger). 
365;  in  li^u  of,  921 
Limbs,  artificial  (Py  Q),  320,  321 
Lingual  cancer,  etiology,  75,  123 


xii  The  Lancet,] 


INDEX  TO  VOLUME  I.,  1919. 


[Jut.y  5,  1919 


Up,  epithelioma  of,  radium  treatment,  388 
Lipomi,  subperitoneal,  1072 
Ups,  artificial  cyanosis  of,  529 
Liquor  in  Ontario,  prescribing  of,  919 
LUte-,  Capt.  C.  B.,  M.C.,  Austr.  A.M.C.  (see 
Obituary  of  the  war) 

Lister,  Col.  W.  T.,  and  Capt.  M.  L.  Hine, 
evulsion  of  optic  nerve,  895;  appointed 
surgeon  oculist  to  His  Majesty's  Household, 
946 

Lister  Institute  of  Preventive  Medicine 
(annual  report),  1089 
L’ltalii  Sanitaria  (review),  748 
Literary  intelligence,  141, 218,  250,  424,  566,687, 
770,823,  863,  1000,  1095,  1138 
Liveing  Dr.  E , obituary.  633 
Liver,  maldeveiopment  of,  744 
Liverpool  Medical  Iustitution  (see  Medical 
Societies) 

Liverpool  University,  pass-lists.  126.  536 
Livingston.  Dr.  G.  R.,  Dr.  J.  W.  Mackie,  and 
Mr.  A.  H.  Tubby,  treatment  of  gunshot 
■wounds,  251 

Livingstone  College,  Leyton,  appeal  for  funds, 
22 

Llewellyn,  Dr,  L.  J.,  and  Dr.  A.  B.  Jones, 
Pensions  and  the  Principles  of  their 
Evaluation  (review),  799 
Lloyd,  Dr.  J.  H , colloidal  silver  in  trench 
fever,  583  ; subacute  trench  fever,  791 
L'oyd,  Mr.  LI.,  lessor  sof  the  louse,  118 
Local  Government  Board  food  inspection,  189  ; 
llegulations,  new,  for  control  and  treatment 
■of  certain  epidemic  diseases,  309 
Local  Government  (Ireland)  Bill,  1008 
Lockhart-Mummery,  Mr.  J.  P.,  and  Dr.  D. 
Pennington,  adhesions  of  the  sigmoid,  254  ; 
chronic  secondary  colitis,  1045 
Locomotor  Apparatus  the  Result  of  War 
Wounds,  Disabilities  of  the  (Prof.  A.  Broca) 
(review),  799 

Loeb,  Dr.  J.,  Forced  Movements,  Tropisms, 
and  Animal  Conduct  (Monograph  on  Experi- 
mental Biology)  (review),  745 
Logie,  Capt. A.  G.  S.,  R.A.M.C.  (see  Obituary  of 
the  war) 

London  Association  of  Medical  Women,  dinner, 
943;  (see  also  Medical  Societies) 

London  County  Mental  Hospitals  (Pv  G), 
401 

London  and  Counlies  Medical  Protection 
Society,  Ltd.,  1137 

London  Hrspital  Medical  College,  lectures, 
1051,  1094 

London  Inter-Collegiate  Scholarship  Board, 
entrance  scholarships  and  exhibitions,  232, 
•915 

London  Panel  Committee,  meeting,  955 
London  School  of  Medicine  for  Women,  post- 
graduate course,  725  ; scholarships,  956  ; 
prize-giving,  1098 

London  School  of  Tropical  Medicine,  pass-lists. 
'639 

London  Temperance  Hospi  al,  meeting.  485 
London  University,  appointments,  88  ; pass- 
lists,  687,  1003,  1051 ; Senate  of,  Prof.  A. 
Schu9ter  and  Dr.  W.  C.  Unwin  reappointed 
members.  577 ; King’s  College,  Department 
■of  Psychology,  lectures,  769  ; University 
College,  Prof.  G.  E.  Smith  appointed  to 
Chair  of  Anatomy,  989 ; C rllege  Hospital  and 
Medical  School  war  memorial,  999 
Louping  ill,  350 

Louse,  lessons  of  the,  118  ; hatching  of,  1132 
Louvain  library,  re-stocking  of,  1042 
Love,  Dr.  J.  K..  Diseases  of  the  Ear  in  School 
Children,  an  Essay  on  the  Prevention  of  Deaf- 
ness (review),  896 

Lowe,  Dr.  E.  C.,  and  Dr.  J.  W.  H.  Eyre,  autumn 
influenza  epidemic  (1918),  553 
Lozenges,  “cofectant,” 24 
Luckes,  Miss  Eva,  death  of,  306 
Luett,  Lieut.  E.  P.  M.,  Austr.  A.M.C.  (see 
■Obituary  of  the  war) 

Lum'eian  lectures  on  cerebro-spinal  fever  (Sir 
H.  Rolleston),  541, 593,  645 
Lumsden,  Dr.  T.,  immuno-transfusion,  814 
Lunacy  in  Egypt,  117 
Lunacy  reforms,  suggested,  229 
Lunatic  asylum  discharges  (Py  Q),  442 
Lunatics,  pauper,  treatment  of  (Py  Q),  686 
Lung  disease,  chronic,  and  influenza,  281,  314  ; 

gangrene,  collapse  therapy  of,  902 
Lung-puncture  in  treatment  of  influenzal 
pneumonia  (Dr.  M.  Benaroyal,  742,  816 
Lupus,  treatment  of,  picric  brass  preparations 
in  (Dr.  II . A.  Ellis),  415,  430, 528, 635 
Xnsk,  Prof.  G.,  Elements  of  the  Science  of 
Nutrition,  third  edition  (review),  745 
Luton,  Capt.  W.  F.,  Can.  A.M.C.  (see 
Obituary  of  the  war) 

Lymph  for  public  vaccination  (Py  Q),  484 
Lymphadenitis  in  right  iliac  fossa  sin  ulat'ng 
appendicitis,  988 
Lymphangeioma  of  tongue,  940 
Lymphoid  tissues,  tuberculosis,  and  sunlighL 
374 

Xysorophus,  946,  1093 


M 

MaeAiister,  Sir  D.,  reappointed  member  of 
the  governing  bodyoftbe  Imperial  College 
of  Science  and  Technologv,  585 
Macaipine,  Mr.  J.  B.,  Wheelhouse’e  operation, 
334  ; urethral  nozzle,  514 
McBride,  Dr.  P..  war  deafness,  157 
McOaul,  Mr.  G B.,  death  of,  368 
MacCombio,  Dr.  J.,  death  of,  823 
McCrea.  Dr.  H.  M . some  pitfalls  of  general 
practice,  1010,  1053 

McGill,  Dr.  J.R.,  Tropical  Surgery  and  Diseases 
of  the  Far  East  (review),  467 
Macdonald,  Dr.  J.  A.  and  others,  portrait  of  Sir 
Clifford  Allbutt,  814 

McDougali,  Dr.  A.,  the  “spectrum”  of  epilepsy, 
157 

MeDowall,  Dr.  C.  F.  F.,  genesis  of  delusions, 
1028 

Macdowell,  Miss  Margaret,  Simple  Beginnings 
in  the  Training  of  Mentally  Defective 
Children  (review).  566 

McEnt're,  Lieut.  Col.  J.  T.,  Mons  Star, 
R.A.M.C.  (see  Obituary  of  the  war) 
MacFadden,  Dr.  A.  W.  j..  Local  Government 
Board  food  inspection,  189 
Macfie,  Dr.  R.  C..  Odes  and  Other  Poem3 
(review),  1117 ; War  (review),  1119 
McGlennan,  Dr.  A.,  and  Dr.  J.  Frledenwald, 
perforation  in  cancer  of  the  stomach,  272 
McGowan,  Dr.  J.  P.,  mutation  of  organisms  of 
the  coiiform-typhoid  groups,  466 
McJunkin,  Prof.  F.  A.,  Clinical  Microscopy  and 
Chemistry  (review),  1028 
Mackay,  Mr.  W.  M , Disease  and  Remedy  of 
Sin  (review),  302 

Mackenzie,  Sir  J., prognosis  in  cardio-vascular 
affections,  715 

Mackie,  Dr.  J.W.,Mr.  A.  H.  Tubby,  and  Dr. 
G.  R.  Livingston,  treatment  of  gunshot 
wounds,  251 

Mackie.  Capt.  T.  J.,  Capt.  L.  F.  Hirst,  Col.  A.  E. 
Tubby,  and  Maj.  A.  R.  Ferguson,  action  of 
flavine,  838 

Maekinnon,  Capt.  F.  I.,  R.A.M.C. (see  Obituary 
of  the  war) 

Maekinnon,  Dr.  Doris,  and  Dr.  W.  Fletcher, 
chronieity  of  dysentery  infection,  1038 
Maclean,  Dr.  H.,  Lecithin  and  Allied  Sub- 
stances, the  Lipins  (review),  745 
MacLelland,  Dr.  R.,  intermit!  ent  hydrops 
aiticulorum,  463 

Macleod,  Dr.  N.,  whooping-cough,  treatment, 
254 

Macleod,  Prof.  J.  J.  R.,  and  Dr.  R G.  Pearce, 
Physiology  and  Biochemistry  in  Modern 
Medicine  (review),  513 

MacMahon,  Mr.  C.,  gunshot  wounds  and  other 
affections  of  the  chest,  697 
Macnamara,  Mr.  N C.,  obituary,  43 
Macphail,  Dr.  J.  M.,  Eyes  Right,  Papers  for 
Teachers  and  Parents  on  the  Hygiene  and 
Treatment  of  the  Eye  (review),  984 
MacRae,  Dr.  D.  M .influenza  and  chronic  lung 
disease,  281 

Maculse,  disease  of  both,  613 
McVaii,  Dr.  J.  C.,  half  a century  of  small-pox 
and  vaccination,  449 

McWalter,  Dr.  J.  C.,  are  relapses  of  bacillary 
dysentery  frequent  ? 529 
McWhirter,  Dr.  A.  T.,  Dr.  H.  Barber,  and  Dr. 
C.  F.  White.  Wassermann  reaction,  a criticism 
of  its  reliability,  502 
Magistrates,  medical,  87 

Magoveny,  Capt.  J.  H , R.A.M.C.  (see  Obituary 
of  the  war) 

Makins,  Sir  G.  H.,  r61e  of  consulting  surgeon 
in  war  (Cavendish  lecture),  1099  ; (leading 
article',  1121 

Makins,  Sir  G.  H.,  and  Dr.  N.  Moore,  position 
of  the  demobilised  practitioner,  439 
Malaria  and  its  Treatment,  in  the  Line  and  at 
the  Base  (Capt.  A.  C.  Alport)  (review), 
616 

Malaria  and  Wassermann  reaction  (Dr.  J.  G. 

Thomson  and  Mr.  C.  H.  Mills),  782 
Malaria,  apyrexial  symptoms,  222 ; recurrent, 
308 ; and  trench  fever  (Dr.  G.  Ward),  6C9 ; in 
England,  risk  of,  677;  during  the  war  (G. 
Paisseau),  749;  care  and  treatment  (Sir 
R.  Ross),  780 ; distribution  of  soldiers 
temporarily  unfit  through  (Prof.  S. 
Jeanselme),  751 ; studies  in  trestment,  756  ; 
mercury  in,  903  ; malignant  tertiaD,  1126 
Malay  States  health  reports,  1011 
Malcolm,  Mr.  J.  D.,  fcetus  and  placenta,  612 
Maldeveiopment  of  the  liver,  744 
Male  urethra,  repair  of  (Mr.  E.  D.  Telford  and 
Mr.  F.  G.  Norbury),  177 
Malformation  of  the  extremities,  hereditary 
(Dr.  W.  J.  Rutherford  and  Dr.  Barbara  G.  R. 
Crawford),  979 

Malignant  tertian  malaria,  1126 
Mallett,  Dr.  F.  R.,  pract’ca  of  tl  e absentee, 
45 


Malone,  Dr.  A.  E.,  and  Dr.  J.  G.  Wardrop, 
recurrent  chyluthorax  following  trauma, 
1116 

Malta  fever,  other  agglutinins  in  cases  of, 
formation  of  (Dr.  L.  T.  Burra),  64 
Manchester  and  District  Radium  Institute, 

323 

Manchester  Literary  and  Philosophical  Society 
(see  Medical  societies) 

Manchester  University,  pass-lists,  536 
Mandibular  bone  grafts,  181 
Mange,  parasitic,  in  horses,  280 
Manion,  Capt.  R.  J.,  M.C.,  A Surgeon  in  Arms 
(review),  1074 

Marchanr,  Mr.  F.  T.,  prophylaxis  in  Influenza, 

393 

Marriage  rate  of  South  Australia,  350 
Marsden,  Dr.  R.  S.,  obituary,  530 
Marshall,  Sir  Horace,  Lord  Mayor,  Hospital 
Sunday,  1093 

Marshall,  Prof.  C.  R . appointed  to  the  Regius 
chair  of  Materia  Medica  and  Therapeutics  in 
the  University  of  Aberdeen,  854  1003 
Martin,  Capt.  J.  S.,  R.A.M.C.  (see  Obituary 
of  the  war) 

Mai  tin,  Louis,  and  Auguste  Pettit,  Spiro- 
chitose  Ieterohemorragique  (review),  800 
Martinet,  Dr.  A.,  Diagnostic  Clinique 
(Examens  et  Symptomes)  (review),  984 
Mary,  Dr.  A.,  origin  of  life,  work  if  late 
Charlton  Bastian,  1133 

Masks,  experiments  on  (Dr.  H.  M.  Leete),  392 
"Mass  meetings”  and  their  representative 
character,  314 

Massage  as  a Career  for  Women  (Beatrice  M. 

Goodall-Copestake)  (review).  617 
Massage,  direct,  of  the  heart,  658 
Masters,  Miss  Helen,  lead  in  the  casserole, 
1002 

Mastoid  operations,  radical  and  modified 
radical,  339 

Materia  Medica  and  Therapeutics,  an  Introduc- 
tion to  the  Rational  Treatment  of  Disease 
(Dr.  J.  M.  Bruce  and  Dr.  W.  J.  Dilling), 
eleventh  edition,  1918  (review),  112 
Maternal  and  infantile  protection  in  Paris 
during  the  war,  38 ; mortality  of  childbirth 
and  the  teaching  of  midwifery  (leading 
article),  802 

Maternity  and  Child  Welfare  : Mothers’ 

pensions  in  the  United  States  of  America, 
191— International  Congress  of  Baby  Weeks  ; 
SaviDg  child  life  in  U.S. A.,  192— Conditions 
of  childbirth  in  India,  435 — Maternity  ; 
nursiDg  in  London,  436— Child  welfare  in 
New  Jersey  ; Importance  of  pre-school 
period  to  the  school  child ; Maternal  nursing 
considered  from  its  evolutionary  and  , 
biological  aspects,  811 — Instruction  and 
supervision  of  expectant  mothers  in  New 
York  city.  995 

Maternity  and  child  welfare  (Py  Q),  321 
Maternity  Charity  of  London,  Royal,  report, 
765  ; hospitals,  institution  of,  91 2 
Matthews,  Capt.  S.  W.,  R.A.M.C.  (seeObituary 
of  the  war) 

Maudsley  lectureship,  1023 

Maxted.  Capt.  G.,  malignant  tumour  of  the  • 
pituitary  body,  613 

May,  Dr.  P.,  Chemistry  of  Synthetic  Drugs, 
second  edition,  1918  (review),  224 
Mayer,  Dr.  L.,  Orthopaedic  Treatment  of  Gun- 
shot  Injuries  (review),  23 
Meachen,  Dr.  G.  N.,  copper  treatment  of  lupus, 
528 

Measles,  resembling  acute  erythema  (Dr.  F.  H. 
Kelly),  255 

Meatless  dietary  in  epilepsy,  1046, 1033 
Medical  administration,  successful,  essential 
principles  of,  356,  441 

Medical  appointments  in  Ireland  during  de- 
mobilisation, 18;  reform  in  Ireland,  274; 
demobilisation  in  France,  477 ; men,  demo- 
bilisation of  (Py  Ql.  321, 360,  535 
Medical  aspects  of  flying  (leading  article),  227  ; 
and  surgical  developments  of  the  war, 
814 

Medical  curriculum  and  biology  (Mr.  T.  G. 
Hill),  273,  312 ; research  in  India,  311 ; 
research  and  its  place  in  the  State  (leading 
article),  517  ; Research  Committee,  medical 
supplement  of.  522 ; research,  coordination 
by  the  State  (Dr.  D.  C.  Watson),  S89,  992 
Medical  Defence  Union,  notification  and  pre- 
vention of  specific  diseases,  362 
Medical  Diary,  49.  88.  126. 162,201,241,282,  322, 
364,  404,  446,  487,  538,  590,  642.  636,  727,  771, 
824,  866,  920,  961,  1012,  1052,  1097,  113S 
Medical  education,  reform  of  (leading  article), 
571 ; evidence  and  trials  in  camera  (leading 
article),  620 ; boards  and  disability  assess- 
ments (Py  Q),  918 

Medical  men  and  income-tax  (Py  Q).  360; 
students,  supply  of,  391 ; men  in  military 
service  (Py  Q),  403  : men  on  Dispersal  Boards 
(Py  Q),  820;  mission  to  Poland,  944;  and 
share  holding,  1045,  1093 
Medical  Missions  (United)  Exhibition,  1140 


The  Lancet,] 


INDEX  TO  VOLUME  I.,  1919. 


[July  5,  1919  xiii 


Modiral  oflicer,  factory.  In  war  and  peace,  447  ; 
Regimental,  the  Whole  Duty  of  (Capt 
P.  Wood)  (review),  466 ; to  the  Hoard  of 
Customs  (Py  Q),  1009 

Medical  oilicers  of  bea'th,  reports,  478,  581 
Medical  Oilicers  of  Schools  Association,  47; 
assistant,  of  asylums  (Py  Q),  359;  officers  in 
Army  of  Occupation  (Py  Q),  402;  officers, 
women,  in  military  hospitals  (Py  Ql,  442; 
Irish  Poor  law,  salaries  of  (Py  Q),  442  ; de- 
mobilisation of  (Py  Ql,  485,  641  ; naval, 
temporary,  gratuities  to  (Py  Ql,  485 ; 
temporary,  release  of  (Py  Q),  686;  Scottish 
parochial  (Py  Q),  918;  Territorial  ami 
demobilisation  (Py  Q),  918,  960  ; officers 
abroad,  relief  of  (Py  Q),  959 
Medical  Ophthalmology  (Dr.  A.  Knapp) 
(review),  23;  and  Surgical  Reports  of  the 
Episcopal  Hospital  (review),  23;  Curriculum, 
Enquiry  into,  by  the  Edinburgh  Patho- 
logical Club  (revitw),  426  ; Electricity, 
Essentials  of  (Dr.  E.  P.  Cumbeibatch), 
fourth  edition,  1919  (review),  514 
Medical  Parliamentary  Committee,  120  ; 
Members  of  Parliament,  dinner,  281 ; 
arrangement  of  conference,  634,  705,  808, 
817,  858  ; progress  of  (leading  article),  801  ; 
candidates  for  Parliament,  35;  representa- 
tion in  the  House  of  Lords,  819 
Medical  practitioner,  outlook  of  (leading 
article),  145;  practice  in  France,  protection 
of,  477 

Medical  practitioners’,  civil,  war  services,  list, 
438 

Medical  profession,  future  of,  141  ; meeting  at 
Wigmore  Hall,  240,  362  ; and  the  trade- union 
question  (leading  article!,  345,  397;  and 
Chief  Secretary  for  Ireland,  812;  meeting 
of,  in  Edinburgh,  1040 
Medical  Quarterly  (review),  463 
Medical  Service,  State,  141,  312 ; school  in  the 
Far  East.  308 ; in  the  Highlands  and  Islands, 
819;  scheme  for  development  of,  820; 
Services  Bill  (leading  article),  941 ; Bill 
(Py  Q),959;  service,  industrial,  1129 
Medical  Sickness,  Annuity,  and  Life  Assurance 
Friendly  Society’s  report,  637,  915 
41  Medical  treatment”  of  empyema,  1127 

MEDICAL  SOCIETIES. 

British  Psychological  Society.— Psycho- 
logy and  medicine,  889 

■Child  Study  Society.— Home  v.  institu- 
tional training  of  young  children,  615 
Liverpool  Medical  Institution. — Annual 
meeting  and  report,  183  — MutaCon  of 
organisms  of  the  coliform-t.ypboid  groups  ; 
Diagnostic  value  of  the  Wassermann  reaction 
in  syphilis,  466 

London  Association  of  Medical  Women.— 
Future  of  the  medical  profession,  141- 
Exhibition  of  cases,  616,  847— Effect  of 
industrial  employment  upon  women,  465 — 
Medical  inspection  of  secondary  schools,  616 
Manchester  Literary  and  Philosophical 
Society.— The  bird’s  brain,  616 
Medical  Society  of  London.— Gonorrhoea 
of  genito-urinary  passages,  discussion,  219  — 
Intrinsic  cancer  of  larynx,  263— Congenital 
stenosis  of  pylorus, 380— Exhibition  of  cases, 
700— Annual  oration,  846— Election  of  officers, 
847 

M edico-Legal  Society.— Position  of  medicine 
in  the  State,  797 

Medico-Psychological  Association  of  Great 
Britain  and  Ireland.— Quarterly  meeting, 
362 — Maudsley  lectureship;  Genesis  of  delu- 
sions, 1028 

North  London  Medical  and  ChiruIigical 
Society. — Relation  of  pathology  to  clinical 
medicine,  300 

North  of  England  Obstetrical  and 
Gynaecological  Society.— Exhibition  of 
cases  and  specimens,  22,  301 — Extra-uterine 
pregnancy ; Radical  cure  of  complete 
procideDtia,  22  — Advanced  extra-uterine 
pregnancy,  301— Tuberculosis  service,  resolu- 
tions passed, £65 

Ophthalmological  Society  of  the  United 
Kingdom.— Abi  trophy  of  the  retinal 
neuro-epithelium  or  “ retinitis  pigmentosa  ” ; 
Results  of  double  scleiwiomy  operation  for 
glaucoma;  Future  o"  s’aucoma  operation; 
Contracted  sockets,  893— Stereoscopic  vision  ; 
Bowman  lecture  on  plastic  operations  on  the 
orbital  region  ; Eyesight  and  education,  894 
IRoyal  Academy  of  Medicine  in  Ireland 
(Section).— 

Obstetrics.— Exhibition  of  cases  and  speci- 
mens ; Abderhalden’s  pregnancy  reaction, 
110— Endothelioma  of  ovary;  Exhibition  of 
specimens,  264 

Boyal  Institute  of  Public  Health.— Pre- 
vention and  arrest  of  venereal  disease  in  the 
Army,  discussion,  109 


Royal  Sanitary  Institute.— Conference  on 
poa'-war  development  relating  to  public 
health,  464 

Royal  Society  of  Mkdicine  (Sections).— 
Management  of  venereal  diseases  in  Egypt 
during  the  war,  140  —Admission  of  pensioners 
to  civil  hospitals,  179-Shock,  discussion, 
256 

Jnacslhetic. — Exhibition  of  cases,  658 
Electro-therapeutics.  — Electrical  methods 
of  measuring  body  temperature;  Electro- 
cardiograph, 564 

Medicine  -Apyrexial  symptoms  of  malaria, 
222— Transfusion  in  diseases  of  the  Mood, 
379 — The  epidemic,  pneumonia  in  Macedonia, 
794 

Obstetrics  and  Gynaecology.  — Reconstruc- 
tion in  t he  teaching  of  obstetrics  and  gynae- 
cology to  medical  students,  discussion,  258 — 
Foetus  during  spontaneous  evolution  ; Extra- 
uterine  pregnancy  contimung  to  term; 
Specimen  shown  105  years  ago ; Four  cases 
of  full-time  ectopic  fregnancy,  611— Con- 
tinued high  maternal  mortality  of  child- 
bearing, 796— Obstetric  helper,  797— Exhibi- 
tion of  cases  and  specimens ; Subperitoneal 
and  retropeiitoneal  lipoma,  1072 
Ophthahnological  and  Laryngological. — 
Injuries  and  diseases  of  the  orbit  and  acces- 
sory sinuses,  614  , 699— Exhibition  of  slides, 
699 

Ophthalmology.  — Retinal  degeneration  ; 
Ivory  exostosis  of  orbit,  299— Exhibition  of 
cases  and  drawings ; Leber’s  atrophy, 
changes  in  sella  turcica;  Sympathetic  oph- 
thalmitis, 300— Exhibition  of  cases  and 
specimens,  613,  1072— Malignant  tumour  of 
the  pituitary  body  ; Migraine,  613 

Otology. — Deafness  associated  with  the 
stigmata  of  degeneration,  182— Radical  and 
modified  radical  mastoid  operation,  339  — 
Septic  infection  of  lateral  sinus  after  injury 
at  operation,  340— New  theory  of  hearing, 
510 — Exhibition  of  cases  and  specimens,  893 
Pathology. — Diffuse  emphysema  of  the 
wall  of  small  intestine,  263— Polymorphism 
of  malignant  epithelial  cell,  743 
Study  o)  Disease  in  Children.— Exhibition 
of  cases,  565,  744,  940 

Surgery.— B-me-grafting,  181 — Carcinoma 
of  appendix,  845 

Scottish  Otological  and  Laryngological 
Society.  — Clinical  meeting;  Election  of 
officers,  1131 

Soci^Tfe  de  Biologie,  Paris.— Summary  of 
papers,  21,  223,  301,  424,  565,  798,  847,  940 

Society  de  Therapeutique,  Paris.  — 
Typhoid  fever  treated  by  colloidal  iron ; 
Treatment  of  influenza  and  infectious 
diseases  of  lymphotherapy  and  hsemato- 
therapy ; Hypodermic  injections  of  euca- 
lyptus oil  in  influenza,  424— Ingestion  of 
adrenalin  and  intravenous  injection  of 
colloidal  quinine  : Bacteriology  of  influenza; 
Lemon  as  a specific  for  glossitis  and  stomat- 
itis, 760— Chemical  composition  of  lemon 
juice ; Action  of  hypochlorites  on  pleural 
false  membranes ; Fixation  abscesses  in 
influenza,  895 — HEematoglobinuric  bilious 
fever  ; Increase  of  weight  effected. by  diet  of 
low  calorific  value,  940 

Tuberculosis  Society.—  Practical  remarks  on 
tuberculosis  in  relation  to  the  upper  air  and 
food  passages,  223— Treatment  of  tuberculous 
glands,  424— Acute  pneumonic  tuberculosis, 
615— Tuberculosis  officers  and  panel  practi- 
tioners, 895— Tuberculosis  in  relation  to  a 
Ministry  of  Health,  1027 

West  London  Mfdico-Chirurgical  Society. 
—Exhibition  of  cases  and  specimens,  300- 
Importance  of  symptoms,  480 


Medical  Society  of  London  and  women,  851, 
894,  989  ; (see  also  Medical  Societies) 

Medical  treatment  of  children  in  Ireland,  401 ; 
Bill  (Py  Q),  534,  686,  770,  819  ; inspection  in 
factories  (Py  Q),  402;  women  and  the  War 
Office  (Py  Q),  402;  inspectors  of  Home  Office 
(Py  Q),  402;  profiteering,  alleged,  526;  in- 
spection of  schools  in  Ireland,  577 ; (Py  Q), 
641,  685  ; demobilised  men  (Py  Q),  640 
Medical  unanimity  and  public  spirit,  the  State 
and  thedoetor(SirH.  Morris),  165;  tradition, 
the,  846 

Medicinal  herb-growing,  1053 

Mfdicine  and  the  Law.— Illicit  traffic  in 
drugs;  An  ingenious  impersonator,  36- 
Frost  v.  King  Edward  VII.  National 
Memorial  Association  for  the  Prevention, 
Treatment,  and  Abolition  of  Tuberculosis, 
37 — Irregular  sale  of  poisons;  Medical 
practitioners  and  the  detection  of  crime, 
120— Inquest  on  “Billie  Carleton,”  236— Dr. 
A.  G.  Bateman,  death  of,  679 — Case  of  De 
Veulle ; Woman  and  the  legal  profession ; 


Trial  of  Col.  Rutherford  ; Cate  of  Dr.  M.  W. 
Colton,  680— Possession  of  cocaine;  Incori- 
clushe  inquest;  Notification  of  oohthalmia 
neonatorum,  948— “ Ragging  ” < f a nurse, 
949  - Lay  members  of  mixed  committees  and 
medical  questions  ; Case  of  Henry  Perry  ; 
Criminal  nr  moral  imbecilo ; Ritter  v. 
Godfrey,  1041 

Medicine,  a fellowship  of  (leading  article),  26; 
Fellowship  of,  emergency  post-graduate 
facilities,  189,400,477;  Inter-Allied  Fellow- 
ship of,  152;  teaching  of  (Dr.  W.  H.  White), 
31  ; sanitation,  and  health  in  India,  127, 163  ; 
and  the  St>te  (Sir  H.  Morris),  165;  and  the 
State  (leading  article),  185 
Medicine,  the  Practice  of  (Sir  F.  Taylor) 
eleventh  edition,  1918  (review),  22;  Clinical, 
System  of  (Dr.  T.  D.  Savill),  fifth  edition, 
1918  (review),  66 

Medicine,  teaching  of  (leading  article),  227  ; 
Parliament,  and  public  (leading  article),  267, 
312;  in  the  House  of  Commons,  320; 
nationalisation  of,  476;  position  of,  in  the 
State,  797 ; social,  in  Vienna,  921 
Medicines  patent  (Py  Q),  401 
Medico-legal  Society  (see  Medical  Societies) 
Medico  Psychological  Association  of  Great 
Britain  and  Ireland  (sec  Medical  Societies) 
Medullary  symptom  complex  (Dr.  S.  A.  Owen 
and  Dr.  P.  A.  Leighton),  1024,  1087 
Mellanby,  Dr.  E.,  rickets,  experimental  investi- 
gation on, 407 

Melville,  Col.  H.  G.,  I.M.S.  (see  Obituary  of 
the  war) 

Memoiandum,  revised,  on  tetanus,  1125 
Meningeal  haemorrhage  in  typhoid  fever,  519 
Meningitis,  pneumococcic,  primary,  623; 

cerebro- spinal  (Mr.  A.  S.  G.  Bell),  887 
Meningococcal  rheumatism  and  arthritis  (Dr. 
P.  Sainton),  1080 

Meningococcic  septicaemia  (Sir  H.  Rolleston), 
541 

Meningococcus,  purulent  broncho  pneumonia 
associated  with,  81 ; brQncho-pneumonia  in 
influenza  (Dr.  W.  Fletcher),  104,  124 
Meningococcus,  the,  a recent  chapter  (leading  • 
article),  1083 

Mental  defectives  in  institutions,  death-rate, 
78 ; (Py  Q),  443  ; After-care  Association,  meet- 
ing, 395,  462  ; disorders  associated  with  old 
age  (Sir  G.  H.  Savage),  1013 
Mental  Disorders  of  War  (Prof.  J.  Lepine) 
(review),  1074 

Mental  statistics  in  Canada,  39 
Mentally  deficient,  accommodation  for  (Py  Q), 
359;  Defective  Children,  Simple  Beginnings 
in  Training  (Miss  M.  Macdowell)  (review), 
566 

Mercier,  Dr.  C.,  Crime  and  Criminals  (review), 
382 

Mercury  in  malaria,  903 

Merklen,  Dr.  P.,  fixation  abscesses  in  influenza, 
895 

Mesentery,  two  tumours  of.  111 
Mesopotamia,  housing  in,  301 
Metcalfe,  Capt.  G.  C.,  R.A.M.C.  (see  Obituary 
of  the  war) 

Methylated  spirits  and  women  (Py  Q),  401 
Metropolitan  Hospital  Sunday  Fund  (leading 
article),  1032 ; the  Lord  Mayor  and,  1093 
Metropolitan  water  supply  during  July, 
August,  and  September,  1918,  90 ; during 
October,  November,  and  December,  1918, 363  ; 
during  January,  February,  and  March,  1919, 
1098 

Metrorrhagia  in  influenza,  156 
Meyer,  Prof.  H.  H.,  and  Dr.  F.  Ransom, 
tetanus  without  trismus,  117 
Microscopic  slides,  method  of  obtaining  good 
surface,  922 

Microscopy  and  Chemistry,  Clinical  (Prof. 

F.  A.  McJunkin)  (review),  1028 
Middlesex  Hospital,  meeting,  639 
Midwifery,  Text-book  of,  for  Students_and 
Practitioners,  second  edition,  1918  (review), 
982 

Midwives  and  burial  certificates  (Py  Q),  959 
Migraine,  613  « 

Migration  of  a round  worm  into  the  ear,  28 
Military  College,  new,  Toronto,  39  ; medical 
officers  and  civilian  practice,  233 
Military  Surgeon  (review),  112,  468 
Milk,  Examination  for  Public  Health  Purposes 
(Mr.  J.  Race),  first  edition,  1918  (review), 
514 

Milk-supply  of  Dublin,  192 ; pure  (Py  Q), 
864 

Miller,  Dr.  H.  C.,  war  neuroses,  766 
Mills,  Mr.  C.  H.,  and  Dr.  J.  G.  Thomson, 
malaria  and  Wassermann  reaction,  782 
Milne,  Capt.  A.  J.,  South  African  M C.  (see 
Obituary  of  the  war) 

Milne,  Mr.  J.  S , Neurasthenia,  Shell  Shock, 
and  a New  Life  (review),  702 
Milroy  lectures  on  half  a centuiy  of  small  pox 
and  vaccination  (Dr.  J.  C.  McVail),  449 
Ministries  of  Health  Bill,  121 


xiv  The  Lancet,] 


INDEX  TO  VOLUME  I.,  1919. 


[July  5,  1919 


Ministry  of  Health  Bill,  319,  359.  360.  401.  442, 
482,  532,  586,  641,  818,  863,  917,  957,  959,  1008  ; 
Action  of  the  General  Medical  Council ; Con- 
joint action  of  the  English  Colleges,  351- 
Views  of  the  Society  of  Helical  Officers  of 
Health,  394— Inspection  of  school  children 
(leading  article),  471— Action  in  Belfast, 
687 

Ministry  of  Health,  281;  (Py  Q),  320;  sepirate 
Bill  for  Scotland  (Py  Q),  361;  and  Ireland 
(Py  Q),  359,  400,  442.  475,476,  577,  582,  631, 
909, 1040;  and  factory  surgeons,  432;  Scottish 
Committee,  433;  for  Egypt  (Py  Q),  485; 
resolutions  of  the  Scottish  medical  profession, 
523;  statement  by  the  Royal  College  of 
Physicians  of  Edinburgh,  523  ; and  Belfast 
doctors,  577  ; and  liquor  control  (I’y  Q),  587; 
Indian,  998  ; the  next  stage  (leading  article), 
1031 

Ministry  of  National  Service,  medical  work  of, 
319 ; Sir  A.  Geddes  thanks  the  Medical 
Department,  580 

Ministry  of  Pensions,  decentralisation  at,  665  ; 
medical  appointments  under,  991 

Missiles  as  emboli  (Sir  J.  Bland-Sutton),  773' 
913 

Missing  officers  and  men  (Py  Q),  320 

Mitchell,  Mr.  C.  A.,  Edible  Oils  and  Fats 
(review),  848 

Mobilisation  and  demobilisation,  medical  work 
of  the  Central  Medical  War  Committee, 
193 

Model  Homes  Exhibition,  963 

Moir,  Mr.  J.  R.,  a freak  of  nature, 
723 


Molybdeno-tungsten  arc  in  treatment  of 
suppurative  lesions  (Mr.  B.  M.  Youno), 
108 

Montreal,  University  of,  1132 

Moor,  Mr.  C.  G.,  and  Mr.  W.  Partridge,  Aids  to 
the  Analysis  of  Foods  and  Drugs,  fourth 
edition,  1918  (review),  848 

Moore,  Dr.  N.,  History  of  St.  Bartholomew's 
Hospital  (review),  425;  and  Sir  G.  H.  Makins, 
position  of  the  demobilised  practitioner, 
439 

Moore,  Mr.  R.  F.,  sympathetic  ophthalmitis 
with  fundus  changes,  300 

Morat,  Prof.  J.-P.,  Traite  de  Physioiogie 
(review),  702 

Morax,  Prof.,  plastic  operations  on  the  orbital 
region,  894 

Morbus  cordis,  congenital,  with  polycyth.-emia, 
700 

Morgan,  Capt.  W.  P.,  adjustable  pipette  for 
automatically  measuring  out  small  volumes 
of  liquid,  1120 

Morison,  Capt.  R.  McK.,  R A.M.C.  (see 
Obituary  of  the  war) 

Morphia,  British-made  (Py  Q),  864 

Morris,  Mr.  B.  J.,  Employment  Opportunities 
for  Handicapped  Men  in  the  Optical  Goods 
Industry  (review),  982 

Morris,  Sir  H.,  plea  for  medical  unanimity  and 
public  spirit,  the  State  and  the  doctor, 
165 


Mortality  and  the  French  Auxiliary  Army 
Medical  Corps,  540 

Mortimer,  Mr.  J.  D.,  “shock”  (so-called', 
397 

Morton,  Dr.  R.,  malignant  stricture  of  the 
oesophagus,  300 

Mosquito  problem  in  Britain,  447  ; larva;  in 
streams,  destruction  of  (Mr.  A.  K.  Henry) 
9C8 


Mothereraft  training  for  girls,  538 
Motor  mechanics  for  cripples,  76 ; nerves  during 
operations,  testing  of,  989 
Motoring— present  and  future,  29 
Mott,  Dr.  F.  W.,  Archives  of  Neurology 
and  Psychiatry  (review),  302;  war  neuroses, 
709 


MoLtram,  Dr.  J.  C.,  Dr.  S.  Russ,  Dr.  Helen 
Chambers,  and  Dr.  Gladwys  M.  Scott, 
experimental  studies  with  small  doses  of 
X rays,  592 

Moure.  Dr,  P.,  and  Dr.  E.  Sorrel,  surgical  com- 
plications following  exanthematic  typhu-, 

Mouth,  Normal  and  Pathological  Histology  of 
(Mr.  A.  llopewell-Smith)  (review),  897 
Mucoid  forms  of  paratyphoid,  237 
Muir,  Dr.  E.,  Kala-azvr,  its  Diagnosis  and 
Treatment  (review),  142 
Muir,  Prof.  It.,  and  Prof.  J.  Ritchie.  Manual  of 
Bacteriology,  seventh  edition,  1919  (review). 
467 

Multiple  epulides,  744 

Munby,  Mr.  W.  M.,  and  Mr.  A.  D.  E.  Shefford, 
bone-grafting  operations,  1070 
Munition  workers,  female,  tuberculosis  In,  432 
Murphy,  Sir  S.  F.,  appointed  to  represent  His 
Majesty's  Government  at  the  forthcoming 
congresses  of  the  Ontario  Medical  Associa- 
tion and  the  American  Medical  Association, 
908 


Murray,  Dr.  G.  R., 
influenza,  12 


comparative  pathology  of 


Murray,  Dr.  L.,  sessile  red  fibroid,  22 

Murray,  Capt.  R.  W.  S.,  R.A.M.C.  (see 
Obituary  of  the  war) 

Muscles,  blood  supply  of  (Dr.  J.  Campbell  and 
Dr.  C.  M.  Pennefaiher),  294 

Musk  in  influenza,  529 

Mustard  gas,  nystagmus  caused  by  (Mr.  II.  P. 
Ratnaker),  423;  its  brief  but  inglorious 
career,  471 

Mutation  of  organisms  of  the  eoiiform  typhoid 
groups,  46S 

Myelitis,  acute  ascending  (Dr.  D.  K.  Adams), 
462 

Myers,  Dr.  B.  E.,  instruction  in  hydrology, 
635 

Myers,  Dr,  C.  S.,  study  of  shell  shock,  51 


N 

Nairn,  Mr.  R , recent  epidemic  of  “ Spanish  ” 
influenza,  635 

Nasal  douche,  50;  obstruction  in  aviators  (Dr. 

D.  Guthrie),  133;  blockage,  invalidism  for  15 
years,  156 

Nash,  Mr.  W.  G.,  unilateral  hydrofhorax  due 
to  disease  below  the  diaph-agm,  378 
National  Conference  on  Infant  Welfare,  895 
National  Food  Reform  Association,  dietaries, 
22 

National  Hospital  for  the  Paralysed  and 
Epileptic,  meeting,  529;  post-graduate 
course  in  neurology,  769 
National  League  for  Health,  Maternity,  and 
Child  Welfare,  meeting,  728 
National  Medical  Service,  what  is  it  worth  ? 
279 

National  register  of  population,  147 
National  Sanatorium  Association,  Canada,  39 
Naval  medical  officers,  temporary,  gratuities 
to  (Py  Q),  485 

Neech,  Dr.  J.  T.,  the  slum-dweller  and  the 
slum-owner,  429 

Nephritis,  Chronic,  Renal  Functions  in. 
Studies  on  (thesis  by  Pasteur- Vallery-Radot) 
(reviewed  by  Prof.  C.  Actaard),  752 
Nerve  and  muscle,  faradic  stimulation  of, 
during  operations  (Mr.  H.  Platt  and  Mr. 

E.  S.  Brentnall),  884 

Nerve-strain  in  London  children,  540,  727 
Nerves,  motor,  testing  during  operations,  989 
Nerves,  Peripheral,  Anatomy  of  (Prof.  A.  M. 

Paterson)  (review),  1074 
Nervous  system,  central,  hysterical  element  in 
organic  disease  and  injury  of  (Dr.  A.  F. 
Hurst  and  Dr.  J.  L.  M.  Symns),  369;  com- 
plications of  exanthematic  typhus  (A. 
Devaux),  567  ; system,  the  sympathetic,  in 
disease,  role  of  (Dr.  L.  Brown),  827, 873,  923, 
965;  system,  autonomic,  arrangement  of, 
951 

Neurasthenia,  Shell  Shock,  and  a New  Life 
(Mr.  J.  S.  Milne)  (review),  702;  and  shell 
shock  (Py  Ql,  725 

Neuro'ogieal  Clinics  (Dr.  J.  Collins)  (review), 
302 

Neurology  and  Psychiatry,  Archives  of  (Dr. 

F.  W.  Mott)  (review),  302 

Neuroses  of  the  war  (leading  article),  71 ; war 
(Dr.  F.  W.  Mott),  709,  766 
Neurosis,  composite,  analysis  of  (Dr.  F.  Dillon), 
57  ; war  (Dr.  W.  Brown),  833 
Neurosyphilis,  Modern  Systematic  Diagnosis 
and  Treatment  in  137  Case-histories  (Dr. 
E.  E.  Southard  and  Dr.  H.  C.  Solomon) 
(review),  301 

Newcastle  Medical  Institute  and  Social  Club, 

1098 

Newcsstle-on-Tyne  Royal  Victoria  Infirmary, 
address  by  Sir  E.  N.  Burnett.  362 
New  houses  for  old  (leading  article),  753 
New  Hunteriana,  269 


New  Inventions  — 

Anesthetics,  a nasal  air-way,  1030 
Apparatus,  new  “606,”  618 
Bed  for  fractures  and  general  hospital 
purposes,  266 

Buchner's  anaercbic  tube,  modified,  226 
“ Dropped-foot  ’’  appliance,  142,  284,  468 
Gland  dissector,  new  pattern,  858 
Nitrous-oxide-oxygen  ether  outfit,  226 
Pipette  for  automatically  measuring  out 
small  volumes  of  liquid,  1120 
Stretching  tables  for  flexed  thigh  stumps 
after  amputation,  984 
Suture  holder,  772 
Urethral  nozzle,  514 

Newlin,  Maj.  G.  E.t  future  o!  American  Red 
Cross  in  Paris,  155 

Newman,  Sir  G.,  appointed  Principal  Medical 
Officer  to  the  Local  Government  Board,  305  ; 
status  of  (Py  Q),  918 
New  Year  honours  deferred,  755 
New  Year's  wish  (leading  article),  25 


New  York,  Correspondence  from  — Recru- 
descence of  influenza ; New  narcotic  drug 
law  for  New  Y’ork  State,  353— Prohibition  in 
the  United  States ; Prohibition  regulations 
for  New  York,  354— Prohibition  and  the 
medical  profession,  523— Diphtheria  in  New 
York  City;  Sir  A.  Pearson  in  New  York; 
Health  Insurance  Bill  and  the  medical  pro- 
fession of  New  York  State.  524— International 
Conference  on  Rehabilhation  of  the  Disabled, 
761;  Hospitals  for  disable!  men;  National 
campaign  against  influenza;  Drug  situation 
in  New  York,  813 -In  aid  of  the  tuberculous 
poor;  Medical  and  surgical  developments  of 
the  war,  814 — Health  of  the  Navy  and  Marine 
Corps;  National  investigation, of  the  drug 
habit;  Health  report  of  New  York;  Dia- 
gnostic Hospital,  New  York ; Venereal 
disease  and  crime ; Death  of  a well-known 
war  nurse;  Prevention  of  typhoid  fever,  959 
— Drug  addiction  in  the  United  States; 
Opposition  to  compulsory  health  insurance, 
1090— Visit  of  foreign  medical  men  to 
America ; Bill  to  restrict  vivisection,  1091 

Nias,  Dr.  J.  B.,  obituary,  396 

Nicholls,  Mr.  F.  L.,  born  in  a well,  364 

Nitch,  Mr.  C.  A.  H.,  and  Prof.  S.  G.  Shattock, 
diffuse  emphysema  of  wall  of  small  intestine, 
263 ; the  late  Dr.  Guy  Black,  1093 

Nitrous-oxide-oxygen  ethtr  outfit,  225,  231 

Noble,  Dr.  T.  P , and  Dr.  A.  B.  Vine,  peri- 
cardiotomy, 107 

Noel,  Mr.  H.  L.  C.,  encephalitis  letha'gica  and 
typhus,  156 

Norbury,  Mr.  F.  G.,  and  Mr.  E.  D.  Te  ford, 
repair  of  the  male  urethra,  177 

Norman,  Sir  W.,  recent  retirement  of,  992 

North  of  England  Obstetrical  and  Gynaeco- 
logical Society  (see  Medical  Societies) 

Notes  and  Short  Comments.— Hospitalsand 
dispensaries  in  India,  1917-18;  Treatment  of 
scurvy;  Nasal  douche,  50 — Colonial  health 
reports,  50,  89,  202,  242.  324.  488,591.  644,  772, 
825,  1011,  1054 -Elec  roly  tie  disinfectant  in 
i .fluenza;  Oil  of  chenopodium  for  anky- 
lostomiasis; Health  teaching ; Metropolitan 
water-supply  during  July,  August,  and 
September,  1918,  90  ; during  October, 

November,  and  December,  1918,  363 — 

Duriug  January  February,  and  March,  1919, 
1098 — "Arellano”  influenza  mask;  Khaki 
monotony,  90  — Health,  medicine,  and 
sanitation  in  India,  127, 163— B srauth  orler; 
Lemon  juice  or  lime  juice.  128,  154— New 
methods  concerning  Imhotep  (Asclepio3); 
Use  of  creos  te  in  influenza,  128  —Health  and 
radiant  heat;  A warning,  164 —Industrial 
unrest  and  the  new  public  health  : Hygienic 
repair  of  the  roads,  202— Lessons  of  the 
influenzal  epidemic ; H ispital  for  Bognor, 
242— Physiology  and  the  food  problem.  233— 
Droppei-foot  appliance;  Health  and  allot- 
ments ; Queen  Mary's  Needlework  Guild ; 
Treatment  of  atenoi  Is,  234— Laws  of  life ; 
Treatment  of  adenoids ; Manchester  and 
District  Radium  Institute,  323— Infants’ 
tenacity  of  life,  .*24,  364—3  >ok3  of  refe  ence, 
324-  The  vital  need,  363— Born  in  a well,  364 
—Vital  need,  a third  factor;  Two  XVII. 
century  physicians,  495 -Summer  time; 
Total  deaths  from  wounds  in  the  great  war; 
Conference  on  influenza  and  its  prevention, 
4C6— Pictorial  symbolism  of  reproduction, 
446  -Physiology  aud  the  study  of  diseases; 
Sphagnum  moss  ; Osteo-arthritis.  447,  592- 
Mosquito  problem  in  Britain ; Factory 
medical  officer  in  war  and  peace,  447— Simple 
aid  in  reducing  pa  aphimos’s.  448— Raffaele 
Paolucci ; Cretan  library;  Osteo-arthritis; 
Life  and  health  in  the  Highlands,  488— 
Mothereraft  training  for  girls,  538— Cause 
or  coincidence;  Universal  language  of 
quantity ; Grain  pests  and  scientific 
accuracy,  539— Mortality  in  the  French 
Auxiliary  Army  Me  tical  Cot;  s ; Nerve  strain 
in  London  children,  549,  727— Saccharose 
injections  in  p iltnonarv  phthisis.  549- 
Need  for  a Food  Board,  591— Safety  of  picric- 
brass  preparations ; The  i b i ■ as  an  impedi- 
ment ; Carriage  of  perishable  foods ; New 
designs  in  surgical  tppUa.  . Wanted,  a 
bungalow,  592— Infant  mortality  and  hous- 
ing, 643 -Practical  war  memorial ; Lea  3 line 
on  tailors'  gums,  a dang  -rons  practice  : The 
child  as  an  inducement;  Health  and  life  inthe 
tropics;  Dry  sweeping  in  railway  carrisges, 
644 — Composition  of  potatoes,  727 — Electrical 
training  for  disabled  men ; National  League 
for  Health,  Maternity,  and  Child  Welfare, 
728— Acetone,  alcohol,  and  benzene  in  the  air 
of  certain  factories;  Suture  holder;  Queen 
Alexandra's  Hospital  for  Officers,  772— Spirit 
duty  (voluntary  hospitals)  grant  ; A tensor; 
Public  house  reform  ; Saccharose  injections 
in  pulmonary  phthisis;  Care  of  books  in 


The  Lancet,]  INDEX  TO  VOLUME  I.,  1919.  [July  5,  1919  xv 


large  libraries,  823— Larrey  and  war  surgery 
(I)r.  \V.  G Spencer),  867,  920,  962— Nee  l for 
physical  education,  867 — New  pattern  gland 
dissector;  Blind  men  on  committees; 
Claxton  ear-c.p;  Imperial  Antarctic  lSxpedl 
tion ; Wanted,  a homo;  New  reflex,  868- 
Social  medicine  in  Vienna;  Royal  St.  Anne's 
School,  Kedhlll ; In  lieu  of  a limb,  921  — 
Epidemiology  of  "Spanish  disease,"  trans- 
mission of  infection  through  ileas  ; Ventila- 
tion in  the  tropics;  Method  of  ob'.ai  .ing  a 
good  surface  on  microscopic  slides ; 
Children’s  Convalescent  Home,  Weston- 
super-Mare;  Toothless  mother;  Smallhold- 
ings and  the  returned  soldier,  922— Model 
Homes  Exhib'tion  ; Children  of  devastated 
Serbia;  Freak  of  Nature,  963— Society  for 
Relief  of  Widows  and  Orphans  of  Medical 
Men;  Case  of  a blind  subject;  Interesting 
experiment  in  rearing  of  calves  on  whey  and 
meals;  Supply  of  drugs,  964— Some  pitfalls 
of  general  practice  (Dr.  H.  M.  McCrea), 
1010,  1053— Medical  students  in  Switzerland  ; 
Ivory  Cross;  Malay  States  health  reports, 
1011— Roman  oculist  seals;  Guardianship 
So-iety  ; A correction,  1012— Medicinal  herb- 
growing  ; Typhus  in  Europi;  Goat  as  a 
milk  supplier;  Enham  Village  Centre, 
1053 — La  Perdita  Sanitaria  ; Fresh  Air  Fund ; 
Spare  time  service  of  the  R.A.M.O.,  1054- 
How  to  start,  and  how  to  succeed,  in  general 
practice  (Dr.  G.  Steele- Perkins),  1097- 
Medical  institute  and  social  club  for  New- 
castle; Prize-giving  at  the  London  School  of 
Medicine  for  Women  ; Pepys  on  blood  trans- 
fusion, 1098 -Cornish  centenarian,  1098 

Notice,  brought  to  (see  Notice  under  War  and 
After) 

Notification  fees  and  the  Association  of  Panel 
Committees,  439  ; of  venereal  diseases  (Py  Q), 
685 ; of  dysentery,  723 

Nurses,  hospital,  accommodation  for  (Pj-  Q), 
770 ; Scottish,  resettlement  of,  812 ; war 
gratuities  to  (Py  Q),  1008 ; in  South  Africa, 
bonus  to,  1026;  Nurses’  Registration  Bill, 
484,  587,  640,  635,  819,  957 ; Cooperation, 
meeting.  535  ; war,  resettlement  of,  1090 

Nursing  Register,  the,  474,528;  associations, 
district,  aud  public  health  (Py  Q),  686; 
service,  inadequacy  of  (Py  Q),  821 

Nursing  sisters  as  anaesthetists,  584 

Nutrition.  Elements  of  the  Science  of  (Prof. 
G,  Lusk),  third  edition  (review),  745 

Nystagmus  caused  by  mustard  gas  (Mr.  R.  P. 
(Ratnaker),  423 


O 


Oatmeal  and  influenza  (Py  Q),  443 
Obituary— 

Alexander,  William,  MD.R.U.I.,  F.R.C.S- 
Eng..  530 

Bennett,  Lawrence  Henry, M. A.,  M.B  Oxon., 
M.R.C.S.  Eng.,  125 

Benson,  Charles  M.,  M.D.  Dub.,  F.R.C.S. 
Irel.,  858 

Blakeway,  Harry,  B.Sc.,  M.S.  Lend., 
F.R.C.S.  Eng.,  858 
Blanchard,  Prof.,  315 

Booth,  James  Mackenzie,  M.A.,  M.D., 
C.M  Aberd.,  860 

Brigstocke,  Richard  Whish,  'M.R.C.S.  Eng., 

L. M.,  L.S.A.,  437 

Brodie,  George  Bernard,  M.D.  St.  And., 
F.R.C.P.  Lond.,  1042 

Buzzard,  Thomas,  M.D.  Lond.,  F.R.C.P. 
Lond.,  82 

Coekin,  Reginald  Percy,  M.D.  Cantab.,  83 
Coldstream,  Alexander  Robert,  M.D.Edin., 
F.R.C.S.  Ivlin  , 530 

Cunliff  -,  Frnest  Nicholson,  M.D.  Manch., 

M. B  . B.S.Lond.,  M.R.C.P.,634 

Dalby,  »’’>r  William  Bartlett,  M.A.  Cantab., 
F.R.C.S.  Eng.,  83 

Davidson,  Sir  James  Mackenzie,  M.B., 
C.M.  Ab'rd  , 633 

Drake-Bro  il  m u: , Edward  Forster,  F.R.C.S. 
Eng.,  860,  953 

Drew,  Clifford  Luxmore,  M.B  , C.M.  Aberd 
993 

Ellis,  William  Ashton,  M.R.C.S.  Eng  ,125 
Gibson,  Howard  Graeme,  M.R.C.S.  Eng.,  395 
Goring,  Charles  Buckmin,  M.D.,  B.Sc. 
Lond.,  914 

Guthrie,  Leonard  George,  M.D.,  B.Ch. 

Oxon.,  F.R.C.P.  Loud.,  44 
Hartley,  Arthur  Conning,  M.D.,  F.R.C.S. 
Bdin  , 437 

Hartlev,  Edmund  Baron,  C.M.G  , V.C., 
M R.C.S.,  633 

Hawes,  Colin  Sadler,  M.R.C.S.  Eng.,  45 
Jaffrey,  Francis,  F.R.C.S.  Eng.,  953 
Lea,  Charles  Edgar,  M.D.  Manch.,  M.ll.C.P. 
Lond.,  953 


Leftwicb,  Ralph  Winnington,  M.D.,  C M. 
Aberd.,  58 ) 

Livcing,  Edward,  M.D.  Camb.,  F.R.C.P. 
Lond..  M.R.C.S.,  633 

Maonamara,  Nottidge  Charles,  F.R.C.S. 

Eng.,  F.R.C.S.  Lei. , 43 
Maroden.  Robert  Sydney,  M.B.,  C.M  Etin., 
D.Sc.,  F.R.S.E  , 530 

Nias,  Joseph  Baldwin,  M.D.  Oxon.,  M.ll.C.P. 
Lond.,  396 

Ogilvie,  George,  M B.,  C.M.,  B.Sc.  E 1 i n . , 
F.li.C  P.  Lond.,  44 

Paterson,  Andrew  Melville,  M.D.  Eiin., 
F.lt.C.S.  Eng.,  314 

Rouquette,  Stewart  Henry,  M.A.,  M.B, 
M.Ch  Cantab.,  F.R.C.S.  Eng.,  579 
Sawyer,  Sir  J..  M.D.,  F.R.C.P.  Lond., 

F.It.S.  Edin.,  239 

Smith,  Frederick  John,  M D.  Oxon., 
F.R.C.P.  Lond.,  F.R  C S.  Eng.,  860 
S’ urge.  William  Allen,  M.V.O.,  M.D., 
F.R.C.P.  Lend.,  633 

Wiglesworth,  Joseph,  M.D.,  F.R.C.P.  Lond., 
1042 


Obituary  of  the  War— 

Ail  ken,  Capt.  R..  R.A.M.C.,  275 
Allen,  Capt.  W.  R.,  lt.A.M.C.,  486 
Bailey,  Capt.  J.  C.  M.,  R.A.M.O.,  O.B.E., 
722 

Bassett,  Lieut.  R.  J , R.A.M  C.,  581 
Begg.  Col.  C.  M..C.B.,  C.M.G  , N.  Z.  M.C., 
315,  531 

Bingham,  Capt.  J,  W.,  R.A.M.C.,  530 
Brown,  Capt.  W.  S.,  lt.A.M.C.,  581 
Browne.  Capt.  W.  S.,  lt.A.M.C..  683 
Campbell,  Capt.  J.,  lt.A.M.C..  912 
Chenoy,  Capt.  F.  B.,  I.M  S.,  398 
Chowdlniry,  Capt,  H.  C R„  I.M.S..  486 
Cocks.  Capt,  J.  S„  R.A.M.O.,  275,  439 
Cotterill,  Capt.  D.,  R.A.M.C.,  42 
Cowper,  Temp.  Surg.  W.  P.,  R.N.,  275, 
439 

Crombie,  Lieut.  W.  M.,  I.M  S.,  358 
Cunl  ffe,  Maj.  E.  N.,  R.A.M. C.,  652 
Duffy,  Capt,  J.  V.,  R.A.M.C.,  194 
Dwyer,  Capt,  J.  J.,  D.S.O.,  R.A.M.C.,  358 
Evatt,  Capt.  J.  M.,  R.A.M  C.,1091 
FedOib.,  Surg.-Cmdr.  F..R.N..1091 
Fisher,  Surg.  Lieut,  E.  G.,  R.N..  1046 
Gibson,  Maj.  H.  G.,  R.A.M  C.  315 
Griffith.  Maj.  H.  H.,  Austr.  A.M.C.,  530 
Haim,  Capt.  C.  C.,  Austr.  A.M.C.,  768 
Henley,  Capt.  E.  A.  W.,  N.  Z M.C..275 
Hobbs,  Surg.  Lieut.  It.  A.,  R.N..  398,  530 
Hojel,  Lieut.  Col.  J.  G.,  C.I.E.,  I.M.S.,  683 
Jluet,  Lieut,  F.  P.  Y.,  Austr.  A M.C.,  438 
Jameson,  Maj.  D.  D.,  M.C.,  Austr.  A.M.C., 
43 

Jones,  Surg.  Lieut.  M.  E.,  R.N..  315 
Keith,  Capt.  G.  B.,  R.A.M. C.,  122 
Keogh,  Surg.  Com.  J.  A.,  R.N.,  275 
Lawrence,  Capt,  H.  R.,  M.C.,  S.  Afr.  M.C., 
41,  194 

Lemarchand,  Surg.  Sub  Lieut.  F.  W., 
R.N.V.R,  398 

Lister,  Capt.  C.  R.,  M.O.,  Austr.  A.M.C., 
195 

Logie,  Capt.  A.  G.  S.,  R.A.M. C„  275 
Luett,  Lieut.  F.  P.  M.,  Austr.  A.M.C.,  315 
I uton,  Capt.  W.  F.,  Can.  A.M.C.,  85, 194 
McEntire,  Lieut. -Col.  J.  T.,  Mons  Star, 
R.A.M.C.,  122 

Mackinnon,  Capt.  F.  I.,  R A.M.C.,  85 
Magoveny,  Capt,  J.  H.,  R.A.M  C.,952 
Martin,  Capt.  J.  S.,  R.A.M.C.,  84 
Matthews,  Capt.  S.  W„  R A.M.C.,  238 
Melville,  Col.  H.  G.,  I.M.S.,  194 
Metcalfe,  Capt,  G.  C.,  R.A.M.C.,  580 
Morison,  Capt,  R.  MeK.,  R.A.M.C.,  952 
Murray,  Capt.  R.  W.  S.,  R.A.M.C.,  952 
O’Keefe,  Capt.  W.  R.,  R.A.M. C„  194 
Parsons-Smith,  Capt,  E.  M.,  R.A.M.C.,  1046 
Perrin.  Maj.  M.  N.,  R.A.F.  Med.  Serv.,  768 
Philson,  C J.  S.C.,  A.M.S.,  438 
Pickthal,  Surg.  J.  M.,  R.w..  84 
Prvce,  Capt.  A.  M.,  R.A.M.C.,  398 
Robinson,  Maj.  H.  H,  M.C.  with  bar,  859 
Sharma,  Lieut.  J.  K.,  I.M.S.,  952 
Spurrell,  Capt.  H.  G.  F,  lt.A.M.C..  43 
Sturdy,  Capt,  A.  C.,  M.C.,  R.A.M.C.,  859, 
999 

Taylor,  Maj.  F.  M.,  R.A.M. C.,  952 
Whitworth,  Capt,  H.  P.,  R.A.M.C.,  122 
Whyte,  Capt,  G.  T.,  R.A. M.C. , 1091 
Wilson,  Cap’.  W.  C.  D.,  R.A.  M.C. , 486.  722 
Young,  Capt.  R.  P.,  Austr.  A.M.C.,  238 

Obstetric  helper,  797 

Obstetrics  aud  gynaecology,  teaching  of,  to 
medical  students,  discussion,  258 
Occupational  fractures,  349 
Odes  and  Other  Poems  (Dr.  R.  C.  Macfie) 
(review),  1119 

(Esophagus,  malignant  stricture  of,  300 

Ogilvie,  Dr.  G.,  obituary,  44 

Oil  of  chenopodium  in  ankylostomiasis,  90 


Oils  and  Fats,  Edible  (Mr.  C.  A.  Mitchell) 
(review),  848  ; Fats,  and  Waxen  Technical 
Hanibook  (Mr.  P.  J.  Fry  er  and  Mr.  F.  E. 
Weston  (review),  897 

O’Keeffe,  Capt.  W.  R.,  R.A. M.C.  (see  Obituary 
of  the  war; 

O’Malley,  Mr.  J.  F.,  circumscribed  laby- 
rinthitis, 893 
Omnopon,  384 
one-eyed  man,  the,  1085 

Onslow,  Mr.  II.,  origin  of  life,  work  of  the  late 
Clia  Iton  Baxtian,  1C01 

Ontario  Medical  Association,  address  In 
medicine,  1132 

Operations,  500  consecutive,  at  Mercer’s  Hos- 
pital, 265;  nerve  and  muscle  during,  faradic 
stimulation  of  (Mr.  H.  Plitt  and  Mr.  E.  S. 
Brentnall),  884 

Ophthalmia  neonatorum,  notification  of,  948 
Ophthalmic  cases,  8670,  analysis  oi.  473; 
operations,  anesthesia  for  (Sir.  C.  T.  W. 
Hirsch),  1C68 

Ophthalmic  practice,  psnel  (Dr.  A.  F.  Fergus), 
758 

Ophthalmitis,  sympathetic,  with  fundus 
changes,  300 

Ophthalmological  Society  of  the  United  King- 
dom, Congress  (see  Medical  Societies 
Ophthalmology,  education  in,  report,  578 
Ophthalmology,  Medical  (Dr.  A.  Knapp) 
(review),  23 

Ophthalmoscope,  familiarity  with,  232 
Opium  Convention  of  1912  (Py  Q),  443,  726 
Optic  nerve,  evulsion  of,  895 
Op  ical  Goo  Is  Industry,  Employment  Oppor- 
tunities tor  Handicapped  Men  (Mr.  B.  J. 
Morris)  (review),  982 

Orbit  aud  accessory  sinuses,  injuries  and 
diseases  of,  614,  699 

Orbital  region,  plastic  operation  on,  894 
Organic  Chemistry,  Recent  Advances  in  (Mr. 
A.  W.  Stewart),  third  edition,  1918  (review), 
617 

Organs  of  Internal  Secretion,  their  Diseases 
and  Therapeutic  Application  (Dr.  I.  G.Cobh), 
second  edition,  19)8  (review),  111 
Ormond,  Maj.  A.  W.,  analysis  of  8670  oph- 
thalmic cases,  473 ; pituitary  tumour,  613 
Orrin,  Mr.  II.  C.,  fracture-dislocation  of 
astragalus,  20 

Orthopiedic  surgery,  physical  treatment  in 
relation  to,  671;  conference  in  Liverpool, 
1003 

Orthopiedic  Treatment  of  Gunshot  Injuries 
(Dr.  L.  Blayer)  (review),  23  ; Effects  of  Gun- 
shot Wounds  aud  their  After  Treatment 
(Dr.  S.  W.  Daw)  (review),  847 
Osier,  Sir  W.,  influenzal  pneumonia.  501 ; 
acute  pneumonic  tuberculosis,  615 ; re- 
stocking of  Louvain  Library,  1042;  presenta- 
tion to,  1128;  anniversary  book,  1138 
Osteo-arthritis  in  right  hip-joint,  447,  488,  592 
Osteomyelitis,  Traumatic,  Chronic,  its  Patho- 
logy and  Treatment  (Dr.  J.  R.  White) 
(review),  1074 
Osteopathy,  949 

Ostitis,  new  method  of  incision  of  tympanic 
membrane  for  (Mr.  R.  Lake),  977 
Otabe,  Dr.  S.,  Science  and  Art  of  Deep 
Breathing  (review),  467 
Otitis,  chronic  adhesive,  893 
“ Ourselves  only,”  858,  9!3,  951 
Outlook  of  the  medical  practitioner  (leading 
article),  145 

Outlook,  the  (leading  article),  1121 

Out-of-school  employment,  907 

Ovarian  eyst,  spontaneous  rupture  (Dr.  D.  N. 

Kalyanvala),  423 
Ovary,  endothelioma  of,  264 
Overy,  Dr.  H.  B.,  causes  and  incidence  of 
dental  caries,  47 

Owen,  Dr.  S.  A.,  and  Dr.  P.  A Leighton, 
medullary  symptom-complex,  1024,  1037 
Oxford  Ophthalmological  Congress,  443,  1135 
Oxygen  in  anaesthesia,  air  for  (Dr.  J.  H. 
Fryer),  216 


P 

Page,  Mr.  C.  M.,  Medical  Field  Sen  ice  Book 
(review),  383 

Paine,  Dr.  S.  G.,  origin  of  life,  work  of  the 
late  Charlton  BastiaD,  1092 

Paisseau,  G.,  malaria  during  the  war,  749 

Palmar  fascia,  unusual  contracture  of  (Dr.  G. 
de  Swietochowski),  298 

Palmer,  Mr.  J.  F.,  hypothermia  in  influenza, 
398 

Pancreatitis  a cause  of  enteralgia  (Dr.  L. 
Brown),  876 

Panel  practice,  the  size  of  (Pv  Q),  403 ; oph- 
thalmic practice  (Dr.  A.  F.  Fergus),  758 

Panel  practitioners,  war  bonus  to  (Py  Q),  321, 
401,  405  ; releasing  (Py  Q),  403;  practitioners 
and  tuberculosis  officers,  895;  Committee, 
London,  meeting,  955 ; practitioners'  re- 
muneration (Py  Q),  959 


xvi  The  Lancet,] 


INDEX  TO  VOLUME  I.,  1919. 


[July  5, 1919 


Paolucci,  Raff aele  488 

Papailopoulos,  I)r.  S.  O.,  ectopic  gestation 
with  an  apparently  imperforate  hymen,  140 
Parrakh,  Dr.  F.  it.,  hamiatemesis  after  abdo- 
minal operation.  529 

Paralysis  agitans  and  the  c rpus  striatum,  77 
Paralysis,  general,  of  the  insane,  treatment 
(Dr.  H.  Campbell  and  Sir  C.  B.tllance),  608 ; 
ascending,  acute  (Dr.  II.  Sutherland),  841 
Pararnoro,  Dr.  It.  II.,  lower  uterine  segment 
and  uterine  tendons,  481 
Paraphimosis,  simple  aid  in  reducing,  448,  815 
Parasitic  mange  in  horses.  280 
Parasitology  (review).  426,  748 
Paratyphoid,  mineral  forms,  237;  new  germ 
(Dr.  L.  Ilirschfeld),  296 

Pardee,  Dr.  I.  II.,  pituitary  headaches  and 
their  cure,  664 

Paris  Academic  des  Sciences,  award  of  prizes, 
83 

P aris,  C o r r es  PQ nd  en c f f ro  M . — D i et  ki tch en s 
for  military  hospitals,  37— Medical  demobili- 
sation in  France;  Influenza  in  Prance; 
Maternal  and  infantile  protection  in  Paris 
during  the  war ; French  doctors  and  the 
excess  profit  s tax,  38— Bill  to  provide  treat- 
ment for  tuberculous  pat.ient.s  ; Compulsoiy 
notification  of  tuberculosis,  233  — Proposal  for 
a Central  Health  Department,  273— Hygiene 
and  the  Frenchmans  house  as  his  castle; 
Recrudescence  of  rabies  in  Paris,  274— Prof. 
Chantemesae,  death  of;  Phthisis  among 
coloured  troops  in  France;  Late  results  of 
gassing,  433— Protection  of  medical  practice 
in  France  ; Medical  demobilisation  ; French 
Orthopaedic  Society,  477— PYench  anti  small- 
pox campaign  during  the  war.  759 — Results 
of  fractures  treated  in  Germany;  Societe  de 
Therapeutique,  760— Compulsory  notification 
of  tuberculosis;  Rise  in  doctor’s  fees,  997  — 
Finger-prints  as  signatures;  Strabismus; 
Hatching  of  the  louse,  1132 

Parker,  Prof.  A.  K.,  Monographs  on  Experi- 
mental Biology,  the  Elementary  Nervous 
System  (review),  702 

Parkinson,  Dr.  J.,  left  sctpular  pain  and 
tenderness  in  heart  disease  and  distress,  550, 
575 

Parkinson,  Dr.  J.  P.,  aplastic  aniemia,  744; 

swelling  of  joints,  910 
Parliament,  medical  candidates  for,  35 

Parliamentary  Intelligence. 

Notes  on  Current  Topics . 

New  Parliamentary  Session  ; Ministry  of 
Health  Bill,  319,  359,  401,  442,482,  532,  586, 
1008— Evils  of  unqualified  dental  practice, 
359 — Medical  treatment  of  children  in 
Ireland.  401.  685— Nurses’  Registration  Bill, 
484,  640,  685— Housing  Bill,  484 — Scottish 
Board  of  Health  Bill  641,  1008 —Prevention 
of  Anthrax  Bill,  685— Pubhc  Health  (Medical 
Treatment  of  Children  (Ireland)  Bill,  685- 
Budget,  770  — Pension  administrations  and 
medical  boards,  770,  818 -Pensions  Com- 
mittee, 917 — Local  Government  (Ireland)  Bill. 
1008— Pensions  and  medical  assessment,  1137 

House  of  Lords. 

April  2nd.— Venereal  infection,  587 
April  15th.—  Shell-shock  patients;  Neur- 
asthenia and  shell -shock.  725 
April  29th.  — Public  Health  (Medical  Treat- 
ment of  Children)  (Ireland;  Bill,  770 
Mai/  1st. — Ministry  of  Health  Bill,  818- 
Medical  representation  in  the  House  of 
Lords;  Nurses’  Registration  Bill;  Medical 
treatment  of  children  in  Ireland,  819 
May  6th. — Scottish  Board  of  Health  Bill ; 
Medical  service  in  the  Highlands  and  Islands, 
819 — Scheme  for  development  of  medical 
service;  Public  Health  (Medical  Treatment 
of  Children)  (Ireland) Bill.  820 
May  8th.— Ministry  of  Health  Bill,  863 
May  15th.— Scottish  Board  of  Health  Bill, 
917 

May  16th.- -Medical  examination  of  dock- 
yard workmen  ; Rabies  treatment,  917 
May 20th.— Ministry  of  Health  Bill,  917 
May  22nd.— Ministry  of  Health  Bill,  957 
May  27th.— Nurses'  Registration  Bill; 
Scottish  Board  of  Health  Bill,  957 

House  of  Commons. 

Medicine  in  the  House  of  Commons,  320 
Feb.  13th. — Artificial  limbs;  After-care  of 
tuberculous  ex-service  men ; Ministry  of 
Health  ; Missing  officers  and  men,  320 
Feb.  l/,th.—  Tuberculous  ex-service  men, 
320 

Fib.  17th.— Irish  housing,  320— Ireland  and 
the  Ministry7  of  Health;  Artificial  limbs; 
War  bonus  to  panel  nractitioners;  Maternity 
and  child  welfare,  321 


Feb.  18th  —Demobilisation of  medical  men; 
Comoating  venereal  disease;  Combating  in- 
fluenza, 321 

Feb.  19lh  — Demobiliia'ion  of  medical  men, 
321— Ireland  and  the  Ministry  oi  Health  ; 
Rat  ies  in  Devon  and  Cornwall;  Medical 
treatment  of  discharged  soldiers  ; Accommo- 
dation for  the  mentally  deficient,  359 

Feb.  20th. — Supply  of  spirits;  Assistant 
medical  officers  or  asylums;  Influenza;  Glen 
Lo.nond  Sanatorium,  359 

Feb.  i'fih.  — Demobilisation  of  panel  practi- 
tioners, 359  — Infl  jenza;  Discharged  tuber- 
culous soldiers.  360 

Feb.  25th.  — Demobilisation  of  medical  men ; 
medical  men  and  income-tax  ; Spirits  for 
medical  use,  360 

Feb.  26th.—  Ministry  of  Health  Bill  (second 
reading),  360— S-parate  Bill  for  Scotland,  361 
— Industrial  Fatigue  Research  Board;  Grants 
to  panel  practi  oners,  401 
Feb  27th. — Women  and  methylated  spirits; 
Patent  med  ciues ; Infiueoza;  Influenza 
pa  ients  in  the  Army;  Discharged  tuber- 
culous soldiers;  London  County  Mental 
Hospitals,  431— Medical  women  and  the  War 
Office;  Promotion  in  the  K.A.M.C.  ; Medical 
officers  in  Army  of  Occupation;  K.A.M.C. 
officers  and  Government  employment;  Rabies 
in  Cornwall  and  Devon.  402 

March  3rd. — Spirits  for  medicinal  uses ; 
Medical  In* pectors  of  Home  Office;  Medical 
women  and  War  Office  employment ; Dental 
surgeons  and  the  Army  gratuity,  402 

March  Uth.—G\en  Lomond  Sanatorium ; 
Medical  inspection  in  factories ; Broncho- 
pneumonia in  the  A.rrny,  402  — Medical  men 
in  military  service  ; Releasing  panel  practi- 
tioners ; Insurance  practice  ; Bonus  to 
panel  practitioners  ; Size  of  panel  practices, 
403 

March  5th.— Women  medical  officers  in 
milit  try  hospitals  ; Physicians’ and  surgeons’ 
voluntary  war  service,  442 
March' 6th.— Lunatic  asylum  discharges; 
Tuberculous  and  shell-shock  cases.  442 
March  10th. -Grants  for  medical  referees; 
Salaries  of  Irish  Poor-law  medical  officers; 
Ministry  of  Health  for  Ireland;  Whisky  for 
medical  purposes;  Qualification  of  apothe- 
caries’ assistants;  Infiuenz*  and  cholera  in 
Bombay,  442  — Oatmeal  and  influenza; 
Opium,  Convention  of  1912,  443 
March  llth  —Demobilisation  of  doctors  and 
nurses;  Institutions  for  mental  defectives, 
443 

March  12th. — Vaccination  ; Small  pox,  484 
March  13th.—  Lymph  for  public  vaccina- 
tion 484  — Salvarsan  substitutes,  485 
March  ISth.— Outbreak  of  cerebro-spinal 
fever ; Demobilisation  of  medical  officers, 
485 

March  19th.  — Gratuities  to  temporary 
naval  medical  officers ; Ministry  of  Health 
for  Egypt.  485 

March  20th. — Port  hospital  accommoda- 
tion, 534 

March  2hfh.— Venereal  diseases;  Medical 
Treatment  of  Children  (Ireland)  Bill,  534 
March  25th. — Demobilisation  of  medical 
men,  535 

March  26th. — Ministry  of  Health  and 
liquor  control ; Clinical  thermometer  tests ; 
Physicians’  and  surgeons’  war  service,  587 
March  27th.— Physical  training  in  schools, 
587 

March  28th.— Nurses’  Registration  Bill,  587 
April  1st.— Tuberculous  officers  ; Scottish 
Board  of  Health  Bill,  588 
April  2nd.— Medical  treatment  of  demobil- 
ised men  ; Closing  the  smaller  military  hos- 
pitals, 640-Butter  for  invalids;  Government 
control  of  hospitals,  641 
April  3rd. — Pressure  on  civilian  hospitals  ; 
Egyptian  Fellaheen  Medical  Service;  Con- 
sumptives in  the  Army,  641 
April  7th.— Medical  inspection  of  school 
children  in  Ireland,  641 
April  Slh. — Demobilisation  of  medical 
officers;  Army  huts  for  tuberculous 
patients,  641 

April  9th. — Ministry  of  Hevlth  Bill,  641 
April  10th. — Salaries  of  health  visitors; 
Notification  of  venereal  disease,  685;  Release 
of  temporarj'  medical  officers  ; Treatment  of 
pauper  lunatics;  District  nursing  associa- 
tions and  public  health.  686 
April  16th.— Tetanus  among  British  troops, 
725  — International  Opium  Convention, 726 
April  30th.— Accommodation  for  hospital 
nurses.  770 

May  1st. — Vivisection  of  dogs;  Insurance 
Act  medical  benefit;  Medical  men  on  dis- 
persal boards  ; Port  sanitary  authorities  and 
hospital  accommodation  for  infectious  cises ; 
Hospital  accommodation  at  West  Ham ; 
Surgical  appliances  for  disabled  soldiers, 
820 — Release  of  Fazakerley  Hospital,  821 


M a y 2nd.— Animals  (Anaesthetic)  Bill ; Pre- 
vention of  anthrax. 821 

May  5th.  — Petrol  supplies,  821 
May  6th.—  Emigration  of  tuberculous 
soldiers;  Inadeq  iacy  of  the  nursing  per  vice; 
Pensions  and  the  medical  referee;  Insurance 
practitioners’  terms,  821 
May  7th.  -B  iiish-maie  morphia;  Sanitary 
officer  and  service  in  Russia,  864 
May  8th.  — Tuberculosis  treatment  in 
London  ; Surplus  army  medical  equipment ; 
Shall  shock  treatment;  Venereal  disease; 
Pure  milk-supply,  864 
May  12th.— Prevention  of  Anthrax  Bill ; 
Physical  unfitness  of  the  nttiun;  Spirits  in 
cases  of  illness;  Healtn  Council  for  Wales; 
Hospital  accommodation  for  civil  neels; 
Hospital  treatment  for  soldiers,  sailors,  and 
pensioners,  865 

May  Status  of  Sir  George  Newman, 

918 

May  15th. — Antirabic  treatment ; Powers 
of  biards  of  guardians,  918 

May  19th. — Red  Cross  nurses  and  war 
gratuities;  Demobilisation  of  field  ambu- 
lance officers;  Vaccine  lymph;  Remelies 
lor  venereal  disease ; Scottish  parochial 
medical  officers,  918 

May  20ih— Territorial  medical  officers  and 
demobilisation;  Medical  boards  and  dis- 
ability assessments,  918 
May  21st.— Shortage  of  medicine  bottles, 
957 

May  22nd.— Midwives  and  burial  certi- 
ficates 959 

May  23rd.—  Digs’  Protection  Bill,  957; 
Panel  practitioners’  remuneration,  959 
May  26th — Ministry  of  Health  Bill,  959 
May  27th.  — Belief  of  meiical  officers 
abroad  ; Prevention  of  Anthrax  Bill,  959 
May  28th.- Medical  Service  Bill,  959; 
Demobilisation  of  Territorial  medical  officers, 
969 

June  2nd.— Ministry  of  Health  Bill ; 
Scottish  Board  of  Health  Bill ; Pool  for 
insurance  practitioners;  War  gratuities  to 
nurses ; Piague  in  Central  and  Ea.tem 
Europe,  1008 

June  3rd.—  Hedical  officer  to  the  Board  of 
Customs,  1009 

June  ith.— Income  limit  under  the  Insur- 
ance Act;  Services  of  medical  m-n  in  the 
war;  Venereal  diseases  among  the  troops; 
Medical  supplies  of  brandy  and  whisky,  1050 
June  51  A.— Vaccination  prosecutions  in 
Wexford  ; Treatment  of  the  blind  in 
Ireland,  1051 

June  ,?/.f  ft.— Tuberculosis  in  the  Navy; 
Medical  assessment  of  disability,  1137 

Parliamentary  Committee,  Medical,  190 ; 
dinner  to  medical  members,  281 ; arrange- 
ment of  conference,  634,  705.  808,  817,  853 ; 
progress  of  (leading  articlej,  801 

Parmelee,  Mr.  M.,  Criminology  (review),  932 

Parnell,  Ideut.-Cmdr.  8.  J.  G.,  and  Lieut.- 
Cmdr.  P.  Fildes,  Wassermann  reaction, 
807 

Parotid,  fistula  of  (Mr.  P.  P.  Cole),  971 

Paroxysmal  tachycardia,  treatment  by  respira- 
tory effort,  853 

Parry,  Judge,  and  Lieut.-Col.  Sir  A.  E. 
Codrington,  War  Pensions,  Past  and  Present 
(review),  799 

Parsons-Smith,  Capt.  E.  M.,  B.A.M.C.  (see 
Obituary  of  the  war) 

Parsons-Smith,  Dr.  B.,  fitness  and  unfiiness  in 
convalescence,  509 

Parthenogenesis  in  vertebrates  (leaiing 
article),  1033 

Partridge,  Mr.  W.,  and  Mr.  C.  G.  Moor,  Aids 
to  the  Aualysis  of  Foods  and  Drugs,  fourth 
edition,  1918  (review),  818 

Pass-lists  : Apothecaries  Society  of  London, 
48,  584— Dublin  University,  Trinity  College, 
School  of  Phasic,  48,  639-Aherdeen 
University,  87,  584  -Liverpool  University, 
126,  536— Boyal  College  of  Physicians  of 
Edinburgh,  Boyal  College  of  Surgeons  of 
Edinburgh,  and  Boyal  Faculty  of  Physicians 
and  Surgeons  of  Glasgow,  199,  768— Boyal 
College  of  Surgeons  of  Edinburgh,  5:6.  955— 
Examining  Board  in  England  by  the  Boyal 
Colleges  of  Physicians  of  L v.don  and 
Surgeons  of  England,  239,  639.  724  —Boyal 
College  of  Physicians  of  London,  239,  763— 
Boyal  Colleges  ot  Physicians  of  London  and 
Surgeons  of  England,  862— Boyal  College  of 
Surgeons  of  England,  862,  914,  1094— Cam- 
bridge University,  724— Bristol  University, 
318— Manchester  University,  536— Durham 
University.  Faculty  of  Medicine,  584,  639  — 
Glasgow  ~ University,  639,  725  — London 

School  of  Tropical  Medicine,  639— London 
University,  687,  1003,  1051— St.  Andrews 
University,  1137 

Pasteur.  Dr.  W.,  epidemic  perineph  ic  sup- 
puration, 1092 


The  Lancet,] 


INDEX  TO  VOLUME  I.,  1919. 


[July  5,  1919  Xvii 


Pasteur- Vallery-lladot,  Thesis  on  Studies  on 
ltonal  Function  in  Chronic  Nephritis 
(reviewed  hy  Prof.  C.  Aohard),  752 
Patent  Modiolnes  (I’y  Q),  401 
Paterson,  Mr.  1 1 . J.,  Queen  Alexandra’s 
Hospital  for  Otlioors,  772 
Paterson,  Prof.  A.  M.,  obituary,  314  ; Anatomy 
of  tho  Peripheral  Norves  (review),  1074 
Pathology,  relation  of,  to  clinical  medicine, 
300 

Paton,  Dr.  It.,  pseudo- paratyphoid  fever,  1071 
Patou,  Mr.  L.,and  Mr.  T.  Collins,  angioma  of 
tho  choroid,  895 

Patrick,  Dr.  A.,  Staphylococcus  aureus 
septicaemia  in  influenza,  137 
Paul,  Mr.  N.,  persistent  pigmentation  due  to 
antipyrin,  1036 

Pauper  lunatics,  treatment  of  (Py  Q),  686 
Pearce,  Dr.  It.  (1 . . and  Professor  J.  J.  It. 
Macleod,  Physiology  and  Biochemistry  in 
Modern  Medicine  (review),  513 
Pcarse,  Dr.  J.,  personal  retrospect  of  general 
practice,  129 

Pearson,  Dr.  M.  GL,  bed  for  fractures  and 
general  hospital  purposes,  266 
Pearson,  Sir  A.,  in  New  York,  524 
Pectoralis  major  muscle,  left,  and  left 
mammary  gland, congenital  absence  of  lower 
portion,  565 

Pecuniary  position  of  hospital  oflicers  (leading 
article),  573 

Pedley,  Mr.  It.  D.,  causes  and  incidence  of 
dental  caries,  80,  155 

Pelvic-femur  splint  and  arm  splint  (Dr.  J.  E. 
Lee),  103 

Pelvic  sarcoma  (Mr.  J.  H.  Hart),  378 
Pembrey,  Dr.  M.  S.,  physical  training  of  the 
open-air  life.  323 

Pennefather,  Dr.  C.  M.,  and  Dr.  J.  Campbell, 
blood  supply  of  muscles,  294 
Pennington,  Dr.  D.,  and  Mr.  J.  P.  Lockhart- 
Mummery,  adhesions  of  the  sigmoid,  254 
Pension  administration  and  medical  boards. 
770 

Pensioners,  admission  to  civil  hospitals,  dis- 
cussion, 179 ; (leading  article),  186 
Pensions  and  the  Principles  of  their  Evalua- 
tion (Dr.  L.  J.  Llewellyn  and  Dr.  A.  B 
Jones)  (review),  799 ; War,  Past  and  Present 
(Judge  Parry  and  Lieut.-Col.  Sir  A.  E. 
Codrington)  (review),  799;  and  medical 
boards,  818 ; and  the  medical  referee  (Py  Q), 
821;  Committee,  917;  and  medical  assess- 
ment. 1137 

Pensions  to  Canadian  soldiers,  232 ; widows’ 
in  the  Navy,  724 

Pepys  on  blood  transfusion,  1098 
Perforating  wound  of  the  heart  (Mai  F C 
Pybus),  1026  J 

Perforation  in  cancer  of  the  stomach,  272 
Pericardial  sac,  recurring  effusion  into  (Dr. 

H.  B.  Roderick  and  Dr.  S.  W.  Curl),  980 
Pericardiotomy  (Dr.  T.  P.  Noble  and  Dr.  A.  B 
Vine),  107 

Perinephric  suppuration,  epidemic,  1001,  1044, 

Peripheral  Nerves,  Anatomy  of  (Prof.  A.  M. 

Paterson)  (review),  1074 
Peritonsillar  abscess  (Dr.  A.  Wylie),  178 
Perol,  M.  Pierre,  and  Prof.  A.  Zimmern, 
Electro-Diagnosis  in  War  (review),  468 
Perrin,  Major  M.  N„  E.A.F.  Med.  Serv.  (see 
Obituary  of  the  war) 

Perrin,  M..  and  G.  Richard,  rupture  of  cardiac 
i valves  due  to  an  explosion,  231 
'Perry,  Henry,  the  case  of,  1041 
Petrol  supplies  (Py  Q),  821 
Petroleum  jellies  ( ‘ Semprolia”  brand),  898 
Pettit,  Auguste,  and  Louis  Martin,  Spiro- 
chetose  Icterohemorragique  (review),  800 
Petty,  Dr.  M.  J.,  hot  liquids  and  cancer,  583 
’harmacology  and  Therapeutics,  Text-book 
(Dr.  A.  It.  Cushny),  seventh  edition,  1918 
(review),  22 

‘ Phases  in  the  Life  and  Work  of  John 
Hunter  ” (Prof.  A.  Keith),  269 
’Dilip,  Sir  R.  W.,  and  Mr.  R.  McK.  Johnston, 
position  of  the  demobilised  practitioner,  4i9 
’hillips,  Mr.  J.,  the  buried  sequestrum,  a 
post-war  problem,  291 

’hilson,  Col.  S,  C.,  A.M.S.  (see  Obituary  of 
the  war) 

'hthisis  in  factory  and  workshop,  15S  ; »mon» 
coloured  troops  in  France,  433  ; pulmonary” 
saccharose  injections  in,  636  ; hilus,  mixed 
infection  in,  1128 

'hysical  and  Occupational  Re-education  of  the 
Maimed  (Dr.  J.  Camus  and  others)  (review), 

183 

'hysical  efficiency,  some  simple  tests  (Dr  M 
Flack),  210 

'hysical  training  in  schools  (Py  Q),  587; 
treatment  in  relation  to  orthopeedic  surgery, 

hysical  training  of  the  open-air  life  (Dr.  M S. 
Pembrey),  323 

hysical  unfitness  of  the  nation  (Py  Q),  865- 
education,  need  for,  867 


Physicians’  and  surgeons’  voluntary  war 
sorvice  (Py  Q),  442,  587 
Physicians,  two  XVII.  century,  405 
Physics  of  shock,  269 

Physiological  Chemistry,  Practical  (Prof.  P.  B. 

Hawk),  sixth  edition,  1919  (review),  983 
Physiological  Feeding  of  Children  (Dr,  E. 

Pritchard)  (review),  1028 
Physiology  and  the  food  problem,  283 
Physiology  for  Medical  Students  and  Phy- 
sicians (Prof.  W.  H.  Howell),  seventh 
odltion,  1918  (review),  984 
Physiology  of  Industrial  Organisation  (Prof.  J. 
Amar)  (review),  265;  and  the  study  of 
diseases,  447  ; and  Biochemistry  in  Modern 
Medicine  (Prof.  J.  J.  R.  Macleod  and 
Dr.  R.  G.  Pearce)  (reviowl,  513;  (Traitd  de 
Phj siologie)  (Prof.  J.  P.  Morat)  (review),  702 
Picric-brass  preparations  in  the  treatment  of 
lupus  (Dr.  H.  A.  Ellis),  415,  430,  528,  592,  635 
Pictorial  symbolism  of  reproduction,  446 
Pigmentation,  persistent,  due  to  antipvrin. 
1036 

Pigmented  connective  tissue,  1072 
Pineo,  Mr.  E.  G.  D.,  and  Dr.  D.  M.  Baillie, 
treatment  of  gonorrhoea  bv  pus  vaccines,  508 
Pitfalls  of  general  practice  (Dr.  H.  M . McCrea). 
1010,  1053 

Pituitary  body,  deficiency  of,  in  a girl  aged  19, 
465;  tumour,  613;  body,  malignant  tumour 
of,  613 ; headaches  and  their  cure,  664 
Place  aux  embusques.  157, 198 
Placenta,  the  retained.  806 
Plague  in  India,  twenty  years  of,  349,  434,  760 ; 

in  Central  and  Eastern  Europe  (Py  Q),  1008  ’ 
Plant  stimulation  by  ultra-violet  rays,  430 
Plastic  vocal  cord  (Dr.  F.  N.  Smith),  108; 
operation  on  face  for  deep  scarring,  300 ; 
operation  on  orbital  region,  894 
Platt,  Mr.  H.,  eradication  of  latent  sepsis,  175  ; 
and  Mr.  E.  S.  Brentnall,  faradic  stimulation’ 
884,  989 

Pieuro-typhoid,  990 

Pneumococcic  meniDgitis,  primary,  623 
Pneumonia,  broncho,-  influenza],  use  of  intra- 
venous iodine  in  (Dr.  D.  M.  Baillie),  423- 
septic,  epidemic,  481 ; influenzal  (Sir  w! 
Osier),  501 ; recent  advances  in  treatment 
(leading  article),  704;  influenzal,  lung- 
puncture  in  (Dr.  M.  Benaroya),  742,  816  ; 
in  Macedonia  and  the  epidemic,  794 
Pneumonia,  epidemic,  study  of,  1086 
Pneumonic  tuberculosis,  acute,  615 
Poisoning,  aspirin  (Dr.  F.  W.  Lewis),  64- 
heroin,  755  • ’ 

Poisons,  irregular  sale  of,  120 
Poland,  medical  mission  to.  S44 
Police  Medical  Service,  appointment  of  com- 
mittee, 665 

Poliomyelitis  and  encephalitis,  notification  of, 

76 

Polycytha-mia,  700  ; with  congenital  morbus 
cordis,  700 ; rubra  with  splenomegaly,  700 
Polygraphs  technique,  advances  in  (Dr.  H.  L 
Flint),  176 

Polymorphism  of  malignant  epithelial  cell, 

Polyneuritis,  acute  infective,  348 
Poiyorrhomenitis  (Dr.  W.  E.  Cooke),  562 
Pool  for  insurance  practitioners  (Py  Q),  1008 
Poona  Seva  Sedan,  805 
Poor  law  dietary,  187 

Population,  national  register  of,  147;  a 
diminishing,  474;  figures  and  the  war. 
1038 

Porteous,  Dr.  A.  B.,  and  Mr.  A.  Fleming, 
blood  transfusion  by  the  citrate  method,  973,' 

988 

Porter,  Miss  A.,  intestinal  entozoa  among  the 
native  labourers  in  Johannesburg,  521 
Port  hospital  accommodation  (Py  Q),  534  820 
Portrait  of  Sir  Clifford  Allbutt,  814,  910 
Portsmouth  Royal  Hospital,  meeting,  632 
Posey,  Dr.  W.  C.,  Hygiene  of  the  Eye  (review), 

184 

Post  graduate  Association,  scheme  for  post- 
graduate medical  education,  393,  757 
Post-graduate  facilities,  development  of,  268 
Post-graduate  mtdical  teaching  in  Glasgow, 

523  ; medical  education  (leading  article),.  703 
Post-graduates,  American,  in  London,  943 
Postinfluenzal  haemoptysis  (Dr.  H.  Wilson), 

Potatoes,  composition  of,  727 

Powell,  Dr.  L.  “ twilight  sleep,”  658 

Powell,  Mr.  W.,  death  of,  953 

Power,  Mr.  D’Arey,  aetiology  of  lingual  cancer, 

75 

Poynton,  Dr.  F.  J.,  accurate  diagnosis  in 
appendicitis,  197 

Practice,  general,  a personal  retrospect  (Dr.  J. 
Pearse),  129,  197 ; civilian,  and  military 
medical  officers,  233;  general,  some  pitfalls 
of  (Dr.  H.  M.  McCrea),  1010,  1053;  general, 
how  to  start  and  how  to  succeed  (Dr.  G. 
Steeie-Perkins),  1097 
Practice  of  the  absentee,  45,  80 
Practices,  buying,  398 ; disposal  of,  913 


Practitioner,  the  demobilised,  position  of,  439  • 
(leading  article),  516 

Pregnancy,  extra  uterine,  22,  611;  tubal,  110- 
reaction,  Ahderhalden’s,  111;  extra  uterine’ 
advanced,  301 ; extra-uterine,  continuing  to 
term,  611  ; ectopic,  full  time,  four  cases, 611 ; 
full-time,  in  a rudimentary  uterine  horn 
612 

Pregnant  women  suffering  from  venereal 
diseases,  residential  treatment,  80 
Presbyopia,  895 
Prescriptions,  disinterested,  1036 
Presentations  and  testimonials : to  Dr 

Ve.mylen,  20;  to  Mr.  S.  Riddell,  424  ; to  Dr! 
N.  Raw,  781 ; to  Mrs.  S.  Payne,  844  ; to  Dr. 
L.  V.  Laurie,  879;  to  Dr.  J.  Culross,  879- 
to  Sir  J.  Barr,  1007  ; to  Sir  W.  Whitla.  1095 
Pressure  on  civilian  hospitals  (Py  Q),  641 
Prest.,  Dr.  E.  E.,  future  of  the  tuberculosis 
problem,  636 

Prevention  of  Anthrax  Bill,  685,  865,  959 
Preventive  medicine  and  industrial  efficiency 
(leading  article),  113 

Prideaux,  Mr.  E.,  war  deafness,  198;  stam- 
mering in  war  psycho-neuroses,  217 
Priestley,  Dr.  A.  II.,  complement-fixation  test 
in  gonococcal  infections,  737 
Primary  syphilis,  diagnosis  of  (Dr  S F 
Dudley),  737 

Primitive  agents  in  treatment,  45 
Prince,  Dr.  N.  C.,  Roentgen  Technic 
(Diagnostic),  (review),  184 
Prison  reform,  policy  of  the  Howard  Associa- 
tion, 1002 

Pritchard,  Dr.  E.,  home  v.  institutional 
training  of  young  children,  615;  abdominal 
tuberculosis,  940;  Physiological  Feeding  of 
Children  (review),  1028 
Procidentia,  complete,  radical  cure,  22 
Profiteering,  alleged  medical,  526 
Prohibition  in  the  United  States,  354;  regula- 
tions for  New  York,  354  : and  the  medical 
profession  of  New  York,  523 
Propaganda,  a study  in,  622 
•’Propeller”  fracture  (Lieut.-Col.  A.  L. 
Johnson)  293 

Prophylactic  measures  against  influenza  at  a 
public  school.  119 ; treatment  of  constipation 
in  child- en  (Cr.  V.  Borland),  459;  inocula- 
tion in  influenza  (leading  article),  572 
P^ophyiaxis  in  influenza  (Mr.  F.  T.  Marchant), 

Prosthesis  of  the  lower  limb.  149 
Pryce,  Capt.  A.  M.,  R.A.M.C.  (see  Obituary  of 
the  war) 

Pseudo  paratyphoid  fever  (Dr.  R.  Paton)  1071 
Psoiiasis  of  13  years’ duration,  847 
Psychiatry,  word-a-sociation  test  in,  234 
Psycho-analysis,  Papers  on  (Dr.  E.  Jones) 
second  edition,  1918  (review),  234;  Theory  of 
(Dr.  C.  G.  Jung)  (review),  234;  aspect  of, 
7C'8 

Psycho-neurosis,  stammering  in  (Mr.  E. 
Prideaux),  217 ; and  protective  mimicrv 
(Dr.  L.  Brown),  832  J 

Psychology  of  internment  (Prof.  R.  Bing  and 
Dr.  A.  L.  Viscber),  696;  and  medicine,  889- 
British  and  German,  1002 
“ Psychology,”  the  word,  1093 
Psychonevroses  de  Guerre,  Traitement  des 
(G.  Roussy.  J.  Boisseau,  and  M.  D’Oelsnitz) 
(review),  1119 

psy|hopathic  criminal,  the  (leading  article), 

Psychopathology  of  Everyday  Life  (Prof  S 
Freud)  (review),  231 

Public  health  aspect  of  tuberculosis,  464 
Public  Health  Council,  Irish,  proposed,  475 
Public  health,  reports  of  medical  officers  of 
health,  478,531 ; work  in  Egypt,  146  ; Depart- 
ment, Egypt,  1916,  annual  report,  681; 
Laboratories,  Cairo,  reports  and  notes,  682 
Public  Health  (Medical  Treatment  of  Children) 
(Ireland)  Bill,  685,  770, 819, 820 ; reconstruction 
and, Ireland,  812  ; for  Canada,  Federal  Depart- 
ment of,  949;  Bill,  South  Africa,  996 
Public  Health,  Royal  Institute  of,  lectures  and 
discussions,  81 ; the  new,  and  industrial 
unrest,  202  ; new  regulations  for  the  control 
of  epidemic  disease,  281 ; (Tuberculosis) 
Regulations,  485 : and  district  nursing  asso- 
ciations (Py  Q),  686 
Public-house  relorm,  826 
Public  spirit  and  medical  unanimity,  the  State 
and  the  doctor  (Sir  H.  Morris),  165 
Pulmonary  tuberculosis,  saccharose  injections 
in,  540,  536,  826 ; trauma  therapeutic,  851 
Pulsating  tumour  of  orbit,  613 
Puncture  fluids,  thoracic  (Dr.  S.  R.  Gloyne), 

P.L.O.  and  trench  fever,  invalidism  caused  by 
(Col.  T.  R.  Elliott,  Capt.  D.  S.  Lewis,  Maj. 

J.  H.  Thursfield,  Maj.  A.  J.  Jex-Blake,  and 
Maj.  M.  Foster),  1C60 
Purefoy,  Dr.  R.  D.,  tubal  pregnancy,  110 
Pure  milk-supply  (Py  Q),  864 
Purulent  broncho- pneumonia  associated  with 
the  meningococcus,  81 


xviii  The  Lancet,] 


INDEX  TO  VOLUME  I.,  1919. 


[July  5,  1919 


Pus  vaccines  in  the  treatment  of  Korl?Uk<*a 
(Mr.  E.  G.  D.  Pineo  and  Dr.  D.  M.  Baillie), 

Fybus,  Maj.  P.  C.,  perforating  wound  of  the 

Fve^rs’urgical  Handicraft  (Mr.  W.  H.  Clayton- 
Greene),  eighth  edition,  1919  (review), 
383 

Pylorio  Btenosie,  c mgenital,  surgical  treat- 
ment, 380,  389 

PyoBalpinx  and  ovarian  abscess,  26b 


Q 

Qualifications  of  apothecaries'  assistants  (Py  Q), 
6 442 

Quantity,  universal  language  of,  539 
Quarterly  Journal  of  Microscopical  Science 
(review), 897  ...  . 

Queen  Alexandra’s  Hospital  for  Officers,  High- 
^ gate,  688, 772 

Queen  Mary’s  Needlework  Guild,  264 
Queen’s  University  of  Belfast,  honorary  de- 
grees. 1137  . 

Quinine  as  an  abortifacient  (Prof.  W.  O. 
Swayne  and  Mr.  E.  Itussell),  641 


R 


Babies  and  il  s treatment  in  this  country  (lead- 
ing article).  74;  atypical,  852  ; treatment 
(Pv  Q).  917,  918 

Babies  in  Paris  274;  in  Devon  and  Cornwall 
(Pv  Q),  359, 402  ; return  of,  706,  756,  806 
Race  Mr.  J.,  Examination  of  Milk  for  Public 
Health  Purposes,  first  edition,  1918  (review), 
614 

Badiant  heat  and  health,  164 
Eadium  Institute  (leading  article),  850 
Eadium  treatment  of  epithelioma  of  the  lip, 
388;  new  method  of  application  in  diseases 
of  the  eye,  895 

Radical  and  modified  radical  mastoid  opera- 
tions (Mr.  J.  S.  Fraser  and  Mr.  W.  T. 
Garretson),339 
Raffaele  Paolucci.  488 
“ Ragging’’  of  a nurse,  949 
Rags,"  legal  definition  of,  991 
Railway  carriages,  dry  sweeping  in.  644 
Rainfall  in  the  north  of  Ireland, 910 

Ramsay  Memorial  Laboratory,  634 

Eamsay,  Mr.  R.  A.,  surgical  treatment  of  con- 
genital pyloric  stenosis.  380,  389 
Hansom,  Dr.  F.,  and  Prof.  B.  H.  Meyer, 
tetanus  without  trismus.  117 
Ransome,  Dr.  A.,  musk  in  influenza, 529 
Rat-bite  fever  (Dr.  R V.  Solly),  458 
Ratnakar,  Mr.  R.  P.,  nystagmus  caused  by 
mustard  gas,  423  . 

Raw,  Dr.  N.,  attenuation  of  human,  bovine, 
and  avian  tubercle  bacilli,  376;  position  of 
medicine  in  the  State,  797 
Reactivation  of  erythema  nodosum  by  tuber- 
culin, 705 

Reconstruction,  hygienic,  of  war  devastation, 
Inter-Allied  Conference  in  Pans,  856 
Reconstruction  (review),  112 
Rectal  ether  anaisthesia  (Mr.  J.  C.  Clayton), 
793 

Rectus  abdominis,  ruptured,  influenzal  (Dr. 

W.  Balgarnie),  843,  912  . 

Rod  Cross,  American,  m Pans,  future  of,  15b  , 
Inter-Allied  Conference,  521  ; workers, 
Scottish  branch,  training  scheme  for,  813; 
nursSs  and  war  gratuities  (Py  Q),  918 
Red  Cross,  British,  demobilisation,  41 ; ambu- 
lances, utilisation  of,  187  ; past,  future,  and 
present  (leading  article),  661 ; ambulances 
for  home  service,  683;  Hospital  at  Netley, 

Redhill,  Royal  St.  Anne’s  Schools,  appeal,  921 
Reflex,  a new,  868  * . . 

Reflexes,  abdominal,  significance  and  surgical 
value  of  (Mr.  D.  Ligat),  729 
Reform  of  medical  education  (leading  article), 
571 

Refraction  of  the  Eye,  Manual  for  Students 
(Mr.  G.  Hartridge),  sixteenth  edition,  1919 
(revieiv),  984  _ 

Regimental  Medical  Officer,  the  Whole  Duty 
of  (Capt.  P.  Wood)  (review),  466 
Register,  national,  of  population.  147 
KegnauU.  Dr.  J.,  anesthetics,  1037 
Regulations.  cerebro  spinal  fever,  1126 
Rehabilitation  of  the  Disabled,  International 
Conference  on,  761 

Reid,  Sir  A.,  and  Dr.  P.  H.  Boyden,  treatment 
of  venereal  disease  212 

Renal  Function  ill  Chronic  Nephritis,  Studies 
in  (thesis  by  Pasteur- Vallery-Radot)  (re- 
viewed bv  Prof.  C.  Achard),  752 
lienney.  Dr.  II.,  trimethenal-allyl-carbide  in 
influenza,  440 


Reproduction,  pictorial  symbolism  of,  443 
ltesearch,  medic  tl*  and  its  place  in  the  State 
(leading  article),  517  ; Committee,  Medical, 
and  the  medical  supplement,  522  ; the  spirit 
o',  624;  clinical,  coordination  by  the  State 
(Dr.  D.  C.  Watson),  989,  992 
Resection,  double,  of  bowel  (Mr.  G.  Taylor), 

461;  in  ussuseeption  treated  by  (Mr.  E.  R 
Flint),  938 

Resettlement  of  war  nurses  1090 
Responsibility,  crime  and  (leading  artic.e), 

1121  , . 

Retina,  angioma  of,  300  ; streaks  in,  613 
Retinal  degeneration  following  intraocular 
foreign  body,  299 
Retinal  vessels,  obstruction  of,  1072 
Revista  Espanola  de  Cirugia  (review),  748 
Revista  Espanola  de  Mediciua  y Cirugia 
(review),  66  . . • 

Reynell,  Dr.  W.  R.,  hysterical  vomiting  in 
soldiers,  18,  118 

Rheumatism  and  arthritis,  meningococcal  (Dr. 

P.  Sainton),  1080 

Richard,  G„  and  M.  Perrin,  rupture  of  cardiac 
valves  due  to  an  explosion.  231 
Richmond,  Dr.  B.  A..  Association  of  Panel 
Committees  and  notification  fees,  439 
Rickets,  experimental  investigation  on  (Dr.  E. 
Mellanby),  407 

Ririeal,  Dr.  S.,  germicidal  valuation  of  dis- 
infectants, 576  . 

Risdon,  Cap'.  E.  F.,  and  Maj.  C.  W.  Waldron, 
mandibular  bone  grafts,  181 
Ritchie,  Prof.  J , and  Prof.  R.  Muir,  Manual  of 
Bacteriology,  seventh  edition,  1919  (review), 

467 

Ritter  v.  Godfrey,  1041 

Rivers,  Dr.  W.  H.  R.,  appointed  prelector  in 
natural  sciences  at  St.  John’s  College, 
Cambridge,  158  ; psychology  and  medic.ne, 

889 

Rivers,  Mr.  W.  C , women  chiefs.  583,  683 
Riviere,  Dr.  C.,  hilus  tuberculosis  in  the  adult, 

213  ; lung-puncture  in  treatmentof  influenzal 
pneumonia,  816  .... 

Rixon,  Mr.  C H.  L.,  hysterical  perpetuation  of 
symptoms,  417 

Roads,  hygienic  repair  of,  202 
“ Roase  Si  ‘gwick”  Fellowship,  1095 
Roberts,  Dr.  B , death  of,  688 
Robertson,  Dr.  A.  W.,  Studies  in  Electro- 
pathologv  (review),  701 

Robertson,  Dr.  O.  H.,  and  Dr.  Airlie  3 . Bock, 
blood  volume  and  related  blood  changes  after 
hiemorrtnge,  852  , 

Robinson,  Maj.  H.  H„  M.C.  with  bar  (see 
Obituary  of  the  war)  _ _ „ , 

Roderick,  Dr.  II.  B.,  and  Dr.  S.  W . Curl, 
recurring  effusion  into  the  pericardial  sac, 

980 

Roentgen  Technic  (Diagnostic)  (Dr.  N.  C. 
Prince)  (review).  184 

Rogers,  Sir  L.,  tribute  to,  112;  colloid  anti- 
mony sulphide  intravenously  in  kaia  azar, 

505 

Rolleston,  Sir  H-,  cerebro-spinal  fever,  541, 593, 
645 

Roman  oculist  seals,  1012 
Rood,  Dr.  F.  S.,  spinal  amesthesia,  14 
Rose,  Dr.  B.  T..  and' Mr.  E.  H.  Shaw,  ectopic 
gestation,  175 

Rose,  Dr.  F G.,  influenza  epidemic  in  British 
Guiana,  421 

Rosenthal,  Dr.  G.,  ingestion  of  adrenalin  and 
intravenous  injection  of  colloidal  quinine, 
760 

Ross,  Mr.  H.  C..  absence  of  cancer  in  the 
Arctic  regions,  528,  1045 
Ross,  Sir  R.,  care  and  treatment  of  malaria, 
780 ; origin  of  life,  work  of  the  late 
Charlton  Bastian,  952 
Roubier,  M.,  tetanus  without  trisn  us,  117 
Rouquette,  Mr.  S.  H.,  obitu  . y,  o', 9 
Roussy,  G.,  J.  Boisseau.  ..ni  M.  D’Oelsnitz, 
Traitement  des  Psych  m vroses  de  Guerre 
(review),  1117 

Rowlands,  Dr.  M.  J.,  present  e,  idemic  of 
influenza,  563 

Roworth,  Mr.  A.  T..  commercial  vaccine 
lymphs,  357  I 

Royal  Academy  of  Medicine  in  Ireland  (see  ( 
Medical  Societies) 

Royal  Army  Medical  Corps  (for  list  of  casualties 
and  honours  see  Royal  Army  Medical  Corps 
under  War  and  After);  auxiliary  funds,  238. 
632;  promotion  ip  (Territorial).  399;  pro- 
motion in  (Py  Q>,  402;  officers  and 
Government  employment  (Py  Q),  402;  j 
war  memorial  to  officers  and  men,  | 
766;  Fund  and  R.A.M.C.  Officers'  Bene- 
volent Society,  858;  Journal,  916;  spire- 
time service,  1054;  temporary  officers, 
1137  „ „ 

“ Royal”  Army  Veterinary  Corps.  29 
Royal  Collegi  of  Physicians  of  Edinburgh,  j 
Royal  College  of  Surgeons  of  Edinburgh,  and  | 
Royal  Faculty  of  Physicians  and  Surgeons  of 
Glasgow,  pass-lists,  199, 768  I 


Royal  College  of  Physiciaus  of  Ireland,  Dr.  H. 
Pringle  elected  Kiug’s  Professor  of  Institutes 
of  Medicine  in  the  School  of  Physio  in 
Irelan  i,  435 

Royal  College  of  Physicians  of  London  and 
Surgeons  of  England,  pass-lists,  862 
Royal  Collegeof  Physiciansof  London,  oomitia. 

236,  687,  768,  862,  1094  ; pass-lists,  239,  768 
Royal  College  of  Surgeons  of  Edinburgh,  pass- 
lists,  536,  955 

Royal  Col  lege  of  Surgeons  of  England,  meeting, 
126,318,  687,862,  1094;  special  examinations 
for  the  primary  F.R.C.S.  Eog.,  200;  pass- 
lists,  862,  914,  1094 

Royal  Faculty  of  Physicians  and  Surgeons  of 
Glasgow,  meetiug,  282 
Royal  Free  Hospital  Fair,  16 
Royal  Infirmary,  Edinburgh : new  appoint- 
ments, 1131 

Royal  Irntitute  of  Public  Health,  lectur-:6  and 
discussions,  81 ; (see  Medical  Societies) 

Royal  Institution,  meeting,  206, 639 
Royal  Medical  Benevolent  Fund,  meeting, 
199  361,  536.  769.  956,  1095 ; War  Emergency 
Fund,  315,  358,  684  . 999  ; dance,  1137 
Royal  Sanitary  Institute  (see  Medical 
Societies) 

Royal  Society  conversazione,  994 
Royal  Society  of  Medicine,  social  evenings, 
270 ; Summer  Congress  of  Laryngology,  306 ; 
the  post-graduate  scheme,  757 ; close  of  the 
se  U.OI1,  1036  ; (see  also  Medical  Societies) 
Rudolf,  Col.  R.  D.,  subacute  trench  fever,  858 
Rupture  of  cardiac  valves  due  to  explosion, 
231  ; spontaneous,  of  ovarian  cyst  (Mr.  D.  N. 
Kalyanvala),  423 

Ruptured  rectus  abdominis,  influenzal  (Dr.  W. 

Balgarnie),  843.  912 
Rural  housing,  937 

Rusk,  Dr.  I(.  R.,  Experimental  Education 
(review),  618 

Russ,  Dr.  5.,  Dr.  Helen  Chambers,  Dr.  Gladwys 
M,.'  Scott,  and  Dr.  J.  C.  Mottram,  experi- 
mental studies  with  small  doses  of  X rays, 
692 

Russell,  Dr.  W.,  influenza  epidemic,  639 
Russell,  Mr.  E.,  and  Prof.  W.  C.  Swayne, 
quinine  ss  an  ab  gtifacient.  841 
Rutherford,  Dr.  L.  T.,  laorymal  gland  in  sur- 
gical amesthesia,  792 

Rutherford,  Lieut.  Col.  N.  C.,  (rial  oi.  630 
Rutberfurd,  Dr.  W.  J.,  war  injury  from  signal 
lights,  741 ; and  Dr.  Barbara  G.  R.  Crawford 
hereditary  malformation  of  the  extrem  ties 

979 

Ryle,  Dr.  J.,  mild  bacillary  dysentery,  937 


Sac,  pericardial,  recurring  effusion  into  (Dn 
H.  B.  Roderick  and  Dr.  S.  W.  Cur!),  9S0 
Saccharose  injections  in  pulmonary  phthisis 
540,  633.  826 

St.  Andrew's  Hospital,  Doibs  Hi.l,  report 

394 

St.  Bartholomew’s  Hospital,  History  of  (Dr.  X 
Moore)  (review).  425 
St.  George's  Hospital,  future  of.  906 
St  John  of  Jerusalem,  Order  of,  appointments 
828, 1098  , , , „ j 

St.  Mark’s  Hospital,  the  Lord  Mayor, 
challenge,  318 

Sainton,  Dr.  P.,  meningococcal  rueumaUsC 
and  arthritis,  1080 

Sakakami.  Dr.  K.,  Dr.  S.  Iwashima,  and  Pro! 
T.  Yamanouchi,  infecting  agent  in  influenzs 
971 

Salaries  of  dispensary  doctors.  121 ; of  Irisl 
Poor-law  medical  officers  (Py  Q),  442;  0 
health  visitors  (Py  Q),  635 
Salvarsan  substitutes  (Py  Q 4S5 
Sanatoria  fur  discharged  soldiers  and  sailor 
suffering  from  tuberculosis,  853 
Saudford,  Mr.  H.,  death  of,  30,  125 
Sanitary  and  insanitary  makeshifts  in  th 
Eastern  war  areas  (Dr.  A.  Balfour;,  604 
Sanitary  officer  and  service  in  Russia  (Py  Q 

Sanitation,  health,  and  medicine  in  Iudia,  US 
163  ; in  the  Near  East  (leading  artielej,  621 
at,  Lahore,  813 

Sanitation  in  War  (Prof.  P S.  Lelein),  thir 
edition,  1919  (review), 514  ; Perfectly  Applie 
(review),  659 

Sanatoriums  for  soldiers  and  sailors,  luib 
Sarcoma  of  cervix,  110;  recurre  it,  afU 
removal  of  apparently  simple  myomati 

301 

Sarcoma,  pelvic  (Mr.  J.  H.  Hart),  378 
Savage.  Sir  G.  H..  Isaac  Dobrea  Chepmell,  15. 
mental  disorders  associated  witn  old  ag 
1013;  meatless  dietary  in  epilepsy,  1046 
Savery,  Mr.  H.  M.,  dislocation  of  teeth,  339 
Savin',  Dr.  Agnes,  medical  effects  of  the  tut 
strike,  279 

Savin.  Dr.  T.  D..  System  of  Clinical  MeAtcin 
tilth  edition,  1918  .review),  66 


The  Lancet,] 


INDEX  TO  VOLUME  I.,  1919. 


[July  5,  1919  xix 


Sawyer,  Sir  J.,  obituary,  239 
Scapular  pain  and  tenderness,  left,  in  heart 
disease  and  distress  (Dr.  J.  Parkinson),  550, 
575 

Scar  tissue,  infective  (Mr.  E.  M.  Corner),  840 
Scarlet  red  powder  as  a tissue  stimulant  (Dr. 
A.  J.  Turner),  463 

School  board  medical  officer  mobbed  in 
Aberdeen,  1131 

School  children,  medical  inspection  of,  199; 

in  Ireland,  medical  inspection  (l’y  Q),  641 
Schools,  secondary,  medical  inspection  of,  616; 
in  Ireland,  997 

Schryver,  Dr.  S.  B.,  Introduction  to  the 
Study  of  Biological  Chemistry  (review),  659 
Schuller,  Dr.  A.,  Roentgen  Diagnosis  of 
Diseases  of  the  Head  (review),  466 
Science  laboratories,  new,  at  Edinburgh,  812 
Scientific  education  and  its  cost  (leading 
article),  428 ; accuracy  and  grain  pests,  539 
Scorpion  stings,  death  from  (Capt  A.  Watson). 
889 

Scotland  (Correspondence  from).— Scottish 
Ministry  of  Health  Committee;  Chair  of 
Therapeutics,  Edinburgh  University  ; Influ- 
enza epidemic  in  Edinburgh  and  district, 
433— Ministry  of  Health,  resolutions  of  the 
Scottish  medical  profession ; Ministry  of 
Health,  statement  of  the  Royal  College  of 
Physicians  of  Edinburgh  ; Post-graduate 
medical  teaching  in  Glasgow,  523— Demob- 
ilisation of  doctors ; Scottish  Universities 
Entrance  Board;  Retirement  of  Sir  T. 
Fraser,  631 — New  science  laboratories  at 
Edinburgh;  Scottish  Western  Asylums 
Research  Institute  ; Resettlement  of  Scottish 
nurses,  812 — Venereal  treatment  centres  in 
Glasgow ; Training  scheme  for  Red  Cross 
workers,  813  ; Prescribing  of  cocaine  ; Pro- 
fessional chemists  and  the  Scottish  Board  of 
Health  ; Affairs  of  Edinburgh  University, 
910— Prospective  vacant  chair  at  Edinburgh 
University ; Meeting  of  the  medical  pro- 
fession in  Edinburgh;  Woman  doctor  sued 
by  member  of  the  Q.M.A.A.C.,  1040-Royal 
Infirmary,  Edinburgh,  new  appointments; 
Scottish  Otological  and  Laryngological 
Society ; School  board  medical  officer 
mobbed  in  Aberdeen,  1131— Winding  up  of 
1st  Scottish  General  Hospital  Gifts  Com- 
mittee, 1132 

Scott,  Dr.  Gladwys  M.,  Dr.  J.  C.  Mottram,  Dr. 
S.  Russ,  and  Dr.  Helen  Chambers,  experi- 
mental studies  with  small  doses  of  X raj  s 
692  ’ 

Scottish  Poor-law  Medical  Officers'  Associa- 
tion, report,  200;  Ministry  of  Health  Com- 
mittee, 433 ; Board  of  Health  Bill,  588,640. 
688,  819,  863,  917,  957,  1008;  Universities 
Entrance  Board,  631  ; Western  Asylums 
Research  Institute,  812;  nurses,  resettlement 
of,  812;  parochiai  medical  officers  (Py  Q), 
918 

Scurvy,  infantile  (Prof.  A.  Harden,  Mr.  S.  S. 
Zilva  and  Dr.  G.  F.  Still),  17  ; treatment  of, 
50 ; teeth,  1229 

Season,  Dr.  J.,  epidemic  of  septic  pneumonia, 

Secondary  schools,  medical  inspection  of,  616 
Secondary  suture  of  wounds  (Mr . R.  A.  Stoney), 
978 

Secretan,  Dr.  W.  B.,  limitations  of  voluntas 
hospitals,  952 
Sedobrol,  384 

Sella  turcica,  changes  in,  300 
Sensation  and  the  cerebral  cortex,  389 
Sepsis,  latent,  eradication  of  (Mr.  H.  Platt),  175 
Septic  infection  of  lateral  sinus  after  injury  at 
operation,  340;  pneumonia,  epidemic]  481 
Septicaemia,  influenzal  (Dr.  A.  Abrahams,  Dr 
N.  Hallows,  and  Dr.  H.  French)  1;  Staphy- 
lococcus auretis,  in  influenza  (Dr.  A.  Patrick) 
137 ; meningococcic  (Sir  H.  Rolleston),  548 
Sequeira,  Dr.  J.  H..  Diseases  of  the  Skin,  third 
edition,  1919  (review),  798 
Sequestrum,  the  buried,  a post-war  problem 
(Mr.  J.  Phillips),  291 

Sera,  Immune  (Dr.  C.  F.  Bolduan  and  Dr.  J. 

Koopman),  fifth  edition,  1917  (review),  746 
Serbian  libraries,  restoration  of,  388 ; books  for, 
398 

Sergent,  M.  Emile,  and  Mile.  T.  Bertrand, 
meningeal  hemorrhage  in  typhoid  fever,  519 
Serum  disease  (Sir  H.  Rolleston),  651 ; anti- 
plague in  influenza,  663;  intrapulmonarv 
mjection  in  influenza,  1087 
Serums  and  vaccines  supplied  to  the  Royal 
Navy,  145 

Seivices  Bill,  Medical  (leading  article),  941  • 
(Py  Q),  959 

Services,  deaths  in:  Surg.-Gen.  Sir  J.  H. 
Thornton,  125;  Deputy  Surg.-Gen.  S.  j] 
Wyniowe,  Brig.  Surg.  Lieut.-Col.  J. 
Robinson,  536;  Lieut.-Col.  J.  G.  Hojel,  638  • 
Lieut.-Col.  E.  F.  Drake-Brockman,  I M S ’ 
82o  ; Maj  -Gen.  P.  M.  Ellis,  A.M.S.,  9S0 


Services,  naval  and  military  medical,  47,  86 
125,  157,  195,  278,  317,  364,'  399,  444,  486,535’ 
589,  638,  684,  722,  764,  822,  861,  915,960,1007, 
1049;  Indian  Medical,  pay  in,  278,444,589 
638,  764,  765,  823,  861,  916,  960,  1008,  1095, 
1135 

Services  of  medical  men  in  the  war  (Py  0). 
1050 

Sessile  red  fibroid,  22 

Seta,  Dott.  Eschilo  Della,  saccharose  injections 
in  pulmonary  phthisis,  826 
Sex  Education  for  Parents  and  Teachers  (Mr. 

W.  M.  Gallighan)  (review),  617 
Share  holding  and  medical  men,  1045,  1093 
Sharma,  Lieut.  J.  K.,  I.M.S.  (see  Obituary  of 
the  war) 

Shattock,  Prof.  S.  G.,  and  Mr  C.  A.  R.  Nitch, 
diffuse  emphysema  of  wall  of  small  intestine, 
263 

Shaw,  Dr.  F.,  extra-uterine  pregnancy,  22 
Shaw,  Mr.  B.  H.,  and  Dr.  B.  T.  Rose,  ectopic 
gestation,  175 

Shaw,  Mr.  E.,  relation  of  pathology  to  clinical 
medicine,  300 

Sheen,  Mr.  A.  W.,  “ trivial  ” eases  at  voluntary 
hospitals,  196 

Shefford,  Mr.  A.  D.  E„  and  Mr.  W.  M.  Munby, 
bone-grafting  operations,  1070 
Shell  shock,  study  of  (Dr.  C.  S.  Myers),  51 ; 
and  tuberculous  cases  (Py  Q),  442  ; patients 
(Py  Q).  725 ; and  neurasthenia  (Py  Q),  725 ; 
treatment  (Py  Q),  864 

Shera,  Dr.  A.  G.,  Vaccines  and  Sera,  their 
Clinical  Value  in  Military  and  Civilian  Prac- 
tice  (Oxford  War  Primers)  (review),  426 
Shettle,  Mr.  H.  W.,  death  of,  688 
Ship  Captain's  Medical  Guide  (Dr.  C.  Burland) 
(review),  23 

Shipway,  Dr.  F.  B„  oil-ether  anesthesia,  659 
Shock  discussion  (Prof.  W.  M.  Bayliss  and  Dr. 

H.  H.  Dale),  256,  375;  physics  of,  269 
Shock,  shell,  study  of  (Dr.  C.  S.  Mvers),  51  ; 
emotional,  on  the  battlefield  (Cl.  Vincent). 
69  ; shell,  and  tuberculous  cases  (Py  Q),  442 ; 
wound,  668 

“ Shock  ” (so  called),  397 
Shufeldt,  Maj.  R.  W.,  adaptation  of  tool 
handles  to  crippled  hands,  664 
Sigmoid,  adhesions  of  (Mr.  J.  P.  Lockhart- 
Mummery  and  Dr.  D.  Pennington),  254 
Signal  lights,  war  injury  from  (Dr.  W.  J. 

Rutherford),  741 
Silicosis  scheme,  the,  907 
Silk,  Dr.  J.  F.  W.,  anesthesia,  a nasal  air-wav 
1030  J 

Simon,  Prof.  S.  K.,  treatment  of  amcebic 
dysentery,  429 

Simple  Beginnings  in  the  Training  of 
Mentally  Defective  Children  (Miss  M 
Macdowell;  (review),  566 
Sin,  Disease  and  Remedy  of  (Mr.  W.  M 
Mackay)  (review'),  302 

Sinclair,  Maj.  M.,  retrogressions  in  the  treat- 
ment of  fractures,  507 

Singer,  Dr.  R.,  and  Dr.  H.  Elias,  war  cures, 
116 

Sinuses,  bone,  treatment  by  solid  metal 
drains  (Mr.  C.  J.  Symonde),  971 
Skin,  Diseases  of  (Dr.  J.  H.  Sequeira),  third 
edition,  1919  (review),  798 
Slesinger,  Mr.  E.  G , compound  fractures  of 
the  upper  limb,  365 
Slum-dweller  and  the  slum-ovuier,  429 
Small  holdings  and  the  returned  soldier,  922 
Small-pox,  recent  incidence  of,  388,  902;  and 
vaccination,  half  a century  of  (Dr  J C 
MeVail),  449;  in  England  and  Wales  (Py  Q)] 
484;  in  London,  t88;  epidemic  expected  in 
Bengal,  760  ; at  Dacca,  813 
Smith,  Dr.  E.,  “ ourselves  only,”  951 
Smith,  Dr.  F.  J.,  obituary,  860 
Smith,  Dr.  F.  N.,  plastic  vocal  cord,  108 
Smith,  Dr.  L.,  tha  obstetric  helper,  797 
Smith,  Dr.  R.  E.,  influenzal  intra-abdominal 
catastrophes,  421 

Smith,  Lieut.-Col.  J.  B , appointed  honorary 
surgeon  to  the  Viceroy  of  India,  311 
^611^*  B ’ ex^ra‘u^er^ne  pregnancy, 

Smith,  Mrs.  A.  H.,  treatment  of  scurvy,  50- 
lemon  juice  or  lime  juice,  164 
Smith,  Pr.jf.  A , Introduction  to  Inorganic 
Chemistry,  ULird  edition,  1918  (review), 

Smith,  P of.  G.  r , the  bird’s  brain,  616  - 
appointed  tochab  of  anatomy  at  University 
College.  Land  -n,  S89 
Smoking,  juvenile,  in  India,  761 
Smvly,  Sir  W.,  two  tumours  of  the  mesentery, 
111  ; accidental  hemorrhage  in  connexion 
with  eclampsism,  133 

Snellen  s types,  standard  illumination  of,  34 
Snowden,  Dr.  E.  N,,  Kemp  Prossor  colour 
scheme,  522 

Snowman,  Dr.  J.,  Lenzmann’s  Manua’  of 
Emergencies,  Medical,  Surgical,  and  Ob- 
stetric (review),  513 
Social  medicine  in  Vienna,  921 


Socidtc  de  Biologle,  Paris  (see  Medical 
Societies) 

Socidte  de  Therapeutique,  Paris  (see  Medical 
Societies) 

Society  for  Relief  of  Widows  and  Orphans  of 
Medical  Men,  meeting,  964 
Society  for  the  State  Registration  of  Trained 
Nurses,  956 

Sockets, contracted,  893 
Soldier’s  Heart  and  the  Effort  Syndrome  (Dr 
T.  Lewis)  (review),  142 

Soldiers,  discharged,  medical  treatment  (Py  Q), 
401*  * tut)erculous,  discharged  (Py  Q), 

Soldiers’,  Invalided.  Commission,  Canada, 
Report  (review),  382 
Solly,  Dr.  R.  V.,  rat-bito  fever,  458 
Solomon,  Dr.  H.  O.,  and  Dr.  E.  E.  Southard, 
Neurosyphilis,  Modern  Systematic  Dia- 
gnosis and  Treatment  in  137  Case-histories 
(review),  301 

Solomons,  Dr.  B.,  sarcoma  of  cervix,  110;  500 
consecutive  operations  at  Mercer's  Hospital, 

Solution  pot.  iodide  (souffron),364 
Sonntag,  Dr.  C.  F.,  temperature  environment 
and  thermal  debility,  836 
Sons  of  medical  men,  deaths  of.  in  the  war 
(see  Sons  under  War  and  After) ; of  medical 
men  (see  Casualty  Lists  under  War  and 
After) 

Sorrel,  Dr.  E.,  and  Dr.  P.  Moure,  surgical 
complications  following  exanthematic 
typhus,  341 

South  Africa,  Correspondence  from. — 
Influenza  mortality  in  South  Africa  ; Cape 
Medical  Council ; Maj.  H.  W.  Sykes. 
E.A.M.C.,  the  late,  395 — Health  in  South 
Africa;  Influenza  epidemic  in  Cape  Town, 
524— Household  refuse ; Alleged  medical 
profiteering,  526  — Influenza  epidemic  ; 
Death  of  Dr.  S.  B.  Syfret,  720 

South  Africa  Public  Health  Bill,  996 
Southard,  Dr.  E.  E.,  and  Dr.  H.  C.  Solomon 
Neurosyphilis,  Modern  Systematic  Dia- 
gnosis and  Treatment  In  137  Case-histories 
(review),  301 

South  Devon  and  East  Cornwall  Hospital, 
report,  862 

Spanish-American  medical  fellowship,  76 
“Spanish  disease,”  epidemiology  of,  trans- 
mission of  infection  through  fleas,  922 
Specimen  shown  105  years  ago,  611 
"Spectrum  ” of  epilepsy,  157 
Spencer,  Dr.  H.  R.,  corns  on  babies’  noses,  583 
Spencer,  Dr.  W.  G.,  JLarrey  and  war  surgery, 
867,920,962  “ J 

Sphagnum  moss,  447 

Spinal  ansesthe’sla  (Dr.  F.  S.  Rood),  14;  gun- 
shot concussion  of  (Henri  Claude  and  Jean 
Lhermitte),  67;  cord,  surgery  of,  in  peace 
and  war  (Mr.  A.  J.  Walton),  243 
Spinal  injury  with  retention  of  urine  (Mr. 

P.  N.  3 ellacott ),  733 ; effusions,  hiemorrhagic 
(Dr.  W.  P.  S.  Branson),  888 
Spirit  duty  (voluntary  hospitals) grant,  826 
Spirit  of  research,  625 

Spit  its,  supply  of  (Py  Q),  359,  360;  for 
medicinal  use  (PyQ),  402,  865 
Spirocbetose  Icterohemorragique  (Louis 
Mai  tin  and  Auguste  Pettit)  (review),  800 
Spirochietes  in  the  blood  In  trench  fever  (Dr 
A.  C.  Coles),  375,  388 

Spirochsetosis  icterohaemorrliagica,  infective 
jaundice  due  to  (Dr.  W.  H.  Willcox',  931 
Splenomegaly  with  polycythemia  rubra,  700 
Splint,  pelvic-femur,  and  arm  splint  (Dr.  J R 
iee),  103 

Spriggs,  Dr.  E.  I.,  examination  of  vermiform 
appendix  by  X raj  s,  91 

Sprue  associated  with  tetany  (Surg.  Capt.  P.W. 
Bassett-Smith)  178 

Spurrell,  Capt.  H.  G.  F.,  R.A.M.C.  (see 
Obituary  of  the  war) 

Squire,  Mr.  R.  H.,  advances  in  treatment  of 
fractures,  80 

Staining  diphtheria  bacillus  (Dr.  P.  L.  Suther- 
land), 218 

Stamm,  Dr.  L.  E.,  medical  aspects  of  aviation. 
206 

Stammering  in  war  psycho- neuroses  (Mr.  E. 
Prideaux),  217 

Staphylococcus  aureus  septicemia  In  influenza 
(Dr.  A.  Patrick),  137 

Starling,  Prof.  E.  H.,  food  in  relation  to  health, 

591 

Stasis,  Intestinal,  Chronic,  Operaiive  Tre?.t- 
ment  (Sir  W.  A.  Lane),  fourth  edition,  1918 
(review),  65;  intestinal,  chronic  (Sir  W.  A. 
Lane),  333;  intestinal  (Dr.  L.  Brown), 

878 

State  and  the  doctor,  medical  un  mimif  y and 
public  spirit  (Sir  H.  Morris),  165;  (leading 
article),  185 ; subsidy  of  tuberculous  labour 
(leading  article),  469 
State  Medical  Service,  141,  312 


xx  The  Lancet,] 


INDEX  TO  VOLUME  I.,  1919. 


[July  5,  1919 


Steele-Perkins,  Dr.  G.,  how  to  start,  ami  how 
to  succeed,  in  general  practice,  1097,  1140 
Stenhouse,  Agnes  L.  and  K.t  Health  Header 
for  Girls  (review),  142 

Stenosis,  pyloric,  congenital,  surgical  treat- 
ment, 380,  389 

Stephen,  Lieut. -Col.  G.  N.,  Boulogne  as  a 
military  medical  base,  664 
Stephens,  Dr.  G.  A.,  lead  line  on  tailors’  gums, 
a dangerous  practice,  644 
Steven,  Dr.  G.  II.,  and  Dr.  D.  Embleton, 
cerebro-spinal  fever,  cases  as  carriers,  788 
Stevens,  Mr.  T.  G.,  subperitoneal  lipoma,  1072 
Stewart,  Dr.  M.  J.,  and  Dr.  H.  L.  Flint,  rapidly 
fatal  ulcerative  endocarditis,  1114 
Stewart.  Dr.  H.  M..  and  Dr.  T.  G.  Brown, 
“ hetera'sthesia,”  79 

Stewart,  Mr.  A.  W„  Itecent  Advances  in 
Organic  Chemistry,  third  edition,  1918 
(review),  617  ; Itecent  Advances  in  Physical 
and  Inorganic  Chemistry,  third  edition,  1919 
(review),  617 

Still,  Dr.  G.  F.,  Prof.  A.  Harden,  and  Mr.  S.  S. 

Zilva,  infantile  scurvy,  17 
Stimulation,  faradic  (Mr.  H.  Platt  and  Mr. 

E.  S.  Brentnall),  884 
Stockman,  Sir  S.,  louping  ill,  350 
Stoddard,  Dr.  J.  L.,  11.  multifermentans 

tenalbm,  13 

Stoicheiometry  (Prof.  S.  Young),  second 
edition,  1918  (review),  224 
Stomach  and  duodenum,  dinner  fork  in  (Mr. 
K.  A.  Lees),  298 

Stomach,  perforation  in  cancer  of,  272;  atonic 
dilatation  of  (Dr.  L.  Brown),  877 
Stomatitis  and  glossitis,  lemon  as  a specific, 
760 

Stonev,  Dr.  Florence,  psoriasis  of  13  years’ 
duration,  847 

Stoney,  Mr.  It.  A.,  secondary  suture  of  wounds, 
978 

Stopford,  Dr.  J.  S.  B.,  gunshot  injuries  of  the 
cervical  nerve  roots,  336 
Strabismus,  new  theory,  1132 
Streaks  in  retina,  613 
Streatfeild  Research  Scholarship,  584 
Street,  Mr.  G.  S.,  At  Home  in  the  War 
(review),  142 

Stretching  tables  for  flexed  thigh  Btumps  after 
amputation,  984 

Stricture,  malignant,  of  thecesophagus,  300 
Strike  in  Belfast,  193 
Strong,  Dr.  H.  J.,  death  of,  315 
Strophanthus  and  strophanthine  (cristallisee), 
384 

Students,  medical,  supply  of,  391 ; In  Switzer- 
land, 1011 

Sturdy,  Capt.  A.  C , M.C.,  R.A.M.C.  (see 
Obituary  of  the  war) 

Sturge,  Dr.  W.  A.,  obituary,  633,  708 
Sugar  in  urine  and  blood,  improved  method 
for  estimation  (Dr.  P.  J.  Cammidge),  939; 
control  in  the  body  (leading  article),  985 
Suggestion,  Advanced  (Neuro-induction)  (Mr. 
H.  Brown)  (review),  302;  Hypnotic,  and 
Psycho-therapeutics  (Mr.  A.  B.  Taplin) 
(review',  302 

Summer  School  of  Civics  and  Eugenics,  549 
Supplement,  medical,  of  the  Medical  Research 
Committee,  522 

Suppuration,  perinephric,  epidemic,  1001, 1044, 
1092 

Suppurative  lesions,  molybdeno  tungsten  arc 
treatment  (Mr.  B.  M.  Young),  108 
Surgeon  in  Arms  (Capt.  R.  J.  Manion,  M.C.) 
(review),  1074 

Surgeons,  sub-assistant,  supply  of,  434 
Surgery,  Aids  to  (Dr.  J.  Cunning  and  Mr. 

C.  A.  Joll),  fourth  edition,  1919  (review),  659 
Surgery  of  the  spinal  cord  in  peace  and  war 
(Mr.  A.  J.  Walton),  243  ; British  military, 
in  the  time  of  Hunter  and  in  the  great  war 
(Sir  A.  Bowlby),  285 

Surgical  Treatment  (Dr.  J.  P.  Warbasee) 
(review).  184 ; complications  following 
exanthematic  typhus  (Dr.  P.  Moure  and  Dr. 
E.  Sorrel),  341 ; appliances,  new  designs,  592  ; 
treatment,  670 ; appliances  for  disabled 
soldiers  (Py  Q),  820 

Surplus  army  medical  equipment  (Py  Q),  864 
Suspension  treatment  of  fractures  of  thigh 
(Dr.  W.  H.  Johnston),  170 
Sussex  Royal  County  Hospital,  meeting,  443  ; 
“Pound  Day,”  504 

Sutherland,  Dr.  H.,  au’otherapy  or  bleeding, 
124  ; acute  ascending  paralysis,  841 ; tubercu- 
losis officers  and  panel  practitioners,  895 
Sutherland,  Dr.  P.  L.,  staining  diphtheria 
bacillus,  218 

Suture  holder,  772  ; secondary,  of  wounds  (Mr. 
R A.  Stoney),  978 

Swayne,  Prof.  W.  C.,  and  Mr.  E.  Russell, 
quinine  as  an  abortifacient,  841 
Sweet,  Dr.  J.  E.,  and  Dr.  H.  B.  Wilmer,  treat- 
ment for  trench  fever,  252 
Swietochowski,  Dr.  G.  de,  unusual  contracture 
of  palmar  fascia,  298 
Swlney  prize,  award,  158,  200 


Syfret,  Dr.  S.  B , death  of,  720 
Sykes,  Maj.  H W.,  R.A.M.C.,  death  of,  395 
Sym,  Dr.  W.  G.,  familiarity  with  the  ophthal- 
moscope, 232 
Symbiosis,  622 

Symns,  Dr.  J.  L.  M.,  and  Dr.  A.  F.  Hurst, 
hysterical  element  in  organic  disease  ami 
injury  of  central  nervous  system,  369 
Symonds,  Mr.  C.  J.,  practice  of  the  absentee, 
45  ; treatment  of  bone  sinuses  by  solid  metal 
drains,  971 

Symptoms,  hysterical  perpetuation  of  (Mr. 

C.  H.  L.  Rixon),  417 ; importance  of,  480 
Syndrome  of  the  foramen  lacerus  posterius, 
188 

Synostosis,  (?)  congenital  (Dr.  Elizabeth  S. 
Chesser),  298 

Synthetic  Drugs,  Chemistry  of  (Dr.  P.  May), 
second  edition,  1918  (review),  224 
Syphilis,  treatment  of  (Dr.  O.  T.  Dinnick), 

1055 

Syphilis,  Wassermann  reaction,  diagnostic 
value  in,  466;  and  Locomotor  Ataxia, 
Intensive  Treatment  by  Aacben  Methods 
(Mr.  R.  Hayes),  third  edition,  1919  (review), 
466  ; primary,  diagnosis  of  (Dr.  S.  F.  Dudley), 
737 

Syphilitic  placentae,  1073 


T 

Tabes  dorsalis,  intravenous  injection  of 
potassium  iodide  in  (Mr.  F.  J.  Devota),  339 
Tachycardia,  paroxysmal,  treatment  by 
respiratory  effort,  853 

Taplin,  Mr.  A.  B.,  Hypnotic  Suggestion  and 
Psycho-therapeutics  (review),  302 
Taylor,  Dr.  J.,  and  Mr.  W.  S.  Edmond, 
advances  in  the  treatment  of  fractures,  46; 
changes  in  the  sella  turcica  in  association 
with  Leber's  atrophy,  300 
Taylor,  Maj.  F.  M.,  R.A.M.C.  (see  Obituary  of 
the  war) 

Tiylor,  Maj.  J.,  teratoma  of  testicular  relic, 
1027 

Taylor,  Mr.  G.,  double  resection  of  bowel,  461 
Taylor,  Sir  F.,  Practice  of  Medicine,  eleventh 
edition,  1918  (review),  22 
Teeth,  dislocation  of  (Mr.  H.  M.  Savery),  399, 
441;  children’s,  905  ; scurvy,  1129 
Telford,  Mr.  E.  D.,  and  Mr.  F.  G.  Narbury, 
repair  of  the  male  urethra,  177 
Temperature  environment  and  thermal  debility 
(Dr.  C.  F.  Sonntag),  836 
Tensor,  a,  826 

Teratoma  of  testicular  relic  (Maj.  J.  Taylor), 
1027 

Territorial  medical  officers  and  demobilisation 
(Py  Q),  918,  960 

Terror-neurosis,  dreams  of,  155 
Testicle,  undescended,  565 
Tetanus,  analysis  of  cases  (Col.  S.  L.  Cummins 
and  Maj.  H.  G.  Gibson),  325;  treated  in 
home  military  hospitals  (Maj. -Gen.  Sir  D. 
Bruce),  331 ; among  British  troops  (Py  Q), 
725 

Tetanus,  revised  memorandum  on,  1125 

Tetanus  without  trismus,  117 

Tetany,  associated  with  sprue  (Surg.  Capt. 

P.  W.  Bassett-Smith),  178 
Therapeutic  pulmonary  trauma,  851 
Thermal  debility  and  temperature  environ- 
ment (Dr.  C.  F.  Sonntag),  836 
Thigh,  fractures  of,  suspension  treatment  (Dr. 

W.  H.  Johnston),  170 
Thiocol,  384 

Thomson,  Dr.  F.,  contact  infection  of  chicken- 
pox,  397 

Thomson,  Dr.  D.,  detoxicated  vaccines,  374  , 
1102 

Thomson,  Dr.  J.  G.,  and  Mr.  C.  H.  Mills, 
malaria  and  Wassermann  reaction,  782 
Thomson,  Dr.  W.  H.,  Treatise  on  Clinical 
Medicine,  second  edition,  1918  (review).  383 
Thomson,  Prof.  A.,  compulsory  Greek  at 
Oxford,  1045 

Thomson,  Sir  J.  J.,  O.M.,  appointed  a member 
of  the  Advisory  Council  to  the  Co  ■ mittee 
of  the  Privy  Council  for  Scientu  c and 
Industrial  Research,  908 
Thomson,  Sir  StClair,  intrinsic  cancer  of 
larynx,  263,  271 

Thoracic  puncture  fluid  (Dr.  S.  R.  Gloyne), 
935 

Thursfield,  Maj.  J.  H.,  Maj.  A.  J.  Jex-Blake, 
Maj.  M.  Foster,  Col.  T.  R.  Elliott,  and  Capt, 
D.  S.  Lewis,  invalidism  caused  by  P.U.O. 
and  trench  fever,  1060 

Thyroid  gland  and  the  sympathetic  nervous 
system  (Dr.  L.  Brown),  831 
Tirard,  Sir  N.,  appointed  consulting  physician 
to  King’s  College  Hospital,  350 
Tissue  destruction,  selective,  430 ; stimulant, 
scarlet  red  powder  as  (Dr.  A.  J.  Turner),  463 
T.N.T.  poisoning,  advisory  committee  on,  47 
Tod,  Mr.  H.,  septic  infection  of  lateral  sinus 
after  injury  at  operation,  340 


Tongue,  lymphangeioma  of,  940 

Tonsil,  endothelioma  of,  300 

Tool  handles,  adaptation  to  crippled  hands, 

664 

Toothless  mother,  the.  922 
Tox.-cmia,  traumatic,  805 

Trade-union  question  and  the  medical  pro- 
fession (leading  article',  345,  397 
Training  and  Rewards  of  the  Physician  (Dr. 

R.  C.  Cabot)  (review),  224 

Traitement  des  Psychonevroses  dc  Guerre  (G. 
Roussy.  J.  Bolsseau,  and  M.  D Oelsnitz) 
(review),  1119 

Transactions  of  the  Sixth  International  Dental 
Congress  (review),  24 

Transfusion  in  diseases  of  the  blood,  379; 
blood,  by  the  citrate  method  (Mr.  A.  Fleming 
and  Dr.  A.  B.  PorteouB),  973,  988 ; of  blood 
(Dr  E.  L Hunt  and  Dr.  Helen  Ingleby),  975, 
988  ; blood,  Pepys  on,  1098 
Transient  hemianopia,  574 
Trauma,  therapeutic  pulmonary,  851 
Traumatic  aneurysm  of  external  carotid  (Dr. 

S.  C.  Dyke),  21 ; lesions,  pathological 
changes  in  (Mr.  A.  J.  Walton),  243 ; toxaemia, 
805 

Traumatic  Osteomyelitis,  ChroDic,  its  Patho- 
logy and  Treatment  (Dr.  J.  B.  White) 
(review),  1074 

Trench  fever  and  P.U.O.,  invalidism  caused 
by  (Col.  T.  R.  Elliott,  Capt.  D.  S.  Lewis, 
Maj.  J.  H.  Thurs6eld,  Maj.  A.  J.  Jex-Blake, 
and  Maj.  M.  Foster),  1060 
Trench  fever,  treatment  (Dr.  J.  E.  Sweet  and 
Dr.  H.  B.  Wilmer),  252;  spiroehsetes  in  the 
blood  in  (Dr.  A.  C.  Coles),  375,  388;  colloidal 
silver  in,  583;  and  malaria  (Dr.  G.  Ward), 
609 ; subacute  (Dr.  J.  H.  Lloyd),  791 ; sub- 
acute, 858 

Treves,  Mr.  E , death  of,  823 
Trimethenal-allyl  carbide  in  influenza,  440 
Tritton,  Sir  E.,  death  of,  45 
“ Trivial”  cases  at  voluntary  ho?pitals,  196 
Tropical  Surgery  and  Diseases  of  the  Far  East 
(Dr.  J.  R.  McDill)  (review),  466 
Tropical  diseases,  new  hospital  for,  946 
Tropics,  health  and  life  in,  644 
Tubal  pregnancy,  110 

Tubby,  Col.  A.  H.,  Dr.  G.  R.  Livingston,  and 
Dr.  J.  W.  Mackie,  treatment  of  gunshot 
■wounds,  251 ; and  Maj.  A.  R.  Ferguson,  Capt. 

T.  J.  Mackie,  and  Capt.  L.  F.  fl'rst,  action 
of  flavine,  838 

Tube  strike,  medical  effects,  279 
Tuberculosis,  hilus,  in  the  adult  (Dr.  C. 
Riviere),  213,  682,  814 ; Service  (leading 
article),  304 ; ex-Service  men,  after-care  of 
(Py  Q),  320:  cutaneous,  chemotherapy  in 
(Mr.  H.  J.  Gauvain),  412;  in  female  muni- 
tion workers,  432  ; public  health  aspect  of, 
464  ; pulmonary,  saccharose  injections  in, 
540,  636,  826;  pneumonic,  acute,  615; 
problem,  future  of,  636;  abdominal,  940 
Tuberculosis  Society  (see  Medical  Societies) 
Tuberculosis  toll  in  Canada,  39 ; service,  con- 
ference on,  119  ; in  relation  to  upper  air-  and 
food-passages,  223 ; in  France,  control  of, 
229 ; compulsory  notification  of,  233,  997 ; 
problem,  future  of  (Mr.  P.  C.  Yarrier-Jones), 
453;  treatment  in  London  (Py  Q',  864; 
officers  and  panel  practitioners,  895;  in  rela- 
tion to  a Ministry  of  Health,  1027 ; in  Navy 
(Py  Q),1137 

Tuberculosis:  Tuberculous  ex-Service  men; 
Suggested  schemefor  a tuberculosis  service  ; 
Government  contributions  to  residential 
treatment  of  tuberculosis;  Hull  After  Care 
Colony;  Bournemouth  After-Care  Colony; 
Welsh  National  Memorial  Association,  310 — 
Compulsory  notification  of  tuberculosis  in 
France;  Decline  of  tuberculosis  in  Trinidad, 
311 -Colonisation  of  the  tuberculous;  Local 
Government  Board  standard  sanatorium,  628 
—Tubercle,  629— Institutional  treatment  for 
insured  persons ; Prevalence  of  tuberculosis 
in  France  ; Tuberculosis  pensions  in  South 
Africa;  American  Red  Cross  Society  in 
France  ; Tuberculous  reports,  854 — American 
Review  of  Tuberculosis  ; North  of  England 
Tuberculosis  Association,  855 
Tuberculous  patients,  Bill  to  provide  treat- 
ment, 233;  soldiers,  discharged  (Py  Q),  401 ; 
glands,  treatment  of.  424 ; and  shell  shock 
cases  (Py  Q),  442;  officers  (Py  Q).  588; 
patients.  Army  huts  for  (Py  Q),  641 ; ex- 
service  men,  after-care  of,  767  ; poor,  in  aid 
of,  814  ; soldiers,  emigration  of  (Py  Q),  821 
Tumour,  cartilaginous,  of  roof  of  the  orbit, 
300 ; pituitary,  613;  pulsating,  of  orbit,  613 ; 
malignant,  of  the  pituitary  body,  613 
Tumours,  cystic,  of  the  vulva,  22  ; two,  of  the 
mesentery.  Ill ; spinal,  clinical  manifesta- 
tions in  (Mr.  A.  J.  Walton),  244 
Turner,  Dr.  A.  J.,  scarlet  red  powder  as  a 
tissue  stimulant.  463 

Turner,  Dr.  A.  L.,  Sir  William  Turner,  K.C.B., 
F.R.S.,  a Chapter  in  Medical  History 
(review),  896 


The  Lancet,] 


INDEX  TO  •VOLUME  I.,  1919. 


[July  5,  1919  xxi 


Turner,  Mr.  Perclval,  buying  practices,  398 

Turner,  Mr.  Philip,  undesceuded  testicle,  565 

Turner,  Sir  William,  K.C.B.,  F.R.S.,  a Chapter 
In  Medical  History  (Dr.  A.  L.  Turner) 
(review),  896 

Tweedy.  Prof.  E.  H.,  lower  uterine  segment 
and  uterine  tendons,  376,  390,  733 

Tweedy,  Sir  J.,  the  late  Henry  Sandford  125  ; 
annual  oration  at  Medical  Society  of  London, 
846 

"Twilight  sleep,”  658 

Tympanic  membrane,  new  method  of  Incision 
(Mr.  It.  Lake).  977 

Typhoid  anil  Paratyphoid  Fever,  Surgical 
Aspects  (Mr.  A.  E.  Webb-Johnson)  (review), 
383 

Typhoid  fever  treated  by  colloidal  iron,  424; 
meningeal  haemorrhage  in,  519 ; fever,  pre- 
vention, 950 

Typhus  and  encephalitis  lethargica,  156 

Typhus,  exanthematic,  surgical  complications 
following  (Dr.  P.  Moure  and  Dr.  E.  Sorrel), 
341 ; exanthematic,  nervous  complications 
(A.  Devaux),567  ; in  Europe,  1053 

Tyrrell,  Dr.  E.  J.,  intolerance  of  aspirin,  1118 


U 


Ulcerative  endocarditis,  rapidly  fatal,  due  to  a 
Gram-positive  pleomorphic  diplococcus  (Dr. 
M.  J.  Stewart,  and  Dr.  H.  L.  Flint),  1114 
Ulster  branch  of  British  Medical  Association, 
1010 

Ultra-violet  rays  and  plant  stimulation,  430 
Unholy  holidays,  904 

Unilateral  hydrothorax  due  to  dis°ase  below 
the  diaphragm  (Mr.  W.  G.  Nash),  378 
United  States  X Kay  Manual  (review),  224 
University  College  Hospital,  report,  585;  and 
hospital  war  memorial,  999 
Urethra,  male,  repair  of  (Mr.  E.  D.  Telford  and 
Mr.  F.  G Norbury),  177 
Urethral  nozzle,  514 

Urology,  Modern  (Dr.  H.  Cabot)  (review),  467 
Uterine  fibroid,  spontaneous  enucleation,  301  ; 
segment,  lower,  and  uterine  tendons  (Prof. 
E.  II.  Tweedy),  376.  390,  431.  723,  815 
Uterus,  special  supports  of,  904 


V 


Vacancies,  weekly  lists  of,  49,  89,  127,  162,  200, 
240,  283,  321,  362,  403,  445.  487,  537,  589,  642, 
686,  726,  770,  824, 865,  919, 961, 1009. 1051,  1096, 

: 1138 

Vaccination  (Py  Q),  484;  public,  lymph  for 
(Py  Q),  484 ; prosecutions  in  Wexford  (Py  Q), 
1051 

Vaccination  and  small-pox,  half  a century  of 
(Dr.  J.  C.  McVail),  449 

Vaccine,  influenza  (mixed),  24;  lymph,  com- 
mercial, quality  of,  306,  3! 3.  357  ; therapy, 
causes  of  failure  (Sir  A.  E.  Wright),  491 ; use 
of,  in  influenza  (Dr.  F.  T.  Cadham),  855 ; 
lymph  (Py  Q),  918 

Vaccines  and  Sera,  their  Clinical  Value  in 
Military  and  Civilian  Practice  (Dr.  A.  G. 
Shera)  (Oxford  War  Primers)  (review),  426 

Vaccines  and  serums  supplied  to  the  Royal 
Navy,  145 

Vaccines,  detoxicated  (Dr.  D.  Thomson),  374  ; 
with  special  reference  to  gonorrhoea,  nasal 
and  bronchial  catarrh,  and  influenza, 
1102  ; influenza,  476 ; pus,  in  the  treatment  of 
gonorrhoea  (Mr.  E.  G.  D.  Pineo  and  Dr.  D.M. 
Baillie),  508;  preventive,  for  influenza, 
707 

Vaccines,  detoxicated  (leading  article),  1123 

Vaccinia,  generalised,  fatal  case,  906;  In  treat- 
ment of  gonorrhoea  (Dr.  D.  Lees),  1107 

V.A.D.,  the  future  of,  77;  and  the  College  of 
Ambulance,  271 

Valenda  spray,  898 

Varrier-Jones,  Mr.  P.  C.,  future  of  tuberculosis 
problem,  453 

Vellacott,  Mr.  P.  N.,  spinal  injury  with  reten- 
tion of  mine.  733 

Venereal  disease  in  the  Army,  prevention  and 
arrest,  discussion.  1C9;  treatment  (Sir  A. 
Reid  and  Dr.  P.  H.  Boyden),  212  314  ; com- 
bating (Py  Q),  321 ; disease(BrevetCol.  L.  W. 
Harrison),  713 ; treatmentcentres  in  Glasgow, 

| 813;  disease  (Py  Q),  864 ; remedies  for  (Py  Q), 

918  ; and  crime,  950 ; among  the  troops 
(Py  Q),  1050 

Venereal  disease,  control  of : Comprehensive 
programme  of  the  National  Council ; Anti- 
venereal  campaign  in  the  United  States,  352 
—In  Ontario,  434, 949— In  Montreal ; Problem 
in  Eastern  Canada,  435 — National  Council 
for  Combating.  ; Red  Cross  Conference  at 
Cannes;  syphilis  number  of  Paris  Medical; 
Flexner’s  “ Prostitution  in  Europe,"  i 130 


Venereal  diseases,  pregnant  womon  suffering 
from,  residential  treatment,  80;  In  Egypt 
during  the  war,  management  of,  140.  198 ; 
mobilisation  of,  230;  (Py<i),  534;  infection 
(P.Y  Q),  587  ; notification  of  (Py  Q),  685; 
diagnosis  of,  and  laboratory  methods,  817, 
859 

Ventilation  in  tho  tropics,  922 
Vermiform  appendix,  examination  by  X rays 
(Dr.  E.  I.  Spriggs),  91 

Vernet,  Dr.  M.,  syndrome  of  the  foramen 
lacerum  posterins,  188 

Vernon,  Dr.  H.  M , causation  and  prevention 
of  industrial  accidents,  549 
Veronidia,  24 

Veterinary  Post-mortem  Technic  (Dr.  W. 

Crocker)  (review),  225 
Veulle,  Do,  case  of,  680 

Vevey,  Dr.  S.  A.  de,  treatment  of  Influenza  and 
infectious  diseases  by  lymphotherapy  and 
bsematot h crapy,  424 

Vincent,  Cl.,  manifestations  of  emotional 
shock  on  the  battlefield,  69 
Vine,  Dr.  A.  II.,  and  Dr.  T.  P.  Noble,  peri- 
cardiotomy, 107 

Virus,  filter-passing,  in  certain  diseases  (Maj.- 
Gen.  Si ^ J.  R.  Bradford,  Capt.  E.  F.  Bashford, 
and  Capt.  J.  A.  Wilson),  169;  in  influenza, 
280,  313 

Viscber,  Dr.  A.  L.,  and  Prof.  R.  Bing,  psycho- 
logy of  internment,  696 
Visual  perception  of  solid  forms,  1072 
Vital  need,  the,  363  ; a third  factor,  405 
Vital  statistics,  Irish,  conditions  of  medical 
service  in  Ireland,  475 

Vital  statistics  of  England  and  Wales  for  1918, 
196  ; of  Calcutta,  233,  857,  913 
Vital  statistics  of  London  during  November, 
1918,  39;  during  December,  161;  during 
January,  1919,  355;  during  February,  479; 
during  March,  721 ; during  Aprii,  911  ; 
during  May,  1136;  during  the  year  1918, 
637 

Vital  statistics  of  1917,  1034,  1126 
Vital  statistics,  urban,  English,  Scotch,  and 
Irish  towns,  40.  83,  126, 161,  237,  275,311,  354, 
391,  444,  480,  527,  582,  636,  720,  769,  823,  859, 
911,  950,  1000,  1051,  1091,  1136 
Vitamlnes,  unknown  but  essential  accessory 
factors  of  diet  (Prof.  F.  G.  Hopkins),  363; 
the  instability  of,  623 

Vivisection  of  dogs(Py  Q),  820  ; Bill  to  restrict, 
1091 

Vocal  cord,  a plastic  (Dr.  F.  N.  ^Smith), 
108 

Voelcker,  Dr.  A.  F.,  polycy  thsemia  rubra  with 
splenomegaly,  700 

Voluntary  hospitals  and  the  work  of  the 
almoner  (leading  article),  849;  hospitals, 
limitations  of,  952 

Vomiting,  hysterical,  in  soldiers  (Dr.  W.  R. 
Reynell),  18,  118 

Vuillet,  Dr.  Henri,  epidemic  diseases  observed 
in  Rumania  during  the  campaign  of  1916-17, 
569 

Vulva,  cystic  tumours  of,  22 


W 


Waldo,  Dr.  F.  J.,  reappointed  coroner  for  the 
city  and  borough  of  Southwark,  537 

Waldron,  Maj.  C.  W.,  and  Capt.  E.  F.  Risdon, 
mandibular  bone  grafts,  181 

Walter,  Dr.  E.  W.  A.,  compulsory  Greek  at 
Oxford,  1000 

Walker,  Dr.  Jane,  State  medical  service,  141 

Wallace,  Dr.  J.  S.,  causes  and  incidence  of 
dental  caries,  238 

Walls,  Dr.  W.  K.,  advanced  extra-uterine 
pregnancy, 301 

Walton,  Mr.  A.  J..  surgery  of  the  Bpinal  cord  in 
peace  and  war,  243 

Wanted,  a bungalow,  592;  a home,  868;  a 
medical  “Labour  Exchange,”  1001 

War  (Dr.  R.  C.  Macfie)  (review),  1119 

War  bonus,  increased,  to  insurance  practi- 
tioners, 1129 

War  cures,  116  ; deafness,  157,  1S8,  238  ; Office 
and  medical  women  (Py  Q),  402 ; memorial,  a 
practical,  644;  neuroses  (Dr.  F.  W.  Mott), 709, 
766;  neurosis  (Dr.  W.  Brown),  833;  injury 
from  signal  lights,  741  ; memorial  to  officers 
and  men  of  the  R.A.M.C.,  766;  gratuities  to 
nurses  (Py  Q),  1008  ; nurses,  resettlement  of, 
1090 

War  pensioners  in  civil  hospitals  (leading 
article),  186 

War,  role  of  consulting  surgeon  in  (Sir  G.  H. 
Makins),  1099 

War  Story  of  the  Canadian  Army  Medical 
Corps  (Col.  J.  G.  Adami)  (review),  111  ; 
Wounds,  Early  Treatment  (Col.  11.  M.  W. 
Gray)  (review),  513;  Wounds,  Locomotor 
Ataxy  the  Result  of,  Disabilities  of  (Prof.  A. 
Broca)  (review),  799 


W*ll,  THE,  AND  AFTER:— 

Brompton  Hospital  for  Consumption, 
report,  581 

Casualties  among  tho  sons  of  medical  men, 
41,  122,  158.  195,  275.  315,  358,  348,  437,  486, 
531,581,  683.  722,  768,  817.  912 
Casualty  list,  41,  84, 158,  275, 315,  358, 398,  486, 

530.  580.  652,  683,  722,  768,  817,  859,  952. 
1046,  1091 

Central  Medical  War  Committee,  medical 
mobilisation  and  demobilisation,  193;  the 
interests  of  those  who  have  been  od. 
service,  357 

Civil  medical  practitioners’  war  services, 
list,  438 

Decorations,  foreign,  160,193,317,531,632, 
956,  1000,  1068,  1091 

Demobilisation  of  the  British  Red  Cross,  41  ; 
medical,  84  ; scheme  of  Central  Medical 
War  Committee,  84 ; and  mobilisation, 
medical,  work  of  the  Central  Medical  War 
Committee,  193 

Despatches,  mentioned  in,  41,  86,  195,  277, 
437,  331,  683  768,  912.  1048,  1091 
Honours  list,  41,  85,  122,  158,  275,  315,  393, 
437,  531,  632,  768,  999,  1046,  1091 
Medical  practitioners',  civil,  war  services, 
list,  438 

Ministry  of  National  Service,  Sir.  A.  Geddes 
t hanks  the  Medical  Department,  680 
Mobilisation  and  demobilisation,  medical, 
work  of  the  Central  Medical  War 
Committee,  193 
Notice,  brought  to,  160,  399 
Portsmouth  Royal  Hospital,  meeting,  632 
Red  Cross,  British,  demobilisation,  41  ; 

ambulances  for  home  service,  683 
Royal  Army  Medical  Corps,  casualties,  41, 
84,  158,  275,  315,  393,  486,  530,  581,  632,  683, 
722,  817,  859,  952.  1046,  1091  ; honours,  41, 
85, 122,  158.  275,  315,  398.  437,  531,  632,  999, 
1046;  auxiliary  funds,  238,  632  ; temporary 
officers,  1137 

Royal  Medical  Benevolent  Fund  War 
Emergency  Fund,  315,  358,  684,  999 
Sanatoria  for  discharged  soldiers  and  sailors 
suffering  from  tuberculosis,  859 
Sons  of  medical  men,  deaths  in  the  war,  41, 
122,  158,  193,  275,  315,  358,  398,  437,  486,531, 

531,  683,  722.  768,  817,  912 

University  College  and  Hospital  War 
Memorial,  999 

Webb,  Col.  A.,  A.M.S.,  appointed  Director- 
General  of  the  Medical  Branch  of  Ministry 
of  Pensions,  238 

War.  the  great,  total  deaths  from  wounds  in, 
406;  the  next,  man  versus  insects,  434; 
lessons  of  (Sir  A.  E.  Wright),  489 
War,  weather,  and  water-supply,  1128 
Warbasse,  Dr.  J.  P.,  Surgical  Treatment 
(review),  184 
Warble  fly,  the,  472 

Ward,  Capt.  Gordon,  apyrexial  symptoms  of 
malaria,  222;  malaria  and  trench  fever,  609  p 
notification  of  dysentery,  723  ; literature  of 
hematology,  817 

Wardrop,  Dr.  J.  G.,  and  Dr.  A.  E.  Malone, 
recurrent  chylothorax  following  trauma,  1116. 
Waring,  Mr.  H.  G.,  admission  of  pensioners 
to  civil  hospitals,  179 
Warning,  164 

Warren,  Mr.  R.,  diaphragmatic  hernia,  1069, 
1089 

Wassermann  reaction,  diagnostic  value  in 
syphilis,  466  ; a criticism  of  its  reliability 
(Dr.  C.  F.  White.  Dr.  A.  T.  McWhirt  r,  and 
Dr.  H.  Barber),  502;  and  malaria  (Or.  J.  G. 
Thomson  and  Mr.  C.  H.  Mills),  782;  tests 
(Dr.  C.  H.  Browning  and  Dr.  E.  L. 
Kennaway),  785  ; significance  of,  807 
Water-supply,  Metropolitan,  during  July, 
August,  and  September,  1918,  £0 ; during 
October,  November,  and  December,  1918, 
363:  during  January,  February,  and  March, 
1919,  1098 

Water-supply,  war,  weather,  and,  1128 
Watson,  Capt.  A.,  death  from  scorpion  stings, 
884 

Watson,  Dr.  D.  C.,  coordination  of  clinical 
research  by  the  State,  989,  992 
Watson-Williams,  Dr.  P.,  chronic  adhesive 
oiitis,  893 

Watts,  Mr.  F.,  Echo  Personalities  (review), 
983 

Webb,  Col.  A.  W„  A.M.S.,  appointed  Director- 
General  of  the  Medical  Branch  of  the 
Ministry  of  Pensions,  238 
Webb-Johnson,  Mr.  A.  E.,  Surgical  Aspects  of 
Tvphoid  and  Paratyphoid  Fevers  (review), 
383 

Weight,  increase  effected  by  diet  of  low 
calorific  *alue,  940 

West,  Dr.  S.,  the  hypothermic,  or  depression, 
stage  of  influenza.  196 

West,  Mr.  J.  L.,  saccharose  injections  in  pul- 
monary tuberculosis,  540 


xxii  The  Lancet.] 


INDEX  TO  VOLUME  I.,  1919. 


[July  5,  1919 


West  London  Medico-Chirurgical  Society  (see 
Medical  Societies) 

Westminster  Hospital,  future  of,  272 
Weston,  Mr.  F.  IS.,  and  Mr.  P.  J.  Fryer, 
Technical  Handbook  of  Oils,  Fats,  and  Waxes 
(review),  897 

Wheelhouse's  operation  (Mr.  J.  B.  Macalpine), 
334 

Whipple,  Mr.  R.  S..  electrical  methods  of 
measuring  body  temperature,  564 ; the 
electro  cardiograph,  564 
Whisky  and  water,  270 
Whisky  for  medical  purposes  (Py  Q),  442 
White,  Dr.  C.  F.,  Dr.  A.  T.  MeWhirter,  and  Dr. 
H.  Barber,  Wassermann  reaction,  a criticism 
of  its  reliability,  502 

White,  Dr.  J.  R.,  Chronic  Traumatic  Osteo- 
myelitis, its  Pathology  and  Treatment 
(review),  1074 

White,  Dr.  W.  H.,  teaching  of  medicine,  31 
White,  Maj.  F.  N.,  twenty  years  of  plague  in 
ndia,  349 

White,  Mr.  C.,  foetus  during  spontaneous 
evolution,  610;  full-time  pregnancy  in  a 
rudimentary  uterine  horn,  612 
Whiteford,  Mr.C.  H.,  discussion  on  shock  at  the 
Royal  Society  of  Medicine,  357 ; a suture 
holder,  772 

Whiting,  Dr.  A.,  Aids  to  Medical  Diagnosis, 
second  edition,  1918  (review),  112 
Whitworth,  Capt.  H.  P.,  R.A.M.C.  (see 
Obituary  of  the  war) 

Whom  the  Kingdelighteth  to  honour,  1039 
Whooping  cough,  problem  in  treatment  (Dr. 
N.  Macleod),  254 

Whyte,  Capt.  G.  T.,  R.A.M.C.  (see  Obituary 
of  the  war) 

Widows'  pensions  in  the  Navy,  724 
Wiglesworth,  Dr.  J.,  death  of,  915, 1042 
Wigmore  Hall,  medical  meeting,  240,  362 
Wilkie,  Dr.  D.  P.  D.,  acute  appendicitis  and 
acute  appendicular  obstruction,  197 
Willcox,  Dr.  W.  H.,  jaundice,  869,  929;  toxic 
jaundice,  871 

Willett,  Dr.  J.  H.,  ectopic  gestation,  22; 
spontaneous  enucleation  of  uterine  fibroid, 
301 

William  Gibson  Research  Scholarship  for 
Women,  585 

Williams,  Mr.  J.  P.,  blackwater  fever,  886 
Williams,  Dr.  Mary  H.,  immunity  in 
“influenza,”  529;  hilus  tuberculosis  in 
children  and  adults,  682 
Williamson,  Dr.  H.,  specimen  shown  105  years 
ago, 611 

Wilmer,  Dr.  II.  B.,  and  Dr.  J.  B.  Sweet,  treat- 
ment for  trench  fever,  252 


Wilson,  Capt.  J.  A.,  Maj. -Gen.  Sir  J.  R. 
Bradford,  and  Capt.  E.  F.  Bashford,  filter 
passing  virus  in  certain  diseases,  169  ; acute 
infective  polyneuritis,  348 
Wilson,  Capt.  W.  D.  C.,  R.A.M.C.  (see  Obituary 
of  the  war) 

Wilson,  Dr.  H.,  post-influenzal  hremoptysis, 

Wilson,  Dr.  R.  M.,  Hearts  of  Man  (review), 

701 

Wilson,  Dr.  W.  J.,  gas  gangrene,  657 
Wilson,  Lieut.-Col.  E.  M.,  lt.A.M  C.  Fund  and 
R.A.M.C.  Officers'  Benevolent  Society, 
858 

Wingfield,  Dr.  R.  C.,  tuberculosis  in  relation  to 
a Ministry  of  Health,  1027 
Wmter,  Mr  F.  I.,  aspect  of  psycho-analysis, 

Wirgman,  Dr.  C.  W.,  preventive  inoculation 
against  influenza,  357 
Wise,  Dr.  C.  n.,  death  of,  443 
Woman  and  the  legal  profession,  680 ; doctor 
sued  by  member  of  the  Q.M.A.A.C.,  1040 
Women  and  methylated  spirits  (Py  Q),  401 ; 
medical,  and  the  War  Office  (Py  Q),  402; 
medical  officers  in  military’ hospitals  (Py  Q), 
442 ; chiefs,  583,  636  683 ; and  the  Medical 
Society  of  London,  851 

Women  in  industry  (leading  article),  899  ; and 
the  Medical  Society  of  London,  851,  944, 
989 

Wood,  Capt.  R.,  Whole  Duty  of  the  Regi- 
mental Medical  Officer  (review),  466 
Wood,  Dr.  H.  B.,  Sanitation  Perfectly  Applied 
(review).  659 

Woodcock,  Dr.  H.  de  C.,  treatment  of  tuber- 
culous glands,  424 

Word-association  test  in  psychiatry.  234 ; 

Studies  in  (Dr.  C.  G.  Jung)  (review),  234 
Words  causing  physical  injury,  270 
Worm,  round,  migration  into  the  ear,  28 
Worster-Drought,  Dr.  C.,  and  Dr.  A.  M. 
Kennedy,  Cerebro  spinal  Fever  (review’), 
1073 

Worth,  Mr.  E.  H.,  “ourselves  only,”  913 
Wound  shook,  668 

Wounds,  gunshot,  treatment  (Mr.  A.  H.  Tubby, 
Dr.  G.  R.  Livingston,  and  Dr.  J.  W. 
Mackie),  251 ; Infected,  treatment  (Mr.  E.  G. 
Slesinger),  367;  war,  6eptic  (Sir  A.  E. 
Wright’,  492;  War,  Early  Treatment  (Col. 
II.  M.  W.  Gray)  (review),  513;  gunshot,  of 
the  chest,  666,  667 ; gunshot,  and  other 
affections  of  the  chest  (Mr.  C.  MacMahon), 
697;  Gunshot,  and  their  After  Treatment, 
Orthopaedic  Effects  (Dr.  S.  W.  Daw)  (review), 
847 


Wounds,  healed,  latent  infection  of  (Sir  K. 
Goadby),  879  ; and  Injuries,  After-Treatment 
(Maj.  R.  C.  Elmslie)  (review),  896 ; secondary 
suture  of  (Mr.  R.  A.  Stoney),  978 
Wright,  Sir  A.  E.,  lessons  of  the  war,  489 
Wright,  Capt.  A.  F„  new  “606''  apparatus,  618 
Wrightson,  Sir  T.,  and  Prof.  A.  Keith,  new 
theory  of  hearing,  510 

Wylie,  Dr.  A.  p9ritonsillar  abscess,  178; 
formalin  spray  in  checking  influenza,  256 


X ray  examination  of  vermiform  appendix  (Dr. 
E.  I.  Spriggs),  91 

X Ray  Technic  (Maj.  A.  C.  Christie)  (review), 
184 ; Manual,  United  States  (review), 
224 

X rays  in  diagnosis  of  appendicitis,  279 
X rays,  experimental  studies  with  small  doses 
(Dr.  S.  Russ,  Dr.  Helen  Chambers,  Dr. 
Gladwys  M.  Scott,  and  Dr.  J.  C.  Mottram), 
692 


Yamanouehi,  Prof.  T.,  Dr.  K.  Sakakami,  and 
Dr.  S.  Iwashima,  infecting  agent  in  in- 
fluenza, 971 

Y.M.C.A.  Agricultural  Training  Colony, 
Kinson,  Dorset,  456 

Yorke,  Prof.  W.,  amcebic  dysentery,  674 

Young,  Capt.  R.  P.,  Aust.  A M.C.  (see  Obituary 
of  the  war) 

Young,  Mr.  B.  M.,  molybdeno-tungsten  arc  In 
treatment  of  various  suppurative  lesions, 
108 

Young,  Mr.  G.,  doable  sclerectomy  operation 
for  glaucoma,  893 

Young,  Prof.  S.,  Stoieheiometry,  second 
edition,  1918  (review),  224 

Yovanovitch,  Mr.  Y.,  children  of  devastated 
Serbia,  963 


Zilva,  Mr.  S.  S.,  Dr.  G.  F.  Still,  and  Prof.  A. 

Harden,  infantile  scurvy,  17 
Zimmern,  Prof.  A.,  and  M.  P’erre  Perol, 
Electro-Diagnosis  in  War  (review),  468 


END  OF  THE  FIRST  VOLUME  FOR  1919. 


Printed  and  Published  by  the  Proprietors,  Waklet  and  Son  (1912),  Ltd.,  at  No.  423,  Strand,  and  Nos.  1 and  2,  Be- '.ford -street,  Strati1., 
in  the  Perish  of  St.  Martin-in-the- Fields,  Westminster,  in  the  County  of  London.— Saturday,  July  5th,  1919. 


THE  LANCET,  July  5,  1919 


®J je  (Saulstairian  fccturcs 

ON 

THE  SPREAD  OF  BACTERIAL  INFECTION. 

Delivered  before  the  Royal  College  of  Physioians  of  London 

By  W.  W.  C.  TOPLEY,  M.A.,  M.D.  Cantab.,  F.R.C.P., 

DIRECTOR  OF  INSTITUTE  OF  PATHOLOGY,  CHARING  CROSS  HOSPITAL. 

LECTURE  I. 

[IN  ABRIDGED  FORM.] 

Mr.  President,  Ladies,  and  Gentlemen,— It  is  my 
•first  and  most  pleasant  duty  to  return  thanks  for  the  honour 
of  selection  as  Goulstonian  lecturer.  It  is  common  with 
lecturers  to  claim  indulgence,  but  I fear  that  in  my  own  case 
the  plea  is  unusually  necessary.  If  the  experimental  part  of 
the  evidence  which  I lay  before  you  is  incomplete,  and  in 
cases  fragmentary,  I would  ask  you  to  remember  that  the 
circumstances  of  the  past  year  have  rendered  research  work 
of  any  kind  far  from  easy. 

In  selecting  a subject  for  such  lectures  as  these  one’s 
thoughts  naturally  turn  to  those  aspects  of  medical  work 
which  have  recently  impressed  themselves  most  forcibly  on 
the  attention.  While  serving  under  Colonel  Hunter  in 
Serbia  during  1915  it  was  my  lot  to  be  witness  what  was,  I 
suppose,  when  considered  in  all  its  aspects,  one  of  the  most 
terrible  epidemics  of  recent  times.  Since  my  return  to  work 
at  my  own  hospital  the  routine  examinations  in  the  labora- 
tory, especially  in  connexion  with  the  military  wards,  have 
kept  constantly  before  us  the  bacteriological  aspects  of 
preventive  medicine  as  applied  to  war  conditions.  It  seemed, 
therefore,  not  unnatural  to  attempt  to  bring  together  such 
data  as  we  possess  with  regard  to  the  spread,  and  especially 
the  epidemic  spread,  of  bacterial  infection  ; and  to  supple- 
ment it,  if  possible,  by  experimental  inquiry  in  the  hope  that 
the  result  might  be  of  interest  to  others,  and  the  certainty 
that  the  exercise  would  at  least  be  of  benefit  to  myself. 

The  Ways  of  Approaching  the  Question. 

The  subject  under  discussion  may  be  approached  from  at 
least  three  sides,  the  epidemiological,  the  bacteriological, 
and  the  biometrical.  The  first  and  third  may  perhaps  be 
regarded  as  identical,  but  the  statistics  of  the  epidemiologist, 
who  is  concerned  mainly  with  the  historical  and  geographical 
aspects  of  his  subject,  differ  so  widely  from  those  mathe- 
matical methods  more  recently  evolved  that  biometrics  has 
developed  a technique  which  it  seems  better  to  regard  as 
belonging  to  a separate  branch  of  biological  science.  While 
it  is  with  the  bacteriological  aspect  of  the  question  that  I 
am  here  mainly  concerned,  yet  it  is  impossible  to  consider 
one  side  of  the  .problem  alone  without  losing  all  sense  of 
proportion. 

The  Epidemiological  Aspect. 

If  we  survey  the  results  hitherto  obtained  in  the 
epidemiological  and  bacteriological  fields  we  note  at  once 
that  the  two  lines  of  inquiry  tend  to  emphasise  two  different 
aspects  of  the  phenomena  observed.  The  epidemiologist 
puts  before  us  a picture  of  certain  diseases,  varying  often 
in  their  less  important  details,  but  showing  a remarkable 
conformity  to  type  when  the  whole  aggregate  of  manifesta- 
tions is  considered,  which  arise  for  some  unaccountable 
reason  and  attack  a larger  or  smaller  portion  of  the  popula- 
tion living  at  the  time.  After  causing  ravages  of  greater 
or  less  extent  they  seem  to  disappear  again  only  to 
reappear  after  a longer  or  shorter  interval,  and  again  run 
their  course.  Moreover,  each  successive  visitation  bears  a 
striking  resemblance  to  its  predecessor,  though  the  total 
number  of  cases,  the  total  mortality  in  any  'one  centre  of 
population,  and  the  distribution  of  the  epidemic  over  the 
inhabited  parts  of  the  earth,  vary  greatly  from  one  outbreak 
to  another. 

Thus  epidemiology  tends  to  lay  stress  on  the  constancy 
of  a disease,  as  some  process  which  continues  through  long 
ages  of  history,  now  rising  to  a climax,  now  relapsing  into 
insignificance,  but  remaining  a constantly  menacing  factor 
among  the  mass  of  circumstances  that  constitute  the  environ- 
ment of  our  species.  Thus  it  is  possible  to  trace  some  of  our 
epidemic  diseases  back  into  tbe  dark  ages  of  medical  history, 

No  5001. 


and  though  we  have  only  to  go  back  a little  way,  as  regards 
historical  time  (to  say  nothing  of  time  as  it  is  regarded  by 
the  biologist  or  geologist),  to  find  the  way  confused  and  the 
shapes  before  us  vague  and  doubtful,  yet  we  can  trace  like- 
nesses that  leave  us  in  little  doubt  that  most  of  the  enemies 
with  whom  we  are  now  engaged  have  troubled  our  fathers 
before  us. 

Bacteriological  Lines  of  Inquiry. 

When  we  turn  to  the  bacteriological  aspect  of  the  question 
we  find  a very  different  picture.  Workers  in  this  field  have 
been  more  concerned  with  the  minute  investigation  of  com- 
paratively small  samples  of  cases  than  with  the  broad  view 
of  an  epidemic  of  disease  as  a biological  process.  By  these 
investigations  they  have  been  able  to  identify  the  causal 
organism  of  certain  of  the  more  important  communicable 
diseases,  and  in  recent  years  have  brought  forward  data  of 
the  greatest  importance  for  a better  understanding  of  the 
factors  involved  in  the  spread  of  such  infections.  The 
foundations  of  bacteriology,  indeed,  rest  on  Pasteur’s  obser- 
vations on  the  nature  and  prevention  of  infections  charac- 
terised by  their  ready  spread. 

Rapid  advance  in  the  investigation  of  epidemic  disease 
along  bacteriological  lines  has,  however,  been  so  far  pre- 
vented by  two  outstanding  difficulties.  The  very  diseases 
which  would  afford  the  most  favourable  field  for  study  are 
just  those  in  which  'the  causal  organisms  are  unknown. 
Scarlet  fever,  measles,  small-pox,  and  chicken-pox,  to 
mention  only  a few  of  the  more  outstanding  examples,  still 
await  a satisfactory  elucidation  from  this  point  of  view. 
We  have  lost  faith  in  one  of  our  supposed  causal  organisms 
during  the  world-wide  influenza  epidemic  which  is  still  with 
us,  and  already  there  are  many  claimants  to  the  vacant 
place,  but  no  one  of  them  has  yet  established  its  position. 

The  other  great  obstacle  we  have  to  face  is  our  inability 
to  convey  to  laboratory  animals  diseases  as  they  occur  in 
man.  We  can  produce  lesions  of  a definite  and  specific 
nature  in  the  majority  of  cases,  but  not  the  actual  disease 
in  all  its  features,  and  among  the  features  most  frequently 
lost  is  that  tendency  to  spread  of  infection  which  we  should 
specially  desire  to  study. 

In  spite  of  these  limitations  much  has  already  been 
accomplished,  and  though  much  remains  to  be  done  there  is 
little  doubt  that  we  are  steadily  gaining  that  knowledge 
which,  if  properly  applied,  will  enable  us  to  deal  effectively 
with  the  great  problem  of  infective  diseases. 

In  any  attempt  to  form  a bacteriological  conception  of 
the  processes  involved  in  the  epidemic  spread  of  infection 
the  ascertained  facts  of  epidemiology  must  be  kept  con- 
stantly in  mind. 

The  Main  Problems. 

We  may  commence  by  asking  ourselves  what  are  the  main 
problems  to  be  solved  and  the  most  striking  phenomena  to 
be  accounted  for,  assuming,  as  we  have,  I think,  the  right 
to  do,  that  the  organisms  which  the  best  bacteriological 
opinion  regards  as  having  established  their  causative  role, 
do  indeed  play  that  part  in  the  diseases  in  question,  and 
that  in  other  cases  we  are  dealing  with  an  unknown  cause 
of  essentially  similar  nature. 

Considering  the  general  picture  presented  by  the  historical 
and  geographical  data  concerning  any  one  of  these  diseases 
which  have  from  time  to  time  assumed  an  epidemic  form, 
the  questions  that  force  themselves  most  prominently  before 
us  are  probably  the  following  : — 

(1)  Since  the  outbreaks  are  separated  from  one  another 
by  intervals  of  time,  during  which  there  may  be  a complete 
absence  of  the  disease  in  its  classical  form,  it  is  necessary  to 
explain  how  and  why  the  specific  virus  remains  dormant  for 
periods  often  extending  over  many  years. 

(2)  If  we  can  obtain  a reasonably  complete  answer  to  this 
preliminary  question,  there  remains  the  problem  of  why  it  is 
that  the  dormant  virus  periodically  awakens  to  activity  and 
gives  rise  to  those  outbreaks  of  disease  which,  in  their 
pandemic  or  epidemic  forms,  show  such  strikingly  constant 
characteristics.  In  seeking  an  answer  to  this  question  it  will 
be  necessary  to  include  as  facts  to  be  explained  those  well- 
known  preliminary  phenomena  which  so  often  precede  the 
appearance  of  an  epidemic. 

(3)  If  it  be  possible  to  form  some  reasonable  conception 
of  the  causes  which  originate  an  epidemic  it  will  still  be 
necessary  to  show  that  such  causes,  operating  further,  will 
tend  to  produce  the  phenomena  which  are  to  be  observed  in 
the  rise  and  subsequent  subsidence  of  the  wave  of  disease. 

A 


2 The  Lanobt,]  DR.  W.  W.  0.  TOPLEY  : THE  SPREAD  OF  BACTERIAL  INFECTION. 


[July  6. 1919 


Any  tenable  theory  must  thus  explain  the  constant  presence 
of  a specific  cause  of  disease  through  long  periods  of  time, 
the  periodic  reappearance  of  the  disease  in  epidemio  form 
and  the  characteristic  form  of  each  such  wave  of  disease  in 
its  rise,  crest,  and  subsidence,  leading  to  another  disease- 
free  period. 

The  Human  Carrier. 

The  gradual  accumulation  of  evidence  pointing  to  the 
importance  of  the  human  carrier  as  a factor  in  the  persist- 
ence of  a bacterial  virus  during  inter-epidemio  periods 
has  profoundly  altered  our  conception  on  these  matters.  In 
how  far  persistence  in  soil,  water,  or  other  inanimate 
habitats  may  contribute  to  the  preservation  of  pathogenic 
bacterial  species,  we  have  po  certain  knowledge  ; nor  have 
we  in  most  cases  adequate  data  on  the  prolonged  existence 
in  other  animal  hosts  of  bacteria  potentially  pathogenic  for 
man — a factor  which  is  probably  of  far  greater  importance. 
The  fact  which  has  been  brought  into  prominence,  and 
which  has  been  more  and  more  clearly  established  as  a 
general  law,  is  the  continued  parasitic  existence  in  man  of 
bacteria  known  to  be  oapable  of  causing  disease,  without 
the  actual  production  of  the  disease  in  question. 

The  extensive  studies  which  have  been  carried  out  in 
connexion  with  the  carrier  problem  have  yielded  data  of  the 
greatest  value  concerning  the  relative  distribution  of  such 
parasites  at  epidemic  as  contrasted  with  non- epidemic  times, 
and  especially  in  epidemic  as  contrasted  with  non-epidemic 
areas.  The  position  as  it  stood  in  1912  is  admirably 
summarised  in  Ledingham  and  Arkwright’s  “ Carrier 
Problem  in  Infectious  Diseases.”  Very  thorough  investiga- 
tions have  been  carried  out  during  the  past  four  years  in 
connexion  with  those  epidemic  diseases  which  have  assumed 
special  importance  under  war  conditions,  and  the  results, 
as  set  forth  in  various  reports  to  the  Medical  Research 
Committee,  to  the  Local  Government  Board,  and  in  other 
papers,  afford  data  of  the  highest  significance. 

Without  considering  in  detail  the  bacteriological  evidence 
in  connexion  with  eaoh  of  those  epidemic  diseases  in  which 
knowledge  of  the  causative  parasite  enables  us  to  pursue  an 
inquiry  along  these  lines,  we  may  summarise  the  relevant 
facts  which  have  come  to  light,  sometimes  in  one  disease, 
sometimes  in  another,  but  which  are  being  more  and  more 
surely  established  as  general  principles  by  the  gradual 
accumulation  of  evidence. 

Summary  of  Present  Knowledge. 

It  seems  to  be  a general  law  that,  where  a given  bacterial 
infection  is  associated  with  the  presence  of  the  causative 
parasite  in  certain  excretions  or  on  certain  mucous  surfaces, 
the  tendency  is  for  the  organism  to  persist  in  such  situations 
for  a certain  short  interval,  usually  a few  weeks,  and  then  to 
disappear.  In  some  cases,  however,  it  persists  over  much 
longer  periods,  sometimes,  as  in  certain  typhoid  carriers,  for 
25  years  or  more.  These  chronic  carriers  form  a relatively 
small  proportion  of  the  persons  infected,  and  in  many  cases 
there  is  a well-defined  association  between  the  carrier-state 
and  some  other  pathological  condition  in  the  host.  Thus 
typhoid  carriers  are  especially  common  among  those  persons 
who  are  suffering  from  lesions  of  the  gall-bladder,  and  hence 
the  condition  occurs  more  frequently  in  women  than  in  men. 
Similary  the  presence  of  enlarged  and  unhealthy  tonsils 
would  appear  to  contribute  to  the  persistent  carrying  of  the 
B.  diphtherise. 

In  the  case  of  many  bacterial  parasites  there  is  ample 
evidence  that  pathogenic  species  are  distributed  fairly  widely 
throughout  the  general  population,  and  it  seems  probable 
that,  if  any  large  sample  of  the  community  could  be 
minutely  investigated,  most  of'  those  bacteria,  which  are 
recognised  to  be  the  cause  of  the  epidemic  diseases  natural 
to  the  locality  concerned,  would  be  detected  in  one  or  more 
of  the  individuals  examined. 

Carrier-rates  among  Contacts  and  JVon- contacts. 

If  such  an  inquiry  be  carried  out  in  an  area  in  which  an 
epidemic  is  actually  occurring  it  will  be  found  that  a pro- 
portion of  individuals,  in  apparently  perfect  health  but  who 
have  been  in  more  or  le«s  intimate  contact  with  cases  of  the 
disease  in  question,  are  harbouring  the  specific  parasite. 
Moreover,  t.he  percentage  of  snch  carriers  among  healthy 
contacts  will  be  considerably  higher  than  among  the  general 
aon-contact  population.  Thus  Graham-8mitb,  from  collected 
records  of  2132  c&refully-made  observations,  gives  a figure  of 


0 18  per  cent,  as  representing  the  carrier-rate  of  virulent 
diphtheria  bacilli  in  normal  non-contacts,  while  the  same 
observer  found  a carrier-rate  of  10 A per  cent,  among  a 
sample  of  normal  contacts.  Stillman  records  a carrier-rate 
of  0 33  per  cent,  for  Type  1 Pneumococci  among  297  normal 
non- contacts,  but  a rate  of  14  9 per  cent,  among  107  healthy 
contacts  with  cases  of  lobar  pneumonia  due  to  infection  with 
a coccus  of  this  type,  and  a multitude  of  similar  examples 
could  be  quoted. 

If  a comparison  be  made  between  healthy  contacts, 
healthy  non-contacts  resident  in  an  infected  area,  and 
healthy  non-contacts  from  an  area  free  from  the  disease  in 
question,  the  cat  ritr-  rates  obtained  may  be  found  to  form  a 
descending  scale.  Flack  reports  a meningococcal  carrier- 
rate  of  8 53  per  cent,  among  1629  healthy  contacts,  of 
5 53  per  cent.  amoDg  651  healthy  non-contacts  from 
epidemic  areas,  and  of  2 18  per  cent,  among  275  healthy 
non-contacts  from  unaffected  localities.  It  is  a point  of 
some  interest  that,  during  a considerable  epidemic,  the 
carrier-rate  amoog  healthy  non-contacts  may  equal  that 
among  healthy  contacts  as  demonstrated  by  Glover  in  the 
case  of  the  Meningococcus. 

If.  instead  of  examining  perfectly  healthy  contacts,  we 
confine  ourselves  to  individuals  resident  in  an  epidemic  area, 
and  suffering  from  some  mild  atypical  infection  of  doubtful 
nature,  which  shows  no  clinical  identity  with  the  epidemic 
disease,  we  find  a sharp  rise  in  the  percentage  of  persons 
from  whom  we  can  isolate  the  specific  organism.  Thus  we 
may  compare  the  70  per  cent,  carrier-rate  for  B.  diphtheria 
obtained  by  Kober  when  examining  139  contacts  suffering 
from  mild  sore-throats  with  the  10  4 per  c-nt.  rate  quoted 
above  for  healthy  contacts.  Similarly,  Billet,  Le  B han,  and 
others,  while  investigating  an  outbreak  of  typhoid  fever  in  an 
infantry  regiment,  examined  the  faces  from  64  atypical 
febrile  cases  which  could  not  be  diagnosed  as  typhoid  on 
clinical  grounds,  and  isolated  the  B typhosus  in  13  instances, 
a carrier-rafe  of  20  3 per  cent.,  which  is  vastly  greater  than 
that  ever  found  in  healthy  contacts. 

Rise  and  It  all  of  Carrier  Rates  in  Relation  to  Epidemics. 

In  the  case  of  cerebro-spinal  fever  certain  additional  (acts 
have  been  established  which  are  of  the  greatest  significance. 
It  has  been  shown  by  many  observers  that  the  rise  in  the 
meniogococcal  ca'rier-rate  quite  definitely  precedes  the  out- 
break of  an  epidemic.  So  uniform  is  this  phenomenon  that 
it  has  been  possible  to  set  up  a tentative  limit  of  20  per  cent, 
as  a danger-line,  and  to  regard  a rise  in  the  carrier -rate 
beyond  this  figure  as  a warning  of  the  imminence  of  an 
epidemic.  Moreover,  it  has  been  established  in  the  case  of 
this  disea-e  that  a decline  in  the  carrier-rate  precedes  the 
decline  of  the  epidemic  in  some  cases,  and  in  others  occurs 
more  rapidly  ; so  that  it  is  usual  for  the  percentage  of 
healthy  carriers  to  sink  to  a relatively  low  level  while  cases 
of  the  disease  are  still  occurring.  (Bruns  and  Hohn,  1907  ; 
Hutchens,  1916;  Johnston,  1916;  Glover,  1918,  &c.)  The 
association  of  a high  carrier-rate  with  overcrowding  has  been 
noted  by  many  obseivers,  and  Glover  has  given  a striking 
demonstration  of  the  way  in  which  the  rate  may  be  caused 
to  fall  by  simply  spacing  out  the  beds  in  a sleeping 
apartment. 

The  Tints  of  Scarlet  lever. 

If  we  turn  from  those  diseases,  in  which  knowledge  of  the 
causative  organism  allows  the  problem  to  be  studied  from 
the  bacteriological  point  of  view,  to  other  diseases  in  which 
such  knowledge  is  still  lacking  we  find  that  clinical  and 
epidemiological  studies  have  yielded  results  pointing  in  no 
uncertain  way  to  conclusions  similar  to  those  arrived  at  by 
research  along  bacteriological  lines. 

Thus  Butler,  in  a careful  study  on  “The  Intermittent 
Infectiousness  of  Scarlet  Fever,”  finds  ample  clinical  and 
statistical  evidence  to  support  theviewibatpersonsn-coverfd 
from  scarlet  fever  may  o >nvey  the  infection  to  others  after 
intervals  of  long  duration,  while  those  who  have  never 
suffered  from  a typical  attack  may  convey  the  disease  to 
persons  with  whom  they  come  in  contact.  He  points  out 
further  that  a statistical  inquiry  into  the  frequency  with 
which  sore-throats  in  other  members  of  a household  precede 
a fully  developed  attack  of  scarlet  fever  in  one  of  them, 
leaves  little  doubt  that  the  typical  case  may  be  the  result  of 
infection  from  the  atypical  one. 

He  concludes  that  there  is  little  need  to  assume  an  extra- 
corporeal habitat  for  the  virus  of  this  disease,  if  we  exclude 


Thb  Lancet,] 


DR.  W.  W.  0.  TOPLEY  : THE  SPREAD  OP  BACTERIAL  INFECTION. 


[ J ui,y  6,  1919  3 


milk,  acting  as  a direct  cultural  material,  and  considers  that 
the  facts  point  rather  to  the  continual  diffusion  among  the 
population  of  the  scarlatinal  virus,  which  from  time  to  lime 
is  communicated  from  person  to  person  in  such  toxic 
quantity  and  degree  as  to  give  rise  to  the  typical  sporadic 
or  epidemic  disease. 

Epidemic)  Diseases  of  Plants. 

It  would  be  of  the  greatest  interest  to  look  for  analogies 
in  the  epidemic  diseases  of  plants.  The  relative  simplicity 
of  the  conditions  would  seem  to  afford  hope  that  the 
essential  processes  might  be  traced  more  surely  ihan  in 
human  and  animal  pathology,  and  that  we  might  thus  gain 
further  insight  into  those  general  principles  which  must 
surely  underlie  the  phenomenon  of  epidemic  parasitic  disease 
of  all  kinds. 

Professor  Blackman,  whose  opinion  I have  asked  on  this 
point,  and  who  has  most  kindly  given  me  the  benefit  of  his 
sptcial  knowledge,  has  pointed  out  to  me  the  difficulties  that 
lie  in  the  way  of  arguing  from  plant  to  animal  disease,  or 
vice  versa.  The  structure  of  the  plant-hosts  does  not  seem 
to  afford  the  opportunity  for  the  continued  existence  of  a 
parasitic  flora  apart  from  disease,  if  we  exclude  cases  of 
true  symbiosis.  There  are  no  regions  comparable  to  the 
respiratory  and  alimentary  tracts,  within  the  body  yet  outside 
the  tissues,  iD  which  such  a flora  might  readily  persist. 
Moreover,  the  annual  death  of  many  of  the  host  species,  wi  h 
the  intervention  of  a relatively  long  period  before  the 
appearance  of  a new  generation,  introduces  a factor  which 
is  altogether  absent  in  the  diseases  affecting  man  and 
animals. 

Another  factor  which  makes  difficult  comparison  between 
plant  and  animal  pathology  is  the  relative  complexity  of  the 
tissue  changes,  and  especially  of  the  immunity  reactions 
in  the  latter.  The  existence  of  a specific  parasite  in  a plant 
itself  constitutes  disease  ; in  man  and  animals  it  is  only  one 
essential  tactor. 

It  seems  that  we  must  be  content  to  await  further  ad  vances 
in  our  knowledge  of  parasitism  in  general  be  ore  attempting 
to  coordinate  the  facts  throughout  the  whole  field,  but  it  is 
impossible  to  doubt  that  closer  cooperation  between 
investigators  in  all  branches  of  biological  science  would  be 
of  mutual  benefit,  and  would  throw  light  on  many  of  our 
most  difficult  problems. 

The  Conception  Reached. 

If  we  now  glance  back  and  see  to  what  point  our  inquiry 
has  so  far  led  us,  we  are  left  with  some  such  conception  as 
the  following  : — 

The  first  difficulty  with  which  we  were  faced  in  forming 
any  theory  of  the  spread  of  bacterial  infection,  which  should 
couform  to  the  known  facts  of  epi  temiology,  was  to  find 
some  explanation  of  the  perpetuation  of  the  virus  during 
inter-epidemic  periods.  The  bacteriological  data  which  have 
been  accumulated,  especially  during  the  last  20  years,  have 
shown  that  the  causative  organisms  of  specific  disea-es  are 
to  be  found  in  apparently  normal  persons  who  give  no 
history  of  having  been  in  contact  with  the  disease  in 
question,  as  well  as  in  healthy  contacts  with  actual  cases  ot 
the  disease.  Moreover,  the  organisms  in  question  have  been 
shown,  in  certain  cases,  to  persist  for  long  periods  of  time 
in  or  upin  the  tissues  of  their  ho-ts,  and  we  must  always 
remember  that  the  difficulty  of  bacteriological  technique  is 
likely  to  lead  to  a serious  under- estimate. 

Clinical  and  epidemiological  investigations  have  yielded 
confirmatory  evidence,  and  we  are  thus  left  with  a con- 
ception of  the  virus  of  a given  disease  being  distributed  fairly 
widely  throughout  the  world  as  an  apparently  harmles" 
parasite  on  the  human  host,  but  taking  on  during  epidemic 
periods  a new  and  sinister  tole,  only  to  relapse  again  into 
comparative  quiescence  as  the  epidemic  subsides. 

We  have  seen  that  while  the  organisms  we  hive  considered 
can  live  as  harmless  parasites  on  normal  and  healthy  persons, 
yet  they  become  much  more  plentiful  when  we  examine 
healthy  contacts,  and  more  plentiful  still  if  we  are  dealing 
with  persons  in  an  epidemic  area  who  are  suffering  from 
atypical  and  apparently  unimportant  illnesses.  Thus  we 
find  that  a clinic  ally  typical  case  of  a given  disease  tends 
to  be  surrounded  by  certain  atypical  cases,  from  whom  the 
causative  organisms  may  be  recovered  by  suitable  methods, 
and  by  a much  wid-r  circle  of  health?  individuals,  many  of 
whom  are  acting  as  carriers  of  the  parasite  in  question. 


LECTURE  II. 

It  is  important  to  keep  clearly  before  us  that  the  facts  as 
to  the  distribution  of  the  bacterial  parasite  during  the 
epidemic  period  may  be  interpreted  in  two  ways.  It  is 
perhaps  natural  to  focus  our  attention  on  the  case  of  disease, 
and  regard  it  as  the  centre  from  which  spread  the  atypical 
ca-es  and  the  healthy  carriers.  There  is,  on  the  other  hand, 
the  alternative  hyp  ithesis  that  the  distribution  of  the 
parasite  is  the  expression  of  a biological  process  which  has 
preceded  the  outbreak  of  diseace.  and  that  the  typical  cases 
are  merely  the  final  results  of  this  process.  We  should  Dot, 
of  course,  minimise  the  importance  of  case-to-ca-e  infection, 
nor  cea-*e  to  believe  that  large  numbers  of  contact  carriers 
derive  the  parasites  they  harbour  from  the  sick  individual. 
The  Epidemic  Curve. 

If  we  now  turn  to  the  consideration  of  those  epidemio- 
logical facts  which  must  be  regarded  as  fundamental  in  any 
attempt  to  form  a bacteriological,  or,  as  I should  prefer  to 
regard  it,  a biological  conception  of  the  proces-es  involved 
in  the  rise  and  fall  of  a wave  of  disease,  we  find  certain 
phenomena  which  from  their  very  constancy  must  be 
regarded  as  of  primary  importance  as  clues  to  the  solution 
of  i he  problem. 

The  most  striking  feature  is  undoubtedly  the  symmetry  of 
the  epidemic  curve.  This  phenomenon  has  been  emphasised 
by  countless  epidemiologists.  The  problem  has  been  clearly 
enunciated  by  Brownlee,  who  shows  that  certain  deductions 
may  be  drawn  with  regard  to  the  possible  factors  involved  in 
the  rise  and  decline  of  the  wave. 

We  must,  then,  be  prepared  to  show  that  those  causes 
which  bring  about  the  rise  of  the  wave  of  disease  will,  by 
their  continued  operation,  directly  or  indirectly  give  rise  to 
a subsequent  decline  in  a way  that  is  compatible  with  the 
symmetry  actually  observed.  It  seems  certain  that  the 
processes  leading  to  the  fall  of  the  wave  must  be  the 
essential  consequence  of  th  >se  causes  which  determine  its 
ri-e.  The  constancy  of  the  whole  process  could  hardly  be 
otherwise  explained. 

There  are  other  features  characterising  considerable 
epidemics  which  must  be  taken  into  account,  and  which 
yield  significant  clues.  Among  these  we  may  particularly 
note  the  occu-rence  during  the  earlier  stages  of  an  epidemic 
of  atypical  cases  of  disease  aud  the  reappearance,  to  a less 
extent,  of  these  atypical  cases  during  the  latter  part  of  its 
decline. 

The  periodicity  of  epidemics  and  the  explanation  of  the 
long  epidemic-free  interval  in  certain  cases  form  another 
aspect  of  the  problem  which  will  be  referred  to  later. 

Origin  and  Rise  of  Epidemic  Wave. 

Considering,  then,  the  rise  and  fall  of  the  epidemic  wave, 
it  is  neces-ary  first  to  find  so  ne  explanation  of  its  origin 
and  rise.  There  are  at  least  three  possible  explanations — 
an  increase  in  the  power  of  the  parasite  to  produce  disease, 
a decrease  in  the  resistance  of  the  host,  and  some  alteration 
in  the  surrounding  circum-tances  which  favours  the  trans- 
ference of  parasi'es  from  case  to  case  without  any  alteration 
in  the  pathogenicity  of  the  one  or  in  the  resistance  of 
the  other.  The  third  of  these  hypotheses  may,  I think,  be 
disregarded.  That  alterations  in  environment  may  be  the 
determining  cau-e  in  initiating  an  outbreak  of  bacterial 
disease  is  prohable  enough;  but  they  will  almost  certainly 
act  through  the  variations  which  they  bring  about  in  the 
other  two  factors.  The  whole  of  bacteriological  knowledge 
is  clearly  against  the  occurrence  of  a considerable  epidemic 
in  which  the  pathogenicity  of  the  parasite  and  the  resistance 
of  the  host  remain  constant. 

Again,  while  we  may  well  believe  a lowered  resistance  of 
a certain  number  of  the  host-species  to  be  an  important 
factor  in  the  initiation  of  the  process,  yet  we  cionot  believe 
that  it  is  the  whole  story.  The  widespread  r wages  of  many 
epidemics  would  seem  altogether  to  preclude  such  an 
explanation.  We  seem  forced  therefore  to  the  conclusion 
that  an  increase  in  the  pathogenicity  of  the  sp-cific  parasite 
is  an  essential  fact  r in  the  rise  of  epidemics,  excluding 
from  this  category  small  spiradic  outbreaks  which  may  be 
due  to  the  introduction  of  a fully  virulent  parasite  by  a 
healthy  carrier  or  tn  some  other  way. 

Decline  of  Epidemic  Wave. 

When  we  consider  the  decline  of  the  epidemic  we  are 
faced  with  three  similar  possible  factors — an  alteration  in 


4 Thb  Lanobt,]  DR.  W.  W.  C.  TOPLEY  : THE  SPREAD  OF  BACTERIAL  INFECTION. 


[July  5,  1919 


the  parasite,  now  in  the  direction  of  lessened  pathogenicity  ; 
in  the  host-species,  in  the  direction  of  heightened  resistance  ; 
or  in  the  environmental  conditions,  resulting  in  lessened 
opportunities  for  the  transference  of  the  parasite.  There  is, 
indeed,  in  the  case  of  any  considerable  epidemic,  a fourth 
possibility  : the  elimination  of  all  susceptible  individuals  by 
an  attack  of  the  disease.  This  explanation  has  been 
unanimously  rejected  by  epidemiologists  on  various  grounds. 
Brownlee,  in  the  paper  referred  to  above,  shows  that  it  is 
entirely  incompatible  with  the  observed  symmetry  of  the 
epidemic  curve,  and  that  a progressive  variation  in  the 
biological  activities  of  the  parasite  seems  to  offer  the  most 
satisfactory  explanation  of  the  facts  observed.  But,  while 
there  seems  little  room  for  doubt  that  increased  patho- 
genicity of  the  parasite  must  play  an  essential  part  in  the 
rise  of  the  wave  of  disease,  it  is  much  more  difficult  to 
decide  on  the  relative  importance  of  variations  in  the  powers 
of  parasite  and  host  in  bringing  about  its  decline. 

Definition  of  Terms. 

r It  is  important  at  the  outset  to  define  our  terms.  “ Resist- 
ance ” or  “ immunity  ” expresses 'the  sum  of  the  defensive 
powers  possessed  by  the  host.  When,  however,  we  turn  to 
the  parasite,  we  find  several  terms  used  to  denote  its  powers 
of  attack,  and  the  limits  of  their  implications  are  not  always 
clearly  defined. 

“ Pathogenicity  ” denotes  simply  the  power  of  producing 
disease,  without  reference  to  the  manner  in  which  it  is 
brought  about.  It  is  a property  of  those  organisms  which 
never  cause  extensive  tissue  invasion,  but  which  produce 
their  effects  by  means  of  powerful  exotoxins,  just  as  much  as 
of  those  organisms  which  give  rise  to  a generalised  infection. 
In  referring  to  an  organism  as  pathogenic  for  man  we  imply 
that  it  produces  disease  under  natural  conditions  ; that  is, 
it  is  naturally  infective,  though  the  degree  of  infectivity 
need  bear  no  relation  to  the  degree  of  pathogenicity.  When 
we  state  that  an  organism  is  pathogenic  for  laboratory 
animals  there  is  no  necessary  implication  that  it  can 
produce  disease  under  natural  conditions. 

“ Virulence  ” has  come  to  mean  the  power  of  a parasite  to 
multiply  within  the  tissues  of  the  host.  An  organism  which 
is  highly  pathogenic  need  not  necessarily  be  virulent. 
Conversely,  it  is  possible,  though  rare,  for  a micro- parasite  to 
be  virulent  but  non-pathogenic.  The  rat  trypanosome 
seems  to  afford  an  example,  but  there  is  no  strict  parallel 
among  bacterial  parasites.  Virulence  is  indeed  an  elusive 
term.  It  is  actually  employed  to  express  the  power  of 
bringing  about  a generalised  infection  of  the  host.  It  pays 
no  heed  to  any  possible  variation  in  the  power  or  rate  of 
multiplication  in  different  tissues,  nor  to  the  capacity  for 
bringing  about  that  initial  invasion  of  the  tissues  on  which 
subsequent  events  depend.  Still  less  is  virulence  synonymous 
with  infectivity  ; and  this  is  a point  which  seems  to  be  too 
little  regarded  in  many  epidemiological  and  bacteriological 
studies. 

As  commonly  employed,  the  term  “infectivity”  denotes 
an  attribute  not  of  the  parasite  but  of  the  diseased  person, 
an  attribute,  moreover,  which  depends  on  the  patient’s 
environment  quite  as  much  as  on  himself.  The  infectivity 
of  the  typhoid  patient  or  carrier  is  in  inverse  ratio  to  his 
personal  cleanliness  and  to  the  perfection  of  the  sanitary 
arrangements  under  which  he  lives.  It  is  in  direct  ratio  to 
his  opportunities  for  contaminating  food  or  drink.  The 
malarial  patient  is  infective  in  the  presence  of  the  anopheles 
mosquito,  how  infective  recent  military  experience  has 
demonstrated.  In  a district  free  from  appropriate 
insect  hosts  the  same  patient  is  no  danger  to  the 
community. 

If  we  employ  the  term  “infectivity”  in  speaking  of  a 
bacterial  parasite,  we  should  mean  that,  under  the  conditions 
existing  in  nature,  it  is  in  a favourable  position  to  obtain 
transference  to  a new  host,  and  that  it  is  possessed  of  those 
biological  attributes  which  will  enable  it,  when  so  transferred 
to  give  rise  to  that  sequence  of  events  which  constitutes  an 
attack  of  disease. 

It  is  incorrect,  therefore,  to  state  that  an  increase  in  the 
virulence  of  a bacterial  parasite  will  conduce  to  epidemic 
spread  of  the  disease  to  which  it  gives  rise.  It  will  only  do 
so  if  there  is  an  adequate  degree  of  infectivity.  In  an 
epidemic  of  any  disease  in  which  virulence  of  the  parasite 
is  an  essential  factor  we  need  an  increase  in  both  attributes 
to  fulfil  the  conditions  required. 


Saprophytic  Spread  of  Organisms. 

In  attempting  to  trace  those  processes  which  lead  to  the 
acquirement  by  the  parasite  of  the  attributes  which  enable  it 
to  give  rise  to  a wave  of  disease,  it  is  necessary  at  the  start 
to  form  some  conception  of  the  manner  in  which  it  spreads 
from  those  relatively  scattered  centres  in  which  we  believe 
such  organisms  to  exist  in  inter-epidemic  periods. 

It  is  of  interest  in  this  connexion  to  turn  again  to  the 
case  of  cerebro-spinal  fever.  The  evidence  which  has  been 
collected  with  regard  to  this  disease  has  already  been 
referred  to,  but  two  further  facts  may  be  emphasised — the 
relatively  small  number  of  the  cases  of  disease  in  any 
epidemic  in  comparison  with  the  very  large  number  of 
persons  who  are  carrying  the  meningococcus,  and  the 
frequent  absence  of  any  ascertainable  connexion  between 
successive  cases. 

Consideration  of  all  the  available  evidence  has  led  to  a 
conception  of  the  spread  of  this  disease  which  has  met 
with  very  general  acceptance,  and  which  is  clearly  outlined 
by  the  authors  of  the  recent  report  issued  by  the  Medical 
Research  Committee.  It  is  suggested  that  the  real  epidemic 
consists  of  a widespread  dissemination  of  the  Meningococcus, 
as  a saprophyte,  in  the  throats  of  the  population  at  large. 
The  organism  is  regarded  as  being  only  a potential  tissue- 
parasite,  and  as  having  only  a low  degree  of  virulence  ; so 
that  in  normal  times  its  spread  is  associated  only  with  cases 
of  disease  among  the  most  susceptible  elements  of  the  com- 
munity, that  is,  among  infants.  At  times,  however,  the 
organism  seems  to  acquire  an  increased  virulence,  and  its 
spread  is  associated  with  a larger  number  of  cases  and 
with  the  attack  of  young  adults  who  are  usually  immune. 

Is  it  possible  that  such  a saprophytic  spread  forms 
the  initial  stage  of  epidemics  in  general  1 Assuming  that  it 
does  so,  ft  is  necessary  to  inquire  whether  there  are  valid 
reasons  for  expecting  such  a process  to  culminate  in  the 
elaboration  of  more  infective  and  more  virulent  varieties  of 
the  parasite  concerned.  Certain  recent  observations  would 
seem  to  afford  ground  for  an  affirmative  answer. 

Rate  of  Multiplication  of  Bacteria  and  Virulence. 

The  rate  of  multiplication  of  bacteria  in  a fluid  culture 
medium  has  been  investigated  by  many  observers,  and  more 
recent  observations  by  Penfold,  Ledingham  and  Penfold, 
and  Chesney  have  yielded  information  of  a very  precise  nature 
on  this  point.  It  has  been  shown  that  there  is  a “lag” 
phase,  in  which  multiplication  of  the  bacteria  increases  in 
rapidity,  at  first  slowly  and  then  more  quickly,  until  a 
uniform  rate  of  maximum  or  logarithmic  growth  is  attained. 
After  a time  the  rate  of  multiplication  decreases,  eventually 
giving  place  to  a phase  in  which  the  death  of  organisms 
exceeds  the  rate  of  generation. 

The  relation  of  virulence  to  the  pha'e  of  growth  of  the 
inoculated  culture  has  recently  been  studied  by  Wadsworth 
and  Kirkbride  in  the  case  of  the  Pneumococcus.  Their 
results  show  clearly  that  an  organism  which  exhibits  only  a 
low  degree  of  virulence  when  injected  in  the  form  of  a 
24-hour  culture  in  liquid  medium  may  be  highly  virulent 
after  being  allowed  to  grow  for  6-8  hours  only  in  the  same 
medium.  The  authors  quote  results  which  they  believe  to 
indicate  a definite  increase  in  virulence  of  a strain  of  pneumo- 
coccus by  repeated  subculture  at  8-hour  intervals,  but  a close 
study  of  the  data  given  leaves  a doubt  whether  the  whole 
matter  is  not  explained  by  the  coincidence  in  any  culture  of 
the  phases  of  maximum  virulence  and  maximum  rate  of 
growth.  This  one  point  is,  in  any  case,  clearly  established, 
and  we  may  assume  that  any  organism  will  exhibit  its  highest 
virulence  under  circumstances  in  which  it  is  multiplying 
with  maximum  rapidity,  and  that  a bacterium  which  under 
normal  conditions  is  practically  non-virulent  may  in  such 
circumstances  show  a virulence  of  quite  definite  degree. 

Increase  in  Virulence  by  Natural  Selection. 

Now  it  will  be  clear  that,  in  the  saprophytic  spread  of  a 
bacterial  parasite,  the  conditions  will  tend  to  encourage  the 
transference  of  those  organisms  which  possess  the  greatest 
power  of  rapid  growth,  for  such  organisms  will  come  to  form 
a considerable  proportion  of  the  local  bacterial  flora  of  the 
host,  and  hence  will  obtain  increased  opportunities  for 
transference  to  other  individuals  of  the  host  species.  In 
this  way  natural  selection  will  operate  in  the  direction  of  the 
dissemination  of  the  variety  of  the  parasite  possessing  a 
maximum  power  of  growth  under  the  prevailing  conditions. 


The  Lancet,] 


l’ROF.  R.  KENNEDY:  ON  THE  PROGNOSIS  OF  NERVE  INJURIES. 


[July  5,  1919 


5 


It  would  seem  probable,  then,  that  a saprophytic  spread  of 
a bacterial  parasite  would  lead  naturally  to  the  selective 
propagation  of  those  forms  which  would  be  especially  likely, 
when  introduced  into  the  tissues,  to  multiply  within  them. 
It  is  probable  that  the  bacteria  living  on  a mucous  surface 
are  continually  being  carried  into  the  tissues  in  small 
numbers,  either  by  the  action  of  phagocytic  cells  or  in  some 
other  way.  The  combination  of  the  power  of  rapid  multipli- 
cation on  the  surface  of  the  mucous  membrane,  with  the 
ability  to  multiply  in  the  tissues  when  access  is  gained  to 
them,  will  render  successful  invasion  extremely  probable. 

If,  then,  the  parasite  forsakes  its  saprophytic  role  and 
produces  a localised  infection  of  the  tissues,  it  may  be 
regarded  as  a “passage”  strain.  Should  this  strain  be 
transferred  to  another  individual,  and  so  on  from  host  to 
host,  the  analogy  of  experimental  passage  would  suggest 
that  an  increase  in  virulence  would  result.  Natural  passage, 
resulting  in  such  heightened  virulence,  has  been  frequently 
suggested  as  a possible  explanation  of  the  evolution  of 
highly  pathogenic  strains  of  bacteria  during  epidemic  out- 
breaks of  disease.  It  is  important,  however,  to  realise  that 
the  analogy  of  experimental  passage  breaks  down  at  a vital 
point. 

, When  we  wish  to  exalt  the  virulence  of  an  organism  for  a 
given  species,  we  proceed  by  transference  from  animal  to 
animal,  always  introducing  the  bacteria  into  the  tissues  by 
mechanical  means.  Thus  we  proceed  by  the  selection  of 
strains  which  are  better  and  better  adapted  for  multiplication 
in  the  tissues,  that  is,  more  and  more  virulent  in  the  strict 
sense  of  the  term  ; but  with  the  ability  of  the  parasite  to 
infect  a new  host  under  natural  conditions  we  are  not 
concerned.  This  attribute  is,  as  we  have  seen  above,  of 
decisive  importance  for  the  production  of  epidemic  disease. 

Tit  sue  Invasion. 

If  we  are  to  accept  a series  of  passages  as  the  natural 
mode  of  acquirement  of  increased  virulence,  we  must  believe 
that  the  chances  of  transference,  and  hence  of  selective 
propagation,  are  increased  by  tissue  invasion.  In  some  cases 
we  find  ample  reason  for  believing  that  such  a result  will 
follow.  Whenever  successful  invasion  results  in  the  forma- 
tion of  lesions  of  mucous  surfaces  the  discharges  from  which 
naturally  pass  to  the  surface  of  the  body  and  are  frequently 
or  continuously  emitted  into  the  surrounding  medium,  it  is 
clear  that  increased  opportunities  for  passage  will  occur. 
In  the  case  of  diseases  transmitted  by  biting  insects  it  is  still 
more  obvious  that  successful  and  generalised  invasion  of 
the  tissues  will  be  a decisive  advantage  in  gaining 
transference  to  a new  host.  Here,  indeed,  we  are  dealing 
with  conditions  which  approximate  closely  to  those  obtaining 
in  experimental  passage. 

It  is  in  many  of  those  infectious  diseases  in  which  we  have 
good  grounds  for  believing  that  transference  from  host  to 
host  occurs  via  the  naso-pharynx  that  we  are  faced  with  the 
most  obvious  difficulty.  In  some  cases  there  are,  indeed, 
local  lesions  which  will  readily  explain  the  infection  of  a 
fresh  host,  but  in  some  others  the  best  clinical  observation 
reports  the  striking  absence  of  local  changes.  Thus  in  the 
case  of  influenza  there  seems  no  doubt  of  the  frequent  absence 
of  naso-pharyngeal  catarrh,  at  least,  during  the  height  of  an 
epidemic,  while  careful  inquiry  has  signally  failed  to  bring 
to  light  any  relation  between  such  catarrhal  changes  and 
cerebro-spinal  fever. 

Though  these  are  real  difficulties,  they  do  not  seem  to  be 
insuperable.  The  absence  of  localised  catarrhal  changes 
during  the  height  of  an  influenzal  epidemic  is  not  paralleled 
in  those  influenza-like  outbreaks  which  occur  during  inter- 
epidemic periods,  and  which,  as  epidemiologists  have  shown, 
tend  to  be  especially  numerous  in  the  period  preceding  an 
epidemic  wave.  It  would  seem  possible  that  it  is  during 
these  premonitory  outbreaks  that  the  preliminary  increase 
in  virulence  occurs. 

Results  of  Postulated  Gradual  Evolution  of 
Virulence. 

In  this  way  we  may  perhaps  explain  the  gradual  evolu- 
tion of  those  virulent  and  infective  organisms  which, 
spreading  among  a population,  cause  epidemics  of  disease. 
If  this  explanation  be  the  true  one,  certain  results  must 
follow. 

During  the  preliminary  stages  the  contest  between  parasite 
and  host  will  result  in  minor  degrees  of  tissue  invasion,  and 
it  is  difficult  to  believe  that  such  a process  will  not  result  in 


the  partial  immunisation  of  the  host.  Again,  since  trans- 
ference from  host  to  host  will  under  natural  conditions  be 
entirely  promiscuous,  it  will  often  occur  that  a given 
parasite  will  be  transplanted  on  a host  who  is  already 
harbouring  the  same  species,  though  possibly  a race  of  a 
different  degree  of  virulence.  In  such  a case  the  newcomer 
will  succeed  or  fail  in  establishing  itself  according  as  it  is 
better  or  worse  adapted  for  life  under  the  conditions  locally 
existing.  Since  it  would  appear  to  be  a universal  rule  that 
competition  is  most  severe  between  nearly  allied  species 
and  between  varieties  of  the  same  species,  it  is  unlikely 
that  the  conditions  can  be  so  favourable  for  the  rapid 
multiplication  of  the  parasite  as  those  existing  when  trans- 
ference occurs  to  a host  in  whom  this  species  is  absent. 

Clearly,  then,  the  optimum  conditions  for  succsssful  and 
continued  passage  will  be  the  close  aggregation  of  a 
previously  ncn- infected  population,  and  such  movement 
among  them  as  will  result  in  the  entrance  to  the  infected 
locality  of  large  numbers  of  non-infected  persons  from  out- 
side areas,  and  the  movement  to  hitherto  unaffected  districts 
of  persons  harbouring  the  specific  parasite.  In  other  words, 
unusual  density  of  population  and  an  unusual  degree  of 
migration  will  afford  ideal  conditions  for  such  a process. 
That  these  conditions  are  those  which  favour  the  occurrence 
of  epidemics  of  disease  is  universally  admitted. 

The  point,  then,  which  it  seems  necessary  to  determine 
is  whether  a series  of  natural  passages  will  indeed  lead 
to  the  evolution  of  strains  of  the  parasite  especially  well- 
equipped  for  producing  disease  on  the  epidemic  scale,  and 
whether  there  is  any  reason  to  believe  that  continued 
variation  along  the  same  lines  will  result  in  such  modifica- 
tions as  will  render  it  less  likely  to  infect  new  hosts. 

(To  be  continued.) 


ON  THE  PROGNOSIS  OF  NERVE  INJURIES. 

By  ROBERT  KENNEDY,  M.A.,  M.D.,  D.Sc.  Glasg., 

ST.  MUNGO  PROFESSOR  OF  SURGERY  IN  THE  UNIVERSITY  OF  GLASGOW  ; 
SURGEON  TO  THE  GLASGOW  ROYAL  INFIRMARY. 


I.  Introductory . 

In  order  to  estimate  the  prognosis  of  nerve  injuries  from 
all  points  of  view  it  is  necessary  to  have  had  not  only  a con- 
siderable number  of  cases,  but  to  have  had  these  under 
observation  for  several  .’years.  Thus  it  is  not  possible  to 
estimate  this  properly  from  cases  under  observation  only 
since  the  beginning  of  the  war ; for  recovery  of  function 
after  nerve  injuries  and  after  operations  for  repair  is  remote 
from  the  date  of  injury  or  operation.  For  this  two  things 
peculiar  to  nerve  iDjuiies  are  responsible.  The  first  is  the 
occurrence  of  nerve  degeneration  after  all  but  the  most  trivial 
injuries  and  the  necessity  of  nerve  regeneration  taking  place 
before  conductivity  is  regained.  The  second  is  the  degenera- 
tion in  the  muscles  supplied  by  the  damaged  nerve.  This 
takes  place  with  great  rapidity,  and  is  such  that  the  muscle 
cannot  become  functional  again  until  it  has  regenerated, 
and  this  restoration  cannot  begin  until  the  nerve  has  already 
regained  its  conductivity. 

Thus,  in  all  cases  recovery  of  the  muscle  after  a nerve 
injury  requires  much  time.  No  other  kind  of  case  is  so 
difficult  to  keep  under  observation  until  the  final  result  is 
attained.  This  is  more  so  with  cases  in  military  hospitals,  as 
such  patients  have  their  homes  widely  separated.  After 
discharge  from  the  army  these  cases  can  be  traced,  but  the 
great  majority  are  living  at  a distance  and  the  reports 
received  of  their  progress  are  very  often  prepared  by 
those  unaccustomed  to  report  on  such  cases,  and  therefore 
usually  unsatisfactory. 

II.  Factors  Influencing  Recovery. 

More  than  in  other  cases  nerve  injuries  are  influenced  by 
many  factors  which  have  a profound  effect  on  the  prognosis, 
causing  at  times  complete  or  partial  failure,  and  in  other 
cases  delay  of  the  recovery  of  function.  These  factors  may 
be  classified  under  the  following  heads. 

A.  Factors  Occurring  at  the  Time  of  the  Injury. 

1.  Sepsis  or  asepsis.—  Without  doubt  one  of  the  causes 
most  unfavourable  to  nerve  regeneration  is  sepsis  in  the 
wound.  At  one  time  this  was  thought  a complete  bar  to 
recovery,  but  this  is  not  always  the  case,  as  certain  cases  in 
which  very  marked  sepsis  has  been  present  have  given  good 


'6  The  Lancet,] 


PROF.  R.  KENNEDY : ON  THE  PROGNOSIS  OF  NERVE  INJURIES. 


[July  5, 1919 


recoveries.  There  appears,  however,  to  be  no  doubt  that  it 
is  always  an  unfavourable  factor,  and  that  it  is  apt  to  lead 
to  changes  in  the  nerve  trunk  and  its  surroundings,  resulting 
in  the  formation  of  cicatricial  tissue  and  permanent  damage 
of  the  nerve  trunk.  Most  of  the  injuries  of  the  nerves  met 
with  during  the  war  have  been  associated  with  sepsis  and 
many  with  large  septic  lacerated  wounds.  Even  when  the 
wound  has  been  a mere  puncture  a bit  of  cloth  has  often  been 
carried  in,  causing  destructive  sepsis.  This  contrasts  with 
the  nerve  injuries  met  with  among  civilians  before  the  war  in 
which  the  lesion  was,  as  a rule,  caused  by  a knife  or  sharp 
and  comparatively  clean  chisel,  or  by  a bit  of  glass  or  the 
like,  making  practically  incised  wounds,  which  in  most 
cases  healed  up  quickly.  Consequently,  earlier  recovery  was 
usually  seen  in  these  cases. 

Although  sepsis  is  so  unfavourable  in  prognosis,  it  does  not 
follow  that  its  absence  means  an  assured  recovery  of  function. 
Take,  for  example,  cases  in  which  there  is  no  open  wound 
and  in  which  the  nerve  has  been  cut  by  the  sharp  fragments 
of  a fractured  bone,  or  where  the  nerve  has  been  ruptured  by 
being  subjected  to  tension.  In  the  large  majority  of  these 
no  spontaneous  recovery  ever  takes  place,  or  at  best  a very 
trivial  one.  Although  no  sepsis  has  occurred  in  these  cases 
other  unfavourable  factors  have  caused  failure  of  recovery. 

2.  The  nature  of  the  damage  to  the  nerve  trunk. — This  also 
has  a very  important  effect  on  prognosis.  The  damage  may 
vary  between  the  extremes  of  slight  compression  of  the 
nerve  trunk  caused  by  a cicatricial  band  to  extensive  loss  of 
substance  of  the  nerve  trunk.  Naturally  the  former  would 
be  regarded  more  favourably,  but  between  the  two  extremes 
are  many  types  of  injury  varying  in  prognosis.  In  general, 
a compression  is  regarded  as  more  favourable  than  a 
severance.  Yet  many  cases  of  the  latter  give  results 
apparently  as  good  as,  and  in  some  cases  better  than,  the 
former,  and,  generally  speaking,  the  results  of  the  two  types 
are  practically  the  same.  Taking  the  simple  fact  of  the 
nerve  injury,  no  case  of  severance  should  give  a better 
result  than  one  of  compression,  but  many  other  factors 
influence  simultaneously  the  result.  Should  the  ends  of  the 
severed  trunk  not  lie  in  close  approximation,  then  the 
probability  of  spontaneous  reunion  is  not  good.  Further, 
if  there  is  separation  to  any  great  extent  the  gap  will  not 
be  bridged  successfully,  and  failure  of  reunion  will  certainly 
result. 

3.  The  surroundings  of  the  damaged  nerve  trunk. — The 
condition  of  the  surroundings  is  very  important.  As  in 
shell  wounds,  much  destruction  implies  cicatrisation  in  the 
vicinity  of  the  nerve,  so  that  even  although  the  nerve  itself 
had  been  in  a condition  for  recovery,  yet  the  development 
of  a mass  of  densely  contracted  cicatricial  tissue  makes  any 
recovery  impossible.  Sometimes  it  apparently  does  not 
require  very  much  contraction  to  destroy  the  function  of 
the  nerve,  the  most  notable  examples  being  in  the  case  of 
the  ulnar  sulcus  and  in  the  aqueduct  of  Fallopius.  In  both 
cases  complete  and  permanent  loss  of  the  conductivity  of 
the  respective  nerves  is  found  from  comparatively  small 
amounts  of  cicatricial  tissue. 

4.  Amount  of  trauma. — A clean  cut  severing  a trunk  as  a 
rule  gives  a better  prognosis  than  when  the  severance  is 
made  as  part  of  a lacerated  wound,  and  when  the  laceration 
is  extreme  the  unfavourable  effect  is  extreme.  The  mode 
of  action  of  trauma  is  apart  altogether  from  any  loss  of 
substance  of  the  nerve  trunk,  and  still  is  unfavourable  even 
although  the  nerve  is  not  actually  divided.  The  harmful 
effect  is  due  to  the  reaction  in  the  tissues,  in  the  nerve  itself, 
and  in  its  surroundings,  of  such  a nature  that  there  is  more 
apt  to  be  a development  of  cicatricial  tissue  and  therefore 
ultimately  compression. 

5.  The  nerves  injured  and  situation  of  the  injury. — Certain 
nerves  are  more  difficult  to  deal  with  than  others,  and  in 
injuries  of  these  prognosis  is  less  favourable.  For  example, 
injuries  of  the  facial  nerve  are  difficult  to  repair.  In  the 
first  place,  injury  in  the  aqueduct  is  practically  impossible  to 
deal  with  because  of  the  surroundings  of  bone.  There  is  no 
difficulty  in  exposing  it  here,  but  the  results  are  unfavour- 
able for  the  reason  stated.  Also,  if  injured  in  its  course  in 
the  parotid  its  repair  is  very  unfavourable  because  of  the 
salivary  gland  ; while  beyond  the  parotid  the  tenuity  of  its 
branches  is  against  the  chances  of  a favourable  reunion.  In 
general,  up  to  a certain  size  the  larger  the  nerve  trunk  the 
more  likely  is  a good  result  either  from  the  point  of  view  of 
spontaneous  reunion  or  of  reunion  by  operation.  In  the 


former  case  the  ends  are  not  so  likely  to  be  separated  by  an 
interval  so  great  in  proportion  to  the  thickness  of  the  trunk 
than  is  the  case  with  nerves  of  greater  tenuity.  In  the  latter 
case  the  larger  trunks  are  more  easily  found  and  less  damage 
is  done  to  the  tissues  in  the  process  of  finding  them. 

Then,  again,  there  is  the  fact  that  the  same  nerve  will 
have  a better  prognosis  in  certain  situations  than  in  others. 
The  best  illustration  of  this  is  the  ulnar  nerve,  which  has  its 
worst  prognosis  when  wounded  in  its  course  in  the  ulnar 
sulcus  unless  operative  means  are  adopted  to  overcome  this. 

Also,  the  level  at  which  a nerve  is  severed  has  its  effects 
on  the  result.  The  most  unfavourable  event  is  when  the  nerves 
are  pulled  from  the  cord,  so  that  the  injury  is  presumably  an 
intrathecal  one.  The  most  frequently  occurring  instance  of 
this  is  in  the  brachial  plexus,  which  is  sometimes  completely 
tom  out  by  a pull  on  the  abducted  arm,  the  effect  being  to 
pull  out  the  nerves  from  the  cord  and  totally  paralyse  the 
arm.  The  arm  then  may  be  amputated  at  the  shoulder,  as 
it  would  only  be  a trouble  to  the  patient,  and  even  then 
sometimes  intolerable  neuralgia  having  its  origin  at  the 
intrathecal  lesion  continues. 

B.  Lapse  of  Time  between  Injury  and  Operation. 

1.  The  progressive  atrohpy  of  musole. — Wasting  of  the  muscle 
supplied  by  the  injured  nerve  is  the  most  serious  effect  of  a 
nerve  lesion,  and  affects  the  prognosis  very  materially.  This 
wasting  commences  immediately  the  nerve  loses  its  con- 
ductivity. It  is  unnecessary  to  go  into  the  exact  changes  in 
the  muscle,  but  their  effect  is  to  cause  the  latter  to  alter 
almost  immediately  in  its  electrical  reactions,  and  when, 
after  a short  time  it  is  exposed,  it  is  paler  than  normal  and 
wasted.  For  a very  long  time  certainly  it  retains  its  responses 
to  galvanic  stimuli,  although  it  goes  on  wasting  until  its  bulk 
is  very  greatly  reduced. 

It  is  this  effect  on  the  muscles  which  must  be  taken  into 
account  very  carefully  in  giving  a prognosis.  In  the  first 
place  recovery  of  motion  will  not  occur  until  the  muscle  is 
again  largely  built  up  and  restored  to  a condition  in  which 
its  electrical  reactions  are  normal.  In  the  second  place  the 
time  required  to  effect  this  will  not  be  the  same  in  each  case, 
but  will  vary  very  widely  according  to  the  extent  of  wasting 
which  has  to  be  made  up  before  recovery  exhibits  itself  to 
the  extent  of  voluntary  movements  being  possible.  Recovery 
of  faradic  irritability  in  the  affected  muscles  is,  as  a rule, 
the  immediate  precursor  of  recovery  of  voluntary  contrac- 
tions in  the  muscle. 

Now  it  is  only  by  a careful  study  of  many  cases  over  long 
periods  that  accurate  data  could  be  got  to  formulate  a law 
as  to  this  recovery.  In  a general  way  it  is  recognised  that  if 
operation  for  the  reunion  of  a severed  nerve  is  long  post- 
poned any  recovery  possible  will  be  much  longer  delayed 
than  if  the  operation  had  not  been  so  delayed.  The  cause  of 
this,  as  just  stated,  lies  principally  in  the  state  into  which 
the  muscles  have  fallen. 

2.  Primary  and  secondary  suture. — In  this  connexion  the 
question  will  arise  to  what  extent  primary  suture  has  the 
advantage  over  secondary  suture.  The  answer  is  that,  other 
things  being  equal,  it  will  secure  the  recovery  of  the  nerve 
at  the  earliest  possible  time  so  as  to  stop  the  degeneration  of 
the  muscle  as  early  as  possible,  and  therefore  be  most 
advantageous.  But  other  things  are  not  always  equal,  for 
in  the  nerve  sections  seen  in  the  war  the  conditions  for 
primary  suture  were  not  favourable  as  a rule,  the  wound 
being  usually  lacerated  and  infected.  In  consequence,  even 
although  the  nerve  has  been  sutured  primarily,  the  result  will 
probably  be  failure,  secondary  suture  being  required.  In  any 
case  no  longer  than  four  months,  everything  being  favourable 
for  further  operation,  ought  to  be  allowed  to  elapse  after  the 
primary  suture  without  resorting  to  secondary  operation, 
unless  some  definite  indication  has  developed  to  prove  that 
the  nerve  is  reuniting. 

Then  with  regard  to  the  question  of  when  to  operate  when 
primary  suture  has  not  been  done,  in  order  to  secure  the  best 
result,  there  may  be  contingent  circumstances  influencing 
the  decision,  such  as  an  open  wound.  In  that  case  the  wound 
must  first  be  induced  to  heal,  as  the  prognosis  of  an  opera- 
tion in  such  circumstances  would  not  be  good.  Should  the 
parts  be  healed  sufficiently  long  and  only  the  question  of 
time  to  be  considered,  then  between  two  and  three  months 
after  the  nerve  section  appears  to  give  a prognosis  of  the 
earliest  possible  recovery.  Under  such  circumstances  the 
best  result  is  a recovery  of  voluntary  movements  in  about 
three  or  four  months  from  the  date  of  operation. 


The  Lancet,] i 


PROF.  R.  KKNNKDY:  ON  THE  PROGNOSIS  OF  NKRVE  INJURIES. 


[.July  5,  1919  7 


When  further  delay  has  taken  place  before  operation  then 
the  waiting  time  after  the  operation  increases  at  a greater 
rate.  Thus  the  examination  of  a number  of  cases  showed 
that  cases  operated  upon  within  three  months  gave  a com- 
mencing recovery  in  three  and  a half  to  four  months,  but  if 
five  or  six  months  elapsed  before  operation  then  seven  or 
eight  months  elapsed  before  any  improvement  in  the  muscles 
occurred.  These  dates  refer  entirely  to  the  recovery  in  the 
muscles.  The  date  of  recovery  of  sensation  is  not  dependent 
on  these  intervals  of  time. 

3.  Operation  after  long  intervals. — When  many  months  have 
been  allowed  to  elapse  before  operation  then  the  date  of 
recovery  of  the  muscles  is  so  remote  and  so  gradual  that  it  is 
very  difficult  to  say  exactly  when  it  has  commenced  to 
exhibit  itself.  These  cases  often  pass  out  of  observation  and 
are  seen  only  after  a long  time,  when  it  is  found  that 
recovery  has  taken  place. 


Fig.  1. — Condition  in  Case  1 before  operati  n and  18  months  after 
division  of  ulnar  nerve  above  wrist.  (Phil.  Trans.,  B,  1897.) 


Case  1. — The  patient  was  a woman  aged  29.  The  ulnar 
nerve  was  divided  above  the  wrist  18  months  previously.  At 
the  operation  the  nerve  was  found  completely  divided  and 
the  ends  separated.  Before  the  operation  the  muscles  in  the 
hand  supplied  by  the  ulnar  had  lost  all  their  voluntary 
power : their  faradic  irritability  was  lost  and  their  responses 
to  the  galvanic  current  were  minimal.  The  muscles  were 
wasted  and  the  skin  glossy ; the  appearance  of  the  hypothenar 
eminence  is  shown  in  Fig.  1. 


The  operation  was  performed  in  January,  1897,  18  months 
after  the  section  of  the  nerve.  Sensation  in  the  insensitive 
area  returned  in  five  days,  indicating  the  recovery  of  the 


Fig.  2.— Condition  in  Case  1 five  years  after  operation.  (Chipault’s, 
Chirurgie  Nerveuse,  vol.  ii.,  Paris,  1903.) 


conductivity  of  the  nerve,  but  no  appearance  of  recovery  of 
the  muscles  was  exhibited  and  the  patient  passed  out  of  view 
and  the  case  was  published  at  this  stage.  She  was  seen 
again  five  years  and  four  months  after  the  operation,  and  it 
was  found  that  a perfect  recovery  of  the  muscles  and  of  the 
movements  had  occurred  in  the  interval.  Fig.  2 show's  the 
reproduction  of  the  hypothenar  eminence  which  had  taken 
place.  The  slight  appearance  of  hyperextension  in  the 
little  and  ring  fingers  was  the  consequence  of  the  long- 
continued  ulnar  attitude,  but  did  not  prevent  the  normal  use 
of  these  fingers. 


Another  case  may  be  quoted  in  illustration  of  this  matter. 
It  was  a case  of  rupture  of  the  fifth  and  sixth  cervical 
nerves  in  the  brachial  plexus. 1 

Case  2. — The  age  of  the  patient  at  the  operation  was 
14  years,  and  the  accident  occurred  at  birth.  The  typical 
paralysis  of  this  condition  was  present  with  atrophy  of  the 
affected  muscles.  At  the  operation  the  fifth  and  sixth 
trunks  were  found  to  have  been  completely  divided  and 
united  by  a scar.  On  stimulation  only  a few  of  the  fibres  of 
the  deltoid  and  biceps  contracted  without  any  movement 
resulting.  The  cicatrix  was  excised  and  the  proximal  two 
trunks  sutured  to  the  three  distal  branches — namely,  supra- 
scapular nerve,  branch  to  the  posterior  and  branch  to  the 
outer  cord  of  the  plexus.  At  five  months  no  improvement 
had  occurred  in  the  movements,  although  the  electrical 
reaction  seemed  improved.  About  two  years  after  the 
operation,  however,  the  movements  had  greatly  improved.'2 
The  forearm  could  then  be  flexed  voluntarily  through  a 
range  of  60°,  and  voluntary  abduction  of  the  arm  was  possible 
through  a range  of  45°.  While  these  movements  were  being 
made  the  biceps  and  deltoid  could  be  felt  to  contract.  Also 
the  atrophy  of  the  biceps  and  deltoid  had  greatly  dis- 
appeared. This  was  the  state  of  matters  on  the  last 
occasion  on  which  the  patient  was  seen.  He  wrote  sub- 
sequently stating  that  his  arm  was  “ all  right  now,” 
meaning,  probably,  that  further  improvement  had  taken 
place.  No  further  occasion  to  examine  him  occurred,  and 
it  has  since  not  been  possible  to  trace  him. 

It  is  thus  seen  that  even  after  long  periods  there  is  a 
possibility  still  of  obtaining  good  results.  It  also  seems  to 
be  the  case  that  although  delay  in  operating  means  an 
increasingly  longer  period  to  wait  for  the  recovery,  after 
longer  delay  before  operation,  the  recovery  takes  place 
in  a more  uniform  interval  of  time.  Thus  for  increasing 
intervals  before  operation  the  waiting  time  after  operation 
increases  up  to  a point  and  then  ceases  to  increase  with 
further  increase  of  the  interval  before  operation. 

C.  factors  Occurring  at  the  Operation. 

1.  Asepsis  or  sepsis. — Asepsis  is  one  of  the  most  important 
conditions  in  operations  for  the  repair  of  damaged  nerves. 
A standard  of  technique  which  may  give  passable  results  in 
certain  other  branches  of  operative  surgery  will  give  poor 
results  in  nerve  surgery.  The  importance  of  this  as  regards 
the  prognosis  is  not  always  kept  in  view.  The  special 
reason  for  this  high  standard  of  aseptic  technique  is  that 
we  are  dealing  with  the  regeneration  of  one  of  the  highest 
types  of  tissue  cells  which,  as  far  as  their  regenerative 
capacity  is  concerned,  are  inferior  to  connective-tissue  cells. 
The  latter,  if  present  in  abnormal  quantity,  are  likely  to 
prevent  the  development  of  nerve  tissue  simply  because  they 
regenerate  more  easily  than  nerve  tissue.  The  consequence 
is  that  compression  will  ultimately  develop  from  the  new- 
formed  connective  tissue  which  is  fatal  to  the  functional 
development  of  any  new  nerve  fibres  which  have  been 
formed. 

It  is  not  only  a question  of  healing  by  first  intention. 
Certain  wounds  may  heal  by  first  intention,  although  a more 
considerable  reaction  has  occurred  in  them  than  in  the  case 
of  other  wounds  in  which  the  state  of  sterility  has  been 
more  successfully  guarded.  Thus  it  is  that  the  surgeon 
whose  technique  has  nearest  approach  to  perfection  will  find 
his  results  better  than  where  the  technique  is  not  quite 
so  good,  although  in  both  cases  all  the  wounds  may  have 
healed  “by  first  intention.”  It  is  not  meant  by  this  to 
maintain  that  no  result  is  possible  should  a wound  even 
suppurate,  for  a good  result  may  take  place  although  sepsis 
has  occurred,  but  in  general  the  results  will  be  better  the 
less  the  reaction  induced  in  the  wound,  and  this  reaction 
can  be  reduced  to  a minimum  by  technique. 

2.  Amount  of  trauma  caused  bg  operation. — Very  important 
is  the  amount  of  force  necessary  at  the  operation  before  the 
scar  is  removed  from  the  nerve  and  its  surroundings  so  as 
to  leave  the  nerve  free  or  before  the  ends  of  the  divided 
nerve  are  freed  from  scar  and  united  by  suture.  Usually  the 
operation,  carried  through  with  the  greatest  gentleness, 
will  give  a quicker  result  than  one  where  force  has  been 
necessary.  The  rule  is  always  to  avoid  force  or  coarseness 
of  manipulation  if  the  object  can  be  attained  without. 
This  rule  applies  to  any  department  of  operative  surgery, 
but  failure  to  observe  it  is  particularly  destructive  of  good 
results  in  nerve  surgery.  When  the  nerve  ends  are  embedded 
in  dense  scar  it  is  not  always  possible  to  get  the  nerve 
trunks  clear  without  considerable  force.  Also,  in  the  case  of 


i Brit.  Med.  Jour.,  1E03,  Feb.  7th. 

A 2 


2 Ibid.,  1904,  Oct.  £2nd. 


8 The  Lancet,] 


PROF.  R.  KENNEDY:  ON  THE  PROGNOSIS  OF  NERVE  INJURIES. 


[July  5,  1919 


a lesion  of  the  ulnar  nerve  in  the  arm  when  the  ends  cannot 
be  united,  without  transferring  the  nerve  out  of  the  sulcus  to 
the  front  of  the  epicondyle,  then  more  trauma  is  inflicted. 
In  such  cases  the  prognosis  is  not  so  good  as  where  minimal 
force  and  manipulation  are  used. 

3.  Coaptation  of  the  nerve  ends. — Another  important  point 
is  the  possibility  of  getting  the  ends  to  meet.  If  they  do 
not  meet,  or  only  do  so  with  tension  on  the  nerve,  then 
the  outlook  is  not  a good  one.  Sometimes  if  the  ends  are 
separated  only  by  a short  interval  conductivity  is  restored, 
but  sometimes  it  is  not.  Nevertheless,  the  failure  to  get 
the  ends  quite  to  meet  is  much  less  serious  than  infection  of 
the  wound  would  be.  When  the  ends  do  not  meet  pulling 
on  the  nerve  trunk  often  succeeds  in  getting  them  together, 
but  the  fibres  of  the  nerve  may  be  ruptured,  and  in  that 
case  will  require  to  regenerate  causing  a further  postpone- 
ment of  the  early  signs  of  reunion.  Excising  a segment  of 
a bone  so  as  to  shorten  the  limb  and  bring  the  nerve  ends 
into  contact  requires  so  much  manipulation  that  the  prognosis 
is  unfavourable. 

4.  The  nature  of  the  suture — The  suture  used  has  some 
importance.  When  sutures  which  cause  irritation  have  been 
used,  such  a formation  of  connective  tissue  may  be  caused  at 
the  seat  of  suture  as  to  strangle  any  young  nerve  fibres  and 
prevent  restoration  of  conductivity.  The  suture  must  be 
carefully  chosen  in  view  of  its  capacity  either  to  be 
encapsuled  by  the  tissue  or  to  be  absorbed  and  to  cause 
the  least  irritation  in  either  process.  Also  those  cases  will 
have  the  best  prognosis  in  which  the  smallest  amount  of 
foreign  material  has  been  left  at  the  seat  of  section  either 
to  be  encapsuled  or  absorbed.  This  applies  to  Cargile 
membrane  or  any  dead  material  employed  to  wrap  round 
the  seat  of  junction,  also  to  thick  sutures  or  many  sutures  at 
one  junction,  all  of  which  are  objectionable. 

5.  The  surroundings  in  which  the  nerve  is  left. — Lastly,  the 
prognosis  is  poor  in  all  cases  in  which  after  the  operation 
the  sutured  or  liberated  nerve  has  unavoidably  been  left  in  a 
bed  of  scar  or  in  a bony  canal  or  furrow.  In  the  former  case 
the  scar  will  contract  and  prevent  the  conductivity  of  the 
nerve  from  being  restored  or  destroy  it  after  it  has  been 
restored.  In  the  latter  case  the  scar  or  neuroma  which  is 
formed  at  the  damaged  segment  of  the  nerve,  because  of 
the  unyielding  boundaries,  will  prevent  conductivity  by 
compression. 

D.  T actors  occurring  after  the  Operation. 

1.  Contraction  of  antagonist  muscle  or  group  of  muscles  — 
After  a satisfactory  operation  a case  may  be  spoiled  by  the 
want  of  attention  to  the  antagonist  of  the  paralysed  muscle 
or  group  of  muscles.  The  paralysed  muscles  may  recover 
their  irritability  and  yet  be  incapable  of  carrying  on  their 
function  because  they  are  stretched  and  cannot  overcome 
the  contractured  muscles.  This  can  be  prevented  by  appro- 
priate fixation  or  even  by  appropriate  passive  movements 
until  recovery  of  the  paralysed  muscle. 

These  contractures  appear  to  be  more  apt  to  occur  in 
injuries  of  certain  nerves,  but  again  they  are  also  found 
in  certain  cases  and  not  in  other  cases  of  injury  of  the 
same  nerve.  The  difference  appears  not  always  to  lie  in 
the  amount  of  attention  given  to  the  limb  throughout  the 
period  of  recovery.  Thus,  although  no  correcting  splint 
has  been  applied,  excellent  recoveries  may  result.  In  some 
cases  most  favourable  results  are  obtained  without  the 
slightest  attention  to  after-treatment. 

For  example,  a case  of  musculo-spiral  paralysis11  after- 
operation  gave  a complete  recovery,  although  the' patient  did 
not  permit  any  after  treatment  whatever.  A fracture  of  thf> 
humerus  was  caused  by  the  patient  being  run  over  by  a 
police  van  from  which  he  had  just  made  his  escape  by  tearing 
up  the  tloor  and  dropping  on  to  the  street.  Two  days  after 
operation  for  nerve  suture  he  left  the  hospital  and  for  about 
ten  days  was  practically  continuously  under  the  influence  of 
drink.  He  then  called  at  the  infirmary  and  had  the  stitches 
removed  from  the  wound,  which  had  healed  perfectly  by 
first  intention.  No  more  was  heard  of  him  till  five  months 
after  operation  when  he  called  again  and  showed  a perfect 
result  and  stated  that  the  recovery  had  become  apparent  to 
him  9k  weeks  after  the  operation.'  In  this  case  the  opera- 
tion was  done  as  soon  as  the  nerve  was  in  the  best  condition 
for  operation,  so  that  a minimum  time  was  allowed  for  the 
development  of  contracture. 

As  a mle,  contracture  will  be  more  likely  to  affect  the 
prognosis  when  recovery  is  longer  delayed,  and  if  it  is 

Chipault's  Chirurgte  Nerveuse,  ii.,  855.  Case  55. 


allowed  to  develop  to  a marked  degree  it  will  seriously 
hinder  the  recovery.  Thus  when  contracture  is  well 
developed  it  often  happens  that  although  there  appears  to  be 
no  recovery  of  the  paralysed  group,  that  group  is  found  on 
electrical  examination  to  give  normal  reactions,  but  the 
functional  recovery  has  been  made  impossible  by  the  over- 
stretching due  to  the  contracture  of  the  antagonist  group. 
This  very  often  is  shown  in  cases  of  foot-drop,  where  not 
only  the  paralysis  of  the  extensors,  but  also  gravity  combine 
to  keep  the  foot  in  a position  of  flexion  and  thus  the  forma- 
tion of  contracture  of  the  flexor  group  is  encouraged.  Unless 
care  is  taken  this  contracture  will  prevent  a functional 
recovery  of  the  muscles.  The  contracture  must  either  be 
prevented  from  forming  or  dealt  with  should  it  already  have 
formed. 

Case  3.— Figs.  3 and  4 show  a foot  in  flexion  and  extension, 
and  in  this  case  there  was  foot-drop  due  to  an  injury  of  the 
external  popliteal  nerve.  It  was  dealt  with  four  months 


Fio.  3.  Fig.  4. 

Case  3. — Recovery  of  extensor  muscles  after  in  jury  of  external  popliteal 
nerve  followed  hy  contraction  of  gastrocnemius  dealt  with  by  stction 
of  tendo  Achillis. 


after  injury,  at  which  time  the  extensor  group  still  showed 
galvanic  reactions  but  no  faradic  responses.  The  patient 
lived  at  a distance  from  the  hospital  and  reported  himself 
after  the  operation  very  seldom.  It  was  found  in  about  three 
months  that  contracture  of  the  gastrocnemius  had  occurred. 
The  tendo  Achillis  was  then  divided  for  the  temporary  relief 
of  the  contracture.  The  patient  did  not  report  himself  again 
for  two  years,  when  it  was  found  that  the  extensor  group 
had  recovered  perfectly,  and  the  tendo  Achillis  not  having 
reunited  the  foot  was  drawn  into  a position  of  calcaneus.  The 
tendo  Achillis  was  then  repaired.  The  patient  then  returned 
to  his  work  as  a miner.  It  is  now  2k  years  subsequent  to 
the  repair  of  the  tendon,  and  a slight  caicaneus  position  still 
remains.  Had  the  patient  been  more  regular  in  his  visits  to 
the  hospital  the  tendo  Achillis  could  have  been  repaired  as 
soon  as  the  extensor  group  had  recovered,  and  thus  the 
development  of  the  calcaneus  prevented.  This  method  is 
advisable  only  when  the  patient  cannot  be  attended  to 
regularly  or  induced  to  wear  a correcting  apparatus  pending 
the  recovery  of  the  muscle. 

2.  Cicatricial  contraction. — In  certain  cases  it  is  learned  on 
questioning  the  patient  that  sensation  was  present  after  the 
receipt  of  the  wound,  and  that  the  antesthesia  developed 
subsequently  at  no  great  time  after  the  injury.  Then,  in  all 
probability,  the  nerve  will  be  found  not  divided,  but  com- 
pressed in  cicatrix.  The  loss  of  sensation  has  been  due  to 
cicatricial  contraction  and  comes  on  gradually.  The  same 
is  sometimes  observed  after  operation,  a very  early  return 
of  sensation  gradually  disappearing  a little  later  and  no 
improvement  again  showing  itself.  This  is  to  be  expected, 
as  already  noted,  when  the  nerve  at  the  operation  is  left  in 
dense  surroundings  or  in  pre-existiDg  cicatrix. 

3.  Overwork  on  recovery. — Muscles  which  have  just 
recovered  their  function  are  incapable  of  doing  much  work, 
any  attempt  by  the  patient  to  make  them  work  will  result 
in  fatigue  which  will  hinder  further  recovery.  The  paralysis 
then  recurs  and  remains  until  the  muscle  from  the  enforced 
rest  again  becomes  functional.  This  may  not  mean  that  the 
man-  is  overworking  his  muscles  by  a return  to  work.  The 
same  thing  can  occur  by  any  ordinary  use  of  the  muscles. 
It  sometimes  happens  that  a man  finds  the  recovering  hand 
strong  enough  to  grasp  the  handle  bar  of  a cycle  and  com- 
mences to  use  this  means  of  locomotion.  This  is  frequently 
followed  by  a recurrence  of  the  paralysis.  It  is  well  to 

1 advise  patients  as  to  the  use  of  the  hand  in  the  early  stages 


The  Lancet,]  DR.  H.  L.  GORDON  : EXE-COLOUR  & ABNORMAL  PALATE  IN  NEUROSES,  ETC.  [July  5,  1919  9 


of  recovery.  Active  movements  should  be  strictly  limited 
until  the  muscles  are  sufficiently  strong. 

III.  Results. 

In  1908  I published  a series  of  all  the  nerves  operated  on 
by  me  to  that  date.  There  were  35  in  all,  but  ten  were  too 
recent  to  give  linal  results.  Some  of  the  latter  were  sub- 
sequently traced  and  found  to  have  given  satisfactory 
results.  There  remains  a series  of  25  observed  for  a 
sufficiently  long  time,  and  of  which  the  main  details  can 
be  seen  by  reference  to  the  work  in  which  they  were 
published.4  A certain  number  of  these  cases  were  found 
at  the  operation  to  be  cases  of  complete  severance  and  the 
remainder  to  be  cases  of  compression. 

For  the  purpose  of  classification  the  results  were  divided 
into  three  categories,  namely:  Complete  Successes,  i.e., 
where  sensation  and  motion  were  restored  so  as  to  give 
restoration  of  normal  function;  Partial  Successes,  i.e., 
where  the  results  left  something  wanting,  although  the 
recovery  was  sufficient  to  give  distinct  improvement;  and 
Failures,  i.e.,  where  no  useful  recovery  resulted. 


Tabular  Statement  of  Results  in  25  Fully  Observed  Cases. 


Complete  sever- 
ance. 

Compression. 

Total. 

Nerve  or  nerves 

03  . 

affected. 

CD 

CD  CD 

<03 

<D 

*-<  _• 

<03  ” 

03 

4-3  ’ 

03 

a 

p 

ft  y 

0 1 

*3  « 
£ 0 
08  « 
Ph  g 

P 

3 

.O 

a 

p 

& 

g S 
§ s 
0 " 

•3  03 
* « 
Ph  2 

P 

‘3 

a 

p 

& 

03 

s 2 

0 S 
0 “ 

3 03 

Z O 
* S 
Ph  g 

P 

3 

pH 

Brachial  plexus 

1 

1 

2 

1 

1 

3 

2 

1 

Median  

3 

3 

3 

3 

Ulnar  

6 

4 

2 

1 

1 

7 

5 

2 

Musculo  - spiral 

3 

2 

1 

3 

3 

5 

1 

Radial  

1 

1 

1 

1 

Median  and  ulnar 
Median,  ulnar,  1 

1 

1 

1 

... 

1 

2 

and  musculo-  > 
spiral  1 

1 

1 

1 

1 

External  pop-  ) 
liteal  ) 

1 

1 

1 

1 

Facial 

1 

1 

1 

1 

Total  results 

15 

11 

4 

10 

1 

3 

25 

18 

7 

Percentage  ... 

73-3 

26-6 

70 

30 

72 

28 

The  accompanying  table  shows  these  results  as  regards 
the  nerve  or  nerves  affected,  the  nature  of  the  lesion, 
viz.,  complete  division  or  compression ; the  whole  of  the 
cases  considered  together  and  the  nature  of  the  results.  It 
is  seen  that  there  are  no  failures,  and  that  the  results  are 
not  greatly  different  as  between  complete  division  and 
compression. 


EYE-COLOUR  AND  THE  ABNORMAL 
PALATE  IN  NEUROSES  AND 
PSYCHOSES. 

By  H.  LAING  GORDON,  M.D.  Edin., 

PHYSICIAN  TO  THE  LANCASTER  CLINIC  OF  PSYCHOTHERAPY. 


The  influence  of  the  individual  factor  in  the  development 
of  neuroses  and  psychoses  is  of  importance  in  relation  to 
their  prevention.  The  lack  of  reliable  data  for  a detection 
or  estimation  of  the  factor,  which  has  also  social  and  economic 
aspects,  becomes  evident  in  examining  soldiers  afflicted  by 
these  disorders.  The  conviction  grows  that  the  part  played 
by  nature,  as  distinct  from  that  of  nurture,  in  the  develop- 
ment of  such  disorders  cannot  yet  be  described  safely  as 
more  than  a susceptibility  (predisposition). 

. view>  however,  that  definite  indications  of  nature’s 
influence  are  demonstrable  before  disorder  reveals  it,  is  held 
widely.  Physical  stigmata  are  pointed  out,  and  the  import- 
ance of  stigmata  cannot  be  overrated  if  their  significance  be 
proved  and  they  provide  a means  of  estimating  the  degree  of 
susceptibility.  But  theii  significance  cannot  be  taken  as 
proved,  and  no  claim  has  been  made  for  their  mensurative 
use.  let  “instability,”  “neurotic  constitution,”  and 

4 Chipault’s  Chirurgie  Nerveuse,  ii. 


“degeneration”  continue  to  figure  freely  in  up-to-date  text- 
books without  explanation  of  their  meaning,  and  stigmata 
to  be  described  under  symptomatology  as  indicative  of  these 
terms.  It  would  appear  that  the  first  two  of  the  terms  are 
meant  to  be  synonymous  with  susceptibility. 

On  this  assumption,  advantage  was  taken  of  the  oppor- 
tunity afforded  by  the  examination  of  a long  series  of  dis- 
charged soldiers  in  whom  susceptibility  to  neuroses  and 
psychoses  had  been  demonstrated  only  by  its  results,  to 
inquire  into  accepted  and  unaccepted  stigmata.  The 
accompanying  notes  on  eye-colour  and  the  abnormal  palate 
represent  the  results  of  observations  forming  part  of  this 
inquiry. 

Eye- colour. 

The  observations  upon  eye- colour  were  made  to  test  a 
prevailing  impression  that  the  sufferers  from  (war)  neuroses 
and  psychoses  are  mostly  dark-eyed,  and  after  these  con- 
siderations : — 

1.  Previously  to  1914  at  least,  it  was  believed  that  nations 
varied  in  susceptibility  to  neuroses  and  psychoses.  The 
susceptibility  of  the  British  was  believed  to  be  low,  that  of 
certain  continental  nations  to  be  high. 

2.  The  dominant  eye-colour  of  these  continental  nations 
is  dark  ; that  of  the  British  is  believed  to  be  light. 

3.  The  impression  that  dark  eye-colour  predominates 
amongst  the  British  (war)  sufferers  from  neuroses  and 
psychoses,  coupled  with  the  impressions  contained  in  (1)  and 
(2),  suggested  that  the  inquiry  might  prove  interesting  and 
possibly  productive.1 

A preliminary  search  was  made  for  records  of  the  relative 
frequency  of  the  different  eye-colours  amongst  our  popula- 
tion but  not  with  satisfactory  result  owing  to  the  variation  in 
standard  of  colour  and  in  methods  of  record  amongst  the 
observers  (Beddoes,  Tocher,  Ripley).  Nevertheless,  the 
inquiry  was  pursued  in  hope  that  reliable  figures  would  be 
produced  by  scientific  observers  in  our  great  armies.  The 
method  of  observation  adopted  was  founded  on  that 
employed  by  Major  C.  C.  Hurst,  F.L.S.,  in  the  Burbage 
inquiry  into  Mendelian  inheritance  in  man,'4  and  based  upon 
the  anatomical  distribution  of  the  eye  pigment. 

“ In  the  albino  pigment  is  absent ; in  the  various  shades  of  blue  eyes 
the  pigment  cells  are  confined  to  the  posterior  surface  of  the  iris, 
whereas  in  grey,  brown,  and  black  eyes  pigment  is  found  also  in  the 
cells  of  the  stroma  and  in  those  of  the  endothelium  on  the  front  of  the. 
iris.”  3 

In  effect  the  method  divides  eyes  into  two  classes  : first, 
those  with  pigment  in  the  posterior  layer  of  the  iris  only  ; 
secondly,  those  with  brown  pigment  also  in  the  anterior 
layer  of  the  iris,  in  the  stroma,  or  in  both.  Hurst  named 
the  first  class  simplex , the  second  duplex , eyes.  Simplex 
eyes  are  therefore  always  some  shade  of  pure  blue  -or  pure 
“grey.”4  Duplex  eyes  comprise  all  other  colours — black, 
brown,  hazel,  yellow,  green,  impure  grey,  and  intermediate 
shades.  Neither  confusion  nor  hesitation  need  occur  if  the. 
question  of  colour  is  steadily  excluded  from  the  simple 
decision  whether  (brown)  pigment  is  present  anteriorly  in 
the  iris  or  not.  The  method — easily  learnt  and  rapidly  carried 
out  by  careful  inspection  laterally  in  a good  light — is 
facilitated  by  Hurst’s  further  subdivision  of  duplex  eyes  into 
self. , ring , and  spotted , according  to  the  pattern  of  distribution 
of  the  anteriorly  placed  pigment. 

The  observations  were  made  in  three  series  of  consecutive? 
cases  (Table  I.)  : — 

Table  1. 


Series  A. 

Series  B. 

Series  C. 

Total. 

1st 

2nd 

3rd 

Is’ 

2nd 

3-d 

100 

700 

100 

100 

100 

100 

100 

100 

cases 

cases 

Simplex  

33 

34 

27 

37 

33 

31 

35 

230  ...  32-85% 

Duplex  

67 

66 

73 

63 

67 

69 

65 

470  ...  67-15% 

m , . t Simplex,  Series  A, 
TotaIs1  Duplex,  „ 


94,  31-33% 
206,  68-67  % 


Series  B,  101,  33-66% 
„ 199.66-34% 


1 An  eminent  physician  assures  me  that  history  supports  a belief  that 
the  blue-eyed  races  have  proved  their  superiority  over  the  brown-eyed 
and  points  to  a number  of  contemporary  illustrations  of  the  fact  that 
great  leaders  are  frequently  blue-eyed,  even  among  the  brown-eyed 
nations.  On  the  other  hand,  there  is  the  epigrammatic  French  view 
(A  de  Candolle)  “ Pigmentation  is  an  index  of  force.” 

- Eugenics  Review,  April,  1912.  :1  Gray’s  Anatomy.  1913,  p.  942. 

4 That  is  to  say  “ grey,”  in  the  opinion  of  some.  It  is  the  absence  of 
pigment  anteriorly  that  matters  rather  than  the  observer's  conceptions, 
of  colour. 


10  The  Lancet,]  DR.  H.  L.  GORDON  : EYE-COLOUR  & ABNORMAL  PALATE  IN  NEUROSES,  ETC.  [July  5,  1919 


In  the  absence  of  statistics  as  to  the  relative  frequency  of 
simplex  and  duplex  eyes  in  our  population,  these  figures 
cannot  be  advanced  to  do  more  than  support  the  prevailing 
impression  that  the  duplex  eye  is  more  frequent  than  the 
simplex  eye  amongst  our  (war)  sufferers  from  neuroses  and 
psychoses. 

Palate. 

The  abnormal  palate  has  a strong  position  in  medical  opinion 
as  a stigma  of  11  degeneration,”  which,  we  are  told,  is  capable 
of  manifesting  itself  in  “nervous  instability.”  Observa- 
tions on  the  palate  were  therefore  introduced  into  the  inquiry 
at  the  suggestion  of  a colleague.  An  attempt  was  made  to 
follow  Peterson’s  classification  of  abnormal  palates,  but  this 
was  discarded  as  too  complicated  and  confusing  as  soon  as 
an  ocular  conception  of  the  normal  palate  had  been  acquired. 
The  method  adopted  finally  took  narrowness  as  a charac- 
teristic and  abandoned  height,  which  experience  suggested 
to  be  more  apparent  than  real,  and  included  the  shape  of 
the  arch  not  only  as  a characteristic,  but  also  as  an  indication 
of  the  intensity  of  the  abnormality,  as  follows  : 

1st  Norman  (N1)  = wide  round  arch  = normal  palate. 

2nd  ,,  (N2)  = narrow  ,,  ,,  = abnormal  (1st  degree). 

1st  Gothic  (G1)  = ,,  oval  ,,  = ,,  (2nd  ,,  ). 

2nd  ,,  (G2)  = „ pointed  ,,  = ,,  (3rd  ,,  ). 

This  division,  like  Peterson’s,  is  arbitrary,  but  has  the 
advantage  of  simplicity.  No  data  were  discovered  in  medical 
literature  for  an  anatomical  division  ; the  normal  width  of 
the  palate  relatively  to  the  dimensions  of  the  facial  skeleton 
does  not  appear  to  have  been  ascertained.  Faute  de  mieux 
the  classification  seemed  to  serve  for  as  accurate  observation 
as  is  possible  at  present  to  the  trained  eye. 

The  palates  were  observed  in  two  series. 

Table  II. 

Series  A {as  above).  163  cases  only. 

Ni  N2  Gl  G2 

28  ...  17-17%  47  ...  28-84%  69  ...  42-34%  19  ...  11-65% 

The  striking  feature  of  the  result  in  Table  II.  is  the  low 

returns  for  the  “normal”  palate  and  for  the  extreme 
degree  of  abnormality,  and  it  was  thought  worth  while  to 
ascertain  how  simplex  and  duplex  eyes  were  distributed  to  the 
varieties  of  palates  in  the  series.  (Table  III.) 

Table  III. 

Series  A ( 163  cases  only). 


Eyes. 

Total 

Nl 

N* 

Gt 

G2 

Simplex 

9 

% 

..  3214 

% 

16  ...  34-05 

% 

18  ...  26  05 

4 

% 

...  21-05 

47 

% 

...  28-83 

Duplex 

19 

..  67-86 

31  ...  65-95 

51  ...  73-95 

15 

...  78-95 

116 

...  71-17 

- 

Series  C.  (100  cases). 

Simplex 

10 

..  47  6 

15  ...  48-7 

9 ...  23-7 

1 

...  10-0 

35 

...  35-6 

Duplex 

11 

..  52-4 

16  ...  51-3 

29  ...  76-3 

9 

...  90-0 

65 

...  65-0 

Above  Cases  Combined {163  cases). 

Simplex 

38-77 

39-75 

25-23 

17-25 

3118 

Duplex 

61-23 

60-25 

74-77 

82-75 

68  82 

The  leading  feature  of  the  result  in  Series  A suggested  a 
further  series  and  Series  C was  undertaken  only  to  ascertain 
if  that  feature  was  maintained,  while  the  results  of  the 
combination  of  Series  A (163  cases)  with  Series  C (100  cases) 
are  also  tabulated. 

It  will  be  seen  that  while  the  percentages  of  the  least 
abnormal  (N-)  show  small  variation  from  those  of  the 
normal  (N1),  those  of  the  abnormal  classes  (N2,  Gl,  G2)  show 
a progressive  increase  of  the  percentage  of  duplex  eyes  as 
the  degree  of  abnormality  of  the  palate  increases.  The 
difference  between  the  percentages  of  duplex  eyes  in  Nl  and 
in  G'  and  G2  is  in  fact  as  definite  as  the  difference  in  palate 
formation.  The  similarity  of  the  percentages  of  N1  and  N2 
may  be  explained,  plausibly  at  least,  by  the  fact  that  the 
departure  from  the  normal  in  N2  consisted  of  narrowness 
without  change  in  arch  formation. 

The  doubt  arises  whether  there  has  not  been  faulty 
classification— that  many  of  N2  should  have  been  classed 
in  N1.  This  doubt  must  beset  such  classifications  until  the 

5 Cf.  Psychological  Medicine,  by  Maurice  Craig.  1917  edn.,  pp.  27,  28. 


width  of  the  palate  relatively  to  the  dimensions  of  the 
facial  skeleton  is  determined.  This  consideration,  however, 
does  not  affect  the  fact  that  the  figures  show  a by  no 
means  negligible  increase  of  the  percentage  of  duplex  eyes 
in  G1  and  in  G-’  (the  definitely  abnormal  palates)  over  the 
percentage  of  duplex  eyes  in  N1  (the  normal  palates). 

Conclusions. 

Definite  conclusions  are  prevented  by  the  facts  already 
noted,  but  the  following  suggestions  seem  justifiable  : — 

1.  That  in  individuals  who  are  susceptible  to  the 
neuroses  and  psychoses  dujilex  eyes  are  more  than  twice  as 
common  as  simplex  eyes. 

2.  That  in  the  same  class  of  individuals  the  narrow  and 
abnormally  arched  palate  (Gl  and  G2)  is  present  in  about 
52  per  cent,  of  cases. 

3.  That  in  the  same  class,  again,  the  proportion  of  duplex 
eyes  to  simplex  eyes  is  markedly  increased  in  those  cases 
with  narrow  and  abnormally  arched  palates  (G1  and  G2)  and 
the  increase  tends  to  intensify  along  with  the  intensification 
of  the  palatal  abnormality. 

Even  if  the  proportion  of  simplex  to  duplex  eyes  given 
does  not  vary  from  the  general  proportion  in  our  population 
and  even  if  the  abnormal  palate  is  indeed  a British 
characteristic,  whatever  its  cause,  the  interest  of  the  third 
conclusion  remains  sufficiently  suggestive  for  further 
investigation  on  a larger  and  more  complete  scale. 

Degeneration. 

A word  must  be  added  on  the  subject  of  the  abnormal 
palate  as  a stigma  of  “ degeneration.”  Bearing  in  mind  the 
view  explaining  the  abnormality  by  the  baneful  influence  of 
adenoids  on  intranasal  air  pressure,  their  presence  was 
looked  for  whenever  recognised  characteristics  of  their 
influence  (adenoid  facies)  were  detected  in  Series  C.c  This 
happened  in  class  G 2 only,  but  in  all  ten  cases ; and 
adenoids  were  found,  or  a history  of  operation,  in  six  of 
these.  By  way  of  control  after  each  case  the  next  case 
classed  as  G 1 was  examined  for  adenoids,  but  without 
result. 

It  would  appear  that  the  reply  of  the  “degeneration” 
theorist  to  the  air  pressure  theorist  has  been  to  sweep  in 
adenoids  as  a stigma.7  I do  'not  venture  to  decide  how  far 
my  figures  may  support  one  side  or  the  other.  The  publica- 
tion of  these  notes,  however,  is  certainly  not  prompted  by  a 
desire  to  strengthen  the  position  of  the  abnormal  palate  in 
the  fabric  of  “ degeneration,”  or  to  nail  up  the  duplex  eye 
as  a new  stigma  ; or  yet  to  justify  the  tendency  to  use 
“ degeneracy  ” and  “ neurotic  constitution  ” as  synonyms. 

Etymologically,  “degeneration”  signifies  downward  de- 
parture from  the  qualities  of  the  race — a definition  offering 
too  welcome  latitude  to  indolent  judgment  and  inviting  us 
to  stigmatise  many  whose  accomplishments  prove  us  wrong. 
If  “degeneration”  and  “neurotic  constitution”  are  to  be 
retained  in  medical  terminology,  then  surely  clear  thinking 
demands  that  they  should  be  raised  to  the  level  of  scientific 
exactitudes. 

I venture  to  repeat  that  susceptibility  to  neuroses  and 
psychoses  is  the  most  our  present  knowledge  permits  us  to 
premise.  So  far  as  the  observations,  of  which  those  recorded 
here  formed  part,  have  gone,  they  create  a belief  that 
reliable  data  for  the  estimation  of  this  susceptibility,  if 
attainable,  may  be  reached  more  readily  through  psycho- 
pathology than  through  somatic  pathology. 

Little  that  is  illuminating  on  this  subject  has  so  far  appeared 
to  my  knowledge  in  the  flood  of  medical  literature  of  the 
war  ; while  Freud,  Adler,  and  Jung  similarly  fail  us,  although 
some  of  the  latter's  abstract  reasoning  in  his  “ Conception 
of  the  Unconscious  ” is  suggestive.  It  is  not  sufficient  to 
speak  of  symptoms  and  pride  ourselves  we  have  proved 
“neurotic  tendencies”'  or  “instability”  without  having 
any  conception  of  their  fundamental  cause.  The  way  of 
enlightenment  may  perhaps  lie  through  further  investigation 
of  the  complicated  psychic  processes  of  the  child,  of  which, 
as  Jung  confesses,  our  knowledge  now  is  meagre. 


Previously  to  observing  Series  C I had  the  advantage  of  a demonstra- 
tion by  Dr.  Harry  Campbell  of  his  well-known  views  on  the  causation 
and  significance  of  the  abnormal  palate.  It  will  be  recalled  that  he  is 
inclined  to  regard  it  as  a British  characteristic,  denying  its  connexion 
with  degeneracy. 

' Cf.  Maurice  Craig,  op.  cit.,  p.  350:  “the  naso-pharyngeal  passages 
are  filled  with  adenoids. 

' Cf.  War  Neuroses,  MacCurdy.  1918.  p.  33. 


The  Lancet,] 


MR.  H.  L.  WHALE:  PITUITARY  TUMOUR  TEE  VIED  BY  OPERATION.  [July  5,  1919  H 


A CASE  OF 

PITUITARY  TUMOUR  TREATED  BY 
OPERATION. 

By'  H.  LAWSON  WHALE,  M.D.  Cantab.,  F.R.C.S.  Eng., 

LARYNGOLOGIST  TO  THE  HAMPSTEAD  GENERAL  AND  TO  THE 
LONDON  TEMPERANCE  HOSPITALS. 


The  following  case  of  pituitary  tumour  is,  1 think,  worthy 
of  record.  Sellar  decompression  and  removal  of  endothelio- 
matous  tissue  from  the  anterior  lobe  of  the  gland  was 
followed  by  great  improvement  in  the  pressure  symptoms. 

Condition  of  Patient. 

"’'Mrs.  , aged  29  years,  consulted  Dr.  C.  0. 

Hawthorne  in  September,  1917.  The  chief  points  in  her 
condition  were  as  follows.  Sight  failing  for  six  months. 
Sleepy  and  easily  fatigued.  Weight,  if  anything,  gaining. 
No  digestive  disturbances.  Married  for  four  years. 
Amenorrhoea  for  four  years.  Patient  was,  for  her  age,  a 
heavy,  lethargic  woman.  Spoke  in  a slow  monotone  and 
walked  slowly.  Wassermann  negative.  On  one  occasion 
only  was  sugar  found  in  the  urine.  Optic  discs  white. 
Vision  : R.,  6/24  ; L.,  6/60.  Visual  fields,  roughly  tested, 
showed  deficiency  in  temporal  halves  nearly  to  fixation 
point  (see  chart).  The  patient  was  seen  by  Mr.  E.  D.  D. 
navis. 

Jn  November,  1917,  patient  was  under  observation  in 
Hampstead  General  Hospital.  Vision  : — R.,  6/18  ; two 

letters,  6/12.  L.,  counted  fingers  at  three  feet.  Temperature 
never  above  normal  and  morning  record  often  97°  F.  Blood 
showed  leucopenia  (2500  white  cells).  Occasional  vomiting 
sometimes  occurring  in  the  morning  before  any  food  had 
been  taken.  In  December,  vision:  R.,  6/18;  L.,  fingers  at 
two  feet.  Thought  her  sight  was  better  than  on  admission. 
The  patient  was  seen  by  Mr.  W.  G.  Howarth.  In  June, 
1918,  after  having  been  to  Yorkshire,  thought  this  had 
resulted  in  a wonderful  effect  on  general  health  and  eye- 
sight. Looked  much  more  alert  and  had  largely  lost  her 


Fig.  2. 


The  pituitary  fossa  is  enlarged  both  ve  ticallv  and  in  the  sagittal 
plane.  The  anterior  clinoids  are  deformed  and  thickened;  the 
posterior  clinoids  are  atrophied,  thick  and  rounded. 


when  sight  (left)  began  to  fail.  Lethargy  was  obvious. 
Her  sugar  tolerance  had  been  tested.  She  took  up  to  5 oz.  in 
eight  hours  without  any  appearing  in  the  urine.  Nose  and 
accessory  sinuses  normal.  Skiagram,  taken  by  Mr.  H.  Wigg, 
showed  a large  pituitary  fossa  (Fig.  2).  Her  husband  was 
decisive  in  preferring  the  risks  of  an  operation  to  a con- 
tinuance or  aggravation  of  her  condition.  A nasal  douche, 
and  urotropin  20  gr.  t.d.s.  were  prescribed  for  four  days  as  a 
preliminary  to  operation. 


Perimetric  charts. — Neither  before  nor  subsequent  to  operation  was  there  any  record  of  vision  in  the  temporal  fields,  excepting  from  March  22nd 
to  March  29th,  between  the  lines  90  and  45  in  the  upper  part  of  the  right  side.  But  the  improvement  in  the  nasal  fields  is  striking. 
Continuous  black  line  ■ Sept.  18th,  1917.  Interrupted  black  line  — _ March  22nd,  1919.  Dotted  line  •••>•••>•••  March  29th,  1919. 

Immediately  previous  to  the  operation  the  fields  were  not  charted,  because  on  the  left  side  she  had  only  perception  of  light. 


former  lethargic  expression.  Vision  : R.,  6/9  ; L.,  per- 
ception of  light  only.  On  Feb.  22nd,  1919,  she  had  been 
seen  as  an  out-patient  on  two  or  three  occasions,  and  lately 
condition  had  been  less  satisfactory.  Vision:  R.,  6/24; 
L.,  perception  of  light  only.  Headaches  began  six  months 
ago  and  were  now  worse,  especially  in  the  mornings. 

On  March  4th  I was  asked  to  see  patient.  Headache  was 
now  acute  and  nearly  constant  in  the  vertex  or  the  occiput. 
Occasionally  there  was  a moderate  degree  of  proptosis  (left), 
which  at  other  times  was  absent  ; divergent  squint  (left). 
Questioned  as  to  previous  diplopia,  patient  stated  that  this 
had  existed  two  years  ago,  but  only  lasted  three  months, 


Operation. 

Operation  was  performed  on  March  8th,  Dr.  B.  W.  Cohen 
assisting.  Preliminary  laryngotomy  had  been  intended,  but 
the  available  tube  was  unsuitable.  As,  the  patient  was 
breathing  badly  under  the  amesthetic  an  airway  had  to  be 
provided  without  loss  of  time.  Rather  than  delay  until  a 
tracheotomy  tube  could  be  boiled  and  inserted  the  available 
tube  was  inserted  through  the  thyro-hyoid  membrane ; 
through  this  tube  Dr.  D.  H.  Fraser  gave  chloroform,  the 
pharynx  being  shut  off  by  sponges.  The  tube  was  withdrawn 
eight  hours  later.  The  left  middle  turbinate  was  now 
removed. 


• 12  The  Lancet,]  MR.  H.  L.  WHALE:  PITUITARY  TUMOUR  TREATED  BY  OPERATION. 


[July  5,  1919 


A modified  Mourn’d  incision  was  made  on  the  left  side. 
The  vertical  limb  of  this  took  the  ordinary  course  down 
along  the  junction  of  nose  and  cheek.  The  horizontal  limb 
passed  outwards  in  the  skin  only  as  far  as  just  beyond  the 
punctum  lacrymale.  Thence  it  was  carried  through  the 
lower  tarsal  plate  and  along  the  deepest  part  of  the  con- 
junctival fornix  for  | in.  The  bone,  now  removed  with  saw, 
chisel,  and  bone  forceps,  was  bounded  as  follows  : mesially, 
by  the  pyriform  opening  and  the  inter-nasal  suture  ; above, 
by  a horizontal  line  cutting  off  a bare  & in.  of  the  nasal 
process  of  the  frontal  bone  ; laterally  and  below,  by  a line 
from  the  centre  of  the  infra-orbital  margin  to  the  middle  of 
the  pyriform  opening  (this  line  just  spared  the  infra-orbital 
vessel  and  nerve)  ; laterally  and  above,  by  a curved  line 
skirting  the  infra-orbital  margin. 

The  naso-antral  party  wall  was  now  freely  cut  away  ; the 
nasal  duct  was  nob  seen  or  recognised.  The  ethmoidal 
gallery  was  nibbled  away  and  the  sphenoidal  cell  identified. 
Of  this  the  whole  outer  wall  was  cut  away.  At  this  stage  I 
had  been  prepared  to  sever  the  bony  septum  from  its  attach- 
ments above  and  to  dislocate  it  temporarily  to  the  right  for 
better  access  to  both  sphenoidal  cells ; this  manoeuvre, 
however,  proved  unnecessary.  The  whole  cavity  was  care- 
fully cleared  of  minute  fragments  of  bone  and  mucosa  and 
swabbed,  and  fresh  adrenalin  applied  for  five  minutes.  The 
sellar  floor  was  now  to  a large  extent  removed  piecemeal  by 
the  use  of  one  of  the  curved  gouges  belonging  to  a West’s 
intra-nasal  dacryocystotomy  set.  The  bone  was  seemingly 
very  thin.  No  force  at  all  was  required. 

What  appeared  to  be  a collapsed  cyst,  which  when  intact 
would  have  been  about  the  size  of  a small  cherry,  presented. 

It  was  removed  ; a 
very  small  amount  of 
clear  fluid  escaped ; 
no  pus  was  anywhere 
encountered.  All  loose 
tissue  was  removed 
from  the  cavity.  A 
long  malleable  probe 
was  now  used  to  ex- 
plore the  depths.  As 
far  as  could  be  dis- 
covered by  this  probe 
and  by  vision  this 
cavity  had  now  been 
emptied.  It  was 
bounded  by  intact 
dura  above  and  on 
both  sides ; the  dura 
pulsated  slightly.  The 
gentlest  exploration 
with  the  probe  pro- 
duced an  alarming 
intermittence  of  the 
pulse,  and  at  this 
moment  Dr.  Fraser 
gave  a hypodermic 
dose  of  pituitrin.  The 
incisions  were  closed, 
except  for  the  lowest 
2 in.  of  the  lateral 
tube  was  inserted  into 
the  antrum.  A single  strip  of  ribbon  gauze  was  passed  up 
the  nose  into  the  pituitary  fossa. 

After-treatment. — Urotropin  was  continued  for  a week. 
The  antral  tube,  changed  daily,  was  discontinued  after  five 
days.  The  nasal  wick  was  continued  for  ten  days.  Once 
daily  the  cavities  were  gently  irrigated  with  hydrarg.  biniod., 
1 in  2000  ; on  the  ninth  day,  when  it  was  judged  that  a 
protective  granulation  barrier  would  have  formed,  this 
lotion  was  preceded  by  hydrogen  peroxide.  After  two 
weeks  the  only  local  treatment  was  an  alkaline  wash  twice 
a day. 

Abstract  of  Dr.  Wyatt  Witigrave's  report. — The  cells  com- 
posing the  fragments  resemble  those  of  the  pituitary  body 
individually,  but  are  not  grouped  like  them.  The  cells  seen 
are  grouped  irregularly,  and  so  are  strongly  suggestive  of  a 
neoplasm.  Only  in  one  place  are  the  cells  arranged  in 
typical  columns.  Seen  under  1/12  oil-immersion  lens, 
certain  intracellular  copper- coloured  granules  show  that  the 
endothelium  of  the  cell  columns  is  neoplastic.  Examples  of 
hetero-mitosis,  such  as  are  usually  seen  in  malignant 


epithelioma,  are  extremely  scarce  ; moreover,  epithelioma 
is  excluded  by  the  absence  of  paranuclei.  The  absence  of 
granulation  tissue  excludes  sphenoidal  cell  disease.  The 
section  resembles  the  anterior  lobe  of  the  pituitary  gland, 
but  with  an  endothelioma. 

Af ter -history . 

The  temperature  was  normal  or  subnormal,  and  pulse 
averaging  80-90  after  the  twelfth  day.  The  external 
strabismus  persisted.  Epiphora  was  present,  but  only 
intermittent  and  of  slight  degree  ; presumably  the  upper 
part  of  the  nasal  duct  is  open  into  the  naso-antral  cavity. 
There  has  been  no  conjunctival  chemosis  or  infra-orbital 
oedema.  The  general  condition  was  brighter,  more  alert. 
For  five  days  patient  complained  of  a trickling  of  fluid 
(?  cerebro-spinal)  into  her  mouth,  but  it  was  not  possible  to 
obtain  any  of  this  for  examination.  For  two  days  she 
vomited  about  once  hourly  clear  greenish  fluid  ; the  vomit- 
ing continued,  with  gradually  abating  frequency,  for  nearly 
a week.  This  duration  made  it  improbable  that  the  anes- 
thetic was  the  cause.  Possibly  the  urotropin,  which  was 
continued  for  a week  after  operation,  was  responsible;  but 
vomiting  was  a feature  of  her  condition  long  before  her 
operation.  The  gastric  irritability  prevented  her  from 
retaining  sugar  when  given  by  the  mouth  to  test  her  sugar 
tolerance.  And  even  when  spontaneous  vomiting  had  ceased 
she  would  not  retain  sugar,  even  when  heavily  flavoured. 
She  was  allowed  out  of  bed  on  the  eighteenth  day. 

Headache  has  been  entirely  absent  since  the  operation. 
The  only  sensation  she  complained  of  was  hyperresthesia  of 
the  scalp,  which  disappeared  with  the  removal  of  the 
bandage.  Patient  had  anosmia.  (N.B. — The  right  nasal 
cavities  were  not  touched  at  operation.) 

Vision. 

Rough  tests  made  during  the  days  following  operation 
showed  that  with  the  temporal  side  of  her  left  retina(nasal  side 
of  field)  she  could  see  as  follows : fingers  on  the  first  day  ; 
type  £in.  high  at  ft.  on  the  third  day  ; type  £ in.  high  at 
the  same  distance  on  the  fifth  day. 

On  March  22nd  (fourteenth  day)  Dr.  Hawthorne  reported 
as  follows: — “Pupil  reactions:  R.,  normal;  L.,  sluggish. 
No  change  in  either  disc.  No  post-operative  oedema  of  discs. 
Vision  : R.,  6/12  ; L.,  6/36.  Test  type  read  R.,  J.  1 slowly, 
J.  2 easily  ; L.,  J.  14.” 

Visual  fields. — See  charts  : for  convenience  of  comparison 
with  the  former  record,  the  perimetric  tracing  already  given 
under  notes  of  Sept.  18th,  1917,  is  reproduced  as  a black 
line.  The  extent  of  the  fields  during  the  period  preceding 
the  decompression  operation  was  not  charted,  because 
there  was  on  the  left  no  field  to  chart  ; at  this  time 
the  raised  intracranial  pressure  was  shown  by  the  head- 
ache also.  (See  Dr.  Hawthorne’s  notes  of  June.  1918, 
and  Feb.  22nd,  1919,  when  the  vision  on  the  left  side 
is  recorded  as  only  perception  of  light.)  The  anosmia 
persisted. 

On  March  29th  (twenty-first  day)  the  sense  of  smell  had 
been  present  during  the  last  48  hours.  She  was  much 
brighter.  No  change  in  optic  discs  or  in  divergent  squint. 
There  was  no  return  of  the  diplopia  from  which  she  had 
suffered  in  1917,  before  her  sight  failed.  Vision: — R.,  6/9. 
L. , 6/36  ; one  letter  6/24.  Type  read  : R. , J.  1 slowly, 
J.  2 easily  ; L.,  J.  10. 

Visual  fields. — See  charts  on  which  the  earlier  tracings 
have  been  superimposed. 

Dr.  Hawthorne’s  notes. — April  2nd.— Blood  pressure  : 
systolic,  100  mm.  ; diastolic,  80  mm.  Visual  fields  not 
materially  affected.  Discs  as  before.  Vision : L , 6/24, 
three  letters.  Type:  R.,  J.  1;  L.,  J.  10.  April  3rd. — 
Yesterday  patient  was  out  on  the  verandah  ; to-day  she  has 
what  she  describes  as  a bilious  attack.  The  inner  canthus 
and  the  region  just  below  it  are  cedematous  and  a little  red, 
for  the  first  time  (/dacryocystitis).  T.,  100 -8°  F.  April  15th. 
— Pyrexia  (April  3rd)  subsided  next  day.  (Edema  at  inner 
canthus  has  subsided.  Sugar  tolerance  tested  as  follows  : 
April  13th.  7 P.M.,  sugar  giii.  given.  Urine  tested  at  11  P.M., 
and  again  at  8 a.m  on  April  14th.  No  glycosuria. 
April  16th. — Discs,  I.S.Q.  Vision:  R.,  6 9;  L.,  6 18. 

Type:  R.,  J.  1 ; L.,  J.  6.  Perimeter  (vide  charts).  To 

discard  eye-shield  or  dressings.  April  21st. — No  more 

photophobia.  June  4th. — Her  husband  writes  : “ her 

health  is  excellent.  She  is  a totally  different  woman,  and 
improves  each  day. 


Fig.  3. 


Photographed  on  May  5th,  two  months 
after  the  operation,  and  two  weeks 
after  the  patient  had  returned  home 
to  the  normal  performance  of  all  her 
household  duties.  The  visible  scar  of 
the  incision,  already  small,  may  later 
be  entirely  obliterated  by  excision. 

nasal  incision,  through  which  a fine 


The  Lancet,] 


CLINICAL  NOTES. 


[July  6, 1919  13 


Cltmal  Itfftes : 

MEDICAL,  SURGICAL,  OBSTETRICAL,  AND 
THERAPEUTICAL. 


THREE  UNCOMMON  ABDOMINAL  CASES 
ILLUSTRATING  SOME  PITFALLS. 

By  Norman  C.  Lake,  M.D.,  M.S.Lond.,  F.R.C.S.  Eng., 

MAJOR,  R.A.M.C.; 

AND 

H.  K.  Kevin,  L.R.C.P.  & S.  Ired., 

CAPTAIN,  R.A.M.C. 


The  following  cases  occurred  within  a short  period  at  the 
Prisoners  of  War  Hospital,  Oswestry.  They  are  recorded 
because  of  their  rarity,  and  also  indicate  some  pitfalls. 

Traumatic  Diaphragmatic  Hernia. 

Case  1.— German  prisoner  of  war,  aged  20.  Wounded 
Sept.  27th,  1918;  admitted  to  this  hospital  Oct.  5th,  1918, 
with  gunshot  wound  of  left  side  of  chest.  Small  entry  mark 
in  fourth  interspace  about  3 inches  from  mid-line ; bullet 
felt  subcutaneously  just  mesial  to  inferior  angle  of  scapula. 
His  field-card  recorded  haemoptysis  for  a few  days  in  France. 
Upon  admission  the  entry  wound  was  a mere  scar ; no 
haemoptysis  or  pathological  sign  in  the  chest.  On  Dec.  11th 
he  was  up  and  due  for  discharge,  but  returned  to  bed  com- 
plaining of  pain  in  the  left  hypochondrium  and  constipation ; 
he  vomited  once  after  food.  No  pathological  lesion  detected  ; 
general  appearance  and  condition  good.  The  following 
morning  he  was  rather  collapsed  ; abdomen  considerably 
distended.  The  pain  in  the  left  hypochondrium  continued  ; 
also  tenderness  present.  Temperature  95'20F.,  pulse  120; 
tongue  dry  and  furred.  The  left  chest  was  abnormally 
resonant  and  the  heart  dullness  obscured.  Two  enemas  were 
given  without  result.  Provisional  diagnosis  was  intestinal 
obstruction,  probably  due  to  band  in  splenic  region. 

Operafion.—Anffisthetisation  was  very  difficult  owing  to 
the  rapidly  increasing  dyspnoea.  Abdomen  was  opened  in 
mid-line  as  rapidly  as  possible  with  a view  to  relieving  this. 
The  distended  intestines  were  allowed  to  come  out  of  the 
wound.  No  relief  to  respiratory  embarrassment.  The 
transverse  colon  was  enormously  distended  ; the  obstruction 
obviously  lay  somewhere  in  the  region  of  the  splenic  flexure 
which  could  be  felt  drawn  up  under  the  left  dome  of  the 
diaphragm.  At  this  point  respiration  ceased  entirely  ; all 
the  usual  means  of  resuscitation  were  employed  with  no 
response. 

Autopsy.— An  aperture  was  found  in  the  tendinous  portion 
of  the  diaphragm  on  the  left  side,  admitting  four  fingers;  a 
considerable  coil  of  the  splenic  flexure  of  the  colon  had 
passed  through  the  opening.  Strangulation  had  occurred 
at  the  sharp  edge  of  the  aperture.  The  bowel  occupied 
practically  the  whole  left  side  of  the  thorax  ; lung  was  com- 
pressed to  a small  mass  on  inner  aspect  and  heart  displaced 
well  to  right. 

The  bullet  in  its  passage  hid  passed  tangentially  across 
the  dome  of  the  diaphragm.  The  scar  so  formed  had  healed 
only  to  yield  later  when  the  intra-abdominal  pressure  was 
raised  by  exertion. 

Internal  Haemorrhage  from  Splenic  Infarct. 

Case  2.— German  prisoner  of  war,  aged  24.  Admitted  to 
this  hospital  on  Sept.  28th,  1918,  with  diagnosis  of  nephritis. 
Upon  admission  the  urine  contained  a small  quantity  of 
albumin,  trace  of  blood,  no  casts.  The  heart  was  enlarged  ; soft 
organic  systolic  bruit  at  apex.  A little  oedema  was  present, 
distributed  generally  over  the  body.  He  was  treated  for 
nephritis  ; not  much  improvement.  On  Dec.  3rd  and  4th  he 
complained  of  pain  in  the  left  hypochondrium  associated 
with  tenderness.  The  following  day  he  suddenly  became 
blanched,  the  pain  meanwhile  increasing,  the  pulse  very 
rapid  and  thin  ; temperature  subnormal.  Shifting  dullness 
in  the  flanks  more  marked  on  the  left  side  was  noted.  A 
diagnosis  of  internal  haemorrhage  from  the  spleen  was 
made  ; cause  doubtful.  Two  or  three  old  and  recent  pin- 
point haemorrhages  in  the  conjunctivae  were  noted ; retinae 
normal. 

Operation.  When  the  patient  reached  the  operating 
theatre  his  general  condition  was  so  bad  that  it  was 
decided  to  transfuse  him  before  operation.  Saline  infusion 
was  immediately  undertaken  and  a donor  found.  Rather 
over  a pint  of  blood  was  transfused  by  the  citrate  method, 
the  biological  test  being  used  for  incompatibilitv.  The 
patient  improved  somewhat,  and  as  it  is  in  our  experience 
better  to  wait  a short  time  after  transfusion  before  anees- 
thetisation,  the  operation  was  delayed.  He  was,  however, 
obviously  still  bleeding  rapidly  and  died  before  operation 
eould  be  undertaken. 


Autopsy. — General  subcutaneous  oedema.  The  heart  was 
very  enlarged;  aortic  and  mitral  valves  sclerosed  and  on  the 
surface  many  old  and  recent  vegetations.  Both  lungs  were 
oedematous.  The  peritoneum  contained  a large  quantity  of 
partially  coagulated  blood.  One-third  of  the  spleen  had 
been  converted  into  a large  infarct  extending  back  to  the 
vessels  in  the  hilum.  Under  the  capsule,  which  had 
ruptured  at  one  spot,  was  a fairly  recent  mass  of  blood 
clot ; hsemorrhage  was  proceeding  directly  from  aperture  in 
splenic  artery.  The  kidneys  were  “flea-bitten”  and  the 
mucosa  of  stomach  and  intestines  showed  similar  points  of 
haemorrhage. 

The  case  was  obviously  one  of  infective  endocarditis,  with 
an  infected  infarct  in  the  spleen  which  had  ulcerated  its  way 
through  the  wall  of  the  splenic  artery. 

Acute  Idiopathic  Dilatation  of  the  Stomach. 

Case  3. — German  prisoner  of  war,  aged  25.  Admitted  to 
this  hospital  on  Feb.  3rd,  1919,  with  diagnosis  of  “ acute 
abdomen.”  On  the  previous  day  after  a midday  dinner  he 
was  seized  with  a sudden  pain  in  the  epigastrium  and 
shortly  afterwards  vomited.  This  seemed  to  give  some 
relief  and  the  case  was  not  thought  serious  until  the  follow- 
ing morning,  when  he  began  to  develop  signs  of  peritonitis. 
No  gastric  history.  Upon  admission  the  condition  was 
serious.  He  was  continuously  vomiting  large  quantities  of 
slightly  blood-stained  material  containing  recognisable  un- 
digested food  from  the  previous  day.  The  abdomen  was 
considerably  distended,  but  at  the  same  time  quite  rigid. 
There  were  shifting  dullness  in  the  flanks  and  tympanitic 
resonance  over  the  front.  The  case  was  anomalous,  but  a 
diagnosis  of  peritonitis,  probably  due  to  perforation  of  a 
pyloric  ulcer,  was  made  and  operation  immediately  under- 
taken. 

Operation. — Abdomen  opened  in  mid-line.  The  peritoneal 
cavity  contained  a large  quantity  of  blood-stained,  thin, 
purulent  fluid.  The  stomach  was  enormously  distended, 
occupying  the  greater  portion  of  the  whole  abdomen;  small 
intestines  collapsed  and  pushed  well  down  into  pelvis. 
Stomach  wall  was  thin  and  in  places  haemorrhagic;  no 
perforation  found.  A gastrostomy  was  performed  by  the 
Kader  method  and  several  pints  of  stomach  contents  were 
drained  off.  A large  tube  was  inserted  down  to  the  duodenal 
region  and  another  into  the  pelvis.  The  abdomen  was  sewn 
up,  subcutaneous  saline  administered,  and  pituitary  extract 
in  5 m.  doses  every  three  hours.  The  gastrostomy  tube 
drained  large  quantities  of  increasingly  blood-stained 
material.  Death  17  hours  after  operation. 

Autopsy. — The  peritoneum  contained  some  blood-stained 
fluid.  The  stomach  was  smaller  than  at  operation,  but  its 
walls  were  so  thin  in  places  as  to  be  quite  transparent.  The 
mucosa  for  the  most  part  was  deeply  haemorrhagic.  The 
distension  involved  the  first  and  second  portions  of 
duodenum ; otherwise  intestines  were  normal.  No  per- 
foration or  stricture ; all  other  organs  quite  normal 
macroscopically. 

The  case  fits  in  with  the  description  of  acute  idiopathic 
dilatation  of  the  stomach,  usually  a post-operative  complica- 
tion. In  addition  we  here  have  a peritonitis  most  marked 
about  the  stomach.  There  are  two  possibilities  : 1.  That 

the  peritonitis  is  the  primary  cause  and  the  dilatation  a 
secondary  paralytic  one.  2.  That  the  dilatation  is  primary 
and  the  peritonitis  due  to  the  migration  of  organisms  through 
the  attenuated  stomach  wall.  The  man  had  been  eating 
salted  herrings  ; large  masses  of  the  sharp  vertebral  spines 
were  found  in  the  caecum,  the  spines  being  so  sharp  as  to 
perforate  the  bowel  wall  on  the  slightest  pressure.  The 
suggestion  arises  that  infection  may  have  been  carried 
through  the  stomach  wall  in  this  manner,  but  the  peritoneum 
usually  deals  very  effectively  with  small  infections  of  this 
nature.  The  case  must,  therefore,  be  left  under  the  heading 
idiopathic. 

We  have  to  thank  Lieutenant-Colonel  R.  Turner, 
B.A.M.C.,  for  permission  to  publish  these  cases. 


A CASE  OF  MULTIPLE  OSTEOMATA  OF  THE 
SKULL  BONES. 

By  C.  N.  Slaney,  M.R.C.S.,  L.R.C.P. 

The  following  case  is  recorded  on  account  of  the  com- 
parative rarity  of  the  condition. 

Account  of  Case. 

The  patient,  aged  40,  destitute  of  relations  and  having 
no  recollection  of  his  parents,  mentally  approximates  to 
the  cerebration  of  a child  barely  a quarter  of  his  own  age. 
To  the  best  of  his  recollection,  in  1888,  when  about  12,  he 
sustained  a blow  on  the  right  lower  jaw  from  a cricket-bat ; 
three  months  later  he  noticed  a swelling  (see  figures,  1).  This 
gradually  increased  in  size,  was  painless,  and  unaccompanied 


14  The  Lancet,] 


CLINICAL  NOTES. 


[July  5,  1919 


by  any  objective  symptoms  except  for  a sensation  of  cramp 
when  he  drank  anything  cold.  This  tumour  was  sub- 
sequently removed  by  operation.  No  evidence  of  fracture; 
right  ramus  of  lower  jaw  was  much  thickened.  In  1890  a 
similar  small  tumour  (2)  appeared  over  the  left  superior 
maxilla,  attributed  to  a blow  by  a stone.  It  was  followed  in 
1893  by  a painless  swelling  (3)  in  the  left  lower  jaw;  no 
trauma.  The  fourth  tumour  developed  gradually  in  1895,  a 
few  months  after  his  discharge  from  hospital;  no  trauma. 


Multiple  osteomata  of  skull  bones. 

Tumour  5,  also  in  1895,  he  attributes  to  knocking  his  head 
against  a wall ; it  became  gradually  larger  in  size,  but  is  now 
stationary.  Probably  the  condition  of  the  right  eye  is  due 
to  a tumour  (6)  similar  to  the  others  ; no  injury.  He  does  not 
know  when  his  eye  trouble  commenced,  possibly  in  1888; 
his  vision  was  defective  when  he  attended  school  that  year. 
The  bony  outgrowths  are  in  lower  jaw  bilateral.  As  a 
whole  they  give  rise  to  no  harmful  pressure  symptoms 
except  in  reference  to  the  right  eyeball. 

The  patient  appears  well  nourished,  is  5 ft.  1 in.  in  height, 
and  weighs  109  lb.  There  is  complete  nasal  obstruction, 
apparently  due  to  a general  swelling  and  turgescence  of  the 
nasal  mucosa;  also  slight  pharyngitis  and  hoarseness  of 
voice.  He  professes  to  see  best  with  a — 12  D.  sphere,  but 
he  prefers  not  to  use  glasses.  The  right  pupil  reacts  to 
light  and  accommodation;  left  pupil  dilated  and  fixed. 
With  the  margins  of  the  orbits  appearing  normal,  there  is  a 
small  hard,  movable  tumour  to  be  felt  under  the  right 
upper  eyelid,  probably  in  relation  with  the  lacrymal  gland. 
The  tissues  of  both  upper  eyelids  are  abnormally  flaccid  and 
overlap  the  corneae  ; an  appreciable  amount  of  the  sclerotic 
is  visible  below  each  cornea,  more  marked  in  right  eye  ; 
lacrymation  is  continuous.  Proptosis  of  the  right  eye- 
ball has  been  present  since  1888;  vision  in  both  eyes  more 
defective  since  1894  and  still  getting  worse.  Some  increase 
of  tension  in  right  eye;  no 


lower  margin  of  the  right  mandible  appears  roughened,- 
probably  as  a result  of  the  operation.  The  alveoli  and  teeth 
are  normal  in  position  and  regular  in  line ; enlarged 
lymphatic  glands  in  submental  and  submaxillary  regions. 
The  outer  aspect  of  the  lower  jaw  appears  normal  on  the 
right  side  from  the  symphysis  to  tumour  4.  No  signs  of 
recurrence.  This  tumour  was  stony  hard. 

2.  There  is  a faint  linear  vertical  operation  scar  on  left 
side  of  nose  about  1'5  cm.  in  length  ; also  on  the  superior 
maxillary  bone  at  this  site  a slight  prominence,  neither 
painful  nor  tender,  but  hard  and  bony. 

3.  This  tumour  extends  from  1 cm.  from  symphysis  to 
within  2 cm.  of  angle  of  left  jaw.  It  envelops  the  lower 
margin  of  the  mandible  and  extends  upwards  to  just  above 
a horizontal  line  level  with  angle  of  mouth.  It  is  painless, 
hard,  irregular  in  outline,  circumscribed,  and  sharply  de- 
fined; skin  not  adherent;  it  moves  with  the  jaw  and'does 
not  interfere  with  deglutition;  no  impediment  to  free 
movements  of  mandible.  Observed  from  inside  the  mouth 
there  is  the  appearance  of  a hard  tumour  growing  from  the 
outer  plate  of  the  mandible  below  the  alveolar  margin  ; there 
is  no  so-called  expansion  of  the  bone,  but  a tendency  to  full- 
ness is  noted  over  the  upper  part  of  the  vertical  ramus  in  the 
region  of  the  parotid  gland,  but  this  fullness  is  not  bony  in 
character.  He  believes  that  this  tumour  is  increasing  in  size. 

4.  This  tumour  extends  from  4 5 c.m.  behind  the  angle  of 
the  right  jaw  to  within  6'5  cm.  of  the  symphysis;  it  does 
not  envelop  the  lower  margin  of  the  bone,  but  extends  up  to 
the  zygomatic  arch;  it  is  well  defined,  both  anteriorly  and 
posteriorly  and  at  its  lower  margin,  but  seems  to  shelve  off 
into  the  surrounding  tissues  at  its  upper  part.  It  is  hard, 
irregular  in  outline,  and  the  margin  of  the  lower  jaw  with 
its  angle  can  be  felt  below  the  tumour,  which  has  the 
appearance  of  growing  from  the  outer  plate  of  the  bone 
below  the  alveolar  margin,  more  or  less  in  an  upward  and 
backward  direction.  The  tumour  moves  with  the  jaw  and 
the  skin  is  not  involved.  He  believes  also  that  this  tumour 
is  increasing  in  size. 

5.  The  tumour  resembles  those  mentioned,  is  hard  and 
bony,  and  painless.  It  appears  as  a circumscribed  irregular 
swelling  on  the  left  side  of  the  frontal  bone  3 cm.  above  the 
orbital  process;  it  is  conical  in  shape,  with  its  apex  pro- 
jecting upwards,  outwards,  and  backwards,  resembling  a 
horn  3 cm.  in  diameter  and  T25  cm.  in  height.  This  tumour 
is  stationary  in  growth,  he  thinks. 

Parkhurst,  I.W. 

A CASE  OF  CONGENITAL  MULTIPLE 
SARCOMATOSIS. 

By  J.  A.  Perciyal  Perera,  L.R.C.P.,  M.R.C.S.. 

LATE  SENIOR  HOUSE  SURGEON,  CHILDREN'S  HOSPITAL,  SHEFFIELD. 


The  following  case  is  of  interest,  on  account  both  of  its- 
rarity  and  of  the  wide  dissemination  of  secondary  growths. 

The  patient,  a full-term  male  baby  a fortnight  old,  was 
•admitted  into  the  Sheffield  Children’s  Hospital,  under  the 
care  of  Dr.  H.  Leader.  Multiple  rounded  and  nodulated 
tumours  were  scattered  throughout  the  body — e.g.,  head. 


apparent  narrowing  of  visual 
fields.  Media  in  both  eyes 
hazy  from  muse*  volitantes  ; 
discs  and  vessels  smaller 
than  usual.  There  are  signs 
of  old  keratitis ; positive 
Wassermann.  His  abdomen 
is  protuberant  and  thorax 
rickety.  There  is  marked 
indrawing  of  the  skin  with 
each  heart  beat  at  its  apex, 
apparently  situated  at  left 
side  of  xiphisternal  notch 
immediately  below  sixth 
costal  cartilage.  No  dullness 
to  right  of  sternum.  His 
cranial  nerves  appear  healthy 
except  for  loss  of  sense  of 
smell.  The  angle  of  the 
mouth  on  the  left  side  is 
drawn  up,  and  he  is  unable 
to  whistle.  The  left  knee- 
jerk  is  absent. 

Description  of  Tumours. 

On  examination  of  the  several  tumours  the  following 
points  are  observed  : — 

1.  There  is  a linear  operation  scar  9 cm.  in  length  along 
the  lower  margin  of  the  mandible  on  right  side  from  angle 
of  jaw  to  symphysis;  this  scar  is  adherent  in  places  to  the 
underlying  bone.  The  inner  aspect  of  the  lower  jaw  is 
smooth  and  regular,  and  appears  normal  on  both  sides;  the 


Case  of  congenital  multiple  sarcomatosis. 

thorax,  abdomen,  upper  and  lower  extremities.  These 
tumours,  present  from  birth,  were  of  varying  sizes,  from 
1 x 1 x 0-5  cm.  to  4 \ 5 x 1 cm.  There  was  superficial  ulcera- 
tion in  the  larger  tumours;  one  or  two  on  cheek  and  legs 
had  started  to  fungate.  The  consistence  ranged  from  jelly- 
like  softness  in  the  more  superficial  ones  to  more  or  less  bony 
hardness  in  ones  attached  to  the  long  bones,  ribs,  and  skull. 

The  child  weighed  10  lb.  on  admission,  and  was  well 
nourished.  He  was  then  suffering  from  diarrhoea  and  also 


The  Lancet,] 


ROYAL  INSTITUTE  OF  PUBLIC  HEALTH. 


[July  5,  1919  15 


bronchitis.  Large  masses,  presumably  enlarged  mesenteric 
glands,  were  felt  plainly  in  the  abdomen.  After  a fortnight 
the  child  died.  I did  a post  mortem  on  it  and  made  the 
following  report. 

External  appearance.  — A well-nourished  male  baby 
weighing  9 1b.  Numerous  rounded  tumour-like  masses 
varying  in  size  from  0 5 x 1 x 0 5 cm.  to  4 x 5 x 2 cm. 
scattered  throughout  the  body.  The  tumours  seemed  to 
arise  from  different  layers  of  the  body  in  different  places — 
e.g.,  some  from  skin,  some  from  connective  tissue,  some 
from  muscles  and  their  tendons,  and  some  from  periosteum. 
Many  of  the  tumours,  especially  the  larger  ones  and  those 
where  pressure  had  been  brought  to  bear  by  the  weight  of 
the  body,  were  ulcerated. 

Internal  examination. — Scalp  and  skull : Numerous  rounded 
growths,  2x3x1  cm.,  ulcerating  through  the  scalp  and 
attached  to  the  diploe  of  the  skull.  Apparently  non- 
capsulated. Brain  and  meninges:  Normal.  Thorax: 

Thymus  gland  normal.  Mediastinal  glands  matted  together, 
very  hard  to  the  touch,  and  very  much  enlarged.  Peri- 
cardium : The  parietal  layer  contains  one  or  two  hard 

rounded  nodules,  2 x 1 x 0'5  mm.,  not  extending  to  inner 
wall.  Heart : Normal.  The  ribs  and  vertebr®  were  studded 
with  tumour-like  growths  apparently  coming  from  the 
periosteum.  Abdomen : Liver : Several  nodules  2 x 3 x 

1-5  cm.  Spleen : Three  nodules  of  various  sizes.  Right 
kidney:  One  nodule  at  lower  pole.  Left  kidney:  Normal. 
The  retroperitoneal  and  mesenteric  glands  matted  together 
into  groups;  very  hard  and  in  places  as  large  as  billiard 
balls. 

Microscopic  examination  of  sections  cut  from  different 
organs  and  done  at  the  Sheffield  University,  revealed  small 
round-celled  sarcoma. 

It  was  quite  impossible  for  me  to  say  where  the  primary 
growth  started.  It  is  possible  it  started  as  a periosteal 
sarcoma  of  one  of  the  bones  and  rapidly  spread  throughout 
the  body  by  metastases. 

As  to  family  history,  father  and  mother  are  healthy,  this 
being  their  first  child. 

I am  indebted  to  Dr.  Leader  for  permission  to  publish  this 
case. 


A CASE  OF  CIRSOID  ANEURYSM  OF  PALM  OF 
HAND. 

By  J.  Todesco,  M.R.C.S.,  L.R.C.P..  D.P.H.  Eng. 


The  following  case  appears  uncommon,  as  there  was  no 
history  of  trauma  or  other  cause  to  explain  the  condition. 

The  patient,  a woman,  aged  58  years,  was  admitted  to 
the  West  London  Hospital  on  April  8th,  1919,  with  the 
history  that  she 
had  first  noticed  a 
swelling  over  the 
palm  of  her  right 
hand  20  years 
ago.  During"  that 
period  it  had 
broken  down  on 
several  occasions, 
with  discharge  of 
pure  blood.  The 
bleeding  had 
never  been  severe, 
and  she  had  been 
able  to  do  her 
house-work.  For 
the  last  ten  weeks 
a similar  swelling 
had  appeared  on 
the  palmar  aspect 
of  the  right  hand 
over  the  terminal 
phalanx  of  the 
middle  finger; 
this  had  broken 
down  and  become 
septic.  (See 
figure.) 

The  patient  said 
that  both  the 
swellings  over 
palm  of  her  right 
hand  and  over 
middle  finger  had 
been  painless,  but 
since  the  latter  had  broken  down  she  complained  of  a 
dull  burning  sensation  in  her  hand.  She  was  married,  with 
four  children  ; had  had  no  miscarriages.  The  Wassermann 
reaction  was  negative;  no  bony  changes  by  X ray;  both 
arms  were  equal  in  length. 


On  examination,  there  was  a rounded  tortuous  pulsating 
tumour  over  centre  of  the  palm  of  the  right  baud,  with  some 
scarring  of  the  skin  near  the  base  of  the  middle  finger.  The 
distal  and  middle  phalanges  of  this  digit  were  gangrenous. 
There  was  also  some  swelling  with  “ mottling  of  skin  ” (which 
was  unbroken)  over  the  two  distal  phalanges  of  the  right 
ring  finger  ; and  some  engorgement  of  veins  of  forearm:  On 
compressing  the  arteries  at  the  wrist  the  swelling  over  the 
palm  got  smaller,  but  on  releasing  pressure  it  swelled  out 
again.  On  auscultation  a distinct  “ souffle  ” was  heard  over 
the  palm,  being  conducted  both  upwards  along  the  proximal 
phalanges  of  middle  finger  and  downwards  towards  wrist. 

Owing  to  spreading  sepsis  and  pain  the  third  finger  was 
amputated  on  April  24th  at  the  metacarpo  phalangeal  joint. 

My  thanks  are  due  to  Lieutenant-Colonel  Donald  Armour, 
R.A.M.C.,  under  whose  care  the  patient  had  been,  for  per- 
mission to  record  this  case,  and  to  Sister  Wilks,  in  charge  of 
the  X ray  department,  for  the  photograph. 


Ulrica!  Societies. 


ROYAL  INSTITUTE  OF  PUBLIC  HEALTH: 

LONDON  CONFERENCE. 


Commencing  on  June  25th  the  Royal  Institute  of  Public 
Health  held  at  the  Guildhall  a conference,  in  which  the 
chief  aspects  of  public  health — the  work  of  the  new  Ministry, 
the  prevention  and  arrest  of  venereal  disease,  housing  in 
relation  to  national  health,  maternity  and  child  welfare,  and 
the  tuberculosis  problem — were  separately  and  fully  dis- 
cussed, the  debates  culminating  in  a series  of  resolutions 
which  focussed  the  present  position  in  regard  to  these 
problems.  The  inaugural  meeting  took  place  at  the  Mansion 
House,  under  the  direction  of  the  Lord  Mayor,  who  was 
supported  by  His  Majesty  King  Manuel,  Earl  Beauchamp, 
Viscount  Knutsford,  Lord  Willoughby  de  Broke,  Lord 
Leverhulme,  and  others. 

The  Lord  Mayor's  Speech. 

The  Lord  Mayor  made  a graceful  reference  to  the 
imminence  of  peace,  and  to  the  generosity  of  Lord  Lever- 
hulme which  had  resulted  in  the  Institute  being  well 
supplied  with  technical  equipment,  thus  enabling  it  success- 
fully to  carry  on  during  the  trying  time  of  the  war.  The 
Institute  was  also  to  be  congratulated  on  at  length  seeing 
established  that  Ministry  of  Health  which  it  had  continuously 
advocated  since  it  was  first  urged  at  the  Dublin  Conference 
in  1892.  The  fine  work  done  by  the  Institute  in  the  30  years 
of  its  existence  strengthened  its  case  for  endowment,  espe- 
cially now  that  there  was  a greatly  increased  activity  in  all 
that  concerned  the  nation’s  health. 

The  Need  for  a Permanent  Endowment  for  Research  Work. 

Lord  Leverhulme  announced  a donation  of  £100  from 
the  King  and  a generous  cheque  from  the  Prince  of  Wales. 
Good  health,  he  said,  was  at  the  very  foundation  of  a large 
and  profitable  output.  In  order  to  carry  out  necessary 
research  work  in  public  health  matters  it  was  essential  that 
the  Institute  should  have  a permanent  endowment,  and  he 
earnestly  appealed  for  financial  support  to  that  end.  One 
of  the  objects  was  to  found  a national  journal  of  preventive 
medicine,  and  for  such  a good  programme  as  the  Institute 
had  set  itself  he  thought  there  was  a good  case  for  a 
substantial  Government  grant.  He  had  always  been  much 
impressed  by  the  Institute’s  economy  of  management  and 
efficiency  of  service,  and  he  was  certain  the  money  received 
would  be  wisely  expended.  £30,000  was  the  sum  asked  for, 
and  he  proposed  a resolution  urging  the  Government  to  make 
a grant  towards  this  amount. 

H.M.  King  Manuel  (an  honorary  Fellow  of  the 
Institute),  in  seconding  the  resolution,  said  that  every- 
thing which  could  now  be  done  for  the  improve- 
ment of  public  health  would  be  of  the  utmost  import- 
ance. We  had  recently  been  living  in  times  when  brains, 
money,  and  everything  we  possessed  were  used  for  purposes 
of  destruction  ; let  the  people  now  do  likewise  in  the  work 
of  reconstruction.  The  one  thing  which  above  everything 
else  won  the  war  was  the  health  of  the  country.  In  con- 
clusion, His  Majesty  trusted  that  the  knowledge  gained  in 
dealing  with  the  men  disabled  in  the  war  would  be  applied 
to  the  case  of  the  civilian  population. 


Cirsoid  aneurysm  of  palm  of  band. 


16  Thb  Lancet,] 


ROYAL  INSTITUTE  OF  PUBLIC  HEALTH. 


[July  5,  1919 


Lord  Beauchamp,  who  was  President  of  the  Berlin 
Conference  before  the  war,  said  we  could  not  expect  satis- 
factorily to  deal  with  the  reconstruction  of  the  national 
life  unless  the  standard  of  health  of  the  community  became 
higher  than  in  the  past  ; and  he  hoped  the  Government 
would  suitably  recognise  the  University  work  being  done  by 
the  Institute  in  preparing  students  for  degrees  in  public 
health. 

Lord  Willoughby  de  Broke  also  supported  the  resolu- 
tion. He  said  the  need  was  to  bring  to  maturity  as  many 
British  boys  and  girls  as  possible,  and  rear  them  in  such 
surroundings,  and  with  such  knowledge  of  the  fundamental 
laws  of  health  as  would  enable  them  to  promote  national 
efficiency  in  the  highest  degree.  In  hoping  for  the  Ministry 
of  Health  a great  and  increasing  success  he  pleaded  for  a 
universal  grasp  of  the  leading  facts  of  science,  which  was  a 
fundamental  necessity  to  the  full  power  of  the  race. 

Further  support  came  from  Sir  Thomas  Oliver  and  the 
Director  of  the  Medical  Department  of  the  Navy,  the  Dean  of 
St.  Paul’s,  and  Lord  Knutsford.  Dr.  J.  Utting  (Liverpool) 
objected  to  the  part  of  the  resolution  which  asked  for  a 
Government  subsidy,  as  it  would  mean,  in  his  opinion,  that 
the  Institute  would  be  under  the  “blighting  influence  of 
bureaucratic  control.” 

The  resolution  was  carried. 

On  the  proposition  of  the  Bishop  of  Hereford,  seconded 
by  Dr.  Mary  Scharlieb,  the  Lord  Mayor  was  cordially 
thanked  for  his  hospitality. 

I.  The  Work  of  the  Ministry  of  Health. 

Dr.  W.  R.  Smith  (Sheriff  of  the  City)  presided  at  this 
session.  He  said  it  was  difficult  to  exaggerate  the  far- 
reaching  importance  of  training  men  and  women  to  take  up 
public  health  work.  The  school  medical  service  originated 
with  the  School  Board  for  London,  and  it  was  now  a great 
satisfaction  to  find  Sir  George  Newman,  late  medical  officer  to 
the  Board  of  Education,  attached  to  the  new  Health  Ministry. 
Many  health  measures  owed  their  origin  to  special  efforts  for 
local  application  only,  efforts  promoted  by  a Health  Com- 
mittee of  some  large  municipality.  This  was  the  case  with 
such  measures  as  the  Infectious  Diseases  Notification 
Act,  that  for  the  notification  of  tuberculosis,  the  Notification 
of  Births  Acts,  while  other  measures  dealt  with  town 
planning,  a pure  milk-supply,  milk  for  mothers  unable  to 
suckle  their  children,  &c.  He  hoped  the  new  Ministry 
would  not  put  into  operation  any  schemes  which  would 
destroy  or  impair  the  usefulness  of  such  bodies.  He  thought 
adequate  support  for  research  should  be  forthcoming  from 
the  Treasury,  and  those  intended  for  conducting  research 
should  receive  careful  training  to  that  end.  They  needed 
to  have  not  only  a scientific  training,  but  patience,  an 
analytical  mind,  and  sound  judgment.  He  pointed  out  that 
great  powers  were  possible  to  the  new  Ministry  through  the 
channel  of  the  Orders  in  Council  that  the  Act  provided  for, 
which  Orders  became  operative  if  no  opposition  came  from 
either  House  within  30  days. 

Sir  H.  Kingsley  Wood,  M.P.,  spoke  at  some  length  on 

The  Central  Organisation  of  the  Health  Ministry. 

He  hoped  that  the  Consultative  Councils  would  receive  the 
benefit  of  the  long  experience  of  the  Institute  of  Public 
Health.  He  thought  that  in  former  days  and  up  till  very 
recently  the  preventive  aspect  of  public  health  had  been  almost 
entirely  lost  sight  of  ; the  problem  had  never  been  adequately 
tackled  as  a whole,  but  had  rather  been  approached  by  jerks, 
stimulated  in  many  cases  by  the  menace  of  an  epidemic  or 
pestilence.  He  agreed  there  had  been  in  this  country  an 
utterly  inadequate  provision  for  research,  a beggarly  £60.000 
a year  being  the  sum  expended  on  it.  A Medical  Research 
Department  was  one  of  the  equipments  of  the  new  Ministry, 
and  this  would  be  under  the  direction  of  the  Privy  Council ; 
nothing  short  of  this  was  adequate  for  a matter  of  such 
world- wide  importance,  for  its  activities  would  embrace  the 
whole  of  the  British  Empire,  with  branches  in  every  part. 
One  of  the  most  serious  indictments  against  our  health  con- 
ditions had  been  that  we  had,  to  a large  extent,  taken  a 
parochial  instead  of  a national  view  of  health  affairs,  and 
that  view  had  been  guided  too  much  by  considerations  as  to 
rate  increases.  For  that  he  considered  the  Government 
were  largely  to  blame,  as  they  had  not  given  sufficient  grants 
to  local  authorities  to  enable  them  to  carry  on  their 
work.  Until  the  formation  of  the  Health  Ministry, 
21  Government  departments  or  sections  were  dealing 
with  health  affairs.  There  were  a large  number  of 


laggard  authorities  which  needed  to  be  stirred  up  to 
the  adoption  of  the  modern  spirit  in  administrative 
affairs.  He  paid  a tribute  to  the  memory  of  Lord 
Rhondda,  who  did  so  much  to  bring  about  what  all 
were  so  pleased  to  see  established.  With  regard  to  tuber- 
culosis, the  employed  class  was  entitled  to  such  provision  as 
had  been  made  for  sanatorium  benefit,  but  a large  mass  of 
people  had  no  right  and  no  access  to  the  same  treatment. 
Many  thousands  of  pounds  were  being  spent  in  connexion 
with  this  disease,  of  which,  he  thought,  about  75  per  cent, 
was  thrown  away. 

Dr.  F.  E.  Fremantle  (consulting  medical  officer  tor 
Herts)  discussed  the  question  of 

Local  Administration  in  Health  Matters. 

He  had  drawn  much  help  from  experience  of  military 
hospitals  during  the  war ; in  civil  work,  however,  consider- 
able latitude  must  be  allowed.  The  ultimate  centre  of  the 
whole  activity  was  the  family  life.  Under  the  new  Ministry 
health  in  the  factory  was  left  out  at  present,  but  he  hoped  it 
would  soon  be  included.  But  little  had  been  done  as  yet  in 
the  matter  of  national  assistance  for  the  poor  professional 
and  commercial  classes.  He  urged  that  there  should  be  one 
authority,  out  of  which  the  separate  activities  should  be 
developed  as  the  need  for  them  arose.  He  believed  in 
cooption  on  central  bodies  of  persons  with  special  knowledge 
which  would  be  useful  to  the  community.  Prevention  and 
cure  could  not,  in  practice,  be  separated,  therefore  there 
should  be  one  administrator  for  both.  The  essence  of  public 
health  progress  should  be  a sense  of  individual  responsibility, 
and  measures  would  be  most  effective  of  which  the  public 
had  become  convinced  as  to  their  necessity. 

Dr.  J.  Middleton  Martin  spoke  of  public  health 
administration  in  Gloucestershire,  of  which  he  is  county 
medical  officer.  He  emphasised  the  serious  factors  of 
distance  and  sparse  populations,  and  therefore  the  need  of 
improved  transport  to  secure  prompt  consultations. 

Lady  Barrett,  M.D.,  dealt  with 

The  Women’s  Aspect  of  the  Work  of  the  Ministry  of  Health. 
The  speaker  made  a strong  plea  for  efficient  home 
administration.  The  unit  of  the  local  area  was  the  home, 
and  the  administrator  of  the  home  was  the  woman.  Housing 
schemes  might  be  perfect,  but  unless  the  women  in  those 
houses  had  the  knowledge  and  the  willingness  to  use  the 
facilities  which  had  been  planned  for  them,  housing  schemes 
would  not  make  any  appreciable  difference  in  the  health  of 
the  country.  The  same  was  true  of  infant  welfare  schemes  ; 
there  must  be  women  workers  who  had  access  to  the  homes, 
otherwise  even  the  women  who  attended  instruction  might 
hear  all  that  was  said  and  yet  go  home  without  doing 
anything.  All  strong  and  irresistible  habits  were  learned  in 
infancy,  and  the  necessary  health  habits  could  only  be  incul- 
cated if  the  women  had  not  only  the  knowledge  but  also  the 
goodwill  to  do  it.  The  people  who  at  the  moment  had  the 
greatest  influence  in  the  home  were  women  of  three  skilled 
functions — nurses,  mid  wives,  and  health  visitors.  These 
women,  therefore,  required  careful  representation  in  con- 
nexion with  the  Ministry  of  Health,  because  they  knew  the 
difficulties  met  with  in  the  practical  application  of  the  various 
schemes.  Men  and  women  were  working  together  for  the 
good  of  the  race  ; it  was  not  a male  race  or  a female  race, 
but  both,  and  therefore  both  should  be  combined  for  teaching 
and  for  administration. 

In  the  further  debate  a large  number  took  part,  and  the 
following  resolutions  were  passed  and  ordered  to  be  sent  to 
the  Ministry  of  Health  : — 

(1)  That  this  Conference  views  with  satisfaction  the  contemplated 
creation  of  Advisory  Councils  in  connexion  with  the  work  of  the  Ministry 
of  Health,  and  urges  that  the  services  of  those  who  have  had  long, 
wide,  and  practical  experience  in  administrative  and  executive  public 
health  should  be  secured  upon  those  councils. 

(2)  That  in  view  of  the  large  national  demands  which  will  be  made  on 
the  Ministry  of  Health  as  an  organising  and  controlling  centre  it  is 
desirable  that  it  should  not  be  burdened  with  functions  and  details 
which  may  result  in  depriving  the  local  authorities  of  a sense  of 
responsibility  and  a sense  of  initiative. 

(3)  That  in  the  view  of  this  meeting  sanitary  inspectors,  health 
visitors,  and  similar  classes  of  public  health  officials  should  be 
adequately  t rained,  and  that  the  present  system  of  examinations  should 
be  coordinated  so  as  to  secure  one  qualifying  examination  for  the  whole 
country. 

(4)  That  in  view  of  the  invaluable  services  rendered  by  women  who 
are  serving  as  elected  or  coopted  members  upon  local  authorities,  or  as 
officials  of  such  authorities,  this  Conference  is  of  opinion  that  women 
should  be  included  in  larger  numbers  on  all  advisory  bodies,  and  that 
greater  facilities  be  provided  for  the  training  of  expert  women  workers 
in  the  homes  of  the  people. 


The  Lancet,] 


KOYAL  INSTITUTE  OF  PUBLIC  HEALTH. 


[July  5,  1919  17 


(5)  That  iu  the  opinion  of  this  Confeience  all  questions  comprised 
within  the  scope  of  port  and  maritime  sanitation  should  rooeivo  the 
earnest  attention  of  the  Ministry  of  Health,  and  in  order  to  ensure 
greater  cooperation  and  confidence  between  British  and  foreign  port 
authorities,  the  widening  and  readjustment  of  t.bo  agreements  reached 
at  the  international  Sanitary  Convention  are  necessary. 

(6)  That  greater  use  should  be  made  of  the  services  of  the  British 
Consuls  in  foreign  ports  in  obtaining  and  transmitting  information 
relative  to  the  sanitary  condition  of  the  ports. 

(7)  That  it  is  desirable  that  smaller  authorities  shou'd  be  joined 
together  with  the  view  of  securing  the  whole  time  services  of  medical 
officers  of  health  and  other  sanitary  officials. 

II.  The  Prevention  and  Arrest  op  Venereal 
Disease. 

The  chair  at  this  session  was  occupied  by  Sir  William 
Millican  (Manchester)  in  the  absence  of  Lord  Sydenham. 
The  chairman  reminded  the  audience  of  the  initial  step  in  a 
national  movement  against  these  diseases  taken  by  Sir 
Malcolm  Morris.  He  impressed  upon  the  meeting  the  wide- 
spread prevalence  of  syphilis  and  gonorrhoea  and  the  large 
number  of  cases  going  about  to-day  in  an  infective  condi- 
tion. He  assumed  that  none  of  those  present  were  anxious 
to  see  a revival  of  the  “ C.D.”  Acts;  the  measure  had 
been  tried  in  nearly  every  country  on  the  globe,  and 
practically  every  country  had  given  it  up  or  was  about 
to.  The  subject  must  be  approached  from  a diSerent 
angle  ; the  public  must  be  educated  and  shown  the  dangers 
of  the  disease  and  the  calamities  which  followed  in  its  wake. 
The  universities  devoted  too  little  attention  to  the  teaching 
of  this  subject  ; so  widespread  a disease  should  be  carefully 
taught  to  all  medical  students.  Women  must  be  properly 
paid  for  their  work,  thus  removing  temptation  from  the 
path  of  the  poor  self-supporting  girl.  He  hoped  to  hear 
opinions  as  to  whether  compulsory  notification  was  advisable, 
now  or  at  any  time.  If  adopted  was  it  likely  to  act  as  a 
preventive  measure  ? A very  important  question  was  that  of 
prophylaxis ; should  it  be  encouraged  by  the  profession  ? 
Further,  should  inmates  of  institutions  who  were  suffering 
from  these  diseases  be  retained  there  until  they  were  cured  ? 
The  present  methods  of  treating  syphilis  were  complicated, 
and  required  considerable  technical  skill,  and  he  thought 
the  aim  of  syphilologists  should  be  to  secure  some  method  of 
treatment  which  was  somewhat  more  simple  and  easily 
applicable,  so  that  it  could  be  put  into  a greater  number  of 
hands.  It  was  quite  a mistake  to  regard  gonorrhoea  in  the 
light-hearted  way  which  many  people  did,  and  it  would  be 
useful  for  this  gathering  to  express  an  opinion  on  this.  He 
regarded  gonorrhoea  as  almost  as  destructive  as  syphilis. 
The  danger  in  the  matter  of  spread  was  not  the  street- 
walker but  the  clandestine  prostitute,  who  used  this  as  a 
means  of  eking  cut  her  underpaid  living.  He  doubted  if 
gonorrhoea,  especially  among  women,  was  ever  cured.  He 
hoped  the  discussion  would  be  focussed  on  a resolution. 

The  Woman's  Standpoint . 

Dr.  Mary  Scharlieb  presented  the  subject  from  the 
woman’s  standpoint,  which  was,  she  said,  in  the  estimation 
of  the  public,  somewhat  of  a novelty  because  women  and 
children  had  been  supposed  to  know  nothing  of  this  evil. 
Those  who  did  not  know  of  an  evil  could  not  protect 
themselves  against  it,  and  it  was  unwise  to  keep  women  in 
ignorance  of  the  troubles  to  which  they  might  become 
victims.  It  was  still  more  criminal  for  parents  to  neglect 
to  teach  their  children  to  value  and  respect  their  Bodies,  and 
how  to  maintain  their  bodies  in  purity,  temperance,  and 
chastity.  When  parents  were  either  unwilling  or  unable  to 
discharge  that  sacred  duty  they  should  suitably  delegate  it 
to  others,  such  as  schoolmasters  and  schoolmistresses.  Dr. 
Scharlieb  proceeded  to  speak  of  these  diseases  as  they  affect 
pregnant  women  and  children  before  and  after  birth.  A 
considerable  percentage  of  the  100,000  deaths  of  unborn 
children  which  occur  every  year  were  due  to  these  diseases. 
In  England  and  Wales  something  like  800,000  babies  were 
born  alive  every  year,  and  of  them  about  100,000  died  before 
the  anniversary  of  their  birth  was  reached,  many  from 
syphilis  which  they  derived  from  their  mother  before 
birth.  20,000  die  within  a week  after  birth.  None 
of  the  ordinary  causes  of  infantile  mortality — bad  air, 
bad  food,  bad  milk,  bad  maternal  management,  whooping- 
cough,  measles,  bronchitis — were  operative  so  soon  after  birth  ; 
the  majority  who  died  so  early  did  so  because  they  were 
born  in  a dying  state,  a heavy  percentage  owing  this  to  infec- 
tion with  syphilis.  It  had  been  calculated  that  about  30  per 
cent,  of  all  the  blindness  of  the  country,  30  per  cent,  of 
the  deafness,  16  per  cent,  of  the  insanity,  and  most  of  the 


feeble-mindedness  was  due  to  venereal  disease.  Gonorrhoea 
as  it  affected  women  was  a loathsome  ailment  and  a dangerous 
disease.  Evidence  was  given  before  the  Royal  Commission 
on  Venereal  Diseases  that  one-half  of  the  sterility  of  the 
country  was  due  to  gonorrhoea,  and  a distinguished  medical 
witness  attributed  one- fourth  of  the  serious  pelvic  conditions 
which  needed  a major  operation  to  the  same  cause.  Yet  an 
Irish  medical  student,  when  asked  how  he  would  treat  these 
diseases,  replied,  “ With  contempt.”  There  were  now  very 
few  large  towns  which  had  failed  to  provide  clinics  and 
schemes  for  treating  these  diseases,  a wonderful  progress  in 
less  than  three  years,  and  the  speaker  urged  the  members  of 
this  Conference  to  do  their  best  to  get  the  work  enlarged. 

The  Civilian  Standpoint. 

Sir  Malcolm  Morris  treated  the  subject  from  the  civilian 
standpoint,  which,  he  said,  was  a more  complex  one  than 
that  of  the  Army,  for  in  the  case  of  the  latter,  masses 
of  men  were  under  strict  discipline  and  instruction,  while 
the  ordinary  population  consisted  of  men  and  women, 
young  and  adult,  some  of  them  not  of  high  intelligence,  and 
with  but  a rudimentary  sense  of  responsibility  ; hence  they 
did  not  seek  advice  until  the  disease  was  far  advanced,  and 
were  apt  to  withdraw  themselves  from  treatment  as  soon  as 
the  obvious  symptoms  were  suppressed.  He  referred  with 
satisfaction  to  the  propaganda  worK  which  had  been  carried 
out  by  the  National  Council  for  Combating  Venereal  Diseases, 
particularly  during  the  war,  in  lecturing  to  two  million  men. 
The  most  promising  form  of  propaganda  was  through 
teachers,  for  no  boy  or  girl  should  go  out  into  the  world 
ignorant  of  sex  perils,  or  of  the  value  of  sexual  continence. 
He  referred  to  the  poster  and  other  propaganda  work, 
and  said  that  the  giving  effect  to  the  Report  of  the  Royal 
Commission  by  the  Local  Government  Board  was  one  of 
the  brightest  incidents  in  the  public  health  administra- 
tion of  this  country.  There  should  be  no  area  without 
facilities  of  ready  access  for  the  treatment  of  these  diseases. 
Some  thought  the  demobilised  soldier  was  spreading  the 
disease  ; others  that  the  soldier  was  really  the  victim  of  the 
non-prostitute  girl  and  woman  who  during  the  war  had  fallen 
into  a loose  mode  of  life.  Relaxations  of  various  kinds  at 
the  present  time  favoured  a recrudescence  of  venereal 
disease,  such  as  followed  previous  wars.  Prophylaxis  he 
did  not  regard  as  a wise,  but  as  a panicky  measure,  though 
he  preferred  not  to  enter  into  the  ethics  of  it.  By  supplying 
a man  with  a prophylactic  outfit,  he  was  released  from 
the  restraint  which  might  otherwise  have  been  operative  ; 
certainly  it  would  not  diminish  a tendency  to  promiscuity. 
Dr.  Otto  May  had  resigned  from  the  National  Council 
because  that  body  did  not  countenance  prophylaxis  in  that 
way,  but  its  policy  was  still  maintained,  for  otherwise  the 
great  moral  forces  of  the  nation  would  be  antagonised  to  the 
Council.  He  moved  : — 

That  in  the  opinion  of  this  Conference  it  is  absolutely  essential, 
alike  from  the  military  and  civilian  standpoints,  including  also  the 
interests  of  women  and  children,  that  legislation  affecting  venereal 
disease  should  be  amended  and  harmonised,  so  far  as  it  possibly  can  be, 
with  legislation  affecting  other  forms  of  communicable  disease,  the  aim 
being  to  ensure  continuity  of  treatment  and  the  prevention  of  the 
spread  of  infection. 

Mr.  E.  B.  Turner  seconded  the  resolution.  He  said 
he  felt  sure  there  would  be  set  up  some  form  of  con- 
fidential notification  of  these  diseases,  which  would  ensure 
that  most  important  desideratum,  continuiiy  of  treatment, 
and  treatment  which  was  efficient  and  skilled.  This  meant  the 
surmounting  of  very  formidable  obstacles.  Very  few  doctors, 
owing  to  the  sacredness  of  professional  confidence,  would 
voluntarily  consent  to  notification,  but  if  it  became  a 
statutory  compulsory  requirement  he  thought  most  would 
soon  fall  into  line  without  trouble.  Legislators  must  be 
shown  the  necessity  for  some  such  revision  in  the  law. 
He  concluded  by  an  appeal  to  do  all  that  was  possible  to 
stop  the  activities  of  the  venereal  quack  by  means  of 
prosecutions. 

Inadequacy  of  the  Present  Measures. 

Dr.  J.  H.  Sequeira,  who  has  charge  of  the  London 
Hospital  Venereal  Clinic,  said  he  was  convinced  more  and 
more  that  the  measures  adopted  at  present  in  combating 
these  diseases  were  inadequate  and  cumbersome,  as  well  as 
expensive  in  time  and  money.  He  described  the  course  of 
treatment,  and  explained  the  need  for  early  advice,  regret- 
fully remarking  that  40  per  cent,  of  those  who  attended  the 
clinic  did  not  complete  the  treatment,  despite  the  organised 


18  The  Lancet,] 


MEDICO-LEGAL  SOCIETY. 


[July  5,  1919 


efforts  to  follow  cases  up  and  the  emphasis  laid  upon  the  taking 
of  the  thorough  course.  From  the  scientific  standpoint  these 
diseases  were  among  the  easily  preventable,  and  the  natural 
question  was,  Why  were  not  prophylactic  measures  more 
thoroughly  carried  out?  The  reason  was  a moral,  not  a 
scientific  one.  For  a long  time  he  was  against  prophylaxis 
in  this  matter  for  that  reason,  but  he  had  had  proof  of  such 
important  results  from  prophylaxis,  which  he  narrated,  that, 
in  view  of  the  great  prevalence  of  the  diseases,  he  had 
changed  his  opinion,  especially  as  he  failed  to  differentiate 
ethically  between  supplying  a man  with  a prophylactic 
outfit,  and  giving  him  an  address  to  which  he  could  go  for 
so-called  “ early  disinfection  ” after  the  risk  had  been  run. 

Sir  Thomas  Barlow  said  that  until  adequate  national 
provision  for  treatment  had  been  set  up  it  was  undesirable 
to  laydown  penal  regulations  regarding  notification.  The 
more  treatment  centres  were  set  up,  and  the  more  a kindly 
and  humane  tone  pervaded  their  administration,  the  more 
would  sufferers  avail  themselves  of  these  means  of  cure.  He 
gave  the  results  arrived  at  by  Dr.  F.  H.  Teale  in  regard  to  the 
antiseptic  function  of  soap  and  water  in  the  case  of  the  gono- 
coccus. Exposed  to  a 2 per  cent,  solution  of  ordinary  yellow 
soap  for  two  minutes,  only  a trace  of  growth  remained,  and 
when  exposed  for  four  minutes  it  gave  no  growth  at  all. 
Answering  Dr.  Sequeira,  he  urged  a full  consideration  of  the 
moral  aspect,  as  sexual  promiscuity  had  been  one  of  the 
fatal  deteriorating  influences  in  civilisation,  seen  in  the  decay 
of  the  Roman  Empire.  A loose  morality  on  this  question 
tended  to  weaken  the  marriage  bond  and  produce  all  its 
dangerous  sequelae.  He  urged  strict  cleanliness,  especially 
after  risk  had  been  run,  but  not  the  supplying  of  a pro- 
phylactic packet. 

Mrs.  Gotto  said  the  question  was  really  as  to  how  to  make 
the  provisions  for  treatment  available  to  a mixed  general 
community  in  a way  which  would  be  helpful  medically 
without  being  harmful  socially.  Social,  medical,  and  ethical 
ideals  converged  into  one,  for  she  did  not  believe  a real  truth 
was  ever  divided. 

Methods  of  Diminishing  Venereal  Disease. 

Dr.  Otto  May  said  that  to  diminish  these  diseases  two 
lines  of  effort  could  be  used — reducing  the  practice  of  sexual 
promiscuity,  or  making  such  promiscuity  less  dangerous.  The 
standard  of  conduct  at  the  present  time  was  very  low.  Only 
9 out  of  100  officers  between  19  and  24  years  of  age  did  not 
admit  sexual  experience  with  females,  a fact  which  connoted 
an  equally  low  standard  in  the  other  sex.  If  that  was  the 
case  after  thousands  of  years  of  ethical  teaching,  did  it  not 
suggest  that  there  would  not  be  much  progress  in  this  matter 
along  that  road  ? With  the  present  delayed  age  of  marriage 
there  was  possibility  of  some  damage  arising  from  enforced 
chastity  ; alienists  knew  that  much  functional  nervous  disease, 
even  going  on  to  homo-sexual  manifestations,  ensued  on 
enforced  chastity.  He  did  not  say  this  by  way  of  apology  or  of 
an  incentive  to  unchastity,  but  the  question  had  to  be  faced. 
As  to  the  dangers  arising  from  promiscuity,  physically  much 
was  possible  in  the  way  of  prevention  by  disinfection  ; the 
chief  difference  of  opinion  was  as  to  the  nature  of  the  dis- 
infection to  be  employed.  But  he  agreed  with  Dr.  Sequeira 
in  seeing  no  ethical  difference  between  telling  people  where 
to  receive  absolution  from  the  effects  of  misconduct  and 
telling  them  where  to  get  a package  which  would  give  them 
similar  absolution.  Hospitals  could  not  be  induced  to 
remain  open  day  and  night  in  order  to  be  ready  to  give  the 
“ early  treatment  ” at  all  hours,  and  every  hour  of  waiting 
increased  the  danger  to  the  victim. 

In  the  further  full  discussion  Mrs.  Palmer  (Southampton) 
urged  the  straight  view  on  this  national  question,  putting 
aside  all  hypocrisy.  Ordinary  people  had  two  powerful 
impulses,  those  of  self-preservation  and  the  exercise  of  the 
sexual  function,  and  it  was  necessary  to  find  out  whether 
our  system  of  society  catered  for  both.  Seeing  the  low 
standard  of  morality  at  present  prevailing,  we  must  not  allow 
high  ethics  to  prevent  us  using  every  means  to  stamp  out 
venereal  disease.  What  people  seemed  afraid  of  was  having 
against  them  the  organised  force  of  the  Church.  It  was 
grievous  that  to  hold  views  favouring  prophylaxis  meant 
resignation  from  the  Council  for  Combating  Venereal 
Disease. 

Mr.  Powell  pleaded  that  life  for  all  classes  of  people, 
must  be  made  fuller  and  sufficiently  interesting ; they 
should  not  feel  that  sexual  intercourse  was  their  only  form  of 
amusement. 


The  Chairman,  in  putting  the  resolution,  said  all  were 
agreed  as  to  the  need  for  teaching  biology  to  children,  and 
the  proper  persons  to  do  it  were  the  father  to  the  son,  the 
mother  to  the  daughter.  But  if  they  objected  to  do  it 
another  means  must  be  open.  He  had  written  to  the  head- 
masters of  every  public  school  in  England  asking  whether 
they  gave  instruction  in  sexual  hygiene.  The  reply  from 
almost  every  headmaster  was,  that  when  they  found  that  the 
boy  had  not  been  told  anything  about  it — which  was  almost 
universal — the  headmaster  took  him  for  a walk  or  had  him  in 
his  study  on  the  eve  of  his  departure  from  school  and  told 
him  what  was  necessary.  That  was  the  next  best  to 
parental  instruction. 

The  resolution  was  carried  with  two  dissentients. 

(To  be  continued.) 


THE  MEDICO-LEGAL  SOCIETY. 


Annual  Meeting  : Election  of  Officers. 

The  annual  general  meeting  of  this  society  was  held  oh 
June  24th  at  11,  Chandos-street,  W.,  Sir  W.  J.  Collins  being 
in  the  chair. 

Mr.  R.  Henslowe  Wellington  was  elected  President  for 
the  ensuing  year;  Sir  J;  Macdonell,  Mr.  A.  H.  Trevor,  Dr, 
M.  I.  Finucane,  Dr.  W.  H.  Willcox,  and  Dr.  F.  G.  Crookshank 
vice-presidents ; Mr.  E.  Goddard  and  Dr.  B.  H.  Spilsbury 
honorary  secretaries. 

The  reports  of  Mr.  Walter  Schroder,  the  honorary 
treasurer,  and  of  the  honorary  secretaries  were  adopted. 

The  Chairman  referred  to  the  work  done  for  the  society, 
since  its  birth  in  1901,  by  the  President-elect  (Mr.  Henslowe 
Wellington)  and  alluded  feelingly  to  the  loss  sustained 
during  the  last  12  months  in  the  deaths  of  two  successive 
Presidents,  Sir  Samuel  Evans  and  Dr.  F.  J.  Smith,  in  their 
terms  of  office. 

At  the  conclusion  of  the  business  of  the  annual  general 
meeting  an  address  was  given  by  Dr.  Lionel  Weatherly, 
entitled — 

“ A Point  of  General  Importance : The  Interpretation  of 
Secs.  Jfl  and  321  (ii.)  the  Dunacy  Act , 1890.” 

Dr.  Weatherly  said  that  he  would  divide  his  address  into 
three  parts  : (1)  a preamble  ; (2)  a story  ; (3)  a moral.  By 
way  of  preamble  he  alluded  to  the  necessity  for  care,  on  the 
part  of  lawyers,  in  the  drafting  of  Bills,  particularly  those 
concerning  matters  of  medical  importance  ; and  he  insisted 
on  the  necessity  for  the  participation  of  medical  interests 
when  such  Bills  or  Acts  are  in  contemplation.  His  “ story,” 
which  was  narrated  impersonally,  referred  to  incidents 
which  are  already  widely  known,  and  was  concerned  with 
the  events  that  followed  the  request  made  to  a consultant 
in  lunacy,  by  the  relatives  of  a certified  lunatic,  to  visit  that 
person  in  a county  asylum  where  he  was  actually  a paying 
patient.  Difficulties  in  obtaining  the  consent  of  the  super- 
intendent of  the  asylum  to  the  proposed  visit  of  the  con- 
sultant were  only  overcome  by  the  issue,  under  pressure,  of 
an  order  for  admission  made  by  a Commissioner  in  Lunacy  ; 
but,  although  physical  admission  to  the  asylum  and  access 
to  the  patient  were  obtained,  the  consultant  did  not  in  the 
event  secure  either  personal  communication  with  any  medical 
officer  of  the  asylum  or  the  opportunity  of  beiDg  informed, 
by  a perusal  of  the  records  or  otherwise,  of  the  patient’s 
case.  Legal  action  was  taken,  on  behalf  of  the  patient’s 
relatives,  with  a view  to  the  overcoming  of  what  was 
considered  to  be  the  intentional  withholding  of  information 
necessary  if  the  visit  was  to  be  other  than  a futility ; 
and  it  was  submitted  that,  on  a certain  interpretation  of 
Secs.  47  and  321  (ii.)  of  the  Act  of  1890,  merely  physical 
admission  to  the  asylum  and  access  to  the  patient  was  not  a 
proper  compliance  with  the  order  of  the  Board  of  Control. 
The  action  failed  ; it  being  held  by  Mr.  Justice  Darling  that 
the  order  had  been  technically  fulfilled,  and  that  there  was 
no  power  in  the  Board  of  Control  to  order  the  production  of 
the  records  to  an  independent  consultant  visiting  a patient 
at  the  request  of  the  relatives. 

Dr.  Weatherly  discussed  the  extent  to  which,  in  his 
opinion,  this  ruling  was  open  to  dispute,  and  urged  the 
necessity  in  the  interests  of  the  insane  for  an  alteration  in 
the  law,  if,  indeed,  it  has  been  correctly  interpreted  by  Sir 
Charles  Darling.  Dr.  Weatherly  drew  attention,  moreover, 
to  an  early  contention  of  the  Board  of  Control  during  the 
progress  of  the  events  narrated,  that  such  a proceeding  as 


The  Lancet,] 


REVIEWS  AND  NOTICES  OF  BOOKS. 


[July  5,  1919  19 


the  visit  of  an  independent  medical  man  to  such  a patient 
in  a county  asylum  is  “ unprecedented  ” ; and  he  emphasised 
the  fact  that  it  had  been  repeatedly  stated  (and  there  was 
nothing  to  show  the  contrary)  that  the  action  taken  by  the 
asylum  superintendent,  whilst  seemingly  of  an  obstructive 
nature,  was  in  no  sense  personal  and  directed  against  the 
particular  consultant  engaged. 

An  important  and  interesting  debate  followed  the  address, 
in  which  Mr.  Gardiner,  Mr.  Harvey  Hartley,  Mr. 
Goddard,  Mr.  Henslowe  Wellington,  Dr.  Crookshank, 
and  others  took  part. 

Summary  of  the  Discussion. 

The  Chairman,  in  summarising  the  discussion,  said  that 
he,  an  erstwhile  chairman  of  the  L.C.C.  and  a member  of  its 
Asylums  Committee,  certainly  did  not  regard  as  “ unprece- 
dented ” the  admission  of  medical  men  to  see  asylum 
patients,  and  to  inquire  into  various  matters  concerning 
them.  But  the  question  was  one  to  be  considered  imper- 
sonally, and  in  discussing  the  purely  legal  aspects  of  the 
case  he  concluded  by  observing  that  there  appeared  to  him 
good  grounds  for  seeking  amendment  of  the  statute.  In 
view  of  the  representations  made  by  the  Medico-Legal 
Society  in  earlier  years  to  successive  Lord  Chancellors  in 
regard  to  death  certification  and  coroner’s  law,  he  did  not 
think  it  would  be  outside  their  province  to  make,  if  so 
disposed,  similar  representations  in  regard  to  this  case  also. 

Dr.  Weatherly  briefly  replied  to  various  questions  put  to 
him,  and  thanked  the  society  for  the  care  and  sympathetic 
interest  with  which  the  subject  had  been  discussed. 


anbr  Itoficw  of  $ook 


A Treatise  on  Orthopedic  Surgery.  By  Royal  Whitman, 
M.D.,  M.R.C.S.  Eng.,  F.A.C.S.,  &c.  Sixth  edition, 
thoroughly  revised.  Illustrated  with  767  engravings. 
London  : Henry  Kimpton.  1919.  Pp.  914  + xii.  36s. 

In  the  preface  to  the  sixth  edition  of  this  well-known 
work  Dr.  Royal  Whitman  instances  the  recent  severe 
epidemic  of  anterior  poliomyelitis  in  New  York  and  its 
vicinity  and  the  crippling  accidents  of  war  as  two  factors 
which  have  definitely  established  the  place  of  orthopaedic 
surgery  in  the  popular  mind.  But  it  is,  as  he  says,  rather 
the  constant  purpose  of  this  specialty  to  prevent  and  correct 
deformity  and  to  preserve  and  restore  function  which 
governs  treatment  from  beginning  to  end,  and  is  its  chief 
distinction.  It  is  not  necessary  to  dwell  upon  the  merits  of 
this  well-known  text-book.  Suffice  it  to  say  that  it  has  kept 
well  up  to  date.  But  the  final  chapter  on  military  ortho- 
paedics, the  addition  of  which  distinguishes  this  edition, 
calls  for  some  comment.  This  chapter  reminds  us  that  the 
military  authorities  of  the  United  States  were  able  to  make 
use  of  the  Allies’  experience  and  that  they  paid  great 
attention  to  the  examination  and  preparation  of  recruits. 
In  this  work  orthopaedic  surgeons  took  a large  share. 
The  primary  examination  decided  whether  a recruit  should 
be  unconditionally  accepted  or  rejected,  or  if  he  should  be 
conditionally  accepted  as  fit  for  certain  duties,  but  not  for 
all  the  strains  of  active  service.  Under  the  rules  of  the 
selective  service  governing  orthopasdic  disabilities  these 
conditional  cases  and  many  of  the  recruits  who  broke  down 
under  training  were  treated  in  special  training-camps,  where 
they  were  divided  into  groups  according  to  the  character 
and  degree  of  their  disability  and  drilled  under  the  super- 
vision of  orthopaedic  surgeons.  Strains  of  the  back  and  weak 
and  disabled  feet  were  the  commonest  disabilities. 

The  regimen  in  these  camps  was  severe  and  calculated  to 
discourage  all  malingering.  Dr.  Whitman  lays  great  stress 
on  the  importance  of  eversion  of  the  front  of  the  foot  as  indi- 
cative of  weakness.  The  normally  low-arched  foot  is  not 
thus  everted  and  is  generally  quite  fit  for  the  strains  put 
upon  it.  Weak  and  flat  feet  appear  to  be  the  bane  of  the 
citizens  of  the  United  States,  and  hence  far  more  is  heard  of 
these  disorders  in  military  orthopiedic  work  there  than  in 
this  country.  Dr.  Whitman  makes  the  interesting  state- 
ment that  although  strain  or  discomfort  in  the  back  is  noted 
in  about  25  per  cent,  of  the  recruits,  in  most  instances  it  is 
relieved  by  the  military  drill  and  by  the  posture  enforced  by 
carrying  the  pack. 


The  treatment  of  fractures,  of  nerve  injuries,  and  the  pre- 
paration of  amputation  stumps  are  adequately  dealt  with, 
but  call  for  no  remark.  They  embody  the  conclusions  to 
which  four  years  of  war  have  led  most  surgeons.  A useful 
section  is  that  on  Attitudes  of  Election,  in  which  the  standard 
position  in  which  an  ankylosed  joint  is  most  useful  is  con- 
sidered for  all  the  chief  articulations.  We  note  that  Dr. 
Whitman  favours  full  extension  as  the  position  of  election 
for  an  ankylosed  knee,  therein  differing  from  Lieutenant- 
Colonel  Brackett,  the  Director  of  Orthopaedic  Surgery  in  the 
United  States  Army,  who  much  prefers  an  angle  of  135°. 
Sir  Robert  Jones,  and  many  other  experienced  surgeons, 
however,  agree  with  Dr.  Whitman,  whose  opinion  appears 
to  us  to  be  a sound  one. 

A short  but  useful  section  on  Reconstructive  Treatment 
concludes  the  chapter  and  the  book. 


Nerve  Injuries  and  their  Treatment.  By  Sir  James  Purves 
Stewart,  K.C.M.G.,  C.B.,  M.D.,  F.R.C.P.,  Senior  Phy- 
sician to  the  Westminster  Hospital,  &c.  ; and  Arthur 
Evans,  M.S.,  M B.,  F.R.C.S.,  Surgeon  and  Lecturer  on 
Surgery  at  the  Westminster  Hospital,  &c.  Second  edition, 
revised  and  enlarged.  London  : Henry  Frowde  and 
Hodder  and  Stoughton.  1919.  Pp.  250.  12s.  Qd. 

We  reviewed  this  book  favourably  on  its  first  appearance. 
In  its  new  edition  it  is  increased  in  size  by  some  40  pages 
and  contains  considerably  more  illustrative  instances  of 
lesions  of  the  various  peripheral  and  cranial  nerves.  The 
authors  have  seen  in  all  some  520  cases  of  nerve  lesion,  and 
they  have  marshalled  their  facts  in  a logical  and  readable 
way.  The  photographs  and  diagrams  number  some  40  more 
than  in  the  original  edition.  In  its  present  form  the  book  is 
sure  of  appreciation  by  neurologist  and  practitioner  alike. 

General  Medicine : Practical  Medicine  Series.  Vol.  I.  Edited 
by  Frank  Billings,  M.S.,  M.D.  Chicago:  The  Year 
Book  Publishers.  1919.  Pp.  622.  $2.50. 

This  volume  is  the  first  of  a series  of  eight,  each  on 
different  aspects  of  medicine,  published  at  intervals  through- 
out the  year,  and  each  reviewing  12  months’  original  work  on 
the  subject  with  which  it  deals.  The  first  volume  on  general 
medicine  covers  considerable  ground,  and  includes  abstracts 
from  papers  on  such  rare  diseases  as  lipodystrophia  pro- 
gressiva. We  find  no  reference  here  to  the  work  of  Dr.  Lewis 
on  the  effort  syndrome.  Possibly  this  is  not  considered  to 
come  within  the  range  of  general  medicine.  The  work  is 
classified  into  various  sections.  That  on  tuberculosis  may 
be  taken  as  a fair  sample  of  the  quality  of  the  whole  volume. 
It  contains  no  striking  papers,  but  some  are  worth  careful 
study,  especially  those  on  errors  in  diagnosis  (p.  25)  and 
Roentgen  ray  diagnosis  of  pulmonary  tuberculosis  (pp.  27  and 
29),  and  on  clinical  experience  with  Koga’s  cyanocuprol 
(p.  59).  The  others  deal  with  a variety  of  subjects,  including 
nomenclature,  system  of  examination,  lung  reflexes,  artificial 
pneumothorax  treatment,  tobacco-smoking,  gastro-intestinal 
disorder,  the  tuberculous  soldier,  and  prognosis.  Writing  on 
the  last  Dr.  Fishberg  omits  to  emphasise  the  prognostic  value 
of  progressive  fibrosis,  and  in  the  paper  on  a system  of 
examination  no  mention  is  made  of  the  importance  of 
determining  the  position  of  the  heart  and  the  area  of 
superficial  cardiac  dullness. 

The  articles  seem  to  be  abstracted  almost  entirely  from 
British  and  American  journals,  from  which  practitioners 
without  knowledge  of  foreign  tODgues  can  make  abstracts 
for  themselves,  but  it  is  clear  that  many  will  not  have  time 
or  desire  to  do  so. 

Irish  Ethno-Botany  and  the  Evolution  of  Medicine  in  Ireland. 
By  Michael  F.  Moloney,  M.B.,  Ch.B.  N.U.I.  Dublin  : 
M.  H.  Gill  and  Son,  Ltd.  1919.  Pp.  96.  4s.  6 d. 

Dr.  Moloney  tells  us  in  his  preface  that  his  book  “aims  to 
give  in  outline  the  evolution  of  medicine  in  Ireland,  and  to 
indicate  the  comprehensive  character  of  Irish  ethno- botany.  ” 
The  outline  is  exceedingly  sketchy  and  we  cannot  see,  so 
far  as  this  book  is  concerned,  that  Irish  folk-botany  differs 
much  from  the  folk-botany  of  England,  Scotland,  or 
Wales.  Those  who  are  acquainted  with  the  FitzPatrick 
lectures  of  the  late  Dr.  Frank  Payne  or  those  of  Sir 
Norman  Moore  will  find  that  very  many  of  the  medicinal 
uses  of  plants  given  by  Dr.  Moloney  are  also  given  by 
the  two  writers  just  cited.  For  instance,  Yarrow — i.e., 
Achillea  Millefolium — is  stated  on  p.  29  by  Dr.  Moloney  to 


20  The  Lancet,] 


NEW  INVENTIONS. 


[July  5,  1919 


have  been  used  as  a cure  for  toothache.  The  same  use  of 
the  same  drug  appears  in  the  Anglo-Saxon  translation  of 
the  Herbarium  of  Apuleius,  quoted  by  Dr.  Payne  in  his 
“English  Medicine  in  the  Anglo-Saxon  Times.”  Again,  Dr. 
Moloney  gives  an  old  Irish  saying  about  salvia,  which  he 
translates  as  follows  : “While  the  sage  is  on  the  mountain 
no  one  should  die.”  In  the  well-known  poem  of  the  School 
of  Salerno,  Regimen  Sanitatis,  \yritten  about  1100  A D.,  we 
find  the  following:  “Cur  moriatur  homo  cui  crescit  salvia 
in  horto  ? ” though  with  great  good  sense  the  writer  gives 
the  answer,  “ Contra  vim  mortis  non  est  medicamen  in 
hortis.”  On  p.  44,  Dr.  Moloney  says  that  saffron  is  used  by 
the  country  people  to-day  “ to  bring  out  the  rash  of  measles.” 
This  use  is  not  confined  to  Ireland,  for  saffron  tea  is  a 
common  English  rural  remedy  for  measles  even  to  the 
present  day.  Dr.  Moloney  gives  a very  full  list  of  plants  used 
in  native  Irish  materia  medica,  but  only  in  a very  few 
instances  does  he  say  for  what  complaints  the  various 
preparations  are  used.  As  to  Part  II.  of  his  book,  which  is 
called  “ History  of  Medicine  in  Ireland,”  it  is  so  slight  as  to 
be  of  little  value.  The  best  features  of  the  book  are  the 
indices,  of  which  there  are  three,  in  Erse,  English,  and 
Latin  respectively. 


Nerves  of  the  Human  Body.  By  Charles  R.  Whittaker. 
F.R.C.S.  Edin.,  Senior  Demonstrator  of  Anatomy, 
Surgeon’s  Hall,  Edinburgh.  Second  edition,  revised  and 
enlarged,  with  plates.  Edinburgh  : E.  and  S.  Living- 
stone. 1919.  Pp.  76.  3s.  6 d. 

' ]Mr.  Whittaker’s  edition  of  the  late  Professor  A W. 
Hughes’s  “Handbook  on  the  Nerves  of  the  Body  ” belongs 
to  the  multum  inparvo  type  of  text-book,  for  it  is  little  more 
than  a catalogue  of  the  peripheral  and  cranial  nerves  and 
sympathetic  system.  So  far  as  it  goes  it  contains  a prac- 
tical compendium  of  knowledge  bearing  on  its  subject,  but 
the  form  in  which  Ihis  is  couched  makes  little  appeal  in 
these  days.  The  book  is  intended,  we  presume,  for  the 
student  of  pure  anatomy,  yet,  even  so,  we  should  like  him 
to  feel  that  anatomical  knowledge  is  garnered  for  the  purpose 
of  its  subsequent  practical  application  in  practice,  whereas 
there  is  a regrettable  want  in  the  book  of  diagrams  covering 
the  points  in  which  anatomy  and  clinical  practice  meet. 
There  are  no  illustrations,  for  instance,  of  the  segmental 
areas  of  the  cutaneous  nerve-supply. 


JOURNALS. 

La  Clinique  Ophtalmoloqique,  November  and  December, 

1918,  and  January,  1919. — The  original  articles  in  this  journal 
include  a description  of  Smith’s  intracapsular  operation  for 
cataract  extraction  illustrated  by  some  excellent  plates 
(A.  S.  and  L.  D.  Green  of  San  Francisco),  articles  by  two  of 
the  editors,  Jocqs  and  Darier,  on  the  treatment  of  detached 
retina  by  puncture  and  subconjunctival  injection,  an  article 
by  Varrey-Westphal  describing  a new  apparatus  for  the 
detection  of  partial  colour-blindness,  and  others,  besides  the 
usual  reviews  of  articles  from  other  journals,  French, 
German,  Italian,  Spanish,  American,  and  a few  English. 

Fourth  Annual  Report  of  the  Ophthalmic  Hospitals  and  on 
Ophthalmic  Progress  in  Egypt  during  the  Years  1915-1916. 
Bv  A.  F.  HauCallan,  Director  of  Ophthalmic  Hospitals. 

1919.  Cairo:  Ophthalmological  Society  of  Egypt.  Bulletin 
of  1918. — From  these  reports  we  learn  that  the  number  of 
permanent  ophthalmic  hospitals  built  in  Egypt  during  the 
ten  years  1907  to  1917  was  13,  and  that  there  were  in 
addition  four  travelling  hospitals.  The  bulk  of  their  work 
is  concerned  with  trachoma  and  its  sequel®,  the  extent  of 
this  scourge  being  indicated  by  the  fact  that  the  proportion 
of  the  infected  pupils  in  the  primary  provincial  schools 
varied  from  61  to  100  per  cent. ! On'  the  other  hand,  the 
danger  of  infection  has  probably  beeu  exaggerated,  for 
Lieutenant-Colonel  J.  W.  Barrett  stated  in  the  discussion 
on  Dr.  MacCallan’s  report  that  from  February  to  November, 
1915,  when  he  was  consulting  oculist  to  the  Forces  in  Egypt, 
he  saw  only  17  cases  of  trachoma  amongst  all  the  troops  that 
came  under  his  notice,  and  most  of  them  were  contracted 
in  Australia.  The  number  of  operations  performed  for  the 
relief  of  trichiasis  and  entropion  in  one  year  was  upwards 
of  26,000.  Next  to  trachoma,  the  chief  cause  of  ophthalmic 
disease  is  the  gonococcus,  and  Dr.  MacCallau  has  for  some 
years  been  noting  the  relation  between  the  activity  of  this 
organism  and  the  rise  of  the  temperature  curve,  which 
appears  to  precede  it  at  an  interval  of  one  or  two  months. 
The  commonest  causes  of  blindness,  apart  from  conjunctival 
infection, are  cataractand  glaucoma,  the  percentage  of  blind- 
ness due  to  the  latter  disease  being  as  high  as  13  9.  The 
glaucoma  is  nearly  all  of  the  chronic  form  and  the  usual 


operation  for  it  undertaken  is  trephining  with  iridectomy. 
Of  the  other  papers  contained  in  the  Bulletin  we  may 
remark  that  in  many  of  them  the  English  sadly  needs 
revision.  Tnere  is  one  coloured  plate  of  a case  of  coloboma 
of  the  choroid. 

The  Optician  and  Scientific  Instrument  Maker. — This  weekly 
publication  is  frankly  a trade  journal,  but  contains  articles 
of  educative  value  to  the  optician  dealing  with  the  theory 
and  practice  of  his  calling.  It  also  contains  many  articles 
dealing  with  the  methods  of  sight-testing,  and  there  is 
much  controversial  matter  in  which  the  claims  of  the  sight- 
testing optician  are  championed.  Into  this  controversy  we 
do  not  propose  to  enter  beyond  pointing  out  that  the  refrac- 
tion of  children  at  any  rate  cannot  be  reliably  estimated 
without  the  use  of  a mydriatic.  We  therefore  regard  the 
directions  for  correcting'  astigmatism  and  other  refractive 
errors  in  children  contained  in  the  number  for  April  25th  as 
a good  deal  worse  than  useless. 


fjUto  Indentions. 


A HUMERUS  EXTENSION  SPLINT. 

The  difficulty  in  obtaining  satisfactory  extension  in 
fracture  of  the  humerus  is  well  known  to  those  who  have 
had  any  large  number  to  deal  with.  If  the  fracture  is 
without  loss  of  substance  and  without  displacement  it  is 
found  advisable  to  apply  some  form  of  extension  if  a perfect 
result  is  to  be  obtained  ; should  there  be  displacement  the 
need  for  extension  becomes  imperative  : if  there  is  displace- 
ment and  loss  of  substance  in  addition — as  so  often  happens 
in  gunshot  injuries — extension  is  necessary  during  the 
cleaning  of  the  wound,  even  if  foreshortening  has  to  be 
resorted  to  later  in  order  to  get  union.  I have  had  the 
splint  made  which  is  here  illus- 
trated. The  principle  is  found 
in  the  lever,  which  is  used  with 
a corkscrew  to  pull  corks.  By 
means  of  a double  toggle  in 
addition  to  the  attachment  at 
the  fulcrum,  the  end  of  the  lever, 
which  is  attached  to  the  lower 
end  of  the  fractured  humerus, 
pulls  in  a straight  line  instead  of 
through  the  arc  of  a circle  as 
would  happen  if  this  double 
toggle  were  not  put  in.  The 


ALLEN  A HAN5URYS 


pparatus  is  attached  to  a Robert  Jones  splint.  . The 
xtension  apparatus  is  indicated  by  the  letters,  a b is  an 
iluminium  plate  fixed  to  the  under  portion  of  the  forearm 
ection  of  the  Jones  splint,  H K represents  a lever  attached  to 
his  plate  at  the  fulcrum  C D,  the  double  toggle  being  shown 
is  B F E.  The  extension  is  fixed  to  the  lower  part  of  the  arm 
w glued  stockingette  and  the  pull  takes  place  from  the 
ower  end  of  it  by  means  of  tape  attached  to  the  lever  at  K, 
he  direction  of  the  pull  being  L K in  the  exact  line  of  the 
ntact  humerus.  Extension  is  obtained  by  an  elastic 
i p ward  pull  at  H by  means  of  rubber  tubing  over  a vulcanite 
3ad  moulded  to  the  lower  end  of  the  forearm  or  it  can  be 
attached  to  the  sides  of  the  Jones  splint.  In  the  sketch  the 
ixtension  is  shown  to  extend  far  up  the  arm,  whereas  it  is 
fixed  to  the  lower  end  of  the  arm  only,  and  the  hand  is 
ffiown  in  a position  midway  between  p onation  and  supina- 
tion, but  in  actual  practxe  the  hand  is  put  up  in  full 
supination;  these  explanations  a-®,  necessary  as  the  drawing 
is  done  so  as  to  be  as  clear  diagrammatically  as  possible. 

Tne  splint  attachment  can  be  obtained  from  Messrs.  Allen 
and  Hanburys,  48,  Wigmore-street.  London.  W. 

Whitby  W.  E.  F.  Tinlky,  M.D.  Durh. 


The  Lancet,] 


THE  PASSING  OF  THE  LOCAL  GOVERNMENT  BOARD. 


[July  5,  1919  21 


THE  LANCET. 


LONDON:  SATURDAY, , JULY 5,  1019. 


The  Passing  of  the  Local  Govern- 
ment Board. 

It  is  with  genuine  feelings  of  regret  that  the 
older  generation  of  medicine  must  witness  the 
passing  away  of  the  Medical  Department  of  the 
Local  Government  Board  ; for,  owing  to  the  fact  that 
the  Board  ceased  to  exist  on  June  30th  last,  its 
powers  and  activities  have  been  transferred  to  the 
new  Ministry  of  Health.  The  annual  reports  of  the 
medical  officers  of  the  Board  embody  the  history  of 
medicine  in  its  practical  and  scientific  aspects  as 
applied  to  public  health  and  the  prevention  of 
disease  in  England  and  Wales,  and  record  a progress 
which  is  admitted  to  stand  unique  among  the 
nations.  Progress  in  public  health  knowledge  has 
been  largely  due  to  the  pioneer  work  of  the  Medical 
Department  of  the  Board,  and  those  who  can  look 
back  on  the  history  of  sanitation  through  any  con- 
siderable period  of  years  will  see  those  decades 
distinguished  by  a gradual  increase  in  sanitary 
efficiency,  originated  or  promoted  by  the  medical 
servants  of  the  Board. 

Forty-eight  years  ago,  when  the  Local  Govern- 
ment Board  was  constituted  by  Act  of  Parliament, 
the  knowledge  of  preventive  medicine  and  public 
health  administration  was  relatively  small,  and  each 
advance  had  to  be  by  way  of  experiment.  It  was  the 
intention  of  the  first  medical  officer  of  the  Board,  Sir 
John  Simon,  to  make  the  Department  a Ministry  of 
Health,  but,  by  an  unfortunate  decision  of  the 
President,  measures  for  the  improvement  of  the 
public  health  were  made  subordinate  to  the 
administration  of  the  laws  for  the  relief  of 
the  poor.  Simon  was  further  hindered  in  his 
efforts  by  another  decision  of  the  President 
which  prevented  the  medical  officer  from  taking 
initiative  action  without  having  first  received  the 
sanction  of  the  lay  secretariat,  who  at  that  time 
neither  understood  nor  appreciated  the  need  for 
sanitary  reform.  Prior  to  the  constitution  of  the 
Local  Government  Board  public  health  legislation 
had  been  scanty  and  imperfect,  and  one  of  the  first 
duties  of  the  Department  was,  with  the  advice  and 
assistance  of  the  medical  officer  and  his  staff,  to 
draw  up  a sanitary  code  for  the  country.  But 
before  this  could  be  done  the  necessary  machinery 
had  to  be  provided,  and  for  this  purpose  .the  Public 
Health  Act  of  1872  was  passed,  which  divided  the 
whole  of  England  and  Wales  into  sanitary  districts, 
and  made  the  appointment  of  medical  officers  of 
health  and  inspectors  of  nuisances  compulsory  in 
every  district.  This  was  followed  by  the  Act  of 
1875,  which  codified  and  extended  all  the  previous 
public  health  legislation.  These  two  Acts  were  the 
foundation  of  real  sanitary  progress  throughout 
England,  and  Wales.  At  the  time  when  the  Board 
was  created  Great  Britain  was  being  ravaged  by  a 


virulent  epidemic  of  small  pox,  accompanied  by 
great  loss  of  life.  This  necessitated  reform  of  the 
existing  arrangements  for  vaccination,  which  was 
accomplished  by  the  passing  of  a series  of 
Vaccination  Acts  and  by  the  inauguration  of  a 
system  of  inspection  by  the  Board’s  medical 
inspectors  with  the  view  of  maintaining  a high 
standard  of  vaccination  throughout  the  country. 
These  measures  did  much  to  diminish  the 
prevalence  of  smallpox,  and  the  subsequent 
inquiries  made  by  the  Medical  Department,  which 
led  to  the  removal  of  small- pox  hospitals  from 
London  and  other  populous  centres,  had  great 
influence  in  arresting  the  spread  of  the  disease. 
We  may  also  refer  to  the  great  campaign 
instituted  by  Sir  John  Simon  for  the  abolition 
of  filth  nuisances,  which  were  then  of  common 
occurrence,  a piece  of  strenuous  work  which  was 
instrumental  in  reducing  the  incidence  and 
mortality  resulting  from  enteric  fever  and  other- 
intestinal  diseases,  while  it  added  much  to  the 
comfort  and  decency  of  life  among  the  working 
classes.  It  had  been  his  intention  to  carry  out  a 
complete  sanitary  survey  of  the  country  and  to 
place  the  results  on  permanent  record,  but  un- 
fortunately he  was  only  allowed  to  do  this 
in  piecemeal  fashion.  Nevertheless,  the  inspec- 
tions made  by  the  Board's  medical  inspectors 
were  productive  of  great  improvement  in  the 
sanitary  circumstances  and  administration  of 
the  districts  visited  by  them.  These  visits  were 
generally  welcomed  by  the  local  authorities  and. 
their  officers,  who  were  anxious  to  discuss  local, 
sanitary  problems  and  obtain  the  advice  and 
assistance  of  the  Board’s  expert  staff.  But,  the 
number  of  medical  inspectors  wTas  totally  inadequate 
to  carry  out  the  policy  for  which  Sir  John  Simon 
and  his  successors,  notably  Sir  Geokge  Buchanan, 
Sir  Bichard  Thorne,  and  Sir  William  Power,  were 
responsible.  Despite  repeated  applications  for 
increase  of  staff,  this  inadequacy  was  allowed  to 
continue  and  may  be  said  to  have  never  been 
removed.  In  view  of  these  various  circumstances  it 
is  the  more  remarkable  that  the  sanitary  progress  of 
England  should  have  been  so  rapid,  but  towards 
the  close  of  the  last  century  the  Medical  Depart- 
ment of  the  Board  made  one  of  its  greatest  moves 
forward.  The  first  essential  of  a scheme  for  the 
administrative  control  of  infectious  diseases  is 
that  accurate  information  respecting  the  number 
and  nature  of  such  cases  should  be  supplied  to  the 
medical  officer  of  health  of  the  district.  This 
involved  a system  of  notification  with  all  the 
trespass  upon  privacy  involved  therein.  To  meet  the 
strong  prejudices  in  certain  quarters  the  Notification, 
Act  of  1889  was  made  adoptive,  and  ten  years  later, 
when  the  value  of  notification  had  been  universally 
acknowledged,  the  measure  was  made  compulsory 
throughout  England  and  Wales  by  the  passing  of 
the  Infectious  Diseases  (Notification)  Extension  Act, 
1899.  It  became  one  of  the  chief  duties  of  the 
Board’s  medical  inspectors  to  make  inquiry  into- 
the  circumstances  associated  with  outbreaks  of 
infectious  diseases,  and  the  long  series  of  reports 
on  the  subject  forms  the  bas  s of  much  of  our 
modern  knowledge  of  the  epi  lemiology  of  the 
indigenous  infectious  diseases.  The  Medical  Depart- 
ment of  the  Board  was  also  largely  responsible  for 
the  reform  in  connexion  with  port  sanitary  adminis- 
tration which  led  to  the  abolition  of  the  obsolete, 
quarantine  regulations  and  their  replacement  by 
a system  of  medical  inspection  of  shipping.  This 
system  has  proved  an  efficient  safeguard  agaiLst 
a 3 


22  The  Lancet,] 


PEACE  AND  FAMINE. 


[July  5.  1919 


the  introduction  of  diseases  from  abroad,  and 
has  been  of  great  value  to  the  maritime 
trade  of  the  country.  To  Sir  Richard  Thorne 
belongs  the  credit  of  having  demonstrated  to  the 
representatives  of  other  nations  at  various  inter- 
national sanitary  conferences  the  beneficial  results 
of  this  system,  and  the  present  international 
sanitary  agreements  are  largely  based  upon  the 
English  model.  To  Sir  Arthur  Newsholme  the 
country  largely  owes  its  increased  sense  of 
responsibility  for  its  childhood,  while  under  his 
dispensation  the  prevention  of  tuberculosis  received 
special  attention. 

It  is  only  by  the  recollection  of  these  different 
landmarks,  and  by  comparison  of  present  conditions 
with  those  existing  at  various  points  in  our  sanitary 
history,  that  the  nature,  quality,  and  extent  of  the 
work  of  the  Medical  Department  of  the  Local 
Government  Board  can  be  adequately  appreciated. 
It  has  been  carried  out,  often  in  circumstances  of 
great  difficulty,  and  its  full  measure  of  success  is 
even  now  scarcely  recognised  by  the  public.  But  it 
has  proved  of  incalculable  value  to  the  country. 
» 

Peace  and  Famine. 

Post-war  conditions  are  in  some  cases  even 
more  terrible  than  those  of  war  itself.  Thus 
Lord  Curzon — and  General  Smuts  adds : “ We 
witness  the  collapse  of  the  whole  political  and 
economic  fabric  of  Central  and  Eastern  Europe. 
Unemployment,  starvation,  anarchy,  war,  disease, 
and  despair  stalk  through  the  land.”  While  our 
public  men  have  waited  until  the  signature  of  the 
Peace  Treaty  to  make  these  terrible  facts  generally 
known,  they  have  long  been  realised  by  the 
initiated.  The  danger  of  epidemic  disease  has 
been  so  real  to  the  inhabitants  of  the  smaller 
European  States  that  certain  of  them,  though  still 
in  a state  of  war,  sent  representatives  to  arrange 
common  measures  of  hygienic  defence  at  a meeting 
held  under  the  presidency  of  Dr.  Ferriere  in 
Vienna.  A sample  or  two  of  the  findings  of  this 
International  Red  Cross  Commission  will  suffice. 
In  the  Budapest  Maternity  Hospital,  where  16,000 
confinements  take  place  annually,  there  were  no 
sheets,1  while  the  mattresses  on  which  patients  lay 
were  filthy  for  the  lack  of  means  either  to  wash  or 
to  disinfect  them.  Dr.  F.  Blanchod,  engaged  in 
fighting  typhus  in  Eastern  Europe, 2 * wrote  of  the 
entire  absence  of  soap,  linen,  and  medicaments,  the 
resistance  of  the  whole  population  being  at  the 
same  time  dangerously  lowered  as  a result  of 
famine  and  fatigue.  Mr.  R.  Katz,  of  Prague,  who 
has  recently  been  travelling  with  the  Hoover  Food 
Mission,  recounts  a terrible  story  of  famine  in  the 
Erzgebirge8- — the  mountainous  district  between 
Saxony  and  Czecho  slovakia.  He  computes  that 
in  these  rural  communities  90  per  ceut.  of  the 
children  are  rachitic,  while  hunger-oedema  is  so 
common  as  to  be  the  rule. 

If  further  proof  were  necessary  of  the  physical 
effects  of  starvation  on  the  population  of  Central 
Europe  a summary  is  now  available  of  Rumpel’s 
address  on  the  effect  of  the  war  on  nutrition, 
delivered  at  the  Hamburg  Medical  Society  at  the 
beginning  of  April.  Loss  of  weight  to  the  extent 
of  20  or  more  per  cent,  he  regarded  as  normal. 
Although  certain  cases  of  gout  and  fatty  heart 
might  have  gained  some  advantage,  yet  in  many 

1 Journal  de  Geneve.  March  22nd. 

2 Gazette  de  Lausanne,  April  25tb. 

2 Vossische  Z ’itung,  June  5th. 


otherwise  healthy  people  a symptom-complex 
developed,  shown  subjectively  by  palpitation  and 
precordial  pain  increasing  to  attacks  of  pseudo- 
angina,  objectively  by  diminution  of  the  cardiac 
dullness,  mobility  of  the  heart  on  change  of  position, 
reduction  of  blood  pressure,  enteroptosis,  wandering 
kidneys,  dropping  of  the  stomach,  tendency  to 
hernia  with  incarceration.  Among  the  children,  in 
whom  during  thefirst  war-yearlittleharm  wasnotice- 
able,  general  weakness  was  now  the  rule,  and  a limi- 
tation of  the  stature  proper  to  their  age.  To  the 
famine  known  as  “ hunger-oedema,”  first  described 
in  1917  by  himself  and  later  by  VON  Jaksch,  22,000 
cases  had  fallen  victim  in  German  Bohemia  alone, 
with  a mortality  of  4 per  cent.  In  Vienna  a condi- 
tion resembling  osteomalacia  had  arisen.  Tuber- 
culosis had  increased  both  in  severity  and  in  con- 
tagiousness. As  regards  illnesses  in  general,  the 
length  of  convalescence  was  increased,  hyper- 
sensitiveness towards  remedies  frequently  showed 
itself,  the  blood  changes  included  an  increase  in 
lymphocytes,  with  many  cases  of  severe  pernicious 
anaemia.  Common  also  were  gastric  ulcer,  the 
gastro-cardial  symptom-complex  of  Roemheld, 
polyuria,  enuresis,  and  rapid  surrender  to  fatigue. 
Apart  from  the  terrible  mass  of  suffering  involved, 
these  observations  are  of  great  intrinsic  interest. 

For  the  relief  of  this  general  distress  our  Treasury 
has  agreed  to  add  an  equal  amount  to  funds  raised  by 
voluntary  organisations.  To  assist  them  in  spend- 
ing wisely  the  important  Memorandum  which  we 
print  on  p.  28  has  been  drawn  up  by  the  Committee 
on  Accessory  Food  Factors  appointed  jointly  by 
the  Medical  Research  Committee  and  the  Lister 
Institute.  The  notes  have  been  compiled  with 
special  reference  to  the  famine  districts  of  Eastern 
Europe,  and  the  advice  set  forth  is  based  upon  the 
present  state  of  our  knowledge  of  the  distribution 
of  accessory  food  factors  in  natural  foodstuffs 
and  of  the  role  played  by  them  in  preventing 
disease  and  in  promoting  health  and  growth. 
The  antineuritic  or  antiberi-beri  factor  (water- 
soluble  B),  the  fat- soluble  A or  antirachitic  factor, 
and  the  antiscorbutic  factor  are  described,  and  the 
foodstuffs  in  which  respectively  they  do  or  do  not 
occur  are  given  in  a table,  which  provides  a 
convenient  form  for  reference.  This  table  is 
more  comprehensive  than  any  yet  published,  and 
indicates  some  interesting  dietetic  differentiations. 
Over  60  foodstuffs  are  thus  catalogued.  Chemists 
have  not  been  able  to  throw  much  light  on  the 
composition  and  character  of  these  accessory 
factors,  which  have,  so  far,  not  been  isolated  in 
their  pristine  state,  and  up  to  the  time  of  the  issue 
of  this  report  their  presence  could  only  be  deter- 
mined by  experiments  with  animals.  So  far  as  is 
known,  the  accessory  food  factors  cannot  be  pro- 
duced by  the  animal  organism,  and  all  animals  are 
dependent  for  their  supply  directly  or  indirectly 
upon  the  plant  kingdom.  On  the  plant,  therefore, 
rests  the  responsibility  of  averting  the  deficiency 
diseases.  In  time  of  peace  the  variety  of  food 
consumed  by  European  nations  protects  them  from 
risk  of  auy  shortage  in  these  essential  substances. 
Under  present  conditions,  however,  in  addition  to 
a general  shortage  of  food,  there  is  also  a great 
restriction  in  variety.  For  the  sake  of  the  popula- 
tions of  Central  and  Eastern  Europe  there  is 
abundant  reason  for  spreading  quickly  a knowledge 
of  the  principles  set  forth  in  this  report  to  guide 
the  new  spirit  of  generosity  and  humanity,  born  in 
the  hearts  of  the  peoples  in  this  great  hour  of 
common  suffering  and  sorrow. 


SEVENTY  YEARS  YOUNG  -DISABLEMENT  AND  ITS  RELIEF. 


[J ujjY  5,  1919  23 


The  Lancet,] 


Seventy  Years  Young. 

It  is  only  15  years  ago  that  Sir  William  Osler 
was  appointed  Regius  Professor  of  Medicine  at 
Oxford.  If  his  friends  on  both  sides  of  the  Atlantic 
— and  no  man  has  more,  or  more  attached 
friends,  most  of  whom  feel  that  he  is  their 
own  private  crony — had  not  united  at  this 
moment  to  give  him  certain  anniversary  volumes 
as  an  expression  of  their  affection,  and  by 
so  doing  revealed  his  birthday,  no  one  would 
have  credited  him  with  three  score  years  and 
ten.  True  he  has  long  been  before  the  medical 
public  and  is  steeped  in  the  wisdom  of  the  ages ; 
more  than  20  years  ago  a distinguished  foreigner, 
meeting  a Johns  Hopkins  physician,  inquired,  “ And 
how  is  your  Osier  ? He  must  be  centuries  old.” 
But  he  is  always  sympathetically  of  the  same  age 
as  the  person  with  whom  he  is  talking;  indeed,  he 
often  remarks  when  anyone’s  age  is  discussed,  “ Oh, 
he  is  our  age.”  Many  a true  word  is  spoken  in 
jest,  and  as  a practical  joker  of  no  mean  ability  the 
Regius  Professor  is  well  able  to  hold  his  own  with 
even  the  youngest  of  us — but  that  is  another  story. 

If  it  is  a great  power,  and  our  American  and 
I Canadian  cousins  certainly  possess  it,  to  get 
at  once  on  good  terms  with  strangers,  it  is  surely 
a much  finer  talent  to  keep  up  these  friendships 
in  the  way  that  the  list  of  contributors  to  his 
anniversary  volumes  proves  Sir  William  Osler  can 
do.  It  is  a long  generation  since  Sir  William  Osler 
left  Canada  for  the  United  States,  but  he  is  always 
acclaimed  as  the  greatest  Canadian  physician. 
It  was  said  on  his  departure  from  Johns  Hopkins 
that  his  American  colleagues  deplored  the  loss 
of  the  man  even  more  than  that  of  the  physician, 
and  that  this  was  a true  saying  is  shown  in  this 
country  by  the  way  he  has  brought  men  together 
in  London  and  Oxford,  which  has  now  become 
the  Mecca  of  the  United  States  and  Canada, 
both  socially  and  medically.  He  was  obviously 
the  proper  chairman,  not  only  for  the  newly  insti- 
tuted Fellowship  of  Medicine,  which  will  welcome 
to  London  and  this  country  generally  visitors  from 
the  Dominions,  America,  and  our  Allies,  but  also 
for  an  efficient  post-graduate  scheme  in  London 
which  is  to  cater  for  their  professional  needs. 
The  Association  of  Physicians  of  Great  Britain  and 
Ireland  was  due  to  his  inspiration,  and  the  Quarterly 
Journal  of  Medicine  has  been  brought  out  under 
his  guidance  since  its  birth  in  1907.  As  President 
of  the  classical  Association  he  has,  like  his  brother 
Regius  professor  at  the  University  of  Cambridge, 
maintained  the  proper  conception  of  the  scholar- 
physician,  equally  versed  in  the  experiences  of  the 
past,  the  potentialities  of  advancing  research,  and 
the  practical  steps  of  progress.  For  Sir  William 
Osler  has  just  been  appointed  a member  of  the 
Standing  Committee  to  inquire  into  the  financial 
needs  of  his  University,  and  to  advise  the  Govern- 
ment as  to  the  application  of  any  grants  that  may 
be  made  by  Parliament  towards  meeting  them. 
University  education  in  the  United  Kingdom  will 
thus  have  the  advantage  of  his  conciliatory  common 
Sense. 

But  in  spite  of  all  these  multifarious  activities 
no  one  can  think  of  the  man  without  recalling  his 
love  for  books  and  their  authors.  As  President 
of  the  Bibliographical  Society,  as  an  active  curator 
of  Bodley’s  library,  and  as  a judicious  collector 
of  incunabula  and  other  considered  treasures,  he 
has  enough  work  to  fill  up  the  spare  time  of  most 
young  men.  Of  his  favourite  authors,  Sir  Thomas 


Browne,  Montaigne,  Oliver  Wendell  Holmes,  and 
the  -Egerton  Yorrick  Davises,  father,  son,  and 
grandson  (a  family  whom  it  is  hardly  an  exaggera- 
tion to  say  he  has  rescued  from  oblivion)  he  probably 
most  closely  resembles  the  Knight  of  Norwich. 
There  are  few  if  any  medical  men  who  can  give 
such  charming  addresses,  full  of  kindly  advice 
and  graceful  humour.  To  read  his“  /Equanimitas  ” 
is  a never  failing  remedy  for  bad  temper  Of  his 
infinite  variety  there  is  much  more  to  say,  but  this 
we  hope  to  be  here  to  do  on  the  100th  birthday 
which  is  his  by  hereditary  right ; and  in  the  mean- 
while we  may  recall  Oliver  Wendell  Holmes’s 
prophetic  dictum:  “To  be  seventy  years  young  is 
sometimes  far  more  cheerful  and  hopeful  than  to 
be  forty  years  old.” 


^nnofatiuns. 


"Ne  quid  nimls.' 


DISABLEMENT  AND  ITS  RELIEF. 

The  evidence  of  Sir  L.  Worthington  Evans, 
Minister  of  Pensions,  given  before  the  Select  Com- 
mittee of  the  House  of  Commons  dealing  with  the 
administration  of  sailors’  and  soldiers’  pensions, 
foreshadows  timely  changes  in  the  method  of  dealing 
with  disabled  men.  The  number  of  pensionable  men 
is  now  720,000,  nearly  half  of  whom,  it  is  estimated, 
require  industrial  training  ; only  11,000  of  these  men 
are  yet  undergoing  training,  while  another  37,000 
are  desirous  of  training.  The  Minister  referred 
to  the  transfer  of  the  work  of  training  disabled 
men  to  the  Ministry  of  Labour,  and  indicated 
that  the  part  of  the  work  retained  by  the  Ministry 
of  Pensions  is  the  training  and  treatment  of  the 
men  so  long  as  it  is  necessary  for  them  to  remain 
under  medical  care.  Not  only  the  men  now  being 
discharged  from  hospital  will  be  admitted  to  the 
six  or  eight  new  residential  convalescent  centres 
soon  to  be  established,  but  also  the  men  discharged 
during  the  war  who  have  been  able  to  follow 
some  employment  (mostly  unskilled)  but  still 
require  medical  treatment  to  make  them  efficient 
citizens.  The  Minister  thought  that  these  centres 
might  usefully  provide  for  the  tuberculous  “of  the 
non-infectious  type  ” and  the  relatively  small 
number  of  men  with  extreme  facial  disfigurement 
for  whom  surgery  could  do  nothing.  The  most 
economical  unit  for  administrative  purposes  in  the 
official  view  is  500.  The  first  centre  to  be  set 
going  will  be  the  converted  filling  factory  at  Hayes 
(Middlesex),  where  there  are  a number  of  isolated 
buildings  convertible  into  dwellings  and  workshops 
served  by  a main  building  suitable  for  administra- 
tive purposes.  As  the  grounds  are  nearly  200 
acres  in  extent  a course  of  agricultural  training 
will  be  available.  Men  passed  on  to  the  industrial 
classes  of  the  Ministry  of  Labour  who  break  down 
during  training  will  be  returned  to  the  convalescent 
centre.  Such  a centre  might  eventually  be  used  as 
a permanent  village  centre  occupied  by  the  men  and 
their  families,  especially  tuberculous  men.  One 
cause  of  delay  in  pensions  work — -excessive  central- 
isation— is  to  be  dealt  with,  as  already  announced, 
by  a welcome  process  of  devolution,  resulting  in 
the  establishment  of  13  regions — two  in  Ireland, 
one  in  Scotland,  one  in  Wales,  and  nine  in  England 
— each  of  which  will  be  in  the  charge  of  a director 
who  will  have  full  powers  in  administrative  matters. 
The  anomalous  and  difficult  position  of  the 


24  The  Lancet,  J 


MONOPHAGISM,  PELLAGRA,  AND  SCURVY. 


[July  5,  1919 


medical  referee  is  to  be  remedied  by  instituting 
Regional  Appeal  Boards  staffed  by  consultants 
properly  selected.  In  future  the  neurasthenic  man, 
for  example,  will  be  actually  seen  by  neurological 
experts,  and  no  awards  will  be  altered  on  inexpert 
hearsay  evidence.  The  man  dissatisfied  with  his 
award  will  still  be  able  to  go  to  his  Local  War 
Pensions  Committee,  who  will  be  entitled  to 
have  the  case  reviewed  by  the  Regional  Appeal 
Board ; their  decision  must,  from  the  nature  of 
the  facts,  obviously  be  final  for  a period.  If  the 
man’s  condition  becomes  altered  he  can  go  to 
the  local  medical  referee,  who  will  have  the 
findings  of  the  Regional  Appeal  Board  before 
him  and  will  be  able  to  certify  to  what  extent  the 
man’s  present  condition  differs  from  the  condition 
found  by  the  board;  the  Local  War  Pensions 
Committee  will  be  able  to  finance  the  man  to  the 
extent  of  this  difference. 


MONOPHAGISM,  PELLAGRA,  AND  SCURVY. 

The  theory  which  connects  the  aetiology  of 
pellagra  with  maize,  originated  by  Lombroso,  has 
for  the  last  ten  years  become  the  subject  of  renewed 
discussion.  While  on  the  one  hand  the  geographical 
distribution  of  this  disease  is  in  close  relationship 
with  maize  cultivation,  laboratory  experiments 
on  the  other  hand  have  furnished  no  positive 
results  in  establishing  this  association.  Professor 
G.  Volpino,1  of  Bergamo,  has  recently  investigated 
the  subject  from  the  point  of  view  of  anaphylaxis 
in  pellagrous  patients  inoculated  with  extract  of 
maize,  and  has  shown  that  the  injection  of 
1 to  2 c.cm.  of  watery  extract  of  spoilt  maize 
produces  in  them  a distinct  reaction  affecting 
the  nervous  system,  the  skin,  and  intestinal 
functions.  Sound  maize  had  not  the  same 
effect.  These  phenomena,  clearly  anaphylactic, 
are  caused  by  a super- saturation  of  the  organism 
of  pellagrous  patients  already  rich  in  maidic 
substances,  by  a new  maidic  substance  intro- 
duced experimentally.  Other  experiments  in 
guinea-pigs  confirmed  this.  These  animals,  after 
an  exclusive  diet  of  maize  for  20  to  30  days, 
were  inoculated  with  0'5-l  c.cm.  of  the  serum  of 
pellagrous  patients  and  died  within  1-3  days,  while 
control  animals  inoculated  with  serum  from  healthy 
individuals  survived,  as  was  the  case  also  with 
other  guinea-pigs  fed  on  ordinary  diet  even  if 
inoculated  with  double  quantities  of  pellagrous 
serum.  An  exclusive  diet  (monophagism)  is  not  of 
itself  invariably  harmful,  especially  when  it  forms 
the  traditional  food  of  the  species;  sometimes, how- 
ever, it  is  not  tolerated  and  causes  pathological 
phenomena,  as  in  beri-beri  (Professor  Volpino  adds) 
and  gout.  The  reasons  why  guinea-pigs  fed 
exclusively  on  maize  die  are  complex;  the  want 
of  antineuritic  and  antiscorbutic  vitamines  is 
probably  less  important  than  the  deficiency  of 
grass,  which  is  the  traditional  food  of  the  species. 
As  a result  of  this,  the  fact  comes  into  play 
that  the  molecular  grouping  of  the  proteins  of 
cereals  are  not  analogous  to  those  of  herbaceous 
proteins,  and  the  amino-acid  content  also  is 
different.  Moreover,  it  is  probable  that  every  kind 
of  unsuitable  diet,  if  persisted  in,  favours  the  entry 
into  the  circulation  of  a definite  quantity  of  protein 
not  completely  split  up  into  amino-acids,  which 
causes,  on  the  one  hand,  alimentary  anaphylaxis, 
and  on  the  other,  the  appearance  in  the  blood  of 

1 Annili  d’  Igieue,  May-September,  1918.  Rome,  Via  Palermo,  58. 


ferments  destroying  the  proteins  themselves.  In 
monophagism,  therefore,  there  has  to  be  taken  into 
consideration  not  only  the  absence  of  certain 
groups,  but  also  the  presence  in  excess  of  other 
groups  which  are  toxo-sensitising.  Pellagra  cannot 
be  caused  by  deficiency  of  proteins  in  a diet  of 
maize,  for  the  amount  of  these  is  enough  to  satisfy 
the  requirements  of  human  food.  It  is  always  a 
disease  of  poverty,  but  the  specific  feature  is  to  be 
found  in  the  toxic  or  toxo-sensitising  action  of  its 
over-abundant  constituents.  In  the  same  way 
Professor  Volpino  considers  that  in  scurvy  there 
i3  a process  of  sensitising  of  the  organism  by  a 
diet  which  is  too  exclusive,  being  deficient  in 
certain  constituents  and  disproportionally  excessive 
in  others.  The  same  is  true  also  of  sprue  and 
beri-beri.  Professor  Volpino,  in  view  of  the  toxo- 
sensitising  factor  in  pellagra,  is  led  to  consider  the 
possibility  of  artificially  increasing  the  resistance 
of  animals  to  an  exclusive  diet.  His  researches 
have  shown  how  this  can  be  done  within  certain 
limits  and  the  possibility  of  the  extension  of  the 
method  to  human  beings.  Dr.  Volpino’s  views, 
which  are  of  a highly  speculative  nature,  will 
find  a suitable  test  in  their  application  to  the 
prophylaxis  of  relapses  in  pellagra. 


HEALTH  WORK  FOR  THE  WHITLEY  COUNCILS. 

About  a year  ago  the  Whitley  Councils  of  the 
Potteries  and  Printers  set  up  a joint  health  com-  I 
mittee  which  sanctioned  an  experimental  scheme 
for  regular  medical  observation  and  research  in 
industry.  The  experiment,  described  by  Mr.  E.  i 
Halford  Ross  in  a lecture  delivered  on  Tuesday  last 
before  the  Industrial  Reconstruction  Council,  was  * 
made  in  two  large  printing  works,  where  the 
employees  were  informed  by  both  their  employer 
and  the  secretary  of  the  trade-unions  that  a 
doctor  would  attend  periodically  to  advise  the 
workers  on  health  matters.  As  a result  many  ; 
came  forward  and  asked  advice.  Observations  J 
were  made  while  work  was  in  progress  and 
much  was  done  to  show  employees  how  they  j 
might  work  under  better  conditions.  In  addition,  ' 
numerous  cases  of  disability  were  discovered  and 
remedied  and  the  experiment  was  considered  to  i 
have  been  most  successful.  Certain  researches 
were  done  concerning  fatigue,  hours  of  work,  the 
provision  of  seats,  and  the  advantages  of  welfare 
work  generally.  It  was  discovered  that  the  health 
committee  of  each  industry  is  the  best  means  of  |i 
carrying  out  this  work.  Each  industry  differs;  <' 
each  has  its  own  requirements.  It  is,  therefore, 
much  better  for  each  industry  to  undertake  its  I 
own  welfare  matters  than  to  leave  it  entirely 
to  any  Government  department.  This  experi- 
ment suggests  that  further  valuable  research 
in  industrial  medicine  might  be  carried  out 
on  a larger  scale  under  similar  conditions. 
Sufficient  work  has  already  been  done  in  London 
during  the  last  two  and  a half  years  to  indicate 
some  of  the  lines  along  which  research  should  be 
pursued.  Catarrh,  bronchitis,  and  chronic  cough 
are  the  most  common  obvious  ailments  which  affect 
the  workers,  and  it  is  very  rare  to  find  a large 
office  without  somebody  in  it  suffering  from  a 
“cold."  It  is  quite  certain  that  a considerable 
sum  of  money  is  lost  in  London  every  week 
owing  to  the  reduction  of  output  caused  by 
these  complaints,  in  addition  to  the  wages  paid 
during  sickness.  It  might  quite  possibly  be 
demonstrable  by  experiment  that  economy  would 


The  Lancet,] 


MENINGITIS  IN  ANTHRAX.— STATE-APPLIED  PHYSIOLOGY. 


be  effected  if  workers  suffering  in  the  early 
stages  of  catarrh  were  persuaded  to  stay  at  home 
until  they  recovered.  Anaemia  is  also  of  frequent 
occurrence  among  thevoung  women  and  girl  workers, 
and  handicaps  their  work  greatly.  Out  of  several 
hundred  employees  examined  in  three  large  cloth- 
ing factories  63  per  cent,  of  the  girls  were  found 
suffering  from  anaemia.  This  common  disease  can 
be  easily  prevented  if  taken  at  once  when  it 
appears.  If  left  until  well  advanced  each  case 
may  require  months  of  treatment.  Its  prevention 
is  a matter  of  education,  and  a little  medical  advice 
to  parents  in  childhood  will  stop  much  of  this 
disabling  affection.  Here  is  a matter  which  an 
industrial  medical  service  could  take  up  at  once, 
and  in  which,  working  in  conjunction  with  the  School 
Medical  Service,  it  would  achieve  wonders  in  a very 
short  space  of  time.  Antemia  has  a most  distract- 
ing effect  on  work,  and  may  last  for  years, 
producing  far-reaching  results  in  motherhood. 
Again,  from  work  that  has  been  carried  out  in 
connexion  with  munition  works  during  the  war  it 
appears  probable  that  improper  feeding  has  been  a 
considerable  factor  in  the  production  of  fatigue, 
and  that  the  short,  hurried,  and  scrambled  mid- 
day meal,  accompanied  by  the  discomfort  of  waiting 
in  queues  and  the  curtailment  of  rest,  has  resulted 
in  a diminution  of  output.  These  questions  are 
for  scientific  study  rather  than  for  political 
speculation,  and  under  the  aegis  of  the  Whitley 
Councils  medical  men  might  well  find  an  oppor- 
tunity for  impartial  observation  in  a sympathetic 
environment. 


MENINGITIS  IN  ANTHRAX. 

At  a meeting  of  the  Societe  Medicale  des  Hopitaux 
of  Paris  MM.  Delater  and  Calmels  reported  a 
case  of  a rare  complication  of  anthrax,  namely 
meningitis.  The  patient,  an  American  soldier,  on 
June  14th  noticed  a pimple  on  the  left  cheek,  which 
was  slightly  swollen.  On  the  following  day  he  was 
sent  to  hospital  because  he  was  feverish.  On  the 
way  he  vomited  three  times  and  momentarily  lost 
consciousness.  When  admitted  he  was  seriously  ill. 
He  was  pale,  covered  with  perspiration,  and 
stuporous.  The  rectal  temperature  was  101'8°  F. 
and  the  pulse  90.  In  the  left  parotid  region  was  a 
“button”  about  1 cm.  in  diameter,  flat,  greyish-white 
in  the  centre,  surrounded  by  a rosy  zone.  The  whole 
parotid  region  was  cedematous,  and  the  condition 
extended  to  the  neck.  There  were  no  enlarged 
glands.  When  put  to  bed  he  at  once  assumed  a 
curled-up  attitude.  Kernig’s  sign  was  positive  and 
the  neck  was  a little  stiff.  There  were  conjugate 
deviation  of  the  head  and  eyes  to  the  right,  lateral 
nystagmus,  and  fibrillary  contractions  of  the  eyelids 
and  lips.  There  was  no  meningeal  streak.  For 
two  hours  the  patient  remained  in  this  state.  Then 
general  convulsions  suddenly  appeared  and  recurred 
every  five  minutes.  In  the  intervals  the  patient 
was  excited,  turned  in  the  bed,  and  tried  to  raise 
himself.  The  attacks  of  convulsions  merged  into 
one  another,  and  death  took  place  four  hours 
after  admission,  just  as  lumbar  puncture  was  about 
to  be  performed.  It  was  performed  immediately 
after  death.  The  liquid,  removed  by  aspiration,  was 
rosy  and  turbid.  To  avoid  error  puncture  was 
performed  in  several  places,  always  with  the  same 
result.  This  rapid  succession  of  meningeal 
phenomena  during  the  time  that  the  patient  was 
in  hospital  rendered  exact  diagnosis  very  difficult. 
There  was  evidently  a very  acute  infection  or 


[Jui.y  5,  1919  25 

intoxication,  and  without  doubt  a close  relation 
between  the  meningeal  condition  and  the  parotid 
lesion.  The  necropsy  showed  soft  oedema  of  the 
parotid  and  cervical  region  extending  beneath  the 
sterno  cleido  mastoid  muscle.  The  internal  jugular 
vein  was  thrombosed.  The  parotid  gland  was  slightly 
congested.  The  meninges  and  cerebral  convolutions 
were  covered  by  a network  of  dilated  veins  filled 
with  very  black  blood.  There  were  no  meningeal 
adhesions.  All  the  thoracic  and  abdominal  organs 
were  normal.  The  hypothesis  of  anthrax  had  not 
been  definitely  entertained  because  the  pustule  had 
not  had  time  to  develop.  Those  who  saw  the 
patient  thought  of  a boil  complicated  by  jugular 
phlebitis,  with  oedema  of  the  neighbouring  parts, 
but  after  the  bacteriological  examination  they 
recognised  that  the  soft  and  extensive  oedema  was 
best  explained  by  the  diagnosis  of  anthrax.  This 
was  made  certain  by  microscopic  examination  of  the 
cerebro-spinal  fluid,  which  showed  numerous,  much- 
altered  polynuclears  and  many  Gram-positive  fila- 
ments, containing  spores,  and  free  spores.  The 
bacteria  had  the  squat  appearance  with  square  ends 
characteristic  of  anthrax.  Cultures  were  typical, 
and  a guinea-pig  inoculated  therewith  died  in 
40  hours  with  the  usual  symptoms  and  lesions. 


STATE-APPLIED  PHYSIOLOGY. 

Mr.  G.  H.  Hoberts,  the  Food  Controller,  recently  told 
the  executive  officers  of  food  control  committees  that 
the  total  cost  of  controlling  the  food  supply  of  the 
country  worked  out  at  about  10 cl.  a year  per  head  of 
the  population.  The  Consumers’  Council  has  since 
decided  that  this  tenpenny  rate  is  well  spent,  and 
has  formally  recommended  the  continuance  of  a 
Ministry  of  Food.  At  the  Carlisle  Cooperative  Con- 
gress last  month  two  resolutions  were  carried,  the 
combined  effect  of  which  would  be  the  continuance 
of  many,  if  not  all,  of  the  measures  taken  during 
the  war  for  regulating  the  distribution  of  food.  A 
member  of  this  congress  declared  that  food  control 
began  two  years  too  late  and  is  ceasing  two  years 
too  soon,  and  this  was  evidently  a view  which 
commended  itself  to  the  majority  of  his  hearers. 
However  insistently  a large  number  of  persons 
have  demanded  the  removal  of  food  control  at  the 
earliest  possible  moment,  its  abolition  is  being 
regarded  by  at  least  as  many  with  apprehen- 
sion. Their  fears  may  be  exaggerated,  the  iniquities 
of  the  food  profiteer  may  not  be  as  black  as 
they  have  been  painted.  But  the  question  does 
arise  whether  the  law  of  supply  and  demand 
can  be  trusted  to  bring  down  prices  rapidly  and 
to  obtain  a just  division  of  available  supplies, 
or  whether  the  limited  amount  of  food  likely 
to  be  put  on  the  market  in  the  near  future 
will  enable  unscrupulous  speculators  to  obtain 
monopolies  which  more  abundant  supplies  would 
render  difficult  or  impossible.  The  average  citizen 
who  dislikes  the  food  profiteer  cordially  at  the 
same  time  has  a suspicion  that  the  law  of  supply 
and  demand  must  ultimately  prevail  against  him. 
Nevertheless,  he  is  anxious  lest  meanwhile  the 
desire,  of  him  who  has  the  longest  purse  to  live 
luxuriously  will  operate  to  the  disadvantage  of 
those  whose  means  are  more  limited. 

The  stringent  application  of  the  coupon  system, 
when  our  supplies  and  our  prospects  of  future 
supplies  were  at  their  worst,  admittedly  effected  a 
necessary  economy.  It  promoted  and  maintained  a 
contented  feeling  among  the  population  in  general. 
Both  good  things.  But  it  did  more  than  this.  It 


26  The  Lancet,] 


DEPOPULATION. — TRAUMATIC  ADDISON’S  DISEASE. 


[July  5,  1919 


enabled  the  whole  nutritive  problem  of  the  country 
to  be  studied  as  never  before  by  the  best  scientific 
brains,  and  this  surely  is  the  most  cogent  argument 
of  all  for  the  existence  and  maintenance  of  food 
control.  It  will  enable  the  nation  to  retain  the 
services  of  their  scientific  food  advisers.  How 
necessary  this  is  the  latest  report  of  the  Food  (War) 
Committee  of  the  Royal  Society,  to  which  -we  have 
already  alluded,  is  sufficient  evidence.  This  con- 
cludes with  the  pregnant  words : “ The  above 
report  shows  how  very  inadequate  is  our  present 
knowledge  of  the  science  of  nutrition,  and  demon- 
strates the  necessity  of  renewed  investigations  on 
almost  every  point  discussed  in  it.”  Sir  Auckland 
Geddes  recently  remarked  that  the  universities, 
through  the  professors  of  the  various  faculties,  had 
contributed  more  fully  to  victory  than  any  other 
organised  section  of  the  community,  and  he  begged 
men  .of  science  in  future  not  to  remain  dumb  at 
critical  periods,  but  to  come  forward  to  help  the 
country.  It  would  be  hard  to  devise  a more 
efficient  medium  for  the  vocal  help  sought  than 
such  a Royal  Society’s  committee.  Professor  E.  H. 
Starling’s  recent  Oliver-Sharpey  Lectures  on  the 
Feeding  of  Nations  : a Study  in  Applied  Physiology, 
were  a luminous  exposition  of  the  results  which 
may  be  thus  obtained.  Even  the  most  cursory  study 
of  these  lectures  should  convince  our  legislators 
that  the  scientific  method  will  and  must  pay.  Let 
them  only  compare  the  debit  and  credit  sides  of  the 
food  balance-sheet.  The  continuation  in  being  of 
an  expert  advisory  committee  at  the  Food  Ministry 
will  serve  to  build  up  a body  of  sound  data  from 
which  the  needs  of  the  community  may  be  accu- 
rately computed.  Nor  is  this  the  only  department 
outside  the  Ministry  of  Health  that  needs  such 
expert  advice.  The  fixing  of  a minimum  wage  is 
ardently  desired.  On  what  basis  should  this  be 
founded,  the  cost  of  living,  the  {esthetic  conditions 
of  labour,  the  amenities  of  life,  or  the  actual  energy 
expended  ? Here  is  another  problem  which  applied 
physiology  should  help  to  solve. 


DEPOPULATION. 

An  aspect  of  the  reconstruction  problem  which 
is  gravely  exercising  statesmen  is  that  of  the  main- 
tenance of  a sufficient  population  to  carry  out  any 
projects  of  reform  which  may  be  deemed  necessary. 
Perhaps,  in  course  of  time,  the  National  Birth-rate 
Commission  may  have  some  helpful  recommenda- 
tions to  offer,  and  meanwhile  those  who  wish  to 
learn  how  the  matter  presents  itself  to  a Frenchman 
may  care  to  read  a work  entitled  “ La  Natalite,” 
written  by  Professor  Gaston  Rageot,1  in  which  he 
discusses  the  economic  and  psychologic  laws  which 
have  determined  modern  views  as  to  the  place  of 
the  child  in  the  social  scheme.  It  is  his  desire,  he 
says,  “ to  dissipate  some  of  the  illusions  which 
envelope  the  problem  of  natality,”  the  principal 
being  the  belief  that  it  is  a simple  one  which  may 
be  solved  by  particular  measures  such  as  the  award 
of  premiums  or  the  grant  of  allowances.  His 
statement  of  the  position  is  philosophical,  and  he 
displays  none  of  the  special  weakness  to  which 
debaters  of  this  subject  are  prone — an  inability 
to  realise  that  the  demolition  of  an  opponent’s  l 
argument  by  means  of  a triumphant  reductio 
ad  absurdum  does  not,  of  itself,  show  that 
one’s  own  case  is  any  better.  A low  birth-rate 
is,  he  finds,  associated  historically  with  extremes  of 
civilisation  which  are  themselves  incompatible 
with  the  existence  of  the  family.  It  is  natural,  he 

1 Paris  ; Ernest  Flammarlon. 


says,  for  human  parents  not  to  concern  themselves 
about  their  children.  “ Ce  n’est  pas  la  nature  qui 
protege  l’enfant,  mais  la  societe.”  And  society  is 
for  each  of  us  only  an  abstraction  which  becomes 
concrete  and  living  when  it  stands  for  “ la  patrie 
en  danger.”  To  the  French  mode  of  devolution  of 
property,  which  has  been  held  to  discourage  the 
production  of  large  families,  he  attaches  little 
importance,  if  only  for  the  reason  that  in  England 
freedom  of  testamentary  capacity  has  not  prevented 
a fall  in  the  birth-rate;  its  effects,  too,  have  varied 
— it  stimulated  natality  under  the  Revolution  and 
depresses  it  to-day.  Summing  up  the  various 
factors  which  he  has  dealt  with  at  length  he 
concludes  that  “ la  fausse  democratic  produit  le 
depeuplement,”  but  he  is  not  without  hope  of 
better  things.  


TRAUMATIC  ADDISON’S  DISEASE. 

The  subject  of  traumatic  Addison’s  disease  is 
discussed  by  Diirck,1  who  reports  the  following 
case.  A hitherto  healthy  man,  aged  48,  was  caught 
between  a railway  carriage  and  a revolving  plat- 
form and  had  four  ribs  fractured.  Apparent 
recovery  took  place,  and  he  was  able  to  resume 
his  work  in  about  six  weeks,  but  a week  later  he 
had  to  give  up  owing  to  weakness  in  the  arms  and 
legs  and  palpitation.  Bronzing  of  the  skin  of  the  face 
and  hands  gradually  set  in  and  the  muscular  weak- 
ness increased.  Treatment  consisted  in  the  adminis- 
tration of  suprarenal  preparations,  and  death  did 
not  take  place  until  about  eight  years  after  the  acci- 
dent. The  autopsy  showed  considerable  bronzing 
of  the  skin  of  the  face,  hands,  forearms,  and  external 
genitals,  and  apparently  complete  absence  of  both 
suprarenals  with  a healed  fracture  of  the  sixth  to 
the  ninth  ribs  on  the  right  side.  On  microscopical 
examination  some  necrotic  fragments  representing 
the  remains  of  the  medulla  of  the  left  suprarenal 
were  found,  while  on  the  right  side  there  was  hardly 
any  trace  of  the  suprarenal,  but  remains  of 
blood  pigment  indicated  that  a hcemorrhage  had 
formerly  taken  place  in  this  situation  a long  time 
previously.  Tuberculosis  could  be  excluded,  and 
there  was  no  evidence  of  syphilis. 


A CHILD-BEARING  STRIKE. 

The  insertion  at  the  front  of  the  most  recent 
number  of  the  Munich  Medical  Journal,  which  has 
reached  us,  of  a polemic  against  a threatened  child- 
bearing strike  in  Bavaria  is  something  of  a portent. 
The  author,  Fritz  Burgdorfer,  a doctor  of  public 
economy  holding  office  in  Munich,  begins  by  calling 
attention  to  the  active  propaganda  at  present  being 
carried  on  in  that  city,  directed  towards  a pre- 
vention of  conception  and  an  encouragement  of 
intentional  abortion,  leading  up  to  a demand 
for  what  amounts  to  a strike  of  child-bearers. 
This  “ communistic  ” programme,  Dr.  Burgdorfer 
tells  us,  assumes  that  the  population  of  Germany 
is  at  present  too  large  by  30  millions,  and 
that  since  under  present  conditions  the  usual 
outlets  in  the  form  of  exported  goods  or  emigra- 
tion are  impracticable,  the  cry  should  be  “ No 
more  children ! ” since  even  a wise  peasant 
does  not  breed  more  cattle  than  he  can  feed. 
Largely  attended  public  gatherings  in  Munich 
have,  we  learn,  been  instructed  in  the  systematic 
use  of  conception-preventing  apparatus,  the  instru- 
ments themselves  being  shown  and  their  applica- 
tion described.  Dr.  Burgdorfer’s  reply  to  all  this  is 

i Aerztl.  3achverstand.-Ztg.,  1919,  sxv.,  73-31. 


The  Lancet,] 


METROPOLITAN  WATER-SUPPLY  RESEARCHES. 


[July  5,  1919  27 


to  quote  at  length  Parts  1 and  2 of  the  1919  Blue- 
book  of  the  Bavarian  Statistical  Office  giving  the 
official  figures  for  the  changes  in  the  population 
during  the  period  of  the  war,  which  is  over.  The 
result  is,  he  truly  says,  extremely  sad.  In  place  of 
the  usual  abundant  excess  of  births  over  deaths 
the  effect  of  the  last  five  years  upon  the  Bavarian 
population  has  been  as  if  : 

(1)  One  year  and  eight  months  long  no  marriages  had 
taken  place. 

(2)  Two  years  long  no  children  had  been  conceived. 

(3)  Three  years  long  double  the  usual  number  of  human 
beings  (excluding  children  under  5 years)  had  died. 

The  married  couples  in  the  country  had  not  only 
substantially  diminished  in  number  but  their 
average  age  had  increased  and  their  procreative 
ability  was  less.  All  in  all,  at  the  end  of  1918  the 
baby  budget  showed  a deficit  of  roughly  400,000. 
Applied  to  the  pre-war  German  Empire  as  a whole, 
of  which  the  Bavarian  population  formed  one- 
tenth  part,  the  profit  and  loss  account  might  be 
so  stated : 800,000  marriages  not  made,  4 million 
children  unborn,  1'6  million  military  persons  died, 
700,000  civil  persons  died  in  consequence  of  the 
hunger  blockade — as  compared  with  normal  times. 
These  massive  figures,  Dr.  Burgdorfer  thinks,  speak 
of  a situation  so  serious  that  the  communistic 
propaganda  must  be  controverted  at  all  costs.  At 
the  moment  there  are  not  too  many  children  but 
too  many  adult  men  in  Germany.  A child-bearing 
strike  would  come  too  late  and  produce  its 
maleficent  results  two  decades  hence,  when  they 
would  be  an  anachronism.  Any  nation  that  practises 
a one-child  system  is  going  to  its  destruction. 
His  motto  is  “ Work,  Peace,  and  Order,”  in  the 
belief  that  “ The  greatest  riches  of  any  people 
consist  in  the  people  itself.” 


METROPOLITAN  WATER-SUPPLY  RESEARCHES. 

The  thirteenth  annual  report  on  the  results  of 
the  chemical  and  bacteriological  examination  of 
the  London  waters  for  the  12  months  ended 
March  31st,  1919,  was  issued  last  week  and 
presents  some  novel  features,  inasmuch  as,  arising 
out  of  the  events  of  the  war,  certain  important 
changes  have  been  introduced  in  waterworks 
procedure.  We  gather  from  the  observations  of 
the  Director  of  Water  Examination  to  the 
Metropolitan  Water  Board,  Sir  Alexander  Houston, 
that  the  new  methods  of  water  purification 
adopted  will  form  the  future  policy  of  the  Board. 
It  is  clear  from  the  report  that  during  the  period  of 
the  war,  and  excepting  temporary  periods  of  unusual 
stress,  the  average  quality  of  London’s  water- 
supply  has  been  wonderfully  well  maintained, 
especially  in  view  of  the  extraordinary  difficulties, 
often  of  a cumulative  sort,  which  the  engineering 
department  has  had  to  face.  Sir  Alexander  Houston 
admits,  however,  that  it  is  disappointing  to  have  to 
point  out  that  for  the  current  year  the  New  River, 
East  London  (Lee),  and  Chelsea  bacteriological 
results  are  the  worst  since  the  work  was  started 
under  his  control.  The  floods  were  responsible  in 
the  first  two  cases,  and  as  regards  Chelsea,  the 
works  “ were  asked  to  do  too  much  in  relation 
to  the  filtration  area.”  The  chlorination  of  the  river 
waters  has  been  continued,  and  this  process,  it  is 
reported,  succeeds  considerably  better  than  storage 
on  the  average,  and  is  practically  three  times 
superior  in  its  winter  effects,  when  both  the  river 
water  and  the  storage  water  give  the  least  satis- 


factory results.  These  statements  are  based  on  the 
results  of  bacteriological  examination  (the  B.  coli 
test).  The  saving  of  coal  by  the  adoption  of  the 
chlorination  method  as  compared  with  the  storage 
method  is  a very  remarkable  factor  in  the  case. 
Chlorination  further  has  an  important  deterrent 
effect  on  the  development  of  alga?  or  other  vegetal 
growths,  often  a source  of  great  inconvenience 
and  trouble  to  water  engineers.  The  Staines 
reservoirs  were  affected  with  these  growths,  which 
showed  prominently  in  the  photographs  taken  of 
the  suspended  matter,  but  they  rapidly  disappeared 
when  chlorinated  river  water  was  once  more  used 
for  supply  purposes.  Again  and  again  these  reser- 
voirs were,  during  flood-time,  heavily  “seeded” 
with  growths,  yet  when  the  floods  subsided  and 
chlorinated  river  water  was  again  the  source  of 
supply  the  growths  vanished  relatively  quickly. 
It  would  thus  seem  to  be  the  case  that  when 
chlorinated  river  water  is  stored  for  only  a short 
time  there  is  no  serious  risk  of  growths,  even  if 
from  time  to  time  a reservoir  water  is  used 
which  contains  growths  in  great  abundance.  These 
water  researches  have  obviously  involved  much 
well-directed  study  and  the  progress  reported  is 
admirable.  


THE  DEATH  OF  LORD  RAYLEIGH. 

The  death  is  announced  of  Lord  Rayleigh,  in 
his  78th  year.  Thus  has  passed  away  one  who, 
from  the  boyish  days  of  his  senior-wranglership, 
had  devoted  his  life,  with  fruitful  results,  to  the 
solution  of  problems  of  fundamental  importance  in 
physical  science.  Director  of  the  Cavendish  Labora- 
tory at  Cambridge,  where  he  occupied  the  chair 
of  experimental  physics,  he  was  led  to  study 
the  physical  properties  of  nitrogen  from  various 
sources,  with  the  result  that  he  found  the  nitrogen 
of  the  air  slightly  heavier  than  pure  nitrogen 
obtained  by  chemical  means.  Could  such  a discovery 
be  made  more  fitly  than  in  the  Cavendish  Labora- 
tory ? The  residue  which  the  great  Cavendish 
obtained  in  1785  after  oxidising  the  nitrogen 
of  the  air  by  “ sparking  ” proved  ultimately  to 
be  the  factor  which  caused  nitrogen  in  Rayleigh’s 
experiment  to  be  heavier.  It  was  a heavier 
gas  mixed  with  the  nitrogen  and  subsequently 
was  isolated  in  a pure  state  and  called  by  Ramsay, 
from  its  inertness,  argon.  This  led  to  the  dis- 
covery of  other  gases  in  the  atmosphere,  and 
the  methods  employed  brought  helium  to  light. 
In  many  other  directions  Lord  Rayleigh  carried 
out  investigations  of  both  scientific  and  practical 
importance.  His  memoirs  on  sound,  electricity,  and 
optics  formed  a series  of  scientific  contributions 
much  valued  by  the  Royal  Society,  of  which  he  was 
President  in  1905.  He  brought  about,  also,  valuable 
reforms  in  the  teaching  of  science  and  in  educa- 
tional methods  generally.  Physical  science  has 
lost  one  of  its  most  distinguished  exponents  by 
the  death  of  Lord  Rayleigh ; he  is  succeeded  in  his 
peerage  by  his  son,  Mr.  R.  J.  Strutt,  F.R.S.,  who  is 
also  a leading  physicist. 


INDEX  TO  “THE  LANCET,”  Vol.  I.,  1919. 

The  Index  and  Title-page  to  Vol.  I.,  1919,  which 
was  completed  with  the  issue  of  June  28th,  is 
published  in  this  number  of  The  Lancet.  We  are 
glad  to  be  able  to  restore  this  pre-war  custom, 
now  that  it  is  justified  by  a more  liberal  supply 
of  paper. 


28  The  Lancet,] 


ACCESSORY  FACTORS  IN  FOOD. 


[July  5,  1919 


ACCESSORY  FACTORS  IN  FOOD. 


The  Memorandum  which  follows  has  been  drawn  up  by 
the  Committee  on  Accessory  Food  Factors,  appointed  jointly 
by  the  Medical  Research  Committee  and  the  Lister  Insti- 
tute, for  the  guidance  of  those  engaged  in  administration  of 
food  relief  to  famine-stricken  districts.  It  is  signed  by  the 
chairman  of  the  committee,  Dr.  F.  Gowland  Hopkins,  F.R.S., 
and  the  secretary,  Miss  Harriette  Chick,  D.Sc. 

Introduction. 

Recent  research  has  shown  that  the  requirements  of  the 
human  organism  as  regards  diet  cannot  be  met  entirely 
by  an  adequate  supply  of  protein,  fat,  carbohydrate, 
inorganic  salts,  and  water.  It  has  therefore  modified  the 
common  belief  of  ten  or  more  years  ago,  when  the  attention 
of  physiologists  was  focussed  upon  the  calorie  or  energy 
value  of  the  diet.  It  is  now  established  that,  in  addition  to 
these  necessary  constituents,  certain  unidentified  principles, 
known  as  accessory  food  factors  or  “ vitamines,”  must  also 
be  present  in  order  to  maintain  health  and  prevent  the 
occurrence  of  “ deficiency  diseases.”  These  subs'ances  have 
not  so  far  been  isolated,  little  is  known  of  their  chemical  or 
physical  properties,  and  at  the  present  time  their  presence 
can  only  be  detected  by  experiments  with  animals. 

These  accessory  factors  or  vitamines  are  widely  distributed 
among  naturally  occurring  foodstuffs,  and  in  time  of  peace, 
under  normal  conditions  of  food  supply,  the  variety  of  food 
consumed  by  European  nations  protects  them  from  risk  of 
any  deficiency  in  these  essential  substances.  Under  the 
conditions  arising  from  the  war  a different  state  of  things 
exists  ; in  addition  to  a general  shortage  of  food  there  is 
also  a great  restriction  in  the  variety  available,  and  danger 
from  “ deficiency  diseases  ” is  to  be  feared. 

Of  these  diseases  scurvy  is  the  best  kaown,  and  the  belief 
that  it  is  caused  by  some  deficiency  in  the  diet  has  long  been 
strongly  held.  Recent  research  has  added  to  the  deficiency 
diseases  beri-beri,  rickets,  and  other  less  well-marked 
di-orders  of  growth  and  departures  from  health. 

The  following  notes  have  been  compiled  by  the  Committee 
on  Accessory  Food  Factors  in  the  hope  that  they  may  afford 
practical  help  to  those  occupied  in  the  administration  of  food 
relief  to  the  famine  districts  of  Eastern  Europe.  The  advice 
given  is  based  upon  the  present  state  of  our  knowledge  of 
the  distribution  of  accessory  food  factors  (vitamines)  in 
natural  foodstuffs  and  of  the  role  played  by  them  in 
preventing  disease  and  in  promoting  health  and  growth. 

Accessory  Food  Factors. 

The  accessory  food  factors  at  present  recognised  are  three 
in  number  : — 

(1)  Antineuritic  or  antiberi-beri  factor,  identified  with 
the  “ water-soluble  B ” growth  factor  of  the  American 
investigators. 

(2)  Fat-soluble  A growth  factor  or  antirachitic  factor. 

(3)  Antiscorbutic  factor. 

As  far  as  is  known  the  accessory  food  factors  cannot  be 
produced  by  the  animal  organism,  and  all  animals  are 
dependent  for  their  supply  directly  or  indirectly  upon  the 
plant  kingdom. 

Distribution  and  Properties  of  the  Accessory  Factors. 

1.  Antineuritic  or  antiberi  biri  factor  (“  water-soluble 
B”  growth  factor  of  the  Americans). — This  vitamine 
prevents  the  occurrence  of  beri-beri  in  man  and  analogous 
diseases  in  animals.  It  is  also  necessary  to  promote  satis- 
factory growth  in  young  animals.  It  is  widespread,  and  is 
found  to  some  extent  in  almost  all  natural  foodstuffs.  Its 
principal  sources  are  the  seeds  of  plants  and  the  eggs  of 
animals,  where  it  is  deposited,  apparently,  as  a reserve  for 
the  nutrition  of  the  young  offspring.  Highly  cellular 
organs,  such  as  the  liver  and  the  brain,  contain  considerable 
amounts  of  this  vitamine  ; flesh  contains  comparatively 
little.  Yeast  cells  are  a rich  source  ; so  also  are  yeast 
extracts — e.g  , “ marmite.”  In  the  case  of  peas,  beans,  and 
other  pulses,  this  vitamine  is  distributed  throughout  the 
seed,  but  with  cereals  it  is  concentrated  in  the  germ  (embryo) 
and  in  the  peripheral  layer  of  the  seed  which  in  milling  is 
peeled  off  with  the  pericarp  and  forms  the  bran. 

Beri-beri  is  occasioned  by  a diet  composed  too  exclusively 
of  cereals  from  which  germ  and  bran  have  been  removed  by 
milling,  as  id  the  case  of  polished  rice  or  white  wheat  flour. 
The  disease  is  common  where  polished  rice  is  the  staple 


article  of  diet  to  an  almost  entire  exclusion  of  other  food- 
stuffs. It  is  rare,  though  not  unknown,  where  white  wheat 
bread  is  eaten,  because  the  consumption  of  this  type  of  cereal 
food  is  usually  accompanied  by  a sufficiency  of  other  food- 
stuffs containing  the  essential  principle.  It  is  unknown 
where  rye  bread  is  the  staple  food,  because  in  the  milling  of 
rye  there  is  no  separation  of  the  germ. 

2.  The  fatsoluble  A growth  factor  or  antirachitic 
factor  necessary  to  promote  growth  and  prevent  rickets  in 
young  animals. — This  vitamine  appears  to  be  necessary  also 
to  maintain  health  in  adults,  and  it  has  been  suggested  that 
war  oedema  may  be  due  to  a lack  of  this  factor  in  the  diet. 
The  main  sources  of  this  factor  are  two  in  number : 
(1)  Certain  fats  of  animal  origin  ; (2)  green  leaves.  The 
most  notable  deposits  of  this  factor  are  in  cream,  butter, 
beef  fat,  fish  oils  (for  example,  cod-liver  oil,  whale  oil),  egg 
yolk.  It  is  present  in  very  small  or  negligible  amount  in 
lard  (pig  fat)  and  in  vegetable  oils,  as,  for  example,  linseed 
oil,  olive  oil,  cotton-seed  oil,  coconut  oil,  palm  oil;  pea-nut 
or  arachnis  oil  is  reported  to  contain  it  in  larger  amount.  It 
will  be  noticed  that  this  factor  is  found  chiefly  in  the  more 
expensive  fats. 

Wnile  green-leaf  vegetables  contain  the  fat-soluble  factor, 
root  vegetables  are  deficient  in  it ; war  oedema  has  been 
frequently  reported  under  circumstances  in  which  root 
vegetables  have  formed  a large  proportion  of  the  diet. 

3.  Antiscorbutic  factor. — This  vitamine  is  necessary  in  a 
diet  for  the  prevention  of  scurvy,  and  is  found  in  fresh 
vegetable  tissues  and  (to  a much  less  extent)  in  fresh  animal 
tissues.  Its  richest  sources  are  such  vegetables  as  cabbages, 
swedes,  turnips,  lettuces,  watercress,  and  such  fruits  as 
lemons,  oranges,  raspberries,  tomatoes.  Inferior  in  value 
are  potatoes,  carrots,  French  beans,  scarlet  runners,  beetroots, 
mangolds,  and  also  (contrary  to  popular  belief)  lime  juice. 
Potatoes,  although  classed  among  the  less  valuable  vegetables 
as  regards  antiscorbutic  value,  are  probably  responsible  for  the 
prevention  of  scurvy  in  northern  countries  during  the  winter 
owing  to  the  large  quantities  which  are  regularly  consumed. 

Milk  and  meat  possess  a definite  but  low  antiscorbutic  value. 

This  vitamine  suffers  destruction  when  the  fresh  foodstuffs 
containing  it  are  subjected  to  heat,  drying,  or  other  methods 
of  preservation. 

All  dry  foodstuffs  are  deficient  in  antiscorbutic  properties  ; 
such  are  cereals,  pulses,  dried  vegetables,  and  dried  milk. 

Tinned  vegetables  and  tinned  meat  are  also  deficient  in 
antiscorbutic  principle.  In  case  of  tinned  fruits  the  acidity  of 
the  fruit  increases  the  stability  of  the  vitamine,  and  prevents 
to  some  extent  the  destruction  which  would  otherwise  occur 
during  the  sterilisation  by  heat  and  the  subsequent  storage. 

An  appended  table  gives  a summary  of  our  knowledge  as  to 
the  distribution  of  these  three  accessory  factors  amoLg  the 
commoner  foodstuffs. 

Practical  Application  of  the  Foregoing  Facts  to  the 
Prevention  of  Disease. 

1.  Prevention  of  beri-beri. — It  is  unlikely  that  any  danger 
of  beri-beri  will  arise  among  the  famine  threatened  districts 
of  Eastern  Europe  as  long  as  wholemeal  flour  from  rye,  wheat, 
barley,  maize,  or  peas,  beans,  and  lentils  are  provided  Mere 
shortage  of  food  does  not  cause  beri-beri,  and  poverty  ensures 
that  the  whole  grain  is  consumed  for  purposes  of  economy. 

2.  Prevention  and  cure  of  rickets  or  qrorcth  failure  in 
children,  or  war  oedema  in  adults. — Evidence  is  accumulating 
that  rickets  is  caused  by  a shortage  not  of  fat  as  such,  but  of 
the  “fat-soluble  growth  factor”  which  is  contained  in 
certain  fats.  Xerophthalmia,  a severe  disease  of  the  external 
eye,  leading,  if  untreated,  to  blindness,  has  also  been 
attributed  to  lack  of  this  factor.  Infants  and  young 
children  must  therefore  be  supplied  with  the  right  hind  of 
fat.  To  prevent  rickets  (1)  full  cream  milk  should  be 
secured  for  artificially  fed  infants  when  possible  ; failing 
that,  (2)  full  cream  dried  milk  or  (3)  full  cream  unsweetened 
condensed  milk.  (2)  is  preferred  to  (3),  and,  in  case  of 
ignorant  or  careless  mothers,  even  to  (1),  in  order  to  prevent 
spread  of  infection  and  intestinal  disorders.  In  all  cases 
where  (2)  or  (3)  are  used  an  extra  antiscorbutic  should  be 
given  (see  below). 

Sweetened  condensed  milk  is  undesirable  for  the  reason 
that  the  degree  of  dilution  required  by  the  high  sugar 
content  renders  the  food,  as  prepared,  deficient  in  the  fat- 
soluble  (antirachitic)  factor  as  well  as  in  fat  and  protein. 

Milk  and  butter  are  the  best  sources  of  the  antirachitic 
(or  fat-soluble)  factor  for  young  and  growing  children  ; 


The  Lancet,] 


ACCESSORY  FACTORS  IN  FOOD. 


[July  5,  1919  29 


Table  showing  the  Distribution  of  the  Three  Accessory  factors 
in  the  Commoner  Foodstuffs. 


Classes  of  foodstuff. 

Fat-soluble 
A or  anti- 
rachitic 
factor. 

Water- 
soluble  B 
or  anti- 
neuritic 
(anti-beri- 
beri) factor 

Fats  and  Oils. 

Butter  

+ + 4- 

0 

Cream  

+ + 

0 

Cod-liver  oil  

+ + + 

0 

Beef  fat  or  suet  

+ + 

Pea  nut  or  arachis  oil 

+ 

Lard  

0 

Olive  oil 

0 

Cotton-seed  oil  

0 

Coco-nut  oil  

0 

Coco  butter  

0 

Linseed  oil  

0 

Fish  oil,  whale  oil,  herring  oil,  &c. 

+ + 

Hardened  fats,  animal  or  vege- 
table origin 

0 

Margarine  prepared  from  animal 
fat 

(See  below*) 

Margarine  from  vegetable  fats 
or  lard  

0 

Nut  butters  

+ 

... 

Meat,  fish,  &c. 


Lean  meat  (beef,  mutton,  &c.) 

+ 

+ 

Liver  

++ 

+ + 

Kidneys  

++ 

+ 

Heart 

++ 

+ 

Brain 

+ 

+ + 

Sweetbreads  

+ 

+ + 

Fish,  white  

0 

Very  slig 
if  any 

fat  (salmon,  herring,  &c .) 

+ + 

, , roe 

Tinned  meals 

+ 

i + + 

'Very  slight. 

Milk,  cheese,  Ac. 

Milk,  cow's  whole,  raw  

+ + 

+ 

i skim  ,,  

0 

,,  dried  whole  

lesstbanf  4 

+ 

,,  boiled  

Undeter- 

.. condensed,  sweetened 

mined. 

4- 

+ 

Cheese,  whole  milk  

4- 

,,  skim 

0 

Fags. 

Fresh  

4-4- 

+ + + 

Dried 

4-4- 

+ + + 

Cereals,  pulses,  &c. 

Wheat,  maize,  rice,  w-hole  grain 

+ 

+ 

1,  germ  

4-4- 

+ + + 

„ bran  

0 

+ + 

White  wheaten  flour,  pure 
cornflour,  polished  rice.  &c. ... 

0 

0 

Custard  powder, egg  substitutes, 
prepared  from  cereal  products 

0 

0 

Linseed,  millet  

4-4- 

' ++  1 

Dried  peas,  lentils.  &c 

Peaflour  (kilned)  

+ + 

0 

Soy  beans,  haricot  beans  

4- 

-j-  4- 

Germinated  pulses  or  cereals  ... 

4- 

+ 4- 

1 egetables  and  fruits. 

Cabbage,  fresh  

“| f” 

4- 

,,  ,,  cooked  

,,  dried  

+ 

t 

,,  canned  

Swede,  raw  expressed  juice  ... 

.T. 

Lettuce  

++ 

+ 

Spinach  (dried)  

++  I 

4- 

Carrots,  fresh  raw  

■j- 

+ 

„ dried  

Very  slight 

Beetroot,  raw,  expressed  juice 

Potatoes,  raw 

,,  cooked 

Beans,  fresh,  scarlet  runners, 

raw  

Lemon  juice,  fresh  

.,  preserved  

Lime  juice,  fresh 

,,  preserved 

Orange  juice,  fresh  

Raspberries  

Apples  

Bananas  

» > OllgUl 

+ 

+ 

::: 

... 

q_ 

Tomatoes  (canned)  

+ 

Nuts 

+ 

+ + 

Miscellaneous. 

Yeast,  dried  

4-4-4- 

4-4-4- 

Q 

.,  extract  and  autolysed  ... 
Meat  extract 

o 

Malt  extract 

4-  in  some 

Beer 

specimens. 

0 

Anti- 

scorbutic 

factor. 


4- 


o' 

+ 

4- 

lessthan4 


:-'0 

? 0 


0 

0 

0 

0 

0 

0 

0 

0 

0 

4-4- 


+ 4-4- 
+ 

V.  slight. 

+ + + 

+ + 

+ 

less  than + 
+ 

+ + 

+ + + 

+ + 

+ + 

V.  slight. 
+ + + 

+ + 

+ 

V.  slight. 
+ + 


o’ 

0 

0 


Value  in  proportion  to  amount  of  animal  fat  contained. 
V . slight  = Very  slight. 


margarines  made  from  animal  fats  are  also  valuable  ; those 
made  from  vegetable  oils  are  to  be  condemned.  If  there  is  a 
shortage  of  butter  it  should  be  reserved  for  children,  but  if 
totally  lacking  the  deficiency  can  be  replaced  by  cod-liver 
oil  and  other  fish  oils  or  by  eggs.  If  all  animal  fats  are 
unavailable  pea-nut  oil  should  be  selected  in  preference  to 
other  vegetable  oils  for  preparation  of  margarines,  See. , and 
some  effort  should  be  made  to  utilise  the  fat-soluble  vitamine 
■contained  in  green  leaves. 

Green  leaves  are  a cheap  and  readily  available  source  of 
the  fat-soluble  vitamine,  and  adults  can  probably  maintain 
good  health  when  animal  fats  are  substituted  by  vegetable 
fats  if  green-leaf  vegetables  are  consumed  in  fair  quantity. 
In  case  of  this  vitamine  the  loss  involved  in  ordinary  cooking 
is  not  serious.  Unfortunately  infants  or  very  young  children 
cannot  take  green  vegetables  in  the  ordinary  way,  but  the 
juices  expressed  from  cabbages  and  other  green-leaf  vege- 
tables, raw  or  even  after  steaming  (not  immersing  in  boiling 
water)  for  a few  minutes,  might  be  given  even  to  infants  if 
all  other  sources  of  this  most  necessary  vitamine  have  failed. 

Purees,  carefully  prepared  from  cooked  spinach  or  lettuce, 
can  be  tolerated  in  small  quantities  (one  teaspoonful  daily) 
by  many  young  infants,  and  the  amount  taken  can  be 
increased  regularly  with  age. 

In  cases  where  rickets  or  growth  failure  or  xerophthalmia 
are  already  well  established  a daily  dose  of  cod-liver  oil  is 
essential  in  addition  to  all  other  procedure. 

Pregnant  and  nursing  mothers  should  have  as  liberal  a 
supply  of  the  fat-soluble  factor  as  is  possible.  Rickets  is  not 
confined  to  artificially-fed  children.  Breast-fed  children 
depend  for  an  adequate  supply  of  fat-soluble  vitamine  on 
the  milk,  which  in  turn  depends  upon  the  diet  of  the  mother. 

3.  Prevention  of  scurvy  : use  of  germinated  seeds. — If  fresh 
vegetables  or  fruits  are  scarce  or  absent  an  antiscorbutic  food 
can  be  prepared  by  moistening  any  available  seeds  (wheat, 
barley,  rye,  peas,  beans,  lentils)  and  allowing  them  to 
germinate.  It  is  necessary,  of  course,  that  these  should  be  in 
the  natural  whole  condition,  not  milled  or  split.  The  seeds 
should  be  soaked  in  water  for  24  hours,  and  kept  moist  with 
access  of  air  for  1-3  days,  by  which  time  they  will  have 
sprouted.  This  sprouted  material  possesses  an  antiscorbutic 
value  equal  to  that  of  many  fresh  vegetables,  and  should  be 
cooked  in  the  ordinary  way  for  as  short  a time  as  possible. 

In  case  of  shortage  it  should  be  remembered  that  salads  are 
of  more  value  than  cooked  vegetables.  The  extent  to  which 
the  antiscorbutic  factor  is  destroyed  during  cooking  depends 
chiefly  upon  the  time  employed.  When-  supplies  are  limited 
vegetables  should  be  cooked  separately  and  for  as  short  a 
time  as  possible  ; they  should  not  be  cooked  for  long  periods 
with  meat  in  soups  or  stews. 

Preserved  foods,  with  a few  exceptions,  may  be  regarded 
as  devoid  of  the  antiscorbutic  principle.  Lemon  juice  retains 
some  value  in  this  respect  ; canned  tomatoes  (and  presumably 
other  tinned  acid  fruits)  have  also  antiscorbutic  value. 

Canned  vegetables  are  useless  for  prevention  of  scurvy,  as  also 
are  dried  vegetables. 

Infantile  scurvy  must  be  considered  separately,  as  many  of 
the  above  foodstuffs  are  unsuited  to  infants  or  young  children. 
To  avert  danger  all  artificially  nourished  infants  should 
receive  an  extra  antiscorbutic.  Cow’s  milk,  even  when  raw, 
is  not  rich  in  the  antiscorbutic  vitamine  ; when  heated,  dried, 
or  preserved,  the  amount  contained  is  still  further  reduced. 
The  most  suitable  antiscorbutic  material  to  use  is  fresh 
orange  juice,  1-3  or  4 teaspoonfuls (5-15 c. cm. )daily,  accord- 
ing to  age.  Raw  swede  (or,  if  unavailable,  turnip)  juice  is  a 
potent  antiscorbutic,  and  an  excellent  subsitute  for  orange 
juice  ; to  obtain  the  juice  the  clean-cut  surface  is  grated  on 
an  ordinary  kitchen  grater  and  the  pulp  obtained  is  squeezed 
in  muslin.  Tomato  juice,  even  from  canned  tomatoes,  and 
grape  juice  can  also  be  used  ; the  latter  is,  however,  less 
potent  than  orange  juice,  and  a larger  dose  should  be  given. 

Pregnant  and  nursing  mothers. — If  babies  are  breast-fed  it 
is  important  that  the  pregnant  and  nursing  mother  should 
receive  an  adequate  supply  of  antiscorbutic  food  in  her  diet. 
The  popular  belief  that  green  vegetables  are  harmful  in  such 
cases  is  often  without  foundation.  Infantile  scurvy  is  not 
unknown  in  breast-fed  children. 

It  is  evident  that  many  of  the  above  deficiency  diseases 
are  rife  among  the  populations  of  Central  and  Eastern  Europe. 

It  is  essential,  therefore,  that  the  principles  set  forth  in  the 
preceding  paragraphs  should  be  fully  understood  by  all 
persons  engaged  in  administering  relief  to  these  districts. 


30  The  Lancet,]  AN  INDUSTRIAL  MEDICAL  SERVICE.— MEDICINE  AND  THE  LAW. 


July  5,  1919 


AN  INDUSTRIAL  MEDICAL  SERVICE. 


II. — How  to  Start  an  Industrial  Medical  Service. 

Social  organisation  has  always  followed  the  lines  of 
evolution,  wherein  the  cell  came  first,  then  a group  of  cells, 
then  a nervous  system  ; similarly,  in  the  social  world  first 
came  the  family,  then  the  tribe,  then  the  governed  nation: 
New  services  should  be  allowed  to  evolve,  and  not  be  forced 
into  existence  on  plans  drawn  up  in  some  official  head- 
quarters. 

The  need  for  an  industrial  medical  service  has  been  dealt 
with  in  a previous  article  ; the  present  intention  is  to  show 
how  it  can  be  started.  Its  subsequent  evolution  may  there- 
after be  safely  left  to  the  future.  The  first  point  to  have  in 
mind  is  that  a medical  service  to  be  effective  should  acquire 
the  momentum  of  popular  interest,  which  can  only  be 
obtained  through  direct  touch  with  the  personality  of  those 
it  serves.  This  is  fundamental,  and  its  absence  in  the  past 
from  public  health  medicine  is  some  explanation  of  why 
the  average  citizen  has  taken  so  little  interest  in  the  health 
of  the  community  of  which  he  is  a part,  although  he  is  only 
too  ready  to  discuss  personal  medical  topics.  The  next 
point  is  consideration  of  the  duties  to  be  undertaken.  These 
concern  industrial  birth,  life,  and  death.  Industrial  birth  is 
the  engagement  of  workers  ; and  here  medical  services  are 
of  great  value.  A medical  officer  acquainted  with  industrial 
processes  may  reject  a heart  case,  a myope,  or  an  incipient 
hernia  for  some  processes,  but  safely  accept  them  for  others  ; 
as  he  gains  more  experience  he  will  choose  persons  for 
special  work  according  to  their  capacity  as  measured 
by  alertness,  physique,  acuity  of  hearing  or  of  vision  ; 
in  short,  he  will  adjust  round  pegs  into  round  holes, 
and  so  do  much  to  avoid  the  great  economic  waste 
of  labour  turnover,  the  result  of  the  present  method  of 
trial  and  error  which  leaves  the  worker  to  try  place  after 
place  until  a congenial  one  is  found ; by  thus  examining 
each  newcomer  personal  contact  is  established  which  should 
never  be  lost.  Industrial  life  is  the  period  of  employment ; 
and  here  skilled  medical  services  are  of  even  more  value  ; to 
determine  the  existence  of  fatigue,  the  optimum  hours  of 
labour,  the  presence  of  faulty  ventilation  or  bad  lighting  ; to 
supervise  the  hygiene  of  workplaces  ; to  arrange  for  dental 
supervision  ; to  deal  with  outbreaks  of  epidemic  disease  ; to 
advise  on  the  provision  of  a canteen  and  its  food-supply,  of 
cloakrooms,  of  washing  facilities,  and  of  suitable  overall 
clothing  ; to  watch  lost  time  and  sickness  records ; to 
supervise  closely  the  health  of  those  employed  on  dangerous 
processes  ; to  organise  first-aid  treatment  and  establish  contact 
with  outside  medical  treatment  ; to  advise  on  compensation 
cases.  Here  personal  contact  should  be  maintained  and 
strengthened,  and  the  medical  officer  become  the  friend  and 
adviser  of  all.  Industrial  death  is  the  cessation  of  employ- 
ment ; and  here  the  medical  officer  should  inquire  closely 
into  the  causation  of  dismissal  or  leaving  so  that  he  may 
ascertain  where  his  practice  is  at  fault ; such  inquiry  should 
be  for  him  what  a post-mortem  is  to  the  physician  and 
surgeon . 

Every  industry  will  have  its  own  special  problems ; but 
the  above  short  summary  of  the  work  to  be  done  suggests 
where  it  must  start — viz.,  in  industry  by  the  retention  of 
whole-  or  part-time  medical  services  by  employers  of  labour. 
The  employer  will  gain  in  the  quality  and  quantity  of  output 
far  more  than  the  salary  he  pays  ; the  worker  will  benefit 
by  improved  health,  happiness,  and  earning  capacity.  A few 
employers  have  already  taken  this  step  ; and  probably  more 
would  follow  if  they  could  obtain  medical  men  adequately 
trained,  but  there  are  not  many  who  on  perusing  the  above 
rough  list  of  duties  would  consider  themselves  trained  to 
undertake  them.  Two  things  are  now  needed,  an  increased 
supply  of  trained  men  and  an  increased  demand  for  their 
services.  The  increased  supply  could  rapidly  be  met  by 
post-graduate  courses  held  at  medical  schools  in  industrial 
areas  ; Birmingham,  Bristol,  Cardiff,  Glasgow,  Manchester, 
and  Sheffield  suggest  themselves.  Practitioners  in  industrial 
areas  all  suffer  from  lack  of  knowledge  of  how  their  patients 
earn  their  livelihood,  and  would  willingly  attend  such  courses. 
One  group  of  the  profession  should  in  this  matter  take  the 
initiative,  both  in  pressing  the  schools  to  start  courses  and 
in  attending  the  courses  ; we  refer  to  the  certifying  factory 
surgeons.  They  already  possess  a recognised  association  and 


are  in  touch  with  the  factories  and  workshops  ; but  the 
duties  entrusted  to  them,  as  they  are  aware,  are  wholly 
inadequate  to  the  needs  of  industry. 

The  increased  demand  would  follow  almost  automatically 
from  the  existence  of  the  supply  for  each  trained  practi- 
tioner in  his  daily  work  would  influence  the  men  and  their 
unions  on  the  one  side,  and  the  employers  and  their  councils 
on  the  other.  Both  sides  would  soon  appreciate  the  value 
of  a medical  attendant  with  an  intelligent  understanding  of 
industrial  problems  and  ready  to  use  his  knowledge  to  their 
advantage. 

Our  appeal,  then,  is  to  the  great  provincial  medical  schools 
to  start  post-graduate  courses  in  industrial  medicine  directed 
to  meet  the  needs  of  the  district,  and  so  be  of  direct  and 
immediate  benefit  to  the  industries  among  whom  they  exist, 
in  the  sure  and  certain  hope  that  the  industries  in  their  turn 
will  react  and  give  greater  financial  support  to  the  schools. 
The  schools  need  financial  support,  and  it  is  more  likely  to 
be  forthcoming  if  the  schools  pay  attention  to  the  particular 
needs  of  industry  and  establish  clearly  the  value  industry 
will  get  in  return. 


MEDICINE  AND  THE  LAW. 


Treatment  by  Correspondence. 

An  inquest  was  recently  conducted  at  Kensington,  by  Mr. 
A.  D.  Cowburn,  on  the  body  of  a woman,  aged  46,  who  died 
from  tuberculosis  and  heart  disease  in  the  absence  of  treat- 
ment by  any  qualified  medical  man.  According  to  the  report 
of  the  proceedings  in  the  Times  for  June  6th,  it  appears  that 
until  April  last  she  had  been  treated  by  a throat  specialist  in 
Brazil,  where  she  was  then  resident,  and  had,  on  coming  to 
England,  applied,  through  her  husband,  to  the  Alabone 
Institute  in  Highbury  Quadrant,  filling  up  a “form,”  and  being 
supplied  with  an  apparatus  for  spraying  the  throat,  and  with 
medicine.  On  May  31st  the  husband , finding  that  her  condition 
was  becoming  very  grave,  wrote  to  the  institute  demanding  the 
personal  services  of  “ the  doctor  who  had  the  case  in  hand.” 
On  the  following  day  it  became  necessary  to  call  in  a local 
medical  man,  who  pronounced  death  imminent,  as  indeed  it 
proved  to  be.  Evidence  as  to  the  pathological  conditions 
found  post  mortem  was  given  by  Dr.  B.  H.  Spilsbury,  who  is 
reported  to  have  said  that,  had  proper  treatment  been  given, 
life  would  have  been  prolonged.  The  husband  of  the 
dead  woman  having  declared  that  he  was  under  the 
impression  that  the  “doctor  at  the  institute  was  a 
qualified  man,”  the  coroner  stated  that  he  intended  to 
call  the  attention  ot  the  proper  authorities  to  the  matter. 
It  appears  certain  that  in  this  case  the  inadequacy,  at  least, 
of  “treatment  by  correspondence”  for  one  in  so  grave  a 
state  of  health,  was  not  appreciated  by  those  on  whom  the 
responsibility  for  her  welfare  devolved  ; but  the  husband 
evidently  believed  that  the  treatment  he  procured  his  wife 
was  legitimate,  and  conducted  by  a qualified  medical  man  in 
a proper  manner,  though  in  absentia.  Any  action  that  may 
be  taken  by  the  authorities  will  probably  be  conditioned 
by  the  strength  of  the  evidence  available  that  the 
husband  had  grounds  extended  to  him  for  this  belief : 
but  it  may  be  that,  even  if  such  evidence  be  not 
forthcoming,  there  is  yet  sufficient  basis  for  action  by  the 
Society  of  Apothecaries,  which  society,  it  will  be  remem- 
bered, has  the  right  to  sue  for  penalties  against  persons 
practising  as  apothecaries  without  its  licence.  The  practice 
of  an  apothecary  consists,  it  is  usually  held,  in  attending  and 
advising  persons  requiring  medical  treatment,  and  in  pre- 
scribing, compounding,  and  supplying  medicine  for  their  cure 
and  relief.  Bone-setters  and  others  of  that  ilk  do  not  there- 
fore expose  themselves  to  the  liability  of  such  action.  But 
it  is  clear  that,  in  the  interests  of  others  who  may  be  misled 
from  one  reason  or  another,  the  activities  of  the  Alabone 
Institute  call  for  close  attention. 

The  Dispensing  of  Prescriptions  at  Night. 

At  a recent  inquest  at  Deptford  it  was  proved  that  an 
insured  person  who  had  received  a prescription  at  eight  in 
the  evening  could  not  obtain  the  medicine  till  the  following 
day  because  the  druggists  available  would  not  dispense  after 
that  hour.  In  the  view  of  the  medical  man  who  gave  the 
prescription,  the  life  of  the  patient,  who  died,  might  have 
been  saved  if  he  could  have  obtained  the  prescription  at 
once.  He  stated  that  similar  cases  were  happening  every 


The  Lancet,] 


MEDICINE  AND  THE  LAW.— AUSTRALIA. 


[July  5,  1919  31 


day.  The  coroner  expressed  the  opinion  that  in  urgent  oases 
druggists  should  be  compelled  to  dispense  at  any  hour  of  the 
day  and  night,  and  that  the  matter  should  be  brought  to 
the  attention  of  the  Insurance  Committee.  This,  tie  was 
informed,  had  already  been  done  without  result.  It  would 
certainly  appear  to  be  useless  for  medical  practitioners  to 
be  compelled,  by  public  opinion  if  not  by  law,  to  attend 
patients  at  all  hours — often  for  illness  which  is  not  serious  or 
urgent — when  in  cases  of  genuine  urgency  the  effort  of  the 
medical  man  is  frustrated  by  the  closing  of  the  druggist’s 
shop.  It  is  for  the  public  to  bring  about  the  remedy  in  their 
own  interests. 

The  Proof  of  Paternity. 

In  a recent  trial  before  Mr.  Justice  Darling  a man  indicted 
under  the  Punishment  of  Incest  Act,  1908,  raised  the  defence 
that  the  girl  with  whom,  according  to  the  evidence,  he  had 
had  sexual  intercourse,  was  not  in  fact  his  daughter.  She 
had  been  born  two  months  after  the  prisoner  married  her 
mother,  but  he  denied  that  he  had  had,  or  could  have  had, 
access  to  the  mother  at  the  time  when  the  child  must  have 
been  begotten.  The  law  presumes  a child  born  in  wedlock 
to  be  the  legitimate  offspring  of  the  marriage,  and  when  the 
Punishment  of  Incest  Act  was  framed,  in  order  to  prevent 
intercourse  between  persons  closely  related  in  blood,  the 
position  of  those  connected  only  by  a legal  presumption 
was  possibly  forgotten  in  the  drafting.  Mr.  Justice  Darling, 
while  referring  to  authorities  of  great  weight  against  the 
course  which  he  took,  relied  upon  the  Poulett  peerage  case 
as  enabling  the  presumption  of  legitimacy  to  be  rebutted. 
He  therefore  left  it  to  the  jury  to  say  whether  the  girl  was 
the  daughter  of  the  prisoner  by  blood  or  not,  and  told  them 
that  it  was  their  duty  to  acquit  him  if  they  were  satisfied 
that  she  was  not  his  daughter  in  the  sense  indicated.  The 
prisoner  was  found  not  guilty  and  discharged.  Defences  of 
this  kind  will  probably  be  heard  of  again  at  similar  trials, 
and  it  is  to  be  hoped  that  they  may  not  lead  to  undeserved 
acquittals. 

Professional  Secrecy  in  the  Eye  of  the  Law. 

An  interesting  statement  was  made  by  the  presiding  judge 
during  the  hearing  at,  the  last  Worcester  Assizes  of  a case  of 
concealment  of  birth.  One  of  the  witnesses,  a medical  man, 
was  called  in  when  the  girl  was  prostrate,  and  after  she  had 
placed  the  body  of  the  baby  under  the  mattress.  He  said  he 
had  to  perform  an  operation  to  save  her  life.  The  judge 
said  he  saw  that  the  doctor  in  his  depositions  had  stated  that 
though  he  knew  the  child  had  been  born,  he  did  not 
think  it  his  duty  to  inform  the  police,  as  it  would  have 
been  a gross  breach  of  professional  confidence.  The 
judge  said  there  was  no  professional  confidence  in  criminal 
cases,  and  it  was  the  doctor’s  duty  to  inform  the  police.  He 
did  not  blame  the  doctor  for  his  view,  but  he  thought  it 
should  be  known  that  his  view  was  wrong,  as  was  that  of  the 
Association  which  advised  him.  The  judge  added  that  if 
a patient  cut  another  person’s  throat  it  would  be  the 
doctor’s  duty  to  inform  the  police.  There  was  no  difference 
between  these  cases.  In  the  result  the  girl  was  found  not 
guilty.  The  question  thus  raised  is,  of  course,  not  new  and 
its  solution  is  not  easy.  It  has  been  frequently  discussed, 
and  an  able  exposition  of  the  whole  subject  was  given  by 
the  late  Dr.  A.  G.  Bateman,  the  Secretary  of  the  Medical 
Defence  Union,  in  a paper  which,  with  a report  of  an 
interesting  debate,  is  to  be  found  in  the  Transactions  of 
the  Medico-Legal  Society  for  1904-05.  It  would  appear 
that  the  dictum  of  the  learned  judge  presiding  at  the  recent 
Worcester  Assizes  is  in  absolute  accord  with  the  strict  letter 
of  the  law.  It  is  equally  clear  that  the  judge  did  not 
consider  that,  in  this  case,  there  had  been  any  but  a 
technical  breach  committed  by  the  doctor.  His  actions 
were  fully  in  accord  with  the  paramount  professional 
opinion  which  finds  it  repugnant  to  assume  the  office  of 
informer,  when  knowledge  of  the  indictable  offence 
is  obtained  in  the  exercise  of  professional  capacity.  This 
opinion  is  clearly  set  out  in  our  columns  this  week  by  Sir 
John  Tweedy,  President  of  the  Medical  Defence  Union. 
Nevertheless,  it  is  well  that  the  letter  of  the  law  should  be 
known,  and  that  the  responsibility  for  non-compliance,  under 
certain  circumstances,  should  be  realised.  A medical  man  in 
the  exercise  of  his  professional  vocation  has  special  oppor- 
tunities for  becoming  aware  of  the  commission  of  offences 
against  the  law,  and  special  confidence  is  reposed  in 
him.  The  law,  however,  while  casting  upon  him  no 
special  duty,  does  not  extend  to  him  the  special  privilege 


that  it  does  to  lawyers,  who  are  exempted  from  disclosure  of 
“professional  secrets,”  even  when  these  relate  to  the 
commission  of  criminal  offences. 

An  Action  for  Negligence. 

Two  consolidated  actions  of  medical  interest  were  recently 
heard  before  the  Lord  Chief  Justice  and  a special  jury.  Mr. 
W.  A.  Bowring  sued  Mr.  M.  L.  Cook  to  recover  the  profes- 
sional charges  for  performing  an  operation  on  Mrs.  Cook. 
Mr.  and  Mrs.  Cook  sued  Mr.  Bowring  for  damages  for 
negligence  in  the  operation  and  in  the  medical  treatment 
of  Mrs.  Cook.  Mr.  Bowring’s  counsel,  after  referring  to  his 
client’s  qualifications,  gave  a brief  review  of  the  case.  The 
plaintiff,  he  said,  was  consulted  by  Mr.  Cook  in  January, 
1917,  about  his  wife’s  condition,  and  made  an  examination 
as  a result  of  which  he  diagnosed  the  case  as  one  of 
fibroid  tumour  incarcerated  in  the  pelvis  and  advised 
an  operation  for  the  removal  of  the  tumour.  For  the 
defence  it  was  alleged  that  the  plaintiff  had  advised  that  Mrs. 
Cook  was  not  pregnant,  when,  in  fact,  she  was,  and  that 
he  had  not  completed  the  operation  which  he  had  advised. 
To  these  allegations  the  plaintiff  replied  that  he  had  stated 
that  it  was  doubtful  whether  Mrs.  Cook  was  pregnant,  and 
that  the  question  of  pregnancy  did  not  affect  the  decision  to 
operate.  In  desisting  from  operating  he  had  acted  in 
accordance  with  the  condition  of  Mrs.  Cook  as  revealed  by 
the  abdominal  section.  Afterwards,  and  as  a result  of  his 
treatment,  the  fibroid  growth  in  the  uterus  subsided,  and 
Mrs.  Cook  regained  her  health.  The  jury,  after  two 
minutes’  deliberation,  found  for  the  plaintiff,  and  judgment 
was  entered  accordingly,  both  on  the  claim  and  counterclaim. 
It  seems  clear  that  Mr.  Bowring,  the  plaintiff  in  this  case, 
acted  throughout  in  a proper  manner,  and  in  accord  with 
the  justifiable  opinions  formed  by  him  at  different  stages 
during  the  progress  of  the  case.  It  would  be  intolerable 
for  a surgeon  who,  during  an  operation,  finds  evidence 
that  satisfies  him  that  a contemplated  procedure  should 
not  be  carried  out,  nevertheless,  under  penalty  of  being 
cast  in  damages,  to  be  forced  to  complete  the  operation 
“ contracted  for”  (if  the  phrase  be  permissible)  or  to  forego 
his  proper  fees.  Mr.  Bowring  is  to  be  congratulated  on  the 
swift  decision  of  the  jury  in  establishing  an  important 
principle.  

AUSTRALIA. 

(From  our  own  Correspondent.) 

The  Second  Wave  of  Influenza. 

Since  the  first  weeks  of  April  the  presence  of  a second 
wave  of  influenza  has  been  manifest  in  Victoria.  The 
hospital  accommodation  has  again  been  severely  taxed,  and 
the  disease  has  been  more  widespread  in  the  community 
than  before.  The  increase  has  been  very  marked  as  a result 
of  the  Easter  vacation,  with  its  overcrowding  in  trains  and 
public  amusements.  The  restrictions  in  force  during  the 
last  epidemic  were  not  reimposed  by  the  Government.  The 
Minister  of  Health  (Mr.  Bowser)  was  last  week  announced  to 
be  suffering  from  overstrain,  and  the  Hon.  Mr.  McWhae  has 
beeD  appointed  acting  Minister.  It  had  been  generally  felt 
that  a stronger  policy  was  required  at  the  Health  Depart- 
ment, and  there  had  been  some  slight  friction  with  the 
Medical  Advisory  Committee  on  account  of  certain  sugges- 
tions being  shelved.  It  is  understood  that  the  new  policy 
will  include  a special  medical  officer,  with  full  discretion  to 
manage  the  hospital  equipment  and  general  direction  of  the 
handling  of  a special  organisation,  apart  from  the  routine 
of  the  Board  of  Health.  As  is  not  unusual,  the  emergency 
hospital  accommodation  has  proved  unsatisfactory  and  in- 
adequate, but  the  chief  difficulty  is  stated  to  be  the  shortage 
of  nurses.  Up  to  the  end  of  April  there  had  been  about 
1500  deaths  from  influenza  in  Victoria.  In  Sydney  the 
disease  became  markedly  epidemic  early  in  April.  Restric- 
tions were  at  once  imposed,  including  the  prohibition  of  all 
public  gatherings  and  the  compulsory  wearing  of  masks. 
The  course  and  severity  of  the  outbreak  appear  to  have  been 
much  the  same  as  in  Victoria.  About  700  deaths  have  so 
far  occurred  in  New  South  Wales. 

It  is  impossible  to  say  what  effect  the  restrictions  have 
had.  Probably  they  have  in  some  degree  mitigated  the 
extent  of  the  outbreak,  but  at  the  same  there  have  been 
other  evils  apparent  as  the  result  of  these  regulations  which 


32  The  Lancet,] 


NOTES  FROM  INDIA.— URBAN  VITAL  STATISTICS. 


[July  5, 1919 


may  have  outweighed  their  possible  good  efiects.  Commerce 
has  been  dislocated,  and  much  hardship  has  resulted  from 
loss  of  employment.  The  coal  trade  has  been  paralysed  by 
conflicting  quarantine  authorities,  and  the  occasion  has  been 
seized  upon  by  the  seamen  to  demand  extra  wages  and 
insurance  against  influenza.  No  definite  conclusion  has  been 
reached  as  to  the  value  of  inoculation  or  masks,  but  the 
most  pregnant  comment  on  these  precautions  is  that  the 
public  has  ceased  to  ask  for  them.  The  Federal  Director- 
General  of  Quarantine,  Dr.  Cumpston,  has  published  an 
analysis  of  some  2000  cases  in  the  quarantine  hospitals.  In 
the  meantime  the  Federal  department  continues  to  issue 
the  vaccine. 

During  the  past  week  the  disease  has  appeared  in  epidemic 
form  in  Queensland  and  South  Australia,  but  so  far  not 
severely. 

The  Legality  of  Mash-wearing. 

During  the  period  of  compulsory  mask-wearing  in  Sydney 
in  January,  Dr.  Fox,  a city  practitioner,  refused  to  adopt  a 
mask  on  the  score  that  it  was  unhealthy.  Dr.  Fox  was 
arrested  and  appeared  before  a magistrate,  by  whom  he 
was  committed  for  trial  before  a higher  court.  The  State 
Attorney- General  has  decided  not  to  prosecute,  but  Dr.  Fox 
is  not  satisfied  with  this  attitude,  and  intends  to  proceed 
against  the  authorities  for  damages. 

Curious  Case  of  Snake-bite. 

A remarkable  happening  is  reported  from  the  Riverina.  A 
resident  of  a riverside  town  caught  a large  specimen  of  a 
Murray  cod,  and  on  opening  the  fish  discovered  a live 
snake,  by  which  he  was  bitten  in  the  attempt  to  withdraw  it. 
He  was  treated  by  a companion  with  a first-aid  outfit  and 
subsequently  by  a medical  man,  and  suffered  no  further 
ill-result. 

Lodge  Dispute  in  Victoria. 

The  dispute  between  the  Friendly  Societies  and  the 
Victoria  branch  of  the  British  Medical  Association  which 
has  been  running  on  since  last  year  is  still  unsettled.  About 
half  of  the  societies  have  agreed  to  accept  the  Association’s 
model  agreement,  but  some  of  the  others  decline  to  come 
in.  Meanwhile  the  former  lodge  doctors  appear  quite 
satisfied  with  the  position,  which  is  that  they  are  paid  by 
the  lodge  for  each  visit.  It  is  said  that  this  results  in  far 
less  work  than  formerly,  and  that  the  remuneration  is 
better.  The  Orders  which  stand  out  are  hoping  that,  the 
war  being  over,  there  will  be  a supply  of  men  willing  to 
take  institute  places  in  spite  of  the  Association’s  refusal  to 
recognise  institutes. 

May  6th. 

NOTES  FROM  INDIA. 

(From  our  own  Correspondents.) 

Calcutta  University  Medical  Schools. 

The  Senate  of  the  Calcutta  University  has  approved  of  the 
affiliation  of  the  Carmichael  Medical  College,  Belgechia,  to 
the  final  M.B.  standard.  This  is  the  second  medical  college 
in  Calcutta  to  affiliate. 

Plague,  Cholera,  Small-pox,  Hookworm. 

The  last  weekly  report  issued  shows  the  mortality  from 
plague  in  India  as  2417  deaths  against  3047  seizures.  In 
the  Bombay  Presidency  there  were  178  deaths  ; in  Madras.  7; 
in  Bengal,  23  ; in  Bihar  and  Orissa,  320 ; in  the  United 
Provinces,  706  ; in  the  Punjab,  1029 ; in  Burma,  63  ; in  the 
Central  Provinces,  32  ; and  in  Mysore,  21. 

By  last  mail  a serious  outbreak  of  cholera  among  the 
employees  of  the  Calcutta  Telegraph  Office  is  reported. 
About  115  telegraphists,  clerks,  and  messengers,  including 
82  Europeans  and  Anglo-Indians  and  30  Indians,  have  been 
attacked. 

There  has  been  a considerable  increase  of  small-pox  on 
the  Kolar  goldfield  during  the  past  month,  as  compared  with 
any  previous  month  since  the  present  outbreak.  There  were 
100  attacks  and  30  deaths,  bringing  the  total  to  275  attacks 
and  88  deaths  since  July  1st,  1918.  There  was  a recru- 
descence of  plague  during  April,  after  a month  of  immunity, 
and  cholera  has  also  reappeared. 

Dr.  J.  Borland  McVail,  Deputy  Sanitary  Commissioner,  has 
opened  a laboratory  at  one  of  the  Bengal  mills  for  the 
investigation  and  treatment  of  ankylostomiasis  among  jute 


mill  employees.  So  far  as  has  been  shown  to  date,  in  spite 
of  the  excellent  sanitary  arrangements  provided  in  the  mills, 
more  than  50  per  cent,  of  the  coolies  are  infected  with  hook- 
worm disease.  The  treatment  is  being  carried  out  by  the 
medical  staff  of  the  mills  with  the  advice  and  help  of  Dr. 
McVail  and  his  staff. 

Town  Planning  at  Lucknow. 

The  Lucknow  Municipal  Board  has  resolved  to  guarantee 
the  payment  of  the  charges  of  a town-planning  expert  to 
enable  the  Lucknow  Improvement  Committee  to  secure  this 
gentleman’s  return  to  India  and  his  advice  on  the  details  of 
the  various  improvement  schemes  during  next  cold  weather. 

Trooping  during  the  Hot  Weather:  Educational  Distractions. 

An  official  communique  published  in  India  states  that 
some  20,000  British  troops  of  the  post-war  Army  are  now 
being  prepared  in  England  for  service  in  India.  It  is 
expected  that  their  despatch  will  commence  in  June.  It 
has  long  been  recognised  that  during  the  Indian  summer 
boredom  has  much  to  do  in  producing  a mental  and  physical 
condition  which  tends  to  the  development  of  disease,  and 
steps  are  being  taken  during  this  hot  weather  to  prevent 
the  ennui  and  lack  of  interest  which  has  been  so  often  the 
curse  of  the  soldiers’  life.  It  has  been  arranged  that  soldiers 
shall  be  afforded  interesting  and  congenial  occupation  in 
their  leisure  hours.  The  Commander-in-Chief  is  anxious 
that  soldiers  should  be  given  opportunities  for  improving 
their  general  education  and  knowledge  and,  where  facilities 
can  be  provided,  for  learning  or  practising  a trade.  The 
aid  of  local  educational  authorities  has  been  freely  drawn 
on  and  instruction  in  a large  number  of  subjects  has  been 
arranged.  The  War  Office,  at  the  instance  of  the  Govern- 
ment of  India,  has  made  a grant  of  £10,000  in  aid  of  this 
educational  scheme.  The  Government  of  India  have  also 
arranged  to  provide  free  passages  for  soldiers  to  and  from 
any  place  in  India  at  which  they  wish  to  spend  their 
furlough.  Last  year  the  Government  spent  half  a lakh  on 
making  the  various  homes  established  more  comfortable  for 
the  men,  and  gave  another  half  lakh  to  the  Y.M.C.A.  for  a 
similar  purpose. 

Reel  Cross  Supplies  for  the  Afghan  Campaign. 

The  Joint  War  Committee  has  made  very  complete  arrange- 
ments in  connexion  with  Red  Cross  supplies  on  the  North- 
West  Frontier  for  the  Afghanistan  campaign.  Main  depots 
have  been  established  at  Peshawar,  Rawalpindi,  Kohat. 
Bannee,  and  Quetta,  with  Red  Cross  commissioners  in  charge 
of  each. 

New  Nursing  Home. 

The  Bengal  branch  of  the  Lady  Minto  Indian  Nursing 
Association  opened  a nursing  home  at  Salt  Hill,  Darjeeling, 
on  May  1st.  The  home  is  chiefly  for  maternity  cases,  but 
other  suitable  non-inf ectious  cases  will  be  admitted. 

June  4th. 


URBAN  VITAL  STATISTICS. 

(Week  ended  June  28th,  1919.) 

English  and  Welsh  Tovms. — In  the  96  English  and  Welsh  towns 
with  an  aggregate  civil  population  estimated  at  16.500,000  persons, 
the  annual  rate  of  mortality,  which  had  been  10'6.  9 9,  and  10'0  per 
1000  in  the  three  preceding  weeks,  declined  to  9'6  per  1000.  In  London, 
with  a population  slightly  exceeding  4,000,000  persons  the  annual 
rate  was  9 0,  or  0'9  per  1000  below  that  recorded  in  the  previous 
week,  while  among  the  remaining  towns  the  rates  ranged  from 
3-4  in  West  Hartlepool,  3'5  in  Eastbourne,  and  4 3 in  Wallasey,  to  15'7  in 
Wigan,  17'2  in  Hastings,  and  201  in  Stockton-on-Tees.  The  principal 
epidemic  diseases  caused  133  deaths,  which  corresponded  to  an  annual 
rate  of  0 4 per  1000,  and  included  44  from  diphtheria,  33  from  measles,  31 
from  infantile  diarrhcea,  17  from  whooping-cough,  and  8 from  scarlet 
fever.  Measles  caused  a death-rate  of  T6  in  Neweastle-on-Tyne  and 
2'7  in  Stock! on-on-Tees.  There  were  2 cases  of  small  pox,  1143  of  scarlet 
fever,  and  1030  of  diphtheria  under  treatment  in  the  Metronolitan 
Asylums  Hospitals  and  the  London  Fever  Hospital,  against  3,  1115, 
and  1085  respectively  at  the  end  of  the  previous  week.  The  causes  of 
32  deaths  in  the  96  towns  were  uncertified,  and  included  3 each  in 
Birmingham,  Leicester,  and  Liverpool. 

Scotch  Towns. — In  the  16  largest  Scotch  towns,  with  an  aggregate 
population  estimated  at  nearly  2.500,000  persons,  the  annual  rate  of 
mortality,  which  had  been  12  3,  12  4,  and  1D0  in  the  three  preceding 
weeks,  rose  to  11*5  per  1000.  The  249  deaths  in  Glasgow  corre- 
si>onded  to  an  annual  rate  of  116  per  1000,  and  included  12  from 
measles,  11  from  whooping-cough,  and  1 each  from  scarlet  fever, 
infantile  diarrhoea,  and  typhus.  The  83  deaths  in  Edinburgh  were 
equal  to  a rate  of  129  per  1000,  and  included  a fatal  case  of  diphtheria. 

Irish  Towns. — The  107  deaths  in  Dublin  corresponded  to  an  annual 
rate  of  13'8,  or  15  per  1000  below  that  recorded  in  the  previous 
week,  and  included  3 from  measles  and  1 each  from  scarlet  fever  and 
whooping-cough.  The  98  deaths  Id  Belfast  were  equal  to  a rate  of 
12  7 per  1000.  and  included  3 from  scarlet  fever  and  1 each  from  diph- 
theria and  infantile  diarrhcea. 


The  Lancet,]  A MONTHLY  RECORD  OF  ATMOSPHEltlC  POLLUTION.—' THE  SERVICES.  [July  5,  1919  33 


A MONTHLY  RECORD  OF  ATMOSPHERIC  POLLUTION. 


Meteorological  Office  : Advisory  Committee  on  Atmospheric  .Pollution  : Summary  of  Reports  for  the  Months 

ending 

April  30th , 1918.  May  31st , 1918. 


Place. 

Rainfall  in 
millimetres. 

Metric  tons  of  deposit  per  square  kilometre. 

Bi 

Metric  tons  of  deposit  per  square  kilometre. 

Insoluble  matter. 

Soluble 

matter. 

Total  solids. 

Included 
in  soluble 
matter. 

Insoluble  matter. 

Soluble 

matter. 

Total  solids. 

Included 
in  soluble 
matter. 

Tar. 

Carbon- 
aceous 
other 
than  tar 

Ash. 

Loss  on 
ignition. 

Ash. 

Sulphate 
as  (S03). 

Chlorine 

(Cl). 

co 

ag 

<6 

Place. 

|.S 

cJ  — 

^ s 

Tar. 

Carbon- 
aceous 
other 
than  tar 

Ash. 

a d 

o o 
ta 

op 
i-3  bt 

Ash. 

Sulphate  i 
as  (SO3).  1 

Chlorine 

(Cl). 

Ammonia 

(NH3). 

England. 

England. 

Leicester 

61 

0T8 

3-33 

610 

3-62 

6-62 

19-85 

1-83 

0-62 

0-22 

London — 

London — 

M e te  o r o logical 

M e t e o r o 1 ogical 

Office 

40 

o-n 

3-88 

4-43 

1-58 

5-81 

15-81 

1-49 

0-68 

0-22 

Office  

85 

0'18 

2'16 

3-48 

3-40 

7-82 

17-04  2-21 

1-20 

0-42 

Embankment 

Embankment 

Gardens  

34 

o-n 

2-20 

3-49 

2-31 

4-14 

12-24 

2-04 

0-64 

0 10 

Gardens  

47 

0'12 

1-73 

2-74 

4-87 

6-53 

15-99  3 73 

0-81 

0-28 

Finsbury  Park  ... 

61 

0-12 

279 

14-46 

1-22 

3-40 

22-01 

I 63 

0-42 

0-12 

Finsbury  Park  ... 

18 

o-io 

1-99 

12-48 

0 90 

4-1C 

19'56  0'76 

0-33 

0-02 

Ravenseourt  Park 

36 

0-16 

2-90 

9-83 

1-88 

2-37 

17-14 

1-33 

0-28 

0 14 

Ravenseourt  Park 

22 

0-06 

2-27 

5 50 

0-80 

1-49 

10-11 

0-89 

0-21 

0-07 

South wark  Park... 

35 

0-05 

0 63 

2-45 

2-02 

3-59 

8-74 

2-22 

0-48 

0-12 

Southwark  Park 

59 

0-09 

1-94 

5-46 

3 20 

5-67 

16-36 

3-54 

0-84 

0-13 

Victoria  Park  ... 

68 

0-08 

3-91 

15-71 

1-35 

335 

24-39 

1-93 

0-43 

0T9 

Victoria  Park 

40 

001 

0-77 

3-72 

076 

2-34 

7-59 

1-30 

0-26 

0-08 

Wandsworth  Com. 

20 

o-oo 

1-30 

7-83 

o-oi 

2-14 

11-27 

0-85 

0-24 

0-04 

Wandsworth  Com. 

20 

Tr. 

0'27 

1-40 

0-77 

1-72 

4-15 

0-93 

0-32 

0-04 

Golden  Lane 

67 

0 11 

3-45 

4 88 

1-88 

3-77 

14-08 

1 85 

0 86 

0-24 

Golden  Lane 

76 

0-27 

447 

4-71 

3-33 

5-45 

18-24 

2-68 

1-48 

0-45 

Malvern* 





— 

— 

— 

— 







Malvern*  ...  . 

— 

— 

— 

Manchester — 

Manchester — 

Queen’s  Park 

73 

— 

— 

— 

— 

— 

14-10 

— 

— 

— 

Queen's  Park 

55 

— 

— 

— 

— 

— 

6-50 

— 

— 

— 

School  of  Techno- 

School  of  Techno- 

logy  

83 

— 

' 183 

— 

— 

— 

16-60 

— 

— 

— 

logy  

40 

— 

— 

— 

— 

— 

12-70 

— 

-- 

— 

Newcastle-on-Tyne 

35 

0-28 

3-19 

8-83 

1-89 

2-31 

16-50 

1-56 

0-36 

0-13 

Newcastle  - on-Tyne 

31 

0T8 

4-23 

7 71 

1-50 

2-87 

16-48 

1-42 

0-44:0-15 

Rochdale  

— 

— 

— 

— 

— 

— 

34-80 

— 

— 

— 

Rochdale 

— 

— 

— 

— 

— 

— 

34-80 

— 

— 

— 

St.  Helens  

93 

D-49 

3-39 

6-13 

3-03 

6-05 

19-09 

3-00 

1-91 

0-46 

St.  Helens  

30 

0-36 

1-67 

3-58 

1-63 

3-48 

10-72 

1-83 

0-83  0-22 

Southport— 

Southport— 

Heskpth  Park  ... 

77 

0-02 

0-49 

0-96 

1-53 

4 40 

7-40 

1-80 

0-31 

0-07 

Hesketh  Park  ... 

27 

0-00 

0 21 

0-36 

0 54 

2-17 

3-28 

0-91 

0-19  0-04 

Woodvale  Moss... 

89 

— 

— 

— 

— 

— 

751 

— 

— 

— 

Woodvale  Moss... 

26 

— 

— 

— 

— 

— 

4-02 

— 

— 

— 

Scotland. 

Scotland. 

Coatbridge  

40 

3-16 

2-11 

6-00 

2-07 

3-78 

14-12 

2 24 

0-17 

0-12 

Coatbridge  

14 

0-06 

0-87 

2-68 

1-08 

1-95 

6-64 

118 

0-08 

0-08 

Glasgow — 

Glasgow — 

Alexandra  Park... 

40 

0-11 

2-52 

5-21 

1-86 

1-54 

11-24 

0-83 

0-07 

o-io 

Alexandra  Park... 

10 

0-10 

2 50 

5-17 

0-46 

0.61 

8-84 

0-42 

0-06 

0-04 

Bellahouston  Park 

63 

0-12 

1-58 

5-99 

2-32 

4-78 

14-79 

2-17 

0-19 

0-06 

Bellahouston  Park 

13 

001 

0-97 

2-59 

0-33 

0-37 

4-27 

0-27 

0-06 

001 

Blythswood-sq. ... 

56 

0-09 

1-32 

5-16 

2-83 

2-47 

11-87 

1-14 

0-14 

0-14 

Blythswood-sq.  ... 

16 

Oil 

2-56 

2-98 

0-43 

0-70 

6-78 

0-56 

0-09 

0-04 

Botanic  Gardens 

63 

0-39 

2-12 

5-85 

7-89 

2-53 

18-78 

1-64 

0-16 

0-05 

Botanic  Gardens 

12 

0-08 

1-34 

3-76 

0-27 

0-78 

6-23 

0-39 

0-05 

0-02 

Richmond  Park... 

56 

J- 16 

1-75 

3-76 

1-70 

3-43 

10-80 

1-73 

0-18 

0T5 

Richmond  Park... 

10 

0-03 

1-12 

2-92 

0-24 

031 

4 62 

0-21 

0-03 

0-02 

Ruchill  Park 

59 

0-40 

2-61 

7-03 

2-46 

2-84 

15-34 

1-45 

0-19 

0-09 

Ruchill  Park 

12 

0T0 

3-51 

1-63 

0-25 

0-65 

6-14 

0-41 

0-06 

0 03 

South  Side  Park.. 

65 

1-32 

2-24 

5-47 

2-16 

5-26 

15-45 

2-32 

0-15 

0-08 

South  Side  Park. 

10 

o-oi 

0-72 

2-72 

0-12 

0-30 

3 87 

0-21 

0 06 

o-oi 

Tollcross  Park  ... 

50 

0-19 

1-31 

3-55 

4-63 

3-47 

13-15 

1-39 

0-14 

0-12 

Tollcross  Park  ... 

11 

o-n 

2-02 

5-25 

0-28 

0-67 

8-33 

0-42 

0-05  0-04 

Victoria  Park  ... 

65 

305 

1-57 

5-18 

5-28 

3 95 

16-03 

202 

0-12 

0-08 

Victoria  Park 

11 

0-02 

0-85 

2 90 

0-20 

0 39 

4-36 

0-28 

0 06  0 02 

Tr.  = trace.  * Observations  suspended  owing  to  war  conditions. 

“Tar”  includes  all  matter  insoluble  in  water  but  soluble  in  CS2.  “Carbonaceous”  includes  all  combustible  matter  insoluble  in  water  and 
in  CS  j.  “Insoluble  ash”  includes  all  earthy  matter,  fuel,  ash,  &c.  One  metric  ton  per  sq.  kilometre  is  equivalent  to:  (a)  Approx.  91b.  per 
acre ; ( b ) 2 56  English  tons  per  sq.  mile ; (c)  1 g.  per  sq.  metre;  ( d ) 1/1000  mm.  of  rainfall. 

The  personnel  of  public  health  authorities  concerned  in  the  supervision  of  these  examinations  and  of  the  analytical  work  involved  remains  the 
same  as  published  in  previous  tables.  The  analyses  of  the  rain  and  deposit  caught  in  the  gauge  at  the  Meteorological  Office  are  made  in 
The  Lancet  Laboratory. 


ROYAL  NAVAL  MEDICAL  SERVICE. 

Temp.  Surg.-Lieut.  W.  P.  Starforth,  who  has  been  invalided  on 
account  of  ill-health  contracted  in  the  Service,  to  retain  his  rank. 

ARMY  MEDICAL  SERVICE. 

Col.  Sir  W.  H.  Horrocks,  K.C.M.G.,  C.B.  (retired  pay),  to  be  temporary 
Director  of  Hygiene  at  the  War  Office,  and  to  be  temporary  Brigadier- 
General  whilst  so  employed. 

Col.  J.  Fallon  retires  on  retired  pay. 

Major  and  Bt.  Lieut. -Col.  C.  W.  Holden,  D.S.O.,  relinquishes  the 
acting  rank  of  Colonel  on  re-posting. 

Major  and  Bt.  Lieut. -Col.  W.  C.  Smales,  D.S.O.,  R.A.M.C.,  from 
Deputy  Assistant  Director-General,  to  be  Assistant  Director  of  Hygiene 
at  the  War  Office. 

Major-Gen.  Sir  W.  B.  Leishman,  K.C  M.G.,  C.B..  F.R.S.,  K.H.P.,  to 
be  Director  of  Pathology  at  the  War  Office. 

Lieut. -Col.  D.  Harvey,  C.M.G.,  C.B.E.,  R.A.M.C.,  to  be  Deputy 
Director  of  Pathology  at  the  War  Office,  and  to  be  temporary  Colonel 
whilst  so  employed. 

Major  A.  C H.  Gray,  O.B.E.,  R.A.M.C.,  to  be  Assistant  Director  of 
Pathology  at  the  War  Office,  and  to  be  temporary  Lieutenant-Colonel 
whilst  so  employed. 

Temp.  Col.  T.  P.  Legg,  C.M.G.,  relinquishes  his  commission  and 
retains  the  rank  of  Colonel. 

The  undermentioned  Temporary  Colonels  relinquish  their  temporary 
commissions  on  re-posting  : H.  G.  Barling,  C.B.  (Lieut.-Col.,  R.A.M.C., 
T.F.),  J.  Swain,  C.B.  (Major,  R.A.M.C,  T.F.). 

ROYAL  ARMY  MEDICAL  CORPS. 

Lieutenant-Colonels  relinquishing  the  temporary  rank  of  Colonel  on 
re-pobting:  F.  J.  Brakenridge,  J.  S.  Gallie,  G.  J.  Houghton,  H.  E.  M. 
Douglas,  W.  Bennett. 

The  undermentioned  relinquish  the  acting  rank  of  Colonel  on 
re-posting:  Capt.  and  Bt.  Major  W.  G.  Wright  ; Lieut.-Cols.  F. 
McLennan,  H.  0.  R.  Hime. 

The  undermentioned  relinquish  the  acting  rank  of  Lieutenant- 
Colonel  on  re-posting:  Maj.  and  Bt..  Lieut.-Col.  J.  G.  Bell;  Majors 
D.  P.  Watson,  T.  H.  Scott,  E.  C.  Phelan,  W.  Egan,  D.  L.  Harding, 
W.  C.  Ntmmo,  C.  Bramhall,  T.  S.  Blackwell,  B.  Johnson,  G.  F. 


Rudkin,  J.  J.  O’Keefe;  Capts.  C.  M.  Drew,  J.  W.  C.  Stubbs,  R.  B. 
Price,  J.  H.  Fletcher,  C.  Helm,  F.  Worthington,  E.  Phillips,  R. 
Hemphill.  W.  J.  Dunn,  R.  R.  Thompson,  L.  F.  K.  Way,  E..W. 
Vaughan,  H.  C.  D.  Rankin  ; Temp.  Capt.  W.  E.  Hallinan.  ■*“ 

To  be  acting  Lieutenant-Colonels  whilst  commanding  Medical 
Units:  Majors  R.  N.  Hunt,  J.  A.  W.  Webster,  N.  E.  Dunkerton,  Capt. 

(acting  Major)  W.  W.  MacNaught.  . 

Lieut.-Col.  G.  A.  T.  Bray,  D.S.O.,  is  placed  on  retired  pay. 

Major  W.  W.  Boyce,  D.S.O.,  relinquishes  the  acting  rank  of 
Lieutenant-Colonel  on  re-posting. 

To  be  acting  Majors ; Capt.  and  Bt.  Major  A.  Shepherd,  S.  W.  Kyle  ; 
Capt.  T.  J.  L.  Thompson  ; Temp.  Capts.  A.  T.  W.  Forrester,  R.  H. 
Stevens,  L.  T.  Giles,  E.  J.  Pehill,  J.  R.  Griffith,  H.  Findlay,  R.  S. 
Woods,  J.  M.  Morris  (whilst  specially  employed) ; Temp.  Lieut. 
J.  E.  G.  Calverley. 

The  undermentioned  relinquish  the  acting  rank  of  Major : Capt.  and 
Bt.  Major  W.  L.  WebBter ; Capts.  R.  C.  Aitebison,  G.  P.  Kidd,  W.  J. 
Knight,  T.  J.  L.  Thompson,  F.  R.  S.  Shaw,  D.  H.  C.  McArthur,  A.  L. 
Stevenson,  R.  H.  Williams,  J.  H.  Baird,  R.  W.  Vint,  T.  D.  Inch,  J.  A. 
Renshaw,  F.  C.  Chandler;  Temp.  Capts.  J.  R.  M.  Whigham,  T. 
Ferguson,  W.  F.  Morgan,  R.  J.  B.  Madden,  G.  B.  McTavish,  A.  R. 
Esler,  E.  F.  C.  Dowding,  H.  J.  Pickering,  F.  J.  O.  King,  A.  J.  Dunlop, 
G.  C.  Linder,  C.  L.  Chalk,  R.  B.  Blair,  H.  B.  Shepherd,  F.  H.  Moxon, 
G.  S.  Brown,  J.  Rodger,  E.  G.  Dingley,  T.  H.  Oliver,  J.  W.  Littlejohn, 
R.  C.  Cooke,  J.  L.  Jackson,  G.  S.  Mur  ay,  W.  C.  Horton,  G.  B.  Elliott, 
W.  H.  Peacock,  H.  G.  Frean,  A.  V.  Craig,  E.  F.  G.  Ward,  F.  W. 

iamond,  C.  Burnham,  P.  J.  Chissell,  J.  S.  Hall,  T.  Stordy,  H.  E. 
Gamlen,  F.  H.  Young,  G.  H.  Culverwell,  W.  K.  McIntyre,  J.  L.  A. 
Grout;  Lieut  (temp.  Capt.)  G.  E.  Spicer. 

Late  temporary  Captains  to  be  Captain  : E.  E.  Frazer,  F.  Wheeler. 
The  undermentioned  Captains  resign  their  commissions : J.  A. 
Andrews,  J.  A.  W.  Ebden. 

Temporary  Lieutenants  to  be  temporary  Captains  : L.  W.  Oliver, 
T.  C.  A.  Sweetman. 

Officers  relinquishing  their  commissions  : Temporary  Lieutenant- 
Colonels,  and  retaining  the  rank  of  Lieutenant-  Colonel : G.  N.  Stephen, 
G.  A.  Bannatyne.  Temporary  Major : A.  F.  Hurst  (granted  the  rank 
of  Lieutenant-Colonel).  Temporary  Majors  retaining  the  rank  of 
Major:  J.  G.  Fitzgerald,  H.  S.  Brander,  E.  F.  Ackery,  G.  S.  Samuelson, 
A.  Robertson,  C.  Christy.  Temporary  Captains  granted  the  rank  of 
Major:  J.  B.  Lowe,  L.  H.  C.  Birkbeck,  J.  V.  Holmes,  W Haward, 
E.  G.  D.  Pineo,  (Acting  Major)  G.  S.  Mill.  W.  E.  Hallinan.  Tem- 
porary Captains  retaining  the  rank  of  Captain : H.  B.  Pare,  W.  A. 


34  The  Lancet,] 


PROFESSIONAL  SECRECY  IN  THE  EYE  OF  THE  LAW. 


[July  5,  1919 


Paterson.  W.  A.  Kees.  R.  W.  L.  Wallace,  P.  O.  W.  Browne.  W.  B. 
Primrose,  A.  M.  Hewat.,  C.  G.  G.  Winter,  A.  R.  P.  Douglas,  K.  C.  B. 
Briscoe.  D.  B Leiteh,  W.  M.  McFarlane.  J.  Rigby,  P.  C.  Bushneil,  H.  R. 
Wright,  A.  Mudie,  T.  G.  Fetherstonhaugh,  A.  Farquhar,  R.  de  V.  King. 
A.  E.  Francis.  E.  Gardner.  J.  A Loughridge.  G.  S.  Murray,  A.  A.  Lees. 
A.  M.  Bayne.  F.  M.  Auld.  A.  P.  Ford,  D.  Gray.  W.  W.  Turner,  H.  E. 
Collier,  E.  R.  Lyth,  A.  II.  M.  Saward,  L.  G.  Leonard.  S.  A.  Tucker.  D.  W. 
Tacey,  H.  H.  P.  Morton.  G.  P.  Taylor,  I.  M.  Frazer,  G.  A.  Ticehurst,  H.  S. 
McSorley,  C.  S.  Stolterfoth  G.  Scullard.  G.  B.  Messenger,  G.  B.  Crawford. 
W.  M.  Johnston,  C.  W.  Ewing.  H.  Findlay,  J.  S.  Dickson,  C.  O Donovan, 
M.  C.  R.  Grahame,  A.  T.  I.  Macdonald,  G.  R.  Potter,  W.  Henderson, 
T.  N.  Darling.  W.  E.  Cooper,  C.  C.  G.  Gibson,  N.  P.  Pritchard,  A. 
Campbell,  L.  Gibbons,  A.  W.  Cochrane,  G.  Hamilton.  E.  V.  Hunter, 
H.  R.  W.  Husbands,  A.  C.  Giles,  L.  L.  Hadley,  C.  C.  B.  Gilmour,  D. 
Ilardie,  C.  A.  Joll,  A.  G.  K.  Ledger,  A.  J.  Andrew,  J.  S.  Taylor, 
I).  A.  Donald,  J.  W.  Lindsay,  J.  O.  Thomas,  H.  Rogers-Tillstone, 
J.  A.  Renshaw,  R.  Kenefick,  H.  V.  Taylor,  F.  C.  Trapnell,  K.  H. 
Bennett,  W.  A.  Murphy,  A.  E.  Hallinan,  B.  D.  Crichton,  J.  L.  H. 
Paterson,  V.  D.  O.  Logan,  T.  Kirkwood,  E.  A.  Donaldson-Sim,  W.  J.  G. 
Johnson,  H.  A.  Cutler,  E.  H.  Jones,  R.  Calleya.  W.  H.  Gowans,  H.  B. 
Clutterbuck,  I.  Feldman,  W.  H.  Brown,  W.  J.  G.  Henderson, 
J.  C.  Bramwell,  R.  B.  Hey  gate,  D.  S.  Harvey,  D.  Johnston, 
L.  W.  Oliver,  A.  Walker,  G.  B.  Mason,  J.  B.  Cook.  H.  L.  Cronk, 
C.  Clyne,  H.  R.  Tighe,  S.  G.  Harrison,  S.  A.  Day,  R.  M.  Moore,  E.  P. 
Dark,  H.  C.  Harrisoo.  Temporary  Lieutenants  retaining  the  rank  of 
Lieutenant : W.  Hickey,  W.  F.  Waugh,  B.  W.  Lacey,  R.  C.  Redman, 
H.  L.  Parker.  Temp.  Hon.  Lieut.  F.  A.  Georger  retains  the  rank  of 
Honorary  Lieutenant. 

GENERAL  RESERVE  OF  OFFICERS. 

Major  A.  F.  Heaton  relinquishes  the  acting  rank  of  Lieutenaut- 
Colonel  on  ceasing  to  command  a Convalescent  Depot. 

SPECIAL  RESERVE  OF  OFFICERS. 

Captains  relinquishing  the  acting  rank  of  Lieutenant-Colonel  on 
reposting : W.  M.  Dickson,  E.  T.  Burke. 

Captains  relinquishing  the  acting  rank  of  Major:  J.  G.  Ronaldson, 
A.  F.  L.  Shields,  W.  Barclay,  R.  Taylor.  A.  R.  Hill,  C.  R.  McIntosh, 
P.  Thornton,  J.  Le  M.  Kneebone,  J.  B.  Cavenagh,  G.  G.  Alderson, 
W.  M.  Biden,  A.  Winfield,  J.  B.  Scott. 

Captains  to  be  acting  Majors  : H.  Rollinson,  T.  Harapson. 

Captains  relinquishing  their  commissions  and  retaining  the  rank  of 
Captain:  I.  D.  Suttie,  J.  M.  Courtney,  R.  R.  Scott. 

TERRITORIAL  FORCE. 

Officers  relinquishing  their  acting  rank  on  ceasing  to  be  specially 
employed : Capts.  (acting  Lieut.-Cols.)  H.  G.  G.  Mackenzie,  J.  W. 
Craven,  W.  Simpson;  Capts.  (acting  Majors)  G.  P.  D.  Hawker,  H.  A. 
Playfair-Robertson,  R.  W.  Swayne,  R.  C.  S.  Smith,  H.  B.  Sproat,  H.  M. 
Fort,  G.  Young,  J.  C.  Marklove,  A.  M.  Mackay,  W.  L.  Cockcroft,  G.  E. 
Nash,  T.  Graham,  N.  H.  H.  Haskins  J.  C.  Denvir. 

Capt.  N.  C.  Rutherford  relinquishes  his  commission. 

Capt.  D.  W.  C.  Jones  is  restored  to  the  establishment  on  ceasing  to 
hold  a temporary  commission  in  the  Army  Medical  Service. 

Capt.  C.  C.  Fitzgerald  is  restored  to  the  establishment. 

Captains  to  be  acting  Majors  whilst  specially  employed : T.  S. 
Worboys,  N.  J.  Wigram,  T.  W.  S.  Paterson. 

1st  Eastern  General  Hospital : Capt.  J.  F.  Gaskell  is  restored  to  the 
establishment. 

1st  Southern  General  Hospital : Capt.  F.  D.  Marsh  is  restored  to  the 
establishment. 

3rd  Southern  General  Hospital : Major  E.  C.  M.  Foster  is  restored  to 
the  establishment. 

5th  Southern  General  Hospital : Major  W.  P.  Purvis  is  restored  to  the 
establishment.  Capt.  (acting  Major)  G.  H.  Cowen  relinquishes  his 
acting  rank  on  ceasing  to  be  specially  employed,  and  is  restored  to  the 
establishment. 

5th  London  General  Hospital : Capt.  (acting  Major)  E.  M.  Corner 
relinquishes  his  acting  rank  on  ceasing  to  be  specially  employed. 

3rd  Western  General  Hospital : Major  (acting  Lieut.-Col.)  W.  M. 
Stevens  relinquishes  his  acting  rank  on  ceasing  to  be  specially 
employed. 

2nd  Northern  General  Hospital:  Major  (acting  Lieut.-Col.)  W. 
Thompson  relinquishes  his  acting  rank  on  ceasing  to  be  specially 

employed.  

ROYAL  AIR  FORCE. 

Medical  Branch.— Lieut.  G.  A.  S.  Madgwick  is  transferred  to 
Unemployed  List. 

Dental  Branch.— Lieut.  H.  H.  Chapman  is  transferred  to 

Unemployed  List.  

AGE  OF  RETIREMENT  IN  THE  I.M.S. 

In  accordance  with  a recent  Royal  Warrant  the  ages  at  which  officers 
of  the  Indian  Medical  Service  holding  administrative  appointments 
shall  be  placed  on  the  Retired  List  are  now  as  follows:  Director- 
General  60,  instead  of  62;  Colonels,  Brevet  Colonels,  and  general 
officers  57.  instead  of  60.  The  age  at  which  Lieutenant-Colonels  and 
Majors  shall  be  placed  on  the  Retired  List  will  remain  unaltered  at  55. 

DEATHS  IN  THE  SERVICES. 

The  late  Surgeon-Commander  Frederick  Fedarb,  R.N.,  who  died  at 
Southsea  on  May  25th  last  at  the  age  of  52,  was  the  only  surviving  son 
of  the  late  Fleet-Engineer  William  Fedarb,  R N.  He  obtained  his 
degree  of  M B.,  C.M.,  at  Glasgow  University  in  July,  1887,  and  joined 
the  Royal  Navy  as  surgeon  in  1890.  lie  did  service  at  home  and 
abroad  and  was  fleet  surgeon  of  H.M.S.  Dreadnought  during  her  first 
commission.  At  the  outbreak  of  war  he  was  principal  medical  officer 
of  the  Boys’ Training  Ship  Impregnable  at  Devonport,  but  early  in 
1916  he  was  appointed  to  II.M.S. Revenge  and  served  in  her  at  the 
battle  of  Jutland.  Dr.  A I.  Etslemont,  ot  Birmingham,  who  was  with 
him  in  Revenge  writes  : “ No  one  could  have  wished  for  a better  * chief  ’ 
or  more  devoted  friend.  Dr.  Fedarb  was  a capable  administrator,  well 
versed  in  all  the  service  routine  and  with  a sound,  up-to-date  know- 
ledge of  his  profession.  He  was  loved  by  all  his  shipmates,  because  of 
his  quiet,  unobtrusive,  kind,  and  generous  disposition,  and  it  was  a 
great  shock  to  hear  of  his  untimely  death.” 


Colonel  Sir  Robert  Armstrong-Jones  has  been 
appointed  a Deputy  Lieutenant  of  the  county  of  Carnarvon. 


Ccrnspitkiue. 


“ Audi  alteram  partem.’* 


PROFESSIONAL  SECRECY  IN  THE  EYE  OF 
THE  LAW. 

To  the  Editor  of  The  Lancet. 

Sir, — The  attention  of  the  council  of  the  Medical  Defence 
Union  has  been  drawn  to  certain  remarks  (reported  in 
Berrow’s  Worcester  Journal  of  Jane  7th)  made  by  Mr. 
Justice  Bray  in  a case  tried  before  him  at  the  Worcester 
Assizes  at  the  beginning  of  this  month.  The  case  in  ques- 
tion was  the  prosecution  of  an  unmarried  woman  for  alleged 
concealment  of  birth.  The  medical  man,  who  was  called 
in  six  hours  after  the  birth,  was  unable  to  find  the  body  of 
the  child,  and  after  considering  the  matter  decided  that  his 
duty  to  the  patient  precluded  him  from  making  any  com- 
munication to  the  police.  The  police,  however,  upon  the 
matter  being  subsequently  notified  to  them,  took  a different 
view  and  adversely  commented  upon  the  doctor’s  conduct. 
He  accordingly  consulted  the  Medical  Defence  Union,  who 
upheld  his  action  in  not  reporting  the  matter  to  the  police 
on  the  ground  that  had  he  done  so  he  would  have  been 
guilty  of  a breach  of  professional  confidence. 

At  the  Assizes  the  woman  was  found  “ Not  guilty.”  At 
the  conclusion  of  the  case  the  judge  called  the  doctor  in 
question  into  the  box  and  addressed  him,  according  to  the 
report  from  which  we  quote,  to  the  following  effect : — 

“ the  judge  said  that  he  saw  that  in  the  depositions  the  doctor 

had  stated  that,  knowing  that  a child  had  been  born  in  the  room, 
probably  recently,  he  did  not  think  it  was  his  duty  to  inform  the 
police;  in  fact,  it  would  have  been  a gross  breach  of  professional 
confidence  if  he  had  informed  the  police,  and  he  protested  most 
strongly  against  the  police  reporting  the  matter.  Tne  judge  added 
that  in  his  opinion  the  doctor  was  quite  wrong.  There  was  no  pro- 
fessional confidence  in  criminal  cases  of  this  kind,  and  it  was  his  (the 
doctor’s)  duty  to  infirm  the  police  at  once  in  a case  like  this.  The 
doctor  could  understand  the  importance  of  it  because  it  was  possible 
that  the  child  might  have  been  still  alive,  and  in  that  case  it  was  the 
duty  of  the  police  to  make  Inquiries.  There  was  no  professional  con- 
fidence to  prevent  him  giving  information  to  the  police.  ‘ I want  you 
to  please  remember  that,’  added  the  judge  ‘ I am  not  blaming  you 
for  taking  that  view,  but  I think  it  is  important  that  it  should  be 
known  that  the  view  you  took  was  wrong.’  ” 

Dr.  Standring  : “ The  Medical  Defence  Union  instructed  me  that  I 
was  absolutely  correct.” 

The  Judge:  “The  Medical  Defence  Union  is  wrong.  If  you  had 
your  attention  called  to  a patient  committing  the  offence  of  cutting 
another  man’s  throat,  it  would  be  your  duty  to  go  and  inform  the 
police.  There  is  no  difference  between  a small  and  a big  offence.” 

Apart  from  the  fact  that  in  the  case  which  had  been  tried 
a verdict  of  “ Not  guilty  ” had  been  returned,  the  council  of 
the  Medical  Defence  Union  is  unable  to  accept  the  analogy 
attributed  to  the  learned  judge  as  a fair  one,  or  to  allow 
that  the  cases  are  in  any  way  comparable.  The  standpoint 
taken  up  by  the  medical  profession  on  this  subject  has  more 
than  once  been  challenged  by  the  legal  profession.  The 
council  nevertheless  maintains  that  the  duty  a medical 
man  owes  to  his  patient  is  paramount.  Assured  as  it  is  on 
this  important  question  the  council  feels  it  incumbent  upon 
it  to  continue  to  advise  any  member  seeking  the  guidance  of 
the  Medical  Defence  Union  that  any  communications  made 
to  him  by  a patient  and  any  information  acquired  by  reason 
of  his  attendance  upon  such  patient  are  confidential,  and 
that  without  the  authority  of  the  patient  a medical  man  is 
precluded  by  the  accepted  canons  of  his  profession  from 
disclosing  such  information  to  anyone.  In  adopting  this 
attitude  the  council  feels  it  will  have  the  support  of  all  those 
members  of  the  profession  who  desire  to  maintain  inviolate 
the  trust  and  confidence  which  is  reposed  in  them  by  their 
patients.  I am,  Sir,  yours  faithfully, 

John  Tweedy, 

President,  Medical  Defence  Union. 

4.  Trafalgar-square,  W.C.2,  June  50th,  1919. 


HOMICIDAL  INSANITY. 

To  the  Editor  of  The  Lancet. 

Sir, — In  the  interesting  leading  article  in  your  issue  of 
Saturday,  June  28th,  on  the  law  and  psychology  of  these 
terrible  cases  one  point  seems  to  me  to  have  been  overlooked. 
I can  hardly  discuss  it  without  reference  to  the  case  recently 
before  the  courts,  because  certain  evidence  in  that  case  has  to 


The  Lancet,] 


EPIDEMIC  PERINEPHRIC  SUPPURATION. 


[July  5, 1919  35 


be  cited,  but  I am  very  unwilling  to  enter  into  any  controversy, 
still  more  to  weight  the  evidence,  for  or  against  a criminal 
of  whose  case  I know  no  more  than  any  other  reader  of  the 
newspapers. 

The  point  I would  touch  upon,  as  far  as  possible  in  the 
abstract,  is  this  : All  alienists  will  agree  that  the  commission  of 
such  a crime  in  an  epileptic  state  is  quite  in  accordance  with 
experience.  Many  of  us  have  seen  crimes  far  more  elaborate 
and  systematically  carried  through  in  such  states  of  auto- 
matism, but  with  this  very  important  difference.  I under- 
stand from  your  columns  that  in  the  case  before  us  the 
criminal  confessed  the  whole  story  to  the  constable  who  took 
him  into  custody.  Now,  in  my  experience  of  such  automatic 
actions,  criminal  or  indifferent,  this  has  never  been  the  case. 
In  the  large  majority  of  instances  in  my  experience  the 
perpetrator  has  had  no  recollection  whatever  of  the  act  or 
series  of  acts  imputed  to  him  ; in  a few  he  has  had  a vague 
recollection  as  of  a dream,  but  would  have  been  quite  unable 
to  tell  the  story  plainly  as  a chain  of  facts  in  which  he  was 
concerned.  Moreover,  these  few  have  regarded  the  events 
as  hardly  connected  with  themselves,  and  even  then  as  an 
unfortunate  accident  which  had  befallen  them  by  no  will  of 
their  own.  I am,  Sir,  yours  faithfully, 

Cambridge,  July  1st,  1919.  CLIFFORD  A.LLBUTT. 


EPIDEMIC  PERINEPHRIC  SUPPURATION. 

To  the  Editor  of  The  Lancet. 

Sir, — Most  medical  officers  would,  I think,  agree  with  the 
remarks  made  by  Dr.  W.  Pasteur  in  his  letter  on  the  above 
subject  in  your  columns  of  June  21st.  Perinephric  abscesses 
containing  Staphylococcus  aureus  were  common  in  France, 
as  they  had  been  in  civil  experience  before  the  war,  and  in 
the  same  way  they  were  usually  related  to  a small  boil  or 
other  known  focus  of  staphylococcal  infection  elsewhere,  a 
focus  that  might  have  become  quiescent  many  weeks  before 
the  development  of  the  perinephric  inflammation.  In  these 
cases,  however,  it  does  not  follow  that  the  “perinephric 
tissue  is  the  site  of  election,”  as  suggested  by  Dr.  Pasteur. 
Perhaps  the  abscess  has  its  origin  more  commonly  in  a 
small  infective  embolus  within  the  kidney,  from  which 
pus  burrows  its  way  outwards,  passing  through  the 
capsule  of  the  kidney,  and  so  developing  into  a large 
extra-renal  collection.  When  abscesses  arising  within  the 
kidney  take  such  an  outward  course  they  do  not  spread 
laterally  between  the  capsule  and  the  kidney  itself.  A 
specimen  in  the  Museum  of  University  College  Hospital 
illustrates  this  process,  with  a tiny  track  of  yellow  doubly 
refractive  fat  in  the  kidney,  and  a considerable  collection  of 
pus  external  to  the  capsule  at  the  upper  pole.  Conversely 
the  embolic  abscess  may  rupture  into  the  pelvis  of  the  kidney, 
and  be  drained  away  so  that  a perinephric  abscess  does  not 
develop. 

More  evidence  from  post-mortem  observations  is  needed  to 
determine  the  local  origin  of  these  perinephric  staphylococcal 
abscesses,  and  to  give  the  answers  to  two  questions  that 
arise  in  connexion  with  Mr.  Joseph  Cunning’s  letter— 
namely : (1)  whether  the  perinephric  abscess  comes  by 
outward  spread  of  infection  from  an  embolus  within  the 
kidney  itself,  or  from  some  other  focus  ? (2)  whether  the 
original  source  of  the  perinephric  suppuration  is  the 
staphylococcal  infection  of  subcutaneous  boils,  or  the 
secondary  staphylococcal  infection  of  the  respiratory  tract 
that  has  occasionally  been  seen  as  a complication  of  influenza, 
and  might  lead  to  an  epidemic  of  such  abscesses  at  a time 
when  complicated  influenza  is  rife? 

It  is  certain  that  the  ordinary  or  sporadic  perinephric 
abscess  in. France  was  the  sequel  of  boils,  just  as  pjjemic 
abscesses  in  other  tissues  (for  example,  in  the  myocardium 
causing  suppurative  pericarditis)  or  virulent  staphylococcal 
septicmmias  have  occasionally  been  seen  with  such  a history, 
when  there  was  no  possibility  of  their  having  been  caused 
by  a staphylococcal  infection  of  the  lungs  coincidently 
with  an  attack  of  influenza.  Among  these  there  is  one 
group  of  cases  of  very  considerable  interest,  where  the 
staphylococcal  infection  from  boils  enters  the  lungs  directly 
and  produces  a picture  somewhat  like  that  of  an  original 
influenza.  Such  cases  were  not,  to  my  knowledge, 
frequent  in  civil  experience,  but  several  pathologists  saw 
them  at  autopsy  during  the  war  in  France.  A descrip- 
tion of  these  cases  was  written  in  1916  by  Captain 


H.  W.  Kaye,  ll.A.M.C. , but  its  publication  was  forbidden  at 
the  time  by  the  military  censorship.  They  presented 
the  signs  of  acute  pulmonary  disease  with  profound 
toxmmia,  and  were  clinically  diagnosed  at  first  as  “pneu- 
monia.” Post-mortem  examination  discovered  innumerable 
small  acute  abscesses  in  the  lungs,  these  being  related  to  the 
lung-vessels  and  not  to  the  bronchi.  An  actively  inflamed 
boil  was  generally  found  close  to  some  tributary  of  the 
superior  vena  cava,  with  pus  tracks  radiating  into  the  tissues, 
and  staphylococci  had  been  present  in  the  blood  during  life. 
Curiously,  no  embolic  abscesses  were  observed  outside  the 
area  of  the  lungs.  Death  usually  results  in  these  acute 
pulmonary  cases,  where  the  resistance  to  staphylococcal 
infection  must  be  very  low  ; but  I have  seen  an  example  of 
double  staphylococcal  empyema,  that  may  have  belonged  to 
this  group,  and  in  which  recovery  followed  upon  drainage 
of  the  pleural  cavities.  It  is  an  extraordinary  fact  that  in 
the  special  skin  hospitals  at  the  base,  where  acute  and  chronic 
boils  were  very  numerous,  deeper  complicating  abscesses 
were  practically  never  seen.  The  proportion  of  cases  with  boils, 
in  which  such  abscesses  occur,  must  therefore  be  very  small. 
Nolf,  Bossaert,  and  Colard,  however  ( Archives  Medicates 
Beiges , Janvier,  1918),  have  insisted  that  a passing 
infection  of  the  blood  and  of  the  urine  by  staphylococci 
is  more  frequently  present  than  has  been  generally 
recognised. 

Staphylococcal  blood  infection  as  a complication  of  true 
influenza  was  described  by  Patrick  and  Garrod  in 
The  Lancet  of  Jan.  25th,  1919.  It  is  quite  probable 
that  a “ boil”  in  the  lung  as  a complication  of  influenza 
may  lead  to  all  the  various  staphylococcal  abscesses  at  a 
distance  that  are  known  to  follow  a subcutaneous  boil,  and 
that  there  may  in  reality  be  such  an  epidemic  as  has  been 
suggested  by  Mr.  Cunning. 

I am,  Sir,  yours  faithfully, 

T.  R.  Elliott, 

Late  Colonel,  A.M.S. ; Consulting  Physician,  B.E.F. 

University  College  Hospital,  July  1st,  1919. 


To  the  Editor  of  The  Lancet. 

Sir, — I shall  be  very  glad  if  you  can  spare  me  a little 
space  for  a few  words  further  on  this  subject.  Neither 
Sir  Thomas  Horder  nor  Dr.  Pasteur  see  any  reason  to 
suppose  that  the  condition  of  perinephric  suppuration  has 
any  causative  relation  to  influenza,  but  consider  it  to  be  a 
staphylococcal  pyaemia.  It  may  smack  of  the  distinction 
without  a difference  type  of  argument  if  I desire  to  state 
that  I feel  it  wrong  to  have  expressed  my  opinion  that  “ the 
recent  epidemic  of  influenza  was  the  primary  disease  in  these 
cases  of  perinephric  suppuration,  ’’and  that  I ought  to  have  said 
as  my  actual  opinion  “ associated  with  a primary  influenzal 
infection.”  But  this  substitution  afEords  me  the  opportunity 
to  meet  Dr.  Pasteur’s  weighty  objection  that  cases  occurred 
in  his  experience  long  before  the  influenza  epidemic 
manifested  itself.  It  is,  of  course,  admissible  that  during 
an  epidemic  any  sort  of  otherwise  unexplained  pyrexia  is 
conveniently  included,  and  my  assumption  that  two  of  my 
cases  of  perinephric  suppuration  occurred  in  patients  who 
had  suffered  from  definite  attacks  of  influenza  is  justly 
criticised.  But  even  at  the  risk  of  being  wearisome  I would 
like  to  reiterate  my  opinion  that  in  these  cases  influenza 
exerted  a determining  influence. 

It  will  be  recalled  that  the  secondary  complications  (the 
dreaded  “ influenzal  pneumonia  ” and  influenzal  septicaemia) 
would  appear  to  be  due  to  organisms  whose  activity  is  exalted 
or  altered  by  a primary  invasion  by  B.  influenza.  It  will 
be  remembered,  also,  that  the  condition  of  “purulent 
bronchitis,”  originally  regarded  as  a sort  of  pathological 
entity,  was  shown  subsequently  to  be  primarily  an  influenzal 
infection,  and  these  cases  occurred  fully  two  years  before 
the  actual  epidemic  of  influenza. 

In  accepting,  then,  the  authoritative  pronouncements  of 
Sir  Thomas  Horder  and  Dr.  Pasteur,  I venture  to  claim  some 
justification  for  my  support  of  Mr.  Cunning  that  the  condi- 
tion of  perinephric  suppuration  was  associated  with  influenza, 
although  I see  that  I was  in  error  in  using  the  term 
“ epidemic  ” in  this  connexion. 

I am,  Sir,  yours  faithfully, 

Adolphe  Abrahams. 

Connaught  Hospital,  Aldershot,  June  28lh,  1919. 


36  The  Lancet,] 


INDUSTRIAL  MEDICAL  SERVICE.— DETOXICATED  VACCINES. 


[July  5,  1919 


INDUSTRIAL  MEDICAL  SERVICE. 

To  the  Editor  of  The  Lancet. 

Sir, — The  leading  article  in  The  Lancet  of  June  21st 
and  the  special  article  in  to-day’s  issue  are  most  timely  and 
apt.  Unfortunately,  during  the  war,  under  the  plea  of 
economy,  the  Government  abolished  the  statutory  inquiry 
by  the  certifying  factory  surgeon  into  the  cause  and  preven- 
tion of  certain  accidents  by  machinery.  These  investiga- 
tions gave  the  certifying  surgeon  a very  real  and  intimate 
knowledge  of  the  working  conditions  and  danger-points  in 
all  the  factories  within  his  district.  This  experience 
familiarised  him  with  the  temperature,  moisture,  dustiness, 
weight-lifting,  periods  of  rest  and  activity,  and  the  strains 
and  stresses  peculiar  to  each  particular  process,  also  the 
mental  and  bodily  exertion  demanded  of  the  workers.  Such 
knowledge  is  essential  to  a medical  man  who  has  to  estimate 
and  certify  that  young  boys  and  girls  are  suitable  or  fit  to 
be  employed  in  a particular  occupation.  The  certifying 
surgeon  of  some  years'  standing  still  retains  in  his  memory 
the  danger-spots  and  unwholesome  parts  in  mill  and  work- 
shop. It  is  surely  highly  important  that  this  close  practical 
intimacy  should  be  restored  or  other  equally  real  routine  of 
duty  inside  the  factory  should  be  given  to  newly  appointed 
certifying  surgeons  to  enable  them  to  judge  wisely  the 
suitability  of  our  youth  to  bear  the  hazards  of  fatigue,  and 
so  minimise  the  ever-present  risk  of  accident  and  ill-health. 

Unfortunately,  this  branch  of  the  factory  department  has 
been  hampered  and  its  value  to  the  community  made  less 
efficient  for  many  reasons.  A recently  appointed  officer  has 
often  an  insufficient  acquaintance  with  the  principles  and 
details  of  industrial  hygiene.  A course  of  instruction  in 
this  subject  is  most  desirable  of  those  selected  for  these 
posts.  He  should  have  more  executive  authority  in 
enforcing  his  recommendations  and  provisional  certificates. 
More  supervision  and  standardisation  of  his  duties  are 
required.  The  public  must  be  better  educated  into  the 
necessity  and  utility  of  this  and  allied  services  so  that  the 
risk  of  clashing  is  avoided  between  parental  gain,  individual 
liberty,  and  the  welfare  of  the  rising  generation.  Lastly, 
the  sixpenny  fee  should  be  abolished.  To  expect  that  a 
satisfactory  examination  can  be  made  and  a certificate  given 
for  such  a sum  is  the  abnegation  of  common  sense 
and  experience.  Reforms  on  the  lines  above  indicated 
and  further  regulations  which  your  articles  and  modern 
opinion  demand  are,  I believe,  appreciated  by  the  heads  of 
the  Factory  Department.  If  carried  out  they  would  rapidly 
build  up  a competent  industrial  medical  service  throughout 
the  country.  I am,  Sir,  yours  faithfully, 

Wigan,  June  28tli, 1919.  R.  PROSSER  \\  HITE. 


DETOXICATED  VACCINES. 

To  the  Editor  of  The  Lancet. 

Sir, — I was  very  much  interested  in  the  excellent  paper  by 
Dr.  David  Thomson  on  detoxicated  vaccines  in  The  Lancet 
of  June  28th.  As  I have  been  working  on  very  similar  lines 
for  over  a year  I should  like  to  raise  a few  points  and  offer  a 
few  suggestions  upon  the  subject. 

1.  to  the  nature  of  the  toxin  removed. — Dr.  Thomson  states 
that  this  is  the  endotoxin,  though  the  impressions  gained 
at  the  present  stage  of  my  investigations  do  not  suggest  this. 
I have  no  evidence  that  it  is  comparable  to  the  exotoxin  of 
B.  diphtheria;,  B.  tetani,& c.,  but  I have  considerable  evidence 
that  it  is  situated  outside  the  organism  and  it  can  be  removed 
without  causing  autolysis  of  the  organisms.  From  the  rough 
chemical  investigations  made  it  appeared  to  be  a nitrogen- 
containing  fat  or  lipoid,  and  at  present  I picture  it  as  an 
external  toxin. 

2.  As  to  the  nature  of  the  precipitate. — In  addition  to  the 
stroma  of  the  organisms  the  precipitate  contains  another 
substance,  which,  I believe,  is  of  considerable  importance  in 
the  production  of  antibacterial  substances. 

3.  Dr.  Thomson  does  not  offer  an  explanation  of  the  rapid 
production  of  immunity  following  administration  of  detoxi- 
cated vaccine.  It  is  difficult  to  understand  how  the  body 
can  be  stimulated  to  produce  antibodies  in  less  than  24  hours, 
and  yet  in  acute  pneumococcal  infections  a corresponding 
sensitised  vaccine  will  give  definite  evidence  of  immunity 
production  in  from  six  to  eight  hours,  and  I have  recently 
modified  my  method  of  making  detoxicated  vaccines  which 

arently  give  similar  results. 

1 agree  with  the  editorial  comment  that  more  evidence 
must  be  produced  before  the  complement-deviation  reaction 


can  be  taken  as  an  indication  of  the  resulting  immunity  titre. 
I should  regard  these  reactions  as  evidence  of  bacterial 
substances  in  the  blood  stream,  but  not  necessarily  immune 
bodies. 

5.  Suggestions  as  to  dosage  and  possible  dangers. — About  a 
year  ago  I was  preparing  detoxicated  vaccines  which  I 
think  would  be  identical  with  those  described  by  Dr. 
Thomson,  though  the  technique  used  was  different,  and  I 
investigated  the  vaccine  so  produced  from  the  following 
standpoints:  (a.)  To  determine  whether  it  was  non-toxic  and 
harmless  to  normal  individuals  and  animals:  (b)  to  deter- 
mine the  effects  when  given  during,  or  at  varying  intervals 
before,  infection  with  the  corresponding  organism  ; (c)  to 
determine  whether  it  was  superior  to  an  ordinary  vaccine  in 
producing  immunity. 

Without  going  into  details,  the  conclusions  arrived  at  were 
that  for  many  organisms,  such  as  streptococci,  pneumococci, 
&c.,  the  detoxicated  vaccine  was  for  practical  purposes  harm- 
less and  non  toxic,  except  in  cases  of  severe  general  infection, 
as,  for  example,  streptococcal  septicaemia.  There  are  also 
organisms  which  may  produce  a severe  toxic  effect,  and 
B.  dysenteries shiga  is  an  example.  Rabbits  appear  to  tolerate, 
without  showing  any  signs  of  discomfort,  enormous  doses  of 
a detoxicated  virulent  strain  of  pneumococcus,  while  they  are 
susceptible  to  comparatively  small  doses  of  Shiga  prepared 
by  the  same  method.  The  signs  and  post-mortem  findings 
do  not  constitute  the  entire  group  of  typical  Shiga  infection, 
but  the  animal  nevertheless  rapidly  dies. 

Dr.  Thomson  has  presumably  worked  out  the  results 
principally  with  the  gonococcus,  and  in  infections  with  this 
organism  evidences  of  general  toxaemia  are  usually  slight. 
Until  the  nature  of  the  immune  bodies  produced  by  this 
form  of  vaccine  has  been  determined — and  I think  they  will 
be  found  to  be  of  a variety  not  usually  produced — I should 
like  to  put  forward  the  following  suggestions  as  to  the  use 
of  this  form  of  vaccine  in  general  infections.  I have  had  no 
experience  with  it  in  gonococcal  infection,  but  have  used  it 
a good  deal  in  other  infections  and  carried  out  a number  of 
animal  experiments. 

(a)  As  to  dosage. — I should  suggest  its  use  more  on  the  usual 
lines  of  administering  sensitised  vaccines,  and  the  method 
I employed  was  to  give  500,  1000,  and  1500  million  on  three 
consecutive  days,  followed  by  a dose  of  1500  million  every 
fourth  or  fifth’ day.  Also,  until  we  know  more  about  the 
exact  results,  I should  regard  2000  million  as  a maximum 
dose,  at  any  rate  in  severe  infections.  This  suggestion  is 
based  upon  conclusions  that  because  a given  dose  is  harmless 
in  a normal  individual  or  in  one  suffering  from  a chronic 
infection,  it  does  not  necessarily  hold  that  the  same  applies 
to  a patient  suffering  from  a severe  acute  infection.  I think 
it  possible  by  the  rapid  production  of  antibacterial  sub- 
stances to  produce  a condition  analogous  to  “ sterile  death  ” 
in  these  cases.  Under  these  circumstances  the  disease  might 
be  cured,  but  the  patient  would  not  survive.  Also  surplus 
vaccine  given  to  a patient  in  extremis  might  unnecessarily 
add  to  the  existing  severe  toxaemia. 

(. b ) When  using  a previously  untried  organism. — I should 
suggest  commencing  with  relatively  small  doses.  I have 
inoculated  myself  with  several  thousand  million  detoxicated 
pneumococci  without  any  local  or  general  ill-effects  ; but  I 
should  not  like  to  have’  to  try  a similar  initial  dose  of 
B.  dysenteries  shiga. 

If  used,  while  bearing  in  mind  the  above  two  factors, 
I am  sure  that  vaccines  prepared  as  described  so  ably  and 
fully  by  Dr.  Thomson  will  be  found  to  be  very  much  more 
effective  than  ordinary  vaccines.  I think,  however,  that 
the  detoxication  process  is  not  quite  complete,  and  I have 
recently  evolved  a modification  which  promises  to  be  a more 
complete  imitation  of  sensitisation.  These  findings  I hope 
to  publish  shortly  when  completed. 

I am,  Sir,  yours  faithfully. 

S.  G.  Billington,  M.B.  Lond., 

Stoke-on-Trent,  June  30th.  1919.  Late  Temporary  Captain,  H.A.M.C. 


The  Gilchrist  Scholarship  for  Women  War 
Workers. — The  Gilchrist  trustees  offer  through  the  council 
of  the  Loudon  i Royal  Free  Hospital  School  of  Medicine  for 
Women  a special  scholarship  tenable  at  the  Medical  School 
by  a woman  who  has  served  under  an  organisation  directly 
connected  with  the  war  during  not  less  than  three  years 
since  August,  1914.  The  scholarship  is  of  the  value  of  £50 
per  annum  for  five  years.  Applications  should  reach  the 
warden  and  secretary  of  the  Medical  School,  8,  Hunter- 
street,  Brunswick-square,  W.C.  1,  not  later  than  July  12th, 
from  whom  the  necessary  form  of  application  and  all 
particulars  may  be  obtained. 


The  Lancet,] 


OBITUARY. 


[July  5,  1919  37 


KT.  HON.  Sill  JOHN  McCALL,  M.D.,  Hon.  LL.D.,  Glasg. 

Sir  John  McCall,  who  died  of  pneumonia  on  June  28tb, 
was  better  known  as  a statesman  than  as  a doctor.  He  was, 
however,  a graduate  of  medicine  in  the  University  of  Glasgow, 
taking  his  M.B.  degree  there  in  1881  when  only  21  years  of 
age,  and  it  was  not  until  1888  that  he  entered  the  political 
world  as  a Member  of  the  Tasmanian  House  of  Assembly. 
He  carried  his  medical  experience  and  qualifications  with 
him  in  his  political  career,  and  in  1903,  when  he  became 
Chief  Secretary,  he  was  responsible  for  an  entire  reorganisa- 
tion of  the  Tasmanian  Department  of  Health.  In  1904  he 
became  M.D.,  and  five  years  later  he  was  appointed  Agent- 
General  for  Tasmania  in  London,  an  appointment  which  he 
held  with  conspicuous  distinction  until  the  time  of  his  death. 
He  was  created  a Knight  Bachelor  in  1911  and  received  the 
K.C.M.G.  in  the  last  Birthday  Honours,  no  doubt  as  a 
recognition  of  the  great  services  he  rendered  in  promoting 
the  welfare  of  Australian  troops  in  hospital  or  billeted 
in  this  country.  He  allowed  himself  practically  no  recrea- 
tions, his  whole  time  being  placed  at  the  disposal  of  his 
fellow  Australians  in  need  of  sympathy  or  advice.  His  career 
as  a medical  statesman  is  finding  a worthy  reproduction  in 
that  of  his  son,  who  is  now  district  medical  officer  and 
medical  officer  of  health  in  Leonora,  West  Australia. 


EDWIN  GREAVES  FEARNSIDES,  M.D.,  B.C.  Camb., 
B.Sc.  Lond.,  F.R.C.P.  Lond.,  M.R.C.S.  Eng., 

MEDICAL  REGISTRAR  TO  THE  LONDON  HOSPITAL  ; AND  ASSISTANT 
PHYSICIAN  TO  THE  HOSPITAL  FOR  EPILEPSY’  AND  PARALYSIS, 
MAIDA  VALE. 

A brilliant  medical  career  has  been  cut  short  by  the 
death  of  Dr.  Edwin  G.  Fearnsides,  which  took  place  on 
June  26th  as  the  result  of  a boating  accident.  Dr.  Fearn: 
sides,  who  was  born  in  1883  at  Horbury,  Yorks,  was  the  son 
of  the  late  Joshua  Fearnsides,  and  was  a successful  student 
at  Cambridge,  the  London  Hospital,  and  at  Berlin.  In  1902 
he  was  senior  scholar  at  Trinity  Hall,  Cambridge,  and 
graduated  in  1906  with  a first-class  in  the  natural  science 
tripos.  In  the  same  year  he  won  the  Anatomy  and  Physiology 
prize  at  the  London  Hospital,  having  in  the  previous  year 
graduated  B.Sc.  Lond.,  taking  first-class  honours.  In  1908 
he  proceeded  to  the  M.B.  and  B.C.  degrees,  and  also  obtained 
the  Conjoint  Diploma  of  the  London  Royal  Colleges  while 
holding  the  appointments  of  clinical  assistant  to  out-patients 
and  house  physician  to  the  London  Hospital.  In  the  follow- 
ing year  he  became  receiving- room  officer,  resident  anaes- 
thetist, and  clinical  assistant  to  the  ophthalmic  department 
and  at  the  Hospital  for  Sick  Children,  Great  Ormond-street, 
clinical  assistant.  He  proceeded  to  the  M.R.C.P.,  and  after 
holding  the  position  of  house  surgeon  to  the  London  Hospital 
in  1910.  he  became  medical  registrar  a year  later.  In  1915  he 
was  deservedly  elected,  on  a very  short  probation,  a Fellow  of 
the  Royal  College  of  Physicians  of  London.  He  was  a Beit 
Memorial  Research  Fellow  and  had  been  assistant  examiner  in 
medicine  for  the  University  of  London.  Late  Major  in  the 
Royal  Air  Force,  he  was  neurologist  to  the  Hospital  for 
Officers  of  the  Royal  Flying  Corps,  and  resident  medical 
superintendent  of  the  Home  of  Recovery,  Highfield.  He  had 
recently  become  a valued  editorial  writer  in  our  columns. 

As  assistant  physician  to  the  Hospital  for  Epilepsy  and 
Paralysis,  Maida  Vale,  Dr.  Fearnsides  found  an  opportunity 
of  perfecting  his  knowledge  of  neurology,  a subject  with 
which  he  was  specially  interested  in  addition  to  general 
medicine,  and  he  contributed  much  to  the  literature  of 
both  subjects.  He  was  the  author  of  the  articles  “ Eosino- 
philia  ” in  Allbutt’s  System  of  Medicine,  “ Parasyphilis 
of  the  Nervous  System  ” (with  Drs.  Head,  Fildes,  and 
Macintosh)  in  Brain , 1913,  and  (with  Dr.  Head)  of 
“Clinical  Aspects  of  Syphilis  of  the  Nervous  System  in 
the  Light  of  Wassermann  Reaction  and  Treatment  with 
Neosalvarsan,”  1914,  as  well  as  of  “Intracranial 
Aneurisms”  and  “Innervation  of  the  Bladder”  in  subse- 
quent years.  In  1914  he  read  a paper  before  the  Electro- 
therapeutical  Section  of  the  Royal  Society  of  Medicine  on 
Diseases  of  the  Pituitary  Gland  and  their  Effect  on  the 
Shape  of  the  Sella  Turcica,  which  was  published  in 
The  Lancet  of  July  4th,  1914,  and  upon  which  valuable 


contribution  to  an  important  study  we  commented 
editorially  in  the  same  issue.  To  the  Section  of  Neurology 
of  the  Royal  Society  of  Medicine,  among  other  valuable 
papers,  he  contributed  one  on  the  Essentials  of  Treatment  of 
Functional  Nervous  Diseases  in  Soldiers,  which  was  reported 
in  our  issue  of  March  23rd,  1918,  and  which  well  illustrates 
his  way  of  approaching  a difficult  practical  subject. 

We  have  said  enough  to  show  that  by  the  untimely  death 
of  Edwin  Fearnsides  the  science  and  practice  of  medicine, 
as  well  as  the  institutions  with  which  he  was  associated,  suffer 
a heavy  loss,  but  above  all  things  Dr.  Fearnsides  was  a fine 
type  of  the  institutional  officer.  “He  was,”  says  the 
secretary  of  one  of  his  hospitals,  “a  great  and  tireless 
worker,  and  he  allowed  nothing  to  stand  in  the  way  of  his 
hospital  work.  He  was  devoted  to  his  patients,  and  particu- 
larly can  this  be  said  of  him  during  the  war,  when  the  func- 
tional side  of  nervous  disease  became  an  urgent  matter. 
During  his  tenure  of  office  as  an  assistant  medical  officerat 
Springfield  War  Hospital,  and  whilst  medical  superintendent 
of  ‘ Highfield,’  Golders  Green,  he  worked  tirelessly  first  for 
serving  soldiers  at  Springfield,  then  for  pensioned  soldiers, 
and  afterwards  for  officers  of  the  Royal  Air  Force  at  ‘ High- 
field.’ As  a colleague  he  was  always  prepared  to  place^his. 


BDYVIN  GREAVES  FEARNSIDES,  M.D. 

services  at  the  disposal  of  others,  and  his  generous  nature 
made  him  a host  of  friends  amongst  his  patients  and 
colleagues,  all  of  whom  will  mourn  his  death.  When  he 
relinquished  his  commission  as  a major  in  the  Royal  Air 
Force  Medical  Service  on  the  31st  May  and  left  London  for 
a holiday  he  was  a tired-out  man  for  the  moment,  but  no 
one  can  doubt  that  he  had  a great  future  before  hitn.” 

A.  S.  MacN.,  an  intimate  friend,  in  an  eloquent 
tribute  to  Fearnsides’s  memory,  dwells  also  in  particular 
upon  the  value  of  his  work  at  the  Home  of  Recovery. 
“At  Golders  Green,”  he  writes,  “Fearnsides  was  most 
successful.  Many  an  ex-soldier  and  ex-airman  who  was 
brought  back  to  health  and  mental  sanity  through 
Fearnsides’s  instrumentality  will  feel  personal  regret  for  the 
loss  of  the  doctor  who  first  took  the  trouble  to  understand 
them.  Fearnsides  was  an  able  thinker.  With  his  chief  and 
friend,  Dr.  Head,  he  was  a pioneer  in  the  interpretation  of 
the  ‘ new  neurology.’  He  was  never  tired  of  teaching  that 
in  medicine  the  individual  was  to  be  considered  and  not  the 
disease.  His  high  intellectual  gifts  were  recognised  by  the 
College  of  Physicians  in  his  election  to  the  F.R.C.P.  at  an 
unusually  early  age.  Though  young  in  years,  already  he 
had  achieved  much.  Had  life  been  spared  to  him  he 
would  have  ranked  as  one  of  our  foremost  thinkers  and 
physicians.  In  conversation  he  often  sketched  out  pro- 
posals for  treatises  the  skeleton-plans  of  which  were 
marked  by  originality  of  thought,  and  which  were 


38  The  Lancet,] 


OBITUARY.— MEDICAL  NEWS. 


[July  5, 1919 


new  aDd  stimulating  in  suggestion.  One,  I remember, 
was  to  give  us  an  entirely  new  conception  of  ‘ pain.’  These, 
alas,  will  now  never  be  written.  Diis  aliter  visum  ! Fate 
snatched  him  from  us  at  the  zenith  of  human  happiness, 
when  his  life  seemed  rich  with  the  promise  of  all  that  was 
good.”  

GEORGE  WILKS,  M.C.,  M.B.  Cantab.,  M.R.C.S.,  L.S.A., 

LATE  MASTER  OF  THE  SOCIETF  OF  APOTHECARIES  AND  PHYSICIAN- 
IN-ORDINARY  TO  THE  LATE  DUKE  OF  EDINBURGH. 

Dr.  George  Wilks,  who  died  on  June  11th  at  his  residence, 
Ashford,  Kent,  aged  79,  was  a native  of  the  town  in  which 
he  lived,  and  the  elder  son  of  George  Frederick  Wilks,  of 
the  near-by  village  of  Charing,  where  his  father  and  other 
members  of  the  family  were  medical  men  before  him.  He 
was  educated  privately  until  the  age  of  13,  when  he  went  to 
King’s  College,  London.  He  afterwards  studied  in  Dresden. 
Returning  to  England,  he  entered  Trinity  College,  Cambridge, 
where  he  graduated  B.A.  in  the  Classical  Tripos  in  1863. 
For  two  years  he  was  a pupil  of  Sir  George  Murray  Humphry 
at  Addenbrooke’s  Hospital,  and  afterwards  a pupil  of  Sir  James 
Paget  at  St.  Bartholomew’s  Hospital.  In  1867  he  proceeded  to 
the  M. C.  degree,  taking  also  the  M.R.C.S.  Eng.  and  the  L. S.  A. 
He  then  started  practice  with  his  father  at  Ashford,  and 
carried  it  on  alone  from  the  time  that  his  father  died 
till  1886,  when  he  was  joined  in  partnership  by  Mr.  E.  G. 
Colville.  From  1907  to  1908  he  was  Master  of  the  Society 
of  Apothecaries  of  London,  and  his  appointment  as  physician - 
in-ordinary  to  the  late  Duke  of  Edinburgh  led  to  his  attend- 
ance on  the  Duchess  at  the  birth  of  the  present  Queen  of 
Roumania  and  the  Princess  Beatrice  of  Orleans. 

Dr.  Wilks  took  an  active  interest  in  municipal  and  social 
matters,  was  a prominent  Freemason,  and  a Vice-President 
of  the  League  of  Mercy.  As  an  active  supporter  of  the 
Ashford  Cottage  Hospital  he  helped  to  free  that  institution 
from  debt,  and  in  1906  was  presented  with  a handsome  silver 
tray  and  a cheque  for  £150  in  recognition  of  his  services  to 
the  institution  as  medical  adviser,  honorary  treasurer,  and 
secretary.  With  his  customary  generosity  he  handed  the 
cheque  to  the  hospital  for  the  formation  of  an  emergency 
fund.  

MICHAEL  JOSEPH  McCARTAN,  L.R.C.P. &S.  Irel.,  J.P. 

The  death  took  place  on  June  27th  at  his  residence  at 
Rostrevor,  co.  Down,  of  Mr.  Michael  McCartan.  Born  in 
1857,  he  was  the  youngest  and  only  surviving  son  of  the  late 
Mr.  Thomas  McCartan,  J.P.,  of  Baymount,  Rostrevor.  In 
1883  he  became  a Licentiate  of  the  Royal  Irish  Colleges, 
and  began  practice  in  Newry,  where  he  also  was 
a member  of  the  Town  Commissioners  ; and  in  1899, 
when  that  body  was  changed  into  the  Newry  urban 
council,  he  was  elected  chairman,  a position  he  held  until 
his  retirement  in  1901,  when,  owing  to  the  state  of  his 
wife’s  health,  he  was  obliged  to  go  to  reside  in  Jersey. 
From  1897  to  1901  he  represented  the  Newry  town  board  on 
the  Carlingford  Lough  Commissioners,  and  he  was  an 
original  member  of  the  Newry  Port  and  Harbour  Trust.  In 
1893  he  was  made  a justice  of  the  peace  for  county  Down. 
In  1901,  in  recognition  of  his  valuable  services  to 
Newry,  he  was  the  recipient  of  a public  presentation, 
which  took  the  form  of  an  address  and  an  oil  portrait,  a 
replica  being  placed  in  the  council  chamber  of  the  Town 
Hall.  In  1909  he  went  to  reside  in  Ristrevor,  and  was  in 
that  year  appointed  dispensary  officer  of  the  Rostrevor  district, 
as  well  as  medical  officer  of  health ; he  was  also  consulting 
medical  officer  of  health  of  the  Kilkeel  rural  district 
council,  and  attendant  on  the  Royal  Irish  Constabulary  in 
Rostrevor,  and  certifying  factory  surgeon.  All  these  posi- 
tions he  held  at  the  time  of  his  death.  He  was  buried  on 
June  29th  at  the  old  family  burying-ground,  Kilbroney, 
Rostrevor.  Mr.  McCartan  was  a skilful  doctor,  a shrewd 
man  of  affairs,  and  greatly  respected  by  his  medical  brethren 
and  his  patients. 


Dispensary  Doctors'  Salaries  in  Ireland. — 

After  an  acrimonious  discussion  the  Ballymena  board  of 
guardians,  on  June  28th,  rescinded  all  previous  resolutions 
on  the  subject,  and'  fixed  the  scale  of  salaries  for  medical 
officers  of  the  union  at  a minimum  of  £120  per  annum, 
rising  by  annual  increments  of  £20  to  £200,  except  in  the 
case  of  the  Ballymena  dispensary  district  where  the 
maximum  was  fixed  at  £220. 


Utefrkal  SUfos. 


University  of  Oxford. — At  examinations  held 
recently  the  following  candidates  were  successful : — 

Second  Examination  for  Degree  of  Bachelor  of  Medicine. 
Materia  Medica  and  Pharmacology.— W . H.  Butcher,  St.  John’s  ; 

T.  Y.  Cathrall,  Trinity;  J.  T.  8.  Hoey,  Jesus;  J.  G.  Johnstone, 

St.  John's;  H.  A.  Osborn,  New;  D.  B.  Pauw,  Trinity;  H.  L. 
Ravner,  Balliol ; M.  E.  Shaw,  New  ; W.  F.  Skaife,  Trinity  ; and 
N F.  Smith,  Billiol. 

Pathology.— T.  A.  Brown,  Exeter;  C.  K.  J.  Hamilton,  Lincoln;  I 
J.  T.  S.  Hoey,  Jesus;  H.  A.  Osborn,  New;  and  H.  L.  Rayner  and 
N.  F.  Smith,  Balliol. 

Forensic  Medicine  and  Public  Hea  th. — L.  G.  Brown,  Balliol ; W.  H. 
Butcher,  St.  John’s;  F.  B.  Chavasse  and  W.  T.  Collier,  Balliol; 

F.  G.  Hobson,  New;  B.  G.  von  B.  Melle,  Brasenose;  O.  B.  Pratt, 
Christ  Church  ; N.  F.  Smith,  Balliol;  and  C.  P.  Symonds,  New. 
Medicine , Surgery,  and  Midwifery. — L.  G.  Brown  and  F.  B.  Chavasse, 
Balliol;  J.  C.  Dixey,  Brasenose;  F.  G.  Hobson,  Queen’s;  O.  B.  ; 
Pratt,  Christ  Church ; N.  F.  Smith,  Balliol ; and  C.  P.  Symonds, 

New'  Master  of  Surgery. 

R.  O.  Ward,  Queen’s. 

University  of  Durham:  Faculty  of  Medicine. 

— At  examinations  held  recently  the  following  candidates 
were  successful : — 

Third  Examination  for  Degree  of  Bachelor  of  Medicine. 
Materia  Medica , Pharmacology,  and  Pharmacy ; Public  Health ; j 
Medical  Jurisprudence , Pathology,  and  Elementary  Bacteriology. — 

Samuel  Eric  Hill  Anderson,  John  Stratton  Brogdon,  James  Struthers 
Clark,  Edward  Thomas  Colville,  Oliver  Colville  (second-class 
honours),  Robert  Collinson  Davison,  Dorothy  Amatt  Dixon  (second- 
class  honours),  Thomas  William  King  Dunscombe,  Eskander  Girgis, 
Barbara  May  Gringing,  Donald  Falconer  Hocken,  William  Ewan 
Douglas  Hodgson,  Harold  Holtby,  Henry  Norman  Clarence  Jaffe, 
George  McCoull,  Robert  Turnbull  Easton  Naismitb,  Carl  Damien 
Newman.  Thomas  Swinhoe  Severs,  Louis  William  Studdv.  William 
Arthur  Tweddle,  William  Christopher  Wardle.  and  Edith  Short 
Williamson. 

Third  Examination  for  Licence  in  Dental  Surgery  (L.D.S.). 
Anatomy,  Physiology,  and  Histology : Dental  Anatomy.  Dental  '< 
Histology,  and  Dental  Materia  Medica.— Montague  Olswang  and 
Gainsford  Reed. 

Royal  College  of  Surgeons  of  Edinburgh. — 
The  following  candidates  have  passed  the  Final  Dental 
Examination  and  have  been  granted  the  diploma 
L.D.S.  R.C.S.  Edin. 

Euphemia  Robs  Hadley,  Thomas  Stewart  Tait,  Andrew  Finlay 
Readdie,  and  Edward  Louis  Adendorff. 

Royal  Society  of  Arts. — The  council  of  the 
Royal  Society  of  Arts  have  awarded  the  society’s  silver 
medal  for  the’  following  papers  read  before  the  society  during 
the  past  session 

Edward  C.  de  Segundo,  A.M.Inst.C.E.,  “The  Removal  of  the 
Residual  Fibres  from  Cotton  Seed  and  their  Value  for  Non-textile 
Purposes.” 

Sir  Frank  Heath,  K.C.B.,  secretary.  Department  of  Scientific  and 
Industrial  Research,  "The  Government  and  the  Organisation  of 
Scientific  Research.” 

Walter  Leonard  Lorkin,  A.M.I.E.E..  “Electric  Welding  and  its 
Applications.” 

W.  Norman  Boase,  C.B.E..  “ Flax— Cultivation,  Preparation, 

Spinning,  and  Weaving.” 

Brigadier-General  Lord  Montagu  of  Beaulieu,  C.S.I.,  “Aviation  as 
Affecting  India.” 

Professor  John  Cunningham  McLennan.  O.B.B  . Ph.D.,  F.R.S., 

“ Science  and  Industry  in  Canada." 

St.  Thomas’s  Hospital  Annual  Dinner. — The 
dinner  of  past  and  present  students  of  St.  Thomas’s 
Hospital  will  take  place  on  Wednesday,  Oct.  1st,  at  the 
Connaught  Rooms,  Great  Queen-street,  W.C.,  Sir  George 
Makins,  G.C.M.G.,  in  the  chair. 

Central  Midwiyes  Board. — A special  meeting  of 
the  Central  Midwives  Board  was  held  at  Queen  Anne’s  Gate 
Buildings,  Westminster,  on  June  18th,  with  Sir  Francis  H. 
Champneys  in  the  chair.  Two  midwives  were  struck  off  the 
Roll,  the  following  charges,  amongst  others,  having  been 
brought  forward  : — 

A case  being  one  of  abortion  and  the  patient  suffering  from  excessive 
bleeding  the  midwife  did  not  explain  that  the  attendance  of  a registered 
medieafpractitioner  was  required,  as  provided  by  Rule  E.  21  (2  and  3) ; , 

the  midwife  neglecting  to  take  and  record  the  pulse  and  temperature 
of  the  patient  at  each  visit,  as  required  by  Rule  E.  14  ; neglecting 
to  enter  her  records  of  pulse  and  temperature  in  a notebook  or  on 
a chart,  carefully  preserved,  as  required  by  Rule  E.  14,  and  falsely 
denying  all  knowledge  of  the  case  wben  questioned  by  the  Inspector  of 
Midwives,  and  making  false  statements  as  to  the  entries  in  her  register 
of  cases.  Being  in  attendance  as  a midwife  at  a confinement,  the  case 
teing  one  of  twins,  and  medical  a'd  having  been  sought  for  both 
children,  the  midwife  neglected  to  notify  the  Local  Supervising 
Authority  thereof,  as  required  by  Rule  E.  22  (1)  (a) ; one  of  the  twin 
children  suffering  from  inflammation  of,  and  discharge  from,  the  eyes, 
she  did  not  explain  that  the  case  was  one  in  which  the  attendance  of 
a registered  medical  practitioner  was  required,  as  provided  by 
Rule  E 21  (5).  and  medical  aid  having  been  sought  for  the  said  child 
she  neglected  to  notify  the  Local  Supervising  Authority  thereof,  as 
required  by  Rule  E.22  (1)  (a). 


The  Lancet,] 


MEDICAL  NEWS.— PARLIAMENTARY  INTELLIGENCE. 


[July  5, 1919  39 


Epsom  College. — The  sixty-sixth  annual  general 
meeting  of  the  Governors  of  Epsom  College  was  held  on 
June  27th  at  37,  Sobo-square,  W.,  when  Sir  Henry  Morris, 
the  treasurer,  presided,  and  was  supported  by  a large 
number  of  governors.  The  treasurer  moved  the  adoption 
of  the  report  for  the  past  year,  which  showed  that  there  was 
a moderate  surplus  on  the  income  and  expenditure  account, 
though  this  could  only  be  looked  upon  as  a temporary 
saving,  in  view  of  the  fact  that  only  pressing  repairs  had  been 
carried  out  at  the  College  owing  to  the  Government’s 
restriction  on  building,  the  lack  of  labour,  and  the  high  cost 
of  materials.  A bequest  of  £5000  less  £500  duty  was  noted 
from  the  late  Mr.  Henry  Duncalfe  for  the  purpose 
of  establishing  annuities  for  “ the  daughters  of  medical 
practitioners  who  shall  be  and  so  long  as  they  shall 
remain  unmarried  and  who  shall  have  attained  the  age 
of  50  years.”  The  pensions  will  be  of  the  annual  value  of 
£30,  and  the  election  remains  in  the  hands  of  the  council 
of  the  College.  The  report  further  stated  that  the  War 
Memorial  Fund,  instituted  by  the  Old  Epsomian  Club  with  a 
view  to  rebuilding  the  nave  of  the  chapel  in  harmony  with 
the  new  chancel  and  to  place  in  it  a suitable  monument 
bearing  the  names  of  old  Epsomians  and  Epsom  masters 
who  have  sacrificed  their  lives  in  the  war,  had  not  been 
responded  to  so  generously  as  the  committee  of  the  fund 
expected.  It  was  pointed  out  that  contributors  to  this  fund 
would  be  given  the  same  voting  privileges  as  those  allotted 
for  contributions  to  the  Royal  Medical  Foundation  of  the 
College.  One  of  the  vice-presidents  of  the  College,  Dr. 
Ralph  Gooding,  had  established,  said  the  report,  a prize  for 
annual  competition  amongst  the  students  of  the  College  to 
be  called  “The  Ralph  Gooding  Botany  Prize.”  The  report 
concluded  by  stating  that  over  800  Old  Epsomians  had  served 
with  the  Forces,  and  that  in  the  Roll  of  Honour  were  included 
122  who  had  died  on  active  service.  72  Old  Epsomians  had 
been  mentioned  in  despatches,  1 was  awarded  the  Victoria 
Cross,  and  83  received  decorations  and  honours  for  war 
services. 

In  proposing  the  adoption  of  the  report  the  Chairman 
drew  attention  to  the  fact  that  the  bequest  from  the  late  Dr. 
Strong,  which  had  been  reported  in  the  press  recently,  was 
left  for  the  specific  purpose  of  increasing  pensions  and  for 
providing  new  pensions.  He  also  mentioned  the  need  of 
special  gifts  for  other  purposes,  such  as  building,  repairs, 
reducing  the  mortgage,  making  good  the  depreciation  of 
stocks,  and  providing  for  increases  in  masters’  salaries.  The 
expenditure  in  future  on  the  last-named  item  would  be 
greatly  increased  owing  to  the  provision  of  higher  salaries 
for  masters. 

The  meeting  was  concluded  by  a unanimous  vote  of 
thanks  to  the  Chairman  for  presiding. 

The  Royal  Society  of  Medicine  has  nominated 
Sir  Humphry  Bolleston  as  representative  of  the  society  on 
the  panel  to  be  appointed  by  the  Minister  of  Health  to 
assist  him  in  selecting  a Consultative  Council. 

The  Research  Defence  Society. — This  society 
held  its  annual  general  meeting  on  June  26th  at  the  house 
of  the  Medical  Society  of  London,  11,  Chandos-street, 
Cavendish-square,  where  it  now  has  its  office  and  official 
address.  Lord  Knutsford  presided,  and  the  meeting  was 
very  well  attended.  A shortaddress  was  given  by  Sir  Anthony 
Bowlby  on  Experimental  Medicine  and  the  Sick  and  Wounded 
in  the  War.  Sir  Frederick  Macmillan  proposed,  and  Captain 
Walter  Elliot  seconded,  a vote  of  thanks  to  him.  The  com- 
mittee’s report  gives  an  account  of  the  society’s  lectures  and 
of  the  measures  taken  against  the  Dogs’  Protection  Bill. 
“ We  have  reason  to  congratulate  ourselves  on  the  strength 
of  the  opposition  to  the  Bill  in  the  newspapers,  in  the  House 
of  Commons,  and  at  the  Home  Office;  and  we  may  fairly 
claim  some  of  the  credit  for  it.  Certainly,  ten  years  ago, 
neither  the  Government  nor  the  press  would  have  been 
so  outspoken  against  a Bill  which  very  naturally  appealed 
to  those  who  had  not  studied  the  subject.”  The  honorary 
treasurer’s  report  stated  that  the  finances  of  the  society  were 
in  a satisfactory  state.  “ We  have  been  able,  after  meeting 
all  our  expenses,  to  invest  £500  in  War  Stock.  This,  added 
to  our  previous  holding — amounting  in  all  to  over  £1500 — 
constitutes  a valuable  reserve  to  meet  any  extra  expenditure 
which  the  work  of  the  society  may  necessitate.”  Captain 
Walter  Elliot,  M.P.  for  Lanark,  has  consented  to  be 
assistant  honorary  secretary,  working  with  Mr.  Paget  as 
honorary  secretary.  The  committee  greatly  hope  that  some 
of  the  society’s  members  will  offer  to  give  one  or  two 
simple,  popular  lantern  lectures  during  the  coming  autumn 
and  winter.  There  is  a steady  demand  for  lectures  on 
such  subjects  as  the  work  of  Pasteur  and  of  Lister,  the 
recent  discoveries  in  preventive  medicine,  and  the  medical 
and  surgical  facts  of  the  war.  It  is  quite  simple  lectures 
that  are  especially  wanted  in  our  small  towns,  our  villages, 
our  schools.  The  Research  Defence  Society  has  a good 
collection  of  lantern  slides,  and  the  honorary  secretary  will 
be  very  glad  to  be  of  any  use  to  anybody  who  will  give  a 
lecture  of  this  kind. 


IParliamentarg  Intelligence. 

NOTES  ON  CURRENT  TOPICS. 

The  Select  Committee  on  Pensions. 

Field  Marshal  Sir  Douglas  Haig  was  a witness  before 
the  Select  Committee  on  Pensions  at  the  House  of  Commons 
on  Tuesday,  July  1st.  In  the  course  of  his  statement 
he  called  attention  to  the  medical  boards.  In  some 
cases,  he  said,  the  members  of  the  board  were  ignorant 
of  the  actual  diseases  suffered.  In  others  they  were 
lacking  in  all  sympathy  and  generosity.  There  was 
no  uniformity  in  their  decisions,  and  some  treated 
every  wretched  individual  who  appeared  before  them  as  a 
malingerer.  He  strongly  advised  the  appointment  of  a 
selected  combatant  officer  to  act  as  assessor,  so  as  to  produce 
some  confidence  in  the  decision.  Again,  in  some  cases  the 
disability  was  reassessed  at  the  Ministry  of  Pensions  tofthe 
individuals  disadvantage.  That  this  should  be  done  without 
the  individual  being  seen  or  heard  was  contrary  to  all  ideas 
of  British  justice.  He  urged  a more  generous  and  sympa- 
thetic treatment  to  all  who  suffered  from  gas  poisoning, 
shell  shock,  and  neurasthenia.  It  was  admitted  that  their 
suitable  employment  was  no  easy  matter.  Employers  were 
shy  of  giving  them  appointments.  The  most  piteous  appeals 
brought  to  his  notice  cried  for  an  immediate  reform  in  the 
method  of  treatment. 

HOUSE  OF  COMMONS. 

Thursday,  June  26th. 

Ministry  of  Health  Appointments. 

Lieutenant-Colonel  Dalrymple  White  asked  the  Prime 
Minister  whether,  as  regards  appointments  to  the  new 
Ministry  of  Health,  consideration  would  be  given  to  the 
applications  of  officers  and  men  who  had  served  throughout 
the  war,  even  though  they  might  be  slightly  over  the  age 
hitherto  laid  down  for  admission  to  the  Civil  Service? — Mr. 
Stanley  Baldwin  (Financial  Secretary  to  the  Treasury) 
replied  : The  normal  age  limits  for  candidates  for  Civil 
Service  appointments  fixed  before  the  war  have  been 
extended  so  that  candidates  at  the  competitions  now  being 
held  under  the  reconstruction  scheme  who  have  served  in 
the  Forces  may  deduct  from  their  age  the  full  period  of  the 
war.  This  extension  will  apply  to  candidates  for  posts  in  all 
Departments  alike,  and  I am  not  prepared  to  make  any 
special  provision  for  the  new  Ministries. 

Hospital  at  Chepstow. 

Mr.  H.  Jones  asked  the  Parliamentary  Secretary  to  the 
Shipping  Controller  whether  the  hospital  built  at  Chepstow 
in  connexion  with  the  national  shipyards,  at  a cost  of  about 
£100,000,  was  now  empty  and  derelict ; whether  such  hospital 
was  built  by  contract;  if  so,  who  was  the  contractor;  when 
was  the  work  commenced  ; and  on  what  date  was  the  con- 
tract signed?— Colonel  Leslie  Wilson  replied  : The  hospital 
at  Mount  Pleasant,  Chepstow,  has  been  taken  over  by  the 
Ministry  of  Pensions  as  from  May  31st  last  for  the  treatment 
of  neurasthenic  and  other  cases.  The  building  was  erected 
by  contract  by  Messrs.  Henry  Boot  and  Sons,  and  was  com- 
menced in  December,  1917.  The  contract  was  finally  signed 
on  August  2nd,  1918. 

National  Insurance  Bill. 

Major  Astor,  Parliamentary  Secretary  to  the  Local 
Government  Board,  presented  a Bill  to  alter  the  rate  of 
remuneration  for  the  purposes  of  exception  from  insurance 
under  the  National  Insurance  Acts,  1911  to  1918,  and  for 
purposes  connected  therewith.  The  Bill  was  read  a first 
time. 

Friday,  June  27th. 

Dogs’  Protection  Bill : Third  Reading  Negatived. 

On  the  motion  for  the  third  reading  of  the  Dogs’  Protec- 
tion Bill  proposed  by  Sir  F.  Banbury, 

Sir  Watson  Cheyne  moved  as  an  amendment  that  “ This 
House  declines  to  proceed  further  with  a measure  which 
would  impose  an  unnecessary  and  vexatious  obstacle  to 
medical  research."  He  said  that  he  had  not  as  yet  spoken 
in  the  House  on  this  Bill.  He  quite  recognised  the  value 
of  the  amendment  moved  on  the  report  stage  as  an  alterna- 
tive to  the  Bill  itself,  but  the  more  he  looked  at  the 
amendment  the  more  he  felt  that  it  introduced  a very  great 
obstacle  to  research  in  these  matters.  It  seemed  a very 
little  thing  to  get  an  additional  certificate,  but  he  would 
show  that  it  really  was  not,  and  the  very  matter  of  getting 
this  additional  certificate  was  an  obstacle  which  ought  not 
to  be  introduced  at  the  present  time.  From  another  point 
of  view  he  did  not  think  this  Bill  should  be  proceeded  with, 
and  that  was  because  it  involved  a very  grave  censure 
upon  a large  body  of  honourable  men  and  a great 
profession  for  which  there  was  no  justification  what- 
ever. He  did  not  think  the  House  realised  what  an 


40  The  Lancet,] 


PARLIAMENTARY  INTELLIGENCE. 


[July  5,  1919 


amount  of  obloquy  had  already  been  thrown  upon  men 
who  were  only  trying  to  do  something  which  might  be  of 
great  use  to  mankind  and  science.  The  Bill  as  it  stood 
practically  stated  that  the  House  had  gone  carefully  into  the 
matter  of  all  these  accusations,  and  it  implied  that  cruelty 
was  being  practised,  that  the  medical  profession  delighted 
in  torture,  and  that  they  could  not  be  trusted  in  the  matter 
of  animals. 

Sir  F.  Banbury:  That  is  not  in  the  Bill. 

Sir  Watson  Cheyne  said  that  he  asserted  that  that  was 
what  it  implied;  and  for  these  reasons  it  was  alleged  that  it 
was  necessary  to  tie  the  hands  of  medical  men  still  further, 
even  though  such  a proceeding  might  involve  a serious  loss 
to  humanity.  He  could  speak  of  this  matter  from  first-hand 
knowledge,  because  at  one  time  he  held  certificates  and  licences 
for  a number  of  years  and  later  on  in  his  career  he  became 
one  of  those  who  had  the  responsibility  of  signing  certificates. 
Having  sketched  with  some  detail  the  rise  of  the  study  of 
bacteriology  in  connexion  with  clinical  medicine  and 
research,  and  the  restrictions  put  upon  animal  investiga- 
tions in  the  past,  Sir  Watson  Cheyne  protested  against  the 
further  restrictions  proposed  by  the  Bill,  which  must  result 
in  lost  enthusiasm  and  belated  work.  He  gave  a vivid 
picture  of  humanitarian  exaggerations,  illustrated  to  the 
House  what  an  “ animal  experiment  ” really  meant,  showing 
why  dogs  were  sometimes  needed  in  the  continuation  of 
research,  why  post-mortem  examinations  could  not  take  the 
place  of  experiments,  and  why  many  experiments,  which 
had  proved  of  immense  value  to  the  world  in  the  past,  might 
have  been  prevented  by  difficulties  in  the  obtaining  of 
certificates  such  as  were  foreshadowed  in  the  Bill.  The 
position  then  might  be  reached  that  we  should  have  to  go  to 
Germany  for  our  discoveries. 

Further  Criticism  of  the  Bad  Effects  of  the  Bill. 

Sir  P.  Magnus  seconded  the  amendment.  He  said  that  the 
Bill  proposed  to  impose  further  restrictions  on  a measure  of 
great  and  fundamental  importance  to  the  health  of  the 
country.  If  it  were  for  no  other  reason  than  preventing 
any  reproach  which  was  implied  in  the  very  title  of  the 
Bill  attaching  to  the  distinguished  medical  men  who  per- 
formed these  experiments,  that  would  be  an  amply  sufficient 
reason  for  rejecting  the  Bill.  If  the  Bill  was  passed  in  the 
form  in  which  it  stood,  ignorant  people  who  subscribed  to 
the  antivivisection  funds  would  go  about  saying  that  the 
Bill  had  been  passed  in  the  House  of  Commons  for  the 
further  restriction  of  experiments  on  animals,  and  that 
although  it  was  true  that  the  Bill  had  been  passed  with 
slight  amendments,  nevertheless  a Bill  had  been  passed 
saying  that  experiments  on  animals  were  cruel  and  inhuman. 
That  would  produce  a very  bad  effect.  Unless  the  Bill  were 
rejected  the  friends  of  antivivisection  would  say  that  they 
had  gained  something  from  its  passing,  and  the  large  sums  of 
money  which  were  absolutely  wasted  in  the  propaganda 
against  vivisection  would  continue  to  be  wasted,  and  the  sums 
of  money  contributed  by  sympathetic  and  benevolent  old 
ladies  of  both  sexes  which  might  be  expended  on  found- 
ing research  laboratories  would  be  expended  in  the  huge 
advertisements  which  met  one  wherever  one  went  in  support 
of  objects  which  were  not  only  useless  but  detrimental  to  the 
purposes  of  medical  research.  By  the  rejection  of  the  Bill 
Parliament  would  show  its  appreciation  of  the  efforts  that 
had  been  made  by  scientific  men  through  these  researches 
to  prevent  and  cure  diseases,  and  it  would  be  an  argument 
in  favour  of  research  generally.  The  Bill  itself  was  very 
inconclusive  and  contradictory. 

Sir  F.  Banbury  said  that  the  mover  of  the  amendment 
seemed  to  have  forgotten  that  a great  change  had  been  made 
in  the  Bill  since  it  obtained  its  second  reading.  All  that  it 
did  now  was  to  require  that  a special  certificate  must  be 
secured  in  the  event  of  a dog  being  used  for  certain  experi- 
ments. The  amendment  by  which  the  form  of  the  Bill  was 
changed  on  the  report  stage  was  recommended  to  the 
House  by  a Member  of  the  Government  on  the  ground  that 
the  Government  wished  to  make  the  measure  accord  with 
the  recommendations  of  the  Royal  Commission,  and  all  that 
the  Bill  now  did  was  to  say  that  a certificate  must  be 
required.  Now  they  had  the  Government  represented  by 
another  Minister  sending  out  a three-line  whip  in  order  to 
cancel  and  render  nugatory  the  amendment  which  they  had 
themselves  put  into  the  Bill  a short  time  ago. 

Hon.  Members  : And  quite  right,  too  ! 

Sir  F.  Banbury  said  it  was  a breach  of  faith  with  the 
House.  (Cries  of  “ No,  no  ” and  “ Nonsense.”) 

Sir  H.  Craik  said  he  did  not  consider  the  attitude  of  the 
Government  as  inconsistent.  He  asked  if  it  was  suggested 
that  men  had  no  right  to  use  animals  for  human  advantage. 
If  a shred  of  danger  to  human  life  was  involved,  would 
anyone  in  order  to  seek  aid  for  a child  of  his  own  or  anyone 
else’s  not  even  ride  a horse  to  the  death '? 

The  Bill  Contrary  to  the  National  Well-being. 

Dr.  Addison  (Minister  of  Health)  said  he  refused  to  bow 
under  the  reproach  poured  upon  the  Government  and  argued 
that  there  was  nothing  inconsistent  in  their  attitude.  They 


had  come  to  the  conclusion  that  notwithstanding  the 
amendment  inserted  on  the  report  stage  they  would 
still  advise  the  House  to  reject  the  Bill.  There  was  no 
inconsistency  in  that  procedure.  The  Bill,  as  it  stood,  would 
permit  a number  of  experiments  on  dogs.  Sir  F.  Banbury 
said  it  was  only  a question  of  a certain  certificate  being 
required.  That  was  just  it ; it  was  something  they  had  to  do 
in  addition  to  what  they  had  to  do  now.  Already  a licence 
must  be  held  for  an  experiment  upon  an  animal,  and  the 
experiment  must  be  performed  in  a licensed  place ; the 
animal  must  be  fully  anaesthetised,  and  must  remain  under 
the  anaesthetic  without  recovery  unless  another  certificate 
was  obtained  to  permit  the  animal  to  recover,  as  was  some- 
times desirable  when  experiments  in  feeding  were  being 
made.  A further  condition  in  regard  to  dogs  and  cats  was 
that  an  additional  certificate  was  required  that  either  a dog 
or  a cat  were  necessary  on  which  to  make  the  experiment. 
By  the  Bill  it  was  proposed  to  add  to  all  these  conditions 
and  qualifications  the  requirement  of  a further  certificate 
that  the  object  of  the  experiment  would  necessarily  be 
frustrated  unless  it  were  performed  on  a dog,  and  that  no 
other  animal  was  available  for  such  experiment.  That  was 
a considerable  thing  to  ask  in  addition  to  all  the  other 
requirements.  The  practical  question  was,  were  they 
justified  in  iimposing  that  further  restriction  on  people  who 
were  already  very  strictly  restricted,  especially  in  the  case 
of  dogs  ? He  had  not  heard  a case  brought  forward  in  which 
there  had  been  an  abuse  of  the  existing  procedure,  or  in 
which  it  had  been  shown  that  the  present  very  exacting 
scheme  of  restrictions  had  been  found  to  be  insufficient. 
There  seemed  to  him  no  reason  for  putting  a further 
restriction  on  research.  Dogs  had  been  used  in  the 
research  in  connexion  with  poisonous  gas  because  with 
them  it  could  be  seen,  as  it  could  not  be  seen  with  horses 
or  mules,  for  example,  whether  the  protection  was 
reasonable  or  not;  and  the  finest  mask  which  w'as  on 
the  battle-field  was  elaborated.  It  would  have  been 
asking  too  much  of  the  men  who  performed  those  experi- 
ments that  they  should  need  all  the  licences  and  certificates 
which  he  had  enumerated.  Then  there  were  the  series  of 
painless  experiments  which  were  going  on  with  relation  to 
rickets  in  children,  which  some  authorities  believed  to  be 
due  to  the  lack  of  a certain  element  of  diet.  Dogs  could  be 
kept  in  a laboratory  and  fed  on  a mixed  diet  at  stated 
intervals,  and  they  were  being  used  for  that  purpose  ; but  it 
would  be  unreasonable  to  require  proof  that  the  experiments 
would  necessarily  be  frustrated  unless  they  were  performed 
upon  dogs.  These  experiments  were  stated  to  be  progress- 
ing, and  it  was  to  be  hoped  that  they  would  be  successful. 
It  was  still  clear  that  as  the  Bill  now  stood  it  would  make 
demonstration  difficult  and  embarrassing,  contrary  to  the 
best  interests  and  well-being  of  the  people.  On  that  account, 
without  any  hesitation,  any  breach  of  faith,  or  any  misgiving, 
he  asked  the  House  to  reject  the  Bill  on  third  reading. 

After  further  discussion  the  House  divided,  when  there 
voted— 

For  the  third  reading 62 

Against  101 

Majority  against  39 

The  Bill  was  accordingly  rejected. 

Nurses'  Registration  Bill. 

The  House  considered  the  Nurses’  Registration  Bill  as 
amended  in  Standing  Committee. 

An  amendment  was  agreed  to  defining  the  term  “ registered 
children’s  nurse  ” as  a children’s  nurse  who  was  for  the 
time  being  registered  in  the  children's  nurses’  supplementary 
register. 

Another  amendment  was  also  agreed  to  raising  the 
membership  of  the  Council  from  42  to  45  members. 

Lieutenant-Commander  Astbury  moved  to  leave  out 
paragraphs  (a)  to  i h)  inclusive  in  Subsection  (1)  of  Clause  4 
relating  to  the  constitution  and  appointment  of  the  Council. 
The  amendment  was  resisted  by  Dr.  Addison  in  the  name 
of  the  Government,  and  the  debate  upon  it  was  adjourned. 

Monday,  June  30th. 

Local  Government  Board  Vote. 

On  a vote  for  £1,330,377  for  the  Local  Government  Board, 

Dr.  Addison  (Minister  of  Health)  said  that  this  Note 
would  in  future  be  incorporated  in  the  Vote  for  the  Ministry 
of  Health.  In  connexion  with  demobilisation,  one  of  the 
earliest  fears  that  had  been  entertained— which  had  been 
justified  to  some  extent  by  the  event — was  that  so  many 
men  serving  overseas  in  countries  where  they  were 
likely  to  be  infected  with  tropical  diseases  of  various 
kinds  might  mean  the  spread  of  the  diseases  in  this 
country.  Au  interdepartmental  organisation  was  accord- 
ingly set  up  to  prevent  the  spread  of  such  diseases,  and, 
in  the  main,  the  methods  which  had  been  adopted  had 
proved  to  be  successful.  In  addition,  a committee  dealt  with 
the  subject  of  tuberculosis,  which  in  many  cases  had  been 
aggravated  bv  hardships  arising  out  of  the  war,  and  the 


The  Lancet,] 


PARLIAMENTARY  INTELLIGENCE. 


[July  5,  1919  41 


Board  hoped  to  receive  their  recommendations  in  a short 
time.  On  .June  1st  the  number  of  soldiers  infected  with  the 
disease  in  institutions  was  2000,  and  on  the  waiting  list  there 
were  364. 

The  Work  of  the  Medical  Department  of  the  L.G.B. 

The  medical  services  of  the  Board,  which  now  became 
merged  in  the  Ministry  of  Health,  were  very  diverse,  but 
with  respect  to  some  of  them  they  were  only  at  the 
beginning.  Up  to  the  present  they  had  had  only  19  cases 
of  small  pox,  all  of  which  had  been  arrested,  and  there  were 
several  cases  of  cholera,  dysentery,  and  so  on,  which  also 
had  been  prevented  from  spreading. 

Rabies. — With  regard  to  rabies,  54  cases  had  been  notified, 
and  six  centres  had  been  established  in  the  country  where 
anti-rabies  vaccine  could  be  obtained.  The  first  19  persons 
affected  had  to  be  sent  to  Paris,  but  subsequently  24 
were  treated  in  England,  and  11  were  afterwards  treated 
with  vaccine  prepared  in  our  own  laboratories.  It  was 
rather  a reflection  upon  us  as  a nation  that  we  were 
dependent  upon  supplies  obtained  from  our  Allies  in  the 
early  stages  of  the  disease.  None  of  the  cases,  he  was  glad 
to  say,  had  developed  into  hydrophobia. 

Influenza. — During  the  six  months  ended  March  31st  in 
England  and  Wales  alone  there  were  136,000  deaths  from 
influenza.  That  indicated  the  necessity  for  spending  money 
in  conducting  research  and  inquiry  into  influenza,  but  at 
the  present  time  he  would  not  hold  out  any  sanguine  hopes 
of  what  they  might  be  able  to  do  in  that  direction.  A great 
deal  of  inquiry  was  necessary  before  they  could  speak  with 
any  hopefulness  on  that  subject. 

Venereal  diseases  was  another  topic  on  which  he  ought 
to  say  a word.  They  had  a number  of  critics  of  the 
action  they  had  taken.  Under  the  Regulations  issued  in 
July,  1916,  75  per  cent,  of  the  cost  of  schemes  designed  to 
conquer  venereal  diseases  was  paid  by  the  State.  There 
were  at  the  present  time  146  centres,  of  which  some  were 
exceedingly  good.  A large  number  of  those  centres  were 
not,  in  his  opinion,  doing  as  well  as  they  would  do  in  time, 
and  they  needed  not  only  140  but  1000  centres  at  the  very 
least.  The  difficulty  was  to  obtain  the  staff  with  the  modern 
training  arising  out  of  the  experiences  of  the  war  to  carry 
them  on.  It  would  only  be  gradually,  and  they  would 
develop  and  train  the  personnel  and  organisation 
throughout  the  whole  country  to  make  the  best  use 
of  these  centres.  The  Board  had  sometimes  been  blamed 
because  they  did  not  support  compulsory  notification.  His 
view — and  he  thought  the  Committee  would  support  him — 
was  that  it  was  quite  hopeless  to  require  compulsory  noti- 
fication until  they  bad  completely  or  substantially  completely 
organised  throughout  the  country  efficient  and  up-to-date 
methods  of  treatment,  otherwise'  they  would  drive  people 
wholesale  into  various  imperfect  methods  and  very  largely 
into  the  arms  of  quacks.  One  very  important  matter  that 
they  had  got  to  work  out  in  detail  was  to  try  to  get 
the  centre  conducted  on  such  lines  that  the  people  needing 
its  assistance  would  readily  go  to  it.  The  numbers  in 
attendance  in  1917  were  205,000  ; in  1918  they  were  488,000. 

Tuberculosis. — With  regard  to  tuberculosis,  although  they 
had  increased  the  number  of  beds  available  by  1500  during 
the  past  year,  their  methods  were  far  from  being  sufficient, 
and  it  was  quite  useless  to  expect  that  they  would  be  able 
successfully  to  cope  with  the  disease  until  they  had  got  an 
improved  state  of  national  housing.  They  had  at  present 
before  them  proposals  for  3300  additional  beds.  The  grants 
made  last  year  were  £385,000. 

Maternity  and  child  welfare  centres  was  another  branch  of 
their  work  which  they  would  have  to  develop,  and  this  went 
hand  in  hand  with  improved  nursing  and  midwifery  services. 
All  these  services  were  to  a great  extent  in  an  experimental 
stage,  and  in  all  of  them  the  limiting  factor  was  the  getting 
of  the  trained  assistance  necessary  to  do  the  work. 

The  blind. — The  latest  development  of  all  was  in  con- 
nexion with  the  treatment  of  the  blind.  A Committee 
which  had  been  working  since  1917  with  certain  regional 
committees  had  made  the  fullest  survey  of  the  blind  popula- 
tion of  the  country  and  had  examined  all  the  institutes 
where  training  was  given.  Just  lately  the  Government  had 
sanctioned  the  provision  of  £125,000  to  be  distributed  in 
assisting  the  blind  in  their  workshops,  in  homes  and  hostels, 
for  home  teaching,  and  for  various  miscellaneous  services  in 
institutions  that  had  been  carefully  examined  and  approved. 

Sir  D.  Maclean  thought  and  Dr.  Addison’s  statement  was 
interesting  but  not  satisfactory.  It  was  shocking  to  hear 
that  in  six  months  the  country  had  suffered  the  loss  of 
136,000  lives,  many  of  them,  no  doubt,  old  people  who  could 
not  pull  their  full  weight  in  the  national  boat,  but  still  the 
majority  men  and  women  in  full  activity.  As  the  health  of 
the  community  ought  to  be  their  first  and  most  important 
care,  he  threw  out  the  suggestion  that  the  right  honourable 
gentleman  should  make  a statement  on  housing  conditions 
and  health  matters  at  least  once  a month  in  order  to 
stimulate  local  authorities  and  to  spread  knowledge  as  to  the 
best  way  of  meeting  what  in  many  cases  were  easily  prevent- 
able diseases. 


Lieutenant-Colonel  Raw  deplored  the  ravages  caused  by 
tuberculosis,  and  said  that  with  the  advent  of  the  Ministry 
of  Health  he  was  certain  that  a much  greater  effort  would 
be  made  to  stamp  out  what  was  a preventable  disease.  There 
should  be  a much  more  generous  system,  and  facilities 
should  be  provided  free  of  charge  at  the  national  expense 
for  treatment  in  the  early  stages  of  tuberculosis.  Preven- 
tion was  far  better  than  cure.  He  suggested  the  advisability 
of  a great  educational  campaign,  the  establishment  of  a 
national  health  institute,  and  the  appointment  of  lecturers 
to  instruct  the  public  that  this  disease  ought  not  to  be  in 
our  midst.  He  went  on  to  criticise  the  milk-supply  of  the 
country. — Lord  H.  Cavendish-Bentinck  complained  that 
the  Government  was  not  doing  all  it  should  do  to  improve  the 
very  unsatisfactory  treatment  which  was  being  accorded  to 
discharged  soldiers  suffering  from  tuberculosis. 

Major  Astor  (Parliamentary  Secretary  to  the  Local 
Government  Board),  replying  to  the  debate,  said  that  the 
Ministry  of  Health  would  embark  on  its  official  career  with 
a real  vision  of  what  it  hoped  to  do.  He  would  not  say  that 
the  number  of  institutions  now  available  for  the  treatment 
of  tuberculosis  was  adequate  either  in  number  or  quality. 
But  there  was  great  difficulty  in  providing  fresh  institutions 
during  the  war.  In  1914  the  number  of  deaths  from  tuber- 
culosis was  38,600  and  in  1917  it  was  43,100.  These  figures, 
however,  must  not  be  taken  too  rigidly.  Allowance  must  be 
made  for  the  fact  that  diagnosis  was  improving.  Still  there 
was  no  diminution.  The  disease  was  one  which  depended 
upon  the  social  conditions  of  the  people,  and  these  had  to 
be  improved.  Generally  speaking,  their  policy  was  more 
and  better  accommodation  and  better  treatment.  He 
believed  that  the  development  of  workshops  and  the  pro- 
vision of  occupation  would  assist  enormously.  The  lines 
they  were  going  on  were  that  it  was  far  better  to  provide 
treatment  for  the  population  as  a whole  than  merely  to 
provide  treatment  for  the  tuberculous  ex-soldier.  The  whole 
tendency  was  against  specialising  in  particular  diseases,  but 
to  make  the  local  authorities  and  medical  officers  competent 
to  deal  with  anything  that  might  arise. 

The  Welsh  Board  of  Health. 

Brigadier-General  Sir  Owen  Thomas  asked  the  Secretary 
to  the  Local  Government  Board,  as  representing  the  National 
Health  Insurance  Commissioners,  if  the  Welsh  Insurance 
Commissioners  had  been  appointed  the  Welsh  Board  of 
Health  under  the  Ministry  of  Health  ; if  so,  whether  he  con- 
sulted the  Members  representing  Wales  before  making  the 
appointment ; and  whether  he  was  aware  that  there  was 
dissatisfaction  in  Wales  with  the  manner  in  which  the 
Commissioners  discharged  their  duties  as  insurance  com- 
missioners.— Major  Astor  replied : The  members  of  the 
Board  of  Health  in  Wales  are  appointed  by  the  Minister  of 
Health  under  Section  5 of  the  Ministry  of  Health  Act,  1919 ; 
the  three  persons  appointed  as  initial  members  have  hitherto 
been  members  of  the  Welsh  Insurance  Commission,  but  the 
Board  is  not  yet  complete.  The  answer  to  the  concluding 
part  of  the  question  is  in  the  negative. 

Sir  O.  Thomas  : Will  the  honourable  gentleman  make 
inquiries  as  to  whether  these  three  gentlemen  have  been  on 
speaking  terms  for  the  last  two  years  ? — Major  Astor  : It 
would  be  very  difficult  to  find  out. 

Tuesday,  July  1st. 

Disabled  Men  and  Compulsory  Insurance. 

Colonel  Ashley  asked  the  Minister  of  Health  whether,  in 
view  oi  the  inequality  of  treatment  meted  out  to  totally 
disabled  pensioners  as  compared  with  partially  disabled 
pensioners  in  the  matter  of  sickness  and  disablement 
benefits,  men  in  receipt  of  disablement  pensions  amounting 
to  over  £26  per  annum  might  be  regarded  as  eligible  for 
exemption  from  compulsory  insurance  or,  alternatively, 
that  no  reduction  of  benefit  should  be  made  to  a man 
drawing  a total  disablement  pension  if  he  was  in- 
capacitated from  following  his  employment  owing  to 
causes  unconnected  with  his  pensionable  disabilities. — 
Major  Astor  replied : A man  in  receipt  of  any  disability 
pension  exceeding  £26  per  annum  is  entitled  to  a certificate 
of  exemption  under  the  National  Insurance  Acts.  It  would 
not  be  feasible  to  carry  out  the  suggestion  contained  in  the 
last  part  of  the  question  owing  to  the  difficulty  in  practice 
of  differentiating  between  incapacity  resulting  from  the 
original  disability  and  incapacity  resulting  from  other  causes. 
But  the  1917  Act  provides  for  the  resumption  of  the  right  to 
full  sickness  benefit  in  the  case  of  any  total  disability  pen- 
sioner who  has,  in  fact,  re-established  his  working  capacity. 


Literary  Intelligence. — Mr.  C.  T.  Kingzett, 
F.I.C.,  the  chairman  of  the  “ Sanitas”  Company,  Ltd.,  and 
one  of  the  founders  of  the  Institute  of  Chemistry,  is  pre- 
paring for  early  publication  by  Messrs.  Bailliere  Tindall,  and 
Cox  (London),  an  abridged  “Popular  Chemical  Dictionary” 
in  a single  volume. — Mr.  Kimpton  will  supply  a copy  of  an 
erratum  slip  for  Macleod's  Physiology  and  Biochemistry  in 
Modern  Medicine,  recently  published,  to  any  reader  who 
desires  it. 


42  The  Lancet,]  APPOINTMENTS.— VACANCIES.— BIRTHS,  MARRIAGES,  AND  DEATHS.  [July  5,  1919 


^pointments. 

Banks,  Cyril.  M B..  B.S.Lond.,  D.P.H.,  has  been  appointed  Medical 
Officer  of  Health  of  Stafford. 

Brewer,  W.  K , M. R.C.S.,  L.R.C.P.  Lond.,  Honorary  Anaesthetist  to 
the  National  Dental  Hospital,  Great  Portland- street. 

Gray’,  H.  T.,  P.K.C.S.,  Honorary  Surgeon  to  the  Infants  Hospital, 
Vincent-rquare,  Westmins’er. 

Tibblfs.  Sydney,  L.R.C.P.  k S.  Kdin.,  Honorary  Ophthalmic  Surgeon 
to  Western  General  Dispensary. 

Royal  West  Sussex  Hospital,  Chichester.— H.  E.  Ruthkrfoord,  M.D., 
B.Ch.,  B.A.O.  Dub.,  Honorary  Physician;  Hamilton,  G.,  M.B., 
B.S.Lond.,  Honorary  Assistant  Surgeon;  and  Eustace,  G.  W., 
M.D.  Dub.,  Honorary  Radiographer. 

St.  Thomas’s  Hospital.— Birley.  J L.,  M.D.,  B.Ch.  Oxon.,  and  Tidy, 
H.  L.,  M.D.,  Ch.B.  Oxon.,  Physicians  in  charge  of  Out-patients; 
Page,  C.  M.,  M.B.,  M.S.  Lond.,  and  Romanis,  W.  H.  C.,  M.B., 
M.C.  Cantab.,  Surgeons  in  charge  of  Out-patients;  Jewesbitry, 
R.  C.,  M.D.  Oxon.,  Physician  in  charge  of  the  Children's  Depart- 
ment; Wyatt,  J.,  M.B.,  B.S.Lond.,  Obstetric  Physician  in  charge 
of  Out-patients  ; Jones,  S'r  Robert,  K B E.,  Director  of  the  Ortho- 
parrtic  Department ; and  Wordley,  E..  M.B.,  B C.  Cantab  , Medical 
Registrar. 


©acaitries. 

For  further  information  refer  to  the  advertisement  columns. 

Ashton  under- Lyne.  Lake  Hospital.— 'Res.  Asst.  M.O.  £300. 

Barnsley,  Beckett  Hospital.— H.S. 

Belgrave  Hospital  Jor  Children,  Clapham  road,  S.  IP.—  Asst.  P.  Also 
Asst.  S. 

Bexley,  Kent,  London  County  Mental  Hospital.— Asst.  M.O.  7 gns  a 
week. 

Birkenhead  Borough  Hospital—  Hon.  Dentist. 

Birmingham  General  Hospital.— Res.  M.O.  £155. 

Birmingham,  St.  Chad's  Hospital,  Edgbaston.—Res.  M.O.  £i50. 
Bradford,  City,  Odsal  Sanatorium.— Res  .Asst.  M.O.  £300. 

Bristol,  Cost-ham  Memorial  Hospital,  Kingswoud.— Res.  M.O.  £200. 

Cape  Town  University,  South  Africa.— Profs,  of  Med.,  Surg.,  Obstet. 
and  Gyn«ec.  £1250  each. 

Carmarthen  Mental  Hospital.— Second  Asst.  M.O.  £250. 

Chelsea  Hospital  for  Women,  A'lhur-street,  S.  II'. — H.S.  £120.  Also 
Regist  rar.  £50. 

Charley  Borough  Education  Committee  — Asst.  Sch.  M.O.  £400. 
Devonport,  Royal  Albert  Hospital.— Res.  H.S.  ±'200. 

Fdinbane,  Isle  of  Skye,  Gesto  Hospital.— Res.  M.O.  £300. 

Evelina  Hospital  for  Children,  Southwark,  S.E.— Hon.  P.  and  S.  to 
Out-patients.  Also  Hon.  Dental  S.  Also  H P.  £160. 

Glasgow  Education  a utliority.— Asst.  M.O.  £400. 

Great  northern  Central  Hospital,  Holloway,  N.— H S.  £150. 

Greenwich  Metropolitan  Borough.— Female  M.O  for  Maternity  and 
Child  Welfare  Work.  £400. 

Greenwich  Union  Infirmary,  Vanbrugh  Hilt,  East  Greenwich,  S.E.— 
Dep.  Med.  Supt.  and  Asst.  Med.  Supt.  £400  and  £300  respectively. 
Hong  Kong.  — Bact.  and  Path.  £600. 

Hospital  for  Consumption  a id  I iseases  of  the  Chest,  Brompton.—H.P. 
Hospital  in  Serbia  — Surgeon. 

Hospital  for  Hick  Children,  Great  Ormond-street,  London.  W.C.— 
P.  and  S.  Also  Surgical  Registrar.  £200  Also  H.S.  £50. 
Huddersfield  County  Borough,  Bradley  Wood  Sanatorium.  Res.  M O. 
Hull,  City  and  County  of  Kingston- upon- Hull  Infectious  Diseases  Hos- 
pitals.-Res.  M.O.  £450.' 

Italian  Hospital,  Queen-square,  London,  W.C.— Hon.  Asst.  S. 

London  ( Royal  Free  Hospital)  School  of  Medicine  for  Women. — Two 
Demstrs.  of  Anat.  £250.  Also  Female  Pharm.  £250. 

London  Temperance  Hospital,  Hampstead-road,  N.  IF.— Cas.  O.  £120. 
Loughborough  and  District  General  Hospital  and  Dispensary.— Res.  H.S. 
£250. 

Liverpool,  Bootle  Hospital,  Derby-road. — Hon.  Ophth.  Surg.  and 
Hon.  Dent.  Surg. 

Maidstone.  West  Kent  General  Hospital. — H.S.  and  Asst.  H.S.  £250 
and  £125. 

Manchester  Children's  Hospital,  Gartside-strect.— Asst.  M.O.  £200. 
Manchester  Children’s  Hospital,  Pendlebury,  near  Manchester.- Res. 
M.O.’s  £150. 

Manchester  City.— M.O.  £450. 

Manchester  Ear  Hospital,  Grosvenor-square,  All  s infs  — H.S. 
Manchester,  St.  Mary's  Hospitals  for  Women  and  Children.— Two  H.S.’s 
£100. 

Merthyr  Tydfil  County  Borough.— Female  M.O.  for  Maternity  and 
Infant  Welfare  Work.  £500. 

Mile  End  Infirmary , Bancroft-road,  E.— First  Asst.  M.O.,  Second 
Asst.  M.O.  £300  and  £250. 

Miller  General  Hospital  for  South  East  London,  Greenivich-roait,  S.E.— 
Hon.  Asst.  Gyuasc. 

Otago  Univers  ty.  New  Zealand.— Prof,  of  Syst.  Med.,  Prof,  of  Clin. 
Med.  an  t Therap.,  and  Lcet.  on  Clin.  Med.  £600,  £500,  and  £400 
respectively. 

Plymouth,  South  Devon  and  East  Cornwall  Hospital.— HP.  £140. 

Port  Sunlight  Cottage  Hospital.—  Res.  M.O.  £250. 

Prince  of  IFafes  s General  Hospital.  Tottenham.  N.— Hon.  Asst,  P., 
Hon.  Med.  Regist..  and  Hon.  Amesth.  Also  Clin.  Assts. 

Queen  Charlotte's  Lying-in  Hospital,  Marylebone-road,  N.W. — Phys.  to 
Out-patients. 

Queen  Mary's  Hospital  for  the  East  End,  Stratford,  E.— Two  Asst. 
Hon.  P.'s. 

Rhondda  Urban  1 istric'  Council.— Asst.  Sch.  M.O’s  and  M.O.H  s. 

£500.  Also  Two  Dent.  Surgeons.  £400. 

Royal  Chest  Hospital,  City-road,  E.C.— Asst.  P. 

Royal  London  Ophthalmic  Hospital,  City  road,  E.C.— Curator  and 
Librarian.  £120. 

Ht.  Bartholomew's  Hospital.— At  at.  Administ.  of  Auaistb. 

S(.  Helens  Education  Committee. — Dentist.  £400. 
if.  [Mary's  llO'pital  for  Women  and  Children,  Plaistow,  E.—P.  to 
In-patients  and  Out  patients,  P.  to  Skin  Out-patients,  Dental  S. 


St.  Peter’s  Hospital,  Henrietla-street,  Covent  Garden,  1F.C.— Anaesth. 
£25. 

Salford  County  Borough  Education  Commit1  ee.— Aset.  School  M.O. 
£400  to  £600. 

Salford  Royal  Hospital.— Three  Anaesths.  £50. 

Sheffield  Royal  Infirmary.—  Asst.  H.P.  £150.  Oph.  H.S.  £150. 
Southampton  County  Borough  Isolation  Hospital.— Res.  M.O.  £400. 
Southern  Rhodesia — District  S.’s.  £375  to  £500. 

University  College  Hospital,  Gower-streel,  W.C.— Clin.  Asst. 

Wakefield  General  Hospital.— 3 an.  H.S.  £150. 

Wigan  Infirmary  —3 on.  H.S.  £225. 

Willesden  Urban  District  Council.— LocamTenens  Ksst.  M.O.  lOgs.  p.w. 
Winchester,  Park  Prewell  Asylum.— Med.  Supt.  £1000. 

Winchester,  Royal  Hampshire  County  Hospital.— Obstet.  P. 
Wolverhampton  and  Staffordshire  General  Hospital. — Path.  A Bac.  £350. 
Also  Res.  M.O  £200. 

Worksop,  Victoria  Hospital  and  Dispensary.— H.S.  and  M.O.  £250  to 
£300. 

York  Dispensary.— Res.  M.O.  £250. 


Kirtjfs,  Carriages,  an&  §eat!js 


BIRTHS. 

Blakeyvay. — On  June  29th,  at  The  Cottage.  Poplar-grove,  Woking,  the 
wife  of  the  late  Harry  Blakeway,  M.8.,  F.R.C.S.,  B.Sc.,  of  a 
daughter. 

Collins.— On  June  26th,  at  the  White  House,  Yoxford,  Suffolk,  the 
wife  of  Dr.  E.  A.  Collins,  of  a son. 

Winder. — On  June  23rJ,  at  Upper  Fitzwilliam-street,  Dublin,  the 
wife  of  Captain  A.  S.  M.  Winder,  R.A.M.C.,  of  a daughter. 

MARRIAGES. 

Hoyye— Barrett.— On  June  24th,  at  St.  Barnabas  Church,  Woodside 
Park,  George  Hubert  HoYve,  L.D.S.  R.C.S.  Eng.,  to  Kathleen, 
elder  daughter  of  the  late  Mr.  S.  G.  Barrett,  of  Liskeard,  Cornwall, 
and  of  Mrs.  Jenking,  Plymouth. 

Phillips — Smith. — On  July  2nd,  1919,  at  All  Saints’  Parish  Church, 
Bradford,  by  the  Rev.  A.  F.  Alston,  James  Phillips,  F.R.C.S.E., 
Major,  li.A.M  C.,  to  Rose  Agnes  Smith,  daughter  of  Mr.  David 
Smith,  of  Windsor-road,  Southport. 

Sillars-Ogilyy'.-Oq  June  26th,  at  the  Parish  Church  of  Clova, 
Kirriemuir,  Joseph  Sillars,  M.B..  C M.,  Kirriemuir,  to  Margaret 
Elizabeth,  youngest  daughter  of  the  late  Mr.  David  Ogilvy  and 
Mrs.  Ogilvy,  Rottal,  Clova. 

Smith— Drummond. — On  June  28th,  at  St.  Augustine’s.  Queen's  Gate, 
Captain  Charies  Rees  Smith,  R.A.M.C.,  to  Helen  Fidena,  youngest 
daughter  of  the  late  John  Drummond,  Esq.,  of  Sevenoaks,  and 
Mrs.  Drummond,  Manson-plaee,  Queen's  Gate,  S.W. 

Williams— Durant.  — On  June  26tb,  at  Highbury  Chapel,  Bristol, 
Captain  Geoffrey  Commeline  Williams,  R.  A. M.C.  (T. F.),  to  Irene 
Mary,  daughter  of  the  Rev.  W.  F.  and  Mrs.  Durant,  of  Woodland- 
road,  Tyndall's  Park,  Bristol. 

DEATHS. 

Cartwright.  — On  June  23rd.  at  Oswestry,  John  Peploe  Cartwright, 
M. R.C.S.  Eng.,  aged  70. 

Fearnsides.— On  June  28th.  as  the  result  of  a boating  accident,  Edwin 
Greaves  Fearnsides,  M.D  . F.K.C.P.,  Ass  stant  Physician  at  the 
Hospital  for  Epilepsy  and  Paralysis.  Maida  Vale,  late  Major, 
R.A.F.  Medical  Service. 

McCall  — On  June  27th,  ->f  pneumonia,  at  a nursing  home.  Sir  John 
McCall,  K.C.M.G.,  M.D.,  LL.D.,  Agent  General  for  Tasmania, 
aged  58. 

Purefoy.— On  June  27th,  at  his  residence,  Merrion-square,  Dublin, 
E.  Dancer  Purefoy,  LL.D.,  M.D.,  F.R.C.S.I.,  late  Master  of  the 
Rctunda  Hospital,  Dublin.  ^ m „ 

Savery.— On  June  25th,  1919,  at  Budleigb  Salterton,  Dsvon,  Dr.  W.  H. 

Simpson^— On  June  27th,  at  Scroope-terrace,  Cambridge,  Captain 
James  Christian  Simpson,  R.A.M.C.  (T.),  M.D.  Edin. 

N.B.—A  fee  of  5s.  is  charged  jor  the  insertion  of  Notices  of  Births, 
Marriages,  and  Deaths. 


BOOKS,  ETC.,  RECEIVED. 


Balk,  John,  Sons,  and  Daniklsson,  London. 

Barbed  Wire  Disease  : A Psychological  Study  of  the  Prisoner  of  War. 
By  A L.  Vischer,  M D.  Translated  from  the  German  with 
additions  by  the  Author.  With  Introduction  by  S.  A.  Kinnler 
Wilson,  M.D.  Pp.  84.  is.  6 d. 

Churchill,  J.  and  A..  London. 

First  Lines  in  Dispensing.  By  E.  W.  Lucas,  F.I.C  , and  H.  B. 


Heffer.  W..  and  Sons,  London. 

Practical  Physiological  Chemistry.  By  S.W.  Cole,  M. A.  oth  ,ed. 
With  Introduction  by  Professor  F.  G.  Hopkins.  Pp.  401.  15s. 


Heinemann,  William,  London. 

Anaisthesia  and  the  Nurse's  Duties.  By  A.  de  Prenderville.  With 
Introduction  by  Sir  James  Cantlie.  K.B.E.  Pp.  100.  3s.  6 d. 
Anaphylaxis  and  Anti-Anaphylaxis  and  their  Experimental  Founda- 
tions. By  Dr.  A.  Besredka  and  Dr.  E.  Roux.  English  edition  by 
S.  Hoodhouse  Gloyne,  M.D.  Pp.  143.  6s. 


Kegan  Paul,  Trench.  Trubner  and  Co..  London. 

Geriatrics:  The  Diseases  of  Old  Age  and  their  Treatment.  By  I.  L. 

Xascher,  M.D.  2nd  ed.  Pp.  527.  21s. 

Rest,  Suggestion,  and  other  Therapautic  Measures  in  Nervous  and 
MentarDiseases.  By  F.  X.  Dercum,  M.D.  2nd  ed.  Pp.  395.  21s. 

Macmillan  and  Co..  London.  . _ 

On  Longevity  and  Means  for  the  Prolongation  of  Life.  By  Sir 
Hermann  Weber,  M.D.,  F.R.C.P.  5th  ed.  Pp.  292.  12s.  net. 


Hurray.  John,  London. 

Heredity.  By  Professor  J.  Artnur  Thomson.  3rd  ed.  Pp.  627.  15s. 

Che  Nile  Mission  Press.  Cairo.  

The  Surgery  of  Egyp*.  By  F.  C.  Madden.  M.D.  Pp.  394. 


The  Lancet,] 


MEDICAL  DIARY,— NOTES,  SHORT  COMMENTS,  ETC. 


[July  5,  1919  43 


Ute&al  far  tjre  ensuing  8®eeh. 


SOCIETIES. 

ROYAL  SOCIETY  OF  MEDICINE,  1,  Wimpole-street,  W. 

MEETINGS  OF  SECTIONS. 

Wednesday,  July  9th. 

NEUROLOGY  (Hon.  Secretary— C.  M.  Hinda  Howell):  at  8.30  p.m. 
Paper  : Colonel  E.  Fatquhar  Buzzard  : Encephalitis  Lethargica  and 
its  Results. 

Colonel  Buzzard  will  also  demonstrate  Cases. 

Friday,  July  11th. 

PSYCHIATRY  (Hon.  Secretaries— Bernard  Hart,  G.  F.  Barham); 
at  8.30  p.m. 

Paper  : Dr.  C.  G.  Jung  (of  Zurich) : The  Problem  of  Psychogenesis 
in  Mental  Diseases. 

NOTICE. 

The  Society's  house  will  be  closed  for  cleaning  during  August. 


The  Royal  Society  of  Medicine  keeps  open  house  for 
medical  officers  of  all  the  Allied  Forces,  and  invites  them 
to  make  free  use  of  its  library  and  rooms.  The  Emergency 
Post  Graduate  Scheme,  under  the  charge  of  the  “Fellow- 
ship of  Medicine,”  is  also  open  to  all  medical  officers. 
Particulars  of  this  will  be  supplied  by  the  Secretary, 
Fellowship  of  Medicine,  1,  Wimpole-street,  London,  W.  1. 


LECTURES,  ADDRESSES,  DEMONSTRATIONS,  &c. 

HOSPITAL  FOR  CONSUMPTION  AND  DISEASES  OF  THE  CHEST, 
Brompton,  S.W. 

Wednesday,  July  9th. — 4.30  p.m.,  Lecture:— Dr.  Gosse  : Kheumatic 
Myocarditis. 

Communications,  Letters,  &c.,  to  the  Editor  have 
been  received  from— 


A.  — Col.  J.  G.  Adami,  C.B.E., 
A.D.M.S.;  Major  A.  Abrahams, 
O.B.E.,  R A M.C.;  Dr.  J.  L. 
Aymard,  Cape  Town;  Sir  T. 
Clifford  Allbutt,  K.C.B.,  Cam- 
bridge. 

B.  — Miss  M.  A.  Broadhurst,  Lond.; 
Dr.  S.  G.  Billington,  Lond.;  Dr. 

J.  Brown,  Blackpool ; British 
Science  Guild,  Lond.;  Major  P. 
Bahr,  D.S.O.,  R.A.M.C.;  Dr 
J.  F.  Briscoe,  Bournemouth ; 
Col.  R.  J.  Blacbham,  C B, 

C. M.G.,  C.I  E. 

C.  — Dr.  H.  G.  P.  Castellain,  Lond.; 
Major  W.  B.  Cosens.  R.A.M.C.; 
Dr.  H.  P.  Cholmeley,  Forest 
Row ; Dr.  F.  G.  Crookshank, 
Lond.;  Dr.  P.  J.  Cammidge, 
Lond. 

D. — Mr.  H.  Dickinson,  Lond.:  Dr. 
J.  F.  H.  Dally,  Lond.;  Mr.  G.  W. 
Dorley-Brown,  Lond. 

E. — Dr.  S.  Elias,  Rotterdam;  Mr. 

D.  L.  Eadie,  Edinburgh ; Col. 
T.  R.  Elliott,  C.B.E.,  D.S.O., 
A.M.S.,  Lond. 

F. —  Dr.  E.  R.  Fothergill,  Hove; 
Mr.  C.  Frankau,  C.B.E.,  D.S.O  ; 
Miss  Kate  Fedarb,  Soutbsea ; 
Capt.  J.  N.  Fergusson,  R.A.M.C. 

G. —  Major  W.  E.  Gallie,  R.A.M.C.; 
Mr.  U.  Ghilardi.  Harrow  ; Dr. 
A.  G.  Gibson,  Oxford  : Col.  G E. 
Gask,  C.M.G.,  D.S.O.,  A.M.S.; 
Dr.  A.  K.  Gordon,  Lond.;  Capt. 
J.  Geoghegan.  R.A.M.C.;  Dr.  A. 
Gresswell,  Lond. 

H. — Hampstead  Medical  War  Com- 
mittee. 

K.  — Dr.  W.  Kidd,  Cheltenham  ; 
Mr.  H.  Kimpton,  Lond. 

L.  — Dr.  T.  M.  Legge,  C.B.B., 
Lond.;  Dr.  C.  E.  Lakin,  Lond.; 
London  (Royal  Free  Hospital) 

Communications  relating  to 


School  of  Medicine  for  Women, 
Warden  of ; Mr.  J.  B.  Lamb, 
Lond.;  Mr.  E.  M.  Little,  Lond  ; 
Dr.  R.  B.  Low,  C.B.,  Lond. 

M. — Dr.  J.  B.  Mennell,  Lond.; 
Minister  of  Health,  Lond.;  Dr. 
H.  A.  Macewen,  Lond.;  Dr.  A.  S. 
MacNalty,  Streatley-on-Thames ; 
Dr.  D.  Macfarlan,  Philadelphia  ; 
Miss  A.  R.  Martin,  Eastbourne. 

N.  — National  League  for  Health, 
Maternity  and  Child  Welfare, 
Lond.,  Sec.  of;  National  Alliance 
of  Employers  and  Employed, 
Lond.,  Sec.  of;  National  Medical 
Union,  Lond.,  Asst.  Sec.  of  ; Mr. 
A.  E.  Newbould,  M.P.,  Lond.; 
N.  E.  O. 

O.  — Dr.  S.  Otabe,  Benenden. 

P. — Dr.  A.  S Percival,  Newcastle- 
on-Tyne ; Mr.  C.  A.  Pannett, 
Lond.;  Dr.  Bedford  Pierce,  York. 

R. — Royal  Society  of  Medicine, 
Lond.;  Dr.  F.  Rees,  Wigan; 
Royal  Society  of  Arts,  Lond., 
Sec.  of ; Dr.  J.  D.  Rolleston, 
Lond.;  Dr.  E.  H.  Ross,  Lond. 

S. — Col.  A.  L.  Smith,  C.A.M  C,; 
Dr.  Sarny  Sabongi,  Abbassieh ; 
Dr.  M.  B.  Shipsey,  Erdington; 
Dr.  E.  B.  Sherlock,  Darenth ; 
Prof.  W.  Stirling,  Manchester; 
Dr.  A.  G.  Sbera,  Lond.;  Messrs, 
Siemens  Bros,  and  Co.,  Lond. 

T. -Dr.  W.  W.  C.  Topley,  Lond.; 
Sir  John  Tweedy,  Lond. 

U. — University  of  Glasgow. 

V.  -Mr.  R.  M.  Vick,  C.B.E..  Lond. 

W.  — Dr.  J.  V.  Watson,  Bolton ; 
Dr.  R.  T.  Williamson,  Manches- 
ter ; Dr.  L.  A.  Weatherly, 
Bournemouth  ; Mr.  A.  C.  Wilson, 
Lond.;  Mrs.  M.  Whyte,  Banteer; 
Dr.  R.  P.  White,  Wigan. 


editorial  business  should  be 
addressed  exclusively  to  the  Editor  of  The  Lancet, 
423,  Strand,  London,  W.C.2. 


The  Hampstead  Medical  War  Committee  announce 
that  Lieutenant  Colonel  J.  R.  Whait,  D.S.O.,  124,  Finchley- 
road,  N.W.3;  Major  H.  Meggitt,  180,  Belsize-ioad,  N.W.  6 ; 
Captain  W.  S.  George,  110,  Finchley-road,  N.W.  3 ; Captain 
A.  W.  George,  “Surrey  House,”  Shootup  Hill,  N.W.  2 ; 
Captain  W.  E.  Hills,  25,  Church  row,  N.W.3;  Captain  H.  C. 
Malleson,  30,  Thurlow-road,  N.W.  3,  are  now  demobilised 
and  have  returned  to  practice. 


$fafas,  S>\q xt  (ftfanramtfa,  atfa 
fa  (Sfamspfaenfs. 

MEDICAL  PIONEER  AERONAUTS. 

By  F.  John  Poynton,  M.D. 

The  Airmen  of  the  Eighteenth  Century. 

TnE  present  seems  to  me  an  opportune  time  to  give  a few 
details,  even  though  imperfect  ones,  of  the  part  taken  by  our 
profession  in  the  birth  of  aeronautics  more  than  a century 
ago.  We  shall  stray  back  to  those  fascinating  times  when 
brave  pioneers,  taking  their  lives  in  their  hands,  struggled 
to  maintain  the  flickering  life  of  this  puling  yet  long-hoped- 
for  infant,  and  we  shall  welcome  with  pride  the  men  of  our 
profession  who  helped  to  lead  the  way,  Tytler  and  Jeffries, 
Sheldon  and  Sakaroff,  among  them.  The  reign  of  Louis  XVI. 
was  drawing  to  a close  when  his  false  brother,  Fgalit6,  the 
first  royal  aeronaut,  was  a witness  of  the  classical  ascents  by 
de  Rozier  and  d’Arlandes.  How  interesting,  too,  it  is  to 
recall  that  Garnerin,  who  first  demonstrated  to  this  country 
the  use  of  the  parachute,  was  aeronautical  adviser  to  the 
great  Napoleon.  These  early  days  were  not  wholly  un- 
scientific, for  experiments  were  made  with  animals  before 
de  Rozier’s  first  ascent  in  1783,  and  1 have  in  my  possession 
an  interesting  little  conversation  in  French  dated  1783  and 
illustrated  by  a pencil  sketch  of  the  Montgolfier  balloon  with 
the  conversationalists  in  the  car.  They  were  a cock,  a duck, 
and  a sheep,  and  their  views  on  their  elevated  position  are 
entertaining.  A problem  for  the  psycho-analyst  is  provided  by 
the  fact  that  the  Comte  d’Arlandes,  who  shared  with  de  Rozier 
the  glory  of  the  first  balloon  ascent,  was  later  broken  for 
cowardice  in  the  French  army.  The  collector  of  medical 
pictures  also  will  be  interested  in  the  first  illustration  of  an 
injured  aeronaut.  This  represents  Arnold,  who  was  pilloried 
in  the  Gentleman's  Magazine  in  1785,  Vol.  II.,  as  “ the 
Unsuccessful  Aeronaut.”  He  is  seen  with  his  balloon  in  one 
corner  of  the  picture,  dressed  in  the  costume  of  the  period, 
stumping  on  a wooden  leg. 

The  First  British  Aeronaut. 

The  first  Briton  to  make  an  ascent  in  this  island  was 
“ ballooning  ” or  “ enterprising  ” Tytler,  who  raised  himself 
some  300  ft.  from  the  Comeby  Gardens,  Edinburgh,  on 
August  27th,  1784.  He  was  a Scot  born  at  Fearn,  and  was  a 
strange  and  erratic  genius  whose  fate  should  stir  pity  in  us, 
if  also,  at  the  same  time,  some  amusement.  A poor  man,  the 
son  of  a Scotch  minister,  he  earned  a little  money  as  a medical 
assistant  on  board  a vessel  plying  to  Greenland,  with  which 
he  completed  an  honourable  student’s  career  at  Edinburgh. 
He  then  made  his  first  mistake,  not  unknown  even  in  these 
days,  by  marrying  a lady  before  he  had  means  to  support  a 
family.  He  failed  to  establish  himself  in  Edinburgh,  and, 
always  ahead  of  his  times,  tried  next  to  conduct  a laboratory 
at  Newcastle.  When  that  failed  he  started  a chemist’s  shop 
at  Leith.  Meantime  his  wife  left  him  and  the  children  and 
retired  to  the  Orkneys.  Now  Tytler  had  a literary  turn  with 
novel  views  on  religion,  and  set  to  work  to  write  some 
essays,  which  he  printed  on  a printing  machine  of  his  own 
invention.  This  effort  attracted  attention  and  he  commenced 
to  establish  a position  for  himself  as  a writer  and  editor.  In 
1776  he  edited  the  second  edition  of  the  Encyclopaedia 
Brittanica,  and  apparently  he  was  now  on  the  up  line  to 
fortune.  However,  in  1783  the  balloon  epoch  commenced, 
and  he  was  badly  bitten  by  the  desire  to  become  an  aeronaut 
and  took  to  the  makiDg  of  fire  balloons.  He  snatched  at 
great  cost  this  one  laurel  leaf,  the  first  ascent  from  the 
ground  in  this  island.  It  was  his  only  successful  attempt, 
and  from  henceforth  Tytler’s  career  was  once  more  downhill. 
Soon  after  he  joined  the  cause  of  the  “ Friends  of  the 
People  ” and  wrote  a seditious  article,  for  which  he  had  to 
fly  the  country.  After  writing  a treatise  on  surgery  in 
Ireland  he  eventually  went  to  America  and  died  at  Salem, 
away  from  all  his  relatives  and  friends. 

The  First  Cross-Channel  Flight. 

Jeffries  was  an  American  physician,  but  unfortunately  at 
present  I have  not  had  the  opportunity  of  discovering 
whether  any  biography  is  extant  of  his  career,  and  would 
welcome  any  information  on  this  point.  He  was  the  hero, 
with  Blanchard,  of  the  first  crossing  of  the  Channel,  though 
he  had  previously  ascended  with  the  same  aeronaut  from  the 
Rhedarium,  near  Grosvenor-square.  The  account  of  this 
Channel  flight  written  by  himself  is  a record  of  serene 
bravery,  for  an  undertaking  of  this  kind  was  a big  thing  in 
those  days.  Strong  adverse  winds  had  delayed  the  depar- 
ture from  Dover,  and  it  was  not  until  Jan.  7tb,  1785, 
that  the  ascent  was  made  on  a still,  bright,  winter  day. 
The  aeronauts  made  very  slow  progress  in  their  balloon, 


44  Thb  Lanobt,]  NOTES,  SHORT  COMMENTS,  AND  ANSWERS  TO  CORRESPONDENTS. 


[July  5,  1919 


for  in  50  minutes  they  were  only  one-third  of  the  way  across 
the  Channel ! Trouble  soon  commenced  and  took  a simple 
shape,  the  balloon  insisting  on  descending  into  the  sea. 
Ballast  was  heaved  over,  and  then  followed  numerous 
pamphlets,  which  one  would  have  thought  from  modern 
experience  of  such  things  would  have  lightened  almost  any- 
thing. For  a while,  indeed,  there  was  an  improvement  but 
not  for  long,  the  precious  instruments  had  to  go,  the  balloon 
trappings,  an  empty  bottle,  their  great  coats,  their  lesser 
coats,  their  breeches,  and  so  on.  But  what  a man ! He 
climbs  up  the  netting  and  is  enraptured  at  the  lovely  view 
he  obtains  as  the  balloon  slowly  revolves!  Underneath  a 
January  sea  is  waiting  for  him,  above  is  a winter  sky, 
and  around  his  immediate  person  a deficit  of  clothing ! 
Fortunately  for  us  all,  just  as  they  neared  the  French  shore 
the  balloon  swept  upward,  cleared  the  cliffs,  and  carried 
them  over  the  forest  of  Guines.  Trouble  was  not  over  yet, 
but  it  was  of  a slightly  different  kind  now,  and  the  doctor’s 
feelings  must  have  been  akin  to  those  of  the  boy  who  eyes 
the  volume  and  character  of  the  birch  that  awaits  him.  It 
will  be  apparent  that  as  the  balloon  was  again  rapidly  falling, 
some  importance  was  to  be  attached  to  the  nature  of  the 
tops  of  the  trees  upon  which  they  were  landing.  Jeffries 
thought  they  looked  both  high  and  hard,  and  he  does 
incidently  admit  that  he  and  his  colleague  were  cold.  Now 
comes  the  acme  of  resource  and  as  great  a proof  of  bravery 
as  ever  the  world  can  claim,  he  remembers  that  their 
bladders  are  full — for  the  weather  was  cold  and  the  bottle 
they  threw  over  was  empty  and  the  reflexes  in  those  hardy 
old  days  were  apparently  impervious  to  fear.  He  estimated 
that  thus  they  lightened  the  balloon  by  some  4 to  5 lb.  and, 
glorious  to  tell,  they  landed  softly  on  those  trees  and  were 
soon  warm  and  safe  in  the  kindly  hands  of  French  hosts. 

A Professor  in  the  Air. 

Sheldon  has  the  credit  of  being  the  first  Englishman  to 
make  a balloon  ascent  in  England.  This  event  was  on 
Oct.  16th,  1784,  although  others  have  maintained  that  Sadler 
held  this  prize,  ascending  on  the  12th  from  Oxford.  There 
can  be  no  doubt,  however,  that  James  Sadler  was  the  first 
English  aeronaut,  for  he  made  many  successful  journeys 
and  had  a great  career  as  the  first  English  aerial  traveller. 
Sheldon  at  this  time  was  professor  of  anatomy  at  the  Royal 
Academy,  and  had  been  a pupil  and  assistant  of  William 
Hunter  in  Great  Windmill-street.  He  subsequently  became 
a surgeon  to  the  Westminster  Hospital  and  later  to  the 
Devon  and  Exeter  Hospital.  Blanchard  took  him  under 
his  wing  and  made  his  fourth  ascent  with  him  from  Chelsea. 
One  enthusiast  described  their  trip  as  “ the  most  extra- 
ordinary voyage  ever  performed  by  a sublunary  being.’’ 
Sheldon,  too,  was  apparently  satisfied,  and  returned  to  his 
anatomical  and  surgical  studies  somewhat  humbled  in 
scientific  spirit,  but  not  altogether  sorry  to  be  once  more  on 
the  surface  of  the  earth.  It  is  of  interest  that  in  the  second 
rapid  ascent  of  the  balloon  Sheldon  complained  of  pain  in 
the  ears. 

Remarkable  Observations. 

Sakarolf  was  a Russian  aurist  who  accompanied  a very 
remarkable  aeronaut,  Robertson,  in  his  Russian  balloon 
ascents  very  early  in  1800.  Robertson  was  one  of  the  few 
balloonists  who  made  a real  success  of  his  job,  for  he  died, 
we  are  informed,  worth  a million  ! He  combined  with 
courage  enterprise  and  a bright  imagination.  He  and  his 
comrades  were  repeatedly  making  strange  discoveries  in  the 
air.  For  example,  one  gentleman’s  head  bulged  so  much 
that  his  hat  would  not  fit,  and  on  another  occasion  their 
voices  became  inaudible.  One  very  interesting  observation 
was,  however,  made  by  Robertson,  that  the  electric  spark  is 
lengthened  in  the  rarefied  atmosphere,  thus  anticipating  by 
many  years  the  Geissler  tubes.  Sakaroff  fades  into  shadow 
before  his  remarkable  comrade,  but  doubtless  he  added  to 
the  early  stock  of  knowledge  upon  ear  troubles  in  aero- 
nautics. These  famous  old  heroes  may  make  us  smile  over 
their  difficulties,  ambitions,  and  boastings,  but  it  is  with 
pride  that  one  reads  that  our  profession,  apart  from  its 
purely  scientific  contributions  to  the  subject,  faced  also  the 
early  practical  dangers  and  brought  us  great  honour. 


COLONIAL  HEALTH  REPORTS. 

Leeward  Islands. — The  total  population  of  the  colony  at  the 
last  Census  was  127,193.  In  the  province  of  Antigua,  with  an 
estimated  population  of  31,782.  the  births  in  1917  numbered 
1076,  being  33-86  per  1000,  the  percentage  of  legitimate 
and  illegitimate  births  being  24-16  and  75-84  respec- 
tively. The  death-rate  was  29-89  per  1000,  and  the  deaths 
of  children  under  one  year,  exclusive  of  stillbirths,  were 
19-79  per  cent,  of  the  total.  In  St.  Kitts  the  birth-rate 
was  34-909  per  1000,  in  Nevis  34  683,  and  in  Anguilla  43  240, 
while  the  death-rate  for  St.  Kitts  was  29-245,  for  Nevis 
21-207,  and  for  Anguilla  14-767  per  1000.  The  illegitimate 
birth-rate  for  St.  Kitts  was  25'832  per  1000,  for  Nevis,  21-774, 
and  for  Anguilla  21  007,  as  against  the  legitimate  birth-rate 
of  9 070,  12-908.  and  22-254  for  St.  Kitts,  Nevis,  and  Anguilla 
respectively.  In  Dominica  the  birth-rate  was  30-65  and  the 


death-rate  28-18  per  1000;  the  illegitimate  births  exceeded 
the  legitimate  by  203.  In  Montserrat  the  birth-rate  was 
37  80  and  the  death-rate  16-21  per  1000.  The  general  health 
was  satisfactory.  During  1917  6174  patients  were  admitted 
into  the  hospitals,  and  there  were  340  deaths  therein.  The 
average  number  of  inmates  in  the  central  lunatic  asylum 
at  Skerrets,  Antigua,  was  153.  There  are  two  leper 
asylums— one  at  Rat  Island,  Antigua,  and  the  other 
at  Fort  Charles  in  St.  Kitts.  The  average  daily  number  of 
inmates  for  the  two  institutions  was  60  males  and  48  females. 

British  Honduras. — The  estimated  mean  population  in  1917 
was  42,732  (21,308  males  and  21,424  females).  The  birth-rate 
was  40-275  and  the  death-rate  31-288  per  1000.  Illegitimate 
births  were  39  57  per  cent,  of  the  total.  The  health  of  the 
Colony  during  the  year  was  remarkably  good,  and  consider- 
able progress  was  made  in  the  campaign  against  the  hook- 
worm disease,  especially  in  the  Orange  Walk  district. 

Sierra  Leone. — The  number  of  European  and  American 
residents  in  1917  was  1090,  of  whom  636  were  military  and  244 
officials.  The  deaths  of  Europeans  numbered  22,  including 
12  landed  from  vessels ; nine  officials  were  invalided  during 
the  year.  The  population  of  the  Colony  at  the  last  Census 
was  75,572  (41,001  males  and  34,571  females).  The  birth-rate 
in  1917  was  20  and  the  death-rate  24  per  1000;  in  Freetown 
the  birth-rate  was  23  and  the  death-rate  33  per  1000.  The 
excess  of  deaths  over  births  registered  in  the  colony  has 
been  apparent  in  the  returns  for  some  years  past  and 
suggests  that  the  population  is  on  the  decrease.  There  is, 
however,  a constant  influx  into  the  peninsula  of  natives 
from  the  Protectorate,  and  the  figures  given  must  in  any 
case  be  accepted  with  caution,  as  the  present  system  of 
registration  can  hardly  be  described  as  effective.  It  is 
impossible  to  give  any  valuable  account  of  the  chief  causes 
of  death,  as  medical  certification  of  death  is  neither  comL 
pulsory  nor  usual.  The  population  of  the  Protectorate 
at  the  Census  of  1911  was  estimated  at  1,327,560,  of 
whom  1,323,151  are  natives  other  than  those  in  military 
barracks,  while  the  remainder,  numbering  3426,  are  non- 
natives. In  both  the  Colony  and  the  Protectorate,  but 
more  especially  in  the  latter,  cases  of  small-pox  made  \ 
their  appearance  from  time  to  time  in  1917,  but  the  infec-  i 
tion  was  prevented  from  spreading  into  an  epidemic!  I 
Thirteen  public  vaccinators  were  appointed,  and  out  of  a 
total  of  105,988  vaccinations  reported  as  performed  68,763 
were  returned  as  successful.  The  number  of  patients  I 
treated  at  hospitals  and  dispensaries  throughout  the  Colony 
and  Protectorate  in  1917  was  51,765.  At  the  Leper  Asylum 
there  were  4 patients  at  the  beginning  of  the  year  and  4 were 
admitted ; 2 died  and  4 absconded.  To  the  European 
Nursing  Home  there  were  138  admissions  during  the  year ; 
of  these,  62  were  officials  and  44  belonged  to  the  mercantile 
and  shipping  communities. 

Straits  Settlements. — The  estimated  population  of  the 
Colony  in  1917  was  809,869,  the  birth-rate  was  30  65  per  1000, 
and  the  death-rate  36  98.  The  principal  causes  of  death 
were  malaria  (3766  cases),  infantile  mortality  (7571),  tuber- 
culosis (3084),  beri-beri  (2075),  and  dysentery  (1054).  There 
were  176  deaths  from  small-pox,  nine  from  cholera,  and  44 
from  plague. 

THE  EUROPEAN  CORN-BORER. 

The  appearance  of  the  European  corn-borer  ( Pyrausta 
nubilalis)  in  certain  parts  of  the  United  States  has  led  to  the 
issue  of  an  Order  in  Council  prohibiting  the  importation  of 
“all  corn  fodder  or  corn  stalks,  whether  used  for  packing 
or  otherwise,  green  sweet  corn,  roasting  ears,  corn  in  the  cob, 
or  corn  cobs  ’’  from  the  .affected  areas  into  Canada.  A 
circular  dealing  with  this  pest,  said  to  be  one  of  the  most 
destructive  that  has  ever  reached  America,  has  been  issued 
by  the  Canadian  Department  of  Agriculture,  and  can  be 
obtained  free  from  the  Dominion  entomologist  at  Ottawa. 

LE  CARNET  DE  POLITESSE. 

The  number  of  necessary  “ carnets  ” — or  booklets  entitling 
the  owner  to  live.  move,  and  have  his  being — has  grown 
exceedingly  in  France,  especially  during  the  war,  for,  in 
spite  of  murmurings  which  are  almost  universal  amongst 
bis  subjects,  Monsieur  Lebureau  is  still  the  reigning  tyrant 
in  French  administration.  That  he  should  have  captured 
the  control  of  politeness  among  a people  world-famous  for 
the  suavity  of  their  manners  is.  indeed,  a notable  tribute  to 
his  stability  and  vigour.  For  many  months  there  have  been 
notices  posted  in  tramcars  and  in  the  metro  reminding 
passengers  that  they  should  give  up  their  seats  to  the 
“mutiles”;  now  it  seems  that  this  has  become  a legal 
obligation.  Every  soldier  who  is  blind  or  so  wounded  that 
standing  becomes  painful  to  him  is  entitled  to  a carnet, 
which  gives  him  precedence  in  the  seating  accommodation. 
Even  the  phlegmatic  Britisher  needs  no  encouragement  to 
make  him  offer  his  seat  to  a disabled  fellow-countryman,  and 
it  is  hard  to  believe  that  any  wounded  soldier,  French  or 
British,  would  stoop  to  enforce  so  obvious  a right.  The 
carnet  de  politesse  is  really  an  official  aspersion  on  the 
nature  of  French  politeness. 


THE  LANCET,  July  12,  1919. 


S|)t  (fmtlstimhra  feriutts 

ON 


THE  SPREAD  OE 


BA.CT 


ER1AL  INFECTION. 


Delivered  before  the  Royal  College  of  Physioians  of  London 


By  W.  W.  C.TOPLEY,  M.A.,  M.D.  Cantab.,  F.R.C.P., 

DIRECTOR  OR  INSTITUTE  01'  PATHOLOGY,  CHARING  CROSS  HOSPITAL. 


Danysz  considers  that  this  proves  that  they  were  neither 
completely  refractory  nor  completely  immunised,  and  that 
their  survival  during  the  epidemic  could  only  be  explained 
by  the  attenuation  of  the  organism.  Though  this  explana- 
tion is  quite  probable,  it’sliould  be  noted  that  feeding  with 
large  quantities  of  culture  is  hardly  a fair  test,  since  size  of 
dose  is  probably  an  all-important  factor,  and  a degree  of 
immunity  which  might  well  have  served  to  preserve  the 
three  survivors  from  the  dangers  of  infection  in  the  cage 
might  prove  ineffective  against  such  a massive  dose  of 
bacilli. 

Production  of  Virulent  Strains. 


LECTURE  II. 

(Continued  from  p.  5 ) 

B.  Danysz  Infections  in  Rodents. 

In  any  attempt  to  obtain  information  on  such  points 
as  these  by  experimental  observation  it  is  clearly  necessary 
to  work  with  some  organism  which  is  known  to  give  rise 
to  epidemic  disease  among  the  animals  utilised.  Such  an 
organism  is  the  bacillus  isolated  by  Danysz,  and  the  fact 
that  the  mouse  is  a susceptible  animal  is  a distinct 
advantage  in  an  inquiry  of  this  type,  where  large  numbers 
of  animals  must  be  employed. 

Many  observations  have  already  been  made  on  the 
effects  produced  by  feeding  cultures  of  this  bacillus  to 
small  rodents,  and  some  of  the  published  reports  contain 
data  of  considerable  interest.  This  is  especially  true  of 
the  communication  in  which  Danysz  describes  the  original 
solation  of  the  bacillus,  the  difficulties  which  he  met  with 
in  attempting  to  increase  its  virulence  to  such  an  extent 
as  to  make  it  practically  useful  in  exterminating  rats  and 
mice,  and  the  effects  produced  by  the  strain  which  he 
finally  obtained. 

The  strain  originally  isolated,  when  fed  to  grey  rats, 
produced  a mortality  of  20-30  per  cent,  some  others 
becoming  ill  but  eventually  recovering^  while  the  remainder 
were  apparently  unaffected.  Many  attempts  were  made  to 
increase  the  virulence  by  passage.  Whether  this  was 
carried  out  by  feeding  or  by  subcutaneous  injection  the 
final  result  was  always  a decrease  instead  of  an  increase 
in  virulence,  when  the  successively  isolated  strains  were 
administered  with  the  food.  Sometimes  there  was  a slight 
increase  in  virulence  up  to  the  second  or  third  passage,  but 
then  it  steadily  decreased,  and  the  final  result  was  always 
the  survival  of  all  the  animals  fed  on  one  of  the  later  strains. 
For  this  reason  it  was  very  rarely  possible  to  go  beyond  10  or 
12  passages.  Passage  obtained  by  allowing  the  animals  of  one 
experiment  to  eat  the  dead  animals  from  the  preceding  one, 
so  as  to  avoid  the  intermediate  growth  in  artificial  culture 
medium,  led  to  exactly  the  same  results.  Passage  carried  out 
in  collodion  sacs  placed  in  the  peritoneal  cavity  again  ended 
in  greatly  reducing  the  virulence  as  estimated  by  feeding. 

Explanation  of  Attenuation  of  Virulence. 

Danysz  suggests  as  an  explanation  of  this  attenuation  of 
the  organism  that  it  has  to  face  different  conditions  in  the 
alimentary  canal  and  in  the  blood  and  tissues,  and  that 
increased  virulence  for  the  latter  produced  by  successive  sub- 
cutaneous injections,  or  in  similar  ways,  results  in  lessened 
virulence  for  the  former.  He  mentions  in  support  of  this 
view  the  fact  that  bacilli  isolated  from  the  blood  or  the 
spleen  at  the  period  when  they  are  beginning  to  pass  from 
the  intestine  into  the  tissues  are  more  virulent,  when  fed  to 
other  animals,  than  organisms  isolated  after  death — that  is, 
after  they  have  multiplied  in  the  tissues  for  some  considerable 
time. 

He  points  out,  further,  that  these  results  indicate  that  in 
epidemics  caused  by  this  bacillus  the  cessation  of  the  epidemic 
will  be  due  to  the  attenuation  of  the  organism,  as  well  as  to 
the  natural  resistance  of  the  rodents.  An  experiment  is 
quoted  in  support  of  this. 

Two  mice,  which  had  become  ill  after  being  fed  on  a 
culture  of  B.  Danysz,  were  placed  in  a cage  with  30  normal 
mice.  At  the  same  time  another  30  normal  mice  were 
divided  into  six  batches,  all  of  which  were  fed  on  the  same 
culture.  All  of  these  latter  died  in  from  four  to  six  days. 
The  first  death  occurred  in  the  large  cage  three  days  after 
the  death  of  the  two  sick  mice.  The  epidemic  lasted  23  days, 
at  the  end  of  which  time  there  were  three  survivors.  These, 
however,  died  a month  later  after  being  fed  on  a similar 
culture. 

No  5002. 


Danysz  then  describes  the  method  by  which  he  ultimately 
succeeded  in  producing  a strain  of  his  bacillus  possessing  a 
markedly  increased  virulence  for  rats,  and  reports  the  results 
of  various  practical  tests  with  regard  to  the  possibility  of 
destroying  these  animals  on  a considerable  scale.  Some- 
times the  method  proved  entirely  successful ; at  others  it 
seemed  to  have  little  effect.  He  calls  attention  to  the 
importance  of  repeated  exposure  of  infected  food  in  the  rat- 
infested  locality  at  10-12  day  intervals,  in  view  of  the 
attenuation  by  natural  passage  referred  to  above. 

It  will  be  observed  that  in  the  above  summary  of  Danysz’s 
paper  the  term  “ virulence  ” has  been  employed  in  describing 
the  power  of  the  bacillus  to  produce  death  or  disease  on 
being  fed  to  rodents.  This  is  the  term  which  he  actually 
employs,  but  it  obviously  covers  several  different  attributes. 

The  reports  of  subsequent  observers  have  been  mainly 
confined  to  the  efficacy  of  the  different  forms  of  virus  placed 
on  the  market  as  a means  for  destroying  rats  and  mice. 
Miihlens,  Dahm  and  Fiirst,  Liston,  and  Bainbridge  have 
all  carried  out  investigations  on  this  point.  There  is  a very 
general  agreement  among  these  observers  that  the  various 
strains  of  bacilli  employed  show  wide  variations  in  the 
mortality  which  they  produce  when  fed  to  rats  under  many 
different  conditions.  The  question  of  the  spread  of  the 
infection  to  roderits  not  fed  with  the  virus  does  not  appear  to 
have  been  especially  studied. 

Experiments  An  B.  Da/uysz. 

In  the  following  experiments  an  attempt  has  been  made  to 
investigate  the  changes  which  may  occur  in  the  patho- 
genicity and  other  biological  characteristics  of  B.  Danysz  as 
the  result  of  repeated  passage  by  feeding,  and  to  arrive  at 
some  conclusion  as  regards  the  propagation  of  the  infection 
from  sick  to  normal  mice. 

The  culture  which  formed  the  starting  point  of  these 
experiments  was  kindly  supplied  to  me  by  Dr.  Arkwright,  of 
the  Lister  Institute.  It  was  originally  obtained  from  the 
Pasteur  Institute  in  Paris,  and  was  the  strain  investigated  by 
Bainbridge  in  1908-09.  The  general  technique  adopted  was 
as  follows  ; — 

Small  pieces  of  bread  were  soaked  with  a 24-hour  broth 
culture  of  the  strain  to  be  examined,  and  these  were  fed  to  a 
varying  number  of  mice,  which  had  not  been  fed  for  12 
hours  previously  and  were  not  fed  again  until  next  day.  In 
general  only  one  feeding  was  carried  out  in  any  one 
experiment,  but  in  a few  cases  the  mice  were  fed  on  two  or 
three  occasions  within  the  first  four  days. 

When  a mouse  was  found  dead  a post-mortem  examination 
was  made,  and  small  portions  of  the  spleen  and  liver  were 
transferred  to  broth  with  due  precautions  as  regards 
sterility.  On  the  following  day  plate  cultures  were  made 
from  the  broth  tube  on  McConkey’s  medium.  After  24  hours’ 
incubation  the  plates  were  examined  and  likely  colonies 
were  subcultured  into  litmus-lactose-peptone-water.  The 
full  fermentation  reactions  were  subsequently  examined 
and  the  organism  was  tested  against  a powerful  agglutinating 
serum.  At  the  same  time  an  agar-slope  culture  was  pre- 
pared, sealed  up  with  paraffin  wax  and  placed  in  the  ice- 
chest.  When  a given  organism  was  fully  identified  as 
B.  Danysz,  and  it  was  desired  to  investigate  its  action  on 
mice,  a'  tube  of  broth  was  inoculated  from  the  agar  culture 
and  incubated  for  24  hours.  The  culture  so  obtained  was 
fed  to  a fresh  series  of  mice  in  the  manner  indicated  above. 
Certain  deviations  were  made  from  this  routine  in  particular 
cases,  but  these  will  be  indicated  where  necessary. 

When  the  broth  tubes  to  which  the  portions  of  spleen  and 
liver  had  been  added  appeared  sterile  after  24  hours’  incu- 
bation, and  the  plates  inoculated  from  them  showed  no 
growth,  they  were  incubated  for  at  least  24  hours  longer  and 
fresh  plate  cultures  made  before  they  were  discarded.  It 
hardly  ever  happened,  however,  that  where  the  first  plate 
cultures  remained  sterile  a growth  was  subsequently  obtained, 
and  broth  tubes  which  appeared  sterile  after  48  hours’ 
incubation  invariably  remained  so. 

B 


46  The  Lancet,]  DR.  W.  W.  0.  TOPLEY  : THE  SPREAD  OF  BACTERIAL  INFECTION. 


[July  12,  1919 


Some  Difficulties  Encountered. 

It  is  well  to  consider  at  the  outset  certain  difficulties  which 
have  been  encountered,  and  which  seem  inherent  in  an 
investigation  of  this  kind.  It  is  by  no  means  easy  to  decide 
in  many  cases  whether  or  no  a mouse  has  died  as  the  result 
of  a B.  Danysz  infection. 

• In  the  first  place,  it  is  not  always  possible  to  make  a post- 
mortem examination.  An  appreciable  proportion  of  the  dead 
mice  are  found  partially  or  almost  entirely  eaten  by  their 
companions. 

In  the  second  place,  the  post-mortem  findings  are  neither 
so  typical  nor  so  constant  that  great  reliance  can  be  placed 
upon  them.  The  spleen  is  usually  enlarged,  often  very  con- 
siderably so.  In  a minority  of  cases  the  spleen  and  liver  show 
multiple  minute  yellow  areas.  There  is  often  an  apparent 
enlargement  of  the  lymphatic  glands  throughout  the  body, 
but  this  would  seem  to  be  a common  feature  in  mice  which 
have  died  from  a variety  of  causes.  The  condition  of  the 
intestines  varies  enormously.  In  almost  all  cases  it  is  the 
small  intestine  which  shows  variations  from  the  normal. 
The  most  common  condition  in  my  experience  has  been  a 
marked  distension  of  this  portion  of  the  bowel  with  a bright 
yellow  fluid.  In  other  cases  the  lower  part  of  the  small 
intestine  is  plum-coloured,  sometimes  nearly  black  and 
apparently  gangrenous. 

A large  number  of  sections  have  been  examined  from  the 
organs  of  the  mice  dying  during  the  course  of  these  experi- 
ments, and  similar  specimens  from  other  mice  have  been 
studied  as  controls.  It  has  not  been  possible,  however,  to 
make  out  any  constant  changes  which  could  be  regarded  as 
diagnostic  of  an  infection  with  B.  Danysz. 

Another  disturbing  factor  is  the  fact  that  a considerable 
proportion  of  the  mice  were  found  to  be  harbouring  intestinal 
parasites  in  the  shape  of  cestode  worms.  Dr.  Leiper  has 


the~'earlier  stages  of  the  experiment,  and  ^partly  in  order 
that  the  survivors  might  be  examined  for  any  possible 
acquired  immunity.  In  mice  kept  over  such  long  periods  it 
is  inevitable  that  death  should  occur  from  causes  other  than 
infection  with  B.  Danysz.  Deaths  which  have  occurred 
from  ascertainable  and  extraneous  causes  have  not  been 
recorded.  Thus  mice  which  showed  serious  wounds  as  the 
result  of  fighting  and  died  within  a short  time  afterwards 
have  not  been  included. 

Results  of  Experiments. 

Chart  I.  records  the  deaths  of  197  mice  which  succumbed 
after  being  fed  in  the  manner  indicated.  The  black  and 
shaded  squares  represent  those  animals  from  which  B.  Danysz 
was  isolated  post  mortem.  It  will  be  seen  that  the  majority 
of  the  deaths  occurred  within  30  days  of  feeding,  and  that, 
while  B.  Danysz  was  isolated  from  a high  proportion  of  the 
mice  dying  during  this  period,  it  was  seldom  recovered 
from  those  dying  at  a later  date.  For  this  reason  the 
records  of  each  experiment  are  only  given  in  the  charts  for 
the  30  days  subsequent  to  that  on  whi^h  feeding  was  carried 
out.  though  in  those  few  cases  in  which  a late  outbreak  of 
disease  occurred  the  fact  is  indicated  in  the  text. 

It  is  not  possible  to  give  full  details  of  the  various  feedings, 
deaths,  and  post-mortem  findings,  but  Chart  II.  indicates 
sufficiently  the  course  of  events  during  a series  of  such 
experiments  lasting  over  about  five  months.  The  number  of 
mice  fed  in  each  case  is  noted,  and  the  deaths  are  recorded 
so  as  to  show  the  time  at  which  they  occurred  and  the 
bacteriological  results  obtained. 

Each  experiment  after  the  first  was  carried  out  by  feeding 
a batch  of  mice  on  a culture  of  B.  Danysz  isolated  from  the 
liver  or  spleen  of  a mouse  from  a preceding  experiment,  the 
object  in  view  being  to  ascertain  whether  any  strains  would 
I be  evolved  showing  striking  variations  as  regards  their  patho- 


0 2 4 6 8 10  20 

Time  in.  days. 


Chart  I. — Showing  Time  Relations  of  the  Deaths  of  107  Mice  Fed  on  Various  Strains  of  B.  Danysz. 


eSxlxu 

30  40 


tfl-R-Ea. 


H H. 


50 


60 


80 


90 


100 


no 


120 


130 


140 


150 


B = MOUSE  FOUND  OEFD  Of 7 KfLL£0  Wff£/Y  DY/MO  - B.Danoj  isolated  post-moat^ 


□ • • * • • " -No  0. Danysz.  * 

S » •»  » BUT  MOT  EXAM/MBP  ROST  - MOAT  £ At . 

kindly  given  me  the  benefit  of  his  great  experience  in  this 
matter,  and  has  examined  some  of  the  specimens  obtained. 
He  informs  me  that  the  degree  of  infection  observed  is  not 
to  be  regarded  as  a heavy  one,  and  gives  it  as  his  opinion 
that  the  only  disturbing  influence  which  the  presence  of 
these  parasites  might  introduce  into  the  general  course  of 
the  experiments  would  be  a certain  degree  of  damage  to 
the  epithelium  which  might  facilitate  tissue  invasion  by  the 
bacterial  parasite. 

Again,  a mouse  may  die  under  circumstances  which  render 
it  almost  certain  that  it  has  succumbed  to  a B.  Danysz 
infection,  and  pure  cultures  of  this  organism  may  be 
obtained  from  the  spleen  and  liver,  and  yet  the  changes 
found  post  mortem  may  be  practically  negligible.  Thus 
the  bacteriological  results  seem  to  form  our  most  certain 
criterion  for  diagnosis,  but  here,  again,  there  are  many  diffi- 
culties to  be  faced.  As  pointed  out  above,  a proportion  of 
the  dead  mice  are  found  partially  eaten.  In  most  cases  the 
deaths  were  preceded  by  little  or  no  evidence  of  illness, 
although  there  were  exceptions  to  this.  As  a rule,  one  or 
more  mice  were  found  dead  when  the  cages  were  examined 
in  the  morning.  It  would  seem  that  post-mortem  decom- 
position sets  in  very  rapidly  in  these  animals,  and  only  a 
minority  of  the  mice  were  in  a condition  which  could  be 
regarded  as  in  any  way  ideal  for  bacteriological  investigation. 
Although  these  facts  must  be  borne  in  mind  in  drawing 
conclusions  from  the  results  obtained,  yet  the  actual  sequence 
of  events,  and  the  bacteriological  results,  leave  little  room 
for  doubt  as  to  the  cause  of  death  in  the  majority  of  cases. 
In  most  of  the  cases  in  which  R.  Danysz  was  isolated  from 
the  organs  it  was  present  in  pure  culture. 

After  a given  batch  of  mice  had  been  fed  on  a particular 
strain  of  the  organism  the  animals  were  watched  over  a 
prolonged  period,  often  several  months.  This  was  done 
partly  to  determine  whether  B.  Danysz  infections  eventually 
develop  in  mice  which  show  no  evidence  of  illness  during 


genicity  when  subsequently  fed  to  further  series  of 
mice.  It  will"  be  observed  that  a proportion  of 
the  mice  were  killed  while  very  ill,  and  these 
are  recorded  among  the  deaths.  No  mouse 
which  became  very  ill  was  known  to  recover,  and  no 
error  will  be  involved  in  this  way.  As  pointed  out  above, 
most  of  the  deaths  have  occurred  in  mice  which  showed  no 
previous  sign  of  illness,  and  definite  symptoms  have  almost 
invariably  been  followed  by  death  within  24  hours. 

Preliminary  feedings  with  the  original  strain  showed 
little  evidence  of  pathogenicity  for  mice,  though  subsequent 
re-testing  at  a much  later  date  has  credited  it  with  more 
definite  results.  For  this  reason  the  original  passage  was 
carried  out  by  feeding  a small  number  of  mice  on  the  usual 
broth  cultures  on  two  occasions  with  an  interval  of  one  day 
between  them,  and  then  killing  one  of  them  with  chloroform 
24  hours  after  the  second  feeding.  Cultures  of  B.  Danysz 
were  obtained  from  the  liver  and  spleen,  and  that  from  the 
spleen  was  used  in  the  next  experiment.  The  survivors 
from  this  preliminary  feeding  showed  no  ill-effects  during 
the  considerable  period  for  which  they  were  kept  under 
observation. 

Examination  of  the  chart  reveals  the  fact  that  the  strain 
from  this  first  mouse  showed  definite  pathogenicity  on  being 
fed  to  the  12  mice  of  Experiment  2.  Eight  of  the  12 
animals  died,  or  were  killed  when  dying,  within  25  days, 
and  from  five  of  these  cultures  of  B.  Danysz  were  obtained 
post  mortem.  On  the  other  hand,  the  deaths  were  unevenly 
distributed  over  the  25  days,  ard  showed  no  tendency  to  be 
accumulated  within  a small  time  interval. 

Experiments  3,  3 a,  3 b,  3 c,  3d,  and  3 K. 

Experiments  3,  3 a,  and  3 B were  carried  out  by  feeding 
12  mice  in  each  case  with  a culture  obtained  from  the  spleen 
of  a mouse  which  had  been  found  dead  during  the  course  of 
Experiment  2.  As  will  be  seen,  the  strains  employed  in 
Experiment  3 and  3 B were  almost  without  effect. 

In  Experiment  3 a six  mice  died  within  the  first  24*days, 
but  the  first  three  of  these  were  found ' almost  entirely 
eaten,  and  in  only  one  of  the  remaining  three  was 


The  Lancet,] 


DB.  W.  W.  0.  TOPLKY  : THE  SPREAD  OF  BACTERIAL  INFECTION.  [July  12, 1919  47 


□ 

□ 

□ 

S3 

> 

Fed  on 

original  strain  « 
of  IS.  danysz. 

□ 

□ 

□ 

□ 

u 

PI 

h 

e 

□ 

H 

E 

0 

H 

B 

Fed  on  strain 
from  spleen  of  E 
A.  Kxp.  1. 

□ 

□ 

□ 

□ 

□ 

□ 

□ 

□ 

□ 

□ 

□ 

Fed  on  strain 
from  spleen  of  " 
11.  Exp.  11.  • 

□ 

□ 

□ 

□ 

□ 

□ 

H 

E 

S 

a 

HI 

Fed  on  strain  — 
from  spleen  of  £ 
C.  Exp.  II. 

□ 

□ 

□ 

□ 

□ 

□ 

□ 

□ 

□ 

□ 

□ 

□ 

Fed  on  strain  £ 
from  spleen  of  >-t 
D.  Exp.  II. 

□ 

□ 

□ 

□ 

□ 

□ 

□ 

□ 

□ 

h 

H 

HI 

Fed  on  strain  £ 
from  spleen  of 
E.  Exp.  II.  ? 

□ 

□ 

□ 

□ 

□ 

□ 

□ 

□ 

H 

n 

I 

0 

H 

Fed  on  strain  £ 
from  liver  of  E 
E.  Exp.  II.  P 

□ 

□ 

□ 

□ 

□ 

□ 

□ 

□ 

H 

H 

H 

H 

Fed  on  strain  *-« 
from  spleen  of  G 
F.  Exp.  II.  P 

□ 

□ 

□ 

□ 

B 

m 

H 

B 

* 

c_ 

B 

SI 

H 

Fed  on  strain  — 
from  spleen  of  7* 
G.  Exp.  Illn.  • 

□ 

□ 

□ 

□ 

□ 

□ 

□ 

□ 

□ 

□ 

□ 

i 

Fed  on  strain  1- 
from  liver  of 
H.  Exp.  IIId.  • 

□ 

□ 

□ 

□ 

□ 

□ 

□ 

□ 

□ 

H 

£ 

e 

Fed  on  strain  ^ 
from  spleen  of  c 
J.  Exp.  IVa.  “ 

□ 

□ 

□ 

□ 

□ 

□ 

□ 

□ 

□ 

□ 

£ 

.SI 

Fed  on  strain 
from  spleen  of  j; 
K.  Exp.  IVa.  • 

' r 

Fed  on  strain  « 
from  spleen  of  < 
G.  Exp.  Illn.  • 

StSHSHBBBEBHSl 

Fed  on  strain 
from  whole  < 

spleen  culture  . 
of  L.  Exp.  lVx. 

□ □□BEE 

Fed  on  strain 
from  whole  5 

spleen  culture  x 
of  M.  Exp.  Vx. 

Key  to  Charts  II.  and  III. 

Each  square  represents  an  individual  mouse  fed  on  strain  indicated. 
A,  B,  C,  &c.  = origin  of  strains  used  in  subsequent  experiments. 

I 1 I = Mouse  killed  while  apparently  healthy  24  hours  after 

LLJ  feeding.  B.  danysz  isolated  P.M. 

| = Mouse  survived  more  than  30  days. 

jl^l  = * Mouse  found  dead.  B.  danysz  isolated  P.M. 

Ij^ll  = *Mouse  killed  while  very  ill.  B.  danysz  isolated  P.M. 

I I /\  = * Mouse  found  dead  or  killed  while  very  ill.  No 

lx  1 danysz  isolated  P M. 

1 1/|  = *Mouse  found  dead  or  killed  while  very  ill.  Not 

1/Nl  examined  P.M. 

* On  day  indicated  in  left  upper  portion  of  square. 

HI  E E HI  HI  H 

Fed  on  strain 
from  strain  "A"  « 1 
from  spleen  of  * 

M.  Exp.  Vx. 

□ S E ® m IS 

Fed  on  strain 
from  strain  “ B " 5 
lrom  spleen  of  h 
M.  Exp.  Vx. 

□□SHE’S 

Fed  on  strain  ^ 
fromstrain  “ C " ^ 
from  spleen  of  £4 
M.  Exp.  Vx. 

□ □□BSE 

Fed  on  strain  ^ 
from  strain  “ D"  f 
from  spleen  of  £ 
M.  Exp.  Vx. 

□ □ E HI  E HI 

Fed  on  strain  ^ 
from  strain  “ E " f 
from  spleen  of  3, 
M.  Exp.  Vx. 

□ □□□EH 

Fed  on  strain  ^ 
from  strain  “ I ” — 
from  spleen  of  & 
M.  Exp.  Vx. 

E H H H □ H 

Fed  on  strain  . 

from  strain  III.  f 
from  spleen  of  2, 
M.  Exp.  Vx. 

HI  HI  E E E E 

z 

Fed  on  strain  ^ 
from  strain  III.  2 
from  spleen  of  & 
M.  Exp.  Vx. 

□ 

□ 

□ 

□ 

□ 

Fed  on  strain  < 
from  spleen  of  2 
N.  Exp.  VI x8.  * 

Chart  II.—  Experiments  Showing  Result  of  Feeding  Successive  Series  of  Mice  on  Cultures  of  Chart  III.— Experiments  Showing  Result  of  Feeding  Successive  Series  of  Mice  on  Cultures 
B.  Danysz  Isolated  from  Mice  Dying  in  Preceding  Experiments.  of  B.  Danysz  Isolated  from  Mice  Dying  in  Preceding  Experiments. 

Deaths  only  Recorded  for  30  Days  after  Feeding.  [Deaths  only  Recorded  for  30  Days  after  Feeding. 


48  The  Lanoet,]  DR.  W.  W.  C.  TOPLEY  : THE  SPREAD  OF  BACTERIAL  INFECTION. 


[July  12, 1919 


B.  Banysz  isolated  post  mortem.  The  deaths  in  this  case 
were  probably  the  result  of  the  feeding,  but  the  connexion 
is  less  definite  than  in  Experiment  2,  and  the  patho- 
genicity of  the  strain  is  less  rather  than  greater.  Thus  in 
these  three  experiments,  in  which  strains  obtained  from 
the  spleens  of  mice  found  dead  during  the  course  of 
Experiment  2 were  utilised,  the  effect  of  passage  had 
been  definitely  to  decrease  the  pathogenicity  for  inice  when 
administered  by  the  alimentary  tract. 

A strain  of  B.  Banysz  isolated  from  the  spleen  of  a 
mouse  of  Experiment  2 which  was  found  dying  on  the  25t.h 
day  after  the  first  feeding  was  fed  to  the  12  mice  of 
Experiment  3 c.  The  results  showed  no  evidence  of  an 
increase  in  pathogenicity. 

The  strain  isolated  from  the  liver  of  the  same  mouse,  the 
culturefromwho.se  spleen  was  employed  in  Experiment  3 C, 
was  fed  to  the  12  mice  of  Experiment  3d.  This  experiment 
gave  results  which  seemed  to  point  to  a definite  variation  in 
the  pathogenicity  of  the  bacillus.  Nothing  whatever 
occurred  during  the  first  nine  days  following  that  on  which 
the  mice  were  fed,  but  on  the  10th  day  one  mouse  was  found 
dead,  two  mice  dying,  and  several  others  obviously  ill. 
One  of  these  succumbed  on  the  14th  day,  but  the  others 
recovered.  This  forms  the  only  instance  in  which  several 
mice,  which  were  obviously  ill,  recovered  from  the  infection. 
The  liver  and  spleen  from  the  mouse  which  was  found  dead 
proved  sterile.  The  two  dying  mice  were  killed,  and 
cultures  from  the  livers  of  both  and  from  the  spleen  of 
one  yielded  pure  growths  of  B.  Banysz.  The  second  spleen 
culture  remained  sterile. 

The  marked  difference  between  the  strains  isolated  from 
the  liver  and  spleen  of  the  same  mouse  of  Experiment  2, 
which  is  indicated  in  this  and  in  the  preceding  experiment, 
is  worthy  of  notice. 

The  strain  isolated  from  the  spleen  of  the  second  of 
the  two  mice  of  Experiment  2,  which  died  on  the  25th 
day  after  feeding,  was  fed  to  the  12  mice  of 
Experiment  3 E.  There  was  a considerable  early  mortality, 
five  mice  dying  between  the  4th  and  7th  day,  but  no 
bacteriological  evidence  was  forthcoming  that  they  had 
succumbed  to  a B.  Banysz  infection. 

Experiments  4 a and  4 b. 

By  far  the  most  definite  evidence  of  pathogenicity  had  so 
far  been  afforded  in  Experiment  3 n.  The  culture  obtained 
from  the  spleen  of  one  of  the  mice  found  dying  on  the 
10th  day  of  this  experiment  was  fed  to  the  12  mice  of 
Experiment  4 a.  The  results  were  definite  and  striking. 
There  was  a period  of  14  days  during  which  nothing 
happened.  Between  the  15Lh  and  the  25th  day,  eight  of  the 
12  mice  died,  or  were  killed  in  a dying  condition.  From  the 
tissues  of  six  of  the  eight  mice  B.  Banysz  was  isolated 
post  mortem.  There  could  be  no  doubt  here  that  a variant 
strain  had  been  isolated  showing  a definite  increase  in 
pathogenicity. 

A culture  obtained  from  the  liver  of  another  mouse  of 
Experiment  3 n,  which  was  found  dying  on  the  same  day  as 
the  mouse  which  yielded  the  strain  used  in  Experiment  4 A, 
was  fed  to  the  12  mice  of  Experiment  4 B.  The  result  was 
in  sharp  contrast  to  that  obtained  in  the  previous  experiment 
for  there  appeared  to  be  an  almost  entire  absence  of 
pathogenicity. 

Experiments  5 A and  5 b. 

In  Experiments  5 A and  5 B strains  were  employed 
from  the  spleens  of  two  mice  found  dying  on  the  17th  day  of 
Experiment  4 A.  The  results  were  curious  and  somewhat 
similar  in  the  two  cases.  Both  strains  appeared  to  be 
almost  devoid  of  immediate  pathogenicity,  but  in  each  case 
a late  outbreak  of  disease  occurred.  In  Experiment  5 A 
three  mice  succumbed  on  the  53rd  day,  and  the  six  survivors 
were  all  found  dead  on  the  74th  day.  From  five  of  these 
last  nine  mice  B.  Banysz  was  isolated  post  mortem. 

In  Experiment  5 b six  mice  died  between  the  56th  and 
the  59'  h day  ; but  since  B.  Banysz  was  in  no  case  isolated, 
it  is  difficult  to  affirm  that  the  deaths  were  due  to  infection 
with  this  organism,  though  the  post-mortem  appearances 
were  entirely  compatible  with  this  being  the  case. 

In  what  way  these  late  deaths  are  related  to  the  original 
feeding  it  is  impossible  to  determine,  but  they  can  hardly  be 
regarded  in  the  same  light  as  the  deaths  occurring  within 
the  first  30  days  of  the  experiment. 


Survey  of  Results : Further  Experiments.  ' 

If  we  survey  the  results  thus  far  obtained  we  see  that  as 
the  result  of  passing  the  original  strain  of  B.  Banysz 
through  a series  of  mice,  the  strain  isolated  from  the  tissues 
of  one  animal  being  fed  to  the  animals  of  the  next  experi- 
ment, a strain  has  been  evolved  showing  a definite  increase 
in  pathogenicity.  In  the  next  passage,  however,  this  patho- 
genicity seems  to  have  been  lost  or  radically  altered.  It  is 
clear,  indeed,  from  the  whole  series  of  experiments  that  this 
loss  readily  occurs  as  the  result  of  passage  carried  out  in 
this  way,  and  the  original  findings  of  Danysz  are  amply  con- 
firmed. That  a definite  increase  in  pathogenicity  may  also 
result  has,  however,  been  established.  Another  fact  is  quite 
definitely  shown.  Strains  obtained  from  mice  killed  when 
very  ill  are  much  more  likely  to  be  pathogenic  than  strains 
from  mice  which  have  been  found  dead.  Here,  again,  the 
results  are  in  accord  with  those  reported  by  Danysz. 

In  order  to  see  whether  a further  increase  in  patho- 
genicity could  be  obtained,  a fresh  series  was  started, 
commencing  with  the  strain  isolated  in  Experiment  3 d, 
which  had  been  fed  to  the  mice  of  Experiment  4 A.  The 
results  are  indicated  in  Chart  III.  The  four  mice  of 
Experiment  4 x were  fed  with  this  strain.  All  four 
succumbed  on  the  13th  day  of  the  experiment.  One  was 
found  dead  and  partially  eaten,  the  other  three  were  dying. 
From  each  of  these  three  B.  Banysz  was  isolated  post  mortem. 

Certain  of  the  previous  experiments  had  indicated  that 
bacilli  of  varying  pathogenicity  might  be  isolated  from  the 
tissues  of  a single  mouse.  For  this  reason  the  broth  culture 
from  the  spleen  of  one  of  the  mice  from  Experiment  4 X was 
fed  to  the  mice  of  the  next  experiment  without  previous 
plating.  A subculture  made  from  it  immediately  beforehand 
gave  a pure  culture  of  B.  Banysz.  The  spleen  tissue  itself 
was  not  fed  to  the  mice. 

The  result  of  this  experiment  (5  x)  was  striking.  Twelve 
mice  were  fed.  Two  died  on  the  4th  day,  one  on  the  5th, 
and  the  remaining  nine  succumbed  on  the  11th  day.  From 
six  of  these  nine  mice  B.  Banysz  was  isolated. 

In  order  to  examine  further  the  possible  differences  of 
strains  of  the  bacillus  isolated  from  the  spleen  of  a single 
mouse  the  following  procedure  was  now  adopted. 

A portion  of  the  spleen  from  one  of  the  mice  which  was 
found  dying  on  the  11th  day  of  the  above  experiment  was 
rubbed  over  the  surface  of  a plate  of  McConkey’s  medium, 
and  then  dropped  into  a tube  of  broth,  which  was  incubated 
for  24  hours.  At  the  end  of  this  time  a second  McConkey 
plate  was  inoculated.  From  the  scanty  growth  which 
developed  on  the  first  plate  eight  colonies  were  subcultured 
into  broth  and  the  tubes  labelled  A-H.  From  the  second 
plate  six  colonies  were  picked  off  and  the  corresponding 
broth  tubes  numbered  1-6.  All  cultures  were  identified  as 
B.  Banysz  by  fermentation  and  agglutination  tests. 

Into  each  of  seven  cages  were  placed  six  mice.  The  first 
batch  were  fed  on  the  broth  culture  obtained  from  the  whole 
spleen  (Exp.  6x).  The  next  five  batches  were  fed  on  cultures 
A-E  obtained  from  colonies  which  developed  on  the  plate 
inoculated  directly  with  spleen  tissue  (Exps.  6x  1-6x5).  The 
last  two  batches  were  fed  on  strains  1 and  3 obtained  from 
colonies  which  developed  on  the  plate  inoculated  from  the 
original  broth  tube  (Exps.  6x6  and  6x7). 

The  chart  shows  the  results.  All  the  strains,  with  the 
possible  exception  of  strain  1,  showed  definite  pathogenicity. 
The  broth  culture  obtained  directly  from  the  spleen  tissue 
was  no  more  pathogenic  than  the  rest.  Strain  3 stands  out 
prominently,  all  the  six  mice  of  this  experiment  succumbing 
within  three  days.  As  B.  Banysz  was  only  isolated  from  one 
of  the  six  mice,  a second  batch  of  the  same  number  were  fed 
on  a broth  culture  obtained  from  the  agar  slope  of  this  strain 
which  had  been  placed  in  the  ice-chest. 

The  result  (Exp.  6x8)  entirely  confirmed  the  high  patho- 
genicity of  the  strain,  all  six  mice  were  found  dead  on  the 
6th  day,  and  from  four  of  them  B.  Banysz  was  isolated 
post  mortem. 

From  the  strain  isolated  from  the  spleen  of  one  of  these 
mice  six  other  mice  were  fed  (Exp.  7 X).  The  loss  of  patho- 
genicity is  obvious,  and  we  see  again  the  tendency  for 
successive  passages  to  lead  to  the  final  loss  by  the  parasite  of 
the  power  of  producing  disease  when  administered  with  the 
food. 

Experiments  to  Test  Results  of  Prolonged  Cultivation. 

To  exclude  the  possibility  of  the  results  noted  being  due  to 
some  extraneous  factor  rather  than  to  variations  in  the  bio- 
logical properties  of  the  bacillus,  and  to  determine  what 


Thm  Lancet,]  MR.  FLEMING  & DK.  PORTKOUS  : STREPTOCOCCAL  INFECTIONS  OF  WOUNDS.  [July  12, 1919  49 


alteration,  if  any,  would  result  from  prolonged  cultivation  on 
artificial  media,  the  strains  which  showed  the  widest  varia- 
tions were  retested  at  subsequent  dates.  As  mentioned 
above,  the  various  strains  isolated  were  grown  on  agar 
slopes,  sealed  with  paraffin  wax,  and  placed  in  the  ice- 
chest.  They  were  subsequently  subcultured  on  to  further 
agar  slopes  at  intervals  of  six  weeks,  the  fresh  cultures,  after 
24  hours  in  the  incubator,  being  preserved  in  the  same  way. 

The  original  strain  was  tested  on  five  batches  of  mice 
between  July,  1918,  and  February,  1919.  On  the  first 
occasion  no  mouse  succumbed  within  30  days.  In  the  later 
experiments  a few  mice  died  in  each  case.  The  highest 
mortality  occurred  in  the  last  test  carried  out,  when  four  of 
eight  mice  died  during  the  30  days  over  which  the  experi- 
ment continued.  From  only  one  of  these  mice,  however, 
was  B.  Danysz  isolated.  Moreover,  the  deaths,  when  they 
occurred,  were  irregularly  distributed  in  time.  On  no  occa- 
sion were  more  than  one  mouse  found  dead  on  any  one  day. 

The  strain  from  the  spleen  of  the  mouse  of  Experiment  3 D 
which  was  used  in  Experiment  4 A was  retested  on  four 
subsequent  occasions  between  September,  1918,  and  February, 
1919.  In  the  first  experiment  8 of  12  mice  died  within 
30  days,  a mortality  of  66  per  cent.  In  the  second  experi- 
ment the  mortality  during  the  same  period  was  100  per 
cent.  In  the  three  subsequent  tests  the  mortality  was  66, 
66,  and  62  per  cent,  respectively.  Moreover,  there  was  a 
most  definite  time  distribution.  In  each  of  the  three  earlier 
experiments  there  was  an  incubation  period  of  12  to  15  days, 
followed  by  an  outbreak  involving  the  death  of  a large  pro- 
portion of  the  mice  within  a few  days.  The  difference 
between  the  results  of  these  experiments  and  those  carried 
out  with  the  original  strain  were  most  striking  when  actually 
observed.  On  the  last  two  occasions  on  which  this  strain 
was  tested  the  tendency  to  produce  a series  of  deaths  within 
a short  time  interval  and  following  a definite  incubation 
period  seemed  to  have  been  lost. 

Similarly,  the  strain  labelled  “ Spleen  3 : 5 x : 9.12,” 
which  was  employed  in  Experiment  6x7,  was  retested  on 
three  occasions  within  the  following  two  months.  It 
showed  on  the  first  three  occasions  a consistent  tendency 
to  produce  a high  and  early  mortality.  Thus  all  the  mice  of 
the  first  experiment  died  within  three  days.  All  the  mice 
of  the  second  experiment  succumbed  on  the  6th  day.  Four 
of  six  mice  fed  in  the  third  experiment  died  on  the  3rd  day, 
while  a fifth  died  on  the  16th.  On  the  last  retesting  this 
strain  seemed  to  have  lost  its  peculiar  properties. 

Two  other  strains  which  had  shown  particularly  low 
pathogenicity  were  subsequently  retested,  and  the  results 
confirmed  those  originally  obtained. 

Thus  two  strains  at  least  were  evolved  which  possessed 
quite  definite  infective  properties.  One  tended  to  produce 
an  outbreak  of  disease  after  an  incubation  period  of  12  to  15 
days.  The  other  led  to  the  death  of  all  the  animals  fed 
within  a few  days.  These  properties  were  maintained  for 
weeks  or  months  under  artificial  cultivation,  but  were 
. gradually  lost,  and  when  finally  tested  the  strains  were 
indistinguishable  from  the  original  strain  of  B.  Danysz. 

No  attempt  was  made  to  maintain  the  pathogenicity  of  the 
cultures  by  special  methods  of  cultivation  and  storage.  The 
exact  combination  of  properties  on  which  this  pathogenicity 
depended  was  a subject  for  surmise,  but  it  was  clearly 
not  simply  a question  of  virulence  in  the  strict  conven- 
tional sense.  It  seemed  better,  therefore,  to  rely  on  the 
simplest  methods  of  culture  and  observe  any  changes 
which  occurred. 

The  results  of  observations  on  the  factors  possibly  con- 
cerned in  the  loss  of  pathogenicity  by  passage,  and  especially 
on  the  question  of  the  spread  of  the  infection  from  the  mice 
fed  on  cultures  of  the  Ijacillus  to  their  normal  companions, 
will  be  considered  in  my  last  lecture. 

Bibliography. — Bainbridge  : Journ.  Path,  and  Bact.,  1909,  xiii.,  442. 
Billet,  le  Bihan  and  others:  Arch,  de  Med.  et  de  Pharm.  Milit..  1910, 
lv.,  259.  Brownlee:  Trans.  Roy.  Soc.  Med.  (Epidem.  Soe.),  1909.  ii.’ 
243.  Bruns  and  Hdhn  : Klin,  jahrb.,  1908,  xviii.,  285.  Butler:  Proc! 
Roy.  Soc.  Med.  (Epidem.  Sec.),  1909,  ii.,  59.  Chesney : Journ.  Exp] 
Med.,  1916,  xxiv.,  387.  Danysz:  Ann.  de  l'Inst.  Pasteur,  1900,  xiv., 
193.  Flack:  Med.  Res.  Comm.  Spec.  Rept.,  Ser.  No.  3,  1917.  Glover] 
Journ.  Hyg.,  1918,  xvii..  350,  367.  Graham-Smith:  The  Bacteriology 
of  Diphtheria,  Camb.,  1908.  Hutchens  : Med.  Res.  Comm.  Rept.,  1916. 
Johnston:  Med.  Res.  Comm.  Rept.,  1916.  Kober:  Zeitschr.  f.  Hyv., 
1899,  xxxi.,  433  Ledingham  and  Arkwright : The  Carrier  Problem  in 
Infectious  Disease*,  Lond.,  1912.  Ledingham  and  Penfold  : Journ.  of 
Hyg.,  1914.  xiv.,  242.  Liston  : Rep.  Bombay  Bact.  Lab.,  1907.  Miihlens, 
Dahm,  and  Fiirst:  Centralb.  f.  Bakter.  ii  Parasitenk,  1909,  Orig.’ 
xlviii.,  1.  Penfold:  Journ.  Hyg.,  1914,  xiv.,  215.  Stillman:  Journ] 
Exp.  Med..  1917,  xxvi.,  513.  Wadsworth  and  Kirkbride:  Journ  Exn 
Med.,  1918,  xxviii.,  791. 


ON 

STREPTOCOCCAL  INFECTIONS  OF  SEPTIC 
WOUNDS  AT  A BASE  HOSPITAL. 

By  ALEXANDER  FLEMING,  F.R.C.S.  Eng., 

HUNTERIAN  PROFESSOR,  ROYAL  COLLEGE  OF  SURGEONS  OF  ENGLAND; 

AND 

A.  B.  PORTEOUS,  M.B.,  B.S.  Lond., 

LATE  PATHOLOGISTS  TO  NO.  8 STATIONARY  HOSPITAL,  B.E.F.,  FRANCE. 

In  connexion  with  streptococcus  infections  of  wounds  at 
base  hospitals  there  are  certain  questions  which  are  of  funda- 
mental importance. 

What  are  the  Types  of  Streptococci  that  Require  to  he 
Seriously  Considered  in  Wound  Infections . ? 

There  is  one  type  of  streptococcus  which  is  predominant 
in  septic  wounds  at  the  base.  This  type  is  responsible  for 
almost  all  the  severe  septic  complications  of  these  wounds. 
It  is  to  be  found  in  pure  culture  in  nearly  all  the  infected 
joiut  cavities  and  fresh  pockets  of  the  wounds,  and  in  our 
experience  it  has  been  responsible  for  all  the  streptococcal 
septicfemia  following  septic  wounds. 

Characters  of  this  streptococcus. — It  grows  in  broth  in  long 
chains  of  regular  cocci.  Some  strains  after  24  hours  show 
very  marked  involution  forms,  the  cocci  being  all  shapes  and 
sizes.  The  culture  in  broth  consists  of  small  woolly  masses, 
which  settle  to  the  bottom  of  the  tube  (or  along  the  side  of 
the  tube  if  it  is  incubated  in  a slanting  position),  leaving 
the  upper  portion  of  the  medium  clear.  On  agar  (Douglas’s 
trypsin  agar)  it  grows  well  in  moderate-sized  colonies,  which 
show  by  transmitted  light  a definite  dark  central  portion, 
while  the  edges  are  slightly  wavy  and  irregular.  It  does  not 
liquefy  gelatin.  This  streptococcus  always  grows  better 
anaerobically,  and  not  Infrequently  when  first  isolated  it  will 
not  grow  aerobically.  After  being  cultivated  for  a short 
time,  however,  it  grows  freely  under  aerobic  conditions.  It 
is  not  constant  in  its  sugar  reactions.  In  the  great  majority 
of  cases  it  ferments  glucose,  lactose,  saccharose,  and  salicin. 
but  not  raffinose,  mannite,  or  inulin.  A few  strains,  however 
(about  12  per  cent.),  ferment  mannite.  These  mannite- 
fermenting  strains  are  identical  morphologically  with  the 
non-mannite  fermenters,  and  it  has  been  shown  by  Douglas, 
Colebrook,  and  Fleming,  in  a report  to  the  Medical  Research 
Committee  not  yet  published,  by  means  of  agglutination  and 
absorption  tests  that  serologically  they  are  also  identical. 

Clotting  of  milk. — This  test  is  very  inconstant,  and  we  have 
found  that  as  regards  the  dotting  of  milk  with  these  strepto- 
cocci very  much  depends  on  the  size  of  the  tube  in  which  the 
test  is  carried  out.  If  the  tube  is  of  large  size  then  the 
clotting  is  always  delayed  and  it  may  even  not  take  place  in 
ten  days,  whereas  in  a small  test-tube  there  is  definite  clotting 
in  24  hours.  In  a series  of  tubes  of  different  sizes  containing 
milk  which  had  been  heavily  implanted  with  Streptococcus 
pyogenes  and  incubated  for  five  days  it  was  observed  that  no 
clotting  had  occurred  in  the  two  largest  tubes,  in  the  third 
tube  clotting  had  occurred  but  there  was  no  contraction  of 
the  clot,  while  in  the  smallest  tube  there  was  firm  clotting 
with  much  contraction  of  the  clot.  This  clotting  of  the 
milk  in  the  smallest  tube  had  occurred  in  the  first  24  hours. 
Even  in  small  tubes,  however,  the  clotting  of  milk  by  Strepto- 
coccus pyogenes  is  quite  inconstant  and  is  worthless  as  a 
test. 

Hamolytic  power.— All  the  strains  of  this  streptococcus 
showed  some  haemolytic  power,  but  there  seemed  to  be 
enormous  differences  in  the  amount  of  hmmolysin  produced 
under  the  same  conditions  by  streptococci  which  were 
isolated  from  the  blood  of  septicmmic  patients.  In  a number 
of  cases  the  hiemolytic  power  was  tested  by  centrifuging  a 
broth  culture  and  incubating  for  two  hours  at  37°  C.  dilutions 
of  the  clear  supernatant  fluid  with  washed  human  red 
corpuscles.  In  most  cases,  however,  the  question  of  whether 
these  streptococci  were  haemolytic  or  not  was  tested  by 
noting  the  appearance  produced  by  their  growth  on  a blood 
agar  plate  (see  Fig.  2). 

Incidence  of  this  streptococcus. — In  a series  of  over  100 
septic  wounds  (fractured  femurs)  which  had  remained  at  a 
base  hospital  for  over  seven  days  this  streptococcus  was 
present  in  almost  every  one.  In  cases  of  a similar  nature 
where  streptococci  were  recovered  from  the  blood  (47  cases) 
the  organism  was  invariably  of  this  type 


50  iHlLANOar,]  MR.  FLEMING  & DR  PORIEOUS  : STREPTOCOCCAL  INFECTIONS  OF  WOUNDS.  [July  12, 1019 


Is  the  “ Hremolytio " Character  of  the  Streptooooous  of 
Fundamental  Importance — i.e. , Can  Non-hasmolytio  Strepto- 
ooooi  he  Ignored  for  Practical  Purposes  in  Wounds? 

As  has  been  stated  above,  the  only  streptococcus  which 
we  have  found  to  give  rise  to  serious  complications  in  a 
wound  is  the  “pyogenes”  type,  which  belongs  to  the 
haemolytic  group  of  streptococci,  and  we  were  forced  to 
consider  the  non-haemolytic  streptococci  to  be  of  only 
secondary  importance.  In  the  more  recent  wounds,  and 
especially  in  the  wounds  in  which  gas  gangrene  had 
developed,  there  is  to  be  found  very  frequently  streptococci 
of  the  “ faecalis  ” type.  These  are  not  present  with  anything 
like  the  same  frequency  in  the  latter  cases.  One  of  us 
(A..F.)  in  conjunction  with  Douglas  and  Colebrook1  showed 
that  streptococci  (and  other  organisms)  had  a powerful  effect 
in  increasing  the  growth  of  anaerobic  bacilli  when  grown 
with  them  in  symbiosis.  It  may  be  that  these  streptococci 

of  the  “ fsecalis  ” type  have  some  importance  in  the  wound  , , , . . . . . 

- ^ c . . ..  ,.  r . , .,  , ,i  these  recoveries  is  not  very  evident.  All  the  patients  who 

on  account  of  this  symbiotic  action,  but  alone  they  do  not  1 , . . , , . .. 

. , c „„  ■ " . . , . .,  , J recovered  were  treated  with  streptococcus  vaccine,  but  it  was 

seem  to  be  of  any  importance  in  wounds  at  the  base.  , , . . . r , . , ..  ’ 


the  characteristic  colour  of  the  discharges.  Other  organisms 
which  spread  around  a wa'd  in  the  same  way  are  B.  proteus 
and  diphtheroid  bacilli.  No.v,  as  the  Streptococcus  pyogenes 
will  grow  in  the  discharges  very  much  more  readily  than 
will  these  other  organisms,  it  would  be  a miracle  if  it  were 
not  spread  in  the  same  way.  It  is  unfortunate  that  infection 
by  streptococcus  does  not  produce  any  characteristic  change 
in  the  smell  or  colour  of  the  discharges,  as  it  does  not 
obtrude  itself  on  the  notice  of  the  surgeon  until  some 
serious  complication  arises. 

Have  any  Points  Bearing  on  the  Methods  of  Recovery  from 
Streptococcus  Infections  Come  to  Light , and , if  so. 

Can  these  be  Explo  .ted  in  Treatment  ? 

In  cases  of  septicaemia  following  serious  wounds  the  pro- 
portion of  recoveries  is  very  small.  Out  of  a series  of 
40  cases  of  septicaemia  following  compound  fracture  of  the 
femur  we  hive  seen  only  four  recoveries.  The  reason  for 


any  importance 

What  is  the  Source  of  the  Streptococci  Found  in  Wounds  ? 

Examinations  at  a C.C.8.  on  recently  inflicted  wounds 
have  shown  that  in  only  about  15  per  cent,  of  cases  is 
Streptococcus  pyogenes  present.  Examinations  at  the  base  in 
cases  which  have  been  in 
more  than  a week  reveal 
the  presence  of  this  organ- 
ism in  over  90  per  cent,  of 
the  wounds. 

During  the  summer  of 
1918  we  examined  a 
number  of  the  gauze  packs 
removed  from  wounds  on 
arrival  at  the  base.  When 
the  patient  had  been  kept 
at  the  C.  C.  S . for  more  than 
three  or  four  days  Strepto- 
coccus pyogenes  was  present 
in  almost  every  case.  These 
cases  correspond,  therefore, 
closely  with  the  patients 
who  have  been  in  base  hos- 
pitals for  more  than  a few 
days.  Where,  however,  the 
patient  had  been  sent 
straight  on  to  the  base  after 
excision  of  the  wound  we 
found  that  Streptococcus 
pyogenes  was  present  only  in 
15  out  of  75, cases.  Although 
in  the  majority  of  the  packs 
from  these  recent  cases  we 
failed  to  find  Streptococcus 
pyogenes , we  were  able  to 
recover  other  microbes  in 
every  case  from  those  por- 
tions of  the  packs  which 
came  from  the  depths  of 
the  wound,  and  often  these  microbes  were  present  in  very 
large  numbers.  The  microbes  isolated  in  these  cases  were 
chiefly  anaerobic  and  aerobic  bacilli  and  staphylococci. 

It  has  been  conclusively  demonstrated  that  Streptococcus 
pyogenes  will  grow  much  better  than  these  other  microbes  in 
the  blood  fluids 2 such  as  would  be  found  in  a recently 
excised  wound,  so  that  had  the  streptococcus  been  present  as 
a primary  infection  it  should  have  been  demonstrable  on 
arrival  at  the  base.  It  is  to  be  noted,  therefore,  that  on 
arrival  at  the  C.C.S.  15  per  cent,  of  the  men  were  infected 
with  Streptococcus  pyogenes;  on  arrival  at  the  base  (when 
the  cases  had  been  sent  straight  on  after  operation)  29  per 
cent,  were  infected,  but  after  a stay  at  the  base  of  a week 
over  90  per  cent,  were  found  to  have  Streptococcus  pyogenes 
in  their  wounds.  It  would  seem  a warrantable  deduction 
from  these  observations  that  the  streptococcal  infection  of 
wounds  is  in  most  cases  a hospital  infection,  and  it  is 
probable  that  in  the  dressing  of  the  wound  the  infection  is 
carried  from  one  patient  to  another. 

It  has  long  been  known  that  B.  pyocyaneus  is  spread  from 
one  patient  to  another  in  a ward  by  faulty  technique  in 
dressing,  as  this  infection  is  manifest  to  the  naked  eye  by 

1 The  Lancet,  1917,  i..  601. 

3 Wright:  Proceedings  of  the  Koyal  Society  of  Medicine,  1915. 


very  difficult  to  demonstrate  in  any  of  these  septicaemia  cases 
any  direct  benefit  from  the  vaccine.3 

In  some  cases  of  pyaemia,  however,  and  in  many  less  severe 
cases,  the  administration  of  streptococcus  vaccine  in  doses 
of  1,009,000  to  5,000,000  was  repeatedly  followed  by  a drop 

in  the  temperature  and  a 
feeling  of  well-being  to  the 
patient.  It  has  often  been 
demonstrated  that,  follow- 
ing the  injection  of  strepto- 
coccus vaccine,  there  is  a 
rise  in  the  amount  of  anti- 
bodies in  the  blood.  In 
cases  of  severe  injury,  such 
as  a fractured  femur,  there 
are  very  often  portions  of 
the  wound  which  are  in- 
efficiently drained  and  to 
which  the  blood  fluids  do 
not  have  access,  and  this 
militates  against  any  very 
dramatic  effect  following 
the  administration  of  vac- 
cine in  such  cases.  We 
hold  a very  strong  opinion, 
however,  that  in  all  septic 
wounds  where  the  surgeon 
secures  good  drainage  no 
harm  would  be  done  and 
much  good  would  result 
from  a routine  administra- 
tion of  stock  streptococcus 
vaccine  in  doses  of  from 
1,000,000  to  5,000,000  once 
a week.  It  is  not  practicable 
to  make  autogenous  vac- 
cines in  every  case,  and  it 
has  been  demonstrated  by 
Douglas,  Colebrook,  and 
Fleming  that  when  an  animal  is  injected  with  one  strain  of 
Streptococcus  pyogenes  it  develops  antibodies  (agglutinins)  to 
the  same  degree  to  all  strains.  It  would  appear,  therefore, 
that  a stock  vaccine  would  be  as  useful  as  an  autogenous  one. 

In  cases  of  septicaemia  it  seems  much  more  likely  that 
streptococci  are  being  continually  thrown  into  the  blood 
stream  from  some  septic  focus  than  that  they  should  actually 
be  growing  and  multiplying  in  the  blend  stream.  If  they 
did  flourish  in  the  circulating  blood,  then  they  should  be 
present  in  much  larger  number  than  fhey  are.  If  lc.cm.  of 
blood  is  taken  from  a septicaemic  patient,  mixed  with  liquid 
agar  at  47°  C.,  and  plated,  it  is  uncommon  to  get  more  than 
100  colonies.  Usually  only  two  or  three  develop. 

This  method  has  been  found  to  be  the  best  for  blood 
culture  in  such  cases.  In  quite  a large  series  of  blood 
cultures  it  has  never  failed  to  reveal  streptococci  when  they 
were  found  in  fluid  cultures,  and  in  two  cases  streptococci 
were  found  when  they  failed  to  develop  from  blood  added  to 


Plite  culture  of  1 c.cm.  of  blood  from  a septicaemic  patient  taken  imme- 
diately after  being  disturbed  by  being  washed.  Mote  tbe  large  number 
of  streptococcus  colonies  and  the  zone  of  haemolysis  around  each. 


s It  should  be  remembered,  however,  that  in  a large  series  of  puer- 
peral septicaemia  cases  in  which  streptococci  were  demonstrated  in  the 
blood  Western  (The  Lancet,  1912.  i.,  351)  by  the  use  of  vaccines 
obtained  a very  high  percentage  of  recoveries  (45  as  against  about  10 
in  a control  series  not  treated  bv  vaccines).  These  puerperal  septi- 
caemias do  not  seem  to  be  very  different  from  septicaemia  following  a 
septic  wound. 


Tea  Lancet,]  DR.  H.  J.  B.  FRY  : CERTAIN  ORGANISMS  ISOLATED  FROM  INFLUENZA  CASES.  [July  12,  1919  51 


broth  or  glucose  broth.  It  has  also  the  great  merit  that  the 
number  of  streptococci  in  the  circulating  blood  can  be 
determined.  The  technique  is  as  follows  : — 

1 c.om.  of  blood  from  the  suspected  septicuemic  case  is 
added  to  about  5 c.cm.  of  water.  The  blood  will  thus  be 
laked  and  the  clotting  power  diminished,  so  that  it  can 
readily  be  carried  back  to  the  laboratory  before  coagulation 
takes  place  It  is  then  mixed  with  about  20  c.cm.  of  agar  at 
47°  C.,  poured  into  a Petri  dish,  allowed  to  set,  and  incubated. 
In  24  hours  the  colonies  can  easily  be  seen. 

Minced  meat  medium,  such  as  is  commonly  used  in  the 
cultivation  of  anaerobes,  furnishes  a better  fluid  medium  for 
blood  culture  in  these  surgical  cases  than  does  broth,  glucose 
broth,  or  citrated  broth.  In  several  cases  we  have  obtained 
growths  of  streptococcus  from  the  blood  in  this  medium 
when  they  failed  to  develop  in  the  broth  cultures.  It  has 
the  advantage  that  anaerobes,  if  present,  will  also  develop. 

The  figure  represents  a plate  made  from  1 c.cm.  of  blood 
from  a patient  with  septicsemia  following  a flesh  wound  in 
the  thigh.  It  shows  very  many  more  streptococci  than  are 
usually  present  in  the  blood.  Two  days  after  the  specimen 
was  taken  the  patient  died,  and  the  autopsy  showed,  in 
addition  to  a septic  thigh  wound,  abscesses  in  the  hand, 
wrist,  both  elbows,  neck,  and  a very  large  abscess  in  the 
buttock.  The  specimen  of  blood  was  taken  immediately  the 
orderlies  had  finished  washing  the  patient,  during  which 
process  he  must  of  necessity  have  been  considerably  dis- 
turbed, and  it  seems  probable  that  the  large  number  of 
streptococci  in  the  blood  was  due  rather  to  this  disturbance 
than  to  their  growth  in  the  blood  stream. 

It  is  unlikely,  also,  that  the  small  number  of  streptococci 
present  in  the  blood  stream  in  the  ordinary  case  of  septi- 
caemia would  be  able  to  flourish  in  that  situation,  as  the  serum 
of  these  patients  show  by  Sir  Almroth  Wright’s  sero-culture 
method  a very  much  enhanced  bactericidal  power  to  Strepto- 
coccus pyogenes .4  (The  bactericidal  power  of  normal  serum 
to  this  microbe  is  practically  nil.) 

So  far  as  we  know,  streptococci  are  destroyed  in  the  body 
by  three  agencies  : (1)  bactericidal  power  of  the  serum  ; 
(2)  direct  bactericidal  power  of  the  leucocytes  (without 
phagocytosis)  ; (3)  phagocytosis  due  to  the  combined  action 
of  the  serum  (opsonic  power)  and  leucocytes.  In  strepto- 
coccal septicaemia  these  are  changed  from  the  normal  as 
follows. 

1.  Bactericidal  power  of  the  serum.  (This,  as  stated  above, 
is  increased.) 

2.  Direct  bactericidal  power  of  the  leucocytes. — It  has  been 
shown  5 that  living  leucocytes  have  the  power  of  destroying 
streptococci  without  ingesting  them.  This  power  of  the 
leucocytes  is  apparently  unaltered  in  septicaemia  cases 
except  that  as  there  is  always  a leucocytosis  in  these  cases 
the  power  is  more  manifest. 

3.  Phagocytosis. — In  some  cases  of  septicsemia  the  serum 
has  lost  completely  or  almost  completely  its  opsonic  power 
(and  also  its  complementing  power).  The  phagocytic  power 
of  the  leucocytes  is  not  diminished. 

It  would  appear  from  these  observations  that,  as  a rule,  it 
is  not  the  circulating  blood  which  is  at  fault  in  cases  of 
streptococcal  septicsemia,  and  in  all  probability  we  have  to 
look  for  some  deficiency  in  the  local  protective  mechanism 
which  allows  access  of  the  streptococci  to  the  blood  stream. 
It  would  seem  to  follow,  also,  that  for  the  successful  treat- 
ment of  a case  of  septicsemia  the  most  essential  element 
would  be  the  thorough  local  treatment  of  the  infected  focus. 

It  has  been  observed  that  when  an  infection  has  become 
circumscribed  by  the  collection  of  leucocytes  in  the  walls 
of  the  wound  and  by  the  other  factors  which  operate 
locally  in  this  connexion,  it  is  very  difficult  to  graft  a 
serious  streptococcal  infection  on  the  wound.  It  follows 
from  this  that  the  utmost  care  should  be  taken  in  the  first 
few  days  after  the  injury  to  keep  out  the  streptococcus 
and  to  avoid  any  treatment  which  will  inhibit  the  defensive 
processes  developing.  In  the  after-treatment  fresh  tissue 
should  only  be  opened  up  when  there  is  a very  urgent 
necessity. 

In  conclusion,  we  wish  to  express  our  thanks  to  Major  M. 
Sinclair  and  our  other  surgical  colleagues  for  permitting  us 
to  make  observations  on  patients  under  their  care  ; to 
Captain  L.  Colebrook  for  permission  to  use  some  of  his 
experimental  work  ; and  to  the  Medical  Research  Committee 
for  supplying  us  with  apparatus  which  made  the  work  easier. 

4 For  this  observation  we  are  indebted  to  Captain  L.  Colebrook. 

5 Wright,  Fleming,  and  Colebrook,  Tue  Lancet,  1918,  i.,  831. 


NOTE  ON 

CERTAIN  ORGANISMS  ISOLATED  FROM 
CASES  OF  INFLUENZA. 

By  H.  J.  B.  FRY,  M.D.  Oxon., 

CAPTAIN,  H.A.M.O.  (T.). 


In  the  course  of  investigation  of  material  derived  from 
cases  of  influenza  during  the  three  waves  of  the  present 
epidemic,  when  searching  for  Pfeiffer’s  bacillus,  Gram- 
negative, “Pfeiffer-like”  bacilli  were  frequently  isolated. 
They  were  not,  however,  haemophilic,  and  grew  rapidly  and 
readily  on  ordinary  agar.  They  have  been  isolated  from 
sputum,  post-mortem  material,  and  in  blood  culture.  The 
organisms  derived  from  the  latter  source  deserve  further 
description. 

They  were  isolated  from  the  blood  of  two  German  prisoners, 
out  of  four  cases  examined,  at  the  commencement  of  the 
third  wave  of  the  epidemic  in  February,  1919.  The  camp 
to  which  the  prisoners  had  belonged  had  escaped  the  two 
previous  waves,  but  was  overwhelmed  by  the  present  one,  a 
large  proportion  of  the  prisoners  being  severely  attacked. 

The  organism  was  obtained  in  2 per  cent,  glucose  broth, 
and  appeared  in  24  hours  in  the  blood  culture,  as  round  or 
oval  Gram-negative  “yeast-like  ” bodies,  3-5/t  long  by  2-4/i 
broad.  Subculture  to  agar  produced,  not  the  above  organisms 
but  Gram-negative  bacilli,  varying  in  size  from  coccal  or 
cocco-bacillary  forms  to  short  filaments.  The  “ yeast-like  ” 
bodies  rapidly  disappeared  from  the  blood  culture,  and  were 
replaced  by  clumps  of  Gram-negative  bacilli,  in  the  neigh- 
bourhood of  which  could  be  seen,  in  some  cases,  Gram- 
negative amorphous  masses,  resembling  the  ruptured  envelopes 
of  the  above-mentioned  “ yeast-like”  bodies. 

Characters  of  Organism  : Pathogenesis. 

The  bacilli  were  pure  in  subculture,  and  had  the  following 
morphological  and  cultural  characters  : — 

Morphology  and  cultural  cha/raoters. — Small  non-sporing 
bacilli,  often  grouped  in  parallel,  or  as  diplo-bacilli,  1-2^  in 
length,  but  varying  in  size  from  coccal  forms  to  short  fila- 
ments. The  smaller  forms  are  actively,  but  the  larger  forms 
are  feebly,  motile.  They  are  Gram-negative  but  not  acid- 
fast.  Polar  staining  is  not  usually  present.  They  are  aerobic 
and  grow  rapidly  and  well  on  agar,  forming  a whitish-grey 
moist  growth  of  circular,  slightly  flattened  colonies,  about 
0 5 mm.  in  diameter.  Viewed  by  transmitted  light,  the 
colonies  are  translucent  and  slightly  iridescent.  In  stab- 
culture  on  gelatin  there  is  a white  growth,  confined  to  the 
needle  track,  without  extension  on  the  surface,  and  the 
gelatin  is  not  liquefied.  Broth  is  rendered  turbid,  with  a 
flocculent,  whitish,  stringy  deposit. 

The  fermentation  reactions  are  as  follows : Acid  pro- 
duction but  no  gas  in  dextrose,  maltose,  and  mannite.  No 
change  in  lactose,  cane-sugar,  salicin,  or  inulin.  Litmus 
milk  is  first  rendered  faintly  acid  and  then  becomes  strongly 
alkaline,  without  any  clotting.  Neutral-red  broth  is  rendered 
alkaline.  There  is  a fairly  well-marked  indol  reaction  after 
48  hours’  growth  in  peptone  water.  Stalactite  growth  was 
not  obtained  in  butter-fat  broth. 

Grown  on  6 per  cent,  salt  agar,  numerous  yeast-like  forms 
were  obtained  resembling  those  obtained  in  the  blood 
culture,  together  with  filamentous,  curved,  and  swollen 
forms.  The  organism  resists  heating  to  65°  C.  for  30  minutes, 
but  is  killed  at  a temperature  of  60°  C.  for  1 hour. 

Pathogenesis. — The  organism  was  highly  pathogenic  to  the 
rat  and  guinea-pig.  0 25  c.cm.  of  a saline  emulsion  of  a 
24-hour  agar  culture  by  intrathoracic  injection  killed  a white 
rat  in  17  hours.  The  lesions  produced  were  ecchymoses  and 
haemorrhagic  extravasations  on  the  surfaces  of  both  lungs, 
which  were  congested  and  cedematous.  The  heart  was 
engorged  and  filled  with  clot.  The  organism  was  recovered 
in  pure  culture  from  heart,  lungs,  and  spleen. 

A similar  dose  by  intrathoracic  injection  killed  a guinea- 
pig  in  five  days,  causing  a slight  caseous  nodule  at  the  site 
of  inoculation,  sero- purulent  effusions  into  both  pleural  sacs, 
and  lobular  pneumonia  with  haemorrhages  in  both  lungs. 
The  bronchial  glands  were  greatly  enlarged  and  showed 
caseous  nodules.  The  heart  was  dilated  and  filled  with 
clot.  The  organism  was  recovered  in  pure  culture  from  the 
pleural  effusion,  lungs,  heart  blood,  tracheal  mucus,  and 
spleen.  By  intraperitoneal  inoculation  death  was  caused 


52  ThhLanobt,]  DR.  H.  J.  B.  FRY  : CERTAIN  ORGANISMS  ISOLATED  FROM  INFLUENZA  CASES.  [July  12, 1919 


in  four  days,  with  sero-fibrinous  peritonitis  and  haemorrhagic 
infarcted  areas  in  the  lungs. 

The  organism  appears,  therefore,  to  be  related  to  the 
haemorrhagic  septicaemic  group  of  bacilli,  and  in  its  cultural 
and  fermentation  reactions  is  somewhat  similar  to  B.  pseudo- 
tuberculosis.  According  to  MacGonkey,1  the  fermentation 
reactions  of  B.  pstudo-tuberculosis  and  of  B.  pestis  are  practi- 
cally identical.  This  is  of  interest  in  view  of  the  general 
resemblance  which  exists  between  the  pathological  changes 
in  the  lungs  in  acute  influenza  and  pneumonic  plague. 
Moreover,  forms  resembling  B.  pestis  were  obtained  in 
culture  from  the  rat.  Similar  forms  have  been  noted  by 
Donaldson  - in  the  sputum,  and  in  the  lung  juice  by  Harris. 3 

One  of  the  patients  from  whom  this  organism  was  isolated 
died,  but  the  other  recovered.  The  serum  obtained  from 
the  blood  of  the  latter  in  the  third  week  after  onset  of  the 
disease  failed  to  agglutinate  the  bacillus  recovered  from  his 
blood.  Complement-deviation  tests  with  the  patient’s  serum 
and  the  organism  as  antigen  appear  to  be  positive,  but 
require  futher  investigation. 

Addendum. — Since  writing  the  foregoing  statement  a 
careful  complement-deviation  test  with  full  technique, 
using  Harrison’s  method,  has  been  kindly  carried  out  for 
me  by  Captain  Lundie,  R.A.M.C.  An  antigen  prepared 
from  the  Gram-negative  bacilli,  together  with  the  serum  of 
the  above-mentioned  patient,  gave  complete  deviation  of 
complement  in  the  followingxlilutions  : — 


Complement:  M.H.D.  units. 


11 

2| 

3 

. 5 

Antigen  control 

_ 

... 

Patient's  serum 

+ + 

+ f 

+ 

- 

+ No  hfemolysis.  — Complete  hsemolysis. 


In  view  of  the  importance  of  the  above  observation,  it 
was  repeated  with  controls  both  for  the  serum  and  the 
antigen.  The  result  was  as  follows  : — 


Complement : M.H.D.  units. 

1 

2 

3 

Controls 'Antig£n  

- 

- 

- 

( Patient  s serum  

+ 

Tr. 

Test— Patient’s  serum 

+ 

+ 

+ 

Tr.  Almost  complete  haemolysis. 


These  observations  therefore  confirm  the  fact  that  in  this 
case  of  “influenza”  antibodies  were  developed  in  the 
patient’s  serum  in  response  to  the  infection  by  the  Gram- 
negative bacilli  isolated  from  his  blood. 

It  is  of  interest  and  some  importance  that  experiments  on 
the  above  lines  with  sera  from  cases  of  “influenza  ” obtained 
during  the  two  preceding  waves  of  the  disease  also  show 
distinct  deviation  of  complement  with  the  above  antigen. 
The  results  of  these  experiments  will  be  published  shortly. 
It  would  be  valuable  to  carry  out  further  observations  with 
sera  derived  from  recent  cases  of  “ influenza,”  if  such  are 
obtainable,  since  the  above  sera  were  naturally  not  fresh. 

The  organism,  however,  appears  to  bear  some  relation  to 
“ influenza  ” not  only  in  it3  manifestation  in  the  third  wave 
of  the  epidemic,  during  which  the  organism  was  isolated, 
but  to  the  two  preceding  waves.  The  presence  of  antibodies 
in  the  sera  suggests  the  possibility  of  the  preparation  of  an 
antiserum. 

What  relation,  if  any,  this  organism  may  bear  to  the  filter- 
passing virus  described  by  Bradford.  Bashford,  and  Wilson  1 
and  other  observers  cannot  here  be  considered,  but  an 
analogy  may  be  noted  in  the  epizootic  pneumo-  pleurisy  of 
horses,  with  which  the  Gram-negative  Pfeiffer-like  B.  bipolar  is 
equisepticus  is  associated.  In  this  disease  horses  have  been 
infected  with  inflammatory  mucus  at  a stage  of  its  micro- 
scopical sterility.5  B.  bipolar  is  equiseptious  belongs  to  the 
group  of  “pasteurella,”  to  which  also  the  organism  above 
described  may  belong. 

Another  Organism. 

In  addition  to  the  above  Gram-negative  bacillus  another 
organism  has  been  found  in  material  derived  from  widely 


different  sources  in  cases  of  inljpenza.  This  organism  has 
the  following  characters  : — 

Morphology. — Round  or  oval  spores,  4- 5/z  in  diameter, 
staining  deeply  with  Gram  in  young  cultures,  but  showing 
Gram-negative  forms  in  older  cultures.  It  is  aerobic  and 
grows  well  at  37°  C.  on  ordinary  media,  especially  those 
containing  glucose.  On  serum-glucose-agar  it  forms  thick, 
white,  confluent  growths.  Individual  colonies  on  agar  are 
white,  moist,  circular  and  opaque,  1 mm.  in  diameter  or 
upwards.  In  gelatin  stab-cultures  growth  is  confined  to 
needle  track,  and  there  is  no  liquefaction  of  the  medium. 
On  media  containing  glucose  there  is  produced  a sweetish 
odour  of  fermentation.  Dextrose  and  maltose  are  fermented, 
but  not  lactose,  cane-sugar,  mannite,  salicin,  or  inulin.  In 
milk  there  is  no  change,  nor  in  neutral-red  broth.  The 
organism  is  not  pathogenic  to  the  rat  by  intraperitoneal  or 
intrathoracic  injection. 

This  organism  has  been  found  in  cases  of  influenza  in  the 
sputum,  urine,  and  even  in  the  faeces  of  influenza  patients 
affected  with  haemorrhagic  diarrhoea,  and  has  been  isolated 
from  the  sputum  and  from  the  lungs  post  mortem.  The 
interest  which  attaches  to  this  organism  lies,  however,  in 
the  forms  which  are  derived  from  it  in  culture. 

Grown  in  a sterile  hanging-drop  of  glucose-broth,  or  in 
culture  on  serum-glucose-agar,  a remarkable  variety  of 
organisms  is  produced.  Not  only  are  large  hvphal  threads 
obtained,  varying  in  their  reaction  to  Gram  staining,  even 
in  the  same  thread,  and  containing  Gram-positive  spore- 
like bodies,  but  from  the  large  spores  or  the  hyphse  are 
derived  by  budding  coccal  forms.  These  are  seen  as  clumps 
of  cocci,  or  as  oval  or  lanceolate  diplococci,  or  in  chains  as 
diplo-streptococci  or  streptococci  composed  of  elements  with 
flattened  opposed  sides.  These  coccal  forms  vary  greatly  in 
the  reaction  to  Gram  staining,  even  in  young  cultures,  so 
that  in  diplococci  one  element  may  be  Gram-positive  and  the 
other  Gram-negative,  and  similarly  in  the  streptococcal 
chains. 

Certain  forms  intermediate  between  the  finer  hyphal 
threads  and  the  coccal  chains  are  seen  as  pleomorphic 
bacilli  in  rosettes  or  clumps  breaking  down  into  coccal 
elements. 

Mention  may  here  be  made  that  various  forms  resembling 
the  above  have  been  obtained  in  blood  cultures  from  cases 
of  influenza  and  in  sterile  catheter  specimens  of  urine.  In 
sputum,  the  large  spores  or  their  derivatives  can  be  seen 
in  cases  of  influenza,  and  their  presence  may  be  of  value 
in  diagnosis. 

The  organism  thus  derived  from  the  large  spore  shows 
considerable  resemblances  to  the  “Organism  D”  described 
by  Donaldson.2  The  streptococcal  forms  isolated  by  plating 
the  growth  obtained  from  the  large  spores  in  a hanging- 
drop  of  glucose-broth  have,  however,  the  following  characters, 
which  differ  in  some  respects  from  “ Organism  D.” 

Short  chains,  usually  not  more  than  8-12  elements, 
strongly  Gram-positive  in  young  cultures,  but  variable  in 
the  chain  in  older  cultures.  Elements  of  the  chain  composed 
more  often  of  diplococci  with  flattened  opposed  sides  than 
of  lanceolate  forms.  Both  types  are,  however,  seen.  Growth 
on  agar  is  slight  or  absent,  but  on  serum -glucose-agar  or 
blood  media  minute  streptococcal  colonies  are  obtained, 
round,  discrete,  and  raised.  The  colonies  appear  sl'ghtly 
granular  by  transmitted  light.  They  do  not  baemolyse 
blood  media.  A slight  granular  deposit  is  formed  in  broth. 
The  fermentation  reactions  are  acid  in  glucose,  lactose,  and 
maltose,  no  change  in  cane-sugar,  mannite,  salicin,  or 
inulin.  Milk  is  acidified  without  clot.  The  reactions, 
therefore,  differ  slightly  from  those  of  Donaldson’s 
organism. 

The  streptococci  thus  obtained  by  plating,  and  the  staphylo- 
coccal forms,  are  not  pathogenic  to  guinea-pigs.  The 
pleomorphic  bacillary  form  is  also  non-pathogenic  to  the 
guinea-pig. 

It  is  of  interest  to  note  that  by  prolonged  growth  (7  weeks) 
in  a glucose-broth  hanging-drop,  very  minute  coccal  forms 
are  obtained,  reaching  the  limit  of  the  microscopical  powers 
available.  Orookshank  has  recently  emphasised  the 
possibility  of  a relation  between  filter-passers  and  non- 
filter-passers. It  was  noted  in  the  Medical  Review  of  the 
Foreign  Press5  that  strangles  has  been  transmitted  by 
means  of  filtrates  of  infectious  material,  a disease  associated 
with  the  Streptococcus  equi,  which  resembles  the  pleomorphic 
organism  of  Rosenow. 


DR.  EARDLBY  HOLLAND:  ANTENATAL  CARE  [JULY  12,  1919  53 


Thb  Lancet,] 


It  can  be  definitely  stated,  however,  that  the  various  forms 
described  here  are  derived  from  the  large  oval  spore  and  are 
stages  in  the  growth  of  that  organism.  This  suggests  that 
influenza  may  be  of  mycotic  origin.  Further  work  is  needed 
and  is  being  carried  out  on  the  above  organisms.  A state- 
ment, however,  of  the  results  at  present  obtained  seemed 
to  be  of  value.  I am  indebted  to  Lieutenant-Colonel  S.  G. 
Butler,  D.S.O.,  R.A.M.C.,  for  facilities  in  connexion  with 
this  work. 

References.— 1.  MacConkey : Quo'ed  in  Manual  of  Bacteriology. 
Hewlett,  1908,  p.  370.  2.  Donaldson  : The  Lancet,  1918,  ii. , 723. 
3.  Harris:  The  Lancet,  1918,  ii.,  877.  4.  Bradford,  Baahford,  and 
Wilson:  The  Lancet,  1919,  i.,  169.  6.  Medical  Supplement  to  Ihe 
Daily  Review  of  the  Foreign  Frets,  October,  1918,  359.  6.  Crookshank 
The  Lancet,  1919,  i.,  314. 


THE  RESULTS  TO  BE  EXPECTED  FROM 

ANTENATAL  CARE.1 

By  EARDLEY  HOLLAND,  M.D.  Lond.,  F.R.C.S.  Eng., 

PHYSICIAN,  CITY  OF  LONDON  MATERNITY  HOSPITAL  ; ASSISTANT 
OBSTETRIC  PHYSICIAN.  LONDON  HOSPITAL. 


I HAVE  lately  become  convinced  that  both  the  medical  pro- 
fession and  the  lay  public  hav^been  engaged  in  so  impetuous 
a pursuit  of  antenatal  work  that  they  have  not  paused  to 
consider  what  results  they  are  really  justified  in  expecting 
from  it.  What  is  the  extent  to  which  stillbirth  and  infant 
disease  and  mortality  may  be  reduced  by  antenatal  work  1 

Some,  and  they  are  the  vast  majority,  expect  too  much. 
They  believe  that  by  something  wonderful,  almost  magical, 
in  treatment  by  drugs,  diet,  rest,  and  general  hygienic 
measures  almost  every  fcetus  doomed  to  death  or  disease  may 
be  made  into  a healthy  infant.  Others,  who,  I am  glad  to 
say,  form  a very  small  minority,  are  convinced  that  antenatal 
care  will  do  positive  harm  by  preserving  the  lives  of  those 
who  would  only  become  unfit  and  degenerate  racial  undesir- 
ables. It  is  easy  enough  to  refute  such  a crude  opinion  as 
this,  but  the  fact  that  it  exists  should  make  us  all  the  more 
careful  to  be  equipped  with  facts  and  figures  in  our  advocacy 
of  antenatal  work. 

The  Need  of  Standardised  Records. 

The  time  has  come  for  us  to  make  an  assessment  of  our 
antenatal  work  ; to  balance  our  accounts  and  to  find  out 
what  are  our  profits  in  relation  to  our  capital  outlay  and 
expenditure.  The  amount  of  time,  energy,  and  labour  put 
into  antenatal  work  at  the  present  day  is  very  great.  Do 
the  benefits  gained  therefrom  represent  a big,  a moderate, 
or  only  an  insignificant  profit  ? We  have  got  to  find  out 
whether  our  results  justify  our  work.  This  paper  has  been 
written  with  that  object,  though  the  facts  at  present  at  my 
disposal  do  not  allow  me  to  do  more  than  generalise.  I 
hope  to  show  that  the  present  rate  of  foetal  mortality  is 
capable  of  being  reduced  by  about  one-half.  But  this  end 
cannot  be  attained  by  antenatal  methods  alone  ; for  not 
only  are  the  majority  of  foetal  deaths  beyond  the  realm  of 
antenatal  care,  since  they  are  the  direct  result  of  the  acci- 
dents and  complications  of  labour,  but  antenatal  care  itself 
depends  for  its  successful  fulfilment  on  a high  standard  of 
midwifery.  Without  wishing  for  a moment  to  minimise  the 
importance  of  the  antenatal  period,  I desire  to  draw  atten- 
tion to  the  even  greater  importance  of  the  intranatal  period 
of  foetal  existence. 

I should  like  to  see  records  kept,  on  a standardised  system, 
at  every  large  maternity  centre  ; this  might  well  be  insisted 
on  by  the  State  department  which  subsidises  such  centres. 
From  the  records  of  pregnancy,  of  labour,  and  of  the  year 
subsequent  to  labour,  both  for  the  mother  and  the  infant,  we 
should  be  able  to  state  the  profits  of  our  enterprise.  We 
should  know  how  many  foetuses  were  saved  from  probable 
death  during  pregnancy,  how  many  from  death  or  injury 
during  labour ; how  many  mothers  were  spared  serious 
illness,  or  possible  death,  from  the  diseases  of  pregnancy  and 
the  injuries  of  labour. 

The  only  records  of  pregnancy  that  have  been  published 
on  these  lines,  so  far  as  I am  aware,  have  come  from  the 
pregcancy  clinic  of  the  Boston  Lying-in  Hospital.  Dr.  F.  S. 


1 A paper  read  on  July  1st  at  the  National  Conference  on  Infant 
Welfare  organised  by  the  National  Association  for  the  Prevention  of 
Infant  Mortality. 


Kellog  considers  what  complications  of  pregnancy  were 
found  amongst  4996  cases.  I will  quote  his  own  words  : — 

“Of  these,  1524  showed  some  abnormality  in  pregnancy, 
30  per  cent. ; albuminuria  without  other  signs  of  toxmmia, 
361,  7 per  cent,  of  all  cases,  23  per  cent,  of  abnormal  cases  ; 
elevated  blood-pressure  without  other  signs  of  toxmmia, 
259  cases,  5 per  cent,  of  all  cases,  16  per  cent,  of  abnormal 
cases;  definite  symptoms  of  tosexmia,  195  cases,  4 per  cent, 
of  all  cases,  12  per  cent,  of  abnormal  cases;  contracted 
pelvis  of  varying  degree,  401,  8 per  cent,  of  all  cases,  26  per 
cent,  of  abnormal  cases;  heart  lesions,  111  cases,  2 per  cent, 
of  all  cases,  7 per  cent,  of  abnormal  cases  ; phthisis, 
10  cases;  antepartum  haemorrhage,  33  cases,  which  is 
07  per  cent,  of  all  cases;  pyelitis,  20  cases;  syphilis  21 
cases;  gonorrhoea,  10  cases;  chronic  nephritis,"  5 cases; 
diabetes,  3 cases;  with  occasional  cases  of  fibroids  in  the 
lower  segment,  ovarian  cysts,  and  other  complications  to 
the  number  of  30;  also  a large  number  of  severe  varicosities 
of  the  leg,  and  a small  number  of  antepartum  phlebitis. 
These  figures  establish  the  fact  that  pregnancy  is  not  the 
normal  physiological  process  it  is  so  broadly  considered,  and 
that  prenatal  care  is  valuable  in  30  per  cent,  of  pregnancies 
that  are  in  some  degree  abnormal ; and  that  the  only  way 
to  include  this  30  per  cent,  is  to  give  it  to  all ; and  that  with 
4 per  cent,  of  all  pregnancies  showing  definite  toxaemic  and 
pre-eclamptic  symptoms,  2 per  cent,  of  all  pregnancies 
showing  heart  lesion,  8 per  cent,  of  all  pregnancies  showing 
some  degree  of  contracted  pelvis,  07  per  cent,  of  all 
pregnancies  showing  antepartum  bleeding,  to  go  no  further, 
prenatal  care  is  not  only  valuable,  but  is  essential.” 

What  is  the  Object  of  Antenatal  Work  ? 

Antenatal  work  has  for  its  aim  the  great  economic 
principle  of  the  prevention  of  waste.  I am  here  dealing 
only  with  the  foetus  ; the  mother  is  another,  a bigger,  and 
— in  my  opinion — an  even  more  important  problem  in  rela- 
tion to  antenatal  work.  I will  merely  mention  that  maternal 
mortality  and  morbidity  are  enormously  greater  in  cases  of 
dead  birth  than  of  live  birth.  This  is  obvious,  since  the 
birth  of  a dead  foetus  is  usually  the  consequence  either  of  a 
pregnancy  disease  or  of  a severe  labour,  with  the  added  risks 
of  maternal  injury  or  puerperal  sepsis. 

Quite  apart  from  the  waste  of  infants,  it  does  not  need  a 
professional  economist  to  appreciate  the  waste  involved  by 
the  birth  of  a dead  foetus.  At  the  best  there  is  a waste  of 
time,  a waste  of  energy,  a waste  of  health,  and  a waste  of 
money  and  material,  distributed  amongst  the  mother  and 
family,  the  doctor,  midwife  and  nurse,  the  National  Health 
Insurance  sickness  and  maternity  benefits.  At  the  worst 
there  may  be  added  to  these  permanent  harm  to  the  mother’s 
health  or  even  the  loss  of  her  life.  The  maternal  mortality 
from  childbirth  is  well  enough  known,  but  we  have  only  a 
glimmering  of  the  severe  and  slight  illnesses  that  result  from 
childbirth.  We  have  not  accurate  figures  for  this,  but  they 
can  and  must  be  got.  As  some  indication  I have  found  that 
40  per  cent,  of  the  patients  who  come  to  my  gynaecological 
out-patients’  department  at  the  London  Hospital  come 
because  of  some  post-parturient  disease,  usually  only  of  a 
minor  nature,  but  all  the  same  it  is  enough  to  produce 
temporary,  if  not  permanent,  discomfort,  or  invalidism,  or 
sterility.  The  only  thiDg  that  can  convert  waste  into  gain  ; 
that  can  compensate  for  the  discomfort,  expense,  and  danger 
of  child-birth,  is  the  birth  of  a healthy  infant.  This  is  the 
object  of  antenatal  care. 

Let  us  consider  what  influence  the  reduction  of  foetal 
mortality  is  likely  to  have  on  the  birth-rate.  The  desirability 
or  otherwise  of  raising  the  birth-rate  is  a controversial 
point  I will  leave  alone.  The  dead  birth-rate  for  viable 
foetuses  is  about  3 per  cent.  Supposing  we  could  by  ante- 
natal work  reduce  foetal  mortality  by  one  half,  and  thus  cause 
an  annual  addition  of  about  12,000  infants  to  the  popula- 
tion, would  the  birth-rate  be  thereby  very  much  influenced  ? 
A birth-rate  of  20  per  1000  would  only  be  raised  to  20  3. 
The  reduction  of  the  dead  birth-rate  by  one  half  would  be 
a most  remarkable  achievement,  but  it  would  only  raise  the 
live  birth-rate  by  a fraction.  If  it  is  desirable  to  raise  the 
live  birth-rate  there  are  quicker  and  more  certain  methods 
of  doing  so  than  antenatal  care.  There  is  a great  deal 
of  confused  thought  and  loose  writing  about  the  tens  of 
thousands  of  babies  lost  annually  to  the  State  from  early 
abortion  and  dead-birth,  excusable  because  it  is  good 
propaganda.  The  birth-rate  is  governed  by  profound 
economic  factors  beyond  the  influence  of  obstetrical  science. 
If  obstetrical  science  could  bring  it  about  that  every  con- 
ception reached  healthy  maturity  the  result  would  soon  be  a 
reduction  in  the  number  of  conceptions. 


54  The  Lancet,] 


DR.  EARDLEVT  HOLLAND:  ANTENATAL  CARE. 


[July  12, 1919 


Importance  of  Improved,  Intranatal  Care. 

Leaving  now  the  objects  for  which  antenatal  work  strives, 
if  results  as  regard. , f«* 

^.0“^  L’“  Sial  "“'“"V  eon. 
”I°»tion  o?  S aints  1 the ^istrlbataon . of  *«<»«» 
of  foetal  deaths  amongst  the  3 per  cent,  death-rate^  an 
the  preventive  means  at  our  disposal  implied  byfche 
expression  ‘ ‘ antenatal  care."  We  *ou>d  ‘h"s  Wb‘e  *o 
divide  foetal  death  into  two  classes,  (1)  Pr^entablean 
C2l  not  preventable,  always  with  the  sure  hop  J 

scienUfic^eseareh,  the  class ‘‘preventable’’ maybe  constantly 
recruited  from  the  class  “ not  preventable. 

Foetal  death  may  occur  during  one  of  two  P®r‘0<?s J fae 

during  the  long  quiescent  period  of  pregnancy, 
onset°of  labour— the  antenatal  period-o,  dan.g ; the  she., 
stormy  period  of  labour— the  intranatal  period.  In  fcb®  sa 
way“ve  must  divide  our  preventive  methods,  our  means  for 
preserving  the  life  and  health  of  the  foetus,  into  two  distinct 
classes — antenatal  methods  and  intranatal  methods.  By 
intranatal  methods  I mean  the  management  of  labour 

normal  or  complicated.  One  of  the  chief  pom  to 

make  is  the  immense  importance  in  the  prevention  of  total 
death  of  the  management  of  the  intranatal  period^  . d 

V.esitate  to  say  that  more  foetuses  can  be  saved  by  improved 
intvanntal  care  than  by  antenatal  caie. 

“if series  of  cases'of  dead  birth  be  investigate l the  first 
great  fact  to  become  clear  is  that  more  foetuses  are  killea 
during  labour  from  injury  or  accidental  complications  than 
die  during  pregnancy  from  to*al  or  maternal  diseas  ■ 
foetus  that  dies  during  the  antenatal  period  is  u^aUy  bom  i 
a state  of  maceration  ; one  that  dies  during  the  intranatal 

neriod  is  in  a fresh  condition.  .. 

P Out  of  every  100  dead-born  viable  foetuses  you . will 
generally  find  about  60  fresh  and  40  macerated.  Although 
the  fresh  foetuses  will  include  a few  that  have  died  fro 
antenatal  causes  shortly  before  the  onset  of  labour  it  is 
reasonably  accurate  to  state  that  60  per  cent,  of  fetal 
mortalitv  is  due  to  the  accidents  and  complications  of 
labour  In  other  words,  60  per  cent,  are  cases  of  intranatal 
death  and  40  per  cent,  of  antenatal  death.  This  alone  is  an 
indication  of  the  immense  importance  of  improved  intianatal 
methods  for  the  reduction  of  foetal  mortality. 

Relation  of  Antenatal  to  Intranatal  Work. 

Another  point  which  leads  to  the  same  conclusion  is  that 
antenatal  work  depends  on  a high  standard  of  intranatal 
work  for  the  fulfilment  of  its  aims.  Antenatal  work  is  the 
strategy,  intranatal  work  the  tactics  of  preventive  obstetrics. 
Consider  for  a moment  the  investigations  we  make  at  an 
antenatal  clinic  : (1)  We  measure  the  pelvis  and  estimate 
the  relative  sizes  of  the  pelvis  and  total  head,  for  we  kno 
the  disasters  of  labour  with  a contracted  pelvis  ; (2)  we  find 
out  the  presentation  of  the  foetus,  for  we  know  that  breech- 
labour  has  an  apppeciable  total  mortality  ; (3)  we  test  the 
urine  for  we  know  the  consequences  of  untreated  toxaimia 
of  pregnancy  ; (4)  we  get  the  history  of  former  pregnancies 
and  labours,  which  often  puts  us  on  the  track  of  syphilis  ; 

(5)  we  examine  the  pelvic  cavity  for  obstructive  tumours  ; 

(6)  we  investigate  the  general  health  of  the  mother,  though 

we  know  that,  with  rare  exceptions,  the  only  unhealthy 
states  of  the  mother,  apart  from  the  toxaemia  of  pregnancy, 
that  cause  total  death  are  syphilis  and  renal  disease,  ihe 
list  seems  short  enough,  but  its  length  is  by  no  means 
commensurate  with  its  great  importance.  , 

Now  let  us  consider  the  treatment  we  adopt  as  the  resu  t 
of  the  above  investigations.  We  find  it  is  chiefly  intranatal. 
The  only  purely  antenatal  treatment  consists  in  the  treat- 
ment of  syphilis  and  in  the  treatment  of  the  appropriate 
cases  of  toxaemia  of  pregnancy  or  of  chronic  renal  disease  by 
the  simple  means  of  diet,  rest,  and  aperients.  Otherwise  we 
depend  on  the  induction  of  premature  labour,  Caesarean 
section,  or  on  the  careful  management  of  labour  with 
instrumental  assistance  when  occasion  demands. 

Causation  of  Foetal  Death. 

I will  now  deal  with  the  causes  of  total  death  and  will  try 
to  indicate  how  many  deaths  are  preventable,  with  special 
reference  to  the  value  of  antenatal  care  in  achieving  this 
object.  There  is  no  need  for  me  to  enter  in  detail  into  these 
causes,  for  this  part  of  the  subject  has  already  been  dealt 
with  by  Dr.  Amand  Routh. 


SSwSESSSS 

Enable  Syphilis  heads  the  list  of  deaths  amongst  macerated 
SSgi  ctoSo  r«!l andotb.r  material  di.ea.ee  and  severe 

irsrswf 

^r^*— 

haemorrhage  instrumental  or  natural  delivery  through  a con- 
tracted  pel v j g°  breech  presentation,  delivery  by  version 
delayed  labour  from  whatever  cause,  prolapse  of  the  cord 
aelayea  laD“ur  f The  most  striking  fact  of  all 

these  fresh  dead-bon, 

show  on  post-mortem  examination,  severe  cer®b[al  J { 
the  form  of  cerebral  bamorrage  and  tearing ^caused  by 
the  dura  mater;  such  injuries  could  only  be  cans  y 
excessive  cranial  stress  during  labour. 


Consideration  of  Cavses  of  Foetal  Death  in  Regard  to  Prevention. 

I will  now  try  to  work  out  how  many  of  these  fatahties 

11L  the  cases  in  broad  clinical  groups.  In  giving  the 
percentage  frequency  “jLfent 

fofthe'purpose,  as  . can  only  W ;*<-£•  what  ^ he 
^ses'o^preve^ive  treatment  ne^can  cinveSien.ly  piece  al. 

J'  antenatal  pmdod  and  ^“S^cHS 

th.aial“°o°f  which  can  be  discovered  daring  the 
antenatal  period  bat  ^chdepend  for  ‘heir  Pjven  .on  ^ 

‘srl.rtSve,ia6,!ry“roS5. 

obstetrical  treatment  can  be  *nned.  and  wd.  ^e.ther 

wmsm 

prolonged.0  labour  from 

“h“mo”hag . Kg  of  tbe  septa  of  the 

‘"neh  t m cause  of  foetal  death  cannot  be  determined. 

£ rs 

area'ofeSplacenta  by  infarction,  tb.se  cases  in  -hint .abloom 

clot  is  found  behind  the  placenta.  /hrtSSbdns,  and 
total  deformity  such  as  anencephaly.  hydrocepnai 

(Edematous  states  of  the  foetus. 


The  Lancet,] 


MR.  W.  0.  RIVERS  : PNEUMOKONIOSIS  IN  MAN  AND  HORSE. 


[July  12,  1919  55 


The  Respective  Value  of  Preventive  Methods. 

I will  now  attempt  to  make  a rough  estimate  of  how  many 
foetal  deaths  are  preventable  and  how  many  are  not  pre- 
ventable, and  will  give  a rough  indication  of  the  preventive 
part  played  by  antenatal  methods  alone,  by  combined  ante- 
and  intranatal  methods,  and  by  intranatal  methods  alone. 


Inci- 

Prevent- 

Ante- 

Ante  and 

Intra- 

dence. 

able. 

natal. 

intranatal. 

natal. 

Syphilis  

15 

15 

15 

Toxsemiaof  pregnancy ... 
Complications  of  labour  ) 

10 

6 

3 

3 

(including  antepartum  > 
haemorrhage)  ) 

50 

30 

1 

9 

20 

Chronic  renal  and  other  ( 

_ 

1 

1 

maternal  diseases  ...  j 

Cause  undeterminable ... 
Relative  placental  in-  ) 

12 

0 

sufficiency  and  retro-  > 
placental  clot  ) 

6 

0 

Fcetal  deformities 

5 

0 

— 

100 

52 

20 

12 

20 

It  is  thus  demonstrable  that  out  of  the  50  percent,  of  foetal 
deaths  which  are  theoretically  preventable,  about  20  per 
cent.,  of  which  three-quarters  are  syphilis,  could  be  pre- 
vented by  antenatal  methods  alone.  We  see  that  12  per  cent, 
depend  for  their  prevention  on  combined  antenatal  and 
intranatal  methods,  and  20  per  cent,  on  intranatal  methods 
alone. 

The  point  to  which  the  foregoing  line  of  reasoning  has 
brought  us  is  that  although  antenatal  work  is  of  immense 
importance,  and  we  must  not  abate  by  one  jot  our  enthusiasm 
for  it,  yet  the  importance  of  the  intranatal  period  and  the 
necessity  of  getting  a better  standard  of  midwifery  must  be 
recognised  much  more  than  it  is  at  present.  This  conclusion 
is  forced  on  us  when  we  realise  that  the  majority  of  dead 
foetuses  have  met  their  death  in  the  intranatal  period,  that 
many  cases  of  intranatal  fcetal  death  occur  from  causes 
beyond  the  control  of  antenatal  care,  and  that  antenatal  care 
itself  depends  on  intranatal  skill  for  its  successful  issue. 

In  conclusion,  I would  appeal  to  this  great  National  League, 
which  has  already  done  so  much  for  maternity  and  child 
welfare,  to  use  its  influence  in  helping  to  bring  about  a 
higher  standard  of  midwifery  practice— an  end  which  can 
only  be  attained  through  the  better  teaching  of  midwifery 
to  medical  students,  midwives,  and  post-graduates  alike,  and 
by  the  establishment  of  enough  maternity  homes  and  hospitals 
to  meet  the  needs  of  our  population. 


PNEUMOKONIOSIS  IN  MAN  AND  HORSE. 

By  W.  C.  RIVERS,  M.R.C.S.,  D.P.H., 

I TUBERCULOSIS  OFFICER,  BARNSLEY  DISTRICT,  WEST  RIDING,  YORKS. 


When  dealing  with  nasal  defect  and  mouth-breathing1  as 
iontributory  causes  to  pulmonary  tuberculosis  I brought 
Eorward  among  a priori  arguments  the  fact  that  the  Equidse, 
which  breathe  exclusively  by  the  nose,  very  rarely  suffer 
Erom  tuberculosis  (especially  the  pulmonary  form),  although 
ao  better  housed  than  cattle,  which  are  very  subject  to  that 
lisease  and  possess  an  air-way  by  the  mouth.  The  thought 
occurred  that  it  would  be  interesting  in  this  connexion  to 
;est  the  comparative  incidence  of  pneumokoniosis  in  man 
ind  horse  working  in  dusty  occupations,  as  in  coal-mines. 
Accordingly,  investigation  and  inquiry  were  begun. 

Vie?vs  of  Various  Investigators. 

Veterinary  authorities  agree  that  pneumokoniosis  is  very 
are  in  horses.  Smith  2 says:  “There  is  no  such  thing  as 
niners’  lung  amongst  them  (coal-pit  ponies),  though  many 
lever  come  to  the  surface  for  years.”  Coal-dust  is  not 
nentioned  amongst  the  causes  of  equine  interstitial  pneu- 
noniain  Friedberger  and  Frohner’s  work.3 4  It  is  put  last  in 
he  list  of  such  causes  by  Hoare,1  and  pneumokoniosis  is 

1 Three  Clinical  Studies  in  Tuberculous  Predisposition.  London: 
Ulen  and  Unwin.  1917. 

2 F.  Smith  : A Manual  of  Veterinary  Hygiene,  London,  1905 

•>  Fnedberger  and  Frohner : Veterinary  Pathology,  translated  bv 
4-  H.  Hages,  London,  1905. 

4  E.  W.  Hoare  : A System  of  Veterinary  Medicine,  ii„  889. 


stated  to  be  only  an  occasional  form  of  equine  chronic 
pneumonia. 

Professor  McQueen  of  the  Royal  Veterinary  College, 
Camden  Town,  kindly  informed  me  that  miners’  lung  was 
very  rare  in  pit  ponies.  He  added  that  an  unpublished 
post-mortem  investigation  of  pit  ponies’  heads  (in  relation  to 
possible  penetration  of  the  facial  sinuses  by  the  coal-dust) 
revealed  that  the  dust  was  nearly  all  stopped  at  the  nose. 
Messrs.  R.  C.  Trigger  and  W.  Trigger,  F.R.C.V.S.,  who 
furnished  the  material,  told  me  that,  clinically,  any  lung 
disease  is  highly  uncommon  in  pit  ponies,  who  nearly  all 
cease  work  from  old  age.  The  latter  added,  however, 
“Post-mortem  examination  often  reveals  extensive  anthra- 
cosis  in  an  otherwise  perfectly  healthy  lung  and  no 
symptoms  in  life.” 

Other  sources. — In  the  Rand  gold-mines,  so  Mr.  Alex. 
Richardson  kindly  writes,  no  animals  are  used  for  haulage 
purposes  ; some  years  ago  a few  mules  were  employed,  but 
nothing  is  discoverable  as  to  their  health.  Dr.  Johnson  5 
kept  white  rats  continuously  down  a Witwatersrand  mine  in 
the  dustiest  spot,  their  conditions  of  life  being  much  worse 
than  those  of  the  miners.  They  developed  silicosis  but  not 
tuberculosis ; their  general  health  was  quite  unaffected. 
Rats  breathe  through  the  nose  exclusively.  In  a discussion 
following  this  paper  the  opinion  was  expressed  that  if  the 
rats  had  been  brought  up  out  of  the  mine  regularly  like  the 
men  they  would  have  developed  hardly  any  silicosis  in  five 
years. 

In  Cornwall,  Dr.  Tonking.  whose  work  on  the  local  miners’ 
phthisis  is  well  known,  tells  me  that  there  are  no  ponies 
underground  in  the  Camborne  district.  In  the  St.  Just 
area  one  mine  uses  them,  but  there,  so  Dr.  Nesbitt  is  good 
enough  to  report,  no  silicosis  or  miners’  phthisis  exists,  save 
a few  cases  returned  from  South  Africa. 

At  Gartverrie,  Scotland,  the  manager  of  the  ganisfer- 
mine  there  (ganister,  a component  of  firebrick,  & c. , is  a 
great  source  of  silicosis)  tells  me  that  men  and  horses  work 
practically  in  an  open  quarry  and  that  silicosis  in  either  is 
unknown. 

In  a discussion  following  a paper  by  Dr.  Haldane,  F.R.S.,0 
Sir  H.  Cunningham  said  the  dust 'of  the  mines — this  dust 
was  not  only  coal,  but  also  stone  or  shale  put  down  to  lessen 
risk  of  coal-dust  explosions — did  not  hurt  the  pit  ponies. 
Another  speaker  instanced  a pony  which  had  worked  in  very 
dusty  parts  of  a mine  for  many  years.  It  was  shot,  and  on 
examination  no  dust  was  found  in  the  lungs.  Dr.  Haldane 
related  having  examined  coal-pit  ponies  killed  in  an 
explosion,  and  having  been  struck  with  the  small  amount  cf 
dust  in  their  lungs,  which  were  comparatively  pink.  He 
supposed  that  the  ponies’  noses  filtered  the  dust  off.  Fit 
ponies  all  looked  well  and  lived  for  many  years. 

Lastly,  there  is  the  case  of  the  great  Alpine  tunnels,  in 
making  which  men  and  horses  were  employed  ; it  is  certain 
that  formerly  both  suffered  a high  mortality.  The  causes  of 
death  in  the  men  are  given  as  ankylostomiasis  and  “acute 
bronchial  and  pulmonary  catarrhs.”  There  is  little  mention 
of  tuberculosis  or  chronic  pulmonary  disease.  What  the 
horses  died  from  1 have  not  been  able  to  ascertain.  But  it 
is  stated  that  there  was  a very  high  C02  content  in  the 
tunnel  air,  often  exceeding  15  per  1000,  so  that  the  railway 
metals  were  chemically  affected.  This  would  probably  lead 
to  acute  pulmonary  ailments  in  the  horses  too;  a certain 
incident  related  to  me  in  connexion  with  coal-pit  ponies 
seems,  at  any  rate,  to  suggest  so. 

Author's  Investigations. 

My  district  contains  many  mines. 

Coal-mines. — I have  visited  three,  one  employing  over  200 
ponies.  What  I heard  and  saw,  with  one  exception,  entirely 
confirmed  the  preceding  literature.  There  were  no  lung 
ailments  among  them  ; they  were  hardly  ever  sick  ; they 
were  invalided  for  old  age;  their  average  working  life  was 
13  years  ; and  so  on.  Certainly  they  all  looked  fat  and  well, 
and  did  not  cough  ; many  were  obviously  old.  They  never 
came  to  the  surface  except  during  a strike.  The  exception 
spoken  of  was  that  in  one  pit  the  stables  had  once,  for  the 
sake  of  proximity  to  work,  been  put  in  the  ‘ ‘ return  ” air-way. 
The  ventilation  of  a coal-mine  is  artificial,  and  for  this 


5 J.  P.  Johnson : Journal  of  the  Chemical,  Metallurgical,  and 
Mining  Society  of  South  Africa,  March,  1917. 

6 J.  S.  Haldane;  The  Effects  of  Dust  Inhalation,  Institution  of 
Mining  Engineers  Annual  Meetiug,  London,  June,  1918. 


56  The  Lancet,]  DR.  J.  GEOGHEGAN  : TUBERCULOSIS  FROM  A WEST  INDIAN  STANDPOINT.  [July  12, 1919 


purpose  there  are  mostly  two  sides  to  a mine,  separated  by  a 
double  set  of  doors  having  a dead  space  between.  On  the 
one  side  is  the  incoming  good  air  from  the  surface,  on  the 
other  the  outgoing  or  return  current.  The  latter  is  stated 
not  to  be  more  dusty  than  the  former,  but  to  contain  some 
CH4  and  a higher  percentage  of  C02.  After  these  ponies 
had  lived  for  a little  in  this  chemically  somewhat  deteriorated 
“return”  air,  against  which  the  nasal  filter  would  be  no 
protection,  they  panted  and  wheezed,  and  one  or  two  died. 
On  changing  the  stables  back  to  the  intake  air- way  the  ponies 
regained  their  health.  It  is  allowable  to  suppose  that  a good 
deal  of  the  equine  mortality  in  the  old  Alpine  tunnel-making 
arose  in  this  way. 

Ganistcr-mines.  — I have  visited  six  mines  and  made 
inquiries  as  to  six  more.  Of  these  12,  four  employed  ponies 
underground  ; the  largest  number  at  any  pit  was  five.  The 
reports  were  that  the  health  of  the  animals  was  excellent. 
However,  it  appeared  that  the  conditions  as  regards  possi- 
bility of  dust  inhalation  were  better  for  the  ponies.  They 
being  required  for  traction  purposes,  waited  in  the  road- 
way while  the  men  were  engaged  at  near  quarters  with  the 
mineral.  This  was  so  at  three  of  the  four  mines,  including 
the  one  in  which  human  silicosis  was  most  common.  At  the 
fourth  the  conditions  under  which  human  and  equine  workers 
were  employed  were  described  as  being  about  equal.  At  this 
place  it  was  claimed  that  an  improved  system  of  ventilation 
had  practically  abolished  silicosis,  but  I was  told  that  when 
the  disease  was  common  in  the  men  nothing  analogous  was 
noticed  in  the  ponies,  and  a mule  had  worked  for  20  years  in 
good  health.  In  all  these  ganister-mines  the  ponies,  unlike 
coal-pit  ponies,  were  stabled  above  ground,  coming  up  after 
a shift  of  work.  The  shallower  depth  and  smaller  extent  of 
the  workings  facilitated  this  practice. 

Conclusions. 

It  will  be  admitted  that  the  trend  of  the  above  evidence  is 
in  favour  of  horses  being  much  less  liable  to  pneumokoniosis 
than  man  is,  and  that  there  is  some  reason  to  think  their 
exclusive  nasal  breathing  responsible  for  this.  With  this 
result  may  be  usefully  coupled  another  similar  one  already 
mentioned— namely,  that#horses  are  also  much  less  prone 
than  man  is  to  tubercle,  especially  pulmonary  tubercle. 

Does  the  same  explanation  hold  ? At  all  events,  it  is  made 
more  likely  by  the  way  this  comparison  of  human  and  equine 
pneumokoniosis  has  turned  out.  Laboratory  experiments 
on  phthisiogenesis  have  often  consisted  in  making  animals 
inhale  or  ingest  dust,  and  mine  experience  is  obviously 
superior,  in  actuality  and  correspondence  to  natural  condi- 
tions, to  laboratory  experiment.  Parenthetically,  it 
contradicts  the  conclusions  of  the  school  of  Calmette  as 
to  the  alimentary  origin  of  pulmonary  tubercle,  conclusions 
already  assailed  by  Cornet,  a fellow  bacteriologist.  For 
these  coal-pit  ponies,  although  their  food  is  now  brought 
down  fresh  to  them  every  day  or  two,  must,  by  living  in  a coal- 
pit for  years  and  champing  their  bits  when  at  work,  swallow 
oreat  quantities  of  coal-dust ; they  must  swallow  much  more 
than  the  men  do.  Yet  Dr.  Haldane  finds  their  lungs  much 
less  black  than  the  men’s. 

The  freedom  of  horses  from  pulmonary  tubercle  cannot, 
on  the  other  hand,  be  explained  by  specific  humoral 
insusceptibility,  as  witness  the  experiments  of  MacFadyean, 
Ravenel,  and  Griffiths  of  artificial  inoculation  of  horses  with 
tubercle,  in  which  copious  pulmonary  lesions  were  produced 
or  fatal  results  reached.  Again,  specific  humoral  insuscepti- 
bility to  tubercle  would  explain  nothing  of  horses’  freedom 
from  pneumokoniosis.  Exclusive  nasal  respiration  will 
explain  both,  and  in  addition  the  especial  rarity  of  the 
pulmonary  location  of  natural  equine  tuberculosis. 

So  much  for  deductions  as  to  the  pathogeny  of  tubercu- 
losis and  ordinary  consumption.  As  for  the  bearicg  upon 
silicosis  and  miners’  phthisis,  it  would  be  of  advantage  to 
have  more  observations.  The  number  of  ganister  pit-ponies 
is  so  very  few,  seeing  that  the  district  I haie  spcken  of 
contains  the  majority  of  these  mines  in  the  whole  country. 
Something  should  be  learnt  from  exposing  ponies  or  mules 
to  the  same  conditions  in  South  African  and  Cornish  mines 
as  produce  human  miners'  phthisis,  or  to  rather  more  severe 
ones.  The  white  rat  is  not  a good  animal  for  experiment  in 
this  connexion,  it  being  notoriously  resistant  even  to  artificial 
inoculation  with  tubercle7 ; whereas  horses  are  distinctly  less 
difficult. 

■ see  Cobbett  The  Causes  of  Tuberculosis,  Cambridge,  1917,  p.  4W. 


In  the  prophylaxis  of  the  grave  South  African  silicosis  it 
might  be  worth  trying  if  measures  like  oral  obturators,  as 
also  nasal  irrigation  after  work,  were  possible  in  practice. 
In  the  few  cases  of  clinical  anthracosis  and  typical  fibroid 
phthisis  (other  than  those  in  men  who  work  in  stony  parts  of 
the  mine,  roof  tenders,  and  so  forth)  that  one  meets  with  in 
colliers,  I have  been  struck  with  the  frequency  with  which 
such  subjects  showed  a wide  atrophic  nose,  which  would  be 
useless  as  a dust-filter.  The  effect  of  all  continuous  dust 
inhalation  is  to  cause  some  slight  degree  of  intranasal 
atrophy,  but  if  a man  came  to  this  work  already  nasally 
atrophic  his  lungs  would  obviously  be  at  a great  disadvan- 
tage. Saenger 1 said  that  in  workers  in  dusty  trades  those 
with  wide  nasal  passages  showed  dust  in  the  respiratory 
tract  as  far  down  as  the  trachea,  which  was  not  the  case 
when  the  nasal  fcssae  were  of  normal  size. 

I wish  to  express  thanks  to  all  of  my  informants. 


8 Saenger:  Centralbiatt  fur  Innere  Medicin,  March  19 -b,  1893,  No.  11. 


TUBERCULOSIS  FROM  A WEST  INDIAN 
STANDPOINT.* 

By  JOSEPH  GEOGHEGAN,  M B..  F.RC.SE, 

TEMP  CAPTAIN.  R.A.M.C.  ; SURGICAL  SPECIALIST.  BELFAST  DISTRICT  I 
LATE  GOVERNMENT  MEDICAL  OFFICER,  TURKS  ISLANDS,  ETC. 


The  Turks  and  Caicos  Islands  form  the  southern  end  of 
the  arc  of  the  Bahamas,  but  are  attached  to  the  government 
of  Jamaica.  GrandTurk  is  the  capital.  The  population,  of  5615 
by  the  Census  of  1911,  is  of  the  usual  original  negroid  stock 
with,  in  cases,  a dilution  of  white  blood  ; there  are  a small 
number  of  whites  to  whom  the  remarks  here  made  do  not 
apply.  The  people  are  of  a hardy,  sturdy  type,  usually 
good  boatmen,  living  by  work  on  the  salt-ponds— which  give 
the  staole  product  of  the  Dependency— sponging,  and 
plantation  labour,  the  last  in  a restricted  and  limited  way. 
The  islands  are  very  barren  ; water  is  scarce,  largely 
dependent  on  the  small  rainfall.  The  climate  is  warm  but 
tempered  by  cool  trade  winds. 


Mortality  from  Tuberculosis. 

During  the  quinquennium  1909-13,  of  the  total  deaths 
registered  in  Grand  Turk,  the  percentage  recorded  as 
due  to  tuberculosis  was  14  4,  indicating  about  4 per  1000  of 
the  population.  No  information  is  available  as  to  the  other 
settlements  of  the  colony  as  a whole. 

The  corresponding  rate  in  England  is  under  1.  In  the 
15  largest  towns  of  Scotland  the  quinquennial  rate 2 at 
slightly  over  1]  (16)  is  the  same  as  that  for  the  United 

States  of  America.  , _ , ™ . 

Comparison  instituted  between  these  figures  and  West 
Indian  statistics  is  not  to  the  benefit  of  the  latter.  In 
Jamaica1  the  death-rate  per  1000  is  under  2;  3 5 for 
Kingston.  In  Grenada 1 for  quinquennium  to  1913  the  per- 
centage of  deaths  due  to  tuberculosis  was  5 72  ; 10  41  for 
the  town  of  St.  George.  In  St.  John’s,  Antigua/  6 13  per 
cent  In  Trinidad  (and  Tobago)  for  quinquennium  (1909-13) 
2 1 per  1000;  5 2 for  the  capital,  Port  of  Spain.  In  the 
Bahamas  the  disease  is  said  to  be  rife.  Dr.  Godfrey 
points  out  for  British  Guiana  that— 

“ the  crowded  villages  near  Georgetown  and  along  the  west 
bank  of  the  Demerara  River  show  phthisical  death-rates  of 
4-2  and  4 3 per  1000  living,  while  the  less  crowded  and 
scattered  villages  of  the  east  bank  and  of  the  sea-coast 
have  lower  rates,  2 2 and  2-8  respectively  On  the  sugar 
plantations,  where  overcrowding  is  forbidden  and  where 
regular  life  obtains,  the  average  phthisical  death-rate  during 
the  vears  1907  to  1910  is  1Y5  per  1000,  while  in  1911  the  rate 
is  0 9,  which  compares  most  favourably  with  any  civilised 

country.”  . , 

The  histories  of  two  families  illustrate  certain  aspects  of 
the  question  ; the  number  could  be  readily  amplified. 

Summed  up,  there  is  in  one  family  the  case  of  a girl  dying 
of  the  disease  ; her  mother  is  now  affected  ; amongst  the 
family  a young  man,  her  uncle,  dies  of  the  disease,  followed 
in  succession  by  his  father  and  his  sister,  his  sister’s  fiancS 
being  left  tuberculous. 

In  the  second  series  instanced  the  disease  commences  in 
iVio  Hpat.h  of  a voung  man  ; then  follows  in  fatal  sequence 


* Abridged  from  a report  submitted  to  the  Colonial  Office. 


The  Lancet,]  DR.  J.  GEOGHEGAN  : TUBERCULOSIS  FROM  A WEST  INDIAN  STANDPOINT.  [July  12, 1919  57 


first  the  father,  then  a brother,  then  a sister,  all  living  and 
dying  in  the  same  house,  and  leaving  affected  a sister  from 
the  house  and  a brother  living  elsewhere.  I have  not  been 
able  to  gain  precise  information  as  to  how  long  the  last  has 
been  in  existence,  but,  be  it  the  origin  or  the  result,  the 
inference  remains. 

In  neither  of  the  series  recorded  is  hereditary  predisposi- 
tion or  transmission  suggested  or  known  to  my  information, 
but  in  the  distinct  lines  of  infection  illustrated  is  shown  the 
impress  of  other  factors. 

Causation. 

All  West  Indian  observers  agree  in  the  opinion  that  the 
incidence  of  phthisis  pulmonalis  greatly  overweighs  other 
tubercular  diseases  which  are  comparatively  infrequent.  In 
this  Dependency  only  two  joint  affections  have  come  under 
my  notice  in  nearly  four  years’  experience,  and  the  glandular 
condition  is  but  seldom  noted.  The  boiling  of  milk  is 
extensively  practised  in  the  West  Indies  ; in  Turks  Islands 
tinned  milk  is  almost  solely  depended  on.  Though  the 
infantile  mortality  rates  in  the  West  Indies  are  admittedly 
high — in  Turks  Islands  for  1914  and  1915,  204  and  229 
respectively — there  are  other  factors  applicable  of  a certain 
importance. 

In  view  of  the  negligible  appearance  of  the  condition  in 
children,!  and  of  the  precise  fields  of  the  respective  bacilli, 
such  a sweeping  statement  that  all  tuberculosis  commences 
in  infancy  (Behring  9)  may  have  an  element  of  truth  in  it, 
but  it  has  no  minimising  influence  on  the  fact  that  pulmonary 
tuberculosis  is  under  suitable  environment  highly  contagious 
in  the  adult.  Accentuation  is  lent  to  the  question  of 
direction  of  contagion  by  recent  views  on  the  respective 
spheres  of  influence  of  the  human  and  bovine  forms  of  the 
bacillus.  The  great  preponderance  of  the  human  type  in 
the  sputum  of  phthisis  pulmonalis  is  emphasised  by  A.  S. 
Griffiths.10 

It  may  therefore  be  concluded  that  it  is  to  the  human 
type  that  the  prevalence  of  pulmonary  tuberculosis  in  the 
West  Indies  is  due.  The  mode  of  spread  is  apparent. 
Given  an  original  focus,  with  or  without  a susceptibility, 
hereditary  or  racial,  the  disease  is  maintained  by  direct 
infection  in  virtue  of  the  general  ignorance  of  hygiene,  in 
particular,  the  closing  of  every  door  and  window  at  night, 
and  the  stopping  up  of  nooks  and  crannies.  This  is 
common  throughout  the  West  Indies.  Only  prolonged 
perseverance  can  overcome  the  hatred  of  fresh  air  at  night. 

Other  factors  may  be  briefly  scanned.  All  the  West  Indian 
towns  have  high  rates  as  contrasted  with  the  country 
districts.  Reliable  information  is  not  to  hand,  but  the  house 
ratio  in  Grand  Turk  is  4 7 by  a recent  census.  Overcrowding 
would  not  seem  to  present  locally  the  terrible  features  of 
slum  life  in  greater  centres.  As  a concomitant  to  over- 
crowding it  will  be  obvious  that  when  a water-supply  is 
inadequate  or  defective  for  any  reason  personal  cleanliness 
may  not  be  of  a high  order.  The  intimate  association 
in  thoroughly  unhygienic  sleeping-places  of  a number  of 
individuals  leaves  little  to  be  desired  from  the  point  of 
view  of  the  bacillus. 

Poverty  is  an  important  aspect.  The  West  Indies 
possess  a varied  and  rich  dietary  scale,  but  in  Turks  Islands 
the  food  as  a whole  is  limited  in  variety,  inferior  in  nature, 
and  deficient  in  freshness.  Starchy  foods  predominate  and 
proteins  are  limited.  If  any  influence  can  be  attributed  to 
food  as  a causative  factor  in  tuberculosis,  the  dietary  habits 
common  to  the  West  Indies  may  permit  views  palpably  in 
alignment  with  those  culminating  in  Philip’s  Zomotherapy. 

Sanitary  conditions  leave  much  to  be  desired.  Public  or 
personal  hygiene  is  unknown  in  the  class  forming  nine-tenths 
Ipf  the  population,  but  in  all  distant  and  small  areas 
sanitation  is  a vexatious  problem. 

The  Question  of  Prevention. 

The  figures  quoted  are  solely  derived  from  the  comparative 
leath-rates,  and  case-mortality  will  vary  under  the  effects 
)f  administrative  control  and  therapeutic  advantages.  In 
England  it  is  said  that,  subject  to  surveillance  from  a reason- 
ably early  stage,  a high  percentage  of  cures  may  be  expected. 
Jrant  Andrew,11  in  his  careful  resume  of  a long  series  of 
lospital  figures,  out  of  800  cases  records  a mortality  of  only 
L9-3  per  cent.  Recent  administrative  attention  cannot  fail 

tAh.ave.never  seen  a case  of  abdominal  tuberculosis  in  the  Turks 
■no  Uaicos  Islands. 


to  have  a repressive  influence  on  the  existence  of  a disease 
so  common  that  no  middle-aged  person  but  bears  the 
stigmata  of  infection.  It  is  only  fair  to  contrast  the  West 
Indies  in  the  possession  of  the  necessities  of  therapy  in  this 
direction  with  Victorian  England,  and  to  express  the  hope 
that  a similar  impetus  of  attention  will  give  commensurate 
results. 

The  present  case- mortality  amongst  those  of  negro  stock 
in  the  West  Indies  is  admitted  by  all  observers  to  be  indubit- 
ably high.  Osier  points  out  that  the  negroes  in  the  Southern 
States  have  an  extraordinarily  high  death-rate,  especially  in 
the  cities.  Of  eight  cases  seen  in  sequence  in  1915  in  Turks 
Islands,  all  in  an  early  stage  (save  one  from  abroad  who  is 
now  alive)  and  all  under  constant  supervision,  no  less  than 
six  were  dead  by  March,  1916.  Phthisis  in  Turks  Islands 
has  a most  fatal  complexion.  Rather  than  that  the  disease  is 
universal  and  widespread,  the  view  should  be  taken  that  it 
is  more  fatal  than  frequent. 

West  Indian  tuberculosis  stands,  therefore,  in  certain 
respects  in  contrast  with  English.  This  point  is  of  high 
importance,  since  it  must  presumably  be  correlated  either 
with  an  absence  of  therapeutic  possibilities  or  with  a 
special  lack  of  immunising  power  in  the  negro.  Whatever 
relation  subsequent  research  establish,  there  can  be  no 
question  but  that  attention  to  personal  hygiene  and  public 
health  must  have  a marked  effect.  Backward  the  West 
Indies  may  be  at  present,  but  the  efforts  recently  begun 
cannot  fail  eventually  to  produce  good  results.  Methods 
dissimilar  to  those  suitable  for  England  are  needed.  The 
people  are  a different  race  and  must  be  approached  in  a more 
elementary  manner.  The  actual  infective  danger  of  phthisis 
is  decidedly  greater  than  in  England,  from  deficient  sanita- 
tion , from  hygienic  ignorance,  and  from  greater  susceptibility  ; 
phthisis  is,  further,  the  stronghold  of  tuberculosis  in  the  West 
Indies,  and  once  successfully  combated  the  other  forms  do 
not  seem  likely  to  give  rise  to  serious  concern. 

The  presence  of  such  devitalising  influences  as  malaria  and 
ankylostomiasis  and  the  difficulties  of  administration  are  not 
lightly  to  be  ignored.  Taking  everything  into  consideration 
it  must  be  admitted  that  the  death-rates,  while  in  cases 
remarkably  low,  preserve  a fair  average.  St.  Lucia  with 
17  4,  St.  Vincent  with  17  56,  Grenada  with  19  27,  Cayman 
Islands  with  7-1,  and  Turks  and  Caicos  Islands  with  14  0, 
may  be  placed  in  contrast  with  Jamaica  with  25  T,  the 
Bahamas  with  26  7,  British  Honduras  with  24  2,  and  British 
Guiana  with  29  2, 12  but  there  are  usually  special  circum- 
stances applicable  in  each  case  which  must  modify  any 
stricture.  The  references  indicate  that  the  West  indies 
cannot  be  expected  at  present  to  maintain  other  than  a fair 
standard.  There  is  a fruitful  field  for  investigation  in  the 
comparative  study  of  tuberculosis  in  the  different  colonies, 
of  which  certain  features  in  common  have  already  been 
established. 

Consideration  of  any  tropical  problem  cannot  fail  to 
recur  to  the  question  of  climate.  It  is,  I believe,  accepted 
that  climate  has  little  or  no  relation  with  the  causation  of 
tuberculosis.  Taking,  however,  such  a group  as  the  Turks  and 
Caicos  Islands,  even  granting  the  unfortunate  series  of  con- 
ditions noted,  where  the  days  are  almost  perpetual  sunshine — 
perhaps  the  best  and  certainly  the  cheapest  disinfectant 
known— there  is  an  inclination  to  demand  greater  confirma- 
tion of  such  a statement.  The  effect  of  a few  degrees  of 
latitude  on  the  sum  of  the  obscure  metabolic  processes  that 
make  up  life  is  well  exhibited  in  the  biological  adaptations 
to  very  varying  conditions  that  will  readily  recur  to  the 
mind.  Man  and  the  tubercle  bacillus  inhabit  the  known 
world,  though  it  is  said  that  the  Bedouin  of  the  Sahara  and 
the  Eskimo  of  the  Far  North  are  free  of  such  an  unnecessary 
adjunct.  Is  a tropical  climate  better  suited  to  the  tubercle 
in  the  lung  or  to  the  tubercle  bacillus  ? Or  is  it  that,  in  the 
extra- corporeal  life  of  the  bacillus,  there  is  an  optimum  of 
climate  for  the  parasite  as  well  as  for  the  host,  which  need 
not  necessarily  coincide? 

References. — 1.  Proceedings  of  the  First  West  Indian  Intercolonial 
Tuber  cun  'sis  Conference,  Trinidad,  1913.  2.  Glaister  : Text-book  of 

Public  Health,  p.  430.  3.  Proceedings,  Ac.,  p.  21.  4.  Ibid.,  p.  28. 

5.  Ibid.,  p.  57.  6.  Ibid.,  p.  99.  7.  Ibid.,  p.  87.  8.  Ibid.,  p.  122. 

9.  Behring ; Quoted  in  Quinquennium  of  Medicine  and  Surgery. 
1906-10,  p.  375.  10.  Griffiths : Tubercle  Bacilli  Derived  from  the 

Sputum,  The  Lancet,  1916,  i.,  723.  11.  J.  Grant  Andrew  : Age,  Incid- 
ence, Sex,  and  Comparative  Frequency  in  Disease,  p.  232.  12.  See 
Colonial  Reports  for  St.  Lucia,  1913,  p.  19 ; St.  Vincent,  1913-14, 
p.  24  ; Grenada,  1913-14  ; Cayman  Islands,  1912-13,  p.  13  ; Jamaica, 
1913-14;  Bahamas,  1912-13,  p.  18;  British  Honduras,  1913,  p.  17  ; British 
Guiana,  1912-13,  p.  23. 


58  The  Lancet,] 


DR.  O.  HEATH  : INFLUENZA-PNEUMONIA. 


[July  12,  1919 


INFLUENZA-PNEUMONIA : 

THE  BACTERIOLOGY  OF  THE  COMPLICATIONS  IN 
FATAL  CASES. 

I3y  OLIVER  HEATH,  M.A.,  M.B.,  B.C.  Cantab., 

CAPTAIN,  K.A.M.C.  (T.C.). 

(From  the  Laboratory  of  the  5th  Northern  General  Hospital.) 


From  the  recent  preliminary  publication  by  Rose  Bradford, 
Bashford,  and  Wilson  1 it  appears  that  they  have  definitely 
unearthed  the  prime  causal  organism  of  the  late  “influenza” 
epidemic.  On  the  other  hand,  it  is  not  so  obvious  that  this 
“ fiitrable  virus  ” is  the  cause  of  the  numerous  deaths. 

The  work  here  recorded  was  commenced  in  October, 
1918,  when  the  epidemic  had  reached  serious  proportions 
in  the  area  served  by  this  hospital.  It  was  undertaken 
•solely  with  the  idea  of  determining  and  isolating  the  micro- 
organisms responsible  for  the  fatal  cases,  with  a view  to 
preparing  an  efficient  vaccine  for  prophylactic  and  curative 
purposes.  Attention  was  concentrated  mainly  on  material 
obtained  post  mortem  as  soon  after  death  as  “ leave  ” could 
'be  obtained,  and  on  specimens  of  the  serous  fluids  taken 
timing  life  with  aseptic  precautions.  The  examination  of 
sputa  was  not  followed  up  to  any  great  extent  owing  to 
shortage  of  staff,  and  because  it  was  noticed  early  that 
frequently  the  most  serious  cases  did  not  expectorate. 

Bacteriological  Findings. 

Post-mortem  examinations. — The  bacteriology  of  the  peri- 
cardial and  pleural  fluids  and  the  lung  “juice”  or  pus  is 
recorded  below.  Four  points  attracted  notice : 1.  The 
frequency  with  which  fluid  was  found  in  the  serous  cavities. 
2.  The  invariable  presence  of  red  blood  cells  in  the  serous 
fluids,  with  a variable  “quantum”  of  pus  and  living 
bacteria.  3.  The  large  proportion  of  fatal  cases  which 
came  from  “low  category”  units— 10  out  of  16.  4.  The 

frequency  with  which  pneumococcus,  streptococcus,  or  a 
diplo-streptococcus  was  isolated  : from  all  except  one,  and 
in  this  one  pneumococci  were  seen  in  the  films,  but  the 
cultures  were  overgrown  by  a coliform  B.  Morgan  No.  I. 

In  the  British  and  foreign  press  attention  has  been  directed 
to  haemorrhagic  lesions  of  the  serous  membranes.  Attention 
is  here  drawn  to  the  frequency  with  which  one  finds,  post 
mortem,  an  “ inflammatory  ” fluid,  containing  living  bacteria, 
in  both  pericardial  and  pleural  fluids. 

The  type  of  coccus  referred  to  as  a “ diplo-streptococcus  ” 
was  a Gram  4-  coccus,  usually  strongly  capsulated,  frequently 
lanceolate  and  suggestiug  pneumococcus,  more  often  rounded, 
but  often  (especially  in  lung  “juice  ” or  pus)  showing  chain 
formation.  Pleomorphism  was  marked.  Large  and  small 
cocci,  Gram  -f  and  Gram  — cocci,  and  large  round  or  pear- 
shaped  forms — “involution  forms” — have  all  been  seen  in 
one  chain  of  cocci.  In  one  sputum  films  showed  only  large 
pear-shaped  forms,  while  the  cultures  yielded  a nearly  pure 
growth  of  this  “ diplo-streptococcus.”  In  culture  this  coccus 
grew  best  on  media  containing  blood,  more  sparsely  on  agar. 
The  colonies  are  pyramidal  and  gelatinous-looking,  and  about 
the  third  day  are  flattened  with  a central  “boss”  which 
may  disappear  later.  Occasionally  gelatinous  lumps  form, 
giving  the  appearance  as  if  one  had  broken  the  medium  in 
planting  the  culture. 

The  results  obtained  from  these  examinations  are  now  set 
out,  the  organisms  isolated  being  indicated  under  (a)  peri- 
cardium, ( b ) pleura,  and  (c)  lungs  : — 

No.  1 (aged  23).— (a)  and  (c)  Pneumococcus  (pure) : (b)  — . 

No.  7 (aged  19). — (a),  ( b ),  and  (c)  Pneumococcus. 

No.  16  (aged  19).— (a)  Pneumococcus  (purei;  ift)-;  (c ; B. 
influenza , pneumococcus. 

No.  17  (aged  30). — (a)  and  (b)  Pneumococcus  (pure) ; 
(c)  pneumococcus,  B.  influenza;. 

No.  18  (aged  28). — (a),  (6),  and  (c)  Pneumococcus. 

No.  19  (aged  27).— Pneumococci  seen  in  films  from  plate 
but  all  cultures  overgrown  by  B.  Morgan  No.  I. 

No.  23  (aged  20). — (o)  Staphylococcus,  diplo-streptococcus- 

( b ) (c)  diplo  streptococcus,  M.  catarrhalis. 

No.  24  (aged  20). — (a)  and  (ft)  Pneumococcus  (pure) ; 

(c)  pneumococcus,  B.  influenza , .1/.  catarrhalis. 

No.  40  (aged  35) — (a),  (6),  and  (c)  Diplo-streptococcus. 

Jt0-  <af5ed  19). — (a),  (ft),  and  (c)  Diplo-streptococcus. 

No.  42  (aged  38).  (a),  (ft),  and  (c)  Diplo-streptococcus. 

1 The  Lancet  and  Brit.  Med.  Jour.,  February,  1919. 


No.  51  (aged  40). — All  cultures  yielded  diplo-streptococcus, 
a short  streptococcus,  a small  Gram  — coccus. 

No.  56  (aged  27).— All  cultures  yielded  streptococcus, 
staphylococcus,  M.  tetragenus. 

No.  57  taged  25). — (a)  Staphylococcus;  (ft)  staphylococcus, 
31.  catarrhalis,  a streptococcus ; (c)  (unfinished  owing  to 
illness). 

No.  58  (aged  51). — All  cultures  yielded  diplo-streptococcus 
and  a few  colonies  of  staphylococcus. 

No.  60  (aged  30). — All  cultures  yielded  diplo-streptococcus, 
a streptococcus,  staphylococcus. 

The  sputa  of  five  of  the  above  were  examined  during  life. 

No.  7.— Minute  quantity.  Purulent.  Many  pneumococci 
seen  in  films  and  isolated  in  pure  culture. 

No.  16. — Purulent.  Many  B.  influenza  and  a few  pneumo- 
cocci in  films  ; both  isolated  in  pure  culture. 

No.  19. — Purulent.  Pneumococci  seen  in  films  of  sputum 
and  of  plate-cultures,  but  cultures  overgrown  by  a coliform 
bacillus. 

No.  40. — Slightly  purulent.  The  M.  catarrhalis  and  a few 
pneumococci  seen  in  film.  Pneumococcus  isolated  in  pure 
culture. 

No.  51. — Mucopurulent.  A few  cocci  resembling  pneumo- 
cocci seen  in  film.  Cultivations  not  made. 

Bacteriology  of  serous  fluids  during  life. — -Two  examinations 
were  made  of  pericardial  and  two  of  pleural  fluids  taken 
during  life.  The  findings  are  now  shown. 

No.  12  (aged  34). — Fluid  from  pleura;  purulent  + + 
pneumococcus  seen;  pneumococcus  isolated. 

No.  39  (aged  26). — Fluid  from  pericardium  ; purulent  ++  ; 
diplo-streptococcus,  streptococcus,  and  staphylococcus 
isolated  (two  examinations). 

No.  50  (aged  25). — Fluid  from  pleura;  slightly  purulent ; 
staphylococcus  and  diphtheroid  bacillus  isolated. 

Notes  on  above  cases  : — 

No.  12. — Sputum  mucopurulent.  Pneumococcal-like 
organisms  not  seen.  Cultivations  not  made.  Patient 
recovered. 

No.  39.  — Sputum  purulent.  Diplococci  resembling 
pneumococci  seen  in  film.  Cultivations  yielded  a nearly 
pure  growth  of  the  diplo-streptococcus.  Patient  died. 

No.  50. — Sputum  contained  fresh  blood  and  clots,  and  was 
purulent.  Later  was  only  purulent.  Cultivations  yielded  a 
streptococcus  and  a diphtheroid  bacillus.  Patient  eventually 
developed  a gangrenous  cavity  in  the  lung. 

Examination  of  sputa. — Forty-six  were  examined,  and 
cultivations  made  from  20  of  these.  Organisms  isolated 
were : Diplo-streptococcus  or  pneumococcus  19,  strepto- 

coccus 1,  M.  catarrhalis  4,  B.  influenza  3,  a diphtheroid 
bacillus  2. 

In  film  preparations  from  all  cases  (46):  Cocci  resembling 
pneumococci  seen  in  44,  bacilli  resembling  B.  influenza  in 
7,  M.  catarrhalis  in  8. 

Summary. 

1.  Pneumococcal  or  streptococcal  organisms  were  found  in 
all  of  16  post  mortems  ; in  2 out  of  3 serous  fluids  taken 
during  life  ; and  in  19  out  of  20  sputa  examined 
bacteriologically. 

2.  Emphasis  is  laid  on  the  hsmorrhagic  and  infective 
nature  of  the  fluids  found  post  mortem. 

3.  Attention  is  drawn  to  the  high  percentage  of  fatal  cases 
which  came  from  “low  categoiy  ” units. 


A meeting  of  the  medical  practitioners  of  Black- 
pool, including  members  of  the  British  Medical  Association 
and  non-members,  was  held  at  the  Town  Hall,  Blackpool, 
on  July  2nd.  Dr.  W.  J.  McL.  Baird,  honorary  secretary  of  the 
Blackpool  division  of  the  British  Medical  Association,  was 
in  the  chair.  Among  other  matters  considered  by  the 
meeting,  Dr.  John  Brown  brought  forward  the  “ forth- 
coming election  of  Direct  Representatives  on  the  General 
Medical  Council.”  He  said  that,  judging  from  a paragraph 
in  the  British  Medical  Journal  of  June  28th,  the  Association 
intended  to  run  as  its  candidates  the  four  gentlemen  who 
were  its  nominees  in  the  last  election.  He  protested 
against  the  action,  as  he  thought  it  unfair  for  the 
Association  to  monopolise  the  representation  of  the  general 
practitioner,  particularly  as  the  Association  did  not  repre- 
sent more  than  half  the  profession,  and  many  of  its  members 
were  not  in  accord  with  its  policy.  The  secretary  for  the 
Blackpool  division  said  that  out  of  some  120  medical  men  in 
the  area  of  this  division  only  39  were  members  of  the 
British  Medical  Association.  ’ The  meeting  unanimously 
resolved  to  support  Dr.  Brown  if  he  decided  to  stand  a - i 
candidate. 


The  Lancet,] 


CLINICAL  NOTES. 


[July  12, 1919  50 


Clinical  Sates : 

MEDICAL,  SURGICAL,  OBSTETRICAL,  AND 
THERAPEUTICAL. 


A CASE  OF  ACUTE  SEPTIC  MENINGITIS  OF 
OTITIC  ORIGIN;  COMPLETE  RECOVERY. 

By  J.  Arnold  Jones,  O.B.E.,  M.B.,  Ch.B.  Manch., 
F.R.C.S.  Edin., 

LATE  TEMP.  MAJOR,  R.A.M.C.  ; AURAL  AND  LARYNGEAL  SURGEON  TO 
THE  BRITISH  FORCES  IN  MACEDONIA;  SURGEON  TO  ST.  JOHNS  HOS- 
PITAL FOR  DISEASES  OF  THE  EAR,  MANCHESTER,  ETC. 


This  case  is  chiefly  remarkable  because  of  recovery. 

The  patient  was  admitted  into  hospital  under  my  care  on 
March  26th,  1918.  A mastoid  operation  had  been  performed 
at  a casualty  clearing  station  14  days  previously.  The  notes 
stated  that  he  had  had  sudden  pain  in  the  right  ear  with 
discharge  ; was  delirious  for  a few  hours  ; vomited.  At  the 
operation  “ offensive  material  ” was  found  in  the  antrum 
£md  cells. 

On  admission  on  March  26th  patient  complained  of  head- 
ache and  pain  in  the  ear.  Pus  was  freely  draining  through 
a small  tube  issuing  from  the  mastoid  incision  aud  also  from 
external  meatus.  Temperature,  99°  F.  No  history  of  old- 
standing  ear  disease.  On  a daily  antiseptic  toilet  the  antro- 
tympanic  cavity  cleared  up,  and  progress  was  good  in  every 
way.  On  May  14th  he  had  an  attack  of  benign  tertian 
malaria  which  responded  readily  to  quinine.  From  the  19th 
to  24th,  diarrhoea ; stools  negative  to  bacilli  and  protozoa. 
On  last  date  diarrhoea  had  ceased  ; complaint  of  headache 
and  some  aural  pain  ; slight  mastoid  tenderness.  Tem- 
perature rose  to  100  °.  On  the  25th  temperature  normal,  but 
other  symptoms  had  increased.  From  examination  with 
aural  speculum  it  was  difficult  to  make  out  the  anatomy  of 
the  operation  cavity,  so  I reopened  it  under  general  anaes- 
thesia. The  antrum  and  tympanum  had  been  thrown  into 
one  cavity  and  their  roofs  were  absent,  exposing  a large  area 
of  dura  covered  with  granulations.  The  antro-tympanic 
cavity  was  thoroughly  cleansed  and  enlarged.  No  pus  was 
found. 

On  May  26th  patient  had  a much  better  night ; the  intense 
headache  had  gone.  He  now  progressed  well  until  June  5th, 
when  he  had  a rigor ; temperature  103°.  Calomel  gr.  3, 
aspirin  gr.  15,  followed  by  quinine  hydrochloride  gr.  20,  given. 
On  June  6th  temperature  102°,  pulse  94.  Complained  of  head- 
ache; vomited  in  afternoon;  no  pain  in  ear;  no  mastoid 
tenderness;  slight  pain  and  rigidity  back  of  neck;  very 
slight  Kermg’s  sign  present.  Reflexes  normal;  no  definite 
signs  of  intracranial  complications. 

On  June  7th  temperature  101-2°,  pulse  90  ; headache 
intense;  slight  retraction  of  head ; Kernig’s  sign  definitely 
present ; no  aural  pain.  Lumbar  puncture ; a test-tube 
full  of  cerebro-spinal  fluid  under  pressure  and  cloudy  in 
appearance  evacuated.  Microscopical  examination  on  the 
spot  showed  numerous  pus  cells.  Subsequent  report  from 
pathologist  showed  Gram  + staphylococci.  Under  general 
anaesthesia  the  antro-tympanic  cavity  was  again  reopened 
and  thoroughly  explored ; no  pus  found.  The  brain  sub- 
stance of  the  middle  fossa  was  explored  with  a needle ; 
negative  result.  On  June  8th  and  subsequent  days  patient 
was  distinctly  more  comfortable.  Headache  and  pain  were 
absent,  but  he  was  drowsy  ; Kernig’s  sign  persisted.  The 
temperature  gradually  came  down. 

On  the  12th  there  was  a turn  for  the  worse.  Temperature 
rose  to  103-6°;  headache,  pain  in  back  and  legs,  was 
increasingly  drowsy,  and  became  slightly  delirious. 
Another  lumbar  puncture ; coconut-milk-like  fluid  with- 
drawn under  pressure,  containing  far  more  pus  cells  than 
before.  Subsequent  report  from  pathologist  showed  Gram+ 
diplococcus  present.  Immediate  improvement  in  all 
symptoms  followed.  The  temperature  remained  in  the 
region  of  102°  for  three  days  and  then  came  down.  On 
July  1st  he  began  to  get  up  from  his  bed,  and  when 
evacuated  to  hospital  ship  on  the  14th,  could  walk  several 
hundred  yards  without  fatigue.  Kernig’s  sign  was  much 
less  marked. 

Cases  o£  definite  septic  meningitis  with  pus  in  the 
cerebro-spinal  fluid  which  recover  must  be  very  rare. 

1 have  never  met  one  in  my  own  practice.  There  are 
two  suggestive  points.  The  organisms  found  in  the 
cerebro-spinal  fluid  were  of  low  virulence,  and  theTesisring 
power  of  the  patient  was  much  weakened  by  malaria. 
Had  his  powers  of  resistance  not  been  weakened  by  malaria, 
it  is  more  than  likely  that  no  suppurative  lesion  of  the  I 
meninges  would  have  occurred.  From  over  three  years’  | 


experience  in  Macedonia  I have  no  hesitation  in  saying  that 
complications  of  middle-ear  suppuration  are  more  common  1 
than  they  would  be  in  England  under  the  same  circum- 
stances, and  the  reason  for  this  is  the  deleterious  effect  of 
malaria  on  the  resisting  powers  of  the  individual.  Organisms 
of  low  virulence  are  thus  able  to  bring  about  infections,  but 
this  very  fact  gives  the  patient  a chance  of  ultimately  over- 
coming them.  Also  noteworthy  is  the  marked  relief  afforded 
by  each  lumbar  puncture. 


A CASE  OF  PERITONITIS  FOLLOWING  A 
NON  PENETRATING  WOUND  OF  THE 
ABDOMINAL  WALL. 

By  A.  E.  Chisholm,  F.R.C.S.  Edin., 

LATE  CAPTAIN,  K.A.M.C. 


That  peritonitis  may  result  from  a nonpenetrating 
wound  of  the  abdominal  wall,  with  the  abdominal  viscera 
showing  no  gross  lesion,  seems  proved  by  the  following  case. 

Acoovnt  of  Case. 

Gunner  J.  H.,  recently  wounded,  was  admitted  into- 
hospital  on  Oct.  2nd,  1917  ; very  collapsed  and  appeared  ter 
have  lost  much  blood.  Entrance  wound,  about  J in.  iff 
diameter,  in  right  buttock  just  external  to  posterior  superior 
spine  of  ilium.  Exit  wound,  about  1 in.  across,  in  lateral 
sector  of  right  iliac  region.  The  patient  was  treated  in  the 
resuscitation  ward  for  some  time  ; no  signs  of  improvement ; 
it  was  decided  to  operate  lest  internal  haemorrhage  was 
going  on. 

I opened  up  the  anterior  wound  and  found  that  the  right 
lateral  peritoneum  was  exposed  in  track  of  missile.  Careful 
examination  by  Lieutenant  Camps,  who  assisted,  and 
myself,  revealed  no  penetration  of  abdominal  cavity.  The 
right  iliacus  muscle  was  severely  lacerated.  Also  fracture  of 
the  right  iliac  bone,  involving  separation  of  greater  part  of 
crest  with  part  of  body  ; comminution  not  very  great.  The 
damaged  tissue  was  cut  away,  but  not  in  region  of  exposed 
peritoneum,  as  it  would  have  necessitated  opening  the 
abdomen.  Bipp  was  rubbed  gently,  in  a thin  layer,  into  the 
raw  surfaces.  The  muscles  and  skin  were  partly  closed  in 
layers,  but  greater  part  of  wound  was  left  open  and  very 
lightly  packed  with  gauze.  The  entrance  wound  was  then 
dealt  with,  the  edges  being  excised  and  subjacent  injured 
tissue  clipped  away  ; bipp  was  applied.  Prior  to  operation 
a catheter  was  passed;  small  quantity  of  clear,  rather  con- 
centrated urine  was  drawn  off ; urine  not  examined. 

On  the  following  day  the  patient  seemed  better;  rather 
persistent  vomiting.  It  is  unnecessary  to  detail  general 
treatment;  various  remedies,  including  alkaline  treatment, 
were  employed.  On  the  morning  of  Oct.  4th  patient  was 
much  worse.  1 c.cm.  of  pituitrin  was  given  hypodermically 
and  sodium  bicarbofiate  and  glucose  solution  intravenously. 
Death  took  place  about  midday.  During  all  this  time  very 
little  urine  passed.  There  did  not  seem  any  very  definite 
indication  to  open  the  abdomen,  especially  as  one  felt 
certain  that  the  parietal  peritoneum  had  not  been 
punctured.  The  man  would  almost  certainly  have  been 
unable  to  stand  such  a procedure. 

Post  mortem. — The  following  conditions  were  found.  Peri- 
tonitis, apparently  rather  subacute,  involving  chiefly  lower 
half  of  small  intestine,  pelvis,  and  region  of  caecum.  There 
were  a good  many  plastic  adhesions  and  patches  of  adherent 
lymph  ; small  quantity  of  dark  reddish  semi-purulent  fluid 
in  pelvis.  No  B.  coli  infection  smell.  The  stomach  was  not 
distended  ; tendency  for  intestines  to  be  somewhat  collapsed, 
except  jejunum,  but  this  was  not  actually  distended.  The 
bladder  contained  only  a little  fluid.  The  appendix  was 
bound  down  over  brim  of  pelvis  by  a recent  soft 
plastic  adhesion  ; otherwise  appeared  healthy.  The 
parietal  peritoneum  in  relation  to  the  wound  was  very 
carefully  examined ; no  perforation  found.  The  small 
intestine  was  carefully  examined  from  the  duodeno- 
jejunal flexure  downwards;  no  perforation;  caecum  and 
ascending  colon  also  appeared  intact.  The  rest  of  the  large 
intestine,  not  in  relation  to  the  wound,  appeared  whole.  On 
opening  the  abdomen  no  free  gas  was  detectable.  The 
kidneys  appeared  rather  cloudy.  A swab  from  fluid  in  the 
pelvis  was  taken,  but  there  had  been  already  contamination, 
being  taken  on  a second  examination. 

Inferences. 

It  would  seem  that  the  intraperitoneal  infection  must 
have  taken  place  in  one  of  three  ways  : 1.  By  direct 
spread  of  infection  from  the  wound  thrpugh  damaged 
parietal  peritoneum.  No  swab  was  taken  from  the  wound, 
but  on  the  day  after  operation  it  looked  fairly  clean.  2.  By 


i See  also  The  Lancet,  1918,  i.,  704. 


60  The  Lancet,] 


ROYAL  INSTITUTE  OF  PUBLIC  HEALTH. 


[July  12,  1919 


escape  of  infection  through  a perforation  in  the  bowel. 
But  one  has  good  reason  that  no  such  perforation  existed. 
3.  By  escape  of  infection  through  contused  bowel.  The 
absence  of  frncal  odour  in  the  peritoneal  exudate  tends  to 
negative  this.  The  probability  is,  I think,  that  the  infection 
spread  through  the  peritoneum  from  the  wound. 

The  treatment  of  such  a case  presents  difficulties.  If  the 
abdomen  had  been  opened  at  the  operation  nothing  patho- 
logical would  have  been  found.  Later  the  indications  for 
opening  the  abdomen  did  not  seem  sufficiently  clear  ; also 
the  patient’s  condition  did  not  warrant  this. 

The  point  arises,  Should  the  soiled  peritoneum  in  such  a 
case  be  freely  clipped  away  in  spite  of  this  involving  the 
formation  of  a communication  between  the  wound  and  the 
abdominal  cavity  ? This  idea  is  carried  out  by  some  in  the 
knee-joint.  A French  surgeon  informed  me  that  if  he  found 
the  outer  surface  of  the  joint  capsule  so  soiled  that  the 
soiled  tissue  could  not  be  removed  without  opening  the 
joint,  he  freely  excised  it,  opening  the  joint  and  after- 
wards stitching  up  the  hole.  Should  this  principle  be 
applied  to  similar  circumstances  where  the  abdomen  is 
involved  ? The  proceeding  would  seem  risky,  and  yet 
possibly  not  more  so  than  in  the  knee-joint.  Of  course,  it 
would  never  do  to  remove  a large  piece  of  parietal  peritoneum 
in  the  wound,  as  it  would  be  impossible  to  close  the  opening. 

Another  Case. 

Since  completing  these  notes  another  somewhat  similar 
case  has  passed  through  my  hands. 

Private  W.  R.,  wounded  on  Feb.  27th,  1918;  operation 
some  12  hours  later.  Entrance  wound  on  right  iliac  crest 
anteriorly.  No  exit  wound.  Severe  fracturing  of  right 
ilium  and  a good  deal  of  laceration  of  right  iliacus  muscle. 
Peritoneum  exposed  in  track  of  missile,  but  not  lacerated. 
Patient  was  greatly  shocked  and  had  apparently  lost  a good 
deal  of  blood.  An  alkaline  intravenous  injection  was  given 
before,  and  a pint  of  blood  after,  operation.  This  consisted 
in  cleaning  up  the  wound  and  clipping  away  as  much 
damaged  tissue  as  was  deemed  wise,  considering  the  patient’s 
poor  state.  The  parietal  peritoneum  was  left  intact.  The 
wound  was  bipped  and  left  open.  Post  mortem  : Peritonitis 
with  signs  of  bruising  of  bowel,  but  no  perforation  detected 
either  of  bowel  or  of  parietal  peritoneum.. 


A CASE  WITH  COMPLETE  CESSATION  OF 
FITS  RESEMBLING  EPILEPSY. 

By  H.  de  C.  Woodcock,  M.D.,  F.R.C.P.  Edin., 
D.P.H.,  &c. 


The  following  case  came  to  my  notice  years  ago. 

A little  Jewish  boy  had  his  tonsils  removed.  He  lost  a 
considerable  amount  of  blood,  and  within  a week  or  two  he 
appeared  to  be  an  epileptic— that  is,  he  had  epileptic  fits. 
Dr.  A.  H.  Clark,  of  Morley,  saw  him,  and  he  was  treated 
with  bromides  without  the  slightest  benefit.  Dr.  Clark  and 
I were  working  together  at  that  time,  and  we  saw  the  case 
together  at  the  boy’s  home.  The  boy  on  this  occasion  was 
undressed  in  my  presence.  As  the  sister  took  off  the  stocking 
from  his  right  leg  the  patient  went  into  an  epileptic  fit  of 
the  classical  type,  beginning  on  one  side  of  the  body  and 
travelling  to  the  other;  clonic  convulsions  following  tonic, 
and  unconsciousness  being  complete.  Recovery  was  speedy. 
On  a subsequent  visit  the  same  phenomena  were  repeated, 
and  it  was  then  that  the  sister  said  : “ Whenever  we  undress 
him  he  has  a fit.”  As  the  treatment  was  doing  no  good  it 
was  discontinued.  Patient  recovered  completely.  I saw 
him  some  years  later,  and  if  the  statement  of  his  friends 
is  to  be  relied  on,  there  had  been  no  subsequent  attacks.  It 
appears  that  peripheral  irritation  had  induced  the  epilepsy, 
and  that  peripheral  irritation  had  continued  to  excite  the 
attacks. 

The  Jews  are  pathologically  peculiar.  The  boy  was  highly 
intelligent  and  sensitive,  and  the  attacks  may  not  have  been 
true  epilepsy  ; all  I can  say  is  that  they  could  not  be  dis- 
tinguished from  true  epilepsy.  Dr.  Clark  and  I,  not  feeling 
secure  in  a position  of  clinicists  in  nervous  diseases,  did  not 
publish  the  case  at  the  time,  but  I have  often  felt  that  I 
must  deliver  myself  of  the  description  of  this,  to  me, 
extraordinary  case. 

Leeds. 


New  Hospital  foe  East  Ham. — The  East  Ham 
Hospital,  which  at  present  consists  of  25  beds,  is  to  be 
enlarged  as  a war  memorial  at  a cost  of  over  £30,000.  Sir 
Samuel  Waring  has  promised  a donation  of  £2000. 


Mleirital  Societies. 


ROYAL  INSTITUTE  OF  PUBLIC  HEALTH: 

LONDON  CONFERENCE. 

( Concluded  fromp.  IS.) 

III.  Housing  in  Relation  to  National  Health. 

In  the  absence  of  Sir  Aston  Webb,  the  chair  was  occupied 
by  Professor  E.  W.  Hope,  medical  officer  of  health  for 
Liverpool.  He  said  he  was  acquainted  with  the  struggles  to 
grapple  with  insanitary  areas,  which  were  the  heritage  of 
woe  bequeathed  by  previous  generations.  The  root  trouble 
was  the  original  vicious  structural  state  of  the  houses. 
22,000  tenements,  many  of  the  back-to-back  character,  and 
leading  to  blind  alleys,  were  the  monument  of  Liverpool’s 
rapid  prosperity,  when  the  one  object  was  to  crowd  as  many 
houses  to  the  acre  as  possible,  and  the  task  of  finding  homes 
for  the  dispossessed  which  followed  on  improvements  was 
left  to  the  present  generation,  and  it  had  been  well  grappled 
with.1  The  three-years  mortality  rate  among  infants  in  the 
insanitary  areas  before  they  were  dealt  with  was  259,  but  in 
the  three  years  1916  to  1918  it  had  dropped  to  162,  and  the 
phthisis  rate  had  been  reduced  from  4 to  19  in  the  same 
time.  The  general  death-rate  was  37  in  the  old,  26  in  the 
new.  The  birth-rate  had  always  been  high,  averaging  45  for 
the  three  years  prior  to  demolition,  and  40  in  the  1916 
to  1918  period — almost  double  that  of  the  country  as  a 
whole.  These  figures  were  in  regard  to  a population  of  12,000. 
Drunkenness  had  decreased,  and  the  condition  of  the  children 
had  definitely  improved.  The  housing  question  was  inseparably 
mixed  up  with  the  welfare  of  the  race,  and  he  hoped  for  a 
continuance  of  interest  now  evoked  by  the  housing  schemes, 
with  which,  he  hoped  would  be  incorporated  better  and 
cheaper  means  of  transport.  The  new  houses  for  this  prolific 
part  of  the  population  should  include  proper  storage  provision 
and  appliances  for  domesticity. 

The  Architectural  Aspect  of  Housing. 

Professor  S.  D.  Adshead,  F.R.I.B.A.,  dealt  with  the 
question  from  the  architectural  standpoint.  He  averred  that 
the  architectural  aspect  of  housing  seemed  to  have  been 
largely  lost  sight  of  ; it  was  an  intangible  quality,  and  might 
be  termed  the  moral  hygiene.  He  thought  the  new  housing 
schemes  should  express  the  new  organisations  of  society,  as 
the  old  water-tight  compartments  of  society  were  giving 
place  to  new  conditions.  There  was  need  for  standardisation 
of  houses,  but  that  did  not  mean  mere  repetition  ; the  old 
days  of  40  and  50  houses  in  a block  of  exactly  the  same 
construction  were  gone.  There  could  be  standardisation  and 
yet  such  variations  as  reflected  the  social  strata  of  the 
workers  of  the  present  day.  Great  variety  could  be  produced 
by  variants  on  only  three  plans,  so  that  standardisation  did 
not  mean  monotony.  There  had  never  been  such  an  oppor- 
tunity as  the  present  for  producing  magnificent  organised 
housing  schemes,  and  he  asked  that  the  old-fashioned  village 
should  not  be  taken  as  the  working  model  for  the  new, 
historically  interesting  though  the  former  was. 

The  Citizen's  Ideals. 

Mr.  Neville  Chamberlain,  M.P.,  voiced  the  point  of 
view  -of  the  citizen  who  was  deeply  impressed  by  the 
difference  he  saw  in  the  best  and  the  worst  parts  of  a city, 
and  whose  earnest  desire  was  to  bring  up  the  general  average 
of  health  and  comfort.  He  assumed  that  the  citizen  was 
willing  to  pay  for  his  ideals  ; indeed,  even  economically,  he 
would  get  back  the  expenditure  on  improvements  by  the 
diminished  poor-law  relief  and  other  accompaniments  of 
poverty  and  ill-health.  The  birth-rates  of  our  cities  were 
invariably  highest  in  the  economically  worst  parts,  and 
schemes  for  betterment  of  those  parts  might  lower  the 
birth-rate;  but  that  was  counteracted  by  a lower  death-rate 
too,  and  if  the  infants  coming  into  the  world  had  a better 
chance  of  surviving  and  living  full  and  useful  lives,  the 
balance  was  certainly  on  the  side  of  advantage.  Large 
hopes  had  been  raised  by  the  mention  of  schemes  which 
should  transfer  families  from  congested  industrial  districts 
to  suburbs,  but  sufficient  account  had  not  been  taken  of 
three  very  important  factors.  First,  it  would  take  years 

1 The  Lahcet,  1910,  i.,  1718  ; ti.,  60. 


Thh  Lanoht,] 


ROYAL  INSTITUTE  OF  PUBLIC  HEALTH. 


[July  12,  1919  61 


to  overcome  the  present  house  shortage,  and  until  that 
was  accomplished  it  was  useless  to  talk  of  sweeping  away 
the  slums.  In  Birmingham  there  were  40,000  back-to- 
back  houses.  The  second  point  was  that  large  numbers 
of  people  did  not  wish  to  leave  the  slum  localities, 
not  because  they  were  satisfied  with  their  housing 
conditions,  but  they  preferred  improvement  on  the 
spot.  Thirdly,  a large  number  did  not  want  to  pay  the 
rent  which  would  be  charged  for  new  suburban  houses.  His 
point  was  that,  even  if  all  slum-dwellers  wished  to  reside  in 
suburbs,  the  provision  for  them  would  require  years  to  bring 
about,  and  meantime  every  effort  should  be  made  to  improve 
their  present  residences.  Partial  reconstruction  would  make 
an  enormous  difference,  and  this  should  not  be  left  to 
private  owners,  some  of  whom,  however  willing,  had  not  the 
necessary  capital  to  carry  out  the  needed  structural  altera- 
tions. Under  Section  4 of  the  Housing  Act  of  1890  a local 
authority  could  pass  a resolution  that  an  area  was  unhealthy 
and  that  an  improvement  scheme  should  be  carried  out  in 
respect  of  it,  and  in  the  new  Housing  and  Town  Planning 
Bill  it  was  recognised  that  it  ought  to  be  possible  to 
purchase  lands  in  such  area  even  before  any  improvement 
scheme  had  been  formulated.  The  need  was  for  a provision 
for  compulsory  purchase. 

Primary  Importance  of  Housing  Schemes. 

Mr.  W.  H.  Cadbury  said  he  agreed  with  those  who  said 
that  every  sovereign  spent  in  the  prevention  of  tuberculosis 
was  of  more  value  than  £10  spent  in  sanatorium  treatment 
and  after-care  schemes,  and  among  preventive  measures  he 
considered  that  housing  schemes  came  first,  especially  when 
due  attention  was  given  to  through-and-through  ventilation. 
Of  600  tuberculous  soldiers  who  had  been  visited  recently, 
107  lived  two  families  in  one  house.  Preference  should  be 
given  to  soldiers  who  had  fought  in  the  war  in  letting  the 
new  houses.  The  birth-rate  in  Birmingham  in  1865  was 
39  per  1000  ; now — 1918 — it  was  19  4,  and  it  was  still  on  the 
decline.  Educated  people  seemed  averse  to  bringing  children 
into  the  world  to  face  overcrowding,  disease,  and  dirt.  The 
Birmingham  scheme  was  started  with  the  stipulation  that 
every  house  should  have  at  least  three  bedrooms,  but,  yield- 
ing to  pressure,  a certain  number  of  two-bedroomed  houses 
had  been  arranged  for. 

Earth  Closets  for  Rural  Areas. 

Sir  Richard  Paget  emphasised  the  importance  of  giving, 
in  the  new  houses,  the  strictest  scientific  attention  to  the 
new  needs  of  the  community.  He  reminded  the  meeting 
that  the  main  requirement  in  ventilation  had  been  shown  to 
be  cool  air  in  motion.  The  rural  bungalow  found  great 
favour  in  his  eyes,  but  with  a cosy  dressing-room,  and  this 
required  a new  design  in  cottage  architecture.  He  also 
advocated  a proper  system  of  earth  closets  for  rural  areas 
and  the  use  of  the  excreta  on  the  garden.  Sir  William 
Crookes  had  estimated  the  loss  of  nitrogenous  garden  manure 
owing  to  the  provision  of  water-closets  at  14  million  pounds 
per  annum.  He  also  advocated  the  use  of  labour-saving 
devices  for  the  kitchen. 

Resolutions  Approved. 

Mr.  Chamberlain  then  moved  the  following  resolution  : — 

This  Conference  is  of  opinion  that  while  every  effort  should  be  made 
to  provide  the  maximum  number  of  houses  on  suburban  sites,  local 
authorities  should  be  given  further  powers  to  enable  them  simul- 
taneously to  improve  housing  conditions  in  the  central  areas  of  large 
towns. 

The  further  discussion  revealed  impatience  at  the  delay  in 
bringing  the  schemes  about.  The  resolution  was  carried, 

6 votiDg  against.  The  following  resolutions  were  also 
approved  : — 

(1)  That  the  Conference  is  of  opinion  that  the  Housing  and  Town 
Planning  Bill  should  include  provision  for  the  registration  and  more 
effective  control  of  the  subletting  of  dwelling  houses,  so  that  adequate 
provision  may  be  made  for  proper  washing,  larder,  laundry,  and 
lavatory  accommodation. 

(2>  That,  notwithstanding  the  facilities  already  granted  under  the 
Orders  of  the  Local  Government  Board  in  regard  to  the  promotion  of 
Housing  and  Town  Planning  Schemes,  the  Conference  is  of  opinion 
that  the  Housing  and  Town  Planning  Bill  now  before  Parliament  should 
be  passed  into  law  without  further  delay. 

(3)  The  Conference  is  of  opinion  that  the  erection  of  dwelling  houses 
in  the  congested  parts  of  cities  and  towns  should  be  minimised,  and 
that  every  facility  should  be  provided  to  ensure  their  erection  in  open 
suburban  areas,  and  that  adequate,  rapid,  and  cheap  means  of  loco- 
motion between  the  dwelling  houses  and  places  of  occupation  should  be 
provided. 

. That,  in  the  view  of  this  Conference,  a wider  and  more  liberal 
interpretation  of  the  by-laws  of  many  districts  is  necessary,  and  in 
others  a more  effective  one,  and  that  full  discretionary  power  should 


be  given  to  the  Ministry  of  Health  to  authorise  modifications  to  meet 
local  conditions.  It  is  also  of  opinion  that  the  improvement  of  the 
conditions  of  rural  housing  is  of  not  less  urgency  than  is  that  of  the 
cities. 

(5)  The  Conference  recommends  that  the  research  now  being  carried 
out  by  the  Government  with  respect  to  building  materials  and  othei 
details  may  be  extended  so  as  to  include  organised  research  as  to  the 
most  efficient  methods  of  ventilation,  heating,  sanitary  and  labour- 
saving  devices,  and  their  application  to  small  houses  in  both  urban  and 
rural  districts. 

IV.  Maternity  and  Child  Welfare. 

Mrs.  Lloyd  George  had  been  invited  to  preside  at  this 
session,  but  found  herself  unable  to  do  so. 

Sir  Francis  Champneys  (Chairman  of  the  Central 
Midwives  Board)  occupied  the  chair,  and  opened  the  debate 
with  an  address  on 

The  Protection  of  Motherhood. 

He  spoke  first  of  the  effect  on  the  child  of  venereal  disease 
in  the  mother.  The  immediate  period  to  give  attention  to 
was  that  of  pregnancy,  parturition,  and  lying-in.  Syste- 
matic attention  to  the  questions  of  pelvic  abnormalities  and 
pelvic  toxsemia,  with  pre-parturition  examination  of  the 
mother,  had  resulted  in  a great  increase  in  national  health. 
Among  the  affluent  the  responsibility  rested  with  the  medical 
practitioner,  in  the  case  of  the  poor  generally  it  rested  with 
the  midwife.  The  Central  Midwives  Board,  however,  dis- 
couraged diagnoses  by  midwives,  but  required  them  to 
inquire  as  to  previous  pregnancies,  and  if  in  any  way 
abnormal  to  advise  the  expectant  mother  to  seek  advice  at  a 
hospital  or  other  suitable  institution.  Should  untoward 
symptoms  occur  she  must  report  them  at  once  ; failure  to  do 
so  was  a penal  offence  and  she  was  liable  to  be  struck  off  the 
Register.  Since  the  first  operation  of  the  Midwives  Act  in 
1902  there  had  been  a distinct  improvement  in  these  matters, 
but  it  had  not  been  materially  advanced,  and  it  was  desirable 
to  ascertain  in  whose  hands  fatal  cases  continued  to  occur. 
It  was  a pity  that  the  request  of  the  Board  that  the  death 
certificate  should  have  a space  for  the  name  of  the  person 
who  delivered  the  child  was  not  granted,  as  this  would  have 
been  very  helpful.  More  information  was  also  wanted  as  to 
the  manner  in  which  sepsis  still  occurred.  There  was  need 
for  many  more  obstetric  institutions,  so  distributed  over  the 
country  that  no  parturient  or  lying-in  woman  should  be 
beyond  the  reach  of  one  of  them,  and  motor  ambu- 
lances should  be  available.  In  1914  there  were  879,096 
live  children  born  in  England  and  Wales.  Stillbirths 
before  28  weeks  of  pregnancy  were  not  yet  regis- 
trable. If  the  average  stay  of  the  mother  in  an 
institution  were  taken  as  25  days,  it  was  calculated  that 
35,164  beds  would  be  required  in  England  and  Wales  per 
annum.  At  the  foundation  of  the  safety  of  the  nation’s 
motherhood  was  the  training  of  the  midwife,  but  the 
energies  of  the  machinery  set  up  by  the  Midwives  Board 
were  largely  diverted  into  training  women  who  never 
intended  to  practise  midwifery  ; a serious  position  now  that 
there  was  none  too  much  material  to  train  on.  In  1918,  of 
19,357  midwives  trained  at  approved  institutions  other  than 
Poor-law,  only  4640  notified  their  intention  to  practise  it,  a 
wastage,  from  this  special  standpoint,  of  294,340  cases  ; 
and,  adding  other  training  centres,  a total  wastage  of 
356,420  cases  ! He  considered  that  candidates  should  be 
required  to  bind  themselves  to  practise  as  midwives  for  a 
definite  term  of  years. 

The  Protection  of  Infants  and  Children. 

Lady  Leslie  Mackenzie  (Edinburgh)  spoke  eloquently  on 
the  question  of  the  protection  of  infancy,  pointing  out  how 
badly  off  were  the  many  parts  of  the  country  where  no 
gynaecologist  was  available  ; the  thoughts  on  this  subject 
were  apt  to  be  focussed  on  the  city  and  the  big  town.  All 
possible  care  should  be  given  to  every  mother  for  the  purpose 
of  ensuring  that  she  reared  a healthy  child  ; and  this  was 
rendered  the  easier  by  the  fact  that  the  Notification  of  Births 
Act  allowed  every  public  health  authority  to  make  whatever 
arrangements  it  thought  fit  to  attend  to  the  health  of 
expectant  and  nursing  mothers,  and  children  up  to  5 years 
of  age.  The  present  rate  of  death  below  3 months  of  age 
was  a disgrace  to  any  civilised  country.  She  insisted  very 
strongly  on  the  need  in  the  young  child  of  personal  nursing 
by  its  mother,  and  the  conscientious  training  of  health 
visitors  as  well  as  nurses  in  the  due  care  of  the  infant. 

Mr.  A.  Carless  dealt  with  the  subject  of  the  protection 
of  childhood,  pointing  his  remarks  by  reference  to  the 
case  of  Dr.  Barnardo’s  Homes,  through  the  doors  of  which 


62  The  LAncet,] 


royal  institute  of  public  health. 


[July  12,  1919 


87,000  children  had  now  passed.  The  death-rate  had  been 
phenomenally  small,  varying  between  7 26  and  11  70  per 
1000.  He  paid  special  attention  to  the  question  of 
sufficient  and  efficient  food  and  plenty  of  sleep  and 
exercise. 

Dr.  C.  J.  Macalister  (Liverpool)  said  that  the  number  of 
children  attending  the  out-patient  departments  of  Liverpool 
was  larger  than  they  could  deal  with.  He  described  a 
scheme  by  which  that  city  was  to  undertake  a clearing- 
house arrangement  for  sending  sick  children  to  the  most 
suitable  institution  for  their  particular  ailment.  He  hoped 
to  see  established  a great  school  for  the  study  of  children’s 
diseases,  which  would  probably  take  up  research  in  children’s 
ailments. 

Resolutions  Approved. 

The  sitting  ended  with  the  passage  of  the  following 
resolutions : — 

1.  That  this  Conference  views  with  great  satisfaction  the  results 
already  obtained  from  efforts  made  to  promote  the  welfare  of  mother- 
hood and  infancy,  and  welcomes  the  prospect  of  fuller  appreciation  of 
the  services  which  can  be  rendered  by  properly  trained  midwives  and 
health  visitors. 

2.  That  the  Conference  considers  the  proper  distribution  of  midwives 
and  health  visitors  should  come  within  the  purview  of  the  Ministry  of 
Health. 

V.  The  Tuberculosis  Problem  under  After-war 
Conditions.  . 

The  concluding  topic  of  the  Conference  was  the  Tuber- 
culosis Problem  under  After-war  Conditions.  The  chair  was 
occupied  by  Professor  Hope. 

Mortality  from  Tuberculosis  in  England  and  Wales. 

Dr.  H.  Hyslop  Thomson  (tuberculosis  officer  for  Herts) 
said  that  in  1911  there  were  in  England  and  Wales  53,120 
deaths  from  all  forms  of  tuberculosis.  In  1914  these  had 
fallen  to  50,298,  but  rose  again  in  1918  to  58,073,  an 
increase  common  to  both  fighting  forces  and  civilians,  with 
a notable  rise  among  asylum  inmates,  in  one  large  asylum 
the  2 per  cent,  of  1914  rising  to  11-7  per  cent,  last  year. 
The  increased  mortality  he  attributed  to  the  depleted 
resisting  power  of  the  population  due  to  a prolonged  war. 
One  of  the  weakest  links  in  systems  for  combating  tuber- 
culosis was  the  present  method  of  notification,  which  included 
no  information  as  to  the  danger  of  infection  and  the  home 
conditions  of  the  patient,  and  it  placed  no  initial  re- 
sponsibility on  the  general  practitioner.  He  considered  that 
the  services  of  the  general  practitioner  needed  to  be  extended 
in  regard  to  the  notification  and  prevention  of  disease.  Dr. 
Thomson  proceeded  to  discuss  the  various  methods  of  pre- 
vention and  treatment  in  detail.  There  should  be  segregation 
of  acute  cases,  and  adequate  treatment  of  the  advanced  ones  ; 
he  recommended  their  compulsory  removal  to  a proper  place. 
Much  of  the  criticism  of  sanatoriums  was  due  to  the  fact  that 
too  much  was  expected  of  them  alone,  though  he  admitted 
that  the  standard  of  such  treatment  throughout  the  country 
left  much  to  be  desired,  both  as  to  uniformity  and  efficiency. 
Sanatorium  treatment  could  not  be  standardised,  but 
certain  general  principles  could  be  universally  adopted. 
There  was  no  other  system  which  arrested  the  progress  of 
the  disease  so  well.  No  patient  should  be  discharged  from  a 
sanatorium  in  whom  there  was  further  possibility  of  improve- 
ment. He  dilated  on  the  very  poor  provision  for  non- 
pulmonary  cases  of  the  disease,  and  entered  into  the  question 
of  domiciliary  treatment,  for  which  there  was  need  of 
systematised  effort  on  a large  scale.  His  concluding  remarks 
dealt  with  after-care. 

The  Disease  and  its  Treatment  in  Service  Men. 

Dr.  Nathan  Raw,  M.P.,  spoke  of  the  disease  and  its 
treatment  among  combatants.  We  must,  he  said,  pay  the 
highest  tribute  to  the  brave  men  who  had  fought  for  us 
and  had  developed  tuberculosis.  A large  number  of  ex- 
service  patients  must  have  had  the  germs  of  the  disease 
before  the  war,  but  the  rigors  and  severities  of  trench 
warfare,  and  the  great  privations  which  soldiers  had  to 
endure  were  agents  in  stirring  into  activity  what  had 
hitherto  been  quiescent  disease.  He  spoke  of  the  desire 
of  the  Government  to  do  everything  possible  for  these  men, 
and  referred  to  the  Commission  which  had  been  appointed  to 
deal  with  the  matter,  of  which  he  himself  was  a member. 
The  number  of  Service  men  afflicted  with  tuberculosis  was 
between  35,000  and  40,000,  but  a fair  proportion  were  in 
the  early  curable  stages,  and  many  others  were  in  a stage 
which  permitted  of  their  useful  employment.  He  promised 


that  the  provision  for  the  ex-service  men  would  be  adequate, 
and  he  hoped  the  report  of  the  Commission  would  soon  be 
issued.  A fact  to  be  reckoned  with  was  that  a large  number 
of  the  victims  of  the  disease  refused  to  enter  a sanatorium, 
and  he  asked  that  every  effort  should  be  made  to  counteract 
the  prevalent  notion  that  tuberculosis,  in  any  stage,  was  an 
incurable  disease. 

Tuberculosis  Communities. 

Dr.  Noel  D.  Bardswell  (medical  adviser  to  the  London 
Insurance  Committee)  dealt  with  the  question  of  tuberculosis 
communities.  He  said  that  unless  the  work  of  the  various 
institutions  could  be  associated  with  after-care,  their  work 
often  fell  to  the  ground.  The  factors  which  rendered 
ineffective  the  work  of  sanatoriums  included  the  habits  of 
the  people,  and  economic  questions,  such  as  a living  wage 
and  housing  accommodation.  The  root  idea  behind  the 
tuberculosis  settlement  was  the  voluntary  segregation  of 
tuberculous  persons  in  a community,  which  would  allow  of 
a more  effective  supervision  than  could  be  exercised  at 
present.  This,  in  order  to  be  efficient,  must  be  made  attrac- 
tive. Another  important  principle  was  the  protection  of  the 
partially  disabled  worker  from  having  to  compete  for  his 
livelihood  against  physically  sound  men  and  women.  These 
patients  could  not  be  dealt  with  to  the  exclusion  of  their 
families  ; hence  the  obvious  need  was  for  small  village  com- 
munities or  something  in  the  nature  of  garden  cities.  The 
prime  object  should  be,  not  to  give  these  patients  seven  or 
eight  weeks  of  sanatorium  treatment,  but  an  opportunity  of 
working  under  favourable  conditions  for  the  rest  of  their 
life.  He  believed  the  ordinary  industrial  occupations  would 
prove  more  suitable  in  the  long  run  than  agricultural 
pursuits,  and  the  opening  was  more  extensive.2  The  case  of 
the  soldier  presented  a good  opportunity  to  put  the  com- 
munity system  to  the  test ; the  soldier  had  his  pension,  and 
would  be  found  very  willing  to  take  up  some  work.  And 
what  was  found  practicable  for  the  discharged  soldier  could 
be  applied  to  the  case  of  the  civilian. 

Mr.  H.  J.  Gauvain  put  in  a plea  for  the  non-pulmonary 
cases,  for  which  nothing  in  an  organised  way  had  yet  been 
done  in  this  country.  One  or  two  large  centres  would  probably 
suffice  for  all  the  cases  of  surgical  tuberculosis  in  the 
country. 

The  Necessity  for  Accurate  Diagnosis. 

Lieutenant-Colonel  W.  Hallock  Hart  referred  to  the 
disease  as  it  affected  the  Canadian  forces  in  the  war,  and 
pointed  out  the  great  importance  of  an  accurate  diagnosis. 
As  director  of  the  hospital  for  tuberculosis  for  Canadians 
here  he  could  speak  of  its  work.  It  had  acted  largely  as  a 
clearing  centre,  because  many  cases  were  sent  back  to 
Canada  as  soon  as  the  disease  was  diagnosed.  He  felt  in 
increasing  degree  the  need  for  educating  the  general  public 
with  regard  to  tuberculosis  ; he  had  had  experience  in  America 
with  the  results  in  educated  communities  and  those  in 
people  who  were  ignorant  on  these  matters.  He  did  not 
consider  that  tuberculosis  had  increased  as  a result  of  men 
being  on  active  service  ; indeed,  he  believed  that  the  open- 
air  life  of  the  Army  had  preserved  the  health  of  many  men 
who  otherwise  would  have  broken  down.  Of  900  cases  he 
saw,  28  per  cent,  were  in  the  incipient  stage,  42  per  cent, 
in  a moderately  advanced  stage,  30  per  cent,  in  an  advanced 
condition. 

The  Need  fur  Combative  Measures  in  Ireland. 

The  Marchioness  of  Aberdeen  spoke  on  the  question  as 
it  affects  Ireland,  pointing  out  the  crying  need  of  combative 
and  remedial  measures  in  the  rural  parts  of  the  country. 
The  educative  campaign  against  tuberculosis  which  took 
place  in  Ireland  a few  years  ago  showed  how  quick  were  the 
Irish  people  to  adopt  the  ordinary  precautions,  such  as  the 
open  window.  But  the  conference  recently  held  in  that 
country  under  the  auspices  of  the  Women’s  National  Health 
Association  showed  that  there  was  scarcely  any  provision  for 
advanced  cases  of  the  disease  ; that  conference  unanimously 
urged  the  putting  into  force  of  compulsory  notification  of 
the  disease.  She  concluded  with  a special  and  moving  word 
on  behalf  of  the  Irish  children. 

Return  to  lamily  Life  a factor  in  the  Eradication  of  the 
Disease. 

Professor  Sir  G.  Sims  Woodhead  said  he  believed  it 
was  possible  to  stamp  out  tuberculosis  ; but  there  would  be 

2 The  Laxcet,  1919,  i.,  456. 


The  Lancet,] 


ROYAL  SOCIETY  OK  MEDICINE:  DISEASE  IN  CHILDREN. 


[July  12,  1919  63 


but  little  chance  of  eradicating  it  unless  the  man  who  had 
been  away  could  be  brought  back  to  his  family  life.  It  was 
not  always  the  most  robust  person  who  was  the  most  resistant 
to  tubercle  ; and  he  urged  that  no  one  measure — such  as 
open  windows  or  good  food — was  sufficient  ; all  means  must 
be  employed,  and  the  machinery  must  not  be  allowed  to  hide 
the  work. 

The  subsequent  speakers  included  Dr.  Nash,  Dr.  S.  Verb 
Pearson,  Mr.  Dag,  Mrs.  Palmer,  Dr.  Sutherland,  Dr. 
Cecil  Wall,  Mrs.  Sandhall,  and  Mr.  Burns. 

Resolutions  Approved. 

The  following  resolutions  were  then  put  and  approved  : — 

1.  That  in  the  opinion  of  this  Conference  schemes  for  the  prevention 
of  tuberculosis  must  be  of  general  apolication,  and  it  recognises 
that  sanatoria,  colonies,  and  other  establishments  for  treatment  and 
segregation  are  of  the  utmost  value  in  the  prevention  of  tuberculosis. 

2.  That  the  Conference  recognises  the  obligation  to  provide  not  only 
for  the  tuberculous  soldier,  but  for  the  tuberculous  wife  or  child  of  the 
soldier  or  civilian  or  for  any  other  member  of  the  population. 

3.  That  this  Conference  recognises  the  necessity  for  adequate  pro- 
vision beiDg  made  for  the  treatment  and  training  of  sufferers  from  non- 
pulmonary  tuberculosis,  more  especially  in  the  case  of  adult  sufferers, 
for  whom  no  provision  has  hitheito  been  available. 

4.  That  in  the  preparation  of  designs  for  the  new  houses  which  are  to 
be  erected  in  the  near  future  special  regard  should  be  taken  to  the  pro- 
vision of  the  best  methods  of  ventilating,  heating,  and  sleeping  accom- 
modation, and  a rigorous  enforcement  of  by-laws  designed  to  protect 
the  dwellings  from  damp,  with  the  object  of  combating  and  preventing 
tuberculosis  by  improving  the  general  health  of  the  community. 

The  Conference,  which  was  carried  on  with  much 
enthusiasm  throughout  aud  was  very  successful,  concluded 
with  the  usual  votes  of  thanks. 


ROYAL  SOCIETY  OF  MEDICINE. 


SECTION  FOR  THE  STUDY  OF  DISEASE  IN  CHILDREN. 

A MEETING  of  this  section  was  held  on  June  20th,  Dr. 
J.  Porter  Parkinson,  the  President,  being  in  the  chair. 

Dr.  Hazel  Chodak  showed  a case  of 

Chorea , Complicated  by  Gangrene  of  the  Fingers. 

The  patient,  aged  12  years,  was  admitted  to  hospital  in 
December,  1918,  suffering  from  chorea  of  a week’s  duration. 
This  was  a first  attack,  and  there  was  no  previous  history  of 
rheumatism  ; no  history  of  shock  or  overwork.  Two  years 
previously  she  had  had  diphtheria,  wjth  a bad  attack  of 
tonsillitis  during  convalescence.  The  mother  had  had 
rheumatism  and  one  sister  had  had  chorea.  On  admission 
the  patient,  a thin  girl,  was  found  to  be  suffering  from  a 
moderately  severe  attack  of  chorea,  all  parts  of  the  body 
being  affected.  There  was  very  little  loss  of  strength  on  the 
left  side,  but  the  right-hand  grip  was  poor  and  feebly  sus- 
tained. All  reflexes  were  exaggerated.  On  examination  of 
the  heart  the  apex  beat  was  found  in  the  fourth  space,  half 
an  inch  inside  the  nipple  line ; a soft  blowing  murmur 
accompanied  the  first  sound  at  the  apex,  and  was  conducted 
a short  way  towards  the  axilla;  the  second  sound  was 
accentuated  at  the  base. 

Ten  davs  after  admission  the  right  hand  began  to  go  white 
and  the  finger-nails  blue,  though  the  hand  did  not  actually 
feel  cold  to  the  touch.  The  onset  might  be  described  as  rapid 
rather  than  sudden,  and  it  was  fully  a week  before  gangrene 
of  the  finger-tips  and  ball  of  the  thumb  had  definitely  set 
in.  During  this  time  the  pallor  spread  up  the  forearm. 
There  was  no  pulse  at  the  wrist,  but  the  brachial  artery 
could  be  felt  pulsating  about  half-way  down  the  upper  arm, 
and  after  a time  there  was  distinct  pulsation  of  the  superior 
profunda  artery.  The  pain,  which  was  also  gradual  in 
onset,  became  very  severe  after  the  first  few  days,  and 
could  only  be  relieved  by  morphia.  Meanwhile  the 
cardiac  signs  showed  changes  in  degree  rather  than  in 
kind.  The  systolic  murmur  became  much  louder  and 
rougher,  while  the  second  sound  at  the  aortic  and  pulmonary 
areas  was  markedly  accentuated.  At  first  the  apex  beat 
remained  within  the  nipple  line,  but  in  a few  days  it  was 
found  to  be  displaced  slightly  outside  the  nipple  line.  The 
pulse,  however,  remainedat  about  80,  and  was  never  increased 
in  frequency,  except  occasionally  when  the  pain  had  been  very 
severe.  The  temperature  throughout  never  rose  above 
99°  F.,  and  was  rarely  as  high  as  that.  Later  still,  the 
brachial  pulse  slowly  disappeared,  and  the  brachial  artery 
could  be  felt  like  a thick  cord  along  the  arm.  The  little 
finger  recovered,  and  lines  of  demarcation  gradually  formed 
on  the  remaining  fingers.  The  ball  of  the  thumb  appeared 
at  first  to  have  escaped,  as  the  discoloured  skin  peeled  away 
from  it,  but  there  must  have  been  considerable  damage  to 
the  muscle,  followed  by  contraction  of  the  scar  tissue,  which 
had  led  to  considerable  deformity  of  the  thumb.  The 
choreic  movements  subsided  rapidly  soon  after  gangrene 
was  established.  The  heart  signs  also  disappeared,  but 
much  more  gradually. 


The  question  of  interest  in  this  case  was  the  exact  cause 
of  the  gangrene.  The  three  possible  causes  of  gangrene 
complicating  chorea  were  : (1)  Embolus ; (2)  arteritis 

(leading  to  thrombosis)  ; and  (3)  arterial  spasm  (resembling 
Raynaud’s  disease).  Raynaud's  disease  was  mentioned 
as  an  infrequent  complication  of  acute  rheumatism,  and 
might  lead  to  local  gangrene,  but  in  this  case  there 
was  extensive  thrombosis  which  could  hardly  have  been 
caused  by  mere  spasm.  As  between  embolus  and  throm- 
bosis, the  diagnosis  was  not  easy.  Dr.  Chodak  did  not  think 
that  the  absence  of  abrupt  onset  negatived  the  embolism 
theory,  as  conceivably  the  artery  might  be  only  partially 
blocked  at  first.  It  was  difficult,  however,  to  feel  con- 
vinced that  there  was  ever  any  gross  organic  lesion  of  the 
heart,  as  the  pulse  and  temperature  kept  so  steady.  At  the 
time,  however,  the  slight  dilatation,  the  character  of  the 
murmur,  and  the  loud  accentuation  of  the  second  sound, 
made  one  believe  that  this  was  the  beginning  of  a rheumatic 
carditis.  There  remained  the  supposition  that  there  was  a 
primary  thrombosis  in  the  brachial  artery.  Arteritis  was  not 
an  infrequent  complication  of  acute  rheumatism,  and 
although  this  was  generally  located  in  the  aorta,  there 
seemed  no  reason  to  suppose  that  the  brachial  artery  might 
not  be  affected  also.  Such  a condition  might  be  speedily 
followed  by  thrombosis.  In  these  cases  the  circulation  was 
usually  kept  up  by  anastomosing  channels,  so  that  gangrene 
did  not  often  occur.  Probably  in  this  child  the  general 
condition  of  debility  and  anaemia  was  a predisposing  cause. 

Dr.  F.  S.  Langmead  showed  a case  of 

Solerodermia  with  Calcification  in  a Mongol. 

The  patient,  a boy,  aged  4|  years,  was  the  last  child  of  a 
family  of  three.  The  mother  was  aged  42  years  at  the  child’s 
birth.  The  other  children  were  aged  17  and  15  years,  ten 
years  elapsing  between  the  last  gestation  and  the  birth  of 
the  patient.  The  mother  said  that  she  had  always  been 
healthy  except  that  she  had  been  anaemic.  During  pregnancy 
she  felt  quite  well.  The  father  and  his  family  were  described 
as  highly  strung  and  nervous.  There  appeared  to  be  no 
neuropathic  tendency  in  the  mother.  No  alcoholic  history. 

Tiie  boy  was  small  and  appeared  healthy  at  birth,  but  the 
mother  noticed  a similar  discolouration  and  rash  to  that 
which  was  now  visible  on  the  knees,  face,  and  hands.  She 
was  sure  that  the  rash  had  always  been  present,  but  had 
varied  in  intensity  from  time  to  time.  He  had  always  been 
backward,  sitting  up  at  10  months,  walking  at  1 year  and 
10  months.  Walking  had  never  been  properly  acquired,  but 
had  been  feeble,  with  the  legs  apart.  Until  the  last  few 
weeks  he  had  ceased  walking  altogether  for  two  and  a half 
years,  and  became  unable  to  stand.  In  October  or  November, 

1917,  he  was  admitted  to  a hospital  for  “ blueness  ” over  the 
fronts  of  the  upper  arms  ; this  had  begun  to  spread  to  the 
chest  over  the  pectoral  muscles,  but  apparently  improved 
considerably  before  his  discharge.  In  December,  1917,  he 
developed  pneumonia,  but  made  a good  recovery.  In  June, 

1918,  lumps  began  to  appear  on  the  surface.  At  first  they 
were  quite  soft  and  limited  to  the  area  over  the  biceps,  but 
about  two  months  later  began  to  harden.  More  recently 
they  had  been  noticed  to  spread  inwards  over  the  pectoral 
region.  Flushing  of  the  face  varied  greatly.  It  had  been 
noticed  for  about  two  years,  and  was  more  marked  on  warm 
days.  The  legs  had  been  noticed  to  be  getting  thinner  for 
about  six  months,  and  about  two  months  ago  stiffness  of 
knees  and  ankles  supervened. 

The  child  was  a moderately  marked  example  of  the  Mon- 
golian variety  of  amentia,  but  with  mental  capacity  above  the 
average  in  such  cases.  The  cheeks  had  a dusky-red,  patchy 
appearance,  the  skin  being  somewhat  atrophic  and  shiny. 
A similar  blotchy  bluish-red  discolouration  was  seen  on  the 
fingers  and  hands  as  far  as  the  wrists.  The  fingers  were 
shiny  and  small,  but  no  definite  sclerodactylia  had  developed. 
The  skin  on  the  knees,  extending  upwards  on  the  outer 
aspects  of  the  thighs,  and  on  the  buttocks  in  the  neighbour- 
hood of  the  ischial  tuberosities,  was  similarly  affected.  On 
the  arms  the  discolouration  had  disappeared,  and  was 
replaced  by  white,  firm,  contracted  skin,  thrown  into 
unevenness  and  puckers  by  subcutaneous  nodules  of  sizes 
varying  from  minute  seed-like  bodies  to  plaques  larger  than 
a shilling.  Some  of  these  were  confluent,  others  discrete. 
They  were  roughly  linear  in  distribution  and  symmetrical, 
though  rather  more  extensive  on  the  left  side  than  on  the 
right.  This  condition  had  spread  inwards  over  the  pectorals, 
and  backwards  over  the  triceps  on  each  side.  On  the  left  it 
reached  somewhat  farther  down  beyond  the  elbow  and  over 
the  extensor  carpi  ulnaris  muscle.  A similar  alteration  of 
skin  and  subcutaneous  tissue  appeared  in  a roughly 
symmetrical  manner  in  other  areas,  notably  on  thighs, 
legs,  and  in  popliteal  spaces.  Some  of  the  subcutaneous 
thickened  areas  were  adherent  to  the  skin,  others 
were  not.  Some  of  the  nodules  were  very  hard,  feeling 


64  The  Lanobt,] 


ROYAL  SOCIETY  OF  MEDICINE  : DISEASE  IN  CHILDREN. 


[July  12,  1919 


almost  like  bone.  Here  and  there  a nodule  had  caused 
redness  and  soreness  of  the  overlying  skin  and  slight  scab 
formation.  X rays  demonstrated  that  the  subcutaneous 
tissue  in  the  nodular  and  thickened  areas  was  sprinkled  with 
small  pleomorphic  calcareous  deposits.  The  muscle  did 
not  seem  to  be  affected,  but  it  was  questionable  whether 
they  were  not  being  gradually  infiltrated  from  the  sub- 
cutaneous layer.  The  movements  were  limited  by  the 
inelasticity  and  fixation  of  the  skin.  In  addition  there  was 
some  limitation  of  movement  of  the  knees  and  ankles  dis- 
proportionate to  the  subcutaneous  hardening,  probably  due 
to  accompanying  synovial  changes. 

The  points  of  interest  were  (1)  the  discolouration  of  the 
skin  dating  from  birth,  and  later  being  replaced  by  sclero- 
derinia  ; (2)  the  calcification  of  the  sclerodermatous  sub- 
cutaneous tissue  (calcinosis,  petrifaction)  1 ; (3)  the  associated 
arthritic  changes  ; and  with  respect  to  the  Mongolism, 
(4)  the  long  period  of  sterility  before  the  child  was  born. 

Mr.  Paul  Bernard  Roth  described  a case  of 
Apophysitis  of  Os  Calais. 

The  patient  was  a boy,  aged  14  years,  who  was  said  to  have 
suffered  for  some  years  with  double  flat-foot.  For  ten  years 
or  longer  he  had  had  trouble  with  his  feet,  and  for  the  last 
two  years  had  had  pains  in  his  feet  and  ankles  up  to  his 
calves  on  running.  When  seen  by  Mr.  Roth  he  could  only 
just  walk  from  his  house  to  the  schoolhouse  (ten  minutes’ 
walk).  He  had  had  various  arch  supports  and  appliances, 
such  as  thickenings  of  the  soles  and  heels  of  his  boots, 
electric  baths  and  massage,  but  the  pain  still  continued. 
On  examination  there  was  found  to  be  a slight  tendency  to 
talipes  valgus  when  he  walked;  all  the  pain  was  at  the  back 
of  the  heel  and  up  the  tendo  Acbillis;  there  were  tender 
spots  on  both  sides  of  the  insertion  of  this  tendon.  He  con- 
sidered the  case  to  be  one  of  inflammation  from  trauma  of 
the  posterior  epiphysis  of  os  calcis. 

Radiograms  showed  a cartilaginous  gap  with  irregular 
ossification  between  the  upper  part  of  the  epiphysis  and  the 
os  calcis,  especially  marked  in  the  left — the  worse — foot,  and 
some  rarefaction  of  the  bone  at  this  point.  As  these  radio- 
grams confirmed  the  diagnosis,  treatment  by  prolonged  rest 
in  bed  was  suggested,  to  be  followed  by  gradually  increasing 
spells  of  walking  in  boots  with  a rubber  disk  fixed 
to  each  heel,  a pad  of  sponge  rubber  beneath  each 
heel  inside  the  boot,  and  a £ in.  valgus  wedge  of 
leather  applied  to  the  inner  side  of  each  sole  and  heel. 
Complete  rest  in  bed  for  six  weeks  was  followed  by  some 
pain,  evidently  due  to  stillness  and  muscular  weakness  from 
his  long  rest.  A month  later  he  was  able  to  walk,  and  even 
to  run  a few  steps  without  pain.  Radiograms  showed  that 
the  wide  cartilaginous  band  with  irregular  ossification  had 
given  place  to  sound  bony  tissue  through  its  entire  length, 
except  a very  small  portion  at  the  top  (most  marked  in  left 
foot)  where  the  junction  of  the  epiphysis  was  not  quite 
complete. 

Dr.  Edmund  Oautley  showed  a case  of 
(?)  Chloroma. 

The  child  had  been  first  admitted  to  hospital  for  screaming 
and  cerebral  irritability,  and  was  found  to  be  feverish  and 
apathetic,  with  right  facial  palsy  and  left-sided  torticollis. 
These  symptoms  were  rapidly  recovered  from,  but  after  dis- 
charge a profound  amemia  developed,  bulging  occurred  in 
the  temporal  region,  and  the  left  kidney  became  palpable. 
Then  paiu  was  complained  of  in  a hip-joint.  The  child 
became  rapidly  worse,  and  a month  later  nodules  appeared 
on  the  head.  The  spleen  and  liver  were  enlarged  and  con- 
siderable increase  in  size  of  lymphatic  glands  was  noticed. 
The  red  blood  cells  were  1,690,000  ; Hb,  25  5 per  cent.  ; 
colour  index,  0 79  ; leucocytes  increased  from  8000  to  14,000. 
Of  these,  the  polymorphs  increased  from  1940  to  5845,  the 
lymphocytes  from  5660  to  7140.  There  were  many  features 
of  chloroma,  including  a faint  greenish  tinting  of  the  skin. 
The  other  possible  diagnosis  was  adrenal  tumour  with 
secondary  neoplasms  in  bone.  In  favour  of  this  was  the 
palpable  left  kidney  which  was  noticed  in  the  earlier 
stages.  Skiagrams  showed  rarefaction  of  femora,  vertex, 
and  occipital  region. 

Multiple  Glandular  Swellings. 

Dr.  Cautley  also  showed  a case  of  Multiple  Glandular 
Swellings  in  a child  aged  1 year  and  9 months.  There  was 
no  family  history  of  tubercle.  The  patient  had  been  ailing 
since  Christmas  with  diarrhoea,  anorexia,  and  malaise. 


1 Vide  F.  l’arkes  Weber,  Brit.  Jour.  Child.  Die.,  x.,  p.  97,  at  the  end 
of  which  article  references  are  given 


Enlarged  glands  were  found  in  the  abdomen.  Others, 
large  and  freely  movable,  were  present  in  the  neck  and 
axillae,  especially  in  the  right.  Red  corpuscles  numbered 
6,000,000;  white4800.  A differential  count  was  not  abnormal. 
The  Wassermann  reaction  was  negative.  The  diagnosis  lay 
between  tuberculosis  and  lymphadenoma,  and  Dr.  Cautley 
favoured  the  latter. 

Dr.  E.  A.  Cockayne  showed  a case  of 
Trophcedema  of  Leg. 

The  patient  was  a boy  aged  8|  years.  There  was  no 
history  of  any  similar  condition  in  the  family.  The  boy  was 
.normal  at  birth.  At  1£  years  there  was  a swelling,  rather 
soft  and  lobulated,  on  the  right  side  in  Scarpa’s  triangle. 
Three  months  later  some  swelling  of  the  right  leg  below  the 
knee  was  noticed,  and  had  increased  ever  since.  When 
exhibited  there  was  swelling  of  the  whole  of  the  right  leg 
below  the  gluteal  fold.  The  thigh  was  soft  and  the  swelling 
in  Scarpa’s  triangle  could  no  longer  be  felt  ; it  was  1 in. 
greater  in  circumference  than  the  left.  The  lower  part  of 
the  leg  and  dorsum  of  foot  were  very  much  swollen  ; circum- 
ference of  right  calf  13|  in.,  left  calf  9£  in.  The  leg  some- 
times pitted  on  pressure.  There  was  no  naevus  and  no 
cyanosis.  The  texture  of  the  skin  was  Dormal.  X rays 
showed  no  difference  in  the  size  of  the  bones.  There  was 
no  lengthening  of  the  right  leg.  The  right  side  of  the  face 
was  a little  longer  than  the  left  and  the  right  palpebral 
fissure  was  wider.  The  condition  caused  the  child  very 
little  inconvenience. 

Dr.  Eric  Pritchard  showed  specimens  from  a case  of 
Purpura. 

The  patient  was  aged  1 year  and  2 months,  and  had  been 
fed  on  milk  ; no  fruit  juice  had  been  given.  The  father, 
mother,  and  another  child  were  healthy.  The  child  had  had 
pneumonia  in  December,  1918,  a burn  on  the  neck  three 
weeks  ago,  and  for  the  past  week  had  had  an  ulcerated 
mouth.  On  May  11th  a bruise  on  the  left  leg  was  noticed, 
which  increased  in  size  so  rapidly  that  the  patient  was 
admitted  to  hospital  on  the  following  day.  On  admission 
the  temperature  was  99 '4=  F.  The  child  was  well  nourished 
but  extremely  pale.  There  were  large  blue  areas  over  the 
left  leg  (6  in.  by  8^  in.)  and  thigh  (2J  in.  by  3j  in.),  a patch 
on  the  right  leg  (3  in.  by  3£  in.),  and  petechial  haemorrhages 
over  both.  Enlarged  glands  were  present  on  the  left  side  of 
the  neck,  and  discrete  glands  on  the  right  side.  Nothing 
abnormal  was  detected  in  the  lungs.  The  heart  was  normal. 
The  gums  were  firm  and  there  was  no  ulceration  ; the  teeth 
were  very  discoloured ; the  liver  extended  1 in.  below  the 
costal  margin.  On  June  12th  the  scrotum  was  very 
cedematous.  A purple  patch  was  present  over  the  left  foot. 
The  child  died  on  the  following  day. 

Post-mortem  examination. — There  was  an  unhealed  ulcer 
on  the  left  side  of  the  neck,  due  to  a burn,  consisting  of  two 
areas  of  about  J in.  diameter  each,  joined  together.  There 
was  a subcutaneous  haemorrhage  about  | in.  across  on 
the  chin,  another  area  of  about  the  same  size  on  the  right 
side  of  the  neck,  and  large  subcutaneous  dark  purple 
haemorrhages  on  both  legs.  On  the  right  side  one  haemor- 
rhage was  about  2 in.  in  diameter  over  the  patella,  another 
large  one  was  situated  on  the  inner  side  and  back  of  the 
middle  of  the  leg,  and  all  but  joined  a third  one  on  the  front 
and  outer  side,  just  above  the  ankle.  On  the  left  side  the 
lower  part  of  the  teg  was  encircled  by  a haemorrhage 
measuring  about  4 in.  from  above  downwards,  and  the 
epidermis  above  it  was  raised  as  a bulla.  Both  kidneys 
with  their  perirenal  fat  were  the  seat  of  extensive  haemor- 
rhages, which  were  almost  entirely  cortical.  Both  testes 
were  dark  red  from  haemorrhage.  The  only  other  haemor- 
rhage was  in  the  middle  portion  of  the  thyroid  gland.  The 
thymus  was  a well-marked  bi-lobed  structure  of  ivory-white 
colour.  The  prepuce  was  cedematous,  the  liver  pale,  and 
the  spleen  slightly  enlarged.  The  heart,  lungs,  pericardium, 
stomach,  intestines,  pancreas,  and  adrenals  were  all  healthy. 

Dr.  Langmhad  said  that  the  appearance  of  the  kidneys 
was  exactly  that  of  acute  lymphatic  leukaemia,  and  suggested 
that  sections  should  be  examined  microscopically. 

Dr.  Pritchard  also  showed  a specimen  of 

Liver  Abscess  with  Septic  Umbilical  Vein. 

The  patient,  a female,  was  aged  5 weeks  and  a full-term, 
breast-fed  child.  The  father,  mother,  and  four  children 
were  healthy.  Vomiting  always  occurred  at  various  intervals 
after  the  feeds,  the  vomitus  being  small  in  amount.  The 
bowels  were  acting  normally.  On  May  29th  the  vomit- 
ing became  more  frequent  and  larger  in  amount,  and  was  of 


The  Lancet,] 


TUBERCULOSIS  SOCIETY. 


[July  12,  1919  65 


a greenish-yellow  colour.  The  bowels  were  constipated. 
The  child  was  admitted  on  May  30th  looking  very  ill, 
though  fairly  well  nourished.  The  temperature  was 
101°  F.,  the  pulse  132,  and  the  respiration  42  per  minute. 
The  vomitus  consisted  of  bright  green  material,  the 
abdomen  was  distended  and  soft,  there  was  no  visible 
peristalsis  or  visible  tumour,  and  the  liver  and  spleen 
were  not  palpable.  The  heart  and  lungs  'were  normal. 
On  May  31st  the  stomach  wash-out  two  and  three- 
quarter  hours  after  feed  contained  1 oz.  of  green  slimy  fluid 
and  an  abnormal  amount  of  acid.  Rectal  lavage  gave  clear 
fluid,  not  offensive.  On  June  1st  a turpentine  enema  resulted 
in  a slight,  yellow  stool  ; another  yellow  stool,  large  in  amount 
and  undigested,  contained  a very  slight  trace  of  mucus.  On 
June  2nd  the  temperature  was  102°  F.,  and  the  child  was 
vomiting  its  broth  and  water.  A small  green  stool  was 
passed  after  a turpentine  enema,  which  did  not  lessen  the 
distension.  Subcutaneous  saline  was  given,  but  the  child  died. 

Post-mortem  examination  showed  the  abdomen  to  be  dis- 
tended. The  peritoneal  cavity  contained  6 oz.  or  8 oz.  of 
yellow  fluid,  and  the  intestines  were  loosely  matted  together 
by  plastic  lymph.  The  umbilicus  had  healed.  When  the 
liver  was  cut  into,  the  part  of  the  vein  within  the  liver  was 
found  to  be  greatly  enlarged  and  to  have  thick  walls,  so  that 
it  measured  about  J in.  in  diameter.  The  lumen,  however, 
was  almost  obliterated,  but  some  greenish  pus  exuded  from  it, 
in  which  Gram-negative  bacilli  were  found.  All  the  organs  in 
the  thorax  were  healthy,  as  were  also  the  kidneys,  stomach, 
and  intestines.  The  hepatic  flexure  of  the  large  intestine 
was  situated,  however,  beneath  the  neck  of  the  gall-bladder, 
the  ascending  colon  lay  close  along  the  right  side  of  the 
spinal  column,  the  caecum  was  situated  over  the  right  ilio- 
sacral  articulation,  and  the  appendix  lay  across  the  fifth 
lumbar  vertebra.  The  spleen  was  rather  firmer  in  con- 
sistence than  usual.  The  adrenals  were  rather  large  and  the 
right  one  was  of  reddish  hue. 

SECTION  OF  OBSTETRICS  AND  GYN. ECOLOGY. 

A MEETING  of  this  section  was  held  on  July  3rd,  Mr.  J.  D. 
Malcolm,  the  President,  being  in  the  chair. 

In  the  absence  of  Mr.  W.  Gilliatt,  his  paper  on 

A Case  of  Obstruction  to  Labour  due  to  Ventrofixation 
was  read  by  Dr.  Comyns  Berkeley. 

The  patient,  a primigravida,  aged  32,  was  admitted  to 
Queen  Charlotte’s  Hospital ; she  had  been  in  labour  five 
days  and  had  had  two  attacks  of  uterine  haemorrhage. 
Examination  showed  a median  sub-umbilical  scar  about 
3|  inches  long.  The  uterus  was  tense  and  asymmetrical, 
and  the  foetal  heart  was  not  heard.  The  cervix  was  displaced 
upwards,  backwards,  and  to  the  right,  and  the  uterus 
seemed  to  be  in  early  tonic  contraction.  Caesarean  section 
was  decided  on  as  the  best  method  of  procedure,  as  on 
examination  under  anaesthesia  the  inaccessibility  of  the 
cervix,  its  size  and  rigidity  excluded  vaginal  methods. 

On  operation,  the  uterus  was  found  fixed  to  the  anterior 
abdominal  wall  by  a thick  tightly  stretched  band  about  2 in. 
long  which  was  attached  to  the  posterior  surface  of  the 
uterus  1 to  1J  in.  behind  a line  joining  the  uterine  ends  of 
the  Fallopian  tubes.  There  was  marked  axial  rotation  of 
the  uterus  through  almost  a quarter  of  a circle,  so  that  the 
right-sided  bulging  mentioned  above  was  at  the  expense  of 
the  posterior  wall  of  the  uterus.  A stillborn  child  lay  in 
a cavity  formed  mainly  by  the  posterior  wall  of  the  uterus, 
which  was  stretched  very  thin.  The  head  was  delivered 
with  difficulty  from  a sacculation  in  the  uterine  wall,  in 
which  it  was  tightly  gripped.  The  patient  recovered  from 
the  operation,  but  died  some  days  later  from  septic  endo- 
carditis. The  nature  of  the  previous  operation  was  unknown 
on  admission,  but  was  afterwards  discovered  to  be  an 
amputation  of  the  cervix  uteri  and  ventrofixation. 

In  the  course  of  the  discussion  on  Mr.  Gilliatt 's  paper,  Dr. 
Lapthorne  Smith  commented  on  the  fact  that  the  ventro- 
fixation had  been  performed  by  attaching  the  posterior  wall 
of  the  uterus  to  the  anterior  abdominal  wall,  and  for  this 
reason  probably  caused  the  obstruction.  His  practice  was  to 
make  the  attachment  from  the  front  wall,  and  below  the  line 
of  insertion  of  the  tubes. — Dr.  Berkeley  concurred  with 
this  view,  and  the  President  suggested  that,  as  a rule, 
ventrofixation  should  not  be  done  in  patients  likely  to 
become  pregnant. 

Demonstration. 

Dr.  Eardley  Holland  gave  a demonstration  on  the 
effects  of  excessive  cranial  stress  in  the  foetus  during  labour, 
and  on  the  mode  of  origin  of  tears  of  the  tentorium  cerebelli 
and  cerebral  haemorrhage. 


TUBERCULOSIS  SOCIETY. 


The  Annual  Meeting. 

At  the  annual  meeting  and  dinner  held  on  June  28th,  Dr. 
Halliday  Sutherland,  the  retiring  President,  outlined  the 
origin  of  the  society,  whose  members  now  numbered  nearly 
200.  Membership  was  open  to  all  interested  in  tuberculosis 
work,  and  with  the  signing  of  peace  it  was  hoped  that  the 
society  would  occupy  a place  of  importance  in  guiding  and 
advising  the  coming  developments  of  tuberculosis  work. 

Dr.  F.  N.  Kay  Menzies  said  that  five  years  ago,  when 
the  London  County  Council  undertook  to  provide  treatment 
for  tuberculous  persons,  there  were  only  a few  beds  and  one 
or  two  dispensaries  available.  Now  there  were  900  beds, 
shortly  to  be  increased  to  1000,  and  every  area  in  the  county 
was  served  by  a dispensary.  The  difficulties  hitherto  exist- 
ing between  the  Council  and  the  Insurance  Committee 
would  soon  be  overcome,  and  he  looked  forward  to  the  union 
of  his  work  with  that  of  Dr.  Noel  Bardswell,  the  medical 
adviser  of  that  body. 

Captain  W.  E.  Elliot,  M.P.,  said  that  the  representation 
of  medicine  in  Parliament  looked  to  the  society  for  guidance 
as  to  the  united  opinion  of  tuberculosis  workers.  He  fore- 
saw developments  in  the  treatment  at  industrial  colonies, 
and  referred  to  the  Hairmyres  Colony  in  Lanarkshire.  More 
thought  should  be  given  to  the  mental  capacity  of  tuber- 
culous men  who  might  be  used  in  the  development  of  electric 
force  and  similar  enterprises. 

Tuberculosis  Work : Hopeful  Outlook. 

Dr.  Nathan  Raw,  M.P. , said  that  now  the  strain  of  war 
was  over  there  was  a very  hopeful  future  to  look  forward  to 
in  tuberculosis  work.  The  problem  had  been  increased 
enormously  by  the  return  of  thousands  of  tuberculous 
discharged  service  men,  whom  it  was  the  country’s  duty  to 
look  after. 

Dr.  Noel  Bardswell  hoped  that  the  society  would 
encourage  expression  of  opinion  from  the  junior  branches  of 
tuberculosis  work.  Their  .present  remuneration  was  inade- 
quate, and  he  thought  that  better  prospects  should  be  offered 
to  them. 

A Social  Problem. 

Dr.  H.  de  Carle  Woodcock,  President-elect,  said  that 
the  tuberculosis  problemvwas  a social  as  well  as  a clinical 
one  and  demanded  administrative  ability  on  the  part  of  the 
tuberculosis  officer.  His  present  position  as  assistant  to  the 
medical  officer  of  health  required  readjustment.  The  tuber- 
culosis officer  should  be  in  control  of  his  own  district  and 
responsible  directly  to  his  public  health  committee.  Referring 
to  the  new  housing  schemes,  he  thought  that  it  would  be  the 
gravest  mistake  to  build  new  houses  and  then  to  allow 
advanced  cases  to  carry  infection  into  them.  Legislation  was 
needed  to  remove  infective  cases  from  overcrowded  areas. 


London  Association  op  the  Medical  Women’s 
Federation. — A meeting  was  held  on  July  1st,  at  11, 
Chandos-street,  Lady  Barrett,  M.D.,  the  President,  being  in 
the  chair. — Dr.  Octavia  Lewin  read  a paper  on  Nasal  Hygiene 
and  National  Health,  and  showed  several  cases  of  children 
successfully  treated  for  nasal  obstruction  and  deafness 
without  operation.  She  also  showed  a case  of  stenosis  of 
the  posterior  nares  following  an  operation  for  adenoids  in  a 
child  who  was  a diphtheria  carrier.  Dr.  Lewin  emphasised 
the  fact  that  many  operations  would  be  avoided  by  proper 
attention  to  the  nose  and  breathing. — Dr.  Eleanor  Lowry 
read  a paper  on  the  Nose  in  Relation  to  General  Diseases. 
She  referred  to  the  importance  of  nasal  obstruction  and  sinus 
suppuration  in  respiratory,  digestive,  and  nervous  diseases, 
and  gave  instances  of  mistakes  in  diagnosis  and  treatment 
of  such  cases.  She  mentioned  some  of  the  superstitions 
held  by  patients  as  to  the  connexion  between  gynecological 
conditions  and  the  nose  and  throat,  and  said  that  it  was  to  be 
regretted  that  similar  statements  were  still  made  in  text- 
books on  gynecology,  and  apparently  copied  into  papers  and 
books  on  the  nose  and  throat. 


The  League  of  Mercy. — Sir  Frederick  Green. 
K.B.E.,  honorary  treasurer  of  the  League  of  Mercy,  has 
presented  £10,000  to  the  League  “ in  the  hope  that  now  that 
His  Royal  Highness  the  Prince  of  Wales  has  consented  to 
become  Grand  President  a new  era  of  activity  of  the  League 
may  be  inaugurated.” 


66  The  Lancet,] 


REVIEWS  AND  NOTICES  OF  BOOKS. 


[July  12,  1919 


JUimtos  anft  Notices  of  5600b. 

A Text-booli  of  Physiology.  By  Martin  Flack,  C.  B.E., 

M.B  , B Ch.  Oxon.  ; and  Leonard  Hill,  M.B.,  F.R.S. 

London  : Edward  Arnold.  1919.  Pp.  800.  25s. 

We  offer  a very  hearty  welcome  to  the  latest  addition  to 
the  list  of  text-books  of  physiology.  There  is  a vigour, 
originality,  freshness,  and  attractive  method  in  the  exposi- 
tion of  certain  parts  of  the  subject  such  as  one  rarely  finds 
in  a text-book.  The  fundamental  facts  and  theories  are  set 
forth  in  an  easily  understandable  form  with  many  an  apt 
comparison  and  illustration.  Although  primarily  written  to 
meet  the  requirements  of  the  medical  student,  it  cannot  fail 
to  prove  of  value  to  the  general  practitioner.  In  the  not 
very  remote  future  “applied  physiology  ” will  come  to  be  an 
integral  part  of  medical  education,  and  the  authors  have  kept 
this  end  in  view.  Only  a few  of  the  great  names  and  epochal 
dates  in  physiological  discovery  have  found  a place  in  the  text. 
By  abbreviating  their  work  in  this  way  the  authors  have,  it 
is  true,  followed  the  example  of  Michael  Foster,  though  we 
hardly  agree  with  their  decision.  The  student  should  know 
at  least  the  century  of  Galen,  Harvey,  Galvani,  Charles 
Bell,  Bernard,  Waller,  and  Helmholtz.  There  is  nothing  in 
the  text  to  indicate  whether  certain  important  discoveries 
were  made  during  this  century  or  two  centuries  ago.  We 
are  unable  to  find  an  allusion  to  Bell’s  law.  If  it  is  in  the 
text,  it  is  not  in  the  index.  This  may  be  the  case,  for  the 
index  is  not  complete. 

The  subject-matter  is  divided  into  13  books — of  unequal 
scientific  and  literary  value — each  of  which  is  composed  of 
several  chapters.  About  70  pages  are  given  to  General 
Physiology,  while  about  180  are  devoted  to  Blood  and  the 
Cii  c Ration  of  Body  Fluids.  The  description  of  Immunity  and 
Allied  Phenomena  is  terse  and  practical,  and  leads 
up  to  the  students’  later  studies  in  these  subjects. 
Book  III.,  on  the  Circulation  of  the  Body  Fluids,  is 
comprehensive  and  well  thought  out.  The  newer  work 
on  Cardiac  Physiology  is  more  successfully  dealt  with  than 
in  any  text-book  with  which  we  are  acquainted.  The 
student  ought  to  be  familiar  with  the  main  facts  of  electro- 
cardiology, and  these  are  admirably  set  forth.  One  chapter 
is  given  to  Effect  of  Change  of  Posture  on  the  Circulation, 
a subject  of  particular  clinical  interest,  and  one  which  has 
not  been  treated  adequately  in  the  past.  The  Circulation  in 
Special  Parts  is  also  excellent.  Respiration  occupies  about 
60  pages — not  too  much,  considering  the  importance  of  the 
subject.  We  are  glad  to  see  that  Dr.  Hill’s  fundamental 
work  is  incorporated,  as  well  as  illustrated  by  several  useful 
diagrams.  The  chapter  on  Principles  of  Ventilation  is  pithy 
and  practical,  and  well  worth  perusal  and  study.  We  regard 
the  chapters  on  Respiration  as  the  most  finished  and  the  best 
in  the  whole  book,  or  perhaps  in  any  modern  text-book. 

Books  V.  and  VI.  (pp.  325-406)  deal  with  General 
Metabolism  and  Dietetics,  and  the  Processes  of  Digestion, 
and  VII.  with  Special  Metabolisms — e.g.,  proteins, 
carbohydrates,  fat,  nucleins.  The  spleen  is  very  cursorily 
dismissed.  These  “books”  have  not  the  same  merit  as 
some  of  the  others.  There  is  evidence  of  imperfect  revision, 
either  on  the  authors’  or  proof-reader’s  part  Some  of  the 
rather  vaguely  described  chemical  processes  might  well  be 
omitted.  We  are  told  that  “appetite  juice”  “may  be 
provoked  by  seeing,  hearing,  by  smelling  food”;  “the  injec- 
tion of  gastric  mucous  membrane  of  guinea-pig  into  rabbit 
may  cause  a specific  cytolysin  to  form  in  the  rabbit’s 
serum”;  and  that  gastric  juice  “is  a clean  watery  liquid.” 
“ Meconium,  the  dark-greenish  fseces  passed  by  the  newly- 
born  child,  are  similarly  acid  in  reaction,  and  inoffensive.” 
Meconium  does  not  find  a place  in  the  index. 

The  Functions  of  the  Kidney,  Skin,  and  Body  Temperature 
form  the  next  sections,  and  of  these  three  the  last  is  by 
far  the  best ; indeed,  it  stauds  out  as  an  excellent  and 
practical  exposition  of  the  subject.  We  should  like  to  have 
heard  more  of  Cushny’s  recent  work  on  the  kidney.  To  the 
ductless  glands  (X.)only  about  20  pages  are  given,  illus- 
trated by  some  good  figures  in  the  text  ; but  even  granting 
the  controversial  nature  of  much  that  is  written  about 
these  glands  and  internal  secretions,  the  subjects  surely 
merit  a more  detailed  survey.  For  the  Tissues  of 
Motion  (XI.),  including  Animal  Electricity,  40  pages 


suffice.  Galvani’s  period  is  not  given,  and  the  omission 
of  the  name  of  Du  Bois-Rejmond  should  make,  to  use 
the  old  tag,  that  philosopher  turn  in  his  grave.  The 
Nervous  System  (XII.)  occupies  185  pages,  and  of  these 
less  than  six  suffice  for  the  “autonomic  system,”  including 
several  large  illustrations.  By  omission  of  some  details 
throughout  the  text  space  would  easily  be  found  for  a fuller 
treatment  of  the  central  and  sympathetic  nervous  systems, 
and  perhaps  also  of  the  cranial  nerves  and  sense  organs. 
A curious  slip  occurs  on  p.  630 — four  of  the  ocular  muscles 
arise  “from  the  back  of  the  eyeball.”  Several  chapters 
on  Growth  and  Reproduction  (XIII.),  which  bring  the  book 
itself  to  a close,  constitute  an  excellent  suggestive  epitome. 
Throughout  the  book  histology  is  only  introduced  to  elucidate 
definition. 

We  hope  that  in  the  second  edition  we  shall  find  that  the 
index  has  been  revised  and  minor  errors  eliminated  from  the 
text.  Perhaps  the  authors  will  change  their  minds,  too, 
about  the  use  of  “ drachms  ” as  a fluid  measure.  Meanwhile, 
we  think  that  this  text-book  of  Flack  and  Hill — both  expe- 
rienced teachers  and  distinguished  investigators— will  prove 
most  acceptable  to  medical  students,  and  more  especially  to 
those  who  are  preparing  for  the  higher  qualifications,  not 
only  on  account  of  the  marshalling  of  the  main  facts, 
but  because  the  subject-matter  is  set  forth  in  a readable  and 
pleasant  form,  while  its  applications  in  practical  medicine 
are  steadily  kept  iD  view. 


Medical  Annual  for  1919.  Bristol  : John  Wright  and  Sons, 
Ltd.  Pp.  675.  £1  net. 

The  editor  is  to  be  congratulated  on  the  success  he  has 
achieved  in  the  production,  under  difficult  conditions,  of  this 
valuable  record  of  medical  progress.  Some  of  the  authors 
appear  to  have  felt  themselves  cramped  in  their  expositions 
of  new  work.  This  is  inevitable  where  so  much  research  has 
been  carried  out  in  certain  special  departments  and  where  so 
many  of  the  conclusions  are  still  in  a controversial  stage. 
The  discussion  on  war  neuroses,  for  example,  is  obviously 
not  a complete  summary  of  the  results  obtained  by  different 
observers  during  the  war.  A good  bibliography  at  the  end 
of  most  of  the  important  articles  serves  to  correct  this 
inequality,  while  providing  useful  assistance  to  those  who 
wish  to  pursue  a particular  subject  further.  The  articles  on 
blood  transfusion  and  amputations  are  adequate  and  well 
depicted.  The  illustrations  in  general,  including  five 
coloured  plates,  are  clearly  printed  on  good  paper.  The 
title-page  of  the  book  would  be  easier  to  find  if  the  advertise- 
ments which  precede  it  were  removed  or  printed  on  coloured 
paper.  The  volume  is,  as  usual,  securely  bound  and  of  a 
reasonable  size. 


Military  Physical  Orthopcedics.  Part  I.  : Gunshot  Wounds 
of  Nerves.  By  Arthur  Stanley  Herbert,  M.D., 
B.S.  Lond.,  Lieutenant-Colonel  (Temporary),  N.Z.M.C., 
P.M.O.  of  the  Rotorua  Orthopaedic  Hospital,  Govern- 
ment Balneologist.  With  62  illustrations  and  12  figures 
in  appendices.  Wellington  : By  Authority  : Marcus  F. 
Marks,  Government  Printer.  1918.  Pp.  136.  6s. 

This  is  a valuable  little  book.  It  represents  the  results  of 
the  experience  of  a surgeon  who,  being  placed  in  charge  of  a 
large  number  of  cases  of  nerve  injury  caused  by  war 
trauma,  worked  out  his  own  methods  of  treating  them 
remote  from  the  great  centres  of  military  orthopaedics.  It 
would  have  been  still  more  valuable  two  years  ago,  bat 
difficulties  in  printing  prevented  its  appearance.  The 
cessation  of  hostilities,  however,  will  not  affect  the 
permanent  value  of  the  work. 

Colonel  Herbert  seems  to  have  been  wonderfully  successful 
in  treating  the  disabilities  following  nerve  injuries  by  means 
of  very  simple  and  cheap  appliances,  and  particularly  in  his 
adaptation  of  the  old  principles  of  elastic  traction  to  suit 
modern  needs.  Artificial  muscles  have  a two-fold  use 
Firstly,  by  supplying  a means  of  movement  and  preventing oi 
correcting  deformities,  and  secondly,  by  preventing  stretching 
of  paralysed  or  weakened  muscles  and  thus  helping  them  t< 
regain  function.  I 

The  importance  of  antagonist  muscles  is  now  wel 
recognised,  and  by  supplying  artificial  antagonists,  elastf 
traction  is  of  great  value.  In  particular  is  the  author 
“long  quadriceps  strap,”  a very  valuable  addition  to  tk 


The  Lancet,] 


REVIEWS  AND  NOTICES  OF  BOOKS. 


[July  12,  1919  67 


armamentarium  of  the  orthopmdic  surgeon.  The  great 
i experience  of  the  author  as  medical  officer  in  charge  of  the 
; New  Zealand  Government  baths  and  sanatorium  at  Rotorua 
i for  12  years  before  the  war  had  well  equipped  him  for  the 
task  which  has  since  fallen  upon  him.  The  beautiful 
, surroundings  of  the  King  George  V.  Hospital  and  of  the 
; sanatorium  invite  open-air  treatment  and  it  appears  that 
nearly  all  cases  are  so  treated.  Colonel  Herbert  is  to  be 
congratulated  on  the  ingenuity  with  which  he  has  devised 
simple  but  efficient  apparatus  and  on  the  good  results 
achieved,  all  of  which  are  well  shown  in  the  excellent 
i illustrations  of  this  book.  It  must  not  be  supposed  that 
because  he  insists  on  the  value  of  these  simple  methods, 
he  neglects  the  ordinary  physiotherapeutic  and  electrical 
methods.  These  latter  are  adequately  described  and  their 
i use  discussed. 

From  the  fact  that  this  volume  is  entitled  Part.  I.  we  hope 
that  we  may  look  forward  to  the  appearance  of  another  part 
dealing  with  injuries  other  than  those  of  nerves. 


The  Theory  and  Practice  of  Massage.  By  Beatrice  M. 
Goodall-Copestake,  Examiner  to  the  Incorporated 
Society  of  Trained  Masseuses  ; Teacher  of  Massage  and 
Swedish  Remedial  Exercises  to  the  Nursing  Staff  of  the 
London  Hospital.  Second  edition.  London : H.  K. 
Lewis  and  Co.,  Ltd.  1919.  Pp.  265.  9.9.  net. 

The  fact  that  only  15  months  have  elapsed  since  the 
appearance  of  the  first  edition  of  this  book  suggests  that  it 
has  met  a need.  Our  criticisms  of  the  first  edition  have 
been  largely  met.  Alterations  in  the  chapters  dealing  with 
fractures,  dislocations,  and  recent  injury  bring  these  matters 
far  more  nearly  into  accord  with  modern  teaching.  Colin 
Mackenzie’s  recent  work  receives  recognition,  with  the 
result  that  the  value  of  the  chapters  devoted  to  nerve 
affections  is  greatly  enhanced.  A new  chapter  on  the 
after-treatment  of  war  injuries  is  occupied  in  the  main  with 
a description  of  Mrs.  Guthrie-Smith’s  well-known  apparatus 
for  the  treatment  of  stiff  joints,  and  the  addition  of  a biblio- 
graphy, though  short,  is  welcome.  Frequent  smaller  altera^ 
tions  in  the  text  tend  to  convey  a sense  of  confidence  that 
was  frequently  lacking  during  the  perusal  of  the  first  edition. 
The  earlier  part  of  the  book  still,  we  fear,  conveys  an 
unwelcome  impression  of  stereotyped  practice. 


Manual  of  Lip-reading . By  Mary  E.  B.  Stormonth. 

London  : Constable  and  Co.  1919.  Pp.  208.  5s.  net. 

Miss  Stormonth’s  “ Manual  of  Lip-reading  ” is  intended  to 
be  an  addition  to  a very  limited  branch  of  literature  which 
it  is  by  no  means  easy  to  extend.  Teachers  of  lip-reading 
are  so  used  to  phonetics  that  perhaps  they  fail  to  realise  how 
little  the  general  public  know  about  them.  Any  book  on 
lip-reading  intended  for  the  use  of  the  uninitiated  should 
begin  with  a clear  setting  out  of  the  phonetic  system  which 
is  therein  adopted.  The  omission  of  such  a chapter  is  a great 
lack  in  Miss  Stormonth’s  book.  Mention  is  made  of  the 
need  of  natural  speech,  and  stress  might  well  be  laid  upon 
the  need  of  distinctness  of  speech.  No  artificial  way  of 
speaking  is  required,  but  slipshod  speech  on  the  part  of  the 
teacher  is  a great  drawback  for  the  pupil.  Apart  from  the 
caution  given  against  the  tendency  of  the  teacher  to 
exaggerate  facial  movements  in  voiceless  speech,  note  might 
be  made  of  the  fact  that  the  use  of  voice  allows  much 
greater  natural  play  to  the  muscles  of  the  face  and  throat. 
This  is  of  considerable  assistance  to  the  learner  and 
should  not  be  ignored.  Miss  Stormonth  seems  to  plunge 
at  early  stages  into  difficult  words,  and  in  dealing 
with  the  sounds  set  for  each  lesson  treats  them  only 
as  initial  sounds.  In  Lesson  I.,  for  instance,  treating  of 
the  sounds  “a”  and  “p,”  a few  preliminary  easy  words 
are  given;  then  such  words  as  “paralysis,”  “particular,” 
and  “paragraph”  are  introduced.  Would  it  not  have  been 
equally  satisfactory  to  have  introduced  the  sounds  in  other 
positions,  as  in  “ tap,”  “ clap,”  “happen,”  “appear”?  The 
same  remark  applies  to  nearly  every  lesson. 

Miss  Stormonth  has  combined  in  a useful  way  the  drill 
in  words  for  the  teaching  of  special  sounds,  with  phrases 
on  the  “Look  and  Say”  method.  The  two  cannot  be 
separated  and  give  life  to  each  other.  Her  advice  as  to 
the  utterance  and  reading  of  sentences  as  a whole  is  very 


important,  whilst  the  use  of  word-building  is  well  thought 
out  and  applied.  She  has  faced,  too,  the  difficulty  of  saving 
the  adult  learner  of  lip-reading  from  intellectual  boredom, 
though  her  stilted  and  unusual  sentences  dealing  with  the 
“ parson  ” and  “ factor  ” are  rather  tiring.  The  latter  part 
of  the  book  is  most  helpful  in  its  classification  of  subjects 
and  collection  of  proverbs  and  phrases,  for  in  the  teaching 
of  lip-reading,  unless  a pareful  plan  is  laid,  most  unwelcome 
blanks  are  liable  to  reveal  themselves  at  inopportune 
moments.  The  book  may  well  prove  of  use,  not  only  to 
amateurs,  but  also  to  those  who  are  already  engaged  in 
teaching  the  art  of  lip-reading. 


Animal  Parasites  and  Human  Disease.  By  Asa  C.  Chandler, 
M.S.,  Ph.D.,  Instructor  in  Zoology,  Oregon  Agricultural 
College,  Corvallis,  Oregon.  London : Chapman  and  Hall, 
Ltd.  New  York : John  Wiley  and  Sons,  Inc.  1918. 
Pp.  570.  21s. 

The  aim  of  this  volume  is  to  present  the  chief  facts  of 
parasitology  as  related  to  human  disease  in  such  a manner 
as  to  appeal  to  the  general  reader  or  to  the  laymen  interested 
especially  in  the  progress  of  preventive  medicine  and  public 
health.  Primarily  the  book  is  not  one  for  the  professed 
parasitologist.  Without  too  greatly  encumbering  the  text 
with  roundabout  phrases,  scientific  terms  have  been  omitted 
or,  where  used,  have  been  explained.  The  book,  it  is  hoped, 
will  supply  the  needs  of  teachers  of  hygiene  and  members  of 
the  public  health  service.  The  work,  too,  will  have  its 
interest  for  the  medical  man.  As  a result  of  the  war  there 
are  probably  more  cases  of  tropical  infections  in  the  British 
Isles  at  present  than  at  any  previous  time,  and  the  author 
will  have  the  satisfaction  of  knowing  that  the  publication  of 
his  book  in  this  country  is  peculiarly  opportune.  Recent 
advances  in  this  particular  branch  of  medical  knowledge  are 
embodied  in  the  text  and  numerous  sections  are  devoted  to 
treatment.  The  book  is  divided  into  three  parts,  dealing 
respectively  with  protozoa,  “worms,”  and  arthropods. 
No  bibliography  is  given.  Instead  there  is  inserted  a list  of 
“sources  of  information,”  which  includes  all  the  leading 
periodicals  in  which  articles  dealing  with  parasitological 
subjects  appear,  as  well  as  a comprehensive  list  of  books 
covering  the  field  of  parasitology  ; it  is  suggested  that 
the  student  will  find  all  the  bibliographical  references  which 
he  may  require  in  these. 

As  would  be  expected  from  an  American  writer,  a telling 
description  of  the  economic  ravages  of  the  hookworm  is 
incorporated.  In  the  Southern  States  no  less  than  2,000,000 
of  the  population  are  affected  by  this  parasite,  and  “ unlike 
many  diseases,  this  one  has  no  tendency  to  weed  out  the 
weak  and  unfit  ; it  works  subtly,  progressively,  undermining 
the  physical  and  intellectual  life  of  the  community,  each 
generation  handing  down  an  increased  handicap  to  the 
next.”  In  the  treatment  of  this  disease  oil  of  chenopodium 
is  rapidly  supplanting  other  remedies  like  thymol,  than 
which  it  is  not  only  more  efficient  but  also  less  dangerous. 
The  book  is  well  up  to  date,  and  there  are  excellent 
chapters  dealing  with  malaria  and  trypanosomiasis,  but 
while  the  results  of  Leiper’s  researches  on  bilharzia  are 
included  in  the  article  dealing  with  schistosomiasis,  we  fail 
to  find  any  reference  to  trench  fever  in  the  section  devoted 
to  lice  and  disease. 

The  book  contains  more  than  250  illustrations,  most  of 
which  have  been  drawn  by  the  author  either  from  specimens 
or  from  other  illustrations.  Pen-and-ink  drawings  have 
been  used  consistently  in  place  of  photographs,  and,  what  is 
important  in  a work  of  this  kind,  in  the  majority  of  figures 
the  magnification  is  indicated. 

The  author  has  succeeded  in  providing  a really  interesting 
and  informing  treatise  on  parasitology  in  its  relation  to 
human  disease,  and  we  think  he  goes  far  to  succeed  in  his 
wish  that  his  book  may  be  instrumental  in  arousing  the 
interest  of  more  students  in  this  branch  of  science  to  the 
ultimate  end  of  enlisting  a larger  number  in  the  ranks  of  its 
workers.  He  insists  that  the  need  of  the  present  time  is 
not  so  much  additions  to  our  knowledge  as  the  efficient 
application  of  what  we  already  know. 


The  degree  of  D.Sc.  hon.  caus.  has  been  conferred 
by  the  University  of  Philadelphia  upon  Professor  A. 
Hopewell-Smith,  M.R.C.S.,  L.D.S. 


68  The  Lancet,] 


REVIEWS  AND  NOTICES  OF  BOOKS.— NEW  INVENTIONS. 


[July  12,  1919 


JOURNALS. 

The  Quarterly  Journal  of  Medicine.  Edited  by  William 
Osler,  J.  Rose  Bradford,  A.  E.  Garrod,  R.  Hutchison, 
H.  D.  Rolleston,  and  W.  Hale  White.  Vol.  XII  , 
No.  47.  April,  1919.  Oxford:  At  the  Clarendon  Press: 
uondon,  Edinburgh,  New  York,  Toronto,  and  Melbourne: 
Humphrey  Milford.  Subscription  25s.  per  annum.  Double 
numbers  17s.  net  each  ; single  numbers  8s.  6 d.  net  each. — 
The  present  number  includes  the  following  papers  : 1.  Intra- 
thoracic  Pressure  in  Haemothorax,  Pneumothorax,  and 
Pleural  Effusion,  and  Effects  of  Aspiration  and  of  Oxygen 
Replacement,  by  George  C.  Shattuck  and  E.  E.  Welles. 
The  measurements  of  intrathoracic  pressure  were  made 
with  a water  manometer  graduated  in  centimetres.  Readings 
showed  that  the  pressure  in  a sterile  haemothorax  changes 
little  in  the  first  16  days  after  wounding,  but  in  the  case  of 
small  haemothoraces  the  respiratory  excursion  of  pressure 
increases  gradually  during  this  time.  Pressures  observed  in 
pleural  effusions  were  similar  to  those  in  haemothorax.  By 
the  simultaneous  replacement  of  fluid  by  oxygen,  volume 
for  volume,  the  existing  pressure  in  the  pleural  cavity  could 
be  maintained.  2.  A Contribution  to  the  Study  of  Contra- 
lateral Signs  in  Gunshot  Wounds  and  Injuries  of  the 
Chest,  by  S.  W.  Curl.  The  author  finds  that  contralateral 
signs  are  common,  contralateral  collapse  being  quite 
frequent.  He  emphasises  the  fact  that  the  combination  of 
physical  signs  supposed  to  be  characteristic  of  solid  lung 
is  extremely  fallacious  and  uncertain,  since  fluid  effusions 
may  give  rise  to  identical  signs.  He  considers  that  examina- 
tion of  cases  by  X rays,  although  helpful,  is  by  no  means 
sufficient  for  the  differentiation  of  solid  lung  from  a pleural 
effusion  ; and  that  the  only  safe  guide  is  the  exploring  needle, 
and  that  this  may  fail  unless  used  with  discretion.  He 
shows  that  in  a small  percentage  of  cases  a fluid  exudate 
may  exist  on  the  side  towards  which  the  heart  is  displaced, 
owing  to  the  concomitant  presence  of  a high  degree  of 
pulmonary  collapse.  3.  Two  cases  of  Endocarditis  due  to 
B.  influenza,  by  Archibald  Malioch  and  Lawrence  J.  Rhea. 
In  these  cases  bilateral  broncho  pneumonia  was  present 
together  with  acute  vegetative  endocarditis.  B.  influenza' 
was  grown  in  pure  culture  from  the  terminal  bronchi  and 
from  the  centre  of  the  vegetations  in  both  cases.  4.  The 
Therapeutic  Action  of  Digitalis  on  the  Rapid  Regular 
Rheumatic  Heart,  by  G.  A.  Sutherland.  The  writer 
illustrates  his  paper  by  accounts  of  ten  cases  in  which  he 
brings  forward  evidence  to  show  that  digitalis  exerts  a 
beneficial  action  even  when  there  is  no  irregularity  of  the 
pulse.  The  drug,  it  is  suggested,  acts  upon  the  auriculo- 
ventricular  node  and  bundle,  and  where  there  is  a sufficiency 
of  sound  contractile  tissue  in  the  ventricles  leads  to  an 
effectual  slowing  of  the  ventricular  rate.  This  contribution 
has  a bearing  upon  a point  at  issue  in  a controversial  corre- 
spondence which  was  carried  on  in  The  Lancet  in  1917. 
5.  Acute  Leukaemia  and  so-called  Mediastinal  Leuko- 
sarcomatosis  (Sternberg),  with  the  account  of  a case 
accompanied  by  Myeloid  Substitution  of  the  Hilus  Fat  of  the 
Kidneys,  by  F.  Parkes  Weber.  Most  cases  of  mediastinal 
leukosarcomatosis  have  not  been  recognised  as  such  until  a 
post-mortem  examination  has  revealed  their  nature.  In  a 
recent  case  the  author  was  able  by  the  microscopical  blood 
picture  and  Roentgen-ray  examination  to  make  the  diagnosis 
of  the  condition  during  life.  The  case  is  of  further 
interest  in  that  post-mortem  examination  showed  the 
presence  of  deep-red,  spongy,  bone-marrow-like  tissue  in 
the  hilus  of  each  kidney.  An  informing  survey  of  the 
literature  accompanies  the  description  of  the  case.  6.  Obser- 
vations upon  Two  Cases  of  Diabetes  Insipidus  : with  an 
Account  of  the  Literature  relating  to  an  Association  Between 
the  Pituitary  Gland  and  this  Disease,  by  E.  L.  Kennaway 
and  J.  C.  Mottram.  In  this  important  paper  data  are  given 
as  to  the  composition  of  the  urine  and  its  molecular  con- 
centration in  comparison  with  that  of  the  serum  in  two 
cases  of  diabetes  insipidus.  The  authors  show  that 
pituitary  extract  given  by  subcutaneous  injection  leads  to 
a diminution  in  the  amount  of  urine  excreted,  and  recom- 
mend the  injection  of  pituitary  extract  as  a means  of 
treatment.  This  anti-diuretic  effect  of  pituitary  extract 
appears  to  be  due  to  its  direct  action  upon  the  kidney. 
The  restoration  of  a normal  state  of  the  urine  when 
pituitary  extract  is  given  in  diabetes  insipidus  provides, 
in  the  authors’  opinion,  the  strongest  evidence  that 
the  normal  activity  of  the  gland  is  concerned,  in  part 
at  least,  in  regulating  the  secretion  of  urine.  While 
the  morbid  anatomical  findings,  till  now  recorded  in  the 
literature,  are  insufficient  to  establish  that  diabetes 
insipidus  is  constantly  accompanied  by  disease  of  the 
pituitary,  there  is  much  to  suggest  that  diabetes  insipidus 
is  dependent  generally  upon  such  morbid  changes.  The 
authors  point  out,  however,  that  disease  of  the  pituitary  can 
occur  without  any  symptoms  of  diabetes  insipidus  super- 
vening. 7.  The  Filter-passing  Virus  of  Influenza,  by  John 
Rose  Bradford,  E.  F.  Bashford,  and  J.  A.  Wilson  ; together 


with  an  Appendix  of  Clinical  Notes  on  the  Cases  of  Influenza 
from  which  the  Virus  was  Recovered,  by  F.  Clayton.  This 
paper  gives  a detailed  account  of  the  extremely  momentous 
investigations  which  the  authors  have  been  carrying  out  in 
their  attempt  to  demonstrate  the  presence  of  a filtrable  virus 
in  the  blood  and  other  material  obtained  from  cases  of 
influenza.1  That  a filtrable  virus  was  associated  with 
influenza  was  first  demonstrated  by  Nicolle  and  Lebailly,- 
who  by  the  sucutaneous  inoculation  into  the  human 
subject  of  a filtrate  of  sputum  from  a case  of  influenza 
produced  a febrile  illness  comparable  with  the  natu- 
rally acquired  disease.  The  methods  employed  by  the 
present  writers  are  those  of  filtration,  cultivation  of  the 
filtrate,  and  animal  inoculation.  The  types  of  filters 
employed  are  the  Berkefeld  N and  V and  the  Massen 
porcelain  filter.  The  filter-passer  has  been  seen  microscopi- 
cally in  the  filtrate  and  has  been  cultivated  therefrom  by 
the  Noguchi  method.  The  organism,  which  has  definite 
morphological  and  cultural  characteristics,  can  be  demon- 
strated in  the  blood,  sputum,  and  other  exudates,  as  well  as 
in  the  tissues  post  mortem  by  appropriate  methods  of  stain- 
ing. Inoculated  into  animals  the  pure  culture  reproduces 
lesions  similar  in  character  to  those  found  in  the  disease  in 
man — viz.,  the  sodden,  haemorrhagic  lung,  the  fatty  change 
in  heart  and  liver,  the  inflamed  kidney,  and  the  peculiar 
haemorrhagic  lesion  in  the  voluntary  and  cardiac  muscles. 
The  organism,  moreover,  can  be  recovered  from  these 
tissues,  so  that  the  conditions  ordinarily  known  as  Koch’s 
postulates  are  fulfilled.  The  whole  horizon  limiting  our 
outlook  over  the  field  of  infective  disease  has  been 
enormously  extended  by  the  application  of  Loefifler  and 
Frosch’s  method  of  filtration  to  the  investigation  of  human 
infections,  and  the  work  of  Sir  John  Rose  Bradford  and  his 
coadjutors  goes  to  show  that  a rich  harvest  awaits  the 
patient  worker  in  this  field^ 

1 The  Lancet,  1919,  i.,  169. 

2 Nicjlleet  Lebailly,  Compt.  Read.  Acid.  Sci.  Paris,  1918.  clvii..  697. 


ftefo  fnimtlioiis. 

A MODIFIED  CATHCART’S  APPARATUS. 

.This  apparatus — in  principle  a Cathcart’s  but  m ire  compact 
and  more  easily  applied — was  devised  in  1915  to  cope  with 
the  spent  fluid  in  the  continuous  iirigation  treatment  of 
wounds.  It 
consists  of  a 
Canny-Ryall 
dropper  con- 
nected to  a 
metal  T and 
siphon  tube 
combined,  the 
whole  sunk  in 
a wooden  block 
which  can  be 
fixed  to  the 
patient’s  locker 
The  illustra- 
t i o n explains 
the  working 
p ri nciple. 

The  amount  of 
fluid  necessary 
to  create  a con- 
tinuous suction 
force  is  7£  oz. 
per  hour  when 
draining  a n 
open  cavity, 
and  consider- 
ably less  when 
the  cavity  to 
be  drained  is 
a closed  one. 

It  has  proved 
useful  in  drain- 
i n g appendix 
and  psoas  ab- 
scesses, the  bladder,  gall-bladder,  and  chest,  and  also  for 
removing  filtrates  in  a small  laboratory.  It  is  made  by 
Messrs.  A.  E.  Braid,  30,  Gower-place,  London,  IV.C.,  and  is 
sold  with  right-  and  left-sided  blocks  from  which  it  is  easily 
removed  for  sterilisation  by  boiling. 

L.  A.  Celestin,  M.C.,  M.D.  Lond. 


The  Lancet,] 


THE  LIQUOll  TRAFFIC  AND  THE  PUBLIC  HEALTH. 


[July  12,  1919  09 


THE  LANCET. 


LONDON:  SATURDAY , JULY  12,  1919. 

The  Liquor  Traffic  and  the  Public 
Health. 

The  responsibility  will  shortly  fall  upon  Parlia- 
ment to  decree  the  measures  to  be  adopted  in  respect 
of  the  liquor  traffic.  The  problem  presented  is  an 
evergreen  one  in  politics — it  is  to  decide  how  and  to 
what  extent  individual  freedom  shall  be  moulded 
for  the  public  good ; but  where  the  control  by 
the  State  of  the  sale  of  liquor  is  concerned  the 
problem  is  one  on  which,  to  a greater  degree 
perhaps  than  on  any  other  social  question,  medical 
opinion  has  the  right  and  the  duty  to  speak 
with  exceptional  weight  of  authority.  For  the 
most  serious  results  which  ensue  from  the  abuse 
of  these  beverages,  and  which,  indeed,  give  to  that 
abuse  the  importance  of  a social  problem,  are  in 
the  main  ultimately  reducible  to  the  injurious 
influence  of  alcoholic  excess  on  the  bodily  and 
mental  health  of  the  intemperate  drinker.  And  this 
fact,  that  the  effects  of  excessive  drinking  are 
chiefly  manifest  in  disordered  health,  is  not  the  only 
reason  why  the  liquor  problem  in  a special  degree 
demands  consideration  from  the  medical  point  of 
view.  The  causes  of  intemperance,  like  its  con- 
sequences, can  only  be  justly  appreciated  when  due 
regard  is  had  to  the  fundamental  facts  concerning 
the  action  of  alcohol  on  the  body ; and,  as  we  shall 
have  occasion  to  remark  later  on,  the  success 
achieved  in  dealing  with  alcoholism  in  this  country 
in  the  last  few  years  was  obtained  through  the 
recognition  of  the  truths  of  physiology  in  the 
enforcement  of  methods  of  regulation  which  were 
definitely  and  avowedly  based  on  the  indications 
of  science.  In  all  its  more  important  aspects  the 
liquor  problem  is  essentially  a medical  problem,  a 
problem  of  hygiene.  And  the  new  Commission,  to 
whose  jurisdiction  the  liquor  traffic  will  be  handed, 
will  have  to  take  this  fact  into  consideration 
throughout. 

The  prevalence  of  alcoholism  under  the  conditions 
obtaining  to- day  presents  a striking  comparison  with 
its  prevalence  in  the  years  before  the  war.  It  is,  of 
course,  to  be  understood  that  the  statistical  evidence 
which  is  available  for  such  a comparison  gives  what 
is  in  certain  respects  an  imperfect  expression  of  the 
facts— that,  for  example,  the  deaths  certified  as  due 
to  alcoholism  represent  only  a part,  and  doubtless 
a small  part,  of  the  mortality  really  attributable 
to  alcoholic  excess.  This  limitation,  however, 
while  it  prevents  us  from  regarding  these  statistics 
as  any  real  measure  of  the  amount  of  alcoholic 
mortality,  does  not  affect  their  value  as  a standard 
for  estimating  the  comparative  frequency  of  in- 
temperance in  the  two  periods  which  we  wish  to 
compare.  Taking,  then,  the  year  1913  as  repre- 
sentative of  the  state  of  things  before  the  war,  it 
appears  from  the  official  returns  that  under  the 
then  existent  conditions  of  the  liquor  traffic  there 
were  in  England  and  Wales  1831  deaths  certified  as 
due  to  or  connected  with  alcoholism,  and  in 
addition  to  these  there  were  3880  deaths  attributed 
to  cirrhosis  of  the  liver,  while  no  less  than 
1226  infants  under  one  year  of  age  were  suffocated 
in  bed,  well  over  a quarter  of  the  latter  fatalities 


occurring  on  Saturday  nights.  Further,  in  those 
Poor-law  infirmaries — unfortunately  few  in  number 
— where  records  on  the  point  were  kept,  there  were 
786  patients  treated  for  delirium  tremens.  In  the 
same  year  the  number  of  convictions  for  drunken- 
ness amounted  to  188,877,  being  at  the  rate  of  1 to 
every  135  of  the  population  over  15  years  of  age. 
If  we  turn  now  to  the  figures  for  the  year  1918, 
we  find  that  deaths  from  alcoholism  numbered 
296,  a reduction  of  over  84  per  cent,  on  the  1913 
level,  and  that  deaths  from  cirrhosis  of  the  liver 
fell  to  1671,  a decline  of  nearly  60  per  cent.,  while 
deaths  of  infants  from  suffocation  numbered  557 — 
that  is  to  say,  they  were  more  than  55  per  cent, 
below  what  they  were  in  1913,  and  the  predominant 
incidence  of  these  deaths  on  Saturday  nights,  so 
marked  in  that  year,  no  longer  existed.  Again, 
in  the  same  institutions  referred  to  above  as 
furnishing  returns  of  cases  of  delirium  tremens, 
the  number  of  patients  treated  for  that  disease 
in  1918  amounted  only  to  32,  thus  showing  a 
decrease  of  no  less  than  95  per  cent,  on  the  figures 
for  1913.  Finally,  convictions  for  drunkenness 
totalled  29,019,  or  very  little  more  than  one-sixth 
of  the  number  recorded  in  1913.  It  might,  perhaps, 
be  suggested  that  the  reduction  in  intemperance 
indicated  by  these  figures  is  to  be  ascribed  in  part 
to  the  absence  on  military  service  of  large  numbers 
of  adult  males,  but  this  explanation  breaks  down 
in  view  of  the  fact  that  the  decrease  has  been 
equally  or  even  more  marked  in  the  case  of  women. 
Thus  deaths  of  women  from  alcoholism  fell  from 
719  in  1913  to  74  in  1918,  a reduction  of  nearly 
90  per  cent. ; deaths  from  cirrhosis  similarly  declined 
from  1665  to  579,  a fall  of  approximately  50  per  cent., 
and  in  the  Poor-law  infirmaries  keeping  records  of 
delirium  tremens  the  cases  of  that  disease  in  women, 
which  numbered  214  in  1913,  were  only  6 in  1918. 
And,  corresponding  with  this  reduction  in  alcoholic 
disease  and  mortality,  convictions  of  women  for 
drunkenness  declined  from  35,765  to  7222,  a reduc- 
tion of  practically  80  per  cent.  These  figures 
provide  adequate  proof  that  during  the  war  there 
has  been  in  this  country  a real  and  substantial 
decrease  of  alcoholism ; and  since  the  greater  part 
of  the  decrease  followed  immediately  on  the 
enforcement  of  the  war-time  regulations  for  the 
control  of  the  liquor  traffic,  it  is  legitimate  to 
conclude  that  these  regulations  were  the  chief 
agents  in  bringing  about  the  improvement  in 
national  sobriety. 

Alcoholism  is,  of  course,  a much  bigger  factor  in 
the  causation  of  disease  and  mortality  than  can  be 
shown  in  official  statistics,  which  necessarily  repre- 
sent only  its  most  extreme  and  obtrusive  results ; 
and  the  improvement  effected  through  the  system 
of  liquor  control  is  correspondingly  more  important 
than  is  indicated  by  the  evidence  summarised 
above ; but  even  if  that  evidence  be  taken  merely 
at  its  face  value,  it  will  enable  us  to  form  some 
idea  of  the  price,  measured  in  terms  of  health  and 
efficiency,  which  the  community  would  have  to  pay 
for  the  full  restoration  of  pre-war  conditions  in  the 
liquor  trade.  Possibly  public  opinion  would  be 
prepared  to  pay  that  price,  heavy  as  it  is, 
if  the  regulations  necessary  for  the  control  of 
alcoholism  constituted  a serious  encroachment  on 
public  freedom  and  convenience.  And  on  such 
grounds  objection  may,  no  doubt,  be  urged,  and 
with  some  reason,  against  certain  of  the  proposals 
which  have  recently  been  advocated  under  the 
guise  of  temperance  reform,  and  notably  against 
the  method  of  direct  limitation  of  the  output  of 


70  The  Lanoet,] 


THE  EPIDEMIOLOGY  OF  PYOGENIC  INFECTION. 


[July  12,  1919 


liquor — a method  which,  when  enforced  by  the  Food 
Controller  in  the  later  stages  of  the  war  as  a 
necessary  measure  for  conserving  cereal  supplies, 
did,  in  fact,  excite  much  irritation  and  unrest  in  the 
industrial  classes.  But  no  such  criticism  can  lie 
against  the  policy  of  controlling  alcoholism  by 
regulating  on  physiological  lines  the  hours  and 
conditions  of  the  sale  of  alcoholic  beverages.  This 
policy  — in  a form  more  stringent,  maybe,  than 
would  be  necessary  or  desirable  in  time  of 
peace — was  adopted  by  Lord  D’Abernon  and  the 
Liquor  Control  Board  for  the  purpose  of  pro- 
moting the  national  efficiency  during  the  war ; 
it  is  a policy  which  does  not  involve  any 
interference  with  the  legitimate  freedom  of  the 
temperate  consumer  of  alcohol,  and  does  not 
occasion  any  appreciable  inconvenience  to  the 
general  public — certainly  none  that  is  worth 
weighing  against  its  great  and  unquestionable 
influence  in  promoting  the  well-being  of  the  com- 
munity. It  contains,  in  a word,  the  minimum 
amount  of  restriction  which  is  consistent  with  effec- 
tive action  in  the  control  of  alcoholism.  And  in  this 
matter  restriction  of  some  sort  is  inevitable ; not 
even  the  most  extreme  individualist  has  seriously 
proposed  that  there  should  be  entire  and  absolute 
freedom  in  the  production  and  sale  of  alcoholic 
beverages.  The  question  is  whether  the  restric- 
tions which  will  be  imposed  by  the  new  Commission 
are  to  be  grounded  on  scientific  principles  and 
directed  to  safeguarding  the  health  and  efficiency 
of  the  nation. 


The  Epidemiology  of  Pyogenic 
Infection. 

No  peace  terms  have  been  signed  in  man’s  war- 
fare with  bacteria,  and  there  is  little  prospect  of  a 
truce  with  the  minute  vegetal  foe.  The  ups  and 
downs  of  the  conflict  have  been  closely  studied  in 
the  case  of  typhoid,  where  success  has  fallen  to 
man,  and  in  so-called  influenza,  where  the  laurels 
must  honestly  be  awarded  to  the  other  side.  Dr.  W.  H. 
Hamer  begins  a report  just  published  with  the  words : 
“ The  year  1918  stands  out  as  a great  influenza  year.” 
Of  equal  interest  is  the  story  of  the  struggle  with 
the  organisms  which  gain  access  to  the  body 
through  obvious  breaches  of  surface.  While  the  war 
hygienist  has  taken  some  credit  for  the  compara- 
tive absence  of  typhoid,  typhus,  and  other  such 
plagues  from  the  Flanders  front,  no  such  congratu- 
lation is  possible  in  regard  to  the  epidemic  diseases 
of  wounds ; for  the  wounded  man,  as  Sir  Almr<5th 
Wright  once  reminded  us,  is  simply  a sick  man 
with  some  surface  discontinuity.  Dr.  W.  W.  C. 
Topley’s  Goulstonian  lectures,  the  second  instal- 
ment of  which  we  print  this  week,  serve  a useful 
purpose  in  bringing  exact  thought  to  bear  upon  the 
spread  of  bacterial  infection  from  the  standpoint  of 
the  bacteriologist.  Three  explanations  are  possible 
when  confronted  with  epidemic  disease : an 

increase  in  the  power  of  the  parasite  to  produce 
disease,  a decrease  in  the  resistance  of  the  host, 
and  some  alteration  in  the  surrounding  circum- 
stances furthering  the  transference  of  parasites 
from  case  to  case.  Dr.  Topley  adds  that  the  whole 
of  biological  knowledge  is  against  the  occurrence 
of  a considerable  epidemic  in  which  the  patho- 
genicity of  the  parasite  and  the  resistance  of  the 
host  remain  constant,  and  rules  out  the  third 
alternative  as  of  minor  importance.  But  he  is 
speaking  primarily  of  infections  which  enter  the 
body  through  an  intact  surface. 


There  is,  however,  one  organism,  which  has 
played  a leading  role  in  the  drama  of  war  wounds, 
in  regard  to  the  spread  of  which  circumstances  may 
chiefly  be  to  blame.  This  is  the  type  of  haemolytic 
streptococcus  described  in  a paper  by  Mr.  A. 
Fleming  and  Dr.  A.  B.  Porteous  on  page  49, 
which  has  been  held  responsible  for  almost  all  the 
severe  septic  complications  of  wounds  in  Flanders 
and  for  all  the  streptococcal  septicaemia.  The 
number  of  its  victims  has  been  so  large  as  to 
constitute  an  epidemic  in  the  strict  sense  of  the 
term,  although  an  epidemic  of  very  special  character. 
Put  briefly,  this  streptococcus  was  found  actually 
responsible  for  a large  number  of  deaths  in  those 
who  “ died  of  wounds,”  for  a still  larger  amount  of 
disability  from  continued  suppuration,  for  various 
forms  of  infected  skin  lesions  and  joint  infections, 
and,  finally,  for  certain  outbreaks  of  pharyngitis 
and  laryngitis,  as  well  as  of  pneumonia  and 
pleflrisy.  An  important  committee  was  set  up  in 
1918  by  the  Medical  Service  in  France  to  deal  with 
it.  Any  complete  report  on  methods  of  prevention 
and  treatment  was  first  impeded  by  the  rapid 
advance  of  the  summer  and  then  cut  short  by 
the  cessation  of  hostilities.  But  the  results  obtained 
threw  some  light  upon  the  origin  of  the  infection. 
At  a research  casualty  clearing  station  it  was 
found  that  of  patients  admitted  to  the  station  a 
few  hours  after  infliction  of  their  wounds  only  a 
small  proportion,  under  15  per  cent,  in  fact,  were 
infected  at  that  time  with  the  haemolytic  strepto- 
coccus. Quite  other  was  the  experience  at  the 
base.  Mr.  Fleming  and  Dr.  Porteous  found  that 
in  a series  of  a hundred  septic  wounds  remaining  at 
a base  hospital  for  over  seven  days  this  strepto- 
coccus was  present  in  almost  every  case.  Infection 
therefore  presumably  arose  somewhere  after  the 
field  dressing  stage.  Following  up  the  search,  they 
examined  during  last  summer  gauze  packs  removed 
from  wounds  on  arrival  at  the  base,  and  found  the 
haemolytic  streptococcus  in  nearly  every  one  when 
the  man  had  been  kept  at  the  casualty  clearing 
station  for  more  than  a week,  whereas  with  the 
man  sent  straight  on  to  the  base  the  organism 
was  present  in  15  out  of  75  excised  wounds — that 
is  to  say,  in  only  20  per  cent. 

It  would  seem,  as  these  authors  state,  a warrant- 
able deduction  that  the  streptococcal  disease 
of  wounds  is  in  most  cases  a hospital  infec- 
tion, probably  conveyed  from  patient  to  patient 
in  the  dressing  of  the  wound.  But  while  ad- 
mitting the  fact  of  infection  at  hospitals,  other 
possibilities  exist  in  regard  to  its  conveyance 
than  by  manual  transmission  from  wound  to 
wound.  At  certain  concentration  camps  in  the 
United  States  of  America  it  was  noted  thac  of  new 
recruits  entering  the  camp  only  a small  proportion 
harboured  streptococci  in  their  throats,  but  after  a 
short  stay  the  majority  were  thus  infected.  It  is  at 
least  possible  that  as  with  the  meningococcus  so  with 
the  streptococcus,  some  people  are  constant  carriers 
of  infection.  Here  Dr.  Topley  is  again  enlighten- 
ing. His  conception  is  of  a virus  of  a given  disease 
being  distributed  fairly  widely  through  the  world 
as  a comparatively  harmless  parasite  on  the  human 
host,  taking  on  during  epidemic  periods  a new  and 
sinister  role.  Under  conditions  of  campaigning 
it  may  well  be  that  the  streptococcus  carried  in 
the  throat  gains  an  increased  power  of  producing 
disease.  Nor  is  the  streptococcus  the  only  pyo- 
genic infection  whose  virulence  or  infectivity 
has  become  enhanced  under  war  conditions. 
Mr.  Joseph  Cunning’s  recent  letter  to  our 


The  Lanoht,] 


THE  SENSE  OF  STABILITY  AND  BALANCE  IN  THE  AIR. 


[July  12,  1919  71 


columns  on  epidemic  perinephric  suppuration 
elicited  from  Sir  Thomas  Horder  the  opinion 
of  a general  rise  in  the  incidence  of  staphylo- 
coccus infections.  Furunculosis,  sycosis,  impetigo, 
blepharitis — all  have  been  rife  of  late  and  individual 
cases  more  severe  than  usual.  Soldiers  returning 
home  have  apparently  brought  with  them  a more 
virulent  strain  of  staphylococcus.  Evidently  pyo- 
genic infections  deserve  the  careful  study  of  the 
epidemiologist. 

1 

The  Sense  of  Stability  and  Balance 
in  the  Air. 

In  the  monograph  on  the  above  subject  recently 
added  to  the  valuable  series  of  special  reports 
published  by  the  Medical  Research  Committee 1 
Dr.  Henry  Head,  F.R.S.,  records  investigations 
made  upon  both  normal  and  abnormal  subjects 
from  the  point  of  view  of  flying.  Of  particular 
interest  is  the  section  dealing  with  the  sensations 
experienced  by  normal  persons  in  heavier-than-air- 
machines.  It  is  shown  that  conscious  stability  and 
comfort  in  the  air  depend  primarily  on  the  normal 
response  of  three  groups  of  sense  organs — namely, 
the  vestibular  apparatus,  the  eyes  (including  the 
eye  muscles),  and  the  proprio-ceptive  system  with 
its  endings  in  muscles,  tendons,  and  joints. 
Defective  response  from  any  one  of  these 
afferent  end-organs  disturbs  the  sense  of  equili- 
brium in  the  air,  and  leads  to  actions  that  affect 
the  stability  of  the  aeroplane.  The  report  indicates 
that  undue  importance  has  hitherto  been  attached 
by  many  experts  to  the  vestibular  apparatus.  It 
has  become  increasingly  apparent  to  those  con- 
nected with  flying  that  although  the  sense  of 
stability  is  dependent  upon  the  integrity  of  the 
vestibular  apparatus,  the  importance  of  the  afferent 
impulses  streaming  in  from  eyes  and  the  proprio- 
ceptive system  must  not  be  overlooked.  An  expert 
pilot  finds  it  impossible  to  fly  a machine  with  his  eyes 
bandaged,  and  under  these  circumstances  derives 
most  of  his  information  from  cutaneous  sensation 
and  from  the  nerve  endings  in  muscles,  tendons, 
and  joints.  It  is  well  known,  as  in  the  case  of  the 
recent  Atlantic  flight  by  Alcock  and  Brown,  that 
when  the  sense  of  vision  is  cut  off  the  pilot  loses 
himself  in  space,  and  may  emerge  from  a fog  or 
cloud  with  his  machine  at  a steep  angle  or  even 
upside  down.  Under  these  circumstances  he  is 
dependent  almost  entirely  upon  instrumental 
guidance  for  flying,  and  it  may  be  that  in  future 
some  instrument,  such  as  Sir  Horace  Darwin’s 
“Turn  Indicator,”  will  be  fitted  to  machines  and 
be  largely  relied  upon  to  give  the  pilot  information 
in  respect  of  his  position  to  the  earth. 

Taking  seriatim  the  chief  points  of  interest 
brought  out  by  Dr.  Head  : While  flying  an  aero- 
plane an  otherwise  healthy  man  may  suffer  from 
disorders  of  vestibular  and  visual  sensibility  due 
to  temporary  causes.  Such  are  giddiness  through 
inability  to  regulate  the  tension  in  the  middle  ear 
with  sufficient  ease  during  a rapid  descent,  and 
defective  visual  orientation  due  to  the  develop- 
ment of  heferophoria  owing  to  disturbance  in 
function  of  the  eye  muscles.  Dr.  Head  shows  that 
in  some  men,  otherwise  normal,  rotatory  stimuli 
produce  a more  powerful  reaction  than  in  the 
majority  of  their  fellows.  They  become  giddy  easily. 
As  children  they  could  not  swing  with  pleasure, 

i Medical  Research  Committee  Special  Report  Series  No.  28.  Reports 
of  the  Air  Medical  Investigation  Committee,  “ The  Sense  of  Stability 
and  Balance  in  the  Air.'' 


and  some  of  them  were  habitually  sick  in  the  train. 
Such  persons  aro  not  suffering  from  a pathological 
condition  ; their  disability  arises  from  the  fact 
that  sensory  impulses  from  the  semi-circular  canals 
are  not  checked  and  controlled  to  the  same  extent 
as  in  the  majority  of  healthy  individuals. 
Consequently,  when  exposed  to  disturbances  of 
equilibrium  to  which  a normal  man  would  adapt 
himself  unconsciously,  they  suffer  from  discomfort, 
become  giddy,  and  may  even  vomit  in  the  air. 
Many  who  were  giddy  when  first  exposed  to 
acrobatic  evolutions  succeed  in  conquering  this 
disability.  They  learn  to  fly  with  ease,  and  the 
acquisition  of  this  new  facility  is  associated  with 
control  of  the  primary  afferent  impulses  from  the 
auditory  and  visual  apparatus.  Any  condition 
which  produces  diminished  control  by  the  highest 
faculties  over  the  activity  of  lower  centres  is  liable, 
however,  to  lead  to  regression  to  the  earlier  mode 
of  reaction.  All  healthy  men  can  be  affected  if  the 
intensity  of  the  rotatory  stimulus  is  pushed  up  to 
sufficiently  high  degree.  This  may  occur  either 
from  the  fact  that  the  head  is  held  in  some  unusual 
position,  as,  for  example,  when  looking  upwards 
during  spinning,  or  the  actual  rotation  may  be 
mechanically  increased  in  rapidity.  In  some  cases 
the  reaction  to  such  excessive  stimulation  takes 
the  form  of  giddiness,  with  or  without  nausea ; 
in  others  it  is  associated  with  that  withdrawal  of 
consciousness  known  as  “ fainting.”  When  a man 
is  made  giddy  he  is  in  a state  of  confusion  with 
regard  to  his  relations  in  space.  In  the  pre- 
liminary stages  of  “ fainting  ” his  horizon  is 
restricted  and  the  world  around  disappears.  Both 
states,  pushed  to  the  limits  of  endurance,  end  in 
unconsciousness. 

Complete  adaptation  to  disturbances  of  equili- 
brium in  the  air  is  associated  with  automatic 
control  of  the  afferent  and  efferent  activities  of 
lower  levels  of  the  central  nervous  system.  The 
normal  pilot  merely  desires  that  his  machine  shall 
behave  in  a certain  manner  and  the  evolution 
occurs.  This  acquired  facility  can  be  disturbed  by 
any  condition  which  leads  to  diminished  control. 
Just  as  a golfer  can  be  “put  off  his  game”  by  some 
physiological  or  mental  state,  so  the  aviator  may 
lose  his  capacity  to  fly  in  consequence  of  conditions 
that  vary  so  widely  as  a gastro-intestinal  attack  or 
domestic  anxiety.  Exhaustion,  insomnia,  the 
distress  of  war  flying,  anxiety,  or  fear  can  all 
lead  to  defective  afferent  and  efferent  control. 
Efficient  automatic  response  is  no  longer  possible, 
and  the  pilot  begins  to  fly  badly  and  to  make  bad 
landings.  This  loss  of  control  over  the  activity  of 
lower  levels  may  be  manifested,  however,  not  only- 
in  bad  management  of  the  machine,  but  also  in 
some  dangerous  reaction,  such  as  “ giddiness  ” or 
“ fainting  in  the  air.  When  this  abnormal 
reaction  assumes  the  form  of  giddiness  and  nausea 
it  is  found  in  most  cases  that  the  patient  has 
suffered  from  some  discomfort  when  he  first 
went  into  the  air.  Inquiry  will  usually  reveal 
also  that  he  was  unable  to  swing  with  pleasure  as  a 
child,  and  that  he  tended  to  be  sick  when  travelling 
by  train.  In  this  group  rotatory  impulses,  when 
released  from  control,  manifested  their  influence  in 
giddiness,  usually  accompanied  by  nausea.  When 
the  reaction  takes  the  form  of  “fainting”  it  is 
generally  found  that  the  subjects  enjoyed  their  first 
flight  and  could  swing  with  pleasure.  Their  resist- 
ance to  vertiginous  impressions  was  high  and  no 
excessive  giddiness  resulted,  but  they  could  induce 
the  effects  of  shock  with  undue  facility.  Dr.  Head 


72  The  Lancet,]  A MEMORANDUM  ON  MALARIA  FOR  GENERAL  PRACTITIONERS. 


[July  12,  1919 


lias  performed  signal  service  in  drawing  attention 
to  the  importance  of  regression  in  the  airman,  and 
showing  that  this  may  be  produced  by  mechanical, 
physiological,  or  psychical  causes. 

In  dealing  with  the  tests  for  estimating  the  sense 
of  balance  used  by  the  Examining  Board  of  the  Air 
Force  Dr.  Head  criticises  them  adversely,  since  the 
results  of  the  tests  employed  have,  as  is  so  com- 
monly done,  been  entered  frequently  under  heads 
such  as  “ nervous  debility,”  “ muscle  sense,”  and 
“vestibular  stability”  rather  than  under  a heading 
indicating  the  actual  tests  employed.  In  his 
opinion  the  tests  do  not  afford  information  in 
regard  to  the  conditions  they  were  designed  to 
investigate.  It  is  shown  that  the  tests  are  of  value 
in  revealing  the  existence  of  some  abnormal  func- 
tional state,  but  are  not  otherwise  an  indication  of 
ability  to  fly.  Dr.  Head,  however,  is  not  correct  in 
his  belief  that  the  results  of  the  tests  employed 
have  not  been  entered  in  detail  on  the  admission 
forms  of  candidates  for  the  Royal  Air  Force,  and  in 
this  way  has,  no  doubt  quite  unintentionally,  done 
an  injustice  to  the  authorities  concerned  in  his 
criticism  of  their  records.  We  understand  that 
many  thousands  of  results  of  tests  have  been  so 
entered,  although,  as  indicated  above,  possibly  under 
a wrong  heading.  A future  study  of  these  data  will 
serve  as  a control  to  the  experimental  conclusions 
arrived  at  by  Dr.  Head  as  a result  of  the  employ- 
ment of  the  same  tests.  In  conclusion,  Dr.  Head 
is  to  be  congratulated  on  the  way  in  which  he 
has  collected,  described,  and  analysed  individual 
examples  of  various  abnormal  states  that  may 
make  their  appearance  during  flight.  The  paper  is 
a stimulating  and  original  contribution  to  the 
medical  aspects  of  flying. 

» 

A Memorandum  on  Malaria  for 
General  Practitioners. 

Sir  Ronald  Ross  and  Lieutenant-Colonel  S.  P. 
James  have  drawn  up,  for  the  information  of 
medical  practitioners,  a booklet  of  suggestions  for 
the  care  of  malaria  patients,  which  has  been  issued 
by  the  Ministry  of  Pensions  and  is  to  be  obtained 
for  1 d.  from  H.M.  Stationery  Office.  An  introductory 
section  calls  attention  to  the  considerable  number 
of  demobilised  men  who  have  become  infected  with 
malaria  during  service  abroad.  These  men  will  be 
entitled  to  receive  treatment  from  Insurance  prac- 
titioners, and  it  is  the  object  of  the  Memorandum 
to  bring  within  small  compass  particulars  as  to  the 
nature  of  thedisease,itsclinical  and  other  characters, 
the  lines  of  treatment  found  to  be  most  successful, 
and  the  measures  necessary  for  preventing  its  spread. 
The  medical  man  to  whom  malaria  is  reported 
must  satisfy  himself  that  the  diagnosis  is  correct, 
supervise  the  treatment  so  as  to  cut  short  the  attack, 
and  notify  the  case  to  the  medical  officer  of  health. 
The  Memorandum  describes  the  three  chief  types 
of  malarial  fever,  giving  the  main  characteristics 
of  benign  and  malignant  forms,  concluding  with 
“ pernicious  symptoms  ” and  the  condition  of 
“ malarial  cachexia.”  Differential  diagnosis  is  con- 
sidered clinically,  microscopically,  and  in  relation 
to  the  “ therapeutic  test.”  Quinine  treatment  and 
after-treatment  are  then  dealt  with  at  length. 
An  appendix  cites  the  relevant  portions  of  the 
Local  Government  Board  regulations  in  regard  to 
notification. 


^nnotatians. 

11  Ne  quid  nlmle.” 

AMERICAN  HOSPITAL  FOR  GREAT  BRITAIN. 

The  plans  for  the  American  Hospital  are  now  in 
so  advanced  a stage  that  a meeting  of  the  Govern- 
ing Council  will  be  held  next  week  at  the  House  of 
the  Royal  Society  of  Medicine,  at  which  Lord 
Reading  (who  has  accepted  the  Presidency  of  the 
Hospital)  and  the  American  Ambassador  have 
promised  to  be  present.  Upon  the  signing  of  the 
Armistice  last  November  the  moment  seemed  ripe 
for  bringing  the  project  of  an  American  hospital  to 
the  consideration  of  the  medical  profession  in  Great 
Britain,  as  well  as  to  the  American  colony  in  London. 
Not  only  were  the  needs  of  the  foundation  of 
such  a hospital  obvious,  but  the  exceptional  oppor- 
tunities of  the  moment  were  never  likely  to 
be  repeated.  The  medical  professions  of  America 
and  Great  Britain  have  hitherto  worked  too  much 
apart,  although  each  has  much  to  learn  from  the 
other.  The  incidence  of  the  war  has  brought  them 
into  closer  contact.  For  two  years  American 
medical  men  have  been  attached  to  British  units  in 
the  field,  and  have  worked  side  by  side  with  their 
British  confreres  upon  the  staffs  of  military 
hospitals  in  all  parts  of  England  and  Scotland.  The 
comradeship  brought  about  by  such  friendly 
cooperation  and  interchange  of  scientific  knowledge 
must  be  of  vast  importance  in  the  future  history  of 
the  two  nations.  A medical  executive  committee, 
consisting  of  Sir  William  Osier,  Sir  Arbuthnot  Lane, 
Sir  Humphry  Rolleston,  Sir  John  Bland-Sutton, 
Mr.  J.  Y.  W.  MacAlister,  and  Mr.  Philip  Franklin, 
sat  in  London  and  discussed  the  scope  of 
the  hospital ; and  at  the  Congress  of  the 

American  Surgical  and  Medical  Associations 
held  in  Atlantic  City  last  month,  Sir  Arbuthnot 
Lane  notified  officially  its  establishment,  pointing 
out  that  no  more  fitting  monument  could 
be  raised  to  the  fallen  than  a hospital  designed  to 
form  the  headquarters  for  American  medical  men 
who  visited  Europe  for  the  purposes  of  post- 
graduate study.  At  this  Congress  the  plans  of 
the  committee  were  received  with  enthusiasm, 
and  Sir  Arbuthnot  Lane  was  assured  by  leading 
American  medical  men  that  their  profession  was 
keenly  alive  to  the  great  value  which  such  an 
institution  might  have  as  a centre  for  study  and 
research. 

A committee  was  then  formed  to  establish  the 
cooperation  of  American  doctors  upon  a definite 
footing  and  to  act  in  conjunction  with  the  executive 
committee  in  London,  and,  if  desirable,  to  operate 
under  the  National  Research  Council  at  Washington. 
This  American  Committee  consists  of  Dr.  George  W. 
Crile,  of  Cleveland,  appointed  by  the  American 
Academy  of  Sciences  on  International  Relations ; 
Dr.  W.  J.  Mayo  and  Dr.  Charles  H.  Mayo,  of 
Rochester,  Minnesota ; Dr.  Albert  J.  Ochsner,  of 
Chicago;  Dr.  Rudolph  Matas,  of  New  Orleans;  and 
Dr.  Franklin  Martin,  of  Chicago,  appointed  by  the 
American  Gynascological  Association.  This  com- 
mittee will  send  a delegate  to  London  to  assist  the 
medical  committee  here  in  the  detailed  organisa- 
tion of  the  hospital,  which  has  been  planned  upon 
the  most  modern  lines  in  every  department  of 
medical  and  surgical  activity  and  of  research  directed 
towards  every  class  of  patient.  A research  institute, 
modelled  upon  the  Rockefeller  Foundation  of  New 
Y'ork,  will  form  an  integral  part  of  the  building. 


The  Lancet,] 


LIGHT  SENSE. 


[July  12,  1919  73 


The  consulting  staff  will  bring  together  distin- 
guished members  of  the  medical  profession  in  the 

I two  countries.  The  visiting  staff  will  be  nominated 
by  the  executive  medical  committee. 

The  governing  council  of  the  hospital,  which 
is  likely  to  have  for  its  patrons  the  highest 
personages  on  both  sides  of  the  Atlantic,  consists  of 
1 many  prominent  members  of  the  American  colony 

I in  London,  including  Mr.  Walter  Blackman,  Mr. 
George  M.  Cassatt,  Mr.  R.  Newton  Crane,  Mr.  Wilson 
Cross,  Mr.  Clarence  Graff,  Mr.  James  Benson 
Kennedy,  Mr.  J.  Blair  MacAfee,  Mr.  George  A. 

1 Mower,  Mr.  F.  E.  Powell,  Mr.  Henry  E.  Stoner,  Mr. 
F.  C.  Van  Duzer,  and  Mr.  E.  Bradner  White,  with 
Mr.  Philip  Franklin  as  honorary  secretary. 


LIGHT  SENSE. 

For  a study  on  the  “ Performance  of  Night' 
glasses”  we  can  recommend  Bulletin  No.  3,  by 
L.  C.  Martin,  D.I.C.,  &c.,  published  for  the  Depart- 

Iment  of  Science  and  Industrial  Research  by 
H.M.  Stationery  Office.  The  whole  subject  of 
light  sense  is  indifferently  understood.  When 
we  pass  from  bright  sunlight  to  a dimly 
lighted  room  we  can  see  nothing  until  our  eyes 
have  become  adapted  to  the  dark.  This  adapta- 
tion is  supposed  to  depend  principally  upon  some 
change  in  the  relation  between  the  bacillary  layer 
of  the  retina  and  the  adjoining  pigment,  and  takes 
three-quarters  of  an  hour  or  more  to  become  com- 
plete, and  in  the  second  place  upon  the  dilatation 
of  the  pupil,  which  occurs  very  rapidly.  It  is  a 
curious  fact  that  the  fovea  is  physiologically 
night-blind,  for  a fully  dark-adapted  or  scotopic 
eye  is  found  to  have  a central  scotoma ; round  the 
fovea  is  a ring  that  is  most  sensitive  to  light,  and 
beyond  this  ring  the  light  sense  fades  gradually 
towards  the  periphery.  Again,  the  scotopic  eye  is 
colour  blind,  but  on  the  admission  of  more  light 
the  first  colours  recognised  are  yellow  and  blue, 
after  them  the  greens,  and,  finally,  the  reds. 
On  a dark  night  the  grass  looks  grey,  while 
the  colour  of  yellow  flowers  may  still  be  dis- 
tinguished, but  the  red  geraniums  appear  black. 
As  there  are  no  rods  in  the  fovea,  though  they  are 
found  in  increasing  numbers  towards  the  periphery, 
it  will  be  seen  that  there  are  some  good  prima  facie 
grounds  for  considering  the  rods  as  the  percipient 
elements  for  light  sense  and  the  cones  for  colour 
sense. 

The  light  sense  may  be  tested  in  two 
different  ways : (1)  Light  difference  (L.D.) : The 
estimation  of  the  smallest  difference  of  brightness 
that  can  be  appreciated  between  two  sources  of 
nearly  equal  luminosity ; and  (2)  light  minimum 
(L.M.) : the  estimation  of  the  smallest  quantity  of 
light  that  can  be  recognised  in  a faintly  illuminated 
patch  on  a black  background.  Ophthalmologists 
find  that  L.D.  is  most  affected  in  diseases  of  the 
optic  nerve,  but  that  L.M.  is  chiefly  diminished 
in  glaucoma  and  in  diseases  of  the  retina  and 
choroid.  It  is  found  that  practice  increases  the  L.D. 
sensibility  enormously,  and,  indeed,  the  results  of 
L.D.  and  L.M.  tests  vary  so  greatly  in  different 
individuals  that  no  definite  value  can  be  assigned 
as  the  standard  of  either.  When  Professor  E.  M. 
Barnard  (Yerkes  Observatory,  U.S.A.)  found  that 
he  could  detect  a wire  at  such  a distance  that 
its  diameter  only  subtended  an  angle  of  0'44” 
(i.e.,  less  than  half  a second)  at  the  nodal  point  of 
his  eye,  it  is  a proof  of  his  extraordinary  sensibility 
to  light  difference ; it  is  no  test  of  his  form  sense. 


The  minimum  visible  for  form  sense  is  53T”,  and 
is  usually  taken  to  be  1\  Many  tests  that 
are  supposed  to  deal  with  the  form  sense  are 
really  only  testing  L.D.  Even  the  dot  test  cards 
that  are  so  frequently  used  fall  under  suspicion 
for  this  reason.  In  practice  this  may  not  be 
very  serious,  as  in  many  callings  an  adequate  light 
sensibility  is  more  important  than  a superior  form 
sense.  On  a dark  night  most  people  have  found  that 
they  see  better  without  their  spectacles  than  with 
them,  as  then  they  are  relying  upon  their 
light  sense  and  not  upon  their  form  sense, 
which  is  improved  by  increased  definition.  Every 
optical  instrument  entails  some  loss  of  light  from 
absorption  and  from  reflection  at  the  surfaces  of 
the  glass ; and  yet,  as  is  well  known,  telescopes 
enable  one  to  see  stars  that  are  invisible  to 
the  naked  eye,  and  night  glasses  are  of  in- 
valuable use  to  the  mariner.  The  principles 
underlying  these  two  instruments  are  entirely 
different. 

The  apparent  brightness  of  a surface  in 
ordinary  circumstances,  if  the  size  of  the  pupil 
remain  constant,  simply  depends  upon  the  in- 
trinsic brightness  of  the  surface.  A piece  of 
white  paper  1 in.  square  at  a distance  of  4 ft. 
is  as  bright  as  a piece  1 ft.  square.  If,  however,  an 
object  be  so  small  that  its  image  only  falls  on  part 
of  a bacillary  element,  unless  it  be  exceedingly 
bright  it  may  not  succeed  in  stimulating  this 
element.  When  faint  stars  are  observed  through  a 
telescope  their  apparent  size  is  not  increased,  for 
they  still  subtend  an  angle  less  than  the  minimum 
visible,  but  all  the  light  which  falls  on  the  object 
glass  may  by  a suitable  eye-piece  be  concentrated  on 
the  observer’s  pupil,  neglecting  the  light  lost  by 
transmission  through  the  instrument.  The  action 
of  the  telescope  is  tantamount  to  increasing  the 
area  of  the  pupil  to  that  of  the  object  glass,  and  hence 
the  brightness  of  the  faint  star  is  virtually  increased. 
If,  however,  the  object  viewed  subtend  an  angle 
(e.g.,  10')  greater  than  the  minimum  visible,  no 
optical  instrument  can  increase  its  brightness  per 
unit  area.  Yet,  as  is  well  known,  in  the  dusk  a 
night-glass  enables  objects  to  be  seen  that  are 
invisible  to  the  naked  eye,  although  telescopes  with 
a magnification  of  20  or  so  will  prevent  objects 
being  seen  that  can  be  dimly  distinguished  without 
it.  Similarly,  all  microscopists  have  noted  that 
when  high  eye-pieces  are  used  the  field  becomes 
much  darker.  This  is  simply  because  the  emergent 
beam  of  light  from  a high  ocular  is  so  thin  that 
oply  part  of  the  pupil  is  filled  with  light ; indeed, 
the  pupil  receives  far  less  light  than  when  a lower 
eye-piece  is  used.  Now  one  advantage  of  a Galilean 
binocular  is  that  the  section  of  the  emergent  beam 
is  never  less  than  that  of  the  pupil  and,  con- 
sequently, no  light  is  lost  from  this  cause.  But  we 
have  said  that  the  brightness  per  unit  area 
cannot  be  increased,  how  then  can  the  visibility 
of  an  object  in  a dim  light  be  increased  by 
night-glasses  ? All  workers  agree  that  the 
minimum  intrinsic  brightness  necessary  for  the 
perception  of  an  object  varies  greatly  with  its 
size.  It  is  clear,  then,  that  night-glasses  with  a 
magnification  of  4 or  6 will  increase  the  visibility 
of  objects  in  a dim  light  owing  to  their  increased 
apparent  size.  We  may  at  once  conclude  that  as 
long  as  the  section  of  the  emergent  beam  is  not 
less  than  the  pupil  of  the  observer’s  eye  advantage 
will  be  gained  by  increasing  the  magnification;  but 
if  the  sectional  area  of  the  emergent  beam  is  less 
than  that  of  the  pupil  the  image  may  become  even 


74  The  Lancet, ] 


THE  BRITISH  SCIENTIFIC  PRODUCTS  EXHIBITION. 


[July  12,  1919 


dimmer  than  the  object  when  seen  by  the  naked 
eye.  Piper1  has  pointed  out  that  in  dark  adap  ed 
eyes  the  light  sensibility  is  about  twice  as  great 
with  both  eyes  as  with  one,  though  in  light- 
adapted  eyes  no  such  binocular  summation  takes 
place.  

THE  BRITISH  SCIENTIFIC  PRODUCTS  EXHIBITION. 

Under  the  auspices  of  the  British  Science  Guild 
a very  interesting  exhibition  of  British  scientific 
productions  was  opened  by  Lord  Crewe  at  the 
Central  Hall,  Westminster,  on  Thursday,  July  3rd. 
Encouraged  by  the  success  which  attended  a 
similar  exhibition  held  last  year  at  King’s  College, 
the  authorities  were  amply  justified  in  promoting 
another  exhibition  this  year,  the  objects  of  which  are 
to  illustrate  recent  progress  in  British  science  and 
invention,  and  to  help  the  establishment  and  develop- 
ment of  new  British  industries.  The  demonstration 
is  most  instructive,  and  evidences  in  many  directions 
the  capacity  and  skill  of  the  British  manufacturer 
in  acquiring  new  industries  and  in  restoring  old 
ones  on  a scientific  basis.  There  is,  indeed,  a wealth 
of  products  shown,  illustrating  in  the  most  satis- 
factory way  a determination  to  press  science  into 
industrial  service  and  to  remove  the  long-standing 
reproach  of  our  dependence  on  other  nations 
for  the  supply  of  many  valuable  and  important 
commodities.  And  there  is  a noble  record  pre- 
sented of  the  work  done  in  the  research  laboratories 
of  the  universities  and  schools  of  England.  All  is  an 
eloquent  story  of  the  successes  gained  by  the  men 
trained  in  the  scientific  and  technical  laboratories. 
Mechanical  science,  physics,  textiles,  electrical 
appliances,  medicine  and  surgery,  paper  and 
illustration,  agriculture,  chemistry,  aircraft,  fuels, 
and  metallurgy  form  most  interesting  sections,  in 
which  examples  are  numerous  enough  of  the 
talent,  skill,  and  energy  not  yet  lost  to  our  race. 
Synthetics  and  dyes  are  conspicuous  illustrations 
of  recent  commercial  successes  resting  on  scientific 
foundations,  and  the  exhibition  of  optical  glass 
and  laboratory  glass  ware  demonstrates  a brilliant 
dual  triumph  of  scientist  and  manufacturer.  The 
great  drug  houses  are  well  represented,  showing 
what  an  essential  equipment  to  the  success  of  their 
business  is  the  research  laboratory.  This  oppor- 
tunity of  witnessing  the  remarkable  developments 
arising  out  of  the  events  of  the  war  which  have 
taken  place  in  so  many  departments  of  our  great 
industries  should  not  be  lost.  The  bearing  of 
science  upon  industrial  success  and  national 
prosperity  is  well  brought  out.  The  exhibition 
continues  until  August  5th. 

THE  MEDICAL  AND  DENTAL  REGISTERS. 

The  official  Register  of  the  General  Medical 
Council,  which  has  just  been  issued,  contains  the 
names  of  43,926  persons,  of  whom  54  per  cent,  are 
on  the  local  Register  for  England,  32  per  cent,  on 
that  for  Scotland,  and  14  for  Ireland.  1077  names 
were  registered  in  1918,  being  the  smallest  number 
recorded  for  a quarter  of  a century  except  at  the 
low  tide  of  1910-11.  On  the  other  hand,  the  net 
increase  of  107  registered  names  at  the  end  of 
1918  as  compared  with  1917  is  quite  without 
precedent  in  its  smallness.  The  previously  leanest 
years  had  some  compensation,  lacking  in  1918,  in 
names  restored  to  the  Register  and  short  death 
rolls.  The  additional  names  registered  during 
1918  included  148  colonial  and  16  foreign 


diplomas,  for  the  most  part  Belgian.  995  names 
have  been  removed  from  the  Register  during  the 
year,  946  on  evidence  of  death.  Only  one  medical 
man  has  formally  removed  his  name  from  the  list 
as  having  ceased  to  practise. 

The  official  Dentists  Register  for  1919  contains  the 
names  of  5567  dentists,  of  whom  13  are  on  the 
colonial  and  19  on  the  foreign  list.  Of  the  5535  ' 
United  Kingdom  dentists,  4290  hold  degrees  or 
licences  in  dental  surgery,  and  1245  are  registered 
on  their  own  declaration  of  being  in  bona-fide 
practice  of  dentistry.  Of  the  former,  461  have 
additional  surgical  or  medical  qualifications,  of  the 
latter  7.  The  number  added  by  registration  during 
the  year  1918  was  131,  being  one  in  excess  of 
the  figure  for  1917  and  barely  one-half  of  the  1915 
record.  102  names  were  removed  on  evidence  of 
death,  none  on  ceasing  to  practise. 


EPIDEMIC  ENCEPHALITIS  (NONA). 

A useful  contribution 1 to  the  subject  of 
epidemic  encephalitis,  from  the  pen  of  Dr.  Peter 
Bassoe,  associate  professor  of  medicine,  Rush 
Medical  College,  Chicago,  shows  that  the  disease 
has  made  its  appearance  in  America,  with  similar 
clinical  and  pathological  features  to  those  fre- 
quently described  in  this  country  and  on  the 
continent.  Sainton  has  attempted  to  give  a defini- 
tion of  the  disease  in  the  following  terms : “ A 
toxic,  infective,  epidemic  syndrome,  characterised 
clinically  by  the  triad  lethargy,  ocular  palsies,  and  a 
febrile  state,  and  anatomically  by  a more  or  less 
diffuse  encephalitis,  most  marked  in  the  grey 
matter  of  the  midbrain.”  It  may  be  questioned, 
however,  whether  any  useful  purpose  is  served  at 
present  by  condensed  definitions  ; Sainton’s  is  not 
sufficiently  explicit  to  be  distinctive.  The  associa- 
tion of  epidemic  encephalitis  with  influenza 
appears  to  be  more  than  a mere  coincidence,  since 
it  has  been  noted  on  a number  of  occasions.  Dr. 
Bassoe  quotes  from  a French  source  that 
Camerarius,  who  described  an  influenza  epidemic 
in  Tubingen  in  1718,  mentioned  a “ sleeping 
sickness  ” in  connexion  with  it.  In  1768,  Lepecq 
de  la  Cloture  recorded  a “coma  somnolentum  ” 
after  influenza,  and  Ozanann  (1835)  mentioned 
epidemics  of  “ catarrhal  fever  ” with  “ soporosite  ” 
as  having  occurred  in  Germany  in  1745,  in  Lyons 
in  1800,  and  in  Milan  in  1802.  No  doubt  much  of 
this  is  vague  and  indeterminate ; influenzal  mening- 
itis is  a different  affection  altogether,  and  what 
(much  or  little)  of  these  epidemic  conditions  should 
be  classed  as  encephalitis  lethargica  is  a matter 
depending  really  on  the  interpretative  proclivities 
of  the  reader.  Dr.  Bassoe  describes  11  cases  in  his 
paper,  and  notes  that  in  no  one  had  there  been 
definite  preceding  influenza,  but  suggests  that  the 
encephalitis  “ may  be  caused  by  a separate  virus, 
which  in  order  to  become  active  must  have  been 
in  contact  at  one  time  or  another  with  that  of 
influenza.”  Be  this  as  it  may,  the  bacteriological 
aspect  of  the  question  has  been  less  completely 
investigated  than  the  clinical  and  pathological,  and 
has  scarcely  passed  the  stage  of  conjecture.  It  is 
an  interesting  observation  that  the  brain-stem  and 
basal  ganglia  are  particularly  liable  to  be  affected 
by  poisons,  endogenous  or  exogenous,  though  why 
this  should  be  so  is  not  at  present  clear.  Dr.  Bassoe 
has  had  the  opportunity  of  making  a complete 
pathological  examination  in  two  cases,  and  has 
found  the  changes  with  which  previous  writers 


1 Ztscb.  f.  Psychol,  u.  Physiol,  d.  Sinnesorg.,  xxxli.,  98.,  1904. 


Journal  of  the  American  Med.  Assoc.,  April  5tb,  1919,  p.  971. 


The  Lancet,] 


SIR  CLIFFORD  ALLBUTT  S PORTRAIT. 


[July  12,  1919  75 


have  made  ns  familiar — oedema,  congestion  and 
minute  hromorrliages,  these  most  numerous  in 
brain-stem,  basal  ganglia,  and  centrum  ovale,  dense 
accumulations  of  small  cells  round  the  vessels, 
and  comparatively  little  evidence  of  necrosis  or 
tissue  destruction.  In  his  cases  there  was  but 
little  sign  of  inflammation  in  cortex  or  meninges. 
He  rnajies  the  interesting  remark  that  there  is  not 
so  much  real  sleep  as  is  indicated  by  the  sleepy 
expression  of  the  patient ; in  fact,  some  actually 
suffer  from  insomnia,  “lethargy”  bearing  the  same 
relation  to  sleep  as  the  compulsive  laughter  of  the 
patient  with  pseudo  bulbar  paralysis  does  to  a 
normal  laugh.  Among  other  clinical  features  also 
observed  in  various  English  cases  may  be  specified 
coarse  choreiform  jerkings,  which  sometimes  have 
become  very  troublesome,  and  which  Dr.  Bassoe 
has  been  able  to  control  temporarily  w7ith  scopol- 
amine. There  is  much  more  evidence  than  the 
casual  observer  would  suspect  to  support  the  con- 
tention that  the  lethargy  of  these  patients  is  a local 
and  not  a general  symptom.  The  laboratory  tests 
of  the  spinal  fluid  in  Dr.  Bassoe’s  11  cases  show 
that  the  cell  content  was  less  than  10  in  the 
majority,  with  a maximum  of  26 ; the  fluid  was 
always  clear,  and  usually  gave  a slight  increase  of 
globulin.  Results  of  cultures  of  blood  and  spinal 
fluid,  both  during  life  and  after  death,  were  nega- 
tive. No  bacteria  were  seen  in  section  of  the 
brain. 


SIR  CLIFFORD  ALLBUTT’S  PORTRAIT. 

The  fund  for  presenting  the  President  of  the 
British  Medical  Association  with  his  portrait 
remains  open  by  request  during  the  present 
month.  Subscriptions  have  recently  been  received 
from  India  and  America.  The  treasurer,  Dr.  G.  E. 
Haslip,  in  a letter  which  appears  in  our  corre- 
spondence columns,  invites  all  those  who  wish  to 
take  part  in  the  presentation,  but  who  have  not 
! yet  notified  their  intention,  to  do  so  without  delay. 
After  the  portrait  in  oils  has  been  painted  it  is 
intended  to  commission  a mezzotint  engraving 
from  it,  which  subscribers  to  the  fund  will  be  able 
to  purchase  for  their  own  collections. 


RABID  IGNORANCE. 

The  worst  kind  of  ignorance  is  that  which  springs 
from  an  instinctive  refusal  to  acknowledge  the 
truth.  The  Arabs  long  ago  recognised  how  obstinate 
and  intractable  is  this  affliction  when  they  said : 
“ He  that  knows  not,  and  knows  not  that  he  knows 
not,  is  stupid.  Shun  him.”  To  argue  with  such 
people  is  clearly  waste  of  time,  for  no  amount 
of  reason  can  prevail  against  a well-established 
complex.  But  to  ignore  the  victims  entirely 
would  be  as  foolish  as  merely  to  avoid  the  company 
of  a dangerous  criminal.  Indeed,  if  the  defini- 
tion of  crime  be  a fairly  broad  one,  such 
people  are  dangerous  criminals,  for,  as  Dr. 
Johnson  says : “ He  that  voluntarily  continues 
ignorant  is  guilty  of  all  the  crimes  that  ignor- 
ance produces.”  The  stamping  out  of  rabies  in 
this  country  30  years  ago  was  carried  through  in 
the  face  of  violent  and  prejudiced  opposition.  It 
could  hardly  be  expected  that  the  arguments  then 
used  against  the  Muzzling  Order  of  1885  should  be 
brought  forward  again  to-day.  Yet  such  does 

actually  appear  to  be  the  case.  At  a recent  meet- 
ing of  the  Animal  Defence  and  Antivivisection 
Society  (in  the  words  of  its  secretary)  strong 
feeling  was  expressed  at  the  unscrupulous  way 
in  which  the  present  scare  is  being  worked 


up.  “ To  prevent  rabies  in  dogs,”  he  writes 
“ it  is  essential  that  they  should  be  well  and 
carefully  fed,  given  plenty  of  water,  enough 
exercise,  and  not  kept  in  the  sun.”  By  such  well- 
meaning  people  the  currency  of  truth  is  debased 
and  it  becomes  important  that  the  real  nature  of 
rabies  and.liydrophobia  should  be  placed  before  the 
public  by  competent  authorities  in  order  that  such 
misleading  statements  as  that  quoted  above  may 
be  recognised  at  their  true  value.  The  Society  for 
the  Prevention  of  Hydrophobia,  founded  in  1886,  is 
still,  we  are  glad  to  say,  in  existence,  and  their  first 
secretary,  Mr.  Frank  Karslake,  has  rendered  a 
valuable  service  in  reissuing  his  pamphlet  first  pub- 
lished in  1889.1  The  arguments  used  in  it  remain  as 
true  to-day  as  they  were  at  that  time,  and  various 
additions  have  been  made  which  bring  them  into 
more  intimate  contact  with  the  world  of  to  day. 
May  it  have  a wide  circulation  amongst  the  open- 
minded  public,  for  it  is  a valuable  prophylactic 
against  the  views  of  those  who  know  not  that  they 
know  not  and  are  still  at  large.  More  than  200 
cases  of  rabies  have  now  been  confirmed,  and  recent 
reports  show  that  the  disease  is  by  no  means 
arrested,  a new  outbreak  having  occurred  this 
week.  Dr.  Addison,  speaking  last  week  on  a 
vote  to  liquidate  the  Local  Government  Board, 
stated  that  54  notifications  had  been  received  of 
persons  bitten  by  rabid  dogs,  and  of  these  19  were 
sent  to  Paris  for  antirabic  treatment  ; 24  were 
treated  in  England  with  vaccine  obtained  from  the 
Pasteur  Institute  in  Paris,  and  11  others  with 
vaccine  prepared  in  the  Board’s  own  laboratory. 
In  no  case  had  hydrophobia  resulted,  and  this 
admirable  achievement  of  preventive  medicine  has 
been  used  by  unscrupulous  persons  to  suggest  that 
no  need  for  any  treatment  exists.  Those  who  have 
been  saved  from  the  risk  of  a painful  and  horrible 
death  will  think  otherwise,  and  the  public  meeting 
held  last  week  in  London  under  the  auspices  of  the 
Kennel  Club  was  unanimous  in  recommending  the 
common- sense  measure  of  a general  Muzzling  Order 
throughout  the  country.  The  Board  of  Agriculture 
may  be  assured  of  the  support  of  well-informed 
public  opinion  in  enforcing  whatever  regulations 
may  be  found  to  be  necessary  once  again  to  deliver 
from  this  curse  both  man  and  his  most  faithful 
beast. 


THE  PATHOGENESIS  OF  DEFICIENCY  DISEASE. 

A very  interesting  contribution  to  the  literature 
of  this  subject  has  recently  been  made  by 
Lieutenant-Colonel  R.  McCarrison,  I.M.S.,  of  the 
Pasteur  Institute  of  Southern  India,  in  the  Indian 
Journal  of  Medical  Research  (vol.  vi.,  No.  3),  in  which 
he  discusses  the  origin  of  diseases  attributed  to  a 
deficiency  of  certain  accessory  food  factors.  He 
draws  attention  to  the  scantiness  of  our  knowledge 
respecting  the  influence  of  “ vitaminic  ” deficiency 
on  the  adrenal  glands,  pancreas,  liver,  spleen, 
thyroid,  pituitary  gland,  and  the  reproductive 
organs,  and  he  endeavours  to  fill  up  some  of  these 
gaps  in  our  knowledge.  Taking  beri-beri  as  the 
typical  deficiency  disease,  he  expresses  the  opinion 
that  “ vitaminic  ” deficiency  is  the  essential 
aetiological  factor  in  the  genesis  of  that  malady,  but 
that  such  deficiency  is  rarely  so  complete  as  to  be 
the  sole  agency  responsible  for  it.  Bacterial 
organisms  of  whatever  kind  that  may  be  isolated 
from  the  blood  in  human  beri-beri  may  invade  the 
blood  and  tissues  under  conditions  of  dietetic 


1 Rabies  and  Hydrooh^bia  : their  Cause  and  Prevention,  by  Frank 
Karslake.  London « W.  an  i G.  Foyle.  Ul).  Price  Is. 


76  rHHLANTCKT,] 


NATIONAL  CONFERENCE  ON  INFANT  WELFARE. 


[July  12,  1919 


deficiency  and  thus  convert  a state  of  potential 
morbidity  into  one  of  kinetic  disease.  Such 
organisms  are  not  the  cause  of  the  malady,  nor 
can  they  be  expected  to  produce  it  in  inoculation 
experiments.  “ They  are  but  weeds  which  flourish 
in  a soil  made  ready  for  them  by  dietetic  deficiency.” 
After  making  many  animal  experiments  and  obser- 
vations Colonel  McCarrison  arrives  at*  the  con- 
clusion that  the  absence  of  certain  accessory  food 
factors  from  the  dietary — improperly  called  “ anti- 
neuritic  ” — leads  not  only  to  functional  degenerative 
changes  in  the  central  nervous  system,  but  to 
similar  changes  in  every  organ  and  tissue  in  the 
body.  The  symptom-complex  resulting  from  the 
absence  of  these  substances  is  due  (1)  to  chronic 
inanition  ; (2)  to  derangement  of  function  of  the 
organs  of  digestion  and  assimilation ; (3)  to  dis- 
ordered endocrine  function,  especially  in  the  adrenal 
glands ; and  (4)  to  malnutrition  of  the  nervous 
system.  Certain  organs  undergo  hypertrophy  and 
others  atrophy.  Those  which  hypertrophy  are 
the  adrenals,  and  those  which  atrophy  are, 
in  the  order  of  severity,  the  thymus,  the 
testicles,  spleen,  ovary,  pancreas,  heart,  liver, 
kidneys,  stomach,  thyroid,  and  brain.  The 
presence  of  oedema  in  the  patient  has  been 
invariably  associated  with  great  hypertrophy  of 
the  adrenal  glands.  Wet  and  dry  beri  beri  are 
essentially  the  same  disease,  the  former  differing 
from  the  latter  in  the  greater  derangement  of  the 
adrenal  glands.  Gastric,  intestinal,  and  pancreatic 
disorders  are  important  consequences  of  a dietary 
too  rich  in  starch  and  too  poor  in  vitamines  and 
the  essential  constituents  of  food.  It  is  suggested 
that  some  of  the  obscure  metabolic  disorders  of 
childhood  might  be  examined  from  this  point  of 
view  as  well  as  from  that  of  endocrine  gland 
starvation.  Profound  atrophy  of  the  reproductive 
organs  is  also  an  important  consequence  of 
vitaminic  deficiency,  leading  to  the  cessation  of 
the  function  of  spermatogenesis.  In  the  male 
human  subject  it  would  result  in  sterility,  and  in 
the  female  in  amenorrhcea  and  sterility.  This 
would  no  doubt  account  in  a great  measure  for  the 
recent  occurrence  of  so-called  “ war  amenorrhcea,” 
about  which  much  has  been  written  recently  in  the 
foreign  press,  and  particularly  in  Germany.  The 
central  nervous  system  atrophies  little,  the  paralytic 
symptoms  in  beri  beri  being  due  mainly  to  impaired 
functional  activity  of  nerve  cells,  much  more  rarely 
to  their  degeneration.  It  is  thought  that  because  of 
their  atrophy,  out  of  all  proportion  to  other  tissues, 
the  thymus,  testicles,  ovary,  and  spleen  provide  a 
reserve  of  accessory  food  factors  for  use  on 
occasion  of  metabolic  stress,  but  this  reserve  is 
rapidly  exhausted.  Finally,  although  deficiency  of 
certain  accessory  food  factors  is  the  essential 
aetiological  factor  in  the  genesis  of  beri-beri, 
Colonel  McCarrison  holds  that  infectious  and 
parasitic  agencies  may  often  be  important  causes 
determining  the  onset  of  the  symptoms  of  that 
disease.  Vitamine  deficiency  renders  the  body  very 
liable  to  be  overrun  by  the  rank  growth  of  bacteria, 
and  it  is  probable  that  varying  metabolic  disturb- 
ances may  determine  the  character  of  these  growths. 
We  are  glad  to  learn  that  Colonel  McCarrison  pro- 
poses to  continue  his  investigations  on  this  most 
interesting  subject,  and  that  he  promises  shortly 
another  contribution  dealing  with  the  effects  of  a 
deficiency  of  accessory  food  factors  on  the  function 
of  the  thyroid  glaud,  with  a histological  study  of 
69  pairs  of  thyroids  removed  in  the  course  of  his 
experiments  on  pigeons  and  other  animals  fed  on  a 
polished  rice  dietary. 


NATIONAL  CONFERENCE  ON  INFANT 
WELFARE. 


Commencingou  July  1st,  the  League  for  Health,  Maternity, 
and  Child  Welfare  held  at  the  Kings  way  Hall  a three  days’ 
conference,  in  which  child  welfare  in  all  its  aspects  was 
discussed.  The  proceedings  were  opened  on  the  first  day 
by  Dr.  Christopher  Addison,  M.P. , who  outlined  the 
objects  of  the  conference. 

The  first  paper  was  read  by  Dr.  Amand  Routh  (consulting 
obstetric  physician  to  Charing  Cross  Hospital)  and  was 
entitled — 

Causes  of  Antenatal , Natal,  and  Neonatal  Mortality. 

He  said  that  the  conference  would  that  day  discuss  how 
to  save  the  lives  and  ensure  the  health  of  babies,  considering 
the  question  from  the  very  beginning  of  life,  from  the 
moment  of  fertilisation  to  the  end  of  the  first  month  after 
birth.  The  natural  increase  of  the  population  had  for  the 
first  time  in  our  statistical  history  ceased,  for  during 
the  six  months  ending  March  31st  last  the  deaths  in 
England  and  Wales  had  exceeded  the  births  by  126,445. 
The  approximate  percentage  causation  of  antenal,  natal,  and 
neonatal  deaths  could  be  given  as  follows  with  fair  accuracy  : 
prematurity,  10  per  cent.  ; syphilis.  20  per  cent.  ; toxaemia, 
10  per  cent.  ; prolonged,  difficult,  or  complicated  labour, 
including  antepartum  haemorrhage,  25  per  cent.  ; other  known 
causes,  10  per  cent.  ; and  “ unknown  ” causes,  25  per  cent. 
The  fact  that  so  large  a percentage  of  the  causes  of  antenatal 
death  was  “unknown”  showed  how  much  research  and 
pathological  team-work  was  still  required. 

The  following  table  gives  an  estimate  of  the  probable  loss 
of  life  between  fertilisation  of  the  ovum  and  the  end  of  the 
first  year  of  life  : — 

Antenatal  and  Infantile  Death-rates  per  1000  Births  of 
Children  of  Married  and  Unmarried  Women,  including 
“Natal”  Deaths,  Based  on  the  Figures  for  England  and 
Wales  in  1917. 


Antenatal. 

Married. 

Unmarried. 

In  latter  12  weeks  

ilSh150 

60  f 

■=  300 

In  former  28  weeks  (estimated) 

Infantile. 

240  j 

Neonatal  (first  month) 

Sh  96 

72  ( 

•=  207 

Remainder  of  first  year 

135  ) 

Estimated  deaths  of  children  per  1000  j 

i 



births  between  conception  and  end  of  ' 
first  year  of  life. 

246 

t 

507 

Note. — The  actual  deaths  of  mothers  per  1000  births  from  causes 
connected  with  pregnancy  and  labour  were : Married,  3'7 ; un- 

married, 679. 


It  was  evident,  therefore,  that  the  unmarried  mcther  and 
her  child  needed  the  care  of  the  State  twice  as  much  as  the 
married  woman  if  they  were  to  be  saved  from  this  double 
rate  of  mortality  and  morbidity. 

At  the  conference  held  last  year  Dr.  J.  W.  Ballantyne 
wisely  advised  that  the  labour  group  of  cases  should  be 
called  distinctively  “natal”  or  “ intranatal,”  and  he  further 
suggested  that  the.  mortality  of  this  period  should  be  con- 
sidered separately,  for  not  only  does  it  include  all  the  opera- 
tions needed  to  save  the  child  in  cases  where  there  is  a 
disproportion  between  the  child  and  the  maternal  pelvis,  but 
all  the  other  complications  of  childbirth,  such  as  maternal 
haemorrhage,  pelvic  tumours,  fcetal  malpresentations,  and 
pressure  on  the  umbilical  cord.  Many  malnourished, 
diseased,  malformed,  and  premature  children  who  fail  to 
survive  their  birth  would  also  belong  to  this  group. 

At  the  same  meeting  of  the  conference  Dr.  Ballantyne 
suggested  that  the  first  month  after  labour  should  be 
designated  “neonatal,”  and  the  phrase  is  now  generally 
adopted.  It  is  known  that  the  deaths  of  this  neonatal 
period  include  37  per  1000  births  of  the  children  of  married 
mothers,  and  72  per  1000  births  of  unmarried  mothers,  or 
about  a third  of  those  who  die  in  their  first  year  of  life. 
These  early  infantile  deaths  comprise  (1)  feeble,  mal- 
nourished or  premature  children  who  survive  their  births, 
50  per  cent,  of  whom  die  in  the  first  24  hours  of  life ; 

(2)  diseased  children,  such  as  those  born  syphilitic ; 

(3)  abnormal  or  deformed  children,  such  as  those  born  with 
hydrocephalus,  spina  bifida,  ventral  hernia,  or  encephalocele  ; 

(4)  many  children  who  may  survive  some  weeks  but  who 
cannot  suck  owing  to  prematurity,  cleft  palate,  hare-lip.  or 
“snuffles.”  This  “ neonatal  ” period  not  only  includes  the 
risks  to  the  premature  or  diseased  child  which  occur  in  the 


The  Lanobt,  ] 


NATIONAL  CONFERENCE  ON  INFANT  WELFARE. 


first  few  days  of  life,  but  also  includes  a period  when  the 
obstetrician  (medical  practitioner  or  midwife)  has  ceased  to 
rttend  and  the  pediatrician  or  infant-welfare  doctor  takes 
on  the  case  of  the  child,  while  the  gynecologist  perhaps  is 
required  for  the  mother. 

Premature  births  are  so  called  if  they  occur  before  the 
thirty-eighth  week  of  gestation.  The  causation  of  prematurity 
has  not  been  satisfactorily  worked  out,  but  is  often  due  to 
Intepartum  hemorrhage,  toxemia,  or  undue  physical  effort 
or  mental  strain  in  the  mother,  or  to  malnutrition  or  mor- 
bidity in  the  child,  which  conditions  should  be  therefore 
viewed  as  the  primary  causes  of  the  foetal  death  rather  than 

Ithe  resulting  prematurity  at  birth. 

Amongst  the  main  causes  of  death  in  both  early  and  late 
pregnancy  is  venereal  disease.  Gonorrhoea  is  very  rarely  the 
cause  of  antenatal  disease  or  death.  Syphilis  is  estimated 

!to  cause  at  least  20  per  cent,  of  the  antenatal  and  neonatal 
deaths,  and,  if  so,  it  would  mean  that  about  27,000  deaths 
would  thus  result  in  England  and  Wales.1  Stillbirths  from 
antenatal  syphilis  in  unmarried  women  are  about  double 

!such  deaths  in  legitimate  pregnancies.  Maternal  toxaemia 
causes  from  10  to  15  per  cent,  of  foetal  deaths.  These 
toxaemias  are  said  to  occur  in  5 per  cent,  of  primigravidae, 
and  are  still  more  frequent  in  unmarried  women  who  have 
to  endure  much  more  mental  strain  during  their  pregnancies. 
Accidents  and  complications  of  childbirth  constitute  the 
largest  group  of  antenatal  and  neonatal  deaths.  Pelvic  con- 
1 tractions,  or  tumours,  or  foetal  mal presentations  are  not  only 
dangerous  to  the  mother  if  the  condition  is  recognised  first 
during  labour,  but  are  still  more  dangerous  to  the  child,  who 
may  have  to  be  sacrificed  to  save  the  mother,  for  obviously 
if  the  mother  cannot  he  delivered  the  mother  and  child 
would  die.  Maternal  haemorrhages,  such  as  those  due  to 
placenta  pnevia  and  accidental  haemorrhage,  especially  the 
concealed  variety,  are  the  most  fatal  of  all  complications  if 
not  treated  promptly.  There  are  other  occasional  maternal 
causes  of  foetal  disease  or  death  which  could  often  be  success- 
fully treated  if  detected  during  pregnancy.  He  would  only 
mention  heart  disease,  Bright’s  disease,  lead  poisoning, 
malignant  disease,  acute  specific  exanthemata,  pneumonia, 
and  other  acute  and  chronic  lung  conditions. 

Dr.  Eardley  Holland  then  read  a paper  on  the  Results 
to  be  Expected  from  Antenatal  Care,  which  we  print  in 
full  in  another  column. 

Dr.  J.  J.  Buchan  (medical  officer  of  health,  Bradford) 
followed  on  the  subject  of 

Antenatal  and  Neonatal  Mortality. 

He  said  : All  those  who  have  followed  closely  during  the 
past  20  years  the  campaign  in  this  country  for  the  reduction 
of  infantile  mortality  will  have  been  struck  with  the  varying 
phases  of  the  movement  and  the  great  number  of  subjects 
investigated  in  relation  to  it.  We  have  learned  much  in  this 
time  of  the  many  factors  that  influence  the  health  of  the 
infant  after  birth  and  much  good  work  has  been  done  to 
reduce  infantile  mortality  in  the  later  months  of  the  first 
year  of  life,  but  the  field  of  knowledge  of  the  conditions 
before  birth  affecting  the  welfare  of  the  child  when  born  is 
almost  unbroken.  We  have  hardly  any  accurate  facts  of 
antenatal  or  neonatal  mortality  ; we  cannot  state  with  any 
degree  of  reasonable  certainty  the  extent,  the  causes,  or  the 
steps  to  be  taken  to  effect  a reduction. 

From  the  published  figures  of  the  Registrar-General  it 
would  seem  clear  that  about  12  per  cent,  of  the  infantile 
mortality  occurs  before  the  infant  is  a day  old  and  about 
25  per  cent,  before  it  is  a week  old,  and  from  35  to  40  per  cent, 
before  it  is  a month  old.  If  to  these  babies  born  living  who 
died  almost  immediately  the  babies  born  dead  are  added, 
the  number  of  deaths  due  to  antenatal  and  neonatal  causes 
is  large  indeed. 

It  would  be  well,  without  going  further,  to  insist  for  the 
moment  on  the  importance  of  increasing  our  avenues  of 
knowledge  so  that  these  deaths  may  be  more  carefully  investi- 
gated Stillbirths  are  not  recognised  by  the  law  for  registra- 
tion purposes,  a great  many  do  not  come  under  the  Notifica- 
tion of  Births  Act,  and  without  doubt  numerous  others 
which  should  come  under  this  Act  escape  notification. 
The  blind  position  of  the  law,  which  only  recognises 
life  as  commencing  after  birth,  is  responsible  to  a great 
extent  for  the  lesser  importance  with  which  these  births 
are  regarded,  and  while  from  its  own  point  of  view  the  legal 


[July  12,  1919  77 


position  is  a reasonable  one  some  means  should  be  devised  to 
bring  all  stillbirths  and  miscarriages,  certainly  after  quicken- 
ing, before  the  notice  of  the  health  authority  in  the  interests 
of  infant  life.  The  Notification  of  Births  Act  requires  the 
notification  of  a stillbirth  occurring  after  the  twenty-eighth 
week  of  pregnancy.  Anyone  who  has  followed  the  adminis- 
tration of  the  Midwives  Act  will  be  struck  by  the  apparently 
small  proportion  of  stillbirths  notified  by  midwives.  This 
arises  chiefly  from  the  fact  that  stillbirths  in  midwives’  cases 
occur  largely  among  those  cases  for  which  they  seek  medical 
aid,  so  that  the  stillbirth  is  ultimately  notified  by  the  doctor 
and  not  by  the  midwife.  Thus,  in  Bradford  during  the  past 
three  years,  while  the  general  rate  of  stillbirths  notified  was 
4 6 per  cent,  of  the  births  notified,  the  stillbirth-rate  among 
doctors’  notifications  was  6 4 and  among  midwives’  notifica- 
tions 3 2 per  cent,  of  births  notified. 

The  causes  of  these  deaths  can  be  classified  in  two  groups, 
those  arising  during  the  actual  labour  and  those  arising  or 
existing  during  the  pregnancy.  Every  improvement  in  the 
midwifery  seiwice  of  the  country  will  tend  to  lessen  materially 
the  deaths  arising  from  neonatal  causes,  but  we  have  not  yet 
seen  any  very  vast  improvement  in  the  midwifery  service  of 
the  country  generally.  Though  the  Midwives  Act  has  now 
been  in  operation  for  many  years,  its  full  benefits  are 
still  to  be  enjoyed  by  the  community,  as  the  bona  fide 
midwives  still  carry  on  large  practices,  and  the  general 
service  of  midwifery  is  not  attracting  those  recently  and 
well-trained  women  whose  names  have  swelled  the  Midwives’ 
Roll.  In  the  towns  of  the  North  of  England  there  is  an 
average  of  70  per  cent,  of  the  births  attended  by  midwives, 
rising  in  some  cases  to  over  90  per  cent.  The  work  these 
women  are  doing  is  of  paramount  importance  to  the  mother 
and  the  child  and  to  the  whole  community,  and  it  is  of  the 
utmost  importance  that  their  ranks  should  be  recruited 
from  the  best  women  trained  in  practical  midwifery. 
In  years  gone  by  the  inefficiency  of  particular  midwives  has 
been  tolerated,  especially  in  some  of  the  worst  districts  of 
our  large  cities  and  towns,  by  the  knowledge  that  if  this 
inefficient  midwife  did  not  practise  there  no  one  else  would. 
She  was  practising  for  a mere  pittance,  irregularly  received, 
and  she  served  to  meet — badly  as  she  did  it— a public  want. 

Since  the  passing  of  the  National  Insurance  Act,  with  the 
inauguration  of  maternity  benefit,  such  circumstances  have 
not  been  so  frequent,  but  nevertheless  I am  afraid  that  in 
many  districts  they  still  do  exist.  A consideration  of  such 
circumstances  as  these  has  led  to  the  inauguration  of  the 
municipal  midwife,  whose  advent  will  probably  do  more  for 
antenatal  and  neonatal  mortality  than  has  yet  been  done. 
At  present,  in  the  City  of  Bradford,  we  have  12  municipal 
midwives  who  are  attending  more  than  half  the  births 
attended  by  midwives  in  the  city.  Antenatal  work  has  been 
constantly  talked  of  these  last  few  years  but  very  little  has 
been  done  anywhere.  It  is  amazingly  difficult  work  to 
develop  ; it  is  easy  to  start  an  antenatal  centre  and  to  set 
aside  hours  for  consultation  and  the  like,  but  this  is  not 
sufficient.  Much  has  to  be  done  to  educate  women  as  to  the 
need  for  antenatal  supervision  and  care,  but  I do  not  think 
that  this  is  best,  if  at  all,  attained  by  a notification  of  preg- 
nancy and  the  appearance  of  another  supervisor  of  their 
health  apart  from  their  midwives  and  their  doctors.  It  is 
necessary  to  enlist  especially  the  midwife  in  the  service  of 
the  antenatal  authority.  The  midwife  has  been  sought  out 
by  the  expectant  mother  herself,  and  will  have  much  more 
influence  with  her  than  anyone  else.  Midwives  themselves 
have  to  be  taught  to  appreciate  the  meaning  and  the 
importance  of  antenatal  work,  and  they  have  to  impress 
upon  their  clientele  the  need  for  early  booking  of 
their  confinement.  The  municipal  midwife  is  required  to 
see  her  patient  very  frequently  before  the  birth  and 
to  seek  the  aid  of  the  antenatal  clinic  on  all  occasions. 
A definite  antenatal  centre,  though  of  very  great  importance 
in  antenatal  work,  is  relatively  of  less  importance  than  a 
well- organised  and  educated  midwifery  service.  Without 
such  a service  the  work  of  the  centre  is  set  at  nought.  We 
have  been  feeling  our  way  for  the  past  few  years  to  ante- 
natal work,  but  as  a result  of  experience  I think  it  can  be 
said  that  it  is  not  much  use  to  establish  antenatal  centres 
without  sufficient  means  of  getting  into  touch  with  the 
work  to  be  done.  Antenatal  centres  must  work  in  close 
association  with  hospital  accommodation  for  gynaecological 
and  maternity  cases,  and  they  have  to  establish  a very 
intimate  cooperation  with  the  means  of  treatment  for 
venereal  disease. 


i The  Lancet,  1918,  i.,  45. 


78  ThsLano3T,] 


AMERICAN  MEDICAL  ASSOCIATION:  ANNUAL  MEETING. 


[July  12.  1919 


Miss  Olive  Haydon  (formerly  sister,  York- road  Lying-in 
Hospital),  in  the  absence  of  Dr.  Vera  Foley,  then  gave  the 
conference  the  benefit  of  her  experiences  on  the  subject  of 

The  Work  of  the  Midwife  in  Relation  to  Antenatal  and 
Neonatal  Mortality. 

The  speaker  began  by  emphasising  : 1.  The  need  of 

educating  women  in  hygiene  and  mothercraft.  2.  The  high 
mortality  during  intra-  and  extra-uterine  life  due  to  pre- 
ventable illness,  and  the  insidiousness  of  the  manifesta- 
tions of  diseases,  such  as  syphilis,  gonorrhoea,  and  the 
toxaemias  of  pregnancy.  3.  The  need  for  further  research 
work  into  the  cause  of  ante-  and  neo-natal  mortality. 
4.  The  difficulty  of  bearing  and  rearing  healthy  children 
in  poverty-stricken  homes  by  unfit  parents. 

Mid  wives,  she  went  on,  besides  practising  independently  and 
as  staff  mid  wives  in  institutions,  are  working  under  medical 
supervision  as  health  visitors,  creche  nurses,  rescue  workers, 
infant  welfare  superintendents.  Personally,  I think  every 
midwife,  when  qualified,  should  practise  her  profession  for 
at  least  a year  before  taking  up  other  work.  This  would 
lead  to  a broader  and  more  sympathetic  attitude  to  those 
who  are  practising  midwives.  To  do  more  efficient  work 
the  midwife  needs  progressive  education  on  broad  lines, 
better  economic  conditions  that  will  allow  her  to  take 
fewer  cases,  and  devote  full  attention  to  each  patient  she 
attends — and  a status  and  consideration  commensurate  with 
the  importance  of  her  work  for  maternity  and  child  welfare. 

In  conclusion,  Miss  Haydon  touched  on  the  midwife’s  work 
vis-a-vis  with  the  patient.  It  is,  she  said,  mainly  threefold — 
educative,  preventive,  and  practical — and  of  these  three 
perhaps  the  most  important  is  the  education  of  the  expectant 
mother,  the  mother,  and  the  baby.  The  education  begins  at 
booking  ; unfortunately,  this  is  seldom  before  the  sixth  month. 
Much  writing  has  already  been  done  on  what  Professor 
Thomson  has  called  “the  docket ” of  the  new-born  child,  and 
much  is  irremediable.  But  the  normal  rapid  growth  and 
devel  ipmeut  of  a normal  foetus  may  be  retarded  or  inter- 
rupted by  the  ill-health  or  excesses  of  the  mother  during 
the  last  three  months ; hence  the  need  for  forewarning 
help  and  continued  careful  observation  for  abnormal  signs 
and  symptoms,  so  as  to  secure  early  medical  treatment 
for  physiological  breakdown  or  infection.  The  former 
history,  the  general  condition,  and  the  physical  examina- 
tion of  the  patient  should  guide  the  midwife  in  dealing 
with  the  patient  and  help  her  to  form  an  opinion  as 
to  whether  it  is  advisable  in  the  interests  of  the  mother  and 
unborn  child  to  be  attended  by  her.  The  midwife  will 
receive  with  caution  and  some  inward  scepticism  theexplana-. 
tion  of  the  causes  of  previous  miscarriages  ; she  knows  that 
thousands  are  attributed  to  shocks  and  falls,  a very  few  to 
albuminuria,  syphilis,  &n. , and  still  fewer  to  the  taking  of 
noxious  drugs  and  drastic  purges.  She  ought  not  to  be 
content  that  a series  of  miscarriages  should  be  attributed 
to  those  refuges  of  the  destitute  “habit”  and  “a  weak 
inside.”  She  may  even  dare  to  inspire  with  optimism  the 
woman  who  has  been  told  she  would  never  carry  a child 
to  full  term.  The  careful  examination  of  the  breasts  and 
nipples  begins  the  education  on  the  value  of  breast-feeding  ; 
careful  investigation  into  the  causes  that  led  to  its  abandon- 
ment with  previous  children  forewarn  and  forearm  the  mid- 
wife. If  it  has  been  given  up  because  the  mother  has  had 
to  go  to  work,  there  is  always  hope  that  she  may  be  con- 
vinced that  her  primary  duty  is  not  washing  or  charing,  or 
any  other  work  in  the  labour  market,  but  the  persistence  in 
breast-feeding.  With  an  eight-hourly  working  day,  and 
four-hourly  feeding,  there  should  now  be  fewer  children  fed 
from  tins  or  poisoned  slowly  with  contaminated  milk, 
deprived  of  its  accessory  growth  products  by  sterilisation. 

The  midwife  is  shrewd  enough  to  know  that  faulty  mother- 
craft,  poverty,  the  health  and  character  of  the  parents,  bad 
hygienic  surroundings  are  far  greater  factors  in  antenatal 
and  neonatal  mortality  than  hard  work,  smoke-laden 
atmosphere,  bad  midwifery,  or  even  those  plagues  of  the 
midwife’s  life — the  “born  before  arrivals.”  A midwife’s 
judgment  of  the  character  and  capacity  of  the  mother  and 
home  life  is  by  no  means  to  be  despised  ; she  has  unique 
opportunities  of  studying  these  in  her  repeated  and 
welcomed  visits  to  the  home. 

Miss  M.  Burnside,  O.BE.,  inspector  of  midwives  and 
county  health  visitor,  Hertfordshire  County  Council,  then 
spoke  on  the  work  of  the  midwife  in  relation  to  antenatal 
and  neonatal  mortality  in  rural  districts. 


The  afternoon  session  on  July  2nd  was  given  up  to  a 
discussion  on  Industrial  Employment  of  Mothers  in  Relation 
to  Infant  Mortality,  when  the  speakers  were  Dr.  Rhoda 
Adamson,  clinical  lecturer  in  obstetrics  at  the  University  of 
Leeds,  Miss  L.  Barker,  of  the  Training  Department,  Ministry 
of  Labour,  and  Mrs.  Holden,  of  Dewsbury.  Both  sessions 
on  July  3rd  were  occupied  in  discussing  the  subject  of  the 
Unmarried  Mother  and  the  Unwanted  Child. 


AMERICAN  MEDICAL  ASSOCIATION  : 
ANNUAL  MEETING. 


The  Seventieth  Annual  Meeting  of  the  American  Medical 
Association  was  held  in  Atlantic  City  from  June  9th  to  13th. 
The  first  day  was  taken  up  with  business  matters  by  the 
House  of  Delegates. 

Report  on  Medical  Education. 

Among  other  questions  of  interest  Dr.  John  A.  Dodson, 
of  Chicago,  submitted  the  report  of  the  Council  on  Medical 
Education.  A fact  in  this  report  worthy  of  emphasis  was 
that  of  the  20,678  students  who  graduated  during  the  past 
six  years  15,025,  or  72  6 per  cent.,  were  admitted  under  the 
higher  entrance  requirements,  and  received  their  training 
in  the  Class  A medical  schools. 

Report  on  Social  Insurance. 

Dr.  Alexander  Lamrert,  of  New  York,  submitted  the 
supplementary  report  of  the  subcommittee  on  social 
insurance.  He  stated  that  during  the  years  1915,  1916, 
and  1917  the  committee  had  inquired  extensively  into  the 
question  of  whether  there  was  a sickness  problem,  what  it 
was,  and  how  it  was  to  be  met.  The  findings  were  that 
2 6 per  cent,  of  the  population  were  seriously  sick  all  the  time, 
15  per  cent,  were  more  or  less  disabled,  and  that  among  the 
38,000,000  employees  in  the  -United  States  there  was  an 
average  of  nine  days’  illness  per  man  per  year.  In 
figures  about  8500,000,000  (£100,000,000)  a year  would 
represent  the  loss  in  wages  by  the  wage- earners  from 
sickness.  The  amount  of  sickness  in  a family  was  found  to  tl 
vary  inversely  as  the  wages  of  the  family ; also  the  sickness  > 
rate  was  higher  in  proportion  as  the  number  in  the  family 
increased.  In  well-to-do  families  the  infant  mortality-rate 
in  America  averaged  41  per  1000  births,  while  among  the 
poor  it  averaged  225  per  1000  births.  Only  25  per 
cent,  of  pregnant  women  received  anything  like  adequate 
antenatal  care.  In  Philadelphia  60  per  cent,  of  the  sick  poor  ; 
had  only  home  care,  and  patent  medicines  were  found  to  be  j 
used  by  from  25  to  50  per  cent,  of  these  persons.  In  about  j 
35  per  cent,  of  the  cases  the  wage-earners  had  sickness 
insurance  amounting  to  10  or  15  per  cent,  of  the  wages  ; 
some  carried  a voluntary  insurance,  but  the  larger  proportion 
had  no  insurance  at  all  against  sickness. 

The  report  considered  the  question  of  sickness  insurance, 
and  after  pointing  out  that  general  insurance  schemes  in 
Germany  and  England  had  not  been  found  to  work  well,  the 
opinion  was  stated  that  a solution  must  be  found  through  the 
organised  aid  of  the  medical  profession  with  the  help  of  the 
State  and  county  medical  societies.  The  medical  profession 
should  decide  whether  better  protection  against  sickness  I 
could  be  obtained  through  the  increase  of  State  Health  | 
Department  control,  or  whether  it  should  be  sought,  as  in 
England,  through  a pro  rata  per  man  per  year  fund. 

Distinguished  Guests. 

The  meeting  proper  began  on  Tuesday,  June  10th.  A 
feature  of  the  meeting  was  the  presence  of  a number  of 
foreign  guests.  Among  these  were  Mr.  Ernest  \V.  Hey 
Groves,  Sir  StClair  Thomson,  Major-General  Sir  Bertrand 
Dawson,  Sir  Shirley  Murphy,  Sir  W.  Arbuthnot  Lane,  Sir  I 
Arthur  Newsholme,  Colonel  Sir  W.  T.  Lister,  and  others,  | 
including  representatives  from  France,  Belgium,  Greece, 
Norway,  Sweden,  Cuba,  and  Japan. 

The  Presidential  Address. 

Dr.  Alexander  Lambert,  the  President-elect,  delivered  [ 
the  presidential  address  on  Medicine,  a Determining  Factor  | 
in  War.  He  pointed  oat  the  success  of  preventive  medicine  ! 
in  the  war  just  over.  As  for  the  lessons  learned  in  deter-  i 
mining  action  in  future,  Dr.  Lambert  thought  that  the 
experience  of  the  last  war  and  the  history  of  recent  I 
wars  had  sho^rn  clearly  that  only  through  proper 


The  Lanoet,] 


AMERICAN  MEDICAL  ASSOCIATION:  ANNUAL  MEETING. 


[July  12,  1919  79 


representation  on  the  general  staff  of  armies  by 
those  men  trained  in  the  methods  of  salvage  and  by 
experts  in  sanitation  could  these  duties  be  efficiently  per- 
formed. The  final  paragraph  of  the  address  discussed  the 
national  control  of  preventable  diseases.  The  war  had 
taught  that  there  remained  economic  value  in  the  maimed 
and  wounded,  and  it  was  the  duty  of  the  State  to  develop 
this  value  to  the  fullest  extent.  The  maiming  and  injury  of 
workers  in  the  everyday  work  of  industry  far  exceeded  each 
year  the  battle  casualties  of  this  war,  and  there  was  an 
economic  necessity  and  duty  to  be  performed  in  the  salvage 
and  reconstruction  of  the  industrially  injured.  The  President 
ended  an  eloquent  address  by  urging  that  it  was  the  duty  of 
the  American  Medical  Association  and  of  each  member  of 
each  State  association  to  press  on  Congress  the  need  for  the 
establishment  of  a National  Department  of  Health. 

Health  of  the  United  States  Navy. 

At  the  meeting  which  was  held  on  the  evening  of 
Wednesday,  June  11th,  national  organisations,  the  activities 
of  each  of  which  have  a definite  medical  interest,  were  repre- 
sented by  speakers  chosen  by  these  organisations.  Among 
these  speakers  was  Commandant  James  R.  Phelps,  U.S.A., 
who  spoke  as  the  representative  of  Surgeon-General  Braisted. 
He  said  that  the  death-rate  for  the  first  year  of  the  war 
in  the  United  States  Navy  was  lower  than  for  the  previous 
year  of  peace.  The  rate  was  8 8 per  1000,  the  lowest  ever 
reached  by  the  naval  or  military  service  at  war. 

The  Public  Health  Service. 

Dr.  C.  C.  Pierce,  of  the  United  States  Public  Health 
Service,  spoke  as  the  representative  of  Surgeon-General 
Blue,  and  outlined  briefly  the  activities  of  the  Public  Health 
Service  in  connexion  with  the  war. 

The  A merican  College  of  Surgeons. 

Dr.  Franklin  Martin,  as  the  representative  of  the 
American  College  of  Surgeons,  spoke  of  the  organisation  of 
that  body,  which  had  been  patterned  after  the  Royal  College 
of  Surgeons  of  England.  They  had  now  a membership  of 
4000  in  the  United  States  and  400  in  Canada. 

War  Surgery  and  the  Surgery  of  Civil  Life. 

In  the  Section  of  Surgery,  General  and  Abdominal,  Dr. 
John  J.  Bottomley,  of  Boston,  the  chairman,  discussed 
briefly  the  influence  of  the  surgery  of  the  great  war  on  the 
surgery  of  civil  life.  He  pointed  out  that  no  entirely  new 
surgical  principle  was  discovered  during  the  war,  but  in 
this  fact  there  was  no  discredit  to  surgery  since  the  long- 
established  principles  upon  which  it  rested  had  emerged 
triumphant  from  a tremendous  test.  At  no  period  of  the 
war  were  the  principles  of  asepsis  and  antisepsis  in 
danger ; their  practice,  however,  was  at  first  rudely 
shaken  because  of  the  novelty  of  military  conditions.  Dr. 
Bottomley  then  dealt  with  the  accomplishments  of  recent 
military  surgery  in  their  relation  to  civil  practice.  It  had 
been  demonstrated,  he  said,  that  even  in  severe  wounds,  with 
existing  contamination,  infection  could  be  prevented  or 
controlled.  Tetanus  had  practically  been  banished  because 
of  the  preventive  property  of  the  antitoxin.  Treatment  by 
magnesium  sulphate  and  carbolic  acid  had  been  definitely 
put  aside.  The  wound  conditions  favouring  the  development 
of  gas  gangrene  were  recognised,  its  pathology  was  known,  and 
the  earliest  signs  of  its  presence  were  tabulated,  and  con- 
sequently its  treatment  was  now  on  a more  scientific  and 
successful  basis.  There  were  promising  indications  that  an 
effective  antitoxin  for  it  might  be  developed.  There  was 
no  longer  any  question  as  to  the  proper  treatment  either  in 
peace  or  war  of  penetrating  wounds  of  the  abdomen.  The 
contention  of  the  civilian  surgeon  had  been  upheld. 
Many  of  our  doubts  as  to  chest  surgery  had  been 
dispelled.  The  need  for  complicated  pressure  apparatus 
had  gone  with  the  establishment  of  the  fact  that  without 
it  the  pleural  cavity  might  be  opened  freely  and  the  lung 
handled  without  special  danger.  Convincing  evidence  had 
established  beyond  doubt  the  position  of  those  who  in  pre- 
war days  asserted  that  synovial  membrane  had  strong 
powers  of  resistance  to  infection,  and  that  drainage  of  joints 
recently  wounded  was  not  only  unnecessary  but  often 
harmful.  The  factors  entering  into  the  production  of  shock 
and  the  details  of  its  treatment  had  been  so  vividly  delineated 
that  no  surgeon  who  had  to  do  with  the  great  industries  in 
which  severe  injuries  were  common  could  afford  to  neglect 
provision  for  the  prompt  and  efficacious  treatment  of  the 
shock  that  might  accompany  them.  The  treatment  of 


fractures  had  been  stabilised  by  the  standardisation  of  splints 
and  other  apparatus  for  immobilisation,  which  had  largely 
supplanted  the  use  of  plaster-of-Paris. 

Influenza  in  the  A . E.  F. 

Among  the  instructive  papers  read  was  one  surveying 
the  epidemic  of  influenza  in  the  American  Expeditionary 
Force,  by  Dr.  Warfield  1.  Longcope,  of  New  York. 

Malaria  Treated  by  Disinfection. 

Another  paper  which  attracted  a good  deal  of  attention 
was  that  by  Dr.  C.  C.  Bass,  of  New  Orleans,  dealing  with 
the  effective  and  practical  treatment  of  malaria  by  dis- 
infecting infected  persons.  From  50  to  68  per  cent,  of  the 
malaria  occurring  in  a representative  malarial  locality  of  the 
United  States  was  relapse  and  not  new  infection.  The  chief 
cause  of  ineffective  treatment  was  the  employment  of 
spectacular  and  unpractical  methods.  The  discomfort  and 
inconvenience  of  quinine  in  solution  was  referred  to  as  an 
example  of  improper  and  unpractical  methods  of  treatment. 
Blood  examination  could  not  be  depended  upon  to  determine 
when  disinfection  had  been  accomplished.  The  only  trust- 
worthy guide  was  the  length  of  time  proper  quinine  treat- 
ment had  been  kept  up.  An  effective  method  of  treatment 
was  to  administer  ten  grains  of  quinine  sulphate  every  night 
before  retiring  for  a period  of  eight  weeks.  This  was  effective 
in  about  90  per  cent,  of  cases. 

War  Hysteria. 

In  the  Section  on  Nervous  and  Mental  Diseases  Dr.  Tom  A. 
Williams,  of  Washington,  D.C.,  read  a paper  on  the  Manage- 
ment of  War  Hysteria.  He  said  that  most  patients  could  be 
restored  immediately  if  skilfully  treated,  but  differentiation 
must  be  made  between  cerebral  commotion  and  chronic 
emotivity.  Cardiac  fatigue  in  hysterical  subjects  often 
suggested  the  long-continued  incapacity  which  might 
manifest  itself  as  an  effort  syndrome.  In  a majority  of 
cases  collective  suggestion  was  an  important  feature  of  treat- 
ment, but  in  a more  complex  case  individual  analysis  was 
essential.  The  methods  most  generally  and  successfully 
used  had  been  : 1.  Direct  suggestion  in  the  early  stages 
at  the  front.  2.  Indirect  suggestion  and  persuasion,  often 
combined  with  torpillage  or  other  uncomfortable  applications 
or  by  isolation.  3.  Best  of  all,  however,  a metamorphosis 
of  the  patient’s  mental  attitude  by  re- educative  procedure 
as  well  as  by  collective  suggestion. 

The  Pituitary  Gland  in  Epilepsy. 

In  the  same  section  Dr.  Beverley  R.  Tucker,  of  Richmond, 
Va.,  in  a paper  on  the  Role  of  the  Pituitary  Gland  in 
Epilepsy,  said  that  he  believed  that  convulsions,  whether 
pathological  and  called  epilepsy  or  otherwise,  were  symptoms 
of  underlying  diseased  conditions,  and  therefore  were  organic 
and  not  functional.  Among  these  underlying  conditions  was 
a secretion  of  the  pituitary  gland.  He  agreed  with  Cushing 
that  the  pituitary  secretion  gave  a substance  which 
had  to  do  with  cortical  cell  stability,  and  that 
when  the  secretion  was  diminished  or  absent  convul- 
sions might  ensue.  Hypopituitarism  was  divided  into 
two  types  : first,  the  congenital  or  chronic  type,  in  which  the 
patient  gave  evidence  in  the  past  of  the  usual  syndrome  of 
the  hypopituitarism,  and  might  have  convulsions  as  be 
approached  adolescence.  The  second  or  transitional  type 
might  present  clinical  evidence  of  normal  or  even  hyper- 
pituitary  secretion  in  the  past,  but  as  adolescence  approached 
diminished  secretion  was  shown  by  lack  of  perspiration, 
increase  in  fat,  increased  sugar  tolerance,  slowed  pulse, 
lowered  blood  pressure,  and  at  times  convulsions.  The 
radiographic  findings  in  the  cases  reported  confirmed  the 
clinical  observations.  The  first  type  showed  a small  fossa 
with  enlarged  processes  and  roughened  sella,  and  the  second 
type  enlarged  fossa  with  large  processes  and  roughened 
sella.  These  bony  outgrowths  encroached  on  the  fossas.  'A 
number  of  cases  were  reported  and  the  satisfactory  result  of 
pituitary  feeding  was  shown. 

The  Therapeutic  Aspect  of  Blood  Tranfusion. 

In  the  Section  of  Pharmacology  and  Therapeutics  Dr. 
Lester  Unger,  of  New  York,  spoke  on  the  Therapeutic 
Aspect  of  Blood  Transfusion,  and  referred  to  the  respective 
merits  and  indications  of  transfusion  with  unmodified  blood 
and  with  citrated  blood.  The  technique  of  the  method 
devised  by  the  author  was  explained,  as  well  as  the 
microscopic  method  of  testing  the  compatibility  of  the 
donor’s  and  recipient’s  blood. 


80  \Thh  Lancet,] 


CONTROL  OF  VENEREAL  DISEASE.— PARIS. 


[July  12, 1919 


Alooholio  Liquors  in  Relation  to  Health. 

Dr.  Lambert  Ott,  of  Philadelphia,  discussed  the  question 
of  light  wines  and  beer  in  relation  to  health,  and  said  that 
after  40  years  of  observance  among  wine,  beer,  and  whisky 
drinkers  he  had  come  to  the  conclusion  that  the  use  of  light 
wines  and  beer  was  healthful,  and  he  thought  that  their  sale 
under  Federal  and  State  supervision  should  be  continued. 
He  was  of  the  opinion,  however,  that  the  sale  should  be 
closely  supervised  to  see  that  no  ingredients  were  used  as 
preservatives  which  would  be  harmful. 


CONTROL  OF  VENEREAL  DISEASE. 


Provision  of  Treatment  Centres. 

Speaking  to  the  Local  Government  Board  vote  in  the 
House  of  Commons  on  June  30th,  Dr.  Addison  suggested 
that  the  work  of  the  146  existing  centres  was  good  but 
susceptible  of  improvement,  while  at  least  1000  such  centres 
would  be  needed.  Organisation  of  these  centres  and 
training  of  the  expert  personnel  were  a matter  of  time,  and 
increase  in  efficiency  could  not  be  other  than  gradual. 
Compulsory  notification  before  efficient  treatment  had  been 
organised  substantially  throughout  the  country  would,  he 
thought,  drive  patients  into  the  hands  of  inexperts  and 
quacks.  The  numbers  in  attendance  at  the  treatment 
centres  approached  half  a million  in  1918,  having  been 
barely  over  200,000  in  the  previous  year. 

Compulsory  Notification. 

The  subject  of  compulsory  notification  of  venereal  diseases 
continues  to  receive  attention.  Committees  have  sat  on  it, 
commissions  have  considered  it,  correspondents  to  the  daily 
press  have  commented  upon  it,  lecturers  have  enunciated 
their  views  upon  it.  It  is  time  to  arrive  at  a decision  as  to 
the  desirability  of  initiating  some  scheme  of  notification,  so 
that  if  the  verdict  be  affirmative  that  scheme  may  be  put 
into  practice  at  once,  or,  if  negative,  our  energies  may  be 
concentrated  on  other  methods  for  the  protection  of  society. 
In  general  we  believe  opinion  to  be  in  favour  of  a system 
of  notification,  if  thereby  a larger  number  of  patients  were 
brought  under  early  treatment.  The  paramount  objection 
advanced  is  the  fear  of  deterring  patients  from  seeking 
qualified  treatment  if  they  knew  that  this  involved  notifica- 
tion. If  an  unsuitable  plan  was  put  into  operation  there 
would,  it  is  true,  be  reason  to  fear  such  a result.  Experience 
in  America  and  Australia,  however,  points  to  an  efficient 
method  to  which  no  objection  can  be  taken.  The  February 
issue  of  National  Health  enunciates  the  main  features  of 
the  American  scheme  : — 

The  physician  in  the  city  of  Chicago,  as  an  instance, 
notifies  the  Public  Health  Department  of  Case  “ A,"  whom 
he  is  treating  for  syphilis.  The  Department  registers  the 
case  with  an  identification  number — e.g.,  Case  5000— and 
sends  to  the  doctor  literature,  each  leaflet  of  which  is 
stamped  with  the  patient’s  registered  number,  to  hand  on  to 
him.  The  patient  is  urged  to  pay  great  attention  to  the 
instructions,  which  are  of  an  educational,  not  a remedial, 
nature.  If  he  desires  for  any  reason  to  change  his  physician, 
all  that  will  be  necessary  for  him  to  do  is  to  report  his  regis- 
tered number  to  the  next  physician  who  takes  up  the  case. 
He  is  informed  that  provided  he  continues  treatment  till 
pronounced  cured,  and  observes  the  necessary  precautions 
to  prevent  spreading  infection,  the  State  is  satisfied,  but  if 
he  fails  to  observe  these  requirements  his  identity  will  be 
disclosed  by  the  physician  to  the  Public  Health  Department, 
which  will  then  take  proceedings. 

The  gist  of  this  scheme  was  laid  before  the  Commission  on 
Birth  Control  by  Miss  Norah  March  on  June  13th,  and 
was  in  harmony  with  the  trenchant  letter  to  the  Times  of 
April  5th  over  the  signatures  of  Sir  William  Osier,  Dr.  Eric 
Pritchard.  Sir  William  Hale  White  SirG.  L.  Cheatle,  Mr.W.  H. 
Clayton-Greene,  and  Sir  James  Purves  Stewart.  As  a result 
of  the  activities  of  the  Local  Government  Board  in  opening 
treatment  centres,  of  the  admirable  propaganda  work  of  the 
National  Council  and  its  branches,  and  last,  but  not  least, 
the  information,  interest,  and  fears  which  are  filtering 
through  the  various  social  strata,  the  demand  is  undoubtedly 
increasing  for  some  form  of  “ Government  action  ” directed 
towards  the  repression  of  venereal  disease.  Altruism  and 
Parliamentary  expediency  for  once  are  in  unison  and  call 
for  an  immediate  constructive  policy.  The  method 
of  notification  adopted  at  first  may  not  be  perfect,  but  if 
elastically  contrived  now  it  can  later  be  modified  by 


experience.  To  reduce  what  opposition  may  still  linger  two 
courses  are  open.  Firstly,  to  inform  large  corporate  bodies, 
representative  of  the  industrial  classes,  of  the  innate  mean- 
ing and  powers  for  good  of  the  scheme  to  be  adopted.  Their 
sympathetic  interest,  thus  gained,  should  influence  or  compel 
acceptance  of  the  scheme  by  their  nominees.  Secondly,  to 
lay  before  the  medical  profession  a concise  and  systematic 
statement  of  the  proposed  scheme  in  all  its  bearings.  This 
would  reach  many  who  are  prevented  by  time  or  distance 
from  attending  meetings  or  conferences.  Where  possible 
addresses  should  be  given  enabling  the  practitioner  to  answer 
objections  encountered  in  the  course  of  his  professional 
work.  Prophylaxis  v.  Early  Treatment. 

Controversy  still  centres  round  the  epoch  at  which  dis- 
infection of  venereal  contact  is  admissible.  Certain  obvious 
facts  are  apt  to  be  overlooked.  Whilst  those  who  oppose 
earnestly  the  issue  of  prophylactic  packets  for  fear  that  such 
facilities  may  tempt  the  fearful  to  plunge  into  venery,  they 
are  apparently  forgetful  of  one  pertinent  fact.  All  their 
arguments  against  the  use  of  packets  are  effectively  adver- 
tising the  existence  of  the  very  articles  they  refuse  to 
sanction  and  are  playing  into  the  hands  of  the  dealer  in 
so-called  rubber  goods  and  the  unscrupulous  druggists,  who, 
without  actually  infringing  the  Venereal  Disease  Act,  are 
bringing  these  articles  more  and  more  prominently  to  the 
notice  of  the  public.  These  facts  must  be  understood  and 
then  faced. 

Nothing  but  good  can  come  of  the  frank  public  discussion 
at  the  Guildhall  Conference  of  the  Royal  Institute  of  Public 
Health  on  June  25th,  of  which  we  published  a long  sum- 
mary last  week.  Sir  Malcolm  Morris,  preferring  not  to 
enter  into  the  ethical  side  of  the  question,  described  pro- 
phylaxis as  a panicky  measure.  Dr.  J.  H.  Seqtreira  admitted 
that  his  opinion  in  regard  to  prophylaxis  had  changed  after 
seeing  important  results  follow  from  it  at  the  treatment 
centre  of  which  he  was  in  charge.  He  was  himself  unable 
to  differentiate  ethically  between  supplying  a man  with  a 
prophylactic  outfit  and  giving  him  an  address  to  which  he 
could  go  for  so-called  early  disinfection.  Sir  Thomas  Barlow, 
whilst  deprecating  the  issue  of  packets,  called  attention  to 
the  value  of  a 2 per  cent,  solution  of  ordinary  yellow  soap  in 
destroying  the  gonococcus.  It  may. usefully  be  recalled  that  : 
the  prophylaxis  at  birth  of  gonorrhoeal  ophthalmia  has  been 
practised  with  conspicuous  benefit  for  many  years. 


PARIS. 

(From  our  own  Correspondent.) 

A League  against  Cancer. 

A vast  international  league  has  just  been  initiated  in 
Paris,  largely  owing  to  the  efforts  of  Professor  Hartmann,  to 
deal  with  all  aspects  of  the  cancer  problem — research,  study 
of  preventive  means,  and  treatment.  It  bears  the  name  of 
Franco-Anglo-American  League  against  Cancer.  Patrons 
are : Lor  i Bertie  of  Thame,  the  British  Ambassador  in 
Paris;  Mr.  William  Sharp,  late  U.S  A.  Ambassador;! 
M.  Mesureur,  director  of  the  Assistance  Publique  in  Paris; 
Dr.  Roux,  director  of  the  Pasteur  Institute  ; Professor 
Roger,  doyen  of  the  Faculty  of  Medicine  ; and  M.  Leclainche,  ' 
inspector-general  of  veterinary  services.  The  administrative 
council  is  made  up  as  follows  : — 

President : M.  Justin  Godart,  late  Under-Seeretarv  of  State  for  the 
Service  de  Sante. 

Uice  Presidents : Professor  Hartmann,  professor  of  clinical  surgery 
in  the  Faculty  of  Medicine;  Sir  John  Filter,  honorary  president,  J 
British  Chamber  of  Commerce : Professor  Mark  Baldwin,  eorre-  , 
sponding  member  of  the  Institute  of  France ; Baron  Edouard  de 
Rothschild.  Other  Members:  Mr.  Laurence  Benet,  Mr.  Walter  Berry 
(President  of  the  U.S.  A.  Chamber  of  Commerce),  Professor  Borrel,  Dr. 
Branch,  Dr.  Cuneo.  Professor  Depage,  Dr.  Dubrujeaud,  Dr.  Helme, 
Major  Lambert,  Augustin  Lumifre,  Professor  Regaud,  Professor 
Roger,  Dr.  Henri  de  Rothschild,  Dr.  Shoninger,  M.  Felix 
Vernes.  M.  Francois  de  Wendel  (deputy).  Treasurer:  M.  Deharme. 
Legal  Advisers  : M.  Boccon-Gibod,  solicitor  ; M.  Chavanne, 

notary.  Scientific  Committee  : Professor  Roger,  Professor  Achard, 
Professor  J.  L Faure,  Professor  Gilbert.  Professor  Hartmann. 
Professor  Letulie,  Professor  Menetrier  (Member  of  the  Academy  o. 
Medicine),  Professor  Borrel  (head  of  the  cancer  laboratory  of  the 
Pasteur  Institute).  Professor  Regaud  (head  of  the  biological  laboratory 
of  the  Radium  Institute).  Professor  Berard  and  Professor  Paviot  (Lyon).  | 
Dr.  Calmette  (Lille),  Professor  Chavannaz  (Bordeaux).  Professor 
Forgue  (Montpellier),  Professor  Depage  and  Professor  Dustin  (Brussels). 
Committee  of  patrones'es  with  the  Dowager  Ducnesse  d'Uzfes  in  France 
and  Ladv  Derby  in  England  at  its  head.  General  Secretary  M.  Robert 
Le  Bret.  2,  Avenue  Marceau,  Paris.  Assistant  Secretary:  Mme.  (Dr., 
Fabre. 


THE  Lancet,] 


URBAN  VITAL  STATISTICS. — OBITUARY. 


[July  12, 1919  81 


A circular  has  been  addressed  to  all  the  medical  men  in 
France  calling  attention  to  the  fact  that  cancer  claims  more 
than  33,000  victims'ayearin  France,  and  last  year  claimed  3420 
in  Paris  alone.  The  circular  insists  on  the  benefits  of  early 
surgical  interference,  which  gives,  at  the  end  of  five  years, 
an  immunity  from  relapse  amounting  to  50  per  cent,  where 
the  breast  is  concerned,  59  per  cent,  for  the  cervix  uteri, 
35  per  cent,  for  the  stomach,  and  45  per  cent,  for  the  rectum. 
The  attention  of  medical  practitioners  is  called  to  the  im- 
portance of  noting  the  slight  early  signs  of  cancer,  and  these 
are  described  minutely  under  the  various  topographical 
headings.  A questionnaire  is  sent  out,  replies  to  which  are 
to  form  the  basis  of  a vast  inquiry,  leading  to  a system  of 
rational  prophylaxis. 

1.  Is  cancer  frequent  or  not  in  the  region  where  you 
practise?  In  your  experience  what  is  the  cause  of  this 
frequency  or  relative  immunity— heredity,  habitat,  manner 
of  life,  Ac.  ? From  the  point  of  view  of  age  has  the  date  of 
onset  of  cancer  been  lowered  ? 

2.  Is  cancer  on  the  increase  amongst  your  patients  ; if  so, 
since  when  ? Has  this  rate  of  increase  been  greater  during 
the  war  ? Have  you  observed  cases  of  cancer  occurring  at 
the  same  time  in  husband  and  wife?  Have  you  noted  the 
existence  of  cancer  in  people  dwelling  together  or  succes- 
sively in  a certain  house  ? 


Medioal  War  Benefit. 

The  medical  benefit  fund  is  a section  of  the  General 
Association  of  the  Doctors  of  France  concerned  with  collect- 
ing subscriptions  to  found  a relief  fund  for  doctors  and  their 
families  in  difficult  circumstances  owing  to  the  war.  More 
than  a million  francs  has  already  been  collected  in  voluntary 
donations  from  the  medical  profession  in  France  and  abroad. 
At  the  last  general  meeting,  at  which  the  Under  Secretary  of 
State  for  the  Service  de  Sante  presided,  held  in  the  large 
amphitheatre  of  the  Faculty  of  Medicine,  it  was  stated  that 
frs.  900,000  had  been  distributed  in  aid  of  the  practitioners 
in  the  devastated  districts,  of  widows  and  orphans  of  medical 
men,  and  of  students  deprived  of  the  necessary  resources  for 
pursuing  their  studies. 

Stereoscopic  Radioscopy . 

Dr.  Chabry  has  devised  a simple  and  ingenious  method  of 
examining  radiograms  in  the  stereoscope  to  produce  a 
striking  effect  of  relief.  Two  plates  having  been  taken  at  a 
different  angle  they  are  reduced  to  stereoscope  dimensions 
and  placed  side  by  side  on  the  same  slide.  The  first  plate  is 
then  reproduced  again  on  the  far  side  of  the  second,  giving 
three  pictures  side  by  side  on  the  same  slide.  The  slide 
thus  prepared  is  placed  in  the  stereoscope,  when  plates  1 and  2 
give  a fine  relief  of  the  anterior  surface,  and  plates  2 and  3 
the  same  relief  of  the  posterior  surface.  By  this  manoeuvre 
it  is  claimed  that  a perfect  localisation  is  obtained,  and  as 
the  dimensions  of  the  slides  are  small  a valuable  docu- 
mentary collection  can  be  made  in  a small  space. 

July  5th. 


URBAN  VITAL  STATISTICS. 

(Week  ended  July  5th,  1919.) 

English  and  Welsh  Towns.— In  the  96  English  and  Welsh  towns 
with  an  aggregate  civil  population  estimated  at  16.500,000  persons 
inm  a.nn"®'  ™te  of  mortality,  which  had  been  9’9,  10  0.  and  9 6 per 
1000  in  the  three  preceding  weeks,  rose  to  lO'O  per  1000.  In  London 
with  a population  slightly  exceeding  4.000.000  persons  the  annual 
rate  was  also  10'0,  against  9'0  per  1000  in  the  previous  week,  while 
among  the  remaining  towns  the  rates  ranged  from  2 9 in  Carlisle 
ir  i i G1"ucf?ter,  and  4’4  in  Newoort  (Mon.),  to  15  7 in  Oxford! 
It  1 ln  Hastings,  and  16'9  in  Wigan.  The  principal  epidemic 
?atTSof  nah18erl  deat5V  which  corresponded  t0Pan  annual 
10tefrom  ° m kTk  1°00,  in°luded  49  from  infantile  diarrhoea, 

ever  T.s  Puthefla’  29  ,.frora  measles,  15  each  from  scarlet 
lapsed  =d  /'bccp’ng-eough  and  5 from  enteric  fever.  Measles 
WarHn^e  death-rate  of  1-4  in  Newcastle-on -Tvne  and  1-5  in 
md  qS,  'f  Tl'.er,e  "'er,e  2 cases  of  email- pox,  1236  of  scarlet  fever, 
Asylums  nLifd,iPhthe/i?u  u?der  treatment  in  the  Metropolitan 
md  into  Hospitals  and  the  London  Fever  Hospital,  against  2,  1143. 
18  dteths at  the  end  °f  the  Drevioua  week.  The  causes  of 
n Smlham  1 °rwn8  wer?  un?eort.ified.  of  which  5 were  registered 
‘ 3 m Liverpool,  and  2 in  Warrington. 

DODuiaHonTt .-I"  the  16  laree8t  Sentoh  toiSis.  with  an  aggregate 
mortiutv  ,at  ne?Hy  2-500,000  persons,  the  annual  rati  of 

' wh!ch  had  been  12  4,  11-0,  and  11-5  per  1000  in  the  three 
iponded  arf’ fel* t0  ? 9 l?er  190°-  n Tbe  213  deaths  in  Glasgow  corre- 
wiZninA  U ™nnaI  rate  of  9 9 per  1000,  and  Included  5 from 
lip^heri;  ?h’e  RQde  mea8les,  3 from  infantile  diarrhma,  and  1 from 
rer  1000  and  ,n  Brtlr?bur«h  were  equal  to  a rate  of  10  7 

'ro m i nf an tU e diar rhm sl  ^ meaS’6S’  2 fr°m  wb°°P^g-cougk,  and  1 

Irate* of  " ’’SVi”  D“b”n  corresponded  to  an  annual 

*-eek  and  ir,’„i°r,s  so  ?er  1000  benw  bbat  recorded  in  the  previous 
The  87  XathsTff  Tt2iffr°fm  mtantlle  diarrhoea  and  1 from  diphtheria. 

Deluded  2 from  tl  were  oT1?1  to  a ratf>  of  11-3  per  1000.  and 
uuea  2 from  scarlet  fever  and  1 from  infantile  diarrhoea. 


RICHARD  DANCER  PURKFOY,  M.D., 

LL.D.  (Hon.  Causa)  Dub., 

PAST  PRESIDENT  OF  THE  ROYAL  COLLEGE  OF  SURGEONS  IN  1KRLAND  ; 

PAST  PRESIDENT  OF  THE  ROYAL  ACADEMY  OK  MEDICINE  IN 
IRELAND;  PAST  MASTER  OF  THE  ROTUNDA  HOSPITAL. 

Dr.  R.  D.  Purefoy  died  at  his  residence  in  Dublin  on 
June  27th,  in  his  seventy-second  year,  after  a brief  illness.  His 
friends  had  noticed  for  some  time  that  his  health  was  failing, 
but  it  was  not  until  a month  or  two  ago  that  he  admitted 
any  loss  of  vigour.  Early  in  June  he  went  to  Newcastle, 
co.  Down,  for  a holiday,  but  he  felt  so  ill  that  he  came  home 
in  a few  days.  He  was  carried  to  his  bed  and  gradually 
sank  to  rest. 

Richard  Purefoy  came  of  a medical  family,  his  father 
practising  as  a doctor  at  Lucan,  a few  miles  from  Dublin. 
His  mother  was  a native  of  Tipperary,  and  it  was  in  that 
county  that  he  was  born.  Educated  at  Raphoe  School, 
co.  Donegal,  and  Trinity  College,  Dublin,  Purefoy  took  his 
medical  degrees  in  1872.  In  1879  he  became  a Fellow  of 
the  Royal  College  of  Surgeons  in  Ireland.  From  the  first  he 
devoted  himself  to  the  obstetric  art,  and  was  successively 
assistant  master  at  the  Coombe  and  at  the  Rotunda 
hospitals.  In  the  latter  he  worked  under  Lombe  Atthill  and 
George  Johnston.  He  was  for  many  years  gynaecologist  to 
the  Adelaide  Hospital,  and  in  1896  he  returned  to  the 
Rotunda  as  Master.  When  his  term  of  mastership  was  ended 
he  was  elected  consulting  gynaecologist  to  the  hospital.  He 
signalised  the  termination  of  his  office  by  presenting  to  the 
hospital  a fully  equipped  clinical  laboratory.  For  many 
years  he  was  very  busy  in  practice,  and  for  a genera- 
tion he  was  one  of  the  leading  obstetricians  and 
gynaecologists  in  Ireland.  In  1912,  after  many  vears’ 
service  as  a member  of  Council,  he  was  unanimously 
elected  President  of  the  Royal  College  of  Surgeons,  being 
the  first  of  his  specialty  to  occupy  the  chair  since  1880, 
when  McClintock  was  President.  It  was  during  his  tenure 
of  office  as  President  that  Purefoy  received  the  honorary 
degree  of  LL.D.  from  the  University  of  Dublin  at  the 
Bicentenary  celebrations  in  1912.  In  1915  he  was  elected 
President  of  the  Royal  Academy  of  Medicine. 

By  Purefoy  none  of  the  many  posts  of  honour  he  held  were 
regarded  as  sinecures.  He  fulfilled  their  duties  in  most 
exact  manner.  The  Rotunda  Hospital  was,  however,  his 
chief  interest  in  life.  No  governor  in  the  history  of  that 
great  charity  ever  held  it  in  closer  affection  or  devoted  more 
time  and  energy  to  its  welfare.  Outside  his  professional 
work  Dr.  Purefoy  was  interested  in  music  and  art.  Possessed 
of  a baritone  voice  of  good  quality,  in  his  younger  days  he 
sang  in  the  choir  of  Trinity  College  Chapel,  and  all  his  life 
he  was  a member  of  many  of  the  musical  clubs  in  Dublin. 
At  the  time  of  his  death  he  was  President  of  a very  ancient 
musical  society — the  Hibernian  Catch  Club,  and  he  also 
collected  pictures,  glass,  and  furniture.  In  private  a 
generous  but  keen  student  of  life,  few  men  of  his  age 
kept  up  so  much  interest  in  the  advance  of  knowledge. 
Masterful  in  his  individuality,  he  did  not  bear  opposition 
easily,  and  while  no  one  could  be  a better  friend  he  was 
frank  in  his  dislikes.  His  disappearance  leaves  a gap  in 
the  professional  and  social  life  of  Dublin,  where  he  was 
for  so  long  a characteristic  and  prominent  figure. 


ALEXANDER  SCOTT,  M.D.  Glasg., 

CERTIFYING  FACTORY  SURGEON,  SOUTH-EAST  GLASGOW  AND  TOLLCROSS. 

The  death  of  Dr.  A.  Scott  brings  a strong  sense  of  personal 
loss  to  medical  men  in  the  West  of  Scotland  as  well  as  to 
many  employers  and  workers  of  industrial  Glasgow.  His 
original  choice  was  the  Ministry  and  his  first  work  was 
teaching,  but  the  very  practical  nature  of  his  sympathy  with 
workers  attracted  him  to  the  practice  of  medicine.  In  1875 
be  qualified  M.B.,  C.M.  in  the  University  of  Glasgow  and 
took  the  M D.  degree  12  years  later.  Early  in  his  medical 
career  he  focussed  his  attention  on  industrial  disease,  and 
his  numerous  contributions  to  the  literature  of  this  subject 
bear  evidence  alike  to  his  medical  acuteness  and  to  his  deep 
interest  in  the  workers’  welfare. 

The  recognition  of  this  work  by  his  colleagues  and  by  the 
Home  Office  was  to  him  not  only  a source  of  honest  pride  and 
satisfaction  but  also  an  inspiration  and  encouragement  to 


82  The  Lancet,] 


PORTRAIT  OF  SIR  CLIFFORD  ALLBUTT.— DETOXICATED  VACCINES.  [July  12^1919 


persevere  Many  medical  teachers  and  practitioners  can 
recall  valuable  advice  and  help  freely  and  generously  given 
As  certifying  factory  surgeon  he  had  many  opportunities  of 
investigating  industrial  conditions,  and  of  these  he  made 
full  use  not  only  as  a clinician  but  also  as  a sociologist,  for 
his  mind  was  too  broad  and  his  sympathy  too  deep  to  be 
fettered  by  the  limits  of  his  official  duties.  Employers  and 
workers  alike  remember  countless  acts  of  unostentatious  help 
for  those  handicapped  in  life  by  physical  defect.  A typical 
instance  may  be  mentioned  as  an  illustration.  A medical 
friend  showed  Dr.  Scott  one  of  the  early  cases  of  cerebro- 
spinal fever  in  1905— a boy  who  recovered  but  with  total 
deafness.  Six  years  later,  when  the  boy  was  ready  to  leave 
the  Deaf-Mute  School,  the  parents  were  surprised  to  find 
that  Dr.  Scott  had  secured  for  him  a situation  in  a drawing 
office,  where  he  could  learn  a profession  in  which  his  deaf- 
ness was  no  bar  to  progress.  In  spite  of  all  his  numerous 
and  varied  duties,  he  had  never  forgotten  the  wasted  figure 
of  the  meningitic  boy  ; and  without  any  hint  or  application 
from  outside,  he  had  taken  charge  of  the  lad’s  future  in  his 
own  quiet  unobtrusive  way. 

To  those  who  knew  him  this  active  practical  sympathy 
explained  much  in  his  nature  besides  accounting  for  his 
reputation  as  a conscientious  and  safe  medical  referee, 
because  it  made  him  almost  unduly  sensitive  to  adverse  or 
unsympathetic  treatment.  Actions  that  outsiders  might 
attribute  to  personal  pique  were  often  only  the  na^'al 
expression  of  his  resentment  against  a harshness  of  treatment 
entirely  foreign  to  his  own  nature.  A native  of  Ayrshire,  he 
was  at  his  best  in  Scottish  song  and  story  ; and  thousands 
have  enjoyed  the  revelation  of  his  strong  personality  in  his 
popular  lectures  on  these  subjects.  A sterling  upright  man 
in  every  relation  of  life,  the  city  of  Glasgow  and  the  ranks 
of  industrial  medicine  are  consciously  the  poorer  for  his  loss 


Comspnknn. 


Audi  alteram  partem.” 


THE  LATE  DR.  E.  G.  FEARNSIDES. 

Supplementing  the  biographical  notices  of  Dr.  E.  G 
Fearnsides,  which  appeared  in  our  last  week  s issue,  Dr. 
Henry  Head  writes  : — 

“ The  death  of  Dr.  Fearnsides  has  left  a gap  in  ranks 
of  the  younger  neurologists  that  cannot  be  filled.  He 
possessed  an  unusually  wide  and  accurate  knowledge  of  the 
physiological  aspects  of  medicine,  especially  neurology. 
His  pride  was  to  be  familiar  with  every  paper  written  by 
Gaskell  and  those  who  drew  their  inspiration  from  him, 
this  made  the  review  of  the  ‘ Innervation  of  the  Bladder  and 
Urethra’  published  by  him  in  Brain  (1917)  so  masterly  an 
exposition  of  the  work  of  the  English  school.  He  was  the 
most  devoted  fellow-worker,  and  formed  the  coordinating 
member  of  the  team  working  on  syphilis  of  the  nervous 
system  at  the  London  Hospital.  No  trouble  was  too  great 
to  perfect  the  records,  for  he  had  a genius  for  order  and 
method,  and  every  patient  we  examined  was  known  to  him 
personally  and  looked  to  him  for  help. 

He  showed  the  same  self-sacrificing  ardour  in  the  service 
of  the  hospitals  to  which  he  was  attached,  and  was  always 
ready  to  take  on  his  shoulders  emergency  duties  without 
hope  of  reward.  Out-patients  have  been  known  to  'weep 
when  they  heard  that  Dr.  Fearnsides  was  no  longerin  charge. 
He  was  beloved  by  his  patients,  for  in  each  case  he  constantly 
exalted  the  importance  of  the  individual  rather *he, 
disease.  This  was  the  secret  of  his  success  at  the  Home  m 
Recovery,  Golders  Green,  subsequently  transferred  to  the 
Royal  Air  Force  as  a hospital  for  officers  suffering  from 
functional  nervous  disorders.  He  will  always  beremembere 
bv  those  who  worked  with  him  as  a physician  of  wide 
interests  and  unbounded  kindness  of  heart. 


Presentation  to  Dr.  Michael  Grabham.  Dr 
Michael  Grabham,  F.R.C.F.,  of  Madeira,  has  been  the 
recipient  of  an  illuminated  address  enclosed  in  a,  silv e: i 
casket,  from  the  British  community,  in  acknowledgment  of 
long  and  unwearying  medical  and  general  Pu^'ic,s^vltche; 
Dr.  Grabham,  a most  hospitable  virtuoso,  received  on  the 
occasion  more  than  a hundred  guests,  to  whom  he 
displayed  the  interesting  collection  of  scienLfic  instru 
ments  china,  and  silver,  which  have  accumulated  in 
his  ancient  Quinta ; and  in  responding  to  the  presentation 
gave  a review  of  medical  progress  since  his  early  days  and 
a recital  on  his  magnificent  organ,  recalling  to  some  of 
those  present  his  past  refined  manipulation  of  the  giant 
inBtruS  in  St.  Paul’s  Cathedral  Dr.  Grabham  was 
an  intimate  friend  of  Thomas  Wakley,  the  eldest,  the 
Founder  of  this  journal,  whom  he  accompanied  to  Madeira 
on  a search  for  health. 


PORTRAIT  OF  SIR  CLIFFORD  ALLBUTT.  ^ 

To  the  Editor  of  The  Lancet. 

g1R The  large  number  of  subscribers  to  the  Fund  for 

presenting  Sir  Clifiord  Allbutt  with  his  portrait  has  proved 
that  the  profession  welcomes  the  opportunity  of  testifying 
to  the  esteem  and  afEection  with  which  he  is  regarded^ 
Subscriptions  have  been  received  from  nearly  a thousand 
members  of  the  profession.  It  had  been  intended  to  close 
the  Fund  at  the  end  of  June,  but  I have  been  asked  to  keep 
it  open  until  July  31st.  I would  ask  all  those  who  wish  to 
take  part  in  the  presentation,  but  have  not  jet  notified  their 
intention,  to  send  their  subscriptions,  which  must  not  exceed 
one  guinea,  without  delay.  Cheques  and  postal  orders 
should  be  made  payable  to  the  “Sir  Clifford  Allbutt 
Presentation  Fund,”  crossed  London  County,  Westminster, 
and  Parr’s  Bank,  and  addressed  to  the  treasurer  of  the 
British  Medical  Association,  429,  Strand,  London,  W.C.  2 
I may  add  that  it  is  intended  after  the  portrait  in  oils  has 
been  painted  to  commission  a mezzotint  engraving  from  it 
which  subscribers  to  the  Fund  will  be  able  to  purchase  for 
their  own  collections.— I am,  Sir,  yours  faithfully, 

G.  E.  Haslip, 

July  7th,  1919. Treasurer. 

DETOXICATED  VACCINES. 

To  the  Editor  of  The  Lancet. 

gIRi Dr.  D.  Thomson’s  article  on  thissubjectin  yourissueof 

June  28th  raises  many  interesting  points  for  bacteriologist  and 
clinician  alike.  The  fact  that  the  toxic  portion  of  a bacterium 
can  be  removed  by  treatment  with  alkalies,  alcohol.  &c.,  was 
noted  by  Vaughan  and  his  co-workers  in  America  some  years 
ago  in  their  work  on  the  cleavage  products  of  bacterial  proto- 
plasm. These  researches,  which  extend  over  a period  of 
nearly  20  years,  were  brought  together  in  book  form  under 
the  title  of  “ Protein  Split  Products  ” shortly  before  the  war. 
The  book  contains  an  immense  amount  of  practical  bio- 
chemical detail  which  I need  not  enter  into,  but  it  also 
contains  the  basis  of  the  work  on  which  the  detoxicated 
vaccine  must  rest.  The  authors  regard  the  bacterium 
as  composed  of  relatively  complex  proteins  which  closely 
resemble  those  of  the  cells  of  the  higher  animals, 
They  found  that  the  cellular  substances  of  bactenK 
yield  cleavage  products  identical  with  those  obtained  b. 
the  hydrolysis  of  vegetable  and  animal  proteins.  In  animal; 
the  toxin  produced  from  the  typhoid  bacillus,  from  eg§ 
albumin,  and  from  the  hemp-seed  kill  laboratory  animals  n 
much  the  same  way,  and,  as  Vaughan  points  out.  there ; i 
“striking  evidence  of  the  similarity  in  the  structure  of  tb 
protein  molecule,  whether  it  be  of  bacte.ial,  animal,  o 
vegetable  origin.”  Vaughan  devised  [atge  copper  tauk 
which  were  capable  of  containing  as  much  as  20  litres  of  agat 
and  by  this  means  was  able  to  produce  enormous  quantitie 
of  growth  for  his  analyses.  Elaborate  precautions  wer 
taken  to  remove  all  traces  of  medium  from  the  growth  an 
when  this  had  been  done  some  60-80  g.  of  purified  celluls 
substance  remained  from  the  growth  in  each  tank.  By  actio 
upon  the  bacteria  with  a 2 per  cent,  alcoholic  solution  < 
caustic  soda  Vaughan  was  able  to  produce  two  distinct  po 
tions,  a toxophor  and  a haptophor  portion.  Careful  chemic 
analyses  were  made,  and  it  was  concluded  from  these  tb: 
the  toxophor  element  obtained  from  the  different  souro 
appeared  to  be  the  same,  whereas  the  haptophor  residue 
each  case  differed  from  that  obtained  from  other  protein 
This  haptophor  residue  when  injected  into  guinea-pigs  co 
ferred  immunity  against  the  living  organism  (e.g.,  in  tl- 
case  of  B coli).  Furthermore,  this  immunity  was  specie 
and  could  not  be  produced  by  other  proteins  such  as  e, 
albumin,  whereas  in  the  case  of  the  toxophor  group  th 
was  apparently  no  specificity.  Vaughan  believes  that  « 
splitting  of  bacterial  protein  into  two  portions  is  carried 
in  the  human  body  by  a proteoljtic  ferment  produced 
certain  cells,  and  that  this  fermeDt  is  specific  for  the  protq 
which  calls  it  into  existence.  A large  number  of  orgams 
were  investigated  in  this  way -B.  typhosus  B.  « 
B.  anthracis , B.  tuberculous,  pneumococcus,  «and  a nmm 
of  saprophytic  bacteria. 


Thu  Lancet,] 


EPIDEMIC  PERINEPHRIC  SUPPURATION. 


[July  12, 1919  83 


The  results  of  this  work  are  obviously  of  far-reaching 
importance.  Not  only  are  they,  as  has  already  been 
remarked,  the  basis  of  vaccine  therapy,  they  are  also 
intimately  bound  up  with  anaphylaxis,  tubercular  hyper- 
sensitiveness, pyrexia,  and  immunity  problems  generally. 
In  tuberculosis  especially  there  is  a large  field  for  research  on 
these  lines,  and  the  authors  appear  to  have  utilised  their 
opportunities  to  their  full  extent.  They  do  not,  however, 
record  much  in  the  way  of  clinical  observation,  and  it  is  on 
these  lines  that  the  next  step  has  to  be  taken.  It  seems 
possible  that  bacteria  possess  an  external  lipoidal  substance 
soluble  in  fat  solvents  and  that  after  this  has  been  removed 
we  have  a protein  base  which  can  be  divided,  as  Vaughan  has 
shown,  into  two  portions.  At  least  three  portions,  there- 
fore, may  enter  into  the  composition  of  the  ordinary  vaccine 
emulsion.  It  is  far  from  unlikely  there  are  others  also,  and  the 
whole  question  affords  a striking  example — if  such  were  needed 
— of  how  crude  our  methods  have  been  in  the  past.  The  use 
of  these  newer  methods  in  vaccine  therapy  on  the  one 
hand,  and  in  the  preparation  of  antigens  for  deviation  of 
complement  reactions  on  the  other,  warrants  very  careful 
clinical  observation  from  independent  observers.  With  such 
observations  used  as  controls  I believe  that  far-reaching 
results  may  be  forthcoming. 

I am,  Sir,  yours  faithfully, 

July  7th,  1919.  S.  ROODHOUSE  GLOTNE. 


EPIDEMIC  PERINEPHRIC  SUPPURATION. 

To  the  Editor  of  The  Lancet. 

Sir, — In  connexion  with  the  interesting  correspondence 
upon  this  subject  which  has  occupied  a place  in  your  recent 
numbers,  it  may  be  worth  noting  that  during  war  service  in 
the  Mediterranean  I saw  an  unusually  large  number  of  these 
cases  as  well  as  of  perinephric  inflammation  which  subsided 
without  operation  after  rest  in  bed.  These  cases  were  very 
common  in  Malta  in  1916  and  the  first  half  of  1917.  There 
was,  so  far  as  I know,  no  influenza  among  the  troops  there, 
but  boils  and  other  cutaneous  sores  were  extremely  common. 
After  the  middle  of  1917  I saw  an  unusually  large  number  of 
such  cases  in  France,  but  they  were  not,  I think,  in  so  great 
a proportion  to  the  total  sick  as  they  were  in  Malta.  The 
prognosis  in  both  places  was  very  good. 

I am,  Sir,  yours  faithfully, 

William  Thorburn, 

Late  Consulting  Surgeon,  British  Armies. 

Manchester,  July  6th,  1919. 


THE  MAINTENANCE  OF  COTTAGE  HOSPITALS. 

To  the  Editor  of  The  Lancet. 

Sir, — There  has  been  considerable  correspondence  in  the 
medical  and  lay  press  as  to  the  need  for  increased  hospital 
accommodation,  especially  of  the  cottage  hospital  type. 
The  difficulty  in  establishing  these  institutions  is  not  so  much 
the  cost  of  building  and  equipping  as  the  fear  that  exists 
that  they  will  be  a continued  and  increasing  drain  upon  the 
charitable  public.  For  this  reason  it  is  important  to  consider 
the  question  of  maintenance  ; there  is  apparently  a general 
agreement  that  this  should  be  as  little  as  possible  dependent 
on  charity. 

Take  the  case  of  an  auxiliary  hospital  with  20  beds  serving 
a population  of  10,000.  One  ward  of  five  beds  would  be  set 
aside  for  maternity  cases.  The  upkeep  of  these  beds  might, 
under  the  Maternity  and  Child  Welfare  Act  of  last  year,  be 
provided,  for  the  greater  part,  by  the  local  authority  ; in  so 
far  as  it  might  not  be,  the  cost  would  be  met  by  the  patients 
occupying  them,  so  that  this  ward  at  any  rate  would  in  no 
way  be  dependent  on  charity.  Another  section  of  the  hos- 
pital would  consist  of  separate  private  beds  for  patients 
willing  to  pay  such  fees  as  would  not  only  cover  the  actual 
cost  of  their  maintenance,  but  would  allow  a certain  profit 
for  the  institution.  The  number  of  these  beds  would  vary 
with  the  character  of  the  population,  perhaps  5 out  of  20. 
This  would  be  no  charge  on  charity.  There  would  remain  ten 
ordinary  hospital  beds.  Some  of  the  patients  occupying  these 
beds  might  be  able  and  willing  to  pay  the  necessary  fees, 
but  the  majority  would  probably  not  be  willing,  or,  if  willing, 
would  not  themselves  be  able  to  pay.  As  yet  we  cannot  look 
for  these  payments  from  the  National  Insurance  Commission, 
Approved  Societies,  or  local  authorities,  although  the  latter, 


under  Section  131,  Public  Health  Act,  1875,  have  the  power  to 
make  them  ; but  we  may  quite  fairly  point  out  to  the  public 
that  the  lime  cannot  be  very  far  distant  when  one  or  other 
of  those  authorities  will  be  called  upon  to  support  these 
hospitals. 

Public  Hospital  I'unds. 

The  most  business-like  system  is  to  pay  for  each  patient 
admitted  the  actual  amount  of  their  cost  to  the  institution. 
To  do  this  it  would  be  much  better  if  the  public,  different 
bodies  of  workers,  and  other  groups  of  persons,  instead  of 
paying  hospitals  indefinite  sums,  for  which  they  expect  an 
indefinite  amount  of  treatment,  would  each  form  their  own 
hospital  fund,  out  of  which  they  would  pay  for  any  patient 
that  they  sent  to  hospital  the  whole  of  the  sum  required. 
This  would  be  a more  business-like  arrangement,  more  fair 
and  satisfactory  for  all  concerned.  Those  using  the  hospital 
would  feel  a greater  sense  of  independence.  There  would 
be  no  differentiation  between  the  patients,  each  of  whom 
would  bear,  directly  or  indirectly,  his  fair  share  of  the 
expenses  of  the  hospital.  Contributors  would  feel  a more 
direct  interest  in  the  management  of  the  institution  and 
would  probably  appreciate  more  fully  the  benefits  that  they 
received. 

If  each  society  or  group  of  persons  had,  as  suggested,  its 
own  hospital  fund  it  would  be  able  to  pay  for  its  own 
patients  as  occasion  arose.  It  would  not  be  bound  to 
support  any  particular  hospital.  Payment  would  be  made, 
not  only  for  the  in-patients,  but  for  such  out-patients  as 
there  might  be.  If  these  hospitals  are  used,  as  it  is 
suggested  they  should  be,  for  various  public  services,  school 
clinics,  maternity  and  child  welfare  centres,  and  so  on,  they 
would  derive  from  these  a certain  income. 

Payment  of  the  Medical  Staff. 

As  to  the  payment  of  members  of  the  medical  staff,  all 
insured  persons  and  others  for  whose  treatment  they  con- 
tract would  be  treated  by  them  in  hospital  without  any 
further  fee.  It  must  here  be  noted  that  there  is  a very  real 
probability  of  the  dependents  of  insured  persons  before  long 
being  granted  medical  and  sickness  benefit.  For  patients  in 
the  maternity  ward,  unless  other  arrangements  are  made, 
medical  men,  when  called  in  by  the  midwife  in  charge, 
would  receive  the  same  fees  as  if  the  patients  were  in  their 
own  homes.  For  the  patients  of  the  public  services  the 
doctor  would  receive  an  agreed  payment,  but  for  all  others 
they  would  make  their  own  arrangements  with  each  patient. 

I am,  Sir,  yours  faithfully, 

Bradford-on-Avon,  July  4th,  1919.  CHAS.  E.  S.  FLEMMING. 


FEES  FOR  SERVICE  ON  PENSION  BOARDS. 

To  the  Editor  o^The  Lancet. 

Sir, — At  a general  meeting  of  the  medical  practitioners  in 
the  Cheltenham  area,  held  at  the  General  Hospital  yesterday 
evening,  at  which  27  were  present,  11  of  whom  were 
demobilised  doctors,  the  following  resolution  was  passed 
nem.  con.  : — 

That  they  were  willing  to  act  on  the  pension  boards  at  a rate 
of  either  (1)  one  guinea  per  session  dealing  with  not  more  than 
five  cases  per  session  ; or  (2)  two  guineas  per  session  lasting 
two  and  a half  hours. 

It  was  further  resolved  that  this  resolution  should  be  sent 
to  The  Lancet. 

I am,  Sir,  yours  faithfully, 

H.  M.  Meyrick-Jones, 

Honorary  Secretary  to  the  Committee  of  Medical 

July  8th,  1919.  Practitioners  in  the  Cheltenhan  Area. 


HUTCHINSON’S  TEETH. 

To  the  Editor  of  The  Lancet. 

Sir,— A recent  experience  has  suggested  to  the  writer 
that  in  the  course  of  time  the  characteristic  notch  described 
by  the  late  Sir  Jonathan  Hutchinson  in  the  upper  central 
incisors  may  disappear.  Some  six  years  ago  a girl  was 
under  my  treatment  for  multiple  ulcerative  adenitis  of  the 
submaxillary  region  and  neck.  She  had  a somewhat 
depressed  bridge  to  the  nose,  and  upper  incisors  which 
showed  a slightly  curving  notch  in  the  cutting  edge.  A 
diagram  was  made  of  these  teeth  in  the  case-book  and  a note 
added  that  they  were  probably  Hutchinson’s  teeth.  A 
Wassermann  test  of  the  blood  yielded  a positive  result  and 
the  case  was  regarded  as  possibly  one  of  mixed  syphilitic  and 


MEDICAL  NEWS. 


[July  12, 1919 


84  THELANOBT,] 


tubercular  iufection.  The  girl  was  treated  with  X rays 
scraping  of  ulcerated  glands,  general  tomes  and  severa 
intravenous  injections  of  neosalvarsan  Lite.  a . 
of  tuberculin  emulsion  was  administered.  Considerable 
improvement  followed  and  the  patient  discontinued 

attTheawar  intervened,  but  soon  after  the  Armistice,  on 
resuming  hospital  attendance,  the  patient  presented  herself 
with  active  recurrence  of  the  adenitis  On  inspection  the 
upper  incisors  no  longer  showed  any  characteristic  notches 
Presumably  the  free  edges  of  the  teeth  had  been  ground  flat 
in  the  interval.  Certainly  no  one  now  looking  at  them  would 
suspect  any  present  or  former  connexion  with  Hutchinson  s 
teeth  I cloPnot  know  if  this  possible  source  of  fallacy  has 
been  noted  elsewhere,  but  think  it  of  sufficient  interest  to 
warrant  a ^ M.D. 

Harley-street , W.,  July  <lh, 


THE  MEDICAL  DIRECTORY. 

To  the  Editor  of  The  Lancet. 
gIR  —The  annual  circular  has  been  posted  to  each  member 
of  the  medical  profession.  If  it  has  not  been  receive  a 
duplicate  will  be  forwarded  on  request.  We  shall  be  grateful 
if  the  recipients  will  return  the  form  by  an  early  pos  . 

We  are,  Sir,  yours  faithfully, 

J.  k.  A.  Churchill. 

7,  Great  Marlborougb-street,  London,  W.  1,  July  7 th,  1919. 


ci  ot  Thomas's  Hosd.  • S.  Somasundram , Ceylon  Med. 

Copl  and  Middlesex  Hosp  ; A E.  Strawbaun,  Cape  Town  and  Guy* 

Midd  esex  Hosp.  ; M.  Thei'er,  St.  Thomas  s Hosp. . Joyce  hlten 

sr* 

and  B.  Zeitoun,  King’s  Coll. 


Pebial 


Royal  College  of  Surgeons  of  England. 

A meeting  of  Fellows  was  held  on  July  3rd  for  the  election 

of  two  Fellows  to  the  Council,  Sir  George  Makins,  the  Presi- 
dent being  in  the  chair.  Tnree  vacancies  should  occur 
annuallv  and  the  term  of  office  of  Sir  George  Makins  would 
have  come  to  'an  end  this  year,  but  as  he  was  President  at 
the  time  of  the  election  he  became  entitled  to  retain  the 
positZ  of  member  of  the  Council  for  another  year.  The 
result  of  the  election  was  as  follows:— 

Votes.  Plumpers,  i Motes.  Plumpers- 

air  n G A W.F.V.  Bonney  130  15 

SMoynihfn  . 404  20  A.  H Tabby  ...  114  7 

C.  S.  Wallace...  274  33  | J.  F.  Jennings,.  113  17 

F.  J.  Steward...  168  ......  51  , 

The  President  declared  Sir  Berkeley  Moynihan  to  be  re- 
elected  and  Mr.  Wallace  to  be  elected  members  of  the  Council. 
There  were  667  postal  votes,  and  6 Fellows  voted  in  person. 
Five  voting  papers  were  wasted,  owing  to  Fellows  voting  for 
more  than  two  candidates.  Mr.  H.  J.  Price  and  Mr.  Willmott 
Evans  acted  as  scrutineers 


University  of  Manchester.— At  examinations 
held  recently  the  following  candidates  were  successful  in 
the  subjects  indicated 

Doctor  of  Mfdicixe. 

J W Bride,  T.  H.  Oliver,  and  C.  R-  Sandiford. 

Final  M B AND  Ch.B.  EXAMINATION. 

Kathleen  Doyle,  Olve  M.  *rc^e,  llTpickeU,  Efime 

RVnerC  aV"h  S^dek.  Annle  G.  Thompson,  Marie  WarJman,  and 

.Sfilsrrff -^Doris  M.  R.  Tompmn 
(dis  inctlon). 

Van  Culler,  Raymond  Williamson,  and  J.  B.  >>  rigLt. 

Third  M.B.  .and  Ch.B.  Bx a. .mi nation.  _ 

Pha  \mac'^°sy-nrj-e  K 1 Bleakiey' T K ^Coope  ,~M  urie?  Coo^e"  Eugenia 
U ^Cooper Tw Dyson  Winifred  M. 

PT  ’N:  Fisher  E S.  Frishman.  E Iward  Gleaves,  W.  H. 
Edgehill,  1.  N „18„,Vh  R„th  Hill  C D.  Hough,  Marguerite  F. 
Gratrix,  Albert  Haworth  Both  Hill  U " j,me|  Lealher, 

i°hH  Lees  W L Maruind,  Alexander  Maude  Eva  le  Messurier. 
p B Mumford,'  Cecil  Nelson  Terence  O Boen,  Us.  Potter.  W.  E 
Powell,  Margaret  Pownal]  J^SgH°^n8°0^sfar^  s®owdoI)’,  Harry 

M B.  ....  q«  B. 

Vincent  Chadwick  and  N.  S.  Craig. 

Diploma  in  Destistky. 

i’cSZo.  E.  Crd.«ll.  B.  L. 

Heelan. 


Examining  Board  in  England  by  the  Royal 
rmTFCFS  of  Physicians  of  London  and  Surgeons  of 
England.— As  the  result  of  the  Second  .Professional  Exami- 
nation  in  Anatomy  and  Physiology,  held  on  June  26th,  27th, 
and  30th,  and  July  1st,  for  which  99  candidates i presented 
thpmaelves  68  were  approved  and  31  were  rejected,  lhe 
following  are  the  names  and  medical  schools  of  the  successful 
candidates: — _ _ _T  ~ 

a Aokrovd  L°eds  Univ. ; M.  T.  Ahmed.  Guy’s  Hosp.  ; J.  V.  D.  Alim 
and  fr  W BaUance  Birmingham  Univ.  ; V.  H.  Barker,  London 
Hosp  ; EL  C Blaekmore,  Univ.  Coll.  ; Dora  Mahalah  Caiman, 
London  Sch.  of  Med.  for  Women  ; N.  L-  CapeueT,  S j.  Bart. ^s  Hosp 
Kathleen  Frances  Cawthorne,  Univ.  Coll. , S.  B.  Chambers,  ±ung 
Coll  ; Elizabeth  Maul  Chiison  London  Sch.  of  Med  : for  W )men  , 
T.  J.  Clayton,  King's  Coll.;  H.  \ . Croucher,  aT??8pp  ,, 
f,oKhfl  Rirmintrham  Univ  : Nancy  Barbara  Darnell,  Univ.  Cull.. 
E nhl 8 Marco  1 laf  1)1  xonj  ' Loiid on  Sch.  of  Med.  for  Women  ; Alice 
Elizabeth  Dove,  Univ.  Coll.  ; Beatrice  Bmily  Ebden,  Kings  Coll.  , 
H O Eks'een  C«pe  Town  Univ.  and  Guy’s  Hos&  ; W.  E.  Farnham 
Birmuigham  Uni iu  ; W.  C.  Faull,  St.  Mary’s  Hosp  ; Dora  Janet 
Fox,  London  Hosp.;  Lena  Bella  Gayer,  London  Sch.  ot  Me  . 
for  Women:  Nancy  Kathleen  Gibbs,  Univ.  Loll.,  Cardin, 
LouiM^atricia  Gordon,  King's  Coll.;  F. 

Hosd  A.  W.  Hall,  Guy’s  Hosp.  ; B J.  Hallowes,  S>t. 

Hosd  • K Hardy,  Guy’s  Hosp.;  T.  H.  J.  Hargreaves,  King  8 
Coll  ; II  w.  Harvey,  Guy’s  Hosp  ; Florence  Reed  Hodges,  London 
Sch  of  Med.  for  Women;  B.  J.  Hodgkinson  Guy  s Hosp  ; G H. 
llogben.  King's  Coll.  ; J.  Holroyd  and  D Hoole.  Manchester  Itn  .. 
W A).  Jenkins,  Middlesex  Hosp. ; II.  B.  JoneB,  Q 8 ®01P’ i 
Karn  Univ  Coll.;  B.  L.  Laver,  Guys  Hosp.;  Alfred  Q Logan 
St  Thomas's  Hosp.  ; O.  E J.  McOustra,  Univ.  Coll.  ; Elizabeth 
Mai tiand-J ones , Univ.  Coll  Cardiff  ; C.  A.  Marxist  Gu£ Glosp^ ; 

5^'eeB  ^^verttunl-cSn  ? HUdaM^re^  Pake^on 
Schlof  Mod.  for  Women  ; A.  Pain,  Middlesex  Hosp. ; B.  K.  R'cbanis^ 
Mt'l'.mirne  Univ.  aud  Kmg’s  Coll.  ; Hilda  Marjorie  Stebbing 
Russell.  London  Sch.  of  Med.  for  Women;  Z Salama.  Cairo  and 
Birmingham  Univs. ; K.  T.  Saravanamuttu,  Madras  Med.  Coll.. 
L Segal,  Erlangen  Univ.;  C.  M.  Sh  rt,  Guys  Hosp.;  H.  L. 


ttmtverrity  of  Durham:  Faculty  of  Medicine. 
-At  toT Svo'catiou  held  on  July  1st  tae  following  degrees 
were  conferred : 

Doctor  o/Mediciru  t Standing. - 

^Thomas  BUnlhard’Sellors  and  Alfred  Frank  Tredgola  (in  absentia). 
.Vaster  of  Surge ry  -William  Robert  Blstob  AAryAe'-Dorothy  Olga 
Bachelor  of  Medtotne  and  ^ Dewar  Charles, 

Sutherland  Bla.r,  Snj«  ChMMrj.  Rrne^  Jame9 

William  Devereux  Ate  R Msns(>or,  Hugh  Ley 

Richard  Hughes.  Leolia^  Wilfrid  Vickers  Potts. 

Licence  in  Dental  Nurperg.-Allan  Uaughan. 


sSSsSSHSflS, 

The  Bight  Hon.  the  WattsNv^u  knf  Co.} 

St.  Mark’s,  NorlhAudley-street  _z02.  Mes|  Churchi 

Ltd.,  £315 ; Mr.  John  l^«to.  £2o2  Ws  . jir  Alexander  Miller,  £200; 

£230;  Brixton  Independent  Church,  tztX)  , m pheee,  London  Wall, 

Lieutenant-0  .lonel  More  George^  Hanover-square. 

with  St.  Mary.  Aldermanbury . £lb6  . ^ bt.  George  £M1  . .yU 

£157;  Wimbledon  Churches  £154  M es^mmste  ^P  K C > £105; 
Saints.  Eiinlsmore-gardens,  £116£'10frB  Ajsh  Oil  and  Cake  Mills  Ltd., 
United  National  Colliepes,  Ltd.,  £ luo.  Moxey.  Savon, 

£105;  Messrs.  W.  Gardiner  and  Co..  Ltd..  Wilsbn,  Sons, 

andCo.,and  BLer  Plate  CoaCo  Ltd  j Alec  RoberU, 

and  Co.,  £105;  St,  Graham-Menzies,  £100; 

£100;  Messrs.  Erlangers,  £100  . Mr. 

Brunswick  Hall,  Whitechapel,  £100. 


L.C.C.  Ambulance  Service. 

^aMt^^s^coasidered^in^co^jun^tion^with 

medical  qualifications,  i Association,  but  after  going 

received  a deputation  fri om  jttee8  are  unanimously 

r»vs.r.rss  ”3  i 01  cou”e’ be  s,v“ by 

Council’s  medical  officer  of  health. 


The  Lancet,] 


THE  SERVICES. 


[July  12,  1919  85 


West  London  Medico- Chirurgical  Society. — 

The  annual  general  meeting  will  be  held  at  the  West  London 
Hospital  on  Friday,  July  18th,  at  5 p.m.  A large  attendance 
is  desired,  as  the  financial  position  of  the  society’s  journal 
will  come  up  for  discussion. 

Hospital  Sunday  Fund  at  Bristol. — £4901  have 

been  collected  for  the  Hospital  Sunday  Fund  at  Bristol ; it  is 
hoped  that  £5000  will  be  eventually  raised.  This  is  a 
“record”  sum  and  gratifying  to  Mr.  J.  H.  Reed,  the 
honorary  secretary  of  the  Fund,  who  is  giving  up  the 
work  in  which  he  has  taken  a great  interest  for  the  past  21 
: years. 

London  and  Counties  Medical  Protection 
Society. — The  annual  general  meeting  of  the  London  and 
Counties  Medical  Protection  Society,  Ltd.,  was  held  on 
July  2nd  at  the  offices  of  the  socie’ty,  32,  Craven-street, 
Strand,  W.C.,  Sir  John  Rose  Bradford  presiding.  Major  C.  M. 
j-  Fegen,  treasurer  of  the  society,  in  proposing  the  adoption 
of  the  annual  report  and  balance  sheet,  said  that  the  society 
was  never  in  a better  financial  position,  the  reserve  funl 
amounting  to  nearly  £25,000.  But  he  gave  it  as  his  opinion 
that  the  reserve  should  be  £100,000.  The  report  having  been 
adopted,  Sir  J.  Rose  Bradford  was  unanimously  re-elected 
i president  of  the  society. 

Royal  Devon  and  Exeter  Hospital. — In 
response  to  the  appeal  for  £20,000  for  the  funds  of  this 
hospital  over  £10,000  have  been  already  received. 

Harrogate  Medical  Society. — A complimentary 
dinner  was  given  at  the  Grand  Hotel,  Harrogate,  on  July  1st, 
by  the  members  of  the  society  who  had  stayed  at  home  to 
those  who  had  served  in  His  Majesty’s  Forces.  About  60  sat 
down,  30  of  whom  were  guests.  The  chair  was  taken  by  Dr. 
John  Gordon  Black,  and  Dr.  D’Oyly  Grange  proposed  the 
health  of  the  guests.  Surgeon-Lieutenant  O’Beirne  Ryan 
responded  on  behalf  of  the  Naval  Medical  Service,  and 
Lieutenant-Colonel  R.  J.  Morris,  Major  Ernest  Solly,  Major 
M.  B.  Ray,  D.S.O.,  ana  Captain  Shepherd  Boyd  for  the 
R.A.M.C. 

Devon  Education  Committee  and  Medical 
Certificates. — At  a recent  meeting  of  the  Devon  Education 
Committee  it  was  stated  that  a country  medical  practitioner 
considered  he  had  a grievance,  as  a statement  had  been  made 
by  the  attendance  subcommittee  that  he  had  given  medical 
certificates  without  cause,  and  he  said  that  as  long  as  that 
statement  was  on  the  committee’s  book  he  would  not  give  a 
certificate.  The  school  medical  officer  for  the  county,  who 
had  examined  the  children  referred  to  in  the  certificate,  said 
that  he  agreed  with  the  medical  man  that  they  were  unfit  to 
attend  school.  It  evidently  appears  as  if  the  medical  man 
had  a grievance. 

London  Dermatological  Society — The  annual 
meeting  of  this  society  was  held  at  St.  John’s  Hospital  on 
June  17th,  Dr.  A.  T.  Bremner,  the  President,  being  in  the 
chair.  After  the  presentation  of  the  annual  report  and  the 
balance  sheet  the  following  officers  were  elected  for  the 
year:— President:  Dr.  Morgan  Dockrell.  Honorary  secretary : 
Dr.  William  Griffith.  Honorary  treasurer : Dr.  \V.  Knowsley 
Sibley.  AcliDical  meeting  followed,  after  which  Dr.Septimu3 
Sunderland  read  a paper  entitled  “ The  Baths  of  Old  London ,” 
the  first  part  of  which  appears  in  this  issue  of  The  Lancet. 

Society  for  Relief  of  Widows  and  Orphans 
of  Medical  Men.— A meeting  of  the  Court  of  Directors  of 
this  society  was  held  on  July  2nd,  Sir  Alfred  Pearce  Gould, 
the  President,  being  in  the  chair.  Twelve  new  members 
were  elected,  this  being  the  largest  number  to  be  elected  at 
any  meeting  since  tie  centenary  of  the  society  in  1888.  The 
death  of  au  annuitant  was  announced  who  had  come  on  the 
funds  in  1890,  her  late  husband  having  paid  in  subscriptions 
£38  17s ; his  widow  and  one  child  had  received  from  the 
society  the  sum  of  £29C0,  the  child  being  still  in  receipt 
of  a grant  of  £50  per  annum.  It  was  pointed  out  that  this 
:ase  was  a striking  example  of  the  benefits  of  joining, 
Eor  relief  is  only  granted  to  the  widows  and  orphans 
of  deceased  members.  The  sum  of  £2036  5s.  was  voted 
for  the  payments  of  the  half-yearly  grants  to  the  widows 
md  orphans  on  the  society’s  books— namely,  50  widows  and 
7 orphans.  In  addition,  the  sum  of  £285  was  voted  as  a 
special  Peace  gift,  each  widow  and  orphan  to  receive  £5. 
The  invested  capital  of  the  society  now  stands  at  £140,000. 
This  cannot  by  the  bylaws  be  decreased,  and  only  the  income 
.derived  from  it  is  used  for  the  payment  of  grants  and 
expenses.  Membership  is  open  to  any  medical  practitioner 
who  at  the  time  of  his  election  resides  within  a 20-mile 
radius  of  Charing  Cross.  The  annual  subscription  varies 
with  the  age  of  the  member  at  the  time  of  his  election,  and 
starts  at  £2  2s.  ; there  are  special  terms  for  life  membership, 
purther  particulars  and  application  forms  may  be  obtained 
rom  the  secretary  at  the  offices  of  the  society,  11,  Chandos- 
'=tree r,  Cavendish-square,  W.  1. 


Cj)t  Set  hires. 


R.A.M.C.  TEMPORARY  OFFICERS. 

As  there  appears  to  be  some  misunderstanding  as  to 
certain  points  in  connexion  with  the  terms  of  the 
recent  offer  1 by  the  War  Office  of  engagement  in  the  Royal 
Army  Medical  Corps  for  service  with  the  Army  of  Occupa- 
tion, the  Director-General,  Army  Medical  Service,  makes 
the  following  explanation. 

(1)  Officers  who  are  at  present  serving  in  the  Royal  Army 
Medical  Corps  under  contracts  for  12  or  6 months  or  other 
definite  stated  periods  will  be  required  to  complete  these 
engagements,  with  the  option  of  entering  into  the  new 
contract  on  termination. 

(2)  Officers  who  are  serving  under  contracts  “ until  the 
termination  of  the  present  emergency”  will  be  eligible  for 
demobilisation  on  the  statutory  date  for  the  end  of  the  war 
which  will  be  published,  and  the  gratuities  payable  under 
such  contracts  will  be  issuable  on  that  date. 

(3)  All  officers  who  are  at  present  serving  may  offer 
themselves  for  service  with  the  Army  of  Occupation  (such 
service  to  commence  on  the  day  following  the  completion  of 
their  present  contracts)  under  the  terms  of  the  recent  offer— 
namely,  for  a period  of  12  months  or  until  their  services 
are  no  longer  required,  whichever  may  happen  first,  at  a 
salary  of  £550  per  annum  plus  rations  or  the  allowance  in 
lieu.  The  sum  mentioned  is  inclusive  of  both  bonus  and 
gratuity,  and  no  additional  emoluments  of  any  kind  are 
issuable. 

(4)  Officers  holding  the  acting  rank  of  Lieutenant-Colonel 
or  Major  will  be  required  to  sign  a contract  embodying  the 
above  terms,  but  will  draw  the  pay  and  allowances  of  their 
acting  rank  whilst  holding  it,  the  contract  terms  as  to 
emoluments  remaining  in  abeyance  during  that  period ; 
they  will  revert  to  contract  rates  on  ceasing  to  hold  the 
acting  rank. 

(5)  Field  officers  of  the  Territorial  Force  and  Special 
Reserve  will  receive  the  pay  and  allowances  of  their  sub- 
stantive field  or  acting  rank. 

(6)  Officers  will  continue  to  draw  children’s  allowance 

for  the  present.  


ROYAL  NAVAL  MEDICAL  SERVICE 

Surg.-Commdr.  (acting  Surg.-Capt.)  P.  W.  Bassett-Smiih  specially 
promoted  to  the  rank  of  Surgeon  Captain  in  recognition  of  services 
ren  tered. 

To  be  temporary  Surge m-Lieutenant : D.  H.  Cameron. 

ARMY  MEDICAL  SERVICE. 

Col.  S.  G.  Allen  retires  on  retired  pay. 

ROYAL  ARMY  MEDICAL  CORPS. 

Lieut.-Col.  S.  H.  Fairrie  retires  on  retired  pay. 

Temp,  Maj.  (acting  Lieut.-Col.)  W.  Robertson  (Captain,  R.A.M.C.,T.F.) 
relinquishes  his  temporary  commission  on  re-posting. 

Captains  to  be  acting  Majors  : K.  P.  Mackenzie,  E.  A.  Slrachan. 

To  be  Captains:  Capt.  (acting  Major)  H.  A.  Sandiford,  fromT.F.  ; 
Temp.  Capts.  C.  B.  Hogg,  E.  E.  Holden,  W.  Moodie,  A.  Mearns,  F.  H. 
Woods,  F.  A.  L’Estrarge. 

Temp.  Capt.  R.  S.  Miller  to  be  acting  Major. 

Lieutenants  (temporary  Captain*)  to  be  Captains : G.  D.  Grippe--, 
G.  T.  Baker,  H.  C.  Watson  (acting  Major)  (and  retains  his  acting  rank), 
G.  T.  Gimlette. 

Capt.  N.  V.  Lothian  to  be  acting  Major  whilst  apes  Lily  employed. 
Capt.  C.  J.  O'Reilly  resigns  his  commission. 

Capt.  L.  G.  Bourdillon  is  seconded  for  service  with  the  Egyptian 
Army. 

To  be  seconded  for  service  under  the  Civil  Admin’stration  of  Meso- 
potamia : Capts.  and  Bt.  Majors  A.  G.  J.  Maellwaine.  L.  Dunbar  ; Capts. 
T.  J.  Hallinan,  P.  A.  With,  O.  D.  Jarvis. 

Temp.  Capt.  H.  F.  Muilan  relinquishes  the  acting  rank  of  Major  on 
re-posting. 

Late  Temp.  Capts.  to  be  Capts.  : R.  Marshall,  H.  W.  M.  Kendall, 
S.  B.  Faulkner. 

To  be  Lieutenants  and  to  be  temporary  Captains  -.  Capts.  G.  H.  Barry 
and  T.  Stanton,  from  Special  Reserve  ; Temp.  Capts.  H.  J.  DavidBon 
and  T.  H.  Twigg. 

Officers  relinquishing  their  commissions  : Temp.  Lieut.-Col.  J.  C. 
Muir,  and  reta’na  the  rank  of  Captain ; MajorW.  C.  Devereux,  and  retains 
the  rank  of  Major.  Temp.  M-  jor  R.  H.  Cooper  granted  the  rank  of 
Lieutenant-Colonel.  Temporary  Majors  retaining  rank  of  Major  : J.  R. 
Bibby,  C.  V.  N.  Lyne  (Major,  retiied,  Indian  Artny',  W.  McDougall, 

A.  Drury.  Temporary  Hon.  Majors  retaining  the  honorary  rank  of 
Major:  W.  K.  Carew,  S.  Bousfield.  Temporary  Captains:  W.  G Cobb, 

B.  Suggit.  Temporary  Captain  granted  the  tank  of  Lieutenant- 
Colonel  : G-  D.  Hindley.  Temporary  Captain  and  Brevet  Major  retaining 
the  rank  of  Brevet  Major:  P.  H.  Bahr.  Temporary  Captains  granted 
the  rank  of  Major:  A.  V.  Poyse*,  W.  F.  Law,  M.  A.  Power,  C.  M. 
Kennedy,  H.  G.  Joyce,  A.  J.  Clayton,  K.  G.  Fraser,  J.  W.  Linnell, 
N.  G.  W.  Davidson,  W.  C.  Horton,  E.  T.  Willans,  E.  W.  Nairn, 
M.  P.  Paton,  G.  T.  Foster  Smilh,  G.  H.  Darlington,  A.  W.  Rowe, 
G.  C.  Chubb,  R.  E.  F.  Pesrse,  H.  F.  Warwick,  L F.  Hemmans, 
A.  C.  Sturroek,  G.  W.  Riddel,  P.  R.  Woodhou  e J.  W.  Applegate. 
Temporary  Captains  retaining  the  rank  of  Captain:  A.  H.  Turner, 
J.  W.  A.  Wilson,  J.  W.  Tocher,  F.  J.  Cutler,  L C.  Dilion-Kelly,  W.  J.  D. 


1 The  Lascet,  June  28th.  p.  1137. 


86  The  Lancet,] 


PARLIAMENTARY  INTELLIGENCE. 


[July  12,  1919 


Bromley.  J.  Loiv,  P.  W.  Moore,  T.  J.  Lloyd,  B T.  Lang,  H Bardsley, 
W.  Browne,  W.  H.  Parkins  m,  C.  W.  Forsyth,  L.  N.  Lee,  K.  Parry,  J. 
Brown,  V.  G.  Maitland,  J.  Graham,  F.Jub\  0 G Lambie,  J.  D. 
Oliver,  E.  J.  Clark.  E.  C.  Malden,  J.  M.  Hall  H C.  Quirke,  C.  D. 
Holdsworth,  D.  M.  Baillle,  L.  D.  Saunders,  G.  S.  Brown,  E.  P.  Scott, 
E H Udall,  E.  W.  Smerdon,  A.  J.  B®adel,  A.  N.  Hodges,  W.  J.  Henry, 
g'.  H.  Steven,  K.  B.  Armstrong,  II.  F*rncombe,  S.  MeMurray,  F H. 
Plckin,  H.  Nunn,  K.  D.  Melville,  J.  R.  Prythereh,  H.  F Blood,  J.C. 
McMillan.  U.  H.  Calvert,  E.  A.  Morgan,  J.  It.  Cameron,  J.  Paton.  A. 
Feiling,  W.  A.  Reynolds.  A.  N.  Hooper.  A.  Rutherford,  R.  Duncan, 
T.  C.  Hvnd.  T.  C.  Innes,  W.  A.  Easton,  W B.  Gordon  C.E.  Ilarrison. 
J W.  Fox,  J.  E.  Finlay,  I).  J.  Evans,  S.  G.  Graham,  J.  B.  Ball,  W.  L. 
Webb.  M.  L.  Farmer,  R.  Cope,  G.  Davidson,  J.  G.  Garson  W.  K.  O. 
Hamilton,  F.  W.  Milne,  M.  J.  Fraser,  M.  D.  Mackenzie,  G.  E Lloyd, 

R E.  Moves,  J.  F.  Jennings,  C.  G.  Mackay,  A.  F.  Morcom, 

A V.  McMaster,  A.  E.  SUffurth.  W.  J.  Woodman,  W.  Dugutd, 

S.  C.  Pritchard,  W.  S.  Sheppard.  A.  H.  Aldridge,  J.  S.  Dunn, 

G.  R.  C.  Wilton,  T.  B.  Welch,  S.  G.  Kean,  F J.  Dunne,  J. 
Watson,  H.  Stokes,  II.  W.  Smith,  R.  M.  Wishart,  H.  E.  S.  Stiven,  A.  R. 
Moore,  R.  Denman.  C.  C.  Morrell.  W.  R.  Wiseman.  R.  G.  Abrahams, 
D A.  Hutcheson,  W Reid,  W.  O.  Roberts.  G.  E.  Stephenson.  N.  M. 
Cummins,  J.  C.  Lorraine.  H.  F.  Mullan,  A.  St.  Johnston,  W K Calwell, 
J.  W.  McLeod,  C.  Cameron,  W.  P.  Morgan.  L.  K.  I',]an?s’1P- n 'x?racy’ 
J.  Wyper,  O.  L.  V.  de  Wesselow.  W.  H.  Thresher.  D Meek  F.  H Moran, 
C T W Hlrsch  J.  B.  Wall,  W.  D.  Kirkwood,  A.  G.  East,  T.  Winning, 
d'.  Wainwright,  J.  H.  Johnston.  J.  Williamson,  G.  B.  Richardson,  J M. 
Taylor,  W.  N.  Montgomery,  P.  Cheal,  L. Wayne- Morgan  G Whittington, 
W.  G.  Silvester,  F H.  Alexan  ter,  J.  E.  R.  Orchard.  D.  P.  Smith, 
W.  E.  Bullock.  C.  W.  Somerville,  A.  K.  S.  Wyborn,  A.  M.  Clark 
Churchill.  M.  S.  Baines.  F.  D.  Cairns,  M.  J.  Ahern,  J.  W.  Cowte,  V/.  V. 
Coffyn  Temporary  Lieutenants  retaining  the  rank  of  Lieutenant : A.  D. 
Pringle,  J.  C.  Bell,  C.  H.  C.  Casen. 


parliamentary  Intelligence. 


HOUSE  OF  COMMONS. 


Canadian  Army  Medical  Corps. 

Temporary  Lieutenant-Colonels  (acting  Colonels)  to  be  temporary 
Colonels:  W.  T.  M.  MacKinnon,  F.  Guest 
Temporary  Majors  (acting  Lieutenant-Colonels)  relinquishing  the 
acting  rank  of  Lieutenant-Colonel : J.  L.  Cock,  G.  W.  Treleaven,  A.  H. 

^Temporary  Captains  (acting  Majors)  relinquishing  the  acting  rank  of 
Major:  C.  K.  Dowson,  R.  B.  Mitchell.  . 

Temporary  Captains  (acting  Majors)  to  be  temporary  Majors : A.  W. 
Bagnall,  H.  C.  Mersereau,  J.  Seager,  H.  K.  Bate3,  II.  H Argu>,  L.  A. 
Richmond,  J.  McCulloch,  F.  T.  Campbell,  H.  M Barrett.  F.  H.  Pratten, 
F W Lees.  E.  Douglas,  L.  C.  Palmer.  A.  P.  Chown,  F.  J Tees,  W.  Y. 
Lamb,  D.  P.  Hanington,  11.  N.  W.  Shlllington,  W.  J.  MacKenzle.  J.  H. 
Moore.  W.  A.  Wilson,  S.  R.  Johnston,  T.  M.  Creighton  F F.  Dunham, 
A.  G.  MacLeod,  D.  A.  Clark,  C.  E.  Preston,  F W.  Blakmnan,  V N. 
MacKay,  J.  A.  Murray,  F.  B.  Bowman,  A.  B.  Schinbein.  M H.  Allen, 
W.  Ross,  W.  G.  Cosbie,  C.  E.  AndermD,  C.  W.  Waldron,  F.  Y. 
Woodbury.  H.  W.  Wadge,  T.  R.  Little,  E.  L.  Pope,  R.  R.  Barker,  H.  G. 

Wood,  J.  J.  Thomson,  H.  O.  Boyd,  A.  Blais. 

Honorary  Captains  (acting  Honorary  Majors)  to  be  Honorary  Majors : 
A.  E.  Clilton,  H.  J.  Testar,  J.  W.  White. 

Honorary  Lieutenants  (acting  Honorary  Captains)  to  be  Honorary 
Captains  . J.  F.  Christie,  H.T.  Cameron,  A.  P.  Ross,  W.  R.  Duff,  H.  G. 
Iliffe,  F.  White. 

GENERAL  RESERVE  OF  OFFICERS. 

Major  J.  W.  Jennings  to  be  Lieutenant-Colonel. 


Wednesday,  July  2nd. 

Treatment  of  Tuberculous  Pensioners. 

Sir  J.  D.  Rees  asked  the  Pensions  Minister  what  steps  he 
proposed  to  take  to  provide  for  concurrent  treatment  and 
trainiDg  on  the  colony  system  of  pensioners  suffering  from 
tuberculosis ; and  whether  he  had  under  consideration  the 
proposals  on  this  behalf  of  the  East  Midlands  Joint  (Dis- 
ablement) Committee.  — Major  Astor  (Parliamentary 
Secretary  to  the  Ministry  of  Health)  replied:  The  Inter- 
Departmental  Committee  on  Tuberculosis  have  under  con- 
sideration the  question  of  the  provision  of  colonies  for  the  con- 
current treatment  and  training  of  discharged  men  suffering 
from  tuberculosis,  and  I understand  that  the  report  of  the 
Committee  is  expected  very  shortly.  My  right  honourable 
friend  .has  been  informed  of  the  proposals  for  the  acquisition 
of  an  estate  in  Derbyshire  for  the  concurrent  treatment  and 
training  of  discharged  men  suffering  from  tuberculosis,  and 
I will  instruct  one  of  the  medical  inspectors  to  visit  the 
estate  and  report  upon  the  scheme. 

Thursday,  July  3rd. 


SPECIAL  RESERVE  OF  OFFICERS. 

Capt.  (acting  Major)  W.  McN.  Walker  relinquishes  the  pay  and  allow- 
ances of  his  acting  rank. 

TERRITORIAL  FORCE. 

Majors  (acting  Lloutenant-Colonels)  relinquishing  their  acting  rank 
on  ceasing  to  be  specially  employed  : J.  W.  Bird,  D.  H.  Weir,  W.  A. 
Thompson,  H.  T.  Samuel, R.  T.  Turner.  . 

Capt.  (acting  Lieut.-Uol.)  E.  Knight  relinquishes  his  acting  rank  on 

ceasing  to  be  specially  employed.  . . , . ..  . 

Major  (acting  Col.)  H.  Richardson  relinquishes  his  acting  rank  on 
vacating  the  appointment  of  Assistant  Director  of  Medical  services. 

Capts.  (acting  Majors)  relinquishing  their  rank  on  ceasing  to  be 
sneciallv  employed  • T.  B.  Layton,  R.  Phillips,  W.  F.  B.  Bensted- 
SmRh  I H Jordan.  P.  S.  Martin,  F.  H.  Robbins,  W.  T.  Gardiner, 
A W.  Hayward,  H.  B.  Cunningham,  J.  C.  S.  Dunn 

Capt.  (acting  Major)  L.  P.  Harris  relinquishes  his  acting  rank  on 
vacating  the  appointment  of  Deputy  Assistant  Director  of  Medical 
Services,  and  is  restored  to  the  establishment. 

Capt.  (acting  Major)  S.  F.  St.  J.  Steadman  relinquishes  his  acting 
rank  on  vacating  the  appointment  of  Deputy  Assistant  Director  of 
Medical  Services.  , . . 

Capt.  (acting  Major)  P.  C.  P.  Ingram  relinquishes  his  commission 
and  is  granted  the  rank  of  Major. 

1st  Eastern  General  Hospital:  Capt.  C.  H.  Budd  is  restored  to  the 
establishment.  . . . ..  . ...  , 

Sanitary  Service : Capt.  W.  Robertson  is  restored  to  the  establish- 
ment on  ceasing  to  hold  a temporary  commission  in  the  R.A  M.C. 

2nd  London  Sanitary  Company  : Lieut.  C.  J.  Regan  to  be  Captain. 


TERRITORIAL  FORCE  RESERVE. 

Capt.  E.  S.  Taylor,  from  2nd  London  Casualty  Clearing  Station  to  be 
Captain. 

ROYAL  AIR  FORCE. 


Medical  Branch.-Cspts.  H.  T.  H.  Butt,  W.  F.  Walker.  R.  H.  Dixon, 
and  Lieut.  G.  M.  Mellor  are  transferred  to  unemploye  i list. 

Dental  Branch. -Lieut.  H.  Wardill  is  traniferred  to  unemployed 
list.  


INDIAN  MEDICAL  SERVICE. 

Majors  to  he  Lieutenant-Colonels  G.  P.  T.  Groube.  E.  D.  Y\  . Greig. 
W E.  McKechnie,  W.  F.  Harvey,  W.  C.  H.  Forster,  J.  J.  Urwin,  D- 
McCay,  A.  B.  Fry,  E.  C.  G.  Maddock,  W.  H.  Dickinson,  A.  W.  luke. 
G.  H.  Stewart. 


At  tlie  last  meeting  of  tlie  Launceston  (Cornwall^ 
board  of  guardians  Dr.  W.  F.  Thompson  resigned  the  post  of 
medical  officer  for  the  No.  3 district  after  35  years  service. 


Welsh  Board  of  Health. 

Brigadier-General  Sir  Owen  Thomas  asked  the  Minister 
of  Health  whether  it  was  proposed  to  give  representation  on 
the  Welsh  Board  of  Health  to  the  executive  committee  of 
the  Welsh  National  Memorial  Association,  to  the  ->orth  and 
South  Wales  nursing  associations,  and  to  the  executives  of 
North  and  South  Wales  soldiers’  and  sailors’  disablement 
committees.— Major  Astor  replied  : As  I stated  in  reply  to 
a question  by  the  honourable  and  gallant  Member  on 
June  30th,  the  Board  is  not  yet  complete  ; but  I may  point 
out  that  Section  5 of  the  Ministry  of  Health  Act  requires 
the  persons  constituting  the  Boards  to  be  officers  of  the 
Ministrv,  and  that  this  requirement  excludes  the  possibility 
of  adopting  the  principles  suggested  in  the  question  as 
determining  the  nature  of  future  appointments  to  the 
Board  The  important  bodies  referred  to  in  the  question 
will  probablv  he  asked  to  suggest  suitable  names  of  persons 
for  membership  of  the  Consultative  Council  of  the  Ministry 
of  Health  in  Wales.  . 

Brigadier-General  Sir  Owen  Thomas  asked  the  M.nister  of 
Health  if  he  would  state  what  was  the  amount  of  the  total 
remuneration  paid  to  those  Commissioners  of  the  elsh 
Insurance  Commission,  now  transferred  to  the  Welsh  hoard 
of  Health,  during  the  period  of  war ; what  time  was  devoted 
bv  them  to  the  specific  duties  of  the  Commission  during  that 
period;  what  was  the  salary  to  be  paid  to the  chairman 

members,  and  officers  of  the  Welsh  Board  of  Health  already 
constituted;  and  what  further  salaries,  if  any,  were  to  be 
paid  to  the  members  of  the  Board  yet  to  be  aPP°mtte.d~: 
Maior  Astor  replied:  The  remuneration  of  the  thiee 
members  of  the  Welsh  Insurance  Commission  who  nave  now 
been  appointed  members  of  the  Welsh  Board  of  Health  was 
at  the  rate  of  £1000,  £1200,  and  £1000  per  annum  respectively, 
and  no  change  has  been  made  in  these  rates  on  their  trans- 
ference The  whole  time  of  the  Commissioners  was  very  fully 
occupied  with  Health  Insurance  work,  except  in  so  far  as  they 
undertook  various  forms  of  temporary  war  work  from  time  to 
time.  The  point  in  the  last  paragraph  of  the  question  has 
not  yet  come  up  for  decision  and  no  decision  has  been  taken 

011  lt-  National  Health  Insurance  Bill. 

Major  Astor  (Parliamentary  Secretary  to  the  Ministry  of 
Health)  moved  the  second  reading  of  the  National  Health 
Insurance  Bill.  He  said  it  was  not  in  any  way  an  attempt 
to  amend  the  Insurance  Act,  1911.  The  whole  object  of 
the  Bill  was  to  maintain  as  far  as  possib,e  the  status  quo. 
Because  of  the  change  in  money  values  a large  number  oi 
people  who  in  1911  were  earning  round  about  £li  0 were 
LowP  earning  something  like  £250.  The  original  Act,  which 
made  insurance  compulsory  for  non-manual  workers  witn 
a low  income,  would,  unless  this  amendment  were  made, 
drive  out  of  insurance  nearly  1,000,000  msured  persons. 
In  selecting  the  figure  of  £250  instead  of  £160  they  bad 
been  guided  by  the  award  of  the  Conciliation  and  Arbitra- 
tion Board  for  Government  employees.  It  would  be  a real 
hardship  if,  having  contributed  over  a considerable  period 
towards  insurance,  anything  up  to  a million  persons 
were  to  lose  the  benefit  of  their  contributions,  and 
toat  would  happen  as  from  June  30th  last  unless 
this  small  Bill  were  passed.  If  this  Bill  ftcere 
passed  a large  number  of  medical  men  who  dealt  with 
insured  persons  would  lose  their  patients.  He  had  received 
deputations  from  medical  men.  There  was  one  point  which 
was  raised,  and  that  was  the  bringing  into  insurance  of  tha. 
very  limited  class— some  20,000  or  oO.OOO  people  so  far  as 


The  Lancet,] 


PARLIAMENTARY  INTELLIGENCE. 


[July  12,  1919  87 


they  were  able  to  estimate — who  would  for  the  first  time  be 
brought  into  insurance.  He  told  the  deputation  that  they 
did  not  want  to  bring  these  people  into  insurance,  but  that 
they  found  it  administratively  impossible  to  exclude  them. 
They  tried  to  frame  a clause  which  would  exempt  them,  but 
were  unable  to  do  so.  He  asked  his  honourable  friends  to  do 
the  same,  and  if  in  Committee  they  were  able  to  put  down 
an  amendment  which  carried  out  their  intention,  and  what 
the  Government  would  like  to  include  in  the  Bill,  they  would 
be  pleased  to  accept  it. 

Criticism  of  the  Bill. 

Major  Farquharson  said  that  he  quite  agreed  that  there 
existed  a necessity  for  some  such  Bill,  and  he  was  quite  sure 
that  the  whole  community,  with  the  medical  profession  as 
well,  would  agree  that  people  who  were  now  insured  persons, 
and  had  been  for  some  time  insured  persons,  should  not 
lapse  their  insurance  benefits  because  of  the  altered  values 
of  money.  But  he  had  to  find  fault  with  the  text,  and  with 
the  effect  of  the  Bill.  The  text  was  so  framed  that  the 
annual  income  was  taken  as  a basis  for  determining  that 
certain  people  should  now  be  in  insurance  who  had  not  been 
in  insurance  before.  The  new  limit  of  £250  meant  that  a 
large  number  of  entrants  into  insurance  benefits  were 
legalised  by  statute.  He  had  not  the  slightest  objection 
to  everybody  and  anybody  obtaining  insurance  benefits, 
but  let  them  remember  that  the  position  they  were  now 
in  was  standardised  and  fixed  by  statute.  The  medical 
men  made  certain  definite  binding  contracts  that 
they  would  attend  people  whose  incomes  did  not 
exceed  £160.  Those  contracts  were  now  in  existence 
and  were  passed  in  review  at  the  end  of  each  year.  The 
medical  profession  had  a right  to  stand  upon  the  sanctity 
of  a contract,  and  to  demand  that  they  should  not  be 
penalised  for  the  benefit  of  any  section  of  the  community. 
He  would  take  this  question  from  the  point  of  view  of  the 
panel  practitioner.  The  Government  had  contracted  with 
him  at  the  present  time  to  do  certain  definite  things  under 
certain  definite  rules.  This  had  been  departed  from.  Take 
the  case  of  the  non-panel  practitioner — the  middle-class  non- 
panel practitioner  attending  people  for  small  fees.  By  this 
Bill  all  these  non-manual  workers,  such  as  clerks,  would  be 
compelled  to  be  insured.  Major  Astor’s  estimate  was 
the  merest  conjecture.  The  number  might  be  very 
large  or  very  small,  but  on  the  one  hand  the  Government 
was  destroying  a contract  of  service  with  the  panel  prac- 
titioners, and  on  the  other  destroying  a great  many  practices 
of  men  working  hard  for  a livelihood.  At  this  time,  when 
great  schemes  of  medical  service  were  coming  before  the 
country,  he  thought  this  was  a most  inopportune  moment 
to  tamper  with  a contract  of  service.  He  appealed  to  the 
Government  to  accept  some  modification  of  the  Bill  which 
would  enable  at  least  a postponement  of  new  entrants  into 
insurance  and  for  the  whole  scheme  of  medical  insurance  to 
be  considered. 

An  Amendment. 

Captain  Ormsby-Gore  moved 

“ That  this  House  declines  to  proceed  with  a measure  which  increases 
the  number  of  persons  compelled  to  make  contributions  towards  the 
funds  administered  by  the  National  Health  Insurance  Commissioners 
without  guaranteeing  acceptable  medical  service  to  all  insured  persons 
and  without  establishing  the  principle  of  free  choice  both  by  patient 
and  medical  practitioner.” 

He  said  that  he  did  think  that  it  was  fair  to  say  that 
sufficient  attention  had  not  been  paid  to  the  point  of 
view  of  panel  doctors  and  also  non-panel  doctors.  The 
intention  of  Parliament  in  the  original  Act,  Clause  15, 
Subsection  (3),  had  not  been  carried  out.  The  National 
Health  Insurance  Commissioners  and  the  Committees  set 
up  under  that  Act  had  not  provided  acceptable  medical 
service  to  insured  persons  where  those  insured  persons 
were  either  unwilling  or  unable  to  make  use  of  the 
services  of  the  panel  doctors.  The  result  was  that  in  the 
town  of  Stafford  a few  panel  doctors  had  far  more  patients 
than  they  could  pay  attention  to,  and  the  remainder  of  the 
doctors  got  nothing  from  the  Insurance  Committee  or  the 
Insurance  Fund.  Stili,  they  were  dealing  with  over  700 
insured  persons,  and  these  had  to  pay  twice  over.  That 
was  a grievance  which  had  to  be  redressed.  If  the  insured 
persons  were  to  be  considered  with  respect  to  wages  the 
doctors  ought  to  be  considered  too. 

Captain  Elliot  seconded  the  amendment.  The  main 
point  he  wished  to  make  was  that  the  Insurance  services  just 
now  from  a medical  point  of  view  were  not  satisfactory 
Great  services  under  the  Insurance  Act  were  still  being  given 
for  charity  as  they  were  before.  The  services  of  consultants 
surgeons,  and  so  on  were  being  given  just  the  same  as  before. 
He  did  not  think  that  was  a fitting  way  for  service  to  the 
sick  of  this  country  to  be  rendered. 

Lieutenant-Commander  Kenworthy  hoped  that  the 
amendment  would  not  be  pressed.  In  most  parts  of  the 
country,  though  possibly  not  in  Stafford,  the  Insurance  Act 
was  giving  satisfaction  to  the  insured.  He  was  interested 
in  the  indignation  of  Major  Farquharson  when  he  told  the 


Government  of  the  hardships  of  the  medical  practitioner  at 
the  present  time  and  threatened  that  the  doctors  would 
form  a trade-union.  They  were  in  a trade-union.  . ^ 

Honourable  Members:  No  ! w '“•<« 

Commander  KenworthY  : Yes,  they  are  in  the  ^most 
exclusive  union  in  the  country. 

Honourable  Members  : No!  No! 

Captain  Elliot  : But  they  do  not  strike. 

Commander  Kenworthy  : They  have  threatened  to  strike 
in  the  past.  Continuing,  the  honourable  Member  said  he 
was  sure  that  Members  on  that  side  of  the  House  would  be 
only  too  glad  to  support  any  motion  made  by  the  Minister 
of  Health  to  increase  the  fees  chargeable  by  panel  doctors, 
for  he  thought  it  was  recognised  that  they  had  a hard  case 
and  that  it  should  be  done.  But  let  them  get  this  Bill 
through  first. 

Sir  P.  Magnus  said  that  while  he  was  prepared  to  support 
the  second  reading  of  the  Bill  he  thought  that  very 
important  and  drastic  changes  should  be  made  in  it. 

After  further  discussion,  Major  Astor  appealed  to  the 
mover  of  the  amendment  not  to  press  it.  The  point  he 
made  he  thought  was  already  met,  as  the  persons  brought  in 
would  have  the  right  of  claiming  a certificate  of  exemption. 
As  regarded  what  Captain  Ormsby-Gore  had  said  about  the 
insured  persons  in  his  constituency,  that  was  not  a matter 
of  legislation  but  of  administration.  He  could  assure  him 
that  the  Minister  of  Health  and  himself  would  go  into  the 
matter  and  see  if  anything  could  be  done.  He  welcomed 
this  opportunity  of  paying  a tribute  to  the  splendid  services 
which  the  medical  profession  had  rendered  to  the  wounded 
in  France  and  England  during  the  war.  They  all  realised 
that,  and  also  the  extent  to  which  they  could  count  upon  the 
profession  in  the  future  in  the  administration  of  the  Ministry 
of  Health. 

Captain  Ormsby-Gore  withdrew  his  amendment  and  the 
Bill  was  read  a second  time  and  referred  to  a Standing 
Committee. 

Friday,  July  4th. 

Nurses’  Registration  Bill. 

The  adjourned  debate  on  the  Report  Stage  of  the  Nurses’ 
Registration  Bill  was  resumed. 

Major  Nall  said  that  he  had  received  a letter  from  the 
College  of  Nurses  intimating  that  on  the  Government 
undertaking  to  introduce  a registration  Bill  for  nurses  they 
were  ready  to  withdraw  their  Bill  in  the  House  of  Lords. 
The  promoters  of  the  Bill  now  before  the  House  had  refused 
a week  ago  to  withdraw  it,  and  as  there  was  now  very  little 
time  to  consider  the  amendments  on  the  paper  he  moved 
that  the  further  consideration  of  the  Bill  should  be  adjourned 
in  order  that  it  might  be  allowed  to  lapse. 

Captain  Barnett  protested  against  the  organised  opposi- 
tion to  this  Bill,  and  said  that  but  for  this  there  would 
have  been  ample  time  to  get  it  through  its  various  stages 
and  send  it  up  to  the  House  of  Lords,  where  some  agree- 
ment might  be  arrived  at.  He  hoped  the  Ministry  of  Health 
would  nevertheless  have  the  courage  to  bring  forward  a 
measure  on  behalf  of  the  Government. 

Major  Astor  nodded  assent. 

The  motion  to  adjourn  the  further  consideration  of  the 
Bill  was  agreed  to. 

Syphilis  Treatment. 

Mr.  Waterson  asked  the  Minister  of  Health  whether  his 
Department  was  taking  any  action  in  regard  to  the  recent 
death  of  a girl  in  St  George’s  Hospital  while  undergoing 
treatment  for  congenital  syphilis ; what  drug  was  used  in 
this  case,  and  whether  it  had  received  the  approval  of  his 
Department ; whether  he  proposed  to  continue  to  approve  of 
the  use  of  such  drugs ; whether  it  was  a fact,  as  stated  by  a 
medical  witness  at  the  inquest,  that  there  had  been  a crop  of 
such  cases  at  Cambridge  and  Dublin  during  the  war  ; how 
many  deaths  of  this  description  had  occurred  in  England  and 
Wales  since  the  beginning  of  the  war ; and  whether  he  would 
make  arrangements  for  the  immediate  report  to  his  Depart- 
ment of  all  such  deaths,  both  among  soldiers  and  ex-soldiers 
and  in  the  general  population,  in  order  that  careful 
records  might  be  available  for  reference  ?— Major  Astor 
(Parliamentary  Secretary  to  the  Ministry  of  Health) 
replied  : The  answer  to  the  first  part  of  the  question 
is  in  the  affirmative.  The  case  referred  to  is  under  inquiry 
by  the  Special  Committee  appointed  by  the  Medical 
Research  Committee  to  investigate  the  results  of  the 
treatment  of  syphilis  by  salvarsan  and  its  substitutes. 
I understand  that  the  drug  used  in  this  case  was 
novarsenobillon,  which  is  one  of  the  drugs  approved  by  my 
Department  for  the  treatment  of  syphilis  and  tested  under 
arrangements  made  by  the  Medical  Research  Committee. 

I am  not  aware  of  any  sufficient  reason  for  discontinuing 
the  approval  of  the  use  of  this  and  similar  drugs.  In 
this  connexion  I may  add  that  I understand  the  coroner’s 
finding  at  the  inquest  on  this  case  was  that  this  drug 
was  properly  administered  and  in  proper  amount.  I 
understand  that  there  have  been  several  fatal  cases 
following,  though  not  necessarily  caused  by,  the  adminis- 


88  The  Lancet,] 


APPOINTMENTS.—' VACANCIES. 


[July  12, 1919 


tration  of  these  drugs  in  military  hospitals  at  Cambridge 
and  Dublin  during  the  war,  and  these  cases  also  are 
under  investigation  by  the  Special  Committee.  No  precise 
information  is  at  present  available  as  to  the  number  of 
deaths  of  this  description  which' have  occurred  in  England 
and  Wales  since  the  beginning  of  the  war,  but  the  total 
number  is,  of  course,  very  small,  especially  in  proportion  to 
the  very  large  number  of  injections  of  such  drugs  taking 
place  daily.  The  suggestion  in  the  last  part  of  the  question 
will  be  considered  with  the  report  of  the  Special  Committee 
when  it  is  received.  Already  my  Department  have  been 
considering  the  desirability  of  requiring  special  reports 
direct  to  the  Ministry  of  all  exceptional  results  following 
the  administration  of  these  drugs. 

Tuesday,  July  8th. 

Medical  Demobilisation. 

Mr.  Macquisten  asked  the  Secretary  for  War  if  he  would 
state  what  was  the  general  policy  of  medical  demobilisation; 
why  the  promise  given  by  the  Ministry  of  National  Service 
in  November,  1918,  that  the  demobilisation  of  medical  men 
with  long  service  or  with  practices  to  return  to  would  be 
effected  rapidly  by  replacing  them  with  newly  qualified 
graduates  had  not  been  given  effect  to ; and  how  many, 
if  any,  temporary  commissions  in  the  Royal  Army 
Medical  Corps  had  been  granted  since  the  Armistice. — Mr. 
Churchill  replied  : The  demobilisation  of  an  individual 
medical  officer  is  left  in  the  hands  of  the  General 
Officer  Commanding  in-Charge  concerned,  and  the  policy 
is  to  release  first  those  who,  on  account  of  age, 
length  of  service,  personal  hardship,  public  expe- 
diency, &c.,  are  considered  most  deserving  of  con- 
sideration. It  will  readily  be  understood  that  even 
then  it  is  impossible  to  meet  every  claim,  as  it  is 
still  found  necessary  to  retain  certain  officers  possessed 
of  special  qualifications  and  for  whom  it  is  found  impossible 
to  find  substitutes.  Any  applications  received  by  the  War 
Office  are  given  every  consideration,  and  when  the  claims  of 
either  an  individual  medical  officer  or  the  application  of  any 
public  body  for  the  services  of  a particular  officer  come  under 
any  of  the  above  categories  every  effort  is  made  to  obtain  his 
release,  but  his  claim  has  to  be  considered  in  conjunction 
with  the  claims  of  other  officers  serving  in  the  same  Command 
at  home  or  Expeditionary  Force  overseas.  No  temporary 
commissions  have  been  granted  in  the  Royal  Army  Medical 
Corps  since  the  Armistice,  but  a new  contract  has  now  been 
approved  whereby  it  is  hoped  that  a large  number  of  recently 
qualified  medical  men  will  volunteer  for  service  overseas, 
and  thus  enable  those  who  have  served  longest  to  be  released. 


BOOKS,  ETC.,  RECEIVED. 

Bailliere,  Tindall,  and  Cox,  London. 

Care  of  the  No;e  and  Throat.  By  W.  Stuart-Low,  F.R.C.S.  Eng. 
Pp.  63.  is.  6 d. 

Cassell  and  Co.,  Ltd.,  London. 

Food  and  Public  Health.  By  W.  G.  Savage,  M.D.  Pp.  156.  5s. 

Infant  and  Child  Welfare.  By  H.  Scurfield.  Pp.  166.  5s. 

The  Story  of  English  Public  Health.  By  Sir  Malcolm  Morris, 
K.C.V.O.  Pp.  166.  5s. 

Churchili,  J.  and  A.,  London. 

Vicious  Circles  in  Disease.  ByJ.  B.  Hurry,  M.D.  3rded.  Pp.377.  15 s. 

A Short  Practice  of  Medicine.  By  Robert  A.  Fleming,  M.D.  3rd  ed. 
Pp.  676.  21e. 

The  Ophthalmoscope.  By  G.  Hartridge,  F.R.C.S.  6th  ed.  Pp.  152. 
6s.  6cL 

Frowde,  H.,  and  Hodder  A Stoughton,  London. 

The  Nervous  Heart.  By  R.  M.  Wilson,  Captain,  R A.M.C,  and  J.  H. 

Carroll,  Major,  M.C.,  U.S.A.  Pp.  136.  6s. 

Constipation  and  Allied  Inte.tinal  Disordeis.  By  A.  F.  Hurst,  M.D. 
2nd  ed.  Pp.  440.  16s. 

Psychoses  of  the  War.  By  H.  C.  Marr,  Lieutenant  Colonel,  R. A.M.C. 
(Temp.).  16s. 

Trench  Fever,  a Louse  borne  Disease.  By  Major  W.  Byam, 
K.A  M.C.,  and  others.  With  Introduction  by  Lieutenant-General 
Sir  T.  H.  Goodwin,  a Foreword  by  Major-General  Sir  David  Bruce, 
and  a Summary  of  the  repoit  of  the  American  Trench  Fever  Com- 
mission by  Lieutenant  R.  H.  Vercoe,  R. A.M.C.  Pp.  196.  10s  6 d. 
Griffin,  Charles,  and  Co.,  London. 

Handbook  of  Medical  Jurisprudence  and  Toxicology.  By  W.  A. 

Brend,  M D.  3rd  ed.  Pp.  317.  10s.  6 d. 

Medical  and  Surgical  Help  for  Shipmasters  and  Officers  In  the 
Merchant  Navy.  By  W.  J.  Smith,  F.R.C.S.  Revised  by  A. 
Chaplin,  M.D.  5th  ed.  Pp.  355.  fs. 

Surgical  Handbook.  By  F.  M.  Caird,  M.B.,aud  C.  W.  Cathcart,  M B 
18tl>  ed.  Pp.  364.  8s.  6d. 

Lewis,  II.  K.,  and  Co.,  Ltd.,  London. 

The  Diagnosis  and  Treatment  of  Heart  Disease.  By  E.  M. 

Brockbank,  M.D.  4th  ed.  Pp.  158.  5s. 

Practical  Vaccine  Treatment  for  the  General  Practitioner.  By  R.  W. 

Allen,  M.D.,  late  Captain,  N.55.M.C.  Pp.  308.  7s.  6<f. 

Massage  and  the  Swedish  Movements.  By  Kurre  W.  Ostrom  (Upsalah 
8th  ed.  Pp.  196.  5s. 

Wright,  John,  and  Sons,  Ltd.,  Biistol. 

On  Gunshot  Injuries  to  the  Blood- Vesst Is.  By  G.  H.  Makins. 
G.C.M.G.,  C.B.  Pp.  252.  21s. 

Year  Book  Publishers,  Chicago. 

Practical  Meoiciue  Serbs.  1919.  Vol.  I.  Edited  by  F.  Billings, 
M.D.  Pp.  622,  $’.50.  1 


^pointments. 


Gamqek,  Leonard  P.,  F.R.C.S,  has  been  appointed  Professor  of 
.Surgery  in  the  Univers  ty  of  Birmingham. 

Goodbody,  F.  W , M.D.  Dub,  M.R.C.P.  Lond.,  Lecturer  In  Medical 
Chemistry  in  Univers  ty  College.  Loudon. 

Gray,  H.  T.,  F.R.C.S.  Eng.,  Honorary  Surgeon  to  the  Infants  Hospital, 
Vlncent-square,  W<  stmlr.s'er. 

Jupp,  Edgar  Norman,  M.D.  Brux.,  L8C  P„  M.R.C.S.,  Medical  Officer 
and  Public  Vaccinator  for  the  North  Chardstock  District  of  the 
Axmlnster  (Devon)  Union. 

Lister,  A.  B.  J..  M»j  .r,  I.MS.,  MB,  BS.Lond.,  F.R.C.S.  Eny.,  an 
Honorary  Surgeon  to  H E.  the  V ceroy  and  Governor  General  of 
India. 

Lumsden,  Thomas,  Medical  Referee  to  the  Ministry  of  Pensions  for 
Westminster. 

Sandiland,  E.  L.,  M B , B.S.  Lond.,  D.P.H.,  Resident  Melical  Officer 
to  the  Croydon  Borough  Sanatorium. 

Shattock,  Clement  E , M.D.,  M.S.,  F.R.C.S.,  Surgeon  to  Out- 
patients, Paddington  Green  Children’s  Hos)  leal. 

Walker,  C.  D , M.B  , Cb.B.  Edin,,  one  of  the  Medical  Referees  under 
the  Workmen's  Compensation  Act,  1906,  for  the  County  Court 
Circuits  Nos.  13  and  18. 

Woodruff,  D.,  Medical  Officer  and  Pubi  c Vaccinator  for  the  No.  9 
District  of  the  Bodmin  (Cornwall)  Union. 

University  <f  St  Andrews.— Price,  L.  T.,  M B.  Ch.B  Edin.,  Professor 
of  Surgery;  Chakteris,  F.  J.,  M B.,  Ch.B.  Giasg  , Professor  of 
Materia  Medica 


Vacancies. 


For  farther  information  refer  to  the  advertisement  columns. 

Bath,  Royal  Mineral  Water  Hospital. — Two  S.’s. 

Birmingham  General  Hospita’.—  Res.  M.O.  £155.  Hon.  S.  Hon. 

Aural  S.  and  Laryngologist.  Asst.P.  £50  Surgical  Registrar.  £'00. 
Bolingbroke  H'Spita Watidsworth  Common,  S.  W.— H.S.  £150. 
Bristol,  Cos-ham  Memorial  Hospital,  Kingswoud.—Res.  M.O.  £200. 
Bury  County  Borough. — Asst.  M.O.H.,  Asst.  Sch.  M.O.,  and  Asst. 
Tubetc  O.  £5C0. 

Bury,  St.  Edmund’s,  West  Suffolk  General  Hospital. — Res.  H.S.  £175. 
Cunteibu-y,  Ken’,  and  Canterbury  Hospital.— Jon.  Res.  M.O.  £150 
Cheam.  Surrey,  St.  Aidhony's  H.spital.  — Hes.  M.O. 

Chelmsford  Borough.— M.O. H.  and  Sch.  M.O.  £600. 

Chelsea  Hospital  for  Women,  Athurst  eet,  S.  W.— H.S.  £120.  Also 
Regist  rar.  £50. 

Charley  Borough  Education  Committee  —Asst.  Sch.  M.O.  £400. 
Darlington  General  Hospital.— H.S.  £225. 

Devonport,  Royal  Albert  Hospital.— Re s.  H.S.  £200. 

Didworthy,  Devon  and  Cornwall  Sana’urium.—  Locum  Tenens.  6 gs. 
a week. 

Edinburgh  City.— Clin.  M.O.  under  Venereal  Diseases  Scheme.  £750. 
Exeter,  Royal  Devon  and  Exeter  Hospital—  Sen.  H.S.  £250. 

Gravesend  Hospital.  — H.S.  4 200. 

Great  Korihem  Central  Hospital,  Hol’oway,  London.— Opb.  S. 
Grosvenor  Hospital  for  Women,  Vincent-square,  Westminster.— Surgical 
Registrar. 

Hospital  for  Consumption  and  T iseases  of  the  Chest,  Brompton.—H.V. 
Hospi'al  for  Sick  Children,  Great  Ormond-slreet,  London,  W.C.— 
P.  and  S.  Also  Surgical  Registrar.  £200.  Also  H.S.  £50. 
Isleworth  Infirmary. — Sec.  Asst,  to  Med.  Supt.  £300. 

Khartoum,  Wellcome  Tropical  Research  Laboratories.  — Assistant 
Bacteriologist.  £E.600 

Leeds  Education  Committee.—  School  M.O. ’a.  £400. 

Leeds  University.— Lect.  in  Experi.  Phys.  £SCO.  Demonstr.  in  Phys. 

£250.  Demonstr.  in  Hi6t.  £250. 

L-wisham  Union,  Fore,  t E ill  District. — M.O.  £185. 

Liverpool,  Fazakerley  Sanatorium  for  Tuberculosis.— Asst . Res.  M.O. 
£250. 

Liverpool  School  of  Tropical  Mediedne.—  Asst.  Lect.  in  Parasitology. 

£250. 

L.C.C.  Hackney  Institut  \ Dalston-lane.  — Lecturer  of  Sanitary  Science. 
30s.  an  attendance. 

London  Hospital,  E.-  Surgical  Registrar.  Also  First  Asst. 

London  Lock  Hospital,  ISS,  Harrow-road,  W ; 91,  Dean-street,  Soho, 
W. — Regis’  rar. 

London  ( Royal  Free  Hospital ) School  of  Medicine  for  Women.— Two 
Demstrs.  of  Anat.  £259.  Also  Female  Pharm.  £250. 

London  Temperance  Hospital.  Hampstead- road,  H. IF. — Asst.  Res.  M.O. 
£120.  Also  Casualty  Officer.  £120. 

Mi  idstone.  West  Kent  General  Hospital.— H S.  and  Asst.  H.S.  £250 
and  £125. 

Manche-ter,  Crostley  Sanatorium  —Asst.  M.O.  £100. 

Manchester  Ear  Hospital,  Grosrenor-sqaare,  All  S ints—ll.S. 
Manchester  Hospital  for  Consumption  and  Disec.s's  of  the  Throat  and 
Chest,— Hon.  Aest.  P. 

Manche-ter  Royal  Eye  Hospital.— Jon.  H.S.  £120. 

Memchester.  St.  Mary's  Hospitals  for  Women  and  Children.—  Three  H.  S.'s 

£100. 

Merthyr  Tydfil  County  Borough.— Female  M.O.  for  Maternity  and 
Infant  Welfare  Work.  £500. 

Metropolitan  Borough  of  Deptford.— Asst.  M.O  H.  £400. 

Otago  Univers  ty,  Sew  Zealand.— Prat,  of  Syst.  Med..  Prof,  of  Clin. 
Med.  ani  Therap.,  and  Lect.  ou  Clin.  Med.  £600,  £500,  and  £400 
res]  evtively. 

Prince  of  Wales’s  General  Hospital,  Tottenham.  A'.  — Hon.  Asst.  P., 
Hon.  Med.  Regist.,  and  Hon.  Anaeslh.  Also  Clin.  Assts. 

Queen  Charlotte’s  Lying-in  Hispital,  Ma rylebme-road,  H.  W.—  Phys.  to 
Out-patients. 

Quern  Mary's  Hospital  forthe  East  End.  Stratford,  E.— Hon.  Ophth.  S.'s. 
Also  H.S. 

Rossall  School,  Fleetwood. — Res.  M.O.  £250. 

St.  Helens  County  Borough.— Asst.  M.O.H.  £500. 

£(.  J -hn’s  Hospital  fer  Disc  set  of  the  Skin,  V),  Leicesler-iquare 
Electro-Therapeutist.  £100. 


Thb  Lanoht,] 


NOTES,  SHORT  COMMENTS,  AND  ANSWERS  TO  CORRESPONDENTS.  [July  12,  1919  89 


St.  Marylebone  General  Dispmsary,  71,  Welbeck- street,  Cavendish- 
square,  IP.— Res.  M.O.  £150. 

St.  Peter's  Hospital,  Henriettct-street,  Covent  Garden,  IK.6\— Anresth. 
£25. 

Sheffield  Royal  Infirmary.— Asst.  H.P.  £150.  Oph.  II. S.  £160. 
Southampton  County  Borough  Isolation  Hospital.  — Res.  M.O.  £400. 
Stockport  County  Borough  Education  Committee. — Sch.  Doctor.  £400. 
Tingwall,  Whiteness,  and  Weisdale  Parish.— M.O  and  Pub.  Vac.  £45 
Tottenham  Maternity  and  Child  Weljare  Committee;  Anlenatal  Clinic. 

— Female  M.O.  £1  11s.  6 d.  per  session. 

University  College  Hospital,  Qower-street,  IV. C.— Res.  M.O.  £150. 
Victoria  Hospital,  Tile-street,  Chelsea.  S.  H’.— H.P.  and  H.S.  £100. 
Wolverhampton  and  Staffordshire  General  Hospital.— Path,  & B ic.  £350 
Also  ltes.  M.O.  £200. 

The  Chief  Inspector  of  Factories,  Home  Office,  S.W.,  gives  notice  of 
vacancies  for  Certifying  Surgeons  under  the  Faotory  and  Workshop 
Acte  at  Basingstoke  (Hants)  and  Newport  (Pembroke). 


Hlarriitgej,  anb  gtaijp. 


BIRTHS. 

Dick.— On  July  3rd,  at  Walton  Lodge,  Walton-on-the-Hill,  the  wife  of 
F.  A.  Dick,  M.B.,  of  a daughter. 

Sells.— On  July  2nd,  at  WestclW  on-Sea,  the  wife  of  Boland  Sells, 

M.R.0.S.,  L.R  C.P.,  of  a son. 

Stowell. — On  July  6th,  at  “ Fir  Grove,”  Northwioh,  Cheshire,  the 
wife  of  Thomas'R.  A.  Stowell,  F.R.C.S.  Eng.,  of  a son. 

MARRIAGES. 

Jones— Dugdale. — On  July  1st,  at  S.  Pollips  Church,  Blackburn, 
William  Edmun  l Jines,  M.R.C.S.,  L.R.C.P.,  of  Blackburn,  to 
Edith  Muriel,  youugest  daughter  of  the  late  Adam  Dugdale  and  of 
Mrs.  Dugdale,  of  Griffin  Lodge,  Blackburn. 

Lynch— Doughty.- Ou  Julr  1st,  at  St.  Peter-upon-Cornhill,  E.C., 
Arthur  Louis  Lynch,  M.D.,  C.M.,  F.R.C.S,  Capt.  R A.  M.C.,  to 
Janet  Hunter  Klizibjth  (Jean)  Doughty,  daughter  of  the  Rev. 
George  Bell  Doughty  an  l Mrs.  Janet  Hunter  Doughty, 
Westbourne-gardens,  W. 

McM  as  ter -Stewart. — On  July  2nd,  at  All  Saints,  Kenley,  Surrey, 
Archibald  Cotterill  McMaster,  M.B.,  F.li  C.3.B.,  to  Netta, 
daughter  of  the  late  James  Henry  Fowler  Stewart,  Ardrots, 
Ross-ffilre. 

DEATHS. 

Collins.— Oq  July  9:h,  at  Sproxton,  New  Wanstead,  Frank  Collins, 
M.R.C.S.,  L.R.C.P.,  suddenly,  after  many  months  of  Ill-health. 

Dodd.— On  July  3rd, at  Drummonl-road,  Bournemouth,  Henry  Allnutt 
Dodd,  M.R.C.S.,  L.S.A  , aged  90. 

Sells.  — On  July  4th,  at  the  R.A.F.  H>«pltal,  Swanage,  Captain 
Clement  Perronet  Sails,  M.O,,  R.A.M.C.  (T.),  aged  2}. 

N.B.—A  fee  of  6s.  is  charged  for  the  insertion  of  notices  of  Births, 
Marriages,  and  Deaths. 


Communications,  Letters,  &c.,  to  tiie  Editor  have 
been  received  from— 

Sec.  of ; London  Dermatological 
Society,  Hon.  Sec.  of ; Mr.  S.  S. 
Lindsay,  Lond.;  Major  J.  H. 
Lloyd,  R.A  M.O. 

M.  — Dr.  C.  A.  Mercier,  Bourne 
mouth  j Mr.  T.  Macquaker, 
Lond.  ; Medico  - Psychological 
Association  of  Great  Britain  and 
Ireland;  Ministry  cf  Heal  h, 
Lond  ; Dr.  A.  S.  MacNalty, 
Lond.;  Dr.  H.  M.  Meyrick-Jones, 
Cheltenham. 

N.  — National  Dental  Association, 
Loud.,  Gen  Sec.  of. 

O.  — Dr.  C.  M.  O'Brien,  Dublin. 

P.  — Dr.  S.  V.  Pearson,  Mundesley  ; 
Panel  Committee  for  the  County 
of  London ; Dr,  H.  R.  Prentice, 
Lond. 

R. — Royal  Institute  of  Public 
Health,  ActiDg  Sec.  of ; Dr.  J.  D. 
Rolleston,  Lond.;  Dr.  J.  N. 
Robins,  St.  Peter's-in-Thanet ; 
Royal  Society  of  Medicin'-,  Lond., 
Sec.  of,  Mr.  W.  H.  C.  Romanis, 
Lond. 

S. — Dr.  A.  G.  Shera,  Eastbourne; 
S;ciety  for  Relief  of  Wi  lows  sun 
Orphans  of  Medical  Men,  Loud  , 
Sec.  of ; Mr.  3.  L.  Sbarna, 
Meerut,;  Dr.  S.  V.  Sunderland 
Lond  ; South  London  Ho  pita! 
for  Women,  Sjc.  f;  Standard 
Motor  Co.,  Lon  1.;  1 ref.  W.  Stir- 
ling, Manchester ; Mr.  R.  E 
Smith,  Barry. 

T.  — Dr.  A.  H.  Thompson,  Lond.; 
Dr  H.  H.  Tooth,  C.B..O.M.G., 
Lond.;  Dr.  W.  W.  C.  Topley, 
Lond.;  Mr.  G.  Tyrrell,  Lond. 

W.  -Dr.  G.  Ward,  Loud.;  Dr.  V.  G. 
Ward,  West  Byfleat ; Dr.  D. 
Walsh,  Lond.;  Mr.  It  L.  M. 
Wallis,  Lond.,  Mr.  F.  T.  Wheatley, 
Sheffield. 


B.  — Dr.  I.  Bram,  Philadelphia; 
British  Temperance  League, 
Lond.,  Sec.  of  ; Mrs.  E.  J.  Brice, 
Taunton  ; Board  of  Agriculture 
and  Fisheries,  Lond.;  Dr.  J. 
Brown,  Blackpool,  Messrs.  Bur- 
roughs Wellcome  and  Co.,  Lond.; 
Mr.  J.  B.  B.  Burke,  Lond. 

C. — Mr.  J.  Cabburn,  Lond.;  Crystal 
Press,  Ltd.,  Loud.,  Sec.  of ; Dr. 
T.  F.  Cotton,  Lon’.;  Dr.  H.  P. 
Cholmeley,  Forest  Row ; Dr. 
A.  G.  Clark,  Bedford  ; Dr.  J.  P. 
Cammidge,  Lond.;  Canadian 
Medical  Directory,  Montreal. 

D.  — Dr.  J.  A.  Delmege,  Lond.; 
Surg.  - Lieut.  - Comm.  S.  F. 
Dudley,  R.N.;  Mr.  L.  I.  Dublin, 
New  York. 

F. — Dr.  C E.  S.  Flemming,  Brad- 
ford on-Avon  ; Mr.  H.  Frankling, 
Harrogste. 

G.  — Mr.  S.  G.  Gould,  Lond.;  Great 
Northern  Central  Hospital,  See. 
of;  Dr.  A.  K.  Gordon,  Lond.; 
Major  W.  E.  Gallie,  C A.M.C.; 
Dr.  A.  Q.  Gibson,  Oxford  Mr. 
G.  E.  Gask,  Lond.  ; Dr.  R.  G. 
Gordon,  Bath. 

H.  — Dr.  E.  Holland,  Lond.;  Dr. 
J.  E.  Hett,  Kitchener;  Pi  of.  A. 
Hopewell-Smith,  Philadelphia; 
Fleet-Surg.  W.  E.  Home,  K.N  ; 
Dr.  H.  Head,  l.ond.;  Dr.  K.  C. 
Hort,  Loud. 

I.  — Ilford,  Medical  Officer  cf 
Health  of;  Imperial  Tiavel 
Bureau,  Lond. 

K.  — Mr.  U.  S.  K wshlk,  Bombay. 

L. — London  County  Council,  Medi- 
cal Officer  of ; Lebanon  Hospital 
for  Mental  Diseases,  Lond.,  Gen. 
Sec.  of ; London  and  Counties 
Medical  Protection  Society,  Gen. 


Communications  relating  to  editorial  business  should  be 
addressed  exclusively  to  the  Editor  of  The  Lancet, 
423,  Strand,  London,  W.C.2. 


Holts,  Sfrori  Commenis,  nub 
to  Comspoitbenls. 

THE  BATHS  OF  OLD  LONDON.1 
By  Septimus  Sunderland,  M.D.  Brux., 

CONSULTING  PHYSICIAN,  ROYAL  WATERLOO  HOSPITAL  FOR  CHILDREN 
AND  WOMEN;  OBSTETRIC  PHYSICIAN  TO  THE  FRENCH  HOSPITAL. 


Part  I. 

“ The  City  of  the  Waters.” 

I LIKE  to  believe  that  the  meaning  of  the  word  London  is 
“The  City  of  the  Waters,”  after  the  derivation  put  forward 
by  Mr.  W.  Owen,  F.S.A.,  editor  of  “Welsh  Archaeology” — 
namely,  Llyn,  meaning  a lake  or  broad  expanse  of  water, 
and  Dyn,  meaning  a town.  Another  derivation  is  Lhong,  a 
ship,  and  Dun,  a town — “ the  town  of  ships.”  On  consider- 
ing the  situation  of  London  on  the  Thames,  with  its 
numerous  tributaries  taking  their  origin  on  the  hills  both 
north  and  south  of  the  Thames  valley,  one  can  understand 
that  the  lands  around  the  town  were  in  former  years  dotted 
with  springs  and  pools. 

I may  remind  you  of  a quaint  quotation  taken  from  a trans- 
lation of  the  “ History  of  London,”  written  in  1180  by 
William  Fitzstephen,  a Canterbury  monk  and  the  friend  of 
Beckett : — 

“ Round  the  city  again,  and  towards  the  North  arise  certain  excellent 
springs  at  a small  distance,  whose  waters  are  sweet,  salubrious,  and 
clear,  and  whose  runnelB  murmur  o’er  the  shining  6tones ; amongst 
these  Holywell  (Shoreditch),  Clerkenwell,  an  1 St.  Clement's  Well  may  be 
esteemed  the  principal,  as  being  much  most  frequented,  both  by  the 
scholars  from  the  school  (Westminster)  and  the  youths  from  the  city, 
when  in  a summer's  evening  they  are  disposed  to  take  an  airing.” 

And  another  quotation  from  the  “ Survey  of  London,”  by 
John  Stowe,  the  English  antiquary  and  historical  writer  of 
the  sixteenth  century,  who,  referring  to  the  thirteenth 
century,  says  : — 

" They  had  in  every  street  and  lane  of  the  city  divers  fair  wells  and 
springs;  and  after  this  mavner  was  this  city  then  s°rved  with  sweet 
and  freBh  waters  which  being  since  decayed,  other  means  have  been 
started  to  supply  the  want.” 

These  quotations  bring  vividly  to  the  imagination  the  exist- 
ence in  the  early  days  of  streams,  ponds,  pools,  wells,  and 
springs,  not  only  on  the  north  side,  but  on  the  south  side  in 
Southwark, Lambeth,  and  contiguous  neighbourhoods.  Most 
of  the  pools  have  been  filled  iu  and  the  springs  and  streams 
diverted  into  sewers. 

Thus  one  knows  that  in  very  early  days  before  Fitz- 
stephen’s  and  after  Stowe’s  time  there  must  have  been  no 
lack  of  facilities  for  bathing  in  the  open. 

The  names  of  many  streets  will  indicate  to  what  extent 
the  existence  of  water  affected  the  nomenclature  of  the 
districts— e.g.  : Bath-street  (Newgate-street),  Bayswater- 
road,  W.,  Brook-green,  Hammersmith. 

Olden  Baths  of  London. 

One  of  the  most  interesting  amongst  the  olden  baths  of 
London  is  the  Old  Roman  Spring  Bath  (or  Plunge  Bath), 
situated  near  King’s  College,  Strand,  because  this  bath 
still  remains  as  one  of  the  few  relics  of  Roman  London. 
It  was  probably  built  about  2000  years  ago,  in  the 
time  of  Titus  or  Vespasian.  It  is  supplied  with  clear 
water  coming  from  springs  at  Hampstead,  and  was  con- 
sidered to  be  the  overflow  from  St.  Clement’s  Holy  Well  in 
the  vicinity.  The  bath,  rounded  at  one  end  and  square  at 
the  other/ is  in  the  centre  of  a fair-sized,  solidly  built, 
vaulted  chamber,  and  lit  by  a little  semicircular  window. 
Its  length  is  13  ft.,  breadth  6 ft.,  and  depth  4 ft.  6 in. 
Charles  Dickens  refers  to  this  bath  in  “ David  Copperfield.” 

The  Templars’  Bath  or  Lord  Essex’s  Bath.  Adjoining  the 
Roman  Bath  and  deriving  its  water-supply  from  it  was 
another  bath,  of  octagonal  shape,  the  Templars’  Bath,  used 
for  three  centuries  by  residents  in  the  Temple  and  closed  in 
1893.  It  was  built  in  1588  by  the  Earl  of  Essex,  whose  house 
was  near.  The  site  is  now  covered  by  the  larder  of  the 
Norfolk  Hotel. 

St.  Agnes-le-Clair  Bath  wa3  situated  on  the  site  now 
named  St.  Agnes  terrace,  near  St.  Luke’s  Hospital,  Old- 
street,  and  is  considered  to  have  been  first  used  in 
1502,  being  supplied  by  the  St.  Agnes-ie-Clair  spring  (one 
of  the  holy  wells  of  London),  although  a Roman  origin 
was  At  one  time  claimed  for  it ; for  in  the  eighteenth  century 
many  ancient  copper  coins,  Roman  relics,  and  other 
antiquities  were  discovered  in  the  bath,  as  well  as  Roman 
tiles.  Some  writers  consider  these  were  brought  thither 
and  cast  into  the  spring  as  votive  offerings.  The  spring  was 
dedicated  to  St.  Agnes  and  called  “le  Clair”  on  account  of 
the  transparency  of  its  waters.  Stowe  speaks  of  them 


1 A paper  read  before  the  Lou  ion  Dermatological  Society  in  su 
abridged  form. 


90  The  Lancet,]  NOTES,  SHORT  COMMENTS,  AND  ANSWERS  TO  CORRESPONDENTS.  [July  12, 1919 


as  “ Dame  Anne’s  the  clear.”  An  advertisement  in 
1758  speaks  of  the  bath  as  being  “ much  applauded 
by  the  learned  physicians  of  old”  “in  rheumatic  and 
nervous  cases  and  headache,  and  for  cutaneous  eruptions 
and  inflamed  eyes.”  In  1854  the  Bath  House  was  damaged  by 
fire  and  the  bath  came  into  disuse. 

The  Peerless  Pool,  Baldwin-street,  City-road,  behind 
St.  Luke’s  Hospital,  was  referred  to  by  Stowe  as  “one 
other  clear  water,  called  Perilous  Pond,  because  divers 
youths  by  swimming  therein  have  been  drowned.”  It  was 
enclosed  in  1743  by  Wm.  Kemp,  a London  jeweller,  who 
changed  its  name  to  Peerless  Pool  and  used  it  as  a bathing 
place.  Fed  by  springs,  this  open  air  pool  measured  170  ft. 
in  length,  108  ft.  in  breadth,  and  from  3 to  5 ft.  in  depth.  It 
was  nearly  surrounded  by  trees  and  marble  steps  led  to  a 
gravel  bottom,  through  which  springs  percolated.  It 
became  a favourite  resort  of  anglers  and  swimmers. 
Peerless  Pool  was  used  as  a bath  until  about  1850,  when  it 
was  drained  and  built  over,  and  its  name  is  commemorated 
by  Bath  Buildings,  Peerless-street,  and  Bath-street,  to  the 
north  and  west  of  St.  Luke’s  Hospital. 

The  Cold  Bath  in  the  New  (Euston)  Road  was  situated 
near  the  old  Adam  and  Eve  Tea  Gardens  at  the  north- 
west end  of  Tottenham  Court-road.  The  bath  was  in  a 
pleasant  garden  and  was  supplied  by  a spring.  The  water 
was  described  as  being  “ beneficial  to  persons  suffering  from 
nervous  disorders  and  dejected  spirits.”  It  was  in  existence 
in  1785,  and  was  then  advertised  as  being  “ in  fine  order  for 
the  reception  of  ladies  and  gentlemen.” 

The  Cold  Bath,  Clerkenwell,  situated  near  the  River  Fleet, 
or,  as  it  was  then  called,  Turnmill  Brook,  not  far  from  the 
spot  where  the  Clerks’  Well  existed  (near  the  present 
18,  Farringdon-street),  was  a cold  spring  which,  in  1697,  was 
converted  into  a bath  by  the  owner  of  the  surrounding 
property,  Walter  Baynes,  and  was  described  as  the  “most 
noted  and  first  about  London.”  The  charge  for  bathing  was 
2s.  or  2s.  6 d,  if  use  were  made  of  the  chair  suspended  from  the 
ceiling  for  lowering  the  patient  into  the  water.  The  water 
of  the  spring  used  for  drinking  and  bathing  was  chalybeate, 
and  was  considered  efficacious  in  the  cure  of  “ scorbutic 
complaints,  rheumatism,  chronic  disorders,  &c.”  It  was 
also  considered  to  “ prevent  and  cure  cold,  create  appe- 
tite, help  digestion,  and  make  hardy  the  tenderest 
constitutions.”  The  bath  was  at  the  height  of  its  reputa- 
tion in  1700.  The  bath  was  enclosed  in  a building 
known  as  Coldbath  House,  surrounded  by  a garden 
with  four  turret  summer-houses.  The  spring  supplied 
20,000  gallons  daily.  In  1815  most  of  the  exterior  of  the 
bath-house  was  removed  to  make  way  for  buildings,  but  the 
bath  itself  remained  as  late  as  1870  (Macpherson).  I believe 
there  is  now  no  trace  of  its  existence.  The  neighbourhood 
was  formerly  known  as  Coldbath  Fields. 

Sun  Tavern  Gap,  at  Shadwell,  marks  the  spot  where  a 
spring  was  discovered  in  1745,  which  was  puffed  by  D.  W. 
Linden,  M.D.,  in  1749,  “for  scorbutic  and  cutaneous  dis- 
orders by  drinking  or  bathing.”  It  was  used  medicinally 
only  for  a short  period,  and  was  known  as  “ Shadwell  Spa 
the  water  was  sold  at  the  Spa  House  in  Sun  Tavern. 

Queen  Anne’s  Bath  was  situated  at  the  back  of  the  present 
No.  35,  Endell-street,  Long  Acre.  The  waters  were  supplied 
from  a copious  spring  containing  iron,  and  were  used  for  rheu- 
matism and  other  disorders.  It  is  said  that  Queen  Anne  used 
to  bathe  there  ; small  rooms  at  the  side  used  to  be  shown  as 
her  toilette  and  dressing-rooms.  The  bath-chamber  was  about 
14  ft.  square,  with  a lofty  groined  dome  roof,  and  its  walls  in- 
laid with  white  and  blue  Dutch  tiles  of  the  sixteenth  century. 

The  New  Spa,  Hampstead,  was  first  mentioned  in  1804 
by  a local  practitioner,  Thomas  Goodwin,  in  a pamphlet 
entitled  “ An  Account  of  the  Neutral  Saline  Waters  Lately 
Discovered  at  Hampstead.”  The  water  contained  magne- 
sium sulphate  and  a bath-house  existed  for  the  immersion 
of  patients  in  the  water  from  the  spring.  This  “ New  Spa  ” 
had  very  little  success.  The  site  was  near  the  present 
railway  station  of  the  L.  & N.  W.  Railway. 

(To  be  continued.) 


COLONIAL  HEALTH  REPORTS. 

Uganda. — According  to  the  Blue-book  for  the  year  1917-18, 
the  population  of  this  Protectorate  is  estimated  at  3,360,439, 
including  570  Europeans  and  3467  Asiatics.  In  1917  the 
cases  treated  in  Government  hospitals  and  dispensaries 
numbered  70,236,  with  967  deaths,  these  figures  not  including 
cases  treated  at  the  military  hospitals  at  Entebbe,  Bombo, 
and  Gulu.  The  number  of  European  officials  resident  was 
378,  among  whom  there  occurred  359  cases  of  illness  and 
2 deaths.  Of  the  total  admissions  to  hospital  112  were  due 
to  malaria  and  11  to  dysentery;  8 European  officials  were 
invalided,  bringing  the  total  number  during  the  last 
seven  years  to  30;  the  causes  of  invaliding  were  general 
debility,  neurasthenia,  tuberculosis,  and  neuritis.  The 
number  of  cases  treated  at  European  and  native 
Government  hospitals  decreased  from  5679,  with  20  deaths  in 
1916,  to  4414  cases  with  6 deaths  in  1917.  Forty-nine  cases  of 
blackwater  fever  were  treated,  of  which  8 were  fatal,  com- 


pared with  46  cases  and  10  deaths  in  the  previous  year.  The 
diseases  which  call  for  special  attention  in  connexion  with 
the  native  population  are  cerebro-spinal  meningitis,  sleeping 
sickness,  plague,  small-pox,  and  venereal  diseases.  Cases  of 
cerebro-spinal  meningitis  treated  in  Government  hospitals 
have  risen  from  4 cases  with  3 deaths  in  1915  to  71  cases  with 
42  deaths  in  1916,  and  469  cases  with  347  deaths  in  1917. 
Besides  these  numerous  deaths  have  taken  place  all  over 
the  country,  cases  having  been  reported  in  every  district 
except  Masaka.  The  disease  has  been  particularly  severe  in 
the  northern  and  north-eastern  parts  of  the  Protectorate. 
It  is  estimated  that  not  fewer  than  5000  deaths  took 
place  from  this  disease  in  the  districts  of  Gulu  and 
Kitgum,  whilst  in  the  Arua  District  of  the  West  Nile  it  is 
considered  that  3000  natives  have  died  from  the  same  cause. 
The  rapid  spreading  of  this  disease  and  the  great  number 
of  deaths  are  due,  first,  to  the  abnormal  collection  and 
movements  of  natives  for  military  purposes,  and,  secondly, 
to  the  shortage  of  the  medical  staff.  Epidemics  of  small- 
pox occurred  throughout  the  Protectorate,  the  Nile  Districts 
and  Lango  being  specially  affected,  and  towards  the  end  of 
the  year  the  mortality  was  severe.  Admissions  of  cases  of 
plague  to  hospital  show  a decrease  from  321  cases  with 
283  deaths  in  1916  to  171  with  143  deaths  in  1917, 
and  the  native  returns  show  a slight  decrease  in 
the  number  of  deaths  compared  with  the  previous 
year.  The  local  sanitary  boards  are  working  in  the  various 
townships  with  good  results,  and  anti-malarial  measures 
improve  the  conditions  of  the  more  important  stations. 

THE  KENSINGTON  WAR  HOSPITAL  SUPPLY  DEPOT. 

The  dep3t  was  registered  in  1916  under  the  War  Charities 
Act,  and  during  the  war  has  turned  out  over  6,000,000  articles, 
valued  at  £300,000,  which  have  been  sent  to  1400  different 
hospitals  at  home  and  abroad.  In  a List  of  Surgical  Appli- 
ances and  Hospital  Requisites  issued  (at  2s.)  by  the  depdt, 
among  the  many  useful  appliances  may  be  noticed  : a finger 
flexion  glove,  consisting  of  a leather  wristlet  with  splint  and 
glove  attached — from  each  finger  of  the  glove  extends  a strap 
which  can  be  fastened  to  a button  on  the  wristlet  ; a Hey 
Groves  humerus  extension  splint  which  can  also  be  used  as 
a stump  tractor  ; a simple  type  of  wood  splint  for  extension 
of  the  forearm ; a Bowlby’s  slung  leg  splint  for  dressing 
wounds  of  the  calf  without  disturbing  a fractured  limb. 
Many  forms  of  pilons  are  illustrated;  they  can  be  obtained 
either  with  belts  for  cases  of  thigh  amputation  or  with 
gauntlets  above  the  knee  for  amputations  lower  down.  The 
work  of  the  dep6t  is  now  being  reconstructed  to  deal  with 
civil  hospitals  aDd  patients. 

A PSYCHOLOGICAL  STUDY  OF  THE  PRISONER 
OF  WAR. 

Dr.  A.  L.  Vischer,  a citizen  of  a neutral  country  with  a 
command  of  three  European  languages,  has  had  a unique 
opportunity  of  visiting  the  great  European  internment 
camps  and  of  investigating  the  mental  changes — we  should 
like  to  call  them  the  metapsychoses — for  which  the  condi- 
tions of  internment  are  responsible.  It  will  be  realised 
when  reading  his  book  on  Barbed  Wire  Disease  1 that  he  has 
made  full  use  of  his  opportunities,  and  in  addition  has  read 
widely  in  the  literature  produced  by  interned  authors.  If  he 
has  paid  less  attention  to  English  writers  than  to  French 
and  German  authors  the  deficiency  has  been  realised  and 
amply  redeemed  in  the  very  able  introductory  chapter 
by  Dr.  Kinnier  Wilson.  There  is  far  more  than  the  loss  of 
liberty  to  prey  upon  the  minds  of  the  internes.  Uncertainty 
of  the"  future,  the  loss  of  privacy,  and  nostalgia,  aggravated 
by  the  restrictions  in  correspondence,  all  play  their  part,  but 
above  all,  the  authors  lay  emphasis  on  the  constant  menacing 
mockery  of  the  barbed  "wire  entanglements.  As  one  of  the 
men  in  Knockaloe  Camp  has  written,  “Physically  the 
prisoner  is  powerless,  but  in  spirit  he  gnaws  unceasingly  at 
the  roots  of  the  thorny  hedge.” 

What  are  the  consequences  which  are  observed  to  follow 
upon  these  changes  in  the  prisoners’  mental  life?  Their 
dreams,  their  irritabilities,  their  depression,  the  exaggera- 
tion of  rumour,  and  the  gradual  starvation  of  libido  have  all 
been  noted  and  recorded  by  Dr.  Yischer,  who  has  also 
inquired  into  the  origins  of  these  phenomena,  their  develop- 
ment, and  the  prospects  of  their  elimination  when  the 
causative  factors  have  been  removed.  The  mental  syndrome 
of  the  intern4  is  then  usefully  compared  with  the  experi- 
ences of  others  who  in  time  of  peace  have  found  themselves 
“ closely  confined  for  an  indefinite  period.”  This  is  often 
the  case  with  the  crews  of  sailing  vessels  on  long  voyages, 
with  polar  and  other  explorers,  and  those  who  have  chosen 
to  live  the  monastic  life.  The  book  is  suggestive  rather  than 
dogmatic  and  will  be  read  with  interest  by  all  who  are  con- 
cerning themselves  with  the  development  of  the  science  of 
abnormal  psychology. 

1 Barbed  Wire  Disease : A Psychological  Study  of  the  Prisoner  of 
War.  By  A.  L.  Yischer,  M.D.  Basle,  M.F.C.S.  Bng.  With  an  Intro- 
ductory Chapter,  by  S.  A.  Kinnier  Wilson,  M.A..  B.Sc.,  M.D.  Edin., 
F.H.C.P.  Loud.  London:  John  Bale,  Sons  and  Danlelsson,  Ltd.  1919. 
Pp.  84.  Price  3s.  6 d. 


THE  LANCET,  July  19,  1919. 


ffjf e (Sffdsfaitiait  futures 

ON 

THE  SPREAD  OF  BACTERIAL  INFECTION. 

Delivered,  before  the  Royal  College  of  Physicians  of  London 

By  W.  W.  C.  TOPLEY,  M.A.,  M.D.  Cantab.,  F.R.C.P., 

DIRECTOR  01'  INSTITUTE  OF  PATHOLOGY,  CHARINO  CROSS  HOSPITAL. 


LECTURE  III.1 

Mr.  President,  Ladies,  and  Gentlemen, — In  the  experi- 
ments recorded  in  my  last  lecture  a culture  of  B.  Danysz 
was  fed  to  a certain  number  of  mice,  and  from  one  of  these, 
killed  24  hours  after  feeding,  a second  strain  of  the  bacillus 
was  isolated.  This  was  fed  to  a further  series  of  mice,  and 
from  the  tissues  of  certain  of  the  animals  which  died,  or 
were  killed  when  dying,  during  the  course  of  this  experiment 
further  strains  were  isolated.  These  in  their  turn  were  fed 
to  other  batches  of  mice,  and  the  process  was  repeated  many 
times.  The  whole  series  of  experiments  lasted  over  about 
nine  months. 

Consideration  of  the  results  showed  that  two  strains  at 
least  possessed,  when  first  isolated,  a greatly  increased  ten- 
dency to  produce  a fatal  illness  in  mice  when  administered 
with  food.  Retesting  of  these  strains  at  later  periods  con- 
firmed their  high  pathogenicity,  but  indicated  a gradual 
return  to  the  original  conditions  under  artificial  cultivation. 
In  many  cases,  however,  the  strain  isolated  from  a mouse  of 
a given  experiment  proved  less  pathogenic  on  being  fed  to 
other  mice  than  the  strain  on  which  the  mouse  itself  had 
been  fed,  and  this  was  particularly  true  of  those  strains 
which  were  isolated  from  mice  which  were  found  dead. 
Each  of  the  two  strains  which  possessed  especially  high 
pathogenicity  rapidly  lost  this  characteristic  on  further 
passage  carried  out  in  this  way. 

In  view  of  the  interesting  results  which  have  been  obtained 
by  close  serological  study  of  different  races  of  the  same 
bacterial  species,  it  seemed  desirable  to  investigate  the  most 
divergent  strains  along  these  lines.  High-titre  agglutinating 
sera  were  obtained  for  six  of  these,  and  48  strains  of  B.  Danysz 
isolated  during  the  course  of  these  experiments  were  tested  as 
regards  their  relative  agglutinability  and  by  cross-absorption 
tests.  In  every  case  the  exact  limit  of  agglutination  was 
determined.  The  results  failed  to  distinguish  in  any  way 
between  the  strains  examined. 

Experiments  with  a View  op  Reproducing  Natural 
Conditions. 

It  is  difficult  to  decide  how  far  the  conditions  in  these 
experiments  reproduce  those  met  with  in  nature.  In  so  far 
as  natural  infection  occurs  by  normal  mice  devouring  their 
companions  who  have  succumbed  to  the  disease,  they  must 
be  very  similar.  If,  however,  the  main  source  of  infection 
under  natural  circumstances  is  the  consumption  by  normal 
animalsTof  food  soiled  with  the  excreta  of  those  which  are 
infected,  there  will  be  additional  factors  which  are  absent 
in  the  experiments  we  have  considered.  There  seems  little 
doubt  that  the  latter  mode  of  infection  is  by  far  the  more 
important,  and  we  are  therefore  not  justified  in  assuming 
that  such  results  as  have  been  obtained  represent  what 
happens  when  passage  occurs  under  natural  conditions. 
They  form,  however,  a valuable  guide  in  interpreting  the 
results  obtained  in  other  experiments,  in  which  the  condi- 
tions were  arranged  to  reproduce,  as  closely  as  possible,  the 
sequence  of  events  which  must  actually  occur  in  the  epidemic 
spread  of  disease. 

In  these  experiments  a certain  number  of  mice  were  fed 
on  a strain  of  B.  Danysz.  Next  day  they  were  transferred 
to  a clean  cage,  and  at  varying  periods  thereafter  normal 
mice  were  added  to  the  cage.  These  were  identified  in  some 
way,  sometimes  by  merely  noting  the  colour  markings,  some- 
times by  marking  them  with  some  distinctive  dye.  The 
deaths  were  noted  as  they  occurred,  and  where  possible  post- 
mortem examinations  were  carried  out.  In  some  experiments 
several  of  the  mice  were  found  partially  eaten.  In  one  of 
them  only  were  a certain  number  of  dead  mice  left  in  the 
cage  for  their  companions  to  devour.  The  results  yielded  no 
evidence  that  this  factor  modified  the  course  of  events  in 
any  way. 

1 LoctureslI.  and  II.  were  published  in  The  Lancet  of  July  5th 
(p.  1)  and  12th  (p.  45),  1919. 

No.  5003. 


The  charts  in  which  the  results  of  some  of  these  experi- 
ments are  shown  are  constructed  as  follows.  On  the  upper 
base-line  are  recorded  the  deaths  as  they  occurred  in  time. 
On  the  lower  base-line  are  recorded  the  number  of  mice  fed, 
the  number  of  normal  mice  added,  and  the  time  at  which  the 
addition  was  made.  The  figures  below  the  base-lines  indicate 
days.  Each  square,  representing  a death  or  the  addition  of 
a normal  mouse,  is  numbered,  and  the  numbers  correspond  ; 
so  that  the  death  of  each  mouse  added  can  be  traced  as 
regards  the  time  of  its  occurrence.  The  mice  which  died  are 
represented  by  hatched  squares  in  each  case,  so  that  the 
plain  squares  on  the  lower  base-line  correspond  to  normal 
mice  which  were  added  to  the  cage  but  survived. 

Results  of  Experiments  - 

The  results  of  one  such  experiment  are  recorded  in 
Chart  IV.  Six  mice  were  fed  on  a culture  of  B.  Danysz. 
Five  days  later  six  normal  mice  were  added  to  the  cage. 
Three  days  later  one  of  these  was  found  dead.  On  the 
fourth  day  from  this  the  first  death  occurred  among  the 
mice  ordinarily  fed,  and  one  of  these  mice  was  found  dead 
on  each  of  the  next  three  days.  One  of  the  mice  added  on 
the  6th  day  of  the  experiment  succumbed  on  the  14th  day 
and  three  on  the  15th.  On  this  day  four  more  normal 
mice  were  added.  One  of  these  died  three  days  later ; 
the  other  three  survived.  Thus  of  six  mice  led  on  this 
strain  of  the  bacillus  four  died.  Of  six  mice  added 
between  the  date  of  feeding  and  the  first  death  which 
occurred  among  the  mice  fed  five  died  and  one  survived.  Of 
four  mice  added  on  the  15th  day  of  the  experiment  one 
died  and  three  survived. 

Chart  V.  shows  the  results  of  another  experiment  with  a 
culture  of  the  same  strain  of  B.  Danysz.  It  will  be  seen  that 
of  the  eight  mice  fed  on  this  culture  five  died.  Of  six 
normal  mice  added  on  the  7tn  day  of  the  experiment, 
three  died  and  three  survived.  Two  mice  were  added  on  the 
10th  day,  and  three  on  the  14th.  All  of  these  survived. 

Chart  VI.  shows  a similar  experiment  with  the  original 
strain  of  B.  Danysz.  Of  the  eight  mice  originally  fed  four 
died.  Three  mice  were  added  to  the  cage  on  the  14th 
day  of  the  experiment.  One  of  these  died  and  the  other 
two  survived.  Two  mice  were  added  on  the  18th  day, 
arid  both  survived. 

Thus  in  each  of  these  three  experiments  when  normal 
mice  were  added  to  the  cage  during  the  early  stages  a large 
proportion  of  them  became  infected  and  died  of  the  disease. 
Mice  added  during  the  later  stages,  however,  showed  an 
increasing  tendency  to  escape  infection,  and  in  some  cases 
all  the  mice  added  at  these  later  periods  survived. 

Chart  VII.  shows  a similar  experiment  on  a larger  scale. 
It  will  be  seen  that  it  is  referred  to  on  the  chart  as  an 
epidemic  due  to  an  unknown  cause..  The  exact  facts  are  as 
follows.  The  experiment  was  an  attempt  to  ascertain 
whether  strains  of  B.  Danysz , possessing  heightened  patho- 
genicity, would  be  evolved  as  the  result  of  natural  passage, 
a possibility  strongly  suggested  by  the  variation  in  this 
direction  which  had  been  observed  in  the  passage 
experiments  carried  out  in  the  manner  indicated  in  my 
last  lecture. 

It  had  already  been  noted  that  mice  exhibited  a very 
definite  age-susceptibility  as  regards  infection  with  this 
organism.  The  experiments  already  considered  were  carried 
out  with  adult  mice.  When  young  mice  were  fed  on  the 
same  culture  an  entirely  different  result  was  obtained.  Thus 
in  one  experiment  six  young  mice  were  fed  on  a 24-hour  broth 
culture  of  this  original  strain.  One  was  found  dead  next 
day,  four  on  the  day  following,  and  the  remaining  mouse 
died  on  the  14th  day. 

An  attempt  was  made  to  utilise  this  special  susceptibility 
of  young  mice  in  the  experiment  under  consideration. 
Four  such  mice  were  fed  with  a 24-hour  broth  culture  of 
the  original  strain,  and  were  transferred  next  day  to  the 
large  cage  in  which  this  experiment  was  carried  out.  This 
was  a long  cage  originally  divided  into  15  compartments, 
each  of  which  would  accommodate  from  two  to  four  mice. 
A communication  was  made  between  each  compartment,  and 
the  food  was  placed  in  a large  centre  compartment  made 
by  removing  the  two  central  partitions.  At  the  time  these 
four  young  mice  were  transferred  to  this  cage  one  was 
obviously  ill.  It  was  found  dying  later  the  same  day  and 
was  then  killed  and  examined  post  mortem.  Two  more  of 
these  four  mice  were  found  dead  on  the  9th  day  after 
feeding.  One  was  examined  after  death,  the  other  was 

C 


92  The  Lancet  ] DR.  W.  W.  0.  TOPLEY  : THE  SPREAD  OF  BACTERIAL  INFECTION. 


[July  19,  1919 


left  in  the  cage  t.o  be  eaten  by  its  companions.  The 
fourth  mouse  was  found  dead  three  days  later,  but  was  too 
decomposed  for  examina  ion.  Thus,  two  of  the  four 
original  mice  were  examined  post  mortem.  The  cultures 
from  one  remained  sterile  ; those  from  the  other  yielded 
only  lactose-fermenting  bacilli. 


The  figures  beneath  each  chart  indicate  time  in  days 


Chart  TV  —Showing  deaths  in  a cage  in  which  were  p'aced  six  mice 
(l)  fed  -n  a24-hnur  broth  culture  of  a sir-itn  of  B.  danysz  (3  D,  21  s 9. 
Spleen),  and  to  which  two  luither  batches  of  normal  mice  were  added 
(2,  3). 


Mice  OI5D 

Jgjt  , , S m^r 

i « a*  o (I  71  p#  h KijuiJ 


Chart  V — Showing  results  of  feeding  eight  mice  (1)  on  culture  of  same 
strain  as  in  previous  expeiiment,  and  adding  normal  mice  to  the  cage 
at  various  intervals  (2,  3,  4). 


Mice  oieo 


• as  6 / « y if  h i?  a « 15  if  1;  n iy  « ji  M » a » rf  v » f » 


Chart  VI  Showing  results  of  feeding  eight  mice  on  a culture  of 
B.  danysz  (original  strain)  and  adding  normal  mice. 


Consideration  of  Results  Shown  in  Chart  VII. 

The  addition  of  normal  mice  aDd  the  deaths  which 
occurred  are  sufficiently  indicated  in  the  chart.  Of  the 
44  mice  which  died  after  being  introduced  to  the  cage 
13  only  were  examined  post  mortem  ; most  of  the  remaining 
dead  mice  were  found  almost  entirely  eaten,  a difficulty 
which  is  particularly  liable  to  be  met  with  when  large 
numbers  of  mice  are  allowed  to  live  together.  Of  the  13 
mice  examined,  seven  yielded  cultures  of  lactose-fermenting 
bacilli  only,  while  the  cultures  from  the  remaining  six  mice 
remained  sterile.  Thus,  during  the  course  of  the 
whole  experiment  B.  Danysz  was  never  isolated  from 
any  of  the  mice  examined.  In  five  of  these  13  mice, 
however,  the  sp'een  was  considerably  enlarged,  in 
five  it  was  slightly  enlarged,  while  in  the  other  three 
it  appeared  normal.  The  post-mortem  appearances 
were,  in  fact,  entirely  compatible  with  death  from  a 
P,  Danysz  inlection,  but  in  the  entire  absence  of  bacterio 
logical  confirmation  it  seems  wiser  to  regard  the  cause  of 
the  epidemic  as  non-proven. 

A p >int  of  some  interest  may.  however,  be  noted.  In 
all  experiments  of  this  kind  it  has  been  found  that  a most 
marked  disproportion  exists  between  the  percentage  of 


recoveries  of  B.  Danysz  from  mice  fed  on  cultures  of  this 
organism  and  from  mice  naturally  infected  through  contact. 
Thus,  while  the  bacillus  has  almost  always  been  isolated 
from  a considerable  proportion  of  mice  fed  on  cultures, 
o' her  mice,  dying  in  the  same  cage  and  during  the  same 
time  interval,  may  yield  entirely  negative  results.  A high 
proportion  of  cultures  from  these  mice  remain  sterile,  while 
others  yield  lactose-fermenting  organisms  only.  The  number 
of  mice  examined  so  far  has  not  been  sufficient  to  exclude 
a mere  chance  coincidence,  but  the  distribution  of  positive 
and  negative  results  has  been  striking,  and  the  matter  is 
being  investigated  further. 

Whatever  the  explanation  may  be,  it  does  not  directly 
concern  us  here.  Regarding  the  course  of  events  in  the 
cage  merely  as  a chance  epidemic,  the  points  already  noted 
are  evident  again.  The  mice  added  in  the  early  stages 
died.  As  the  epidemic  progressed  a proportion  of  the 
newcomers  survived.  At  a later  stage,  when  deaths  were 
still  occurring  in  the  cage,  the  risk  of  infection  seemed  to 
fall  to  a minimum,  for  almost  all  mice  added  at  this  stage 
survived. 

Experimental  Evidence  of  Loss  of  Infectiyity. 

If  we  consider  the  results  of  these  experiments  one 
conclusion  seems  inevitable.  Whatever  part  other  factors 
may  play,  the  cessation  of  the  epidemic  is  actually  due  to 
the  loss,  on  the  part  of  the  parasite,  of  the  power  to  infect 
fresh  individuals.  It  is  impossible  to  conceive  that  in  every 
experiment  chance  should  have  intervened  by  selecting 
especially  resistant  mice  as  the  individuals  to  be  added 
during  the  later  stages. 

Direct  evidence  on  this  point  has  been  obtained  in  the 
following  way.  In  the  experiment  recorded  in  Chart  IV. 
there  remained,  at  the  time  of  the  last  death,  six  survivors. 
Twenty-three  days  later  all  these  mice  were  alive  and 
apparently  in  perfect  health.  On  this  day  three  normal 
mice  were  fed  on  a culture  of  the  same  strain  of  B.  Danysz 
as  that  employed  in  the  original  feeding  and  were  trans- 
ferred to  the  cage  later  in  the  day.  Fifteen  days  later  a 
fresh  outbreak  of  infection  occurred,  which  lasted  for  five 
days  and  led  to  the  death  of  two  of  the  three  mice  which 
had  been  fed  and  added  to  the  cage  and  of  three  of  the  six 
survivors  from  the  original  epidemic.  It  seems  clear,  there- 
fore, that  the  surviving  mice  were  not  immune  against  the 
risk  of  naturally  occurring  infection. 

Cross-infection  in  regard  to  Epidemic  Period. 

The  evidence  of  the  loss  of  infectivity  on  the  part  of  the 
parasite,  during  the  later  stages  of  the  spread  of  a B.  Danysz 
infection  among  mice,  finds  support  in  certain  observations 
on  naturally  occurring  epidemics  in  man.  In  the  paper 
already  quoted  Brownlee  gives  some  striking  figures 
regarding  cross-infection  in  hospital  wards  from  cases 
which  were  admitted  for  some  other  disease,  but  which 
were  subsequently  found  to  have  been  incubating  measles. 
He  has  tabulated  the  number  of  such  cases  which  did  or  did 
not  lead  to  the  infection  of  other  patients  in  the  ward, 
according  as  the  incubating  cases  were  admitted  during  the 
rise  or  decline  of  a measles  epidemic  or  during  an  inter- 
epidemic period.  Twenty-eight  such  cases  were  admitted 
during  the  ascent  of  the  wave.  In  24  of  them  cross- 
infection occurred.  Four  cases  were  admitted  during  the 
descent  of  the  wave,  and  cross-infection  occurred  in  two  of 
the  four.  Nine  caces  were  admitted  during  an  inter- 
epidemic period,  and  six  of  these  failed  to  give  rise  to 
cross-infection.  The  6gures  are  small  but  highly  suggestive. 

It  is  clear  that  where  it  is  possible  to  compare  the  curves 
of  morbidity  and  mortality  during  a given  epidemic  the 
relation  of  these  to  each  other  will  afford  information 
bearing  on  this  point.  In  certain  cases  where  this  has 
been  done  the  crest  of  the  morbidity  curve  has  preceded, 
by  a varying  time-interval,  the  crest  of  the  curve  of  mortality, 
and  this  is  what  we  should  expect  from  the  considerations 
outlined  above. 

Virulence  of  Organisms. 

If  we  inquire  the  cause  of  this  loss  of  infectivity  on  the 
part  of  the  virus  one  factor  may  be  at  once  eliminated.  The 
parasite  does  not  cease  to  be  infective  because  it  is  no  longer 
virulent. 

Those  strains  of  B.  Danysz.  isolated  during  the  course  of 
the  earlier  experiments,  which  showed  the  greatest  divergence 
as  regards  their  ability  to  infect  via  the  alimentary  canal, 


Thb  lanobt,] 


DR.  W.  W.  0.  TOFLEY  : THE  SPREAD  OK  BACTERIAL  INEEOTION.  [JULY  19, 1919  93 


have  been  repeatedly  tested  as  regards  their  virulence  on 
intraperitoneal  injection.  The  results  have  been  remarkably 
uniform  with  the  five  strains  tested.  Intraperitoneal  injec- 
tion of  0 5 c.cm.  and  0 25  o.cm.  of  a 21-hour  broth  culture 
has  always  been  followed  by  death,  usually  within  24  hours. 
The  majority  of  mice  receiving  0-025  c.cm.  have  died  within 


hlCE  ADDED' 


■ f s 4 i { -j  * f to  ii  i*  15  ti  18  >4  \j  i»  y «o  » n o h n ;6  fl  » y n u 

Q MICE  SURVIVED, 
gg  MIC-E  DIED-  • 

Chabt  VII.— Showtog  course  ot  epidemic,  of  unknown  cause,  occurring 
in  a large  cage  to  which  normal  mice  were  added  at  irregular 
intervals. 

48  hours.  Mice  receiving  0 0025  c.cm.  or  0 00025  c.cm. 
have  usually,  succumbed  after  a more  prolonged  interval 
(4-10  days).'  Mice  injected  with  0 000025  c.cm.  and 
0 0000025  c.cm.  have  never  shown  any  ill  effects. 

Thus  a strain  which  failed  to  cause  the  death  of  a single 
mouse  within  25  days  of  beiDg  administered  with  the  food, 
and  finally  led  to  the  death  of  one  of  six  mice  fed,  always 
caused  death  in  four  days  when  0 00025  c.cm.  of  a 24  hour 
broth  culture  was  inoculated  intraperitoneally. 

Control  tests,  made  with  killed  broth  cultures  to  allow 
for  the  element  of  toxicity,  sometimes  produced  late  death 
(5-10  days)  when  0 5 c.cm.  of  a killed  culture  was  injected. 
Smaller  quantities  produced  no  apparent  effect. 

The  question  as  to  whether  the  especially  infective  strains 
were  also  more  than  usually  virulent  cannot  be  answered 
satisfactorily  from  the  results  of  these  tests.  In  some  cases 
the  virulence  tests  were  cot  carried  out  for  some  time  after 
the  isolation  of  the  strain.  Although  there  was  still  a 
definite  difference  in  the  effects  produced  by  feeding  at  the 
time  when  the  virulence  of  the  strains  was  tested,  yet  it  was 
not  so  marked  as  at  the  time  of  isolation.  The  fact  which 
emerges  clearly  is  that  an  almost  completely  non-infective 
strain — that  is,  one  which  produces  no  illness  when  taken 
with  the  food — may  be  fully  virulent  when  inoculated  into 
the  peritoneal  cavity. 

Cause  of  Loss  of  Infectivity. 

To  what,  then,  are  we  to  ascribe  the  loss  of  infectivity  on 
the  part  of  the  parasite?  It  must  clearly  be  due  to  some 
deficiency  which  hinders  it  in  its  passage  from  host  to  host. 
Its  power  for  multiplication  in  the  tissues  in  general  is  not 
lessened.  It  seems  at  least  possible  that  it  is  the  power  for 
multiplication  elsewhere  that  is  at  fault. 

Danysz,  as  noted  above,  has  suggested  that  increased 
virulence  for  the  tissues  resulting  from  passage  by  sub- 
cutaneous injection  or  in  some  other  way  results  in  a loss 
of  virulence  in  the  alimentary  canal.  It  is  probable  that  in 
the  spread  of  bacterial  infection  the  parasite  actually  passes 
through  successive  phases  of  biological  activity.  It  must 
live  and  multiply  under  very  varying  conditions.  In  an 
infected  host  it  is  living  as  a true  tissue-parasite.  If  it  be 
transferred  to  the  naso  pharynx  or  to  the  alimentary  canal 
of  a fresh  individual  of  the  hcst  species,  it  must  be  able  to 
accommodate  itself  to  the  new  conditions.  For  in  the  absence 
of  active  multip'ication  it  is  highly  unlikely  that  successful 
tissue  invasion  will  be  brought  about.  If  the  parasite  is  to  be 
conveyed  from  host  to  host  by  a biting  insect,  then  it  must  face 
the  change  in  environment  from  the  tissues  and  blood  stream 
of  the  host  to  the  alimentary  canal  of  the  insect  carrier. 


Indeed,  it  is  probably  the  fact  that  during  the  spread  of 
infection  the  parasite  is  subjected  to  a regular  succession  of 
environmental  changes.  Failure  of  accommodation  at  any 
stage  may  clearly  prevent  the  infection  of  a fresh  host.  Now 
there  is  abundant  evidence  that  adaptation  to  a new  environ- 
ment may  be  associated  with  a lessened  ability  to  thrive 
under  the  old  conditions.  If  the  origin 
and  rise  of  an  epidemic  wave  do  indeed 
depend  on  the  factors  which  have  been 
considered  in  the  earlier  part  of  these 
lectures,  there  seems  to  be  an  adequate 
reason  for  believing  i hat  continued  varia- 
tion of  the  parasite  in  the  same  direction 
would  lead  to  the  decline  of  the  wave. 

The  Possible  Course  of  the  Process. 

It  was  suggested  that  a saprophytic 
spread  of  the  micro-organism  concerned, 
associated  with  an  increasing  ability  to 
multiply  rapidly  under  the  conditions  locally  existing,  might 
form  the  earlier  stages  of  the  process.  Reasons  were  given 
for  believing  that  this  increase  in  the  rate  of  multiplication 
would  itself  tend  to  increase  the  probability  of  successful 
tissue-invasion  and  that  successful  transference  to  new  hosts 
might  lead  to  the  natural  selection  of  strains  or  varieties 
possessing  increased  powers  of  multiplication  within  the 
tissues — that  is,  increased  virulence. 

It  would  consort  well  with  all  our  knowledge  on  such 
matters  if  a gradual  increase  in  virulence  were  associated 
with  a gradual  loss  of  the  ability  to  live  under  the  earlier 
saprophytic  conditions.  We  should  thus  have  a loss  of 
infectivity,  unassociated  with  a loss  of  general  virulence,  the 
combination  of  biological  attributes  which  the  experimental 
results  seem  to  require. 

Whether  or  no  bacterial  parasites  pass  through  develop- 
mental cycles,  similar  to  those  known  to  occur  in  other 
living  O'ganisms,  is  a question  which  has  s< ill  to  be 
answered.  It  would  seem,  however,  that  the  essential 
phenomenon  of  an  epidemic  may  be  the  progress  of  the 
virus  through  a cycle  of  selective  variations  which  must  be 
retraversed  in  each  successive  wave. 

The  accompanying  diagram  indicates  roughly  the  possible 
course  of  such  a process.  The  line  indicating  the  variation 
in  the  rate  of  multiplication  as  a saprophyte  must  be  taken 
to  represent  the  degree  of  adaptation  for  life  in  the  naso- 
pharynx or  in  the  alimentary  canal  of  the  host  or  in  the 
body  of  some  insect  cartier.  It  should  almost  certainly  be 
represented  not  as  one  line  but  as  a whole  series  of  curves, 
corresponding  to  successive  environmental  changes.  In  the 


Diagram  indicating  p >ssihle  explanation  of  the  acquirement  and  loss 
bv  a bacterial  virus  of  the  property  of  infectivity  curing  the  cour-e 
of  an  epidemic.  T>  e contlnu  us  line  in  ievtes  rate  of  growth  as 
saprophyte  and  the  broken  line  rate  of  growth  -s  " tistue- parasite” 
(virulence!.  A-B,  period  of  “infectivity  ” and  duration  of  epidemic. 

same  way  the  curve  indicating  variation  in  the  rate  of 
multiplication  in  the  tissues  represents  the  degree  of 
adaptation  for  life  under  these  very  different  conditions. 

The  increase  in  the  rate  of  saprophytic  growth  is 
followed  after  a time  by  a gradual  increase  in  the  rate  of 
parasitic  growth  in  the  strai  s successively  evolved  ; but  at 
some  point  in  the  rise  of  the  latter  curve,  the  curve  of  true 
virulence,  there  commences  an  as-ociated  fall  in  the  curve 
representing  the  potentiality  of  saprophytic  existence.  It 
is  during  the  period  in  which  both  these  curves  are  at  an 
abnormally  high  level  that  the  parasite  possesses  infec- 
tivity, and  it  is  during  this  same  period  that  the  epidemic 
occurs. 


94  The  Lancet,]  DH.  w.  W.  0.  TOPLKY  : THE  SPREAD  OF  BACTERIAL  INFECTION. 


[July  19, 1919 


It  has  already  been  noted  that,  in  an  outbreak  of  cerebro- 
spinal fever,  the  carrier-rate  begins  to  fall  while  the 
epidemic  is  at  its  height.  Here,  again,  we  have  an  indica- 
tion of  a loss  of  capacity  for  saprophytic  growth  in  an 
increasingly  virulent  parasite  preceding  the  decline  of  a 
wave  of  disease. 

Capacity  ol  Bacterial  Parasites  for  Variation. 

It  might,  perhaps,  be  supposed  that  the  acceptance  of 
such  a view  as  this  would  involve  the  belief  that  any 
bacterial  parasite,  given  the  requisite  environmental  con- 
ditions, might  give  rise  to  epidemic  disease.  Neither 
clinical  nor  bacteriological  experience  would,  however,  lend 
any  support  to  such  a view.  The  constancy  of  the  charac- 
teristic features  of  a given  epidemic  disease,  when  viewed  as 
a whole,  strongly  indicates  a uniform  and  specific  virus.  The 
results  of  countless  attempts  to  increase  the  virulence  of 
different  bacteria  have  shown  conclusively  that  while  with 
some  species  this  may  be  done  with  certainty,  with  others 
the  most  prolonged  efforts  in  this  direction  have  proved 
entirely  fruitless. 

It  would  seem  that  we  are  dealing  with  a more  or  less 
specific  capacity  for  variation,  analogous  to  the  acquired 
capacity  for  bringing  about  certain  fermentations,  which  has 
been  studied  by  Penfold  and  others.  As  the  result  of 
certain  environmental  changes  the  bacterial  parasite  will 
vary  in  a particular  direction,  but  the  ability  to  react  in  this 
way  must  be  regarded  as  something  inherent  in  the 
organism  itself. 

The  Selective  Localisation  of  Bacteria. 

Recent  work  on  the  selective  localisation  of  bacterial 
parasites,  and  especially  of  members  of  the  streptococcal 
group,  has  afforded  evidence  which  has  an  important 
bearing  on  the  point  at  issue. 

Rosenow,  in  several  communications,  has  dealt  in  detail 
with  this  matter.  He  has  found  that  strains  of  streptococci, 
isolated  from  particular  lesions  in  man,  have  tended  to 
produce  a high  percentage  of  lesions  in  the  same  tissues  or 
organs  when  inoculated  intravenously  into  rabbits. 

One  example,  which  is  of  particular  interest  from  the 
point  of  view  of  progressive  adaptation  to  life  in  different 
tissues,  may  be  referred  to  in  more  detail.  Rosenow  found 
that  strains  of  streptococci  isolated  from  cases  of 
appendicitis,  gastric  ulcer,  and  cholecystitis  resembled 
one  another  very  closely  in  cultural  and  other  ways.  He 
found  also  that  the  general  virulence  was  greater  in  strains 
isolated  from  gastric  ulcer  than  in  those  isolated  from 
appendicitis,  and  greater  still  in  strains  isolated  from 
cholecystitis.  The  table  shows  the  results  he  obtained  by 
the  intravenous  inoculation  of  such  strains  at  the  time  of 
isolation,  after  prolonged  cultivation,  and  after  passage. 


Table  showing  Elective  Localisation  of  Streptococci  Obtained 
from  Various  Sources  when  First  Isolated  after  Cultivation 
on  Artificial  Media  and  After  Passage. 


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C *e 
«•£ 

33 

Ulcer. 

3 

*5 

0 

« 

e 

a 

* 

Appendicitis— 

When  isolated  

14 

68 

7. 

68 

7 

6 

7i 

\ 

Later  

8 

26 

15 

19 

15 

4 

0 

After  passage  

7 

22 

45 

45 

30 

40 

0 

Ulcer  of  stomach  — 

When  isolated  

18 

103 

3 

60 

60 

20 

3 

Later  

8 

22 

5 

5 

0 

5 

0 

After  passage  

7 

39 

0 

23 

33 

30 

15 

Cholecystitis  — 

15 

When  isolated  

12 

41 

0 

39 

80 

5 

Later  

5 

14 

14 

28 

14 

7 

0 

After  passage  

4 

16 

0 

31 

13 

56 

19 

The  above  table  is  taken  from  the  data  given  by  Rosenow  in  a paper 
on  “ The  Elective  Localisation  of  Streptococci." 


Some  Significant  Facts. 

Several  most  significant  facts  can  be  observed.  At  the 
time  of  isolation  the  appendix  strains  seldom  gave  rise  to 
lesions  of  the  stomach  or  gall-bladder  in  the  rabbits  inocu- 


lated with  them.  After  passage  they  caused  a considerable 
percentage  of  lesions  of  these  organs  among  the  rabbits 
inoculated,  while  there  was  a slight  decrease  in  the  per- 
centage of  appendicular  lesions  produced. 

The  strains  obtained  from  cases  of  ulcer  of  the  stomach 
or  duodenum,  when  first  isolated,  produced  a high  per- 
centage of  lesions  of  these  organs,  but  very  few  lesions  of 
the  appendix.  The  relative  number  of  gall-bladder  lesions 
produced  was  considerably  higher  than  with  recently 
isolated  strains  from  appendicitis.  After  artificial  cultiva- 
tion, when  some  loss  of  general  virulence  might  be  expected 
to  have  occurred,  the  proportion  of  appendicular  lesions 
produced  by  the  gastric  and  duodenal  strains  was  slightly 
raised,  but  the  proportion  of  lesions  of  the  stomach,  duodenum, 
and  gall-bladder  was  considerably  lowered.  After  passage 
the  percentage  of  lesions  in  the  appendix,  stomach,  and 
duodenum  was  less  than  at  the  time  of  isolation,  but  the  pro- 
portion of  rabbits  showing  gall-bladder  lesions  was  raised. 

Similarly  the  strains  isolated  from  cases  of  cholecystitis 
caused  no  appendicular  lesions,  but  a considerable  proportion 
of  lesions  of  the  stomach  and  duodonum  and  a very  high 
percentage  of  lesions  of  the  gall-bladder.  Artificial  cultiva- 
tion resulted  in  a loss  of  the  power  of  affecting  the  gall- 
bladder, but  an  increase  in  the  tendency  to  localisation  in 
the  appendix.  Passage  resulted  in  little  change  so  far  as 
these  three  organs  were  concerned. 

The  production  of  lesions  of  the  pancreas  by  these  strains 
is  particularly  interesting.  No  appendicular  strain  affected 
this  organ.  Three  per  cent,  of  the  rabbits  inoculated  with 
strains  from  the  stomach  and  duodenum  showed  pancreatic 
lesions.  After  artificial  cultivation  none  did  so.  After 
passage  15  per  cent,  of  rabbits  showed  lesions  in  this  organ. 
With  the  gall-bladder  strains  lesions  of  the  pancreas  were 
produced  in  5 per  cent,  of  the  rabbits  inoculated  with  the 
cultures  when  first  isolated.  After  artificial  cultivation 
this  property  seemed  to  be  entirely  lost.  After  passage  the 
proportion  of  pancreatic  lesions  was  raised  to  it)  per  cent. 

Clinical  observation,  indeed,  yields  abundant  evidence  of 
the  tendency  for  certain  organisms  to  produce  lesions  in 
definite  tissues.  Moreover,  the  changes  in  type  of  a given 
disease  during  the  course  of  an  epidemic,  and  in  successive 
epidemic  waves,  strongly  suggests  progressive  adaptation  on 
the  part  of  the  parasite  to  life  in  different  tissues. 

Resistance  of  the  Host. 

Though  reasons  have  been  given  for  believing  that  the 
outstanding  feature  in  the  subsidence  of  an  epidemic  is  a 
loss  of  infectivity  by  the  bacterial  virus,  yet  the  resistance 
of  the  host  cannot  be  a negligible  factor.  It  will  operate 
by  decreasing  the  concentration  of  susceptible  individuals, 
and  hence  the  chances  of  successful  transference.  It  may 
clearly  play  an  important  part  in  contributing  as  an  environ- 
mental factor  to  the  progressive  variation  of  the  parasite. 

There  is  no  sufficient  evidence  as  yet  to  enable  us  to  form 
an  opinion  as  to  the  exact  way  in  which  this  factor  of 
immunity,  or  the  opposite  condition  of  sensitisation,  may 
affect  the  whole  process.  Probably  they  play  a most 
important  part,  but  the  fact  remains  that  the  virus  itself  is 
ultimately  altered  in  such  a way  that  it  can  no  longer  infect 
normal  individuals  of  the  host-species,  and  this  must  be 
regarded  as  the  essential  point. 

Similarly,  the  factor  of  bacterial  symbiosis  is  probably  of  the 
highest  importance,  but  here,  again,  we  must  wait  for  more 
exact  knowledge. 

Variation  of  Parasite  during  an  Individual  Attack 
AND  DURING  COURSE  OF  EPIDEMIC. 

It  is  of  considerable  interest  to  compare  the  changes  in 
the  biological  characteristics  of  the  parasite  during  a single 
attack  of  disease  with  the  variations  which  occur  during 
the  whole  course  of  an  epidemic.  The  results  recorded  by 
Danysz,  and  the  confirmatory  evidence  obtained  in  the 
present  experiments,  make  it  clear  that  strains  of  the  bacillus 
isolated  during  the  earlier  stages  of  the  disease,  or  before 
death,  are  far  more  likely  to  be  infective  to  other  mice  than 
strains  isolated  after  death — a fact  which  may  probably  be 
interpreted  in  the  same  way  as  the  loss  of  infectivity  during 
the  decline  of  an  epidemic. 

There  is  a very  general  consensus  of  opinion  that  many 
infectious  diseases  exhibit  their  maximum  infectivity  during 
the  earlier  stages  of  an  attack.  Conraai  has  attempted  to 
trace  the  period  of  infection,  as  regards  the  stage  of  disease 
in  the  infecting  case,  in  85  contact  cases  of  typhoid  fever. 


The  Lancet,] 


DR.  W.  W.  C.  TOPLEY  : THE  SPREAD  OF  BAOTEItlAL  INFECTION.  [July  19.  1919  95 


According  to  the  figures  he  obtained  it  appeared  that  49  of 
these  85  secondary  cases  were  infected  during  the  first  week 
of  the  primary  case,  16  during  the  second  week,  and  10  during 
the  third. 

Klinger  analysed  812  contact  cases  in  a similar  manner. 
He  arrived  at  the  conclusion  that  33  of  these  cases  were 
infected  during  the  first  week  of  the  incubation  period  of  the 
primary  case,  which  was  taken  to  be  14  days,  while  150 
were  infected  during  the  second  week  of  this  period.  Thus, 
183  secondary  cases  were  the  result  of  infection  during  a 
period  when  the  patients  forming  the  primary  cases  were 
not  obviously  ill,  but  when  they  must  have  been  excreting  the 
specific  organism.  The  figures  for  contact  cases  traceable 
to  infection  during  the  first  four  weeks  of  the  infecting  case 
were  187,  158,  116,  and  59  respectively.  Klinger’s  figures 
thus  corroborate  those  given  by  Conradi,  with  the  additional 
suggestion  of  the  importance  of  the  incubation  period  from 
this  point  of  view. 

A very  recent  communication  by  Thomson,  relating  to 
cross-infection  in  a hospital  ward  in  the  case  of  chicken-pox, 
records  observations  which  suggest  that  the  contact  infec- 
tivity  of  this  disease  undergoes  a marked  decrease  about 
the  end  of  the  first  week  of  the  eruption. 

Here  again,  then,  clinical  and  epidemiological  evidence 
supports,  and  is  supported  by,  that  obtained  along 
bacteriological  lines.  It  would  seem  that  the  cycle  of  varia- 
tion passed  through  by  the  parasite  during  an  isolated  attack 
of  disease  is  very  similar  to  that  traversed  by  the  same 
bacterial  virus  during  an  epidemic  wave. 

The  Inter-epidemic  Period. 

If  this  conception  of  the  epidemic  spread  of  bacterial 
infection  be  the  true  one,  it  may  be  inquired  whether  it 
throws  any  light  on  the  loDg  epidemic- free  intervals  in  some 
cases,  and  the  periodicity  of  the  outbreaks  in  others.  The 
subject  is  far  too  large  and  too  complex  to  be  considered  here 
in  any  but  the  briefest  and  most  tentative  way  ; but  certain 
consequences  would  arise  from  such  a process  which  seem  to 
offer  a possible  explanation  of  some  of  the  phenomena 
observed. 

The  process,  viewed  from  the  standpoint  of  the  bacterium, 
has  been  conceived  as  a progressive  variation  in  the 
direction  of  adaptation  to  increasingly  parasitic  conditions 
of  life.  But  the  virulent  variety  evolved,  so  well  adapted 
for  its  parasitic  role,  will  have  become  so  ill  suited  to 
life  outside  the  body,  and  especially  to  life  under  those 
special  conditions  which  have  to  be  faced  on  the  way  to 
successful  infection  of  a new  host,  that  it  will  gradually  die 
out  from  mere  inability  to  secure  for  itself  those  environ- 
mental conditions  which  are  necessary  for  its  continued 
propagation. 

Thus,  at  the  end  of  such  a cycle  we  should  be  left  with 
scattered  centres  in  which  the  virus  was  still  existing  in 
some  earlier  phase,  but  in  order  to  produce  a fresh  wave 
of  disease  the  whole  of  the  latter  part  of  the  cycle  must 
be  passed  through  afresh.  Now  it  has  been  seen  already 
that  the  essential  condition  for  such  a process  is  a 
sufficient  concentration  of  susceptible  individuals,  a factor 
whose  importance  in  initiating  epidemics  has  been  empha- 
sised by  many  epidemiologists,  such  as  Farr,  Davidson,  and 
Hamer.  This  condition  will  clearly  not  exist  if  the  epidemic 
has  been  a large  one,  for  a considerable  proportion  of  the 
population  will  have  had  conferred  upon  them  an  increased 
degree  of  resistance. 

The  length  of  the  inter-epidemic  period  will  depend  on 
many  factors : the  extent  of  the  epidemic,  and  hence  the 
relative  number  of  the  population  possessing  heightened 
resistance ; the  natural  persistence  of  such  acquired 
immunity,  which  we  know  to  vary  with  different  diseases  ; 
and  such  factors  as  age  susceptibility,  which  may  involve 
long  periods  of  time  before  a sufficient  concentration  of 
susceptibles  is  obtained  for  the  start  of  another  cycle  of 
variation. 

One  fact  must  be  emphasised.  A degree  of  immunity 
quite  insufficient  to  protect  against  a highly  infective  virus — 
that  is  to  say,  against  an  attack  of  the  disease  during  an 
epidemic  period — may  well  be  sufficient  to  hinder  or  prevent 
those  earlier  transferences  which  form  an  essential  part  of 
the  process. 

If  the  inter-epidemic  period  be  a long  one  the  centres  of 
increased  prevalence  of  the  specific  virus  will  certainly  have 
diminished  in  number  and  extent,  and  it  may  need  special 
environmental  conditions,  such  as  the  increased  over- 


crowding and  increased  migration  which  war  involves,  to 
start  the  cycle  again. 

Secondary  Epidemic  Waves. 

In  a completely  stationary  population  it  would  be  difficult 
to  fit  the  occurrence  of  secondary  epidemic  waves  into  such 
a conception  as  that  here  outlined.  Under  modern  condi- 
tions, however,  such  stationary  populations  do  not  occur  in 
big  cities.  If  there  be  a steady  influx  of  new  individuals 
secondary  waves  are  less  difficult  to  account  for.  Fresh' 
susceptibles  arriving  at  the  epidemic  centre  during  the  rise 
and  crest  of  the  wave  will  probably  fall  ready  victims.  As 
the  wave  subsides,  however,  these  fresh  arrivals  will  tend  to 
escape,  and  they  will  be  so  diluted  by  the  immune  popula- 
tion that  they  will  not  form  a soil  suitably  distributed  for 
the  start  of  a fresh  cycle. 

We  may  suppose  that  there  will  be  a gradual  reaccumula- 
tion of  a susceptible  population  ; but  although  this  may 
reach  a sufficient  density  to  allow  of  the  propagation  of  a 
second  wave  of  disease,  yet  it  will  probably  never  equal 
that  initially  existing.  Hence  the  rise  of  the  wave  will 
probably  be  less  steep  and  sudden,  and  the  crest  flatter,  than 
in  the  primary  wave.  These  features  actually  occur,  as  has 
been  pointed  out  by  Greenwood  and  others,  in  the  case  of 
influenza. 

Influenza. 

In  the  case  of  this  disease,  at  least,  there  is  a definite 
increase  in  mortality  during  the  secondary  wave.  It  is 
possible  that  one  factor  contributing  to  this  is  the  presence, 
scattered  among  the  community,  of  strains  of  the  virus  which 
already  possess  in  some  degree  those  attributes  which  go  to 
make  up  infectivity.  If  the  new  cycle  of  variation  were  to 
progress  from  this  relatively  advanced  phase,  and  the  spread 
of  infection  were  to  radiate  from  many  scattered  centres,  it 
would  seem  probable  that  an  unusually  large  proportion  of 
highly  virulent  strains  would  make  their  appearance  before 
the  final  phase  was  reached  and  before  the  loss  of  infectivity 
caused  the  subsidence  of  the  wave. 

The  interval  between  the  primary  and  secondary  waves,, 
and,  indeed,  the  very  occurrence  of  the  latter,  will  depend 
on  the  rate  of  the  influx  of  the  fresh  population — that  is, 
largely  on  the  ease  of  transit  and  the  circumstances  which 
may  render  migration  abnormally  great  or  small.  There 
seems  here  a possible  explanation  of  the  variation  observed 
in  successive  epidemics  of  influenza. 

The  solitary  epidemic  of  1847-48,  the  period  1889-94,  with 
its  four  waves  separated  by  relatively  long  intervals  of  time, 
and  the  present  visitation,  with  the  rapid  sequence  of 
primary  and  secondary  waves,  followed  after  another  short 
interval  by  a third,  correspond  with  the  increase  in  the  ease 
and  rapidity  of  transit  which  has  occurred  during  the  same 
period,  and  hence  with  the  rapidity  with  which  a relatively 
susceptible  population  will  tend  to  reaccumulate  in  an 
affected  district.  During  the  past  months  there  have  been 
many  additional  factors  tending  to  an  enormous  increase  in 
migration,  leading  to  the  same  result. 

The  Carrier  Problem. 

Ass'uming  that  the  epidemic  spread  of  bacterial  infection 
follows  the  lines  indicated  above,  we  may  inquire  how  far  it 
may  affect  our  conception  of  the  role  of  the  human  carrier. 

Temporary  Carriers. 

Carriers,  as  we  have  seen,  may  be  divided  into  two  fairly 
well-defined  classes,  according  as  they  carry  the  specific 
organism  concerned  over  short  or  prolonged  periods.  The 
latter  type  of  carrier  is  in  a very  small  minority  and  often 
exhibits  peculiarities  which  appear  to  predispose  to  the 
carrier  state. 

The  temporary  carriers  may  again  be  subdivided  according 
as  they  have  or  have  not  recently  passed  through  an  attack 
of  the  disease  in  question.  Of  these  two  varieties  of 
temporary  carriers  we  should  seem  to  be  justified  in  paying 
relatively  slight  regard  to  those  individuals  who  have 
recently  recovered  from  an  attack,  so  far  at  least  as  they 
may  be  supposed  to  constitute  important  sources  of  imme- 
diate infection.  Experimental  and  clinical  evidence  indicates 
that  in  such  late  stages  of  the  disease  the  infectivity  of  the 
virus  is  at  a minimum.  The  danger  of  these  temporary 
carriers  lies  rather  in  the  possibility  that  they  may  develop 
into  the  chronic  variety. 

Temporary  carriers  who  have  not  passed  through  a recent 
attack  would  have  to  be  regarded  as  manifestations  of  a 
general  biological  process  leading  up  to  an  outbreak  of  disease, 
c 2 


96  The  Lancet,]  DR.  W.  W.  C.  TOPLEY  : THE  SPREAD  OF  BACTERIAL  INFECTION. 


[July  19,  1919 


Experience  does  not  support  any  expectation  that  it  would 
be  possible  to  eliminate  such  carriers  from  the  general 
population  during  the  pre-epidemic  stage  by  any  method 
which  would  be  practicable  from  an  administrative  point  of 
view,  save,  perhaps,  under  special  local  conditions.  The 
discovery  of  a rise  in  the  carrier-rate  of  such  an  organism  as 
the  Meningococcus  may,  however,  constitute  a most  useful 
warning  of  the  imminence  of  an  epidemic,  and  lead  to 
the  putting  into  force  of  those  preventive  measures  whose 
efficacy  has  been  proved. 

Chronic  Carriers. 

The  chronic  carrier  is  a far  more  difficult  problem.  His 
importance  as  a possible  centre  for  the  spread  of  fresh 
infection  has  been  abundantly  demonstrated,  in  the  case  of 
typhoid  fever  at  least.  Whatever  attempt  may  be  made  to 
minimise  the  part  played  by  certain  notorious  carriers,  it  is 
difficult  to  believe  that  impartial  judgment  can  give  any 
other  verdict  on  the  whole  facts.  The  case  of  “Typhoid 
Mary,”  of  American  fame,  may  leave  room  for  doubt;  but 
there  are  so  many  classical  instances,  including  such  con- 
vincing cases  as  that  of  the  Folkestone  milker,  that  the 
potential  infectivity  of  carriers  of  this  kind  would  seem  to 
be  clearly  demonstrated. 

There  are  two  ways  in  which  we  might  hope  to  prevent 
the  harmful  activities  of  such  individuals.  By  rigorous 
bacteriological  examination  it  might  be  possible  to  detect 
those  persons  who  continue  to  carry  the  specific  organism 
from  the  actual  attack  onwards.  Such  a scheme,  however, 
presents  difficulties  so  formidable  as  to  exclude  its  actual 
enforcement.  The  control  which  it  would  be  necessary  to 
exercise  over  the  movements  of  convalescent  patients  would 
hardly  be  submitted  to.  The  possibilities  of  evasion  by 
presenting  false  specimens  for  examination  would  be  infinite 
in  many  cases.  Moreover,  the  marked  intermittency  of  the 
excretion  of  the  specific  organism  suggests  that  no  measure 
of  control,  short  of  repeated  bacteriological  examination 
lasting  over  many  years,  would  avail  to  eliminate  all  these 
unfortunate  individuals. 

Our  knowledge  of  the  infectivity  of  the  chronic  carrier 
may,  however,  be  utilised  in  another  way,  which  ofiers  far 
greater  hope  of  useful  results.  If  the  possibility  of  this 
source  of  infection  be  constantly  kept  in  mind  in  investi- 
gating epidemics  of  disease,  then  we  may  sometimes  trace 
the  trouble  to  its  source,  and  by  controlling  the  movements 
of  the  carrier  prevent  further  infections  occurring.  The 
possibility  of  the  control  of  the  movements  and  activities  of 
a proved  chronic  carrier  is,  of  course,  a purely  legislative  and 
administrative  problem. 

Consideration  of  the  famous  typhoid  carriers  strongly 
suggests  that  their  occupation  is  a matter  of  primary  im- 
portance. Nearly  all  have  been  in  some  way  directly 
concerned  in  the  handling  of  food  and  drink.  Limitation 
in  the  direction  of  preventing  them  engaging  in  work  of  this 
kind  would  probably  reduce  their  potential  infectivity  to  a 
minimum. 

Another  fact  seems  worthy  of  notice.  The  chronic  typhoid 
carrier  does  not  seem,  in  most  cases,  to  form  the  starting 
point  of  an  epidemic  spread  of  infectioh  in  the  sense  con- 
sidered above.  He  seems  rather  to  pass  on  to  his  victims, 
through  the  medium  of  food  or  drink,  fully  infective  bacilli. 
Moreover,  his  activities  in  this  direction  are  strikingly  inter- 
mittent. It  seems  possible  that  the  bacilli  which  he  is 
harbouring  in  his  alimentary  canal  or  elsewhere  are  of  a low 
degree  of  infectivity,  but  that  at  intervals  some  environmental 
change  leads  to  variation  in  the  direction  of  an  increase  of 
this  attribute,  and  that  it  is  under  these  circumstances  that 
infection  of  other  individuals  occurs. 

The  experimental  and  the  clinical  results  recorded,  and . 
especially  those  obtained  by  Rosen ow,  would  suggest  that  it 
is  not  only  in  the  spread  of  infection  from  case  to  case,  but 
in  the  progressive  involvement  of  different  tissues  in  the 
same  patient  that  variation  in  the  biological  activities  of  the 
parasite  may  form  an  essential  factor.  The  progressive 
involvement  of  tissues  in  such  a disease  as  tuberculosis 
might  be  largely  explained  on  such  a view. 

The  Possible  Prevention  of  Epidemic  Spread  of 
Infection. 

If  only  we  had  the  requisite  knowledge  as  regards  the 
causative  organisms  of  the  more  important  infective  diseases, 
and  could  establish  a systematic  survey  of  the  bacterial  flora 
of  reprt  sentative  samples  of  the  population,  it  would  seem 


that  we  might  obtain  warning  of  the  approach  of  an  epidemic 
during  the  early  stages  of  the  process  and  before  the  actual 
commencement  of  the  wave  of  disease.  If  this  were  possible 
there  seems  some  ground  for  hope  that  something  could  be 
done  to  check  the  process  in  its  earlier  stages.  In  normal 
times,  when  considerations  of  public  health  are  not  over- 
ruled by  still  more  urgent  necessities,  it  should  not  be 
impossible  so  to  alter  the  environmental  conditions  that 
serious  obstacles  would  be  placed  in  the  way  of  the  continued 
variation  of  the  virus. 

Information  is  needed  on  many  points.  The  normal 
bacteriology  of  such  an  important  locality  as  the  naso- 
pharynx is  not  known  with  any  exactitude.  Modern  sero- 
logical methods  have  placed  at  our  disposal  an  instrument 
for  the  more  exact  differentiation  of  bacterial  types  which 
should  prove  of  the  greatest  service  in  any  such  inquiry.  If 
any  work  along  such  lines  as  these  is  to  bear  fruitful  results, 
uniformity  of  technique  among  the  observers  engaged  upon 
it  is  an  essential  factor.  The  work  already  carried  out  by 
the  Medical  Research  Committee  gives  good  ground  for  the 
belief  that  much  that  has  proved  impossible  in  the  past  will 
be  attainable  in  the  future. 

The  factors  which  tend  to  render  the  host-species  more 
susceptible  to  attack,  and  especially  the  effect  of  such 
relatively  simple  matters  as  differences  in  temperature, 
atmospheric  moisture,  &c.,  are  still  very  imperfectly  under- 
stood. The  observations  of  Leonard  Hill  offer  an  example 
of  the  valuable  information  which  may  be  obtained  by  work 
along  these  lines. 

The  success  of  prophylactic  inoculation  in  preventing  the 
spread  of  epidemic  infection  has  been  amply  demonstrated 
in  certain  diseases.  Experience  would  suggest  that  it  is  in 
the  prevention  rather  than  in  the  treatment  of  disease  that 
bacterial  vaccines  will  find  their  permanent  place.  It 
seems  possible  that  they  may  act  largely  by  decreasing 
that  concentration  of  susceptible  individuals  which  is  an 
essential  factor  during  the  earlier  stages  of  the  spread  of 
infection.  As  pointed  out  above,  a degree  of  resistance 
quite  ineffective  against  a highly  infective  parasite  might  be 
of  decisive  importance  at  this  stage. 

Although  the  facts  recorded  above,  when  considered  as 
a whole,  would  appear  to  be  most  satisfactorily  explained 
along  the  lines  indicated,  the  problem  must  be  finally 
solved  in  the  light  of  further  evidence  accumulated  from 
all  possible  sources.  It  is  only  by  the  combined  efforts  of 
all  workers  in  this  field  of  biology  that  we  are  likely  to 
acquire  that  knowledge  which  is  so  important  for  the  pre- 
vention of  disease. 

The  inquiry  can  clearly  be  extended  on  the  experi- 
mental side.  Further  work  along  these  and  similar  lines  is 
being  carried  out  in  my  own  laboratory.  There  seems  no 
reason  why  many  of  the  conclusions  arrived  at  throughi 
biometrical  investigations  should  not  be  tested  by 
experiments  of  this  kind. 

I should  wish  to  record  my  indebtedness  to  Dr.  Arkwright 
for  supplying  me  with  cultures  and  sera  ; and  to  Dr.  Leiper 
and  Professor  Blackman  for  the  benefit  of  their  opinion  on 
certain  points.  I am  also  indebted  to  Dr.  S.  G.  Platts  for 
much  assistance  during  the  earlier  part  of  these  investiga- 
tions, and  very  especially  to  Mrs.  Phyllis  Worthington  and 
to  Dr.  M.  A.  Omar  for  their  constant  help  during  many 
months. 

Bibliography.— Brownlee : Train.  Roy.  Soc.  Veil.  (Bpidem.  Sec.), 
1909,  li. , 243.  Conradi  : Deutscb  Med.  Wocb.,  1907,  1684.  Danysz : 
Arm.  de  1'Inst.  Pasteur,  1900,  xiv.,  193.  Davidson  : Quoted  by  Hamer, 
q.v.  Farr:  Vital  Statistics,  Lond.,  18S5.  Greenwood:  Brit.  Med. 
Jour.,  1918,  ii.,  563.  Hamer:  The  Lancet,  1906,  i.,  569,  655,  733. 
Leonard  Hill : The  Lancet,  1913,  i..  1285.  Klinger  : Arb.  a.  d.  Kaiserl. 
Gesundb,  1909,  xxx.,  584.  Penfold:  Journ.  Hvg..  1912,  xii.,  195. 
Rosenow:  Journ.  Amer.  Med.  Assoc.,  1915,  Ixv.,  1687,  and  many  other 
papers.  Thomson:  The  Lancet,  1919,  i.,  397. 


Cornwall  Medical  Charities. — At  the  recent 
meeting  of  the  Committee  of  the  King  Edward  VII. 
Memorial  Fund  (Cornwall),  which  was  held  at  Truro,  the 
sum  of  £170  was  allocated  to  various  Cornish  medical 
institutions. 

Somerset  County  Council  and  Tuberculosis. — 
The  Tuberculosis  Subcommittee  of  the  Somerset  County 
Council  recommended  the  purchase  of  135  acres  of  land  at 
Lincombe  Hill,  near  Weston-super-Mare,  for  the  provision 
j of  a permanent  tuberculosis  sanatorium,  and  this  has  been 
adopted  by  the  council.  The  price  of  the  land  was  £3250. 


The  Lancet,] 


DR.  J.  DORGAN  : CEREBRO-SI’INAL  FEVER. 


[July  19,  1919  97 


CEREBRO-SPINAL  FEVER. 

REMARKS  ON  ITS  EPIDEMIOLOGY,  PREVENTION,  AND 
CLINICAL  FEATURES. 

By  J.  DORGAN,  M.B.  R.U.I.,  D.P.H.,  D.T.M., 

LIEUTENANT  COLONEL,  R.A.M.C. 


This  article  is  written  to  bring  forward  for  criticism  and 
inquiry  a somewhat  new  aspect  of  the  epidemiology  and  pre- 
vention and  clinical  features  of  cerebro-spinal  fever.  It  is 
based  on  the  investigation,  by  the  writer  and  other  officers, 
of  an  epidemic  at  a large  X Garrison  in  March,  1916.  A 
full  report  was  submitted  at  the  time  to  Surgeon-Colonel 
R.  J.  Reece,  C.B.,  who  with  Lieutenant-Colonel  M.  H.  Gordon, 
C.M.G.,  has  controlled  the  investigation  and  preventive 
measures  regarding  this  disease  in  the  United  Kingdom  for 
the  past  four  years.  Further  confirmatory  facts  have  since 
been  brought  to  the  notice  of  these  officers  in  official  reports, 
letters,  and  verbal  discussions. 

The  revised  system  of  prophylaxis  for  1918  1 has  recently 
reached  the  writer  in  Mesopotamia.  It  is  noted  that  the 
principal  recommendations  embody,  without  comment,  the 
lines  of  prevention  which  were  urged  in  the  report  of  1916, 
and  which  had  been  repeatedly  pleaded  for  during  the 
intervening  two  years. 

Circumstances  in  which  the  Investigation  was  Carried  Out. 

The  writer  was  employed  in  March,  1916,  in  coordinating 
the  investigation  and  prevention  of  a large  epidemic  at 
X Garrison,  having  been  detailed  by  the  War  Office,  on  the 
request  of  Colonel  Reece  for  the  services  of  a regular 
R.A.M.C.  officer  with  special  military  sanitary  experience. 
F urther  investigation  was  afterwards  carried  out  at  certain 
other  stations,  and  in  April,  1917,  the  writer  had  the 
advantage  of  further  study  at  the  Central  Cerebro-spinal 
Fever  Laboratory,  whilst  doing  duty  there  for  a short  time. 

The  following  officers  were  associated  with  the  writer 
at  X Garrison,  Professor  C.  Samut,  Temporary  Captain, 
R.A.M.C.,  assisted  by  Captain  Walter  Scott,  was  responsible 
for  the  bacteriological  investigation  of  the  patients.  His 
report  at  the  time  contained  much  that  was  original  and 
interesting,  and  much  of  it  has  since  been  confirmed  by  other 
workers.  Captains  R.  R,  Armstrong  and  Napier  were 
detached  from  the  Central  Cerebro-spinal  Fever  Laboratory. 
Their  work  was  in  connexion  with  the  search  for  carriers. 
At  the  end  of  the  epidemic  Captain  W.  J,  Tulloch  continued 
their  work  on  the  carriers  then  in  isolation.  He  was  also 
detailed  by  Colonel  Gordon  from  the  Central  Laboratory 
staff.  Captains  S.  Trevor  Davies  and  E.  G.  Pringle  were 
specially  selected  to  undertake  the  clinical  charge  of 
patients,  and  in  their  reports  had  given  full  details  of  the 
clinical  aspects  of  the  disease,  with  particular  reference  to 
atypical  and  irregular  cases. 

The  report  presented  by  the  writer  at  the  close  of  the 
epidemic  included  reports  on  the  special  subjects  dealt  with 
by  the  other  officers.  It  is  regretted  that  it  was  not  possible 
to  publish  the  full  report  at  that  time  or  later.  Permission 
was  obtained  to  publish  an  article  in  June,  1917,  written  on 
the  same  lines,  but  a hurried  departure  on  active  service  left 
the  arrangements  incomplete.  This  is  now  written  in  mid- 
summer in  Mesopotamia,  under  the  disadvantage  that  the 
deductions  of  the  1918  season  are  unknown  to  the  writer. 
Yet  it  is  confidently  believed  that  the  views  expressed  in  1916 
as  a result  of  well-considered  evidence,  will  be  confirmed, 
rather  than  refuted,  by  the  experience  of  yet  another  year. 

The  conclusions  of  the  1916  report  were  as  follows 
I.  The  prevalence  of  atypical  and  unrecognised  forms  of 
cerebro-spinal  fever.  II.  The  prime  importance  of  these 
atypical  forms  in  the  spread  of  the  disease.  III.  There  is 
no  evidence  at  X Garrison  to  show  that  carriers  convey  active 
infection.  The  statistics  as  to  carriers  are  conflicting  and 
inconclusive,  and  their  isolation  is  impracticable,  irrational, 
and  unjustifiable.  I\ . The  infection  in  cerebro-spinal 
fever  is  not  to  be  feared  under  good  conditions  of  housing 
and  ventilation.  The  early  isolation  of  mild  and  severe 
cases,  and  the  provision  of  free  ventilation,  compulsorily, 
and  with  sufficient  warmth,  during  the  time  of  seasonal  pre- 
valence, constitute  the  most  effective  means  of  prevention. 

1 R.A.M.C.  Journal,  January,  1918. 


I.  The  Prevalence  of  Atypical  and  Usually  Unrecognised 

Forms  of  Cerehro  spinal  Fever. 

At  an  early  stage  of  the  epidemic  attention  became  directed 
to  the  close  relationship  between  patients  definitely  diagnosed 
cerebro-spinal  fever  and  certain  other  patients  suffering  from 
indefinite  febrile  symptoms.  The  difference  between  the 
two  forms  of  illness  is  in  the  degree  and  intensity  rather 
than  in  the  fundamental  characters  of  the  symptoms.  As  a 
rule,  the  symptoms  of  the  indefinite  illness  were  compara- 
tively mild  and  commonplace,  and  such  as,  to  an  ordinary 
observer  when  taken  individually  and  in  the  absence  of  am 
epidemic,  would  not  necessarily  suggest  meningitis.  Intense 
headache,  more  or  less  pain  and  stiffness  of  back  and  neck, 
vomiting,  and  insomnia  were  always  complained  of.  The 
patient  was  apathetic  and  drowsy  ; he  answered  questions, 
but  rarely  enlarged  on  his  symptoms,  and  evidently  pre- 
ferred to  be  left  quiet  and  alone.  On  closer  examination 
Kernig's  sign  was  more  or  less  positive  ; attempts  to  move 
the  neck  caused  distinct  pain,  the  pulse  was  slow,  and  other 
signs  were  often  to  be  found  denoting  cerebral  irritation. 
After  a few  days’  fever  the  symptoms  usually  subsided,  the 
patient  was  left  prostrate,  and  convalescence  was  slow. 
Relapses  were  liable  to  occur,  which  sometimes  assumed  the 
characteristic  form  of  cerebro-spinal  fever. 

At  times  an  acute  and  fatal  illness  was  associated  with 
the  proved  cases,  the  symptoms  of  which  were  more  or  less 
obscure  when  critically  examined.  Such  patients  were  often 
brought  to  hospital  in  a drowsy  or  delirious  condition.  A 
very  acute  and  oedematous  form  of  bronchitis  or  broncho- 
pneumonia often  quickly  supervened,  and  death  occurred 
rapidly  with  signs  of  septic  intoxication.  Various  sympto- 
matic diagnoses  were  made  of  such  cases,  and  the  cause  of 
death  was  variously  given — influenza,  bronchitis,  broncho- 
pneumonia, asthma,  pneumonia,  being  the  most  common 
diseases  registered. 

It  was  decided,  therefore,  to  test  such  obscure  cases  found 
in  association  with  the  genuine  disease.  Meningococci  were 
found  in  the  spinal  fluids  of  many  patients  whose  symptoms 
would  not  have  ordinarily  suggested  meningitis.  We  had 
reasons,  moreover,  for  believing  that  many  of  our  negative 
results  were  due  to  the  failure  of  modern  technique  to  demon- 
strate the  meningococcus. 

Suspicion  was  at  first  aroused  as  to  a relationship  between 
the  above  types  of  illness,  not  only  by  the  similarity  of  the 
symptoms,  but  also  by  the  manner  in  which  they  were  found 
associated  in  billets,  tents,  barrack  rooms,  and  regiments. 
It  is  impossible  to  give  details  of  the  numerous  instances 
investigated  by  the  writer  where  the  evidence  definitely 
pointed  to  the  conclusion  that  both  conditions  were  but 
variations  of  a single  disease. 

Convenient  illustrations  of  atypical  and  unrecognised  cases 
are,  however,  given  on  p.  58  of  the  Medical  Research  Com- 
mittee’s Report,  Series  3.  Captain  M.  Flack,  of  the  Central 
Cerebro-spinal  Fever  Laboratory,  has,  however,  mentioned 
them  here  as  his  examples  of  infection  by  carriers.  This 
point  will  be  discussed  later. 

Some  Circumstantial  Evidence. 

In  the  first  family  the  father,  a soldier,  was  definitely  ill, 
with  headache  and  pain  in  the  back,  on  his  arrival  home  on 
leave.  Two  days  afterwards  one  of  his  children  was  taken 
to  a general  hospital  with  symptoms  of  cerebro-spinal  fever. 
Next  day  another  child  was  taken  to  an  isolation  hospital 
and  died  of  cerebro-spinal  fever.  The  first  child  was  dis- 
charged from  the  general  hospital  in  a few  days,  the 
symptoms  having  aborted,  being  brought  home  by  an  elder 
sister  on  a Thursday.  The  latter  died  of  fulminating  cerebro- 
spinal fever  which  developed  on  the  Sunday  following,  she 
having  evidently  been  infected  by  the  unrecognised  disease 
in  the  younger  member  of  the  family. 

In  the  second  family  a child  was  taken  ill  and  died  next 
day  of  cerebro-spinal  fever.  Three  other  children  were  taken 
ill  with  fever.  One  of  them  who  had  no  marked  meningitis 
symptoms,  and  in  whom  the  blood  and  spinal  fluid  were 
apparently  sterile,  yet  was  subsequently  accidentally  found 
to  have  suffered  from  cerebro-spinal  fever  by  the  finding  of 
the  meningococcus  in  the  fluid  of  a swollen  knee-joint.  The 
diagnosis  of  the  other  two  children  is,  however,  not  given. 
All  three  are  known  to  have  been  treated  in  the  isolation 
hospital. 

The  following  story  was  told  to  the  writer  by  a soldier 
who  came  to  be  swabbed  at  the  Central  Cerebro-spinal  Fever 


98  The  Lancet,] 


DR.  J.  DORGAN  : CEREBRO  SPINAL  FEVER. 


[July  19,  1919 


Laboratory.  He  recently  had  suffered  from  a severe  attack 
of  so-called  influenza  whilst  with  his  regiment.  He  was, 
however,  only  detained  in  hospital  for  three  days  and  then 
got  week-end  leave  home.  He  described  his  illness  as  being 
very  severe  and  as  “absolutely  flattening  him  out.”  He 
suffered  from  headache,  backache,  and  vomiting.  Three 
days  after  his  arrival  home,  his  child  developed  cerebro- 
spinal fever,  and  on  the  following  day  his  wife  took  very  ill 
with  influenza.  He  believed  he  caused  her  illness,  her 
symptoms  being  very  much  the  same  as  his  own,  although 
she  was  confined  to  bed  for  14  days,  attended  by  a doctor. 
His  unit  was  infected  with  cerebro  spinal  fever  ; there  were 
no  others  in  the  family  and  they  had  little  outside  com- 
munication with  other  persons,  and  he  proved  not  to  be  a 
carrier. 

Statistical  Data. 


Instead  of  further  repetition  of  suchlike  circumstantial 
evidence,  which  came  to  our  notice  at  X and  other  garrisons, 
it  is  proposed  to  argue  the  relationship,  from  statistics  and 
facts  showing  the  proportionate  incidence  of  cerebro-spinal 
fever  and  possibly  unrecognised  forms  of  the  same  disease,  in 
various  units  and  stations,  These  statistics  show  that  in 
Connexion  with  each  outbreak  there  is  a coincident  and 
proportionate  outburst  of  cases  of  pyrexia  of  uncertain  origin, 
the  symptoms  of  which  are  compatible  with  those  found  in 
cerebro-spinal  fever. 

In  O Block  barrack  building  at  X Garrison  there  were 
nine  diagnosed  cases  of  cerebro-spinal  fever  (three  fatal)  in 
March,  1916.  About  120  men  occupied  the  six  rooms  and 
comprised  a half  company.  In  addition,  there  were  18  other 
men  admitted  to  hospital  during  the  month  suffering  from 
febrile  symptoms.  Three  of  these  also  died,  four  others  were 
punctured,  having  definite  meningitic  symptoms.  Three 
others  were  mentioned  as  having  been  swabbed  as  a 
preliminary  to  puncture,  and  in  fact,  in  the  light  of  after 
knowledge,  they  all  might  have  been  cases  of  cerebro-spinal 
lever  There  were  13  cases  of  cerebro-spinal  fever  in  this 
battalion  as  compared  with  nine  in  this  half  company,  and 
the  latter’s  admissions  for  indefinite  pyrexias  were  likewise 
disproportionate  to  the  admissions  for  such  illness  for  the 
rest  of  the  battalion. 

The  writer  had  an  opportunity  of  studying  an  outbreak 
which  had  just  concluded  at  H Garrison  in  1916.  Twenty 
cases  had  been  recorded.  The  question  whether  there  had 
been  unrecognised  cases  was  the  special  subject  of  inquiry 
at  this  station.  The  medical  officers  reported  a very  severe 
outbreak  of  influenzal  illness,  chiefly  localised  in  certain 
units.  Many  obscure  deaths  had  occurred.  The  nursing 
sisters’  report  books  at  the  Central  Hospital  were  examined 
by  the  writer,  and  in  this  way  a fairly  accurate  clinical 
picture  was  obtained  of  the  symptoms  of  the  patients.  Case- 
sheets  were  available  in  certain  cases.  The  names  of 
40  persons  were  thus  selected  as  being  possibly  cases  of 
cerebro-spinal  fever,  the  symptoms  being  more  or  less 
suggestive. 

When  the  names  were  afterwards  allocated  to  their  units 
the  result  was  remarkable,  and  is  given  below  in  graphic 
form.  (Fig.  1)  It  shows  that  the  units  chiefly  infected 


35 

30 

25 

20 

15 

10 


Fid.  1. 

0 Pyrexia. 


with  cerebro-spinal  fever  were  infected  proportionately  with 
an  illness,  the  symptoms  of  which  were  in  close  accord  with 
the  symptoms  of  the  definite  disease.  Certain  units  were 
free  from  both  forms  of  illness.  The  40  names  were  selected 
as  most  suspicious  from  amongst  the  names  of  some  hundreds 
of  admissions  during  the  same  period.  The  chief  symptoms 
which  influenced  the  selection  of  these  names  were — severity 
of  headache,  backache,  rigidity,  vomiting,  and  delirium. 


The  rapid  death  of  an  otherwise  healthy  soldier,  without 
definite  cause,  was  in  itself  a sufficient  reason  for  suspicion 
in  certain  fatal  cases.  In  others,  the  prolongation  and 
irregularity  of  the  fever,  with  relapses  and  slow  con- 
valescence, seemed  more  in  accordance  with  the  signs  of 
meningococcal  infection  than  with  any  other  definite  known 
disease.  In  many  of  these  the  possibility  of  cerebro-spinal 
fever  was  mentioned,  and  sometimes  lumbar  puncture  was 
performed  with  negative  results. 

From  the  proportionate  incidence  of  proved  cases  of 
cerebro- spinal  fever  and  probable  and  possible  cases,  the 
inference  is  justified  that  at  this  station  the  disease  was  more 
widespread  than  indicated  by  the  reported  cases. 

At  D Garrison  there  were  21  cases  with  10  deaths.  Twelve 
of  the  cases  occurred  in  one  battalion,  the  strength  of  which 
was  one-ninth  part  of  the  strength  of  the  whole  garrison. 
All  the  cases  occurred  between  March  15th  and  April  6th. 
The  infection  was  imported  by  a draft  which  arrived  on 
March  10th.  In  addition  to  the  12  cases  of  cerebro-spinal 
fever  in  this  unit,  there  were  12  other  persons  who  died  from 
various  febrile  conditions  amongst  patients  admitted  during 
the  above  infective  period,  the  symptoms  again  being  com- 
patible with  cerebro-spinal  fever.  The  remaining  eight-ninths 
of  the  garrison  had  only  four  such  deaths  from  febrile 
diseases.  This  extraordinarily  high  death  rate  in  this 
battalion  during  the  infective  period  is  most  remarkable, 
especially  as  the  unit  was  at  other  times  healthy,  and  for  the 
periods  of  six  weeks  before  and  after  this  period  it  had  only 
1 febrile  death  out  of  24  for  the  rest  of  the  garrison.  Again, 
there  were  18  patients  punctured  at  this  station  with  negative 
results  ; of  these,  12  belonged  to  the  highly  infected  battalion, 
and  4 of  these  12  died. 

It  seems  undoubted,  therefore,  that  in  this  battalion  many 
persons  died  of  cerebro-spinal  fever  in  addition  to  those 
returned  as  such,  and  that  many  of  those  suspected  cases 
which  were  punctured  but  which  failed  to  receive  bacterio- 
logical confirmation  were  in  reality  suffering  from  the 
disease. 

At  X Depot  there  were  20  cases,  variously  distributed 
amongst  four  out  of  the  five  regiments  stationed  there. 
The  medical  officer  in  charge  informed  the  writer  that  there 
were  large  numbers  suffering  from  a severe  type  of  influenzal 
disease  in  the  hospital  about  the  same  time,  many  of  which 
had  symptoms  which  approximated  to  those  of  cerebro- 
spinal fever.  He  kindly  collected  for  me  the  numbers  of 
such  patients  admitted  per  1000  of  strength.  This,  with 
the  case-incidence,  is  given  below  for  each  regiment,  and 
it  is  noticed  that  they  are  in  correspondence.  (The  carrier 
percentage  is,  however,  in  the  reverse  ratio  of  the  cases.) 


Units  

A 

B 

C 

D 

E 

Cases  C.-S.F 

7 7 

4 

2 

0 

Uncertain  pyrexia  per  1000  .. 

. 117 

92 

42 

28 

20 

Carrier  percentage  

22 

30 

24 

42 

35 

Causes  of  Xon  - recog  n i tion  of  Cases. 

Many  cases  of  cerebro-spinal  fever  escape  recognition 
because  : ( a ) they  are  not  suspected  clinically  ; ( b ) they  fail 
to  be  tested  by  lumbar  puncture  ; (e)  modern  bacteriological 
methods  frequently  fail  to  demonstrate  meningococci,  par- 
ticularly in  early  and  irregular  cases. 

(«)  Many  cases  are  not  suspected  clinically , as  mentioned, 
when  taken  individually,  and  in  the  absence  of  an  epidemic. 
The  laboratory  at  X Garrison  dealt  with  a large  area  of 
country,  in  addition  to  the  garrison,  which  was  under  our 
immediate  observation.  All  the  patients  whom  we  investi- 
gated were  either  of  the  acute  fulminating  type  or  else  had 
been  ill  for  several  days  or  weeks  before  the  possibility  of 
cerebro-spinal  fever  arose.  Whilst  working  at  the  Central 
Laboratory  in  May,  1917,  the  writer  visited  with  Captain 
Glover  seven  definitely  proved  cases  of  cerebro-spinal  fever. 
Four  of  these  had  been  for  long  periods  under  observation 
in  well-known  London  hospitals  before  an  appeal  was  made 
to  the  Central  Laboratory.  Two  of  them  had  been  invalided 
from  France  as  unrecognised  cases. 

( b ) Many  suspected  cases  fail  to  be  tested  by  lumbar  puncture. 
Often  facilities  for  puncture  are  not  immediately  available. 
Lumbar  puncture  is  regarded  by  many  as  a serious  operation, 
and  as  such  is  only  performed  when  the  symptoms  are  most 
definite  and  persistent.  It  often  happens  that  symptoms, 
which  are  at  first  characteristic,  subside  rapidly,  and  before 
time  has  been  found  to  perform  lumbar  puncture  the  whole 
clinical  picture  has  altered  and  puncture  is  not  performed. 


The  Lanoht,] 


DR.  J.  DORGAN  : CEREBRO-SPINAL  FEVER. 


[July  19,  1919  99 


Numerous  instances  occurred  at  the  stations  investigated 
by  the  writer,  where  it  was  mentioned  in  the  notes  of  the 
irregular  type  of  patients  that  the  question  of  performing 
lumbar  puncture  was  considered,  but  for  one  reason  or 
another  it  was  not  performed.  The  failure  to  puncture  must 
occur  much  more  frequently  in  civil  practice  and  in  sporadic 
cases,  where  each  patient  is  not  under  particular  observation. 

It  may  be  here  mentioned  that  at  X Garrison  in  1916  and 
1917  there  were  1000  lumbar  punctures  performed  by  Captains 
Trevor  Davies,  Pringle,  and  Scott.  There  were  no  untoward 
results.  The  benefit  to  the  patient  from  lumbar  puncture 
alone  is  undoubted.  No  definite  opinion  was  formed  as  to 
the  benefit  or  otherwise  of  serum.  A group  of  patients,  to 
whom  no  serum  was  given,  did  equally  well  with  those  to  whom 
it  had  been  given.  There  appeared  to  be  no  definite  and 
regular  reactionary  improvement,  such  as  one  should  expect 
after  a specific  serum.  All  varieties,  as  supplied  by  Colonel 
Gordon,  were  tried.  The  more  the  existence  of  mild  and 
abortive  types  of  the  disease  is  recognised  the  less  will  be 
the  tendency  necessarily  to  attribute  beneficial  results  to  the 
serum  administered. 

Baoteriological  Diagnosis. 

(o)  Many  oases  fail  to  receive  a true  diagnosis  owing  to  the 
frequent  failure  of  modern  bacteriological  technique.  In  all 

the  diagnosed  cases  (150)  at  X Garrison  in  1916  a Gram- 
negative intracellular  diplococcus  was  seen  in  the  spinal 
fluid.  In  more  than  half  of  the  cases  it  was  grown  in 
culture  and  agglutinated.  Twenty-one  cultures  were  sub- 
mitted to  Colonel  Gordon  at  the  Central  Laboratory  and  he 
agglutinated  18  of  these  to  his  types,  3 others  being  con- 
taminated. The  following  table  gives  the  numbers  of 
examinations  made  of  spinal  fluids  throughout  the  epidemic 
at  X Garrison  and  also  the  results : — 


- 

No.  exa- 
mined. 



No. 

negative. 

Per- 

centage 

negative. 

- 

No.  exa- 
mined. 

No. 

negative. 

Per- 

centage 

negative. 

Week  ending — 
March  11  ... 

19 

1 

5 

Week  ending — 
April  15  ... 

26 

9 

34 

„ 18  ... 

25 

2 

8 

22  ... 

13 

9 . 

69 

„ 25  ... 

11 

1 

9 

29  ... 

23 

12 

§2 

April  1 ... 
„ 8 ... 

23 

24 

3 

13 

May  6 . . . 

8 

4 

50 

7 

29 

Total 

172 

i 

48 

27% 

The  special  study  of  atypical  cases  began  early  in  April. 
It  caused  an  increase  in  the  negative  results.  During  the 
last  three  weeks  the  percentage  of  negative  returns  increased 
greatly.  During  this  last  period  a positive  bacteriological 
result  was  only  recorded  when  the  organism  was  grown  on 
culture.  This  was  in  accordance  with  instructions  received 
from  Colonel  Gordon.  There  was  no  doubt  that  during  this 
period  many  of  these  cases,  returned  as  negative,  were 
actually  suffering  from  cerebro-spinal  fever.  The  symptoms 
in  many  cases  were  open  to  no  doubt,  and  one  intracellular 
organism,  identical  with  the  meningococcus,  was  seen  in  the 
spinal  fluid. 

Captain  Samut,  in  his  report  of  1916,  had  shown  the 
increasing  difficulty  of  demonstrating  meningococci  in  the 
fluid  from  early  and  milder  cases  where  the  fluid  is  clear. 
The  difficulty  of  obtaining  a culture  increases  under  like 
conditions.  Sometimes,  however,  an  abundant  growth  was 
obtained  on  culture  of  fluids  in  which  the  meningococcus 
could  not  be  seen,  and,  on  the  other  hand,  a purulent  fluid, 
in  which  meningococci  could  be  seen  in  abundance,  some- 
times failed  to  give  a growth. 

At  X Garrison  at  this  time  we  were  making  a study  of 
irregular  types  at  the  earliest  possible  moment  after  the 
onset  of  symptoms,  and  a large  number  of  negative  results 
were  to  be  expected,  and  were  it  not  for  Captain  Samut’s 
painstaking  researches  it  is  believed  our  negative  results 
would  have  been  still  higher. 

It  was  sometimes  found  that  patients  suffering  from 
meningitic  symptoms  gave  an  apparently  sterile  fluid  on 
first  puncture,  yet  on  repeating  the  operation  at  a later 
date  meningococci  were  abundantly  present.  Captain  Scott 
in  1917  showed  the  writer  a patient  at  X Garrison ; 
clinically,  the  symptoms  left  the  diagnosis  in  no  doubt, 
yet  it  was  not  until  the  fourth  puncture  that  meningococci 
could  be  found. 


It  would  appear,  therefore,  that  neither  the  failure  to  find 
organisms  on  direct  examination,  nor  a negative  cultural 
result,  can  be  relied  upon  to  exclude  a diagnosis  of  cerebro- 
spinal fever.  In  the  second  family  mentioned  above  a child 
whose  blood  and  spinal  fluid  were  both  (apparently)  sterile 
was  afterwards  diagnosed  by  finding  the  meningococcus  in 
a synovial  fluid. 

Other  writers  have  noticed  the  weak  points  of  bacteriology 
in  the  diagnosis  of  this  disease.  Worster-Drought  2 said  that 
“bacteriological  results  are  apt  to  be  misleading,  if  relied 
upon,  as  clinical  symptoms  are  often  well  advanced  before 
organisms  can  be  either  seen  or  grown.”  Gaskell  found 
fluids  sterile  at  one  puncture  and  positive  at  the  next,  and 
6 out  of  25  clinically  definite  cases  failed  to  show  the 
meningococcus.  In  the  R.N.  Reports  of  1915-16,  it  is 
stated  that  “ at  Shotley,  there  were  11  cases  bacteriologically 
diagnosed,  and  there  were  11  others  in  which  lumbar  puncture 
was  performed  with  negative  results.  Some  of  the  latter 
suffered  from  severe  and  persistent  headache  at  the  time, 
and  in  some,  paralysis  and  mental  derangement  followed.” 

II.  The  Prime  Importance  of  Unrecognised  Cases  in  the 
Spread  of  the  Infection. 

It  would  appear  that  indefinite  cases,  which  often  pass 
unrecognised,  are  in  reality  the  more  numerous,  and  that 
comparatively  few  progress  to  the  stage  where  the  symptoms 
are  unmistakable.  The  indefinite  cases  are  usually  found 
associated  with  others  of  the  usually  accepted  types,  and 
between  the  two  extremes  are  intermediates  of  all  stages  of 
severity. 

The  apparently  sporadic  occurrence  of  the  majority  of  cases 
of  this  disease  has  often  been  commented  upon.  Two  or  more 
adult  patients  are  not  often  found,  associated  in  infection, 
and  possessing  all  the  classical  signs  of  cerebro-spinal  fever. 
Yet  in  our  experience  at  X and  other  stations,  it  has  nearly 
always  been  possible  to  trace  a connexion  between  such  definite 
cases,  and  others  who  have  suffered  from  a form  of  pyrexia 
of  uncertain  origin.  This  connexion  is  chiefly  noticed 
where  the  conditions  as  to  housing  and  ventilation  are 
unsatisfactory.  In  children,  however,  it  is  far  from  un- 
common to  find  one  or  more  unequivocal  cases  amongst  the 
other  children  exposed  to  the  infection.  This  frequency  of 
multiple  infection  in  children  may  be  explained  by  the 
intense  susceptibility  of  those  of  tender  age  to  reflex  irrita- 
tion of  the  central  nervous  system,  so  that  even  a slight  dis- 
turbance more  often  provokes  in  them  characteristic  cerebral 
phenomena,  and  cerebro-spinal  fever  is  generally  recognised 
as  a disease  of  childhood.  The  meningeal  scream  and  con- 
vulsion of  a child  cannot  but  suggest  meningitis,  whereas 
the  headache,  backache,  fever,  and  vomiting  of  an  adult  may 
frequently  fail  to  do  so. 

The  diagnosis  of  cerebro-spinal  fever  is  therefore  probably 
more  frequently  and  accurately  made  in  children,  and  this 
largely  serves  to  explain  the  greater  infectivity  and  the 
higher  incidence  of  the  disease  as  reported  amongst  them. 
In  adults,  on  the  other  hand,  the  variability  of  the  symptoms 
frequently  tends  to  the  non-recognition  of  many  cases  and  to 
the  consequent  failure  in  tracing  the  infective  connexion 
between  different  forms  of  the  same  disease. 

Variation  in  Resulting  Infection. 

The  effects  produced  by  a given  dose  of  meningococci 
depends  on  the  susceptibility  of  the  patient  rather  than  on 
the  virulence  of  the  organism,  because  the  infection  received 
from  an  acutely  severe  case  may  result  only  in  a mild  and 
indefinite  illness  in  the  person  next  infected,  and,  on  the 
other  hand,  a patient  with  a mild  illness  may  reproduce  a 
most  virulent  infection  in  another. 

This  mutation  in  the  type  of  resulting  infection  is  well 
illustrated  in  the  two  families  already  mentioned.  In  the 
first  family  the  first  child,  whose  symptoms  were  so  mild 
that  the  disease  was  unrecognised,  infected  its  eldest  sister 
with  fulminating  cerebro-spinal  fever.  In  the  second 
family  an  acutely  fatal  disease  resulted  in  three  other 
children  being  variously  attacked,  one  of  whom  was  proved 
to  be  suffering  from  cerebro-spinal  fever,  although  it  had  no 
marked  meningitic  symptoms,  and  the  cerebro-spinal  fluid 
was  apparently  sterile  and  uninvolved. 

Though  as  a rule  the  onset  of  cerebro-spinal  fever  is  sudden 
and  definite,  yet  a considerable  number  of  patients  develop 
the  disease  insidiously.  A close  study  was  made  of  the 


2 Brit.  Med.  Jour.,  Nov.  18th,  1916. 


100  The  Lancet,] 


DR.  J.  DORGAN  : CEREBRO-SPINAL  FEVER. 


[July  19,  1919 


interval  between  onset  of  symptoms  and  admission  to  hos- 
pital in  45  consecutive  cases  at  X Garrison  ; it  was  found  to 
average  50  hours.  During  this  time  they  were  treated  as 
extern  patients,  and  must  have  constituted  a virulent  focus 
of  infection  to  their  comrades  in  barracks.  The  fact  that 
unrecognised  and  irregular  types  tend  to  be  more  insidious 
in  their  onset  than  the  definite  and  fulminating  forms  causes 
the  former  to  be  a much  greater  danger  than  the  latter  in 
the  spread  of  the  disease. 

As  already  stated,  the  possibility  of  irregular  and  unrecog- 
nised forms  of  cerebro- spinal  fever  was  first  suspected  by 
the  writer  by  the  undoubted  association  between  proved  cases 
and  certain  other  febrile  conditions,  which  differed  in  the 
intensity  rather  than  in  the  essential  characters  of  the  sym- 
ptoms. Very  many  individual  instances  could  be  given  of  a 
similar  nature  to  the  three  families  mentioned  above.  The 
evidence  in  these  cases,  though  circumstantial,  yet  was  so 
often  repeated,  and  of  such  a conclusive  nature  when 
investigated  on  the  spot,  that  it  perforce  led  to  no  other 
conclusion  than  that  such  variation  of  symptoms  as  existed 
were  due  to  the  susceptibility  of  the  patient  and  not  to  any 
difference  in  the  common  infecting  organism. 

Again,  the  simultaneous  outbreaks  of  vague  febrile  diseases 
occurring  in  constant  connexion  with  epidemics  of  cerebro- 
spinal fever,  and  the  exactly  proportionate  incidence  of  both 
illnesses  in  various  units  and  garrisons,  as  pointed  out  above, 
cannot  be  due  to  the  chance  incidence  of  two  separate  out- 
breaks in  all  of  the 
units  concerned,  and 
the  inference  is  again 
more  than  justified 
that  a single  organism 
is  responsible  for  both 
types  of  illnesses. 

The  occurrence  of 
these  indefinite 
febrile  outbreaks  has 
been  constantly  noted 
by  all  observers.  Dr. 

W.  H.  Hamer,  medi- 
cal officer  of  health 
of  the  London  County 
Council,  has  given 
most  interesting 

evidence  of  the  asso-  

ciation  between  them 
and  epidemics  of  cerebro-spinal  fever.  In  the  Royal 
Naval  Reports  for  1914-16  the  frequency  with  which 
unrecognised  or  aborted  cases  occurred  amongst  contacts 
of  actual  cases  is  discussed.  Dr.  Bruce  Low,  commenting 
on  an  outbreak  at  Northampton  several  years  ago,  wrote  as 
follows  : — 

“There  were  also  in  this  instance,  coincidently  with  the 
30  unequivocal  cases,  several  others  of  an  anomalous  sort, 
mostly  amongst  persons  who  had  been  in  contact  with  one 
or  other  of  the  patients  who  had  been  seriously  ill ; these 

cases  resembled  influenza  and  all  recovered This  is 

the  more  interesting  from  the  fact  that  the  serious  cases 
and  those  with  only  influenza-like  symptoms  occurred  side 
by  side.” 

III.  Carriers. 

There  is  no  evidence  at  X Garrison  to  shore  that  carriers 
convey  active  infection.  The  statistics  as  to  carriers  are 
conflicting  and  inconclusive.  Their  isolation  is  impracticable 
and  unjustifiable. 

At  X Garrison  520  carriers  were  isolated  for  varying 
periods  up  to  four  months.  187  carriers  had  been  detected 
amongst  the  contacts  of  cases  and  333  from  the  general  body 
of  troops  examined  when  leaving  the  station  on  active  service 
or  otherwise.  Captains  Armstrong  and  Napier  had  isolated 
most  of  these  on  the  result  of  morphological  appearances 
because  time  did  not  permit  of  serological  tests  of  the 
greater  number  of  swabs.  At  the  close  of  the  epidemic 
Captain  W.  J.  Tulloch  was  deputed  by  Colonel  Gordon  to 
complete  the  examination  of  the  324  men  then  remaining  in 
isolation.  This  officer  found  that  103  of  these  were  not 
infected  with  an  agglutinable  organism,  consequently,  as 
Colonel  Gordon  mentions,  “persons  harbouring  such  non- 
agglutinable  meningococci  should  not  be  regarded  as,  or 
treated  as,  carriers  of  the  organism.” 

Of  the  original  520  persons  in  isolation  there  were  there- 
fore at  least  150  men  who  were  not  carriers  at  all.  If 
carriers  are  capable  of  carrying  infection  it  seems  extra- 


ordinary that  each  of  these  soldiers  escaped  infection  when 
surrounded  by  400  virulent  carriers.  They  lived  together 
for  weeks  and  months  in  the  hospital  enclosure  under  some- 
what unsatisfactory  conditions. 

Neither  did  any  of  the  400  active  carriers  develop  the 
disease,  nor  any  of  the  504  known  carriers  isolated  by  the 
Central  Cerebro-spinal  Fever  Laboratory  as  a result  of  the 
swabbing  at  X Depot  in  the  following  year.  Colonel 
Gordon  says,  “ Only  occasionally  does  the  meningococcus 
succeed  in  passing  the  barrier  of  the  mucous  membrane  of 
the  naso-pharynx  and  penetrating  to  the  meninges.”  Surely 
it  ought  to  have  succeeded  in  some  of  these  1000  men. 

It  is  well  known  that  carriers  practically  never  develop  the 
disease.  So  much  so  that  it  has  been  suggested  that  they 
acquire  an  immunity.  This  is  negatived  at  X Garrison, 
because  one  known  carrier  contracted  the  disease  whilst 
employed  as  a nurse  in  the  cerebro-spinal  wards.  He  lived 
apart,  and  evidently  got  infected  from  his  patients.  Another 
ex-carrier  got  the  disease  three  weeks  after  his  discharge 
from  the  isolation  camp,  after  three  negative  swabs.  Of 
course,  immunity  does  not  explain  why  none  of  the  150  false 
carriers  failed  to  become  infected. 

The  Carrier  Hypothesis. 

At  X Garrison  14,000  men  were  examined  to  find  the 
carriers  as  above.  About  200  per  day  were  tested.  These 
numbers  constitute  a record  for  an  epidemic,  and  they  are 

Fig.  2. 


cases  per  week. 


_ . carriers  per  cent. 


sufficiently  large  to  give  a fair  index  of  the  daily  carrier-rate 
throughout  the  course  of  the  epidemic.  As  seen  from  the 
chart  (Fig.  2),  the  carrier-rate  at  the  period  of  maximum 
incidence  was  low,  but  as  the  cases  ceased  to  occur  the 
percentage  rose  to  a high  figure (33  per  cent.).  These  figures 
show  that  a low  carrier  index  may  coincide  with  a high  case 
incidence,  and  vice  versa,  and  might  be  taken  to  indicate 
that  cases  produce  carriers,  but  not  carriers  cases. 

The  principal  argument  in  favour  of  the  carrier  hypothesis 
has  been  the  frequent  discovery  of  a carrier  amongst  the 
contacts  after  the  diagnosis  of  a case.  The  above-mentioned 
two  families  are  the  two  instances  of  “ evidence  ” of  infection 
of  cases  by  carriers  as  brought  forward  by  Captain  Flack.  In 
the  first  family  the  father  had  been  definitely  ill  on  arrival 
home,  and  his  children  took  ill  two  and  three  days  after  his 
arrival,  and  in  the  other  family  the  father  had  been  10  days  at 
home  before  his  four  children  took  ill,  which  would  seem  to 
indicate  that  the  latter  was  in  no  way  concerned  with  the 
infection  of  his  children.  Both  of  the  fathers  were  found  to 
be  carriers  after  the  illness.  In  the  third  family  mentioned 
by  the  writer  the  father  apparently  infected  his  child  with 
cerebro-spinal  fever  and  wife  with  “influenza,”  but  in  his 
case  he  was  not  a carrier. 

Carriers  are  found  in  all  communities  in  larger  or  smaller 
numbers.  In  order  to  establish  a case  in  favour  of  the 
carrier  having  caused  the  case,  it  is  necessary  to  prove  that 
the  carrier,  found  as  a contact,  is  actively  pathogenic  and 
different  from  the  numerous  other  carriers  universally  present, 
or,  that  the  proportion  of  carriers  found  amongst  non- 
contacts is  comparatively  small  compared  with  the  numbers 
found  amongst  actual  contacts  of  the  patients.  No  one 
has.  however,  attempted  to  show  a difference  between 
pathogenic  and  non-pathogenic  carriers.  Neither  have 
any  statistics  been  produced  to  show  a difference  in 
the  percentage  of  carriers  among  contacts  and  non-contact 
carrier  groups. 


The  Lancet,] 


DR.  J.  DORGAN  : CEREBRO  SPINAL  FEVER. 


[July  19,  1919  101 


Some  Statistics  in  regard  to  Carriers. 

At  X Depot,  which  has  been  the  test  station  for  the 
officers  of  the  Central  Cerebro-spinal  Fever  Laboratory,  it 
was  shown  that  no  more  carriers  are  to  be  expected  amongst 
contacts  than  amongst  those  persons  in  no  way  connected 
with  the  patients — there  being  34  per  cent,  in  each  case  at 
this  station.  At  X Garrison  our  own  experience  was  the  same, 
there  being  the  same  number  of  carriers  amongst  the 
population  generally  as  there  were  amongst  those  persons  in 
close  contact  with  the  patient. 

Whilst  working  at  the  Central  Laboratory  in  1917  Captain 
Tulloch  kindly  allowed  the  writer  to  examine  his  series  of 
results  of  examination  of  type  in  the  naso-pharynx  of 
carriers  found  in  connexion  with  definite  cases  of  cerebro- 
spinal fever.  He  agreed  that  there  was  no  undue  prevalence 
of  the  type  as  found  on  spinal  puncture  and  that  found  in 
the  naso  pharynx  of  the  carriers.  Such  a prevalence  would 
be  expected  if  a relationship  existed  as  regards  infection 
between  case  and  carrier. 

At  X Garrison  there  were  no  carriers  found  in  connexion 
with  45  of  the  150  cases  in  this  epidemic,  250  persons 
having  been  examined  as  contacts  of  these  cases.  They 
were  well  chosen,  being  chiefly  those  occupying  the  same 
tent,  billet,  or  barrack  room  as  the  patient.  This  is  rather 
remarkable,  as  the  carrier-rate  generally,  as  shown  above, 
was  high. 

Three  soldiers  at  X Garrison  were  negative  in  their  naso- 
pharynx within  24  hours  of  the  onset  of  the  acute  symptoms 
of  cerebro-spinal  fever  ; two  others  were  negative  48  hours  and 
two  72  hours  before  the  onset  (and  two  more  were  likewise 
negative  within  72  hours  of  being  taken  ill).  These  men 
happened  to  be  swabbed  as  contacts  immediately  after  the 
-diagnosis  of  a previous  case. 

Captains  Armstrong  and  Napier  examined,  at  the  writer’s 
request,  the  throats  of  41  cerebro-spinal  fever  patients  on 
admission  to  hospital.  In  19  only  was  the  meningococcus 
shown  to  be  present.  Captain  Glover  repeated  the  same 
test  in  the  following  year,  also  at  the  writer’s  request,  in 
4 proved  cases  we  visited  together,  and  in  only  one  of 
these  was  the  meningococcus  found  in  the  naso-pharynx. 
The  swabs  were  taken  and  the  cultures  examined  with 
especial  care. 

Route  of  Infection. 

Many  patients  consequently  who  develop  cerebro-spinal 
fever  are  apparently  not  infected  by  the  meningococcus  in 
their  naso-pharynx  either  at  the  onset  of  the  symptoms  or 
within  the  period  immediately  preceding  the  onset.  It 
would  seem,  therefore,  that  such  patients  have  not  received, 
nor  are  they  likely  to  convey,  infection  via  the  naso-pharynx. 

Colonel  Gordon,  with  whom  the  writer  has  discussed  the 
above  findings,  makes  no  comment  on  this  work  of  officers 
from  his  own  laboratory  when  he  says  that  “ the  meningo- 
coccus is  invariably  to  be  found  in  the  naso-pharyngeal 

secretion  at  the  onset  of  the  disease Only  occasionally 

■does  the  meningococcus  succeed  in  passing  the  barrier  of 
the  mucous  membrane  of  the  naso-pharynx  and  penetrating 
to  the  meninges.” 

The  opinions  of  many  other  observers  are  directly  contra- 
dictory to  these  views.  Surgeon-General  Rolleston,  in  his 
account  of  Cerebro-spinal  Fever  in  the  Navy,3  says  that 
“ During  the  acute  stage  of  cerebro-spinal  fever  swabs  from 
the  naso-pharynx  are  often  negative.  Out  of  33  cases, 
bacteriologically  proved,  meningococci  were  found  in  7,  or 
21  per  cent,  only.”  These  results  are  in  agreement  with 
von  Lingelsheim’s  figures  of  635  cases  of  cerebro-spinal  fever 
with  146,  or  22  per  cent,  of  positive  cultivations,  from  the 
naso-pharynx,  and  with  those  of  Gaskell  and  Foster,  who 
likewise  found  that  only  25  per  cent,  of  their  cases  were 
infected  in  their  naso-pharynx.  Netter’s  results  show  that 
only  60  per  cent,  are  infected.  In  the  Special  Advisory  Com- 
mittee’s report  it  is  mentioned  that  “the  meningococcus  has 
been  much  less  commonly  found  in  the  naso-pharynx  of 
actual  sufferers  than  might  have  been  expected.” 

Recent  work  has  thrown  considerable  doubt  on  the  long- 
established  belief  that  meningococci  pass  direct  through  the 
nasal  mucous  to  the  meninges.  In  many  cases,  certainly, 
the  blood  is  infected  prior  to  the  cerebro-spinal  fluid,  which 
apparently  often  remains  free  of  infection  throughout,  as  in 
the  case  of  the  child  already  mentioned.  It  is  more  in 
accordance  with  modern  ideas  that  the  transmission  should 
be  via  the  blood. 


3 The  Lancet,  Jan.  13th,  1917. 


Types  of  Organism. 

The  chief  argument  in  support  of  the  carrier  theory  given 
by  Colonel  Gordon  is  that  he  invariably  finds  the  naso- 
pharynx infected  by  the  same  type  of  organism  as  is  found 
in  the  spinal  fluid.  This  evidence  is  already  disproved,  as 
above,  by  his  own  staff  and  others,  who  more  often  than  not 
failed  to  find  the  meningococcus  in  the  naso-pharynx.  He 
believes  that  four  types  of  meningococci  exist,  which  are 
specifically  distinct  “and  not  transient  and  unstable  variants 
of  a single  micro-organism.”  Again,  other  workers  are  unable 
to  agree  with  him  in  this.  Walker  Hall  and  others  find  that 
the  types  are  subject  to  mutation  on  culture.  Bassett-Smith 
found  that  of  107  carriers  who  had  more  than  one  positive 
examination,  more  than  half  of  them  showed  a variation  of 
the  Gordon  type  on  subsequent  swabbings.  Eastwood, 
Griffiths,  and  Scott  believe  that  the  distinction  between 
types  is  arbitrary  and  depends  on  the  chance  selection  of 
strains. 

Colonel  Gordon  has  recently  1 replied  to  the  contradictory 
observations  (by  other  workers)  with  regard  to  his  classifi- 
cation of  meningococci.  He  explains  their  results  as 
follows  : — 

“ The  research  is  of  a distinctly  arduous  character — 
demanding  a very  high  degree  of  dexterity  that  can  only  be 
acquired  by  continuous  and  persevering  effort — even  minute 
errors  may  mar  or  upset  the  result.  In  our  experience  at 
the  Central  Laboratory  it  requires  at  least  six  weeks’  hard 
work  before  even  a trained  bacteriologist,  with  considerable 
serological  experience,  can  sufficiently  master  the  technique 
to  obtain  consistently  satisfactory  results.  Similarly,  when 
he  goes  on  a holiday,  even  for  a week,  it  requires  at  lease 
another  week’s  work  before  the  necessary  unconsciout 
manipulative  dexterity  returns.  After  that  degree  of  dexterity 
is  reached  irregular  results  are  far  less  frequent  than  before.” 

It  would  seem  as  if  the  technique  is  so  far  above  the 
ordinary  well-trained  bacteriologist  that  it  loses  much  of  its 
practical  value. 

Two,  three,  or  four  of  these  specifically  distinct 
organisms  are  present  in  most  epidemics.  This  seems  very 
incredible  from  an  epidemiological  point  of  view.  It  is 
comparable  to  finding  para.  A and  B and  typhosus  bacilli, 
irregularly,  in  the  investigation  of  a definitely  localised 
epidemic  of  typhoid  fever.  It  would  mean  that  each  out- 
burst of  cerebro-spinal  fever  is  due  to  two,  three,  or  four 
distinct  organisms  being  simultaneously  let  loose  to  produce 
infection.  This  seems  so  unlikely  that  it  causes  us  again  to 
hesitate  before  accepting  the  view  that  four  specifically 
distinct  organisms  are  concerned  in  epidemics  of  cerebro- 
spinal fever. 

The  Isolation  of  Carriers. 

The  prophylaxis  for  1918,  as  approved  by  Colonel  Gordon, 
is  given.'1  The  sixth  and  last  recommendation  is  “that 
large  sample  swabbings  (100  men)  be  taken  weekly  as  a 
guide  to  the  current  carrier-rate.”  It  is  understood  that 
case-contacts  were  to  be  swabbed  as  before,  and  that 
carriers  from  both  sources  were  isolated.  Such  a proposal 
appears  unsound  and  unjustifiable  if  it  has  involved  the  loss 
of  man-power  by  isolation  of  carriers,  as  in  former  years.  It 
can  only  be  hoped  to  discover  a small  proportion  of  carriers 
by  this  procedure,  for  as,  ordinarily,  samples  represent  but  a 
small  fraction  of  the  whole  population  so  therefore  the 
carriers  found  in  sample  groups  represent  the  same  fraction 
of  the  total  number  of  persons  carrying. 

The  practical  effect  of  such  a scheme  was  illustrated  at 
X Garrison  in  1916.  At  the  close  of  the  epidemic  there  the 
writer  reported  as  follows  : — 

“ It  was  decided  to  stop  the  further  swabbing  of  drafts  and 
to  discharge  the  carriers  then  in  isolation,  further  cases 
having  ceased  to  occur.  It  seemed  no  longer  logical  to  detain 
in  strict  isolation  400  men  when  recent  swabbing  results 
indicated  that  there  were  at  least  5000  carriers  living  at  large 
amongst  the  troops.” 

The  discharge  of  the  carriers  was,  however,  counter- 
manded by  Colonel  Reece  and  the  further  history  is  given 
by  Captain  Tulloch  in  the  Medical  Research  Committee’s 
Report,  Series  3,  but  60  of  them  had  actually  been  discharged 
without  ill-effects. 

Again,  at  X Depot,  which  had  been  under  the  continual 
observation  of  the  officers  of  the  Central  Laboratory  for  two 
years,  it  was  known  that  during  the  epidemic  half  of  the 
population  (5500)  were  carrying,  yet  at  the  same  time  about 
200  healthy  men  were  detained  as  carriers  in  hospital. 

* R.A.M.C.  Journal,  January,  1918.  5 Ibid.,  p.  35. 


102  Thh  Lanoht,] 


DR.  J.  DORGAN  : CEREBRO-SPINAL  FEVER. 


[July  19,  19-9 


At  X Garrison  and  at  X Depot  the  samples  were  taken  on 
a record  scale,  17,500  men  having  been  swabbed  and  over 
a thousand  carriers  isolated,  yet  at  no  one  time  did  the 
carriers  amount  to  one-twelfth  part  of  the  total  number  of 
carriers  available.  The  population  in  both  was  largely  a 
floating  one. 

There  is  no  reason  why  case  carriers  should  be  isolated 
any  more  than  carriers  from  sample.  At  the  above  depot  the 
carrier-rate  amongst  the  two  groups  was  exactly  the  same 
(34  per  cent.),  and,  as  previously  stated,  no  one  has  ever 
suggested  that  the  carrier  found  in  connexion  with  a case 
differs  in  any  way  as  regards  infection. 

The  possibility  of  failure  in  detecting  a carrier  would 
appear  to  be  at  least  20  per  cent.,  judging  by  the  writer’s 
examination  of  the  results  of  repeated  swabbings  of  chronic 
carriers,  where  intermittent  negative  results  were  followed 
by  positive  findings.  Fildes  and  Wallis  6 report : — 

“ If  two  consecutive  negative  swabs  (the  Navy  require  six) 
are  taken  as  the  index  of  cure,  no  less  than  36  per  cent,  of 
men  will,  in  fact,  not  be  cured  and  will  be  returned  to  the 
community  in  the  same  condition  as  they  were  before  they 
were  isolated.”  And  they  concluded  as  follows  : “One-third 
of  the  men  recover  spontaneously.  None  of  the  methods  of 
treatment  tested  has  any  conspicuous  merit,  nor  has  any  one 
obvious  advantage  over  another.” 

It  seems  most  irrational,  therefore,  to  elaborate  an 
extensive  system  of  control  which  fails  in  detecting 
infection  in  nearly  a quarter  of  the  cases  examined  and 
which  permits  more  than  a third  of  the  infected  persons 
to  be  discharged  uncured,  and  which  detains  healthy  men 
for  a treatment  which  possesses  no  obvious  merit.  More- 
over, the  isolation  of  case  and  sample  carriers  can  never 
hope  to  deal  with  more  than  one-twelfth  of  the  total 
numbers  of  carriers  in  a community. 

Methods  of  Treatment  of  Carriers. 

The  impracticability  of  former  methods  of  preventive 
control  by  isolation  of  carriers  has  now  evidently  become 
apparent  (vide  Colonels  Reece  and  Gordon).  It  is  recently 
admitted  that  “ when  the  carrier- rate  is  high  this  procedure 
loses  its  value,”  and  consequently  a new  procedure  has  been 
adopted — “ inhaling- room  treatment,  which  offers  valuable 
help  at  any  point  where  isolation  breaks  down.”  This  treat- 
ment is  still  in  an  experimental  stage,  and  up  to  the  com- 
mencement of  1918  no  tangible  evidence  was  produced  of  its 
value.  It  would  seem  to  be  a tactical  measure,  which 
serves  to  focus  the  attention  on  a healthy  carrier,  and 
covers  the  retirement  from  the  former  position  which  had 
become  untenable. 

Various  types  of  inhalers  have  been  already  tried— the 
Lingner-Gordon,  Falmouth,  and  Levick.  The  last  type, 
which  was  issued  in  large  numbers  in  1917,  appears  to  have 
been  replaced  by  the  Hine  pattern  in  1918,  the  advantage  of 
which  is  that  ‘‘the  atmosphere  is  not  vitiated  by  the  fumes 
of  the  burning  spirit,  as  with  the  Levick  spray.”  Many 
disinfectants  have  likewise  been  tried.  The  results  from 
chloramine  appeared  to  have  been  considered  the  best : — 

“Though  still  somewhat  few  in  number,  they  are  more 
than  encouraging,  chloramine  having  given  better  results 
than  any  other  antiseptic  yet  tried  in  this  way.”  Yet  the 
next  year  at  the  X Depot  it  was  mentioned  that  “as  the 
treatment  was  new  it  was  considered  advisable  in  this 
instance  to  begin  with  zinc  sulphate,  because  it  is  less 
irritating  than  chloramine.”  Yet  the  previous  year  Colonel 
Gordon  reported  that  “ the  results  with  zinc  salts  were  dis- 
appointing, but  they  served  to  emphasise  the  success  of 
those  obtained  with  chloramine.  Only  one  known  carrier 
could  be  subjected  to  the  zinc  spray— this  carrier  required 
no  less  than  70  inhalations  before  he  could  be  discharged.” 

The  above  extracts  from  published  reports  of  Colonel 
Gordon  and  the  officers  of  the  Central  Cerebro-spinal  Fever 
Laboratory  are  given  to  show  on  what  little  evidence  these 
officers  have  submitted  to  the  public  this  new  form  of 
treatment. 

Fildes  and  Wallis  included  chloramine  in  their  tests  as  to 
the  value  of  local  antiseptic  in  the  treatment  of  carriers,  and 
their  opinion  has  been  given  above  of  the  value  of  this  and 
other  forms  of  nasal  disinfection. 

1 he  writer  has  not  had  much  definite  personal  knowledge 
of  the  value  of  the  treatment.  The  published  results  are 
tew  and  without  statistical  value.  It  has  been  claimed  that 
i 1 is  equally  effective  in  reducing  the  incidence  of  measles, 
s ire-throats,  See.  The  writer  noted,  however,  that  at 


D Garrison  the  battalion  which  had  been  severely  infected 
by  cerebro-spinal  fever  and  which  underwent  elaborate 
spraying  afterwards  suffered  abnormally  from  such  com- 
plaints as  compared  with  other  units  who  were  not  being 
sprayed,  there  being  72  cases  of  measles  and  an  excessive 
amount  of  bronchial  catarrh  in  the  sprayed  battalion 
during  April,  1917.  The  spraying  arrangements  were  under 
the  personal  supervision  of  Major  Hine  and  other  officers 
from  the  Central  Laboratory.  The  local  opinion  was 
unfavourable  to  the  spray. 

IV.  Prophylaxis. 

The  infection  of  cerebro-spinal  fever  is  not  to  be  feared 
under  good  conditions  of  housing  and  ventilation.  The  early 
isolation  of  mild  and  severe  cases  and.  the  provision  of  free 
ventilation  compulsorily , and  with  sufficient  marmth  during  the 
time  of  seasonal  prevalence,  constitutes  the  most  effeotwe  means 
of  prevention. 

The  proposed  prophylaxis  of  the  disease  in  1918  is  given 
by  Captain  Glover.7  The  measures  indicate  a considerable 
change  from  the  policy  of  former  years,  and  as  they  are 
stated  to  have  been  submitted  to  the  advice  and  criticism  of 
Colonel  Gordon  it  may  be  taken  that  they  embody  the 
general  aspect  of  control  of  the  disease  in  the  immediate 
future.  They  are  as  follows  : — 

(i.)  Spacing  out  of  the  beds  with  a minimum  interval— 
reduction  of  numbers  from  the  mobilisation  to  the  peace 
scale  of  accommodation  ; the  provision  of  increased  warmth 
and  extra  fuel;  the  overcrowding  of  Y.MC.A.  and  other 
institutes,  and  medical  inspection  rooms  to  be  limited. 

(ii.)  Special  ventilation  to  be  arranged,  the  windows  to  be 
fixed  open,  and  new  ventilating  apertures  to  be  provided. 

(iii.)  Inoculation  to  be  postponed  until  the  second  month 
of  service. 

(iv.-vi.)  The  remaining  measures  deal  with  the  spraying  of 
all  troops  for  six  days  each  month,  and  the  sample  swabbing 
of  100  men  weekly  to  afford  a guide  to  the  carrier  index. 
The  expediency  of  the  two  latter  proposals  has  already  been 
fully  discussed. 

For  the  first  time  it  is  noted  that  primary  importance  is 
attached  to  ventilation  and  overcrowding.  Formerly  such 
factors  were  not  regarded  as  of  importance  by  the  officers 
of  the  Central  Laboratory,  judging  by  the  conditions 
described  as  prevailing  at  X Depot  at  the  commencement 
of  the  epidemic,  a station  which  was  under  the  personal 
observation  of  these  officers  for  over  a year  before,  as  a test 
in  preventive  measures,  and,  in  fact,  it  was  stated  that  “ it 
cannot  be  said  that  there  were  many  cases  to  be  attributed 
to  overcrowding.  ” 

Overcrmvding  and  Defective  Ventilation. 

The  influence  of  overcrowding  and  defective  ventilation  as 
factors  in  the  spread  of  cerebro-spinal  fever  was  very 
definitely  laid  down  in  the  writer’s  report  of  the  epidemic  at 
X Garrison  in  1916.  The  following  extracts  are  given  : — 

“ The  infection  of  cerebro-spinal  fever  is  not  to  be  feared 
under  good  conditions  as  to  housing  and  ventilation. 
Accommodation  was  supplied  on  war  scale,  nominally  at 
40  square  feet  per  man,  but  it  was  found  that  this  space  was 
not  always  available.  The  weather  was  abnormally  cold  and 
wet,  and  natural  ventilation  was  reduced  to  a minimum,  all 
doors  and  windows  being  closed.  Orders  were  found 
insufficient  to  prevent  this.  The  shape  of  the  barrack 
rooms  did  not  permit  of  a sufficient  interspace  between  the 
beds.  Unless  sufficient  fresh  air  is  provided  compulsorily 
and  scientifically — i.e..out  of  reach  of  the  soldier  and  with 
regulated  draught— it  will  not  be  of  practical  benefit,  as  it 
will  be  put  out  of  action.  It  is  at  night  that  ventilation  is 
essential.  Extra  blankets  should  be  provided  to  lessen  the 
discomfort  of  cold  air.  Kinemas  and  crowded  institutes  are 
to  blame  for  many  cases  of  cerebro-spinal  fever,  the 
Y.M.C.A.  huts  being  the  worst  offenders.  I have  inspected 
such  places  at  niaht,  and  from  these  visits  I am  convinced 
that  they  are  a most  potent  cause  of  spread  of  the  infection. 

On  April  2nd,  1916,  the  minimum  floor  space  was  increased 
to  60  square  feet.  The  doors  and  top  sashes  of  all  windows 
I were  fixed  in  an  open  position  or  else  removed.  The  barrack 
rooms  were  inspected  nightly  by  company  and  medical 
officers  to  ensure  that  ventilation  was  maintained.  It  is 
believed  that  the  absence  of  further  cases  amongst  the 
troops  remaining  in  barracks  was  due  more  to  the  com- 
pulsory fresh  air  than  to  the  smaller  proportionate  increase 
of  floor  space  which  it  had  been  possible  to  obtain.  (The 
troops  had  again  been  temporarily  on  the  reduced  scale 
owing  to  unavoidable  reasons). 


6 The  Lancet,  Oct.  6th,  1917. 


: R.A.M.C.  Journal,  January,  1918. 


The  Lancet,] 


MB.  W.  H.  BATTLE  : TRAUMATIC  RUPTURE  OF  THE  INTESTINE.  [July  19,  1919  [U:j 


The  lesson  would  appear  to  be  that  ventilation  should  be 
compulsorily  given,  and  on  a large  scale.  If  absolutely 
necessary,  moderate  overcrowding  on  mobilisation  scalemay 
be  permitted  if  the  fullest  use  is  made  of  fresh  air.  The 
incidence  of  cerebro-spinal  fever  is  dependent  on  the 
thermometer.  When  the  weather  is  cold  ventilation  is 
decreased  automatically.  Sunshine  has  no  effect  in  prevent- 
ing infection,  unless  accompanied  by  heat,  as  infection  takes 
place  in  barracks  and  other  places  after  sundown.  Rainfall 
has  no  effect,  neither  has  the  barometer.” 

The  proposal  to  defer  inoculations  until  the  second  month 
of  service  will  not,  it  is  believed,  reduce  the  well-known 
increased  incidence  of  the  disease  amongst  recruits.  It  is 
based  on  the  known  fact  that  about  40  per  cent,  of  patients 
have  been  inoculated  within  a week  of  the  onset  of  their 
illness,  but,  under  present  conditions,  it  is  usual  for  such  a 
proportion  of  men  to  have  received  a dose  of  inoculation 
or  vaccination  during  each  week  of  their  early  service. 

Practical  Measures  Advocated  in  Original  Report. 

In  conclusion,  the  following  paragraphs  may  be  repeated 
as  concluding  the  original  report : — 

“ The  occurrence  of  a definite  case  is  heralded  as  a rule 
by  indefinite  cases,  and  such  should  be  an  indication  for  all 
concerned  to  take  such  steps  as  the  aetiology  of  the  disease 
suggests.  It  is  not  sufficient  to  issue  orders  regarding  open 
windows  and  overcrowding.  The  rooms  should  be  visited  by 
company  and  medical  officers  to  ensure  that  instructions  are 
carried  out.  Windows  and  doors  will  need  to  be  screwed 
permanently  open  or  removed.  Dark  blinds  over  the 
windows  will  need  to  be  removed  at  ‘Lights  out,’  but 
blankets  and  fires  should  be  provided  to  lessen  the  dis- 
comfort of  cold  air.  The  ventilation  and  crowding  of 
institutes  requires  most  careful  watching  and  personal 
inspection  at  the  busy  period  of  the  evening. 

On  the  occurrence  of  a case  in  the  barrack  room  extra 
precautions  will  be  taken  on  the  lines  mentioned,  and  a 
watch  kept  for  febrile  illnesses  amongst  the  remainder.  Any 
men  suffering  from  severe  headache,  backache,  and  vomit- 
ing should  be  early  admitted  to  hospital  under  observation. 
The  contacts  of  a case  do  not  require  to  be  isolated  or 
swabbed.  They  can  continue  their  outdoor  work  as  usual 
and  sleep  in  the  infected  room  for  a week  at  least.  During 
this  quarantine  period  free  ventilation  should  be  insisted 
upon.  All  febrile  cases  amongst  the  troops  generally  should 
be  at  once  detained  in  hospital. 

These  remarks  are  written  in  the  hope  that  they  may 
cause  others  to  consider  the  possibility  and  importance  of 
atypical  and  unrecognised  forms  of  this  disease,  from  the 
point  of  view  of  diagnosis,  treatment,  prognosis,  and 
prevention.  The  early  isolation  of  mild  and  severe  cases, 
rather  than  of  carriers,  together  with  the  provision  of  free 
ventilation,  is  suggested  as  the  basis  of  preventive  measures. 

We  claim  to  have  established  a case  in  favour  of  the 
prevalence  of  mild  and  atypical  cases  of  cerebro-spinal  fever. 
The  influence  of  such  cases  in  determining  the  spread  of 
this  disease  ia  shown  by  the  proportionate  incidence  of 
definite  and  indefinite  illnesses,  in  units  and  garrisons,  as 
well  as  by  the  many  individual  instances  of  mutual  infection 
between  them  both.  If  the  existence  of  these  cases  be 
admitted,  it  seems  necessary  in  these  circumstances  to 
believe  that  mild  and  severe  forms  are  equally  potent  and 
important  factors  as  regards  the  spread  of  infection  if  it  is 
considered  that  mild  breeds  severe  and  the  severe  mild,  the 
resultant  disease  being  dependent  only  on  the  susceptibility 
of  the  patient  receiving  the  infection.  Such  considerations 
necessarily  involve  a review  of  the  previous  methods  of  the 
prevention  of  cerebro-spinal  fever.”  (1916  Report.) 

Postscript. 

The  following  extract  from  the  Medical  Supplement  (July, 
1918),  compiled  by  the  Medical  Research  Committee,  has 
just  reached  the  writer — after  writing  the  above.  It  is  given 
here  as  it  completely  confirms  the  main  contentions  in  the 
article. 

“The  significance  of  meningococcic  carriers  in  the  spread 
of  the  disease,  as  reflected  in  German  medical  opinion,  is 
summarised  by  Galambos,  who  says  that  though  sporadic 
cases  of  cerebro-spinal  fever  were  observed  in  the  various 
theatres  of  war  there  were  never  any  epidemic  outbreaks. 
G.  B.  Gruber  regards  the  search  for  meningococci  carriers 
and  their  isolation  and  disinfection  as  unnecessary,  and 
states  that  as  regards  importance  they  are  on  a par  with 
pneumococci  carriers.  Feser  is  of  the  same  opinion  and  has 
never  seen  a proved  case  of  infection  by  contact.  The  search 
for  carriers  is  considered  by  Klinger  and  Fourmann  to  be 
both  unnecessary  and  impracticable.  Meningococci  were 
never  isolated  from  the  naso-pharynx  of  18  cases  of  cerebro- 
spinal fever  under  Galambos’s  observation,  and  no  carriers 
were  found  among  the  contacts  of  the  patients ; he  is  con- 
vinced that  isolation  of  healthy  carriers  has  no  influence  in 
preventing  the  incidence  of  the  disease.” 


TRAUMATIC  RUPTURE  OP  THE 
INTESTINE. 

By  W.  H.  BATTLE,  F.R.C.S.  Eng., 

SURGEON  TO  ST.  THOMAS'S  HOSPITAL,  ETC. 


During  the  past  five  years  many  accounts  of  the  modern 
treatment  of  gunshot  wounds  of  the  abdomen  have  been 
published,  and  the  results  have  fully  confirmed  the  opinion 
held  by  most  surgeons  as  to  the  importance  of  interference 
as  early  as  possible,  given  fairly  satisfactory  surroundings. 
This  conviction  led  those  in  charge  of  the  medical  arrange- 
ments with  the  British  armies  to  make  special  provision  for 
dealing  with  this  class  of  case  as  soon  as  possible,  thus 
enabling  a large  proportion  to  be  treated  successfully.  These 
results  have  never  been  equalled  in  previous  wars,  and  will 
probably  never  be  surpassed. 

Traumatic  Rupture  of  Intestine  without  External  Lesion. 

In  civil  life  the  same  need  of  prompt  action  arises  in  cases 
where  reason  exists  to  suspect  a perforation  or  laceration  of 
some  part  of  the  gastro-intestinal  tract,  whether  there  be  a 
lesion  of  the  overlying  structures  or  not.  If  no  lesion  of  the 
skin  is  evident  (and  in  many  cases  of  abdominal  injury  where 
the  intestine  has  been  ruptured  it  has  not  been  possible  to 
find  any)  it  requires  firmness  to  induce  the  patient  to  submit 
to  operation  before  peritonitis  has  made  the  need  for  opera- 
tion obvious  to  the  patient’s  friends.  Waiting  imperils 
success  and  often  ensures  failure.  It  is  not  always  remem- 
bered by  those  in  charge  that  septic  peritonitis  will  be 
commencing  within  six  hours  and  quickly  spreads  when  it 
has  begun. 

Traumatic  rupture  of  the  intestine  without  an  external 
wound  is  one  of  the  catastrophes  of  civil  life  against  which 
it  is  not  possible  to  guard.  There  are  many  ways  of  causa- 
tion, but  practically  no  remedy  without  operation,  and  early 
operation.  Peritonitis  of  the  worst  type  inevitably  super- 
venes. Although  a few  cases  have  been  saved  by  surgical 
interference  when  peritonitis  has  been  advanced,  the  loss  of 
every  hour  makes  the  odds  against  recovery  more  formidable. 
It  is  far  better  to  operate  in  a doubtful  case  and  find  con- 
tusion or  slight  laceration  of  some  internal  organ  than  to 
allow  a valuable  life  to  be  sacrificed  through  a mistaken 
trust  in  the  possibilities  of  treatment  miscalled  conservative. 

In  some  of  the  more  serious  cases  the  shock  is  so  intense 
that  although  the  surroundings  may  be  favourable  the 
surgeon  is  compelled  to  wait.  Still,  there  is  a great  responsi- 
bility on  him  to  take  the  measures  best  calculated  to  enable 
the  essential  operation  to  be  done  as  soon  as  possible. 

Record  of  Case. 

The  following  is  the  record  of  a case  of  rupture  of  the 
jejunum  with  laceration  of  the  mesentery  and  intraperi- 
toneal  haemorrhage. 

A boy,  aged  15,  was  admitted  to  St.  Thomas’s  Hospital  on 
August  29th,  1916.  At  mid-day  he  was  riding  a tradesman’s 
tricycle,  when  a van  ran  into  it  and  knocked  him  off.  He 
was  unable  to  give  a clear  account  of  the  accident.  He  was 
suffering  from  shock  and  complained  of  severe  abdominal 
pain.  Normal  urine  was  withdrawn  by  catheter.  He  was 
put  to  bed  and  warm  blankets  and  hot- water  bottles  applied. 
At  2 p.m.  the  shock  was  still  very  severe  and  he  complained 
much  of  the  severity  of  the  abdominal  pain.  He  was  white, 
with  blanched  lips,  a subnormal  temperature,  and  pulse  of 
118.  He  was  lying  on  his  left  side  with  limbs  and  trunk 
flexed.  Respiration  almost  entirely  thoracic,  the  abdomen 
not  moving.  The  muscles  of  the  abdominal  wall  were  rigid, 
but  not  board-like,  and  he  was  generally  tender  in  this 
region.  Pain  was  referred  to  a point  about  3 inches  above 
the  umbilicus  under  the  left  rectus  muscle.  No  evident 
injury  to  the  skin.  Dullness  on  percussion  extended  from 
the  left  flank  to  the  level  of  the  umbilicus  when  he  was 
examined  in  the  position  assumed  as  the  most  comfortable. 
During  the  afternoon,  whilst  we  were  waiting  for  him  to 
revive  somewhat  from  his  collapsed  state,  he  vomited  and 
became  restless ; there  was  also  increasing  dullness  in  the 
abdomen  and  continuing  pain. 

Operation.— At  4 p.m.  a general  anaesthetic  was  administered 
and  the  abdomen  opened  by  a vertical  incision  about  6 inches 
long  to  the  left  of  the  middle  line.  The  rectus  sheath  was 
opened  and  the  muscle  drawn  outwards.  The  peritoneum 
had  a bluish  colour  from  underlying  blood,  which  escaped  in 
considerable  quantity  when  the  incision  was  extended.  There 
was  so  much  more  than  is  usual  in  these  cases  of  traumatic 
rupture  of  intestine  that  the  spleen  and  liver  were  at  once 
examined ; they  were  without  trace  of  injury.  When  the 


104  ThbLanobt,]  MR.  W.  H.  BATTLE:  TRAUMATIC  RUPTURE  OF  THE  INTESTINE. 


[July  19, 1919 


omentum  bad  been  displaced  to  the  left  a large  transverse 
rupture  of  the  jejunum  presented.  This  was  situated  about 
6 inches  from  the  duodeno-jejunal  junction  and  extended 
over  five-sixths  of  the  circumference  of  the  gut,  there  being 
only  a strip  of  the  mucous  membrane  on  the  mesenteric 
aspect,  which  appeared  normal.  This  was  wrapped  in  gauze 
to  prevent  further  escape  of  fseculent  fluid  until  the  source 
of  the  bleeding  had  been  discovered.  This  proved  to  be  a 
tear  in  the  mesentery  behind  the  lacerated  gut;  in  this  a 
vessel  of  some  considerable  size  had  been  torn.  Other  small 
lacerations  were  found  near  it,  whilst  an  irregular  laceration 
of  the  parietal  peritoneum  to  the  right  of  the  spine,  about 
the  level  of  the  umbilicus,  required  one  or  two  sutures.  The 
tear  in  the  jejunum  was  also  bleeding  and  the  edges  were 
bruised,  so  after  the  application  of  clamps  excision  of  this 

art  was  performed,  for  a distance  of  3 inches  above  and 

inches  below  the  rupture,  and  an  end-to-end  union  made. 
The  mesenteric  lacerations  were  sutured.  No.  1 silk  was 
used  for  the  anastomosis,  an  inner  continuous  uniting  all 
the  coats,  and  an  outer  Lembert,  also  continuous,  covering 
in  the  line  of  union.  The  abdomen  was  cleansed,  but  owing 
to  the  evident  contamination  from  intestinal  contents  a tube 
was  left  in.  The  small  intestine  was  nowhere  inflamed,  but 
near  the  tear  were  some  brownish  patches,  which  did  not 
come  away  on  sponging.  During  the  operation  saline  was 
infused  intravenously.  The  pulse  rose  to  160,  falling  later 
to  120. 

On  the  following  day  the  pulse  was  improving  though 
still  rapid,  and  the  boy  was  better.  On  the  31st  he  com- 
plained of  pain  and  tenderness  in  the  abdomen,  and  vomited. 
The  lungs  appeared  clogged  with  mucus,  there  being  moist 
sounds  all  over.  Respiration  48,  pulse  130.  Dr.  G.  Hoffmann, 
who  saw  him  for  me,  advised  adrenalin  and  a mixture  con- 
taining potassium  iodide.  Atropine  and  morphia  injections 
were  required  to  relieve  his  pain.  There  was  little  discharge 
from  the  tube,  which  was  removed  on  the  fifth  day. 

On  Sept.  2nd  the  bowels  acted  freely,  but  his  chest  com- 
plication did  not  recover  until  Sept.  5th,  when  the  pulse  had 
come  down  to  96  and  the  temperature  returned  to  normal. 
He  left  the  hospital  for  a convalescent  home  on  Sept.  27th. 

A few  months  later  he  had  a somewhat  severe  attack  of 
pain  in  the  abdomen  which  alarmed  him,  but  this  was  traced 
to  over-indulgence  in  raw  chestnuts,  and  soon  passed  off 
after  appropriate  treatment. 

Diagnosis. 

After  an  injury  which  may  have  caused  a rupture  of  some 
part  of  the  intestinal  tract  there  may  be  a group  of  symptoms 
making  diagnosis  certain  and  enabling  decision  at  once,  but 
there  is  no  one  symptom  always  present.  Certain  cases  do 
not  show  leading  symptoms  until  some  hours  have  passed, 
and  then  a rapid  change  takes  place. 

It  is  not  necessary  here  to  repeat  a list  of  symptoms  which 
are  very  well  illustrated  by  the  above  case,  and  which  are 
found,  luckily,  in  a majority.  There  is  an  agreement  about 
this  group  and  the  indications  to  be  generally  expected, 
which  I have  dealt  with  elsewhere.1  I should  like  to  draw 
attention  to  two  points  : (1)  the  occasional  rise  of  tempera- 
ture ; (2)  the  state  of  the  abdomen. 

A rise  of  temperature  to  103°  F.  and  over  may  be  found  when 
other  symptoms  are  not  well  marked,  and  should  be  regarded 
as  indicating  a definite  lesion  of  the  wall  of  the  gut,  and 
one  which  requires  repair.  There  may  not  be  a lesion  which 
has  opened  the  lumen  of  the  bowel ; it  may  only  involve  the 
external  layers,  but  it  may  become  complete  secondarily  ; 
therefore  it  requires  repair.  Incipient  inflammation  of  the 
lungs  secondary  to  an  accompanying  traumatism  of  the  chest 
must  be  excluded  by  examination. 

The  usual  state  of  the  abdomen  is  one  of  immobility  due 
to  rigidity  of  the  muscles,  and,  although  there  may  be  great 
tenderness,  there  is  seldom  dullness  in  the  flanks.  There 
may  be  dullness  directly  over  the  lesion,  but  this  is  usually 
quite  restricted  in  amount  and  due  to  collapsed  gut  with 
slight  haemorrhage  and  some  escape  of  contents.  If  there  is 
abnormal  dullness  in  the  flanks,  it  may  be  the  result  of 
haemorrhage  from  laceration  of  the  mesentery,  spleen,  or 
liver.  But  the  instances  in  which  the  state  of  the  abdomen 
is  recorded  with  reference  to  this  point  are  not  so  numerous 
as  we  could  desire. 

The  presence  of  free  gas  in  the  peritoneum,  even  in  small 
quantity,  appears  to  be  somewhat  rare  if  we  consider  the 
number  of  cases  in  which  it  was  found  when  the  peritoneum 
was  opened.  Mention  is  made  of  it  in  5 only  of  the  series 
of  132  brought  together  by  Berry  and  Giuseppi ; of  these, 
4 were  ruptures  of  the  jejunum,  the  opening  in  one  instance 
being  the  size  of  a threepenny-bit  ; in  1 it  was  present  on 
the  twelfth  day  after  a secondary  perforation  an  inch  below 

i The  Lancet,  1916,  i.,  587. 


the  sutured  one.  Others  appear  in  records  to  which  we  have 
access  at  the  present  time,  but  in  only  one  successful  case,  an 
operation  20  hours  after  the  injury,  was  there  distension  with 
loss  of  liver  dullness.  Loss  of  liver  dullness  after  sub- 
cutaneous rupture  of  the  intestines  usually  indicates  a late 
stage,  and  is  of  bad  prognosis,  being  caused  by  overlapping 
of  the  hepatic  border  by  distended  and  paralysed  intestine. 
Berry  and  Giuseppi  say 

“ In  several  cases  in  which  operation  was  not  undertaken 
until  absence  of  liver  dullness  had  been  noted,  not  one  of 
these  recovered.” 

In  traumatic  rupture  there  is  collapse  of  the  gut  near  the 
laceration,  and  the  contents  of  the  intestinal  canal  are  there- 
fore less  likely  to  escape  than  they  are  when  a pathological 
perforation  is  present.  Free  gas,  and  in  large  quantity,  is 
common  after  perforation  of  an  anterior  gastric  ulcer,  but 
if  the  ulcer  is  small  there  may  be  none.  It  is  seldom 
capable  of  demonstration  after  duodenal  or  jejunal  perfora- 
tions, although  some  may  be  found  when  the  peritoneum  is 
opened.  Emphysema  of  the  abdominal  wall  without 
accompanying  fracture  of  ribs  indicates  a lesion  of  the 
duodenum  or  large  bowel. 

Operation. 

The  special  points  to  be  remembered  in  the  operation  for 
suspected  rupture  of  the  intestine  are  the  following  : — 

1.  The  incision  should  be  a long  one,  extending  well 
above  the  umbilicus,  as  this  gives  best  access  to  the  root  of 
the  mesentery,  and  permits  of  most  rapid  examination  of  the 
abdominal  contents.  If  the  rectus  muscle  is  temporarily 
displaced  outwards  and  the  posterior  layer  of  the  sheath 
divided  well  to  the  left  of  the  mid-line  (and  it  is  best  to 
place  the  whole  incision  to  the  left)  there  will  be  no  danger 
of  subsequent  hernia. 

2.  Blood  or  fluid  which  has  accumulated  should  be  washed 
away  with  moist  sponges  and  a search  made  for  the  source 
of  the  bleeding.  When  hemorrhage  has  been  arrested  the 
damaged  section  of  gut  is  looked  for ; this  will  usually  be 
found  in  a line  between  the  point  struck  and  the  spine. 
Before  this  is  treated  search  should  be  made  for  a second 
point  of  rupture,  for  there  is  more  than  one  in  some  20  per 
cent.  Apparently  lesions  of  the  upper  jejunum  have  proved 
difficult  to  find,  for  those  in  this  position  have  been  over- 
looked in  several  instances,  only  to  be  revealed  post  mortem. 
Ruptures  of  the  duodenum  give  the  most  anxiety,  because 
there  is  usually  excessive  shock  causing  delay  in  the  opera- 
tion, great  difficulty  in  localising  the  lesion,  and  when  it  is 
found  more  manipulation  is  needed  to  remedy  the  damage, 
the  time  thus  required  further  imperiling  the  success  of  the 
operation. 

3.  Treatment  of  the  lesion  found  will  depend  upon  the 
extent  of  damage  to  bowel  wall  and  to  mesentery.  A large 
laceration  may  be  clean  edged  and  as  safely  secured  with  a 
double  suture  of  silk  or  other  material  as  those  of  smaller 
size,  but  if  the  damage  to  the  wall  of  the  bowel  is  severe  or 
there  is  another  opening  close  to  the  one  which  was  first  dis- 
covered it  may  be  necessary  to  resect  and  perform  an  anas- 
tomosis. The  sutures  will  thus  be  placed  in  healthy  tissue 
and  valuable  time  saved.  It  is  quite  impossible  to  lay  down 
hard-and-fast  lines  as  to  whether  the  laceration  should  be 
sutured,  resected,  &c.,  or  not.  Most  recoveries,  as  would  be 
expected,  were  after  rapid  suture.  The  use  of  Murphy’s 
button  did  not  prove  very  satisfactory,  partly  because  it  was 
used  by  operators  who  were  hurried  by  the  critical  state  of 
their  case.  Temporary  artificial  anus  in  the  small  gut  is  only 
to  be  tried  when  there  is  no  time  for  anything  beyond.  Still, 
it  must  be  recollected  that  John  Croft’s  first  case  lived  one 
month,  only  dying  then  (after  secondary  resection)  from 
exhaustion. 

4.  Closure  of  the  abdominal  incision  may  be  effected  in 
the  majority  without  drainage  of  the  peritoneum  ; if  drainage 
is  required  a suprapubic  ‘ 1 stab-incision  ” will  suffice,  the 
tube  being  passed  deeply  into  the  pelvis.  The  course 
followed  should  depend  on  the  presence  or  absence  of 
peritonitis  and  the  possibility  of  cleansing  the  infected 
peritoneum.  When  in  doubt  drain  and  place  the  patient  in 
the  Fowler  position.  When  drainage  is  established  much 
benefit  may  be  derived  from  the  use  of  continuous 
administration  of  saline  by  rectum  during  several  hours. 

Statistical  Data. 

In  compiling  statistics  of  a series  of  cases  such  as  these  it 
is  somewhat  difficult  to  avoid  overlapping,  and  therefore  a 


The  Lancet,] 


MR.  S.  MORT  : SOLID  PARAFFIN  WAX  IN  FAOIAL  SURGERY.  [J  uly  19,  1919  1 05 


want  of  accuracy,  unless  great  care  is  exercised.  The  avail- 
able records  extend  for  useful  purposes  from  the  first  case 
operated  on  by  John  Croft  in  1888  to  the  end  of  last  year, 
1918.  In  the  oration  on  Internal  Abdominal  Injuries  given 
before  the  Medical  Society  of  London  2 (1910),  a list  was 
given  adding  to  that  by  Berry  and  Giuseppi.3  Another 
useful  addition  was  made  by  Raymond  Johnson  1 in  1914, 
whilst  St.  Thomas’s  Hospital  Reports  and  the  medical 
journals  have  supplied  others,  completing,  I believe,  the  list 
of  those  available  from  Great  Britain.  This  gives  a total  of 
221,  comprising  200  males  and  21  females. 

Of  these,  43  are  derived  from  the  records  of  St.  Thomas’s 
Hospital,  of  which  number  33  were  submitted  to  operation 
and  11  recovered.  In  10  no  operation  was  performed, 
chiefly  because  the  condition  was  too  bad  from  shock, 
general  peritonitis,  or  the  complication  of  some  severe  injury. 
One  refused  operation.  Of  these,  life  was  prolonged  in 
four  for  six  days,  eight  days,  four  weeks,  and  four  weeks 
respectively.  Of  the  general  series,  124  operations  were 
performed  with  48  recoveries  and  76  deaths. 

The  hospital  cases  (St.  Thomas’s)  are  all  given  and 
include  every  case  admitted,  whether  moribund  or  not, 
whereas  the  other  statistics  are  from  many  sources  and  put 
the  results  in  too  favourable  a light.  Many  fatal  cases  have 
not  been  published. 

Cause  and  Site  of  Rupture. 

The  cause  of  the  rupture  is  shown  in  the  accompanying 
table,  which  also  gives  the  part  of  the  bowel  injured.  I 
have  not  included  two  cases  of  traumatic  rupture  produced 
by  gunshot  of  the  wall  of  the  abdomen  without  wound  of  the 
peritoneum,  although  from  a surgical  point  of  view  they  are 
unusually  interesting.5  No  case  is  included  from  any  of  the 
hospitals  since  those  published  in  the  list  given  by  Raymond 
Johnson,  unless  published  separately  in  the  Journals.  This 
statement  does  not  include  St.  Thomas’s  Hospital. 


- ' 

Duo- 

denum. 

Jejunum. 

Ileum. 

Small 

gut. 

Large 

gut. 

Totals 

Run  over  in  street 

16 

■41 

13 

1 

3 

74 

Kick  on  abdomen 

1 

17 

10 

— 

— 

28 

Crushed  

8 

6 

8 

— 

3 

25 

Struck  by  moving  body 

4 

18 

11 

— 

2 

35 

Fall  of  weight  on  body... 

— 

6 

6 

— 

— 

12 

Fall  

2 

12 

11 

— 

2 

27 

Other  causes 

1 

11 

- 

1 

1 

14 

— 

32 

111 

59 

2 

11 

215 

Position  and  cause  not  given  in  6.  Of  the  21  females  15  were  run  over 
In  the  street. 

Summary  of  Other  Cases. 


Other  cases  which  have  been  under  my  care  are  the 
following : — 

Male,  aged  24.  Jejunum,  ruptured  in  two  places : (1) 
Resection  of  13  inches,  and  lateral  anastomosis  ; (2)  end-to- 
end  with  plates.  Six  hours  after  kick  from  horse.  Lived 
6 days  ; peritonitis  from  giving  way  of  suture  in  end-to  end 
anastomosis. 

Male,  aged  27.  Ileum  ; rupture  1 inch ; sutured  ; drainage. 
Fifteen  hours  after  run  over  drunk  ; 10  days  later  abdominal 
wound  gave;  re-sutured.  Albuminuria  and  pulmonary 
symptoms.  Lived  26  days. 

Male,  aged  50.  Ileum  ; 3 ruptures  ; sutured  ; drainage. 
Immediate  operation  when  admitted  on  fourth  day  with 
peritonitis ; died  a few  hours  later. 

Female,  aged  33.  Splenic  flexure ; openings  into  peri- 
toneum sutured.  Retroperitoneal  opening  sutured  ; drainage 
of  this.  Operation  10  hours  after  run  over.  Recovered. 

Male,  aged  5.  Ileum.  Small  opening  sutured;  3 hours 
after  knocked  down  by  horse.  Broncho  - pneumonia. 
Recovered. 

Male,  aged  15.  Jejunum.  Resection  and  end-to-end 
anastomosis  for  transverse  rupture.  Laceration  of  mesen- 
tery. Acute  bronchitis.  Recovery.  Case  described  above. 

Two  other  instances  admitted  to  my  wards.  1.  Rupture 
of  duodenum.  Operation  abandoned  because  of  rapid 
collapse  of  patient,  did  not  permit  of  adequate  exploration. 
2.  Operation  by  resident  assistant  surgeon  after  secondary 
giving  way  of  damaged  part  was  unsuccessful,  and  peri- 
tonitis proved  fatal. 


2 See  also  The  Acute  Abdomen.  2nd  edi  W.  H.  Battle. 
3 TraDS.  Roy.  Soc.  Med.,  ii.,  1909. 

* Loc.  cit.,  No.  3,  1914. 

5 Meyer,  Dew,  and  Stokes  : The  Lancet,  1915,  ii.,  1140. 


A NOTE  ON 

THE  VALUE  OF  SOLID  PARAFFIN  WAX 
IN  FACIAL  SURGERY. 

By  SPENCER  MORT,  M.D.,  Ch.B.  Glasg., 
F.R.C.S.,  F.R.S.  Edin., 

LIEUTENANT-COLONEL,  R.A.M.C.,  COMMANDING-  SPECIAL  MILITARY 
SURGICAL  HOSPITAL,  EDMONTON,  LONDON  ; LATE  ASSISTANT 
REGIUS  PROFESSOR  OF  SURGERY,  UNIVERSITY  OF  GLASGOW. 


For  years  melted  wax  has  been  advocated  in  filling  in 
defective  parts  and  raising  the  skin  and  superficial  tissues  of 
depressed  areas,  especially  in  injuries  and  defects  of  the 
nose.  Since  the  war,  I have  operated  on  a good  many  cases 
of  facial  deformities,  particularly  in  the  earlier  months 
before  the  Special  Face  Hospital  was  established  at  Sidcup. 

I regard  all  facial  defects  as  worthy  of  the  highest  art  of 
surgery.  Patience,  with  dexterity,  will  repay  all  the  trouble 
expended,  as  a good  result  will  brighten  a patient’s  life. 

Having  experimented  with  all  kinds  of  plastic  and  solid 
material  for  the  reconstruction  of  face  defects,  I suggest  solid 
wax,  pure  hard  paraffin,  of  melting  point  110°-115°  F.,  for 
introduction  into  the  tissues  as  a permanent  splint.  Melted 
paraffin  has  many  disadvantages,  and  personally  I find  it 
almost  hopeless.  The  syringe  usually  gives  great  trouble, 
and  the  wax  is  put  in  hot  and  scalding  or  else  it  solidifies  in 
the  needle.  Press  hard  on  the  plunger  and  a quantity  may 
suddenly  be  thrown  under  the  skin,  solidifying  in  a lump  at 
the  wrong  place,  and  not  to  be  extracted  without  scarring. 
Further,  melted  wax  will  adapt  itself  to  the  skin  tissues 
probably  in  the  wrong  place,  instead  of  which  we  should 
have  skin  tissue  moulded  and  adapted  to  the  shape  of  the 
wax.  Cases,  too,  have  been  known  of  sudden  blindness 
following  melted  wax  injections. 

For  these  reasons,  principally,  I am  using  solid,  cold  wax, 
cut  to  shape,  and  introduced  through  a small  prick.  All  the 
above  disadvantages  are  eliminated. 

Technique. 

The  following  is  the  technique  in  the  case  of  saddle-nose  : 
(1)  Sterilise  the  wax  efficiently  by  melting  in  a pot.  If 
surgical  wax  is  not  obtainable  a Price’s  candle  melted  is  a 
good  substitute.  (2)  Make  a quarter-inch  prick  near  the 
depressed  part  with  a tenotome.  (3)  Elevate  around  the 
incision  to  the  required  extent  with  a small  elevator. 
(4)  Have  the  wax  poured  out  to  depth  of  about  half  an 
inch  in  a porringer  and  solidified  in  a basin  of  cold  sterile 
water.  (5)  Remove  the  wax  en  bloc  from  the  small  dish  with 
an  elevator.  (6)  Break  to  size  (it  will  not  cut  properly)  and 
afterwards  trim  the  small  splint  to  shape  with  a knife.  The 
little  shaped  splints  are  about  j X J X } inch.  Several  may 
be  deposited  in  the  one  subcutaneous  tunnel.  (7)  Push 
the  wax  into  its  place  through  the  incision,  stitch  the 
wound  with  a fine  catgut  stitch,  and  apply  a collodion 
gauze  dressing.  It  will  be  found  best  in  practice  to  do 
these  operations  in  stages,  and  just  too  little  at  a time. 
More  can  be  done  later.  Small  pieces  of  wax  will  lie 
in  the  tissues  undisturbed  and  unabsorbed  ; larger  bits 
might  work  out  through  the  wound.  A useful  practical 
hint  is  to  avoid  smearing  the  little  incision  with  wax, 
as  this  tends  to  delay  primary  union  of  the  skin  edges. 
Rather  drop  the  piece  right  into  the  undermined  skin, 
then  push  it  home.  At  the  conclusion  of  the  operation 
a vigorous  massage  of  the  nose  while  the  patient  is  still 
under  the  general  anaesthetic  will  be  fotind  to  give  an  artistic 
finish  to  the  part.  The  operation  is  splendidly  simple  in 
actual  detail. 

In  conclusion,  I have  found  melted  wax  of  no  service  for 
hide-bound  scars  to  be  elevated.  These  must  be  raised  by 
undermining  with  a raspatory  through  a small  incision  and 
kept  in  position  by  a solid  bar  of  wax.  The  cases  I have 
recently  operated  on  have,  indeed,  been  gratifying  in  their 
success,  and  so  I venture  to  propose  this  method  for  certain 
special  surgical  cases.  A depressed  skin  deformity  of  an 
unsightly  nature  on  any  part  of  the  body  may  be  similarly 
treated. 

Edmonton. 


At  Ilfracombe  it  has  been  decided  to  provide  an 
X ray  apparatus,  with  a suitable  building,  in  connexion  with 
the  Tyrrell  Cottage  Hospital,  as  a war  memorial.  The  cost 
of  the  scheme  is  about  £ 1000. 


106  The  Lancet,]  DK.  R.  M F.  PICKEN  : EXPECTATION  OF  LIFE  IN  TUBERCULOSIS.  [July  19,  1919 


THE 

EXPECTATION  OF  LIFE  IN  PULMONARY 
TUBERCULOSIS, 

WITH  SPECIAL  REFERENCE  TO  PENSIONS  ASSESSMENT. 

By  RALPH  M.  F.  PICKEN,  M.B.,  Ch.B.,  B.Sc  Glasg., 
D.P.H.  Camb., 

ASSISTANT  MEDICAL  OFFICER,  HEALTH  DEPARTMENT,  GLASGOW. 

In  assessing  the  disability  of  discharged  men  for  pension 
purposes  various  factors  require  to  be  considered.  In  practice 
the  probable  percentage  defect  of  working  capacity  over  a 
certain  period  is  the  main  concern  of  a Medical  Board  ; but 
other  forms  of  disability  have  bearing  on  pension  assessment, 
and  an  important  one  is  the  extent  to  which  disease  or 
injury,  attributable  to  or  aggravated  by  Army  service,  is 
likely  to  shorten  life. 

In  many  cases  of  gunshot  wound,  for  instance,  although 
working  capacity  is  impaired,  it  can  safely  be  assumed  that 
the  probable  length  of  life  will  not  materially  differ  from 
that  of  the  average  individual  of  the  same  age.  Where, 
however,  the  disability  arises  from  certain  types  of  injury, 
and  especially  from  disease,  it  includes  curtailment  of  life 
as  well  as  immediate  reduction  of  working  capacity,  as,  for 
instance,  in  cases  of  malaria,  nephritis,  chronic  dysentery, 
heart  disease,  pulmonary  tuberculosis,  &c.  In  some  diseases, 
indeed,  it  is  possible  that  this  factor  is  more  important  than 
the  other. 

For  most  of  these  diseases,  however,  insufficient  informa- 
tion is  available  to  enable  the  probable  duration  of  life  to  be 
estimated,  but  it  should  be  possible  to  come  to  some  estimate 
in  the  case  of  pulmonary  tuberculosis,  which  has  now  been  a 
notifiable  disease  for  a number  of  years,  and  concerning 
which  fairly  reliable  statistics  are  in  existence.  Paren- 
thetically, it  may  be  remarked  that  if  such  information  can 
be  utilised  for  national  purposes,  it  is  an  argument  for  some 
form  of  notification  of  diseases,  whether  they  come  under  the 
category  of  infectious  or  not. 

The  figures  quoted  in  this  article  have  been  taken  from 
a detailed  analysis  of  the  after-history  of  cases  of  pulmonary 
tuberculosis  compiled  for  departmental  purposes. 

Expectation  of  Life  in  Notified  Male  Cases  of  Pulmonary 
Tuberculosis. 

Table  I.  shows  the  percentage  of  male  survivors  distri- 
buted in  age-groups  at  May  31st,  1917,  of  patients  who  were 
notified  as  suffering  from  pulmonary  tuberculosis  during  the 
calendar  years  1910  (when  notification  was  introduced)  to 
1916,  and  concerning  whom  information  was  available  at 
the  date  of  inquiry.  The  average  time  between  the  notifica- 
tion of  each  group  and  the  date  of  inquiry  varies,  therefore, 
from  rather  less  than  seven  years  to  less  than  one  year. 

Table  I. 


Pulmonary  tuberculosis : 7169  male  patients  notified  1910-1916 ; 
percentage  surviving  at  May  31st.  1917. 


Year 

notified. 

Age-groops. 

15-20 

20-25 

25-35 

35-45 

45-55 

55-65 

65+ 

1910 

123 

13-7 

141 

19-4 

260 

21  0 

9 8 

1911 

15-6 

176 

20-6 

18  8 

16-9 

4-8 

Nil. 

1912 

25-5 

27-1 

224 

27-0 

16  8 

124 

67 

1913 

300 

301 

30-5 

263 

15-7 

10-6 

40 

1914 

31-5 

38-2 

35-6 

350 

31-8 

27  5 

5-4 

1915 

38-5 

47-9 

43-2 

37  9 

34  6 

21-4 

14  3 

1916 

60  9 

781 

60 '9 

53-4 

42-4 

47-1  ( 

265 

Patients  under  15  years  of  age  are  not  included,  partly 
because  there  is  a high  proportion  of  wrong  diagnoses  at 
these  ages  and  partly  because  such  statistics  would  not  be 
applicable  to  ex-service  men.  It  will  be  observed  that, 
especially  at  the  higher  ages,  the  percentage  survival  of  cases 
notified  in  1910  is  actually  higher  than  among  those  notified 
in  more  recent  years,  indicating  that  at  the  commencement 
of  notification  there  was  a greater  tendency  to  notify  elderly 
patients  who  were  probably  suffering  from  some  other 
disease,  such  as  chronic  bronchitis.  It  will  also  be  noted 


that  the  percentage  survival  of  cases  at  the  age-period  20-25 
is  consistently  somewhat  higher  than  in  other  age-groups. 
Apparently  the  disease  kills  less  rapidly  at  these  ages. 

The  general  trend  of  the  figures  suggests  that  if  the 
information  covered  a longer  period  of  time  the  percentage 
survivals  would  follow  the  course  of  a geometric  progression. 
If  the  survivals  for  the  age-groups  15-45  (comprising  5033 
cases)  are  combined,  eliminating  the  less  accurate  readings 
at  higher  ages,  and  a curve  is  drawn  approximately  to  fit 
the  percentages,  it  is  found  that,  especially  for  survivals 
after  two  or  three  years,  the  curve  follows  approximately 
that  of  a geometrical  progression  and  a factor  can  be  easily 
calculated  which  will  carry  it  on  until  it  meets  the  base  line. 
From  a combination  of  the  actual  and  hypothetical  figures, 
rearranged  to  give  survivals  at  6 months,  l£  years,  years, 
and  so  on  from  the  date  of  inquiry,  an  expectation  of  life 
has  been  calculated  and  found  to  be  3-4  years.  A separate 
estimate  for  the  age-group  20-25  gives  an  expectation  of 
3-5  years,  the  difference,  therefore,  being  so  slight  as  to  be 
negligible,  in  view  of  the  fairly  large  error  carried  by  any 
such  rough  method. 

“ Arrested  ” or  “ Improved  ” Cases. 

The  above  calculations  apply  to  all  male  notified  cases  at 
the  ages  mentioned.  The  average  age  of  these  patients  at 
date  of  notification  closely  approximates  to  30  years.  They 
include  cases  at  all  stages  of  disease  and  probably  many  in 
whom  the  diagnosis  is  wrong. 

It  is  important  to  obtain  some  estimate  of  the  expectation 
of  life  of  patients  in  an  early  and  hopeful  stage  of  the 
disease  and  in  whom  also  the  diagnosis  has  been  established 
with  reasonable  accuracy.  For  this  purpose  the  after-history 
of  a group  of  patients  of  the  sanatorium  1 grade  when  they 
first  came  under  notice,  was  followed.  Only  those  who  were 
discharged  from  sanatorium  with  disease  ‘ ‘ arrested  ” or 
“ improved”2  were  included,  and  all  those  concerning  whom 
the  diagnosis  was  considered  wrong  or  very  doubtful,  as  well 
as  those  about  whom  information  ,*vas  not  available  at  the 
date  of  inquiry,  were  discarded.  The  absence  of  tubercle 
bacilli  in  the  sputum  was  not  regarded  as  an  essential  factor 
in  diagnosis,  as  it  is  a well-established  fact  that  many  true 
cases  of  pulmonary  tuberculosis  occur  in  whom  tubercle 
bacilli  are  rarely  or  never  found  in  the  sputum.  The  patients 
were  mostly  insured  persons  coming  from  and  returning  to 
homes  in  Glasgow. 

Table  II.  deals  with  a group  of  male  patients  admitted  to 
sanatorium  for  the  first  time  and  discharged  therefrom  with 
disease  “arrested”  or  “improved”  between  1911  and 
May  31st,  1916,  comprising  631  cases.  It  shows  the  per- 
centage of  survivals  at  May  31st,  1916,  May  31st,  1917.  and 
May  31st,  1918.  Deterioration  is  obviously  occurring  rapidly. 

Table  II. 


Pulmonary  tuberculosis  : 631  male  cases  discharged  from  sanatorium 
with  disease  “arrested  ’’  or  “ improved ” before  May  31st,  1916. 


Date  of  inquiry. 

Per  cent. 

Average  time  elapsed  since 

surviving. 

discharged  from  sanatorium. 

May  31st,  1916  

81-4 

22  months. 

May  31st.,  1917  

66-8 

34 

May  31st,  1918  

55-0 

46 

The  information  can  be  analysed  in  more  detail,  however, 
and  may  be  stated  as  in  Table  III. 


Table  III. 

Pulmonary  tuberculosis  ; 631  male  cases  discharged  from  sanatorium 
with  disease  “ arrested  ” or  11  improved  ” before  May  31st,  1916. 


Date  of 
enquiry. 

Per  cent,  surviving  after  lapse  of  average 
periods  from  discharge  in  months. 

6 

18 

30 

42 

54 

66 

May  31st,  1916 

97-2 

79-4 

734 

725 

| — 

— 

May  31st,  1917  ... 

! — 

82-6 

667 

58-2 

53  3 

— 

May  31st,  1918  ... 

— 

- 

67-7 

589 

45-8 

44-0 

Averages  ... 

S7'2 

810 

69-6 

61-9 

48-3 

440 

i The  term  s'natorium,  as  used  here,  does  not  include  tuberculosis 
hospitals  for  advanced  or  chronic  cases. 

2 Roughly,  75  per  cent,  of  discharged  sanatorium  males. 


The  Lanoht,] 


DR.  R.  M.  F.  PICKEN  : EXPECTATION  OF  LIFE  IN  TUBERCULOSIS.  [July  19,  1919  1Q7 


In  this  table  the  percentage  of  survivors  is  again  shown 
separately  at  May  31st,  1916,  May  31st,  1917v  and  May  31st, 
1918,  but  the  cases  have  been  split  up  into  groups  discharged 
severally  at  intervals  of,  on  the  average,  six  months  up  to 
5j  years.  The  results,  where  they  exist  for  the  same  period 
in  more  than  one  group,  are  combined  in  the  last  line  of  the 
table,  so  as  to  reduce  errors  of  chance.  These  percentages 
form  the  basis  of  a very  crude  life  table  and  the  expectation 
of  life  calculated  as  above  is  found  to  be  6 6 years.  The 
average  age  is  again  30  years. 

Expectation  of  Life  compared  with  the  Normal. 

The  expectation  of  life  calculated  for  so-called  “ arrested  ” 
cases  alone  is  certainly  greater,  but  the  number  of  cases  is 
so  small  (117  males)  that  it  is  impossible  to  place  much 
reliance  on  any  conclusion  drawn  from  their  study.  The 
expectation  of  life  calculated  as  before  is,  roughly,  14  years. 
This  figure  must  be  regarded  as  little  more  than  a guess.  It 
is  probably  too  high,  since  the  cases  in  whom  arrest  was 
obtained  included  a number  where  an  element  of  doubt  as  to 
the  diagnosis  remained.  Moreover,  it  must  be  admitted  that 
the  difierentiation  of  mere  improvement  from  arrest  depends 
largely  on  the  predilections  of  the  medical  officer  estimating 
the  result  of  treatment,  so  that  patients  discharged  from  one 
sanatorium  as  “arrested  ” would  be  discharged  from  another 
as  “improved  ” and  vice  versa. 

Now  the  expectation  of  life  of  a male,  aged  30  years,  in 
Glasgow  was  29  68  years  for  the  period  1881-1890, 3 and 
may  be  taken  for  practical  purposes  as  30  years  for  the  period 
covered  by  this  inquiry.  The  expectation  of  life  of  the 
“arrested  ” case  of  pulmonary  tuberculosis  is  therefore  less 
than  half  the  normal,  and  of  the  “ arrested  ” and  “ improved” 
ex-sanatorium  cases  taken  together  roughly  a fifth  of  the 
normal. 

In  view  of  the  fact  that  the  average  age  of  discharged 
tubercular  soldiers  is  probably  under  30  and  the  normal 
expectation  of  life,  therefore,  greater  than  30  years,  the 
probable  curtailment  of  life  itself  would  appear  to  be 
justification  for  assessing  for  pensions  purposes  all  verified 
cases  of  tuberculosis  with  “arrested”  disease  at  least  at 
50  per  cent.,  and  preferably  at  60  per  cent.  In  the  opinion 
of  the  writer,  fitness  for  work  should  not  be  stressed  in  fixing 
the  minimum  assessment. 

Graduated  Assessment. 

The  graduated  assessment  of  disability  in  cases  of 
pulmonary  tuberculosis,  according  to  the  character  and 
stage  of  the  disease,  presents  difficulties  which  are  of  the 
same  nature  as  those  discussed  at  the  commencement  of  this 
article. 

Broadly  speaking,  a patient  who  is  suffering  from  the 
more  chronic  form  of  the  disease,  who  will  not  derive  benefit 
from  sanatorium  treatment,  and  who  is  not  urgently  requiring 
a bed  in  a hospital,  will  benefit  psychologically  and  will  not 
materially  suffer  from  a moderate  amount  of  work  of  a 
suitable  kind,  although  his  prospect  of  life  is  brief.  It 
would  seem  desirable  to  avoid  creating  an  impression  that 
the  pursuit  of  employment  on  the  part  of  an  ex-service  man 
will  affect  the  assessment  of  his  pension,  and  rather  to  aim 
at  providing  him  with  maintenance  on  a level  entirely 
dependent  upon  the  character  and  stage  of  the  disease. 
Further,  the  local  authorities  responsible  for  the  institutional 
treatment  of  tuberculosis  admit  many  patients  for  preventive 
reasons  and  not  mainly  because  of  the  patient’s  clinical  condi- 
tion. The  tendency  is  to  assess  such  men  as  totally  disabled. 
The  ex-service  man  who  has  a comfortable  home  and  chooses 
to  remain  there  and  to  do  a certain  amount  of  work  suffers 
in  comparison  with  the  careless  patient  who,  on  account  of 
his  poor  home  surroundings,  is  admitted  to  an  institution  and 
is  therefore  assessed  as  a person  requiring  institutional 
treatment.  Practically,  the  problem  can  best  be  solved  by  a 
liberal  assessment  in  all  unequivocal  cases  of  tuberculosis  of 
the  lung,  and  the  inquiry  recorded  above  indicates  the 
justification  for  such  a policy  even  toward  arrested  cases. 

Difficulties  in  Estimating  the  Activity  of  the  Disease. 

The  presence  of  disease  which  is  actively  progressive,  as 
indicated  by  bacteriological  and  X ray  examination,  physical 
signs,  continued  loss  of  weight,  swinging  temperature 
(actually  observed  or  recorded  by  the  medical  officer  of  a 
Public  Health  Department  or  institution  dealing  with  the 

3 A New  Life  Table  for  Glasgow,  by  Dr.  A.  K.  Chalmers. 


case),  rapid  and  unstable  pulse,  &c.,  is  sufficient  ground  for 
an  assessment  of  100  per  cent. 

The  graduated  assessment  of  men  below  100  per  cent, 
but  above  the  minimum  assessment  permitted  is  bound  to  be 
associated  with  a large  error,  and  the  solution  is  probably 
to  be  found  in  diminishing  the  number  of  possible  intervals. 
The  writer’s  own  experience  is  that  the  more  familiar  one  is 
with  this  disease  the  more  one  will  hesitate  to  make  a 
prognosis,  and  assessment  is,  after  all,  a prognosis  in  accurate 
terms.  The  chronic  fibroid  type  of  disease  may  be  associated 
with  a considerable  degree  of  unfitness  for  work  and  yet  with 
comparatively  prolonged  life.  On  the  other  hand,  the 
expectation  of  life  of  a patient  with  a small  active  lesion  at 
one  apex  may  be  very  much  shorter. 

In  the  writer’s  opinion  the  extent  of  lung  tissue  involved 
is  of  limited  value  for  prognostic  or  assessment  purposes,  and 
forms  of  classification  such  as  the  Turban,  Turban- Gerhardt, 
or  that  based  on  the  number  of  lobes  diseased,  suffer  in 
practice  from  the  undue  emphasis  laid  on  the  local  condition 
as  estimated  by  physical  examination.  Even  where  provision, 
in  the  classification  is  made  for  taking  account  of  the 
patient’s  general  condition,  the  majority  of  observers  are 
naturally  influenced  in  their  estimation  of  the  general  con- 
dition by  their  observation  of  the  extent  of  lesion.  A 
measure  of  the  activity  is  what  is  wanted,  and  disease  of 
low  activity,  but  not  arrested,  would  naturally  fall  into  the 
intermediate  grade. 

Proposed  Method  of  Assessment. 

The  method  suggested  is  that  cases  of  tuberculosis  should' 
be  assessed  in  three  grades  : all  those  with  actively  pro- 
gressive disease  at  100  per  cent. , those  in  whom  the  disease 
is  arrested  at  60  per  cent,  or  50  per  cent.,  and  all  those 
intermediate  at  80  per  cent,  or  70  per  cent.  It  requires  to. 
be  emphasised  that  the  presence  of  actively  progressive 
disease  is  to  be  estimated  not  merely  by  the  presence  of 
r&les  or  of  tubercle  bacilli  in  the  sputum,  but  should  be 
based  more  on  the  patient’s  general  condition,  especially  as 
observed  after  the  lapse  of  a period  of  time  since  his  dis- 
charge from  the  Army  ; but  in  this  matter  the  writer  believes 
that  guidance  of  the  highest  value  may  be  obtained  from 
examination  by  X rays.  Whatever  may  be  the  limits  of 
X ray  examination — and  these  remain  to  be  clearly  defined — 
there  is  no  doubt  that  actively  progressive  disease  shows  very 
clearly  on  a properly  taken  X ray  negative  as  clouded  or 
steamy  shadowing. 

The  proportion  of  ex-service  men  falling  to  be  assessed  as- 
“ arrested  ” cases  will  probably  be  fairly  high.  It  is  a fact  that 
many  discharged  soldiers  who  first  showed  evidence  of  tuber- 
culosis in  the  Army,  and  in  whom  the  records  indicate  that 
the  diagnosis  has  been  accurate  (showing,  for  instance,  the 
presence  of  tubercle  bacilli  in  the  sputum),  are  working 
regularly  after  a year  or  two  and  keeping  in  remarkably  good 
health  without  ever  having  received  sanatorium  treatment. 
Many  of  these  men  who  come  before  pensions  boards  show- 
no  present  signs  whatever  of  disease. 

The  facts  suggest  that  ordinary  treatment  in  a military 
hospital  has  been  sufficient  in  their  case  to  effect  an  arrest 
of  the  disease,  and  it  is  possible  that  they  are  evidence  of 
the  value  of  early  diagnosis,  arrived  at  as  the  result  of  the 
readiness  of  men  on  Army  service  to  report  sick  before  they 
have  reached  that  degree  of  infirmity  which  generally  leads 
a man  in  civil  employment  to  give  up  work  and  seek  treat- 
ment. It  is  possible,  also,  that  many  men  with  fairly  strong 
natural  immunity  to  tuberculosis  have  contracted  the  disease 
under  abnormal  war  conditions  of  physical  and  mental  stress 
associated  with  a manner  of  life  conducive  to  infection,  and 
that  as  soon  as  they  have  been  removed  from  these  condi- 
tions their  natural  recuperative  powers  have  effected  a cure. 
However  this  may  be,  the  impression  of  the  writer  is  that 
the  percentage  of  “ arrests”  among  discharged  soldiers,  and 
particularly  among  those  who  were  not  sent  to  sanatorium 
direct  from  the  Army,  is  above  the  level  of  civilian 
experience. 

The  policy  suggested  implies,  of  course,  that  the  greatest 
care  will  be  taken  to  eliminate  all  cases  of  wrong  diagnosis, 
and  there  is  no  doubt  many  such  have  occurred  among  men 
discharged  from  the  Army  as  suffering  from  tuberculosis. 
The  elimination  of  these  will  probably  become  simpler  in  the 
course  of  time,  but  in  the  meantime  cases  in  which  there  is 
grave  doubt  whether  the  men  ever  suffered  from  tuberculosis 
might  be  dealt  with  entirely  on  their  own  merits  and; 


108  The  Lancet,]  DR.  A.  K.  GORDON  : LYMPHOIDOCYTE  AND  ITS  CLINICAL  SIGNIFICANCE.  [July  19,  1919 


irrespective  of  any  definite  grading  adopted  for  established 
tuberculosis.  All  men  in  whom  there  is  a record  of 
tubercle  bacilli  in  the  sputum,  even  if  unequivocal  physical 
signs  have  never  been  detected,  must,  for  practical  purposes, 
be  regarded  as  definite  cases,  although  in  some  instances 
confusion  of  specimens  submitted  to  a bacteriologist  may 
have  occurred. 

Summary. 

1.  The  expectation  of  life  of  males  aged,  on  the  average, 
30  years,  notified  in  Glasgow  as  suffering  from  pulmonary 
tuberculosis  is  about  3]  years. 

3i.  The  expectation  of  life  of  male  cases  at  a sufficiently 
''early  stage  of  the  disease  to  raise  hope  of  recovery  is  about 
' 6^  years. 

3.  The  expectation  of  life  of  male  sanatorium  cases  dis- 
charged with  the  disease  “arrested”  is  estimated  at  some- 
where about  14  years. 

4.  The  normal  expectation  of  life  of  all  males  in  Glasgow 
at  the  age  of  30  years  may  be  taken  as  30  years,  but  was 

.probably  higher  for  the  period  covered  by  this  inquiry. 

15.  The  above  calculations,  applied  to  the  assessment  of 
soldiers  and  sailors  discharged  with  pulmonary  tuberculosis, 
justify  a minimum  assessment  of  50  or  60  per  cent.,  and  this 
should  apply  to  men  in  whom  the  disease  appears  to  be 
arrested  for  the  time  being. 

6.  All  cases  where  the  disease  is  actively  progressive,  as 
measured  by  general  signs  and  symptoms,  physical  signs, 
bacteriological  and  X ray  examination,  should  be  assessed  at 
100  per  cent,  disability. 

7.  All  others — i.e. , cases  of  low  activity  such  as  those  of 
the  chronic  fibroid  type — should  be  placed  in  one  grade  at 
70  or  30  per  cent,  disability. 


THE  LYMPHOIDOCYTE  AND  ITS  CLINICAL 
SIGNIFICANCE. 

By  A.  KNYVETT  GORDON,  M.B.,  B.C.  Cantab., 

FORMERLY  DEMONSTRATOR  OF  PATHOLOGY’,  ST.  MARY’S  HOSPITAL  ; 
AND  LECTURER  ON  INFECTIOUS  DISEASES  IN  THE  UNIVERSITY 
OF  MANCHESTER. 


The  lymphoidocyte  is  now  regarded  as  the  original 
ancestor  both  of  the  red  and  white  corpuscles  of  the  circu- 
lating blood.  Amongst  the  evidence  for  this  view,  weight 
may  be  attached  to  the  fact  that  in  the  foetus  up  till  about 
the  sixth  month  it  is  the  only  blood  cell  found  in  the  lymph 
nodes  and  bone-marrow.  From  this  period  onwards  the 
intermediate  forms  leading  to  the  fully  developed  erythro- 
cytes and  leucocytes  begin  to  appear  in  a definite  sequence. 
After  birth  the  lymphoidocyte  is  never  found  in  the 
peripheral  circulation  in  health,  but  may  be  present  in 
certain  diseases.  When  we  attempt,  however,  to  determine 
its  pathological  distribution  in  the  blood  we  are  met  with 
two  initial  difficulties. 

Nomenclature  of  the  lymphoidocyte. — The  first  is  one  of 
nomenclature.  Such  is  the  confusion  in  which  the  litera- 
ture of  htematology  has  become  involved  by  the  multiplica- 
tion of  terms  that  the  lymphoidocyte  is  found  to  possess  no 
fewer  than  89  synonyms.  In  the  case  of  some  authors  it  is 
almost  impossible  to  ascertain  to  what  type  of  cell  their 
communications  refer. 

The  panoptic  stain. — Secondly,  it  is  essential  that  the 
panoptic  stain  shall  be  employed,  otherwise  the  charac- 
teristic structure  of  the  nucleus,  by  which  the  lymphoidocyte 
can  easily  be  recognised,  is  not  well  brought  out.  With 
Jermer’s  or  Wright’s  stain,  for  instance,  a lymphoidocyte 
may  easily  be  mistaken  not  only  for  the  pathological  leucc- 
blast,  but  even  for  a normal  large  hyaline  cell.  The  same 
difficulty  occurs,  though  to  a less  extent,  with  Leishman’s 
stain,  which  has  also  the  disadvantage  of  occasionally  giving 
rise  to  nuclear  precipitates.  It  follows,  therefore,  that  many 
of  the  deductions  of  Ehrlich  and  his  school  before  the  intro- 
duction of  the  panoptic  stain  must  be  received  with  caution. 

After  making  such  allowance  as  is  possible  for  these 
difficulties,  we  find  that  the  occurrence  of  the  lymphoido- 
cyte in  the  peripheral  circulation,  though  recognised  in  the 
case  of  the  leukmmias,  particularly  those  of  the  lymphatic 
type,  is  not  mentioned  in  other  diseases.  The  tacit 
assumption  is  made  that  its  presence  is  associated  with  a 
marked  total  lymphocytosis.  I fail  to  find  any  reference  in 


the  English  text-books  of  pathology  to  its  clinical  prevalence, 
though  Gruner  gives  a full  account  of  its  biology. 

Recently,  however,  I have  had  the  opportunity  of 
examining  blood  films  from  a series  of  cases  of  subacute 
bacterial  endocarditis  of  the  Libman  type  under  the  care  of 
Captain  H.  J.  Starling,  M.D.,  at  the  Sobraon  Military 
Hospital.  Working  with  the  panoptic  stain  and  full  controls 
I have  so  far  found  it  in  10  out  of  11  cases  in  the  following 
proportions  : — 

Case  1,  6 per  cent. ; 2, 10  per  cent. ; 3,  2 per  cent. ; 4,  6 per 
cent. ; 5,  4 per  cent. ; 6,  7 per  cent. ; 7,  7’5  per  cent. ; 8,  7 per 
cent. ; 9,  8 per  cent. ; 10,  5 per  cent. 

This  type  of  endocarditis  appears  to  be  invariably  fatal, 
and  of  these  cases  Nos.  3,  4,  5,  6,  and  7 are  already  dead  and 
1 is  moribund. 

As  I hope  to  publish  the  hasmatology  of  these  cases 
in  extenso  later  on,  I do  not  give  further  details,  my  present 
object  being  simply  to  record  the  presence  of  lymphoido- 
cytes.  I may  say,  however,  that  in  no  case  was  a marked 
leucocytosis  present,  and  that  it  is  possible  to  exclude  any 
type  of  pernicious  anaemia  or  leukaemia.  It  is  evident, 
therefore,  that  their  occurrence  is  not  limited  to  the  essential 
blood  diseases. 

The  question  then  arose  whether  the  appearance  in  the 
peripheral  blood  of  this,  the  most  primitive,  type  of  cell, 
might  not  be  of  wider  distribution  and  significance,  whether 
it  might  not  possibly  be  a sign  of  grave  illness  from  divers 
causes.  I therefore  examined  films  from  certain  other  cases, 
with  the  following  results  : — 

Case  11  and  12. — Moribund  from  old  age,  there  being  no 
clinical  or  pathological  sign  of  any  other  disease  ; lymphoido- 
cytes  present  in  both  to  the  extent  of  6 per  cent,  and  2 per 
cent,  respectively.  Both  films  showed  a moderate  total 
leucopenia  with  slight  relative  lymphocytosis.  Neither 
patient  incidentally  had  shown  any  sign  of  influenza  or 
tuberculosis. 

Case  13.  — Moribund  from  gangrene  of  both  legs. 
Lymphoidocytes  2’5  per  cent. 

Case  14.— Diabetes.  Lymphoidocytes  2-5  per  cent. 

Case  15. — Carcinoma  of  liver.  Lymphoidocytes  4 per  cent. 

The  lymphoidocyte  is  well  recognised  in  hsematological 
literature,  and  many  excellent  drawings  of  it  are  published 
in  the  Folia  Hrematologica  and  in  Gruner’s  Biology  of  the 
Blood  Cells.  The  cell  varies  in  size,  but  is  usually  about 
that  of  a large  hyaline  ; its  nucleus  rarely  fills  the  cell  and 
is  usually  oval  or  slightly  notched.  It  stains  more  faintly 
than  that  of  either  a leucoblast  or  a large  lymphocyte  or 
hyaline,  and  is  distinguished  by  containing  from  two  to  four 
definite  nuclei.  The  protoplasm  is  scanty,  basophilic,  and 
never  granular. 

It  would  seem  desirable  that  extended  investigation  should 
be  made  on  the  pathological  distribution  of  the  lymphoidocyte 
in  order  that  its  full  significance  in  the  peripheral  blood  may 
be  determined.  I publish  this  note,  therefore,  mainly  with 
the  object  of  drawing  the  attention  of  other  workers  to  the 
point.  I should  add  that  the  staining  reactions  were  con- 
trolled by  observations  of  normal  blood  and  marrow  films, 
which  were  repeated  on  the  examination  of  each  case. 
Typical  lymphoidocytes  were  obtained  for  comparison  from 
smears  from  foetal  bone-marrow,  and  from  two  cases  of 
myeloid  and  lymphoid  leukaemia  respectively. 

So  far  films  from  the  blood  of  TO  patients  who  were  not 
suffering  from  any  obviously  fatal  disease  have  been  examined, 
but  without  finding  any  cells  that  even  resembled  the 
lymphoidocyte.  These  comprise  : Influenza  + pneumonia,  6 ; 
carbon  monoxide  poisoning  (recovering),  1 ; aortic  disease 
with  fair  compensation,  3. 


Royal  Cornwall  Infirmary,  Truro.  — The 
governors  of  this  charity  have  recently  issued  an  appeal 
for  £8000  in  order  to  equip  the  institution  with  adequate 
modern  sanitary  accommodation  and  to  make  provision 
against  fire,  and  also  for  other  improvements.  About  £3000 
have  been  raised  for  the  scheme. 

Dr.  W.  S.  Thayer,  of  the  Johns  Hopkins  Medical 
School,  Baltimore,  in  a paper  read  before  the  Annual 
Congress  of  American  Physicians  and  Surgeons,  advocated 
the  establishment  of  rehabilitation  camps  for  civilians  in 
time  of  peace,  and  said  that  the  practicability  of  such  a 
course  had  been  shown  by  the  war. 


The  Lancet,] 


ROYAL  SOCIETY  OF  MEDICINE:  SECTION  OF  PSYCHIATRY.  [July  19,  1919  109 


Utokal  jfe&s. 


ROYAL  SOCIETY  OF  MEDICINE. 


SECTION  OF  PSYCHIATRY. 

A meeting  of  this  section  was  held  on  July  11th,  Dr. 
William  McDougall,  the  President,  being  in  the  chair. 
After  announcing  a letter  of  regret  for  his  unavoidable 
absence  from  Dr.  Bernard  Hart,  the  President  formally 
introduced  Professor  JuNG,  who  had  come  from  so  great  a 
distance  to  read  his  paper  on 

The  Psychogenesis  of  Mental  Disease. 

Professor  Jung  dealt  with  the  history  of  the  materialistic 
dogma  in  psychiatry,  according  to  which  a disease  of  the 
mind  is  a disease  of  the  brain.  Even  to-day  the  alienists 
considered  physical  aetiology  a matter  of  primary  import- 
ance and  psychogenesis  as  of  very  secondary  interest.  He 
quoted  instances  to  show  how  this  leads  frequently  to 
the  neglect  of  important  psychological  factors.  The  origin 
of  this  misconception  was  to  be  found  in  our  system  of 
education.  The  neurologist  receives  a grounding  in  the 
natural  sciences  only,  whereas  a knowledge  of  psychology  is 
essential  to  everyone  who  may  be  called  on  to  treat 
mental  disease.  Then,  too,  under  the  present  system 
only  the  most  extreme  cases  of  disease  come  before 
the  alienist,  who  has  thus  no  opportunity  to  study  the  early 
phases  of  mental  disease.  Apart  from  minor  troubles  such 
as  phobias  and  obsessions,  paranoia,  hysteria,  katatonia,  and 
dementia  prsecox  were  the  chief  diseases  in  which  no  histo- 
logical changes  could  be  found  in  the  brain.  He  admitted 
that  in  the  last  named  changes  did  sometimes  occur,  but 
suggested  that  the  toxins  which  produced  degenerations 
might  be  formed  in  the  course  of  the  disease  and  be  a 
secondary  factor.  Neurasthenia  might  be  regarded  as  a 
mild  form  of  dementia  prsecox,  and  in  many  cases  the 
disease  never  reaches  that  aggravated  form  in  which  it  is 
usually  regarded  as  almost  incurable.  The  worst  cases  of 
katatonia  were,  he  thought,  often  due  to  the  mal- 
administration of  overcrowded  asylums,  for  cases  of 
dementia  prsecox  reacted  to  their  environment  in  a way 
which  would  hardly  be  expected  if  one  were  dealing 
with  an  organic  disease. 

Illustrative  Cases. 

Professor  Jung  then  related  four  cases  of  katatonia  in 
support  of  his  thesis  that  this  disease  is  psychogenic  in 
origin.  In  the  first  case  the  patient  had  had  an  unhappy 
love  affair  in  a certain  town,  as  a result  of  which  he  had 
quitted  the  locality,  intending  never  to  go  back.  On  account 
of  the  fact  that  he  had  relatives  in  the  district  he  did, 
however,  eventually  return,  and  on  this  occasion  was  seized 
with  his  first  attack  of  katatonia.  He  recovered  and 
remained  perfectly  well  until  he  again  revisited  the  scenes 
of  his  unhappy  experience.  Immediately  upon  returning  for 
the  second  time  he  once  more  became  katatonic.  So  that  in 
six  years  the  only  occasions  on  which  the  patient  was  seized 
with  this  illness  were  those  on  which  he  was  confronted  with 
a powerful  array  of  distressing  memories.  Another  con- 
vincing narrative  was  told  of  a woman  who,  in  the  course 
of  a family  fracas,  had  been  stigmatised  by  her  husband  as 
“mad,”  whereupon  she  had  said,  “ Very  well,  if  you  call  me 
mad  you  shall  see  what  it  is  like  to  be  mad,”  and  had  at 
once  become  so  violent  that  she  was  removed  to  the  mental 
clinic.  There  she  had  speedily  regained  a great  measure 
of  calm,  but  it  was  judged  she  should  be  kept  under 
observation.  She  remained  calm  until  she  found  that  she 
was  under  restraint  and  could  not  immediately  return  to  her 
home  and  then  she  again  became  very  violent,  so  that  it  was 
at  last  found  necessary  to  remove  her  to  another  part  of  the 
building.  Here  she  recognised  that  she  was  among  people 
who  were  definitely  insane  and  cried  out  as  before,  “If 
you  think  me  mad  you  shall  see  what  it  is  like  to 
be  mad,”  and  then  fell  into  a condition  of  katatonia. 
A psychological  predisposition  was  not  enough  in  itself  to 
cause  a psychosis.  In  the  absence  of  any  mental  conflict 
nothing  abnormal  might  ever  be  remarked.  But  it  was  to 
be  noted  that  such  predisposition  tended  to  produce  conflicts 
and  so  to  establish  a vicious  circle  of  disease.  Only  when  the 


patient  finds  that  he  cannot  help  himself,  and  that  nobody 
is  able  to  help  him,  does  he  become  panic-stricken  and  so 
insane. 

Treatment  of  the  Psychoses. 

Dealing  with  the  treatment  of  the  psychoses,  Professor 
Jung  said  that  it  was  perhaps  too  soon  to  give  an  opinion  on 
the  value  of  psychotherapy.  Most  of  the  cases  which  he 
had  explored  by  analysis  had  been  much  too  complicated  for 
him  to  deal  with  them  in  the  course  of  a single  lecture. 
He  had,  however,  met  with  one  or  two  more  simple  cases, 
and  one  of  these  he  related  in  considerable  detail.  The 
case  in  point  was  that  of  a girl,  quiet  and  retiring  by  nature, 
who  quite  suddenly  developed  symptoms  of  mental  disoider. 
She  said  that  she  spoke  with  God  and  with  Jesus  about 
war  and  peace  and  the  sins  of  men.  When  seen  by  Professor 
Jung  she  was  entirely  unemotional,  and  exhibited  no 
curiosity  concerning  her  visitor  or  the  nature  of  his  visit. 
She  admitted  having  had  these  conversations,  but  could 
not  remember  what  had  been  said.  When  it  was  urged  that 
she  must  have  heard  about  matters  of  great  importance  and 
she  should  have  made  some  notes  of  what  she  had  learned,  she 
showed  a calendar  whereon  she  had  simply  marked  the  date 
when  these  conversations  had  taken  place.  She  displayed,  in 
fact,  no  intelligent  interest  in  the  unusual  event.  She  denied 
having  had  any  religious  troubles,  but  it  was  learned  from 
the  mother  that  on  the  evening  preceding  her  hallucinations 
she  had  returned  from  a religious  meeting  somewhat  excited, 
and  had  announced  her  complete  conversion.  Recognising 
that  taciturnity  is  a mechanism  of  self-defence,  Professor 
Jung  had  proceeded  patiently  to  analyse  this  case,  and  in 
three  sittings  had  traced  the  girl’s  history  through  a recent 
disappointment  in  love  to  a shock  which  she  had  received  some 
years  previously  when  at  the  age  of  16  she  had  been  severely 
punished  for  encouraging  an  aged  idiot  in  certain  obscene 
actions.  It  was  at  this  time  that  she  had  become  a quiet, 
rather  shy  girl,  for  previously  she  had  exhibited  a quite 
normal  display  of  youthful  spirits.  This  case  was,  in 
Professor  Jung’s  opinion,  clearly  one  of  dementia  prsecox 
of  psychogenic  origin.  The  conflict  in  this  instance  had  led  to 
a complete  severance  of  emotional  rapport  with  the  world  of 
men.  In  a personality  where  there  existed  a tendency 
towards  dissociation  the  same  conflict  would  have  caused  not 
dementia  prsecox  but  hysteria.  It  was  10  years  since  the 
speaker  had  first  claimed  that  destructive  changes  associated 
with  dementia  prsecox  are  secondary  manifestations  of  disease, 
though  he  did  not  deny  that  in  certain  cases  they  might  be 
the  primary  cause  of  disorder. 

The  Discussion. 

In  the  course  of  the  subsequent  discussion  Dr.  W.  H.  B. 
Stoddart  said  that  what  criticism  he  had  to  offer  came 
from  one  who  was  already  converted  to  the  psychogenic 
origin  of  mental  disorders.  Certain  organic  changes  had, 
however,  been  observed  in  connexion  with  dementia  prsecox 
which  could  not  be  overlooked.  General  paralytics  whose 
disease  was  unquestionably  organic  in  origin  did  react  very 
markedly  to  environment.  He  was  not  convinced  that  the 
cases  which  Professor  Jung  described  were  all  of  the  kind 
which  is  generally  known  as  dementia  prsecox  in  this 
country. 

Dr.  Henry  Head  questioned  whether  such  a disease  as 
dementia  prsecox  really  existed.  There  were  cases  which 
began  in  the  classical  way  and  then  became  atypical — that 
is  to  say,  they  recovered.  In  any  case,  it  was  the  mental 
condition  which  was  of  importance  rather  than  the  nomen- 
clature. A disease  might  have  a psychogenic  origin  in  some 
cases  and  an  organic  origin  in  others.  This  was  clearly  the 
case  in  exophthalmic  goitre,  whose  occasional  psychogenic 
origin  had  been  clearly  demonstrated  by  the  recent  air- 
raids. 

Dr.  William  Brown,  speaking  as  a psychologist, 
expressed  his  great  indebtedness  to  Professor  Jung  for  his 
stimulating  address.  He  emphasised  the  need  for  a pro- 
longed investigation  into  the  synthesis  of  mental  disorders, 
quoting  cases  from  his  own  experience,  including  one  of 
disorientation  which  had  ultimately  yielded  to  analytical 
treatment  only  when  a memory  dating  from  the  second  year 
of  life  had  been  recalled.  The  question  of  the  possible 
psychogenesis  of  epjlepsy  was  also  raised  in  the  course  of 
the  discussion. 

Professor  Jung,  in  replying,  stated  that  in  cases  of  major 
epilepsy  psycho- therapeutic  methods  were  of  little  success. 


110  The  Lancet,] 


REVIEWS  AND  NOTICES  OF  BOOKS. 


[July  19,  1919 


anfr  $tatices  of  ^ooks. 


The  Pituitary.  A Study  of  the  Morphology,  Physiology, 

Pathology,  and  Surgical  Treatment  of  the  Pituitary, 

together  with  an  Account  of  the  Therapeutical  Uses  of 

the  Extracts  Made  from  this  Organ.  By  W.  Blair  Bell. 

London  : Bailli6re,  Tindall,  and  Cox.  1919.  Pp.  348.  30s. 

During  the  last  two  decades  much  has  been  written  about 
the  pituitary  gland,  but  still  much  remains  to  be  done  ere  we 
•can  say  much  definitely  about  its  functions  and  inter-relations. 
Dr.  Blair  Bell’s  own  experimental  work,  begun  in  1906,  was 
primarily  undertaken  to  elucidate  the  relationship  of  the 
pituitary  to  the  female  genital  functions  and  to  determine 
the  physiological  and  therapeutical  importance  of  extracts 
made  from  this  organ.  It  soon  became  evident  that  such 
studies,  to  be  profitable,  must  be  based  on  a comprehensive 
investigation  of  the  morphology,  physiology,  and  pathology 
of  this  gland  and  its  relations  to  metabolism  in  general  and 
to  the  other  endocrine  glands  and  those  that  form  hormono- 
poietic  secretions.  The  outcome  of  such  research  is  the 
splendidly  illustrated  volume  under  review. 

The  text  is  divided  into  four  parts.  The  development, 
anatomy,  histology,  and  comparative  anatomy  are  set  forth 
in  Part  I.  (pp.  3-78).  The  scientific  study  of  the  pituitary 
began  in  1838,  when  Rathke  described  the  origin  of  the 
hypophysis  from  the  primitive  alimentary  canal.  We  cannot 
follow  the  author  into  the  many  details  of  the  comparative 
anatomy  of  the  pituitary.  Suffice  it  to  note  that  in  all 
vertebrates  higher  than  the  elasmobranchs  there  is  a 
definite  pars  nervosa.  Extracts  made  from  this  structure 
are  active  in  all  respects. 

Part.  II.  (pp.  79-214)  deals  with  the  physiology  of  the 
gland  and  the  methods  for  the  investigation  of  its  functions. 
Certain  physiological  states  are  associated  with  marked 
changes  in  the  pars  anterior.  In  pregnancy,  both  in  animals 
and  women,  this  part  enlarges — there  is  an  increase  in  the 
degree  of  eosinophilia  or  by  chromophobia(  ‘ ‘ pregnancy  cells  ”) 
— the  essential  change  during  pregnancy  is  towards  greater 
activity.  Hibernation — e g.,  in  hedgehog  and  dormouse — also 
produces  striking  histological  appearances,  both  in  the 
epithelial  elements  of  the  partes  anterior  and  intermedia — 
the  secretory  cells  of  this  organ.  In  the  pars  intermedia 
vesicles  with  hyaline  (?  colloid)  contents  are  almost  always 
found,  and  may  represent  its  normal  secretion.  Herring 
found  “ hyaline  ” bodies  in  the  pars  nervosa,  derived,  he 
thinks,  from  the  pars  intermedia  which  pass  via  the  infun- 
dibulum into  the  third  ventricle,  and  so  into  the  cerebro- 
spinal fluid.  The  author  does  not  agree  with  this  view.  He 
thinks  that  the  cells  of  the  pars  intermedia  produce  the 
pressor  substance  which  he  calls  “ infundibulin,”  and  that 
this  secretion  and  that  of  the  posterior  lobe  are  taken  up  by 
the  blood  stream.  Therapeutically  the  most  fruitful  results 
seem  to  be  obtained  by  intravenous  injection  of  extracts  of 
the  organ  as  a whole  or  of  its  individual  parts.  Next  the 
author  deals  with  the  effects  of  destruction  and  partial 
or  total  removal  of  the  gland  with  the  operative 
-technique,  describing  a large  number  of  his  own  experi- 
ments, and  others  also  on  separation  and  compression 
of  the  stalk.  The  author  agrees  with  Paulesco  and 
•Cushing  that  total  extirpation  or  removal  of  very  large 
portions  of  the  pars  anterior  is  fatal,  also  that  the  removal 
of  the  pars  posterior  produces  no  symptom's.  The  author 
also  finds  that  the  genitalia  not  only  do  not  atrophy,  but 
continue  to  develop  in  the  young  female  after  removal  of 
this  portion  of  the  pituitary.  He  differs  from  Cushing  in 
finding  that  in  none  of  the  cases  in  which  portions  of  the 
pars  anterior  were  removed  did  dystrophia  adiposogenitalis — 
with  its  lowered  blood  pressure  and  sugar  tolerance — super- 
vene. This  syndrome,  however,  occurs  after  compression 
and  separation  of  the  infundibular  stalk.  The  author 
reconciles  these  diverging  views  by  assuming  that  this 
syndrome  is  primarily  produced  by  insufficiency  of  the  pars 
anterior,  and  that  the  only  sure  way  to  effect  this  is  to  inter- 
fere with  the  blood-supply.  The  inter-relations  of  pituitary 
activity  with  that  of  the  thyroid  and  ovaries  is  fully  dealt 
with. 

Part  III.  (pp.  215  300)  deals  with  disorders  associated  with 
the  pituitary  and  their  treatment.  The  author  deals  with 
hyperpituitarism  and  acromegaly,  and  desctibes  the  cases 


which  he  has  treated  ; also  with  hypopituitarism,  which  i3 
usually  not  manifested  until  the  child  is  growing  up.  The 
types  before  and  after  puberty  are  described  and  illustrated, 
including  dystrophia  adiposogenitalis.  The  surgical  treat- 
ment of  pituitary  disease  is  fully  dealt  with  and  admirably 
illustrated. 

Part  IV.  (pp.  301-329)  deals  with  the  therapeutic  uses  of 
pituitary  extracts  for  which  there  are  as  many  names  as 
trade  firms  manufacturing  them.  The  extracts  used  were 
made  from  the  whole  gland  (pituitarin),  pars  anterior 
(hypophysin),)  pars  posterior  (infundibulin).  The  prepara- 
tions are  made  as  dried  or  liquid  extracts.  The  former  are 
given  by  the  mouth,  but  infundibulin  is  given  intra- 
muscularly ; this  should  be  done  with  caution.  The  indications 
for  their  use  are  carefully  noted  and  special  attention  Is  given 
to  the  use  and  pressor  effects  of  infundibulin  in  shock, 
collapse,  sepsis,  serum-sickness,  spasmodic  asthma,  chronic 
asthenia  with  low  blood  pressure,  and  in  obstetrical  cases — 
in  which  latter  its  uses  and  contra-indications  are  specially 
described.  The  author  gives  the  results  of  his  experience  in 
the  use  of  these  extracts  in  other  diseases,  but  they  do  not 
seem  to  be  very  encouraging.  He  says  : 

“Tbe  most  notable  effects  and  benefits  of  pituitary  medication  a’e 
obtained  in  those  cases  in  which  a rapid  result  is  desirable.  In  such 
circumstances  the  extract  used  is  that  made  from  the  pars  posterior, 
and  its  action  is  exerted  upon  all  the  unstriped  muscle-tissues  of  the 
bodv.” 

We  congratulate  Dr.  Blair  Bell  on  the  success  of 
his  endeavour  to  lift  a corner  of  the  veil  that  still 
enshrouds  the  secrets  of  the  pituitary  body.  Much  work 
has  still  to  be  done  before  the  potentialities  are  laid  bare. 
Perhaps  the  author,  who  has  already  done  so  much  original 
work  to  this  end,  will,  in  days  to  come,  reveal  to  us  some- 
thing more  of  these  fascinating  mysteries. 


The  Practical  Medicine  Series  for  1918~.  Vol.  VII.  : Shin 
and  Venereal  Diseases.  Edited  by  Oliver  S.  Ormsby, 
M.D.,  and  J.  H.  Mitchell,  M.D.  Chicago:  The  Year 
Book  Publishers.  SI. 40.  Price  of  the  series  of  eight 
volumes,  $10  00. 

This  volume  is  one  of  a series  of  eight  issued  at  monthly 
intervals,  covering  the  entire  field  of  medicine  and  surgery, 
each  volume  aiming  at  completeness  on  the  subject  treated  for 
the  year  prior  to  publication.  The  aim  is  commendable  and 
well  realised  in  the  present  volume  on  Skin  and  Venereal 
Diseases.  The  amount  of  information  it  contains  is  large 
and  it  is  presented  in  a stimulating  manner.  Due  attention 
is  given  to  the  sociological,  as  well  as  to  the  purely  clinical 
aspect  of  venereal  disease.  This  is  evidenced  by  the  sections 
on  Venereal  Disease  contracted  in  the  Army,  and  the 
Teaching  of  Syphilis.  Under  the  heading  of  Gonorrhoea 
there  is  an  interesting  note  on  phlebitis  of  the  deep  dorsal  j 
vein,  a subject  to  which  little  attention  has  been  devoted. 
An  attractive  feature  is  the  criticism  offered  by  the  editor 
on  the  various  statements  enunciated  in  the  text. 


The  Ophthalmoscope  : A Manual  for  Students.  ByGuSTAVUS 
Hartridge,  F.R.C.S.  Sixth  edition.  With  65  illus-  j 
trations  and  four  plates.  London  : J.  and  A.  Churchill. 
Pp.  152.  6s.  6 d. 

The  first  half  of  this  book  deals  with  the  theory  of  i 
ophthalmoscopic  images  and  gives  practical  instruction  in  j 
the  use  of  the  ophthalmoscope,  covering  largely  the  same  I 
ground  as  the  author's  book  on  Refraction.  The  second  I 
half  deals  with  the  normal  fundus  and  a few  of  the  abnormal  j 
conditions  most  usually  found.  Two  coloured  plates  of 
varieties  of  the  normal  fundus  will  be  found  useful  by  the 
student,  but  the  illustrations  of  abnormal  conditions  might 
well  be  improved. 

.4  Woman  Doctor:  Mary  Murdoch  of  Hull.  By  Hope 
Malleson,  B.A.  With  a Preface  by  L B.  Aldrich- 
Blake,  M.S.,  M.D.  Lond.  With  portrait  illustrations 
London  : Sidgwick  and  Jackson,  Ltd.  1919.  Pp.  231.  I 
4s.  6 d. 

The  life  of  a good  physician  is  always  worth  recording  for 
the  sake  of  the  medical  generations  to  come.  Many  students 
—and  especially  the  women  students — will  find  inspiration 
in  the  story  of  Mary  Murdoch's  life.  But  we  feel  with  Dr. 
Aldrich-Blake  that  this  biography  deserves  a recognition 
beyond  that  of  the  medical  profession.  Her  insight  into 
human  need  and  her  rich  possession  in  the  fruits  of  human 


The  Lancet,] 


REVIEWS  AND  NOTICES  OF  BOOKS. 


[July  19,  1919  m 


happiness  qualify  this  busy  practitioner  as  an  example  to  all 
who  are  striving  for  a higher  conception  of  citizenship  in  the 
world.  The  biographer  has  wisely  allowed  Mary  Murdoch  to 
speak  very  largely  for  herself,  and,  indeed,  no  art  could 
improve  upon  the  transparent  sincerity  of  her  finely  written 
letters.  Collected  in  an  appendix  are  to  be  found  also  some 
of  her  enthusiastic,  yet  well-balanced  lectures  and  addresses, 
together  with  obituary  notices  published  at  the  time  of  her 
death,  and  amongst  these  last  the  one  which  appeared  in  our 
columns  on  April  1st,  1916.  We  can  well  believe  that  the 
people  of  Hull  still  mourn  and  still  miss  their  beloved  doctor. 


A Handbook  of  Medical  Jurisprudence  and  Toxicology.  By 
William  A.  Brend,  M.A.  Camb.,  M.D.,  B.Sc.  Lond., 
Lecturer  on  Forensic  Medicine,  Charing  Cross  Hospital. 
Third  edition,  revised.  London  : Charles  Griffin  and  Co., 
Ltd.  1919.  Pp.  317.  10s.  6 d. 

The  third  edition  of  Dr.  Brend’s  useful  little  book  has 
been  enlarged  and  brought  up  to  date,  the  chapter  on  insanity 
and  other  abnormal  mental  conditions  having  been  entirely 
rewritten.  Both  this  chapter  and  the  preceding  one  on  the 
forms  of  insanity  are  as  good  as  can  be  expected  in  so  small 
a space.  The  section  on  insanity  and  criminal  responsibility, 
dealing  with  the  history  and  application  of  the  M‘Naughton 
ruling,  is  particularly  clear  and  interesting.  The  book  is 
essentially  a convenient  work  of  reference,  and  if  read  as 
such  in  connexion  with  law  cases  of  current  interest  will 
prove  of  value  alike  to  the  general  practitioner  and  to  the 
medical  student. 


JOURNALS. 

The  Journal  of  Physiology.  Edited  by  J.  N.  Langley, 
D.Sc.,  F.R.S.  Vol.  LII.,  No.  6.  Cambridge  University 
Press.  1919.  Pp.  391-474.  9s. — The  Rate  of  Diffusion  of 
Gases  through  Animal  Tissues,  with  some  Remarks  on 
the  Coefficient  of  Invasion,  by  August  Krogh.  It  would  seem 
that  the  supply  of  oxygen  to  cells  has  never  been  systematic- 
ally investigated  hitherto.  The  author  describes  fully  his 
series  of  ingenious  experiments.  The  diffusion  constant  for 
a gas  through  a substance  is  defined  as  the  number  of  c.cm. 
(0°  C.  aud  760  mm.  flg)  penetrating  through  0 001  (1  J) 
thickness  and  1 sq.  cm.  surface  per  minute  "when  the 
pressure  difference  is  one  atmosphere.  The  diffusion 
constant  for  oxygen  through  animal  tissues  increases  with 
increasing  temperature— about  1 per  cent,  per  degree,  taking 
the  rate  at  20  as  unity.  Diffusion  of  gases  through  animal 
tissues  is  much  slower  than  through  water  or  gelatin.  The 
absolute  diffusion  constants  for  oxygen  at  20  are : water, 
0 34  ; gelatin,  0 28;  muscle,  014;  connective  tissue,  0T15 ; 
chitin,  0 013  ; indiarubber,  0 077.  The  “ invasion  coefficient  ” 
for  oxygen  into  water  is  many  times  higher  than  the  “ deter- 
minations ” hitherto  made  would  indicate. 

The  Number  and  Distribution  of  Capillaries  in  Muscle, 
with  Calculations  of  the  Oxygen  Pressure-Head  Necessary 
for  Supplying  the  Tissue,  by  August  Krogh.  To  utilise  the 
foregoing  data  it  was  necessary  to  know  further  the  rate  at 
which  oxygen  is  used  up  by  the  tissue  in  question,  and  the 
average  distance  which  an  oxygen  molecule  has  to  travel 
from  a capillary  into  the  tissue  before  entering  into  chemical 
combination.  As  the  capillary  arrangements  in  striped 
muscle  are  fairly  regular,  this  tissue  was  chosen  as  the  basis 
for  study.  To  this  end  blood-vessels  of  certain  muscles  in 
different  animals  were  injected.  It  was  found  that  in 
striated  muscles  the  capillaries  are  arranged  with  such 
regularity  along  the  muscular  fibres  that  each  capillary  can 
be  taken  to  supply  a definite  cylinder  of  tissue,  the  average 
cross-section  of  which  can  be  determined  by  counting  the 
capillaries  in  a known  area  of  the  transverse  section.  The 
number  of  capillaries  per  sq.  mm.  of  the  transverse  section 
of  striated  muscle  appears  to  be  a function  of  the  intensity 
of  the  metabolism,  being  higher  in  small  mammals  than  in 
larger  forms.  The  necessary  oxygen  pressure-head  deduced 
from  the  total  number  of  capillaries  is  in  all  cases  extremely 
low. 

Influence  of  Saprophyte  Bacteria  on  Oxidation  in  Higher 
Animals,  by  I.  Kianizin.  (Fifth  series.)  This  is  a short 
and  interesting  paper.1  (1)  The  Respiratory  Response  to 
Anoxaemia;  (2)  The  Efiect  of  Shallow  Breathing,  by  J.  S. 
Haldane,  J.  C.  Meakins,  and  J.  G.  Priestley.  As  to  (1)  it  is 
known  that  ordinarily  the  respiration  is  regulated  with  the 
utmost  delicacy  in  correspondence  with  the  CO-2  tension  of 
the  blood  passing  through  the  respiratory  centre,  and  that 
the  centre  actually  responds  to  increased  hydrogen-ion  con- 
centration. The  apparatus  used  is  described.  In  each  case 
the  subject  of  the  experiment  was  sitting  at  rest  while 
breathing  from  the  apparatus.  Records  were  taken  with 


1 A summary  of  previous  work  will  be  found  in  the  Journal  of 
Physiology,  1.,  1916. 


each  variation  of  the  composition  of  the  air  breathed 
— e.g.,  3-82  per  cent. — 4-29  per  cent.  CO-2 ; other  observa- 
tions were  made  on  altering  the  proportion  of  oxygen 
in  the  inspired  air.  It  was  found : 1.  The  respiratory 
response  to  anoxaemia  is  in  three  stages : (a)  Increased 
depth  of  respiration  and  increased  ventilation  per  minute 
owing  to  lowered  CO2  threshold;  (6)  periodic  breathing 
unless  the  anoxaemia  is  considerable  ; (c)  frequent  and  corre- 
spondingly shallow  breathing.  2.  Excess  of  CO2  (increased 
hydrogen-ion  concentration)  causes  a considerable  and  per- 
sistent increase  in  depth  of  respiration  and  relatively  slight 
increase  in  frequency.  This  response  is  in  marked  contrast 
to  the  response  to  want  of  oxygen.  3.  The  maximum  increase 
in  lung  ventilation  is  obtained  when  excess  of  CO2  and 
anoxaemia  are  both  present.  As  to  (2),  shallow  breathing, 
there  are  two  theories  as  to  the  harmonising  of  the  regu- 
lation of  respiration  with  the  metabolism  of  the  body— viz., 

(a)  that  it  is  a matter  of  reflex  nervous  control ; and 

( b ) that  it  is  a chemical  regulation.  Investigations  showed 
that  there  is  a distinct  connexion  between  the  nervous 
control  and  the  chemical  control.  The  authors’  investiga 
tions  were  carried  out  on  men  suffering  chronically  from 
the  effects  of  gas  poisoning  and  from  a group  of  symptoms 
known  as  D.A.H.,  “soldier’s  heart,”  “irritable  heart,” 
“ effort  syndrome,”  attention  being  given  to  the  regulation 
of  the  depth  of  respiration,  more  especially  to  the  effects  of 
shallow  breathing.  “Irritable  heart  ” is  characterised  by 
breathlessness  on  exertion,  rapid  pulse,  fainting  attacks, 
giddiness,  exhaustion,  lassitude,  headache,  irritability,  Ac. 
These  patients  invariably  show  a remarkable  type  of 
breathing,  which  is  rapid — 20  to  60  or  more  per  minute — and 
shallow — 250  to  350  c.cm. — and  on  exertion  the  rate  increases 
very  abnormally,  while  the  increase  in  depth  is  abnormally 
small.  Their  alveolar  CO-2  is  abnormally  low.  The  patients 
are  like  a normal  individual  at  high  altitudes,  where  the 
diminished  oxygen  tension  of  the  inspired  air  pro- 
duces the  same  series  of  defects.  All  showed  shallow 
rapid  breathing.  The  concertina-like  apparatus  used  for 
regulated  limitation  of  the  air  inspired  at  each  breath  is 
described  and  by  it  records  of  rate  and  depth  of  the  respira- 
tions were  also  obtained.  It  was  found  that  shallow 
breathing  caused  unequal  ventilation  of  the  lungs,  and  this 
in  turn  produced  anoxaemia  and  consequently  periodic 
respiration  and  other  symptoms.  As  to  the  effect  of  posture 
on  the  type  and  rate  of  respiration,  the  recumbent  position 
is  normally  associated  with  slowing  and  deepening  of  the 
respiration,  and  if  the  deepening  is  prevented  symptoms  of 
anoxaemia  are  produced.  Similar  effects  on  the  respiration 
were  produced  by  abdominal  and  thoracic  constriction — e.g., 
by  use  of  corsets.  These  and  other  observations  are  regarded 
as  affording  an  explanation  of  orthopneea.  In  any  condition 
such  as  bronchitis,  asthma,  and  emphysema,  in  which  the 
even  distribution  of  the  air  in  the  lungs  is  hindered  by  local 
narrowing  of  the  bronchi  or  local  impairment  of  the  lung 
elasticity,  imperfect  oxygenation  of  the  mixed  arterial  blood 
must  tend  to  be  produced  in  the  same  way  as  in  shallow 
breathing. 

The  Physiological  Action  of  Extracts  of  the  Electrical 
Organs  of  the  Skate  ( Raia  clavata ) and  Torpedo  (T.  mar- 
morata),  by  P.  T.  Herring.  Extracts  of  the  fresh  organs 
made  with  Ringer’s  fluid  were  used,  and  their  effects  tested 
on  the  sartorius  of  the  frog,  on  mammalian  blood  pressure, 
and  volume  of  some  organs.  Electrical  organs  do  not 
contain  a hormone  capable  of  influencing  the  contraction  of 
cross-striated  muscle.  The  extracts  showed  no  special 
effects  upon  smooth  muscle,  cardiac  muscle,  blood  pressure, 
or  kidney  secretion. 

The  Supply  of  Oxygen  to  the  Tissues  and  the  Regula 
tion  of  the  Capillary  Circulation,  by  August  Krogh. 
Direct  observations  by  transmitted  and  direct  illumina- 
tion were  made  on  the  capillaries  of  the  muscles  of 
the  tongue  of  deeply  narcotised  frogs,  and  also  on 
other  adjacent  muscles,  and  on  the  muscles  of  urethan- 
ised  guinea-pigs  by  reflected  light.  Capillaries  are  not 
mere  passive  tubes  with  the  blood  flowing  through 
all  of  them  at  rates  which  are  determined  by  the  state  of 
constriction  or  dilatation  of  the  corresponding  arterioles. 
Observations  by  reflected  light  on  the  resting  muscles  of 
frogs  and  guinea-pigs  showed  that  most  of  the  capillaries 
are  in  a state  of  contraction  and  closed  to  the  passage  of 
blood.  By  tetanic  stimulation  of  the  muscle  or  by  gentle 
massage  a large  number  of  capillaries  are  opened  up.  They 
can  be  observed  to  contract  again  afterwards.  In  spon- 
taneously contracting  muscles  a large  number  of  capillaries 
are  likewise  opened.  The  average  diameter  of  the  open 
capillaries  in  resting  muscle  is  much  less  than  the  average 
dimensions  of  the  red  corpuscles,  which  become  greatly 
deformed  during  their  passage.  In  working  muscles  the 
capillaries  are  somewhat  wider.  The  oxygen  pressure  in 
resting  muscles  is,  sometimes  at  least,  very  low,  but  in 
working  muscles  it  approaches  very  near  to  that  of  the 
blood.  The  capillaries  are  not  merely  passively  dilated  by 
blood  pressure,  but  constantly  perform  active  variations  in 
calibre.  Clinical  hyperaemia  and  anaemia  are  due  mainly  to 


112  The  Lancet,] 


REPORTS  AND  ANALYTICAL  RECORDS. 


[July  19,  1919 


changes  in  the  calibre  of  capillaries  and  the  number  of  open 
capillaries.  The  arterio-motor  and  capillario-motor  systems 
seem  to  act  in  opposite  directions. 

This  is  a very  interesting  volume. 

Studium.  Revista  di  Scienza  Medica.  June,  1919.  Pp.40. 
Naples:  Corso  Umberto  I.  154.  Price  2 lire. — After  three 
years  of  cessation  owing  to  the  war  the  publication  of  this 
monthly  periodical  has  been  resumed  under  the  editorship 
of  Dr.  Tommaso  Senise.  We  cordially  welcome  the  re-issue 
with  a passing  tribute  to  the  artistic  design  on  the  cover, 
with  the  inscription  of  “ Scientia  Lux  Lucis,”  which  recalls 
the  style  of  Walter  Crane.  The  new  number  contains  an 
editorial  review  of  the  literature  of  the  influenza  epidemic, 
with  special  reference  to  articles  by  Tr^molieres  and 
Rafinesque  in  the  Presse  Mtdicale  of  last  February,  by 
Professor  J.  Boni  in  L’  Ospedale  Maggiore,  Dr.  E.  Ruggieri 
in  the  Riforma  Medica,  F.  Schuffer  in  the  Rivista  Critica  di 
Clinica  Medica,  and  others. — Among  other  items  one  of  the 
most  important  is  the  report  by  Professor  Leonardo 
Bianchi  to  the  After-war  Commission,  on  the  Biophylaxis 
and  Prophylaxis  of  Neurosis  and  Psychosis.  In  this  report 
he  urges  the  necessity  of  modifying  the  Italian  law  of  1904 
concerning  insane  people  and  asylums.  This  law  enacted 
that  reception  into  an  asylum  was  to  be  limited  to  those  who 
were  a danger  to  themselves  or  to  others  ; it  was  a measure 
of  public  safety,  not  a conception  of  treatment.  The  insane, 
the  report  insists,  must  be  treated  under  all  circumstances 
and  not  only  when  they  are  dangerous;  the  estimate  of 
public  safety  emanates  from  a society  saturated  with  bureau- 
cracy from  which  the  social  scope  of  treatment  is  banished, 
to  say  nothing  of  that  of  educating  the  weak-minded. — 
Professor  A.  Cardarelli  contributes  a clinical  lecture  on 
Severe  Intercostal  Neuralgia  Symptomatic  of  Aneurysm  and 
New  Growths,  and  the  editor  has  an  illuminating  paper  on 
a New  Method  of  Investigating  the  Functions  of  the  Central 
Nervous  System.  This  method  consists  in  an  experimental 
production  of  iscbmmia  in  different  areas  of  the  brain  by 
ligature  of  the  arteries  supplying  those  areas. — In  the  section 
devoted  to  Reviews,  the  more  modern  methods  of  treating 
tuberculosis  are  dealt  with,  notably  that  of  Lo  Monaco,  by 
injections  of  saccharose. — There  are  also  many  extracts  from 
current  medical  literature,  notices  of  recent  books,  and 
general  news.  The  Studium  has  now  reached  its  ninth  year 
of  existence  and  we  wish  it  every  success  in  the  future. 


Reports  anfc  ^nalgtital  ^Recarbs 

FROM 

THE  LANCET  LAB0KAT0KY. 


UMBROSE. 

(Allen  and  Hanburys,  Ltd.,  7,  Vere-street,  Cavendish-square, 
London,  W.  1.) 

The  “barium  meal”  used  in  radiological  practice  should,, 
of  course,  be  quite  insoluble  in  water  or  acids,  as  the  soluble 
barium  salts  are  highly  poisonous.  This  means  that  only  the 
pure  insoluble  sulphate  should  be  used  for  the  purpose  when 
barium  is  substituted  for  bismuth.  There  is  no  difficulty  in 
obtaining  quite  pure  barium  sulphate  free  from  soluble  salts, 
as  is  shown  to  be  the  case  with  “umbrose.”  Shaken  for 
several  hours  with  dilute  hydrochloric  acid  the  filtered  fluid, 
according  to  our  examination,  showed  no  trace  of  barium  at 
all.  This  simple  test,  it  seems  to  us,  should  always  be  carried 
out  before  using  the  preparation  for  radiological  exami- 
nation, as  serious  accidents  have  arisen  either  through  the 
sulphate  being  contaminated  with  soluble  barium  salt  or 
through  the  substitution  of  the  carbonate  or  even  sulphide. 
Such  cases  have  been  reported  in  our  columns.  Umbrose  is 
mixed  with  a certain  proportion  of  convenient  pabulum — 
e.g.,  cocoa,  arrowroot,  dried  milk — and  leaves  on  ignition  a 
pure  white  residue  of  barium  sulphate,  amounting,  according 
to  our  analysis,  to  74  per  cent.  A reliable  shadow-meal  is 
thus  presented. 

OMN OPON - ATRIN AL  “ROCHE.” 

(Hofemann  La  Roche  Chemical  Works.  Ltd.  (Switzerland), 

7 and  8,  Idol-lane,  London,  K.C.  3 ) 

Containing  the  alkaloids  of  opium  in  their  entirety  and  in 
a soluble  form,  omnopon  has  recently  been  combined  with 
atrinal,  a sulphuric  ester  of  atropine  (not  the  ordinary 
sulphate),  as  a preliminary  and  adjunct  to  narcosis  by 
inhalation.  Claims  are  made  in  favour  of  its  advantages 
compared  with  the  morphine  and  atropine  sulphate  combina- 
tion, on  the  grounds  that  it  is  less  toxic  than  atropine,  its 
paralysing  action  on  the  pneumogastric  is  less  pronounced, 


while  it  avoids  the  increased  blood  pressure  following  the 
use  of  ordinary  atropine  salts.  It  is  also  stated  that  it  has 
no  unfavourable  effect  on  respiration.  The  combination  is 
an  interesting  one  and  the  claims  made  are  of  importance. 
Each  ampoule  contains  IT  c.cm.  of  fluid,  representing 
0 02g.  omnopon  and  O OOlg.  atrinal. 

CHELTINE  FOODS  (MILK  AND  MALTED  AND  STRICT 
DIABETIC). 

(The  Cheltine  Food  Co.,  Cheltine  Works,  Cheltenham.) 

We  have  received,  amongst  others,  three  specimens  of 
the  milk  and  malted  foods  made  by  the  above  company. 
Nos.  1 and  2 are  designed  for  infant  feeding,  and  No.  3 
for  invalids  and  patients  with  weak  digestive  function. 
Our  analysis  sets  out  their  composition  per  cent,  as 
follows  : — 


Milk  and  Malted  Food. 

No.  1. 

No.  2. 

No.  3. 

Moisture  

5-30  ... 

4-35  .. 

. 5-60 

Ash  

1-70  ... 

305  .. 

1-75 

Fat 

7-94  ... 

12-48  .. 

7-88 

Protein 

1411  ... 

17  00  .. 

. 11-27 

Sugars 

14-85  ... 

22-30  .. 

. 12-00 

Starch  and  dextrin 

56-10  ... 

40-82  .. 

. 61-50 

Total  matters  soluble  in 
cold  water  

[34-25  ... 

36-75  .. 

. 26-50 

Food  No.  1 is  intended  for  infant  feeding  up  to  the  fifth 
month,  when  it  is  replaced  by  food  No.  2.  In  each  case 
the  food  is  directed  to  be  prepared  with  diluted  cow’s 
milk.  It  will  be  noted  that  No.  2 is  richer  in  all  food 
materials,  fat,  protein,  and  sugar,  than  No.  1,  from  which  it 
may  be  fairly  inferred  that  more  milk  is  used  in  this  case. 
The  conversion  of  starch  by  malt  is  not  complete  in  both 
cases,  but  a greater  conversion  is  shown  in  No.  2.  Food 
No.  3 shows  still  more  unconverted  starch  and  dextrin,  which, 
however,  are  readily  dissolved  or  assimilated  as  the  result  of 
partial  digestion  with  active  malt.  In  addition,  we  have 
received  two  foods  described  respectively  as  (4)  diabetic 
strict  flour  and  (5)  diabetic  strict  food.  The  main  question, 
of  course,  in  regard  to  these  latter  foods  is  the  amount  of 
sugar  they,  are  capable  of  yielding  on  hydrolysis.  The  results 
obtained  in  our  experiments  were  as  follows,  in  terms 
of  reducing  sugar  after  digestion  with  acid  : — No.  4,  1816 
per  cent,  and  No.  5,  16-00  per  cent.  They  contain,  therefore, 
about  a fourth  only  of  the  quantity  of  sugar-yielding 
substances  in  ordinary  flour,  the  carbohydrates  being 
replaced  largely  by  assimilable  proteins. 

ELIXIR  YADIL. 

(Clement  and  Johnson,  1a,  Sicilian  avenue,  London.  W.C.  1.) 

Reference  has  been  made  in  our  columns  1 to  the  employ- 
ment of  yadil  in  influenza  when  its  administration  internally 
appeared  to  ward  off  the  complications  of  that  disease.  Its 
active  constituent  is  described  as  trimethenal-allyl  carbide, 
a substance  related  to  the  essential  oil  of  garlic.  The 
ordinary  preparation  has  a decided  smell  and  taste 
resembling  garlic,  and  for  those  patients  who  find  objec- 
tion to  these  characteristics  an  elixir  is  now  prepared  with 
suitable  adjuvants  and  aromatics  obscuring  the  allylic  odour 
and  taste.  It  is  an  amber-coloured  fluid  with  sweet  and 
aromatic  flavour.  Its  antiseptic  properties  are  claimed  to  be 
established  in  clinical  practice. 

SUPEROL. 

(K.  Rayment,  2,  Broad  Street-place,  Blomfield-street, 
London,  E.C.  2.) 

Chinosol  will  be  barely  familiar  under  the  name  of 
“Superol,”  which  is  now  being  imported  into  this  country 
from  the  Amsterdam  Superphosphate  Works  by  the  above 
agent.  A good  deal  of  work  has  been  done  in  regard  to 
determining  the  germicidal  value  of  chinosol,  and  while  in 
some  directions  it  compares  unfavourably  with  other  anti- 
septics, it  possesses  certain  advantages  of  its  own.  Those 
whose  experience  with  its  application  was  satisfactory  and 
who,  through  the  war,  were  unable  to  get  supplies,  as  it 
was  exclusively  produced  in  Germany,  may  be  interested  to 
know  that  its  manufacture  has  been  undertaken  by  the  above 
company  under  the  name  of  “Superol.”  It  is  identical, 
according  to  our  examination,  with  chinosol,  a combination 
of  potassium  sulphate  with  oxy-chinoline  sulphate,  the  base 
being  prepared  by  the  oxidation  of  nitro- benzene  and  aniline. 

1 The  Lancet,  March  15th,  1919,  p.  440. 


The  Lancet,] 


THE  FEDERATION  OF  MEDICAL  AND  ALLIED  SOCIETIES. 


[July  19,  1919  H3 


THE  LANCET. 


LONDON:  SATURDAY , JULY  Id,  1919. 


The  Federation  of  Medical  and 
Allied  Societies. 

It  will  be  remembered  that  at  a conference 
between  the  Medical  Parliamentary  Committee  and 
the  representatives  of  other  allied  organisations 
held  in  May  last  certain  resolutions  were  come  to 
which  were  published  in  The  Lancet  the  following 
week.1  The  resolutions  provided  for  the  constitu- 
tion of  a permanent  body  with  various  duties 
towards  the  medical  profession  and  towards  the 
public,  while  the  drafting  of  a financial  scheme 
under  which  the  work  would  be  done  was  left  to 
the  existing  committee,  acting  as  a provisional 
body  with  the  responsibility  of  making  a report. 
The  report,  it  was  agreed,  would  be  submitted  to  the 
representatives  of  the  whole  constituent  bodies,  and 
being  approved,  a new  executive  would  come  into 
being,  when  all  the  preliminary  stages  might  be  con- 
sidered over.  That  was  the  project  and  so  much  has 
now  been  done.  The  Medical  Parliamentary  Com- 
mittee has  been  reborn  in  what  it  is  hoped  will  be  a 
permanent  shape  ; it  has  been  renamed  ; its  support 
for  the  future  is  under  actual  consideration,  and  it 
yet  has  to  justify  its  existence  by  its  works.  Such 
is  the  outcome  of  the  meeting  held  at  the  College 
of  Ambulance  last  Friday,  when  the  representatives 
of  47  medical  and  allied  societies  met  the  pro- 
visional Medical  Parliamentary  Committee,  heard 
their  report  on  the  future  constitution,  and  in  the 
main  adopted  their  scheme. 

For  reasons  which  seemed  sufficient  to  the 
majority  of  those  at  the  meeting,  the  Medical  Par- 
liamentary Committee  now  takes  to  itself  the 
clumsier  but  more  definite  name  of  British  Federa- 
tion of  Medical  and  Allied  Societies,  a brief  discus- 
sion on  this  alteration  of  title  answering  an 
eternally  old  question  by  replying  that  “ British  ” 
can  be  used  as  an  adjective  connoting  all  our  Irish 
interests  and  all  those  of  our  Dominions  over  the 
seas.  Those  who  look  at  the  resolutions  passed  at 
the  large  meeting  in  May — and  we  hope  that  many 
will  do  so — will  allow  that  for  the  rest  the 
scheme,  which  has  now  been  adopted,  for 
carrying  on  the  Federation  under  a change  of 
lame,  and  under  some  variance  of  scope  owing 
)o  the  multiplication  of  interests,  has  throughout 
fie  same  general  idea,  and  that  this  idea 
las  prevailed  since,  at  the  meeting  of  the  medical 
srofession  in  Steinway  Hall  in  October  last  year, 
fie  Medical  Parliamentary  Committee  came  into 
sxistence.  At  tfiat  first  meeting  Dr.  Christopher 
Iddison.  moved  a successful  resolution  to  the  effect 
hat,  in  the  interests  of  national  health  it  is 
essential  that  the  considered  views  of  the  medical 

1 The  Lancet,  May  10th,  p.  808. 


profession  should  be  voiced  by  representative 
medical  men  in  the  House  of  Commons.”  At 
the  meeting  last  May  the  formation  of  a 
permanent  medical  committee  was  agreed  upon 
by  general  resolution,  having  for  its  objective 
to  supply  expert  information  on  health  ques- 
tions to  medical  Members  of  Parliament,  to 
warn  the  bodies  constituting  the  committee  of 
impending  legislation  affecting  such  questions,  to 
facilitate  communication  between  any  of  those 
bodies  where  they  were  particularly  interested, 
and,  lastly,  to  assist  in  increasing  medical  repre- 
sentation in  Parliament.  The  story  is  one  of 
natural  evolution.  The  stage  has  now  been  reached 
when,  to  carry  out  this  programme,  an  executive 
has  been  elected  and  plans  have  been  formulated 
for  raising  the  necessary  funds.  Finance,  as  ever, 
lags  behind,  and  while  the  meeting  last  week 
recognised  the  merits  of  the  scheme  proposed  by 
the  Medical  Parliamentary  Committee  for  financing 
the  Federation  in  the  future,  discussion  of  the 
subject  in  detail  is  promised. 

So  much  for  what  is,  and  while  past  experience 
of  unified  movements  within  our  ranks  makes 
optimistic  prophecy  risky,  we  see  no  reason  why 
the  new  Federation  should  not  have  before  it  an 
immediately  and  widely  successful  career.  Of 
course,  if  the  Federation  is  not  supported  it  will 
not  be  a Federation,  and  will  effect  nothing  ; 
equally,  of  course,  those  who  decide  to  join  the 
movement  only  when  it  is  successful  may  in  this 
case  find  themselves  with  no  movement  to  join. 
But  there  is  so  much  work  ahead  of  the  new 
Federation,  and  so  real  and  wide  a feeling  that 
this  work  should  be  done,  that  we  refuse  to  believe 
that  any  apathy,  at  this  critical  stage,  will  be 
allowed  to  nullify  the  strenuous  efforts  of  the  past 
six  months. 

♦ 

Hack  v.  Hack  and  Munden. 

Mr.  M.  M.  Munden  is  to  be  congratulated  upon  the 
verdict  of  the  jury  in  the  unsuccessful  petition  for 
divorce  in  which  he  was  cited  as  co-respondent  by 
Mr.  H.  S.  Hack,  the  husband  of  one  of  his  patients. 
The  evidence  in  the  case  has  been  reported  in 
unusual  detail,  and  it  was  evident  that  the  nauseous 
story  told  by  the  respondent  and  her  maid,  together 
with  the  letters  produced  by  the  latter,  could  yield 
no  verdict  other  than  that  returned.  This  was 
made  all  the  clearer  when  Mr.  Munden  himself  had 
been  in  the  witness-box  and  when  his  evidence  had 
been  corroborated  by  his  wife.  The  story  which 
had  to  be  met  was  one  lacking  in  practically  all 
those  elements  of  probability  which  are  usually 
present  in  the  accounts  of  alleged  conjugal  infidelity 
laid  before  the  divorce  court.  Mrs.  Hack  was  the 
patient  of  Mr.  Munden  from  May,  1913,  to  the 
autumn  of  1917,  and  she  was,  as  he  fully  recognised, 
suffering  from  alcoholism  and  hysteria.  He  also 
attended  her  for  more  than  one  miscarriage. 
According  to  Mrs.  Hack,  he  seduced  her  in  the 
drawing-room  in  1914,  and  from  that  time  onwards 
committed  adultery  with  her  on  various  occasions 
under  the  cloak  of  professional  attendances,  for 


114  The  Lancet,] 


THE  CONDITIONS  OF  ASYLUM  MEDICAL  SERVICE. 


[July  19,  1919 


which,  in  fact,  he  charged  as  such.  On  one  of  the 
dates  assigned  to  these  acts  Mrs.  Munden  was 
waiting  outside  the  house  in  the  motor-car,  in 
which  she  frequently  accompanied  her  husband  on 
his  rounds.  This  in  itself  would  be  a story  of 
unusual  depravity  and  recklessness  on  the  part  of 
a medical  man  who  had  himself  been  recently 
married,  whatever  might  be  the  physical  or  mental 
condition  of  the  patient  with  whom  he  was 
intimate.  When  it  is  remembered,  however,  that 
Mr.  Munden  was  attending  Mrs.  Hack  for  alcoholism 
and  hysteria,  which  was  not  in  dispute,  it  will  be 
seen  at  once  that  only  the  strongest  proof  of 
infatuation  in  no  common  degree  on  his  part  could 
render  the  allegations  credible. 

Folly  and  imprudence  have  limits  even  in  those 
rendered  blind  by  passion  to  the  likelihood  of  such 
a woman  betraying  her  lover,  but  in  the  case  of  Mr. 
Munden  and  Mrs.  Hack  there  was  not  a tittle  of 
evidence  of  even  the  most  casual  friendship,  or  the 
most  ordinary  social  intercourse.  That  he  visited 
his  patient  as  a medical  man  at  intervals  was 
common  ground,  and  no  witness  on  behalf  of  the 
petitioner  attempted  to  prove  anything  more.  Nor 
was  there  even  anything  to  suggest  that  Mr.  and 
Mrs.  Munden  did  not  live  together  as  a perfectly 
united  married  couple.  In  these  circumstances  it 
was  only  natural  that  Mrs.  Munden  Bhould  be  able 
to  support  her  husband  in  his  statement  that  he 
was  only  absent  for  the  period  necessary  for  a 
professional  visit  on  a night  when  Mrs.  Hack  and 
her  maid  swore  that  he  spent  at  least  two  hours  in 
the  bedroom  of  the  former.  In  the  same  way  the 
doctor’s  wife  could  state  to  a material  extent  what 
took  place  on  another  occasion  when  h’er  husband 
and  herself  were  interrupted  at  dinner  by  a visit 
from  Mrs.  Hack,  who  was  taken  by  him  into  the 
surgery  and  afterwards  got  rid  of.  There  was  a 
singular  absence  of  independent  testimony  from 
the  whole  case.  Among  the  facts  referred  to,  how- 
ever, were  the  damning  letters  produced  by  the 
maidservant,  to  whose  custody  the  respondent  had 
entrusted  them.  They  were  written  to  Mrs.  Hack 
by  other  men  than  the  co-respondent,  in  terms  that 
will  have  been  noted  by  all  who  read  them,  and 
among  them  was  no  line  of  writing  from  Mr. 
Munden.  In  short,  the  co-respondent,  so  far  as  the 
evidence  went,  had  never  sent  to  the  respondent 
anything  more  incriminating  than  a prescription ; 
and  he  will  have  the  heartiest  sympathy  of  all  in 
the  position  in  which  he  found  himself  placed. 

Medical  men  know  well  that  the  case  of  Hack  v. 
Hack  and  Munden  is  not  an  isolated  one,  but  an 
example  of  a class.  It  is  a rare  example  of  what 
may  occur,  but  by  no  means  without  parallel.  It  is 
a danger  which  has  to  be  faced  by  members  of 
nearly  all  branches  of  the  medical  profession,  that 
at  any  time  a woman  with  whom  they  have  been 
alone  may  make  against  them  a charge  of  undue 
intimacy  or  of  improper  conduct  of  some  kind 
without  any  ground  whatever  for  doing  so.  There 
is  no  absolute  safeguard  against  such  charges,  nor, 
of  course,  can  we  say  that  on  all  occasions  when  a 
medical  man  sees  a female  patient  alone  he  ought 
to  have  a third  person  present.  This  would  be  a 


counsel  of  perfection  which  in  practice  would  not 
be  possible  of  fulfilment.  Precautionary  steps  may 
be  taken  in  cases  where  symptoms  displayed  by  the 
patient  point  to  their  being  desirable,  but  always 
the  principal  safeguards  for  the  doctor  would  appear 
to  consist  in  confining  the  interview  to  the  limit  of 
time  necessary  for  the  matter  in  hand,  and  the 
keeping  of  strict  records  made  with  the  least 
possible  delay,  which  should  contain  all  essential 
details  of  the  patient’s  condition  with  the  treatment 
recommended.  The  ethical  rule  which  restrains  a 
medical  practitioner  from  discussing  even  with  his 
wife  the  diseases  or  idiosyncrasies  of  his  patients 
deprives  him  of  a limited  form  of  protection 
which  he  might  otherwise  have,  this  being 
especially  so  when  there  is  no  professional 
colleague  with  whom  to  discuss  any  salient  points 
in  the  case  or  in  the  demeanour  of  a patient. 
Another  way  of  avoiding  risk  is  to  refuse  attend- 
ance, but  it  is  a dangerous  method  for  a young 
doctor  to  adopt— it  does  not  improve  his  practice, 
and  might  lead  to  his  being  asked  to  formulate  his 
reasons  for  his  unusual  conduct.  A practitioner 
cannot  be  blamed  for  continuing  his  attendance 
in  risky  circumstances  any  more  than  a barrister 
can  be  blamed  for  continuing  his  advocacy  on 
behalf  of  a client  of  whose  probity  he  feels 
doubtful.  The  medical  man  will,  however,  exercise 
prudence  and  care  in  future  attendances  on  such 
a patient,  confident  in  his  own  integrity  and 
honour,  and  not  without  some  faith  in  the  time- 
honoured  maxim  which  ascribes  ultimate  victory 
to  truth.  To  join  one  of  the  defence  societies  is 
absolutely  necessary  for  the  medical  practitioner, 
and  we  congratulate  the  Medical  Defence  Union  on 
securing  the  complete  acquittal  of  their  member 
from  a ruinous  charge. 


The  Conditions  of  Asylum  Medica: 
Service. 

The  Asylums  Committee  of  the  London  County! 
Council  has  just  presented  its  report  to  the  Council 
on  a revised  scale  of  remuneration  and  other 
improvements  in  the  conditions  of  service  of  the 
assistant  medical  officers  at  the  Council’s  mental 
hospitals.  It  may  be  recalled1  that  shortly  before 
the  war  the  discontent  with  their  position  felt  b\ 
asylum  officers  throughout  the  country  resulted 
in  a movement  for  association  to  protect  their 
interests  and  advance  the  status  of  asylum  service 
In  May,  1914,  -a  petition  was  presented  by  tbt 
assistant  medical  officers  of  the  London  asylum, 
to  the  County  Council  asking  for  a bettermen 
of  their  conditions  of  service  and  pay.  I 
deputation  then  received  explained  the  difficult; 
experienced  by  the  Council  in  obtaining  the  star 
for  its  mental  hospitals  by  adducing  three  cause 
for  the  unpopularity  of  the  service.  The  specialt; 
of  mental  diseases  is  alone  in  this  countr; 
in  not  enjoying  a teaching  centre;  opportunity 
for  advancement  in  the  lunacy  service  are  prac 
tically  non-existent;  and,  thirdly,  outside  th 

i The  Lancet.  1914,  i.,  116. 


Thk  Lanoejt,] 


THE  OSLER  PRESENTATION. 


[July  19,  1919  H5 


strictly  limited  number  of  superintendentships 
the  conditions  of  asylum  service  preclude  any 
prospect  of  living  a life  of  reasonable  freedom 
and  responsibility.  The  deputation  suggested  that 
facilities  should  be  given  for  study-leave  sufficient 
to  enable  medical  officers  to  obtain  a diploma  in 
psychological  medicine,  and  that  officers  should  be 
seconded  for  the  purpose  of  holding  clinical  posts 
at  the  Maudsley  Hospital,  of  taking’  post-graduate 
courses  elsewhere,  or  of  carrying  out  research 
work.  It  was  finally  urged  that  permission  to  marry 
should  not  be  withheld  from  any  medical  officer  on 
the  permanent  staff  after  a reasonable  length  of 
service. 

The  war  postponed  consideration  of  these 
suggestions,  and  now  that  the  matter  comes  up 
again  for  decision  the  Committee  admits  that  the 
difficulties  have  increased  rather  than  diminished, 
in  view  of  the  greater  scarcity  of  qualified  medical 
men  and  the  growing  attraction  for  the  medical 
entrant  of  other  branches  of  public  service.  In 
view  of  this  the  Committee  proposes  a drastic 
revision  of  the  remuneration  scale,  the  rate  of  pay 
for  the  first  assistant  being  fixed  at  £700,  equivalent 
to  £875  with  the  present  war  bonus  and  percentage 
additions.  His  colleagues  would  similarly  look  to 
a salary  running  up  to  £755,  £650,  and  £553  respec- 
tively in  ascending  order  of  seniority.  This  scale 
to  count  for  the  larger  mental  hospitals  with 
2000  or  more  patients.  It  is  further  proposed  to 
remove  the  restriction  upon  the  civil  state  of 
.medical  officers  below  the  grade  of  second  assistant, 
■and  to  put  them  in  this  respect  in  the  same  position 
as  the  senior  assistant  who  already  finds  suitable 
accommodation  provided  for  him  as  a married  man 
within  the  asylum  precincts.  Sympathetic  con- 
sideration has  been  given  to  the  points  raised  in 
regard  to  education,  special  medical  qualifications, 
and  leave,  and  a further  vital  change  is  submitted 
for  the  approval  of  the  Council — namely,  not 
to  appoint  any  officer  in  future  exclusively 
to  a single  institution,  but  to  leave  open  the 
question  of  transfer  from  one  mental  hospital  to 
another. 


The  time  is,  indeed,  more  than  ripe  for  the 
suggested  reforms.  The  life  of  the  asylum  medical 
officer  has  in  the  past  tended  neither  to  the 
efficiency  of  the  service  nor  to  the  development 
of  the  medical  officer’s  own  powers  and  character. 
The  disabilities  in  regard  to  marriage  could  hardly 
have  been  enforced  by  any  authority  possessed  of 
human  sympathy  and  social  imagination.  To  the 
Ministry  of  Health,  under  the  recent  Act,  it  is 
lawful  to  transfer  by  Order  in  Council  any  powers 
and  duties  of  the  Secretary  of  State  under  the 
Lunacy  Acts.  The  London  County  Council  has 
already,  without  pressure  from  above,  begun 
to  set  its  house  in  order  in  regard  to  a proper 
mental  medical  service,  but  it  remains  to  be  seen 
whether  the  service  can  become  such  as  it  should 
be,  in  the  interests  of  staff  and  patients,  without 
being  placed  under  the  Minister  who  directs  the 
other  public  health  services  of  the  country.  The 
quasi-autonomy  of  the  Board  of  Control  is  an 
anachronism. 


^nnotdians. 

" He  quid  nlmls.” 

THE  OSLER  PRESENTATION. 

A distinguished  company,  which  included  the 
President  of  the  General  Medical  Council,  the 
Director-General  of  the  Army  Medical  Service,  and 
the  High  Commissioner  for  Canada,  assembled  on 
Friday,  July  11th,  at  the  House  of  the  Royal  Society  of 
Medicine,  to  do  honour  to  Sir  William  Osier  on  the 
eve  of  his  seventieth  birthday.  Sir  Clifford  Allbutt 
presented  the  two  large  octavo  volumes  of  essays 
written  by  pupils,  colleagues,  and  friends  in  all 
parts  of  the  British  Dominions  and  America, 
alluding  feelingly  to  Sir  William  Osier’s  leadership 
in  the  relief  of  sickness  and  adversity,  and  to  the 
fruitfulness  of  the  marriage  of  science  and  letters 
exemplified  in  his  career,  concluding  with  the 
words  : — 

“In  these  volumes  we  hope  you  will  find  the  kind  of 
offering  from  your  fellow- workers  which  will  please  you 
best ; immaterial  offerings  indeed,  but  such  as  may  outlive 
a more  material  gift.  As  to  you  we  owe  much  of  the 
inspiration  of  these  essays,  and  as  in  many  of  their  subjects 
you  have  taken  a bountiful  part,  so  by  them  we  desire  to 
give  some  form  to  our  common  interests  and  affections. 

We  pray  that  health  and  strength  may  long  be  spared  to 
you  and  to  her  who  is  the  partner  of  your  life  ; and  that  for 
many  years  to  come  you  will  abide  in  your  place  as  a Nestor 
of  modern  Oxford,  as  a leader  in  the  van  of  Medicine,  and 
as  an  example  to  us  all.” 

Sir  William  Osier,  in  responding  to  the  gift, 
recalled  his  own  vagrant  career — as  a student  in 
Toronto,  Montreal,  London,  Berlin,  and  Vienna, 
as  a teacher  in  Montreal,  Philadelphia,  Baltimore, 
and  Oxford.  Loving  the  profession  of  medicine 
and  [believing  ardently  in  its  future,  he  had  been 
content  to  live  in  it  and  for  it.  We  may  recall  his 
own  words  spoken  14  years  ago  in  taking  leave  of 
his  friends  in  the  United  States  : — 

I have  loved  no  darkness, 

Sophisticated  no  truth. 

Nursed  no  delusions. 

Allowed  no  fears. 

In  the  spirit  of  equanimity,  which  he  then  praised, 
he  has  borne  success  with  humility,  the  admiration 
of  his  friends  without  pride,  and  has  stood  the  test 
of  sorrow  with  unflinching  courage.  The  14  years 
among  us  have  brought  Sir  William  Osier  in  full 
measure  the  affection  of  us  all. 


DEGENERATION  AND  REGENERATION  IN  THE 
PERIPHERAL  NERVES. 

Professor  Onari  Kimura,  of  the  Pathological 
Institute  of  the  Imperial  University  at  Sendai, 
Japan,  has  published  an  elaborate  monograph  1 on 
degeneration  and  regeneration  in  the  peripheral 
nerves,  with  especial  reference  to  non-traumatic 
cases  and  experimental  beriberi,  embodying 
the  results  of  a long  series  of  investigations 
on  non-traumatic  “ neuritis.”  His  researches 
were  conducted  on  some  20  fowls  and  pigeons,  in 
which  typical  “ polyneuritis  ” was  produced  by 
feeding  on  polished  rice  for  varying  periods  and  in 
varying  combinations,  fully  detailed  in  the  mono- 
graph. By  way  of  comparison,  some  16  dogs  and 
guinea-pigs  were  subjected  to  nerve  section  with 
immediate  enclosing  of  the  central  end  in  an  animal 

1 Mitteilungen  a.  d.  pathologischen  Institut  der  Kaiserlichen 
Universitat  zu  Sendai,  Japan,  1919,  erster  Band,  erster  Heft,  pp.  1-160. 


116  Thh  Lanobt,] 


INSURANCE  FOR  MEDICAL  MEN. 


[July  19,  1919 


membrane  filled  with  fresh  blood,  or  the  cut  ends 
were  placed  in  apposition  in  various  ways — e.g.,  in 
one  case  they  were  surrounded  by  a mass  of 
brain-substance  taken  fresh  from  another  guinea- 
pig.  The  minute  histological  investigation  of  a 
human  case  of  acute  tuberculous  polyneuritis 
and  of  progressive  hypertrophic  interstitial 
neuritis  (Dejerine-Sottas)  was  also  undertaken. 
As  Professor  Kimura  intends  to  deal  with  the 
traumatic  material  in  a subsequent  communica- 
tion, his  allusions  to  it  are  brief,  but  he  points  out 
that  regeneration  in  section  cases  is  different  from 
what  obtains  in  non-traumatic  cases,  to  which  he 
devotes  almost  the  whole  of  his  paper.  The 
pathological  changes  in  the  nerves  and  muscles  of 
birds  fed  on  polished  rice  are  essentially  of  a 
regressive- degenerative  character.  In  the  muscles 
simple  atrophy  and  fatty  degeneration  are  the  chief 
changes,  but  they  are  not  of  primary  significance, 
for  often  within  one  week  of  the  resumption  of 
normal  feeding  wasted  muscles  recover  their 
ordinary  volume  and  apparently  also  their  full 
functional  power.  The  severity  of  the  anatomical 
changes  in  the  peripheral  nerves,  in  experimental 
“ rice-neuritis,”  bears  no  constant  parallel  relation- 
ship to  the  clinical  symptoms.  In  their  essentials 
they  consist  of  a pure  degeneration ; in  no  instance 
did  Professor  Kimura  find  any  sign  of  alterations  of 
an  inflammatory  nature.  Degeneration  does  not  by 
any  means  always  commence  at  the  periphery  of  the 
nerve  fibres ; on  the  contrary,  it  may  appear  anywhere 
along  the  course  of  a nerve,  sometimes  at  different 
levels  in  different  fibres  of  the  same  nerve. 
Further,  normal  and  degenerated  fibres  are  seen 
side  by  side.  The  suggestion  is  made  that  experi- 
mental “ neuritis  ” is  a general  affection  of  the 
nervous  system,  with  local  lesions  at  sites  that  are 
somehow  predisposed.  Lower  extremities  are  much 
more  usually  affected  than  upper,  with  special 
incidence  on  the  peroneal  nerves.  The  first  recog- 
nisable sign  of  degeneration  is  in  the  axon, 
frequently  noted  when  the  myelin  sheath  is  still 
intact,  nor  does  it  necessarily  progress  distally 
bv  a mere  Wallerian  process,  for  the  morbid 
agent  may  attack  spots  beyond  the  original 
lesion.  Once  the  nerve  fibre  gets  to  the  stage 
of  complete  myelin  degeneration  no  axon  can 
be  found  in  it ; in  fact,  the  latter  disappears 
before  any  complete  break-up  of  myelin.  The 
myelin  fragments  are,  according  to  all  appearance, 
absorbed  in  situ  after  being  dissolved  or  otherwise 
chemically  modified  by  some  (?  fermentative)  func- 
tion of  the  cells  of  the  sheath  of  Schwann,  or 
stream  in  this  dissolved  state  towards  lymph  and 
venous  channels ; in  the  human  cases,  however, 
there  was  evidence  of  direct  phagocytic  activity  for 
the  scavengering  of  some  at  least  of  the  degenera- 
tive products.  When  a fibre  in  a state  of  complete 
myelin  disintegration  is  seen  to  contain  within  its 
neurilemma  an  axon,  such  axon,  according  to  Pro- 
fessor Kimura,  is  invariably  a new  formation — 
i.e.,  a regenerated  axon.  To  the  problem  of  regenera- 
tion in  non-traffmatic  “neuritis''  he  devotes  an 
important  part  of  his  research.  His  view,  supported 
by  much  histological  evidence, is  that  the  wayis  paved 
for  the  new  axons  by  protoplasmic  prolongations 
of  the  cells  of  the  neurilemmal  sheath,  that 
these  link  up  to  form  more  or  less  “ solid 
protoplasmic  paths,  filling  the  otherwise  nearly 
empty  fibre.  In  or  through  this  protoplasm  the 
new  axon  makes  its  appearance,  either  by  direct 
outgrowth  from  the  proximal  end,  or — a very 
important  alternative — by  differentiation  from  this 


ribbon-like  protoplasm,  beginning  at  the  end 
nearest  to  the  old  axon-stump,  and  spreading  link 
by  link  peripheral-wards.  It  is  commonly  a simple, 
smooth,  delicate  axon,  with  neither  whorl  nor  end- 
bulb  formation  on  its  course,  thereby  differing  from 
what  is  seen  in  the  majority  of  cases  of  regenera- 
tion after  trauma.  Much  importance  in  this  matter 
is  attached  by  the  author  to  the  intactness  of  the 
neighbouring  connective  tissue  supporting  the 
nerve.  For  the  equally  interesting  question  of  the 
origin  of  the  new  myelin  formation  these  researches 
of  Professor  Kimura  unfortunately  do  not  serve; 
he  merely  indieates  the  possibility  of  part  of,  the 
protoplasmic  bridges  within  the  fibre  sheath  being 
allocated  to  that  purpose.  It  is  to  be  regretted, 
also,  that  he  modestly  considers  his  experimental 
material  too  meagre  for  any  exhaustive  con- 
tribution to  the  problem  of  the  pathogenesis 
of  beri-beri,  or  “ rice-neuritis,”  and  contents 
himself  with  a review  of  the  literature 
and  present  state  of  knowledge  on  this  vexed 
question.  He  remarks  with  justice  that  little 
enough  attention  has  been  paid  to  the  actual 
pathology  of  the  deficiency  diseases,  and  is  not 
clear  that  the  “ monophagismus  ” group  of  beri- 
beri, scurvy,  Barlow’s  disease,  and  pellagra  contains 
conditions  essentially  alike  in  their  pathogenesis. 
Whether  “ ein  schadliches  plus  ” beyond  mere 
partial  starvation  is  essential  Professor  Kimura 
does  not  allow  himself  to  say,  but  he  quotes  with 
approval  the  opinion  of  Eijkman — which  for  that 
matter  had  been  expressed  before — that  absence  of 
some  essential  element  in  food  may  allow  the 
development  of  some  nerve  poison  to  which  the 
symptoms  are  attributable.  The  monograph  is 
illustrated  with  admirable  coloured  drawings,  andf 
micro-photographs  reproduced  in  collotype,  and 
there  is  a very  long  bibliography. 


INSURANCE  FOR  MEDICAL  MEN. 

The  Managing  Committee  of  the  Medical 
Insurance  Agency  met  last  week  and  found  itself 
able  to  make  substantial  interim  allotments, 
amounting  to  £455— £125  to  the  Royal  Medical 
Benevolent  Fund,  £125  to  the  Royal  Medical 
Benevolent  Fund  Guild,  £105  to  Epsom  College  Royal 
Medical  Foundation,  and  £100  to  the  Royal  St.  Anne’s 
School.  In  this  way  the  committee  was  fulfilling 
one  of  its  prime  objects.  For  the  Agency,  when 
founded  12  years  ago  with  the  intention  of  assisting 
medical  men  to  obtain  the  best  terms  of  insurance 
of  all  kinds,  has  from  the  first  kept  in  mind  as 
one  of  the  chief  reasons  for  its  existence  the 
practical  aid  of  the  benevolent  institutions  of  the 
profession.  The  Royal  Medical  Benevolent  Fund 
is  the  most  largely  benefited  of  such  institutions 
in  the  recent  distribution,  but  its  record  deserves 
that  this  should  be  so,  while  its  offspring, 
the  Guild,  is  doing  most  admirable  work,  the 
special  feature  here  being  the  personal  interest  of 
individual  ladies  in  the  work.  It  has  seemed  to  the 
Agency  that  one  of  the  most  practical  means  it 
could  take  to  help  less  fortunate  members  of  the 
profession  was  to  contribute  to  the  education  of 
children.  This  it  has  done  by  subscriptions  to 
Epsom  College,  where  boys  are  received  on 
the  foundation,  and  to  the  Royal  St.  Anne’s 
School,  where  girls  obtain  an  excellent  educa- 
tion. This  benevolent  side  of  the  Agency’s  work 
has  commended  it  to  many  members  of  the 
profession,  though  not  to  so  many  as  might  have 
been  expected  to  resort  to  it.  Last  year  the  total 


The  Lancet,]  PENTOSURIA.— PRACTICAL  ISSUES  ON  THE  ALCOHOL  QUESTION.  [July  19,  1919  ]]7 


distributed  from  the  Agency’s  medical  benevolence 
account  was  £1002  10s.,  including  contributions  of 
£150  to  the  War  Emergency  Fund  of  the  Royal 
Medical  Benevolent  Fund,  and  £100  to  the  Belgian 
Doctors’  and  Pharmacists’  Relief  Fund.  At  the  same 
time  the  insurers  received  an  advantage  by  the 
return  out  of  the  commissions  received  by  the 
Agency  of  certain  sums  which  in  1918  totalled  £697. 
Since  the  foundation  of  the  Agency  £7200  have  been 
returned  in  this  way  to  insurers,  a sum  which 
represents  a direct  saving  to  the  profession. 
The  Agency  is  not  bound  to  any  particular 
companies  or  forms  of  policy,  and  is  able 
to  advise  medical  practitioners  contemplating 
insurance  as  to  the  best  form  of  policy  to  suit  their 
particular  conditions.  The  life  insurance  business 
conducted  through  the  Agency  is  considerable,  and 
it  is  confidently  anticipated  that  as  the  conditions 
disturbed  by  the  war  become  more  stable  this  form 
of  business  will  largely  increase.  The  insurance 
of  motor-cars  is  growing  into  an  extensive  branch 
of  energy ; in  spite  of  the  difficulties  in  the  way  of 
motorists  created  by  the  war  and  the  shortage  of 
petrol  and  of  cars  the  number  of  motor  insurances 
has  increased,  and  experience  has  proved  that  the 
Agency,  owing  to  the  amount  of  business  it  conducts 
in  this  direction,  is  able  to  assure  to  its  clients  that 
their  claims  shall  be  promptly  and  generously  met. 
In  presenting  the  financial  report  the  chairman, 
Dr.  G.  E.  Haslip,  was  able  to  speak  in  the  most 
hopeful  terms  of  the  future  of  the  Agency,  and 
mentioned  that  vacancies,  due  to  deaths  of  several 
members  of  the  committee,  had  been  filled  by  the 
election  of  Dr.  E.  Weaver  Adams,  Dr.  H.  A.  Des 
Voeux,  Lieutenant-Colonel  R.  H.  Elliot,  I.M.S.,  Dr. 
R.  A.  Gibbons,  and  Dr.  R.  Langdon-Down. 


PENTOSURIA. 

The  occurrence  of  pentoses  in  the  urine  is 
not  so  rare  an  event  as  is  commonly  supposed. 
Pentosuria  is  not  necessarily  associated  with  any 
morbid  symptoms,  and  does  not  of  itself  call  for 
any  particular  treatment ; the  importance  of  the 
condition  arises  from  the  fact  that  its  presence 
may  lead  to  a hasty  diagnosis  of  diabetes,  with  con- 
sequent dietetic  restrictions  which  are  unnecessary. 
Two  distinct  types  may  be  recognised : (1)  the 
alimentary  form,  in  which  the  sugar  is  1-arabinose 
and  the  urine  rotates,  polarised  light  to  the  right ; 
(2)  true  or  essential  pentosuria,  in  which  the  sugar 
is  usually  i-arabinose  and  the  urine  is  optically 
inactive,  unless  some  other  sugar  is  present  as  well. 
Alimentary  pentosuria  is  apt  to  cause  mistakes 
in  diagnosis,  especially  at  this  time  of  the  year 
when  fruit  is  being  eaten  more  extensively  than 
at  other  seasons.  The  tolerance  limit  for  pentoses 
is  small,  about  half  a gramme,  and  even  in  healthy 
people  a surfeit  of  cherries  will  cause  the  appear- 
ance of  the  sugar  in  the  urine.  Plums,  goose- 
berries, strawberries,  apples,  and  other  fruits  in 
sufficient  amount  may  give  rise  to  a similar  result. 
The  amount  of  sugar  excreted  is  usually  small, 
0'5  per  cent,  or  under,  and  as  arabinose  does  not 
reduce  as  readily  as  dextrose  the  reaction  is 
delayed  and  is  often  of  a peculiar  type.  When, 
for  example,  the  urine  is  added  to  Fehling’s  or 
Benedict’s  solution  and  boiled  no  change  occurs 
for  a time,  but  after  continued  boiling  the  colour 
of  the  solution  suddenly  changes  to  green,  no 
turbidity  occurring  even  when  the  heating  is  pro- 
longed. A small  percentage  of  dextrose  or  other 
reducing  substance  may  give  a similar  result. 


More  characteristic  is  the  orcin  reaction,  best 
carried  out  in  the  form  of  Bial’s  test.  4-5  c.cm. 
of  Bial’s  reagent  (0'5  gr.  orcin,  250  c.cm.  fuming 
hydrochloric  acid,  sp.  gr.  1T95,  and  12  drops  of 
liq.  ferri  perchlor.)  are  heated  to  boiling  in  a 
test-tube  and  1 c.cm.  of  the  urine  added  ; on 
standing  a green-blue  colour  develops  when  a 
pentose  is  present.  If  the  solution  is  cooled, 
extracted  with  amyl  alcohol,  and  the  extract 
examined  with  the  spectroscope,  it  shows  a band 
between  the  red  and  yellow  (C  and  D).  Glycuronic 
acid  may  give  a similar  reaction,  but  it  also  gives 
Tollen’s  naphthol-resorcinol  test.  The  most  con- 
clusive evidence  is  furnished  by  preparing  the  di- 
phenylhydrazone  with  a melting-point  of  216-218°  C. 
for  the  1-arabinose  derivative  and  204-205°  C.  for  the 
i-arabinose  compound,  and  the  parabrom-phenyl 
osazone  which  melts  at  196-200°  C.  in  the  case  of 
1-arabinose  and  200-202°  C.  for  the  inactive  form. 
As  pentoses  are  not  fermented  by  yeast  the  reducing 
power  of  the  urine  in  cases  of  pure  pentosuria  is 
not  impaired  by  mixing  it  with  yeast  and  standing 
in  a warm  place  for  24  hours. 


PRACTICAL  ISSUES  ON  THE  ALCOHOL 
QUESTION. 

We  welcome  the  scientific  investigation  of  alcohol 
with  reference  to  practical  issues.  No  one  drinks 
a dilution  of  pure  alcohol  and  water,  and  yet 
hitherto,  whilst  interesting  evidence  has  been 
accumulated,  physiological  experiments  have,  in 
the  main,  been  based  not  on  the  actual  beverages 
consumed  by  the  public,  but  literally  on  C2H6OH 
+ H>0.  That  formula  does  not  by  any  means 
present  the  story  of  such  beverages  as  claret, 
sherry,  port,  beer,  champagne,  and  so  forth,  none  of 
which  is  a mere  dilution  of  pure  alcohol,  and  it  is 
well  known  that  these  various  alcoholic  bever- 
ages differ  in  their  effects.  The  effervescent 
wine  champagne,  for  example,  has  a different 
effect  from  claret,  though  both  contain  the  same 
amount  of  alcohol.  There  are  important  varying 
factors  in  the  numerous  alcoholic  beverages  con- 
sumed by  the  public  which  must  count  in  regard 
to  their  effects.  A mixture  of  whisky  and  water, 
for  example,  is  below  the  specific  gravity  of  water, 
whilst  wines  and  beers  are  above  this  point  on 
account  of  the  solid  matters  in  solution.  Osmotic 
pressure  must  therefore  vary,  and  with  it  the  rate 
of  diffusibility  of  the  alcohol. 

In  an  important  investigation  undertaken  for 
the  Medical  Research  Committee  by  Dr.  Edward 
Mellanby,1  bearing  on  the  absorption  into,  and  dis- 
appearance from,  the  blood  of  alcohol  under  different 
conditions,  these  points  find  interesting  illustration. 
It  is  shown  that  differences  in  intensity  of  intoxi- 
cating symptoms  obtained  by  taking  the  same 
amount  of  alcohol  in  one  or  several  drinks  depend 
on  the  type  of  beverage  drunk  and  the  interval 
between  the  drinks.  Foodstuffs  inhibit  intoxica- 
tion in  consequence  of  their  action  in  delaying  the 
absorption  of  alcohol  from  the  alimentary  canal.  The 
most  effective  inhibitor  is  milk,  the  action  of  which 
appears  to  be  dependent  to  some  extent  on  its  fat 
content.  Its  specific  influence  in  delaying  absorp- 
tion more  than  counterbalances  its  general  effect 
as  a fluid,  and  Dr.  Mellanby  comments  upon  the 
striking  differences  observed  in  the  effects  of  a dose 
of  alcohol  when  given  two  hours  after  the  consump- 

1 Special  Report  Series,  No.  31.  National  Health  Insurance,  Medical 
Research  Committee  : Alcohol : Its  Absorption  into,  and  Disappear- 
ance from,  the  Blood  under  Different  Conditions.  London:  Published 
by  His  Majesty's  Stationery  Office. 


118  The  Lancet,  | THE  CONSULTATIVE  COUNCILS  OF  THE  MINISTRY  OF  HEALTH. 


[July  19,  1919 


tion  of  half  a litre  of  water  and  after  half  a litre  of 
milk  respectively.  In  the  first  case  a dog  may 
become  incapable  of  standing  or  walking,  in  the 
latter  case  it  may  show  no  sign  whatever  of 
unsteadiness.  Whisky  is  found  to  be  more  intoxi- 
cating than  stout,  partly  because  of  its  greater 
concentration  of  alcohol,  and  partly  because  stout 
contains  something  which  inhibits  the  absorption 
of  alcohol  to  some  extent.  These  results  are 
interesting  in  discussing  the  factors  influencing 
intoxication.  It  is  found  that  intoxication  is 
related  to  the  amount  of  alcohol  in  the  blood  and 
probably  to  the  rate  of  accumulation  in  the  blood. 
Dilute  solutions  of  alcohol  are  less  intoxicating 
than  strong  solutions  containing  the  same  amount 
of  alcohol,  the  difference  becoming  more  marked 
the  greater  the  quantity  of  alcohol  consumed  and 
the  greater  the  dilution.  These  results  have  an 
important  bearing  on  the  question  of  what  consti- 
tutes an  intoxicating  liquor,  a question  which  is 
being  fought  out  in  the  U.S.  courts  in  connexion  with 
the  legality  of  the  sale  of  2 75  per  cent,  (alcohol)  beer 
under  prohibition.  Dr.  Mellanby’s  investigation 
was  confined  to  the  use  of  dogs  as  subjects,  but  the 
various  factors  shown  to  affect  the  results  in  a dog 
are  likely  to  have  a corresponding  influence  in  man, 
and  similar  experiments  so  far  being  carried  out  on 
human  beings  indicate  that  the  results  are  strictly 
comparable.  There  is  one  difference,  however, 
noted.  The  hind  legs  of  a dog  are  the  first  to  show 
weakness,  and  it  is  this  which  makes  it  more  diffi- 
cult for  a dog  t6  stand  still  than  to  walk  when 
intoxicated.  In  other  words,  in  walking  the  weak- 
ness of  the  hind  legs  is  compensated  for  by  the 
front  legs  and  the  muscles  of  the  other  parts,  and 
collapse  prevented.  In  man  the  whole  support  of 
the  body  depends  upon  the  legs,  and  the  base  of  the 
standing  man  is  relatively  much  smaller  than  that 
of  the  dog.  Consequently,  balance  is  a more  diffi- 
cult matter  in  an  intoxicated  man,  and  therefore 
unsteadiness  is  a more  predominant  feature  in  the 
complete  picture. 

The  report  is  one  of  the  best  contributions  on  the 
practical  side  of  the  question  that  has  been  issued, 
and  the  evidence  that  the  effect  of  alcohol  is 
cumulative  because  its  disappearance  from  the 
blood  is  remarkably  slow  is  not  the  least  import- 
ant observation  made — apparently  it  makes  no 
difference  whether  a given  amount  of  spirit  is  taken 
in  one  dose  or  in  divided  doses  at  intervals  which 
may  extend  to  two  hours. 


THE  CONSULTATIVE  COUNCILS  OF  THE  MINISTRY 
OF  HEALTH. 

The  draft  orders  establishing  Consultative 
Councils  under  the  Ministry  of  Health  for  England 
and  Wales  are  now  being  issued.  There  are  five 
of  these  Councils,  four  for  England  and  one  for 
Wales.  The  English  Councils  are  to  give  expert 
advice  in  connexion  with : (1)  Medical  and  allied 
services ; (2)  local  health  administration ; (3) 

National  Insurance  ; and  (4)  general  health  ques- 
tions. Each  English  Council  will  be  composed  of 
20  members,  and  the  Minister  and  Parliamentary 
Secretary  to  the  Ministry  will  be  respectively 
President  and  Vice-President.  The  Welsh  Council, 
with  the  same  ex-officio  officers,  will  consist  of 
30  members  chosen  to  give  advice  under  all  four 
of  the  English  sub-headings.  The  period  of  office 
is  for  three  years,  and  during  the  first  three  years 
one-third  of  the  Council  will  retire  by  lot,  but  can 
be  reappointed  for  one  further  term  of  three  years. 
The  personnel  will  consist  of  women  as  well  as  men. 


ENCEPHALITIS  LETHARGICA. 


During  the  past  year  reports  have  been  received 
which  show  that  cases  with  the  symptomatology 
of  encephalitis  lethargica  have  occurred  in  many 
countries.  There  appears  to  be  practical  unanimity 
that  the  disease  is  to  be  regarded  as  distinct 
from  the  encephalitic  form  of  poliomyelitis.  Many 
observers  are  of  the  opinion  that  it  is  a disease 
allied  to  poliomyelitis ; while  others,  mainly  those 
who  have  made  a special  study  of  the  history  of 
the  disease,  incline  to  the  view  that  encephalitis 
lethargica  is  associated  in  some  intimate  causal 
manner  with  influenza.0  The  latter  point  out  that 
previous  recorded  epidemics  of  lethargy  have 
been  associated  in  point  of  time  with  epidemics 
of  influenza,  and  they  suggest  that  an  attack 
of  influenza  either  predisposes  the  patient  to 
the  lethargy  or  in  some  unexplained  way 
activates  the  virus  of  lethargic  encephalitis. 
The  symptomatology  of  the  recorded  cases  is  the 
fairly  constant  one  which  is  already  familiar  to 
readers  of  The  Lancet.  The  various  epidemics 
differ,  however,  in  the  severity  of  the  individual 
attacks,  and  particularly  in  the  mortality  which,  in 
the  case  of  the  Australian  epidemic,  was  as  high  as 
70  per  cent.  The  pathological  reports  on  the  fatal 
cases  show  constant  involvement  of  the  basal 
ganglia  and  the  pons  by  an  encephalitic  process, 
characterised  by  well-marked  perivascular  lympho- 
cytic infiltration  with  occasional  venous  thrombosis 
and  necrosis  of  the  brain  substance.  The  severe 
cases  show  generalisation  of  this  process  in  the 
central  nervous  system.4  Inoculation  experiments 
were  particularly  striking  in  the  case  of  the 
Australian  epidemic.  The  virus  produced  typical 
lesions,  not  only  when  inoculated  into  monkeys, 
but  also  on  injection  into  sheep  and  into 
a horse  and  a calf.  Herein  it  differed  markedly 
from  the  virus  of  poliomyelitis,  to  which  the 
monkey  alone  has  been  proved  to  be  susceptible.5 
In  another  group  of  cases,  on  the  other  hand, 
experimental  inoculation  produced  clinical  and 
pathological  evidence  that  the  disease  was  acute 
poliomyelitis  with  an  unusual  distribution  of  the 
lesions.2  On  the  whole,  it  would  appear  that  while 
the  symptomatology  of  encephalitis  lethargica  may 
occur  as  a result  of  the  lesions  of  epidemic  polio- 
myelitis, yet  there  exists  a disease  sui  generis 
which  produces  such  symptoms  as  a constant 
feature,  owing  to  the  regularity  with  which  it 
involves  the  basal  ganglia.  Further  light  on  the 
symptomatology  of  the  disease  was  thrown  by  Dr. 
E.  Farquhar  Buzzard  in  his  paper  read  before  the 
Neurological  Section  of  the  Royal  Society  of 
Medicine  on  July  10th.  Ip  a considerable  number 
of  cases  which  he  put  on  record  the  initial  stage, 
presenting  cranial  nerve  palsies  associated  with 
lethargy,  was  followed  by  the  appearance  of  various 
involuntary  movements  of  the  face,  tongue,  and 
limbs.  The  character  of  these  movements  was 
athetoid,  with  some  features  strongly  reminiscent 
of  chorea,  but  a general  characteristic  of  all  was 
the  absence  of  interference  with  the  due  per- 
formance of  voluntary  movements.  In  this  they 
resembled  the  involuntary  movements  seen  in 
paralysis  agitans,  and,  indeed,  in  one  of  the  cases 
described  by  Dr.  Buzzard  the  aspect  of.  the  patient 
suggested  this  diagnosis.  As  is  well  known,  the 
lesion  of  Parkinson’s  disease  is  localised  in  the 
basal  ganglia,  and  cases  of  disseminated  sclerosis  in 
which  the  patches  occur  in  the  same  region  exhibit 
sleepiness  and  drowsiness  to  a marked  degree.  It 
appears,  therefore,  that  lethargy  may  take  its  place 


The  Lancet,] 


TREATMENT  OF  ANTHRAX  BY  LOCAL  INJECTION  OF  SERUM.  [July  19,  1919  119 


among  the  true  localising  signs  of  cerebral  lesions. 
Such  being  the  case,  it  is  to  be  expected  that  any 
disease  producing  a lesion  in  this  region  may  cause 
lethargy.  As  Sir  Thomas  Barlow  pointed  out  in 
the  course  of  the  discussion,  one  of  Dr.  Buzzard’s 
cases  might  well  have  been  a case  of  measles  with 
encephalitis  as  a complication.  So  far  during  this 
year  true  encephalitis  lethargica  has  appeared  only 
sporadically,  and  under  such  circumstances  the 
separation  of  a disease  with  such  a complex 
symptomatology  presents  great  difficulty.  Dr. 
Buzzard  indicated  the  importance  of  the  further 
development  of  our  knowledge  of  filter-passing 
organisms  in  connexion  with  diseases  in  this 
category. 

References. 

1.  Bassoe,  Peter : Epidemic  Encephalitis  (Noma),  Jour.  Araer.  Med. 
Assoc.,  April  5th,  1919. 

2.  Breinl,  A. : Clinical,  Pathological,  and  Experimental  Observations 
on  the  “ Mysterious  Disease.”  A Clinically  Aberrant  Form  of  Acute 
Poliomyelitis,  Med.  Journ.  of  Australia,  March  16th  and  23rd,  1918. 

3.  Burger  and  Pocquet:  L'Encephalite  Lethargique,  Archives 

Medicales  Beiges. 

4.  Buzzard,  E.  Farauhar : Lethargic  Encephalitis,  Med.  Soc.  Lond., 
Dec.  9th,  1918. 

5.  Cleland  and  Campbell : Acute  Encephalo  myelitis,  Brit.  Med. 
Jour.,  May  31st,  1919. 

6.  Crookshank : A Note  on  the  History  of  Epidemic  Encephalo- 
myelitis, Proc.  R.S.M.,  1919,  xii.,  Sec.  Hist.  Med. 

7-  Ely  i Lethargic  Encephalitis,  Jour.  Amer.  Med.  Assoc.,  April  5tb, 

8.  Shultheiss,  H.  -.  Einige  Beobachtungen  iiber  den  Verlauf  der 
epidemischen  Grippe  bei  Kindern,  insbesondere  iiber  einen  Fall  von 
Landrysoher  Paralyse,  Schweitz.  Corr.  Bl„  Nov.  2nd,  1918. 


TREATMENT  OF  ANTHRAX  BY  LOCAL  INJECTION 
OF  SERUM. 

In  the  American  Journal  of  the  Medical  Sciences 

for  June  Dr.  Joseph  C.  Regan  and  Dr.  Catherine 
Regan  have  reported  a case  of  anthrax  which,  in 
addition  to  other  features  of  interest,  seems  to 
indicate  the  value  of  a new  method  of  treatment — 
the  local  injection  of  anti-anthrax  serum.  A man, 
aged  26  years,  was  admitted  to  hospital  on  Nov.  21st, 
1918,  as  a case  of  parotitis.  On  the  18th,  while 
shaving,  he  cut  himself  on  the  right  side  of  the  neck. 
He  lathered  soap  over  the  wound  with  a new  shaving 
brush  which  he  had  washed  and  placed  in  boiling 
water.  Next  day  about  noon  he  complained  of 
headache,  backache,  and  pains  all  over  the  body. 
Towards  evening  the  neck  became  stiff,  especially 
on  the  right  side,  so  that  it  hurt  him  to  turn  his 
head.  This  he  attributed  to  a small  pustule  which 
had  developed  at  the  wounded  spot.  During  the 
night  he  had  a chill  and  felt  feverish.  On  the 
20th  swelling  of  the  neck  was  more  marked  and 
was  tender.  On  the  23rd  he  came  under  observa- 
tion. His  voice  was  hoarse.  The  throat  was  con- 
gested. Over  the  right  interscapular  region  a few 
moist  rales  were  heard  on  inspiration.  On  the 
right  side  of  the  neck,  1£  in.  below  the  angle  of  the 
jaw,  was  a considerable  swelling  with  a pustule 
about  25  mm.  in  diameter  in  the  centre,  like  a 
vaccination  lesion  on  the  ninth  day.  In  the  centre 
of  the  pustule  was  a black  depressed  eschar, 
surrounded  by  an  elevated  white  border.  At 
the  outer  margin  of  the  eschar  were  a number 
of  small  elevations  resembling  vesicles,  which 
discharged  continuously  serous  fluid.  The  sur- 
rounding tissues  were  very  oedematous.  Smears 
and  cultures  were  taken  from  the  ulcerative 
surface,  exposed  by  lifting  the  margin  of  the 
eschar,  and  showed  anthrax  bacilli.  This  was 
verified  by  inoculation  of  a mouse.  A culture  from 
the  patient’s  blood  was  sterile.  On  the  24th,  at 
10  a.m.,48  c.cm.  of  anti-anthrax  serum  were  injected 
into  the  muscles  of  the  right  buttock,  and  in  the 
evening  10  c.cm.  into  the  indurated  tissues  around 


the  pustule.  From  99°  F.  at  8 a.ji.  the  temperature 
rose  to  101°  at  8 P.M.,  and  returned  to  99°  on  the 
following  morning.  This  was  regarded  as  a serum 
reaction.  On  the  25th  the  oedema  had  slightly 
extended,  and  the  lesion  seemed  more  definitely 
elevated.  30  c.cm.  of  serum  were  injected  into  the 
right  buttock,  and  10  c.cm.  into  the  region  around 
the  pustule.  On  the  26th  the  inflammation  and 
swelling  rapidly  subsided.  On  the  27th  the  pustule 
had  shrunk  considerably  and  lost  its  red  areola. 
The  most  marked  swelling  was  localised  in  a mass 
of  glands  below  the  angle  of  the  jaw.  Twelve  c.cm. 
of  serum  were  injected  in  their  neighbourhood.  On 
the  29th  another  intramuscular  injection  of  30  c.cm. 
was  given  and  the  glandular  swelling  subsided 
rapidly.  Recovery  ensued.  The  anthrax  bacillus 
was  cultivated  from  the  shaving  brush.  Only  serum 
treatment  was  used.  Its  success  rendered  excision 
of  the  lesion  unnecessary.  The  local  injection  of 
serum  does  not  appear  to  have  been  previously 
tried.  The  mildness  of  the  attack,  despite  the 
situation  of  the  pustule  in  the  neck,  is  noteworthy. 


MEDICAL  BOARDS  OF  THE  MINISTRY  OF 
PENSIONS. 

Medical  practitioners  wishing  to  serve  on  the 
Boards  of  the  Ministry  of  Pensions,  and  especially 
those  who  have  had  practice  and  experience  in  the 
diagnosis  and  treatment  of  war  diseases  such  as 
trench  fever,  dysentery,  malaria,  &c.,  are  requested 
to  communicate  with  the  Commissioner  of  Medical 
Services  of  the  Region  in  which  they  reside.  The 
names  and  addresses  of  the  Commissioners  and  the 
boundaries  of  their  Regions  are  given  below  : — 

London  and  South-Eastern  Region:  Dr.  H.  J.  Neilson: 
Hotel  Windsor,  Victoria-street,  S.W.  1.  County  Boundaries  : 
The  City  of  London  and  Metropolitan  Police  Districts,  and 
the  counties  of  Kent,  Surrey,  and  Sussex. 

Eastern  Region : Dr.  T.  Basil  Rhodes,  80,  Westbourne- 
terrace,  Paddington,  W.  2.  County  Boundaries:  Norfolk, 
Suffolk,  Cambridgeshire,  Oxfordshire,  Huntingdonshire, 
Bedfordshire,  Berkshire,  Buckinghamshire,  Northampton- 
shire, Leicestershire,  Rutlandshire,  Hertfordshire,  and  Essex 
(except  the  portion  of  the  two  latter  included  in  London  and 
South-Eastern  Region). 

South-Western  Region  : Dr.  J.  Young,  5a,  Union-street, 
Bristol.  County  Boundaries:  Gloucestershire,  Wiltshire, 
Dorset,  Somerset,  Devonshire,  Cornwall,  Hampshire,  Isle  of 
Wight. 

West  Midland  Region  : Dr.  E.  R.  Hill,  Queen’s  College, 
Paradise-street,  Birmingham.  County  Boundaries  : Stafford- 
shire, Shropshire,  Herefordshire,  Worcestershire,  and 
Warwickshire. 

East  Central  Region : Dr.  Gibbs  Lloyd,  Acting  Commis- 
sioner, Basinghall  Buildings,  Basinghall-street,  Leeds. 
County  Boundaries:  Yorkshire  (except  the  Cleveland 

district  on  the  north,  which  is  included  in  Northern  Region, 
Middlesbrough  Area),  Derbyshire  (except  district  included 
in  Chester  (new) ),  Nottinghamshire,  and  Lincolnshire. 

North-Western  Region:  Dr.  A.  H.  Williams,  1,  North- 
parade,  Deansgate,  Manchester.  County  Boundaries : 
Lancashire,  Cheshire,  Isle  of  Man, and  portion  of  Derbyshire 
embracing  Glossop  and  New  Mills. 

Northern  Region  ; Dr.  W.  Lloyd  Reade,  47,  Pilgrim-street, 
Newcastle-on-Tyne.  County  Boundaries  : Northumberland, 
the  town  of  Berwick,  Durham,  the  Cleveland  district  of 
Yorkshire,  Cumberland, and  Westmorland. 

Welsh  Region:  Dr.  Bickerton  Edwards,  30,  Park-place, 
Cardiff.  County  Boundaries:  The  whole  of  Wales  and 
Monmouthshire. 

Scottish  Region:  Dr.  G.  H.  Gibson,  59,  Cockburn-street, 
Edinburgh.  The  whole  of  Scotland. 

Irish  Region  : Dr.  D.  A.  Carruthers,  41,  Upper  Fitzwilliam- 
street,  Dublin.  The  whole  of  Ireland. 

It  is  understood  that  the  remuneration  will  be 
1 guinea  per  session  of  2£  hours  for  ordinary 
members  of  the  Board  and  2 guineas  per  session 
for  specialist  members  of  the  Board. 


120  The  Lancet,] 


A NATIONAL  COLLECTION  OF  WAR  SPECIMENS. 


[July  19,  1919 


A NATIONAL  COLLECTION  OF  WAR 
SPECIMENS. 

As  our  readers  are  already  aware,  the  Council  of 
the  Royal  College  of  Surgeons  of  England,  at  the 
request  of  the  Army  Council,  placed  its  Museum, 
workrooms,  and  staff  at  the  disposal  of  the  Royal 
Army  Medical  Corps  at  an  early  phase  of  the  war 
for  the  purpose  of  building  up  a national  collection 
to  represent  the  injuries  and  diseases  suffered  by 
soldiers  under  modern  conditions  of  warfare.  From 
the  conservator’s  annual  report,  dealing  with  the 
welfare  of  the  Museum  during  the  past  12  months, 
we  learn  that  altogether  4000  specimens  have  been 
received,  chiefly  from  hospitals  in  France,  although 
a representative  series  was  also  obtained  from 
base  hospitals  in  the  Eastern  Mediterranean. 
Over  1200  of  these  specimens  have  already  been 
examined,  mounted,  described,  and  placed  on 
exhibition  in  the  Museum.  At  the  conclusion 
of  fighting  plans  had  to  be  considered  regarding 
the  future  of  the  War  Office  or  national  collec- 
tion : (1)  as  regards  its  housing  and  upkeep  ; (2)  as 
regards  its  completion.  The  future  home  of  the 
collection  remains  unsettled,  the  War  Office  having 
no  building  at  its  disposal  sufficient  to  accommo- 
date a collection  which  requires  the  floor- space  of 
three  of  the  larger  rooms  of  the  Museum  for  its 
display.  As  these  rooms  are  now  needed  for  their 
pre-war  purposes,  the  Council  of  the  College  has 
consented  to  devote  the  floor-space  and  galleries 
of  one  room  for  the  display  of  the  national  collec- 
tion until  the  War  Office  has  determined  on  its 
future  home  and  upkeep.  Whatever  plan  may  be 
adopted  it  is  to  be  hoped  that  the  collection  will  be 
placed  where  it  may  be  available  for  study  by  civilian 
surgeons  as  well  as  by  officers  of  the  Royal  Army 
Medical  Corps — that  it  may,  indeed,  form  a bond 
between  the  civil  and  military  branches  of  the 
profession.  The  main  burden  of  preparing  the  collec- 
tion— certainly  the  most  extensive  and  instructive 
of  its  kind  ever  assembled — has  fallen  on  Professor 
S.  G.  Shattock  and  Mr.  Cecil  Beadles,  and 
arrangements  are  now  being  made,  so  we  are  given 
to  understand,  between  the  Director-General  of 
Army  Medical  Services  and  the  Council  of  the 
College  to  secure  the  services  of  these  two 
gentlemen  in  completing  the  collection — a task 
which  will  entail  at  least  two  more  years 
of  labour.  Not  only  has  the  Museum  of  the 
College  served  the  needs  of  our  own  Medical 
Service,  but  also  those  of  Canada,  Australia,  and 
New  Zealand.  Of  the  4000  specimens  forwarded 
to  the  Museum  about  1600  of  them  were  collected 
by  the  Colonial  Medical  Services,  and  these  have 
recently  been  removed  from  the  Museum  to  form 
teaching  collections  in  Canada.  Australia,  and  New 
Zealand.  Thus,  in  spite  of  a much  depleted  staff, 
the  Museum  of  the  College  was  able  to  render  a con- 
siderable service  by  securing  definite  and  per- 
manent records  of  our  medical  and  surgical  experi- 
ence of  modern  warfare.  Further,  we  learn  from 
the  conservator’s  report  that  the  Museum  is  being 
gradually  restored  to  its  pre-war  state,  but  that  it 
will  not  be  fully  open  for  study  until  October  next. 
The  indiscriminate  bombing  carried  on  by  the  enemy 
made  it  necessary  to  remove  all  the  spirit  specimens 
— some  12,000  in  number — to  the  cellars  in  the  base- 
ment of  the  College,  and  their  return  is  possible  only 
when  the  War  Office  specimens  have  been  arranged 
in  the  room  now  set  aside  for  their  display.  The 
opportunity  has  also  been  taken  of  effecting  some 
very  desirable  alterations  in  the  arrangement  of 


the  contents  of  the  Museum.  In  spite  of  the  war 
we  are  glad  to  note  that  many  valuable  donations 
have  been  made  to  the  collection,  and  that  researches 
of  value  have  been  carried  out.  Mr.  Alban  Doran 
continues  to  compile  a catalogue  of  the  surgical 
instruments,  which  will  form  a standard  history  of 
surgical  invention — one  which,  we  hope,  the  Council 
of  the  College  may  see  its  way  to  publish  some 
future  day.  

MEDICAL  AID  FOR  CROFTERS  AND 
COTTARS. 

In  one  important  section  of  Great  Britain  a 
form  of  State  medical  service  has  been  a going  | 
concern  for  a number  of  years,  and  deserves 
the  close  attention  of  all  those  interested  in  the 
reconciling  of  private  and  State-subsidised  practice.  | 
The  medical  service  now  obtaining  in  the  Highlands  ' 
and  Islands  of  North  Britain  is  described  by  the  j 
Statutory  Board,  which  has  charge  of  it,  as  a \ 
spontaneous  growth  combining  in  certain  districts 
the  efficiency  of  a private  or  competitive  service 
with  the  stability  of  an  official  service  provided  by  j 
the  State.  The  Board  constituted  under  the  < 
Highlands  and  Islands  Grant  Act  of  1913  for  the 
period  of  four  years  has  been  continued  on  account 
of  war  conditions,  and  has  just  presented  its  fifth 
report.  Of  the  schemes  prepared  and  approved  in 
1914  by  the  Secretary  for  Scotland  only  those 
involving  grants  to  medical  practitioners  and  to  J 
district  nursing  associations  have  come  into  effect. 
The  scarcity  both  of  doctors  and  nurses  was  | 
naturally  enhanced  during  the  year  1918  covered  by 
the  present  report.  The  serious  situation  created 
by  the  influenza  pandemic  was  only  met  by 
the  high  sense  of  individual  duty  prevailing 
in  the  service.  The  medical  service,  which 
has  now  stood  the  test  of  three  years’  experience, 
covers  143  practices,  nine  of  which  in  normal  times 
require  the  cooperation  of  two  doctors.  In  spite  of  I 
depleted  staff  the  year  1918  saw  an  increase  of 
7 per  cent,  in  the  travelling  and  of  21  per  cent,  in 
the  number  of  visits  over  the  preceding  year.  I 
We  note,  however,  that  the  increase  is  confined  to 
patients  coming  within  the  Board’s  scheme,  and 
is  balanced  by  an  almost  corresponding  decrease  in  ' 
respect  of  private  practice.  In  point  of  fact,  at  the 
present.time  about  four-fifths  of  the  entire  medical 
service  rendered  to  the  crofters  and  cottars  is  subsi- 
dised or  maintained  from  public  sources.  In  some 
of  the  poorer  districts  the  amount  of  private  practice 
is  now  almost  negligible.  Travelling  grants  enable 
practitioners  to  visit  distant  patients  at  low 
uniform  fees  ; these  grants  in  1918  amounted,  in 
the  case  of  poorer  practices,  to  a sum  producing  a 
net  income  of  about  £360  a year,  and  in  the 
aggregate  to  some  £32,000.  The  nursing  service 
was  recently  referred  to  by  Mr.  Munro,  Secretary 
for  Scotland,  in  reply  to  a question  in  the  House 
of  Commons.  A scheme  at  present  before  the 
Treasury  would  have  the  effect  of  increasing  the 
nurses'  remuneration  by  approximately  30  per  cent, 
on  the  pre-war  figure.  The  number  of  nursing 
associations  on  the  grant  list  is  stated  in  the 
report  to  be  38  and  the  total  number  of  nurses 
employed  98,  of  whom  49  are  fully  trained.  The 
cost  of  this  service  for  the  year  in  question 
amounted  to  £4000.  Partly  trained  nurses  have 
been  perforce  accepted  during  the  war  years,  but 
some  of  these  have  already  been  replaced  by  others 
with  higher  qualifications,  and  on  the  new  county 
(as  opposed  to  the  parish)  basis  specialised  schemes 


The  Lancet,] 


BRITISH  FEDERATION  OF  MEDICAL  ANI)  ALLIED  SOCIETIES.  [July  19,  1919  121 


of  public  welfare  are  contemplated,  in  addition  to 
the  general  nursing  work  of  the  area.  £130-£135 
for  a fully  trained  nurse  and  £100-£110  for  a mid- 
wife or  nurse  with  intermediate  qualifications  are 
the  rates  of  remuneration  suggested  by  the  Board 
as  meeting  present  requirements.  Although  the 
remaining  schemes  under  the  Board’s  mandate 
have  been  practically  in  abeyance  during  the  war, 
a study  of  the  report  will  not  fail  to  bring  home  to 
the  careful  student  the  lesson  of  what  can  be 
attained  by  a judicious  blending  of  public  and 
private  effort. 

THE  CARRIER  AND  THE  ATYPICAL  CASE. 

Much  is  to  be  gained  from  an  extended  study  of 
those  diseases  which  tend  to  appear  and  to  spread 
in  closely  aggregated  communities.  Among  such 
diseases  cerebro  spinal  fever  occupies  a prominent 
place.  In  the  present  issue  of  The  Lancet  we 
publish  an  article  by  Lieutenant-Colonel  J.  Dorgan, 
R.A.M.C.,  which  raises  many  points  of  importance, 
especially  with  regard  to  the  administrative 
methods  to  be  adopted  when  dealing  with  an 
outbreak  among  a population  living  under  army 
or  institutional  conditions.  His  contention  is  that 
the  atypical  and  unrecognised  case  is  the  factor  of 
primary  importance  in  the  spread  of  the  disease, 
while  the  healthy  carrier  is  relatively  innocuous. 
He  supports  his  view  with  circumstantial  and 
statistical  evidence,  laying  stress  upon  the 
acknowledged  fact  that  the  healthy  carrier  is 
seldom  known  either  to  develop  the  disease  him- 
self or  to  transmit  it  to  others.  Proof  of  trans- 
mission is,  in  the  nature  of  things,  very  difficult  to 
establish,  since  the  carrier  is  usually  discovered 
after  the  case  of  infection.  But  the  occurrence  in 
an  epidemic  of  atypical  infections  due  to  the 
meningococcus,  as  adduced  by  Dr.  Dorgan,  is 
closely  paralleled  by  the  well-attested  occur- 
rence of  atypical  ca'ses  in  the  course  of  any 
considerable  outbreak  of  diphtheria,  or,  indeed, 
by  our  knowledge  of  almost  all  epidemic 
diseases.  It  would  be  of  interest  to  know  how  the 
meningococcus  carrier-rate  among  patients  suffering 
from  such  atypical  attacks  compares  with  that  in 
healthy  contacts  and  non-contacts  living  in  the 
epidemic  area  in  view  of  the  wide  differences  which 
have  been  demonstrated  under  similar  circum- 
stances in  other  diseases.  While  Dr.  Dorgan  regards 
the  susceptibility  of  the  individual  rather  than 
the  virulence  of  the  organism  as  the  determining 
factor  in  the  occurrence  or  non- occurrence  of 
meningitis  in  a person  exposed  to  infection,  his 
article  may  be  read  in  conjunction  with  the  con- 
cluding instalment  of  the  Goulstonian  lectures  on 
the  Spread  of  Bacterial  Infection,  which  appears 
in  our  present  issue.  The  primary  importance 
of  persons  suffering  from  atypical  infections  in 
the  spread  of  cerebro- spinal  fever  would  agree 
well  with  Dr.  W.  W.  C.  Topley’s  suggestion  as 
to  the  possible  mode  of  origin  of  an  outbreak 
of  disease.  In  his  view  a variation  in  the 
biological  properties  of  the  parasite  would  be  the 
essential  factor,  and  the  high  potential  infectivity 
of  the  atypical  case  as  compared  with  the  healthy 
carrier  would  find  its  explanation  in  the  fact  that 
the  former  was  harbouring  the  more  infective 
organisms.  Either  view  would  depreciate  the 
general  application  of  measures  of  isolation  in 
dealing  with  healthy  carriers,  while  emphasising 
the  crucial  importance  of  improving  environmental 
conditions,  more  especially  by  the  elimination  of 
overcrowding  and  the  provision  of  free  ventilation. 


BRITISH  FEDERATION  OF  MEDICAL  AND 
ALLIED  SOCIETIES 

(IATE  MEDICAL  PARLIAMENTARY  COMMITTEE). 


At  the  Conference  between  the  Medical  Parliamentary 
Committee  and  the  representatives  of  other  organisations 
held  on  May  2nd  1 it  was  decided  that  the  giving  of  effect  to 
seven  resolutions  then  passed  should  be  left  to  the  existing 
provisional  committee.  On  Friday  last,  July  11th,  at  a 
meeting  held  in  the  College  of  Ambulance,  this  provisional 
committee  submitted  its  report. 

Dr.  Arthur  Latham,  honorary  secretary  of  the  Medical 
Parliamentary  Committee,  was  unanimously  elected  to  the 
chair,  when  he  explained  the  absence  of  Sir  Watson  Cheyne, 
who  had  hitherto  occupied  the  position  of  chairman.  Owing 
to  ill-health  and  the  pressure  of  his  Parliamentary  duties 
Sir  Watson  Cheyne  found  himself  unable  to  give  the  neces- 
sary time  to  the  affairs  of  the  organisation,  and  he  had 
written  regretting  the  necessity  for  his  retirement  from  the 
office  of  chairman,  which  was  entirely  due  to  physical 
disabilities  and  not  to  any  differences  of  opinion. 
He  found  it  inadvisable  to  accept  any  outside  work, 
especially  in  the  present  conditions  of  travelling, 
and  he  was  able  to  do  his  Parliamentary  work  by 
attending  to  that  and  that  alone.  He  was  pleased, 
he  added,  to  leave  his  name  on  the  committee.  In 
view  of  Sir  Watson  Cheyne’s  resignation,  said  Dr.  Latham, 
the  provisional  committee  had  invited  Sir  Malcolm  Morris  to 
be  chairman,  and  he  had  accepted  the  position,  but  was 
unable  to  preside  at  the  present  meeting  owing  to  an 
important  engagement  previously  entered  into.  Dr.  Latham 
read  a letter  from  Sir  Watson  Cheyne  expressing  his  pleasure 
that  Sir  Malcolm  Morris  should  take  his  place,  and  in  this 
letter  he  indicated  as  pressing  matters  in  which  the  activities 
of  the  organisation  would  be  most  useful — the  Bill  just 
introduced  to  raise  the  insurance  limit  to  £250,  and  the 
Medical  Service  Bill  which  Dr.  Addison  would  bring  in  next 
winter. 

The  Future  Policy  before  the  Meeting. 

Dr.  Latham  then  explained  the  policy  of  the  Medical 
Parliamentary  Committee,  which  was  intended  to  be  con- 
structive by  collecting  the  opinions  of  all  branches  of  the 
medical  profession  on  matters  of  public  health.  This  idea 
was  submitted  to  the  Conference  on  May  2nd,  when  certain 
resolutions  were  passed,  and  a provisional  committee 
was  empowered  to  put  these  resolutions  into  shape,  and 
form  a new  federated  body.  So  far  no  less  than  47 
societies  had  accepted  representation  on  this  committee, 
and  it  was  hoped  that  the  number  would  be  increased 
when  the  ideas  of  the  committee  were  better  under- 
stood. However,  he  thought  that  to  persuade  the 
representatives  of  47  societies  associated  with  and  allied  to 
the  medical  profession  to  sit  round  one  table  was  something 
of  an  achievement.  The  business  of  the  present  meeting 
would  be  the  appointment  of  an  executive  in  order  that 
work  might  be  started  at  once,  while  some  additional  members 
would  have  to  be  coopted  and  the  question  of  the  title  of  the 
organisation  discussed.  The  name  Medical  Parliamentary 
Committee  had  unfortunately  given  rise  to  the  idea  that 
the  body  was  going  to  do  something  which  it  never  intended 
to  do.  The  name  savoured  too  much  of  politics.  Lastly,  it 
would  be  necessary  to  discuss  the  question  of  finance. 

The  minutes  of  the  meeting  on  May  2nd  were  taken  as  read, 
when  some  discussion  arose  respecting  the  hour  of  meeting, 
as  the  time  most  convenient  to  London  and  country  members 
respectively  clashed,  while  a time  that  would  be  generally 
convenient  to  the  medical  profession  might  not  suit  the  repre- 
sentatives of  allied  bodies.  It  was  felt  that  the  convenience  of 
provincial  representatives  should  be  considered  in  order  that 
the  organisation  might  be  Enabled  to  get  the  views  of 
members  throughout  the  country.  On  the  suggestion  of  the 
Chairman,  the  matter  was  left  in  the  hands  of  the  executive 
committee. 

The  Societies  Represented. 

Dr.  N.  Howard  Mummery,  the  honorary  organising 
secretary  of  the  Medical  Parliamentary  Committee,  then  read 


1 The  Lancet,  May  10th,  p.  808. 


122  The  Lancet,]  BRITISH  FEDERATION  OF  MEDICAL  AND  ALLIED  SOCIETIES. 


[July  19,  1919 


the  names  of  the  societies  attending  and  their  representatives 


as  follows  : — 

Association  of  Certifying  Factory 
Surgeons  (Incorporated) 

Association  of  Medical  Officers  of 
Health. 

Association  of  British  Postal 
Medical  Officers. 

Association  of  Panel  Committees. 

Association  of  Public  Vaccinators. 

Association  of  School  Medical 
Officers  of  Scotland. 

Birmingham  and  District  General 
Practitioners’  Union. 

British  Dental  Association. 

Brighton  and  District  Medico- 
Ciiirurgical  Society. 

British  Science  Guild. 

Central  Committee  for  the  State 
Registration  of  Nurses. 

College  of  Nursing.  Ltd. 

Council  of  British  Ophthalmo- 
logists. 

Eastern  Valley  Medical  Associa- 
tion. 

Harveian  Society. 

Harrogate  Medical  Society. 

Incorporated  Midwives  Institute. 

Infirmary  Medical  Superintend- 
ents' Society. 

Irish  Medical  Association. 

Leeds  and  West  Riding  Medico- 
Chirurgical  Association. 

London  Dermatological  Society. 

Manchester  Odontological  Society. 

Medical  Officers  of  Schools’  Asso- 
ciation. 

Medical  Women’s  Federation 

Medico-Psychological  Association 
of  Great  Britain  and  Ireland 


Medico-Political  Union. 

Metropolitan  Police  Surgeons' 
Association. 

Midland  Medical  Society. 

Midland  Obstetrical  and  Gynaeco- 
logical Society. 

National  Association  for  the  Pre- 
vention of  Tuberculosis. 

National  Council  for  Combating 
Venereal  Diseases. 

National  Medical  Journal. 

National  Medical  Union. 

New  London  Dermatological 
Society. 

North  London  Medical  and 
Chirurgical  Society. 

North  of  England  luberculosis 
Society. 

Pathological  Society  of  Great 
Britain  and  Ireland. 

Pharmaceutical  Society  of  Great 
Britain. 

Physiological  Society. 

Poor-law  Medical  Officers' Associa- 
tion. 

Reading  Pathological  Society. 

Royal  Institute  of  Public  Health. 

The  Royal  Society  of  Medicine. 

Scottish  Union  of  Medical  Women  : 
Eastern  Branch  and  Western 
Branch. 

South  - West  London  Medical 
Society. 

Southampton  Medical  Parlia- 
mentary Committee. 

State  Medical  Service  Association. 

Tottenham  Medical  Union. 

Tuberculosis  Society. 


The  Council  of  the  British  Medical  Association  had  not,  he 
said,  sent  a representative,  but  the  matter  would  come  up  for 
discussion  at  the  next  general  meeting  of  the  members. 


The  Provisional  Report. 

The  report  of  the  provisional  subcommittee  was  then  voted 
upon  paragraph  by  paragraph,  when  Dr.  A.  E.  Boycott, 
representing  the  Pathological  Society  of  Great  Britain  and 
Ireland,  remarked  that  if  he  voted  for  or  against  a proposi- 
tion he  must  not  be  taken  as  pledging  his  society.  Other 
representatives  being  in  a similar  position,  the  Chairman  was 
subsequently  asked  for  a ruling  on  the  matter,  when  he  said 
that  what  was  wanted  was  the  definite  opinion  of  representa- 
tives, though  this  would  not  necessarily  commit  their 
societies.  Without  such  definite  opinions  the  committee 
could  not  come  to  a satisfactory  conclusion  on  any  subject, 
and  he  thought  it  was  the  duty  of  all  representatives  to  vote 
on  the  matter  before  them.  The  report  ran  as  follows  : — 

Report  of  the  Provisional  Subcommittee  Appointed  by  the 
Medical  Parliamentary  Committee  at  the  Conference  held 
at  the  Central  Hall,  Westminster,  on  May  2nd,  1919. 

In  pursuance -of  the  resolutions  passed  at  the  Conference 
on  May  2nd,  1919,  the  provisional  subcommittee  have  to 
report 

1.  That  the  office  of  the  committee  has  been  temporarily 
established  at  20,  Hanover-square,  London,  W.l. 

2.  That  the  subcommittee  has  met  on  five  occasions  for 
the  purpose  of  deliberation  and  conduct  of  business. 

The  following  resolutions,  as  recorded  in  the  minutes  of 
these  meetings,  have  been  passed: — 

(а)  The  appointment  of  a provisional  chairman  in  the  place  of  Sir 
William  Watson  Cheyne,  resigned.  This  office  has  been  offered  to,  and 
has  been  accepted  by,  Sir  Malcolm  Morris,  K.C.V.O. 

(б)  The  appointment  of  a provisional  organising  secretary.  This  office 
has  been  offered  to,  and  has  been  accepted  by,  Dr.  N.  Howard  Mummery, 
who  has  offered  to  act  in  an  honorary  capacity  until  the  Conference 
called  for  July  11th,  1919. 

3.  That  the  necessary  estimated  annual  and  preliminary 
expenditure  is  as  follows  : — 


Annual  Expenditure. 

Rent,  of  office  £200 

Material  and  incidental 

expenses  300 

Salaries  of  organisin  g secro  ■ 
tary,  clerk,  and  lobby 
correspondent 1326  f 

Annual  £1826 


Preliminary  Expenditure. 
Office  fittings  and  furni- 
ture   £92 

Expenses  of  incorpora- 
tion   100 

£192 


Total  for  first  year £2018. 


4.  That  in  the  opinion  of  the  provisional  subcommittee 
the  time  has  now  been  reached  when  it  is  essential  to  further 
expansion  and  increased  activities  that : — 

(i.)  The  committee  should  establish  a Federation  under  the  title  of 
“ The  British  Federation  of  Medical  and  Allied  Societies  " to  carry  on 
the  work  commenced  by  the  Medical  Parliamentary  Committee.  Only 
thus  can  it  acquire  the  financial  basis  necessary  to  its  further  existence. 


(ii.)  That  such  Federation  should  form  itself  into  an  incorporated 
association,  limited  by  guarantee  and  not  having  a share  capital,  under 
the  Companies’  Acts,  1908-1917.  That  it  be  registered  under  the 
Board  of  Trade  (Section  20)  with  limited  liability,  without  the  word 
“ Limited  ” after  its  name,  but  with  the  word  “ Incorporated  ” added. 

In  this  form  it  is  expressly  laid  down  that  it  cannot  be  considered  a 
“trade-union.”  That  it  be  registered  under  the  title  of  “The  British 
Federation  of  Medical  and  Allied  Societies  (Inc.),”  late  Medical  Parlia- 
mentary Committee. 

5.  That  the  representatives  of  the  affiliated  and  allied  • 
bodies  and  the  coopted  members  shall  form  the  Council  of 
the  Federation. 

6.  That  an  executive  committee  be  elected  to  carry  out 
the  business  of  the  Federation,  with  power  to  engage  the 
services  of  the  necessary  officers  and  servants  on  the  salaried 
list,  obtain  the  necessary  permanent  officers  of  the  Federa- 
tion, with  power  to  appoint  subcommittees,  and  to  incur  the 
necessary  preliminary  expenses. 

7.  That  the  following  financial  scheme  be  adopted  and 
incorporated  in  the  articles  of  association 

(а)  Entrance  fee. 

(l.)  For  each  association,  society,  or  allied  body  represented  on  the 
Council  of  the  Federation  a sum  of  not  less  than  two  guineas  (£2  2*.). 

(ii.)  For  each  coopted  member  of  the  Council  of  the  Federation  a sum 
of  riot  less  than  two  guineas  (£2  2s.). 

(iil.)  At  a later  date,  to  be  fixed  when  deemed  appropriate  by  the 
Council  of  the  Federation,  for  each  directly  elected  representative  of 
the  medical  profession  a sum  of  not  less  than  one  guinea  (£1  Is.). 

(б)  Annual  subscription. 

(i.)  That  members  of  each  association,  society,  or  allied  body  repre- 
sented on  the  Council  of  the  Federation  be  asked  through  the  various 
executives  of  those  bodies  to  subscribe  to  the  funds  of  the  Federation  a 
sum  of  not  less  than  half  a guinea  and  thereby  constitute  themselves 
members  of  that  Federation. 

(ii.)  For  each  coopted  member  of  the  Council  of  the  Federation  a 
sum  of  not  less  than  two  guineas  (£2  2s.). 

(iii.)  Subject  to  par.  7 (a)  (iii.)  above  a sum  of  not  less  than  one 
guinea  (£1  Is.). 

(c)  Guarantee  fund. 

To  meet  immediate  requirements  credit  be  obtained  from  a banker  in 
the  sum  of  two  thousand  pounds  (£2000)  secured  by  the  personal 
guarantee  of  selected  members  of  the  Council  of  the  Federation,  or 
other  members  who  may  offer  to  act  in  that  capacity.  Provided  that 
ten  guarantors,  each  in  the  sum  of  £20C,  or  20  guarantors,  each  in  the 
sum  of  £100,  be  the  number  necessary ; or  such  proportion  of  each  as 
may  be  deemed  advisable.  Such  guarantees  to  be  required  only  until  ' 
funds  are  available  from  entrance  fees  and  subscriptions. 

The  first- sections  of  the  report  were  passed  subject  to  some 
discussion.  , 

On  par.  4,  referring  to  the  change  of  name,  the  Chairman 
said  that  many  people  thought  the  organisation  was  going  to 
engage  in  politics,  and  the  name. Parliamentary.  Committee 
was  not  understood.  The  industrial  bodies  of  the  country 
usually  called  their  organisations  “federations,”  and  he 
thought  it  would  make  clearer  the  objects  of  the  present 
body  if  the  name  Federation  rather  than  Parliamentary  Com- 
mittee were  adopted.  After  some  discussion  the  change 
was  agreed  to,  the  Chairman  stating,  in  answer  to  a question,  | 
that  the  change  of  name  did  not  imply  any  change  in  the 
policy  and  objects  of  the  Medical  Parliamentary  Committee.  | 

The  Guarantee  hind. 

On  par.  7.  dealing  with  the  financial  scheme,  some  dis- 
cussion arose  as  to  the  powers  and  responsibilities  of  the 
various  societies  represented  in  regard  to  the  payment  of 
subscriptions  by  their  members,  the  Chairman  pointing  out 
that  any  society  which  did  not  agree  with  any  of  the  resolu- 
tions that  might  be  passed  in  regard  to  finance  had  a perfect 
right  to  withdraw.  At  present  the  Federation  had  no  money, 
and  it  was  necessary  if  work  was  to  be  done  that  there 
should  be  a guarantee  fund. 

Dr.  C.  Buttar  said  he  had  hoped  that  each  society  would 
contribute  according  to  membership.  As  more  and  more 
societies  joined  6d.  a head  would  cover  the  whole  of 
the  finances  required.  As  long  as  the  Federation  did  not 
appeal,  as  it  ought  to  do,  to  each  individual  of  the  medical 
profession,  a payment  of  so  much  per  head  per  member  of  a 
society  would  be  the  best  arrangement. 

Finally,  it  was  decided  to  leave  the  matter  for  the  present 
in  the  hauds  of  the  executive  committee  to  draw  up  a scheme 
for  raising  funds  which  should  be  submitted  to  the  various 
societies  asking  for  an  expression  of  opinion,  while  at  the 
next  general  meeting  the  representatives  of  these  societies 
should  be  empowered  to  vote  on  a-scheme. 

A guarantee  fund  of  approaching  £1300  was  then 
announced. 

Cooption  of  Members  of  the  Council  of  the  federation. 

The  number  of  representatives  of  the  Council  is  53,  and 
the  number  of  coopted  members  10,  of  whom  2 may  |be 


Thh  Lanoht,] 


NATIONAL  CONFEKENOE  ON  INFANT  WELFARE. 


[July  19,  1919  123 


engaged  in  consulting  medical 
accordingly  coopted  : — 

Mr.  J.  Y.  W.  MacAlister. 

Mr.  Frauk  Coke  (Ashford). 

Dr.  W.  Hodgson  (Crewe). 

Sir  Thomas  Parkinson. 

Dr.  Howard  Marshall  (Ciren- 
cester). 

The  Exec  util 


practice.  The  following  were 

Mr.  E.  F.  White. 

Dr.  Arthur  Shadwell. 

Lieut. -Col.  F.  E.  Fremantle. 
Sir  Bertrand  Dawson. 

Mr.  • J.  P.  Lockhart- 
Mummery. 
e Committee. 


The  following  Executive  Committee  of  20  (of  whom  4 may 
be  engaged  in  consulting  practice  with  power  to  add  to 
their  number)  was  elected  : — 

Dr.  Rashell  Davison,  Association  of  Medical  Officers  of 
Health. 

Dr.  H.  J.  Cardale,  Association  of  Panel  Committees. 

Mr.  C.  F.  Rilot,  British  Dental  Association. 

Sir  Ronald  Ross,  British  Science  Guild. 

Mrs.  Bedford  Fenwick,  Central  Committee  for  the  State 
Registration  of  Nurses. 

Mr.  Comyns  Berkeley,  College  of  Nursing,  Ltd. 

Mr.  Frank  Coke,  Medico-Political  Union. 

Miss  Rosalind  Paget,  Incorporated  Midwives  Institute. 

Dr.  Jane  Walker,  Medical  Women’s  Association. 

Dr.  R.  H.  Cole,  Medico-Psychological  Association. 

Mr.  E.  B.  Turner,  National  Council  for  Combating  Venereal 
Diseases. 

Dr.  Edwin  Smith,  National  Medical  Union. 

Mr.  Rowsell,  Pharmaceutical  Society  of  Great  Britain. 
Professor  Starling,  Phvsiological  Society. 

Dr.  A.  Withers  Green,  toor-law  Medical  Officers’  Association. 
Dr.  W.  Pasteur,  Royal  Society  of  Medicine. 

Dr.  Chalmers  Watson,  Scottish  Union  of  Medical  Women. 
Dr.  Halliday  Sutherland,  Tuberculosis  Society. 

Dr.  S.  Squire  Sprigge. 

Dr.  Arthur  Shadwell. 

Ex-officio. 

Chairman  : Sir  Malcolm  Morris,  K.C.V.O. 

Vice-chairmen  : Dr.  Arthur  Latham,  Dr.  E . H.  M.  Stancomb. 
Hon.  Treasurers  : Sir  Thomas  Horder,  Dr.  J.  F.  Gordon  Dill. 
Hon.  Secretary  : Dr.  Charles  Buttar. 


NATIONAL  CONFERENCE  ON  INFANT 
WELFARE. 

( Continued  from  p.  78.) 

At  the  afternoon  session  on  July  2nd  Dr.  Rhoda 
Adamson,  clinical  lecturer  in  obstetrics  at  the  University 
of  Leeds  and  honorary  medical  officer  to  the  Leeds  Maternity 
Hospital,  spoke  on  the  subject  of  the 

Industrial  Employment  of  Mothers  in  Relation  to  Infant 
Mortality. 

She  insisted  that  the  most  suitable  person  to  attend  to  the 
young  child  was  the  child’s  own  mother.  Failing  which, 
these  duties  were  best  carried  out  by  someone  trained  in 
infant  care.  That  if  the  mother  was  employed  in  some 
industry  away  from  home  she  had  to  make  some  provision 
for  the  care  of  her  young  children  during  the  hours  that  she 
could  not  be  with  them,  and  the  well-being  of  the  children 
depended  very  much  upon  the  type  of  care  the  mother  was 
able  to  substitute  for  that  of  her  own.  She  thought  that 
employment  of  married  women  was  largely  a matter  of 
custom  in  some  localities  and  hard  necessity  in  others 
Some  women  continued  to  work  after  marriage  at  the 
same  trades  that  employed  them  while  unmarried 
because  they  preferred  this  type  of  work  to  the  dull 
routine  of  housework  to  which  they  were  unaccustomed 
and  because  they  could  marry  earlier  when  the  house  con- 
tained two  breadwinners.  Others,  as  a matter  of  course, 
gave  up  all  active  wage  earning  employment  on  a marriage 
which  had  been  postponed  until  the  husband  was  able  to 
support  a wife  and  family  with  his  unaided  earnings.  Others 
were  driven  to  seek  paid  employment  at  some  later  period  after 
marriage  because  the  family  income  without  their  help  was 
not  sufficient  to  maintain  it.  Under  this  heading  the  speaker 
included  widows  with  insufficient  pensions  and  married  women 
with  invalid  or  lazy  husbands.  The  children  of  the  home- 
keeping mother  were  mol  e usually  breast-fed  during  the  earlier 
months  of  infancy,  she  said,  because,  from  her  point  of 
view,  this  method  was  more  economical  and  simpler  than 
any  other  method.  The  children  of  the  mothers  working 
away  from  home  were  sometimes  breast-fed  at  night  and 
bottle-fed  by  day,  but  more  usually  entirely  bottle-fed. 


The  first  method  was  generally  recognised  as  being  the  most 
desirable  and  to  give  the  infant  a far  greater  chance  of  life 
during  the  early  weeks  after  birth  than  bottle-feeding  with 
whatever  mixture  happened  to  be  chosen  as  a substitute. 
If  the  mother  was  unable  to  nurse  her  child  the  preparation 
of  an  artificial  bottle-feed  required  much  care  and  attention  ; 
it  could  not  with  safety  be  left  to  a woman  to  carry  out  by 
the  light  of  nature  in  a casual  way.  It  was  essential,  she 
thought,  that  the  mother  should  stay  at  home  herself  or  that 
there  should  be  adequate  provision  of  well-staffed  day 
nurseries  in  all  areas  where  mothers  of  young  children  were 
compelled  to  leave  them  because  of  employment  away  from 
home.  She  emphasised  the  fact  that  the  health  of  young 
children  was  very  largely  dependent  upon  their  share  of 
fresh  air  and  sunlight  and  the  general  cleanliness  of  their 
surroundings.  So  that  children  living  in  the  country,  even 
though  in  poor  homes,  were  healthier  than  those  brought  up 
in  crowded  slum  areas,  though  in  such  cases  the  family 
income  might  be  much  greater.  In  towns,  therefore,  it  was 
essential  that  the  children  should  be  taken  out  of  doors  by 
their  mothers  or  else  placed  in  an  open-air  shelter  in 
connexion  with  some  day  nursery. 

The  Provision  of  Nurseries  and  the  Need  of  a State 
Allowance  for  Mothers. 

Failing  the  general  institution  of  endowment  of  mother- 
hood and  the  exclusion  of  such  mothers  from  industrial 
employment  while  in  receipt  of  an  allowance,  it  appeared 
essential  to  procure  the  general  provision  of  nurseries 
capable  of  accommodating  young  children  as  daily  or 
permanent  boarders.  Such  nurseries  were  costly  to  estab- 
lish and  expensive  in  their  upkeep,  and  no  working  woman 
could  by  her  regular  payment  be  expected  to  defray  her 
share  of  expense  of  such  a nursery  without  some  additional 
grant  towards  the  cost  from  local  or  central  government 
funds.  If,  therefore,  the  State  might  in  either  case  be 
expected  to  contribute  towards  the  expense  of  maintenance 
and  care  of  children  of  the  working  classes  it  appeared  more 
reasonable  to  pay  the  mother  to  carry  out  these  duties  rather 
than  some  other  disinterested  institution.  The  speaker 
suggested  that  such  State  allowance  should  be  optional, 
to  be  claimed  by  the  mother  if  she  saw  fit,  and  that 
coupled  with  its  payment  should  be  inspection  to  ensure 
that  it  was  being  applied  for  the  benefit  of  the  children 
and  incidentally  also  for  the  mother.  It  was  well  recognised 
that  an  infant  ran  the  greatest  risk  of  death  during  the  first 
three  months  after  birth.  Therefore,  if  some  scheme  could 
be  devised  to  make  it  possible  for  mothers  of  children 
under  three  months  old  to  remain  at  home  personally  to 
nurse  and  care  for  their  children  a certain  saving  of  infant 
life  might  be  brought  about.  The  present  factory  regula- 
tions of  the  Home  Office  excluded  a mother  from  industrial 
employment  for  four  weeks  after  the  birth  of  a child,  this 
exclusion  having  been  enjoined  in  the  interests  of  the 
health  of  the  mother,  but  with  this  four  weeks’  exclusion 
there  was  no  provision  whatever  for  the  financial  help  of  the 
mother  to  maintain  herself  and  the  child,  and  therefore  it 
possibly  involved  underfeeding  of  both  mother  and  child. 
Personally  Dr.  Adamson  was  not  in  favour  of  any  law  or  Home 
Office  regulation  directed  towards  the  exclusion  of  all  married 
women  with  children  from  industrial  employment  for  any 
period,  however  short.  She  considered  that  the  average 
mother  of  young  children  would  prefer  to  stay  at  home  and 
look  after  them  if  the  family  income  did  not  need  to  be 
augmented  by  her  industrial  employment.  She  thought  that 
the  effect  of  exclusion  of  such  women  from  factory  work 
would  be  two-fold,  some  would  practise  some  form  of  birth 
control  to  avoid  the  risk  of  losiDg  their  work,  and  others  who 
had  not  avoided  parenthood  would  be  driven  into  less  well 
paid  employment,  such  as  domestic  work,  which  still  necessi- 
tated their  absence  from  their  home  and  children. 

Miss  L.  Barker,  O.B.E.,  of  the  Training  Department, 
Ministry  of  Labour,  said  that  mothers  were  forced  into 
industry  by  their  husbands  being  : (1)  dead  ; (2)  disabled  ; 
(3)  out  of  health  ; (4)  of  such  a low  category  industrially  as 
to  be  unable  to  earn  a fair  wage  ; (5)  gone  away,  leaving 
wife  and  children  ; (6)  out  of  employment.  She  would  like 
to  see  creches  established,  with  hours  to  fit  those  of  the 
working  mother,  and  with  rules  framed  to  avoid  the  ill- 
effects  of  broken  treatment  of  child  during  week-end  (over- 
feeding and  the  like).  Also  some  sort  of  centre  to  which 
elder  children  could  be  sent  during  out-of-school  hours,  whtn 


[July  19,  1919 


124  The  Lancet, ] 


MEDICINE  AND  THE  LAW.— TUBERCULOSIS. 


the  mother  was  working.  Creches  should  have  a training 
service  or  school  for  nursemaids  attached,  and  the  attend- 
ance at  lectures,  needlework  classes,  &c.,  of  mothers  whose 
children  are  in  residence  should  be  one  of  the  terms  under 
which  the  child  is  accepted.  Creches  or  nursery  schools 
mi-'ht  well  be  centres  for  antenatal  teaching  also.  Her  per- 
sonal experience  was  that  the  health  and  general  physique 
of  children  at  creches  and  babies’  homes  at  Woolwich  were 
increased  in  contrast  with  those  not  cared  for  in  this  way. 

Baok-to-baok  Houses. 

Mrs.  Holden  (Dewsbury),  in  emphasising  the  unhealthiness 
of  back-to-back  houses,  quoted  the  following  table  from  a 
pre-war  report  of  the  medical  officer  of  health  for  Dewsbury 

Back-to-back  houses.  Thiough 

> „ houses. 

Not  Mot  hers  not 

working.  working. 

. 360  78 

34  5 

94  64 


• Working. 

Number  of  children  born  ...  108 

Number  dying  under  1 year  40  . 

Rate  per  1000  deaths  570  . 

She  summed  up  her  arguments  against  the  employment  of 
the  nursing  mother  in  industry  by  stating  that  first,  the 
strain  of  the  double  duty  is  too  much  for  the  mother  ; 
secondly,  equally  important,  the  atmospheric  conditions  of  a 
home  shut  up  the  greater  part  of  the  day  are  bound  to  be  bad 
for  all,  especially  the  young  children. 


has  now  ended  in  the  plaintiff’s  favour,  medical  evidence 
having  been  given  on  both  sides  as  to  the  safety  or  otherwise 
of  marriage  in  view  of  the  condition  of  the  plaintiff  s health. 
She  had  been  under  treatment  at  the  Downs  Sanatorium, 
Sutton,  for  tuberculosis,  so  that  there  was  evidence  of  her 
having’ at  one  time  suffered  from  the  disease  ; but  the  ques- 
tions left  to  the  jury  indicate  the  facts  which  Mr  Justice 
McCardie  considered  essential  to  the  establishment  of  the 
defence  set  up.  The  questions  left  to  the  jury  and  the 
answers  given  were  : — 

(11  “ Was  the  plaintiff  suffering  from  tuberculosis  on 
June  1st,  1918  (the  date  on  which  the  parties  became 

pn0ft26d)  ^ — “NO.”  , . . 

(2)  ‘‘  Was  the  plaintiff  unfit  through  tuberculosis  to  marry 

either  (a)  on  October  28th,  1918;  (fcj  at  Christmas,  1918;  or 
(cl  within  a reasonable  time  afterwards  Ho. 

(3)  “ Did  the  plaintiff  know  on  June  1st,  1918,  that  she  was 
suffering  from  tuberculosis  ? ” No  answer  was  given  to  this 
question,  which,  it  apparently  was  considered  should  be 
answered  if  Question  (1)  had  received  an  affirmative  reply. 

The  case  at  any  rate  seems  to  show  that  the  courts  will 
recognise  the  undesirable  nature  of  a marriage  between 
persons  one  of  whom  is  tuberculous,  and  will  regard  the 
breaking  off  of  an  engagement  between  them  as  justified, 
but  the  various  aspects  of  the  question  would  perhaps  ha\  e 
been  more  clearly  considered  if  the  facts  had  been  found  to 
justify  a judgment  for  the  defendant. 


MEDICINE  AND  THE  LAW. 


Medial  Fees  in  Court. 

It  was  reported  recently  in  the  daily  press  that  in  an 
action  for  damages  at  Westminster  County  Court  against  the 
London  County  Council  Mr.  Blackwell,  counsel  for  a carman, 
said  that  a woman  doctor  from  the  Royal  Free  Hospital  had 
been  subpoenaed  to  give  evidence.  She  had  been  offered  a 
guinea  but  wrote  that  “ she  could  not  think  of  accepting  so 
inadequate  a fee.”  The  judge,  Sir  Alfred  Tobin,  said  he 
understood  from  the  registrar  that  the  correct  fee  was 
one  guinea  plus  travelling  expenses,  whereupon  Mr.  Blackwell 
replied  that  in  this  case  the  expenses  would  be  a few  pence. 

“ Fortunately  we  can  get  on  without  her  now.”  His  honour 
is  then  reported  to  have  observed : “ It  is  a great  contempt  of 
court  for  the  lady  not  to  come  when  proper  fee  is  offered.  If 
any  application  was  made  to  me  to  deal  with  it  I should 
know  how  to  do  so.  I would  deal  as  severely  as  I can,  for  it 
is  most  important  that  justice  should  be  assisted  and  not 
impeded.”  Those  who  are  conversant  with  county  court 
methods  will  not  too  readily  assume  that  learned  counsel  was 
correctly  instructed  when  he  declared  that  the  lady  had  been 
subpoenaed.  Many  house-surgeons  and  physicians,  before 
now,  have  been  induced  to  appear  in  this  species  of  action, 
have  given  really  expert  evidence,  and  have  failed  to  receive 
even  the  usual  fee  allowed  by  the  rules.  But  there  is,  of 
course,  no  legitimate  excuse,  if  a subpoena  has  been  accepted, 
for  failure  to  appear,  save  physical  disability  or  the  order  of 
a higher  court ; and  a witness  who  has  accepted  subpoena 
must  be  content  to  receive  the  fees  allowable  by  the  rules 
of  the  particular  court,  unless  the  solicitor  in  charge  of  the 
case  is  willing  to  pay  something  more  substantial.  An 
unwilling  witness  may,  however,  always  refuse  to  attend, 
save  after  subpoena,  to  take  the  oath  unless  paid  the 
regulation  fee,  and,  having  taken  the  oath,  to  testify  other- 
wise than  as  to  the  facts  unless  paid  a fee  satisfactory  to 
himself. 

Tuberculosis  and  Marriage. 

The  second  trial  of  the  case  of  Porter  v.  Barnard  has 
ended  in  a verdict  for  the  plaintiff  for  £250,  the  judgment 
including  the  costs  of  both  trials.  The  plaintiff  had  first  met 
the  defendant,  who  at  that  time  was  fourth  engineer  in  a 
tramp  steamer,  in  Richmond  Park.  He  was  then  home  for 
a brief  period  of  leave  and  he  invited  the  plaintiff  and  her 
sister  to  tea.  After  the  acquaintance  had  been  renewed 
during  a later  return  of  the  defendant  to  his  home  he  became 
engaged  to  be  married  to  the  plaintiff.  Before  the  pro- 
posed marriage  took  place,  however,  the  question  of  whether 
the  plaintiff  was  suffering  from  tuberculosis  arose,  and  the 
defendant’s  father,  being"  a medical  practitioner,  made  an 
examination,  from  which  he  concluded  that  it  was  undesirable 
that  she  should  be  married.  The  breaking  off  of  the  engage- 
ment led  to  the  action  for  breach  of  promise  of  marriage  which 


TUBERCULOSIS. 


After-  care  Jot  Consumptives. 

However  adequate  may  be  the  medical  treatment  pro- 
ided  by  county  council  and  insurance  committees,  there 
Iways  remains  a need  for  voluntary  help  in  the  matter  of  the 
are  of  the  tuberculous.  Rather  than  appiy  for  Poor-law 
elief  many  a worker  will  continue  in  his  employment 
ntil  medical  treatment  can  be  of  little  use  to  him,  while  in 
ases  where  medical  treatment  has  already  been  given  a 
vmpathetic  interest  in  his  family  difficulties  from  some 
oluntary  committee  with  a financial  backing  will  often  make 
11  the  difference  between  a complete  cure  and  a relapse 
'he  reports  of  the  various  care  committees  in  the  county  of 
Lancashire  show  that  during  the  past  year  279  patients  have 
,een  assisted  in  various  ways.  Help  most  frequently  takes 
he  form  of  extra  food  and  clothing.  The  loan  of  bedsteads 
nd  bedding  for  those  who  would  otherwise  be  unable  to 
leep  in  separate  beds  is  an  important  part  of  the  w0^.  but 
he  personal  interest  of  the  members  of  the  committee  is 
irobably  the  most  important  of  all,  though  it  does  not  appear 
>n  the  balance-sheet.  * i 

Segregation  of  Advanced  Consumptives. 

At  the  request  of  the  Southwark  borough  council  the  town 
Jerk  the  medical  officer  of  health,  and  the  tuberculosis  officer 
iave’prepared  a report  on  (1)  the  question  of  the  provision  oy 
he  Suite  of  accommodation  other  than  that  provided  by 
nstitutions  maintained  by  voluntary  charitable^  bodies,  in 
which  persons  in  an  advanced  stage  of  consumption  can  end 
their  days  • and  (2)  the  question  of  compulsory  powers  oeing 
5v*n  to  local  authorities  to  remove  cases  where  it  can  be 
shown  that  the  patients,  having  regard  to  their  surrounding-, 
are  a'danger  to  the  health  of  those  with  whom  they  reside 
\nth  regard  to  the  first  point,  the  report  states  that  as  ar 
back  asT913  at  a conference  of  London  sanitary  authori 
convened  by  the  London  County  Council,  the  chairman  of 
the  conference  drew  attention  to  the  necessity  for  providing 

advanced  consumptives  should  be  mise 

X”’  .far  “V 

cL 

sumptives  will  voluntarily  enter  a workhouse  infi  m^  Th 

medical  officer  of  health  has  now  been 

that  if  the  borough  council  makes  an  aPP‘  . , 

Council  will  be  prepared  to  bear  all  f e “^"^  Counci 
The  acquiring  of  this  hospital  woul  n P compuison 

recommending  legislation  giving  powers  for  the  compu  . 


Vhb  Lakobt,] 


foOTES  FROM  INDIA. 


[July  19,  1919  126 


removal  of  dangerous  infectious  cases  of  tuberculosis  from 
their  homes  to  an  institution.  This  question  is  dealt  with  in 
the  second  part  of  the  report,  which  points  out  that  com- 
pulsory powers  of  removal  by  local  authorities  in  respect  of 
certain  cases  of  infectious  disease  already  exist  under  the 
Public  Health  (London)  Act,  1891,  but  that  this  does  not 
extend  to  tuberculosis. 

"Article  7 of  the  Tuberculosis  (in  hospital)  Regulations,  1911, 
provides  that  nothing  in  the  Regulation  shall  authorise  or  require  a 
medical  officer  of  health  or  a local  authority  to  put  in  force  any  enact- 
ment which  renders  a consumptive  or  the  person  in  charge  of  the 
patient  or  any  other  persons  liable  to  a penalty,  or  subjects  the  person 
to  any  restriction,  prohibition  or  disability  affecting  himself  or  his 
employment,  occupation  or  means  of  livelihood  on  the  ground  of  his 
suffering  from  tuberculosis. 

Compulsory  powers  of  removal  have,  however,  been  obtained  by 
some  of  the  provincial  councils  under  private  Acts  of  Parliament— e.g., 
the  St.  Helens  Corporation  Act  of  1908. 

The  Public  Health  (Prevention  and  Treatment  of  Disease)  Act, 
1913,  also  contains  a special  clause  dealing  with  treatment  of  tuber- 
culosis. Sec.  3 empowers  any  sanitary  authority  to  make  any  such 
arrangement  as  may  be  sanctioned  by  the  Local  Government  for  the 
treatment  of  tuberculosis;  this  power  to  be  in  addition  to  and  not  in 
derogation  of  any  other  power.” 

If  this  section  be  acted  upon  it  may  become  the  practice 
of  one  borough  compulsorily  to  remove  advanced  con- 
sumptives, whilst  another  might  adopt  less  drastic  means. 
Having  regard  to  the  fact  that  a certain  percentage  of  con- 
sumptive cases  are  a danger  and  cause  of  infection  to  others, 
and  refuse  to  enter  an  institution  or  take  steps  to  prevent  the 
spread  of  the  disease,  compulsory  removal  should  be  general 
throughout  the  country  in  certain  cases.  The  Tuberculosis 
Regulations  of  1911  should  be  extended  so  as  to  give  the 
medical  officer  of  health  power  to  order,  with  due  legal 
precautions,  the  compulsory  removal  of  a case  where  it  is 
clearly  proved  that  such  a case  is  tending  to  spread  the 
disease  and  the  affected  person  refuses  to  take  advantage  of 
voluntary  measures  offered. 

The  Hairmyres  Colony. 

The  British  Journal  of  Tuberculosis  for  July  makes 
Mr.  J.  E.  Chapman’s  memorandum  on  “ Colonies”  (L.  G.  B. 
Reports  on  Public  Health  Subjects.  New  Series.  No.  122)  the 
occasion  for  a long  and  useful  review  of  the  place  of  such 
colonies  in  the  anti-tuberculosis  campaign.  An  interesting 
experiment  was  confirmed  on  June  14th  when  the 
Hairmyres  Colony  was  officially  opened  by  the  Secretary  for 
Scotland.  As  long  ago  as  1905  the  district  committee  of  the 
Middle  Ward  of  Lanarkshire  made  a beginning  in  the 
systematic  treatment  of  pulmonary  tuberculosis  under  a 
system  of  voluntary  notification.  Since  that  time  their 
hands  have  been  greatly  strengthened  by  the  coming  of  com- 
pulsory notification  and  the  provisions  in  the  Insurance  Act 
for  the  treatment  of  tuberculosis.  Experience  has  shown 
them  that  the  method  of  treating  consumptives  for  three 
months  in  a sanatorium  and  then  allowing  their  patieilts  to 
compete  for  a livelihood  in  the  open  market  of  labour  was 
satisfactory  neither  from  the  clinical  point  of  view  nor  from 
that  of  the  local  authority  which  was  constantly  called  upon 
to  provide  treatment  for  cases  of  relapse.  The  colony  will 
be  peopled  by  children  as  well  as  by  selected  cases  of  adults 
in  whom  the  disease  has  been  arrested  by  sanatorium  treat- 
ment. The  former  will  be  taught  in  open-air  schools,  and 
the  latter  trained,  under  medical  supervision,  in  various  out- 
door industries,  such  as  market-gardening,  bee-keeping, 
poultry-farming,  and  forestry. 

A Colony  Scheme  for  the  East  Midlands. 

The  Mayor  of  Nottingham  with  Major  Brockington,  of 
Leicester,  recently  presented  a tuberculosis  colony  scheme 
to  the  Minister  of  Pensions  on  behalf  of  the  East  Midlands 
Joint  Committee.  The  site  chosen  by  the  committee  for  the 
establishment  of  a training  colony  is  at  Bretby  Hall,  near 
Burton-on-Trent.  The  Derby  borough  committee,  which  is 
at  present  dealing  with  a large  number  of  applications  from 
emsumptives,  has  passed  a resolution  strongly  urging  the 
Government  to  give  effect  to  the  scheme. 

Anti-tuberculosis  Campaign  in  Bombay. 

The  annual  report  of  the  King  George  V.  Anti-Tuberculosis 
League  shows  an  increase  in  the  amount  of  treatment 
provided,  the  patients  treated  being  1215,  as  compared 
with  972  in  1917.  On  Dec.  7th,  1918,  Lord  and  Lady 
Willingdon  opened  a sanatorium,  which  has  been  erected  by 
the  league  from  voluntary  subscriptions.  Up  to  the  end  of 
last  year  treatment  was  given  for  the  most  part  in  the  two 
dispensaries,  in  which,  since  1913,  more  than  4000  cases  have 
received  treatment.  About  three-quarters  of  these  cases  had 


tuberculosis  of  the  lungs  and  the  remainder  were  chiefly 
cases  of  tuberculous  glands.  Domiciliary  treatment  has  also 
been  supplied  by  the  doctors  and  nurses,  and  the  occasion 
made  use  of  for  much  valuable  propaganda.  This  part  of 
its  work  is  rightly  regarded  by  the  officers  of  the  league  as 
very  important,  since  consumption  spreads  to  a great  extent 
among  the  uneducated  natives  who  have  no  conception  of  its 
infectivity.  For  the  enlightenment  of  these  classes  lectures 
are  arranged  in  the  different  native  languages  and  pamphlets 
are  distributed  describing  the  early  signs  of  consumption, 
and  giving  instructions  for  its  treatment  in  the  home.  A 
systematic  examination  of  school  children  has  convinced  the 
medical  officers  that  early  tubercle  can  often  be  diagnosed 
by  loss  of  weight. 

The  American  Tuberculosis  Association. 

At  the  annual  meeting  of  this  association  held  recently  in 
Atlantic  City  Sir  William  Osier  was  elected  a vice-president. 
A resolution  was  adopted,  viewing  with  grave  concern  the 
efforts  being  made  in  certain  quarters  to  have  the  Daylight 
Saving  Bill  repealed,  and  protesting  against  any  attempts  to 
impede  the  operation  of  such  law.  The  great  help  it  was  at 
the  present  time  in  preserving  the  health  of  the  country 
generally  was  emphasised.  The  Army  medical  officers 
present  discussed  the  responsibility  of  the  Government  for 
the  proper  care  and  treatment  of  the  tuberculous  soldier 
prior  to  his  return  to  civilian  life.  A representative  from 
Surgeon-General  Estes  Nichols’s  office  (of  No.  16  General 
Hospital)  then  described  a plan  which  was  under  con- 
sideration. It  was  proposed,  he  stated,  to  give  treatment  in 
special  reconstruction  towns  or  communities,  which  would 
be  located  upon  lands  in  the  National  forests,  the  idea  being 
to  attract  the  patients  to  healthful  wood-working  industries, 
and  to  afford  them  an  opportunity  to  retain  control  of  the 
land  holdings  after  they  were  cured.  They  would  be  under 
proper  medical  supervision,  but  not  to  the  same  extent,  of 
course,  as  during  their  time  in  a sanatorium.  Such  com- 
munities would  require  financial  assistance  at  first,  but 
eventually  should  become  self-supporting. 

The  Hog  as  a Test  for  Bovine  Tubercle. 

Dr.  Burton  Rogers,  of  Chicago,  Illinois,  has  recently  drawn 
attention  to  the  value  of  the  hog  as  an  indicator  of  the 
existence  of  bovine  tuberculosis  on  a farm.  Wherever  pigs 
and  cows  are  kept  together  it  is  found  that  the  former 
greedily  devour  the  fasces  of  the  latter  ; indeed,  the  symbiosis 
is  often  purposely  arranged  in  order  that  cowsheds  may  be 
kept  clean.  The  tuberculous  cows  swallow  their  sputum, 
and  the  bacilli  thus  pass  out  in  their  faeces,  with  the  result 
that  the  pigs  become  infected.  Among  40  million  hogs 
examined  by  American  veterinary  inspectors  in  1917 
3,974,000,  or  nearly  10  per  cent.,  were  found  to  be  tuber- 
culous. Dr.  Rogers  points  out  that  if  the  pigs  slaughtered 
and  subsequently  examined  had  been  previously  labelled 
with  the  name  of  the  farm  on  which  they  were  reared, 
valuable  presumptive  evidence  of  the  existence  of  bovine 
tubercle  and  of  its  localisation  to  specific  farms  would  have 
been  obtained  and  could  have  been  used  with  great 
advantage  in  a campaign  to  eradicate  the  disease  from 
among  cattle. 


NOTES  FROM  INDIA. 

(From  our  own  Correspondent.) 

An  Indian  Ministry  of  Health. 

The  conference  of  provincial  medical  and  sanitary  officers 
recently  summoned  by  the  Government  of  India  has  con- 
cluded its  meetings  at  Simla  under  the  presidency  of 
Sir  San  Karan  Nair,  member  of  the  Viceroy’s  Council  for 
Education  and  Sanitation,  who  invited  his  hearers  to  con- 
sider how  a central  health  organisation  could  coordinate  the 
work  of  preventive  action,  clinical  practice,  and  medical 
research.  As  regards  the  question  of  assistance  to  the 
provinces  in  severe  epidemics,  he  made  the  suggestion  of  a 
mobile  corps,  lent  in  normal  times  to  the  provinces  to 
supplement  the  provincial  staffs,  but  subject  to  the  with- 
drawal by  the  Government  of  India  acting  on  the  advice  of 
its  Public  Health  Board,  in  order  to  concentrate  in  any  area 
where  extensive  epidemic  disease  had  broken  out.  The 
function  of  the  corps  would  include  popular  education  in 
preventive  methods.  A resolution  was  passed  calling  for  the 
establishment  of  a Central  Public  Health  Board  consisting 


126  Thb  Lanoet,] 


A CRITICISM  OF  THE  MEMORANDUM  ON  MALARIA. 


[July  19,  1919 


of  official  and  non-official  members,  and  the  creation  of 
similar  boards  in  the  provinces.  The  conference  laid  stress 
on  the  importance  of  certain  kindred  measures  such  as  the 
establishment  of  an  epidemiological  statistical  bureau,  the 
increase  of  curative  medical  staffs,  the  multiplication  of 
dispensaries,  and  the  future  development  of  research 
facilities  on  the  lines  of  the  Central  Research  Institute. 

Lahore  Milk-supply. 

In  the  course  of  the  campaign  which  he  has  inaugurated 
against  food  adulteration  the  officer  commanding  the  Lahore 
area,  now  under  martial  law,  has  come  across  some  surprising 
figures  in  regard  to  the  milk-supply.  Of  large  numbers  of 
samples  that  have  been  analysed  only  two  have  been  found 
absolutely  pure,  the  extent  of  adulteration  varying  from  2 to 
34  per  cent.,  with  a general  average  of  not  less  than  10  per 
cent.  About  2000  maunds  of  milk  per  diem  are  consumed 
in  the  Punjab  capital,  which  would  mean  that  200  maunds 
of  water  are  being  daily  sold  as  milk.  As  the  price  of  milk 
is  3 annas  per  seer,  or  Ks.7'8  per  maund,  the  Lahore  public 
are  daily  being  robbed  of  Rs.1500,  or,  say,  Rs.5£  lakhs,  per 
annum.  Heavy  fanes  and  sentences  of  imprisonment  under 
martial  law  have  for  the  moment  practically  stamped  out 
the  practice  of  adulteration,  with  the  rather  amazing  result 
that,  the  available  number  of  cows  remaining  the  same, 
there  is  a distinct  shortage  of  milk. 

The  Red  Cross  in  India. 

The  Indian  Joint  War  Committee  of  the  Order  of 
St.  John  of  Jerusalem  and  the  British  Red  Cross  Society  have 
just  issued  their  report  on  last  year’s  activities.  The  figures 
of  expenditure  in  the  various  centres  in  which  Indian 
Expeditionary  Forces  were  engaged  and  in  India  itself  speak 
eloquently  of  the  extent  of  its  operations.  The  total 
expenditure  during  the  year  was  51|  lakhs  of  rupees 
(£300,000  sterling)  ; 373  lakhs  were  expended  on  account  of 
Mesopotamia,  over  13  on  East  Africa,  Egypt,  and  Palestine, 
and  the  remainder  was  made  up  by  expenditure  on  the  Marri 
and  Waziristan  operation  and  on  hospitals  in  India  itself. 
The  expenses  of  management  amount  only  to  63  per  cent, 
(or  just  over  3 pies  in  the  rupee)  of  the  total  expenditure. 
The  history  of  the  year  shows  great  progress  in  the  assump- 
tion by  Government  of  responsibility  for  this  type  of 
expenditure.  The  standard  supply  of  Government  equip- 
ment to  military  hospitals  and  field  medical  units  has  been 
greatly  extended,  and  numerous  articles  originally  classed  as 
“comforts”  are  now  recognised  as  “necessaries.”  The 
burden,  which  will  in  the  future  fall  on  Red  Cross  activities, 
will  thus  be  materially  lightened. — The  Baluchistan  Red 
Cross  and  Comforts  Fund  has  undertaken  to  supply  the  whole 
of  the  troops  in  the  East  Persian  Cordon  and  on  the  lines  of 
communication  with  regular  consignments  of  tobacco  and 
other  amenities,  which  are  sent  to  each  unit  in  rotation. 

The  Health  of  the  Army  in  India. 

The  annual  report  of  tfae  Sanitary  Commissioner  with  the 
Government  of  India  has  just  been  published.  The  figures 
presented  compare  favourably  with  those  of  the  two  preceding 
years  ; for  1917  the  death-rate  was  4’83  per  1000,  as  against 
6 54  in  1916,  5 95  in  1915,  and  4 51  the  ratio  for  the 
pre-war  quinquennium,  while  the  admission  ratio  is  stated 
at  7717  per  1000,  comparing  with  772  in  1916, 823  1 in  1915. 
and  567  2 in  the  quinquennium  before  the  war.  There  was  a 
substantial  increase,  however,  in  the  ratio  of  constantly 
sick,  even  when  comparison  is  made  with  the  two  pre- 
ceding years,  the  figures  for  1917  being  45  66  per  1000, 
while  the  ratio  was  39  75  in  1916  and  39  08  in  1915. 
This  difference,  we  are  told,  is  “accounted  for  chiefly 
by  the  increased  number  of  admissions  for  two  diseases 
which  require  prolonged  treatment — namely,  venereal  disease 
and  malaria — of  which  diseases  the  average  constantly  sick 
ratio  has  increased  5 '33  per  1000.”  The  ratio  of  men 
sent  home  invalided  was  considerably  smaller  than  in  the 
two  preceding  years,  though  very  much  greater  than  in  the 
pre-war  period.  Malaria  was  again  the  great  cause  of  sick- 
ness and  inefficiency  among  the  British  troops  in  India.  The 
mortality  rate  among  the  IndUn  troops  showed  a marked 
increase,  the  figure  being  1151  per  1000  as  compared  with 
8-97  in  1916  and  8 55  in  1915.  An  increase  in  venereal 
disease  was  also  experienced  among  the  India  troops,  the 
chief  factor  in  which  is  reported  to  have  been  the  large 
number  of  young  recruits  constantly  joining  stations  and 
replacing  the  trained  men  going  on  active  service. 


Cornspanbeiue. 


" Audi  alteram  partem." 

A CRITICISM  OF 

THE  MEMORANDUM  ON  MALARIA. 

To  the  Editor  of  The  Lancet. 

Sir, — You  published  in  The  Lancet  of  July  12th  a note  | 
upon  the  Memorandum  on  Malaria,  recently  issued  by  the 
Ministry  of  Pensions,  and  purporting  to  assist  the  prac- 
titioner in  dealing  with  malaria  and,  in  particular,  with  the  j 
diagnosis,  treatment,  and  prevention  of  this  disease.  Bearing 
the  name  of  Sir  Ronald  Ross,  this  Memorandum  is  certain 
to  receive  considerable  attention,  and  to  a smaller  circle  the 
name  of  his  collaborator,  Lieutenant-Colonel  S.  P.  James, 
will  be  equally  well  known. 

Perusal  of  this  Memorandum  shows  that  it  is  written  by 
those  who  have  but  little  knowledge  of  the  circumstances  of 
general  practice  and  leads  one  to  suppose  that  adherence  to 
its  precepts  would  be  of  grave  disadvantage  to  our  patients, 
particularly  pensioners,  and  ourselves.  There  is  also  a 
wider  point  of  view.  This  is  an  official  Memorandum,  and 
may  be  presumed  to  carry  on  the  army  policy  of  occasional 
issue  of  memoranda  on  diseases  of  immediate  importance. 
The  policy  was  admirable,  but  the  actual  memoranda  were  • 
often  of  dubious  value.  One  might  well  have  hoped  that  the 
Pensions  Ministry  would  have  sought  to  improve  on  this.  It  | 
has  not  done  so.  If  the  criticisms  I make  are  sustained  | 
there  can  be  no  doubt  that  the  pamphlet  ought  to  be  super- 
seded forthwith. 

Criticisms  and  Reasons. 

I make  the  following  criticisms,  for  each  of  which  1 
adduce  reasons,  viz.  : — 

(1)  That  the  description  of  malaria  given  is  not  that  of  the 
form  of  malaria  which  will  give  us  most  trouble  in  tfae 
British  Isles,  and  is,  moreover,  calculated  rather  to  obscure 
than  to  elucidate  the  nature  of  the  disease. 

(2)  That  tfae  methods  of  diagnosis  on  which  most  emphasis 
is  laid  are  of  little  or  no  value  to  the  practitioner  in  the 
British  Isles,  and  that  important  methods  of  diagnosis  have 
been  omitted. 

(3)  That  tfae  treatment  suggested  is  not  adapted  to  the 
class  of  case  to  be  treated,  is  in  part  dangerous,  and  errs 
gravely  in  emphasising  the  value  of  quinine  and  excluding 
other  faotors  necessary  for  recovery. 

1.  Description  of  Malaria. 

The  reasons  for  my  first  criticism  are  as  follows.  The 
description  of  malaria  as  a morbid  process  takes  up  most  of 
the  paragraphs  headed  “The  Diagnosis  of  Malaria.”  It  is 
almost  wholly  devoted  to  the  nature  and  periodicity  of  acute 
attacks  of  fever.  Particular  emphasis  is  laid  on  periodicity. 
Only  in  the  rarest  cases  is  the  general  practitioner  likely  to 
be  able  to  keep  or  obtain  any  accurate  record  of  his  patient’s 
temperature.  These  paragraphs  are  therefore  almost  useless.  > 
The  description  of  a rigor  is,  of  course,  accurate  enough,  bat 
the  general  practitioner,  faced  with  a definite  rigor  in  a 
patient  returned  from  abroad,  and  probably  volunteering  the 
information  that  he  has  an  attack  of  ague,  has  no  need  to 
read  up  the  symptoms  of  malarial  rigor.  The  symptoms  of 
the  apyrexial  stage  are  hardly  mentioned,  and  the  disease 
is  dealt  with  as  if  it  consisted  of  a sequence  of  rigors 
with  an  absolutely  inactive  infection  between  times. 
This  is  scientifically  incorrect  and  misleading,  and 
clinically  very  fallacious.  However,  it  is  admitted  that 
a succession  of  rigors  may  give  rise  to  certain  signs, 
See.  These  are  described  under  the  heading  “ Malarial 
Cachexia.”  I quote,  “ Considerable  enlargement  of  the 
spleen  and  severe  anaemia  are  the  obvious  clinical 
physical  signs.”  “ Serious  symptoms  are  usually  absent 
unless  the  patient  is  suffering  from  another  disease.” 
“Chronic  irregular  ‘low’  fever  is  not  present.”  “As 
a rule,  patients  suffering  from  this  condition  are  not 
emaciated.”  One  can  only  remark  that  if  such  a condition 
as  considerable  splenic  enlargement  and  severe  anaraia 
without  serious  symptoms  or  fever  or  emaciation  does 
actually  exist,  I never  had  the  fortune  to  see  it  in  one  of 
Sir  Ronald  Ross’s  own  hospitals.  It  may  occur  in  the  tropics, 
but  it  does  not  at  home.  My  experience  in  two  special 
malaria  hospitals  strongly  suggests  that  this  sort  of  olinloal 


TheLancet,]  TRAINING  OF  JUNIOR  OFFICERS  OF  INDIAN  MEDICAL  SERVICE  IN  INDIA.  [July  19,  1919  1 27 


picture-making  is  inaccurate  and  misleading  when  addressed 
to  practitioners  in  the  British  Isles,  and  is  therefore  wholly 
out  of  place  in  the  Memorandum.  There  is  also  a list  of 
“the  chief  ‘ pernicious  ’ symptoms  sometimes  met  with  in 
oases  of  acute  malarial  fever.”  These  are  useful  in  their 
place,  but  they  are  not  nearly  so  useful  as  would  have 
been  some  account  of  the  symptoms  as  we  shall  see  them 
and  as  they  have  actually  been  seen  in  the  hospitals  over 
which  Sir  Ronald  Ross  held  sway.  I would  instance 
chronic  tachycardia  and  “ effort  syndrome,”  chronic  head- 
ache and  depression,  chronic  pains  in  the  side,  &c.  I 
have  dealt  with  these  elsewhere.1  My  subsequent  experience 
has  shown  me  that  I was  right  in  supposing  that  it  was  such 
symptoms  as  these  that  were  going  to  be  the  despair  of 
medical  referees,  medical  boards,  and  practitioners,  whereas 
those  of  the  acute  attack  presented  no  difficulty.  I should 
like  further  to  state  that  these  symptoms  were  studied  only 
with  the  strongest  official  discouragement,  even  to  the  extent 
of  refusal  of  permission  to  publish  any  paper  on  them.  That 
this  should  be  so  makes  one  doubly  anxious  to  raise  discussion 
on  the  deductions  of  Sir  Ronald  Ross  and  others  from  the 
same  material,  for  the  two  different  views  we  have  of  the 
disease  as  seen  at  home  are  scarcely  compatible,  and  it  is 
well  that  truth  should  prevail. 

2.  Methods  of  Diagnosis. 

My  second  point  is  that  the  methods  of  diagnosis  on  which 
most  emphasis  is  laid  are  of  little  or  no  value  to  the  prac- 
titioner in  the  British  Isles.  These  methods  are  three.  The 
first  is  entitled  “ Clinical  Symptoms  and  Signs.”  The  only 
one  mentioned  is  periodic  fever.  This  is  the  one  sign  of  which 
the  practitioner  can  hardly  hope  to  get  accurate  record. 
The  second  is  “The  Results  of  Blood  Examination.”  No 
mention  is  made  of  what  results  are  to  be  expected,  pre- 
sumably nothing  but  the  presence  of  the  parasite  suffices. 
Yet  there  are  other  important  points  in  the  blood  examina- 
tion— e.g.,  pigment  cells  ; and  even  if  the  practitioner  may 
be  presumed  to  be  too  busy  to  examine  his  own  blood  slides, 
he  might  at  least  be  put  in  a position  to  understand  a 
specialist  report  on  the  same.  The  third  point  is  “The 
Effects  of  Therapeutic  Doses  of  Quinine.  ” We  may  sometimes 
be  driven  to  this  resort,  and  it  is  one  to  bear  well  in  mind, 
but  it  is  not  the  kind  of  method  which  much  enhances  one’s 
reputation  among  patients,  and  it  is  absolutely  useless  unless 
fever  be  actually  present.  Most  of  the  pensioners  who  have 
come  to  me  for  advice  had  to  be  diagnosed  by  means  other 
than  any  of  these  three,  and  so  also  will  they  have  to  be 
diagnosed  and  their  pensions  assessed  by  medical  boards  and 
referees.  No  other  method  of  diagnosis  is  mentioned.  Might 
not  the  hyperalgesic  areas  described  by  Carmalt  Jones  have 
been  just  mentioned?  Is  not  herpes  labialis  important  con- 
firmatory evidence  where  a recent  attack  is  alleged,  or  peri- 
splenitis, or  slight  jaundice?  I feel  fully  justified  in  the 
statement  that  the  methods  of  diagnosis  laid  down  are  of 
little  use  to  practitioners,  while  those  omitted  would  have 
been  of  great  assistance. 

3.  Treatment  Suggested. 

My  third  point  is  that  the  treatment  suggested  is  not 
adapted  to  the  class  of  case  to  be  treated,  is  in  part 
dangerous,  and  errs  gravely  in  emphasising  the  value  of 
quinine  and  excluding  other  factors  necessary  for  recovery. 
The  treatment  advocated  is  quinine  and  nothing  else.  This 
is  to  be  given  for  three  months  after  each  acute  attack.  I 
have  seen  a great  many  patients  from  Sir  Ronald  Ross’s 
hospitals,  and  never  did  I meet  one  who  could  suggest  he 
was  cured  by  any  method  of  giving  quinine.  Some  had  had 
heroic  doses,  some  had  had  none.  One  of  the  latter  was 
cured,  many  of  the  former  were  certainly  not.  This  is  a 
vexed  question,  but  I would  ask  fellow-practitioners  dealing 
with  malaria,  which  is  being  overcome  by  the  natural  resist- 
ance of  the  body  in  this  country,  not  to  follow  methods  which 
may  be  suitable  for  those  who  are  liable  to  frequent 
reinfection — a distinction  between  cases  which  Sir  Ronald 
Ross  does  not  seem  to  make  or  to  consider  to  have  any 
bearing  on  treatment.  The  treatment  I brand  as  dangerous 
is  that  by  the  intramuscular  route  The  instructions  are 

11 the  operation  presents  no  difficulty.  The  stab  should 

be  made  deeply  into  the  gluteal  muscle  and  the  solution 
injected.”  The  result  of  such  instructions,  or  lack  of 
more  definite  instructions,  resulted  in  so  many  paralysed 

1 Proc.  Roy.  Soc.  Med.,  1919,  xii.,  Section  of  Medicine,  pp.  15-36. 


limbs  that  I was  informed  by  an  officer  on  a hospital  ship 
that  each  boat  was  bringing  home  four  or  five  cases. 
Certainly  there  followed  stringent  orders  that  intra- 
muscular quinine  must  only  be  given  under  the  super- 
vision of  the  officer  in  charge  of  a medical  division. 
Moreover,  Colonel  Leonard  Dudgeon  has  recently  most 
ably  demonstrated  the  destructive  results  of  intramuscular 
injections.  Are  we  to  learn  our  lessons  so  badly  that  this 
method  is  still  to  be  advocated  with  all  the  weight  of  Sir 
Ronald  Ross’s  name  and  the  approval  of  a Government 
department?  We  may  well  say,  “ Pity  the  poor  pensioner.” 
Finally,  I desire  to  draw  attention  to  the  total  lack  of  any 
mention  of  the  general  hygienic  treatment  of  malaria  as 
carried  out  in  convalescent  camps  and  of  the  peculiar 
measures  adapted  to  the  successful  treatment  of  such  other- 
wise fatal  complications  as  blackwater  fever,  and,  generally 
speaking,  the  “pernicious”  symptoms  referred  to  in  the 
Memorandum. 

The  Author's  Views. 

I fully  recognise  the  fact  that  I am  pitting  the  opinions 
of  an  unknown  individual  against  those  of  an  acknowledged 
authority.  But  the  practical  results  of  this  authority  and  a 
genuine  interest  in  the  welfare  of  pensioners  compels  me 
to  the  opinion  that  it  is  high  time  someone  spoke  up.  I 
would  state  my  own  views  on  the  diagnosis  and  treatment 
of  malaria  as  follows  : — 

1.  The  diagnosis  of  malaria  as  seen  between  actual 
attacks  in  this  country  can  only  be  made  by  careful 
investigation  of  all  the  symptoms,  including  particularly 
those  mentioned  in  the  paper  referred  to,  and  only  by  such 
careful  attention  can  any  proper  estimate  of  the  degree  of 
disablement  be  made. 

2.  The  most  important  principle  in  the  treatment  of  malaria 
in  pensioners  is  the  improvement  of  the  natural  resistance  of 
the  body  with  the  aid  of  as  little  quinine  as  possible. 

I am,  Sir,  yours  faithfully, 

Gordon  Ward,  M.D.  Lond. 

Sevenoaks,  Kent,  July  14th,  1919. 


TRAINING  OF  THE  JUNIOR  OFFICERS  OF  THE 
INDIAN  MEDICAL  SERVICE  IN  INDIA. 

To  the  Editor  of  The  Lancet. 

Sir, — The  enclosed  letter,  addressed  to  the  Secretary  of 
State  for  India,  if  published  in  The  Lancet,  should  arouse 
professional  interest  in  a very  important  question. 

I am,  Sir,  yours  faithfully, 

G.  J.  H.  Evatt,  M.D., 

July  10th,  1919.  Major-General  (retd.). 

[Enclosure.] 

From  Major-General  Sir  George  J.  H.  Evatt,  K.C.B.,  M.D., 

Junior  United  Service  Club,  London,  S.W.  1. 

To  the  Right  Hon.  the  Secretary  of  State  for  India, 

India  Office,  London.  July  10th,  1919. 

Sir, — I have  the  honour  to  submit  the  following  proposals 
as  to  further  training  in  India  of  the  young  officers  of  the 
Indian  Medical  Service  before  appointment  to  any  medical 
post  in  India. 

(2)  All  newly  appointed  medical  officers  to  be  detained  at 
Bombay  on  arrival  for  six  weeks  and  to  be  constituted  in  a 
“class”  to  study  Health  Conditions  and  Sanitary  Arrange- 
ments in  and  about  Bombay  city  and  neighbourhood. 

(3)  Representative  officials  of  local  experience  to  show  and 
explain  to  the  class  of  young  officers  : — 

(a)  The  system  of  Drainage  of  Bombay  city. 

(b)  The  Sewerage  system  of  Bombay  city  and  district. 

(c)  The  Water-supply  system  as  to  collection,  storage,  and 
distribution. 

( d ) Public  Baths  and  Wash-houses. 

(i e ) Segregation  of  Infectious  and  Contagious  Diseases, 
arrangements  for  prevention  and  treatment  of  Cholera, 
Small-pox,  Plague,  Malaria.  Segregation  hospitals.  Vaccina- 
tion in  full.  Leprosy  to  be  studied  in  full. 

(f)  Hospitals  in  Bombay  to  be  visited  as  to  structure. 
Training  of  nurses.  Convalescent  establishments  attached 
to  hospitals.  The  cost  and  expenditure  of  hospitals  and  the 
means  of  raising  funds  explained. 

(g)  Lunacy  and  Lunatic  Asylums  to  be  fully  visited  and 
explained  to  the  young  officers  in  a class  by  efficient 
specialist  officer. 

(h)  The  Races  of  the  Indian  People  to  be  explained  by  a 
skilled  specialist  in  this  racial  subject. 

(j)  The  Creeds  and  Castes  of  the  Indian  People  to  be 
popularly  explained  to  the  young  officers. 

(fc)  Outline  description  of  the  Indian  Empire,  its  Presi- 
dencies, Native  states.  Provinces,  and  description  of  Govern- 
ment methods.  The  Province  and  the  District. 


128  The  Lancet,] 


INDUSTRIAL  MEDICAL  SERVICE. 


[July  19,  1919 


(l)  The  Methods  of  dealing  with  prisoners  under  confine- 
ment in  jails  throughout  the  country.  Jails  to  be  visited 
and  explained  to  the  young  officers  very  fully. 

(m)  The  Cantonment  of  Poona  to  be  visited,  studied,  and 

explained  by  competent  local  officers.  Barracks  and  hos- 
pitals to  be  seen.  . 

(n)  The  class  to  he  controlled  by  the  Director  of  Medical 
Services,  Bombay,  who  would  nominate  instructors  and 
maintain  discipline  during  the  course. 

(o)  Detention  Allowance  to  be  granted  to  the  young 
officers.  A medical  officer  not  under  the  rank  Of  Major  to 
be  attached  to  the  class  pro  tem.  as  Discipline  Officer  and 
Director  of  Studies  and  Chief  Instructor.  Two  officers  as 
assistant  instructors  could  be  allowed. 

(p)  An  Examination  might  be  held  at  the  termination  of 
the  class  to  see  what  progress  has  been  made. 

(, q ) Certain  public  men  who  would  represent  sections  of 
the  Indian  people  to  be  invited  to  address  these  young 

officers  during  the  course  of  study.  , . 

I should  be  glad  to  have  an  acknowledgment  of  this 
letter  Your  obedient  servant, 

Loudon,  1919.  G.  J.  H.  EVATT,  M.G. 


INDUSTRIAL  MEDICAL  SERVICE. 

To  the  Editor  of  The  Lanoet. 


civilian  community.  Cases  will  arise  in  which  the  apparent 
interest  of  the  factory  runs  counter  to  that  of  the  man,  as 
when  tuberculosis  or  venereal  disease  is  in  question.  How. 
then,  can  a doctor  serve  both  masters  fairly  and  please  both  ? 
He  will  also  run  the  risk  of  losing  practice  if  he  does  not 
please  the  worker  and  his  wife  by  his  decisions. 


Sir, — Dr.  Prosser  White’s  letter  in  The  Lancet  of 
July  5th  emphasises  two  of  the  most  important  duties  of 
a real  factory  doctor — i.e.,  close  familiarity  with  actual 
working  conditions  and  the  necessary  investigation  of  all 
cases  of  injury.  To  familiarise  himself  properly  with  the 
conditions  of  employment  and  with  the  reactions  of  the 
workers  to  their  work  the  doctor  should  practically  live  and 
work  amongst  his  workers.  Periodical  inspection  by  a trained 
observer  can,  perhaps,  do  much,  but  even  in  his  case  several 
days  spent  in  the  factory  would  throw  light  on  much  that 
passes  unnoticed  or  appears  obscure  on  a cursory  inspection 
and  would  familiarise  him  with  the  local  difficulties  which 
his  full-time  colleague  appreciates  so  thoroughly.  For  the 
purpose  of  prevention  of  accident  and  disease  the  constant 
supervision  of  the  factory  M.O.  and  of  his  “tentacles  i.e., 
the  foremen,  works  managers,  &c.,  who  work  with  him  to  the 
common  end  of  good  output,  health,  and  content  of  workers 

is  far  more  valuable  to  both  workers  and  management  than 

occasional  visits  by  headquarters  staff  and  by  the  C.F.S. 
when,  and  not  till  when,  some  trouble  has  occurred.  More- 
over, the  full-time  man  will  have  examined  every  worker  and 
carded  his  findings  for  reference.  This  index  will  serve  as 
evidence  in  case  of  a claim  for  compensation  under  the 
Workmen’s  Compensation  Act. 

The  Industrial  “ Expert." 

In  the  second  of  your  special  articles  on  an  industrial 
medical  service  you  suggest  that  it  is  for  the  Certifying 
Surgeons’  Association  to  organise  proper  training  schemes 
for  the  training  of  the  industrial  specialist.  But  in  so  doing 
the  interests  of  the  full-time  medical  officer  and  that  of  the 
lay  workers  in  the  factory  should  be  studiously  borne  in 
mind.  In  practice  full-time  medical  officers  handle  many 
things  which  at  first  sight  do  not  appear  strictly  within  the 
duties  of  a medical  man,  such  as  absenteeism  and  its  preven- 
tion, causes  of  wastage  of  factory  personnel,  the  administra- 
tion of  the  Workmen’s  Compensation  Act,  canteen  supervision, 
and  the  investigation  of  many  grievances  of  workmen  (since 
there  is  very  often  a medical  side  to  such). 

I can  scarcely  consider  the  quarterly  inspection  of  workers 
as  adequate  to  detect  hygienic  faults.  Nor  is  it  satisfactory 
to  leave  the  working  out  of  the  remedies  to  an  “ expert 
from  headquarters,  invaluable  though  his  advice  may  be  in 
its  proper  place.  The  full-time  medical  officer  is  also  in  a 
better  position  to  get  faults  remedied  than  the  headquarters 
man,  since  he  can  continue  worrying  the  management  until 
the  fault  is  remedied. 


Supply  and  Demand. 

It  is  true  enough,  as  stated  in  the  article,  that  supply 
creates  demand  ; and  here  trained  factory  doctors  are  the 
supply.  But  demand  should  be  stimulated  simultaneously, 
and  that  was  why  I wrote  to  the  Times  and  Cassier's 
Monthly  rather  than  in  the  first  instance  to  medical  papers. 
The  daily  press  has  avoided  such  subjects  till  lately,  perhaps 
fearing  that  the  political  aspect  of  attempts  to  benefit  the 
condition  of  workers  might  do  them  harm.  Managers  in  the 
past  have  regarded  the  doctor  askance,  since  it  is  through 
his  certificates  that  they  have  lost  labour.  Some  of  them 
are  beginning  to  see  that  had  the  doctor  been  in 
charge,  they  might  have  at  least  lost  less  labour, 
since  he  would  probably  have  sent  the  worker  off 
duty  sooner,  and  so  prevented  a prolonged  illness.  More- 
over, the  full-time  man  is  far  more  in  a position  to 
judge  whether  the  disease  or  injury  was  in  fact  due  to 
factory  conditions  than  an  outsider,  since  he  should  have  at 
his  disposal  the  records  of  work  done  by  each  worker  on  any 
day,  as  well  as  legal  evidence,  with  witnesses’  names,  in  case 
of  accident,  besides  a more  intimate  knowledge  of  the 
factory  conditions  and  of  any  peculiarities  in  the  way  of 
special  poisonings  or  disorders  due  to  special  processes  used 
in  the  factory.  The  value  of  a full-time  doctor  previously 
trained  in  factory  medicine  and  law,  as  well  as  in  the  other 
accessory  subjects  needed  by  a factory  doctor,  will  be 
evident  to  an  enlightened  manager,  and  such  a doctor  will 
stand  a better  chance  of  getting  a good  appointment.  It  is 
of  no  use  to  supply  these  men  without  some  sort  of  guarantee 
that  they  will  get  suitably  paid  jobs.  If  we  would  raise  the 
demand  for  trained  factory  doctors,  we  should  address  the 
managers  in  terms  of  output,  the  workers  in  those  of  wages, 
and  the  general  public  in  those  of  industrial  peace  ana 
health.  The  three  things  are  synonymous,  but  the  form  in 
which  they  appeal  to  the  different  classes  concerned 
varies,  and  should  be  considered  in  our  appeals.  The 
type  of  man  to  train  as  a factory  doctor  is  the  enthusiast 
with  the  doggedness  of  the  “importunate  widow.”  He 
should  have  had  some  training  in  research  methods,  anc 
should  be  a good  physiologist  and  psychologist,  knowiDt 
something  of  mass-psychology. 

I am,  Sir,  yours  faithfully, 

July  5th,  1919.  H-  George  P.  Castellain.  ; 


The  Factory  Doctor  and  Private  Practice. 

It  is  doubtful  how  much  private  practice  a factory  doctor 
should  undertake.  On  the  one  hand,  he  should  be  in  touch 
with  the  modern  developments  of  medicine,  but  on  the  other 
it  is  his  duty  to  treat  the  factory  rather  than  the  individual 
worker,  which  means  that  his  function  is  preventive  rather 
than  curative  so  far  as  the  individual  is  concerned.  The 
workman’s  panel  doctor  is  the  man  to  represent  the  private 
interests  of  the  individual.  Moreover,  the  man  has  a legal 
right  to  free  choice  of  doctor,  and  an  attempt  to  force  him  to 
choose  the  factory  doctor  is  scarcely  to  be  desired  in  a 


EPIDEMIC  PERINEPHRIC  SUPPURATION. 

To  the  Editor  of  The  Lancet. 

Sir, —The  recent  letters  in  The  Lancet  on  the  abovi 
subject  must  have  been  of  great  interest  to  a large  numbe 
of  medical  officers  who  have  served  abroad  during  the  las 
few  years.  In  Macedonia  there  were  many  cases  : th< 
diagnosis  was  complicated  by  the  prevalence  of  large  an< 
tender  livers  and  spleens.  Lieutenant-Colonel  J.  Patrick  ant 
the  writer  collected  the  notes  of  some  20  cases  last  year,  ant 
this  number  falls  far  short  of  the  total  that  occurred  in  th 
Force.  As  regards  bacteriology,  Staphylococcus  aureus  i 
undoubtedly  the  usual  organism  present  in  the  pus.  In  on 
case  Captain  R.  R.  Elworthy  isolated  a Staphylococcus  albv 
and  this  was  confirmed  by  Colonel  Leonard  Dudgeon 
Dr.  W.  Pasteur  may  be  interested  to  hear  that  I know  o 
five  cases  who  died  of  staphylococcal  pyeemia.  In  at  leas 
one  of  these  Staphylococcus  aureus  was  isolated  by  bloo< 
culture.  As  regards  his  statement  that  “ the  urine  neve 
contained  pus,”  pus,  in  quantities  varying  from  a trace  t 
a’  considerable  quantity,  was  present  in  half  our  cases 
Albumin  w'as  present  in  rather  more  than  half,  and  Staph  yu 
oocous  aureus  was  isolated  from  the  urine  in  rather  less  tha 
half  the  cases.  ^ 

Radiographic  examination  was  helpful  in  some  cases,  th 
usual  signs  being  a haziness  on  the  affected  side  with  los 
of  definition  of  the  kidney  shadow  and  of  the  shadow 
thrown  by  the  psoas  and  quadratus  lumborum.  Diminutio 
of  the  movement  of  the  diaphragm  on  the  affected  side  wa 
also  noted  in  some,  with  absence  of  elevation  of  the  dome 
a point  which  helped  to  differentiate  a right  perinephri 


Thh  Lanoht,] 


OBITUARY. 


abscess  from  a hepatic  abscess.  The  vertebral  shadows  were 
normal.  All  the  cases  referred  to  occurred  before  the  influenza 
scourge  reached  the  Balkans.  I have  no  reason  to  think 
that  influenza  affected  the  incidence  of  the  perinephric 
infection,  though  I have  heard  of  cases  in  which  this  abscess 
occurred  in  patients  suffering  from  influenza  and  pneumonia. 

I am,  Sir,  yours  faithfully, 

H.  A.  T.  Fairbank, 

Major,  R.A.M.C.  (T.F.),  lato  Lieutenant-Colonel;  Assistant 
Consulting  Surgeon,  IS.S.F. 

Harley-street,  W.,  July  9th,  1919. 


THE  POSITION  OF  NATIONAL  STATISTICS. 

To  the  Editor  of  The  Lancet. 

Sir, — It  is  a matter  of  common  knowledge  to  all  who  have 
had  occasion  to  use  official  statistics,  whether  published  or 
departmental,  that  the  national  and  imperial  equipment  for 
obtaining  and  publishing  statistical  data  is  very  imperfect  in 
its  scope  and  inadequate  in  its  machinery.  Further,  the 
efforts  made  are  departmental,  are  under  no  common  con- 
trolling or  directing  authority,  and  suffer  very  gravely  from 
lack  of  coordination.  There  is  no  need  to  adduce  proofs  of 
these  statements  nor  to  enumerate  the  various  efforts,  fruitless 
in  the  main,  which  have  hitherto  been  made  to  remedy  these 
defects. 

The  Council  of  the  Royal  Statistical  Society  have  appointed 
a special  committee  to  deal  with  the  subject  in  the  belief 
that  the  time  is  now  ripe  for  a new  movement  in  the  direction 
of  reform  and  that  the  consciousness  of  the  existing  defects 
is  present  to  the  minds  of  His  Majesty's  Ministers,  Members 
of  Parliament,  and  civil  servants,  as  well  as  to  others 
interested  in  statistics.  It  is  proposed  to  petition  His 
Majesty’s  Government  to  set  up  a Parliamentary  Committee 
to  examine  the  whole  question  of  the  collection  and  presenta- 
tion of  public  statistics,  and  to  report  on  means  of  improve- 
ment. It  is  believed  that  this  method  of  procedure  is  more 
likely  to  be  effective  than  the  pressing  of  specific  pro- 
posals on  His  Majesty’s  Ministers.  The  officers  of 
local  governing  and  other  public  bodies,  as  well  as  of 
scientific  societies,  are  being  invited  to  bring  the  matter 
at  once  before  their  councils.  Moreover,  publicists  and 
others  who  are  known  to  be  interested,  are  being  approached 
directly. 

We  ask  the  courtesy  of  your  columns  to  lend  support 
to  this  movement,  and  invite  your  readers  to  help  with 
their  influence  and  signatures.  The  Council  will  be  glad  if 
all  who  are  disposed  to  sign  such  a petition  would  com- 
municate with  the  Secretary,  Official  Statistics  Committee, 
Royal  Statistical  Society,  9,  Adelphi-terrace,  W.C.  2.  A 
copy  of  the  petition  will  then  in  due  course  be  sent  to  them 
for  signature.  I am,  Sir,  yours  faithfully, 

Geoffrey  Drage, 

July  10th,  1919.  Chairman,  Official  Statistics  Committee. 


HUTCHINSON’S  TEETH. 

To  the  Editor  of  The  Lancet. 

Sir, — The  point  raised  by  Dr.  David  Walsh  in  a letter  in 
your  issue  of  July  12th  has  been  dealt  with  by  two  masters 
of  the  craft.  Sir  Jonathan  Hutchinson,1  in  an  original  com- 
munication to  the  Pathological  Society,  made  the  following 
statement : — • 

“The  recognition  of  the  subjects  of  inherited  syphilis,  by  means  of 
their  incisor  teeth,  can  only  be  effected,  with  any  confidence,  between 
the  ages  of  8 and  from  25  to  30.  Later  than  31  the  notches  have 
generally  been  worn  level,  and  the  teeth  merely  resemble  those  of  a 
much  older  person.  I have  seen  teeth  preserving  their  peculiar 
syphilitic  stamp  in  patients  of  middle  age,  but  in  a large  majority  of 
instances  such  is  not  the  fact.” 

Professor  A.  Fournier,2  in  his  lectures  on  the  subject, 
states — the  translation  is  a literal  one  : 

“A  second  point,  and  one  of  real  practical  interest : the  Hutchinson 
tooth  modifies  itself  in  form  beyond  the  age  of  adolescence  and  finishes 
by  losing  absolutely  its  characteristic  notch.  Under  the  influence  of 
functional  use  the  arch  of  the  free  border  diminishes  progressively  in 
height,  and  the  mathematical  rise  is  lowered.  It  might  be  described 
as  an  arch  which  is  falling  in.  There  comes  a time  when  the  curve  of 
the  arch  is  scarcely  perceptible.  The  arch  appears  to  have  straightened 
itself  out.  Finally,  all  trace  of  the  notch  disappears,  and  the  free 
border  transforms  itself  into  a nearly  straight  line.  To  be  precise,  from 
the  age  of  20  to  22  years,  the  notch  is  markedly  lessened. 


1 Trans.  Path.  Socty.,  x.,  296. 

La  Syphilis  Hereditaire  Tardive,  1886,  pp.  91,  92. 


[July  19,  1919  129 


at  25  it  iH  almost  straight.  At  this  period  there  still  exists,  fora 
certain  time  at  least,  a certain  sign  which  allows  us  to  recognise  a lesion, 
it  u the  bevel  of  the  anterior  border  of  the  notch.  Remember  that  the 
Hutohinson  notch  is  cut  away  from  above  downwards,  and  from  before 
backwards  at  the  expense  of  the  anterior  border.  This  hevol,  which 
caps  and  dominates  the  notch,  is  naturally  only  affected  in  tho  later 
stages,  by  the  rubbing  away  of  the  tootb,  therefore  it  persists,  and  is 
quite  easily  recognisable,  at  a period  when  the  notch  has  disappeared. 
It  constitutes,  therefore,  the  last  trace  of  the  lesion.  After  the  age  of 

25  years  the  bevel  in  its  turn  becomes  effaced  this  fact  is  so  well 

known  that  it  has  been  very  truly  stated  that  after  the  thirtieth  year 
the  Hutchinson  tooth  no  longer  exists.” 

To  illustrate  his  lecture  Fournier  showed  a case  which 
must  have  very  closely  resembled  the  case  described  by  Dr. 
Walsh.  I am,  Sir,  yours  faithfully, 

G.  D.  Kettlewell. 

V.D.  Clinic,  South  Devon  and  East  Cornwall  Hospital, 

Plymouth,  July  12th,  1919. 


FREDERICK  PAGE,  M.D.  Edin.,  F.R.C.S.  Eng., 
D.C.L.  Durh., 

EMERITUS  PROFESSOR  OF  SURGERY  IN  THE  UNIVERSITY  OF  DURHAM. 

Professor  F.  Page  died  at  his  residence,  20,  Victoria-square, 
Newcastle-on-Tyne,  on  July  3rd,  at  the  age  of  79  years. 
He  was  the  son  of  a well-known  surgeon  in  Portsmouth,  and 
after  a private  school  education  entered  Edinburgh  Uni- 
versity, where  he  graduated  M.D.  in  1868,  becoming  house 
physician  at  the  infirmary,  and  then  enlarging  his  range  of 
vision  by  a trip  to  Western  Australia,  where  he  held  a 
position  at  the  Colonial  Hospital,  Perth.  Four  years  on  the 
junior  staff  of  the  Royal  Infirmary,  Newcastle-on-Tyne, 
determined  his  stay  in  the  city  with  which  his  professional 
and  public  activities  were  thereafter  identified.  As  a 
surgeon  his  reputation  soon  extended  beyond  the  Royal 
Infirmary  and  the  Fleming  Memorial  Hospital  for  Sick 
Children,  where  his  attendance  was  assiduous.  He  became 
professor  of  surgery  in  the  University  of  Durham  and 
registrar  of  the  College  of  Medicine,  receiving  in  1888  the 
degree  of  M.A.  (hon.  causa),  and  examining  in  clinical 
surgery  at  his  old  University  of  Edinburgh.  To  a number 
of  special  hospitals  he  was  also  attached  in  a consulting 
capacity.  To  most  men  these  onerous  duties  would  have 
afforded  sufficient  outlet  for  their  powers,  but  Page  contrived 
to  reconcile  a life  of  public  service  with  his  many  pro- 
fessional engagements.  He  was  on  the  Commission  of  the 
Peace,  becoming  chairman  of  the  visiting  committee  of  prison 
justices  and  presided  over  the  licensing  committee  for  the 
city.  In  private  life  his  tastes  were  literary  and  dramatic. 

Professor  Page  married  in  1876  the  eldest  daughter  of 
Mr.  John  Graham  and  niece  of  Professor  T.  Graham,  F.R.S. , 
sometime  Master  of  the  Mint,  by  whom  he  had  a son  and 
two  daughters.  


Sir  J.  H.  MEIRING  BECK. 

The  death  of  Senator  Sir  J.  H.  Meiring  Beck,  M.R.C.P., 
F.R.S.E.,  Minister  of  Posts  and  Telegraphs  in  General  Louis 
Botha’s  Cabinet,  is  a great  loss  to  the  Union  of  South  Africa. 
Sir  Meiring  Beck  was  a true  South  African,  and  his  chief 
aim  during  his  political  life  was  to  heal  racial  estrange- 
ments and  mollify  party  asperities.  While  a loyal  adherent 
of  General  Botha,  he  was  popular  with  all  political  parties. 
He  combined,  in  fact,  in  no  small  degree  the  best  attributes 
of  a cultured  English  gentleman  with  the  fervour  of  the 
Africander  patriot.  Born  at  Worcester,  Cape  Province,  in 
1856,  he  was  educated  at  the  South  African  College,  Cape  Town, 
and  afterwards  studied  medicine  in  Edinburgh,  Berlin,  and 
Vienna.  At  Edinburgh  he  graduated  with  first-class  honours, 
gaining  the  Beaver  Scholarship.  He  practised  at  Kimberley, 
Worcester,  and  Rondebosch,  becoming  President  of  the 
Colonial  Medical  Council  and  President  of  the  British  Medical 
Association,  Cape  Town.  For  over  20  years  he  was  a 
member  of  the  Cape  University  Council. 

Sir  Meiring  Beck  represented  his  native  town  of  Worcester 
in  the  Cape  Parliament,  was  a Cape  delegate  at  the  National 
Convention  of  1908-9,  and  on  the  creation  of  the  Union  was 
made  a Senator.  After  filling  the  post  of  chairman  of  com- 
mittees in  the  Senate  he  became  Minister  of  Posts  and 
Telegraphs  in  1916. 


130  The  Lancet,] 


MEDICAL  NEWS. 


[July  19  1919 


lltoital  JUtos. 


Royal  College  of  Surgeons  of  England. — A 
quarterly  meeting  of  the  Council  was  held  on  July  10th,  Sir 
George  H.  Making,  the  President,  being  in  the  chair. — The 
President  reported  the  result  of  the  recent  meeting  of 
Fellows  for  the  election  of  two  members  of  Council  as 
given  in  The  Lancet  of  July  12th,  and  Sir  Berkeley 
Moyniban  and  Sir  Cuthbert  Wallace  were  introduced  and 
made  declarations  in  the  terms  of  the  oath  prescribed  by 
the  Charter  of  1800  and  took  their  seats  as  members  of  the 
Council.— It  was  resolved  to  grant,  in  conjunction  with  the 
Royal  College  of  Physicians  of  London,  Diplomas  in  Public 
Health  to  12  successful  candidates  (11  men  and  one  woman). 
— The  recent  resolution  of  the  General  Medical  Council  that 
every  student  should  be  required  in  future  to  attend  a 
practical  course  in  ophthalmology  was  considered,  and 
it  was  resolved  to  refer  it  to  the  Committee  of 
Management  for  consideration. — A letter  was  read 
from  the  secretary  of  the  Joint  Matriculation  Board 
of  the  Universities  of  Manchester,  Liverpool,  Sheffield, 
and  Birmingham,  inquiring  if  the  College  would 
accept  the  school  certificate  issued  by  the  Board  for  the 
purpose  of  the  exemption  of  the  holder  of  such  a certificate 
from  the  Preliminary  examination.  The  matter  was  referred 
to  the  Committee  of  Management. — A letter  was  read  from 
Dr.  F.  YVood  Jones  resigning  his  appointment  as  Examiner 
iu  Anatomy  under  the  Conjoint  Examining  Board  in  con- 
sequence of  his  having  been  appointed  to  the  chair  of 
anatomy  in  the  University  of  Adelaide. — It  was  resolved 
that  Dr.  Wood  Jones’s  resignation  should  be  accepted  and 
should  take  effect  on  his  departure  from  England  in  the 
autumn.  It  was  further  resolved  that  he  should  be  per- 
mitted to  deliver  his  Arris  and  Gale  lecture  in  October 
next. — The  President  reported  his  attendance  at  meetings 
of  the  panel  to  assist  the  Minister  of  Health  in 
the  formation  of  a Consultative  Medical  Council.  A 
letter  was  read  from  Dr.  Christopher  Addison,  stating 
that,  with  the  advice  of  the  temporary  panel  constituted  in 
accordance  with  the  terms  of  his  letter  of  May  27th  last,  b& 
had  framed  the  list  of  bodies  to  be  invited  to  suggest  the 
names  of  persons  suitable  to  become  members  of  the 
Consultative  Council  on  Medical  and  Allied  Services  to  be 
set  up  in  England  under  the  Ministry  of  Health  Act,  1919, 
and  asking  the  Royal  College  of  Surgeons  of  England  to 
furnish  him  with  the  names  of  six  persons  who,  in  its 
opinion,  would  be  specially  suitable,  if  appointed  by  him, 
to  serve  upon  the  Council  as  first  constituted  ; poiuting  out 
that,  while  it  is  desirable  that  the  Minister  should,  before 
coming  to  his  decision,  have  as  large  a range  as  practicable 
of  persons  willing  and  suitable  to  serve  only  a relatively 
small  proportion  of  the  persons  whose  names  are  suggested 
cau  in  the  first  instance  find  a place  upon  the  Council,  the 
total  membership  of  which  might  with  advantage  be  kept 
below  the  maximum  number  of  20  contemplated  by  the 
Order;  and  stating  that  the  Act  provides  for  the  payment 
to  members  of  the  Council  of  a subsistence  allowance  and 
reasonable  compensation  for  loss  of  remunerative  time  and 
for  the  repayment  of  travelling  expenses.  The  matter  was 
referred  to  a committee  to  consider  and  report. — Sir 
George  Makins  was  re-elected  President,  and  Sir  Anthony 
A.  Bo  wl  by  aud  Sir  John  Bland-Sutton  were  elected  Vice- 
presidents.  Sir  D’Arcy  Power  was  re-elected  a member  of 
the  Executive  Committee  of  the  Imperial  Cancer  Research 
Fund.— The  next  meeting  of  the  Council  will  be  held  on 
Thursday,  July  24th. 

University  of  Bristol.— The  following  pro- 
fessorial appointments  have  been  made  Chair  of  Educa- 
tion : Helen  Marion  Wodehouse.  M.A.,  D.Phil.,  Principal  of 
the  Bingley  Training  College,  Yorkshire;  Henry  Overton 
Wills  Chair  of  Physics:  Arthur  Maunering  Tyndall,  D.Sc., 
Acting  Head  of  the' Department  of  Physics  in  the  University 
during  the  war ; Henry  Overton  Wills  Chair  of  Physiology: 
George  A.  Buckmaster,  M.A.,  M.D.,  D.P.H.,  Assistant 
Professor  of  Physiology  in  the  University  of  London. 

At  examinations  held  recently  the  following  candidates 
were  successful : — 

Degrees  of  M.B.,  Cb.B. 

Fin  il  Exaviinatinn,  V irt  I.  only  ( including  Forensic  Medicine  and 
Toxicology). — Hilda  M , ry  Brown., 

Second  Examination,  Part  II.  (completing  exami  lotion). — Macdonald 
Critchley,  John  Hukio  Duerden.  and  Phyllis  Thekla  Siepmann. 

Diploma  in  Dental  Surgery. 

Final  E.caminaH in.— Violette  B m-geois. 

Third  Examination. — Edward  Jaiue»  Tucker. 

Second  Examination.  — Norman  Harry  Bodonham  an!  Kenneth 
George  Hyland. 

Diploma  in  Public  Health. 

Alison  Bdgar  Wilson. 


University  of  Manchester. — The  following  have 
obtained  the  Diploma  in  Public  Health  of  the  University;— 

A.  W.  Baker,  G.  H.  T N.  Clarke,  C.  J.  Crawford,  C.  C.  Hargreaves, 

A.  Heath.  J.  L.  Meynell,  E.  N.  Himsbi  tom,  II.  F.  Shekion,  and 
E.  H Walker. 

Royal  College  of  Physicians  of  Edinburgh, 
Royal  College  of  Surgeons  of  Edinburgh,  and  Royal 
Faculty  of  Physicians  and  Surgeons  of  Glasgow.— The 
following  candidates  have  passed  the  Triple  Qualification 
Examinations : — 

Final  Ex4.mina.tion. 

John  Stewart  Marshal!  Connell,  Robert  Berry  Forgan,  Poon  Lip  Loh, 
Thomas  Lloyd  Eiwards,  John  Kohler  Steel.  John  Fraser  Kerr, 
Shem  Stein.  Thomas  Richard  O'Keeffe.  William  Gibb.  Daniel  Adrian 
Stegm  tn,  Maurice  Julius  Woodberg.  and  Jung  Bahadur  Singh. 
Medicine — Norman  Joseph  Patterson,  Mandavam  Anandampillay 
Part  has*  rat  by  Iyengar,  Gord  >n  Beveridge,  Thomas  Dier.  L^wis 
Rifkind,  John  Alfred  Alexander  Duncan,  and  John  Richard  Larson* 
Surgery . — Thomas  Dier,  Thorrus  Ferguson  Minford,  and  Thomas 
Bianey. 

Midwifery.— Norman  Joseph  Patterson,  Handayarn  Anandampillay 
Parthasarathy  Iyengar,  Gordon  Beveridge,  Lewis  Rifkind,  Patabondi  , 
Martin  Fernando,  James  I nnes  Coventry,  John  Alfred  Alexander 
Duncan,  and  John  Richard  Larson. 

Medical  Jurisprudence.— Tnoraas  Arnold  us  du  Toit,  Andrew  Gold, 
Douglas  Chieue  Scotland,  Thomas  Dier,  George  Murray  Shaw 
Lindsay,  Wiliam  Grant,  Henry  Godfrey  Fitz-Maurice,  Jessie 
Melville  Lyall  Wright.  Joseph  Butler  D >bs>n,  J mies  MaeC  ashan, 
James  Sydney  Alexander  R )dgers,  Robert  Smith, and  Johu  Richard 
Larson. 

Royal  College  of  Surgeons  of  Edinburgh. — 

At  a meeting  of  the  College  held  on  July  11th  the  following 
candidates, having  passed  therequDite  examinations  between 
March  17th  and  20th,  were  admitted  Fellows: — 

Joshua  Isadore  Baez*,  Robert  Chalmers,  James  Erlank,  Aubrey  Scott  . 
Gille-t.  Eoen  Stuart  Burt  Hamilton,  Maurice  Bertram  Lawrie, 
George  Millar,  Sengarap  llai  Ponniah,  Alan  Tboma  Roberts,  George 
Johu  Chase  Smyth,  Harvey  Heury  Vincent  Welch,  and  John  Benscn 
Young. 

University  of  Aberdeen  : Graduation  Ceremony. 

— Tne  summer  graduation  ceremony  was  held  on  July  llth,  '. 
when  Sir  Douglas  Haig  and  Sir  Roger  Keyes  attended  to  - 
receive  the  honorary  degree  of  Doctor  of  Laws,  which  was 
also  conferred  upon  Sir  James  Cantlie,  Emeritus  Professor 
John  Tneodore  Cash,  Sir  David  RarcHe  (ia  absentia),  member 
of  tbe  Senate  of  the  University  of  Queensland  and  late 
Lieutenant-Colonel,  R.A.M.C.,  Sir  James  Porter,  late  • 
Director-General,  Nav.il  Medical  Department,  and  Dr.  John 
Scott  Riddell,  Director  of  the  North-Eistern  District  Red 
Cross  Society.  The  foil  swing  degrees  were  also  conferred  : — -1. 

D SCTOR  OF  M EDIOINE  (M.D.). 

Francis  James  Browne  (highest  honours  for  thesis),  William  Wilson 
Ingrain  (commendation),  Alfrel  George  Brown  Duncan  (Honours), 
Archie  Reith  Fraser  (honours).  George  A lain,  Ratau  Edulji  Dastur,  >. ' 
Andrew  Smith  Leslie,  David  Murdoch  Marr,  and  Cameron  . < 
Macdonald  Nicol. 

Bacaelor  of  Medicine  (M.B  ) and  Bachelor  of  Surgery  (Ch.B.). 
John  Allan,  Annie  Anderson,  William  Anderson,  Margaret  Mitchell  . 
Chapman,  James  Sylvester  Cook,  James  Civne  Trigue  Crowden, 
‘Elizabeth  May  Dow,  Dorothy  Margaret  Jane  Emslie,  William  . 1 
Alexander  Falconer,  John  Fielder,  Alexander  Coutts  Fowler,  , 
tAlexander  Eiw.r  1 Gammie  (second-class  honours),  "Coral  Ogilvie 
Gordon  (second-class  houours),  James  Ironside  Hutcheson,  Mary 
Victoria  Littlejohn,  Bethia  Muir  Newlan 's,  Margaret  Porbeous,. 
Lewis  Stevens  R bertson,  Keith  Sarjent  Roden,  Irene  Tomina  Joan 
Ruxton,  (George  Alexander  Shepherd  (second  class  honours),  Henry 
Toird,  Atholl  Taomsin,  an  I Louise  Tomory. 

* Passed  Final  Professional  Examination  with  distinction, 
t Passed  Final  Professional  Examination  with  much  distinction. 

The  John  Murray  medal  and  scholarship  were  awarded  to  1 
Dr.  George  Alex  inder  Shepherd, 

University  of  Dublin,  Trinity  College,  School 
of  Physic. — At  examinations  held  recently  the  following  . ; 
candidates  were  successful : — 

Final  Medical  Examination. 

Part  I..  Materia  Med ica  and  Therapeutics,  Medical  Jurtspru  lence 
and  Hygiene,  Pathology  —Albert  Victor  John  Russell  (high  marks), 
George  Hall  Davis  (high  marks).  Taeodor  ltadloff  ant  Edmund 
Cyril  Smith  (equal)  (high  marks),  Francis  Victor  Small,  Joseph 
Hirscbmann,  Harold  Os  in  on  i Hotmeyer,  Johan  Frederick  Wicht.:  | 
Mervyn  Edmund  McBrian.  Margarelta  Tate  Stevenson,  Cecil 
Emrys  McQuade  and  E-sie  Stuart  Smyth  (eq  ia>),  Emily  ElspetE 
Grace  Bailue,  Barney  Moshalowltz,  Thomas  Falklani  Litton  Cary  [ 
and  Nannette  Norris  (equal),  William  Richard  Burns,  John  Henry 
B-enell  Crosbie.  and  WiH'am  Bru  -e  B"iggs. 

Pathology  only  (completing  examination).—  James  Alexander  Acheson. 
Materia  Medica  and  Therapeutics  Medical  Jurisprudence  and 
Hygiene.  — Johu  Russell  Craig  Francis  Young  Pratt,  Robert 
Sturgeon  Chapman.  Thomas  Gerald  Warham,  John  Douglas 
Thompson,  Albert  Stauley  Brad  law,  and  William  Harden  Sm'tb. 
Richaid  Victor  Dowse,  John  Carson  Brennan,  and  Henry  Allman 
Lavelle. 

Part  11.,  Medicine. — Cyril  Daniel  Brink.  John  Caarles  Joseph 
Callanan,  William  Frederick  McConnell,  and  James  Sinclair  Quin 
(equal).  Gerald  Fi'zMaurice  Keatinge  and  Leslie  James  Nugent 
(equal),  Jessie  Gilbert,  Mary  Christina  Sheppard,  Thomas  James 
Ru-sell  Warren,  Erie  Stuart  Ewing  Mack.  Albert  William  Damley 
Magee,  and  Samuel  John  Laverty,  Henry  Blundell  Van  der  Merwe, 
and  Victor  George  Walker  (equal). 


The  Lancet,] 


MEDICAL  NEW?. 


[July  19, 1919  131 


Surgery.— James  Sinclair  Quin.  Albert  Hugh  Thompson,  Richard 
Counihan,  Cecil  Joseph  Quinlan,  Thomas  James  Russell  Warren, 
Gertrude  Rice,  Beeher  Fit /.James  Haythornthwai'e,  Frederick 
William  Godbey,  Charles  Cuing  Ambrose,  William  Joseph  Hogan 
and  Thomas  Madill  (equal),  Patrick  Casey,  Frederick  John  Dymoke, 
and  Albert  William  Darnley  Magee. 

Midwifery.— Leonard  Ahrahamson  (high  marks),  Frederick  William 
Roliertbon  (high  marks).  John  Gerard  Holmes.  John  Henry 
Cooliean . Janie  Millar  Cummins.  Harris  Cohen,  Cyril  Daniel  Brink, 
Klleen  Hilda  Dowse.  Thomas  Madill,  Richard  Ksmonde  Murphy, 
Thomas  Donald  Gordon,  Francis  John  Gerard  Battersby,  Abgar 
Read  Aldin,  and  Samuel  Reginald  Hill. 

Diploma  in  Public  Health. 

Part  II..  Sanitary  Engineering,  Vital  Statistics  and  Public  Health 
Law,  Hygiene  and  Epidemiology  —Henry  Cunningham  Mulholland, 
Beattie  Lyons.  Robert  Condy,  Gilbert  Marshall,  Cecil  William 
Clements  Robinson,  and  Charles  Ernest  Moore. 

Queen's  University  of  Belfast.— At  the  gradua- 
tion ceremony  on  July  9th  a distinguished  honorary  graduate 
■was  Viscount  Brvce,  on  whom  was  conferred  the  degree  of 
LL.D.  Sir  David  Semple,  M.D.,  had  the  honorary  degree 
of  D.Sc.  conferred  upon  him  in  recognition  of  his  original 
researches  in  enteric  fever,  tetanus,  and  bacterial  vaccine 
therapy.  Lieutenant-Colonel  Robert  McCarrison  received 
the  honorary  degree  of  LL.D.  (in  absentia)  for  his  brilliant 
researches  in  goitre  and  the  ductless  glands,  while  Lieutenant- 
Colonel  J.  A.  Sinton,  V.C.,  received  the  honorary  degree  of 
M.D.  in  recognition  of  his  early  distinctions  and  of  his 
valour  in  the  field.  The  following  degrees  by  examination 
in  medicine  were  conferred  : — 

M.V.— Eileen  M.  Bell  (with  distinction  and  gold  medal),  Nathaniel 
Beattie,  Joseph  Corker,  Caroline  V.  Lowe,  James  Lyons,  and  Peter 
P.  Wrtght. 

M.E.,  B.Oh.,  B.. 1.0. —William  R.  Abernethy,  Samuel  Ballantine, 
Hugh  Carson.  Thomas  J.  A.  Connolly,  Eric  A.  Davison,  Samuel 
Hall,  Beniamin  Herbert,  John  M.  Hruey,  Daniel  J.  M’Gurk, 
William  C.  M'Kee.  Thomas  H.  M'Kenna,  Mary  M.  Merrick,  Robert 
Nimmons,  David  G.  Roulston,  Alexander  M‘M.  W.  Segerdal,  Ruth 
M.  Slade,  and  Henry  W.  Wild. 

Diploma  in  Public  Health.— Ivie  Aird,  John  B.  Alexander,  Samuel  T. 
Beggs,  James  Boyd,  Llewellyn  D.  I.  Graham,  William  M'De/mott, 
Edward  B.  C.  Mayrs,  Thomas  Milling,  Frederick  A.  E.  Silcock, 
James  Tate,  Percival  S.  Walker,  and  George  Wilscn. 

The  South  London  Hospital  for  Women. — The 
third  anniversary  of  the  opening  of  the  hospital  was  cele- 
brated on  July  9th,  when  purses  representing  a total  collec- 
tion of  £700  were  handed  to  Lady  Carisbrooke.  Lady 
Londonderry,  chairman  of  the  board  of  management,  drew 
attention  to  the  fact  that  a sum  of  £7000  was  required 
before  the  end  of  the  year  to  meet  anticipated  ordinary 
expenditure. 

Metropolitan  Hospital  Sunday  Fund.  — The 
following  are  among  the  amounts  received  at  the  Mansion 
House  up  to  July  11th,  the  total  amount  being  then  £56,000  : 

St.  Columbu  s Chutch  of  Seoiland,  Pont  street,  £575 ; St.  James's, 
Piccadilly,  £380;  Christ,  Church,  Laucaster-gate,  £296;  Holy  Trinity, 
Sloane-street,  £278 ; St.  Paul’s,  Knightsbridge,  £227 ; St.  Peter's, 
Eaton-square,  £214;  St.  Simon's,  Upper  Chelsea,  £173;  St.  Jude's, 
Kensington,  £146  ; St.  Stephen's,  Avenue-road,  £132;  St.  Stephen's, 
Gloueester-road,  £130;  Holy  Trinity,  Kensington  Gore.  £122;  Greek 
Church.  Bayswater,  £121  ; Essex  Church,  Kensington,  £119  ; St. 
Petei’s,  Cranley-gardens,  £109;  Christ  Church.  Mayfair,  £108;  Cannon 
B-ewery  Co.,  Ltd.,  £105;  St.  Mary  in  the  Boltons,  £103;  Temple 
(burch,  £102. 

Royal  Medical  Benevolent  Fund.— At  the 
last  meeting  of  the  committee,  held  on  July  8th,  20  cases 
were  considered  and  £200  voted  to  15  of  the  applicants.  The 
following  is  a summary  of  some  of  the  cases  relieved 

Widow,  aged  52,  of  L.S.A.  Lond.  who  practised  at  Leyton  and  died 
in  1914.  Receives  £2  10s.  per  week  from  the  sale  of  the  practice,  and 
£2  from  children.  Has  five  children,  only  the  two  eldest  working,  the 
third  at  home,  and  the  two  youngest  at  school.  Requires  help  owing 
lo  the  increased  cost  of  living.  Relieved  four  times,  £35.  Voted  £10.— 
Daughter,  aged  64,  of  M.R.C.S.  Eng.  who  practised  at  Blackbeath  and 
died  in  1881.  Suffers  from  chronic  ill-health  and  is  entirely  dependent 
on  her  sister,  who  applies  for  her.  Her  only  income  is  £5  from  invest- 
ments. Relieved  14  times,  £131.  Voted  £10  in  two  instalments. — 
Widow,  aged  39,  of  M.D.  Durh.  who  practised  at  Tamworth  and  died  in 
1917.  Was  left  totally  unprovided  for  with  seven  children,  now  aged 
17-3  years.  Only  the  eldest  is  working,  and  she  helps  all  she  can. 
Applicant  receives  £150  from  dividends,  and  about  £52  by  letting  rooms. 
Brother-in-law  pays  rent,  and  relations  help  a little  with  education. 
Relieved  twice,  £30.  Voted  £12.— Daughters,  aged  48  and  47,  of 
M.R.C.S.  Eng.  who  practised  at  Poplar  and  died  in  1892.  They  live  on 
the  West  Coast  and  take  in  paying  guests,  and  during  the  last  12 
months  have  made  £70.  Reno  and  rates  £79.  They  find  it 
necessary  to  apply  for  help  owing  to  the  very  short  season  in  1918, 
and  the  increased  cost  of  living.  Relieved  six  times,  £60.  Voted  £10.— 
Widow,  aged  53,  of  L.R.C.P.  & S.  Edin.  who  practised  at  New  Quay  and 
died  in  1893.  Applicant  suffers  from  ill-health  and  is  unable  to  work. 
Has  two  sons,  who  are  both  in  the  Navy,  and  help  whenever  po  sible. 
Pays  £6  a year  rent.  Relieved  16  times.  £161.  Voted  £18  in  two 
instalments. -Daughter,  aged  67.  of  M.R.C.S.  Eng.  who  practised  at 
Liverpool  and  died  in  1885.  Receives  £30  from  another  charity  and  £7 
from  dividends.  Lives  with  sister,  and  they  sha-e  the  rent,  which  is 
£17.  Suffers  irom  ill-health  and  deafness  and  is  unable  to  work. 
Relieved  five.times.  £58.  Voted  £18  in  12  instalments. — Widow,  aged 
65,  of  M.B.  Dub.  who  practised  at  Acton  and  died  in  1912.  Applicant 
was  left  with  four  children.  iib'V  all  married  and  only  able  to  help  very 
slightly.  She  earns  a little  by  needlework.  Has  let  her  flat  for  £2  2i.  a 


week  until  July  14th.  Rent  £50.  Unable  to  manage  owing  to  high 
cost  of  living.  Relieved  three  times.  £25  Voted  £12  in  12  Instalments. 
— Widow,  aged  70,  of  M.  D.  Glasg.  who  practised  at  Dennistoun  and 
died  in  1876.  Applicant  lives  jvitli  married  daughter  and  is  too  old  to 
work.  She  receives  £20  from  another  charity  and  £48  from  children. 
Suffers  from  rheumatism  and  neuritis.  Relieved  five  times,  £60.  Voted 
£18  in  12  instalments.— Daughter,  aged  63.  of  L.It.C.P.  Edin.  who  prac- 
tised at  Holloway  and  died  in  1884.  Only  income  £40  a year  from 
another  charity.  Suffers  from  ill-health,  which  prevents  her  from 
working.  Rent  £41.  Relieved  15  times,  £139.  Voted  £18  in  12 
instalments. 

Subscriptions  may  be  sent  to  the  acting  honorary  treasurer, 
Dr.  Samuel  West,  at  11,  Chaudos-street,  Cavendish-square, 
London,  W.  1. 

Sir  Arbuthnot  Lane,  on  the  invitation  of  the 
to  nmittee  of  the  French  Hospital,  Shaftesbury-avenue, 
will  act  as  senior  surgeon  to  the  institution. 

Mr.  G.  G.  Henderson,  M.A.,  D.Sc.,  LL.D..,  F.I.C., 
has  been  appointed  Regius  professor  of  chemistry  in  tho 
University  of  Glasgow  in  the  room  of  the  late  Professor 
John  Ferguson. 

The  late  Dr.  Arthur  Fuller. — Dr.  Arthur 
Fuller,  who  died  at  Kimberley  on  June  2nd,  was  a well- 
known  citizen,  having  long  been  a member  of  the  hospital 
board  and  school  board.  He  was  at  the  time  of  his  death 
President  of  the  South  African  Permanent  Mutual  Building 
and  Investment  Society. 

The  Chemists’  Exhibition. — More  than  usual 
interest  was  taken  in  the  Chemists’  Exhibition  opened 
at  the  Northampton  Institute,  Clerkenwell,  on  Monday, 
July  14th,  inasmuch  as  the  occasion  marked  the  revival  of 
a demonstration  held  annually  previously  to  the  war.  A 
period  had  elapsed,  therefore,  in  which  pharmaceutical 
developments  had  taken  place,  and  a stimulus  had  beeD  given 
to  the  preparation  of  so  many  drugs  not  before  made  in  this 
country.  These  facts  made  the  exhibits  peculiarly  attrac- 
tive and  served  to  swell  both  the  number  of  exhibitors  and 
visitors.  Pride  was  manifest  in  British  manufactures,  and 
the  various  products  shown  were  a proof  chat  foreign 
monopoly  in  this  section  of  industry  need  no  longer  exist. 
Altogether  the  exhibition  was  a credit  to  the  great;  British 
drug  houses,  and  it  is  to  be  followed  by  a medical  exhibition 
to  be  held  in  the  Central  Hall , Westminster,  from  Oct.  6th-10th 
next. 

A Crematorium  for  the  Cape. — The  Health 
Committee  of  the  Capetown  Town  Council,  having  had 
remitted  to  it  for  consideration  the  subject  of  the  establish- 
ment of  a crematorium  in  the  city,  reports  that  the  method 
of  disposing  of  dead  bodies  by  cremation  is,  there  is  no 
doubt,  the  most  sanitary,  but  that  if  a crematorium  is  to  be 
established  it  should  be  under  the  control  of  the  Burial 
Board,  and  not  of  the  municipality.  The  city  council 
apparently  not  possessing  powers  to  establish  a crematorium, 
it  would  be  necessary  for  special  legislation  to  be  enacted  to 
enable  one  to  be  instituted.  Iu  submitting  a report  from 
the  medical  officer  of  health  on  English  cremation  procedure, 
the  committee  recommended  that  the  matter  be  brought  to 
the  notice  of  the  Minister  of  the  Interior,  Sir  Thomas  Watt, 
with  a view  to  a Bill  being  submitted  to  the  Union  Parlia- 
ment under  which  a crematorium  could  be  established.  The 
question  will  be  considered  by  the  Gape  Municipal  Asso- 
ciation at  the  session  to  be  held  at  Mossel  Bay. 

Medico-Psychological  Association  op  Great 
Britain  and  Ireland. — The  annual  meeting  of  the  associa- 
tion will  be  held  from  Tuesday  to  Thursday,  July  22nd  to 
24th,  at  York,  under  the  presidency  of  Dr.  Bedford  Pierce. 
On  Monday,  July  21st,  the  council  will  meet  at  5.30  p.m  at 
the  Medical  Society’s  Rooms,  17,  Stonegate,  l’ork.  On 
Tuesday  the  annual  meeting  will  commence  at  11  a.m.  at 
“ The  Retreat,”  when  the  following  officers  will  be  proposed 
for  the  year  1919-20: — President:  Dr.  Bedford  Pierce.  Presi- 
dent-elect: Dr.  W.  F.  Menzies.  Ex-President : Lieutenant- 
Colonel  John  Keay.  Treasurer:  Dr.  James  Chambers. 
Editors  of  Journal  : Dr.  J.  R.  Lord  and  Dr.  Thomas  Drapes. 
General  Secretary:  Major  R.  Worth.  Registrar:  Dr.  A.  A. 
Miller.  A paper  will  then  be  read  by  Dr.  G.  R.  Jeffrey  entitled 
“ Notes  ou  a Case  Treated  by  Hypnotic  Suggestion.”  At 
3 p.m.  prizes  and  medals  awarded  during  the  year  will  be 
presented,  and  the  presidential  address  will  then  be  delivered 
by  Dr.  Pierce.  Dr.  G.  L.  Brunton  will  read  a paper 
entitled  “ Notes  on  the  Cytology  of  the  Cerebro-spinal 
Fluid.”  The  annual  dinner  will  take  place  at  7.30  p.m.  at 
the  Station  Htftel,  York.  On  Wednesday,  at  the  Bishop’s 
Room  in  St.  William’s  College  at  10  a.m.,  papers  will  be  read 
as  follows : “ The  Value  of  Treatment  by  Psychological 
Analysis,”  by  Dr.  J.  W.  Astley  Cooper;  ‘‘An  Analysis  of 
200  Cases  of  Mental  Defect,”  by  Dr.  J.  E.  Middlemies. 
Wednesday  afternoon  and  Thursday  are  devoted  to  social 
entertainment  of  which  a special  programme  has  been 
issued. 


132  The  Lancet,]  THE  SERVICES.  [July  19,  1919 


ftbc  Services. 

0 


THE  CASUALTY  LIST. 

The  names  of  the  following  medical  oflicers  appear  among  the 
casualties  announced : — 

Accidentally  kilted. — Capt.  R.  C.  Dickson,  R A.M.C.  (8.R.),  qualified 
at  Edinburgh  in  1911,  and  joined  the  R A M.C.  shortly  afterwards. 

Died. — Lieut.  Col.  J.  Gould,  C.B.K.,  I.M.S  , was  a student  at  Univer- 
sity College,  Liverpool,  and  qualified  at  Manchester  in  1890,  and  joined 
the  I.M.S.  shortly  afterwards. 

Casualties  among  the  Sons  of  Medical  Men. 

Lieut.  G.  Allison,  Gurkha  Rifles,  killed  in  action  on  the  Indian 
frontier  on  June  8th,  1919,  elder  son  of  Dr.  T.  M.  Allison,  of  Newcastle- 
upon-Tyne.— Second  Lieut  G.  M.  Dickson,  Black  Watcb.  killed  in 
action  in  France.  October,  1918,  and  Capt.  It.  O.  Dickson,  R. A.M.C  (S.R.), 
accidentally  killed  on  service  in  India,  June,  1919,  eons  of  the  late 
Dr.  G.  C.  Dickson,  of  Carnoustie,  Scotland. 

THE  HONOURS  LIST. 

The  following  awards  to  medical  officers  are  announced  : — 

C. M.G. — Surg.-Cmdr.  J.  Chambers,  R N.,  for  valuable  services  as 
operating  surgeon  at  the  Royal  Naval  Hospital,  Chatham,  since 
December,  1915. 

ODE.— Surg.-Cmdr.  B.  H.  J.  Browne,  R.N.,  for  valuable  services  as 
principal  medical  officer  on  the  staff  of  t he  Vica-Admiral  Commanding 
the  Bittle  Cruiser  Force.  Surg.  Lt.-Cmdr.  E.  L.  Markham,  K.N.. 
for  valuable  services  in  II.M.S.  t'aradoc.  6th  Light  Cruiser  Squadron. 
Surg.-Cmdr.  F.  \V.  Parker,  R.N.,  for  valuable  services  as  senior  medical 
officer.  R.N.  Sick  Quarters  Invergordon. 

D. S.O. — Surg.  Lieut. -Crodr.  N.  S.  Meiklejohn,  R.N.,  for  distinguished 
services  In  H.M.s.  Caledon,  as  Senior  Medical  Officer,  1st  Light 
Crni,er  Squadron. 

Military  Cross.— Temp.  Capt.  John  Campbell,  R.A.M.C.,  tor  con- 
spicuous gallantry  and  devotion  to  duty  north  of  Sherqaf,  on 
Oct.  27lb/28tb,  1918;  he  showed  great,  skill  and  a total  disregard  of 
danger  in  tending  the  wounded  under  nre  ; on  several  occasions, 
owing  to  the  intensity  of  the  enemy's  fire,  he  had  to  move  his  aid-post, 
but  in  spite  of  all  difficulties  lie  managed  to  evacuate  all  cases 
successfully. 

The  name  of  Surg. -Lieut.  W.  A.  Mallam',  R N.V.R.,  has  been 
brought  to  the  notice  of  ihe  Adniralty  for  valuable  services  in  the 
prosecution  of  the  war. 

Foreign  Decorations.  — French.  — Croix  de  Guerre..— Col.  J.  D. 
Alexander,  D.S.O.  ; Be.  Lt.-Col.  (temp.  Lt.-Col.)  E.  B Bird.  D.S.O., 
R A.M.C. (T.F.) ; Temp.  Capt.  (acting  Maj  ) A.  J Blake,  M.C. , H. A M C. 
(T  F.);  Temp.  Capt.  (acting  Maj.)  A.  W.  S.  Cbrist'e,  R.A.M.C.  ; Bt.-Col. 
(temp.  Col.)  H.  E.  M.  Douglas,  V.C.,  C.M  G..  D.SO.,  R.A.M.C.; 
Capt.  (acting  Lt.-Col.)  W.  R.  Gardner,  D.S.O.,  R A.M.C.  (S.R.) ; 
Capt.  C.  F.  Hacker,  M.C.,  R.A.M.C.;  Capt.  YV.  J.  Knight, 
M.C.,  R.A  M.C.  ; Lt.-Col  (temp.  Col)  L.  N.  Lloyd.  C.M  G., 
D.S.O.,  R.A.M.C.;  Capt.  S.  McCausland.  M.C.,  H.AjM.C.  (T.F.); 
Temp.  Capt.  J.  C.  Ogilvie.  M.C..  R.A.M.C.;  Maj.  (acting  Lt.-Col) 
D.  de  C.  O'Grady,  R.A.M.C.;  Capt.  (acting  Lt.-Col.)  E.  Phillips.  M.O., 
R.A.M.C.  ; Lt.-Col.  (temp.  Col.)  11.  S.  Rocb,  C.M.G.,  D.S.O..  R.A.M.C.  ; 
Temp.  Capt.  (acting  Lt.-Col.)  1,.  D.  Shaw,  D.S.O.,  R.A  M.C. ; Capt. 
(acting  Maj.)  J.  R.  N.  YVarourton  M.C..  R.A.M.C.(S.R.). 

Greek.— Medal  of  Military  Merit,  Snd  Class:  Surg.-Cmdr.  T.  W. 
Myles,  R.N.  

The  Terri  orial  Decoration. — The  Territorial  Decoration  has  b»en 
conferred  upon  the  undermenti  med  officers  of  the  Terrltoriil  Force:  — 
Array  Medieil  Senice:  Col.  G.  H.  Edington.  Roval  Army  Med  cal 
Corps:  Lts.-Col.  J.  S.  Warrack,  J.  Smart,  K.  J.  Cross,  John  McKis, 
Maj.  (temp.  L'.-Col.)  J M.  G.  Breraner.  Maj  (acting  Col.)  D.  Rorie. 
Maj  (acting.  Lt.-Col.)  W.  F.  Roe,  Majs.  F.  W.  Bailey.  H.  Stallard,  A.  F. 
Rutherford,  V.  Howard.  N.  Maclaren,  F.  B Jetferiss,  H.  YV.  Pritchard, 
Vi.  Bryce,  A.C.  Karquharson,  F J.  Oxley.  YY\  YV.  Jones,  E.  G.  Stocker. 
J.  Evans,  B.  E idenbrooke  (T.F.R.),  J.  N.  Mae^ullan,  E.  M.  Dver.  C J. 
Martin.  H.  F.  Horne,  Capts.  (acting  Mats.)  C.  T.  Holland,  A.  P.  YVatson, 
Capt.  and  Qr.-Mrs.  J.  Boxall,  J.  H.  Maunder. 

ROYAL  NAVAL  MEDICAL  SERVICE. 

Surg.-Comdr.  E.  G.  E.  O'Leary  is  placed  on  Retired  List  at  own 
request. 

YV.  J.  Morris  and  J.  F.  Pace  to  be  Surgeon-Lieutenants. 

ARMY  MEDICAL  SERVICE. 

Col.  T.  Du  B.  Whaite  is  placed  on  retire  1 pay. 

Temp.  Col.  A.  H.  Tubby  (Lieutenant-Colonel,  R.A.M.C.,  T.F.) 
relinquishes  bis  temporary  commission  on  re-posting. 

Teinp.  Col.  Sir  H.  M.  Rigby  (Brevet  Lieutenant-Colonel.  R.A.M.C.. 
T.F.)  relinquishes  his  commission  on  ceasing  to  be  specially  employed 
and  on  re-posting. 

Temp.  Col.  H.  Mcl.  YV.  Gray  (Major,  R.A.M.C.,  T.F.)  relinquishes  his 
temporary  commission  on  re-posting. 

ROYAL  ARMY  MEDICAL  CORPS. 

Lieutenant-Colonels  relinquish  the  temp  n-ary  rank  of  Colonel  on 
ceasing  to  be  specially  employed  : K.  YY\  YV.  Cochrane.  L.  N.  Lloyd. 

Major  and  Brevet  Lieut.-Col.  M.  G.  YVinder  relinquishes  the 
temporary  rank  of  Lieutenant-Colonel  on  re-posting. 

The  undermentioned  relinquish  the  acting  rank  of  Lieutenant- 
Colonel  on  re-posting  : Maj  irs  ft.  E.  U.  Newman,  1^  M.  O'Neill.  R.  F.  M. 
Fawcett,  YV.  J.  YVaters,  U.  H.  A.  Emerson.  L.  Y\  Thurston  (on  ceasing 
to  command  a Medical  Unit) ; Capts.  H.  A.  Harbison,  G.  P.  Taylor, 
C.  Clarke,  F.  H.  Laing,  A.  J.  Hickey.  T.  A.  YY'eston,  J.  R.  Hill,  H.  H. 
Leeson  (on  ceasing  to  command  a Field  Ambulance)  ; Temp.  Capts. 
J.  G Johnston,  K.  G.  Fraser. 

Temp.  Lieut.-Col.  K.  G.  Qauntlett  (Captain,  R.A.M.C.,  T.F.), 
relinquishes  his  temporary  commission  on  ceasing  to  be  specially 
employed  and  on  re-posting. 


The  undermentioned  fo  be  acting  Lieutenant-Colonels  whilst 
commanding  Medical  Units:  Majors  A.  S.  YYTllfams,  E.  M.  O'Neill, 
A.  M.  Rose,  (Brevet  Lieut.-Col.)  C.  YYr.  Holden  ; Capts.  (acting  Major) 
T.  A.  YY'eston,  E.  A.  Sutton ; Temp.  Capts.  (acting  Majors)  R.  S.  Dewar. 
K.  G.  Fraser. 

Ma  jor  E.  E.  Parkes  to  be  acting  Lieutenant-Colonel  whilst  specially 
employed. 

Temp.  Capt.  J.  B.  Butler  to  be  acting  Major  whilst  specially 
employed. 

The  undermentioned  to  be  Captains:  Capt.  YV.  H.  Cornelius,  from 
Spec.  HeB  ; Temp.  Capts.  R.  H.  Lucas,  P.  J.  S.  O’Grady. 

Late  temporary  Captain  to  be  Captain  : J.  E.  English. 

Temp.  Capt.  F.  F.  Middleweek  relinquishes  tha  temporary  rank  of 
Ma  jor  on  ceasing  to  command  troops  on  a Hospital  Ship. 

Temporiry  Lieutenants  to  be  temporary'  Captains:  A.  H.  Marsh, 
YY\  H.  YYr.  McYY'hirter,  F.  P.  Hoarder,  J.  Butterworth,  D.  D, 
F^rquharson,  F.  H.  Nixey,  D.  H.  Vickery. 

To  be  Lieutenants  and  to  be  temporary  Captains : Capts.  M.  C. 
Paterson  (from  Spec.  Res.),  P.  A.  Stewart  (from  Spec.  Res.);  Temp. 
Capts.  C.  H.  C.  Bvrne,  A.  J.  Bado,  G.  YV.  B.  Shaw. 

Office's  relinquishing  their  comraissiois  :— Temp.  Lieut. -Cols.  A. 
Balfour  and  J.  YV.  YV.  Stephens  (retain  the  rank  of  Lieutenant- 
Colonel).  Temporary  Majors  retaining  rank  of  Major:  J.  M. 
Crocker,  F.  M.  R.  YY'alshe,  J.  C.  Pounden,  G.  Schofield.  Temp. 
Hon.  Major  G.  Hodge  (retains  the  honorary  rank  of  Major).  Temp. 
Capts.  J.  C.  Drysdale,  H.  Greenwood  (on  transfer  to  the  R.A  F.), 
H.  E.  S.  Stiven  (granted  rank  of  Lieutenant-Colonel).  Tem- 
porary Captains  granted  the  rank  of  Major:  R.  Edward,  D.  0. 
Riddel,  H.  B.  Graham,  K.  K.  B rnie,  J.  G.  Ilerth.  J.  H.  Jones. 
D.  M.  Morison.  Temp.  Hon.  Capt.  (acting  Major)  O.  H.  Stansfield 
(granted  the  honorary  rank  of  Maj  r).  Temporary  Cap’ains  retaining  the 
rank  of  Captain  : C K.  Fenn,  D.  MacIntyre.  E.  Morgan,  P.  A.  Rostant-, 
A M.  Ross.  C.  L.  Sproule,  O C Gruner.  J.  R.  Rees,  YV. 
Robinson,  R.  Park,  T.  Milling,  E.  N.  Russell.  A.  F.  Galloway. 
J.  M.  Johnson,  C.  A.  Lawrence,  H.  E Scoones,  J.  H.  Sutcliffe, 
J.  A.  Y’enning,  A.  J.  Kae,  D.  R E.  R .berts.  D.  Smith,  G.  B.  Kennedy, 
YV.  Ruche.  M.  Davidson.  J.  Goss,  G.  T.  O Donnell.  O.  P.  N.  Pearn, 
F.  YYr.  Howland.  R.  J.  Hutchinson.  G.  Deerv.  Y".  E.  Somerset.  J.  J. 
Delany,  F.  J.  YVa'dmeier,  T.  G.  YY7akeling,  J.  YV.  Sutherland.  T.  F.  Griffin, 
D.  YVatson,  F.  O.  Stedman.  C.  Benneit,  K.  J.  Yeo,  J.  L.  B.  Dixon, 
A.  L Krogh.  J.  Appleyard.  J.  G.  Forbes.  B.  G.  Klein,  H.  Yr.  Deakln, 
YV.  Bain,  M.  Scott,  E.  YVordley,  A.  F.  Ross,  T-.  H.  Campbell, 
F.  H.  -YlcCaughey,  A.  L Robinson,  T.  F.  Dillon.  J.  Nunan,  A.  i.ang- 
will.  C.  U.  Burgess,  H.  G.  Frean.  A.  B.  Cheves.  L.  R.  G.  de  Glanvitle, 
N.  Matthews,  J.  Healey-,  A.  YV.  D.  Coventon.  M.  J.  Landy,  K.  McLay. 
J.  F.  Paul,  J.  L.  Pearce,  YV  MeAlpine,  C.  YV.  J.  Dunlop.  R.  B.  Rad- 
cliffe.  T.  J.  D.  Quigley,  P.  C.  Leslie.  F.  S.  Turner,  YV.  R.  H.  Smith, 

C.  G.  Adams.  H.  A.  C.  Swertz,  E.  A.  Hunting  tf.  Graham,  8.  YV.  Iron- 
side. N.  MacLeod,  F.  C.  Matthew.  A.  Rhodes,  YV.  E.  YValler.  F.  YV.  Grant, 
H.  YV.  Smartt,  A.  F.  Readdie,  C.  F.  D ew.  H.  Keighley,  C.  B.  Davies. 
P.  J.  Maguire,  G.  C.  F.  P.oe,  E.  C.  A.  Smith.  E.  E.  Paget- Tomlinson, 
YYr.  L.  Stuart.  Temporary  Lieutenant  grauted  rank  of  Captain  : F.  G. 
McGuinness.  Temporary  Lieutenants  retaining  the  rank  of  Lieu- 
tenant: E.  Ringrose,  A.  Prentice,  J.  C.  Lougbridge,  E.  YV.  Dewey,  C.  H. 
Lee,  E.  D.  Tuwnroe. 

Canadian  Army  Medical  Corps. 

Temporary  Majors  (acting  Lieutenant-Colonel*)  to  be  temporary 
Lieutenant-Colonels  : S.  R.  Harrison.  C.  Hunter,  K.  It.  Selbv.  YV.  A.  G. 
Bauld,  J.  G.  YYT  Johnson.  F.  H.  Mrekar.  A.  E.  H.  Bennett,  YV.  M.  Hart. 

D.  A.  L.  Graham.  A.  L Johnson,  R.  St.  J.  MacD  maid,  R.  H.  M. 
Hardisty,  T.  H McKillip,  H.  H.  MacDermot,  F.  A.  C.  Scrimger,  G.  A 
Platt,  G S.  Strathv,  G.  Musson.  J.  T.  Hill. 

Temporary  Captains  (acting  Majors)  to  be  temporary  Majors : J.  A.  M 
Hemmeon.  F.  B.  Macintosh,  K.  a.  MacKenzie.  G.  YV.  A Aitken. 

Temp.  Capt.  A B.  James  to  be  acting  Major  while  employed  at 
No.  11  Canadian  General  Hospital. 

Temp.  Major  J.  McYV.  Taylor  aid  Temp.  Capt.  H.  A.  Mitchell  retire 
ia  the  British  Isles. 

SPECIAL  RESERVE  OF  OFFICERS. 

Capts.  YV.  S.  YYrallace  and  A.  YV.  A.  Davies  reliaquish  their 
commissions  and  retain  the  rank  of  Captain. 

Capt.  YYT.  R.  Gardner  relinquishes  the  actiDg  rank  of  Lieutenant- 
Colonel  on  re-posting. 

Capt.  (acting  Major)  J.  F.  YY*.  Sandison  to  be  acting  Lieutenant- 
Colonel  whilst  commanding  a Medical  Unit. 

TERRITORIAL  FORCE. 

Lieut.-Col.  (acting  Col.)  E.  B.  Dowsett  relinquishes  his  acting  rank 
on  vacating  the  appointment  of  Assistant  Director  of  Medical  Se -vines 
Majors  (acting  Lieutenant-Colonelsi  relinquishing  t heir  acting  rank 
on  ceasing  to  be  specially  employed  : D.  F.  Todd,  J.  O.  Sumroernayes. 
J.  Gray,  H.  E.  S.  Richards. 

Capt.  E.  G.  Gauntlett  is  restored  to  the  establishment  on  ceasing  to 
hold  a temporary  commission  in  the  R.A.M.C. 

Capis.  (acting  Majorsi  K.  C.  Plummer,  K.  S.  Taylor,  P.  R.  Bo’us. 
H.  J.  D.  Smythe,  A.  L.  Sharpin,  H.  YV.  Bayly.  J.  H.  Lloyd,  and  A.  YY' 
Stot'  relinquish  their  acting  rank  on  ceasing  to  be  specially  employed. 
Captains  to  be  acting  Majors  whilst  specially  emnloyed  : A.  Rankine. 

E.  G.  T.  Poynder,  H.T.  Jones,  F.  R.  Humphreys,  K.  I.  S.  Smith. 

Capt.  J.  A.  Parsons  is  restored  to  the  establishment 

Capt.  A.  Fordyce  relinquishes  his  commission  and  retains  the  rank  of 
Captain. 

1st  Scottish  General  Hospital : Capt.  (acting  Maior)  C.  Ker 

relinquishes  the  acting  rant  of  Major  on  ceasing  to  be  specially 

employed. 

3rd  Scottish  General  Hospital : Capt.  (acting  Major)  R.  Fullartoc 
relinquishes  his  acting  rank  on  ceasing  to  be  specially  employed. 

5th  Southern  General  Hospital : Capt.  (acting  Major)  P.  H.  Green 
relinquishes  the  acting  rank  of  Major  on  ceasing  to  be  specially 
employed,  and  is  restored  to  the  establiibment. 

2nd  Eastern  General  Hospital : Capt.  (acting  Maj  >r)  R.  Whittingtor 
relinquishes  his  acting  rank  on  ceasing  to  be  specially  employef. 

3rd  London  General  Hospital : Capt.  (Brevet  Major)  A.  H.  Gosae  ii 
restored  to  the  establishment, 

1st  London  Sanitary  Company : Capt.  (Brevet  Major)  C.  C.  Frye  If 
restored  to  tbe  establishment. 


The  Lancet.] 


URBAN  VITAL  STATISTICS.— PARLIAMENTARY  INTELLIGENCE. 


[July  19,  1919  133 


ROYAL  AIR  FORCE. 

Medical  Branch.— The  undermentioned  are  transferred  to  Unemployed 
List:  Major  H.  F.  Horne;  Capt.  (acting  Major)  A.  H.  Todd;  Capte. 
M.  R.  Dobson,  T.  R.  F.  Kerby,  F.  Irvine,  J.  A.  Gordon,  D.  Cameron 
(R. T.F.),  J.  C.  H.  Allan  ; Lieuts.  A.  G.  Graham,  H.  W.  Toms, 
O.  F.  Conoley. 

A.  G.  Graham  is  granted  a temporary  commission  as  Captain. 

Dental  Branch.— Capt.  J.  Barratt  is  transferred  to  Unemployed  List. 


INDIA  AND  THE  INDIAN  MEDICAL  SERVICE. 

The  King  has  approved  the  retirement  of  Lient.-Col.  C.  T.  Hudson 
and  Capt.  C.  C.  Mecredy  in  consequeuce  of  ill-health.  The  King  has 
also  approved  the  relinquishment  of  temporary  rank  of  Capt.  J.  H. 
Parry 

Medical  Corps. — T.  F.  Pedley  to  be  Lieutenant-Colonel ; E.  F.  Neve 
and  O.  H.  Elmes  to  be  Captains  ; and  A.  D.  Cameron  to  be  Lieutenant 
in  the  Medical  Corps,  Indian  Defence  Force. 

Lieut.-Col.  A.  W.  R.  Cochrane,  Superintendent,  King  Edward  VII. 
Memorial  Sanatorium  at  Blowati,  has  been  appointed  a Civil  Surgeon, 
Second  Class,  with  effect  from  May  8th.  Lieut.-Col.  J.  C.  Lamont 
resigns.  Lieut.-Col.  C.  H.  Bensley,  Inspector- General  of  Prisons, 
Central  Provinces,  has  been  appointed  Acting  Inspector-General,  Civil 
Hospitals  pro  tem.  The  services  of  Major  J.  M.  Holmes,  Deputy 
Sanitary  Commissioner  and  Health  Officer,  Imperial  City,  Delhi,  have 
been  replaced  at  the  disposal  of  Government  of  India  Army  Depart- 
ment. Mr.  T.  Harvey,  Sanitary  Engineer,  will  hold  charge  of  the  office  of 
Health  Officer,  Imperial  City,  in  addition  to  bis  own  duties.  Col.  M.  C. 
MacWatt,  Inspector-General,  Civil  Hospitals,  Punjab, has  been  appointed 
Acting  Director  General.  Indian  Medical  Service,  vice  Major-General 
W.  R.  Edwrards,  C.B.,  C M.G.,  on  leave  in  Kashmir.  Maj  'r  R.  M.  Dalziel, 
Superintendent,  of  Central  Jail.  Multan,  has  been  appointed  officiating 
Inspector-General  of  Prisons,  Punjab,  relieving  Major  W.  T.  Finlayson. 
Major  W.  G.  Hamilton  has  been  appointed  to  act  as  Superintendent, 
Presidency  Jail,  during  the  absence  on  deputation  of  Lieut.-Col.  F.  S.  C. 
Thompson.  Major  J.  P.  Lynch,  lt.A.M.C.,  has  been  appointed  to  hold 
medical  charge  of  the  Civil  Station  of  Birrackpore,  vice  Capt.  I).  J. 
McLaren,  R.A.M.C.  Major  E.  O.  Thurston  has  been  appointed  Civil 
Surgeon  of  Hooghly.  Bt.  Lieut.-Col.  C.  A.  Gill  has  been  reappointed 
Chief  Malaria  Medical  Officer.  Punjab,  on  reversion  from  military  duty, 
relieving  Major  C.  E.  Sout.hen,  Chief  Plague  Medical  Officer.  Punjab, 
of  the  additional  charge.  The  services  of  Major  J.  E.  Clement,  Super- 
intendent, Central  Jail,  Lucknow,  and  A.  W.  Overbeek- Wright,  Super- 
intendent, Lunatic  Asylum,  Agra,  are  placed  at  the  disposal  of  the 
Government  of  India  Aimy  Department.  Major  C.  L.  Dunn,  whose 
services  have  been  placed  at  the  disposal  of  the  United  Provinces 
Government  by  the  Government  of  India,  has  been  appointed  a Deputy 
Sanitary  Commissioner. 

AUXILIARY  ROYAL  ARMY  MEDICAL  CORPS  FUNDS. 

The  usual  quarterly  committee  meeting  was  held  on  Friday, 
July  4th,  at  11,  Chandos-street,  Cavendish-square,  W.,  when  12 
grants  were  made  to  cases  in  the  Benevolent  Branch  for  Officers, 
amounting  to  £898.  Requests  for  relief  should  be  addressed  to  the 
Honorary  Secretary,  Sir  William  Hale  White,  at  11,  Chandos-street, 
London,  W.  1. 

DEATHS  IN  THE  SERVICES. 

A telegram  from  Aden  reports  the  death  of  Colonel  Jay  Gould, 
I.M.S.,  C.B.E.,  formerly  Deputy  Director-General,  I.M.S.,  Simla. 
Colonel  Jay  Gould  only  recently  took  up  the  appointment  of  A.D.M.S., 
Aden  Forces.  He  was  one  of  the  best-known  officers  in  the  I.M.S. 
Formerly  medical  officer  of  the  14th  Lancers  and  Central  India  Horse, 
he  has  been  employed  as  a medical  staff  officer  at  Naini  Tal  ani  Simla. 


URBAN  VITAL  STATISTICS. 

(Week  ended  July’  12th,  1919.) 

English  and  Welsh  Towns. — In  the  96  English  and  Welsh  town*, 
with  an  aggregate  civil  population  estimated  at  16.500,000  persons, 
the  annual  rate  of  mortality,  which  had  been  10-0,  9 6,  and  10  0 in  the 
three  preceding  weeks,  further  rose  to  10T  per  1000.  In  London,  with 
a population  slightly  exceeding  4.000,000  persons,  the  annual  rate 
was  10  0 per  1000,  and  coincided  with  that  recorded  in  the  previous 
week,  while  among  the  remaining  towns  the  rates  ranged  from  2 8 in 
Leytjn,  4 2 in  Edmonton,  and  4 7 in  Gillingham  and  in  Eastbourne,  to 
16*0  in  Great  Yarmouth,  18  5 in  Rochdale,  and  18’8  in  Brighton.  The 
principal  epidemic  diseases  caused  117  deaths,  which  corresponded  to 
an  annual  rate  of  0 4 per  1000,  and  included  36  from  infantile  diarrhoea. 
28  from  measles,  23  from  diphtheria,  15  from  scarlet  fever,  9 
from  whooping-cough,  4 from  enteric  fever,  and  2 from  small- 
pox. Measles  caused  a death-rate  of  1*8  in  Newcastle-on-Tyne ; 
the  2 fatal  cases  of  small- pox  belonged  to  the  metropolitan  borough  of 
Woolwich.  There  were  6 cases  of  small-pox,  11348  of  scarlet  fever, 
and  1068  of  diphtheria  under  treatment  in  the  MetroDolitan 
Asylums  Hospitals  and  the  London  Fever  Hospital,  against  2,  1236, 
and  990  respectively  at  the  end  of  the  previous  week.  The  causes  of 
31  deaths  in  the  96  towns  were  uncertified,  of  which  9 were  registered 
in  Birmingham,  4 in  London,  and  3 in  Carlisle. 

Scotch  Towns. — In  the  16  largest  Scotch  towns,  with  an  aggregate 
population  estimated  at  nearly  2.500,000  persons,  the  annual  rate  of 
mortality,  which  had  been  11*0,  11*5.  and  9 9 in  the  three  preceding 
weeks,  rose  to  110  per  1000.  The  225  deaths  in  Glasgow  corresponded 
to  an  annual  rate  of  10  5 per  1000,  and  included  6 from  whooping- 
cough,  3 from  measles,  2 from  infantile  diarrhoea,  and  1 each  from 
enteric  fever  and  scarlet  fever.  The  72  deaths  in  Edinburgh  were 
equal  to  a rate  of  112  per  1000,  and  included  3 from  whooping-cough 
and  1 each  from  measles  and  scarlet  fever. 

Irish  Towns. — The  102  deaths  In  Dublin  corresponded  to  an  annual 
rate  of  13T,  or  0 4 per  1000  above  that  recorded  in  the  previous 
week,  and  Included  3 fatal  cases  of  infantile  diarrhcei.  The  90  deaths 
Id  Belfast  were  equal  to  a rate  of  11*7  per  1000.  and  included  3 from 
scarlet  fever  and  1 each  from  enteric  fever  and  whooping-cough. 


^arliatMittarg  Intelligence. 

HOUSE  OF  COMMONS. 

Wednesday,  July  9th. 

Venereal  Disease  at  Hull. 

Mr.  Robert  Young  asked  the  Minister  of  Health  whether 
lie  had  investigated  the  circumstances  attending  the  deaths 
of  three  men  within  10  days  after  treatment  for  venereal 
disease  at  the  Royal  Infirmary,  Hull  ; what  was  the  drug 
used  ; whether  it  had  the  approval  of  his  Department ; and 
whether  he  could  supply  any  information  on  these  cases.— 
Dr.  Addison  replied  : Yes,  sir  ; the  three  cases  occurred  in 
May,  and  my  Department  instituted  inquiry  forthwith.  No 
drug  was  used,  the  deaths  in  each  case  following  on  exa- 
mination only.  Fuller  investigation  is  proceeding,  and  a 
report  will  be  received  in  due  course. 

Finances  of  Irish  Hospitals. 

Mr.  Edward  Kelly  asked  the  Chief  Secretary  to  the  Lord 
Lieutenant  of  Ireland  whether  the  Richmond,  Hardwicke, 
and  Whitworth  Hospitals,  and  the  Westmoreland  Lock 
Hospital,  had  hitherto  been  wholly  supported  by  moneys 
appropriated  by  Parliament ; whether  he  was  aware  that  no 
payment  had  been  made  towards  the  support  of  these 
hospitals  since  April,  1918  ; that  it  had  been  found  impossible 
to  finance  these  institutions  on  the  old  grant;  that  the 
governors  recently  resigned ; that  there  was  at  present  no 
means  of  paying  current  maintenance  expenses  ; and  if  he 
could  say  what  steps  the  Irish  Government  had  taken  to 
avoid  the  necessity  of  these  hospitals  having  to  close  down  for 
want  of  funds.— Mr.  Macpherson  replied  : Reference  to  the 
Vote  for  Hospital  and  Charities  (Ireland)  shows  the  estimated 
income  of  these  hospitals,  exclusive  of  the  Parliamentary 
Grant.  In  the  case  of  the  House  of  Industry  Hospitals,  the 
income,  apart  from  the  annual  grant  of  £7600,  is  estimated  at 
£9206  for  the  current  year.  A payment  of  £3000  on  account 
of  this  grant  was  made  in  April  last  and  a payment  of  like 
amount  will  be  made  this  month.  The  annual  grant  of 
£2600  to  the  Westmoreland  Lock  Hospital  was  paid  in  April 
last.  Application  has  been  made  by  the  Governors  of  the 
House  of  Industry  Hospitals  for  increased  financial  assist- 
ance from  public  funds  and  the  Treasury  have  not  seen 
their  way  to  consent  to  any  increass  in  the  grant  of  £7600  a 
year.  A further  application  for  assistance  has  been  received 
from  the  Board  of  Superintendence  on  behalf  of  the  hospitals 
mentioned  in  the  question  and  certain  other  Dublin  hospitals 
that  are  aided  from  the  Parliamentary  Vote.  This  applica- 
tion is  at  present  before  the  Treasury.  The  resignations 
tendered  by  the  Governors  of  the  House  of  Industry 
Hospitals  have  not  been  accepted,  and  the  Irish  Government 
has  been  advised  that  the  responsibility  for  the  management 
of  these  hosptals  still  remains  with  them. 

Thursday,  July  10th. 

Medical  Treatment  of  Soldiers. 

Lieutenant-Colonel  Walter  Guinness  asked  the  Pensions 
Minister  whether  he  was  aware  that  under  existing  regula- 
tions no  provision  was  made  for  admission  to  suitable  insti- 
tutions of  men  discharged  from  the  Army  on  account  of 
neurasthenia,  melancholia,  and  epilepsy  in  Ireland;  whether 
melancholia  cases  brought  on  by  shell  shock  and  amputation 
of  limbs  had  in  consequence  been  admitted  to  lunatic  asylums 
in  Ireland  where  they  were  treated  as  pauper  lunatics;  and 
whether  he  would  take  steps  to  provide  maintenance  and 
treatment  for  such  cases  in  special  institutions. — Sir  J. 
Craig  (Parliamentary  Secretary  to  the  Ministry  of  Pensions) 
replied  : There  are  two  institutions  in  Ireland  available  for 
neurasthenics.  As  far  as  I am  aware  there  are  no  epileptic 
colonies  in  Ireland  with  which  arrangements  for  the  reception 
of  discharged  men  can  be  made,  and  it  is  therefore  necessary 
to  bring  the  few  cases  of  epilepsy  to  England.  Men  are  only 
placed  in  asylums  if  they  are  certified  under  the  lunacy  laws, 
and  I am  now  arranging  that  men  so  certified  shall  be  treated 
as  Service  patients. 

Lieutenant-Colonel  Guinness:  What  in  effect  will  be  the 
difference  between  the  treatment  of  Service  patients  and  the 
ordinary  pauper  patient? — Sir  J.  Craig:  Oh!  very  great. 
Special  arrangements  will  be  made  by  the  medical  officers. 
There  is  a distinct  difference  between  the  two  classes. 

Tuberculous  Ex-Soldiers. 

Lord  Henry  Cavendish-Bentinck  asked  the  Minister  of 
Health  whether  he  was  aware  that  the  East  Midlands 
Joint  Disablement  Committee  had  1282  cases  of  demobilised 
soldiers  suffering  from  tuberculosis  in  their  area;  and 
whether,  in  order  to  provide  concurrent  training  and 
treatment  on  the  colony  system  for  these  men,  they  applied 
in  October,  1918,  to  the  Pensions  Ministry  and  later  to  the 
Local  Government  Board  for  financial  assistance,  but 
could  get  no  more  satisfactory  reply  than  that  both  Depart- 
ments were  discussing  with  each  other  the  question  of  the 


134  The  Lancet.] 


APPOINTMENTS.—' VACANCIES. 


[July  19, 1919 


treatment  of  tuberculous  discharged  men. — Dr.  Addison 
replied : I have  no  recent  information  as  to  the  total 
number  of  demobilised  soldiers  suffering  from  tuberculosis 
in  the  particular  area  referred  to  in  the  question,  but  I may 
say  that  the  number  of  such  cases  in  residential  institutions 
on  July  1st  was  183,  and  the  number  on  the  waiting  list  was  24. 
Tbe  proposal  to  provide  a colony  for  the  concurrent  training 
and  treatment  of  tuberculous  men  in  this  area  was  first  brought 
to  tbe  notice  of  my  Department  at  the  end  of  May  when  that 
particular  subject  of  colony  treatment  had  already  been 
specially  referred  to  the  Departmental  Committee  set  up 
by  the  Minister  of  Pensions  and  myself.  Their  report  will, 
it  is  hoped,  be  issued  very  shortly,  and  I will  then  see  that 
suitable  steps  are  taken  as  soon  as  possible. 

Lord  H.  Cavendish-Bentinck  : Will  adequate  and  imme- 
diate steps  be  taken  to  carry  out  the  recommendations  of 
the  Committee? — Dr.  Addison:  I must  see  what  the 
recommendations  are  first. 

Friday,  July  11th. 

Income  Limit  under  the  National  Insurance  Acts. 

The  report  of  the  resolution  declaring  it  expedient  to  raise 
the  remuneration  for  exception  from  insurance  under  the 
National  Insurance  Acts  from  £160  to  £250  a year  was 
agreed  to. 

Monday,  July  14th. 

Scottish  Board  of  Health. 

Mr.  Macquisten  asked  the  Secretary  for  Scotland  if  he 
would  state  when  the  Scottish  Board  of  Health  was  to  be 
constituted  in  terms  of  the  Act;  whether,  though  uncou- 
stituted,  it  had  been  acting  since  July  1st ; and  whether  he 
would  give  an  assurance  that  nothing  should  be  done  by  the 
Board  as  at  present  constituted  except  routine  administra- 
tion work,  and  delay  all  questions  of  appointments  and 
arrangements  for  administrative  duties  until  the  Board  was 
properly  constituted. — Mr.  Munro  replied : I am  advised 
that  the  Board  was  duly  constituted  under  Section  1 of  the 
statute,  with  powers  duly  exercisable  as  from  July  1st.  Its 
personnel  is  now  complete.  Meanwhile  only  duties  of  the 
routine  kind  referred  to  by  my  honourable  and  learned 
friend  have  been  discharged. 

Tuberculosis  Treatment. 

Mr.  Foreman  asked  the  Minister  of  Health  if  he  .could 
inform  the  House  of  the  number  of  persons  in  the  County  of 
London  suffering  from  tuberculosis  known  to  the  authorities 
to  require  sanatorium  treatment  and  for  whom  no  accom- 
modation was  available,  and  to  see  whether  steps  could  be 
taken  to  utilise  as  sauatoriums  auxiliary  or  other  war  hos- 
pitals no  longer  required  for  war  casualties. — Major  Astor 
(Parliamentary  Secretary  to  the  Ministry  of  Health'  replied  : 
The  figures  necessarily  vary  from  week  to  week.  There  are 
approximately,  as  far  as  the  County  of  London  is  concerned, 
some  1700  persons,  including  children,  in  residential  sana- 
toriums  500,  of  whom  more  than  half  are  children,  await- 
ing entrance.  All  possible  steps  are  being  taken  since  the 
diminution  of  the  difficulties  occasioned  by  war  conditions  to 
increase  the  accommodation,  including  the  adaptation  of 
buildings  that  were  provided  for  war  purposes  as  far  as  these 
can  be  made  suitable. 

Dr.  Delvin  asked  the  Pensions  Minister  whether  his 
attention  had  been  called  to  the  treatment  of  discharged 
soldiers  suffering  from  tuberculosis  ; whether  he  was  aware 
that  these  men  were  unable  to  procure  employment 
because  of  the  disease  they  suffered  from,  as  no  employer 
wanted  consumptive  workmen ; and  whether  he  would 
arrange  that  these  men  were  therefore  allowed  the  full 
100  per  cent,  disablement  pension  to  help  them  to  exist 
during  the  few  years  they  might  expect  to  live.— Sir  J. 
Craig  (Parliamentary  Secretary  to  the  Pensions  Ministry) 
replied  : The  question  of  tuberculosis  as  affecting  dis- 
charged soldiers  has  recently  been  considered  in  all  its 
aspects  by  an  inter-Departmental  Committee.  Their 
report  is  expected  within  the  next  fortnight  and  will  be 
immediately  taken  into  consideration. 

Artificial  Limbs. 

Sir  Donald  Maclean  asked  the  Pensions  Minister  whether 
he  would  consider  the  advisability  of  publishing  from  time 
to  time  in  the  daily  press  photographs  or  sketches  of  the 
latest  improvements  in  artificial  limbs,  so  that  men  disabled 
in  the  war  might  have  the  latest  information  for  the  pur- 
pose of  enabling  them  to  minimise,  as  far  as  possible,  the 
effects  of  their  disability. — Sir  J.  Craig  replied:  My  right 
honourable  friend  is  obliged  to  the  right  honourable 
Member  for  his  suggestion,  and  will  consider  how  far  it  is 
practicable.  Arrangements  are  being  made  to  exhibit  at 
repair  depots  the  various  artificial  limbs  available,  so  as  to 
give  a choice  of  limbs  within  limits  approved  by  the 
surgeons  to  the  disabled  men. 

Sir  D.  Maclean  : Will  the  honourable  gentleman  let  me 
have  a letter,  or  will  he  publish  a list  of  these  repair  depots, 
so' that  disabled  men  can  have  an  opportunity  of  knowing 


where  they  can  go  for  their  information  ? — Sir  J.  Craig  : My 
right  honourable  friend  is  much  obliged  to  the  right  honour- 
able gentleman  for  his  suggestion,  which  is  quite  valuable. 
In  connexion  with  this  and  other  schemes  I am  sure  he  will 
be  only  too  glad  to  give  the  information. 

Ad  hoc  Dental  Committee. 

Mr.  Seddon  asked  the  Secretary  of  State  for  the  Home 
Department  whether  the  ad  hoc  Committee  recommended 
by  the  Departmental  Committee  on  Dentistry  had  been 
selected  ; and  whether  all  existing  societies  of  dental  practi- 
tioners would  be  included  in  the  selection. — Mr.  Shortt 
replied  : No  consideration  has  yet  been  given  to  the  forma- 
tion of  the  ad  hoc  Committee  referred  to  in  the  honourable 
Member’s  question.  This  is  a matter  that  must  obviously 
be  postponed  until  the  legislation  that  will  be  necessary  to 
give  effect  to  the  recommendations  of  the  Dentists  Act 
Committee  is  in  a fair  way  of  accomplishment. 


^jpinkeds. 


Successful  applicants  Jor  vacancies , Secretaries  oj  Public  Institutions , 
and  others  possessing  information  suitable  for  this  column , are 
invited  to  forward  to  The  Lancet  Office,  directed  to  the  Sub- 
Editor,  not  later  than  9 o'clock  on  the  Thursday  morning  oj  each 
week,  such  information  for  gratuitous  publication. 

Baxter,  C.  B.,  F.R.C.S.  Edin.,  has  been  appointed  Honorary  Assistant 
Surgeon  to  the  Royal  Berkshire  Hospital. 

Forsyth,  J.  A.  Cairns,  M.Sc.,  M.B  , F.R.C.S.,  Surgeon  to  the  French 
Hospital,  London. 

Lake,  Norman  C.,  M.D.,  M.S.,  D.Sc.,  F.R.C.S.,  Assistant  Surgeon  to 
Charing  Cross  Hospital. 

Lewis,  Thomas,  M.D,  F.R.C.P  , D.Sc.,  F.R.S.,  Honorary  Consulting 
Physician  to  the  Ministry  of  Pensions. 

Lyons.  W.  C.,  M.B.  Edin.,  D.P.H.,  Assistant  Medical  Officer  (Venereal 
Diseases.  &c.),  County  Borough  cf  South  Shields. 

Martin, 'Douglas,  MB.  E tin,  D.T.M.,  D P.H.,  Assistant  Medical 
Officer  (Tuberculosis),  County  Borough  of  South  Shields. 

Mathieson,  D.  Morley.  vi  D Edin.,  Oh.B.,  D.P.H.,  Medical  Officer  cf 
Health.  County  Borough  of  Birkenhead. 

Oates,  G.  E.,  M.D.,  B S.  Lond.,  D.P.  H , Medical  Officer  of  Health  to 
the  Metropolitan  Borough  of  Bethnal  Green. 

Stiles,  Sir  Harold  J.,  to  the  Chair  of  Clinical  Surgery  in  the  Uni- 
versity of  Edinburgh. 

Wear.  A.  W.,  M.B.  Durh.,  D.P.H.,  B.Hy.,  Assistant  Medical  Officer 
(Diseases  of  Children),  County  Borough  of  South  Shields. 

White,  H.  V.,  M.D.  Manch.,  Honorary  Ophthalmic  Surgeon  to  the 
Salford  Ro;al  Hospital. 

Fxench  Hospital,  Shaftesbury-a venue.— McClure,  J.  Campbell,  M.D., 
Physician  to  In-patients  ; Forsyth,  J.  Cairns.  F.H.O.S.,  Surgeon 
to  In-patients;  Crookshank,  F.  G..  M.D.,  Physician  10  Out- 
patients ; Brossy,  Jean,  M.D.,  Physician  to  Out-patients  ; Rowe, 
Robert  M , F.R.C.S.,  Surgeon  to  Out-patients;  McHoul.  James, 
F.R.C.S.,  Ophthalmic  Surgeon  to  Out  patieats ; Brau.v,  Jean, 
M.D.,  Physician  to  Out-patients  (Genito- urinary  Diseases)  ; 
Hernam an- Johnson,  F , M.D.,  Radiologist. 

Certifying  Surgeons  under  the  Factory  and  Workshop  Acts: 
Knowlfs,  R.  O,  M.D.  Liverp.  (Birkenhead);  Robertson,  A., 
L.R  C.P.,  L R.C.S.  Edin.  (Dumbarton). 


©acanrits. 


For  farther  information  refer  to  the  advertisement  column*. 
Birmingham  General  Hospital.— Res.  M.O.  £155.  Asst.  P.  £50. 
Surgical  Registrar.  £200. 

Birmingham,  SellyOak  Infirmary  and  House. — Asst.  M O.  £275. 
Bolingbroke  Hospital,  Wandsworth  Common,  S.W. — H.S.  £150. 
Bournemouth,  Royal  Victoria  and  West  Hants  Hospital,  Boscombe 
Branch.— lies.  M.O.  £250.  Also  Second  Res.  M.O.  £200. 
Brighton,  Hove,  and  Preston  Dispensary. — Res.  M.O.  £200. 

Brighton,  Sussex  Throat  and  Ear  Hospital,  Church-street — Asst.  Hon.  S. 
Bury  County  Borough. — Asst.  M.O.H.,  Asst.  Seh.  M.O.,  and  Asst. 
Tubeie.  b.  £500. 

Bury  St.  Edmund’s,  West  Suffolk  General  Hospital. — Res.  H.S.  £175. 
Cairo,  Egyptian  Government  School  of  Medicine. — Professors  and 
Lecturers.  £E.1000  and  £E.600.  Also  Radiologist  and  Lect.  in 
Radiology,  £E.5C0,  Anesthetist  and  L‘. ct.  in  Anaesthetics.  £8.500, 
and  Registrar  and  Tutor,  £E.600. 

Canterbury.  Kent  and  Canterbury  Hospital.— Jun.  Res.  M.O.  £150. 
Capetown  Free  Dispensary. — M.O.  £5C0. 

Coventry  and  Warwickshire  Hospital. — Hon.  Surg.  Staff. 

Devonpirrl,  Royal  Albert  Hospital .— Res.  H.S.  £200. 

Dorchester,  Dorset  County  Council. — Asst.  M.O.  £4C0. 

Dundee  Corporation  — Asst.  Tuberc.  O.  and  Asst.  M.O.  £300. 

EcclesaU Bierloui  Union. — Res.  M.O.  £600. 

Edinburgh  City.— Clin.  M.O.  under  Venereal  Diseases  Scheme.  £750. 
Elizabeth  Garrett  Anderson  Hospital,  Euslon-road.— Female  Senior 
Asst.  ±200 

Exeter,  Royal  Devon  and  Exeter  Hospital. — Sen.  H.S.  £250. 

Gravesend'  Hospital.— H.S.  £200. 

Great  Northern  Central  Hospital.  Ilollouay.  London.— Oph.  S. 

Hospital  for  Consumption  and  Diseases  of  the  Chest,  Brompton. — H.P. 
Jslewortli  Infirmary. — Sec.  Asst,  to  Med.  Supt.  £300. 

Khartoum,  Wellcome  Tropical  Research  Laboratories.  — Assistant 
Bacteriologist.  £E.6C0. 

Leeds  University.— Lect,  in  Experi.  Phys.  £5C0.  Demonstr.  in  Phys. 
£250  Demonstr.  in  Hist.  £250. 

Leicester  Royal  Infirmary—  Teo  Hon.  Asst.  P.  and  one  Hon.  Asst.  S. 


The  Lancei,]  BIRTHS,  MARRIAGES,  AND  DEATHS.— NOTES,  SHORT  COMMENTS,  ETC.  [July  19,  1919  ] 35 


Liverpool,  Fazakerley  Sanatorium  for  Tubercidosis.-A.-iSt.  Itae.  M.O. 
£250. 

Liverpool  School  of  Tropical  Me  Heine.—  Asst.  Lect.  in  Parasitology. 
£250 

Liverpool.  Stanley  Hospital. — H.P.  and  H.S. 

London  Hospital,  E.— Surgical  Registiar.  Also  First  Asst. 

Manchester,  Ancoals  Hospital.  — H.P.  £150.  Also  Hon.  P.  and 
Radiol  >gist 

Manchester  Northern  Hospital  for  Women  and  Children,  Park-place, 
Cheetham  Hill-road.  — Hon.  Asst.  P. 

Manchester  Royal  Eye  Hospital. — Jun.  H.S.  £120. 

Middlesex  Hospital  Medical  School.— Demonstrator.  £200. 

National  Hospital  for  Diseases  of  the  Heart,  Westmoreland-street,  !ir. — 
Res.  M.O.  £100.  Also  Non-Res.  M.O.  £50. 

New  Zealand  — Path,  and  Bact.  for  Pub.  Health  Dept.,  Auckland.  £710. 
Otago  Uaivers:ty,  New  Zealand.— Prof . of  Syst.  Med.,  Prof,  of  ulin. 
Med.  and  Therap.,  and  Lect.  on  Clin.  Med.  £600,  £500,  and  £400 
respectively. 

Plymouth,  South  Devon  and  East  Cornwall  Hospital.— H.P . £140. 
Queen's  Hospital  for  Children,  Hackney  road,  Bethnal  Green,  E. — 
Temp.  M.O.  1 guinea  per  attendance. 

Queen  Mary's  Hospital  for  the  East  End, Stratford,  E.— Hon.  Aural  S. 

Two  Asst.  Hon.  P.'s.  Also  H.S. 

Rossnll  School.  Fleetw  >od.—  Res.  M O.  £250. 

St.  George's  Hospital,  S.  IK. — Two  Cao.  Officers.  £150. 

St.  Helens  County  Borough.— Asst.  M.O.H.  £500.. 

Sheffield  Royal  Infirmary.—  Asst.  H.P.  £150. 

Smyrna  Mission  and  " Beaconsfleld  Memorial  Hospital.  — Medical 
Missionary.  £250. 

South  London  Hospital  for  Women.  South  Side.  Clapham  Common,  S'.  IP. 

Female  H.S.  £100. 

Surrey  Education  Committee.— Sch  Dentist.  £400. 

Taunton,  Somerset  and  Bath  Asylum,  Co'ford. — Asst.  M.O.  £300. 
TinQwa.ll,  Whiteness,  and  Weisdale  Parish.— M.O  and  Pub.  Vac.  £45 
Tottenham  Maternity  and  Child.  Weltare  Commute  , Antenatal  Clinic. 

— Female  M.O.  £1  11s.  6 d.  per  session. 

University  College  Hospital,  Gower-street,  W.C.— Res.  M.O.  £150 
Victoria  Hospital,  Tite-street,  Chelsea  S.  I!’.  — H.P.  and  B.S.  £100. 
West  Riding  County  Council,  Treatment  of  Venereal  Diseases.  - Asst. 
£550.  Also  Sch.  Oculist.  £450. 


Tae  Chief  Inspector  of  Factories,  Home  Office,  S.W.,  gives  notice  cf 
vacancies  for  Certifying  Surgeons  under  the  Factory  and  Workshop 
Ads  at  Ascot  (Berks),  Dundee  (Forfar),  Falkland  (Fife),  Lavenham 
(Suff  ilk),  Llanfair  Caereinion  (Montgomery),  Newhaven  (Sussex), 
Nottingham,  North  (Nottingham),  Scarborough  (Yorks,  North 
Riding),  Tvnemouth  (Northumberland),  Waiisend  (Northumber- 
land), and  Yethoim  (Roa  burgh). 


lpri|s,  Utarriagts,  snb  ialjji. 


DEATHS. 

FiNCH  White. — On  July  8th,  after  a few  days'  illness,  of  pneumonia 
following  influenza.  Finch  Waite,  M.E.C.S.,  L.R.C.P.,  Vanbrugh 
P rk,  BUckheath,  London,  and  KiUaloe,  co.  Clare,  aged  47  years. 
Holding. — On  July  6th,  at  Hazeldene,  Dendy-road,  Paignton,  S.  Devon, 
Charles  Holding,  L.R.C.P.  & S.  Edin.,  aged  48  years. 

fee  of  5s.  is  charged  Jor  the  insertion  of  Notices  of  Births, 
Marriages , and  Deaths. 


Ccramunications,  Letters,  &cM  to  tiie  Editor  have 
been  received  from— 


A.  — Dr.  A Ashkenny,  Bcocken- 
hurst ; Dr.  R.  W.  Allen,  Lond. 

B. — Mrs.  O.  R.  Buxton,  Lond  ; 
Dr.  A.  Balfour,  Lond.;  Rev.  T.  P. 
Brocklehurst,  Giggleswick ; Surg.- 
Comm.  W.  Bastian,  R.N.;  Bristol 
University,  Registrar  of  ; British 
and  Colonial  Pharmacist , Editor 
of  ,•  Mr.  I Back,  Lond. 

C. — Dr.  H.  G.  P.  Castellain,  Lond.; 
Dr.  N.  H.  Choksy,  Bombay ; Mr. 
H.  G.  Commings,  Lond.;  Prof. 
E.  P.  Cathcart,  Lond.;  Major  T. 
Cherry,  A.A.M.C.;  Mr.  G.  D.  H. 
Cole,  Lond.;  Dr.  F.  G.  Crook- 
shank,  Lond.;  Dr.  J.  Cates,  St. 
Helens;  Mr.  K.  Cumming, 
Lond. 

D.  — Dublin  School  of  Physic, 
Registrar  of ; Prof.  S.  Delepine, 
Manchester ; .Mr.  J.  Driberg, 
Loud.;  Mr.  G.  Drage,  Lond.;  Dr. 
G.  Dundas,  Middlesbrough. 

E.  — Sir  G.  Evatt,  Lond.;  Edinburgh 
Royal  College  of  Surgeons,  Clerk 
to. 

F.  — Mr.  H.  A.  T.  Fairbank,  Lond.; 
Dr.  C.  E.  S.  Flemming,  Brad- 
ford-on-Avon  ; Mrs.  K.  Fedarb, 
SovjLthsea;  Mr.  R.  S.  Foss,  Lond,; 
“Fisherman,’  Torquay. 

G.  — Dr.  S.  R.  Gloyne,  Lond.;  Mr. 
J.  N.  Glaister,  Ohertsey. 


[ H,— Major  W.  E.  Horae,  R.A  M.C.; 
Prof.  I.  W.  Hall,  Bristol ; Dr.  H. 
Head,  Loud.;  Mr.  S.  Hebarch, 
Lond. 

J.  — Mr.  M.  H.  Judge,  Lond 

K.  — Dr.  T.  G.  Kelly,  Desford ; Mr. 
F.  Karslake,  Lond.;  Prof.  A. 
Keith,  Lond.;  Dr.  A.  B.  Kings- 
ford.  Lond. 

L.  — Mr.  E.  M.  Little,  Lond. 

M.  — Dr.  R.  A.  Morton,  Lond.; 
Major  A.  Macdonald,  R A.M.C.; 
Ma-thusian  League,  General  Sec. 
of ; Medical  Women’s  Federation, 
Ssc.  of;  Metropolitan  Hospital 
Sunday  Fund,  Sec.  of. 

N. — National  Council  for  the  Un- 
married  Mother. 

O. — Mr.  S.  Otabe,  Lond. 

P.  — Dr.  B.  Pierce,  York;  Major 
F.  J.  W.  Porter,  R.A.M.C.;  Mr, 
H.  C.  Palmer,  Lond. 

R. — Royal  Medical  Benevolent 
Fund,  Sec.  of ; Mr.  W,  Roberts, 
West  gate-on- Sea ; Mr.  W.  E.  Rose- 
dall,  Maidenhead. 

S.  — Prof.  W.  Stirling,  Manchester; 
Mr.  D.  M.  Shaw,  Lond. 

T.  — Dr.  J.  Tatham,  Oxted  ; Dr. 
A . L.  Taylor,  Liber  ton ; Dr.  F.  E. 
Taylor,  Lond  ; Dr.  A.  T.  Todd, 
Huddersfield. 

W,^-Dr.  F.  J.  Waldo,  Lond. 


Communications  relating  to  editorial  business  should  be 
addressed  exclusively  to  the  Editor  of  The  Lancet 
423,  Strand,  London,  W.C.2. 


$jte,  Sjiort  Cfloimtnts,  anb  ^nskrs 
to  Cflrrespimkttts. 

THE  BATHS  OF  OLD  LONDON. 

By  Septimus  Sunderland,  M.D.  Brux. 

Part  II. 

FLoatmg  Baths. 

The  Folly,  a “ castellated  houseboat,”  was  usually 
anchored  opposite  Somerset  House  Gardens  soon  after  the 
Restoration,  and  was  used  as  a musical  summer-house 
in  part  of  the  seventeenth  and  eighteenth  centuries. 
Pepys  visited  this  in  1668.  It  was  generally  fixed  on  the 
south  side  of  the  river,  near  the  foot  of  Cuper’s  stairs,  which 
led  to  Cuper’s  Pleasure  Gardens,  on  part  of  which  the 
present  Royal  Waterloo  Hospital  for  Children  and  Women 
now  stands.  During  the  time  of  William  III.  and  Mary 
(1689  to  1702)  it  was  frequented  by  the  fashionable  classes, 
aBd  on  one  occasion  by  the  Queen.  Later  it  became  the 
resort  of  a low  class  of  society,  was  allowed  to  fall  into  decay, 
and  was  broken  up  about  1750.  It  is  probable  that  at  one 
time  it  was  also  used  a3  a floating  bath. 

John  Timbs,  writing  in  1868,  mentions  the  fact  that  there 
were  two  floating  baths  upon  the  Thames  "in  our  day,”  and 
says  that  in  plan  they  were  somewhat  similar  to  The  Folly. 
One  of  these  was  situated  near  Hungerford  Bridge,  for 
bathers  of  both  sexes,  and  contained  filtered  water. 

Sweating  Baths. 

In  England  in  the  thirteenth  century  the  hot-air  or  vapour 
baths  introduced  by  the  Crusaders  were  given  in  establish- 
ments called  "hot-houses”  and  were  much  in  request,  as 
were  similar  ones  in  the  large  cities  of  Europe.  The  hot 
vapour  baths  were  tried  for  leprosy,  which  was  prevalent  in 
those  days,  as  well  as  for  syphilis,  hut  with  bad  results. 
There  were  separate  baths  for  lepers.  Shakespeare  and  Ben 
Johnson  mention  sweating  baths  in  tbeir  writings  as  “hot- 
houses.” In  the  old  play,  “The  Puritan,”  one  of  the 
characters,  referring  to  an  arduous  undertaking,  says, 
“ Marry,  it  will  take  me  much  sweat ; it  were  better  to  go  to 
16  hot-houses.” 

In  the  year  1517,  when  there  was  the  second  epidemic  of 
the  “ sweating  sickness  ” in  England,  the  English  were 
accused  of  gross  feeding,  of  much  intemperance,  and  of 
causing  relaxation  of  their  skins  by  spending  so  much  time 
iu  hot-air  baths.  This  shows  that  these  baths  remained 
popular  in  England  at  a time  when  they  were  beginning  to 
be  less  used  abroad.  Later  in  England  there  were  periods 
of  comparative  disuse  until  the  end  of  the  seventeenth 
century  when  they  reappeared  and  became  popular  in 
London  under  the  Italian  name  of  "bagnios”  (place,  for 
sweating)  or  the  Arabic  name  of  "hummum”  (a  warm 
bath) ; these  were  on  the  principle  of  the  Roman  hot-air  or 
vapour  baths.  The  various  bagnios  or  hummums  estab- 
lished in  London  appear  to  have  become  of  doubtful  repute, 
and  frequented  by  evil  characters  ; these  circumstances  led, 
after  a time,  to  the  suppression  of  the  institutions.  The 
practice  of  cupping  was  prevalent  in  those  days  and  for  a 
long  time  afterwards,  associated  with  hot  baths. 

The  Duke’s  Bath  or  Bagnio,  minutely  described  in  1683  by 
Samuel  Haworth,  M.D.,  Physician  to  James  II.  when  Duke 
of  York,  as  “erected  near  the  west  end  of  Long  Acre  in  that 
spot  of  ground  called  ‘ Salisbury  Stables,’  ” was  a stately 
oval  edifice,  paved  with  marble,  and  within  the  wall  were 
ten  seats,  such  as  were  formerly  in  the  baths  at  Bath. 
When  the  Duke  of  York  came  to  the  throne  in  1686  these 
baths  were  improved  and  reopened  as  the  King’s  Bagnio, 
and  an  advertisement  then  stated  “ there  is  no  other  bagnio 
in  or  about  London  besides  this  and  the  Royal  Bagnio  in 
the  City,”  the  reference  to  the  “ Royal  Bagnio  ” being  in  all 
probability  intended  for  the  bagnio  in  Bagnio  Court, 
described  below. 

The  Bagnio  (the  Royal  Bagnio)  in  Bagnio  Court  (altered 
to  Bath-street  in  1843),  Newgate-street,  was  built  by  Turkish 
merchants,  and  first  opened  iu  December,  1679,  for  sweating, 
hot  bathing,  and  cupping  ; 4s.  was  the  charge  to  each 

person,  and  certain  days  were  reserved  for  ladies.  Strype 
wrote:  "This  bagnio  is  much  resorted  unto  for  sweating, 
being  found  very  good  for  aches,  Ac.,  and  approved  of  by 
our  physicians.”  The  cupola  roof,  and  walls  set  with  Dutch 
tiles,  were  described  by  Hatton  in  1708.  It  was  subsequently 
used  as  a cold  bath.  Dr.  Frederick  Gervis,  of  Torquay, 
informed  me  that  about  1860  he  and  other  medical  students 
of  the  old  St.  Thomas’s  Hospital,  Borough,  often  bathed  in 
this  cold  plunge  bath,  which  was  lined  with  white  marble 
and  was  fed  by  very  cold  clear  water  always  flowing  out  of  a 
well-carved  white  lion’s  mouth.  It  was  at  that  time  spoken 
of  as  the  " King’s  Bath  ” and  was  situated  in  a court  on  the 
north  side  of  Newgate-street. 


136  The  Lancet,]  NOTES,  SHORT  COMMENTS,  AND  ANSWERS  TO  CORRESPONDENTS. 


[July  19,  1919]  | 


The  various  bagnios  and  hummuma  were  again  sup- 
pressed, but  later — namely,  in  1765— vapour  baths  in  Cheyne 
Walk  were  established  by  Dominiohetti,  which  were  used 
for  a time,  medicated  with  herbs.  The  Somerset  Street 
Baths,  similar  to  those  instituted  at  Brighton  by  Mahomed 
as  medicated  vapour  baths,  were  in  use  near  the  close  of 
the  eighteenth  century  and  became  popular  for  vears.  In 
“ Metropolitan  Improvements,  or  London  in  the  Nineteenth 
Century,”  is  a print  dated  1828,  showing  the  building  where 
the  Koval  York  Baths,  Regent’s  Park,  can  be  seen  to  this 
day  in  York  Terrace.  They  were  used  until  three  years  ago. 
The  building  now  contains  a fair-sized  Turkish  bath,  with 
three  hot  chambers  and  a shampooing  room,  which  was 
formerly  supplied  from  a spring,  and  a rest  room.  There 
are  also  about  12  small  bathrooms,  with  old-fashioned 
ordinary  baths  to  which  pumps  are  attached.  Medicated 
baths  used  to  be  given  in  these  rooms.  In  1860  a handsome 
Turkish  bath  was  erected  in  Victoria-street,  Westminster, 
but  has  since  been  demolished.  The  Hammam,  opened  in 
1862  in  Jermyn-street,  St.  James’s,  has  been  popular  for 
many  years  and  still  exists. 

Baths  and  trash-houses. — It  is  permissible  to  add  that  baths 
and  wash-houses  for  the  working  classes  originated  in  1844 
with  “an  association  for  promoting  cleanliness  among  the 
poor.”  A bath-house  and  a laundry  were  fitted  up  in 
Glasshouse  Yard,  East  Smithfield.  The  association  also 
gave  whitewash  and  lent  pails  and  brushes  to  those  willing 
to  cleaDse  their  own  dwellings.  This  successful  experiment 
led  to  the  passing  of  an  Act  of  Parliament  “ to  encourage  the 
establishment  of  baths  and  wash-houses,”  of  which  there 
are  so  many  at  the  present  day. 

(To  be  concluded .) 


THE  WOMEN’S  HOLIDAY  FUND. 

An  appeal  emanating  from  this  fund,  issued  by  the  Bishop 
of  London  and  others,  pleads  for  assistance  on  behalf  of  poor 
women  and  their  babies  in  need  of  a holiday  but  unable  to 
afford  to  go  away  from  home  without  help.  “ Never 
before,  perhaps,  in  the  history  of  this  society,”  says 
the  appeal,  “have  holidays  been  so  much  needed  and 
desired.  The  strain  and  anxieties  of  the  long  war  and 
the  epidemics  of  influenza,  which  have  left  their  mark  on 
hundreds  of  homes,  have  brought  many  a poor  hardworking 
woman  very  near  to  breaking  point.  Already  applications 
have  been  received  from  women  who  have  not  had  a holiday 
for  20  or  30  years,  in  some  cases  from  those  who  have  never 
had  one  in  their  lives.”  In  1913  1240  women  and  155  babies 
were  sent  away,  but  during  the  last  five  years,  owing  to  the 
high  prices  and  the  heavy  railway  fares,  the  work  of  the 
society  has  been  much  limited.  Donations  will  be  acknow- 
ledged by  Miss  Cooper,  Secretary,  Women’s  Holiday  Fund, 
76,  Denison  House,  Yauxhall  Bridge-road,  London,  S.W.l. 

A PROPHECY  OF  AVIATION. 

To  the  Editor  of  The  Lancet. 

Sir, — In  Henry  Maty’s  “New  Review;  with  Literary 
Curiosities  and  Literary  Intelligence  for  the  Year  1785  ” is 
noticed  at  some  length  a book  with  the  title,  “ Symposia,  or 
Table  Talk  in  the  Month  of  September,  1784,  being  a 
Rhapsodical  Hodge-podge,  containing,  among  other  Things, 
Balloon  Intelligence  for  the  Years  1785,  1786,  and  1787.”  Its 
publication  shows  that  “flying"  had  distinctly  a vogue  in 
this  country  nearly  a century  and  a half  ago  ; and  Dr.  F.  J. 
Poynton’s  very  interesting  “details”  in  The  Lancet  of 
July  5th  supports  the  fact.  The  following  extracts  are  culled 
from  Maty’s  “New  Review”  and  taken  from  the  “Table 
Talk":— 

“ We  are  happy  to  assure  our  readers  that  the  Air  Carriages  are  found 
to  be  of  such  utility,  that  they  are  daily  increasing  in  number  through- 
out the  Kingdom  : no  less  than  fifty  Balloons  were  at  their  moorings  in 
the  various  inns  in  Reading,  in  their  way  from  Bath  to  London.” 

Then  follows  a computation  that  100,000  horses  which  had 
been  engaged  in  town-to-town  traffic  were  displaced  by 
balloons,  and  consequently  the  price  of  grain  had  fallen 
considerably.  Again,  the  officers  of  the  packets  conveying 
the  “ foreign  and  Irish  mails"  were  petitioning  for  pensions, 
their  services  no  longer  being  necessary.  A traveller  from 
India  asserts  that  he  had  not  suffered  from  heat  when  over 
the  “ burning  sands  of  Arabia,"  as  he  could  always  “chuse 
an  atmosphere  agreeable  to  the  heat  of  the  climate."  “ Till 
the  wild  Arabs  have  adopted  Balloons,"  he  says,  " this  mode 
of  travelling  renders  people  secure  from  the  plunder  of  those 
lawless  marauders."  A “ grand  Balloon  race  over  Salisbury 
Plain  for  10,000  guineas  " is  mentioned,  as  well  as  a grand 
sweep-stake"  between  certain  ladies,  the  odds  being  “greatly 

in  favour  of  Lady , she  having  been  accustomed  to  soar 

above  the  clouds  long  before  the  invention  of  Balloons.”  A 
“Man  of  Fashion ” writes  a book  of  6 vols.  12mo,  entitled 
“ Balloon  Tales  : Being  an  Account  of  a Variety  of  Intrigues 
carried  on  in  the  Air.”  Leather  goes  down  in  price,  saddles, 
bridles,  Ax.,  not  being  wanted.  Ox-beef  and  mutton  touch 
2 \d.  per  lb.  at  Smithfield  “ owing  to  the  diminution  of  horses 


in  this  country.”  In  France  desertions  from  the  Army  are 
ascribed  to  the  facilities  offered  by  balloons,  as  also  the 
“ easy  concealment  and  escape  of  villains  of  all  denomina- 
tions from  the  hands  of  justice.”  The  effect  of  the  change 
upon  the  medical  profession  is  shown  in  the  following 
quip:— 

“ We  hear  there  will  be  a great  sale  of  carriages  belonging  to  the 
Physicians,  Apothecaries,  Surgeons.  Corn-Cutters,  and  Quack- Doctors 
In  this  Metropolis,  f >r  it  seems  the  Synod  in  Warwick  Lane  have  come 
to  a resolution,  and  have  given  orders  accordingly,  that  all  the  above 
denomination  of  people,  shall  either  walk  or  vis’t  their  patients  in 
Balloons  in  future,  as  the  rumbling  of  chariots  is  very  afflicting  to 
people  in  fevers  and  other  disorders  which  affect  the  spirits  ; and  more- 
over, as  they  will  be  relieved  from  the  expence  of  keeping  carriages,  they 
are  to  lower  the  fee  in  future  to  half  the  present  sum.  We  think  the 
resolution  redounds  greatlv  to  the  honour  of  the  College.  Indeed,  the 
fees  of  the  Faculty  have,  of  late  years,  been  so  exceedingly  high,  that 
few  people  could  afford  to  be  ill,  and  at  the  same  time  to  be  properly 
attended.” 

In  a synopsis  of  the  other  contents  of  the  book  this  item  is 
curious  : “ Meditations  on  a Balloon,  by  Cadwallader  Cruden, 
son  to  the  renowned  Alexander  the  Correcter.”  Search  for 
information  respecting  Jefferies  would  be  facilitated  if  Dr. 
Poynton  had  given  the  name  in  full. 

1 am,  Sir,  yours  faithfully, 

Westgate-on-Sea,  July  12th,  1919.  W.  R. 

PEACE  CELEBRATIONS  AND  PRECAUTIONS 
AGAINST  FIRE. 

We  are  glad  to  note  that  the  British  Fire  Prevention 
Committee  of  8,  Waterioo-place,  Pall  Mall,  London,  S.W.l, 
have  issued  a timely  warning,  pointing  out  the  dangers  of 
inflammable  materials  such  as  flags  and  bunting,  celluloid, 
paper  lanterns,  and  other  decorative  articles  commonly  used 
at  a time  of  rejoicing.  The  public  are  well  advised  to  bear 
these  precautions  in  mind.  Copies  of  the  warning  are 
obtainable  upon  written  application  at  the  above  address. 

THE  “ADELAIDE”  PATENT  GARTER. 

We  have  had  submitted  to  us  an  ingenious  form  of  garter- 
suspender,  which  on  the  score  of  economy  in  material  has 
an  advantage  over  the  method  of  suspending  stockings  from 
the  shoulder  or  from  the  waist.  A ribbon  of  elastic  is 
formed  into  a figure  of  8,  the  ribbon  being  kept  in  place 
where  it  crosses  by  a slotted  tab  of  leather.  The  two  loops 
having  been  superimposed  they  are  drawn  over  the  foot  and 
adjusted  respectively  above  and  below  the  knee,  the  part 
where  the  ribbon  crosses  being  placed  in  the  space  behind 
the  knee.  Means  are  provided  for  altering  the  size  of  the 
loops  so  as  to  fit  the  leg.  The  invention  is  quite  comfortable 
in  use,  there  is  no  undue  pressure,  and  the  stockings  do  not 
wrinkle  or  get  out  of  place. 

MEAL  SERVICE  IN  MILITARY  HOSPITALS. 

The  problem  cf  serving  meals  in  a military  hospital  is 
much  the  same  in  the  United  States  as  in  our  Army,  but  in 
1918  special  attention  was  given  in  the  United  States  to  the 
need  for  avoiding  waste  of  food.  It  was  necessary  that  every 
man  should  have  enough,  but  that  no  food  should  be  wasted, 
as  every  ounce  of  surplus  food  was  required  for  the  peoples 
of  Europe,  hence  the  remark  of  Major  R.  G.  Hoskins, 
“ Every  garbage  can  full  of  wasted  food  costs  at  least  one 
human  life,”  which  shows  how  seriously  the  United  States 
threw  itself  into  the  war.  The  Military  Surgeon  for  March, 
1919,  shows  that  there  are  two  systems  of  serving  food  in 
U.S.  military  hospitals,  one  is  similar  to  our  own,  the  meals 
being  issued  to  the  patients  on  their  tables : the  other, 
called  the  “ cafeteria  " system,  in  which  the  patients  come  into 
the  room,  pick  up  their  plates,  Arc.,  from  a table,  and  pa3s  a 
counter  where  they  make  a selection  of  the  food  they  desire, 
in  nature  and  quantity,  from  the  serving  dishes,  and  then 
pass  to  the  tables  where  they  eat  it.  This  is  a copy  of  the 
method  in  those  American  restaurants  called  “cafeterias,” 
where  there  are  no  waiters,  but  each  patron  walks  to  the 
counter  and  selects  his  “order"  for  himself.  Opinion  seems 
to  be  divided  as  to  the  system  which  gives  the  better 
result.  Patients  are  instructed  to  leave  at  the  end  a “ clean 

Elate,”  and  therefore  not  to  take  too  much  on  their  plates  at 
rst,  but,  if  necessary,  to  come  back  for  a second  helping, 
and  thus  it  is  found  that  rather  more  food  is  eaten  than  if 
large  helpings  are  given  at  first,  as  the  plates,  less  loaded, 
look  more  appetising  and  encouraging.  It  is  noted  by 
Major  A.  G.  Wilde  that  constant  supervision  is  required  in 
hospitals  to  secure  that  food  is  well  cooked  and  attractively 
presented,  as  well  as  being  properly  varied.  He  also  notes 
what  everyone  in  charge  of  a hospital  not  rigidly  in  routine 
must  have  observed,  that  cooks  are  always  anxious  to  get 
away  and  scheme  to  have  the  meals  issued  earlier  than  they 
are  ordered,  and  that  consequently  the  meals  are  apt  to  be 
cold  when  served.  

Captain  W.  C.  Stevenson,  R.A.M.C.,  and  Colonel  A.  E. 
Webb  Johnson,  D.S.O.,  have  been  appointed  Knights  of 
Grace  in  the  Order  of  the  Hospital  of  St.  John  of  Jerusalem 
in  England. 


THE  LANCET,  July  26,  1919. 


^rris  an b ©ale  f ccfurc 

ON 

THE  INITIATION  OF  WOUND  SHOCK  AND 
ITS  RELATION  TO  SURGICAL  SHOCK. 

Delivered  before  the  Royal  College  of  Surgeons  of  England 

By  E.  M.  COWELL,  D.S.O.,  M.D.  Lond.,  F.R.C.S.  Eng., 

ASSISTANT  SURGEON,  CROYDON  GENERAL  HOSPITAL. 


Introduction. 

Mr.  President  and  Gentlemen, — The  problems  of 
“shock”  have  occupied  the  miuds  of  both  clinical  and 
laboratory  workers  tor  many  years,  providing  always  one 
of  the  greatest  anxieties  the  operating  surgeon  has  had 
to  face.  Much  has  already  been  said  on  this  subject 
and  an  extensive  literature  has  gradually  accumulated. 
In  the  present  lecture  it  is  my  purpose  to  describe  in 
some  detail  several  observations  which  I have  been  able 
to  make  on  the  “initiation,”  pathogenesis  or  onset  of  wound 
shock  in  the  trenches  of  the  Western  front. 

The  adoption  of  the  idea  that  no  human  suSering  should, 
if  possible,  be  allowed  to  occur  in  vain  ; and  that  every 
opportunity  should  be  taken  by  the  clinical  observer  not 
only  to  relieve  the  individual,  but  also  to  consider  the  com- 
munity at  large,  has  been  peculiarly  applicable  to  the 
particular  aspect  of  war  surgery  at  present  under  considera- 
tion. From  the  first,  in  the  experience  of  surgeons  on  the 
Western  front,  the  mortality  of  the  wounded  from  shock  has 
been  distressing.  The  question  that  occurred  to  the  inquiring 
medical  officer  was,  first,  “What  can  I do  for  this  case?” 
and,  secondly,  “What  lines  of  preventive  treatment  can  I 
suggest  l”  Now,  we  ask  ourselves,  “How  can  we  apply 
our  knowledge  of  wound  shock  to  the  advantage  of  civilian 
surgery  ? ” 

Terminology. — In  order  to  avoid  confusion  in  speaking  of 
the  condition  of  “shock”  in  war  surgery  I have  introduced 
the  term  “wound  shock.”8  This  suggestion  has  been  adopted 
by  Professor  W.  M.  Bayliss4  and  other  writers,  and  has  so 
far  not  been  replaced.  Lieutenant-Colonel  W.  B.  Cannon  re- 
discovered the  Hippocratic  term  “ exsemia, ” and  has  used 
the  word  as  describing  the  fundamental  pathological  principle 
at  work  in  producing  the  condition — i.e.,  the  body  is  “drained 
of  blood.”3  From  time  to  time  cases  of  death  from  pure 
shock  may  possibly  occur,  but  in  war  surgery  I believe  no 
case  has  yet  been  reported  where  it  was  possible  to  exclude 
either  macroscopic  or  microscopic  anatomical  damage  in  one 
of  the  vital  organs.  In  the  cases  of  shock  met  with  in  civil 
surgery  there  are  almost  invariably  factors  of  severe  tissue 
trauma,  toxaemia,  haemorrhage,  or  psychical  disturbance 
present,  which  our  study  of  wound  shock  has  shown  to  play 
such  an  important  part  in  the  initiation  of  the  condition.  I 
have  had  no  personal  experience  of  death  from  pure  “nervous 
shock.”  Such  deaths,  I imagine,  do  not  occur  unless  there 
is  some  latent  cardiac  weakness. 

Methods  op  Obtaining  Clinical  Data. 

During  the  past  three  years  many  clinical  notes  with 
blood-pressure  observations  have  been  collected  from  patients 
arriving  in  from  2-24  hours  at  the  operating  centre  (C.C.S.) 
after  being  wounded.  As  a rule,  if  they  were  going  to 
develop,  the  symptoms  of  wound  shock  were  present  on 
arrival  at  the  hospital,  and  nothing  was  known  as  to  the 
exact  order  in  which  they  had  supervened.  It  was  decided, 
therefore,  to  establish  the  time  relations  of  the  onset  of  the 
condition. 

A series  of  observation  posts  was  organised,  beginning  at 
the  various  points  in  the  firing  line,  where  the  man  might 
be  wounded,  back  through  a series  of  relay  stations,  until 
finally  he  reached  the  hands  of  the  surgeon.  As  he  passed 
through  each  place  notes  were  made  on  a card  attached  to 
the  patient,  together  with  details  of  the  pulse-rate  and  blood- 
pressure  readings,  taken  by  means  of  a spring  sphygmomano- 
raeter  I accompanied  some  of  the  most  important  cases 
through  the  whole  journey,  and  made  records  at  frequent 
intervals.  At  different  points  of  the  firing  line  studies  of 
normal  soldiers  were  made  under  varying  conditions. 
Occasionally  I was  able  to  follow  through  a case  whose 
blood  pressure  I had  observed  shortly  before  the  wound  was 

No,  5004. 


received.  The  main  result  of  this  work  was  the  classification 
of  the  shock  cases  into  primary  and  secondary,  the  details 
of  which  will  be  referred  to  later. 

Physiological  Studies  op  the  Fighting  Soldier. 

In  order  to  investigate  the  factors  which  might  be  present 
before  the  man  was  wounded,  and  which  might  predispose 
to  wound  shock,  I spent  some  time  living  in  the  trenches, 
watching  the  soldier  under  different  circumstances,  and 
taking  blood-pressure  observations  as  often  as  possible.  The 
average  maximum  systolic  pressure  was  found  to  be 
110-125  mm.  of  mercury  and  the  diastolic  or  minimum 
75-80  mm.  In  the  unwounded  the  variatiSns  were  those  of 
hypertension,  and  were  generally  found  in  men  subjected  to 
stress  or  excitement. 

Perhaps  one  ot  the  most  fascinating  subjects  in  physiology 
is  the  study  of  the  reaction  of  the  body  to  excitement.  Of 
the  psychical  stimuli  which  result  in  extensive  physiological 
processes,  that  of  the  excitement  of  battle  probably  comes 
first,  converting  the  normal  human  machine  into  a fighting 
mechanism.  Cannon,4  and  also  Elliott,5  found  that,  as  the 
result  of  excitement  in  cats,  sympathetic  stimulation  set  free 
adrenalin,  which  could  be  detected  in  the  circulation  soon 
after  the  initial  stimulus  was  applied.  The  main  effects  of 
this  circulating  adrenalin  are  to  increase  the  heart-rate,  raise 
the  blood  pressure,  set  free  glucose  from  the  liver  in  response 
to  the  demand  of  the  muscles  for  more  foodstuff,  inhibit  the 
movements  of  the  alimentary  canal,  and  diminish  the 
coagulation  time  of  the  blood.  The  utility  of  these  bodily 
changes  is  obvious,  enabling  the  man  to  do  more  muscular 
work,  withstand  fatigue  longer,  and,  in  the  event  of  his 
being  wounded,  hastening  haemostasis.  As  will  be  shown 
later,  it  is  possible,  however,  that  the  secretion  of  adrenalin 
over  a prolonged  period  may  be  harmful,  and  that  prolonged 
excitement  may  prove  to  be  one  of  the  factors  in  the 
initiation  of  wound  shock.  The  observations  I have  been 
able  to  make  on  the  effects  of  excitement  on  soldiers  show 
that  a stimulus  such  as  exposure  to  the  danger  of  enemy 
fire,  produces  a reaction  which,  as  might  be  expected,  varies 
greatly  according  to  the  individual.  Intellectual  develop- 
ment, temperament,  habitual  exposure  to  danger  in  war  or 
civilian  occupation,  and  fatigue,  all  have  a bearing  on  the 
physiological  reaction  as  estimated  by  the  sphygmomano- 
meter. The  effect  of  temperament  is  shown  in  the  following 
cases. 

At  2 a.m.  on  a dark  night  in  the  autumn  I was  able  to 
collect  records  from  sick  men  in  a battle  aid-post  situated  in 
a well-known  sector  of  the  line.  (Fig.  1.)  The  men  under 
observation  were  all  slightlv  wounded  and  had  just  dropped 
back  into  the  trench  after  having  “gone  over  ttie  top  ” on  a 
raid.  The  artillery  and  machine-gun  fire  to  which  they  had 
been  exposed  was  severe.  The  men  were,  in  civil  life,  farm 
labourers  of  particularly  phlegmatic  temperament. 

No.  1. — A slight  wound  of  the  face.  The  man  took  every- 
thing as  a matter  of  course,  and  sat  quiet  without  speaking. 
Pulse  76.  B.P.  115  mm. 

No.  2. — Bullet  wound  of  the  hand  ; some  pain.  This  man 
was  talkative ; later  sang  and  showed  signs  of  mild  excite- 
ment. Pulse  126.  B.P.  130. 

The  other  four  men  had  all  come  in  at  the  double  and  were 
panting  when  first  seen.  Pulses  and  respirations  slowed 
quickly  on  resting. 

No.  3 — Slight  wound  of  chin.  R.  36.  P.  144.  B.P.  115. 

No.  4. — Perforating  bullet  wound  of  arm.  This  man  was 
rather  pale,  but  was  quite  cheerful,  and  had  not  lost  blood. 
Pulse  120.  B.P.  120. 

No.  5. — Slight  bomb  wound  of  the  buttock.  P.  124. 
B.P.  115. 

No.  6. — Slight  wound  of  the  face.  This  man  was  of  less 
robust  physique  than  the  others  and  looked  in  a bad  way, 
with  a pale  face  and  weak  voice.  He  wanted  to  lie  down, 
having  given  in  completely.  There  was  no  serious  wound 
to  account  for  this.  P.  112.  B.P.  120. 

Observations  on  Garrison  of  a Detached  Outpost. 

A few  weeks  later  I was  able  to  take  advantage  of  the 
full  moon  to  collect  blood-pressure  records  of  a garrison  of  a 
detached  outpost  situated  in  a new  part  of  the  line  that 
was  somewhat  exposed.  The  men  were  organised  into  a 
series  of  posts,  where  they  had  been  on  duty  for  four  nights 
and  four  days,  with  only  brief  snatches  of  sleep  in  the  day- 
time. The  nights  were  cold,  and  although  the  men  were 
well  fed,  the  water  ration  was  only  10-15  oz.  per  man  per 
diem.  The  following  figures  were  written  down  in  the 
order  in  which  the  readings  were  made.  When  the  enemy 
fire  came  within  a few  yards  a note  was  made  as  shown  on 
the  chart.  (Fig.  2.):J 


D 


Post. 


138 


Thk  Lancet,]  , MR.  E.  M.  COWELL  : THE  INITIATION  OF  WOUND  SHOCK. 


[July  26,  1919 


Bl’. 


Remarks. 


B.P. 


Remarks. 


1 118-80 
126-90 
116-80 


-Quiet. 


120-80 

116-75 

140-80 


Fairly  quiet. 


136-85 

120-80 

120-80 

140-80 

120-75 

130-80 

110-60 

120-65 


■ Quiet,.  Several 
' Verey  lights. 


150-90 
150-90 
150-80 
140-70 
140-70 
160-90  (at 


110-80  (e) 
120-60 


1 (e)  Two  years  in 
j the  line. 


140-90  la)  I 


| In  sap  leading  to 
I enemy's  lines. 
y (a)Twolastmen 
| just  knocked 
down. 


138-80 

130-75 

120-85 

130-90 

130-80 

124-70;/) 

136-70 


Important  M.G. 
position. 

{/)  Very  cold. 


Quiet,  but  not 
very  far  away 
from  3.  ( b ) 

N. O.O. in  charge, 
(c)  O.C.  o n 
his  round. 


Quiet. 

(d)  Sergeant. 


Slightly  active. 


Sentries  at  Ooy. 
Hqrs.  (ft)  Two 
years  in  the 
line. 


. Stretcher-baarers 
and  guide. 


) Patrol  party  after 
> hours  march 
t in  the  trenches. 


pain,  looked  pale,  and  was  still  sweating  Profusely.  His 
hands  were  cold  and  clammy,  pulse  96,  pressure  100-70.  Od 
arrival  at  the  clearing  station  an  hour  later  h,s ,pf“  sf9  7n 
only  100  but  the  pressure  had  further  dropped  to 
Operation  was  immediately  performed,  haemorrhage  stowed, 
and  ten  rents  in  the  bowel  repaired.  The  man  8 co“d’t*°“ 
was  serious  for  some  hours,  but  he  responded  to  treatment 
and  eventually  recovered.  (Fig.  5.)  . 

i2t  Ou  a cold,  wet,  muddy  night  a man  was  seriously 
wounded  by  a shell  while  digging  a new  trench.  He  was 
brought  to' the  advanced  dressing- station  50  minutes  later 
and  kfound  to  have  sustained  severe 

including  compound  fractures  of  femur  and  home res. 
The  exposed  lacerated  muscle  looked  like  dead  t's8ue, 
there  were  no  vessels  of  any  size  bleeding  and  hardly 
capillary  oozing.  The  blood  pressure  was  40  mm.  Mentally 
the  patient  was  quite  bright  and  resp°D8ive,  so  that  the 
medical  officer  in  charge  of  the  case  remarked  how  wonder- 
fully fit  he  was.  The  man  was  dead,  however,  within  the 
hour.  (Fig.  6.) 

Secondary  If  ound  Shock. 

In' a large  proportion  of  the  serious  wounds  symptoms  of 
shock  supervene  after  the  lapse  of  some  hours.  Early 
observations  showed  no  alteration  in  pulse-rate  or  blood 
pressure  level.  During  the  next  few  hours,  however,  in  the 
presence  of  certain  factors,  the  pressure  was  found  to  fall 
the  pulse-rate  to  rise,  and  the  state  of  shock  to  become 
established  To  these  cases  I have  given  the  name 
secondary  wound  shock.”  I will  first  d«cribe  two  cases 
where  wound  shock  did  not  develop,  although  its  onset  might 
have  been  expected. 


The  evidence  provided  by  these  readings  seems  to  afford 
clinical  support  to  the  experimental  observations  of  Cannon 
and  Elliott,  already  referred  to.  It  will  be  seen  on  examining 
the  chart  that  at  the  posts  where  there  was  special  danger 
there  the  men  were  found  to  show  the  greatest  reaction.  A 
large  number  of  blood-pressure  observations  were  taken  of  men 
of  all  ages  and  regiments  in  different  parts  of  the 
areas  in  quiet  times.  The  average  was  found  to  be  1Z5-11U. 
or  even  lower  occasionally.  For  the  sake  of  comparison  I 
have  picked  out  at  random  th«  blood  pressures  of  12  groups 
of  men  and  plotted  them.  (Fig.  3.) 

Blood  Pressure  in  the  Wounded. 

At  the  present  I am  dealing  only  with  observations  made 
in  the  line,  as  soon  as  possible  after  the  man  was  hit.  lor 
readings  made  on  later  cases  I must  refer  to  the  paper 
written  by  Fraser  and  myself  in  1917.  In  the  trivial 
wounds,  while  transient  psychical  disturbances  sometimes 
result  and  the  man  becomes  momentarily  faint,  the  hypo- 
tension does  not  exist  long  enough  to  be  measured.  On  the 
other  hand,  in  slight  wounds  the  pressure  is  more  often 
raised  For  example,  a strong  healthy  young  gunner  was 
slightly  wounded  with  a few  shell  splinters.  He  walked  to 
the  dressing-station  and  was  seen  half  an  hour  later.  His 
face  was  flushed  and  his  pressure  was  180-100.  Twenty 
minutes  later  it  was  160-90,  aD  hour  later  126-80.  His 
colour  was  now  normal  and  he  was  sleepy,  (fig.  4. ) 
Examination  of  large  numbers  of  wounded  make  it  possible 
to  divide  wound  shock  into  primary  and  secondary  varieties. 

Primary  Wound  Shock. 

Serious  wounds  do  not  always  produce  shock.  Where, 
however,  the  damage  sustained  by  the  body  is  such  that 
anatomical  death  must  supervene  unless  surgical  interven- 
tion is  possible  or  available,  the  pressure  falls  with  great 
rapidity  and.  the  symptoms  of  wound  shock  are  found  to 
have  become  established  as  soon  as  the  patient  is  seen.  In 
war  surgery,  at,  any  rate,  it  is  doubtful  if  such  a state  of 
affairs  ever  occurs  apart  from  haemorrhage.  To  this  cflass  ot 
case  1 have  given  the  name  “primary  wound  shock.  It 
is  an  unavoidable  condition,  but  one  which  in  favourable  cases 
may  be  kept  from  progressing  and  later  terminate  in 

The  following  illustrative  cases  of  primary  wound  shock 
may  be  quoted  : — 

(1)  Au  ambulance  driver,  as  he  stepped  off  his  car  on 
arrival  at  the  dressing-station  one  bright  sunny  morning , 
was  hit  in  the  abdomen  by  a shell  fragment  He  fell  do«  n , 
was  carried  in,  and  put  on  the  dressing-table  at  once.  As 
he  was  being  attended  to  he  drew  the  attention  of  the 
medical  officer  to  his  profuse  sweating.  I saw  him 
30  minutes  later  as  he  passed  the  next  re  ay  post  onhia 
way  to  the  operating  centre.  He  then  complained  of  severe 


ill  One  dark  night  the  driver  of  a gun  team  was  hit  in  the 
abdomen  by  a small  shell  fragment.  He  got  off  his  horse  to 
make  inquiries  for  the  dressing-station,  and  then  rode  nearly 
“mUe  before  being  seen  by  the  medical  officer.  He  was  then 
auite  fit,  with  a blood  pressure  of  120,  which  did  not  drop 
either  before  or  after  admission  to  hospital.  At  the  opera- 
tion two  small  rents  in  the  small  bowel  were  found  and 


S6(2i  One  evening  a man  on  a ration  party  was  hit  in  the 
thigh  bv  a shell  fragment  at  the  moment  he  was  passmg  the 
of the  aid-post.  He  was  carried  down  a few  seconds 
later  and  found  to  have  sustained  a compound  fracture  of 
the  femur.1  I found  his  pressure  120-80  and  pulse-rate  72. 
He  was  immediately  splinted  and  sent  on  to  the  dressmg- 
statffin  “hTre  he  remained  under  observation  for  six  hours 
and  finally  reached  the  casualty  clearing  station  without  at 

any  time  showing  hypertension,  (rig*  ■ 

In  the  next  two  cases  the  wounds  were  by  no  means 
serious  in  themselves,  but  secondary  wound  shock  developed. 


(3)  A man  belonging  to  the  garrison,  whose  pressures  are 
recorded  in  Fig.  2,  was  wounded  by  a bomb  which  partly 
shattered  the  forepart  of  his  foot  and  spnnk  ed^ns  neck 
and  shoulder  with  tiny  fragments.  His  chum,  stana 
bv  his  side,  was  killed.  The  blood  pressure,  which 
was  110-70  a short  while  previously,  was  still  the  same 
immediately  after  he  was  wounded.  It  was  a c°ld  dt; 
with  a chilly  wind,  and  as  the  man  was 
high  along  shallow  trenches  winding  over  a hill  he  became 
eotder  and  colder.  .At  this  time,  too,  there  was  occasional 
enemy  activity.  Bv  the  time  he  reached  the  aid-post  an 
hour  'and  a half  later,  he  was  pulseless.  Two  hours  later, 
when  examined  at  the  next  post,  he  was  still  pulseless  and 
r^er.ous  view  was  taken  of  bis  condition  He  was  hurried 
nn  to  the  casualty  clearing  station,  where  he  arrived  with  a 
nressure  of  80-65'and  no  palpable  pulse.  After  being  warmed 
up  m bed  the  pulse  soon  returned  and  the  3Jiock  passed  o 
in  the  absence  of  anv  heroic  measures  of  treatment.  (Fig.  »•> 

4i  Earlv  oue  night  in  October  a young  soldier  on  a wiring 
partv  sustained  t£o  simple  perforating ■ machme-gur gullet 
wnnruls  through  the  fleshy  part  of  the  thigh,  xnere  was  no 
ext e nsi v e ' facera  tion  of  the  muscles  and  no  hoemorrhage. 
Ifter  a two  hours’ carry  in  the  cold  1 saw  him  at  the  aid- 
nost  Ilis  condition  appeared  grave,  his  face  was  pale  an 

did  not  fall  again.  (Fig.  9.) 

The  following  cases  deal  with  amputa’ion  of  limbs  by 
gunshot  wounds  and  the  question  of  toxemia  playing  a part 
in  the  onset  of  shock. 


(5)  When  going  down  a communication  trench  about  two 
to  be  a strong  burly  lance-corporal  with  some  reputa 


The  Lancet,] 


MR.  E.  M.  COWELL  : THE  INITIATION  OF  WOUND  SHOCK. 


[July  26,  1919  139 


125 

110 


Chart  of  blood  pressure  of  six  phlegmatic 
soldiers  after  a trench  raid. 


Chart  showing  blood  pressure  records  under  stress.  J Machine 
gun  bullets.  * Rifle  g-enades.  4.  Very  lights.  § ohell. 


Note.— The  dotted  lines  on  each  chart  at  110  and  125  mm.  indicate 
the  normal  limits  of  blood  pressure. 


mm. 

150 


100 


50 


=S= 


Groups  1 


10  11 


12 


Chart  showing  blood  pressure  of  soldiers  at  rest,  in  groups 
picked  out  at  random. 


mm. 

180 

1E0 


100 


50 


Hours  12  3 

Hypertension  following  a 
trivial  wound. 


mm. 

125 


WO 


Hours  12  3 

Primary  wound  shock,  Case  1, 
ambulance  driver. 


125 

100 


50 


jTT 


"■VT 
1 fife 


Stretcher  ADS.  - 


tm 


LOT 


im 


FFF 


e-; 


±t+ 


Leaui ny-\-y\  6‘gr.j-  t \ j 


eaum<j+- M c, 

j-H  > 


Hours  1 2 3 4 5 6 8 

Compound  fracture  of  the  femur  caused  by  shell  fragment.  Absence  of 
wound  shock. 


125 

100 


50 


Hours  1 2 

Primary  wound  shock.  Case  2, 
severe  multiple  wounds. 


100 


50 


XP  Cold  carry 
l '.  over  a 
j l lie i ntly  hill 


8 


-ft 


±bt+ 


----- 


■r- 


fH4 


-^.Warmth  -j 


Hours  1 2 3 4 5 7 

Secondary  wound  shock.  Case  3,  bomb  wound  of  neck  and  foot,  not  severe. 


sa  boxer  in  the 
battalion.  He  had 
been  wounded 
about  an  hour 
before  by  a trench 
mortar,  which  had 
carried  away  hia 
left  teg  a hand’s- 
breadth  below  the 
knee,  and  at  the 
same  time  severely 
injured  the  right 
tarsus.  He  lay 
quite  calmly-  on 
hia  stretcher,  and 
answered  ques- 
tions readily.  The 
pulse  was  96,  and 
the  systolic 
pressure  115.  None 
of  the  symptoms 
or  signs  of  shock 
were  present; 
what  little  haemor- 
rhage there  had 
been  had  stopped. 

The  man  was 
warmed,  given  as 
much  cold  water 
as  he  wanted,  had 
his  wounds 
dressed,  was  well 
wrapped  up,  and 
then  sent  on  his 
journey.  I fol- 
lowed him  for  the 
next  three  hours 
a,nd  took  frequent 
pressure  readings. 

When  I left  him 
his  face  had 
become  flushed 
and  the  pulse-rate 
had  crept  up  to 
120,  but  the 
pressure  remained 
level  at  114-70.  On 
arrival  at  the 
casualty  clearing 
station  an  hour 
later  his  pressure 
had  fallen  to  88-62 
and  the  pulse-rate 
risen  to  144.  The 
muscles  of  the 
stump  were  found 
to  show  signs  of 
gas  gangrene. 

After  reamputa- 
tion his  condition 
improved,  and  he 
eventually  re- 
covered. (Fig.  10.) 

This  case  I re- 
garded at  the  time 
as  an  example  of 
bacterial  toxEemia. 

McNee3  and  others 
have  drawn  atten- 
tion to  the  speed  at 
which  anaerobic 
infections  may 
become  estab- 
lished and  produce 
their  potent 
effects.  Recent 
work  by  Bayliss 
and  Cannon,1 
which  will  be  dis- 
cussed in  detail 
later,  introduces 
the  possibility  of  a new  factor,  that  of  absorption  of  the 
toxic  products  resulting  from  disintegration  of  muscle  tissue 
apart  from  infection.  In  this,  if  immediate  amputation  had 
been  performed,  or  at  any  rate  a ligature  tied  round  the 
stump  to  prevent  absorption,  the  secondary  wound  shock 
would  in  all  probability  have  been  averted.  In  the  next  case 
this  principle  of  treatment  was  adopted  with  success. 

, (6)  A strong  muscular  soldier  received  a severe  shell 

wound  o i the  left  arm,  shattering  the  humerus.  Within  a 


short  time  the  medical  officer  in  the  trenches,  who  was 
familiar  with  the  view  expressed  in  the  preceding  para- 
graph, saw  the  man  and  performed  immediate  amputation 
under  an  anesthetic,  thereby  removing  all  the  traumatised 
tissue.  Four  hours  later  I saw  the  patient  at  the  next  relay 
post.  He  was  pale  but  quite  fit,  with  a maximum  blood 
pressure  of  140  and  a pulse-rate  of  90. 

It  has  been  frequently  noted  clinically  that  a patient 
under  operation  for  removal  of  a shattered  limb  would  show 
an  increase  in  pulse-rate  and  respiration  with  lowering  of 


140  The  Lancet,] 


MR.  E.  M COWELL:  THE  INITIATION  OS'  WOUND  SHOCK. 


[July  26,  1919 


the  blood  pressure  a few  minutes  after  the  tourniquet  had 
been  relaxed.  Latterly  we  have  taught  that  in  cases  where 
the  application  of  a tourniquet  was  necessary  the  medical 
officer  should  apply  it  as  near  to  the  damaged  tissue  as 
possible,  so  as  to  allow  of  amputation  with  the  original 
tourniquet  in  situ. 


10 


Relation  of  Primary  to  Secondary  Shock. 

Fig.  11 8 shows  diagrammatically  the  possibilities  in  a case 
of  primary  wound  shock.  From  a practical  point  of  view 
the  importance  of  closely  watching  the  patient  during  the 
period  immediately  subsequent  to  the  onset  of  shock  cannot 
be  too  urgently  insisted  on.  Otherwise  the  favourable 
moment,  B,  wiil  be  missed,  and  the  primary  merge  into 
secondary  shock  without  the  patient  being  given  the  benefit 
or  opportunity  of  surgical  intervention.  The  behaviour  of 
the  blood  pressure  in  secondary  wound  shock  is  charted 
diagrammatically.  (Fig-  12.) 

A ygravation  of  Wound.  Shock  by  Suryical  Operation  and 
Other  Factors. 

Marshall  has  published  records  of  the  blood  pressure  in 
the  wounded  during  operation.10  Here  are  a few  illustrative 
charts  from  my  own  cases. 

(a)  This  patient  came  into  the  hospital  within  20  hours  of 
receiving  a gunshot  wound  with  fracture  of  the  right  fibula. 
On  admission  the  maximum  pressure  was  130,  which  fell  to 
120  at  the  end  of  the  first  operation.  Next  day  gas  gangrene 
developed,  necessitating  the  amputation  of  the  limb.  After 
operation  the  pressure  had  fallen  to  80.  It  was  recognised 
that  the  cause  of  toxamiia  was  now  removed,  and  that  there 
was  no  hremorrhage  to  treat.  The  patient  was  kept  warm, 
given  plenty  of  fluids,  and  in  a few  hours  the  blood  pressure 
had  completely  regained  its  former  level.  (Fig.  13.) 

( b ) S. -Major was  admitted  12  hours  after  sustaining  a 

shell  wound  of  the  thigh.  At  the  operation  the  fragment 
was  found  to  have  torn  the  femoral  vein,  and  the  patient  lost 
a certain  amount  of  blood  before  the  vein  could  be  sufficiently 
exposed  to  be  sutured.  The  pressure  fell  from  118  to  90  mm., 
and  in  this  case  was  immediately  restored  by  an  intravenous 
injection  of  guin  saline.  Fifteen  hours  later  the  shock-like 
condition,  so  often  associated  with  the  presence  of  gas 
gangrene  infection,  was  observed.  This  necessitated  excision 
of  the  affected  muscle  (sartorius)  and  a further  intravenous 
injection  of  the  gum  saline.  (Fig.  14.) 

(c)  During  operation  in  gunshot  wounds  of  the  abdomen 
a fall  of  blood  pressure  may  be  produced  by  one  of  three 
conditions,  as  Marshall  has  pointed  out.10  1.  Manipulation 
of  gut  or  omentum  outside  the  abdominal  cavity.  2.  Occur- 
rence of  copious  bsemorrhage.  3.  Change  of  posture  at  the 


end  of  operation  from  dorsal  to  lateral.  Reference  to 
Fig.  15  illustrates  the  last-named  cause  of  sudden  drop  in 
pressure.  This  observation  was  made  before  I was  aware- 
of  the  possibility  of  such  an  occurrence. 

Summary  of  Recent  Investigations. 

Clinical  Observations. 

From  the  early  clinical  studies,  which  have  already  been 
described  in  detail,  the  factors  which  predominate  in  the 
pathogenesis  of  wound  shock  are  : — 

(1)  Pre-wound  factors  of  fatigue,  exposure,  lack  of  fluids, 
and  presence  of  excitement. 

(2)  Post-wound  factors  of  pain,  haemorrhage,  cold,  and 
absorption  of  bacterial  or  tissue  toxins. 

Pathological  Studies. 

The  idea  that  the  origin  of  shock  was  entirely  due  to  the 
action  of  unknown  psychical  disturbances  and  vague  nervous 
influences  producing  vaso-motor  disturbances,  which  required 
to  be  controlled  by  such  measures  as  the  wearing  of  pneu- 
matic suits,  is  now  replaced  by  a more  definite  pathological 
picture.  Recent  investigation  shows  that  in  addition  to 
arterial  hypotension  the  following  series  of  definite  facta 
may  be  demonstrated  in  an  established  case  of  shock. 

1.  Capillary  stasis  and  increased  permeability  of  the  vessel 
walls.  2.  Reduction  of  the  blood  volume  following  haemor- 
rhage and  factor  (1).  3.  Absorption  of  toxic  products  from 

infected  or  damaged  tissues,  or  both  combined.  Possibly 
also  toxaemia  from  hypersecretion  of  adrenalin.  4.  Diminu- 
tion of  intracellular  oxygenation,  leading  to  irrecoverable 
damage  of  the  finer  nerve  cells.  5.  Presence  of  acidosis  in 
the  blood  (reduction  of  the  alkali  reserve).  6.  Profound 
lowering  of  body  temperature.  7.  Toxic  action  of  certain 
anaesthetics.  8.  Effects  of  haemorrhage.  The  above  factors 
form  a symptom-complex  of  the  nature  of  a vicious  circle, 
rendering  the  condition  once  established  extremely  difficult 
to  combat. 

Examination  of  the  body  after  death  has  revealed  little  of 
importance.  The  observations  that  are  of  value  have  been 
made  by  laboratory  workers,  who  have  been  able  to  keep  in 
close  touch  with  the  operating  theatre,  resuscitation,  and 
post-operative  wards. 

(1)  Capillary  stasis  and  permeability . — Sherrington  and 
Monkton,  in  1893,n  observed  the  concentration  of  the  blood 
in  shock’  by  measuring  the  specific  gravity  and  finding  it 
increased.  Marshall,  in  1916,  found  that  the  hemoglobin 
percentage  was  increased  in  the  blood  in  cases  of  shock. 
Cannon  and  Fraser  confirmed  this  in  1917 , and  found  evi- 
dence of  concentration  of  both  systemic  and  capillary  blood. 
The  curve  shown  in  Fig.  16  illustrates  how  quickly  the 
pressure  drops  as  fluid  leaves  the  circulation  in  established 
shock . 

(2)  Reduction  of  blood  volume. — N.  M.  Keith,  and  later 
O H.  Robertson,  measured  the  blood  volume  directly  by 
the  vital  red  method,  and  have  been  able  to  construct 
curves  of  concentration  and  subsequent  dilution  of  the 
blood  during  the  period  of  recovery.  This-  work  has  brought 
forward  evidence  as  to  the  way  in  which  fluid  is  best 
absorbed  by  a patient  with  a low  pressure.  “Forced 
fluids”  given  by  mouth  or  rectum  (O.  H.  Robertson)  are 
often  as  efficacious  as  when  administered  intravenously.  It 
is  doubtful,  in  cases  of  shock  with  low  pressure,  whether 
subcutaneous  saline  is  absorbed  at  all  unless  the  condition  is 
not  severe  or  the  patient  is  already  recovering.  This  work 
solves  the  problem  of  the  lost  blood  in  shock.  At  any  rate, 
in  an  established  case  the  blood  is  not  “pooled”  in  the 
splanchnic  area,  but  is  diminished  in  quantity  because  of  its 
concentration. 

(3)  Various  toxic  causes  of  shock. — Clinical  evidence  for  the 

support  of  the  adrenalin  theory  has  already  been  produced. 
(Fig.  2 ) Experimentally  Cannon  and  also  Elliott-1  have 
demonstrated  the  presence  of  adrenalin  in  the  circulating 
blood  of  animals  under  emotional  stress.  Bedford  has  been 
able  to  show  the  presence  of  adrenalin  in  the  blood  of 
animals  suffering  from  experimental  shock.  Bainbndge  and 
Trevan"  found  that  intravenous  injection  of  small  doses  ot 
adrenalin  into  an  animal  after  20  minutes  induces  the  same 
concentration  of  the  blood  already  described.  » 

Dales  “histamine  shock”  opens  up  a large  held  ot 
thought  Dale  and  his  co-workers  found  that  suitable 
dose!  of  histamine  (10  mgm.  for  a large  cat)  produce  a 
profound  drop  in  blood  pressure,  with  capillary  stasis  and 


The  Lancet,] 


MU.  E.  M.  COWELL:  THE  INITIATION  OF  WOUND  SHOCK. 


[July  26,  1919  14 [ 


11 


Primary  wound  shock  curves  (diagram- 
matic). Following  a severe  anatomical 
injury,  instant  wound  shock  may 
develop,  Which  may  be  fatal  in  a 
shorter  or  longer  time,  as  shown  at  A or 
A'.  Under  favourable  circumstances  the 
pressure  may  rise  to  B.  dropping  later 
to  C.  At  this  point,  the  primary  has 
merged  into  secondary  wound  shock. 


12 


Secondary  shock  curves  (diagram- 
matic). In  many  of  the  cases  of 
moderately  severe  wounds  the  pressure 
will  remain  level  at  A.  In  others  it 
falls  with  the  establishment  of  secondary 
wound  shock,  B.  At  this  point  the 
patient  may  react  quickly  to  treatment, 

C,  or  after  more  prolonged  treatment  at 

D,  to  E.  In  the  absence  of  favourable 
circumstances,  the  pressure  goes  steadily 
down,  and  tbe  case  terminates  fatally 
in  from  12-24  hours,  F. 


subsequent  concentration  of  the  cir- 
culating blood.  Smaller  doses  produce 
a vaso-dilation,  for  which  evidence  is 
produced  to  show  that  it  is  capillary 
in  origin.15  This  work  deserves  con- 
sideration in  conjunction  with  Bayliss’s 
investigations  on  muscle  trauma.  Bayliss 
and  Cannon  1 found  that  within  an  hour 
after  producing  a compound  fracture  of 
the  femur  in  an  anaesthetised  cat  signs 
appeared  similar  to  those  seen  in 
secondary  wound  shock.  The  pressure 
gradually  went  down,  pulse-rate  and 
respiration  increased,  the  blood  became 
concentrated,  and  finally  the  animal 
died.  This  occurred  just  as  rapidly 
when  the  limb  was  isolated  from 


14 


Hypotension  associated  with  (1)  haemorrhage, 
(2)  toxcemia.  The  triangle  indicates  opera- 
tion, haemorrhage;  the  next  sign,  injection 
of  gum  salioe.  The  arrow  denotes  onset  of 
gas  gangrene  ; following  sign,  operation  + gum 
saline. 

the  central  nervous  system,  so  that 
the  possibility  of  its  being  due 
to  the  transmission  of  harmful  afferent 
stimuli  was  negatived.  When,  however, 
the  returning  blood  stream  was  inter- 
rupted no  lowering  of  the  pressure 
resulted,  and  the  animal  remained 
in  good  condition  until  the  clips  on  the 
vessels  were  removed. 
As  soon  as  the 
returning  bio ’d 
reached  the  body, 
down  came  the 
blond  pressure.  It  is 
probable  that  some 
tissue  poison  is  set 
free  from  the  trau- 
matic myolysis  which 
has  resulted,  pro- 
ducing effects  like 
histamine.  This  ex- 
perimental work  con- 
firms the  clinical 
observations  made  on 
the  human  subject. 
Two  years  ago  I tried, 
unsuccessfully,  to  stop 
the  onset  of  shock  by 
inducing  regional 
anaesthesia  (nerve 
blocking). 

(4)  Intracellular 
sub  o xy  g e n a t i o n. 
— Mott 17  has  exa- 
mined the  brains  of 
cases  of  fatal  wound 
shock,  and  found 
evidence  of  early 
cytolysis  of  certain  of 
the  cells  of  the  cortex 
and  basal  nuclei. 
These,  however,  he 
considers  secondary  to 
the  low  blood  pressure 


13 


Primary  surgical  shock,  spontaneous  recovery.  The  arrow  indicates 
receipt  of  wound,  and  the  other  signs  <1)  operation  and  (2)  amputa- 
tion for  gas  gangrene. 

15 


wounding 

Chart  showing  sudden  drop  in  blond  pressure  on  change  of  posture, 
denoted  by  second  arrow.  Operation  indicated  by  first  arrow. 


16 


Chart  showmg  blood  pressure  on 
admission  (denoted  by  arrow) ; imme- 
diate administration  of  two  pints 
of  normal  saline  followed  by  rise  and 
rapid  fail  of  blood  pressure,  death  at 
4.30  a.m. 


142  The  Lancet,]  MR.  E.  M.  COWELL:  THE  INITIATION  OF  WOUND  SHOCK.  [July  26,  1919 


and  not  of  primary  origin.  From  clinical  experience  after 
the  maximum  pressure  has  remained  at  60-70  mm.  for 
from  4-6  hours,  the  patient  cannot,  as  a rule,  be 
resuscitated,  even  by  blood  transfusion.  The  damage  to 
the  finer  cells  from  lack  of  tissue  oxygen  has  been  too 
great ; in  other  words,  the  process  of  tissue  death  has 
advanced  too  far  for  recovery  to  take  place.  Haldane  has 
suggested  pushing  the  oxygen  treatment.  But  even  if  pure 
oxygen  were  breathed  the  plasma  will  only  carry  2 per  cent, 
more  oxygen  than  normally.  Practically  the  treatment  with 
oxygen  has  not  been  successful.  Morphia,  by  depressing  the 
respiration,  increases  cyanosis,  especially  in  patients  after 
haemorrhage.  Experience  has  shown  that  such  cyanotic 
shock  cases  react  extremely  badly  to  ordinary  methods  of 
treatment,  and  the  only  possible  way  of  increasing  the 
oxygenation  of  the  body  is  to  give  more  oxygen-carrying 
material  in  the  shape  of  haemoglobin  by  blood  transfusion. 

(5)  Acidosis  (acidcemia  Wright). — In  1917  a number  of 
observations  were  made  by  Cannon,2  using  the  v.  Slyke 
apparatus,  on  the  alkaline  reserve  of  the  blood  in  the 
wounded  with  low  blood  pressures.  These  findings  were 
confirmed  by  others  on  cases  of  experimental  shock.  Since 
the  alkali  reserve  was  found  reduced  in  direct  relation  to 
the  drop  in  pressure,  the  question  immediately  arose  as  to 
whether  this  might  not  be  one  of  the  primary  causal  factors. 
While  this  was  being  decided  experimentally,  alkaline 
intravenous  therapy  was  practised,  undoubtedly  with  benefit 
in  certain  cases.  This  important  question  has  now  been 
settled  and  is  fully  discussed  in  Report  No.  7 of  the  Shock 
Committee. ls  The  results  of  the  various  sets  of  experiments 
may  here  be  summarised. 

(i)  “ Simple  acidosis  ” in  the  sense  of  a reduction  of  the 
alkali  reserve  of  the  blood,  even  though  it  be  severe  and 
prolonged,  does  not  cause  shock,  or  indeed,  any  perceptible 
impairment  of  the  circulation  or  other  vital  organs  in  the 
otherwise  normal  animal  at  rest. 

(ii)  In  the  case  of  animals  subjected  to  haemorrhage, 
histamine  shock,  injection  of  adrenalin  or  peptone,  there 
was  no  evidence  of  the  symptoms  being  modified  by  acidosis. 

(iii)  Experimentally  in  dogs  it  has  been  found  (Cannon) 
that  the  pressure  could  be  kept  at  80  mm.  for  an  hour 
without  a reduction  in  the  alkali  reserve.  Below  60,  however, 
a reduction  always  occurred.  After  a 20  per  cent,  haemor- 
rhage a pressure  of  80  mm.  in  an  hour  reduces  the  alkali 
reserve — i.e.,  produces  acidosis.  This  evidence  agrees  with 
clinical  observations  already  quoted. 

(iv)  Evidence  is  adduced  by  Wright  and  others19  showing 
that  the  toxaemia  of  gas  gangrene  is  accompanied  by  an 
acidosis. 

Therefore,  from  a practical  point  of  view,  the  acidosis  is 
merely  to  be  regarded  as  a symptom  of  the  lowered  blood 
pressure  and  defective  circulation.  If  steps  are  taken  to 
improve  these  the  acidosis  disappears.  The  benefits  claimed 
clinically  from  hypertonic  alkaline  treatment  would  probably 
have  been  more  striking  if  gum-saline  had  been  used  instead. 

(6)  The  body  temperature  in  shock. — Sufficient  emphasis 
has  been  laid  on  the  ill  effects  of  cold.  During  a surgical 
operation,  not  only  is  the  quantity  of  heat  lost  by  the  surface 
of  the  body  increased,  but  the  heat  production  itself  is 
diminished.  In  a series  of  wounded  presenting  low  blood 
pressures,  the  temperature  taken  of  the  interior  of  the 
thigh  muscles  was  found  to  be  as  far  below  the  normal  as 
94°  F.  and  even  occasionally  lower.  In  this  connexion  it  is 
interesting  to  note  that  Peter  Lowe,  writing  on  shock  early 
in  the  seventeenth  century,  describes  the  condition  as  being 
due  to  loss  of  “ vital  heat.”20 

(7)  The  toxic  action  of  certain  anaesthetics  in  shock. — In  the 
light  of  what  has  already  been  said  on  the  lack  of  sufficient 
circulating  fluid  and  deficient  oxygenation  of  the  tissues,  it 
is  obvious  that  the  greatest  care  must  be  taken  to  avoid 
further  depression  pf  external  or  internal  respiration. 
Buckmaster -' concludes  that  chloroform  combines  with  the 
corpuscles  and  directly  interferes  with  their  function  of 
transporting  oxygen  from  the  lungs.  One  would  expect  a 
similar  action  with  ether,  but  1 believe  this  has  not  yet  been 
worked  out.  Gas  and  oxygen  anaesthesia,  as  advocated  by 
Crile,  Boyle,  Lockhart-Mummery,  Marshall,  and  others,  does 
not  possess  this  disadvantage,  and  either  by  itself  or  combined 
with  some  form  of  nerve  blocking,  is  the  only  anesthetic 
justifiable  in  all  cases  where  hypotension  exists. 

(3)  Effects  of  heemorrhage. — Enough  has  already  been  said 
to  sho  v how  serious  is  this  factor.  The  circulating  fluid  in 


shock  is  becoming  diminished  all  the  time  and  any  further 
loss  is  not  only  felt  directly,  but  speeds  up  the  concentra- 
tion process.  O.  H.  Robertson  considers  that  with  a total 
haemoglobin  reduced  to  25  per  cent.,  transfusion  (of  blood) 
is  indicated. 

Any  one  of  the  above-mentioned  factors  may  become  the 
starting  point  of  a vicious  circle — expressed  diagrammatically 
thus  (Fig.  17).  17 


WOUND. 

Hypotension  as  result 
of  baerrorrhage,  pain,  ’ 
cold,  toxins. 


1 


Diminished  cardiac  output. 
Lessened  oxygen  intake. 


Intracellular  suboxygenation 
(damage  to  cortical  cells). 


Capillary  stasis. 
Concentration  of  plasma. 


Diminished  circulating 
fluid. 


Towering  of  body 
temperature. 

Gas. — There  is  a condition  which  clinically  and  patho- 
logically closely  resembles  that  seen  in  shock — i.e.,  that 
found  in  men  suffering  from  the  effects  of  poisoning  by  a 
gas  such  as  phosgene.  Here  the  man  is  prostrated,  blue  and 
cold,  with  a weak  pulse  and  low  pressure.  The  same 
phenomena  of  blood  concentration  and  increased  viscosity 
are  also  present.  A few  of  the  cases  of  wound  shock  are 
undoubtedly  complicated  by  gas  poisoning ; but  for  the 
most  part  gas  does  not  play  a practical  part  in  the  causation, 
of  shock. 

Comparison  of  Wound  Shock  and  Surgical  Shock.  , 

Just  as  wound  shock  may  be  produced  in  a few  minute# 
(primary  wound  shock),  so  in  certain  rare  instances  surgical 
shock  may  develop  as  the  result  of  a sudden  nerve  stimulus, 
with  or  without  haemorrhage,  or  in  an  operation  probably  in 
association  with  an  unsatisfactory  state  of  anaesthesia.  These 
instances  are  uncommon,  and  show  themselves  as  cases  of 
cardiac  weakness  or  inhibition,  demanding  special  treatment, 
such  as  cardiac  massage. 

The  bulk  of  the  cases  of  surgical  shock,  however,  corre-: 
spond  to  the  common  variety  of  wound  shock — i.e.,  the 
secondary  shock — the  pressure  falling  towards  the  end  o( 
operation  or  even  after  the  patient  has  been  returned  to  bed. 
Undue  anxiety,  chilling,  pre-existing  bacterial  toxemia,  or 
hemorrhage  are  all  pre-operative  factors  to  be  taken  into 
consideration.  During  the  operation  further  loss  of  heat, 
the  amount  and  nature  of  the  anaesthetic  employed,  the 
question  of  hemorrhage,  and,  most  important,  the  amount 
of  trauma  to  which  muscle  tissue  is  subjected,  all  play  a part 
in  the  production  of  secondary  surgical  shock. 

With  regard  to  tissue  trauma,  as  Major-General  Wallace 
has  pointed  out,  the  amount  of  shock  resulting  from  a fore- 
quarter amputation,  where  the  limb  is  removed  along  tissue 
planes,  and  where  only  a small  muscular  mass  is  divided,  is,  , 
as  a rule,  small  compared  with  the  amputation  through  the 
hip-joint,  where  large  muscular  .masses  are  traumatised.  The  '• 
beneficial  effect  of  regional  or  spinal  anaesthesia  may, 
perhaps,  be  explained  on  these  lines.  There  is  complete 
relaxation,  permitting  of  the  handling  and  retraction  of  the 
muscle  substance  with  the  least  amount  of  bruising  and 
damage.  The  handling  of  the  more  important  organs  does 
not  in  itself  necessarily  produce  shock.  I have  taken  con- 
tinuous pressure  readings  while  the  lung  was  being  “exterior- 
ised" and  the  bilum  dragged  on,  without  being  able  to  detect 
aDy  tendency  to  hypotension. 

Asphyxia  pallida  neonatorum . — Buried  under  the  obscuritj 
of  this  ancient  term  is  a variety  of  surgical  or  traumatic 
shock,  to  which  very  little  attention  has  been  paid.  Here, 
for  example,  after  being  half-crushed  and  severely  bruisec 
in  a ca-e  of  difficult  labour,  the  little  patient  is  pale  and 
flabby,  with  weak  heart-beats  and  a failing  circulation.  In 
fatal  cases  haemorrhages  may  be  demonstrated  in  the  muscles 
as  well  as  in  the  viscera,  all  pointing  to  tissue  trauma 
(Spencer).  It  would  be  interesting  to  know  what  changes 
are  present  in  the  circulating  blood.  Clinically  such  case 


The  Lancet,] 


MR.  E.  M.  COWELL:  THE  INITIATION  OK  WOUND  SHOCK. 


[July  26.  1919  1 4 3 


react  well  to  warmth,  the  application  of  which  in  the  form 
of  a hot  bath  has  been  customary  for  many  generations. 
In  addition,  in  severe  cases  I found  in  1910  thab  even  normal 
saline  injected  intravenously  often  produced  a rapid  improve- 
ment. It  is  possible  that  Bayliss’sgum  saline,  cautiously  given 
in  small  doses,  may  prove  of  oven  greater  value.  The  tech- 
nique of  intravenous  medication  in  the  new-born  is  simplified 
by  the  fact  that  the  umbilical  vein  is  patent  and  available, 
at  any  rate  for  the  first  half-hour  of  life.  This  method  of 
treatment  is  probably  widely  practised,  but  I have  been 
unable  to  find  io  referred  to  in  the  literature. 

Present  Conception  op  Shock. 

J.  P.  Lockhart-Mummery,  in  his  Hunterian  lectures, 
1905, 20  defined  shock  as  a condition  “ resulting  from  a fall 
in  general  blood  pressure  due  to  exhaustion  of  the  vaso- 
motor centre,”  and  distinguished  shock  from  collapse, 
where  the  “ fall  in  general  blood  pressure  is  due  to  inhibi- 
tion of  the  vaso-motor  centre  or  loss  of  circulating  fluid.” 
In  addition  to  the  confusion  arising  from  such  a distinction 
there  is  no  physiological  evidence  upon  which  such  theories 
can  even  be  based.  If  any  difference  in  meaning  is  made 
use  of  between  shock  and  collapse  it  should  be  one  of  time 
relationship  rather  than  anything  else.  At  the  present  time 
the  term  “collapse”  is  used  to  describe  the  symptom- 
complex  resulting  from  the  effects  of  more  or  less  prolonged 


rectum.  If  the  pressure  does  not  quickly  rise  gum  saline  is 
given  intravenously.  Wnen  it  is  thought  that  actual  loss  of 
blool  is  the  chief  factor,  then  transfusion  of  whole  blood 
should  be  carried  out  with  as  little  delay  as  possible.  By 
these  means  the  patient's  condition  can  be  sufficiently 
improved  to  allow  of  the  surgeon  performing  anatomical 
repair  and  getting  rid  of  toxic  material. 

3.  Daring  operation  in  such  cases,  or  where  the  anatomical 
interference  contemplated  is  at  all  extensive,  the  surgeon 
should  insist  on  gas  and  oxvgen  either  alone  or  combined 
with  regional  anaesthesia.  During  the  operation  a falling 
pre-sure  may  be  counteracted  by  giving  500-1000  c.cm. 
6 per  cent,  gum  solution  in  normal  saline.  There  is  no 
evidence  of  any  permanent  benefit  following  the  injection 
of  pituitrin,  adrenalin,  ergot  preparations,  atropine,  caffeine, 
camphor,  strychnine,  or  any  of  the  numerous  drugs  recom- 
mended from  time  to  time. 

[Drawings  and  diagrams  were  here  shown  illustrating  some 
of  the  methods  of  treating  the  early  stages  of  wound  shock, 
as  interesting  some  who  have  not  had  the  privilege  of  treat- 
ing the  soldier  in  the  trenches  or  on  the  battlefield.] 
(Fig.  18.)  The  greatest  interest  has  been  displayed  by 
officers  and  other  ranks  of  the  R.  A.M.O.  since  the  commence* 
ment  of  the  antishock  campaign.  In  the  latter  days  of 
trench  warfare  it  was  not  possible  to  go  into  any  well- 
established  dressing-station,  whether  it  whs  a converted 


18 


Patient  heating  up. 

Diagrams  illustrating  method  of  applying  warmth. 


Patient  ready  for  transport. 


low  blood  pressure  (Bayliss).  Any  vaso-motor  disturbances 
that  may  be  detected  are  transitory  and  of  infinitely  less 
value  than  the  loss  and  concentration  of  circulating  fluid. 
I would  suggest  from  the  practical  standpoint  the  view  that, 
with  given  causal  factors,  while  primary  shock  is  generally 
inevitable,  secondary  shock  is  mainly  preventable.  Reference 
to  Fig.  18  will  explain  diagram matically  the  present  con- 
ception of  shock  and  explain  the  symptom-complex. 

General  Management  of  the  Case. 

It  was  said  in  criticism  of  the  papers  by  Cannon,  Fraser, 
and  myself 3 that  the  discussion  of  treatment  was  meagre 
when  compared  with  the  chapters  devoted  to  clinical  and 
pathological  study.  But  once  our  knowledge  of  a morbid 
process  is  brought  on  to  a sound  clinical  and  pathological 
basis  the  application  of  therapeutic  principles  follows  as  a 
matter  of  course. 

fcrom  what  has  b°en  previously  said,  the  surgeon  in 
treating  shock  should  bear  in  mind  the  following  points. 

1.  The  psychical  aspect  of  the  case.  Any  undue 
apprehension  or  excitement  should  be  allayed  by  quiet 
persuasion,  suggestion,  or  by  the  use  of  small  doses  of 
morphia  if  necessary.. 

2.  The  loss  of  circulating  fluid  and  body  heat.  In 
preparing  a case  of  stuck  for  operation  what  has  come  to 
be  known  in  war  surgery  a*  “resuscitation”  is  carried  out. 
Warmth  is  applied  by  the  most  suitable  means  at  hand 
while  the  patient  is  made  as  comfortable  as  possible  and 
allowed  to  rest.  Fluids  are  freely  supplied  by  mouth  or 


“pill-box,”  brewery  cellar,  or  deep  dug-out,  without  finding 
a well-organised  method  of  combating  wound  sh  mk. 

In  conclusion,  I have  to  thank  the  authorities  of  the  Royal 
Army  Medical  Corps  for  their  ready  assistance  in  making  it 
possible  forme  to  carry  out  these  observations.  Major-General 
Sir  Cuthbert  Wallace,  K.C.M.G.,  C.B.,  Professor  Bayliss, 
Dr.  Dale,  and  the  members  of  the  Shock  Committee,  I wish 
to  thank  for  their  heloful  advice.  To  Major-General  Sir  Id.  N. 
Thompson,  K C.M.G  , C.B.,  D.S.O.,  I wish  to  express  my 
gratitude  for  his  sympathy  and  courtesy  in  giving  the 
greatest  possible  help.  Finally,  I wish  to  thank  the 

President  and  Council  of  the  College  for  the  honour  of 
allowing  me  to  have  brought  before  you  a subject  so  largely 
of  interest  to  the  military  surgeon. 

Bibliography.— 1.  Bayliss,  W.  M.  : Oliver-Sharpey  Lectures,  1918 - 

2.  Cannon,  W.  B. : Report  i i . , Shock  Committee,  M.R.C.,  1917. 

3.  Cowell  and  Fraser:  Idem.  4.  Cannon.  W B : B >dily  Chanyesin 
Few,  Hunger,  Pain,  and  Rage.  New  York  5 Elliott,  T.  R. : Journ. 

| of  Phys..  xliv..  p.  374.  6.  B '.inbridge  and  Trevan  : Memorandum 

! M.R.C.,  Feb.  27th,  1917.  7.  Bedford:  Quoted  in  (1).  8.  Cowell,  E.  M.  : 
Report  ii . , M R.C.,  1917.  9.  Mc  Mee,  J.  W.  : Gas  Gangrene.  Brie.  Med. 
Jour.,  June  3rd,  1917.  10.  Marshall,  G. : Brit.  Med.  Jour.,  June  3rd, 
1917.  11.  Sherrington  and  Monkton  : Proe.  Rov.  Soc.,  1893.  12.  Cujnon, 
Fraser,  and  Hooper:  Report  ii.,  M.R.C.  13.  Robertson.  H.  O.,  and 
Bock.  A.  V. : Report  vi.,  M.R  C.  14.  Dale  and  Laidlaw  : Memorandum 
M.R.C.,  February.  1917.  15.  Dale  and  Richards:  Journ.  of  Phvs., 

lii.,  July,  1918.  16.  Wallace  and  others:  Brit.  Med.  Jour.,  June  3rd, 
1917.  17.  Mott,  F.  W. : Quoted  by  (l).  18.  Report  yii.,  M.R.C. . 1918. 
19.  Wright,  Sir  Almroth  : The  Lancet.  1918,  i.,  763.  20.  Lockhart- 
Mummery,  J.  P.  : Hunterian  Lectures,  The  Lincet,  vol.  L,  1905. 

1 21.  Buekmaster,  G.  A.:  Journ.  Phys.,  xli  , 246,  22..  Criie,  G.  W. : 
Harveian  Lecture.  1937-8,  Phil,  and  Lond  m.  23.  Lockhart-Mummery, 

| J.  P.,  The  Lancet,  1916,  ii.,  12.  24.  Sherrington  and  Copeman  : Journ. 
of  Phys.,  1893. 


144  The  Lancet,]  DRS,  TOOTH  & PRINGLE  : JAUNDICE  AMONG  BRITISH  TROOPS  IN  ITALY.  [July  26, 1919 


JAUNDICE  AMONG  THE  BRITISH  TROOPS 
IN  NORTHERN  ITALY. 

By  H.  H.  TOOTH,  M.D.Camb.,  C.B.,  C.M.G., 

LATE  CONSULTING  PHYSICIAN  IN  ITALY  ; 

AND 

E.  G.  PRINGLE,  M.D.  Lond.,  M.R.C.S.,  L.R  C.P.  Lond., 

LATE  CAPTAIN,  R.A.M.C. 


Note  by  H.  H.  T. 

In  August,  1918,  I saw  with  Captain  H.  G.  Broadbridge, 
R.A.M.C.,  who  was  in  charge  of  the  “Signal  Schools” 
Hospital  at  Valsanzibio,  about  25  km.  south  of  ViceDza,  a 
group  of  ten  cases  from  the  signal  schools  camp  in  the 
mountains  close  by.  They  presented  many  features  in 
common,  as  follows  : — 

Onset  sudden  without  rigor,  so  sudden  that  the  exact  hour 
of  the  first  symptom  could  be  given  in  most  cases.  The 
first  symptoms  were  “ dizziness,”  a general  feeling  of  illness, 
and  headache,  at  first  slight  hut  growing  in  severity  during 
the  succeeding  two  or  three  days ; this  symptom  was 
common  to  all.  These  men  were  admitted  on  the  day  of 
onset  with  temperatures  of  between  101°  and  105°,  and  this 
fever  was  maintained  with  irregular  fluctuations,  but 
rarely  falling  to  100°,  for  6-8  days,  except  in  one  fatal 
case  in  which  it  fell  during  the  fourth  day  to  97-6°,  and  on 
the  sixth  and  seventh,  the  day  of  death,  to  96-6°.  The  pulse 
as  a rule  was  not  commensurate  with  the  temperature  ; for 
instance,  in  one  case  the  readings  are  T.  103-6°,  P.  100,  R.  30, 
and  similar  readings  might  be  multiplied.  The  rapid 
respiration  rate  is  suggestive  of  pulmonary  complication, 
but  I found  no  signs  in  those  I examined.  Pains  general,  or 
in  the  legs  or  back,  occurred  in  eight.  In  nearly  all 
suffusion  of  the  conjunctivas  was  noted  as  an  early  symptom, 
and  in  half  of  them  soreness  or  redness  of  the  fauces,  and 
three  showed  herpes  labialis.  Of  this  group  only  one 
developed  moderate  catarrhal  lung  symptoms.  In  no  case 
was  the  spleen  or  liver  enlarged. 

In  addition  to  these  cases  Captain  Broadbridge  writes  that 
shortly  after  this  18  more  were  admitted  from  the  same 
source,  and  these  he  considered  to  be  cases  of  so-called 
“ epidemic  pyrexia.” 

Taken  as  a whole,  these  two  groups,  totalling  28  cases, 
from  one  camp  presented  a general  symptomatic  similarity 
to  the  type  of  influenza  which  had  been  rife  amoDg  the 
troops  and  civil  population  for  some  months  previously.  But 
amoDg  them,  and  in  their  onset  and  symptoms  indistinguish- 
able from  the  rest,  were  six  cases  (21  4 per  cent.)  which 
developed  jaundice,  and  as  jaundice  was  very  common 
at  that  time  they  seem  worthy  of  special  notice.  This 
jaundice  appeared  on  about  the  sixth  or  seventh  day  of 
the  illness,  except  in  the  fatal  case  in  which  it  occurred  on 
the  fourth.  Two  of  these  I saw  on  my  visit,  and  the  others 
developed  after  it,  but  unfortunately  I was  prevented  by 
illness  from  following  them  further. 

Sapper  G.  H. D.,aged 26, suddenly  became  “dizzy” and  chilly 
at  6 p.m.  on  July  24th.  He  was  admitted  the  same  evening, 
with  T.  101°,  P.  102,  and  R.  22,  headache  and  pains  in  the 
calves,  and  suffusion  of  the  conjunctivas  appeared  the  next 
day.  The  fever  was  maintained  at  between  101°  and  102-6° 
for  four  days,  fell  to  100°  on  the  sixth,  on  which  day  he  was 
jaundiced  without  any  additional  symptoms  except  for  a 
crop  of  slightly  raised  purpuric  blotches  about  the  left  loin 
and  abdomen.  * With  the  fall  of  temperature  the  pulse-rate 
became  abnormally  slow,  46-66.  He  was  transferred  to 
No.  9 C.C.S.  and  from  there  evacuated  to  the  base.  No 
further  notes  are  forthcoming,  but  from  our  experience  we 
should  suspect  a continuance  of  low-grade  fever. 

Driver  J.  H.,  aged  20.  Sudden  onset  with  “ giddiness”  at 
9 a.M.  on  July  26th,  slight  sore-throat  and  general  pains. 
Admitted  same  day  with  a temperature  of  102-4°,  rising  to 
103-6°,  falling  suddenly  to  97-8°  on  the  morning  of  the  third 
day,  but  rising  again  the  same  day  to  101-6°.  On  the  fourth 
day  jaundice  appeared  and  the  temperature  fell  from  102-  to 
97-6°,  aud  finally  to  96  6°.  The  pulse-rate  was  100  when  the 
fever  was  at  its  highest,  and  respirations  30  without 
pulmonary  signs.  The  jaundice  became  very  intense,  the 
tongue  thickly  coated  white,  and  he  suffered  from  repeated 
vomiting,  intermittent  headache,  and  severe  general  illness. 
No  physical  signs  referable  to  heart,  lungs,  liver,  or  spleen 
were  found  at  any  time.  He  died  in  No.  9 C.C.S.  on  the 
seventh  day  of  his  illness.  The  post-mortem  report  is  as 
follows : — “ Acute  pancreatitis.  All  tissues  and  organs 
deeply  stained.  The  pancreas  was  swollen  and  haemorrhagic. 
Inflammatory  swelling  around  the  orifice  of  the  bile-duct, 
and  also  adhesion  at  the  foramen  of  Winslow.  No  free  fluid 
in  the  lesser  sac.  Liver,  spleen,  kidneys,  and  other  organs 
apparently  healthy  except  for  bile-staining." 


Most  unfortunately  no  microscopical  or  bacteriological 
report  on  these  organs  has  come  from  the  laboratory  owing 
to  a change  of  pathologists  at  that  time,  and  an  important 
link  which  might  have  thrown  light  on  this  and  the  other 
milder  cases  is  thus  lost. 

We  have  here,  then,  a group  of  28  cases  having  common 
characters  in  the  early  stages,  as  to  onset  and  symptoms  and 
from  the  same  place.  Some  of  them  develop  jaundice,  and, 
judged  by  the  course  of  other  cases  to  be  detailed  later  by 
E.  G.  P.,  probably  ran  a long  course  of  low  fever.  Others, 
the  majority,  are  non-icteric.  The  icteric  forms  resemble 
clinically  the  spirochetal  type.  Have  the  non-icteric  cases 
the  same  infective  origin?  Or  are  all  influenzal,  as  one  at 
first  thought,  with  catarrhal  jaundice  as  a complication. 

If  so,  why  should  such  a simple  complication  so  materially 
change  and  lengthen  the  further  course  of  the  disease  ? Or, 
lastly,  have  we  two  epidemic  diseases  occurring  coincidently  ? 

I have  but  little  information  as  to  the  later  stages  of  this 
group,  except  inferential.  One  icteric  case  returned  to  duty 
in  18  days,  an  unusually  short  course.  One  died  as  reported 
above.  Four  were  evacuated  to  the  base  or  to  France,  and 
of  these  1 only  came  under  our  observation  subsequently. 

Of  the  non-icteric  cases,  3 were  evacuated  to  the  base ; of 
12  there  is  no  information.  The  remaining  7 were  returned 
to  duty  from  the  local  schools  hospital  or  the  C.C.S.  after 
varying  periods  of  stay  in  hospital — namely,  2 for  three 
days  only,  2 for  17  days,  3 for  18,  21,  and  42  days  respec- 
tively— an  average  stay  of  17  days.  Most  of  these  periods 
are  long  for  the  type  of  uncomplicating  influenza  then 
prevalent.  _ , 

The  special  interest  to  us  in  this  group  lies  in  the  first-hand 
information  at  the  earliest  of  a type  of  jaundice  of  which  we 
saw  a considerable  number  of  instances  in  the  later  stages  at 
the  base,  cases  in  which  this  information  was  very  meagrely 
recorded  on  the  field  medical  card. 

In  order  to  obtain  some  collective  information  on  points  ; 
such  as  are  discussed  in  the  following  analysis,  Colonel 
Howell,  A.D.M.S.,  L.  of  C.,  caused  reports  on  all  cases  of 
jaundice  to  be  returned  by  medical  officers  of  all  units  on 
L.  of  C.  and  base  area  during  the  months  of  September,  , 
October,  and  November,  which  also  include  a few  in  July, 
August,  and  December.  As  might  be  expected,  these 
returns  are  very  variable  in  value,  but  an  analysis  of  them 
brings  out  some  information  after  all  reservation  has  been 
made.  128  returns  of  cases  of  jaundice  came  to  hand,  of 
these  17  were  rejected,  leaving  111  for  consideration. 

Analysis  of  Returns. 

Seasonal  incidence.—  The  greater  number  of  cases  occurred  ' 
in  the  months  of  September  and  October,  58  and  38, 
respectively,  96  in  all.  In  August  16,  in  July  3,  in  November 
5,  and  in  December  3,  totalling  123  returns  in  which  a date  i 
was  given. 

Regional  incidence. — The  greater  number  of  returns  are  of 
cases  occurring  in  the  forward  area— i.e.,  in  the  front  line 
12,  or  just  behind  it  16,  the  remainder  being  between  this 
and  Vicenza  21,  and  south  of  Vicenza  28,  2 from  Padua. 
Thirteen  came  from  places  which  cannot  be  identified  on  the 
map  but  were  certainly  in  one  of  these  regions,  so  that  92 
came  from  the  forward  area  (90  per  cent.).  Ten  only  came 
as  isolated  cases  from  places  on  the  L.  of  C. 

“ Catarrhal  ” cases , 84  returns.— These  are  cases  which  are 
stated  to  have  had  no  fever  at  any  time,  but  included  among 
them  are  three  which  had  a very  slight  short  rise  above 
normal.  The  symptoms  at  onset  in  41  are  abdominal,  pain 
in  the  epigastrium  and  indisposition,  nausea  7,  general 
malaise  5,  diarrhoea  2 only,  headache  and  vomiting  13, 
vomiting  4,  72  in  all. 

Onset  of  jaundice  from  the  first  day  of  illness.  Fifty-eight 
returns  are  available  for  this  point.  Fifty  cases  developed 
jaundice  on  various  days  from  the  first  to  the  eighth,  and  of 
these  37  up  to  the  fourth  day,  in  16  jaundice  was  practically 
the  first  symptom.  Of  these  58  cases  the  average  day  of 
onset  was  the  fourth. 

Where  a record  of  the  first  appearance  of  bile  in  the  urine 
is  made  this  symptom,  as  might  be  expected,  precedes  the 
disappearance  of  the  skin  colouration  by  two  or  three  days. 

Date  of  reappearance  of  bile  in  the  stools.  This  was 
noted  in  only  29  cases,  and  it  is  a very  variable  one,  from  the 
third  to  the  twenty-first  day.  The  average  day  is  the  twelfth, 
and  that  is  probably  an  outside  time. 

Date  of  disappearance  of  icteric  tinge  from  skin  and  con- 
junctive. This  is  a small  point,  but  as  a -eturn  was  made 


Thb  Lanoht,]  DRS.  TOOTH  k PRINGLE  : JAUNDICE  AMONG  BRITISH  TROOPS  IN  ITALY.  [July  26,  1919  145 


in  31  the  figures  may  be  mentioned.  The  largest  number, 
20,  fell  between  the  eighteenth  and  twenty-seventh  days. 
The  shortest  period  was  8 days  from  the  onset  of  jaundice, 
the  longest  31  days,  the  average  being  21. 

Albuminuria  was  recorded  in  25  cases  and  absent  in  42  in 
the  67  cases  in  which  an  examination  was  made.  44  returns 
are  silent  on  this  point.  Spirochetes  negative,  micro- 
scopically by  inoculation  in  2. 

These  returns  of  catarrhal  jaundice  are  given  for  what  they 
are  worth.  They  came  from  all  parts  of  the  war  area,  but 
mainly  from  the  more  active  forward  area.  They  present 
elusive  clinical  features  contrasting  in  this  respect  with  the 
pyrexial  group  now  to  be  analysed. 

Analysis  of  Pyrexial  Group. 

Jaundice  with  a definite  pyrexial  onset. — A comparatively 
small  but  important  group  of  27  cases  (24  per  cent,  of  the 
whole  number),  it  includes  the  cases  referred  to  in  E.  G.  P.’s 
note  {infra),  but  not  those  of  H.  H.  T. ’s  group  in  the  first 
part  of  this  article.  The  onset  is  noted  as  sudden  in  at 
least  14  of  them,  probably  in  all.  In  17  the  temperature  is 
recorded  as  from  99°  to  104°,  and  in  those  in  which  it  was 
not  recorded  on  the  field  medical  card  the  symptoms  were 
such  that  a high  temperature  was  practically  certain.  Among 
thesymptoms  at  onset  were  returned  : abdominal  pain,  mostly 
epigastric,  general  pains,  headache,  epistaxis,  sore-throat, 
vomiting,  diarrhoea  only  in  two. 

Initial  fall  in  temperature.  This  was  noted  in  17  cases, 
in  11  of  which  the  fall  took  place  on  the  fourth  to  the  ninth 
day,  the  shortest  period  being  the  fourth,  the  longest  the 
fourteenth  day  from  the  onset  of  the  illness,  giving  as  an 
average  day  the  eighth.  The  fall  of  temperature,  which 
generally  marks  the  onset  of  the  jaundice  is  followed  by 
a short  apyrexial  period.  This  is  returned  in  14  cases,  in 
9 of  which  it  lasted  for  from  2 to  6 days,  the  average  period 
from  these  figures  is  5-7  days,  which  is  probably  an  outside 
estimation.  The  apyrexial  interval  is  followed  by  a variable, 
but  generally  prolonged,  period  of  irregular  low  grade  fever, 
as  described  below  by  E.  G.  P.,  19  returns  give  information 
on  this  point,  but  in  some  the  temperature  had  not  become 
normal  at  the  time  of  the  return,  so  that  the  average  made 
is  probably  somewhat  within  the  truth.  The  shortest  period 
of  secondary  fever  is  given  as  8 days  and  the  longest  is  57, 
the  average  being  33  days. 

Onset  of  jaundice. — This  was  noted  in  all  the  27  returns. 
In  20  of  them  the  day  of  onset  was  from  the  third  to  the 
eighth,  10  being  the  third  or  fourth.  The  appearance  of 
jaundice  tends  to  precede  that  of  the  initial  fall  in  the 
temperature,  but  that  particular  point  is  made  in  fewer 
cases.  The  average  day  of  onset  is  the  sixth  (strictly  5 9). 
In  the  catarrhal  group  this  day  would  appear  to  be  earlier — 
i.e.,  fourth,  average. 

Reappearance  of  bile  in  the  faeces  dated  from  the  onset  of 
jaundice.  As  this  is  an  indication  of  the  duration  of 
obstruction  it  is  a fact  of  some  importance,  and  a return  was 
made  in  19  cases,  but  unfortunately  in  about  half  of  these 
the  early  note  is  defective,  and  it  is  only  stated  that  at  the 
time  of  admission  to  the  unit  in  the  base  area  the  stools  con- 
tained bile.  The  obstruction  period  is  therefore  certainly 
less  than  the  figures  at  our  command  would  warrant.  It  is 
disappointing  that  an  observation  so  simple,  and  yet  so 
interesting,  should  have  been  made  in  so  few  cases.  With 
this  reservation,  in  15  the  fceces  were  said  to  be  bile-coloured 
in  from  6 to  12  days  after  the  appearance  of  the  jaundice. 
An  average  of  8 days  of  obstruction  for  the  19  cases  is 
probably  too  long,  and  6 days  is  likely  to  be  nearer  the  truth. 

Disappearance  of  bile  from  the  urine,  noted  in  16  returns 
to  occur  at  all  periods  from  the  eighth  to  the  forty-sixth  day, 
gives  an  average  day  as  the  twenty-first. 

Disappearance  of  icteric  tinge  in  skin  and  conjunctivas, 
mentioned  in  21  returns,  was  complete  in  the  average  by 
the  thirty-fifth  day. 

Albuminuria. — A note  on  the  urine  is  made  in  25  returns, 
information  having  been  required  as  to  the  presence  of 
albumin,  casts,  and  spirochetes.  Albumin  is  definitely 
stated  to  be  present  in  12  cases,  and  casts  in  5 of  them. 
The  remainder  were  returned  as  negative.  As  to  spirochetes 
there  is  no  evidence  that  they  were  specially  searched  for 
except  in  E.  G.  P.’s  returns,  and  he  records  a negative  result 
in  all  the  cases  examined  microscopically — i.e.,  12,  in  4 of 
which  also  inoculation  of  guinea-pigs  was  performed  without 
effect. 


Note  by  E.  G.  P. 

This  note  is  based  upon  29  cases  of  jaundice  under  observa- 
tion at  a stationary  hospital  at  the  base  during  the  months  of 
August,  September,  and  October,  1918.  The  cases  were 
drawn  from  the  front  line,  intermediate,  and  base  areas. 

They  fell  naturally  into  two  divisions  : 1.  The  catarrhal 
type,  in  which  fever  was  entirely  absent  or  very  slight — that 
is,  not  over  100 J F.—  during  the  first  few  days  of  illness.  Of 
these,  there  were  17,  and  in  two  cases  only  a record  of  any 
fever.  2.  The  pyrexial  type,  which  again  divided  itself  into 
two  classes  : (a)  initial  fever  followed  by  a long-continued 
low  grade  of  fever,  in  all  seven  cases  ; ( b ) initial  fever, 
followed  by  a secondary  rise  of  limited  duration,  five  cases. 

All  the  29  cases  fell  within  these  divisions,  and  so  far  as 
is  known  there  was  no  case  which  presented  a high  grade  of 
initial  fever  which  was  not  followed  by  the  long- continued 
low  grade  of  fever  or  by  fever  of  a relapsing  type.  Of  the 
29  cases  only  two  originated  at  the  base  itself,  and  these 
were  of  true  catarrhal  type.  The  others  originated  either  in 
the  front  line  itself  or  in  the  advanced  lines  of  communica- 
tion. Except  for  the  two  catarrhal  cases  mentioned  above 
these  cases  did  not  arrive  at  the  base  until  ten  days  or  more 
bad  elapsed  from  the  commencement  of  the  illness,  and 
therefore  one  had  to  depend  upon  the  information  to  be 
obtained  from  the  field  cards  or  from  the  patients  themselves, 
guided  by  the  records  on  the  field  cards. 

Although  the  pyrexial  type  is  that  which  presents  the 
most  interesting  features,  it  will  be  useful  to  give  a descrip- 
tion of  the  catarrhal  cases,  as  it  will  serve  as  a useful  contrast 
to  the  pyrexial  cases,  and  will  also  be  a record  of  catarrhal 
cases  occurring  in  Northern  Italy. 

The  catarrhal  cases , then,  were  as  a rule  distinguished  by 
a gradual  onset,  by  absence  of  or  only  slight  fever  at  the 
onset,  by  the  tendency  to  early  onset  of  jaundice,  by  the 
presence  of  clay-coloured  stools,  by  the  symptoms  being 
mostly  referable  to  the  intestinal  tract  rather  than 
generalised,  by  the  rapid  onset  of  convalescence  after  the 
disappearance  of  the  jaundice,  and  by  the  absence  of  tachy- 
cardia as  a sequela.  The  cases  varied  in  severity  from  a 
very  slight  illness  to  one  of  a moderate  grade  of  intensity. 
General  symptoms,  such  as  headache,  dizziness,  giddiness, 
pains  in  the  back  and  limbs,  cough,  may  be  present,  but  they 
do  not  form  the  prominent  features  of  the  illness.  These 
were  referable  to  the  intestinal  tract  and  abdomen,  and  in 
addition  to  the  jaundice  consisted  of  loss  of  appetite,  furring 
of  the  tongue,  thirst,  abdominal  pains,  nausea  or  vomiting, 
constipation  or  diarrhoea.  Some  abdominal  pain  was  always 
Kresent,  but  it  varied  very  much  in  severity  from  the  ordinary 
epigastric  pain  of  indigestion  and  irregular  griping  abdo- 
minal pains  without  abdominal  tenderness  to  constant  severe 
pain  with  distension  and  a general  abdominal  tenderness, 
but  this  latter  was  unusual.  The  position  of  the  pain  or 
tenderness  in  these  cases  is  of  importance,  as  only  five  of 
them  referred  it  to  the  region  of  the  gall-bladder  or  right 
costal  margin , the  others  referring  it  to  either  the  epigastrium 
or  generally  to  the  abdomen.  In  addition  to  the  symptoms 
mentioned  above,  others  occasionally  noted  were  insomnia, 
general  weakness,  pains  in  the  chest,  drowsiness.  One 
patient  had  a fine  petechial  rash  on  the  chest  and  abdomen 
on  the  tenth  day  of  illness,  and  one  said  that  at  the  beginning 
of  the  illness  there  were  streaks  of  blood  in  the  vomit.  None 
complained  of  itching  of  the  skin  and  none  had  epistaxis  or 
herpes. 

The  jaundice  was  characterised  by  a tendency  to  appear 
early  in  the  course  of  the  case.  In  the  two  cases  which 
were  local  admissions  the  jaundice  was  present  in  both 
on  the  first  day,  but  taking  the  whole  17  cases,  in  11  the 
jaundice  appeared  during  the  first  five  days  of  the  illness. 
The  early  onset  of  the  jaundice  was  accompanied  by  a corre- 
spondingly early  appearance  of  bile  in  the  urine  and  dis- 
appearance of  bile  from  the  stools,  these  events  generally 
showing  themselves  on  the  same  day  or  the  day  after  the 
appearance  of  ‘the  jaundice.  The  bile  reappeared  in  the 
stools  in  two-thirds  of  the  cases  within  two  weeks,  and  in  all 
within  three  weeks,  of  the  onset  of  the  illness.  But  dis- 
appearance of  the  bile  from  the  urine  was  of  later  date,  in 
two-thirds  within  three  weeks  and  in  all  within  four  weeks. 

The  skin  was  normal  in  all  but  one  within  a month  and 
was  either  coincident  with,  or  followed  in  a few  days,  the 
disappearance  of  bile  from  the  urine,  but  the  conjunctive 
showed  a tendency  to  remain  coloured  for  a distinctly  longer 
time  than  the  skin,  but  only  in  one  case  for  over  a week. 
d 2 


146  The  Lancet,]  DRS.  TOOTH  & PRINGLE  : JAUNDICE  AMONG  BRITISH  TROOPS  IN  ITALY.  [July  20,  1919 


In  all  the  cases  when  bile  was  present  in  the  urine  albumin 
was  also  present,  and  in  all  when  the  bile  disappeared  the 
albumin  also  disappeared.  In  2 cases  casts  were  present  in 
the  urine  ; in  one  they  were  hyaline  in  character,  in  the 
other  granular. 

The  spleen  was  enlarged  to  percussion  in  9 cases,  and  in 
two  of  these  instances  was  palpable.  The  liver  was  enlarged 
to  percussion  in  6 cases,  but  was  never  palpable. 

The  position  of  the  apex  beat  of  the  heart  was  noted 
in  every  case,  as  it  is  of  importance  with  relation  to 


enlargement  of  the  liver,  and  in  5 of  the  cases  where  the 
liver  was  enlarged  to  percussion  the  apex  beat  was  found  in 
the  fourth  left  interspace.  The  pulse- rate  in  13  of  the  17  cases 
was  abnormally  slow.  Two  cases  showed  reduplication  of 
the  heart  sounds. 

The  examination  of  the  stools  showed  in  3 cases  out  of 
the  17  the  presence  of  the  ova  of  Triehocephalus  dispar , but 
as  these  ova  were  very  commonly  found  in  Italy  in  the  stools 
of  patients  of  all  sorts,  surgical  and  medical,  it  cannot  be 
said  that  they  should  be  regarded  as  a cause  of  the  jaundice 
when  present  in  this  proportion. 

One  of  the  cases  was  a convalescent  dysentery,  and  in 
another  the  jaundice  appeared  while  the  patient  was  in 
hospital  suffering  from  a boil  of  the  thigh. 

All  cases  except  one  were  convalescent  within  one 
month  of  the  onset  of  the  disease. 

The  pyrexial  cases  now  claim  our  consideration, 
and  they  fall  into  two  classes  according  to  the  type 
of  fever.  Those  with  : (1)  an  initial  fever  of  about 
seven  to  ten  days  with  an  interval  of  five  to  seven 
days,  in  which  the  temperature  remains  about  the 
normal,  followed  by  a long-continued  low  grade  of 
fever  which  lasts  from  about  30  to  60  days.  (Chart  1.) 

(2)  An  initial  fever  of  about  seven  to  ten  days  with 
an  interval  of  five  to  seven  days,  in  which  the 
temperature  remains  about  the  normal,  followed  by 
a secondary  rise  of  about  seven  days’  duration,  and 
that  again  sometimes  followed  by  a short  tertiary 
rise,  after  which  the  temperature  tends  to  settle  to 
the  normal  in  distinctly  less  time  on  the  average 
than  in  the  first  class  of  case.  (Chart  2.) 

Of  the  12  pyrexia)  cases,  there  were  seven  in  the 
first  class  and  five  in  the  second  class,  and  apart 
from  the  type  of  fever  and  perhaps  a marked  lemon 
tinge  of  the  skin  in  the  first  class  there  was  very 
little,  if  any,  difference  in  the  symptoms  in  the  two  classes, 
although  in  the  second  class  there  was  not  the  same 
uniformity  of  severity  as  in  the  first. 

The  seven  cases  with  a continued  fever  were  all 'acute  in 
onset,  and  the  attack  severe  and  prolonged.  The  symptoms 
were  those  which  mark  the  onset  of  an  acute  pyrexial 
attack — vie.,  shivering  and  chill,  high  fever,  sudden 
malaise,  aching  of  the  head,  body,  and  limbs,,  thirst, 
marked  weakness,  sore-throat  or  injection  of  fauces,  giddi- 
ness and  dizziness,  photophobia,  suffusion  of  eyes,  stiffness 
of  neck  muscles,  accompanied  by  or  followed  in  the  course 
of  a day  or  two  by  abdominal  symptoms,  pains  in  the 
stomach,  vomiting,  constipation  or  diarrhcea,  jaundice 
appearing  between  the  fourth  and  seventh  days,  commonly 


on  the  sixth  day  of  the  illness.  With  the  onset  of  jaundice 
there  was  a rapid  decline  of  the  fever,  but  although  the 
patient  generally  felt  better  there  was  usually  some  drowsi- 
ness, apathy,  very  foul  tongue,  and  bad  appetite,  perhaps 
epistaxis  or  a petechial  rash.  The  jaundice  rapidly  became 
very  marked  and  very  gradually  died  away,  but  bile  was 
absent  from  the  urine  in  all  the  cases  at  least  three  weeks 
before  the  fever  entirely  died  away.  • With  the  disappear- 
ance of  the  jaundice  the  skin  assumed  the  lemon  tint,  and 
anaemia  was  marked  in  all.  The  lemon  tint  made  it 
extremely  difficult  to  say  when  the  jaundice 
had  really  disappeared,  as  the  two  merged  into 
one  another.  By  the  end  of  the  second  week 
the  continued  fever  had  generally  started  on 
its  long  and  tedious  course,  during  which  it 
often  stayed  monotonously  about  99°  for  some 
weeks.  With  regard  to  the  abdominal  condi- 
tions, the  local  symptoms  did  not  compare  in 
intensity  with  the  more  general  ones,  but 
the  abdomen  was  usually  tender,  sometimes 
swollen,  and  the  tenderness  and  pain  showed 
a marked  preference  for  the  region  of  the  gall- 
bladder and  the  right  lower  costal  margin 
rather  than  the  epigastrium.  The  condition  of 
the  bowels  was  at  the  onset  of  the  illness  either 
one  of  constipation  or  of  diarrhoea,  generally 
the  former.  One  patient  had  herpes  which 
developed  on  the  sixth  day  with  the  jaundice, 
and  one  had  swelling  of  the  glands  of  the  neck 
accompanying  his  sore-throat.  Two  had  sore- 
throat  which  was  of  a severe  character,  but  in 
neither  was  it  the  initial  symptom.  All  the 
cases  were  extremely  tedious  in  their  con- 
valescence, the  fever  not  abating  in  the  least  severe  until  six 
weeks  had  elapsed  from  the  beginning  of  the  illness,  and 
one  had  fever  lasting  ten  weeks.  After  the  fifth  week  there 
was  a marked  tendency  to  tachycardia. 

There  were  five  cases  with  the  second  type  of  pyrexia. 
Two  of  these  presented  the  same  sudden  onset  and  symptoms 
as  the  first  group.  A short  synopsis  of  their  symptoms  is 
appended.  These  two  men  belonged  to  the  same  battalion 
and  were  both  stationed  at  Arzignano.  The  one  was  taken 
ill  a day  previous  to  the  other.  They  were  not  companions, 
nor  was  there  any  apparent  connexion  between  them  in  their 
duties.  Their  temperature  charts  show  a remarkable  simi- 
larity ; the  clinical  picture  of  their  cases  was  also  similar. 


Case  1.  l’te.  L.  Date  of  onset.  31.7.18.  Onset  very  I 
sudden,  with  sickness,  diarrhcea,  pains  all  over  the  bodv, 
headache  and  fever,  pains  in  the  stomach,  and  cough.  ! 

2.8.18  : Jaundice  and  herpes.  5.8.18  : Jaundice  very  marked,  ^ 
cough,  headache,  pains  in  the  stomach.  11.8.18':  Tongue 
very  dirty,  liver  enlarged  and  tender,  but  not  palpable.  ! 

14.8.18  : 1’ain  in  the  splenic  region,  with  a fine  friction  over  ; 
the  spleen.  No  evidence  of  splenic  enlargement.  26.9.18 : ' 
Alveolar  abscess.  29.9.18  : Pleural  friction  at  the  right  base,  j 
back  and  front,  of  a coarse  character. 

Case  2.  Pte.  D.  Date  of  onset,  1.8.18.  Onset  very  sudden,  i 
with  pains  in  the  head,  fever,  and  shivering.  2.8.18  : Slight 
epistaxis.  3.8.18:  Haemoptysis  and  great  weakness.  4.8.18:  i 
Temperature  104-2°;  jaundice.  5.8.18:  Jaundice  marked  I 
and  pains  in  the  stomach.  6.8.18:  Herpes  of  lips  and  left  ! 
cheek.  11.8.18  : Deep  jaundice,  erythematous  and  urticarial  ! 


Chart  1.— Pyrexial  Type  1.  Gnr.  P.  Initial  fever  followed  by  long-con- 
tinued low  grade  fever.  This  chart  was  continued  to  the  60th  day. 
with  irregular  daily  variations  of  temperature  from  normal  to  99'8Q. 


T.-ik  Lanobt,]  DRS.  TOOTH  & PRINGLE  : JAUNDICE  AMONG  BRITISH  TROOPS  IN  ITALY.  [July  26,  1919  147 


rash  of  forearms,  chest,  and  abdomen.  Lower  liver  edge 
tender  but  not  palpable.  Spleen  not  enlarged.  13.8.18:  Some 
small  petechiro  in  rash.  15.8.18:  Rash  almost  disappeared. 
16.8.18  : Temperature  102-4°  ; apathetic.  19.8.18  : Tempera 
ture  103-2°;  vomiting  and  severe  pains  in  the  back  ; liver  and 
spleen  not  enlarged.  23.8.18  : Fever  gone  and  patient  rapidly 
improving  in  general  condition. 

Roth  showed  a tendency  to  tachycardia  after  the  fifth 
week. 

The  other  three  cases  included  in  this  group  did  not  show 
the  same  severity  of  symptoms,  and  their  fever  was  neither 
so  high  nor  so  prolonged,  but  they  all  had  an  initial  fever 
followed  by  a secondary  fever  of  limited  duration. 

The  question  then  arises.  Do  these  two  groups  of  pyrexial 
cases  own  the  same  cause  ! As  their  symptoms  are  so  much 
alike  and  their  only  difference  appears  to  be  the  type  of 
fever,  it  seems  that  this  question  must  be  answered  in  the 
affirmative. 

Taking,  then,  these  pyrexial  cases  as  one  group,  in  the  12 
cases  observed,  the  earliest  appearance  of  jaundice  was  on 
the  third  day,  in  2 the  jaundice  appeared  on  the  fourth,  and 
in  the  remainder  between  the  fifth  and  tenth  days,  the 
commonest  day  being  the  sixth.  Bile  appeared  in  the  urine 
shortly  after  the  onset  of  the  jaundice,  but  with  regard  to 
the  stools  there  was  nothing  like  the  same  constancy  of  dis- 
appearance of  the  bile  from  the  stools,  as  in  the  catarrhal 
cases.  Sometimes  the  stools  were  clay-coloured,  but  very 
often  some  amount  of  bile  persisted  in  the  stools  throughout 
the  illness.  Bile  was  present  in  the  urine  in  most  instances 
up  to  the  fourth  or  fifth  week.  Another  feature  with  regard 
to  the  severe  types  was  that  the  jaundice  improved  in  spite  of 
the  persistence  of  the  fever,  and  in  most  instances  the 
temperature  was  still  febrile  after  the  bile  had  entirely 
disappeared  from  the  urine. 

The  skin  and  conjunctivas  were  not  generally  normal  until 
the  fifth  to  the  eighth  week,  and  the  skin  and  conjunctivfe 
both  seemed  to  approach  to  the  normal  at  the  same  time,  but 
owing  to  the  lemon-tinted  skin  in  the  majority  of  cases  it  was 
difficult  to  say  when  the  bile  exactly  disappeared  from  the 
skin.  Casts  were  found  in  the. urine  in  5 cases  out  of  the  12. 
In  1 hyaline,  in  2 granular,  and  in  the  other  2 hyaline, 
granular,  and  epithelial.  Epithelial  casts  were  not  found  in 
the  catarrhal  forms.  Albumin  was  present  in  the  urine  in 
all  cases  when  bile  was  present.  The  spleen  was  enlarged  to 
percussion  in  5 cases,  and  in  one  of  these  it  was  palpable, 
this  proportion  not  differing  greatly  from  that  found  in  the 
catarrhal  cases.  The  liver  was  enlarged  to  percussion  in  9 
cases,  in  one  of  which  it  was  palpable,  the  proportion  here 
being  much  greater  than  in  the  catarrhal  forms.  The  posi- 
tion of  the  apex  beat  of  the  heart  was  in  the  fourth  space 
in  6 out  of  the  8 cases  in  which  it  was  noted,  and  the 
liver  was  not  enlarged  in  the  2 cases  where  it  was  in  the 
normal  position.  The  maximum  point  of  pain  or  tender- 
ness in  the  abdomen  was  in  the  position  of  the  gall- 
bladder or  under  the  right  costal  margin  in  6 cases  out  of 
11,  in  the  epigastrium  in  3,  in  the  splenic  region  in  1,  and 
in  the  left  side  of  the  abdomen  in  1.  This  tendency  for  the 
pain  to  be  situated  in  the  right  hypochondrium  is  doubt- 
less in  correlation  with  the  greater  proportion  of  cases  of 
hepatic  enlargement  in  these  cases  as  compared  with  the 
catarrhal  ones.  The  pulse-rate  at  the  commencement  of  the 
illness  seemed  to  vary,  in  some  cases  being  slow  in  com- 
parison with  the  temperature,  in  others  commensurate  with 
the  fever,  but  with  the  onset  of  the  jaundice  it  became 
abnormally  slow  in  comparison  with  the  fever,  the  lowest 
pulse- rate  noted  being  32. 

The  examination  of  the  stools  of  these  12  cases  disclosed 
the  presence  of  the  ova  of  parasitic  worms  in  6 of  the  12,  the 
ova  of  Trichucephalus  dispar  only  in  3,  the  ova  of  Ascaris 
lumbricoides  only  in  1,  the  ova  of  Trichocephalus  dispar  and 
ascaris  in  1,  and  the  ova  of  Trichocephalus  dispar  and  an 
adult  ascaris  in  1.  As  has  been  observed  previously,  these 
ova  were  quite  commonly  found  amongst  the  troops  in  Italy, 
but  the  proportion  found  in  these  cases  seemed  to  be  above 
the  average. 

A blood  count  taken  from  Pte.  D.  on  the  seventeenth  day  1 
of  the  disease  during  the  secondary  rise  of  temperature 
showed  4,096,000  red  cells  and  7000  white  cells  with  nothing 
distinctive  in  the  differential  count.  Blood  pressure  estima- 
tions showed  nothing  abnormal. 

Five  of  the  pyrexial  cases  were  examined  as  to  the  presence 
of  the  enteric  group  of  organisms  in  urine  and  fasces,  three 
of  the  first  group  and  two  of  the  second.  In  all  of  these 
enteric  group  organisms  were  absent. 


Blood  cultures  were  taken  from  Pte.  D.  and  Pte.  L.,  the 
first  being  negative  and  the  second  showing  a growth  of 
Staphylococcus  aureus,  probably  a contamination. 

Investigations  were  undertaken  as  to  the  presence  of  the 
Spiroohata  ioterohee m orrh agice.  In  four  of  the  cases,  two  of 
each  group  of  the  pyrexial  types,  a guinea-pig  was  inoculated 
but  without  result.  All  cases,  both  pyrexial  and  catarrhal, 
had  a microscopical  examination  made  of  the  urine,  but  the 
spiroebsete  was  never  found.  Nevertheless,  in  spite  of  these 
negative  results  as  to  the  presence  of  the  spirochaste,  it  is 
felt  that  this  may  be  a possible  cause  of  the  pyrexial  cases, 
as  they  agree  in  their  clinical  character  with  the  disease  so 
well  described  by  Dawson,  Hume,  and  Bedson  in  their  paper 
on  spirochsetal  jaundice,  although  they  do  not  specifically 
describe  cases  with  low  continued  fever.  There  were  no 
deaths  among  these  29  cases. 

Conclusion. — During  the  months  of  August,  September, 
and  October,  1918,  there  were  prevalent  amongst  British 
troops  in  Northern  Italy  two  types  of  jaundice — namely, 
catarrhal  and  pyrexial.  The  pyrexial  cases  again  were  sub- 
divided into  two  groups,  those  with  initial  fever  followed  by  a 
long  low  continued  fever,  and  those  with  initial  fever  followed 
by  a secondary  fever  of  limited  duration.  These  pyrexial 
cases  apart  from  the  temperature  presented  the  same  clinical 
features  and  showed  a great  resemblance  to  cases  of  spiro- 
cbretal  jaundice,  but  there  was  no  bacteriological  evidence 
to  support  this  view. 

I must  add  my  indebtedness  to  Lieutenant-Colonel  C. 
Bramhall,  R.A.M.C.,  for  allowing  these  cases  to  be  under 
my  care,  and  to  Major  W.  Broadbent,  R.A.M.C.,  for  his 
suggestions  and  interest  in  these  cases. 

Concluding  Remarks. 

We  regret  that  by  the  force  of  circumstances  the  clinical 
facts  in  this  communication  are  not  supported  by  more  bac- 
teriological evidence.  The  bacteriological  examinations  were 
made  by  Captain  W.  Broughton-Alcock  and  Captain  A.  N. 
Smith,  to  whom  we  are  much  indebted,  and  whose  technique 
is  beyond  question.  The  inoculations  on  guinea-pigs  were 
made  on  the  sixteenth,  seventeenth,  eighteenth,  and  twenty- 
seventh  days  of  the  disease,  respectively,  and  therefore 
within  the  recognised  limit  of  28  days,  but  were  all  negative 
as  to  spirochfetal  infection. 

We  are  forced,  therefore,  to  suspect  that  there  may  be 
some  infection  other  than  spirochretal,  though  clinically 
similar  to  it,  and  that,  if  so,  all  these  cases,  with  or  without 
jaundice,  may  have  this  infection  as  a common  causal  factor. 
Nevertheless,  we  do  not  feel  able  to  exclude  dogmatically 
the  spirochfetal  factor,  in  spite  of  negative  bacteriological 
results,  in  the  face  of  the  clinical  resemblance  of  our  cases 
to  those  published  by  the  Japanese  and  British  observers. 

Although  jaundice  may  occur  as  a complication  of 
influenza,  it  is  certainly  not  common  in  most  civil  epidemics, 
yet  it  is  striking  that  in  our  first  group  these  icteric  cases 
should  be  so  intimately  associated  in  origin  with,  and  so 
similar  in  their  early  symptomatology  to,  what  seem  to  be 
“epidemic  pyrexial”  cases,  and  this  circumstance  gives  an 
added  interest  to  epidemic  fever  or  influenza  which  raged  in 
Italy  from  the  early  months  and  onwards  of  1918. 

We  conclude  with  offering  our  thanks  to  the  A.D.M.S., 
L.  of  C.,  Colonel  Howell,  for  cooperation  in  obtaining 
returns,  and  the  medical  officers  of  all  units  for  furnishing 
them. 


Livingstone  College. — Dr.  T.  Jays,  who  has 
worked  in  different  capacities  with  the  Church  Missionary 
Society  and  the  Student  Christian  Movement,  has  become 
vice-principal  at  Livingstone  College,  and  with  his  wife  will 
reside  in  the  College.  In  addition  to  helping  the  principal, 
Dr.  Jays  will  take  the  lectures  previously  delivered  by 
Colonel  G.  B.  Price,  who  is  now  working  with  the 
Ministry  of  Pensions.  Before  the  College  reopens  on 
Oct.  1st  a short  course  of  15  lectures  on  Personal  Care  of 
Health  in  the  Tropics  will  be  given  from  Sept.  22nd-25th  by 
I the  principal,  vice-principal,  and  probably  Colonel  Price. 
These  lectures  are  open  to  men  and  women,  and  are  intended 
for  those  who  expect  to  reside  or  travel  in  the  tropics.  They 
would  be  of  use  to  missionaries,  nurses,  explorers,  members 
of  the  services,  Government  officials,  commercial  men,  Ac. 
Application  for  terms  and  conditions  of  attendance  should 
be  made  previous  to  the  lectures  to  the  Principal,  Living- 
stone College,  Leyton,  E.  10,  who  will  be  pleased  to  answer 
any  questions  with  reference  to  these  lectures  or  concerning 
the  full  nine  months’  course  at  Livingstone  College,  which 
will  commence  on  Wednesday,  Oct.  1st,  1919. 


148  The  Lancet,]  DR.  S.  V.  PEARSON:  THE  EFFEOTS  OF  ARTIFICIAL  PNEUMOTHORAX.  [July  26,  1919 


THE  EFFECTS  OF 

ARTIFICIAL  PNEUMOTHORAX. 

By  S.  VERB  PEARSON,  M.D.  Cantab., 
M.R.C.P.  Loni>., 

SENIOR  RESIDENT  PHYSICIAN,  MUNDESLEY  SANATORIUM. 


This  article  is  based  upon  the  experience  gained  from  21 
patients  with  severe  pulmonary  tuberculosis  whose  pneumo- 
thorax 1 induced  artificially,  except  in  one  case  (No.  19), 
between  August,  1910,  and  December,  1910.  The  exception 
had  developed  a spontaneous  hydro-pneumothorax  which  I 
converted  into  a controlled  pneumothorax. 

Striking  Results  of  Artificial  Pneumothorax. 

This  series  includes  all  those  so  treated  by  me  duriDg  this 
period  in  whom  the  pneumothorax  obtained  was  complete  or 
nearly  complete.  Eleven  of  the  21  are  alive,  and  all  save 
two  of  these  are  enjoying  good  health  and  following  their 
usual  vocation. 


6 

Sex  and  age. 

Date  of 
induction  of 
pneumo- 
thorax. 

o3 
; c 
xt 

1 Whether  fluid 
present. 

1 Whether  fluid 
tapped. 

| Date  of  last  (or 
| latest)  injec- 
tion of  gas. 

Interval  between 
most  recent 
refills  of  gas. 

Amount  of  gas 
takenatmost 
1 recent  refills. 

Present  state. 

i 

M.,  34 

13/8/10 

R 

+ 

+ 

Sept.,1911 

4 w. 

c.cm. 

Died  Jan.,  1915. 

2 

M.,  30 

23/5/11 

L 

+ 

+ 

Feb.,  1919 

7 w. 

600 

Well ; working. 

3 

M.,  42 

14  11  11 

K 

+ 

4- 

June,  1917 

about 

350 

Died  July,  1918. 

4 

F.,  22 

20/11/11 

L 

+ 

+ 

Dec.,  1912 

2 y. 
2j  w. 

180 

Died  March,  1913. 

5 

F..  17 

1/1/12 

H 

- 

- 

Mar.,  1914 

6 w 

500 

Died  June,  1916. 

6 

F.,  17 

28/2/12 

L 

- 

- 

May,  1913 

4 w. 

700 

Died  Feb.,  1915. 

7 

M.,  24 

13/1/13 

L 

+ 

- 

Feb.,  1915 

6 w. 

9C0 

Well;  working; 

8 

M.,  23 

21/3/13 

L 

+ 

- 

Feb.,  1919 

3i  m. 

375 

about  to  marry. 
Well ; working. 

9 

M.,  34 

7/7/13 

H 

+ 

+ 

May,  1917 

2-2  m. 

400 

„ 

10 

M.,21 

2/11/13 

L 

- 

- 

Feb.,  1919 

5 w. 

1100 

„ 

11 

38 

5 11/13 

K 

- 

- 

Apr.,  1914 

2 \v. 

600 

Died  April,  1914. 

12 

F.,  33 

17  11/13 

11 

+ 

+ 

May,  1915 

3 w. 

120 

Died  August,  1915. 

13 

M„  35 

3/1/14 

K 

- 

- 

Feb.,  1914 

10  d. 

650 

Died  Feb.,  1914. 

14 

M.,  40 

7/1  14 

L 

+ 

- 

Jan.,  1919 

3 m 

900 

Well ; working. 

15 

F.,  39 

8 8 14 

L 

+ 

+ 

Feb.,  1915 

2 w. 

2C0 

Died  March,  1915. 

16 

M.,  46 

8/9/14 

H 

+ 

+ 

May,  1918 

12  m. 

700 

See  below  (a). 

17 

M„  26 

2/12/14 

L 

- 

- 

Sept. ,1918 

2 m. 

600 

See  below  ( b ). 

18 

F.,  21 

4/6/15 

R 

+ 

- 

Jan.,  1919 

6 w. 

600 

Well;  working; 

19 

M.,  53 

28/4/16 

R 

+ 

Feb.,  1918 

1 m . 

300 

married  in  1918. 
Died  March,  1918. 

20 

M.,23 

21/7/16 

R 

+ 

+ 

Feb.,  1919 

2 m. 

500 

Invalid. 

21 

F.,  35 

11/9/16 

L 

+ 

- 

Dec.,  1918 

2£  m. 

1000 

Well ; working. 

y,  years  ; m,  months  ; w,  weeks  ; d,  days. 

(a)  Breathing  apparatus  good,  but  somewhat  incapacitated  by  bone 
tuberculosis ; (6)  Fairly  well,  free  from  symptoms,  but  not  capable  of 
much  work. 

Nearly  all  of  the  ten  who  have  died  had  their  symptoms 
much  alleviated  and  their  lives  materially  prolonged,  in 
several  instances  by  years,  during  which  they  enjoyed  fairly 
good  health  and  followed  their  occupations.  The  restoration 
to  health  and  activity  of  most  of  the  11  is  wonderfully 
complete. 

For  example,  No.  10  writes  (January,  1919) : “ I have  no 
trouble,  enjoy  good  health,  and  I am  quite  unconscious  of 
the  fact  that  I am  only  using  one  lung.  I feel  a perfectly 
normal  individual.” 

No.  7’s  doctor  wrote  (December,  1918) : “ He  feels  in  perfect 
health.  Can  walk  up  hills  better  than  his  sister,  who  is  a 
strong,  healthy  girl." 

And  No.  14,  a doctor  working  regularly  as  a sanatorium 
physician  for  the  past  four  years,  now  cycles  occasionally 
15  to  20  miles  in  a day,  or  does  a quiet  half  day’s  shooting. 

These  results  can  justifiably  be  called  remarkable  when  it 
is  observed  that  they  are  obtained  for  people  whose  state 
was  generally  of  such  a nature  that  only  a few  months  of 
serious  invalidism  could  have  been  anticipated  under  the 
ordinary  regime.  The  history  of  most  of  them  is  well 
exemplified  by  that  of  Nos.  2,  7,  and  12. 


No.  2 had  been  to  two  or  three  sanatoriums  during 
the  years  before  admission  to  Mundesley ; he  had  bad 
laryDgeal  as  well  as  severe  pulmonary  lesions. 

No.  7 had  been  under  sanatorium  treatment  without 
avail  in  Devonshire  and  Mundesley  for  nearly  two  years 
before  the  induction  of  the  pneumothorax,  and  had  had 
serious  symptoms  for  longer  than  this. 

No.  12  bad  been  ill  for  3i  years  before  compression 
therapy  was  started  ; she  had  been  unable  to  take  exercise 
on  account  of  fever  for  15  months  ; she  had  half  a mugful  of 
muco  purulent  expectoration  containing  tubercle  bacilli. 

Every  case  in  the  series  had  expectoration  containing 
tubercle  bacilli.  But  the  nature  and  severity  of  the  condition 
of  these  cases  can  be  judged  by  reference  to  my  previous 
writings  on  this  subject.1  The  gist  of  the  matter  is  that  in 
nearly  every  case  a situation  had  been  reached  which  was 
quite  hopeless  apart  from  artificial  pneumothorax. 

A striking  contrast  to  these  results  is  to  be  found  by 
following  up  the  after-history  of  those  patients  for  whom 
artificial  pneumothorax  was  attempted  unsuccessfully 
because  of  adhesions,  including  under  this  head  those  in 
whose  cases  pneumothorax  treatment  was  abandoned  at  an 
early  date  because  of  the  ineffectual,  partial  nature  of  the 
pneumothorax  produced.  During  the  same  period  (August. 
1910,  to  December,  1916)  I tried  to  induce  a pneumothorax 
but  failed  completely  on  account  of  adhesions  in  six  cases, 
and  I induced  only  an  ineffective,  partial  pneumothorax  soon 
abandoned  in  seven  other  cases.  All  save  one  of  these 
patients  are  dead.  The  one  still  alive  does  not  enjoy  good 
health  and  is  unable  to  follow  his  occupation.  The  average 
length  of  life  of  the  twelve  who  died,  from  the  date  of  the 
attempt  to  induce  a pneumothorax,  was  probably  con- 
siderably under  two  years  (I  have  not  all  the  data 
for  arriving  at  this  average).  Whereas  the  average 
length  of  life  of  those  who  died  in  spite  of  the  artificial 
pneumothorax  treatment  was  2a  years,  though  the  number 
includes  3 who  only  lived  lj,  4J,  and  6 months  respec- 
tively. And  in  the  case  of  those  with  an  effective  pneumo- 
thorax who  are  still  alive  the  average  time  to  present  date 
from  the  date  of  the  induction  of  the  artificial  pneumo- 
thorax amounts  to  4 j years,  the  longest  time  (No.  2)  being 
7 J years  and  the  shortest  (No.  21)  2^  years. 

Factors  affecting  the  Course  of  Treatment. 

In  the  rest  of  this  article  I shall  deal  with  the  results  and 
complications  of  artificial  pneumothorax  as  they  affect  the 
course  of  the  treatment.  As  usual,  difficulties,  failures, 
and  mistakes  have  taught  me  more  in  the  course  of 
the  last  8)  years  than  all  the  routine  management  of  those 
cases  which  have  gone  forward  smoothly.  As  usual,  too, 
in  reviewing  one’s  experience  one  finds  that  set  rules  are 
hard  to  lay  down.  Circumstances  vary  widely.  Each  factor 
at  any  particular  juncture  must  be  taken  on  its  merits  and 
weighed  before  a step  is  taken.  But  a few  useful  conclu- 
sions may  be  enunciated  none  the  less. 

(<r)  In  the  earlier  stages  of  the  treatment,  say  up  to 
about  18  months,  I believe  there  is  greater  likelihood  of 
making  a mistake  by  injecting  gas  too  seldom  and  taking 
the  pressures  too  high  rather  than  erring  in  the  opposite 
directions. 

(i)  I am  convinced  that  abandonment  of  the  injections  of 
gas  in  a successful  case  after  too  short  a period  is  a far 
worse  error  than  the  continuance  of  refills  for  too  long.  I 
believe  No.  6 might  have  maintained  perfectly  good  health 
had  the  treatment  not  been  abandoned  too  soon,  I may  add, 
through  no  fault  of  the  patient  or  of  mine.  About  18  months 
after  starting  the  pneumothorax  and  about  three  months 
after  stopping  it,  having  been  in  apparent  perfect 
health  for  nearly  the  whole  of  this  time,  she  was  looking 
upon  herself  as  a perfectly  normal  individual,  and  was 
allowed  to  work  eight  hours  a day  studying  at  a college. 
Relapse  set  in  about  six  months  later,  the  pneumothorax 
could  not  be  re-established,  and  the  disease  spread  far.  In 
the  case  of  No.  5,  too.  whose  subsequent  history  was  some- 
what similar,  I am  much  inclined  to  think  from  subsequent 
experience  that  a further  year  of  refills — i.e.,  3;  years 
instead  of  24— might  have  produced  a permanently  good 
result. 


1 E.g.,  to  articles  In  The  Practitioner  iSeptember,  1911)  on  “The 
Choice  of  the  Patient  for  Artificial  Pneumothorax,"  and  in  the  British 
Medical  Journal  (Oct.  12th.  1912),  where  further  details  and  a more 
ample  history  of  several  of  the  patients  can  be  found.  In  the  present 
series.  Nos.  1 and  2 are  Nos.  1 and  4 in  the  first  article,  and  Nos.  3, 
4,  5,  and  6 are  Nos.  3,  2,  4,  and  5,  respectively,  in  the  second  paper. 


The  Lancet,]  UR.  S.  V.  PEARSON:  THE  EFFECTS  OF  ARTIFICIAL  PNEUMOTHORAX  [July  26,  1919  149 


(c)  It  is  by  no  means  an  . invariable  rule  for  the  pleural 
surfaces  to  become  adherent  after  injections  have  been 
given  up.  A patient  not  included  in  this  series  because  not 
originally  “blown  up”  by  me  consulted  me  five  years  ago. 
It  was  decided  to  attempt  to  give  an  injection  of  gas, 
though  no  refill  had  been  given  for  just  over  two  years. 
Rather  to  our  surprise  several  hundred  c.cm.  of  nitrogen 
were  injected  without  difficulty.  This  patient’s  artificial 
pneumothorax  was  started  abroad  ten  years  ago.  He  has 
been  earning  his  living  for  the  last  8]  years.  Again,  No.  2 
in  this  series  once  went  about  15  months  without  a refill. 
He  then  met  with  a street  accident,  and  a few  weeks  later, 
feeling  uncomfortable,  consulted  me.  I withdrew  two  and  a 
half  pints  of  deeply  blood-stained  fluid  from  his  left  chest 
and  gave  1400  c.cm.  of  nitrogen.  This  was  on  April  24th, 
1915.  Since  then  he  has  continued  to  have  occasional 
refills,  because  he  felt  better  with  them  than  during  the 
many  months  of  their  abandoment.  No.  3,  too,  once  went 
two  years  between  injections,  but  then  he  had  an  appreciable 
amount  of  fluid  in  the  chest  probably  throughout  this  time. 

I shall  make  further  reference  to  his  case  below. 

(d)  Every  endeavour  should  be  made  to  keep  the  pneumo- 
thorax cavity  always  a closed  one.  The  only  excuse  for  dis- 
regard of  this  rule  seems  to  me  to  be  the  presence  of  secondary 
micro-organisms.  In  none  of  my  cases  has  this  happened. 
In  passing  I may  mention  that  after  careful  search  tubercle 
bacilli  can  be  found  in  the  purulent  sediment  from  the  fluid 
in  many  of  these  cases,  I should  think  in  about  75  per  cent, 
of  those  with  fluid.  If  once  a tube  is  put  into  a tuberculous 
pyothorax  cavity  the  chances  are  that  a permanent  sinus 
persists,  requiring  all  the  bother  of  dressings  at  least  once  a 
day,  and  bringing  every  likelihood  of  secondary  infection, 
however  much  care  is  taken  to  avoid  it.  Case  No.  1 suffered 
from  at  least  one  of  these  disabilities  for  several  years,  and 
they  might  in  all  probability  have  been  avoided. 

(e)  Those  cases  which  develop  fluid  at  any  time  in  the 
course  of  the  treatment  want  watching  with  special  care.  It 
is  amongst  these  patients  that  sequelas  requiring  careful 
handling  are  particularly  likely  to  occur.  Under  this  head 
there  are  many  important  points,  and  they  demand  several 
paragraphs.  But  before  dealing  with  them  I will  describe 
briefly  some  other  peculiarities  which  are  met  in  the  later 
periods  of  the  treatment,  say  after  the  second  year.  These 
can  be  classified  under  the  heads  of  anatomical  and 
physiological. 

Anatomical  Considerations. 

It  is  surprising  how  small  the  visible  |deformity  of  the 
chest  is  in  these  cases.  Little  difference  is  observable  on 
casual  inspection,  sometimes  only  very  slight  inclination  to 
the  “ barrel-shaped  ” type  of  thorax,  and  to  diminished 
movement  on  one  side.  Case  No.  7 was  passed  for  military 
service  in  August,  1914,  only  to  have  his  schemes  thwarted 
by  his  practitioner.  But  in  1915  he  attested  under  the 
Derby  scheme  and  was  passed  Class  A. 

None  the  less  in  many  cases  the  ribs  come  very  close 
together  by  degrees,  and  in  most  the  inflated  side  of  the 
thorax  comes  to  be  partly  filled  by  much  displaced  mediastinal 
and  subdiaphragmatic  organs.  On  the  left  side,  e.g.,  the 
heart  may  come  to  be  quite  3 in.  outside  the  nipple  line  and 
displaced  upwards  considerably  as  well,  while  the  stomach 
comes  quite  high  in  the  chest.  My  impression  is  that  great 
displacements  are  commoner  on  the  left  side  than  on  the 
light.  Occasionally  the  mobility  of  the  mediastinum  and  its 
contents,  which  varies  in  different  individuals,  is  largely 
lost,  and  the  heart  becomes  more  or  less  anchored,  displaced 
to  the  side  with  the  compressed  lung.  But  more  frequently 
the  displacement  is  altered  in  amount  by  a refill,  even  years 
after  the  starting  of  the  pneumothorax.  Seldom,  however, 
does  a refill  really  late  in  the  course  of  the  treatment  lead 
to  any  considerable  displacement  of  organs  away  from  the 
side  of  the  compressed  lung. 

Considerable  thickening  of  the  pleura,  especially  of  the 
parietal  pleura,  occurs  in  a moderate  number  of  patients  by 
about  the  third  year.  The  practised  hand  can  usually  feel 
and  gauge  this  at  the  time  when  the  needle  is  inserted  for  a 
refill,  and  the  golden  rule  must  be  observed  of  never  giving 
any  gas  unless  the  appropriate  oscillations  are  present.  My 
needle  once  got  into  the  pericardium,  and  I found  well- 
marked  negative  oscillations,  but  synchronous  with  the  heart 
beat.  Naturally  I withdrew  the  needle,  afterwards  giving  an 
ordinary  refill.  There  was  no  untoward  result. 


On  another  occasion,  on  introducing  the  needle  rather 
deeply  to  get  through  a thick  pleura  in  a high  position 
rather  far  back  in  the  axilla  of  a patient  who  had  been 
having  refills  for  several  years  at  three-monthly  intervals,  a 
soft  sibilant  squeak  was  audible  at  the  very  end  of  each 
inspiration  referred  to  the  chest  by  the  patient.  The  pressure, 
as  shown  by  the  manometer,  was  much  below  zero,  but  the 
oscillations  were  not  free.  When  I withdrew  the  needle  a 
little  the  squeak  stopped,  the  negative  pressure  became  more 
pronounced,  and  the  oscillations  much  greater.  I concluded 
I had  wounded  the  lung  a trifle.  An  ordinary  refill  took  place 
and  no  adverse  symptom  whatsoever  arose. 

Physiological  Peculiarities. 

Under  the  head  of  physiological  peculiarities,  belonging 
more  especially  to  the  late  stages  of  the  treatment,  the 
low  pressure  readings  are  important,  because  before  starting 
the  refill  of  gas  preparations  for  the  low  negative  pressures 
must  be  made.  These  are,  of  course,  prone  to  occur, 
especially  when  the  intervals  between  refills  are  long — two 
or  more  months.  Under  such  circumstances  it  is  necessary 
to  see  that  there  are  about  7 to  10  cm.  or  more  for  some 
cases  of  a negative  pressure  in  the  gas  bottle  just  before 
starting,  and  to  take  care  that  the  bulb  at  the  top  of  the 
negative  stem  of  the  manometer  is  large  enough — a state  of 
affairs  not,  I fear,  usually  to  be  found  in  the  apparatus 
hailing  from  the  instrument-makers.  As  an  illustration  of 
such  readings  (when  below  -34  approximate  only)  I append 
the  following  from  Case  14  : — 


Date  of  refill. 

Starting 

pressures. 

Amount  of 
gas  given. 

Ending 

pressures. 

25/8/17 

-32 

-12 

800 

• -8-2 

29/11  17 

-44 

-20 

925 

-13  -6 

22/2. 18 

-42 

-22 

800 

-13  -6 

27/4/18 

-40 

-16 

930 

-9-5 

Another  fairly  common  physiological  peculiarity  worth 
mentioning,  a fortunate  one,  but  one  which  needs  vigilance 
and  guardianship,  is  the  restoration  to  health  of  a person 
accustomed  to  severe  illness,  possibly  for  years.  He  may  on 
this  account  be  disinclined  to  continue  the  refills  of  gas  for 
a reasonable  time  ; and  he  may  get  careless  about  his  health. 
Such  carelessness,  in  accordance  with  all  the  general  prin- 
ciples applicable  to  such  a class  of  case,  simply  courts 
relapse,  disaster,  and  death.  In  this  connexion,  too,  those 
who  absorb  the  gas  comparatively  quickly  should  be  espe- 
cially cautious  to  refer  regularly,  at  not  too  long  intervals, 
to  their  doctors,  lest  undesired  premature  re-expansion  of 
the  lung  accompanied  by  adherence  of  its  surface  set  in 
through  leading  too  strenuous  a life.  At  the  other  extreme 
amongst  the  restored  is  to  be  found  occasionally  one  who  is 
over-reluctant  to  abandon  the  refills,  or  to  reduce  thdir 
frequency  to  a sufficient  moderation.  Bat,  as  I have  already 
indicated,  this  is  an  error  on  the  safe  side. 

The  Presence  of  Fluid. 

Now  with  regard  to  cases  in  which  fluid  arises,  and  it 
must  be  borne  in  mind  that  this  includes  about  70  per  cent, 
of  all  cases,  the  course  of  the  treatment  is  nearly  always 
rather  more  complicated  than  when  there  is  no  fluid.  Not 
invariably  though,  because  sometimes  effusion  occurs  and 
then  dries  up  again  spontaneously  without  disturbing  events 
materially.  Even  in  such  circumstances,  however,  there  is 
commonly  some  interference  with  the  spacing  of  the  injec- 
tions of  gas.  But  this  subject  has  been  fairly  adequately 
dealt  with  in  the  previous  literature  on  artificial  pneumo- 
thorax, so  I will  pass  on  to  further  points.  In  reference  to 
the  incidence  of  fluid  in  these  cases  (see  above  table) 
two  points  must  be  observed,  viz  : The  4-  sign  indicates  the 
presence  of  fluid  in  the  course  of  the  treatment,  extending 
over  years  in  many  cases,  even  when  the  amount  of  the 
fluid  has  been  small,  and  its  interference  with  the  health 
and  comfort  of  the  patient  inappreciable.  Secondly,  the 
4-  sign  in  the  next  column  may  mean  only  one  aspiration  or 
several. 

Occasionally  it  may  happen  that  it  is  a little  difficult  to 
distinguish  between  fluid  in  the  stomach  and  in  the  chest, 
more  particularly  on  the  left  side,  of  course  It  must  be 
remembered  that  the  stomach  gets  into  a high  position,  and 
that  some  patients  are  apt  to  anticipate  a pleural  splash.  I 


] 50  The  Lanobt,]  DR.  S.  V.  PEARSON  : THE  EFFECTS  OF  ARTIFICIAL  PNEUMOTHORAX.  - [July  26,  1919 


have  had  three  or  four  doctors  amongst  these  patients,  and 
one  of  these  even  raised  the  question,  quite  justifiably,  as  to 
whether  a curious  little  flapping  splash  was  not  due  to  peri- 
cardial fluid.  The  occurrence  of  this  splash  only  bothered 
the  patient  in  one  position  and  it  synchronised  with  the 
heart  beat.  But  we  were  able  by  careful  examination, 
though  not  quite  easily,  to  localise  the  fluid  to  a displaced 
and  slightly  dilated  stomach.  When  fluid  was  present  in 
this  organ  and  a certain  position  was  taken  up  the  heart 
jogged  it  and  a slight  splash  reverberated  through  there 
being  a sounding-box,  so  to  speak,  just  above  it  in  the  shape 
of  a small,  old-established  pneumothorax  cavity.  It  is  usually 
quite  easy  to  localise  the  fluid  by  means  of  percussion,  x ray 
examination,  to  a small  extent  by  the  sensations  of  the 
patient,  and  especially  by  noticing  the  peculiarly  metallic, 
ringing  nature  of  the  splash  when  the  fluid  is  within  the 
chest  as  compared  with  its  duller  resonance  to  the  ear, 
applied  by  stethoscope  or  held  close  to  the  patient  when 
shaken,  if  the  fluid  is  only  a stomach  splash. 

Cases  Illustrating  Points  in  Relation  to  Presence  of  Fluid. 

A partial  account  of  events  in  the  cases  of  two  patients 
(Nos.  3 and  12)  will  best  serve  to  bring  out  certain  other 
difficulties  and  pitfalls  connected  with  the  presence  of  fluid 
during  the  late  stages  of  the  treatment. 

First,  a few  facts  regarding  fluid  withdrawals  in  Case 
No.  3.  But  these  do  not  include  all  such  facts  about  him,  as 
during  the  course  of  his  7f  years  of  life  after  the  first 
“blowing  up”  he  consulted  many  physicians  at  home  and 
abroad,  and  on  one  or  two  occasions  other  than  those  noted 
here  I believe  he  had  fluid  withdrawn  and  replaced  by  gas. 


Date. 

Pressures. 

Fluid 

with- 

drawn. 

Gas 

Ending 

pressures. 

At 

starting. 

During 
of  era'  ion. 

given. 

27/3/12 

+ 3+6 

c cm. 
400 

c.cm. 

3/4/12 

2420 

2600 

+ 18  +23 

18/5/12 

+10  +15 

475 

800 

+ 6 +12 

12/9/12 

-16  -20 

3650 

1200 

-4+1 

4/12/12 

0+6 

125 

+ 8 +13 

5 12/12 

-30  -22* 

8/12/12 

2150 

1900 

+ 8 +16 

3/5/17 

— 12t 

550 

350 

+ 8 +12 

6/6/17 

+ 8 +12 

100 

+ 19  +25 

8/6/17 

5501 

— 4* 

* After  t,  pint  of  fluid  had  been  withdrawn, 
f After  559  e.cm.  of  fluid  had  been  withdrawn. 
I After  much  pus  had  been  coughed  up. 


I should  mention  incidentally  that  this  patient  did 
not  lead  a very  invalid  life  most  of  the  7f  years.  He 
held  a prominent  place  both  in  public  life  and  in  the 
business  world.  Though  in  1912  he  returned  for  a time 
to  his  public  duties  he  wisely  gave  these  up  after 
a few  months.  He  maintained  the  supervision  of  his 
big  business  and  of  his  private  concerns  fairly  inti- 
mately until  about  14  months  before  his  death,  though 
taking  a few  months’  holiday  every  now  and  then,  and 
generally  spending  such  periods  in  a sanatorium  in  England 
or  abroad.  I believe  his  death  was  accelerated  by  the  com- 
plications which  arose  in  connexion  with  the  fluid  in  the 
right  chest.  During  1915  and  1916,  when  on  the  continent, 
he  consulted  one  or  two  prominent  foreign  specialists — i.e., 
Professor  Saugmann — at  whose  sanatorium  lie  stayed  for  a 
short  time,  and  Dr.  L.  Spengler.  They  advised  leaving  the 
fluid  alone  as  it  appeared  to  have  become  limited,  stationary 
in  amount,  and  turbid  in  consistence.  When  I saw  the 
patient  again  after  a long  interval  at  the  end  of  December, 
1916,  I concurred  in  this  view,  though  finding  considerable 
dullness,  & c.  I ascribed  some  of  the  dullness  to  thickened 
pleura.  The  patient  stopped  rather  over  two  months  in  the 
Mundesley  Sanatorium  at  this  juncture,  and  left  in  a fairly 
good  state.  About  two  months  later  he  became  feverish  and 
ill,  and  on  readmission  on  May  25th,  1917.  his  state  was 
unsatisfactory.  The  upper  half  of  the  right  lung  presented 
signs  at  first  taken  by  myself  and  colleague  for  massive 
consolidation.  Over  the  front  of  the  fifth  rib  anteriorly 
was  a swelling  mistaken  at  first  for  a cold  abscess 
connected  with  tuberculous  disease  of  the  rib.  Sub- 


sequently the  true  state  of  affairs,  a pyothorax  point- 
ing anteriorly,  was  diagnosed,  but  not  until  early  June. 
The  withdrawal  of  550  c.cm.  of  fluid  on  May  31st  had  been 
deceptive.  Dr.  M.  F.  Squire,  my  assistant,  and  I thought  we 
had  got  most  of  the  semi-purulent  fluid  out;  but  we  had  not, 
evidently  being  baulked  by  its  flakiness,  though  we  did  use  a 
fairly  large  aspirating  needle.  Again,  we  probably  made  a 
mistake  in  raising  the  pressures  to  a maximum  of  +•  25  cm. 
of  water  on  June  6th.  Unfortunately,  our  plans  for  a further 
and,  if  possible,  a complete  aspiration  of  fluid,  were  anti- 
cipated by  an  hour  by  the  bursting  of  the  pyothorax 
internally  through  the  lung.  The  withdrawal  after  this  of 
what  fluid  we  could  get  out  by  aspiration,  in  the  hope  of  the 
hole  in  the  lung  healing,  was  of  no  avail.  Later,  on  account 
of  the  weakening  effects  of  distressing  cough  and  copious 
purulent  expectoration,  it  seemed  best  to  introduce  a tube. 
This  was  accordingly  done  on  August  7th,  1917,  by  Mr. 
Lawrie  McGavin  under  copious  injection  of  a local  anaesthetic. 
The  general  condition  of  the  patient,  and  the,  by  this  time, 
moderate  tuberculous  infiltration  of  the  left  lung,  put  a 
general  anaesthetic  out  of  court.  The  operation  was  well 
stood  and  did  much  good,  and  the  patient  was  able  to  get 
about  a little  for  a good  many  months. 

The  history  of  Case  12  is  very  similar  to  the  case  just 
described.  She  first  developed  fluid  one  year  after  the 
initial  injection  (given  Nov.  17th,  1913).  It  was  first 
tapped  six  months  later — namely,  on  June  5th,  1914.  After 
about  three  tappings  during  the  next  nine  months  it 
had  become  turbid  and  seemed  to  show  no  great  inclina- 
tion to  reaccumulate.  The  ribs  got  very  close  together. 
Restoration  of  health,  though  gratifying  for  a time,  never 
became  complete,  and  about  May,  1915,  the  disease  in  the 
sounder  left  lung  had  advanced  a good  deal.  Difficulties 
arose  in  maintaining  the  pneumothorax  and  in  regard  to  the 
fluid.  These  difficulties  were  due  to  incomplete  collapse  and 
re-expansion  of  the  lung  with  formation  of  adhesions  at  the 
top  of  the  chest  posteriorly,  to  the  turbidity  of  the  fluid  and 
the  purulent  flakes  in  it,  and  to  the  great  proximity  of  the 
ribs  in  the  only  region  where  it  was  convenient  and  suitable 
to  try  to  inject  gas.  These  difficulties,  combined  with  the 
other  circumstances  of  the  case  at  this  juncture,  decided 
Dr.  C.  Lillingston,  under  whose  care  the  patient  then  was, 
in  consultation  with  myself,  to  abandon  further  attempts  at 
injecting  gas  or  withdrawing  fluid.  This  decision  was 
arrived  at  on  June  1st,  1915.  Three  months  later  the  patient 
had  a sudden  severe  fit  of  coughing  and  every  indication 
that  the  fluid  in  the  pleural  cavity  had  burst  through  into 
the  lung.  She  died  a few  days  later.  In  the  middle  of  the 
previous  April  I had  made  the  following  note  in  the  form  of 
a question  : — 

“ How  far  is  each  of  the  following  factors  responsible  for 
the  present  unsatisfactory  condition  : (1)  Activity  of  disease 
in  the  sounder  lung  ; (2)  activity  of  disease  in  uncompressed 
part  of  the  right  lung;  and  (3)  pleurisy  and  fluid  on  com- 
pressed side?”  I have  no  doubt  now  that  I underestimated 
the  third  factor,  and  that  had  we  made  a bold  and  successful 
effort  to  withdraw  fluid  again  and  replace  by  gas  the  con- 
dition of  the  patient  would  have  been  bettered  and  in  all 
probability  her  life  prolonged. 

Further  Points  in  Regard  to  Fluid. 

Besides  the  lessons  already  indicated  in  the  course  of 
describing  the  events  which  occurred  to  these  two  patients 
one  or  two  further  morals  can  be  drawn  from  experience 
with  these  and  other  patients.  Fluid  generally,  especially  in 
the  early  stages  of  the  treatment,  tends  to  keep  intrapleural 
pressures  up.  It  is  more  likely  to  be  followed  by  thickened 
pleura  and  adhesions,  possibly  sudden  ones,  than  when  there 
is  no  fluid.  Hence,  it  is  customary  to  keep  pressures  rather 
higher  in  such  cases  than  in  those  not  developing  fluid, 
particularly  because  a moderate  degree  of  pressure  is  thought 
to  keep  fluid  from  accumulating  too  readily.  It  is  a good 
rule  not  to  interfere  with  fluid  unless  obliged  to  through  the 
chest  becoming  very  full  or  for  some  similar  reason.  But 
both  these  rules  can  be  followed  too  closely  in  the  late  stages 
of  the  treatment.  In  such  stages — e.g.,  during  the  fourth 
year  after  the  initial  induction — in  cases  of  fluid  where  an 
effective  pneumothorax  has  been  produced,  it  is  as  well 
sometimes  not  to  be  too  readily  deterred  from  con- 
tinuing the  treatment  by  such  difficulties  as  fluid 
getting  into  the  gas  needle  or  pus  flakes  into  the 
fluid  needle.  The  remedy  for  each  of  these  troubles  is 
obvious — namely,  withdrawal  of  fluid  and  reduction  of 


The  Lancet,]  DR.  A.  COMPTON  : OEREBRO-SPINAL  FEVER  & ATMOSPHERIC  HUMIDITY.  [July  26,  1919  151 


pleural  pressures  thereby  before  attempting  to  give  a refill  of 
gas  in  the  one  case,  and  the  use  of  a larger  bored  needle  or 
trocar  and  cannula  for  aspiration  in  the  other.  In  con- 
nexion, however, . with  the  latter  means  of  overcoming 
difficulty  in  withdrawal  of  fluid,  the  possibility  of  leaving  a 
sinus  must  be  mentioned  : to  be  avoided  by  preventing  too 
big  an  accumulation  of  fluid  and  too  high  a pressure,  and  by 
appropriate  manipulation  of  the  skin  and  of  the  insertion  and 
extraction  of  the  instrument.  Local  anaesthesia  is  helpful 
and  generally  advisable  for  fluid  aspiration.  With  its  aid 
chest  punctures  need  not  be  too  charily  undertaken. 

One  further  point  in  connexion  with  fluid  is  illustrated  by 
reference  to  Case  14,  some  of  whose  pressure  readings  at 
refills  in  the  fourth  year  of  treatment  are  given  above  as  an 
example  of  low  pressures.  In  this  case  no  fluid  arose  until 
April,  1917 — i.e. , 39  months  from  the  commencement  of 
treatment — by  which  time  the  intervals  between  refills 
extended  to  seven  weeks,  and  minimum  pressures  of  - 18 
and  -24  were  found  just  before  beginning  an  injection.  At 
no  time  since  then  has  fluid  had  to  be  withdrawn,  nor  has  it 
become  in  any  way  more  than  a trifling  nuisance.  It  seems 
obvious  that  in  this  case  fluid  has  arisen  in  response  to 
nature’s  abhorrence  of  a vacuum.  Since  the  lung  in  his  case, 
as  sometimes  happens,  shows  little  inclination  to  re-expand, 
the  obvious  course  of  treatment  is  to  give  an  occasional  dose 
of  gas  to  meet  nature's  demands  in  a more  comfortable,  con- 
trollable, safe,  and  convenient  manner  than  is  done  by  the 
effusion  of  fluid. 

Indications  for  Cessation  of  Treatment : Spacing  of  Doses. 

This  leads  me  to  one  or  two  final  matters  for  considera- 
tion, the  most  important  of  which  is  : What  are  the  indica- 
tions for  stopping  the  treatment?  If  I myself  had  to  have 
resort  to  an  artificial  pneumothorax  I should  like  to  have  it 
kept  up  for  at  least  three  years,  provided  it  was  an  effective 
one  and  this  were  possible.  And  under  the  three  following 
circumstances  I advise  continuing  with  an  occasional 
injection  for  at  least  41  years — namely  (1)  if  the  patient 
is  over  33  years  and  has  lost  the  resilience  and  recuperative 
powers  of  youth  ; (2)  if  the  compressed  lung  was  a fairly 
useless  one  before  the  initial  injection,  and  if,  in  addition, 
it  was  producing  chronic  poisoning  ; and  (3)  if  things  are 
going  well  during  the  maintenance  of  the  compression. 

Compression  may  have  to  be  maintained  indefinitely 
— e.g. , in  Cases  2,  8, 10,  and  14 — either  because  the  patient’s 
state  is  more  comfortable  and  he  feels  surer  of  himself  with 
periodic  refills,  or  because  the  compressed  lung  does  not 
re-expand.  On  the  other  hand,  compression  with  an  effec- 
tive pneumothorax  may  have  to  be  abandoned  prematurely 
because  of  activity  of  disease  in  the  sounder  lung  or  because 
of  re-expansion  of  the  compressed  lung  and  adhesions.  But 
in  the  first  case  most  probably  this  is  due  to  an  error  in  the 
choice  of  the  patient  for  this  method  of  treatment,  and  in 
the  second  case  most  probably  carelessness  in  not  watching 
the  patient  and  giving  refills  sufficiently  often  is  the  cause  of 
re-expansion  and  adhesions. 

Occasionally  the  treatment  has  to  be  abandoned  after  a 
long  time,  because  a day  comes  when  it  is  found  very 
difficult,  or  even  impossible,  to  continue  it.  In  giving  details 
above  aboutiCase  12  I have  indicated  the  sort  of  combination 
of  circumstance  which  may  lead  to  this,  though  admitting 
that  in  this  particular  case  we  were  too  easily  deterred  from 
persevering  by  the  difficulties  encountered.  But  more  usually, 
if  the  pneumothorax  cavity  cannot  be  found,  it  is  in  the  case 
of  a patient  in  good  health  who  has  been  having  treatment 
for  four  or  five  years  ; under  such  circumstances  it  does  not 
matter  much.  It  is  better,  however,  to  choose  the  time  of 
leaving  off  injections  voluntarily  by  persuading  the  patient 
not  to  let  too  long  elapse  before  he  sees  his  doctor  about  his 
condition  and  about  a possible  refill. 

No  hard-and-fast  rules  can  be  laid  down  respecting  the 
spacing  of  doses  in  the  late  stages  of  the  treatment,  nor 
respecting  the  pressures.  Compare,  for  example,  Case  10 
with  Case  8.  No.  10,  whose  present  satisfactory  condition 
I have  already  referred  to,  does  not  like  to  let  his  pressures 
go  below  a mininum  of  -14  or  thereabouts,  nor  to  prolong 
the  interval  appreciably  beyond  five  weeks.  Whereas  No.  8, 
starting  a pneumothorax  only  about  seven  months  earlier 
— namely,  in  March,  1913 — is  quite  happy  to  allow  four 
months  between  refills  ; his  pressures  do  not  fall  much  below 
No.  10's,  however,  and  probably  this  slower  absorption 
accounts  for  the  difference  between  them.  Both  lead  quite 
active  and  more  or  less  normal  lives. 


Causes  of  Death. 

One  or  two  more  notes  giving  a few  further  details  of 
interest  regarding  the  patients  of  this  series  seem  desirable. 
Most  of  those  who  died  succumbed  to  the  advance  of  the 
pulmonary  tuberculosis.  In  Case  11  death  took  place  six 
hours  after  a refill,  and  may  possibly  afford  an  exception 
to  the  rule  holding  good  throughout  this  series,  comprising 
many  hundreds  of  injections — namely,  that  no  unfortunate 
effect  ever  arises  from  injecting  gas  into  the  thorax 
when  the  necessary  simple  precautions  are  taken.  This 
patient  felt  perfectly  all  right  for  two  hours  after 
his  refill.  He  dressed  and  came  down  to  dinner, 
when  he  was  seized  with  sudden  dyspnoea.  This  was  not 
relieved  by  letting  gas  out  again,  a procedure  which  revealed 
the  fact  that  no  hole  in  the  compressed  lung  had  developed. 
Suspicions  fell  on  a spontaneous  pneumothorax  on  the 
opposite  side  of  the  chest,  the  occurrence  of  which  accident 
accounted  for  death  in  Case  19.  Unfortunately,  no  necropsy 
was  possible.  In  Case  13  the  condition  was  of  South  African 
mining  origin,  and  this  probably  augmented  its  hopelessness. 
No.  15  died  of  tuberculous  meningitis.  .No.  9 nearly  died 
some  months  after  the  induction  of  the  artificial  pneumo- 
thorax, but  eventually  his  health  became  well  restored. 
Once  he  got  for  a few  days  disconcerting  mediastinal 
interstitial  emphysema — the  only  instance  I have  experienced 
of  this  complication. 

In  conclusion,  I may  mention  that  the  following  physicians, 
amongst  others,  have  aided  me  with  their  advice  or  have 
participated  in  the  treatment  at  some  juncture  or  other  in 
the  course  of  events  in  one  or  more  of  the  cases  in  this  series, 
and  I herewith  acknowledge  their  help  with  much  gratitude  : 
A.  Latham,  T.  D.  Lister,  Hector  Mackenzie,  J.  J.  Perkins, 
A.  G.  Phear,  Clive  Riviere,  Jane  Walker,  R.  A.  Young,  F.  W. 
Burton-Fanning,  C.  Lillingston,  John  Hay,  A.  C.  Inman, 
A.  de  W.  Snowden,  A.  Lewth waite,  M.  F.  Squire,  L.  Whittaker 
Sharp,  Esther  Carling,  E.  G.  Colville,  C.  V.  Knight,  H.  H. 
Brown,  and  J.  D.  McKelvie. 


OUTBREAKS  OF  CEREBRO-SPINAL  FEVER 
IN  RELATION  TO  ATMOSPHERIC 
HUMIDITY  : 

INFLUENCE  OF  THE  HUMIDITY  OF  OVERCROWDING. 
By  ARTHUR  COMPTON,  M.B.,B.Ch.(R.U.I.),D.Sc.(N.U.I.) 

EX-CAPTAIN,  R.A.M.C.  ; LATE  OFFICER  COMMANDING  NO.  32  MOBILE 
BACTERIOLOGICAL  LABORATORY,  E.E.F.  ; FORMERLY  OFFICER 
IN  CHARGE,  MILITARY  BACTERIOLOGICAL  LABORATORY, 

DORSET  DISTRICT. 


Cerebro-spinal  fever,  as  a disease,  being  supposed 
to  be  comparatively  rare  in  Egypt,  some  investigation  of  the 
question  appeared  desirable  in  view  of  obtaining  if  con- 
firmed helpful  sidelights  on  prevention  for  our  own  more 
temperate  climate. 

Moreover,  having  as  the  result  of  previous  work 1 2 in  the 
Dorset  District  (England)  developed  the  hypothesis  that : 
atmospheric  humidity — more  especially  indoor  humidity, - 
operating  through  overcrowding  and  insufficient  ventilation 
— was  a climatic  factor  which  favoured  outbreaks  of  the 
disease,  when  the  meningococcus  was  about,  it  became 
important  to  test  this  hypothesis  for  a country  like  Egypt, 
'where  at  times  a very  moist  atmosphere  prevails.3  If  the 
observation  in  regard  to  comparative  rarity  of  the  disease  in 
that  country  were  exact,  and  our  humidity  hypothesis 
otherwise  stood  unassailed,  the  explanation  could  practically 
a priori  only  be  : comparative  absence  of  the  meningococcus 
in  Egypt.  And  that  explanation  appeared  the  more  probable 
in  view  of  the  abundant  sunshine  of  Egypt : it  being  well 
known  that  “ carrier  rates  ” in  England  are  lowest  during 
summer  months,  when  sunshine  is  at  its  maximum. 

Scope  of  Investigation. 

To  test  these  various  ideas  was  the  principal  object  of  the 
work  with  which  this  paper  deals,  and  for  the  purpose  of 

1 Arthur  Compton  : Jour.  R.A.M.C..  November.  1915,  546-570; 
Comptes  rendus,  1915,  clxi..  472  ; The  Lancet,  1916.  i.,  255. 

2 Arthur  Compton  : Third  Report  to  the  War  Office  on  C.-S.F.  in  the 
Dorset  District,  Nov.  1st,  1917  (not  yet  published). 

3 ‘ Alexandria  is  quite  unsuited  as  a residence  for  invalids,  its 

climate  being  damp  and  windy ; and  under  these  circumstances 
alternations  of  heat  and  cold  are  extremely  trying.''  Huggard  : A 
Handbook  of  Climatic  Treatment,  London.  1906,  1S9. 


152  The  Lancet,]  DR.  A.  COMPTON : CERBBRO-SP1NAL  FEVER  & ATMOSPHERIC  HUMIDITY.  [July  26,  1919 


the  investigation  use  has  been  made  of  a small  outbreak 
of  the  disease,  some  10  cases  in  all,  which  occurred  in  the 
Alexandria  District,  E.E.F.,  during  February  and  March, 
1918,  just  prior  to  my  arrival  in  Egypt. 

In  the  necessarily  brief  investigation  which  it  was  possible 
for  me  to  make,  for  I was  limited  by  military  necessity  to  a 
three  weeks’  time-limit,  four  main  points  were  set  out  to  be 
investigated  : (1)  To  what  extent  the  Alexandria  District 
was  affected  by  the  disease  (Studies  in  Statistics) ; (2)  the 
relation  of  the  cases  in  the  above-mentioned  outbreak  to 
atmospheric  humidity  (Studies  in  Outdoor  Humidity)  ; (3) 
to  what  degree  humidity  was  high  indoors — evidence  of 
“ overcrowding  ” and  insufficient  ventilation — in  the  sleeping 
quarters  where  the  cases  had  occurred  (Studies  in  Ventila- 
tion) ; (4)  to  what  extent  the  meningococcus  was  about 
(Studies  in  “ Carrier  rates  ”). 

For  the  investigation  I am  indebted  to  Lieutenant-Colonel 
M.  H.  Gordon,  R.A.M.C.,  and  Major  T.  G.  M.  Hine, 
K.A.M.C.,  for  a small  supply  of  Central  Laboratory  medium 
(pea-flour-agar  and  serum),  agglutinating  sera  of  the  four 
defined  epidemiological  types  of  meningococci,  and  West’s 
naso-pharyngeal  swabs.  In  all  respects, 
therefore,  the  work  was  comparable,  in  so 
far  as  medium  and  technique  4 were  con- 
cerned, with  previous  work  in  England. 

Statistical  Study. 

Table  I.  gives  the  number  of  cases 
(military)  of  the  disease  occurring  in 
the  Alexandria  District  for  the  three 
years  1915  16,  1916-17,  and  1917-18, 
as  compiled  from  the  official  “weekly 
returns”  in  the  A.D.M.S.  Office, 

Alexandria  ; and  for  comparison  1 have 
given  the  corresponding  numbers  dealt 
with  by  the  Dorset  District  Military 
Bacteriological  Laboratory  during  the 
same  periods,  the  military  populations  of 
both  areas  being  approximately  the 
same. 

A glance  at  Table  I.  reveals  that  the 
disease  has  been  rarer  in  the  Alexandria 
District  (Egypt)  in  the  proportion  of 
40/117=1/2-9  = 1 3 approx.,  as  compared  with  the  Dorset 


have  been  noticed  in  Table  I.,  during  that  year  only 
three  cases  in  all  are  recorded  as  having  occurred  in  the 
area.  Whether  it  may  afford  an  explanation  or  not,  it  is 
interesting  to  note  that  during  eight  weeks  (July  2nd  till 
August  28th)  Mex  Camp  was  quite  unoccupied.  This  camp 
is  ordinarily  occupied  by  British  West  India  troops, 
among  whom  during  February  and  March,  1918,  the  10  cases 
of  1917-1918  (Table  II.)  occurred.  It  is  with  these  10 
cases  that  this  investigation  primarily  deals. 

Studies  in  Out- door  Humidity. 

Of  the  10  Mex  Camp  cases  of  February  and  March,  1918, 
Fig.  1 gives  their  approximate  distribution  on  an  “out-of- 
doors”  8 A.M.  Alexandria  humidity  chart  (from  the 
meteorological  readings  of  Mr.  H.  Sherif,  Kom-el-Nadura 
Observatory). 

As  it  has  not  been  possible  to  ascertain  the  exact  date  of 
onset  of  the  disease  for  these  cases  (see  Appendix),  this  has 
had  to  be  allowed  for.  The  position  of  each  name  on  the  chart 
(Fig.  1)  is,  therefore,  that  of  the  day  before  the  date  given 
in  official  records  when  the  patient  was  admitted  to 


Fig.  1.— Distribution  of  the  10  Mex  Camp  eases  of  cerebro-spinal  fever  shown 
on  an  out-of-doors  percentage  humidity  chart. 


District  (England),  for  the  three  years  in  question. 
Table  I. — Cases  oj  Cerebro-spinal  Fever. 


The 


Year. 

Alexandria  District 
(Egypt). 

Dorset  District 
(England). 

July,  1915-June,  1916  

22  cases. 

55  cases. 

July,  1916-June,  1917  

3 „ 

49  „ • 

July,  1917-June,  1918  

15  „ 

13  „ 

— 

40  „ 

117  ., 

observation,  therefore,  in  regard  to  comparative  rarity  of  the 
disease  in  Egypt  would,  from  this  analysis,  appear  to  be 
more  or  less  borne  out.  But,  although  this  is  so,  it  is  evident 
that  Egypt  is  far  from  being  exempt  from  the  disease. 

When  the  Alexandria  District  numbers  are  rearranged  in 
terms  of  station  (camps,  hospitals,  &c.)  the  above  table 
becomes  instructive.  This  has  been  done  in  Table  II. 

Table  II. — Incidence  at  Various  Stations. 


Year. 

Sidi  Bishr. 

Mex. 

Metras. 

efi 

*5- 

efl 

Abouklr. 

d m 

5 o ^ - « 

A a- S • ~ 

« O 3 G. 

r G ^3  jz  ® 

^ HP  S 

* «c 

1915-1916  ... 

3 

9 

1 

_ 

— 

— 4 2 

1916-1917  ... 

1 

- 

1 

l 

— 

— - — 

1917-1918  ... 

“ 

10 

— 

1 

1 

2 — 1 

Table  II.  shows  that  Mex  Camp  is  the  centre  in  the  area 
which  has  given  rise  to  most  cases  of  the  disease,  except 
that  in  1916-17  it  entirely  escaped.  But,  as  will  already 

* See  War  Office  Memorandum  on  Cerebrospinal  Fever.  24  (ien. 
No  3695  A.M.D.  2. 


hospital.  Considering  an  out-of-doors  relative  humidity  of 
over  75  per  cent,  as  constituting  a moist  atmosphere,  it  will 
be  seen  that  the  cases  practically  all  occur  in  connexion  with 
periods  when  such  a standard  out-of-doors  was  exceeded. 
What  it  was  indoors  in  the  men's  tents,  where  presumably 
they  took  ill — which  is  what  we  should  like  to  know — is  not 
revealed  by  Fig.  1,  but  some  idea  of  what  it  probably 
was,  will  appear  presently,  when  Fig.  2 comes  to  be  studied. 
Suffice  it  in  passing,  then,  to  note  that  this  small  outbreak  at 
Mex  Camp,  Alexandria,  in  no  way  conflicts  with,  but,  on  the 
contrary,  fully  bears  out,  our  hypothesis  connecting  the 
disease  with  a high  degree  of  atmospheric  humidity. 

Indoor  Humidity  and  Ventilation  Studies. 

Having  previously  shown  that  indoor  relative  humidity 
readings  taken  at  “lights  out”  and  at  “reveille,”  compared 
with  outdoor  morning  readings,  may  be  utilised  as  a simple 
method  2 — which,  so  far  as  I am  aware,  is  original — to  gauge 
the  efficiency,  or  otherwise,  of  ventilation  in  sleeping- 
quarters,  from  the  point  of  view  of  overcrowding,  I have  had 
such  readings  taken  from  a particular  tent  at  Mex  Camp 
pointed  out  to  me  as  where  several  of  the  recent  cases  had 
taken  ill.  As  suitable  controls,  corresponding  readings  were 
taken  simultaneously  in  a tent  and  in  a hut  at  No.  21  General 
Hospital,  Alexandria. 

That  overcrowding  and  insufficient  ventilation,  as  evidenced 
by  their  effects  on  indoor  humidity,  may  be  the  better 
appreciated  in  what  follows,  the  following  additional  details 
in  regard  to  these  three  sites  where  hygrometers  were 
installed  will  be  of  interest : — 

(It  Tent  Mex  Camp.  “ Bell " model,  of  approximately 
600  c.ft.  capacity  in  D Co.  “ lines,"  5 men  of  the  British 
West  India  Regiment  occupying  the  tent  during  the 
investigation. 

(2)  Tent  No.  21  General  Hospital.  “ Bell  ” model,  of  the 
same  capacity,  occupied  during  the  investigation  by 
5 R.A.M.C.  orderlies,  but  presumably  better  ventilated  in 
that  the  flaps  of  the  tent  were  always  kept  well  open  at 
night. 


The  Lancet,]  DR.  A.  COMPTON  : CEREBRO-SPINAL  FEVER  k ATMOSPHERIC  HUMIDITY.  [July  26,  1919  1 53 


(3)  Hut  No.  21  General  Hospital.  Hut  No.  9 officers’ 
quarters,  of  approximately  2000  c.ft.  capacity  (22  x 10  x 9), 
occupied  by  one  person,  the  hut  having  two  windows  facing 
the  sea  practically  always  open. 


Fig.  2 - Giving  a graphic  reDresentation  of  percentage  relative 
humidity  in  three  neighbouring  quarters,  for  the  same  period. 

Fig.  2 gives  the  graphical  representations  of  the  readings 
taken  in  the  quarters  (1),  (2).  and  (3)  respectively.  To 
estimate  the  efficiency,  or  otherwise,  of  ventilation  from  such 
graphs,  the  following  differential  table  (No.  III.),  which  is 
a resume  of  data  established  by  us  in  a previous  work,2  will 
be  required  for  reference. 

Table  III. 

Goop  Ventilation.  Bap  Ventilation, 

* 1.  Relative  Position s of  the  Three  Curves. 

“Morning  out-of-doors  "highest,  “Reveille"  highest,  “lights 

“ reveille  " intermediate,  “lights  out  ” intermediate.  “ morning  out- 
out"  lowest.  of-doors  ” lowest. 

2.  Displacement  Between  the  « Reveille"  and  “ Lights  Out  ” Curves. 

The  displacement  is  usually  The  two  curves  are  more  or  less 
small,  the  two  curves  being,  as  it  wi del//  separated, 
were,  packed  together  throughout 
their  course. 

3.  Relation  of  Ihe  " Reveille"  Carve  to  the  Other  Two. 

Its  position  being  intermediate  Rising  to  a higher  level  than  the 
to  the  other  two  it  generally  other  two,  being  often  situated  in 
follows  a course  related  to  them  the  region  of  complete  saturation, 
more  or  less  mathematically  as  a it  follows  a more  or  less  inde- 
mean to  two  extremes.  pendent  course. 

4.  Relation  of  the  "Morning  Out-of-doors"  Curve  to  the  Other  Two. 

In  good  ventilation  the  other  In  bad  ventilation  the  other  two 
two  curves  being  relatively  lower,  curves  being  relatively  higher 
wmie  the  “morning  out-of-doors"  causes  the  level  of  the  “morning 
curve  is  in  a sense  constant,  out-of-doors " curve  to  appear  corn- 
causes  the  latter  curve  to  appear  paratively  much  lower 
comparatively  higher  : as.  indeed, 
it  usually  is  actually. 


Judged  by  the  criteria,  of  Table  III.,  it  will  be  seen  that 
the  curves  appertaining  to  the  hut  (No.  21  General  Hospital) 
portray  a better  ventilation  than  those  of  the  tent  (No.  21 
General  Hospital),  and  these  latter  a better  ventilation  than 
those  of  the  tent  (Mex  Camp).  In  other  words,  the  ventilation 
in  the  B.W.I.  tent  at  Mex  Camp  is  shown  to  be  worse  than 
that  of  the  R.A.M.C.  orderlies’ tent  at  the  No.  21  General 
Hospital,  and  that  of  the  officers’  hut  at  No.  21  General 
Hospital  best  of  all.  The  importance  of  this  finding  will 
be  evident.  It  points,  I think,  to  insufficiency  of  ventila- 
tion, to  deal  with  the  excessive  indoor  humidity  consecutive 
on  the  overcrowding  present  in  the  Mex  tent,  as  responsible 
for  the  outbreak  in  that  camp  of  February  and  March,  1918, 
the  meningococcus  being  about.  Indeed,  as  the  “ reveille  ” 
curve  for  Mex  Camp  (see  top  diagram,  Fig.  2)  indicates,  as  a 
rule,  a high  morning  humidity  bordering  on  saturation- 
bet  ween  80  and  100  per  cent. — it  will  be  obvious,  on  our 
humidity  hypothesis,  that  a “carrier”  sleeping  in  such  a 
tent  would  run  a greater  risk  of  developing  the  disease  than 
if  he  slept  in  a tent  of  the  No.  21  General  Hospital  standard 
of  ventilation  and  humidity  ; for,  theoretically,  as  has  been 
emphasised  by  me  elsewhere,5  good  ventilation,  by  counter- 
acting the  effects  of  indoor  humidity,  means  diminished  risk 
of  the  “carrier”  infecting  his  comrades  and  of  the 
“ carrier  ” himself  becoming  a case. 

Studies  in  “ Carrier  Rates.”  6 

The  object  in  view  being  to  determine  to  what  extent  the 
meningococcus  was  about,  as  many  men  were  swabbed  in  the 
district  as  it  was  possible  to  handle  with  the  small  supply  of 
special  medium  at  disposal  and  the  limited  time  available. 
Some  310  non-contacts  (from  Mex  and  Mustapha  Camps,  and 
Nos.  19  and  21  General  Hospitals)  were  thus  swabbed  ; also, 
some  24  direct  and  indirect  “ contacts  ” of  an  actual  case, 
Pte.  G.  (see  Appendix),  readmitted  to  hospital  as  a case  of 
relapse  on  April  25th  at  the  time  this  investigation  was  in 
progress. 

From  two  lumbar  punctures  of  April  25th  and  26th 
respectively,  a Type  III.  (Gordon)  meningococcus  was  grown 
from  the  cerebro-spinal  fluid  of  the  case  (G.)  showing 
perfect  agglutination  up  to  a serum  dilution  of  1 : 400  after 
24  hours  at  55°C.,  being  quite  untouched  by  Types  I.,  II., 
and  IV.  sera. 

Contacts. — Of  the  above  case  (G.)  there  were  8 
contacts  who  had  inhabitated  the  same  marquee  with  him 
during  two  days  (April  23rd  to  25th)  at  Mustapha  Camp. 
These  were  swabbed  on  April  26th,  and  all  gave  negative 
results.  In  addition,  there  were  at  Mex  Camp  5 men  who 
were  doubtful  contacts,  in  the  sense  that  they  had  been  in 
contact  with  G.  some  time  previously,  and  11  other  men 
who  had  been  in  contact  with  these  5.  The  16  were 
swabbed  on  April  2^th  ; 15  were  negative,  and  1 gave  a 
meningococcus-like  organism,  which  subsequently  by  the 
agglutination  test  proved  to  be  non-agglutinable  and  was 
reported  as  negative. 

It  is  not  without  interest  that  one  of  the  five  Mustapha 
contacts,  Pte.  B.,  was  a recovered  case,  having  had  the 


disease  in  February,  1918  (see  Appendix). 

Table  IV. 

Date. 

Station. 

No. 

swabbed. 

(A) 

(B) 

25.4.18 

Mex. 

50 

5 

2 

27.4.18 

,, 

31 

2 

0 

30.4.18 

Mustapha. 

50 

4 

0 

2.5.18 

,, 

52 

2 

1 

5.5.18 

No.  21  Gen.  Hosp.,  Alex. 

55 

3 

0 

7.5.18 

No.  19 

12 

0 

0 

8.5.18 

No.  21  ,. 

60 

3 

0 

Totals  

310 

19 

3 

(A)  Number  giving  meningococcus-like  organisms  (cult.  app.  and 
micros,  app.). 

(B)  Number  giving  epidemiological  meningococci  (Gordon)  — i.e., 
meningococcus-like  organisms  agglutinated  by  one  of  the  four  types 
of  antisera. 


5 Arthur  Compton : Comptes  rendus,  1917,  elxv.,  75 ; Ann.  Inst. 
Past..  1918,  xxxil.,  130. 

o I desire  here  to  thank  Staff  Sergeant  J.W.  J Leighton,  B.Sc.  Lond., 
R.A.M.C.  (T  ),  for  his  valuable  assistance  in  this  work.  , 


154  ThhLanobt,]  DR.  M.  WHITE:  MALARIA  FROM  THE  SURGEON’S  STANDPOINT. 


[July  26,  1919 


Non- contacts. — Table  IV.  summarises  the  findings  with 
regard  to  the  naso-pharyngeal  swabs  taken  from  non- 
contacts at  various  centres  in  the  district.  The  3 “ agglutin- 
able  ” meningococci  found  all  belonged  to  Type  II.  strain  ; 
and  while  1 agglutinated  up  to  a dilution  of  1 : 400,  the 
remaining  2 only  agglutinated  up  to  a dilution  of  1 : 100. 
Of  the  19  meningococcus-like  organisms  met  with  in  the 
naso-pharynx  during  the  course  of  the  investigation,  the 
fermentation  reactions  of  10  of  them  which  survived  sub- 
culture were  determined  ; as  also  those  of  the  meningo- 
coccus G.  isolated  from  the  cerebro-spinal  fluid.  Table  V. 
gives  a summary  of  these  fermentation  tests  : — 


Table  V. 


Lab. 

No. 

If 

agglutin- 

able. 

Type. 

Fermentation 

reactions. 

i 

Lab. 

No. 

If 

agglutin- 

able. 

Type. 

Fermentation 

reactions. 

Glue. 

Malt.  Sacc. 

Glue. 

Malt. 

Sacc. 

62 

- 

+ 

+ - 

238 

- 

+ 

+ 

- 

89 

- 

+ 

+ - 

316 

- 

+ 

+ 

- 

107 

- 

+ 

+ 

326 

- 

+ 

+ 

- 

116 

- 

+ 

+ 

328 

- 

+ 

+ 

- 

140 

II. 

+ 

+ - 

G. 

III. 

+ 

+ 

- 

158 

- 

+ 

+ 

Glue.,  glucose.  Malt.,  maltose.  Sacc.,  saccharose. 


As  will  be  seen,  both  the  epidemiological  (“  agglutinable  ”) 
and  the  other  (“  non-agglutinable  ”)  meningococci  found 
during  the  course  of  the  investigation  all  give  the  same 
fermentation  reactions.  This  corresponds  with  previous 
experience. 

As  a practical  Army  measure,  however,  only  “agglutin- 
able ” meningococci  are  recognised  as  constituting  true 
“carriers.”  This  is  based  on  the  teaching  of  the  Central 
Cerebro-Spinal  Fever  Laboratory,  London,  which  holds  that 
only  men  harbouring  meningococci  agglutinating  with 
standard  type  sera  up  to  a dilution  of  at  least  1 : 200,  after 
24  hours  at  55°  C.,  as  against  controls,  are  to  be  considered 
as  constituting  an  immediate  source  of  danger.  Meningo- 
cocci from  cerebro-spinal  fluids  show  agglutination  up  to 
this  titre  and,  as  a rule,  beyond. 

In  the  present  investigation,  in  order  to  standardise 
results,  complete  macroscopic  agglutination,  after  24  hours  at 
55°  C. , in  one  or  more  of  the  dilutions  usually  put  up  1 : 100, 
1 : 200,  and  1 : 400,  as  against  the  normal  serum  control,  has 
been  recognised  as  constituting  a positive  result ; this 
standard  having  been  adopted  by  me  in  previous  work. 

It  will  thus  be  seen  from  the  summary  of  results  given 
in  Table  IV.  that  “sample  swabbing”  in  the  Alexandria 
District  (Egypt)  has  only  yielded  3 “carriers”  among  310 
non-contacts  swabbed — i.e.,  a “carrier  rate”  of  only  1 per 
cent.  The  standard  of  the  Central  Cerebro-Spinal  Fever 
Laboratory,  London,  being  adopted,  this  “carrier  rate” 
would  be  lower  still. 

General  Conclusions. 

The  foregoing  studies  of  cerebro-spinal  meningitis  in 
Egypt  add  little  that  is  new  to  our  knowledge  of  the 
disease  and  its  prevention.  But,  they  afford  a striking 
confirmation  of  the  hypothesis  previously  advanced  by  us 
associating  outbreaks  with  a high  degree  of  atmospheric 
humidity  when  the  meningococcus  is  about. 

A “carrier  rate”  of  only  1 per  cent,  among  “non- 
contacts ” taken  at  random  in  the  Alexandria  District 
(Egypt),  and  constituting  therefore  a fairly  good  “ sample  ” 
— a9  against  a rate  10  or  even  20  times  as  high  in 
England  under  similar  circumstances,  i.e.,  working  with 
the  same  medium  and  technique — suggests  an  explanation 
of  the  comparative  immunity  of  Egypt  from  the  disease. 
With  the  meningococcus  so  little  about,  atmospheric 
humidity  in  Egypt  gets  little  chance  to  precipitate 
outbreaks. 

We  have  indicated  by  ventilation  studies,  based  on  the 
hygrometric  state  of  the  atmosphere  met  with  indoors  in 
occupied  quarters  during  sleeping  hours,  how  the  greatest 
attention  requires  to  be  paid  to  ventilation  as  a corrective 
to  overcrowding,  in  view  of  keeping  the  indoor  humidity 
as  low  as  possible, — considering  the  part  attributed  by  us  to 
atmospheric  humidity  in  the  setiology  of  cerebro-spinal 
fever. 


Appendix. 


Cases  of  Cerebro-spinal  lever  at  Mex  Camp  during  February 
and  March,  1918. 


Name 

Date  of 

Name 

Date  of 

and 

Regiment. 

admission 

and 

Regiment. 

admission 

Reg.  No. 

to  hospital. 

Reg.  No. 

to  hospital. 

T.,  68687 

5th  B.W.I. 

5.2.18 

G.,  9054 

5th  B.W.I. 

11.3.18 

F.,  6791 

>*  t* 

6.2.18 

M.,  6485 

It  •» 

16.3.18 

U„  6505 

• t V* 

8.2.18 

To.,  6714 

»•  ft 

17.3.18 

S.,  6548 

2nd  W.I.R. 

8.2.18 

J„  6954 

17.3.18 

B.,  6771 

(att.  B.W.I.). 
5th  B.W.I. 

25.2.18 

E.,  6788 

..  .. 

25.3.18 

MALARIA  FROM  THE  SURGEON’S 
STANDPOINT.1 

By  MARGUERITE  WHITE,  M.D., 

ATTACHED  BOYAL  ARMY  MEDICAL  CORPS  ; SURGICAL  SPECIALIST, 
ST.  ELMO  MILITARY  HOSPITAL,  MALTA. 


The  only  type  of  malaria  to  be  considered  from  the 
surgeon’s  standpoint  is  the  subtertian  or  malignant  tertian. 
In  the  quartan  type  the  Plasmodium  malaria  goes  through 
the  entire  process  of  reproduction  in  the  circulating  blood, 
and  does  not  especially  accumulate  in  any  one  organ  or 
produce  special  effects.  The  tertian  type,  produced  by  the 
Plasmodium  vivax,  also  goes  through  its  life-cycle  in  the 
blood,  and  although  the  tertian  sporulating  forms  are  found 
in  the  internal  organs,  such  as  the  spleen,  they  do  not  tend 
to  accumulate  in  these  organs  or  produce  special  effects. 
The  third  type,  the  subtertian  or  malignant  tertian,  caused 
by  the  <estivo-autumnal  parasite,  sporulates  almost  entirely 
in  the  internal  organs,  attacking  any  organ  and  producing 
symptoms  peculiar  to  the  disease  of  that  organ  : on  the  heart 
causing  endocarditis  or  myocarditis,  on  the  lung  a pneu- 
monia, on  the  spleen  a splenitis  and  perisplenitis,  on  the 
pancreas  an  acute  hasmorrhagic  pancreatitis,  on  the  liver  a 
hepatitis,  &c.  Castellani  and  Chalmers,  in  writing  of  sub- 
tertian malaria,  say : — 

“ These  parasites  seem  to  affect  the  red  corpuscles  so 
profoundly  that  they  are  liable  to  adhere  to  the  walls  of  the 
capillaries,  in  which  the  parasite  sporulates : hence  it  may 
produce  severe  local  sjmptoms,  due  to  the  mechanical 
blocking  of  capillaries  and  the  intense  local  action  of  the 
toxin  ; thus  it  is  associated  with  what  is  called  the  malig- 
nant fevers — i.e.,  the  fevers  which  produce  local  effects  on 
one  or  more  organs.”2 

In  two  and  a half  years  on  the  island  with  the  British 
Expeditionary  Forces  the  number  of  cases  I have  seen  in 
which  malaria  has  proved  to  be  the  direct  cause  of  surgical 
ailments  referable  to  one  organ  have  been  comparatively 
small  and  with  a very  small  mortality.  Malaria  as  a com- 
plication in  surgical  cases  and  malaria  simulating  certain 
diseases  are  far  more  common,  especially  the  first,  where  all 
the  symptoms  may  indicate  some  other  illness,  for  instance, 
after  a gunshot  wound  of  the  head  (and  this  is  frequent)  the 
symptoms  may  all  point  to  a cerebral  abscess,  but  under 
quinine  therapy  the  urgent  symptoms  disappear  and  recovery 
is  uninterrupted. 

The  classification  is  only  made  for  the  purpose  of  descrip- 
tive surgical  pathology.  Clinically,  it  is  all  malaria,  and 
the  treatment  spells  quinine  and  quinine  only.  In  some  of 
the  sequel®  of  malaria  surgery  may  have  to  be  resorted  to, 
as  in  cases  of  ruptured  spleen  or  the  splenomegaly  of  chronic 
malaria,  drainage  of  the  abdomen  in  malarial  cirrhosis,  &c. 
Decapsulation  of  the  kidney  has  also  been  done  for  suppres- 
sion of  urine  in  cases  of  blackwater  fever  on  the  island. 

Reports  and  Discussion  of  Cases. 

A number  of  cases  were  recorded,  but . space  does  not 
permit  of  all  being  printed. 

Case  2.  Acute  luemorrhayic  pancreatitis  due  to  malaria. — 
Patient,  aged  26,  invalided  for  malaria  and  admitted  with 
this  complaint.  He  was  in  hospital  about  six  weeks ; he  had 
three  slight  attacks  of  malaria  (subtertian),  rings  and 
crescents  found  in  blood.  The  clinical  findings  were  nil, 
except  a palpable  spleen,  temperature  in  each  attack  not 


1 Paper  read  before  the  Conference  of  Medical  Officers,  Malta. 

2 Text-book  on  Tropical  Medicine,  by  Castellani  and  Chalmers. 


The  Lancet,] 


DK.  M.  WHITE:  MALARIA  FROM  THE  SURGEON’S  STANDPOINT.  [JULY  26,  1919  155 


higher  than  102  F. ; patient  recovered  rapidly  from  attacks. 
General  health  excellent;  sent  to  convalescent  camp  and  a 
few  weeks  later  to  active  service  camp.  After  about  a week 
at  the  latter  he  was  readmitted  as  a surgical  case.  While  on 
duty,  he  was  suddenly  sei::ed  with  a severe  pain  in  upper 
abdomen ; carried  to  his  tent.  He  was  sent  to  hospital 
immediately. 

On  admission  he  was  very  collapsed,  sweating  profusely  ; 
pulse  120,  weak  and  intermittent;  abdomen  distended  and 
rigid,  with  marked  resistance  in  epigastrium ; drawn 
anxious  look;  temperature  98  ; a few  hours  later  101°; 
appeared  very  ill.  At  laparotomy  a few  hours  later  there 
was  some  free  bloody  fluid  in  the  abdomen ; pancreas  was 
enlarged  and  congested  ; small  petechial  hmmorrhages  and 
fat-necrosis  in  surrounding  tissues  and  mesentery.  Appendix 
normal  ; liver  and  spleen  slightly  enlarged  and  congested. 
The  abdomen  was  closed  without  drainage ; intra- 
muscular quinine  gr.  10.  During  the  first  24  hours 
after  operation  he  collapsed  twice ; stimulants,  artificial 
respiration,  and  oxygen.  Next  day  he  was  much  better, 
but  sweating  profusely.  After  this,  under  quinine, 
recovery  was  rapid  and  uninterrupted.  He  was  allowed  up 
at  end  of  second  week.  Temperature  became  normal  on 
the  third  day  and  remained  so  as  long  as  patient  was  in 
hospital. 

I have  seen  one  other  case  on  the  island  in  which  the 
diagnosis  was  made  of  acute  pancreatitis,  which  cleared 
up  rapidly  under  quinine.  Surgical  interference  is  contra- 
indicated, as  the  pancreatitis  is  due  to  a capillary  thrombosis 
formed  by  the  massing  of  the  parasites  and  pigment. 

These  malarial  abdominal  infections  are  always  due  to  the 
subtertian  parasites,  and  if  the  parasites  attack  one  par- 
ticular organ  there  will  be  symptoms  referable  to  that  disease. 
In  this  case  the  pancreas  was  the  principal  organ  to  be 
attacked,  and  the  symptoms  were  those  of  an  acute  pan- 
creatitis from  other  causes.  This  explains  the  rapid  recovery 
of  these  patients  under  quinine  therapy  if  promptly  and 
efficiently  given,  otherwise  they  rapidly  die,  or  the  organ 
becomes  so  damaged  that  it  is  unable  to  perform  its 
function. 

Pseudo-appendicitis. — 1 have  seen  many  of  these  cases  on 
the  island  due  to  malaria,  which  cleared  up  rapidly  under 
intramuscular  quinine.  If  the  diagnosis  is  made  surgical 
interference  is  not  necessary.  The  cause  of  the  pain  on  the 
right  side  is,  I believe,  a referred  pain  due  to  an  acute 
splenitis,  which,  in  my  own  observations,  has  always  been 
present,  although  in  some  cases  it  may  be  due  to  the 
localisation  of  the  parasite  in  the  intestinal  mucosa. 

I have  had  many  cases  of  appendicitis,  both  catarrhal  and 
suppurative,  in  malarial  patients  and  the  only  point  in  the 
differential  diagnosis,  as  far  as  I have  been  able  to  observe, 
is  the  white  cell  count.  In  both  classes  of  cases  all  Murphy’s 
symptom-complex  are  present  except  Ieucocytosis — i.e.,  pain, 
vomiting,  a little  temperature,  and  rigidity  of  the  right 
rectus.  In  pseudo-appendicitis  or  pseudo-cholecystitis  due 
to  malaria  one  finds  a marked  leucopenia,  with  a decrease  in 
the  polymorphs  and  a high  mononuclear  count.  In  true 
cases  of  appendicitis  complicated  with  malaria  one  finds  a 
relative  Ieucocytosis,  with  an  increase  in  the  polymorphs. 
The  non-discovery  of  the  malarial  parasites  in  the  peripheral 
blood  is  of  no  account  in  the  diagnosis. 

Malarial  attack  followinq  operation. — The  following 
explains  why  an  operation  brings  on  an  attack,  and  often 
of  a very  severe  nature,  and  nearly  always  atypical  in 
persons  who  have  never  previously  suffered  from  one. 

“ It  is  a well-known  fact  that  the  plasmodium  can  exist 
in  the  spleen  of  persons  who  show  no  signs  of  fever  or 
malaria  cachexia,  and  go  through  their  life-cycle  there,  but 
it  would  appear  that  they  are  restrained  from  invading  the 
circulation  by  the  action  of  some  antitoxin  and,  therefore,  do 
not  increase  to  such  numbers  as  to  cause  toxic  symptoms. 
Thus  it  is  obvious  if  the  restraining  influences  which 
conduce  to  the  condition  of  latent  malaria  are  removed,  an 
attack  of  malaria  will  follow.”  3 

It  is  practically  always  the  condition  of  latent  malaria 
in  patients  which  is  the  most  annoying,  though  rarely 
fatal,  complication  in  surgical  cases.  These  patients  give 
no  history  of  having  had  malaria,  and  usually  a history 
of  perfect  health  up  to  the  time  they  were  wounded.  The 
surgeon  operates  quite  confidently  that  everything  will  be 
all  right,  then  24  to  48  hours  after  operation  an  impending 
attack  of  malaria  is  often  foreshadowed  by  these  symptoms, 
and  I have  noticed  this  especially  in  bone  and  joint  cases. 
The  patient  complains  of  severe  pain  in  the  wound  ; the 


latter  looks  unhealthy  ; joints  often  become  very  swollen  and 
exquisitely  painful,  the  least  movement  causing  much  pain. 
The  temperature  at  this  time  is  subnormal,  but  in  a few  hours 
rises  to  105°  or  106°,  without  a rigor.  If  I happen  to  see 
the  patient  at  this  stage,  I give  immediately  quinine  gr.  15, 
intramuscularly. 

I have  had  a number  of  these  cases  under  my  care,  and 
have  found  that  the  impending  attack  cannot  be  prevented 
by  giving  quinine  at  this  stage,  although  it  may  be  con- 
siderably shortened,  and  by  giving  another  dose,  also  intra- 
muscularly, the  next  day  a second  attack  is  rare. 

Delayed  wound  healing  is  also  a feature  in  this  type  of 
case.  Wounds  look  unhealthy,  granulate  over,  only  to  break 
down  again  in  a few  days.  Some  of  them  resemble  syphilitic 
sores,  and  often  it  is  only  with  a negative  Wassermann  and 
response  to  quinine  therapy  one  becomes  convinced  that 
malaria  is  the  setiological  factor. 

I have  never  seen  these  conditions  in  known  treated  cases 
of  malaria.  As  a prophylaxis  against  post-operative  attacks 
of  malaria  I have  found  15  gr.  of  quinine  intramuscularly 
the  night  before  operation  extremely  valuable. 

Case  7.  Camouflaged  malaria. — Patient  aged  21.  Service 
3|  years.  Had  been  in  Salonika  one  year.  Admitted  to 
St.  Elmo  Hospital  on  diagnosis  of  gunshot  wound  of  right 
elbow-joint.  No  history  of  malaria  or  dysentery  ; had  felt 
well  up  to  time  he  was  wounded.  On  admission  temperature 
102°,  pulse  118.  Patient  very  weak  and  ansemic  ; great  pain 
in  arm  ; headache,  dizziness,  and  ringing  in  ears.  Examina- 
tion revealed  very  little  apart  from  the  wounded  arm,  which 
was  swollen,  cyanotic,  and  tender  from  shoulder  to  finger- 
tips. Elbow  especially,  swollen  ; pus  streaming  out  of  a 
pin-point  opening  on  anterior  side  just  over  brachial  artery. 
Glands  in  the  axilla  were  enlarged  and  tender.  Day  after 
admission  severe  headache ; face  very  flushed.  He  had 
several  fainting  attacks  ; proposed  operation  for  drainage  of 
elbow-joint  postponed.  Temperature  102°;  pulse  130,  very 
weak  and  intermittent.  Strychnine  and  digitalis  were 
given  during  the  day. 

Next  day  his  general  condition  had  improved  somewhat, 
and  under  ether  anaesthesia  the  elbow-joint  was  drained  ; 
no  attempt  at  resection  on  account  of  serious  condition. 
During  the  next  two  days  he  improved  greatly.  Tempera- 
ture not  above  99 ' and  pulse  100;  ate  well  and  slept  well; 
complained  of  nothing  but  a feeling  of  giddiness,  which  he 
said  he  had  had  for  some  weeks  before  he  was  wounded. 

On  the  evening  of  the  second  day  following  his  operation, 
without  any  warning,  and  while  talking,  he  had  three  severe 
epileptiform  convulsions,  became  very  violent,  and  relapsed 
into  unconsciousness.  Next  morning,  as  he  was  still 
unconscious,  a lumbar  puncture  was  done ; spinal  fluid 
under  greatly  increased  pressure,  but  clear.  A white  blood 
count  was  made  and  film  taken  for  malaria  ; catheterised 
specimen  of  urine  showed  a faint  trace  of  albumen,  but  no 
casts.  The  bacteriological  report  of  spinal  fluid  negative  ; 
sugar  reaction  present.  Films  negative  to  malaria.  White 
blood  count  was  8600 ; polymorphs,  60  per  cent. ; lymphocytes, 
29  per  cent.;  large  mononuclears,  5 per  cent.  Patellar 
reflexes  were  absent;  Babinsky  and  Kernig  signs  absent; 
some  slight  retraction  of  head.  Major  W.  H.  Kiep  examined 
the  eyes ; report  negative. 

During  the  next  24  hours  patient  still  remained 
unconscious ; temperature,  102° ; pulse,  130 ; involuntary 
urination  and  deftecation.  Lumbar  puncture;  fluid  still 
under  greatly  increased  pressure,  but  clear  ; bacteriological 
report  as  before  ; films  again  negative  to  malaria.  The  arm 
looked  unhealthy  and  the  edges  of  the  wound  gangrenous, 
with  a very  offensive  odour;  amputation  was  discussed,  but 
decided  to  try  intravenous  quinine  first.  Quinine  hydrochlor., 
gr.  15,  in  10  oz.  normal  saline  given ; another  lumbar 
puncture  at  same  time.  Two  hours  after  the  injection  he 
commenced  to  perspire  profusely;  16  hours  later  perfectly 
conscious  ; temperature,  98°  ; pulse,  90  ; patient  very  weak. 

From  this  time  recovery  was  uninterrupted,  quinine 
hydrochlor.,  gr.  15,  was  given  daily  intramuscularly  for  a 
week,  then  twice  a week  for  four  weeks.  The  arm  cleared 
up  rapidly.  During  the  next  ten  weeks  in  hospital  he  had  no 
further  rise  of  temperature  and  was  sent  to  England  as  a 
walking  case.  Malaria  parasites  were  never  found  in  the 
blood,  and  the  spleen  was  only  just  palpable. 

This  was  a case  of  camouflaged  malaria,  where  all  symptoms 
indicated  some  other  illness.  The  septic  condition  of  the 
arm  followed  by  the  sudden  coma  pointed  to  an  extension  of 
the  infected  foci  to  the  brain,  with  a resulting  cerebral 
abscess,  especially  with  the  negative  history  of  malaria  and 
the  absence  of  parasites  in  the  blood.  The  white  cell  count 
and  the  absence  of  any  localisation  symptoms  were  the  only 
two  factors  in  the  probable  diagnosis  of  a cerebral  malaria. 
Later  the  prompt  response  to  quinine  therapy  and  the  rapid 
recovery  left  no  doubt  as  to  the  diagnosis. 


3 From  Text-book  of  Castellani  and  Chalmers. 


156  The  Lancet,] 


CLINICAL  NOTES. 


[July  26, 1919 


The  complications  of  camouflaged  malaria  are  the  most 
fatal  in  surgical  cases,  as  they  are  usually  rapidly  fatal,  and 
while  one  is  trying  to  make  a diagnosis  the  patient  dies. 
Castellani,  in  writing  of  cerebral  malaria,  says  : — 

“ No  diagnosis  of  hemiplegia  or  of  any  brain  or  spinal 
disease  without  such  obvious  cause  as  traumatism  should  be 
made  in  malarious  districts  without  first  examining  the 
blood  to  see  whether  the  subtertian  p'arasite  is  present.” 

I do  not  think  he  goes  far  enough  in  this  statement,  as 
in  the  most  serious  and  fatal  of  my  cases  parasites  have  never 
been  found  in  the  peripheral  blood.  Splenic  punctures  have 
not  been  made,  or  the  parasite  would  undoubtedly  have 
been  found  there,  but  1 have  relied  on  the  white  cell  count, 
especially  in  the  presence  of  suppuration  and  the  large 
spleen,  and  corroborated  it  by  the  final  test  of  the  response 
to  quinine  therapy. 

A case  (No.  8)  was  recorded  of  purpura  hasmorrltagica  due 
to  malaria,  or,  as  Castellani  calls  it,  hemorrhagic  pernicious 
fever.  Fortunately  this  very  fatal  complication  is  rare. 
The  hemorrhages  appear  during  the  attacks  but  never  during 
the  intermission.  Untreated  it  rapidly  produces  severe 
anemia,  with  thread  pulse,  delirium,  and  death ; often  all 
treatment  is  of  no  avail.  Operations  on  these  patients  are 
absolutely  contraindicated  unless  it  is  the  question  of  the 
life  of  the  patient,  and  then  every  precaution  should  be 
.taken  to  guard  against  and  prevent  haemorrhage.  Even  the 
extraction  of  a tooth  has  led  to  fatal  results  in  these  cases. 

The  relation  of  quinine  to  haemorrhages  is  still  a debated 
question.  My  own  experience  tends  towards  the  view  that 
the  quinine  has  very  little,  if  anything,  to  do  with  it.  Where 
I have  observed  a tendency  to  haemorrhage  in  malarial 
patients  post-operative  or  otherwise  I always  give  quinine 
hydrochlor.  in  small  doses,  with  large  doses  of  calcium  lactate 
and,  if  necessary,  horse  serum. 

The  last  case  recorded  (No.  9)  was  one  of  amputation  of 
the  leg.  The  most  interesting  thing  about  this  case  is  that  for 
nearly  two  years  under  certainly  not  the  most  ideal  conditions 
in  Salonika  the  patient  had  no  relapse  of  malaria  in  a known 
subtertian  infection.  I mention  the  case  especially  as  it 
proves  that  the  parasite  may  remain  dormant  for  years  in  the 
system  and  the  patient  in  perfect  health.  Suddenly  it  may 
light  up  when  the  vitality  of  the  body  is  lowered  and  pro- 
duce an  attack  of  a very  serious  nature.  Also  the  sudden 
acute  dilatation  of  the  heart  in  these  cases  is  very  common, 
often  proving  fatal. 

Conclusions. 

These  surgical  manifestations,  complications,  and  sequel® 
usually  result  from  a neglected  and  undiagnosed  malaria  or 
from  a malaria  inefficiently  treated  with  quinine.  The  fact 
that  there  have  been  so  few  on  the  island  speaks  well  for 
the  promptness  and  efficiency  of  the  treatment  and  the 
correctness  of  diagnosis. 

There  is  no  difficulty  in  recognising  the  quartan  and 
the  simple  tertian  variety,  as  the  attacks  are  usually  typical 
and  parasites  can  always  be  found  in  the  peripheral  blood  if 
films  are  taken  at  the  proper  time.  The  difficulty  in 
diagnosis  is  the  subtertian,  with  its  many  masks  and 
innumerable  sequel®,  and  it  is  this  type  which  is  most 
often  untreated  because  undiagnosed. 

It  is  to  be  doubted  whether  any  of  us  realise  sufficiently 
what  a protean  disease  malaria  is,  and  the  points  to  be 
emphasised  are : — 

1.  That  an  operation  often  brings  on  an  attack  of  malaria 
of  a very  severe  nature,  and  an  acute  dilatation  of  the  heart 
during  or  following  an  operation  is  very  frequent,  often 
proving  fatal,  and  the  utmost  precautions  should  be  used  in 
regard  to  anaesthetics  for  these  malarial  patients.  Ether 
given  by  the  Vernon  Harcourt  method  is  the  safest ; chloro- 
form, in  my  opinion,  is  absolutely  contraindicated. 

2.  That  the  malarial  parasites  of  subtertian  malaria  may 
attack  any  organ,  giving  all  clinical  symptoms  of  disease  of 
that  organ,  as  the  surgeon  who  has  no  experience  of  malaria 
will  find  to  his  cost. 

3.  That  the  negative  history  of  malaria  and  the  absence  of 
parasites  in  the  blood  is  of  no  account  iruthe  diagnosis  of  a 
positive  malaria. 

4.  That  in  a malarial  patient  convulsions  and  coma  occur 
in  an  apparently  healthy  man  without  any  warning,  and 
that  it  is  not  uncommon  for  a man  with  acute  cerebral 
malaria  to  be  arrested  for  drunkenness  ; and  that  in  every 
case  of  brain  or  spinal  disease,  or  other  obscure  complaints 
occurring  in  men  who  have  been  East,  malaria  is  one  of  the 
first  things  that  should  be  considered  by  the  surgeon. 


5.  That  the  subtertian  malaria  may  simulate  almost  any 
disease,  surgical,  mental,  or  medical.  It  may  produce  such 
insidious  symptoms  that  when  the  patient  feels  ill  enough  to 
see  a doctor  treatment  is  of  little  avail. 

6.  In  the  acute  attacks  there  may  or  there  may  not.  be  a 
chill,  and  parasites  may  or  may  not  be  found  in  the  blood  in 
this  type. 

The  patient  may  have  no  idea  himself  that  he  has  malaria, 
and  herein  lies  the  danger.  A man  with  a subtertian  infec- 
tion is  always  in  danger  of  his  life,  and  too  much  importance 
cannot  be  attached  to  the  question  as  to  the  care  of  these 
malarial  victims  in  England  after  they  return  to  their  homes. 
As  Professor  Osier  wrote  some  years  ago  : “ There  is  no  other 
disease  which  compares  with  it,  except  perhaps  tuberculosis, 
in  the  extent  of  its  distribution  and  its  importance  as  a 
killing  and  disabling  disease.” 


dlinital  Itotcs . 

MEDICAL,  SURGICAL,  OBSTETRICAL,  AND 
THERAPEUTICAL. 


A CASE  OF  MULTIPLE  EPULIDES. 

By  W.  Warwick  James,  F.R.C.S.  Eng.,  L.D.S., 

DENTAL  SURGEON,  ROYAL  DENTAL  HOSPITAL  ; ASSISTANT  DENTAL 
SURGEON,  MIDDLESEX  HOSPITAL,  ETC. 


In  the  following  case  the  growth  of  a fibrous  epulis  (to  be 
more  definite,  hypertrophy  of  the  fibrous  tissue  of  the  gingival 
muco-periosteum)  has  been  associated  with  each  tooth  of  the 
temporary  and  permanent  series  which  has  erupted. 

Account  of  Case. 

The  patient,  a girl  now  aged  11,  was  admitted  into  hospital 
in  May,  1912,  when  a portion  of  the  tissue  was  examined 
microscopically.  Some  uncertainty  existed  as  to  its  nature. 
A further  • section  showed  it  to  be  purely  fibromatous.1 
The  gingival  margins  were  considerably'  enlarged  and 
nodular.  The  tissue  particularly  involved  was  appa- 
rently the  gum  margin  and  the  neighbouring  portion, 
but  not  the  greater  part  of  that  covering  the  roots.  As 
the  result  of  treatment  it  would  seem  that  the  periodontal 
membrane  is  also  involved,  the  bone  is  not  involved  ; X ray 
photographs  showed  no  changes.  The  growth  had  extended 
round  the  crowns,  in  parts  even  reaching  to  the  top  of  the 
teeth,  and  also  in  thickness.  In  the  early  stages  it  appears 
markedly  vascular  and  somewhat  denuded,  but  later  it 
seems  less  vascular  and  is  mottled  with  faintly  yellowish- 
brown  patches.  There  was  no  tendency  in  the  tissue 
to  break  down  except  where  injured  by  opposing  teeth. 
Growth  is  slow,  the  increase  being  marked  by  months 
rather  than  weeks.  Patient  suffered  no  pain;  general 
health  seemed  affected,  probably  owing  to  difficulty 
in  eating.  The  growth  superficially  resembles  a simple 
fibrous  epulis,  but  is  sessile,  while  the  simple  epulis  is  nearly 
always  pedunculated. 

Of  particular  interest  is  the  effect  of  treatment,  and  this 
coincides  with  the  records  of  other  cases,  and  of  that  of  a 
simple  fibrous  epulis.  Seven  separate  operations  have  been 
performed  and  an  attempt  was  made  to  save  the  teeth,  but 
recurrence  followed.  All  the  temporary  and  eight  of  the 
permanent  ones  have  been  extracted,  the  growth  completely 
excised,  and  the  margins  of  the  alveolus  removed.  The 
stages  of  the  operations  were  as  follows:  All  the  temporary 
incisors  and  the  first  temporary  molars  were  extracted  and 
the  growth  removed,  whilst  the  abnormal  tissue  was  cut 
away  freely  down  to  the  bone  margin  round  the  remaining 
eight  teeth.  Where  the  teeth  remained  the  growth  recurred 
and  in  July,  1912,  the  four  molars  were  removed  as  being  less 
accessible'than  the  canines,  and  the  tissue  again  pared  away 
round  the  latter.  In  October,  1912,  the  canine  teeth  were 
similarly  treated.  The  child  was  now  nearlv  5 years  old. 

No  change  took  place  for  about  two  years,  nor  was  there 
any  sign  of  a similar  growth  until  after  the  first  permanent 
molars  appeared,  when  the  condition  recurred  in  about  a 
year  and  the  previous  operation  was  repeated.  In  October, 
1917,  the  maxillary  incisors  had  erupted,  with  recurrence  of 
the  condition,  and'  although  it  was  suggested  upon  the  lower 
incisors  it  was  not  marked.  An  operation  removing  the 
tissue  around  the  upper  incisors  without  the  teeth  was 
unsuccessful  and  the  teeth  -were  removed  in  November. 

The  present  condition  shows  the  lower  canines  involved, 
also  the  left  lower  second  premolar,  which  is  erupting  into 
the  socket  of  the  first  permanent  molar.  The  same  change 

The  Lancet,  1919,  i„  744. 


The  Lancet,] 


REVIEWS  AND  NOTICES  OF  BOOKS. 


[July  26,  1919  157 


is  taking  place  with  regard  to  the  right  upper  premolar, 
which  is  erupting  into  the  socket  of  the  first  permanent 
molar.  The  gum  presents  the  reddish,  somewhat  denuded 
appearance  described,  which  seems  the  first  indication  of 
the  growth,  although  in  parts  it  is  reaching  the  nodular 
stage.  The  patient  has  been  wearing  a vulcanite  block  to 
bite  upon  ; the  pressure  from  this  seems  to  have  arrested 
the  development  of  the  condition  in  one  part. 

Remarks. 

The  child  has  been  strong  and  healthy  from  birth,  except 
for  whooping-cough  and  an  attack  of  what  the  mother 
describes  as  “dry  eczema  ” prior  to  the  appearance  of  the 
mouth  condition  at  the  age  of  3 years.  No  rickets.  She 
was  not  nursed  for  more  than  a few  weeks. 

She  is  not  a mouth-breather,  a fact  of  interest,  as  much 
hypertrophy  of  the  gingival  tissues  is  frequently  seen  in  the 
front  part  of  the  mouth  in  such  patients.  Such  a condition 
is  of  an  infective  nature,  and  the  changes  are  in  marked 
contrast  to  those  in  the  present  case.  In  mouth-breathers 
the  swelling  of  the  tissues  conforms  accurately  to  the  line  of 
contact  with  the  lips,  so  that  when  the  lips  are  pulled  back 
there  is  no  hesitation  in  saying  that  mouth-breathing  exists. 
In  cases  of  hypertrophy  the  lips  may  be  apart  on  account 
of  the  bulk  of  the  growth.  The  condition  in  this  patient 
would  probably  be  described  as  hypertrophy,  and  although 
a certain  number  of  cases  have  been  recorded,  they  are 
undoubtedly  rare.  , 

The  hypertrophy  seen  in  adults  is  generally  due  to  chronic 
infection,  and  involves  the  bone  as  well  as  the  gingival 
tissue.  Perhaps  the  commonest  type  is  a marked  thickening 
of  the  bone  and  the  gum  in  the  region  of  the  maxillary 
molars,  although  several  cases  have  been  recorded  where  the 
whole  of  the  alveolar  margin  has  been  involved,  but  the 
maxilla  appears  to  be  affected  more  often  than  the  mandible 
in  children. 

Christropher  Heath  has  described  a similar  case  to  the 
one  now  reported.  Cases  mentioned  by  him  occurred  at  the 
ages  of  8,  2£,  7,  4,  and  2 years,  the  three  latter  in  one 
family.  In  all  the  cases  recorded  the  mental  condition  was 
defective.  In  another  case  recorded,  very  similar  to  the 
present  one,  the  child  was  4£  years  old  and  healthy.  After 
describing  this  case,  he  says,  “In  conclusion  I should  say 
that  nothing  less  than  complete  removal  of  the  affected 
alveolus  seems  to  offer  any  hope  of  alleviating  these  cases.” 
As  far  as  I can  ascertain,  the  length  of  history  of  this 
particular  case  is  greater  that  that  of  any  recorded  cases. 

As  it  is  difficult  definitely  to  classify  these  cases,  the  term 
epulides  is  used  in  its  widest  sense,  but  if  they  were  allotted 
to  a definite  class,  it  is  probable  that  hypertrophy  would  be 
the  correct  description.  It  seems  a very  drastic  procedure 
to  remove  every  tooth  and  so  render  the  child  edentulous.  It 
is  true  we  can  provide  an  artificial  substitute,  if  nothing 
short  of  extraction  can  be  accomplished. 

A CASE  OF  HERMAPHRODISM. 

By  W.  Danne,  L.R.C.P.  Edin.,  L.R.C.S.  Irel. 

The  following  case  is  described  on  account  of  its  rarity. 
The  only  similar  one  I can  find  is  in  the  1891  edition  of 
“ Diseases  of  Women  ” by  Gaillard  Thomas,  but  in  his  case 
there  were  both  scrotum  and  testicles.  It  would  be  interest- 
ing to  learn  if  anyone  else  in  this  country  has  seen  a similar 
instance. 

Quite  lately  a woman  with  well-developed  breasts  and 
nothing  characteristic  of  a male  in  her  voice  or  general 
appearance  was  brought  to  me.  She  was  40  years  of  age  and 
was  going  to  be  married  soon,  but  as  she  had  a “ lump  in  the 
privates”  she  wished  me  to  remove  it.  On  examination 
there  was  no  trace  of  a vagina  and  the  “ lump  ” proved  to  be 
a small,  well-formed  penis,  with  prepuce,  which  could  be 
retracted  and  the  glans  exposed.  This  penis  was  capable  of 
erection,  and  per  urethram  she  menstruated  regularly  every 
month  as  well  as  micturated.  Also  she  appeared  to  have 
nocturnal  emissions  at  intervals,  with  sexual  feeling.  Per 
rectum  the  anterior  rectal  wall  was  very  thin,  and  through 
it,  lying  towards  the  left,  could  be  felt  a modified  uterus  of  a 
fair  size,  but  with  only  one  cornu.  I could  find  neither 
ovaries  nor  testicles,  and  no  evidence  of  a scrotum. 

I told  her  nothing  could  be  done  to  fit  her  for  marriage, 
and  this  opinion  was  confirmed  by  Mr.  D.  C.  Iiayner.  As 
she  still  was  anxious  that  something  should  be  done  I sent 
her  to  Dr.  James  Oliver,  who  agreed  that  it  was  a case  for 
which  no  operation  was  possible. 

Bristol. 


atti  Stotices  of  mk 


The  Early  Diagnosis  of  Tubercle.  (Oxford  Medical  Publica- 
tions.) By  Clive  Riviere,  M.D.,  F.R.C.P.  Second 
edition.  London  : Henry  F’rowde  ; Hodder  and  Stoughton. 
1919.  Pp.  314.  10.s.  6 cl. 

The  second  edition  of  Dr.  Riviere’s  book  on  the  early 
diagnosis  of  tuberculosis  is  quite  a bulky  volume  for  a work 
limited  to  a single  aspect  of  one  disease.  The  author  in  his 
preface  notes  that  the  present  edition  has  been  revised  and 
expanded,  and  that,  for  the  first  time,  a fairly  adequate 
description  is  given  of  hilus  tuberculosis  in  the  adult.  This 
book  is  excellent,  but  it  is  impossible  to  read  it  without 
coming  to  the  conclusion  that  the  author  has  evolved 
a machinery  so  complicated  that  many  of  his  readers 
will  feel  baffled  as  well  as  helped  by  it.  As  he  says  : 

“ Many  of  the  older  methods  have  been  amplified  and 

improved,  and  valuable  new  ones  have  been  introduced.” 
Would  that  be  had  been  more  willing  to  “ scrap  ” as  well  as 
to  amplify  and  improve ! The  author  is  an  enthusiastic 
“percussionist,”  and  he  attaches  far  more  importance  to 
percussion  than  to  auscultation  of  the  chest.  There  can  be 
no  doubt  that  he  has  reduced,  or  let  us  rather  .say  exalted, 
percussion  to  a fine  art.  Take  the  following  sentence  for 
example  : — 

"Gentle  percussion  is  of  two  kinds:  (a)  One  in  which  the  soft  stroke 
is  ‘ carried  through,’  whereby  the  depths  of  the  lung  are  reached  more 
truly  than  by  heavy  percussion  ; (b)  what  may  be  called  light,  ' flipping  ' 
percussion  directed  to  the  discovery  of  surface  changes,  and  whereby  a 
thickened  pleura  may,  perhaps,  be  distinguished  from  impairment  due 
to  underlying  lung.” 

It  is  clear  that  the  author  has  not  only  assimilated  all  the 
available  teachings  of  the  art  of  percussion  ; he  has  added 
to  it  himself.  But  there  is  surely  as  little  hope  of  his  readers 
gaining  the  same  skill  in  percussion  as  of  Paderewski  turning 
out  pianistic  replicas  of  himself  by  writing  a text-book  on 
his  art.  The  author's  praise  of  the  X rays  is  measured,  and 
he  has  found  that  in  most  cases  they  are  superfluous.  Having 
damned  them  with  a halting  testimonial,  he  proceeds  to  give 
an  excellent  account  of  their  interpretation  in  disease  of  the 
lungs— an  account  which  is  the  more  concise,  objective,  and 
detached  for  being  given  by  an  agnostic.  The  chapter 
dealing  with  tuberculin  reveals  the  author’s  wide  know- 
ledge of  a subject  obscured  by  the  prodigious  output  of 
mediocre  workers  ; and  he  has  reduced  his  encyclopaedic  raw 
material  to  an  eminently  readable  and  concise  finished 
product.  But  in  the  chapter  on  the  temperature  he  has 
edited  his  sources  of  information  with  less  discrimination, 
and  instead  of  confining  himself  to  the  best  monographs  on 
the  subject,  he  quotes  over  a score  of  writers,  leaving  the 
reader  to  pick  out  what  he  likes  best.  Part  II.  deals  with 
tuberculosis  in  children  and  represents  about  one-third  of 
the  book.  Here  the  author  contributes  much  useful  informa- 
tion, full  measure,  pressed  down. 

This  book  is  first-class  matter  from  a first-class  source  ; its 
chief  fault  in  this  age  of  hustle  is  a surfeit  of  information, 
and  it  is  to  be  hoped  that  the  third  edition,  which  will  no 
doubt  soon  be  called  for,  may  show  more  signs  of  condensa- 
tion than  of  expansion. 


Dental  Surgery  and  Pathology.  By  J.  F.  Colyer,  F.R.C.S., 
L.D.S.,  Dental  Surgeon  to  Charing  Cross  Hospital  and 
the  Royal  Dental  Hospital  ; Examiner  in  Dental  Surgery, 
Royal  College  of  Surgeons  of  England.  Fourth  edition. 
With  illustrations.  London  : Longmans,  Green,  and  Co. 
1919.  Pp.  899.  32«.  net. 

The  importance  of  a knowledge  of  pathology  to  the  dental 
surgeon  can  hardly  be  over-estimated ; for  now  it  is  becoming 
universally  recognised  that  the  gravest  results  may  follow 
septic  processes  in  the  mouth,  and  that  many  general  diseases 
are  to  be  attributed  directly  to  infection  proceeding  from 
this  source.  It  is  clear,  therefore,  that  we  must  look  to  the 
dental  surgeon  for  the  recognition  of  the  existence  at  an 
early  stage  of  those  septic  conditions  which  may,  if  neglected, 
prove  to  be  the  forerunners  of  very  serious  morbid  conditions. 
Dental  students,  therefore,  are  fortunate  to  be  in  a position 
to  possess  such  a work  as  this  in  which  the  true  principles  of 
pathology  in  relation  to  the  teeth  are  fully  expounded  and 
clearly  enunciated.  The  ideal  principle  of  dental  treatment 


158  The  Lancjet,] 


REVIEWS  AND  NOTICES  OF  BOOKS. 


[July  26, 1919 


should  ever  be  the  prevention  of  sepsis,  and  the  ideal  of 
dentistry  will  only  be  attained  when  preventable  diseases 
associated  with  the  teeth  shall  have  ceased  to  exist. 

Mr.  Colyer  has  described  fully  all  the  abnormalities  to 
which  teeth  are  subject,  and  the  methods  by  which  these 
abnormalities  may  be  remedied  ; he  has  discussed  very 
thoroughly  all  the  theories  as  to  the  nature  and  causes  of 
caries,  and  he  comes  to  the  conclusion  that  the  prevalence 
of  caries  in  modern  races  is  due  to  the  soft  character  of 
the  food  and  the  increase  in  the  use  of  carbohydrates 
which  undergo  rapid  fermentation.  The  importance  of 
periodontitis  is  fully  recognised,  and  the  author  finds  that 
the  evidence  points  to  the  disease  being  started  by  injury 
of  the  gingival  margin  from  food  debris  or  by  the  local 
action  of  toxins  as  seen  in  the  marginal  gingivitis  of 
mouth-breathers  ; and  the  prevalence  of  the  disease  at  the 
present  day  he  attributes  to  the  character  of  modern  diet,  for 
much  of  our  food  is  prepared  in  such  a way  that  it  accumu- 
lates readily  round  the  teeth  and  is  of  a nature  easily 
to  undergo  fermentation.  The  chapter  on  fractures  of  the 
jaw  is  adequate,  and  no  excess  of  space  is  devoted  to 
gunshot  fractures,  for  in  civil  practice  such  fractures  are 
very  rare. 

There  are  two  points  in  this  work  that  deserve  special 
mention.  One  of  these  is  the  very  full  provision  of  illustra- 
tions— a sufficient  number  of  illustrations  goes  far  to  assist 
the  student  in  the  thorough  comprehension  of  a subject. 
The  other  point  is  the  very  complete  index.  A work  like 
this  should  prove  of  interest  not  only  to  dental  students 
and  dental  surgeons,  but  also  to  very  many  members  of 
the  medical  profession  who  have  nothing  directly  to  do 
with  dentistry  ; from  it  they  will  learn  much  that  will  be 
of  value  in  the  treatment  of  patients  suffering  from  many 
diseases,  and  they  will  appreciate  more  fully  than  many 
do  now  the  importance  of  early  attention  to  morbid  con- 
ditions of  the  teeth  in  the  treatment  of  disease  in  other 
parts  of  the  body. 

JOURNALS. 

The  British  Journal  of  Children's  Diseases.  Vo).  XVI., 
April-June.  Edited  by  J.  D.  Rolleston,  M.D.— Dr.  Edmund 
Cautley  contributes  an  article  on  Duodenal  Stenosis,  in 
which  he  reviews  the  literature  and  reports  a personal  case 
in  a male  infant  aged  12  months.  He  states  that  the  charac- 
teristic feature  of  the  condition  is  vomiting,  with  the  usual 
signs  of  obstruction.  It  may  occur  even  if  no  food  is  given 
by  mouth,  the  stomach  becoming  distended  by  normal  secre- 
tion. Bilious  vomiting  occurs  in  about  90  per  cent,  of  the 
cases,  and  if  the  obstruction  is  above  the  entrance  of  the 
common  duct  is  probably  due  to  an  aberrant  branch  opening 
into  the  dilated  first  part  of  the  duodenum.  Hsematemesis 
is  not  uncommon.  Inanition,  wasting,  and  constipation 
naturally  develop.  If  food  is  taken  and  life  prolonged,  as 
in  some  cases  in  which  adult  life  and  even  middle  age  have 
been  reached,  the  stomach  and  first  part  of  the  duodenum 
become  dilated  and  hypertrophied,  and  there  is  marked 
gastric  peristalsis.  The  symptoms  are  practically  the  same 
as  those  of  congenital  hypertrophic  stenosis  of  the  pylorus, 
unless  bilious  vomiting  is  also  present.  A dilated  first  part  of 
the  duodenum  gives  the  sensation  of  a pyloric  tumour,  but  it 
is  neither  so  hard  nor  so  defined  as  in  pyloric  hypertrophy. 
No  medical  treatment  is  of  real  benefit,  but  life  has  been 
saved  in  isolated  cases  by  early  operation.  Many  of  the 
infants  are  premature.  In  Dr.  Cautley’s  case  an  exploratory 
operation  was  made,  but  the  state  of  the  child  did  not 
warrant  gastro-enterostomy  and  death  took  place  a week 
later.  At  the  autopsy  the  stomach  was  found  to  be  dilated 
and  hypertrophied,  and  the  pylorus  widely  dilated.  The 
first  part  of  the  duodenum  was  dilated  into  a more  or  less 
spherical  sac  over  2 in.  in  diameter.  The  second  part  for  a 
distance  of  an  inch  was  extremely  stenosed,  merelyadmitting 
the  passage  of  a probe,  and  the  duct  entered  about  the  middle 
of  the  stenosed  portion.  There  were  no  other  abnormalities. — 
In  a paper  on  Catarrhal  Jaundice  in  Children,  Dr.  E. 
Bronson  reports  a number  of  cases  of  catarrhal  jaundice 
associated  with  influenza  in  children,  and  classifies  them 
under  the  following  groups:  (1)  those  in  which  jaundice 
followed  exposure  to  influenza,  but  which  did  not  develop 
influenza  in  the  ordinary  sense ; (2)  cases  which  developed 
jaundice  as  a sequel  to  an  attack  of  influenza  ; (3)  doubtful 
cases  in  whioh  there  was  no  known  exposure  to  influenza.— 
In  a Note  on  Influenza  in  Infants,  Dr.  C.  Achard,  of  Paris, 
states  that  though  one  of  the  peculiarities  of  the  present 
epidemic  has  been  the  rarity  of  the  disease  at  this  age,  he 
has  had  the  opportunity  of  observing  32  cases  under  2 years 
of  age  in  the  creohe  at  the  Hdpital  Necker.  In  six  cases  the 
disease  was  uncomplicated  and  recovery  took  place,  in  12 
there  was  bronchitis  or  slight  pulmonary  congestion  with  one 


death,  and  in  13  broncho  pneumonia  developed  with  seven 
deaths.  Achard  concludes  that  influenza  in  the  infant  is  by  no 
means  exceptional,  and  that  the  form  and  gravity  of  the 
disease  may  vary.  The  infant  does  not  possess  any  real 
immunity  but  is  merely  less  exposed  to  contagion  from 
without,  the  infection  being  chiefly  contracted  from  the 
mother. — Mr.  Ralph  Thompson  records  a case  of  Ectopia 
Vesicae.  in  which  he  performed  a successful  operation  in  the 
fifth  month  of  life.  In  his  discussion  of  the  anatomy  of  the 
condition  he  comes  to  the  following  conclusion:  (1)  Ectopia 
vesicae  is  a body  cleft  due  to  the  formation  of  a groove  in  the 
allantois,  which  secondarily  affects  the  cloaca  ; (2)  epispadias 
is  not  analogous  to  hypospadias,  but  is  evidence  of  a bifid 
or  double  genital  eminence  being  formed  from  the  cloaca 
which  is  cleft  secondary  to  the  allantois ; (3)  the  cause  of  the 
deformity  must  be  above  rather  than  below. — A case  of 
Urethrocele  is  described  by  Mr.  Pybus  in  a male  child, 
aged  3 years.  The  penis  was  considerably  enlarged, 
measuring  3§  inches  in  length,  and  became  ballooned 
during  micturition.  The  urine  was  ammoniacal  and  con- 
tained nus.  Death  took  place  a week  after  an  operation  at 
which  the  redundant  portion  of  the  urethra  was  removed. 
The  autopsy  showed  considerable  hypertrophy  of  the 
bladder,  marked  dilatation  of  the  ureters,  and  of  a less 
degree  of  the  renal  pelves,  one  of  which  was  inflamed. — Dr. 
Parkes  Weber  and  Mr.  T.  H.  Gunewardine  report  a new 
case  of  Lipodystrophia  Progressiva  in  a girl  aged  12£,  in 
whom  the  disease  had  set  in  five  years  previously. — Dr.  John 
Thomson  contributes  a note  on  a case  of  Myasthenia  Gravis 
in  a girl  aged  111  years,  which  proved  fatal  in  nine  months’ 
time. — Mr.  Haldin  Davis  gives  an  account  of  the  Willesden 
Ringworm  Clinic,  which  he  established  in  the  spring  of  1913, 
since  when  441  cases  had  been  submitted  to  X ray  treatment. 
No  instances  of  X ray  burn  or  permanent  alopecia  occurred. 
Owing  to  the  speed  with  which  cases  can  be  cured  by  X rays, 
Mr.  Davis  states  that  the  cost  of  treatment  is  nearly  defrayed 
by  the  additional  grant  earned  from  the  Board  of  Education 
and  by  the  saving  of  school  time  which  would  have  been  lost 
under  the  older,  slower  methods  of  treatment. — A Retrospect 
of  Otology,  1918,  is  contributed  by  Mr.  Macleod  Yearsley. — 
The  abstracts  from  current  literature  are  devoted  to  acute 
infectious  diseases,  disorders  of  metabolism,  diseases  of  the 
urogenital  system,  dermatology  and  syphilis,  and  otology, 
rhinology,  and  laryngology. 

In  the  Slilitarij  Surgeon  (Washington,  D.C.,  U.S.A.)  for 
April  Colonel  Qualls  and  Captain  Meylackson  give  an  account 
of  a large  venereal  clinic  in  Maryland.  The  clinic  received 
about  50  fresh  cases  daily ; some  85  per  cent,  of  the  infec- 
tions were  contracted  in  civil  life,  9 per  cent,  of  whites  and 
39  per  cent,  of  negroes  being  found  infected  on  entry.  Details 
of  the  organisation  required  to  deal  rapidly  and  effectively 
with  this  mass  of  cases  are  given,  and  should  be  read  by  all 
interested.  In  13,159  persons  treated  by  prophylaxis  126 
cases  developed,  but  only  11  amongst  those  who’ took  the 
treatment  within  an  hour  of  exposure. — Captain  L.  C.  Frost 
insists  that  cases  of  shell  shock  must  be  treated  at  once 
by  experts  within  the  battle  area. — Colonel  Lynch  and 
Lieutenant-Colonel  J.  G.  Cumming  urge  that  infection  of 
sputum-borne  diseases  in  the  army  occurs  rather  through 
mess  utensils  than  by  the  air  of  the  barrack-room,  and  set 
out  the  need  for  washing  these  in  water  that  is  boiling. 
They  found  that  in  certain  civilian  groups,  numbering  in 
all  20,000  people,  those  whose  dishes,  etc.,  were  machine- 
washed  suffered  far  less  from  influenza  than  did  those  whose 
mess-kits  were  washed  by  hand.  They  desire  to  see  a 
lavatory  established  near  the  mess-room  in  all  barracks, 
so  that  the  men  may  get  into  the  disease-averting  custom 
of  washing  the  hands  before  each  meal.  They  fonnd 
that  even  in  a smart  regiment  not  quite  a quarter  of 
the  men  do  so  now.  The  U.S.  base  hospital  at  Etretat 
learned  to  save  their  orderlies  from  trench  fever  by  cleaning 
patients  on  entry,  and  by  putting  the  orderlies  dealing  with 
new  entries,  their  clothing  and  effects  into  louse-proof  suits, 
double  pyjama  suits  sprayed  with  creosote  oil.  One  clerk 
appeared  to  have  become  infected  through  carelessly 
sitting  on  the  stretchers  of  the  new  entries  while  taking 
their  “ particulars.” — Major  Dodge,  reporting  on  638 
operations  for  hernia,  mentions  that  after  it  became  a 
routine  for  all  operation  cases  to  gargle  with  a 1 in  10,000 
solution  of  quinine  sulphate  post-operative  pneumonia 
ceased  to  occur,  and  no  one  using  that  gargle  got  pneumonia 
during  the  October  influenza  epidemic,  though  several  had 
influenza.  The  quinine  gargle  is  supposed  to  be  specific 
against  the  pneumococcus. — Lieutenant-Colonel  J.  T.  Rugh 
discusses  leggings  and  puttees,  and  concludes  that  no 
complaint  can  be  made  against  them  if  they  fit. 


Centenarians. — Mrs.  Esther  Carter  died  recently 
at  East  Molesey,  Surrey,  in  her  102nd  year.  The  deceased 
was  born  at  Weymouth,  and  visited  her  birthplace  upon  the 
100th  anniversary  of  her  birthday. — Miss  Eleanor  Patteson. 
who  completed  her  100th  year  two  months  ago,  died  on 
July  18th  at  Bath. 


Tbe  Lancet,] 


AN  AMERICAN  HOSPITAL  IN  LONDON. 


[July  26,  1919  1 59 


THE  LANCET. 


LONDON:  SATURDAY , JULY 26,  1019. 


An  American  Hospital  in  London. 

We  publish  in  another  column  the  account  of  a 
notable  meeting  held  at  the  House  of  the  Royal 
Society  of  Medicine  on  Thursday,  July  17th, 
when  the  formal  foundation  was  inaugurated  of 
an  American  Hospital  in  London,  to  be  a rallying 
point  for  American  post-graduate  students  and  all 
members  of  the  medical  profession  in  America 
sojourning  on  our  side  of  the  Atlantic  ; to  be  the 
natural  shelter  for  American  citizens  in  our 
midst  and  needing  hospital  attention ; and  (to 
quote  the  words  of  the  main  resolution  epitomis- 
ing the  movement)  “ to  commemorate  the  coopera- 
tion of  the  medical  men  of  the  United  States 
and  of  Great  Britain  during  the  European  War 
and  tn  strengthen  the  friendship  existing  between 
the  two  nations.”  Lord  Reading,  who  presided  at 
a meeting  which  was  characterised  alike  by  the 
brevity  of  the  oratory  and  the  directness  of  the 
results,  said  happily  and  wittily  that  the  case  for 
the  foundation  of  an  American  hospital  in  London 
was  so  strong  that  had  he  been  sitting  “ in 
another  place  ” he  must  immediately  have  given 
judgment  in  favour  of  its  supporters.  And  this 
must  be  the  verdict  of  all  who  have  thought  over 
the  matter. 

The  foundation  of  the  American  Hospital  in 
London  has  been  largely  the  conception  of  Mr. 
Philip  Franklin,  an  American  citizen  some  years 
resident  in  England,  a Fellow  of  the  Royal  College 
of  Surgeons  of  England,  and  a member  of  the 
honorary  staff  of  many  institutions,  civil  and 
military.  To  his  energy,  prevision,  and  tact  the 
fact  is  owing  that  the  hospital  has  now  been  defi- 
nitely founded,  and  founded  with  the  remarkable 
promise  of  success  which  is  sufficiently  indicated 
by  the  names  pledged  to  support  it.  And  if  ever 
the  right  seed  was  sown  in  the  right  soil  at  the 
right  time  this  was  such  a fortunate  sowing. 
Mr.  Franklin  has  practically  found  no  critics  of 
his  idea  or  intention,  though  we  may  be  perfectly 
certain  that  he  came  across  many  whose  approval 
was  more  verbal  than  practical.  We  have  in  these 
columns  on  many  occasions  alluded  to  the  fact,  not 
so  difficult  of  explanation  as  it  may  appear,  that  the 
vast  city  of  London  has  not  hitherto  been  recog- 
nised as  a centre  for  post-graduate  medical 
teaching  by  foreigners,  while  until  recently  what 
post-graduate  teaching  there  has  been  has  been 
individual,  sporadic,  and  ill-organised.  Greater 
London,  with  a population  of  about  seven  millions 
and  an  area  of  seven  hundred  square  miles, 
containing  within  its  boundaries  all  sorts  and 
conditions  of  men  contracting,  or  liable  to  contract, 
every  pathological  condition  that  can  occur  in  an 
inclusive  index  of  disease,  has  never  been  sought 
out  by  foreigners,  and  not  even  by  our  blood 
relatives  who  speak  our  tongue,  the  Americans, 
as  a post-graduate  centre.  The  fault  has  been  our 
own,  and  is  only  partly  condoned  by  the  fact  that 
the  enormous  figures  concerned  have  rendered  any 
complete  system  of  inter-organisation  difficult.  Our 
wealth  of  material  has  never  until  now  properly 
been  centralised;  our  far-scattered  hospitals  have 
only  recently  begun  to  join  in  a unified  plan  of 


education  ; while  for  the  stranger,  and  even  lor 
the  American  guest,  there  has  been  as  yet  no 
centre  at  which  he  could  obtain  information  or 
get  into  some  human  relations  with  his  professional 
colleagues  in  this  country. 

The  American  Hospital  is  to  prove  itself  a visible 
sign  of  a complete  change  of  spirit.  As  is  well 
known,  there  is  in  London  now  a post-graduate 
scheme  in  connexion  with  the  Fellowship  of 
Medicine,  and  this  organisation,  started  on  emer- 
gency lines,  is  sure  to  develop  into  a permanent 
organisation.  The  American  Hospital,  over  and 
above  its  position  as  a general  hospital  ministering 
to  American  needs,  will  be  the  place  where  the 
American  doctor  will  turn  instinctively  when  he 
arrives  on  our  side  of  the  Atlantic  for  multifarious 
information  as  to  how,  having  such  and  such  time 
at  his  disposal,  and  such  and  such  money  to  spend, 
and  such  and  such  plans  for  the  completion  and 
development  of  his  medical  education,  he  should 
best  proceed.  The  information  given  him  will 
enable  him  to  make  full  use  of  such  post-graduate 
organisation  as  we  have,  while  his  presence  among 
us  will  spunis  on  to  see  that  that  organisation  is 
good  and  intending  to  be  better.  Then  will  London 
take  its  rightful  place  as  a great  post-graduate 
centre. 

♦ 

The  Study  of  Wound  Shock. 

The  fundamental  cause  of  wound  shock  still 
remains  obscure.  With  this  confession  of  ignorance 
Captain  N.  M.  Keith,  R.A.M.C.,  opens  a report 1 of 
the  special  investigation  committee  set  apart  by 
the  Medical  Research  Committee  to  inquire  into 
surgical  shock  and  its  allied  conditions.  And  he  goes 
on  to  say  that,  while  no  single  fetiological  factor- 
can  be  recognised  as  the  invariable  initial  cause, 
the  various  secondary  factors  which  obviously  con- 
tribute in  many  instances  towards  the  production 
of  the  finished  article  are  in  no  better  case,  as  when 
these  are  eliminated  by  early  preventive  treatment 
the  condition  of  shock  often  persists  nevertheless, 
and  the  patient  succumbs.  Keith’s  contribution  is 
to  make  quite  clear  that  reduction  of  total  blood  and 
plasma  volume  are  striking  and  important  features 
in  wound  shock ; that  after  moderate  luemorrhage 
without  shock  the  total  blood  volume  is  rapidly 
restored,  while  in  shock  itself  recovery  is  accom- 
panied by  restoration  of  blood  volume.  An 
important  indication  in  the  treatment  of  serious 
cases  of  wound  shock,  therefore,  is  to  increase  the 
amount  of  fluid  in  the  circulation,  which  can 
only  be  done  by  intravenous  infusion.  His  observa- 
tions help  to  diminish  the  complexity  of  the  patho- 
logical picture  of  shock  and  to  replace  the  vague 
assumption  of  nervous  influence  by  substantial 
knowledge  of  altered  blood  states  and  changed 
blood  volumes. 

When  Keith  began  his  work  at  a casualty  clear- 
ing station  in  the  spring  of  1918  our  conception 
of  the  pathology  of  wound  shock  was,  speaking 
broadly,  that  of  a condition  of  circulatory  failure 
with  low  blood  pressure  and  increased  permeability 
of  the  capillaries,  due  to  a combination  of  one  or 
more  of  the  factors  of  cold,  pain,  haemorrhage,  and 
toxaemia  at  work  in  an  exhausted. system.  Keith 
made  available  a new  series  of  data — namely,  the 
actual  records  of  blood  and  plasma  volumes.  The 
old  idea  of  the  pooling  of  blood  in  the  splanchnic 
area  had  already  been  abandoned  by  the  Betliune 

1 N.  M.  Keith  : Blood-Volume  Changes  in  Wound  Shock  and  Primary 
Haemorrhage.  Special  Report  Series  No.  27.  Medical  Research  Com- 
mittee. H.M.  Stationery  Office.  Price  9cl. 


160  The  Lancet,]  THE  NORTH-EASTERN  KAILWAY  STRIKE  AND  EYESIGHT  TESTS. 


[July  26,  1919 


group  of  investigators,  but  beyond  observations  on 
concentration  of  the  blood  no  new  facts  then 
emerged.  Keith  used  the  vital  red  method  of 
measuring  the  blood  volume  direct,  introduced  by 
him  in  1915  2 and  used  by  Robertson  and  Bock  in  a 
parallel  investigation;’  Since  vital  red  does  not 
yet  appear  in  the  physiology  text- books  it  may  be 
well  to  interpose  that  it  is  a dye  of  the  triphenyl- 
methane  series,  non-toxic  and  readily  sterilised. 
Ten  c.cm.  or  so  of  a 1‘5  per  cent,  solution  injected 
into  a vein  mixes  uniformly  with  the  circulating 
blood  within  five  minutes,  staining  the  plasma,  so 
that  a determination  of  the  tint  of  a withdrawn 
sample  enables  the  total  blood  volume  to  be  calcu 
lated.  On  these  simple  colorimetric  lines  the  dimin- 
ished blood  volume  in  soldiers  suffering  from 
wound  shock  was  found  to  bear  definite  relationship 
to  the  severity  of  the  patient’s  clinical  condition. 
In  the  29  cases  studied  the  estimated  blood  volume 
ranged  from  52  to  85  per  cent,  of  the  normal,  while 
the  plasma  was  correspondingly  reduced  to  62-90 
per  cent.  In  order  to  determine  the  part  played  by 
haemorrhage  in  the  deficiency  of  blood  in  the  cir- 
culation observations  were  made  on  donors  after 
supplying  blood  for  trarlsfusion.  Withdrawal  of 
quantities  up  to  800  c.cm.  was  followed  by  a rapid 
return  of  the  blood  volume  to  its  original  level. 
This  level  was  sometimes  reached  within  an  hour, 
and  occasionally  the  compensatory  process  persisted 
until  an  actual  increase  in  blood  volume  resulted. 
When,  however,  the  loss  of  blood  is  excessive,  or 
when  severe  trauma  is  present,  a shock-like  con- 
dition follows  which  is  distinguished  by  a failure  of 
the  normal  process  of  rapid  restoration.  Shock 
may  be  accompanied  by  a fall  in  the  circulating 
blood  volume  even  without  htemorrhage.  From  a 
clinical  study,  combined  with  blood-volume  obser- 
vations, cases  were  divided  into  three  groups : — 

Group  I. — The  less  severe  cases,  without  distressing 
symptoms,  with  a pulse-rate  of  90  110,  a systolic  blood 
pressure  above  95  mm.  Hg,  and  the  blood  volume  not  reduced 
below  75  per  cent,  of  the  normal. 

Group  II. — Into  this  class  fall  the  serious  cases,  where 
the  pulse-rate  is  120-140,  the  systolic  pressure  below 
90  mm.  Hg,  and  the  total  blood  volume  between  65  and 
75  per  cent,  of  the  normal. 

Group  III. — The  men  dangerously  ill,  with  imperceptible 
pulse,  a systolic  pressure  below  60  mm.  Hg,  a heart-rate  of 
120  160,  and  a blood  volume  below  65  per  cent,  (frequently 
50-60  per  cent.)  of  the  normal. 

In  this  third  group,  when  the  low  pressure  has 
continued  for  more  than  a brief  period,  recovery 
is  almost  impossible.  The  intracellular  oxygena- 
tion of  the  tissues,  including  the  sensitive  cortical 
nerve  cells,  has  been  interfered  with,  and  the 
damage  cannot  then  be  repaired  even  by  transfusing 
whole  blood.  But  Keith  reports  the  case  of  a 
soldier  who  had  sustained  an  extensive  com- 
minuted fracture  of  the  femur  without  external 
wound,  in  whom  blood  volume  was  reduced  to 
64  per  cent,  of  the  normal,  pulse-rate  120,  and 
maximum  blood  pressure  70  mm.  Hg,  but  in  whom, 
under  warmth  and  fluids  by  the  mouth,  the  pulse 
slowed,  blood  pressure  rose,  and  the  blood  volume 
increased  400  c.cm.  by  the  next  day. 

These  observations  should  be  read  in  conjunction 
with  Mr.  E.  M.  Rowell’s  instructive  Arris  and  Gale 
lecture  on  the  Initiation  of  Wound  Shock,  which  we 
print  in  our  current  issue.  Mr.  Cowell's  work  is 
based  upon  blood  pressure  observations  made  over 

- N.  M.  Keith,  1,.  G.  Rowntree,  and  J.  T.  Qeraghty,  Arch.  Int.  Med., 
Chicago,  October.  1915. 

3 O.  H.  Robertson  and  A.  V.  Bock  : Memorandum  on  Blood  Volume 
• after  Ha'mon  hage.  No.  6.  Reports  of  the  Special  Investigation  Com- 
mittee on  Surgical  Shock  and  Allied  Conditions. 


a period  of  three  years  at  various  points  in  the 
firing  line,  and  often  actually  in  the  front  trench. 
Some  of  these  observations  have  been  recorded  in 
an  early  report 4 of  the  special  investigation  com- 
mittee already  mentioned.  Criticism  has  been 
levelled  against  the  preponderance  in  this  report 
of  clinical  data  over  practical  deductions  for  treat- 
ment. But  Mr.  Cowell  very  rightly  points  out  that 
once  the  knowledge  of  wound  shock  is  brought  on  to 
a sound  clinical  and  pathological  basis  the  applica- 
tion of  therapeutic  principles  will  follow  as  a 
matter  of  course.  His  summary  of  recent  investi- 
gations focusses  very  convincingly  the  varied 
sources  of  new  knowledge  on  to  a screen  where 
their  practical  bearing  can  be  clearly  seen.  It 
is  now  established  that  in  cases  of  severe  wound 
shock  the  infusion  of  normal  or  even  hyper- 
tonic saline  has  but  a momentary  effect “ on  the 
circulation.  In  uncomplicated  cases,  too,  sodium 
bicarbonate  solution  gives  no  better  results.  Trans- 
fusion of  blood,  or  its  substitute  Bayliss’s  gum 
saline  solution,  gives  a more  lasting  rise  in  blood 
pressure,  since  the  added  fluid  remains  within 
the  vessels.  In  Keith’s  experience  the  results  of 
gum  and  blood  were  practically  identical,  and  the 
success  or  failure  of  either  depended  largely  upon 
whether  the  blood  volume  was  sufficiently  restored 
after  their  injection.  The  subcutaneous  route  for 
fluid  administration  is  useless,  because  of  the 
sluggish  peripheral  circulation  and  consequent 
slow  absorption.  The  futility  of  relying  on  any  of 
the  numerous  drugs  commonly  recommended  to 
raise  the  blood  pressure  is  emphasised  by  Mr. 
Cowell  and  will  readily  be  understood  in  the 
light  of  Keith’s  work.  These  are  important  and 
fruitful  deductions,  and  their  application  to  the 
surgical  shock  of  civilian  practice  should  not  tarry. 


The  North-Eastern  Railway  Strike 
and  Eyesight  Tests. 

Last  week  the  locomotive  men  and  the  firemen 
at  Carlisle  objected  to  the  eyesight  test  laid  down 
by  the  North-Eastern  Railway  Company,  and  came 
out  on  strike  as  a protest.  The  strike  that 
ensued  crippled  all  the  industries  on  the  North- 
East  coast,  the  price  of  all  food  has  risen,  and 
the  transport  of  passengers  has  been  restricted 
to  those  who  were  able  to  hire  motor-cars  or 
aeroplanes.  The  National  Union  of  Railwaymen 
negotiated  with  the  North-Eastern  Railway  Company, 
and  it  is  understood  that  they  were  united  on  one 
point — that  the  Board  of  Trade  should  speedily  set 
up  a national  eyesight  test.  The  strike  has  ended 
on  this  understanding.  Hitherto,  unfortunately, 
no  standard  of  vision  has  been  prescribed  for  the 
various  railway  employees ; it  rests  with  each 
company  to  make  and  enforce  such  regulations  as 
they  may  consider  necessary.  As  the  safety  of  the 
travelling  public  is  involved,  this  is  clearly  a 
matter  for  a Government  department  to  arrange. 
The  nature  of  the  tests  is  for  ophthalmic  experts 
to  decide,  after  being  given  every  facility  by  the 
railway  companies  to  learn  the  special  visual 
requirements  of  the  service.  It  is  necessary  to 
point  out  that  the  standard  vision  of  6 6 (or 
standard  form  sense)  is  by  no  means  always 
associated  with  a good  light  sense,  and  for  an 
engine-driver  it  is  absolutely  essential  that  he 
should  be  able  to  detect  the  signal  lights  readily 

4 E.  M.  Cowell  ■ Investigation  of  the  Nature  and  Treatment  of 
Wound  Shock  and  Allied  Conditions,  No.  2,  same  reports. 

5 J.  Fraser  and  E.  M.  Cowell  : No.  2 same  reports. 


The  Lancet,] 


THE  EMERGENCE  OF  THE  HEALTH  VISITOR. 


[July  26,  1919  161 


oil  a dark  night ; indeed,  this  is  much  more 
necessary  than  a standard  form  sense.  In  a good 
light  a candidate  may  pass  all  the  usual  tests  with 
Sujllen’s  types  and  the  colour  tests  with  Holmgren’s 
wools  easily,  but  he  might  fail  deplorably  if  the 
light  were  dim.  The  lantern  test  with  the  necessary 
coloured  glasses  seems  to  be  the  best  colour  test 
for  locomotive  men  and  for  sailors,  but  it  would 
appear  that  more  attention  should  be  devoted  to 
the  examination  of  light  sense. 

The  promise  of  the  President  of  the  Board  of 
Trade,  Sir  Auckland  Geddes,  that  a national 
eyesight  test  for  railwaymen  shall  be  established 
within  a month  comes  none  too  soon.  Indeed,  it 
is  regrettable  that  such  a test  was  not  established 
long  ago,  instead  of  leaving  a difficult  matter  to  be 
decided  separately  by  each  railway  company,  with 
the  result  of  the  dissatisfaction  recently  manifested 
on  the  North-Eastern  Railway.  In  the  case  of  the 
Mercantile  Marine,  in  which  similar  dissatisfaction 
used  to  exist,  a Departmental  Committee  was  set 
up  by  the  Board  of  Trade  in  1912  and  its  recom- 
mendations for  a national  test  were  adopted,  with 
results  that  are  said  to  be  satisfactory.  On  this 
committee  two  ophthalmologists  held  seats,  and  it 
is  essential  that  in  deciding  on  the  railway  tests 
also,  ophthalmologists  should  be  brought  into 
consultation.  One  of  the  most  important  tests 
is  that  for  colour  vision.  As  has  been  proved 
by  Dr.  F.  W.  Edridge-Green,  the  old  Holmgren 
wool  test  is  both  inefficient  and  dangerous  in  that 
.it  rejects  some  who  ought  to  be  passed,  while,  on 
the  other  hand,  a large  number  will  pass  it  easily 
whose  future  employment  is  dangerous.  The  wool 
test  has  now  been  replaced  by  most,  if  not  all,  of 
the  railway  companies  by  some  form  of  lantern 
test.  This  should  be  made  compulsory,  and  no 
lantern  should  be  used  which  has  not  means  for 
regulating  the  luminosity  of  the  lights  shown,  as 
otherwise  a man  who  cannot  distinguish  in  a fog 
between  a red  and  a green  light  might  be  passed. 
The  degree  of  visual  acuity  necessary  for  engine- 
drivers  and  firemen  is  a matter  that  certainly 
requires  a uniform  settlement.  On  one  railway  the 
present  standard  is  6/12  in  the  better  eye,  6/18  in 
the  worse,  without  glasses.  Is  6/12  good  enough  ? 
Is  not  6/18  an  unnecessarily  high  standard  for 
the  worse  eye  ? A man  with  6/6  vision  in  one 
eye  and  6 60  only  in  the  other  would  certainly 
have  better  vision  with  the  two  eyes  than  one 
with  6/12  and  6/18  respectively.  The  only  dis- 
advantage that  the  former  might  be  under  would 
be  the  possibility  of  getting  a spark  from  the 
engine  in  his  better  eye.  The  question  of  the 
employment  of  spectacles  should  be  answered,  and 
a rough  but  efficient  test  for  the  visual  fields 
should  be  established  to  exclude  any  with  such 
disease  as  retinitis  pigmentosa,  in  which  central 
vision  may  remain  good  till  a late  period. 

The  detection  of  tobacco  amblyopia  is  a matter 
of  very  great  importance  at  the  present  time,  when 
this  disease  is  more  prevalent  than  formerly.  No 
man  should  enter  the  railway  service  without 
being  told  the  facts  as  to  tobacco  blindness  and 
the  importance  of  taking  early  advice  in  case 
of  gradual  diminution  of  vision,  which  will 
often  save  him  from  the  necessity  of  having  to 
throw  up  his  job.  As  toxic  amblyopia  is  fairly 
frequent  even  in  those  who  smoke  with  modera- 
tion, and  as  its  characteristic  symptom  is  the 
early  onset  of  a macular  scotoma  for  green  and 
red,  it  would  seem  necessary  for  engine-drivers  and 
watchmen  to  be  tested  for  this  complaint  every  six 
months  or  so,  and  locomotive  firemen  at  least  every 


year.  When  recognised  early,  recovery  may  be 
almost  guaranteed  in  eight  or  ten  weeks,  if  the 
required  treatment  is  duly  carried  out. 

« 

The  Emergence  of  the  Health 
Visitor. 

Three  classes  of  women  have  come  to  be  very 
closely  associated  with  the  medical  practitioner  in 
his  work  as  indispensable  helpmates,  whether  on 
the  remedial  or  preventive  side.  In  order  of 
emergence  these  are,  of  course,  the  midwife — 
whose  history  goes  back  into  the  unknown  ; the 
nurse — whose  founder,  in  the  modern  sense  of 
the  title,  was  Florence  Nightingale  ; and  the 
health  visitor  — who  scarcely  existed  before 
the  London  County  Council  Act  of  1908.  The 
nurse’s  work  is  purely  remedial,  to  her  both 
patient  and  doctor  alike  turn  in  sickness ; but 
medicine  is  becoming  increasingly  preventive,  and 
unless  specially  trained  in  the  mechanism  of  health 
the  nurse  may  be  as  inadvertently  dangerous  to  the 
well  child  as  she  is  mercifully  helpful  to  the  sick 
one.  The  midwife’s  habitat  is  normal  physiological 
function,  and  the  Board  which  controls  her  strictly 
defines  the  variations  from  the  normal  which 
are  her  concern.  The  health  visitor  arose  for 
the  purpose  of  advising  on  the  proper  nurture, 
care,  and  management  of  young  children,  of 
promoting  cleanliness  as  the  basis  of  health,  and 
of  carrying  out  (in  the  words  of  the  Act  of  1908) 
such  other  analogous  duties  as  might  be  assigned  to 
her.  No  one  then  could  foresee  to  what  extent 
these  analogous  duties  might  grow'  in  ten  years’ 
time  or  be  expected  to  devise  in  advance  the 
training  best  suited  to  meet  them.  The  Local 
Government  Board  at  that  time  regarded  the  full 
nursing  certificate  or  the  diploma  of  the  Central 
Midwives  Board  as  satisfactory  evidence  of  qualifica- 
tion. Time  has  not  justified  this  claim,  and  the 
most  successful  health  visiting  is  now  found 
to  be  done  by  women  of  good  education  with  some 
previous  training  in  social  science.  To  define  and 
promote  the  best  type  of  training  for  the  health 
visitor  has  for  some  time  been  an  objective  of  the 
National  Association  for  the  Prevention  of  Infant 
Mortality,  and  the  scheme  for  training  just  issued 
as  Circular  4 (M.  and  C.W.  10)  by  the  Ministry  of 
Health  may  be  regarded  as  the  fruition  of  their 
labours.  At  the  same  time  appear  the  draft  regula- 
tions (Cmd.  255,  price  Id.)  of  the  Board  of  Educa- 
tion, laying  down  the  conditions  under  which  in 
future  grants  will  be  made  in  aid  of  health  visiting. 
Briefly,  a good  preliminary  education  and  a course 
of  two  years  will  be  required  of  candidates 
without  previous  special  training,  one  year 
to  be  devoted  to  theory  and  one  to  practice.  In 
the  case  of  fully  trained  nurses,  previous  health 
visitors,  or  those  holding  a university  degree  or  its 
equivalent,  one  year’s  training  may  be  remitted. 
A certificate  will  be  granted  after  examination, 
and  subsequent  to  a certain  date,  of  which  notice 
will  be  given,,  no  uncertificated  appointment  of 
health  visitor  may  be  made  by  any  local  authority. 
Further  details  will  be  found  in  the  documents  to 
which  a reference  has  been  given.  Restrictive  in 
form  only,  the  regulations  are  a charter  for  the 
approved  health  visitor  which,  by  protecting  her 
from  unqualified  competition,  will  afford  a much 
needed  stimulus  to  the  supply  of  the  better  class  of 
visitor.  The  Ministry  of  Health  was  bound  to 
protect  in  this  way  one  of  its  principal  agents  in 
health  work,  and  has  done  well  in  making  this 
reform  its  first  public  action. 


]62  The  Lancet,] 


BETTER  INSURANCE  PRACTICE. 


[July  26,  1919 


Annotations. 

“ Ne  quid  nlmlB.” 

BETTER  INSURANCE  PRACTICE. 

The  Special  Conference  of  Representatives  of 
Local  Medical  and  Panel  Committees,  convened  in 
London  on  July  17th  and  18th  by  the  Insurance 
Acts  Committee  of  the  British  Medical  Association, 
was  chiefly  concerned  with  the  conditions  of  service 
under  the  National  Health  Insurance  Acts  and  with 
possible  extensions  of  this  service.  Any  discussion 
of  the  rate  of  remuneration  of  the  panel  practi- 
tioner for  his  services  was  expressly  ruled  out,  the 
determining  of  the  proper  amount  of  the  capitation 
fee  per  insured  person  being  left  for  a future 
occasion.  The  basis  of  discussion  wTas  the  long 
and  closely  reasoned  report  of  112  paragraphs 
issued  by  the  Medical  Department  of  the  Associa- 
tion in  May  last  for  the  consideration  of  panel 
committees  and  individually  to  every  member  of 
the  medical  profession,  as  well  as  the  memorandum 
of  discussions  convened  by  the  Insurance  Com- 
missioners, to  which  allusion  was  made  in  a leading 
article  in  our  columns  on  June  14th.  A summary 
of  the  report  and  its  recommendations  appears  on 
p.169  of  the  present  issue.  Report  and  memorandum 
together  cover  the  whole  field  of  insurance  practice, 
and  it  speaks  volumes  for  the  foresight  and  dialectic 
skill  with  which  they  were  drawn  up  that  no  con- 
siderable principle  contained  in  them,  and  little 
even  of  detail,  were  overturned  by  a conference 
consisting  of  individuals  deeply  concerned  to  make 
the  best  of  both  the  present  and  the  future.  Accept- 
ance of  an  amendment  standing  in  the  name  of 
Stockport  opposing  the  limitation  of  individual 
panels  of  insured  persons  to  3000  was  the  nearest 
approach  to  an  adverse  vote.  This  amendment 
was  carried  by  a small  majority,  but  with  the 
proviso,  emanating  from  the  London  repre- 
sentatives, that  the  Panel  Committee  must  accept 
the  unpleasant  duty  of  adjudicating  the  efficiency 
of  any  practitioner  exceeding  this  limit  when  called 
upon  to  do  so  by  an  insurance  committee.  The 
conference  set  its  face  sternly  against  discourage- 
ment of  large  panels  by  any  lowering  of  the  capita- 
tion fee,  holding  that  such  a suggestion  of  reduction 
on  taking  a quantity  was  derogatory  to  the  respon- 
sible and  honourable  character  of  panel  practice. 
No  one,  however,  had  a word  of  condonation  for 
the  single-handed  practitioners  alleged  to  have 
more  than  6000  patients  on  their  lists.  Necessitated, 
possibly,  by  war  emergency  such  ill-directed 
ambition  can  hardly  long  survive  the  pressure  of 
public  opinion. 

The  question  of  the  precise  amount  of  the 
capitation  fee  being  thus  excluded,  discussion 
centred  round  the  provision  of  an  adequate  service 
under  conditions  agreeable  and  convenient  alike 
to  doctor  and  patient,  assuming  that — its  scope 
being  known — such  service  would  be  adequately 
remunerated  by  the  Ministry  of  Health.  In  his 
opening  address  Dr.  H.  B.  Brackenbury  cited  a few 
instances  in  which  panel  practice  had  recently  not 
shown  amenities  to  the  insured  person.  It  was 
difficult,  he  said,  for  the  panel  patient  to  obtain 
the  administration  of  an  anaesthetic  when  required 
for  a minor  operation,  in  certain  areas  he  might 
have  to  wait  in  a queue  to  obtain  advice  and  treat- 
ment at  all ; and  if  doubt  should  arise  as  to  his 
being  a panel  patient,  medical  assistance  might  be 


sought  unavailingly  in  case  of  serious  emergency. 
Panel  practitioners  are,  we  feel  sure,  as  anxious 
as  the  Government  and  the  public  to  obtain 
a medical  service  where  these  things  do  not 
occur.  On  the  practitioner’s  side  there  is  a 
widespread  feeling,  amounting  to  a sense  of 
soreness,  that  certain  special  services  which 
are  the  patient’s  right  under  the  Insurance 
Acts  are  nevertheless  outside  the  range  of 
general  practitioner  treatment,  and  should  not 
be  demanded  of  him  without  special  remunera- 
tion. Such  services  include,  for  instance,  the 
administration  of  general  anaesthetics,  attend- 
ance at  miscarriages,  and  possibly  the  treatment  of 
fractures  and  dislocations,  and  visits  paid  at  night. 
Existing  regulations  admit  of  these  services  being 
made  a prior  charge  on  the  local  medical  fund.  If 
this  fund  itself  is  sufficient — i.e.,  if  the  capitation 
fee  is  large  enough — it  is  clear  that  a first  charge  on 
the  general  fund  is  as  favourable  a form  of 
remuneration  for  special  services  as  a special  fund 
created  for  the  purpose.  No  one  contended  that 
Parliament  was  likely  to  sanction  an  unlimited 
fund  for  this  purpose,  but  the  Stockport  repre- 
sentative was  able  to  show  by  actual  figures  that 
the  amount  of  these  special  services  rendered  by 
practitioners  in  his  district  was  strictly  propor- 
tional to  the  special  remuneration  available,  and 
not  to  the  demand  for  such  services.  Abstention 
from  service  where  the  demands  are  demonstrably 
unreasonable — which  is  not  fairly  to  be  called 
shirking,  though  the  term  is  thus  applied — cannot 
be  regarded  as  an  inherent  sin  of  insurance 
practice ; and  the  view  expressed  in  the  report  of 
the  Insurance  Acts  Committee  finally  prevailed, 
although  by  a hairsbreadth.  Panel  practice,  it 
will  be  seen  by  this  report,  will  not  have  the 
additional  complication  of  special  pools  for  special 
purposes.  Thus  many  important  matters  seem  to 
have  been  settled,  bub  the  real  struggle  will  come 
with  the  fixing  of  the  new  capitation  fee. 


THE  CAIRO  SCHOOL  OF  MEDICINE. 

The  winter  session  of  the  School  of  Medicine  at 
Cairo,  under  the  Egyptian  Ministry  of  Education, 
begins  on  Oct.  4th,  and  it  is  the  intention  of  the 
Ministry  to  make  the  school  at  this  crisis  in  the 
development  of  Egypt  worthy  of  its  great  historical 
and  ethnological  position.  The  school  was  inspired 
originally  by  French  surgeons  of  the  time  of 
Napoleon,  and  has  occupied  its  present  site  since 
1837.  The  existing  hospital  of  600  beds  is  housed 
in  a building  entirely  inadequate  for  its  purpose, 
and  the  school  itself  has  to  refuse  two-thirds  of  its 
yearly  average  of  150  applicants,  but  the  enlarge- 
ment and  remodelling  of  both  are  under  con- 
templation by  the  Government  of  Egypt  in 
association  with  the  proposed  foundation  of  a 
University.  But  the  Egyptian  Educational 
Mission  is  not  willing  to  let  the  proper  develop- 
ment of  the  school  await  any  extensive  scheme 
of  rebuilding,  and  the  all-important  matter  of 
an  adequate  teaching  staff  is  being  handled  forth- 
with. Reference  to  our  advertisement  columns 
will  show  a number  of  vacant  posts  for  which  the 
combined  annual  pay  is  over  £10.000.  The  Egyptian 
students  have  been  out  on  strike  since  March  9th 
last,  and  there  is  a strong  feeling  amongst  them 
that  the  staff  should  be  recruited  from  men  of 
Egyptian  nationality  so  far  as  this  is  possible.  For 
the  present,  however,  there  are  no  Egyptians  with 
the  necessary  qualifications.  The  whole-time  pro- 


The  Lancet,] 


AN  AN'i HROPOMETRIC  SIR  Ef. 


[July  26,  1919  163 


fessorship  of  surgery  is  an  innovation  and  designed 
to  attract  someone  wlio  is  keen  on  teaching  and 
research.  The  professor  of  pharmacology  will 
have  hospital  beds  at  his  disposal  and  a free  field 
for  research  in  the  treatment  of  Egyptian  diseases, 
and  occupants  of  these  chairs  will  presumably 
become  professors  in  the  faculty  of  medicine  when 
the  University  takes  shape.  The  lecturer  on 
pathology  will  have  a specially  attractive  field  of 
work  open  to  him,  for  many  pathological  problems 
still  await  solution  in  Egypt.  The  lectureships  are 
designed  to  encourage  research  among  Egyptians, 
some  of  whom  are  already  being  trained  in  England. 
But  we  are  informed  that  none  of  the  appointments 
are  earmarked  for  any  local  or  other  candidate. 
The  selection  will  be  made,  in  the  first  instance,  by 
small  expert  boards  in  England,  the  final  selec- 
tion taking  place  in  Egypt  on  the  recommendations 
of  these  boards.  We  wish  every  success  to  this 
practical  effort  for  placing  medicine  on  a substantial 
foundation  in  Cairo. 


THE  AFTER-HISTORY  OF  WAR  NEPHRITIS. 

Merklen  and  Desclaux1  examined  26  men  who  had 
been  temporarily  discharged  from  the  Army  for 
chronic  nephritis  one  year  previously,  and  sum- 
marised their  observations  as  follows : 1.  Six  men 
had  no  albuminuria  nor  any  signs  of  renal  or 
cardiac  disturbance.  There  was  no  rise  of  blood 
pressure,  and  the  heart  was  of  normal  size  on 
radioscopic  examination.  They  might  therefore  be 
regarded  provisionally  as  cured.  2.  Three  men 
showed  cardio  vascular  symptoms  only,  such  as  an 
increase  in  size  of  the  left  ventricle,  accentuation 
of  the  second  aortic  sound,  a high  blood  pressure, 
and  palpitation.  3.  Seventeen  cases,  or  two-thirds 
of  the  total,  showed  various  symptoms  of  chronic 
nephritis,  and  albuminuria  was  present  in  every 
case.  Though  it  is  impossible  to  form  a general 
prognosis  in  nephritis  owing  to  the  variable 
character  of  the  affection,  the  writers  feel  justified 
in  concluding  that  at  the  end  of  a year  the  majority 
of  men  who  have  been  discharged  from  the  Army 
for  nephritis  will  still  present  symptoms  of  the 
condition.  

AN  ANTHROPOMETRIC  SURVEY. 

The  data  obtained  by  the  late  Ministry  of 
National  Service  when  examining  recruits  in  regard 
to  their  fitness  for  a soldier’s  life  are  in  the 
possession  of  the  Minister  of  Pensions  and,  in  reply 
to  a deputation  from  the  British  Association, 
Colonel  A.  L.  A.  Webb,  Director  of  Medical 
Services,  stated  on  July  18th  that  the  various 
regional  reports  had  been  arranged  and  would 
shortly  be  ready  for  publication.  Measurements, 
such  as  height,  body-weight,  and  chest  perimeter, 
in  relation  to  age  and  occupation,  have  great 
objective  value,  while  other  data  are  more  or  less 
vitiated  by  the  personal  equation  of  the  recorder. 
Many  attempts  have  been  made  to  obtain  simple 
criteria  of  working  ability.  As  long  ago  as  1846 
Mr.  John  Hutchinson  read  before  the  Royal 
Medical  and  Chirurgical  Society  a paper,  fully 
reported  in  our  columns  at  the  time,  dealing  with  a 
method  of  detection  of  disease  by  the  spirometer. 
This  engine  long  fell  out  of  repute,  but  recently  a 
definite  minimum  standard  of  vital  capacity  was 
set  up  as  a condition  of  admission  to  the  Air  Force, 
and  Professor  Georges  Dreyer  laid  stress  upon  this 
measurement  in  a paper  read  before  an  Inter-Allied 
Sanitary  Congress  of  Aeronautics  held  at  Rome  in 
February  last.  A single  observation  of  certain 

1 Bull,  et  Mem.  Soc.  Med.  de  H6p.  de  Paris,  1919,  xliii.,  434-7. 


anatomical  and  physiological  data,  carefully  made 
and  recorded,  may  have  value  when  dealing  with 
the  population  as  a whole,  but  how  much  greater 
would  be  the  value  of  continuous  exact  records, 
such  as  are  now  within  the  grasp  of  the  Ministry 
of  Health.  The  policy  of  the  Insurance  Com- 
missioners has  been  to  demand  from  its  medical 
staff  a number  of  entries  so  vast  as  to  alienate  most 
panel  practitioners  for  all  time  from  statistical 
method.  These  entries  are  recalled  at  the  end 
of  each  year,  thus  rendering  them  unavailable 
for  further  reference.  A tithe  of  this  labour- 
spent  on  a continuous  record  card  would  have 
produced  results  far  exceeding  in  value  those  of  the 
National  Service  inquiry.  The  panel  conference, 
which  we  deal  with  elsewhere,  had  something  of 
this  possibility  laid  before  it  last  week. 


THE  CEREBRAL  COMPLICATIONS  OF  MUMPS. 

Though  a typically  harmless  disease,  mumps 
may  rarely  be  attended  by  serious  and  even  fatal 
complications.  In  the  Index  Catalogue  of  the 
Surgeon-General’s  Library  six  deaths  from  mumps 
are  recorded.  Death  is  probably  always  due  to 
cerebral  complications.  About  150  cases  of  cerebral 
complications  have  been  reported.  In  the  Archives 
of  Internal  Medicine  for  June  Lieutenant  R.  L. 
Haden.  U.S.  Army,  has  published  nine  cases  which 
were  observed  at  Camp  Lee,  Va.,  U.S. A.,  among  476 
cases  of  mumps,  and  he  has  reviewed  the  literature 
of  the  subject.  The  nature  of  the  cerebral  com- 
plications has  been  much  discussed.  Before  the 
advent  of  lumbar  puncture  it  was  considered  as 
meningismus,  but  with  demonstration  of  pleocytosis 
of  the  spinal  fluid  it  was  looked  on  as  meningitis. 
In  simple  mumps,  according  to  Dopter,  the  cerebro- 
spinal fluid  is  normal.  Many  things  point  to  the 
conclusion  that  the  lesion  is  an  encephalitis  and 
not  simply  a meningitis.  In  most  cases  the  cerebral 
symptoms  are  out  of  all  proportion  to  the  meningeal 
reaction,  as  shown  by  the  condition  of  the  cerebro- 
spinal fluid.  The  common  symptoms  are  high 
fever,  headache,  nausea,  and  vomiting.  Usually 
there  is  only  slight  rigidity  of  the  neck  and  Kernig’s 
sign  is  not  well  marked.  Numerous  cases  of  involve- 
ment of  the  cerebrum  alone  are  on  record.  In 
these  there  are  no  definite  meningeal  signs,  and 
the  cerebrospinal  fluid  is  normal.  Among  the 
symptoms  observed  in  31  cases  reported  by  Acker 
were  unilateral  convulsions,  monoplegia, hemiplegia, 
aphasia,  disturbances  of  speech,  psychoses,  dis- 
turbances of  sensation,  and  stupor  These  point  to 
affection  of  the  brain  substance.  Other  symptoms, 
such  as  bradycardia,  headache,  vomiting,  and  optic 
neuritis  are  probably  due  to  intracranial  pressure. 
The  few  necropsies  recorded  have  shown  congestion 
of  the  brain  with  only  serous  meningitis.  In  the 
nine  cases  reported  by  Lieutenant  Haden  the 
symptom- complex  was  fairly  uniform.  Usually  as 
the  parotitis  was  subsiding  the  temperature  rose, 
with  little  change  in  the  pulse-rate,  severe  head- 
ache, nausea,  and  vomiting.  Often  the  patient  had 
orchitis.  On  examination  he  was  dull,  answered 
questions  slowly,  showed  slight  stiffness  of  the 
neck,  a suggestion  of  Kernig’s  sign,  and  variable 
reflexes.  Lumbar  puncture  yielded  clear  fluid 
under  increased  pressure  with  lymphocytoses.  In 
a few  cases  increased  pressure  was  the  only 
abnormality.  Smears  and  cultures  were  made 
from  the  fluid  in  all  cases,  but  in  only  one  were 
organisms  (Gram-positive  cocci)  found.  Such  cocci 
have  been  described  by  several  observers  as  the 
organisms  causing  the  disease,  although  a filterable 


164  The  Lancet,] 


A FLOATING  SCHOOL  OF  TROPICAL  MEDICINE. 


[July  26,  1919 


virus  has  also  been  suggested.  The  fluid  in  this 
case  was  turbid.  Lumbar  puncture  proved  effectual 
therapeutically.  The  temperature  usually  fell 
quickly  to  normal  and  the  headache  was  relieved. 
The  following  case  may  be  taken  as  typical. 
A wagoner,  aged  21  years,  was  admitted  to  hospital 
on  Feb.  3rd,  1919,  complaining  of  headache,  swelling 
of  the  neck,  and  occasional  nausea.  Three  weeks 
ago  he  first  noticed  the  swelling.  On  admission  the 
right  submaxillary  glands  were  swollen,  the  tem- 
perature and  pulse  were  normal.  On  Feb.  5th  the 
left  parotid  became  swollen,  and  on  the  9th  bilateral 
orchitis  was  noted.  On  the  10th  the  patient  became 
very  dull  and  suffered  from  headache  and  vomiting. 
The  temperature  was  105°  F.  and  pulse  180.  On  the 
11th  he  was  very  drowsy  and  still  vomiting,  There 
was  definite  stiffness  of  the  neck.  The  knee-jerks 
were  not  obtainable.  Ivernig’s  sign  was  positive 
and  Babinski’s  negative.  Lumbar  puncture  yielded 
clear  fluid  under  increased  pressure,  and  the 
patient’s  condition  immediately  improved.  On  the 
13th  the  pulse  was  only  48  and  the  temperature 
subnormal.  He  said  that  he  could  not  see  well, 
and  during  the  night  became  delirious.  On  the 
14th  he  was  stuporous  with  the  head  retracted ; 
the  pupils  teacted  sluggishly.  The  temperature 
was  97°  and  pulse  44.  The  deep  reflexes  could  not 
be  elicited.  Next  day  he  was  much,  improved. 
Rapid  recovery  followed.  The  following  were  the 
laboratory  findings : Feb.  12th,  leucocyte  count, 
6200.  Differential  count  : small  mononuclears, 
48  per  cent.  ; large  mononuclears,  6 per  cent. ; 
eosinophils,  5 percent.;  polymorphonuclears, 41  per 
cent.  Feb.  11th,  cerebro  spinal  fluid  contained 
10  cells  per  c.mm.,  all  mononuclears.  Feb.  14th, 
the  fluid  contained  only  5 cells  per  c.mm.  Sugar 
was  present  on  both  occasions. 


A FLOATING  SCHOOL  OF  TROPICAL  MEDICINE. 

To  most  of  us  the  stimulus  of  encouragement 
and  criticism  is  necessary  to  bring  forth  our 
best,  and  the  foregathering  of  workers  on  kindred 
subjects  at  the  regular  meetings  of  learned  societies 
has  often  acted  like  the  piece  of  leaven  in  the 
amorphous  dough  or,  as  we  should  now  say,  as  a 
catalyst  in  a mass  reaction.  This  stimulus  has 
been  wanting  to  most  workers  in  tropical  medicine, 
cut  off  for  months  or  years  from  their  friends  and 
critics,  and,  in  addition,  borne  down  by  conditions  of 
great  bodily  discomfort.  Small  wonder  that  under 
these  circumstances  the  best  work  has  not  always 
been  done,  although  the  history  of  tropical 
medicine  is  punctuated  with  individual  brilliant 
successes.  Nine  years  ago,  in  a letter  to  our  own 
columns,1  Dr.  Andrew  Balfour,  struck  with  the 
usefulness  of  the  Wellcome  floating  laboratory  on 
the  Nile,  suggested  the  extension  of  the  marine 
floating  laboratory  for  the  purpose  of  visiting  any 
desired  portion  of  the  globe  and  bringifig  back  a store 
of  material  for  museum  and  teaching  purposes.  By 
such  a perpetual  Challenger  expedition  diseases 
could  be  studied  on  the  spot,  parasites  observed  in 
a living  state,  and  tutorial  classes  given  to  suc- 
cessive crews  of  students  desirous  of  obtaining  a 
nearer  insight  into  the  fascinating  problems  of 
disease  and  its  prevention  in  hot  countries.  Dr. 
Balfour’s  suggestion  passed  unheeded,  and  it 
remained  for  Dr.  Louis  Sambon,  in  a lecture 
delivered  before  the  Royal  Society  of  Medicine 
on  June  14th  last,  by  arrangement  with  the 

1 The  Lancet,  1910,  ii„  55. 


West  India  Committee,  to  develop  the,  theme  of 
bringing  students  periodically  into  the  tropics 
by  means  of  a floating  school.  The  islands  of  the 
Lesser  Antilles,  which  he  had  recently  visited,  were 
ravaged  each  by  its  particular  breed  of  epidemic,  and 
nothing  would  coordinate  the  isolated  efforts  of 
medical  officers  on  these  lonely  isles  so  thoroughly 
as  a regular  circulation  of  expert  advice  and  help. 
He  advocated  a development  on  international  lines, 
having  already  received  encouragement  from  the 
French  and  Italian  Governments.  The  idea  thus 
timely  set  forth  was  not  allowed  to  drop  and  came 
up  for  discussion  at  a private  meeting  held  under 
the  chairmanship  of  Sir  Humphry  Rolleston  on 
Thursday,  July  10th,  at  the  same  place.  Here 
Dr.  Balfour  set  out  the  views  summarised  above, 
adding  the  further  claim  of  a floating  laboratory  as 
a link  between  the  Dominions  and  the  Mother 
Country.  Sir  David  Bruce  and  Dr.  G.  C.  Low, 
among  others,  doubted  the  feasibility  of  the  float- 
ing school  as  a substantial  agent  of  research,  the 
latter  pointing  out  that  sleeping  sickness  and  kala- 
azar  at  all  events  could  not  be  studied  on  the  littoral. 
The  extended  establishment  of  local  shore  labora- 
tories appealed  to  the  majority  of  those  present  for 
thepurposeof  actual  research  work,  neithernostalgia 
nor  rolling  and  pitching  apparatus  being  specially 
conducive  to  the  desirable  mental  detachment.  Sir 
Thomas  Horder  voiced  the  general  consensus  in 
finding  the  floating  school  an  attractive  idea  for 
teaching  purposes,  adding  that  finance  should  not 
be  an  impediment  if  the  ruling  authorities  were 
satisfied  of  the  practicable  character  of  the  pro- 
posal. A committee  was  appointed,  with  Dr.  Balfour 
as  chairman,  and  Dr.  Low,  Dr.  R.  T.  Leiper,  and 
Dr.  Sambon  as  secretaries,  to  inquire  into  the 
question  in  all  its  aspects.  We  are  inclined  to 
agree  with  Dr.  Balfour,  who  has  from  first  to  last 
been  the  moving  spirit  in  the  proposal,  that  the 
cost  of  such  a floating  school  might  reasonably  be 
regarded  by  Parliament  and  public  in  the  same 
light  as  polar  expeditions.  The  adventures  and 
prizes  are  much  the  same,  the  gain,  indeed,  pre- 
sumably much  greater : the  difference  consists 
chiefly  in  the  substitution  of  pith  helmets  and 
mosquito  nets  for  fur  caps  and  mocassins.  Within 
a generation,  if  ankylostomiasis  and  pellagra  are 
not  then  extinct,  we  doubt  not  that  the  floating 
school  will  be  a routine  method  of  education  and 
preventive  study.  

CRIME  AND  RESPONSIBILITY. 

That  “ insanity  is  not  an  absolute  defence,”  and 
that  what  is  called  the  defence  of  insanity  to  the 
charge  of  murder  requires,  for  success,  not  merely 
the  proof  of  insanity,  but  that  of  insanity  of  such  a 
nature  as  to  carry  with  it  irresponsibility  to  the 
law,  is  clearly  shown  by  Section  2 (1)  of  the  Trial  of 
Lunatics  Act,  1883,  in  which  the  following  form  of 
words  is  employed : “ insane  .so  as  not  to  be 

responsible  according  to  laic  for  his  actions  at  the 
time  the  act  was  done.”  Formerly,  many  judges 
refused  in  court  to  allow,  when  in  murder  cases 
the  “ defence  of  insanity  ” was  raised,  evidence  to  be 
given  by  experts  as  to  the  existence  of  insanity  in 
the  broad,  or  medical,  sense ; but  nowadays  prac- 
tically every  judge  allows,  as  did  Sir  Charles  Darling 
in  the  recent  case  of  Perry,  testimony  of  such 
nature  to  be  given  before  attention  is  directed  to 
the  more  stringent  issue  of  legal  responsibility.  It 
is  generally  by  the  application  of  the  M'Naughton 
Rules  that  this  question  of  responsibility  is 
decided,  but  there  are  not  wanting  judges  who 


The  Lancet,] 


TUB  SUPPLY  OF  DRUGS  DURING  THE  WAR. 


[July  26,  1919  165 


will  direct,  in  accordance  with  the  view  of  the 
late  Sir  James  Stephen,  that  responsibility  may  be 
abrogated  by  loss  of  control,  if  arising  from  mental 
disease  or  infirmity,  and  not  from  the  accused 
person’s  own  conduct.  Such  elasticity  is  permissible 
in  practice  because,  after  all,  the  M'Naughton 
Rules  are  not  part  of  the  statute  law  which  is 
applicable  to  civilians.  In  respect  of  military  law 
it  is  otherwise.  Reference  to  the  “ Manual  of 
- Military  Law  ” (chap,  vii.,  par.  9)  will  satisfy  those 
to  whom  the  point  is  unfamiliar  that,  in  the  case  of 
a member  of  His  Majesty’s  Army  under  trial  by  court- 
martial,  the  question  of  responsibility,  if  a defence 
of  insanity  be  raised,  can  only  be  resolved  by  a rigid 
and  undeviating  application  of  the  M'Naughton 
Rules.  The  effect  of  this  is  that  when,  either  in  the 
course  of  trial  or  afterwards,  medical  testimony  is 
adduced,  or  a Medical  Board  is  constituted  to  inquire 
into,  as  is  said,  the  state  of  mind  of  the  accused,  the 
medical  witnesses  are  required  to  testify,  or  the 
Board  to  direct  inquiries,  not  to  the  general  ques- 
tion of  the  accused’s  sanity  or  insanity  at  the  time 
of  inquiry  or  anteriorly,  but  to  the  specific  ques- 
tions implied  in  the  Rules.  All  other  considerations 
are  irrelevant ; the  problem  is  simply  whether  or  no 
it  can  be  said,  at  a certain  date,  that  a certain  person 
was,  at  an  anterior  date,  in  such  a state  of  mind 
that  he  did  not  know  the  nature  and  quality  of  his 
act  or  that  what  he  was  doing  was  wrong.  There  is 
no  room  for  elasticity  of  interpretation ; and  the 
question  of  impulsion,  or  lack  of  control,  cannot  be 
raised.  That  this  is  a perfectly  fair  representation 
of  the  procedure  in  vogue  is  known  at  any  rate  to 
some  of  those  who  have  lately  served  overseas  ; and 
official  confirmation  is  afforded  by  the  answer  given 
by  Mr.  Macpherson,  in  the  House  of  Commons  on 
April  11th,  1918,  to  a question  put  to  him  some  time 
previously  by  Sir  William  Job  Collins.1  No  great 
effort  is  required,  then,  to  realise  how  readily  the 
specific  instructions  addressed  to  a Medical  Board 
may  determine  the  infliction  of  the  last  penalty 
upon  an  officer  or  man  who,  under  the  influence  of 
temporary  mental  disorganisation  produced  by 
physical  agencies,  commits  the  supreme  military 
offence  of  “desertion  in  the  face  of  the  enemy,”  or 
of  apparent  cowardice.  The  military  necessity  for 
such  stringency  is  not  a matter  on  which  we 
express  any  opinion  ; but  the  facts  are  as 
stated.  The  ultimate  consequence  to  Perry,  alias 
Beckett,  of  his  acts  has  been  his  execution  ; but  he 
enjoyed  more  generous  opportunity  under  the 
English  common  law  than  would  have  been  his 
had  he  left  a post  of  military  duty  under  that  kind 
of  mental  compulsion  best  known  to  those  who 
have  experienced — or  feared  it. 


THE  SUPPLY  OF  DRUGS  DURING  THE  WAR. 

A very  interesting  Memorandum  was  issued 
from  His  Majesty’s  Stationery  Office  this  week 
(Cmd.  183)  on  the  special  measures  taken  by  the 
National  Health  Insurance  Commission  (England) 
in  relation  to  the  supply  of  drugs  and  other 
medical  stores  during  the  war.  It  shows  how  the 
critical  position  in  regard  to  the  supply  of  drugs 
created  by  the  sudden  and  unexpected  outbreak 
of  war  was  dealt  with.  Immediate  steps  had 
to  be  taken  to  conserve  existing  stocks  and 
to  encourage  the  production  in  this  country 
of  drugs  for  the  supply  of  which  we  had 
hitherto  been  wholly  or  mainly  dependent  upon 

1 The  Lancet,  1918,  i.,  587. 


enemy  countries.  Conspicuous  service  was  rendered 
by  the  Royal  Society,  while  the  energy  and  enterprise 
shown  by  the  chemical  manufacturers  ol  the  country 
will  lead  to  permanent  results  of  the  utmost  im- 
portance to  the  medical  needs  of  the  community. 
The  requirements  of  the  Forces  and  of  the  civil 
population  wore  met  after  a little  inevitable  shortage 
experienced  at  the  beginning.  The  Chairman  of 
the  Committee,  Mr.  Waldorf  Astor,  concludes  his 
prefatory  note  by  saying  that  the  fine  chemical 
industry  has  been  very  greatly  developed  and 
extended,  and  that  this  country  is  now  capable  of 
manufacturing  on  a large  scale  all  the  important 
medicinal  chemicals  which  before  the  war  were 
practically  a German  monopoly.  Thus  ground  has 
been  regained  which  should,  in  point  of  fact,  never 
have  been  lost.  The  Memorandum,  opportunely 
enough,  provides  a key  to  many  of  the  scientific 
products  now  being  exhibited  by  the  British  Science 
Guild  at  the  Central  Hall,  Westminster. 


HUGH  OWEN  THOMAS. 

The  Medical  Institution  of  Liverpool  have 
organised  a scheme  for  the  perpetuation  of  the 
memory  of  Hugh  Owen  Thomas,  a pioneer  worker 
in  orthopaedic  surgery.  Hugh  Owen  Thomas  was 
born  in  1834  and  studied  medicine  at  Edinburgh  in 
the  days  of  Goodsir,  Syme,  Spence,  and  Simpson, 
with  Turner  as  demonstrator  of  anatomy.  Later 
he  entered  University  College,  London,  and  qualified 
as  a Member  of  the  Royal  College  of  Surgeons  of 
England  in  1857.  On  returning  to  Liverpool  he 
took  up  surgical  work  in  connexion  with  workmen’s 
societies  and  at  the  docks,  his  practice  being  almost 
entirely  concerned  with  accidents,  deformities,  and 
joint  diseases.  He  instituted  a free  clinic  at  his 
surgery  on  Sundays — a recognised  practice  before 
the  establishment  of  out-patient  departments  at 
the  hospitals — and  devised  and  made  his  own  splints, 
employing  a blacksmith  and  various  artisans  in  their 
construction.  Later  he  himself  became  an  expert 
metal-worker,  laying  great  stress  on  the  careful 
fitting  of  all  splints  and  their  correction  from  time 
to  time  under  his  own  supervision.  In  1871  he 
described  an  ingenious  method  of  wiring  fractures 
of  the  lower  jaw,  and  soon  afterwards  published 
an  important  work  on  the  treatment  of  the  diseases 
of  the  hip,  knee,  and  ankle  joints.  The  appliances 
which  he  invented  have  not  been  improved  upon 
in  principle,  and  in  joint  diseases  his  splints  enable 
sufferers  to  enjoy  fresh  air  and  exercise,  as  they 
did  upon  their  invention  half  a century  ago.  He 
was  without  doubt  one  of  the  founders  of  modern 
orthopaedic  surgery,  and  the  appeal  for  funds  to 
endow  a worthy  memorial  to  his  work  in  the  city 
where  his  whole  life  was  spent  should  certainly 
meet  with  a generous  response.  Subscriptions 
should  be  sent  to  Major  C.  Thurstan  Holland,  at 
the  Medical  Institution  of  Liverpool,  and  crossed 
“Hugh  Owen  Thomas  Memorial.” 


The  House  and  Library  of  the  Royal  Society  of 
Medicine  will  be  closed  during  the  whole  of  August  for 
repairs  and  cleaning. 

A dinner  will  be  held  in  London,  at  a date  to 
be  arranged,  for  all  R.A.M.C.  (T.F.)  officers  ; will  those  who 
are  interested  and  would  be  likely  to  attend  kindly  com- 
municate with  Lieutenant-Colonel  A.  R.  Henchley,  D.S.O., 
R.A.M.C.  (T.F.),  care  of  Holt  and  Co.,  44,  Charing  Cross.  It 
would  facilitate  matters  if  London  officers  would  say 
wh  ther  they  would  kindly  serve  on  the  committee. 


166  The  Lancet,] 


THE  AMERICAN  HOSPITAL  FOR  GREAT  BRITAIN. 


[July  26,  1919 


THE  AMERICAN  HOSPITAL  FOR  GREAT 
BRITAIN. 


The  American  Hospital  for  Great  Britain,  to  which 
allusion  has  been  made  frequently  in  our  columns,  was 
formally  founded  on  Thursday,  July  17th,  at  a meeting  at  the 
House  of  the  Royal  Society  of  Medicine. 

Lord  Reading,  the  Lord  Chief  Justice  of  England,  pre- 
sided over  the  meeting  of  supporters  of  the  hospital,  and  in 
a brief  but  happily  worded  speech  laid  stress  on  the  coopera- 
tion that  had  existed  between  Americans  and  British 
during  the  later  stages  of  the  war.  He  pointed  out  that  from 
the  very  beginning  of  the  war  a certain  number  of  American 
medical  men  had  worked  in  British  hospitals,  and  that  out  of 
the  cordial  relations  thus  established  had  arisen  the  idea 
that  there  should  be  founded  an  American  hospital  in 
London  both  for  the  reception  of  sick  Americans,  and  to  act 
as  a centre  for  post-graduate  work  in  London  among 
Americans  who  hitherto  have  pursued  such  studies  mainly 
in  Berlin  or  Vienna. 

Mr.  Philip  Franklin,  who  has  been  a moving  spirit  in 
the  foundation  of  the  American  Hospital  for  Great  Britain, 
then  made  a statement  in  which  he  pointed  out  the  need  for 
an  American  Hospital  in  London,  which  the  American 
medical  man  could  make  his  headquarters  when  engaged  in 
organised  post-graduate  work. 

In  the  absence  of  the  American  Ambassador,  Mr.  Newton 
Crane  moved,  and  Sir  W.  Arbuthnot  Lane  seconded,  the 
following  resolution  : — - 

“That,  in  commemoration  of  the  cooperation  of  the 
medical  men  of  the  United  States  and  of  Great  Britain 
during  the  European  War,  and  to  strengthen  the  friendship 
existing  between  the  two  nations,  the  American  Hospital  for 
Great  Britain  be,  and  is  hereby,  founded  for  the  medical 
and  surgical  treatment  of  patients  of  all  classes,  irrespective 
of  creed  or  nationality,  and  for  the  promotion  of  scientific 
study  and  research.” 

Sir  Humphry  Rolleston,  President  of  the  Royal  Society 
of  Medicine,  then  moved  a resolution  that  a governing  body 
should  be  constituted.  Sir  John  BlandSutton  seconded 
and  paid  an  eloquent  tribute  to  the  value  of  the  work  done 
by  lay  boards  in  administration  hospitals. 

The  following  were  constituted  the  original  members  of 
the  council 


His  Excellency  the  American 
Ambassador. 

Mr.  Walter  Blackman. 

,,  George  M.  Cassatt. 

,,  R.  Newton  Crane. 

,,  Wilson  Cross. 

,,  James  E.  Dunning. 

,,  J.  Grant  Forbes. 

,,  Philip  Franklin. 

,,  Clarence  Graff. 


Mr.  Robert  Grant,  jun. 

,,  James  Benson  Kennedy. 
,,  J.  Blair  MacAfee. 

,,  George  A.  Mower. 

,,  Francis  E.  Powell. 

,,  H.  Gordon  Selfridge. 

,,  Henry  E.  Stoner. 

,,  Lawrence  L.  Tweedy. 

,,  F.  C.  Van  Duzer. 

,,  E.  Bradner  White. 

,,  Robert  Skinner. 


Mr.  F.  E.  Powell  moved,  and  Mr.  Walter  Blackman 
seconded,  a resolution,  which  was  unanimously  adopted, 
constituting  the  Medical  Committees  in  Great  Britain  and 
in  the  United  States,  the  following  being  the  selected 
personnel  : — 


Of  the  Medical  Committee  in  Great  Britain : 

Sir  William  Osier,  Regius  Professor  of  Medicine,  University 
of  Oxford. 

Sir  W.  Arbuthnot  Lane. 

Sir  Humphry  Rolleston,  President  of  the  Royal  Society  of 
Medicine. 

Sir  John  Bland  Sutton,  Vice-President  of  the  Royal  College 
of  Surgeons  of  England. 

Mr.  I.  S.  W.  MacAlister,  Secretary  of  the  Royal  Society  of 
Medicine. 

Mr.  Philip  Franklin,  Joint  Honorary  Secretary  of  the 
Fellowship  of  Medicine. 

With  power  to  add  to  their  number. 


Of  the  Medical  Committee  in  the  United  States: 

Dr.  George  W.  Crile,  of  Cleveland,  nominated  by  the 
American  Academv  of  Science  on  International  Relations. 
Dr.  W.  J.  Mayo,  of  Rochester,  Minnesota. 

Dr.  Charles  H.  Mayo,  of  Rochester,  Minnesota. 

Dr.  Albert  J.  Ochsner,  of  Chicago. 

Dr.  Rudolph  Matas,  of  New  Orleans. 

Dr.  Franklin  Martin,  of  Chicago,  nominated  by  the 
American  Gynecological  Association. 

With  power  to'  add  to  their  number. 


Mr.  Philip  Franklin  was  then  unanimously  appointed 
honorary  secretary  to  the  hospital,  while  it  was  left  in  the 
hands  of  a small  subcommittee  to  invite  the  support  of 
certain  vice-presidents.  The  committee  also  decided  to 
appoint  legal,  financial,  and  appeal  committees.  The  meeting 
terminated  with  a cordial  vote  of  thanks  to  the  Royal 
Society  of  Medicine  for  its  hospitality  and  assistance  to  the 
movement. 

In  replying,  Sir  Humphry  Rolleston  wisely  took  the 
opportunity  of  pointing  out  that  this  movement  was  in  no 
sense  in  rivalry  to  the  existing  post-graduate  work  in 
London,  but  would  prove  a source  of  support  and  inspiration 
of  such  efforts. 


THE  MINISTRY  OF  HEALTH: 

ORGANISATION  OF  MEDICAL  STAFF. 


ON  the  establishment  of  the  Ministry  of  Health  the 
medical  staffs  of  the  Local  Government  Board  and  of  the 
National  Health  Insurance  Commission  have  been  brought 
together  to  form  the  main  portion  of  the  medical  staff  of 
the  Ministry,  but  on  a newly  organised  system,  and  with 
considerable  additional  posts. 

The  Minister  has  appointed  Sir  George  Newman,  K.C.B., 
as  Chief  Medical  Officer  of  the  Ministry,  with  status 
corresponding  to  that  of  a secretary  of  the  Ministry.  By 
arrangement  between  the  President  of  the  Board  of  Education 
and  the  Minister,  Sir  George  Newman  retains  his  position  as 
Chief  Medical  Officer  of  the  Board  of  Education. 

Five  new  posts  of  “Senior  Medical  Officer”  have  been 
established,  with  status  corresponding  to  that  of  Assistant 
Secretary.  To  these  the  Minister  has  appointed  the 
following  : — 

Dr.  G.  S.  Buchanan,  C.B. 

Dr.  Janet  M.  Campbell  (who  will  also  by  arrangement  with 
the  President  of  the  Board  of  Education  act  as  Chief  Woman 
Medical  Adviser  of  that  Board). 

Dr.  F.  J.  H.  Coutts. 

Dr.  A.  W.  J.  MacFadden,  C.B. 

Mr.  J.  Smith  Whitaker  (who  will  also  act  as  Medical 
Adviser  to  the  National  Health  Insurance  Joint  Committee). 

The  whole  of  the  rest  of  the  established  medical  staff  of 
the  Ministry  will  be  in  one  grade,  to  be  known  as  “ Medical 
Officers.”  They  will  comprise  the  remainder  of  the  existing 
medical  staffs  of  the  Local  Government  Board  and  of  the 
Insurance  Commission,  with  the  addition  of  new  officers  still 
to  be  appointed  as  the  additional  services  may  require.  The 
following  appointments  have  so  far  been  made  : — 

Dr.  Irene  Cecil  Davy  EatoD. 

Mr.  Major  Greenwood  (Medical  Statistics). 

Dr.  Florence  Barrie  Lambert  (Remedial  Treatment). 

Dr.  Jane  Holland  Turnbull,  C.B.E.  (Obstetrics  and  Gynae- 
cology). 

Besides  this  regular  staff,  arrangements  have  been  made 
whereby  the  Ministry  may  secure  the  services,  from  time  to 
time,  of  specialists  and  others  on  a part-time  basis  ; amongst 
these  are  included  at  present  the  following  : — 

Dr.  Maurice  Craig  (Psychological  Medicine). 

Colonel  L.  W.  Harrison,  D.S.O.  (Venereal  Diseases). 

Sir  David  Semple  (Rabies). 

F urther  appointments  will  be  announced  as  they  are  made. 


Portsmouth  and  South  Hants  Eyf.  and  Ear 
Hospital. — At  the  annual  meeting  of  this  institution,  held 
on  July  14th,  it  was  reported  that  overtures  had  been 
received  from  the  Royal  Portsmouth  Hospital  with  a view 
to  amalgamation,  but  that  the  committee  had  not  felt 
justified  in  altering  the  present  arrangements.  The  financial 
statement  showed  a small  deficit  of  £148  on  the  year’s 
working. 

Presentations  to  Medical  Men.  — On  the 
occasion  of  the  closing  of  the  Hart  House  V.A.D.  Hospital, 
Burnham,  Somerset,  Dr.  N.  O’Dell  Burns,  the  honorary 
medical  officer  in  charge,  was  presented  with  a silver 
cigarette  case  as  a mark  of  respect  and  esteem. — Dr.  W.  R. 
Newton  Cole.  St.  Tudv,  Cornwall,  has  been  presented 
with  a clock  and  an  album  containing  the  names  of  300 
subscribers,  as  a mark  of  respect  and  esteem,  on  the  occasion 
of  his  retiring  from  active  work  after  37  years’  residence  in 
the  village. 


The  Lancet,] 


WOMAN  IN  INDUSTRY. 


[July  26,  1919  If, 7 


WOMAN  IN  INDUSTRY. 


I.  Woman’s  Economic  Value  in  Relation  to  Health. 

The  ability  of  women  to  compete  on  equal  terms  with  men 
in  industry  and  the  principle  of  “ equal  pay  for  equal  work  ” 
is  very  fully  discussed  in  the  Report  of  the  War  Cabinet 
Committee  on  Women  in  Industry,  which  has  lately  been 
published.  Dr.  Janet  Campbell  deals  with  the  Health  of 
Women  in  Industry,  and  in  her  memorandum  brings  out 
important  points  with  regard  to  men’s  and  women’s  work 
which,  although  well-known  to  physiologists  and  students  of 
industrial  medicine,  have,  so  far,  not  been  given  sufficient 
prominence  in  actual  practice.  No  one  has  ever  denied  that 
a woman  is  handicapped  on  account  of  her  potential  mother- 
hood, but  this  handicap  is,  as  a rule,  far  greater  than  is 
necessary.  Those  who  are  engaged  in  looking  after  the  health 
of  girls  employed  in  offices  must  have  realised  that  much  of 
the  tribulation  and  inability  to  carry  on  which  occur  at  the 
menstrual  periods  is  avoidable,  and  is  much  increased  by 
ignorance  of  the  elements  of  hygiene  and  the  laws  of  health. 
Decayed  teeth  are  only  too  common  among  all  classes  of 
workers,  the  constipation  of  women  is  proverbial,  digestive 
disturbances  are  not  unusual,  anaemia  is  essentially  an  ailment 
of  girls  and  young  women,  and  it  is  a well-known  fact  that 
girls  and  women  often  forego  proper  meals.  All  this  tends 
to  a lowered  state  of  vitality,  which  is  still  more  accentuated 
during  menstruation. 

Disadvantages  of  Women  Workers  as  Compared  with  Men. 

Only  in  very  rare  and  exceptional  cases  is  it  possible  to 
compare  with  any  degree  of  fairness  the  ability,  both 
physical  and  mental,  of  men  and  women.  Their  upbringing 
has  been  different  and  their  training  and  development  have 
been  forced  along  different  lines.  Among  the  children  of 
the  poor  the  boys,  during  out-of-school  hours,  are  given  the 
open-air  work  to  do,  such  as  carrying  messages,  &c.,  whilst 
the  girls  are  cooped  up  indoors  helping  with  the  domestic 
work.  Teachers  in  secondary  schools  complain  that  it  is 
impossible  to  send  a girl  up  for  a certain  examination  at  the 
same  age  as  a boy.  She  is  usually  about  a year  behind, 
not,  as  they  say  most  definitely,  on  account  of  her 
lower  mental  capacity  or  of  an  even  slightly  lower 
grade  of  intelligence,  but  because  she  has  no  proper 
time  for  her  home  work  and  because,  being  engaged  in 
household  tasks,  she  comes  to  school  with  her  brain 
more  tired,  her  mind  less  receptive,  and  her  memory  less 
retentive.  The  same  handicap  follows  her  through  life.  If 
she  is  living  at  home  and  going  out  to  work  there  are  still 
household  duties  which  she  is  expected  to  carry  on,  although 
nothing  of  the  kind  is  expected  from  her  brothers.  In  the 
poorer  classes,  as  a mother  of  a family  compelled  to  go  out 
to  work,  it  is  still  her  duty  to  keep  the  home,  cook  the  meals, 
and  do  the  family  washing.  A dish  for  the  dinner  is  unusual, 
as  it  means  more  washing  up,  so  the  mother  spends  her  time 
going  backwards  and  forwards  from  the  fireplace  to  the  table 
helping  the  rest  of  the  family  to  food.  She  herself  has  for 
her  dinner  “whatever  is  left,”  and  this  occurs  as  a matter 
of  course.  There  seems  no  doubt  that  less  and  poorer  food, 
combined  with  domestic  duties,  has  an  extremely  deleterious 
effect  on  women’s  work,  and  handicaps  them  to  a very  marked 
degree  in  competition  with  men  for  work  and  wages.  Miss 
Anderson,  in  her  evidence  before  the  Committee,  pointed  out 
that  “a  limitation  of  hours  was  necessary  in  the  national 
interest,  in  order  to  enable  women  with  domestic  responsi- 
bilities to  carry  on  their  home  duties.”  Miss  Martindale 
“showed  that  night-shifts,  and  especially  permanent  night- 
shifts,  are  particularly  harmful  to  women  with  domestic 
responsibilities,  as  it  is  more  difficult  for  them  to  obtain 
adequate  sleep  ; they  invariably  do  their  own  housework 
during  the  day  and  their  rest  is  subject  to  continual 
interruptions  ; their  work  becomes  inferior  in  quality  and 
their  health  suffers.  ” There  are  no  doubt  profound  physio- 
logical differences  between  men  and  women,  as  Dr.  Campbell 
insists,  but  there  has  been  no  proper  evaluation  of  these 
differences,  and  until  the  question  has  been  more  fully 
elucidated  there  is  no  reason  to  conclude  that  women’s 
handicaps  are  physiological  and  unalterable.  A great 
difficulty  arises  in  the  case  of  the  married  woman  who 
has  a baby  and  who  has  to  add  to  the  family  income. 
For  the  national  welfare  the  baby  should  be  breast-fed  ; for 


the  family  welfare  the  mother  must  go  to  work.  It  seems 
to  us  that  the  only  way  out  of  the  difficulty  is  the  institution 
of  creches  in  connexion  with  the  factories  where  nursing 
mothers  are  employed,  which  should  be  under  the  super- 
vision of  the  doctor  who  is  also  in  charge  of  the  health  of 
the  mothers,  and  where  time  should  be  allowed  every  four 
hours  for  breast-feeding. 

An  Old  Problem  in  a New  Aspect. 

These  are  some  of  the  more  obvious  considerations  that 
arise  on  a first  survey  of  the  report,  but  they  lie  at  the  root 
of  the  whole  of  social  and  industrial  medicine.  They 
are  the  justification  for  the  call  for  more  effective  super- 
vision and  for  energetic  research  into  the  causes  of 
industrial  fatigue  and  the  methods  of  preventing  disease 
directly  or  indirectly  due  to  occupation.  Employers  of  the 
more  educated  type  of  labour  do  already  to  some  extent 
provide  efficient  supervision,  preliminary  medical  examina- 
tion, and  medical  advice.  But  such  conditions  as  decayed 
teeth,  unhealthy  throats,  and  defective  eyesight  usually 
remain  unrealised  and  untreated  among  employees  of  the 
poorer  classes.  In  what  follows  the  vast  problem  of  industrial 
health  from  the  woman’s  point  of  view  is  studied  largely  in 
Dr.  Campbell’s  own  words. 

II.  The  Personal  Health  of  the  Woman  Worker. 

In  her  memorandum  on  the  Health  of  Women  in  Industry, 
included  in  the  Report  of  the  War  Cabinet  Committee  on 
Women  in  Industry,  Dr.  Janet  Campbell  points  out  that  in 
considering  the  position  of  women  in  industry  and  their 
capacity  and  power  of  continuance  to  compete  equally 
with  men  two  essential  principles  can  never  be  dis- 
regarded, namely  : (1)  the  profound  physiological  differences 
between  the  man  and  the  woman  ; and  (2)  the  woman’s 
potential  function  of  motherhood  and  child-bearing.  The 
woman’s  abdominal  muscles  are  longer,  and,  as  a rule, 
less  well  developed  ; they  act  under  greater  mechanical  dis- 
abilities on  account  of  the  relatively  greater  length  of  the 
abdominal  cavity,  the  greater  area  of  the  abdominal  wall, 
and  the  larger  size  of  the  pelvic  cavity.  This  natural 
weakness  is  not  infrequently  accentuated  by  habits  of  dress 
and  by  lack  of  proper  use  and  training  of  the  muscles.  The 
effect  of  pregnancy,  especially  when  repeated,  is  usually  a 
further  weakness  and  stretching  of  the  abdominal  walls, 
which  result  in  a less  effective  support  of  the  internal 
organs.  The  muscular  system  of  the  girl  and  young 
woman  can  be  greatly  developed  by  suitable  nutrition  and 
training,  but,  in  this  country  at  any  rate,  the  smaller  size 
of  the  bones,  together  with  the  mechanical  disadvantages  of 
the  general  build  and  an  inherent  physiological  difference 
not  to  be  overcome  rapidly,  if  at  all,  by  any  method  of 
upbringing,  make  it  unlikely  that  women  can  become  equal 
to  men  in  physical  strength,  and  suggest  that  uncontrolled 
competition  between  men  and  women  in  matters  requiring 
considerable  muscular  energy  is  undesirable.  The  greater 
weight  of  the  man  is  itself  an  advantage  where  heavy  work 
is  concerned,  and  the  strength  of  his  muscles  and  joints 
makes  him  less  liable  to  instability  or  accident  from  sudden 
or  violent  jerks  or  strains. 

Owing  possibly  to  the  greater  fineness  and  delicacy  of  her 
skin  and  the  greater  deposit  of  adipose  tissue,  a woman 
usually  reacts  more  quickly  than  a man  to  an  unsatisfactory 
atmospheric  environment,  and  particulasly  to  ill  ventilation 
and  high  temperatures.  She  loses  heat  from  the  surface  of 
the  body  less  rapidly  than  the  man,  and  therefore  feels  low 
temperatures  less  and  high  temperatures  more. 

There  seems  no  reason  to  believe  that  the  special  senses  of 
a woman  (sight,  healing,  touch,  taste,  smell)  cannot  be 
trained  as  highly  as  those  of  a man,  though  there  may  be 
certain  differences  in  the  two  sexes.  As  regards  the  central 
nervous  system , there  is  probably  little  difference,  except  as 
regards  a woman’s  higher  degree  of  emotional  expression. 
Professor  Sherrington  stated  that,  ]udging  by  certain  simple 
sensory  tests,  the  young  woman’s  delicacy  of  sensation  is 
possibly  less  than  the  young  man’s,  but  the  more  complex 
the  test  the  smaller  the  difference. 

Maternity . 

The  function  of  maternity,  even  when  potential  only, 
necessarily  imposes  on  the  woman  disabilities  from  the 
point  of  view  of  physical  strength  and  efficiency.  The 
structure  of  her  body  is  framed  with  a view  to  pregnancy 
and  childbirth,  and  is  less  well  adapted  to  muscular  exertion 


168  The  Lancet, J 


WOMAN  IN  INDUSTRY. 


[July  26,  1919 


than  that  of  the  man  : she  is  further  subject  to  periodical 
functional  disturbances  which  tend  to  render  her  nervous 
and  muscular  energy  somewhat  unequal  and  varied.  Inter- 
ruption of  employment  due  to  childbearing  and  lactation  is 
an  economic  handicap  to  the  married  woman  ; pregnancy 
places  a considerable  physiological  strain  upon  the  general 
metabolism  which  requires  adequate  physical  compensation 
if  the  woman  is  to  maintain  her  health  and  strength.  She 
is  also  exposed  during  this  period  to  various  dangers,  some 
of  them  chiefly  physiological  in  origin,  others  due  to  more  or 
less  unsatisfactory  treatment  at  the  time  of  her  confinement, 
but  the  results  of  which  may  persist  as  permanent  disabilities 
and  render  her  less  fit  for  her  ordinary  occupation  and  less 
able  to  resist  subsequent  strain  or  fatigue. 

Nutrition. 

One  of  the  primary  requirements  for  healthy  physiological 
development  is  satisfactory  nutrition. 

The  habit  of  the  woman  is  to  consume  less  than  the  man 
even  when  ample  food  is  available  ; this  habit  is  far  more 
marked  among  working-class  women  and  girls,  who  are 
frequently  not  in  a position  to  provide  themselves  with  an 
adequate  diet.  The  average  wages  earned  by  women  before 
the  war  made  it  impossible  for  them  to  procure  good  and 
substantial  food  ; their  diet,  besides  being  less  in  quantity, 
was  less  satisfactory  in  quality  than  the  diet  of  men  in  their 
own  position.  It  is  a matter  of  common  knowledge  that 
the  mothers  of  working-class  families  often  suffer  from  an 
inadequate  diet ; when  the  wages  are  insufficient  the  needs 
of  the  father  as  bread-winner  almost  necessarily  come  first, 
those  of  the  children  next,  the  mother’s  last. 

Fatigue , the  true  index  of  which  is  diminished  capacity, 
results  in  reduced  output,  even  before  it  is  observed 
subjectively  by  the  worker.  Persistent  fatigue,  shown 
in  reduced  physical  capacity,  results  in  the  loss  of 
resistance  to  disease  or  an  unsatisfactory  environment, 
which  are  further  reflected  in  returns  of  sickness,  of 
broken  time,  and  of  the  number  of  accidents  recorded. 
Fatigue  naturally  occurs  earlier  in  under-paid,  under-fed 
persons  ; the  secondary  results  of  overstrain,  including 
sickness,  are  most  common  and  excessive  among  this 
class  of  worker,  which  is  mainly  comprised  of  women  and 
girls.  It  is  a frequent  cause  of  complaint  that  women 
workers  are  worse  time-keepers  than  men  ; omitting  such 
reasons  as  domestic  duties  and  temporary  physiological 
incapacity,  fatigue,  whether  giving  rise  to  actual  sickness  or 
not,  will  inevitably  tend  to  increase  absence  and  unpunctu- 
ality. Accidents  have  been  shown  to  be  most  common 
during  the  period  of  the  day  when  fatigue  is  most  pronounced 
and  to  be  due,  in  some  degree  at  any  rate,  to  diminished 
capacity  leading  to  inattention  and  carelessness. 

j Prolonged  standing  is  a not  uncommon  cause  of  excessive 
fatigue  in  women.  Women  who  have  borne  children  are 
likely  to  suffer  more  from  continual  standing  than  unmarried 
girls,  and  are  more  apt  to  develop  varicose  veins,  internal 
displacements,  or  other  disabling  conditions  in  consequence. 
In  order  to  avoid  unnecessary  fatigue  and  conserve  physical 
energy,  it  is  important  that  suitable  seats  should  be  provided 
for  women  engaged  in  occupations  involving  constant  stand- 
ing, even  if  occasional  advantage  only  can  be  taken  of 
them. 

Lifting  heavy  weights  is  another  source  of  overstrain  and 
possible  injury.  Women  are  less  able  to  lift  weights  than 
men,  but  are  usually  better  able  to  deal  with  small  compact 
objects  than  with  bulky  articles  of  the  same  weight.  Part 
of  their  natural  disability  can  be  overcome  with  training, 
and  in  certain  factories  selected  women  have  shown  them- 
selves surprisingly  competent  in  the  handling  of  heavy 
weights. 

Aneemia  is  present  in  greater  or  less  degree  in  a very  large 
number  of  working  girls.  It  certainly  reduces  their 
efficiency,  sometimes  to  a considerable  extent,  hinders 
their  full  physiological  development,  and  may  predispose  to 
more  serious  diseases. 

Overstrain  also  results  in  greatly  reduced  industrial 
efficiency.  The  over-tired  woman  performs  her  task  at 
an  excessive  expenditure  of  nervous  energy.  If  long  con- 
tinued, this  results  in  a serious  lowering  of  vitality  and  the 
power  to  resist  disease  (for  example,  tuberculosis,  infectious 
diseases,  & c.),  it  renders  her  less  capable  of  performing 
maternal  functions  such  as  nursing  her  baby,  and  it 
prematurely  wears  her  out  and  makes  her  an  old  woman 


long  before  her  time.  Overstrain  may  result  from  the 
nature  of  the  work  alone,  but  is  far  more  likely  to  be 
associated  with  undue  speeding  up  or  competition  with 
physically  stronger  workers  of  either  sex. 

Incidence  of  sickness. — Th^  operation  of  the  National 
Health  Insurance  Act  revealed  for  the  first  time  the  remark- 
able incidence  of  minor  and  major  sickness  among  girls  and 
young  women,  an  incidence  which  compared  most  unfavour- 
ably with  the  sickness  rates  for  men.  The  report  of  the 
committee  appointed  to  inquire  into  the  alleged  excessive 
claims  in  respect  of  sickness  benefit  contains  important 
evidence  in  this  connexion.  This  chronic  ill-health  among 
working  women  was  ascribed  to  low  wages  resulting  in 
badly  prepared  and  insufficient  food,  and  to  conditions  of 
employment,  such  as  long  hours,  long  standing,  lack  of  fresh 
air,  and  long  intervals  without  food. 

Dr.  Benjamin  Moore,  in  an  article  on  factory  and  work- 
shop conditions  and  the  prevalence  of  pulmonary  phthisis, 
has  pointed  out 1 that  after  the  thirtieth  year  there  was 
a great  preponderance  of  the  disease  among  urban  males 
which  is  not  shared  by  urban  females,  no  such  disparity 
being  observed  between  rural  males  and  rural  females. 
This  is  ascribed  to  the  daily  occupation — (1)  the  long- 
continued  strain  ot  work  under  unhealthy  conditions,  and 

(2)  the  infection  of  men  (thus  reduced  in  resisting  power) 
by  fellow  workers  actually  at  work  alongside  them  while 
suffering  from  open  phthisis.  Since  1914  the  mortality  rate 
among  urban  women  has  shown  a substantial  increase.  This, 
Dr.  Stephenson  thinks,  may  well  be  due  to  the  introduction 
of  many  thousands  of  women  into  industrial  life. 

III.  The  Effect  of  Industrial  Employment  on 
Motherhood. 

It  is  difficult  to  determine  the  effects  of  employment  on 
the  function  of  motherhood.  As  Dr.  Campbell  says,  “It 
may  be  personal  and  physiological,  but  it  is  difficult  to 
separate  this  from  social  and  national  welfare.” 

The  direct  result  upon  the  reproductive  system  of  the 
woman  is  probably  largely  negligible,  except  in  the  case  of 
multiparous  women  engaged  in  heavy  or  fatiguing  work. 
The  influence  of  employment  in  causing  an  impairment  of  the  1 
general  health  and  vitality  is  certainly,  if  indirectly,  consider- 
able. The  effect  of  the  increasing  employment  of  women  on 
the  birth-rate  has  probably  been  to  accelerate  somewhat  the  ’ 
steady  decline  which  has  been  observed  since  1876,  and  the  ■ 
figures  relating  to  occupations  in  which  married  women’s 
labour  is  common  suggest  that  this  result  would  become 
more  pronounced  if  the  proportion  of  employed  married 
women  was  much  increased.  The  influence  of  employment 
upon  the  infant  mortality  rate  is  not  altogether  clear.  The 
industry  associated  with  the  highest  infant  mortality  rate  is  { 
mining,  in  which  there  is  little  employment  of  married 
women,  but  the  housing  and  sanitation  are  notably  inferior  , 
and  the  standard  of  general  hygiene  and  domestic  comfort  is  ' 
low.  Almost  as  high  infant  mortality  rates  are  associated 
with  the  pottery  and  textile  industries,  in  which  many 
married  women  are  employed  for  long  hours  away  from 
home.  The  regular  employment  of  the  mother  necessarily 
deprives  her  infant  of  its  natural  food,  which  is  the  greatest 
safeguard  to  its  healthy  growth  and  development,  and  also 
of  the  careful  and  constant  attention  which  is  so  necessary 
to  its  successful  nurture.  On  the  other  hand,  poverty  or  an 
insanitary  environment  may  have  an  even  more  injurious  ■ 
effect  than  the  mother’s  absence.  This  is  borne  out  by  the 
low  infant  mortality  rates  in  1916  and  1917,  years  during 
which  a continually  increasing  number  of  married  women 
was  being  employed.  The  infant  mortality  rate  has  shown 
its  most  rapid  decline  in  the  last  decennium,  during 
which  industrial  employment  of  women  has  increased.  1 
In  1899  the  infant  mortality  rate  for  England  and  Wales 
was  163  ; in  1902  it  was  133  ; in  1908,  120  ; in  1911,  a year 
of  heat  and  drought,  it  was  130,  but  dropped  in  the  follow- 
ing year  to  95.  In  1915  it  rose  to  110,  but  in  1916  it  was  j 
91.  the  lowest  recorded  rate.  In  1917  it  again  rose  slightly 
to  97.  but  there  has  been  no  substantial  interruption  in  the 
steady  downward  tendency.  The  chief  direct  causes  of 
deaths  amongst  infants  are  : (1)  premature  birth,  atrophy,  j 
marasmus,  and  congenital  defect : (2)  diarrhoea  and  enteritis  ; j 

(3)  bronchitis  and  pneumonia. 

Among  the  various  general  influences  which  affect  infant 
mortality,  the  most  important  would  seem  to  be  poverty,  j 

1 The  Lanckt,  Nov.  9th.  1918,  p.  618. 


ThiLanobt,]  INSURANCE  ACTS  COMMITTEE  OF  THE  BRITISH  MEDICAL  ASSOCIATION.  [July  26, 1919  169 


bad  housing  and  insanitation,  the  lack  of  education  of  the 
mother,  and  the  occupation  of  the  parents.  Poverty  and 
bad  housing  are  often  inseparable;  ill-paid  work  and  a low 
standard  of  domestic  hygiene  are  usually,  though  not  always, 
associated.  A hand-fed  baby  is  much  less  likely  to  thrive  in 
such  circumstances  than  in  a well-to-do  household. 

Parental  Occupation  and  its  Effect  on  Infant  Mortality. 

With  regard  to  the  effect  on  the  infant  mortality  rate  of 
the  occupation  of  the  parents,  it  is  shown  that  the  mortality 
in  the  middle  classes  is  only  61  per  cent,  of  the  total  infant 
mortality  of  the  country,  which  suggests  that  practically 
40  per  cent,  of  the  mortality  could  be  avoided  if  the  health 
conditions  of  infant  life  in  general  could  be  approximated  to 
those  in  the  middle  class.  The  observation  is  not  a new 
one,  for  in  the  classic  inquiry  carried  out  by  Sir  John 
Simon  and  Dr.  Greenhow  for  the  old  Board  of  Health,  in 
the  middle  cf  the  last  century,  into  the  sanitary  state 
of  the  people  of  England,  it  was  noted  that  one  of  the 
causes  of  the  high  rate  of  infant  mortality  then  existing 
was  the  occupational  differences  among  the  inhabitants 
in  certain  large  towns  where  women  were  greatly  engaged 
in  branches  of  industry  away  from  home.  In  such  circum- 
stances the  houses  were  usually  ill-kept,  and  infants  who 
should  have  been  on  the  breast  were  improperly  fed, 
starved,  or  quietened  with  opiates.  After  consideration 
of  subsequent  investigations  in  England  and  Scotland  by 
other  authorities,  including  the  Home  Office  inspectors, 
Sir  George  Newman  (“Infant  Mortality,”  1906)  concludes 
that  in  towns  where  women  are  largely  employed  in 
factories,  the  disadvantages  to  the  health  and  life  of  their 
infants  are  enormously  increased  on  account  of  : (1)  the  in  juries 
and  diseases  to  which  women  and  girls  in  factories  are  liable  ; 
(2)  the  strain  and  stress  of  long  hours  of  hard  work  to  the 
pregnant  woman  ; and  (3)  the  absence  from  home  of  the 
mother  and  the  infant.  The  results  of  an  investigation  of 
Dr.  J.  Robertson,  of  Birmingham,  carried  out  in  two  wards 
where  the  wages  were  low  and  the  industrial  employment  of 
women  was  common,  suggest  that  poverty  was  more 
injurious  to  infant  life  than  the  employment  of  the  mother. 
Dr.  G.  Reid,  medical  officer  of  health  for  Staffordshire,  in  his 
report  for  1910,  shows  that  the  infant  mortality  rate  was 
greatest  and  had  declined  least  in  the  five  large  towns  in  the 
county  having  the  highest  proportion  of  married  and  widowed 
women  industrially  employed.  Industrial  employment  of 
women  leads  to  the  neglect  of  breast-feeding,  and  the  infant 
may  be  left  in  the  charge  of  an  unskilled  “ minder  ” instead 
of  being  sent  to  a properly  managed  creche.  As  a result 
epidemic  diarrhoea  and  nutritional  disturbances  are  more 
common,  the  infant’s  chance  of  survival  during  the  first 
years  of  its  life  are  diminished,  and  its  liability  to  subse- 
quent weakness  and  debility  are  increased.  The  areas  in 
which  the  infant  mortality  rate  is  highest  are  the  mining  and 
manufacturing  districts.  In  the  mining  districts  the  cause 
is  probably  to  be  found  in  defective  housing  and  sanitation, 
overcrowding,  and  the  low  standard  of  general  hygiene.  In 
the  pottery  and  textile  trades  it  is  probably  due  to  low  wages 
and  the  handling  by  the  mothers  of  a substance  specifically 
dangerous  to  infant  life — namely,  lead. 

Married  women’s  labour  must  be  regarded  from  various 
points  of  view  : (1)  the  direct  effect  on  the  health  of  the 
mother  while  she  is  bearing  or  nursing  a child  ; (2)  the 
general  effect  on  her  health  in  view  of  her  domestic 
responsibility  and  duties ; and  (3)  the  effect  on  her  home  and 
children. 

Besides  its  effect  on  the  birth-rate  and  on  infant  mortality, 
the  employment  of  married  women  may  react  directly  on 
the  personal  health  of  the  expectant  and  nursing  mother, 
and  on  her  general  physical  strength  at  other  times  by 
imposing  a double  burden  of  factory  labour  and  domestic 
duties,  while  lack  of  “mothering”  may  lead  to  the  moral 
and  physical  injury  of  the  children.  Employment  under 
suitable  conditions  is  not  in  itself  injurious  to  the  pregnant 
woman,  while  the  money  thus  earned  may  enable  her  to  be 
properly  fed — a matter  of  the  highest  importance.  If  the 
work  causes  undue  fatigue  or  involves  strain  or  violence  it 
may  give  rise  to  general  or  local  injury  and  lead  to 
premature  confinement  or  complications  of  pregnancy. 
Section  61  of  the  Factory  and  Workshops  Act,  1901,  provides 
that  a woman  shall  not  return  to  work  within  four  weeks  of 
giving  birth  to  a child  and  is  generally  observed,  because 
most  women  do  not  desi  re  to  return  to  work  until  at  least  a 


month,  and  usually  longer,  after  their  confinement.  It 
would  be  undesirable  to  extend  this  period  unless  grants  in 
aid  were  available  to  assist  the  mother. 

Wayes  in  Relation  to  Health. 

The  results  of  employment  of  women  under  war  conditions 
have  emphasised  the  important  to  health  of  the  good  food, 
clothing,  and  domestic  comfort  which  can  beobtained  when  the 
wages  represent  a reasonably  adequate  recompense  for  labour. 
They  have  also  proved  that  properly  nourished  women  have 
a much  greater  reserve  of  energy  than  they  have  usually 
been  credited  with,  and  that  under  suitable  conditions  they 
can  properly  and  advantageously  be  employed  upon  more 
arduous  occupations  than  has  been  considered  desirable  in 
the  past,  even  when  these  involve  considerable  activity, 
physical  strain,  exposure  to  weather,  &c.  Light  sedentary 
occupations  are  not  necessarily  healthy  occupations.  The 
commercial  futility  of  unduly  long  hours  of  work  and  of 
overtime  has  been  demonstrated  repeatedly,  together  with 
the  benefit  to  health  and  to  output  of  shorter  hours,  of  the 
abolition  of  work  before  breakfast,  and  of  properly  arranged 
spells  and  pauses.  There  is  advantage  to  the  employer 
as  well  as  to  the  workpeople  in  the  provision  of  factory 
canteens,  well-equipped  surgeries  and  rest-rooms,  suitable 
arrangements  for  sanitation  and  hygiene,  and,  when 
necessitated  by  the  nature  of  the  work,  of  protective 
clothing. 

Physical  Strain  on  the  Worker  with  a Family. 

Dr.  Campbell  points  out  the  great  physical  strain  which 
is  placed  upon  the  woman  who  is  industrially  employed  and 
also  has  a home  and  family  to  manage.  This  strain  is  often 
unrealised  because  the  woman  shoulders  this  heavy  burden 
patiently  as  a matter  of  course  and  without  complaint.  That 
she  is  often  surprisingly  successful,  though  at  the  expense 
of  her  own  youth  and  physical  vigour,  is  no  reason  why  the 
nation  should  be  content  to  allow  its  mothers  to  wear  them- 
selves out  in  a life  of  colourless  drudgery  and  a continual 
struggle  with  difficulties  which  frequently  prove  too  great  to 
be  overcome,  and  of  the  results  of  which  there  is  ample 
evidence  in  the  sickness  returns  under  the  National  Health 
Insurance  Act.  In  addition  to  the  general  physical  strain,  a 
woman  who  has  had  children  is  more  liable  than  one  who  has 
not  to  various  forms  of  injury  and  disability  arising  from  heavy 
work,  work  involving  constant  standing  and  so  forth.  Patho- 
logical conditions  following  upon  confinement  are  likely  to 
be  accentuated  and  prolonged  by  certain  forms  of  factory 
work.  In  such  circumstances  it  is  not  possible  for  a woman 
to  give  her  children  that  care  and  attention  which  are  needful 
for  healthy  physical  development  and  for  the  prevention  of 
avoidable  defects  and  ailments,  or  to  make  her  home  as 
pleasant,  comfortable,  and  hygienic  as  she  would  otherwise  do. 

I (To  be  concluded.) 


INSURANCE  ACTS  COMMITTEE  OF  THE 
BRITISH  MEDICAL  ASSOCIATION: 

REPORT  ON  THE  REVISION  OF  THE  CONDITIONS 
OF  SERVICE. 


The  report  on  the  revision  of  the  conditions  of  service 
under  the  National  Health  Insurance  Acts  and  on  possible 
extensions  of  service,  drawn  up  in  May  last  and  circulated  for 
discussion  by  local  medical  and  panel  committees,  was  passed 
substantially  as  presented  by  the  Special  Conference  held  at 
the  Connaught  Rooms,  London,  on  July  17th  and  18th  : — 
Summary  of  the  Main  Changes. 

A summary  of  the  main  changes  that  would  take  place  in 
the  present  terms  and  conditions  of  service  in  the  event  of 
the  suggestions  contained  in  the  report  being  carried  into 
effect,  was  included  in  the  report  as  follows  : — 

(i.)  The  central  pool  for  the  year  would  be  actuarially  fixed  before  the 
beginning  of  the  year  and  the  amount  payable  for  the  year  to  the 
practitioners  collectively  of  each  area  (the  local  pool)  would  be  known 
before  the  work  of  the  year  was  commenced. 

(ii.)  The  distribution  of  this  known  amount  would  he  made  to 
practitioners  definitely  quarter  by  quarter  soon  after  the  work  of  the 
quarter  was  completed. 

(iii.)  A first  charge  on  the  local  pool  would  be  the  payment  of  an 
agreed  fee  in  every  area  for  the  administration  of  general  anaesthetics, 
aud  a second  charge,  if  the  practitioners  of  any  area  so  wished,  would 
be  the  payment  of  an  agreed  fee  for  attendance  at  miscarriages  or  for 
any  one  or  mote  of  a number  of  other  specified  special  services. 


170  Thh  Lancet,] 


THE  OXFORD  OPHTHALMOLOGICAL  CONGRESS.  1919. 


[July  26,  1919 


(iv.)  The  distribution  of  the  remaining  portion  of  the  local  pool  would 
then  be  made  to  practitioners  in  amounts  proportionate  to  the  names 
on  each  list,  subject  to  some  minor  variations  in  the  values  to  be 
attached  to  some  names  to  meet  special  cases. 

(v.)  The  present  calculations  and  accounts  for  temporary  residents 
and  other  like  classes  would  be  done  away  with,  the  payments  for 
these  classes  being  secured  in  the  general  distribution. 

(vi.)  The  practitioners  of  an  area  would  have  no  financial  interest  in 
the  amount  of  the  drug  fund,  the  responsibility  for  any  deficit  in 
which  would  be  assumed  by  the  Treasury,  but  from  the  drug  fund  two 
payments  would  be  made  to  all  practitioners:  (a)  a small  capitation 
fee,  uniform  for  the  whole  country  in  respect  of  drugs  supplied  in 
emergencies;  (b)  a capitation  fee,  which  might  be  variable  from  area  to 
area  <>r  from  practice  to  practice,  in  respect  to  dressings. 

(viij  Rural  and  semi-rural  practitioners  in  every  area  would  receive, 
in  addition  to  the  foregoing  : (a)  a payment  from  the  drug  fund  in 
respect  of  patients  for  w hom  they  dispense,  fixed  yearly  on  such  a basis 
as  to  secure  that  the  remuneration  would  be  equal  in  every  relevant 
respect  to  that  of  the  pharmacists;  ( b ) a payment  from  a special 
mileage  or  travelling  fund  calculated  according  to  data,  which  would 
aim  at  securing  for  them  an  amount  corresponding  as  nearly  as  possible 
to  the  excess  cost  of  the  necessary  travelling  (including  extra  time 
spent)  over  that  of  an  urban  practitioner. 

(viii.)  There  would  be  a high  limit— say,  3C00— fixed  for  the  whole 
country,  beyond  which  no  practitioner  would  be  allowed  to  accept 
names  on  his  list  ; but  this  limit  would  be  for  individual  practitioners 
only.  Every  opportunity  would  be  afforded  for  arrangements  in  the 
nature  of  partnership  or  assistantships,  and,  in  the  case  of  practi- 
tioners whose  lists  were  above  the  prescribed  limit  on  the  day  on  which 
the  limitation  became  operative,  a period  of  one  year  would  be  allowed 
for  the  required  reduction  of  the  list,  the  practitioner  himself  having 
a voice  in  the  exact  method  by  which  the  reduction  should  be  effected. 

(ix.)  It  would  be  possible  for  a practitioner  to  come  on  the  panel  of 
an  area  under  a special  arrangement  by  which  he  would  be  guaranteed 
a small  minimum  payment  for  a period  of  two  years,  irrespective  of  the 
number  on  his  list,  provided  that  he  undertook  certain  special 
obligations. 

(x.)  The  machinery  for  keeping  lists  would  be  in  some  respects 
altered  so  as  to  eliminate  the  causes  of  some  of  the  errors  that  have 
hitherto  prevailed  ; at  the  same  time  the  necessity  for  minute  correct- 
ness would  become  relatively  less  important  than  hitherto 
(xi.)  The  present  agreement  between  the  practitioner  and  the 
Insurance  Committee  would  be  abolished,  and  the  contract  would  take 
the  form  of  a letter  from  the  practitioner  accepting  the  published  terms 
and  conditions. 

(xii.)  Specific  arrangements  would  be  made  by  which  a practitioner 
could  conditionally  charge  a fee  (a)  in  cases  in  which  there  is  a doubt 
as  to  whether  the  patient  is  entitled  to  medical  benefit;  (b)  in  cases 
where  the  service  to  be  rendered  is  alleged  to  be  outside  the  scope  of 
medical  benefit,  but  in  which  the  practitioner  claims  to  be  specially 
qualified  to  render  it,  the  amount  of  the  fees  in  each  case  being  deducted 
from  subsequent  payments  to  the  practitioner  should  it  be  determined 
that  the  treatment  was,  in  fact,  due  under  the  contract. 

(xiii.)  It  would  be  permissible  for  a practitioner  to  arrange  with 
fellow  practitioners  to  undertake  on  his  behalf  certain  kinds  of  treat- 
ment which,  though  within  the  scope  of  the  contract,  he  was  not,  in 
fact,  in  the  habit  of  undertaking  in  the  case  of  his  private  patients — 
e.g.,  minor  surgical  operations. 

(xiv.)  The  requirements  with  regard  to  (a)  attendance  on  an  insured 
person  in  an  emergency  ; (6)  the  provision  of  a deputy  during  absence  ; 
ic)  adequate  surgery  and  waiting-room  accommodation  ; ( d ) the  main- 
tenance of  a satisfactory  standard  of  competence  as  well  as  of  conduct, 
would  be  strengthened. 

(xv.)  The  arrangements  for  records  and  for  certification  would  be 
revised  with  a view  to  making  them  less  laborious  and  more  useful. 

(xvi.)  Certain  additional  services  would  be  established— e.g.,  consulta- 
tions and  specialised  treatment,  laboratories — and  the  arrangements 
with  the  tuberculosis  service  would  be  reviewed  ; in  every  case  the 
general  practitioner  would  have  duties  in  connexion  therewith  ; he 
would  be  encouraged  to  associate  himself  with  the  work  thereof  ; and 
he  would  have  the  right,  if  possessing  the  necessary  special  qualifica- 
tions, of  being  appointed  to  give  the  service  in  tne  same  way  as  a 
consultant  or  specialist. 

(xvii.)  Medical  referees  would  be  appointed  with  responsible  duties, 
which  would  include  their  acting  indirectly  in  a supervising  capacity 
over  the  administration  of  the  clinical  services. 

(xviii  ) The  machinery  for  dealing  with  alleged  breaches  of  agree- 
ment would  be  made  more  clear,  and  alterations  would  be  made  so  as  to 
remedy  some  points  which  appear  inequitable  to  practitioners. 

The  limitation  of  the  number  of  the  panel  list  was  defeated 
at  the  Conference,  the  division  being  a close  one. 

Recommendations. 

The  following  definite  recommendations  were  appended  to 
the  report  : — 

(I.)  That,  subject  to  a full  consideration  of  any  suggestions  from 
Local  Medical  and  Panel  Committees  or  from  the  Group  Conferences, 
and  subject  also  to  any  resolutions  of  the  July  Conference,  the  Insur- 
ance Acts  Committee  be  authorised  to  negotiate  definitely  with  the 
Central  Government  Department  for  new  terms  and  conditions  of 
service  for  1920  on  the  lines  of  this  report  and  of  the  two  interim 
reports  already  issued. 

(II.)  That  the  Insurance  Acts  Committee  be  requested  throughout 
such  negotiations  to  keep  in  touch  with  Local  Medical  and  Panel  Com- 
mittees and  with  other  professional  organisations  with  a view  to  a 
decision  at  the  October  Conference  on  the  question  of  the  amount  of 
remuneration  which  practitioners  would  agree  to  accept  for  the  services 
to  be  rendered. 

(III.)  That  as  regards  the  additional  services  for  insured  persons 
suggested  in  the  report,  it  is  important  that,  as  from  early  in  1920.  these 
services  should  be  regarded  as  an  essential  part  of  the  whole  service, 
though  in  practice  they  might  be  developed  only  gradually. 

(IV.)  That  the  Ministry  of  Health  should  consider  as  soon  as  possible 
through  its  Medical  Consultative  Council  the  order  in  which  and  the 
method  by  which  such  services  should  be  extended  to  the  non-insured 
population  ; but  that  in  this  connexion  it  is  essential  (a)  that  a general 
practitioner  service  should  be  established  for  any  class  of  persons  before 


such  additional  services  are  made  freely  available  for  that  class ; (b) 
that  general  practitioners,  if  possessed  ot  the  necessary  aualifications. 
should  be  eligitde  to  render  such  additional  services ; (c)  that  the 
clinical  staff  of  any  such  additional  service  should  be  engaged  on  a part- 
time  basis  and  should  be  remunerated  on  a time  basis,  and  that  a 
medical  committee  should  play  an  important  part  in  its  selection. 

(V.)  That  the  Insurance  Acts  Committee  be  authorised  on  behalf  of 
Local  Medical  and  Panel  Committees  and  in  conjunction  with  other 
professional  organisations  to  continue  to  hold  ‘ round  table  confer- 
ences " with  the  central  Government  department  with  regard  to  the 
extension  of  the  service  to  the  dependants  of  insured  persons,  the 
provision  of  residential  institutional  treatment,  and  the  administrative 
arrangements  which  should  be  established  for  the  proper  provision  and 
supervision  of  the  service. 

And  these  were  confirmed  by  the  vote  of  the  Conference. 


THE  OXFORD  OPHTHALMOLOGICAL 
CONGRESS,  1919. 


Annual  Meeting. 

The  tenth  annual  meeting  of  the  Oxford  Ophthalmological 
Congress  was  held  on  July  10th  and  11th  last  in  beautiful 
weather.  Members  were  lodged  in  Keble  College  and  the 
scientific  proceedings  took  place  in  the  Department  of  Human 
Anatomy  of  the  University  (kindly  lent  for  the  purpose 
by  Professor  Arthur  Thomson),  where  technical  and  com- 
mercial museums  were  also  arranged. 

The  programme  was  opened  on  July  10th  by  an  address 
of  welcome  by  the  Master,  Mr.  Sydney  Stephenson. — Major 
Walter  H.  Kiep,  R.A.M.C.,  read  a paper  on  the  Ocular 
Complications  of  Dysentery,  which  was  followed  by  a 
good  discussion  on  the  subject.— Major  Edgar  H.  Smith, 

R. A.M.C.,  read  a communication  dealing  with  “Quinine 
Amaurosis,”  well  discussed  by  the  members  present. — Dr. 
William  McLean,  of  New  York,  described  his  further 
experimental  studies  in  intra-ocular  pressure  and  tonometry, 
and  exhibited  his  latest  model  tonometer. 

A discussion  on 

l Preventive  Ophthalmology 

was  introduced  by  Colonel  J.  Herbert  Parsons,  C.B.E., 
consulting  ophthalmic  surgeon  to  the  Forces.  Colonel 
Parsons  pointed  out  that  the  scope  of  his  subject  dealt  with 
the  prevention  of  damage  (a)  to  the  individual,  and  (6)  to 
others,  (a)  Included  many  subjects,  such  as  prevention  of 
damage  to  the  eyes  from  accidents,  defective  illumination, 
deleterious  rays  and  organisms,  and  the  prevention  of  damage 
to  health  from  headache,  accident,  fatigue,  &c.  ; (4)  included 
regulations  for  the  prevention  of  the  transference  of 
contagious  disease  and  rules  for  Navy,  Army,  Air  Force, 
Mercantile  Marine,  railways,  motor  industry,  cinemas,  and 
so  forth.  The  problems  of  preventive  ophthalmology  con- 
stituted a question  of  collective  action,  and  were  of  particular 
value  at  the  moment,  when  projects  of  reconstruction  were 
to  the  fore.  In  connexion  with  the  prevention  of  accidents 
to  the  eyes  in  factories,  there  is  urgent  need  of  a scale  of 
awards  for  compensation  founded  upon  scientific  principles. 
The  formulation  of  regulations  for  the  public  services 
demanded  (1)  a widening  of  the  basis  of  education  of 
ophthalmologists  ; (2)  cooperation  between  ophthalmologists 
and  other  experts  ; and  (3)  improvement  in  the  methods  of 
examination  of  candidates  and  the  selection  of  examiners. 

After  the  discussiou  the  Doyne  Memorial  medal  was  pre- 
sented to  Colonel  Parsons  by  the  Deputy  Master,  Mr. 
Philip  H.  Adams.  In  the  afternoon  members  and  their 
friends  were  entertained  to  tea  in  the  gardens  of  Trinity 
College  by  Mr.  D.  N.  Nagel,  M.A.,  and  Miss  Nagel.  In  the 
evening  the  annual  dinner  of  the  Congress  was  held  in  the 
hall  of  Keble  College,  some  70  members  and  visitors  being 
present.  The  toast-list  was  commendably  brief. 

After  dinner  the  annual  general  meeting  of  the  Congress 
was  held  in  the  junior  common  room  at  Keble  College. 
Among  other  things  it  was  determined,  on  the  motion  of 
Mr.  J.  B.  Story,  to  make  representations  to  the  General 
Medical  Council  in  support  of  those  recently  preferred  to 
that  body  by  the  Council  of  British  Ophthalmologists  con- 
cerning the  instruction  and  examination  of  medical  students 
in  eye  work.  Readers  of  The  Lancet  are  aware  that  the 
recommendations  in  question  have  been  rejected  by  the 
General  Medical  Council. 

On  July  11th  the  proceedings  began  with  a paper  by  Dr. 

S.  Lewis  Ziegler,  of  Philadelphia,  on  the  Problem  of  the 
Artificial  Pupil  ; Knife-Needle  rersnt  Scissors. — Dr.  P. 
Baillart,  of  Paris,  followed  with  a communication  dealing 


The  Lancet,] 


TUBERCULOSIS.— MEDICINE  AND  THE  LAW. 


[.July  26,  1919  171 


■with  his  dynamometer  for  determining  the  blood  pressure  in 
the  branches  of  the  central  retinal  artery. — Mr.  A.  F. 
MacCallan  (Cairo)  read  a paper  on  the  Seasonal  Variations 
of  Acute  Conjunctivitis  in  Egypt. — Colonel  A.  H.  Tubby 
entered  a suggestive  plea  for  investigation  as  to  any  possible 
connexion  between  skeletal  asymmetry,  on  the  one  hand, 
and  defects  of  the  eye,  on  the  other. 

A discussion  upon  Employment  for  the  Blind  was  intro- 
duced by  three  blind  speakers  namely,  Mrs.  Adolphus 
Duncombe,  Captain  Pkirson  Webber,  and  Captain  Towse, 
V.C.,  and  it  is  to  be  hoped  that  useful  action  will  be  under- 
taken by  the  Congress  in  connexion  therewith. 

In  the  afternoon  the  Ashhurst  War  Hospital  at  Littlemore, 
near  Oxford,  was  thrown  open  to  members  by  Lieutenant- 
Colonel  T.  S.  Good,  R.A.M.C. 

The  Congress  was  well  attended,  and  a pleasing  feature 
was  the  presence  of  representatives  from  Canada,  Australia, 
Egypt,  the  United  States,  France,  and  Norway. 


TUBERCULOSIS. 


The  Establishment  and  Conduct  of  a Tuberculosis  Sanatorium. 

The  Department  of  Health  of  the  city  of  New  York  has 
published  a monograph  of  138  pages  on  the  above  subject 
by  Dr.  Charles  B.  Slade,  visiting  physician  to  the  Municipal 
Sanatorium  at  Otisville.  This  book  is  full  of  good  and  much- 
varied  advice,  and  deals  with  as  widely  different  subjects  as 
climate,  building  plans,  and  the  qualifications  to  be  found 
in  the  ideal  sanatorium  physician.  Even  the  attitude  of 
residents  to  a sanatorium  in  their  neighbourhood  is  dis- 
cussed. The  author  calculates  that  sanatorium  accommoda- 
tion should  be  provided  for  not  less  than  1 to  3 per  1000 
of  the  community  for  which  it  is  established.  A complete 
sanatorium,  with  a capacity  for  500  or  more  patients, 
should  consist  of  five  units — a reception,  a men's,  a 
women’s,  a children’s,  and  an  administration  unit.  A 
medical  superintendent  should  be  “of  good  moral' 
character  and  temperate  habits,”  and  he  should  have  prac- 
tised his  profession  with  reasonable  success  for  several 
years,  have  had  one  to  three  years’  “ internship  ” in  a general 
hospital,  several  years’  experience  in  outdoor  clinics  for 
tuberculosis,  some  familiarity  with  the  conduct  of  sana- 
toriums,  and  a wide  knowledge  of  people.  The  monograph 
also  discusses  such  vexed  questions  as  the  remuneration  of 
work  done  by  patients  and  ex-patients.  The  physical 
examination  of  the  chest,  the  daily  routine  of  a sanatorium, 
principles  of  treatment,  after-care,  and  a host  of  other 
subjects  come  under  review. 

Annual  Report  of  the  Tuberculosis  Officer  for  Wigan. 

This  report,  which  is  for  1918,  in  addition  to  giving  the 
usual  statistics,  records  the  fact  that  the  cases  received 
direct  from  the  Army,  through  the  Insurance  Commissioners, 
were  in  a comparatively  early  stage  of  the  disease,  and  the 
prospect  of  restoration  to  working  capacity  was  correspond- 
ingly good.  But  48  -8  per  cent,  of  the  217  deaths  between 
July,  1912,  and  Dec.  31st,  1918,  occurred  within  six  months 
of  application  for  sanatorium  benefit.  This  deplorably  high 
percentage  is  regarded  as  absolute  proof  of  the  urgency  of 
the  need  for  still  further  cooperation  between  the  panel 
doctors  and  the  tuberculosis  dispensaries. 

Trudeau  Sanatorium  : Thirty-fourth  Annual  Report. 

Of  the  259  patients  discharged  in  the  year  under  review, 
52 -9  per  cent,  were  classified  as  cases  of  arrest  or  quiescence. 
In  a further  13 T per  cent,  the  disease  was  improved,  and  in 
17-7  per  cent,  the  patients  were  either  not  tuberculous  or 
classified  merely  as  tuberculosis  suspects.  A notable  fact  was 
the  increasing  number  of  patients  in  whom  the  diagnosis 
of  tuberculosis  was  in  doubt  (42),  and  this  was  interpreted 
as  the  result  of  the  widespread  educational  campaign  that 
had  taught  patients  to  seek  advice  early,  and  physicians  to 
send  more  persons  with  suspicious  symptoms  for  observa- 
tion. The  staff  has  found  the  study  of  these  cases  most 
instructive  and  excellent  material  for  demonstration  to  the 
Trudeau  School.  The  good  results  achieved  by  the  radical 
hed-rest  method  have  been  maintained,  but  graduated 
exercise  was  the  treatment  adopted  for  the  majority. 
Tuberculin  was  largely  discontinued  and  artificial  or 
natural  light  treatment  was  adopted  in  a few  cases.  The 


inltuen/.a  vaccine,  which  was  given  to  a large  number  of 
patients,  seemed  to  be  harmless  as  well  as  prophylactic. 
No  fewer  than  125  former  patients  and  members  of  the  stall 
joined  the  various  services  ; with  what  result  is  not  stated. 
The  work  of  the  X ray  laboratory  included  2000  examinations, 
requiring  5000  plates,  and  1500  fluoroscopic  examinations. 
The  principal  occupations  for  the  patients  were  basket- 
making, clay-modelling,  photography,  and  typewriting. 
At  the  fourth  session  of  the  Trudeau  School  of  Tuberculosis, 
25  physicians  and  medical  students  were  enrolled  ; of  the 
59  physicians  trained  during  the  four  sessions,  most  have 
taken  a definite  position  in  tuberculosis  work. 

Injections  of  Sicoharose  in  Pulmonary  Tnberoulosis. 

Writing  in  the  Corresp.  Bl.  f.  Schweiz.  Ant.  for  April  12th 
Dr.  P.  von  Sohulthess-Rechberg  notes  that,  in  his  experience, 
the  beneficial  action  of  saccharose  in  pulmonary  tuberculosis 
appears  to  be  limited  to  a reduction  of  the  sputum.  Of  the 
nine  patients  thus  treated  six  reacted  with  severe  local  as 
well  as  with  general  disturbances,  and  also  with  a rise  of 
temperature.  One  patient  died  a fortnight  after  the  treat- 
ment was  started,  and  four  gave  it  up  on  account  of  the 
reactions  provoked.  In  four  cases  the  reduction  in  the 
amount  of  sputum  varied  between  20  and  80  per  cent.  In 
all  but  one  case  there  was  no  corresponding  improvement 
in  the  physical  signs.  The  most  important  observation  in 
this  series  of  cases  is  that  the  injections,  whatever  their 
merits,  are  liable  to  provoke  serious  and  even  dangerous 
reactions. 


MEDICINE  AND  THE  LAW. 


Professional  Secrecy  : The  Military  Aspect. 

The  question  of  professional  secrecy,  difficult  enough  in 
England,  is  in  France  posed  on  a somewhat  different  basis. 
At  a meeting  of  the  Societe  de  Medecine  Legale  (de  Paris), 
according  to  the  Presse  Medicate  (1919,  xxxvii.,  367),  M. 
Granjux  discussed  some  military  aspects  of  the  problem,  for 
apparently  there  have  been  medical  “ incidents  ” and,  it  is 
suggested,  administrative  ‘ ‘ errors  ” that  have  provoked  public 
comment.  At  any  rate,  M.  Granjux  feels  that  two  separate 
sets  of  circumstances  should  be  distinguished.  In  the  first,  a 
soldier  (officer  or  man)  reports,  or  “ goes  sick,”  as  we  say,  and 
is  seen  by  the  medical  officer  in  the  course  of  familiar  routine. 
The  ordinary  social  and  ethical  relationship  and  obligations, 
as  between  doctor  and  patient,  do  not  then  obtain  ; military 
administration  and  disciplinary  necessities  alone  are  involved, 
and  the  civil  issue  of  professional  secrecy  cannot  arise. 
In  the  second  case  recognised  by  M.  Granjux,  the  circum- 
stances, though  not  unknown,  are  less  familiar  to  those  who 
have  served  in  the  R.A.M.C.  We  are  here  asked  to  consider 
the  case  of  a “ militaire  ” (officer  or  man)  who  seeks  the 
advice  or  services  of  the  doctor  without  first  going  through 
the  process  of  “reporting  sick.”  Then,  says  M.  Granjux, 
the  surgeon  must  respect  his  patient’s  confidence.  It  appears, 
however,  that  when  a “ militaire  ” who  has  thus  sought  and 
obtained  the  advice  of  his  battalion  medical  officer  is  after- 
wards compelled  to  “go  sick,”  the  ethical  rule  recognised 
by  all  officers  of  the  Corps  de  Sante  is  to  forget  all  that  has 
passed,  and  to  begin  again  on  a purely  military  and  official 
footing. 

The  Civil  Aspect. 

At  the  same  session  as  that  at  which  the  military 
difficulty  was  discussed,  M.  Berthelemy  reopened  the  civil 
question,  which  has  become  recently,  in  France,  of  some 
moment.  While,  on  the  one  hand,  the  proposal  to  make 
obligatory  the  notification  of  tuberculosis  has  provoked 
many  objections  ; on  the  other,  the  crusade  against  criminal 
abortion  bids  fair  to  involve  doctors  in  many  difficulties.  As 
is  well  known,  the  French  Penal  Code,  by  Article  378,  con- 
stitutes the  violation  of  professional  secrecy  a punishable 
offendfe,  save  only  when  the  breach  is  in  response  to  the 
definitely  imposed  legal  obligation  to  give  information  under 
certain  circumstances.  As  the  result  of  certain  decisions 
of  the  Cour  de  Cassation,  however,  the  law,  in  the  words  of 
M.  Berthelemy,  has  Converted  the  custom  of  professional 
secrecy  into  a tyrannical  obligation  laid  upon  medical  men, 
overriding  the  social  duty  of  assisting  justice.  And 
M.  Berthelemy  thinks  that  it  has  been  an  error  thus  to 
convert  what  should  be  a facultative  means  of  escape  from 


172  The  Lancet,] 


AUSTRALIA.— URBAN  VITAL  STATISTICS. 


[July  26, 1919 


the  witness-box  into  an  absolute  prohibition  of  the  right  to 
perform  a duty  to  society. 

We  gather  that  it  is  now  proposed,  in  certain  legal  instru- 
ments designed  to  check  the  practice  of  criminal  abortion, 
to  enforce  the  rigid  application  of  the  doctrine  of  pro- 
fessional secrecy  by  the  clearest  legal  provision — the  impulse 
coming  from  the  public  rather  than  from  the  profession. 
M.  ’ Berth61emy  thinks,  however,  that  it  were  better  for 
medical  men  to  be  absolved  from  the  social  duty  in  particular 
circumstances  rather  than  to  be  forbidden  ever  to  perform  it. 

An  International  Contrast. 

This  striking  contrast  then  obtains  : that  while  in  Eogland 
the  effect  of  the  strict  interpretation  of  the  law  is  to  impose 
on  medical  men  the  “ social  duty  ” of  giving  information  of 
the  commission  of  a crime,  and  is  in  opposition  to  the  views 
of  that  body  of  professional  opinion  (recently  voiced  by  Sir 
John  Tweedy)  which  clings  to  the  sanctity  of  the  pro- 
fessional secret  as  a professional  privilege  ; in  France,  on 
the  other  hand,  there  is  an  apparently  strong  current  of 
professional  resentment  against  the  proscription  by  the  law 
of  the  right  to  exercise,  save  under  extremely  limited  condi- 
tions, the  duty  to  society.  It  is  not  suggested  for  one 
moment  that  our  French  brethren  are  less  scrupulous  than 
are  we  in  their  allegiance  to  the  spirit  and  letter  of  the 
Hippocratic  oath,  but  they  are  clear-headed  and  logical 
enough  to  recognise  the  possible  evil  to  the  State  if  medical 
men,  in  response  to  public  clamour,  are  forced  to  “contract 
out  ” of  social  obligations  which  are  not  less  incumbent  on 
them  than  on  others. 


AUSTRALIA. 

(From  our  own  Correspondent.) 

The  Influenza  Epidemic. 

The  progress  of  epidemic  influenza  has  shown  little  that 
is  new  during  the  past  month.  In  Sydney  there  has  been  a 
gradual  decline,  and  early  in  May  the  Government  removed 
all  restrictions,  including  the  wearing  of  masks  in  trains  and 
trams.  There  are  no  figures  which  are  at  all  accurate  as  to 
the  extent  of  the  outbreak,  but  the  number  of  deaths  will  be 
not  short  of  1000  in  New  South  Wales  for  the  present  wave. 
In  Melbourne  the  attack-rate,  as  gauged  from  the  death- 
rate,  has  been  curiously  steady,  and  from  20  to  30  deaths 
are  being  still  reported  daily  for  the  whole  of  Victoria.  The 
disease  has  been  just  as  prevalent  in  country  districts  as 
in  towns,  and  severe  cases  are  as  often  met  with. 
Brisbane  is  now  definitely  suffering  from  an  epidemic, 
but  as  yet  the  dimensions  are  not  alarming.  Adelaide 
has  also  now  become  infected,  although  the  number  of 
cases  is  not  great.  Several  well-known  medical  men  have 
succumbed  to  the  disease  in  different  States,  and  scarcely 
any  practitioner  has  escaped  more  or  less  severe  infection. 
The  resident  medical  officers  at  all  hospitals  have  been  at 
some  time  patients  during  the  past  few  months. 

There  is  as  yet  no  clear-cut  evidence  as  to  the  value  of  any 
preventive  measure  adopted  during  the  epidemic,  but  opinion 
is  crystallising  that  nothing  so  far  attempted  has  been  of  any 
avail  in  staying  the  spread  of  influenza.  The  experience  of 
public  mask-wearing  in  Sydney  does  not  support  the  idea 
that  it  is  worth  while,  and  it  has  been  regarded  by  all  as 
very  irksome  and  disagreeable.  Inbalatoiiums  in  which 
medicated  steam  was  supplied  for  a few  minutes  were  loudly 
advocated  by  some,  but  in  Sydney  the  medical  committee, 
after  employing  them,  condemned  them  as  harmful.  In 
Melbourne  they  were  nfever  used  except  by  the  Public  Health 
Department  at  a hospital  and  at  the  quarantine  grounds. 
Inoculation  may  be  said  to  have  lost  most  of  its  friends  and 
supporters,  both  lay  and  professional.  Some  observers  still 
persist  that  it  modifies  the  symptoms,  but  this  is  purely  a 
personal  opinion,  and  no  evidence  in  support  of  the  assertion 
is  produced. 

In  Victoria  the  acting  Minister  of  Health  has  appointed 
Dr.  H.  Newton  as  controller  of  influenza  hospitals,  and  has 
also  created  an  additional  staff  of  transport  and  organisation 
in  connexion  with  the  epidemic  aspect  of  influenza.  This 
work  was  in  the  hands  of  the  chairman  of  the  Board  of 
Public  Health,  but  it  has  proved  too  much  for  a single 
direction,  and  the  change  was  made  in  response  to  public 
clamour  for  more  vigorous  action.  No  considerable  steps 
have  as  yet  resulted  from  the  new  policy. 


Melbourne  University:  an  Ovsrcrorvded  Medical  School. 

The  Council  of  the  Melbourne  University  approached  the 
Victorian  Government  with  a request  for  money  in  order  to 
provide  increased  accommodation  for  students.  Every  school 
is  said  to  be  overcrowded,  but  the  urgent  requirement  is  in 
the  medical  school,  which  during  the  past  two  years  has  been 
taxed  to  breaking  point  to  find  room  for  first-  and  second-year 
students.  It  was  proposed  some  time  ago  to  remove  the 
medical  school  to  a separate  site  in  the  vicinity  of  the 
hospitals,  but  this  scheme  failed  to  attract  political  support, 
although  it  was  approved  by  the  profession  and  by  some  of 
the  University  staff.  The  Premier  was  sympathetic  to  the 
recent  deputation  and  has  undertaken  to  find  a sum  of 
£200,000  to  build  and  equip  new  class-rooms  and  laboratories. 

Venereal  Disease. 

A return  has  been  issued  of  the  number  of  cases  of  venereal 
diseases  notified  in  Victoria  for  the  year  1918.  It  appears 
that  6790  persons  were  affected  (State  population  about 
1,250,000).  Gonorrhoea  was  returned  alone  in  4878  cases, 
syphilis  in  1686,  and  the  two  in  combination  in  99  patients. 
The  remainder  were  various  combinations  of  infection.  In 
Victoria  the  diseases  are  compulsorily  notifiable  and  there 
are  penalties  for  neglecting  treatment.  There  are  clinics 
for  treatment  managed  wholly  hy  the  Government,  and  some 
of  the  general  hospitals  have  been  brought  into  the  scheme 
although  the  provision  on  this  regard  is  not  yet  very  great. 

Personal. 

Colonel  H.  Maudsley,  C.M.G.,  C.B.E.,  has  arrived  in 
Melbourne  after  an  absence  of  four  years  on  duty  with  the 
A.A.M.C.  in  Egypt  and  England.  Colonel  Maudsley  is 
lecturer  on  medicine  in  the  University  of  Melbourne  and  will 
take  up  bis  position  shortly. 

Lieutenant-Colonel  Sir  James  Barrett,  K.B.E.,  has  also 
returned  to  Melbourne  and  resumed  private  practice. 

The  death  is  announced  of  Surgeon-General  Sir  W.  T. 
Williams,  who  was  the  Director-General  of  the  Common- 
wealth Military  Forces  at  the  outbreak  of  war,  but  resigned 
owiDg  to  ill-health.  General  Williams  had  a distinguished 
record  in  the  Boer  war  with  the  New  South  Wales  contingents,  ! 
and  was  the  first  Director-General  of  the  Federal  military 
organisation. 

.May  27th.  


URBAN  VITAL  STATISTICS. 


VITAL  STATISTICS  OF  LONDON  DURING  JUNE,  1919. 

In  the  accompanying  table  will  be  found  summarised  statistics 
relating  to  sickness  and  fnortality  in  the  City  of  London  and  in  . 
each  of  the  metropolitan  boroughs.  With  regard  to  the  notified 

cases  of  Infectious  disease  it  appears  that  the  number  of  persons  j 

reported  to  be  suffering  from  one  or  other  of  the  ten  diseases 
notified  in  the  table  was  equal  to  an  annual  rate  of  4'7  per  , 

1000  of  the  population,  estimated  at  4,026.901  persons  ; in  the 

three  preceding  months  the  rates  had  been  4*5,  4'6,  and  4'5  per  1000. 
Among  the  metropolitan  boroughs  the  lowest  rates  from  these  notified 
diseases  were  recorded  in  Hammersmith,  the  City  of  Westminster*  1 
Hampstead,  St.  Pancras,  the  City  of  London,  and  Wandsworth ; and  the 
highest  in  Chelsea,  Holborn,  Bethnal  Green,  Stepney,  and  Southwark. 
Two  cases  of  small-pox  were  notified  during  the  month,  against  7,  2, 
and  3 in  the  three  preceding  months;  these  cases  belonged  respectively 
to  Stepney  and  Lambeth.  The  cases  of  small-pox  under  treatment  in 
the  Metropolitan  Asylums  Hospitals  at  the  end  of  the  month  numbered  2, 
against  6,  1,  and  3 at  the  end  of  the  three  preceding  months.  The  pre- 
valence of  scarlet  fever  was  slightly  more  than  in  the  preceding  month  ; 
this  disease  was  proportionally  most  prevalent  in  Finsbury.  Stepney, 
Southwark,  Lambeth.  Deptford,  and  Greenwich.  The  Metropolitan 
Asylums  Hospitals  contained  1132  scarlet  fever  patients  at  the  end 
of  the  month,  against  1009,  1C43,  and  1066  at  the  end  of  the  three 
preceding  months;  the  weekly  admissions  averaged  157,  against 
126,  138.  and  150  in  the  three  preceding  months.  The  number 
of  notified  cases  of  diphtheria  was  the  same  as  in  the  preceding 
month ; the  greatest  prevalence  of  this  disease  was  recorded  in 
Kensington,  Chelsea,  Holborn,  Shoreditch,  Bethnal  Green,  and 
Southwark.  The  number  of  diphtheria  patients  under  treatment 
in  the  Metropolitan  Asylums  Hospitals,  which  had  been  1152,  1134, 
and  1086  at  the  end  of  the  three  preceding  months,  numbered 
1021  at  the  end  of  June;  the  weekly  admissions  averaged  138, 
against  164,  151,  and  145  in  the  three  preceding  months.  Twenty-four 
cases  of  enteric  were  notified  during  June,  against  13.  18,  and^  22 
in  the  three  preceding  months;  of  these  cases,  5 belonged  to  Ken- 
sington, 3 to  Poplar.  2 to  Paddington,  and  2 to  Lewisham  There  were 
25  cases  of  enteric  fever  under  treatment  in  the  Metropolitan  Asylums 
Hospitals  at  the  end  of  the  month,  against  16,  16,  and  19  at  the  end 
of  the  three  preceding  months ; the  weekly  admissions  averaged  5, 
against  3,  2.  and  3 in  the  three  preceding  months.  Erysipelas  was 
proportionally  most  prevalent  in  Stoke  Newington,  Holborn,  Bethnal 
(ireen.  Poplar,  and  Southwark.  The  18  cases  of  puerperal  fever  notified 
during  the  month  included  2 each  in  Islington,  Poplar,  Wandsworth, 
Camberwell,  and  Deptford.  Of  the  14  cases  of  cerebro-spinal  meningitis 
2 belonged  to  Battersea  and  2 to  Greenwich ; while  of  the  6 cases  of 
poliomyelitis  2 belonged  to  St.  Marylebone. 


The  Lancet.] 


URBAN  VITAL  STATISTICS. 


[July  26,  1919  | 73 


ANALYSIS  OP  SICKNESS  AND  MORTALITY  STATISTICS  IN  LONDON  DURING  JUNE,  1919. 


(Specially  compiled  for  The  Lanokt.) 


Notified  Cases  of 

Infectious  Disease. 

Deaths  from  Principal  Infectious  Diseases. 

Cities  and 
Boroughs. 

Estimated  civi 
population,  191 

M 

| 

i 

M 

Scarlet  fever. 

Diphtheria.* 

Typhus  fever. 

Enteric  fever. 

1 Other  con- 
| tinued  fevers. 

Puerperal 

fever. 

| Erysipelas. 

ii 

V w 
O P 

£’3 

o>  <x> 

CD  3 
o 

+3 

<0 

o> 

a 

o 

’o 

Ph 

5 

O 

H 

Annual  rate 
per  1000 
persons  living. 

0 

1 

Measles. 

| Scarlet  fever. 

| Diphtheria.* 

1 Whooping- 
cough. 

| Enteric  fever. 

Diarrhoea  and 
enteritis  (undei 
2 years). 

Total. 

Annual  rate 
per  1000 
persons  living. 

Deaths  from  al 
causes. 

Death-rate  p 
| 1000  living. 

LONDON 

4,026,901 

2 

654 

570 

24 

_ 

18 

151 

14 

6 

1439 

4-7 

j 

23 

6 

37 

6 

— 

35 

107 

03 

3011 

97 

West  Districts  : 

4-3 

Paddington  

122,507 

— 

12 

18 

— 

2 

— 

1 

6 

— 

I 

40 

— 

1 

— 

— 

— 

— 

1 

2 

0-2 

83 

8-8 

Kensington  

161,535 

— 

14 

34 

— 

5 

— 

1 

7 

1 

— 

62 

53 

1 — 

4 

— 

2 

— 

— 

1 

7 

0-6 

140 

12-0 

Hammersmith 

114,952 

— 

10 

14 



— 

— 

1 

1 

1 

— 

27 

3'1 

— 

— 

1 

— 

1 

— 

3 

5 

0 6 

72 

8-2 

Fulham  

145,186 

— 

24 

16 

— 

— 

— 

1 

5 

— 

46 

4-1 

— 

1 

— 

— 

— 

— 

i 

2 

0-2 

95 

85 

Chelsea  

57,368 

— 

11 

16 



1 

— 

— 

— 

— 

— 

28 

6-4 

— 

— 

— 

1 

— 

— 

— 

1 

0-2 

45 

10-2 

City  of  Westminster 
North  Districts  : 
St.  Marylebone  ... 

122,046 

— 

10 

6 

— 

— 

— 

— 

5 

1 

— 

22 

2'3 

1 

1 

— 

— 

— 

— 

— 

1 

o-i 

93 

9-9 

92,796 

— 

16 

16 



— 



3 

2 

37 

5-2 



1 

1 

1 

1 

— 

i 

5 

0 7 

74 

10-4 

Hampstead  

75,649 

— 

5 

6 

— 

1 

— 

— 

— 

— 

— 

12 

2'1 

— 

— 

— 

1 

— 

— 

i 

2 

0-3 

49 

8-4 

St.  Pancras  

186,600 

— 

26 

15 

_ 

— 

— 

— 

7 

- 

1 

49 

3 4 

— 

3 

1 

— 

— 

i 

5 

0-3 

142 

99 

Islington 

297,102 

— 

40 

59 

— 

1 

— 

2 

10 

1 

— 

113 

50 

— 

1 

— 

3 

— 

— 

3 

7 

0-3 

238 

10-4 

Stoke  Newington... 

47,426 

— 

9 

5 

— 

— 

— 

3 

— 

17 

4-7 

— 

— 

— 

1 

— 

— 

— 

1 

03 

40 

IPO 

Hackney 

196,598 

— 

36 

30 

— 

1 

— 

— 

5 

_ 

— 

72 

4-8 

— 

— 

— 

5 

— 

— 

2 

7 

0-5 

154 

10-2 

Central  Districts  : 

Holborn  

35,303 

— 

6 

13 

— 

— 

— 

2 

— 

— 

21 

7-8 

— 

— 

28 

10 '3 

Finsbury  

68,011 

• 

14 

10 

— 

24 

4-6 

— 

65 

12-5 

City  of  London 

16,138 

— 

1 

1 

— 

— 

— 

— 

— 

— 

— 

2 

1-6 

— 

— 

— 

— 

— 

— 

— 

— 

— 

9 

7 3 

East  Districts : 

Shoreditch  

89,675 

— 

2 

19 

— 

1 

— 

— 

4 

1 

— 

27 

3'9 

— 

— 

— 

— 

— 

— 

— 

— 

— 

83 

121 

Bethnal  Green 

107,362 

— 

21 

22 

— 

— 

— 

— 

10 

— 

I 

54 

6'6 

3 

— 

2 

— 

— 

2 

7 

0-8 

88 

10  7 

Stepney  

232,010 

1 

76 

40 

— 

1 

— 

— 

9 

1 

— 

128 

7-2 

— 

1 

1 

1 

1 

— 

3 

7 

04 

179 

10-1 

Poplar  

143,443 

— 

19 

13 

— 

3 

— 

2 

8 

— 

— 

45 

4-1 

— 

1 

— 

2 

— 

— 

2 

5 

0-5 

115 

10-5 

South  Districts : 

Southwark  

167,936 

— 

60 

41 

— 

1 

— 



12 

1 

— 

115 

89 

— 

— 

— 

7 

1 

— 

— 

8 

06 

121 

9 4 

Bermondsey  ...  ... 

107,635 

— 

14 

19 

— 

1 

— 

— 

4 

— 

— 

38 

46 

— 

1 

— 

— 

— 

— 

— 

1 

o-i 

86 

10  4 

Lambeth 

272,038 

1 

59 

23 

— 

1 

— 

1 

13 

1 

— 

99 

4-7 

— 

2 

— 

5 

— 

— 

4 

11 

0-5 

227 

109 

Battersea 

150,023 

— 

20 

21 

— 

— 

— 

1 

6 

2 

— 

50 

4-3 



— 

— 

— 



— 

1 

1 

o-i 

107 

93 

Wandsworth 

300,787 

— 

36 

19 

— 

1 

— 

2 

6 

1 

1 

66 

2-9 

_ 

— 

— 

2 



— 

1 

3 

o-i 

202 

8 8 

Camberwell  

239,461 

— 

32 

28 

— 

— 

— 

2 

11 

— 

— 

73 

4'0 



1 

1 

— 

2 



5 

9 

0'5 

169 

92 

Deptford 

103,527 

— 

22 

9 

— 

— 

— 

2 

5 

— 

— 

38 

4-8 



1 

— 

— 

— 

— 

— 

1 

O'l 

60 

7 6 

Greenwich  

90,440 

— 

19 

10 

— 

1 

— 



— 

2 

— 

32 

4 6 



— 

1 

— 

* 

— 

1 

2 

0-3 

62 

89 

Lewisham  

161,405 

— 

25 

23 

— 

2 

— 

1 

7 

i 

— 

59 

4 8 



— 

— 

1 





1 

2 

02 

£6 

7'8 

Woolwich 

131,942 

— 

15 

24 

— 

1 

— 

1 

2 

— 

— 

43 

4'2 

— 

1 

— 

3 

— 

— 

1 

5 

0-5 

89 

8 8 

Port  of  London  ... 

* Including  membranous  croup. 


The  mortality  statistics  in  the  table  relate  to  the  deaths  of  civilians 
belonging  to  the  several  boroughs,  the  deaths  occurring  in  institutions 
having  been  distributed  among  the  boroughs  in  which  the  deceased  had 
previously  resided.  During  the  four  weeks  ended  June  28th  the  deaths 
of  3011  London  residents  were  registered,  equal  to  an  annual  rate  of  9 7 
per  1000  ; In  the  three  preceding  months  the  rates  had  been  20'9,  15  0, 
and  11*1  per  1000.  The  death-rates  ranged  from  7*3  in  the  City  of 
London,  7‘6  in  Deptford,  8 2 in  Hammersmith,  8‘4  in  Hampstead,  and 
j 8*5  in  Fulham,  to  10  7 in  Bethnal  Green,  10  9 in  Lambeth,  11*0  in  Stoke 
Newington,  12  0 in.Kensington,  12’1  in  Shoreditch,  and  12*5  in  Finsbury. 

! The  3011  deaths  from  all  causes  included  107  which  were  referred  to  the 
principal  infectious  diseases  ; of  these,  23  resulted  from  measles.  6 from 
scarlet  fever,  37  from  diphtheria,  6 from  whooping-cough,  and  35  from 
diarrhoea  and  enteritis  among  children  under  2 years  of  age.  No 
death  from  any  of  these  diseases  was  recorded  in  Holborn,  Finsbury, 
the  City  of  London,  and  Shoreditch.  Among  the  metropolitan 
boroughs  the  lowest  death-rates  from  these  diseases  were  recorded 
in  the  City  of  Westminster,  Bemondsey,  Battersea,  Wandsworth,  and 
Deptford  ; and  the  highest  in  Kensington,  Hammersmith,  St. 
Marylebone,  Bethnal  Green,  and  Southwark.  The  23  deaths  from 
measles  were  less  than  a fifth  of  the  average  number  in  the  corre- 
sponding period  of  the  five  preceding  years ; of  these  deaths  4 
belonged  to  Kensington,  3 to  St.  Pancras,  3 to  Bethnal  Green,  and  2 to 
Lambeth.  The  6 fatal  cases  of  scarlet  fever  were  7 below  the  average 
number.  The  37  deaths  from  diphtheria  were  one  less  than  the 
average;  of  these  deaths  7 belonged  to  Southwark,  5 to  Hackney,  5 to 
Lambeth,  3 to  Islington,  and  3 to  Woolwich.  The  6 fatal  cases  of 
whooping-cough  were  one-twelfth  of  the  average  number ; of  these, 
2 belonged  to  Camberwell.  No  death  from  enteric  fever  was  recorded 
during  the  month,  against  an  average  of  9.  The  35  deaths  from 
diarrhoea  and  enteritis  among  children  under  2 years  of  age  were 
20  less  than  the  average  number;  of  these  deaths,  5 belonged  to 
Camberwell,  4 to  Lambeth,  3 to  Hammersmith,  3,to  Islington,  and  3 to 
Stepney.  In  conclusion,  it  may  be  stated  that  the  aggregate  mortality 
from  these  principal  infectious  diseases  in  London  during  June  was 
66  per  cent,  below  the  average. 


(Week  ended  July  19th,  1919.) 

English  and  Welsh  Towns. — In  the  96  English  and  Welsh  towns, 
with  an  aggregate  civil  population  estimated  at  16,500,000  persons, 
the  annual  rate  of  mortality,  which  had  been  9'6,  lO'O,  and  10’1  in  the 
three  preceding  weeks,  declined  to  9 0 per  1000.  In  London,  with 
a population  slightly  exceeding  4,000,000  personp,  the  annual  rate 
was  9-2.  or  0 8 per  i000  below  that  recorded  in  the  previous  week, 
while  among  the  remaining  towns  the  rates  ranged  from  3’3  in 
Norwich,  4*4^n  Wakefield,  and  4‘5  in  Coventry,  to  13  8 in  Stoke-on- 
Trent,  14  2 in  Gillingham,  and  14’7  in  Darlington  and  in  Sunderland.  The 
principal  epidemic  diseases  caused  109  deaths,  which  corresponded  to 
an  annual  rate  of  0’3  per  1000,  and  included  35  from  diphtheria,  34  from 
infantile  diarrhoea,  19  from  measles,  11  from  whooping-cough,  6 from 
scarlet  fever,  and  4 from  enteric  fever.  The  mortality  from  these 
diseases  showed  no  marked  excess  in  any  town.  There  were  5 cases 


of  small-pox,  1438  of  scarlet  fever,  and  1100  of  diphtheria  under 
treatment  in  the  Metropolitan  Asylums  Hospitals  and  the  London 
Fever  Hospital,  against  6,  1348,  and  1C68  respectively  at  the  end  of 
the  previous  week.  The  causes  of  21  deaths  in  the  96  towns  were 
uncertified,  of  which  4 were  registered  in  Birmingham,  and  2 each  in 
London,  Stoke-on-Trent,  Middlesbrough,  Darlington,  and  Gateshead. 

Scotch  Towns. — In  the  16  largest  Scotch  towns,  with  an  aggregate 
population  estimated  at  nearly  2,500,000  persons,  the  annual  rate  of 
mortality,  which  had  been  11*5.  9 9,  and  110  in  the  three  preceding 
weeks,  fell  to  10  6 per  1C00.  The  227  deaths  in  Glasgow  corresponded 
to  an  annual  rate  of  10  6 per  1000,  and  included  10  from  whooping- 
cough,  4 from  diphtheria,  and  3 each  from  measles  and  infantile 
diarrhoea.  The  59  deaths  in  Edinburgh  were  equal  to  a rate  of  9’1  per 
1 1000,  and  included  1 each  from  measles,  whooping-cough,  and  infantile 
I diarrhoea. 

Irish  Towns. — The  70  deaths  in  Dublin  corresponded  to  an  annual 
rate  of  9 0,  or  4*1  per  1000  below  that  recorded  in  the  previous 
week,  and  included  6 from  infantile  diarrhoea.  The  84  deaths  in  Belfast 
were  equal  to  a rate  of  10  9 per  1000.  and  included  1 each  from  measles, 
scarlet  fever,  diphtheria,  and  infantile  diarrhoea. 


Bristol  Hospital  Sunday  Fund.— Mr.  J.  H. 
Reed  has  retired  from  the  honorary  secretaryship  of  this 
fund  after  21  years,  during  which  time  nearly  £47,000  have 
been  collected  for  the  Bristol  medical  charities,  and  the 
annual  total  of  a few  hundreds  increased  to  £5300. 

Donations  and  Bequests. — By  the  will  of  the 
late  Mr.  W.  Shepherd,  of  Clapbam  Park  and  Guildin- 
hurst  Manor,  Sussex,  who  left  property  of  the  value  of 
£600,000,  the  testator  has  bequeathed  the  larger  part  of 
this  sum  to  London  hospitals.— Under  the  will  of  the 
late  Mr.  Longueville  Gladstone,  of  Liverpool,  the  testator 
has  left  £1000  to  the  Liverpool  Royal  Infirmary,  £700  to  the 
Royal  Southern  Hospital,  £500  each  to  the  David  Lewis 
Northern  Hospital,  Stanley  Hospital,  and  the  School  for  the 
Indigent  Blind,  and  £2000  for  such  other  charities  as  the 
executors  and  Mayor  of  Liverpool  may  select.— The  late  Miss 
Mary  Austin,  of  Bath,  has,  among  other  bequests,  left  £500 
each  to  the  Finsbury  Dispensary,  Clerkenwell,  and  to  the 
Norwood  Cottage  Hospital,  and,  on  the  death  of  her  sister, 
£500  each  to  the  Middlesex  Hospital,  Westminster  Hospital, 
Guy’s  Hospital,  and  the  Royal  United  Bath  Hospital.— 
Subject  to  the  life-interest  of  two  sisters,  the  late  Dr.  J. 
Duff,  of  Chester,  has  left  by  will  property  of  the  value  of 
£9752  to  Glasgow  University  to  form  a Fellowship  for  the 
elucidation  of  malignant  diseases. 


174  The  Lancet,] 


INCIPIENT  MENTAL  DISEASES. 


[July  26, 1919 


Correspondence. 

■*  Audi  alteram  partem.” 


INCIPIENf  MENTAL  DISEASES. 

To  the  Editor  of  The  Lancet. 

Sir, — In  reports  of  committees,  in  articles  in  medical 
papers,  in  books  recently  published,  and  in  last  year’s  report 
of  the  Board  of  Control  the  early  treatment  of  these  cases 
without  certification  and  by  simple  notification  has  been 
earnestly  suggested.  Now  a whisper  reaches  me  that  during 
the  next  session  the  Ministry  of  Health  intend  to  bring  in  a 
short  Bill  dealing  with  these  cases,  and  my  very  heart 
rejoices. 

One  great  drawback  to  the  early  treatment  of  mental 
diseases  has  not  only  been  the  Lunacy  Act  of  1890,  but  also 
the  curious  unreasonable  attitude  of  the  general  public,  ,who 
still  insist  in  looking  at  mental  disease  as  a “stigma  ” on 
the  family.  By  allowing  these  cases  to  be  under  the  Board 
of  Control,  which  deals  only  with  mental  diseases,  and  under 
their  supervision,  as  suggested  in  their  last  year’s  report,  this 
“ stigma  ” would  still  exist  ; whereas  if  these  cases  are  dealt 
with  by  the  Ministry  of  Health,  together  with  all  sorts  of 
other  diseases,  the  idea  of  “stigma”  will  be  done  away 
with. 

There  are,  however,  some  important  points  to  be  con- 
sidered and  brought  to  the  notice  of  the  general  public. 

(1)  There  seems  to  be  difficulty  in  the  minds  of  those  who 
are  bringing  in  this  Bill  as  to  the  way  in  which  these  cases 
should  be  defined.  Should  they  be  called  : (a)  not  certified 
cases,  ( h ) uncertifiable  cases.  Personally  I prefer  the 
latter  definition,  as  the  first  one  leaves  the  question  open  as 
to  whether  or  no  they  are  certifiable. 

(2)  Supervision. — These  cases  must  be  under  some  super- 
vision. I feel  sure  the  Ministry  of  Health  will  deal  with 
these  cases  with  regard  to  proper  supervision  in  the  most 
humanitarian  manner.  The  Board  of  Control,  in  their  1918 
report,  agree  as  to  the  necessity  of  supervision,  bnt  do  not 
see  their  way  to  carry  it  out  with  their  present  staff  and  the 
work  they  have  already  in  hand,  so  it  ought  to  be  a comfort 
to  them  to  find  the  Ministry  of  Health  are  takiDg  up  this 
matter. 

(3)  As  to  who  should  take  charge  of  these  cases  it  seems 
to  be  obvious  that  the  more  skilled  supervision  and  treat- 
ment they  come  under  the  greater  will  be  their  chance  of 
recovery.  Single  cases  may  be  in  some  instances  easily  and 
properly  placed,  but  I am  strongly  of  opinion  that  “approved 
homes”  for  such  cases  should  be  permitted,  as  are  now 
allowed  for  cases  of  mental  deficiency.  Such  approved 
homes  should  be  under  the  charge  of  experienced  physicians 
if  good  results  are  to  be  obtained. 

(4)  Limitation  of  sojourn  for  such  cases.  It  has  been 
suggested,  both  by  the  Board  of  Control  and  committees, 
that  such  period  should  be  for  six  months  only.  To  my 
thinking  this  is  utterly  wrong,  unless  such  period  be  renew- 
able in  certain  cases.  A patient  may  be  nearly  well  when 
the  six  months  has  expired.  To  suddenly  take  such  a patient 
from  the  care  and  treatment  and  the  environment  in  which 
he  or  she  has  got  well  to  some  new  home  surroundings  and 
treatment  might  be  fatal.  I therefore  consider  that  the  six 
months  should  be  renewable  in  certain  cases. 

We  who  have  spent  our  lives  in  treating  mental  diseases 
in  all  stages  have  only  one  wish,  and  that  is  to  increase  the 
recovery  rate  of  mental  diseases,  which  has  stood  still  during 
the  last  60  years.  I trust  my  suggestions  will  meet  not 
only  with  your  approval,  but  with  that  of  the  medical  pro- 
fession, the  general  public,  and  the  Ministry  of  Health. 

I am,  Sir,  yours  faithfully, 

July  2iot,  1919.  Lionel  A.  Weatherly,  M.D. 


PARAFFIN  WAX  IN  FACIAL  SURGERY. 

To  the  Editor  of  The  Lancet. 

Sir, — In  your  issue  of  July  19th  Lieutenant-Colonel 
Spencer  Mort  contributes  a very  interesting  and  carefully 
thought-out  article  on  this  subject,  and  advises  the  use  of 
paraffin  wax  for  facial  scars  and  depressions  of  contour  of  the 
face.  There  is  no  doubt  that  his  method  of  insertion  of 
paraffin  wax  is  the  most  practical  and  fruitful  in  giving  good 


immediate  results.  I cannot,  however,  let  the  opportunity 
pass  without  entering  a protest  against  the  practice  of 
insertions  into  the  facial  tissues  of  any  foreign  body,  and 
of  wax  in  particular.  Before  my  department  was  moved 
en  bloc  to  Sidcup  it  had  been  clearly  shown  by  myself  and 
my  colleagues  that  the  natural  tissues  of  the  body,  in  the  form 
of  autologous  grafts  or  tissue  flaps,  give  ultimate  results 
quite  as  cosmetic  as  those  of  any  foreign  body  implantation. 

In  regard  to  paraffin,  in  1916  I was  inserting  it  in  blocks, 
and  I also  used  the  syringe  method,  which  gives  such 
excellent  immediate  results  with  those  who  are  familiar  with 
the  method,  particularly  the  Bond  Street  beauty  specialists. 

I thoroughly  agree  with  Colonel  Mort  in  condemning  this 
practice  ; in  fact,  I should  go  so  far  as  to  say  that  the  injec- 
tion of  melted  paraffin  into  the  face  is  a practice  that  should 
be  prohibited  by  law.  A solid  block  of  paraffin  wax  is  better 
than  the  injected  wax,  in  that  the  late  bad  results  are  fewer 
and  more  easily  dealt  with  ; at  the  same  time,  fibrosis  must 
naturally  occur  round  any  block  of  paraffin  in  the  attempt,  .j 
sometimes  successful,  of  the  tissues  to  get  rid  of  the  foreign 
body.  When  placed  deep  I admit  little  harm  comes  there- 
from, but  I think  the  practice  is  a retrograde  step. 

The  class  of  case  with  which  Colonel  Mort  states  he  has 
had  the  best  results— viz. , depressed  scars— can  easily  be 
remedied  by  excision  of  the  scar  tissue  and  the  use  of  sub- 
cutaneous flaps  to  build  up  the  contour.  In  the  larger 
depressions  cartilage  implantations  or  muscle  flaps,  combined 
with  complete  and  total  excision  of  the  scar,  give  the 
most  perfect  results  possible.  This  opinion  is  shared  by 
all  my  facial  colleagues  at  the  Queen’s  Hospital,  and,  in 
particular,  by  our  consulting  surgeon,  Sir  William  Arbuthnot 
Lane.  I am,  Sir,  yours  faithfully, 

H.  D.  Gillies,  F.R.C.S., 

London,  July  23rd,  1919.  Major,  B.A.M.C. 


NATIONAL  HEALTH  INSURANCE  AND  THE 
MEDICAL  GUILD. 

To  the  Editor  of  The  Lancet. 

gIRi i have  been  instructed  by  Dr.  John  Playfair,  the 

President,  and  the  Executive  Committee  of  the  Medical 
Guild  to  submit  for  your  consideration  the  following  sug-  i 
gestions  embodied  in  certain  resolutions  passed  at  recent  i 
meetings  of  the  Guild,  after  full  consideration  of  the 
Memorandum  of  the  Insurance  Commissioners  and  the  report 
of  the  Insurance  Acts  Committee  of  the  British  Medical 
Association  on  the  Revision  of  the  Conditions  of  Service 
under  the  National  Health  Insurance  Acts  and  possible 
extensions  of  service  : — 

(1)  That  professional  attendance  and  treatment  given  to  j 
any  insured  person  by  any  registered  medical  practitioner  < 
acting  solely  on  the  usual  understanding  subsisting  between 

a practitioner  and  his  private  patient  shall  be  recognised  as 
medical  benefit  for  that  person,  and  such  person  shall  receive 
a just  contribution  from  moneys  provided  for  medical  benefit  ' 
towards  the  payment  of  such  attendance  and  treatment. 

(2)  That  obstetric  practice  should  not  be  included  within 
the  range  of  National  Health  Insurance. 

(3)  That  tuberculosis  should  be  excluded  from  the  range  of 
National  Health  Insurance. 

(4)  That  the  National  Health  Insurance  Acts  as  at  present 
administered  should  not  be  extended,  with  the  exception  of 

specialists’ advice  to  the  present  insured. 

(5)  That  a State  Medical  Service  is  of  urgent  necessity  for 
the  genuinely  necessitous  classes  of  the  community  and  for 
them  only. 

With  regard  to  the  first  of  these  resolutions  or  suggestions, 
it  has  been  estimated  that  there  are  approximately  20.000j, 
insured  persons  in  Edinburgh  who  receive  professional 
attendance  and  treatment  from  non-panel  practitioners,  and 
as  this  number  is  increasing  annually  it  is  a matter  of 
justice  that  those  persons  should  be  allowed  a money  con- 
tribution towards  payment  of  such  attendance  and  treatment, 
especially  when  the  fact  is  taken  into  account  that  the  large 
sum  of  money  for  payment  of  the  medical  benefit  of  those 
persons  is  being  paid  to.  or  distributed  among,  the  panel 
practitioners  who  do  not  work  and  never  wifi  have  the 
opportunity  of  working  for  this  money.  This  statement  is 
applicable  to  ether  towns  and  cities. 

I am.  Sir,  yours  faithfully. 

Frederick  Porter, 

Edinburgh.  July  15tb,  1919.  Honorary  Secretary. 


The  Lancet,]  THE  ORIGIN  OF  LIFE:  WORK  OF  THE  LATE  CHARLTON  BASTIAN.  [July  26,  1919  175 


THE  ORIGIN  OP  LIFE:  THE  WORK  OF  THE 
LATE  CHARLTON  15  ASTI  AN. 

To  the  Editor  of  The  Lancet. 

Sir, — Dr.  Albert  Mark’s  letter  in  The  Lancet  of  Jane  28th 
is  most  interesting,  and  his  experiments  show  that  Dr. 
Bastian’s  results  are  probably  due  to  chemical  actions  of 
a catalytic  nature  ; but  the  influence  of  osmotic  pressure,  by 
diffusion  effects  in  colloid  solutions,  is  also  an  important 
factor  that  must  not  be  neglected  in  such  operations.  Dr. 
Stophane  Leduc  has  obtained  some  very  remarkable  results 
in  this  connexion.1  Artificial  bodies,  known  since  Butschli's 
day  as  simulacra , can  be  brought  about  apparently  without 
the  aid  of  life.2  In  many  chemical  reactions,  as  well  as 
purely  physical  ones,  there  is  a swift  passage  of  electrons, 
both  positive  and  negative,  through  the  medium  in  which  the 
reaction  takes  place.  I may  perhaps  mention  in  this  con- 
nexion the  very  beautiful  experiments  by  Emil  Hatschek,3 
which  show  on  a larger  scale  that  the  swift  passage  of  a 
body,  or  even  a drop  of  liquid,  through  a “gel”  can  give 
rise  to  motions  of  the  nature  of  vortices  in  the  “gel,” 
resembling  organisms  ; and  I conceive  that  many  chemical 
reactions  and  the  emission  of  a and  /3  particles  from  radio- 
active substances,  immersed  in  colloid  mediums,  should  do 
so  likewise,  producing  such  vortex  motions  resembling 
bacteria  on  a much  smaller  scale.  In  fact,  I have  described 
phenomena  of  this  kind  in  Nature  (May  25th,  1905),  and  in 
the  Fortnightly  Review  (September,  1905),  as  well  as  in  my 
book  “The  Origin  of  Life,”  1906.  These  bodies,  which  I 
called  at  the  time  radiobes  owing  to  their  mongrel  origin, 
differ  considerably  from  the  precipitated  products  of  barium, 
strontium,  or  lead,  as  might  have  been  expected.  But  this 
is  a point  that  some  observers  seem  to  have  overlooked,  for  the 
products  of  radium  are  something  more  than  mere  pre- 
cipitates as  their  behaviour  shows,  and  have  many  of  the 
properties  of  living  organisms,  though  not  all  of  them,  since 
they  do  not  produce  subcultures,  perhaps  owing  to  the 
medium  being  unsuitable,  as  in  Dr.  Mary’s  experiments. 
It  seems  to  me,  then,  that  both  Dr.  Bastian  and  Dr. 
Mary’s  results  may  be  explained  by  the  setting  up  of 
such  vortex  motions  through  catalysis  and  the  rapid  inter- 
change of  electrons  which  it  involves,  whilst  in  some  cases 

I by  mere  diffusion  and  osmosis,  as  in  the  experiments  of 
M.  Leduc  already  referred  to.  But,  as  I have  found,  the 
immersion  of  a radio-active  substance  in  a colloid  medium 
facilitates  their  production,  and  this,  no  doubt,  for  the 
dynamical  reasons  which  I have  just  endeavoured  to  explain. 
I am.  Sir,  yours  faithfully, 

Kingston  Hill,  July  17th,  1919.  J.  BUTLER  BURKE. 


QUININE  AS  A PROPHYLACTIC  IN  MALARIA. 

To  the  Editor  of  The  Lancet. 

Sir, — When  serving  at  Sierra  Leone  about  ten  years  ago  I 
came  across  the  following  extract  from  the  medical  history 
of  the  war  in  the  Gold  Coast  Protectorate  in  1873,  written 
by  Deputy  Surgeon-General  Sir  A.  D.  Home,  V.C.,K.C.B.: — 

“The  use  of  quinine  as  a prophylactic  against  ‘fever  ’ to  the  troops 
on  the  Gold  Coast  had  been  one  of  the  sanitary  instructions  of  the  D.G. 
-issued  to  the  P.M.O.  on  his  assuming  charge. 

It  need  not  be  said  "bat  the  use  of  the  drug  in  this  way  to  men 
employed  on  duty  on  malarious  coasts  is  an  established  practice  in  the 
Navy,  one  recommended  by  the  authority  of  high  professional  opinion 
as  to  its  value.  Accordingly,  Army  medical  officers  serving  on  the 
Coast  were  requested  in  Departmental  orders  to  give  quiniue  daily  in  a 
prophylactic  dose. 

It  was  not  possible  to  procure  the  information  asked  for  as  to  the 
influence  of  quinine  in  warding  off  attacks  of  fever,  as  medical  officers 
had  been  changed  so  frequently  and  the  composition  of  the  detach- 
ments had  varied  so  much  that  continuous  observation  of  the  same 
individuals,  even  for  one  month,  was  unattainable. 

On  so  important  a subject,  however,  in  the  absence  of  precise 

Idata,  it  may  be  desirable  to  state  the  conclusions  come  to  with  respect 
to  it  from  observation. 

With  regret,  and  heartily  wishing  that  my  opinion  may  be  over- 
thrown by  others,  I have  to  say  that  I did  not  recognise  any  value  in 
quinine  given  prophylactieally.  It  neither  seemed  to  ward  off  attacks 
or  to  mitigate  the  severity  of  malarious  fevers  in  those  attacked.  With 
the  exception  that  in  some  mer  a daily  3 gr.  dose  produced  transient 
deafness,  and  in  a few  others  nausea,  no  untoward  symptoms  followed 
the  use  of  the  medicine.  On  the  other  hand,  I was  unable  to  agree 
with  the  startling  opinion  seriously  propounded  to  me  by  some  men  of 
the  West  India  Regiment  encamped  at  Port  Napoleon,  that  the  quinine 
given  dally  as  a prophylactic  had  given  them  the  ague  from  which  they 
suffered.”  J 

Inuring  the  year  I acted  as  senior  medical  officer  every 
soldier  stationed  at  Freetown  got  10  gr.  on  Thursday  and 

1 See  his  “Mechanism  of  Life,”  translated  by  Dr.  Deane  Butcher,  1911. 
2 Microscopic  Foam  and  Protoplasm,  1894. 

3 Proc.  Roy.  Soe.,  Series  A,  yol.  xcv.,  No.  669. 


15  gr.  on  Friday.  I kept  its  administration  in  the  hands  of 
one  officer  whom  I placed  in  charge  of  the  Tower  Hill 
Hospital,  and  in  order  that  there  should  be  no  break  I 
arranged  to  keep  him  there  for  the  whole  year. 

He  reported  25  per  cent,  less  attacks  than  during  the 
previous  year  1 

I consider  that  if  he  had  been  able  to  report  a diminution 
of,  say,  75  per  cent.,  one  would  have  been  justified  in  think- 
ing that  quinine  in  these  doses  had  acted  as  a prophylactic. 
Tlie  number  of  cases  might  easily  vary  to  the  extent  reported 
from  other  causes. 

Curiously  enough,  a soldier  of  the  West  India  Regiment 
told  me  that  his  bi-weekly  dose  of  quinine  was  invariably 
followed  by  an  attack  of  ague. 

I am,  Sirs,  your  faithfully, 

F.  J.  W.  Porter, 

Bombay,  June  14th,  1919.  Major,  ll.A.M.C.  fretd.). 

PROFESSIONAL  SECRECY  IN  THE  EYE  OF 
THE  LAW. 

To  the  Editor  of  The  Lancet. 

Sir,— Sir  John  Tweedy’s  letter  in  your  issue  of  July  5th, 
dealing  with  the  accepted  canons  of  the  medical  profession 
in  disclosing  the  confidences  of  patients,  suggests  an  analogy 
with  confidences  made  to  the  clergy.  Some  of  your  clientele 
are  old  enough  to  recall  the  “ Road  ” murder,  which  for  a 
long  time  baffled  detection.  Then  the  Rev.  A.  D.  Wagner, 
who  was  vicar  of  St.  Paul’s,  Brighton,  and  who  ran 
an  Anglican  Conventual  establishment  in  that  town, 
induced  one  of  his  penitents,  who  had  confessed  to 
him  that  she  was  guilty  of  the  crime,  to  make  a 
clean  breast  of  it  to  the  civil  authorities.  If  I remember 
rightly,  for  it  was  in  the  early  “ sixties,”  the  line  that  this 
clergyman  took  was  that  he  himself  was  unable  to  divulge 
what  had  been  told  to  him  under  confessional  secrecy,  but 
that  he  made  it  very  patent  to  this  poor  unfortunate  girl  that 
if  she  was  truly  penitent  she  should  make  an  open  confession 
of  the  murder  she  had  committed,  which  confession  at 
the  same  time  would  exonerate  such  as  were  still  under 
suspicion  of  having  been  the  perpetrators. 

Even  now  there  is  being  discussed  in  the  United  States  a 
very  interesting  example  of  a refusal  to  betray  trust.  Four 
years  ago  Judge  Lindsey,  of  Denver  Juvenile  Court,  had 
before  him  a certain  boy  with  whom  he  had  talked  in  his 
capacity  as  Juvenile  Judge,  and  to  whom  he  had  given  his 
solemn  promise  that  he  would  not  disclose  any  state- 
ment the  boy  made  to  him.  Plainly  the  element  of  confi- 
dence between  the  judge  and  the  child  is  essential  to  the 
success  of  the  Juvenile  Court.  As  plainly,  to  destroy  this 
relationship  would  be,  in  effect,  to  nullify  and  set  aside  the 
chief  end  and  purpose  of  the  Juvenile  Court. 

I am.  Sir,  yours  faithfully, 

Theodore  P.  Brocklehurst, 

July  14th,  1919.  Rector  of  Giggleswick-in-Craven. 


PENTOSURIA. 

To  the  Editor  of  The  Lancet. 

Sir, — With  reference  to  your  annotation  under  the  above 
heading  in  The  Lancet  for  July  19th  (p.  117),  my  experi- 
ence may  be  interesting  as  bearing  on  the  frequency  with 
which  this  condition  is  met  with.  During  the  month  of 
June  I saw  56  cases  diagnosed  as  diabetes  mellitus,  and  of 
these  11  proved  to  be  passing  pentoses  in  their  urine ; 
9 were  found  to  be  of  the  alimentary  type,  the  charac- 
teristic diphenylhydrazone  and  para-bromphenylosazone  of 
1-arabinose  being  recovered  from  the  urine  ; and  2 were 
cases  of  true,  or  essential,  pentosuria,  the  first  examples  of 
this  condition  met  with  in  England,  I believe.  One  of 
these  cases  of  essential  pentosuria  passed  i-arabinose  alone  ; 
the  other  excreted  a mixture  of  this  sugar  with  dextrose  and 
pseudo-lmvulose.  Under  treatment  the  dextrose  and  pseudo- 
ltevulose  soon  disappeared  from  the  urine  of  the  latter, 
leaving  the  inactive  pentose.  These  cases  are  being  investi- 
gated fuither,  but  it  is  interesting  to  note  that  both  of  them 
had  been  treated  for  diabetes  for  some  time  before  I saw 
them,  one  for  16  years  and  the  other  for  one  year.  In  4 of 
the  cases  of  alimentary  pentosuria  1-arabinose  was  the  only 
sugar  found  in  the  urine,  in  4 it  was  associated  with  more 
or  less  dextrose,  and  in  1 there  was  a small  percentage  of 
true  lmvulose.  My  observations  suggest  that  alimentary 


176  The  Lancet,] 


THE  SERVICES. 


[July  26,  1919 


pentosuria  is  comcnoDly  associated  with  hepatic  disturb- 
ances, and  it  is  partly  to  this  that  the  lowered  tolerance  for 
pentose  is  probably  due.  The  amount  of  fruit  taken  by 
these  patients  was  in  no  case  large,  and  in  all  of  them 
analysis  of  the  urine  revealed  evidence  of  hepatic 
insufficiency.  I am,  Sir,  yours  faithfully, 

P.  J.  Cammidge. 

Nottlngham-place,  Marylebone,  W.,  July  13tb,  1919. 


THE  ABILITIES  OF  THE  DISABLED. 

To  the  Editor  u/The  Lancet. 

Sir, — On  Fridav.  July  25th,  a meeting  has  been  arranged 
in  Central  Hall,  Westminster,  at  3 P.M.,  specially  designed  to 
interest  and  enccrurage  men  who  have  suffered  some  physical 
disability  during  the  war.  The  meeting  is  under  the  joint 
auspices  of  the  British  Red  Cross  and  the  London  War 
Pensions  Committee,  and  Sir  Laming  Worthington  Evans 
will  preside.  Two  of  the  speakers,  both  of  whom  have 
suffered  the  loss  of  more  than  one  limb  and  have  “made 
good”  in  the  face  of  incredible  handicaps,  will  give  demon- 
strations of  what  is  possible  with  the  simplest  of  artificial 
appliances.  Interesting  cinematograph  films  will  be  shown, 
and  all  discharged,  disabled,  and  demobilised  men  will  be 
heartily  welcome  ; admission  is  free. 

I am,  Sir,  yours  faithfully, 

(Mrs.)  Ethel  M.  Wood, 

Secretary.  London  War  Pensions  Committee. 

Bloomsbury-square,  W.C.,  July  16th,  1919. 


SUPERANNUATION  OF  SCOTTISH  POOR-LAW 
MEDICAL  OFFICERS. 

To  the  Editor  of  The  Lancet. 

Sir, — A deputation  will  shortly  wait  on  the  Secretary  for 
Scotland  with  the  object  of  having  the  Scottish  Poor-law 
medical  officers  placed  on  a similar  footing  as  respects 
superannuation  with  their  English  and  Irish  brethren.  The 
Poor-law  medical  officers  of  the  Highlands  and  Islands  who 
serve  under  the  Highlands  and  Islands  Medical  Service 
Board  stand  on  a different  footing  from  other  Scottish  Poor- 
law  medical  officers,  their  returns  from  private  practice  being 
very  small  and  their  income  being  mainly  derived  from 
Government  sources.  It  is  therefore  desirable  for  this  group 
of  Poor-law  medical  officers  to  come  under  a separate  scheme 
of  superannuation,  similar  to  that  which  at  present  obtains 
in  the  case  of  medical  officers  serving  in  the  Navy  and 
regular  Army.  I am,  Sir,  yours  faithfully, 

July  16th,  1919.  VOX. 


ENCEPHALITIS  LETHARGICA. 

To  the  Editor  of  The  Lancet. 

Sir,— In  the  course  of  your  article  on  this  subject  in 
The  Lancet  of  July  19th  (p.  118)  the  following  sentences 
occur  : — 

“Many  observers  are  of  the  opinion  that  it  is  a disease 
allied  to  poliomyelitis;  while  others,  mainly  those  who  have 
made  a special  study  of  the  history  of  the  disease,  incline  to 
the  view  that  encephalitis  lethargica  is  associated  in  some 
intimate  causal  manner  with  influenza.®  The  latter  point 
out  that  previous  recorded  epidemics  of  lethargy  have  been 
associated  in  point  of  tivie  with  epidemics  of  influenza,  and 
they  suggest  that  an  attack  of  influenza  either  predisposes  the 
patient  to  the  lethargy  or  in  some  unexplained  way  activates 
the  virus  of  lethargic  encephalitis.” 

As  the  number  (6)  bears  reference  to  an  historical  paper 
by  myself,  I have  ventured  to  italicise  several  words,  and 
will  be  obliged  if  you  allow  me  the  opportunity  of  saying 
(«)  that  I can  myself  form  no  idea  of  what  is  meant  by  the 
“view”  that  encephalitis  lethargica  is  associated  in  some 
“intimate  causal  manner  ” with  influenza;  and  ( b ) that  I 
would  be  the  last  to  claim  credit  for  the  amusing  “pre- 
disposition” and  “ activation  ” hypotheses  that  someone  has 
put  forward  in  explanation  of  what  is  indisputable. 

My  belief  is,  simply,  that  no  one  who  has  studied  the 
historical  evidence  can  deny  the  “ clinical  affinities  and 
epidemiological  liaison  between  what  we  now  call  forms  of 

epidemic  encephalo-myelitis  and  meningitis  and  the 

epidemic  catarrhal  fever,  or  influenza.”  1 

It  is,  moreover,  just  those  who  have  studied  the  historical 
as  well  as  the  clinical  and  pathological  evidence  who  support 


the  view  that  you  have  allowed  me  to  put  forward  in 
your  columns  (May,  1918)— namely,  that  the  epidemic  of 
“encephalitis  lethargica”  last  year  was  really  a manifesta- 
tion of  Heine-Medin  disease,  or  (to  use  the  term  which 
seems  to  give  least  offence)  of  epidemic  encephalo-myelitis 
and  meningitis,  of  which  “acute  anterior  poliomyelitis” 
represents  but  a particular  phase. 

This  view,  as  it  appears  from  the  special  report  of  the 
Local  Government  Biard  on  “encephalitis  lethargica” 
(pp.  2 and  63),  is  substantially  that  held  by  Sir  William 
Osier,  and  Dr.  Draper  of  the  U.3.  Army — a fact  which, 
rather  singularly,  has  hitherto  escaped  comment. 

I am,  Sir,  yours  faithfully, 

Wimpole-street,  IV.,  July  19th,  1919.  F.  G.  CROOKSHANK. 


fbc  $erbias. 


MENTIONED  IN  DESPATCHES. 

The  names  of  the  following  are  amoagst  those  mentioned  for  dis- 
tinguished and  gallant  services  in  a very  lengthy  despatch  received 
from  the  Oommaiider-in-Chief  of  the  British  Forces  in  France,  covering 
the  period  from  Sept.  16th,  1918,  to  March  15tb,  1919 
Army  Medical  Hen-ice.— Col.  J.  D.  Alexander,  D.S.O.  ; Capt.  (acting 
Maj.)  T.  H.  Balfour,  M.C. ; Col.  F.  \V.  Begbie ; Lt  -Col.  (temp.  Col.) 

W.  Bennett,  D.S.O. ; Temp.  Capt.  (acting  Major)  W.  S.  ->.  Berry:  Col. 

W.  W.  O.  Beveridge,  C B..  D.S.O.;  C >1.  K.  J. B ackham,  C M.G.,  C.I.K., 
D.S.O.;  Lt.-Col.  (acting  Col.)  W.  K.  Blackwell,  C.M.G.  ; Capt.  (acting 
Maj.)  H.  E.  A.  Boldero  ; Capt.  and  Bt.  Maj  (acting  Maj)  L.  G.  Bour- 
dillon.  D.S.O.,  M.C.  ; Lt.  Col.  (temo.  Col.)  A.  W.  N.  B iwen,  D.S.O.; 
Lt.-Col.  and  Bt.  Col.  F J.  Brakenridge.  C.M.G. ; Col.  H.  A.  Bray, 
C.M.G. ; Temo.  Capt.  (acting  Maj.)L.  R.  B<-o9ter;  Maj.  and  Bt.  Lt.-Col. 

C.  G.  Browne,  D.S.O.;  Lt.-Col.  (temp.  Col.)  B B.  Burke.  D.S.O.; 

Maj.  Gen.  (temp.  Lt. -Gen.)  C.  H.  BurtCnae'l,  K.C.B.,  C.  M.G..  K.  H.S. ; 

Lt, -Col.  (temp.  Col.)  J.  H.  Campbell,  D.S  O. ; Maj. -Gen.  H.  arr,  C.  B ; 

Col.  J.  Clay;  L’.-Col.  (acting  Col.)  H.  Colllnson.  C.M.G.,  D.S  O ; Maj,  . 

D.  M.  Corbett;  Capt.  (aoting  Maj.)  W.  V.  Corbe't;  Capt.  (acting  Maj.)  j 

J.  Dale;  Lt.-Col.  B.  R Dennis,  O.B  E. ; Lt.-Col.  (acting  Col.)  T.  F.  ] 
Dewar,  C.B..  T.D. ; Capt.  (acting  Maj.)  R.  F.  O T.  Dickinson  ; Lt.-Col. 
and  Bt.  Col.  (temp.  Col.)  H.  E.  M.  Douglas.  V.C..  C.M.G..  D.S  O.  ; 
Capt,  (acting  Maj.)  C.  R.  Dudgeon,  M.C. ; Col.  H.  N.  Dunn.  O.M.G.,  J 
D.S.O.;  Maj.  J.  S.  Dunne.  D.S.O.;  Lt.-Col.  (temp.  Col.)  O.  W.  A. 
Eisner.  D.S.O.;  Lt -Col.  (temp.  Col.)  H.  B.  Fawcus.  C.M.G..  D.S.O.;  j 
Capt.  (acting  Major)  A.  McL.  Feme,  M.C. ; Col.  K.  H.  Firth.  C.B.  ; 1 

Lt.-Col.  (acting  Col.)  FitzG.  G.  Fitzgerald.  D.S.O. ; Lt.-Col.  (temp.  Col.)  ; 
T.  Fraser,  D.S.O.  ; Capt.  (acting  Maj.)  T.  L.  Fr*‘er  ; Capt,  (acting  .Maj.)  ] 
H.  Gale,  D.S.O.;  Lt.-Col.  (temp.  Col.)  J.  S.  Gillie,  C.M.G..  D S.O. ; I 
Maj. -Gen.  J.  J.  Gerrard,  C.B. ; Col.  T.  W.  Gibbard.  C.B.,  K.H.S.  ; Capt, 
(acting  Maj.)  G.  F.  P.  Gibbons;  Capt.  (acting  Maj.)  A.  J.  Gibson,  j 
D.S.O  ; Lt.-Col.  (acting  Col.)  G.  M Goldsmith;  Col.  U.  W.  Grattan, 
D.S.O.;  Capt.  (acring  M«.j.)  W.  T.  Hare.  M.C. ; L’.-Col-  (temp.  Crl.)  I 

J.  A.  Hartigan,  C.M.G..  D.S.O  ; Capt.  (acting  Maj.)S.  M.  ttawersley. 

M.C.  ; Maj.  A.  H.  Heslop,  D.S  O.;  Col.  (temp.  Maj. -Gen.)  Sir  S.  Hickson,  , 

K. BE..C.B,  K.H.S.  (R.P.);  Maj.  (temp.  Lt.-Col.)  F.  D.  G.  Howell.  1 

D.S.O.,  M.C. ; Lt.-Col.  (anting  Col.)  C.  H.  Howkins,  D.S.O. ; Col.  W E.  B 
Hudles  .on.  C.  M.G..  D.S.O. ; Lt.-Col.  (temp.  Col.)L.  Humpnry,  C.  M.G.;  1 

Lt.-Col.  (temp.  Col.)  D O.  Hyde.  D.S.O.;  Col.  (temp.  Maj. -Gen.)  Sir  1 

J.  M.  Irwin.  K. C.M.G  . C.B  ; Temp.  Capt.  (acting  Maj.)  F.  PI  Jo-celvne,  1 

M.C.:  Col.  F.  Kelly,  T.D. ; Lt.  (temp.  Capt.)  (acting  Maj.)  M.  B.  King,  a 
M.C. ; Temp.  Cipt.  (acting  Maj.)  C.  Kingston;  Capt.  (acting  Lt.-Col. > < 

F.  R.  Laing;  Maj.  (acting  Lt.  Col.)  R VV.  D.  Leslie  ; Maj.  (acting  Col  ) 1 

C.  H.  Lindsay  C.M.G.,  D.S.O. ; Capt.  (acting  Maj  iD.  C Macdonald,  1 
M.C. ; Lt.-Ooi.  (temp.  Col.;  T.  C.  Mackenzie.  D S.O. ; Lt.-Col.  (acting 
Col.)  A M.  MaeLaughlin  ; Col  R.  L.  R Macleod,  C.  B. ; Capt,  (acting  i 
Maj.)  W.  W.  MacNaught.  M.C. : Capt.  (acting  Mai  ) E B.  Marsh.  . 
M.C.  ; Lt.-Col.  (acting  Col.)  W.  R.  Matthews,  D S.O.  ; Lt.-Col.  1 
(temp.  Cul.)  K.  MjDonnell,  D.S.O.:  Lt.-Col.  (ac’ing  Col.)  F.  j 
McLennan,  D.S.O.;  Capt,  (ac  ing  Lt.-Col.)  O.  W.  McSheeby.  I 

D. S.O.;  Col.  J.  Meek,  C.B. ; Capt.  (acting  Maj.)  H.  A. ' I 

Mills;  Capt.  (acting  Maj.)  J.  M.  Mi^te.  M.C. ; Lt.-Col.  I 
(acting  Col.)  E.  C.  Montgomery-Smith,  D.S.O.  ; Col.  F.  J.  Morgan, 

C. M.G.;  Col.  G.  A.  Moore,  C.M.G.,  D.S.O.;  Col.  (temp.  Maj.-  1 
Gen.)  S.  G.  Moores,  C.B.,  C.M.G.  ; Maj. -Gen.  Sir  M.  W.  O'Keeffe, 

K.  C.M.G.,  C.B. ; Capt.  (acting  Maj.)  M.  Vv.  Paterson,  M.C. ; Col  R.  H. 
Penton,  D.S.O. ; Col.  C.  E.  Pollock,  D.S.O. ; Lt.-Col  (temp.  Col.)  J. 
Powell,  D.S.O. ; Col.  H.  V.  Prynne.  D.S.O. ; Maj.  J D.  Richmond,  ] 

D. S.O.;  Maj.  M.  B.  H.  Ritchie.  D.S.O.;  Capt.  (acting  Maj.)  R L. 
Ritchie  ; Capt.  (acting  Maj. I A.  L.  Robertson ; Capt,  (acting  Maj  i \V.  H. 
Rowell ; Maj.  and  Bt.  Lt.-Col.  (temp.  Lt.-Col.)  E Ryan.  C.  M.G..  D S.O.;  / 
Lt.-Col.  (temp  Col.)  A.  H.  Safford ; Lt.-Col.  (temo.  Col  ) J.  P.  Sliver, 
D.S.O. ; Temp.  Cant,  (acting  Maj.)  G.  W.  Smith  ; Lt  -Col.  S B.  Smith, 
D.S.O.  ; Col.  J.  C.  B.  Stathani.  C.M.G  ; Lt.-Col.  G.  N.  Stephen;  Capt. 
(acting  Maj.)  A.  D Stirling.  D S.O. ; Maj.-Gen.  H.  N.  Thompson.  C.B., 

C.  M.G.,  D.S.O. ; Maj.-Gen.  J.  Thomson,  C.B. ; Col.  H.  S.  Thurston,  C.B., 
C.M.G.;  Capt.  (acting  Maj.)L.  R.  Tosswill  (T.F.) ; Maj.  (acting  Ll.-Colj 
W.  F.  Tyndale.  C.M.G.,  D.S.O.;  Temp.  Capt.  (acting  Maj.)  F.  B. 
Winfield ; Lt.-Col  (acting  Col  ) K.  A.  Wraith,  D.S.O. 

Consultants. — C >1.  H.  A.  Ballance.  C.B. : Lt.-Col.  S.  G.  Barling; 
Temp.  Maj  -Gen.  Sir  A.  A.  Bowlhv.  K. C.M.G..  K.C.Y.O., C.B.  ; Temp. 
Maj.-Gen.  Sir  J.  R.  Bradford.  K. C.M.G.,  C.B. ; Temp.  Col.  W P.  S. 
Branson;  Col.  H.  A.  Bruce  : Temp.  L’.-Col.  H.  Burrows.  O.B.E. ; Temp. 
Lt.-Col.  R.  H.  Cooper;  Col.  S.  L Cummins,  C.M.G.;  Col.  T.  R. 
EUiott,  D.S.O,;  Temp  Col.  C.  H.  S.  Frankau,  D.S.O.;  Temp.  Capt. 
(acting  Lt.-Col.)  F.  Fraser;  M<j.  (temp.  Lt.-Col.)  A.  M.  H Gray; 
Temp.  Maj.-Gen.  Sir  W.  P.  Herringham,  C.B. : Temp  Lt.-Col  G.  M. 
Holmes,  C.M  G. ; Temp.  Col.  W.  T.  Lister,  C.M.G.  ; Maj.  (acting  Lt.- 
Col.)  H.  MacCormac;  Temp.  Col.  C.  H.  Miller;  Temp  Col.  W.  Pa-  ear, 
C.M.G.;  Col.  K M.  Pilcher.  C.B. . D.S.O.;  Lt.-Col.  W.  Thorburn.  C.B. ; 
Temp.  Maj  -Gen.  C.  S.  Wa’lace,  C.B.,  C.M.G. ; Temp.  Col.  A.  E.  Wett>- 
Johnson,  D.S.O. 


1 Proc.  Roy.  Soc.  Med.,  1919,  vol.  xii.,  Sect.  Hist.  Med. 


The  Lancet,] 


THE  SERVICES. 


[July  26,  1919  177 


Royal  Army  Medical  Corps.— Ma.j.  (temp.  Lt.-Ool.)  I).  Ahern,  U.S.O.; 
Maj.  (acting  Lt.-uol.)  R.  B.  Ainsworth,  D.S.O.;  Temp.  Capt.  (acting 
Maj.l  il.  C.  Alexander;  Temp.  Capt.  F.  J.  Allen.  vt.O.  ; Temp.  Capt. 
T.  S.  Allen;  Capt.  (acting  Ma.j.)  VV.  B.  Allen.  V.C..  D.S.O..  M.C.  ; 
Ma.j.  A.  C.  Amy.  1)  S.O.  ; Temp.  Capt.  (acting  Ma.j.)  J.  It.  Anderson  ; 
Temp.  Capt.  W.  Anderson;  Temp.  Capt.  (acting  Ma.j.)  W.  B.  O.  Angus, 
M.C. ; Lt.-Col.  M.  H.  Babingt.on,  D.S.O. ; Temp.  Capt.  L.  W.  Bain, 
M.C.;  Ma.j.  J.  El.  Harbour;  Temp.  Capr.  K.  P.  Bashford  ; Lt.-Ool* 
<temp.  Col.)  H.  It.  Bateman,  D.S.O. ; Temp.  Capt.  (acting  Ma.j.)  P.  G. 
Bell,  M.C.  ; Maj.  (aeiing  Lt.-Col.)  VV.  J.  E.  BoH,  D.S.O.  ; Tem|).  Capt. 
G.  W.  Beresford  ; Capt.  A.  W.  Bevis ; Capt.  (acting  Lt.-Col.)  P.  K. 
Bissell ; Temp.  Capt.  G.  W.  Bissett, ; Temp.  Capt.  (acting  Maj.)  P.  L. 
Blaher;  Maj.  R.  B.  Black,  D.S.O.  (It.  of  O.);  Temp.  Capt.  E.  VV.  Blake  ; 
•Capt.  and  Bt.  Ma.j.  (acting  Lt.-Col.)  H.  H.  Blake  ; Temp.  Capt.  V.  II. 
Blake;  Capt.  (acting  Lt.-Col.)  .1,  I).  Bowie,  D.S.O.  ; Temp.  Capt.  C.  E. 
Boyce  ; Map  (acting  Lt.-Col.)  W.  W.  Boyce,  D.S.O. ; Temp.  Capt.  A.  B. 

Brook;  Teinp.  Ma.j.  H.  VV.  Bruce;  Ma.j.  (acting  Lt.-Col.)  J.  C.  G. 

Carmichael;  Temp.  Capt.  (acting  Ma.j.)  A.  M.  Caverhill;  Capt.  (acting 
Lt.-Col.)  C.  Clarke,  D.S.O.;  Tamp.  Capt.  (acting  Maj.)  G.  Clarke; 
Temp.  Capt.  H:  K.  Clutterbuck;  Maj.  (acting  Lt.  Col.)  T.  S.  Coates, 
O.B.E.  ; Capt..  (temp.  Ma.j.)  E.  E.  Collard  ; Temp.  Capt.  (acting  Map) 

,J.  R.  Collins;  Temp.  Capt.  C.  G.  Colyer;  Temp.  Capt  (acting  Ma.j.) 

•J.  D.  Cooke;  Temp.  Capt.  (acting  Maj.)  R.  C.  Cooke,  D S.O.,  M.C.; 
Col.  R.  J.  Copeland ; Temp.  Capt.  W.  j.  Corbett ; Temp.  Capt.  C.  C.  C. 
Court;  Temp.  Capt.  J.  Coutts;  Temp.  Hon.  Maj.  E.  G.  Crabtree; 
Ma.j.  and  Bt.  Lt.-Col.  (acting  Lt.-Col.)  B.  A.  Craig;  Temp.  Capt.  J.  G. 
Craig;  Temp.  Capt.  VV.  Craig;  Maj.  (acting  Lt.-Col.)  J.  M.  M Craw- 
ford; Temp.  Hon.  Maj.  B.  Crothers ; Temp.  Capt.  J.  Cruickshank; 
Temp.  Capt.  A.  J.  VV.  Cunningham;  Maj.  ,7.  F.  Cunningham ; Temp. 
Capt.  W.  B.  Dalgleish  ; Temp.  Qrmr.  and  Lt.  G.  J.  Darke  ; Temp.  Capt. 
<acting  Lt.-Col.)  H.  S.  Davidson;  Temp.  Capt.  H.  R.  Davies;  Capt. 
•(acting  Lt.-Col.)  R.  M.  Davies  ; Temp.  Capt.  S.  T.  Davies  ; Temp.  Capt. 

G.  de  H.  Dawson.  M.C.;  Temp.  Capt.  (acting  Maj.)  VV.  Deane  ; Maj. 
(acting  Lt.-Col.)  G.  De  la  Corn*;  Temp.  Capt.  A.  VV.  Dennis ; Temp. 
•Capt.  E.  R Dermer;  Temp.  Capt.  R.  S.  Dobbin  ; Temp.  Capt.  (acting 
Ma.j.)  A.  VV.  H.  Donaldson;  Lt.-Col.  C.  G.  Douglas,  M.C. ; Maj.  .7.  II. 
Douglass;  Ma.j.  (acting  Lt.-Col  ) C.  M.  Drew  : Temp.  Hen.  Lt  -Col.  G. 
Dreyer;  Temp.  Capt.  J.  D.  Drioerg,  M.C. ; Temp.  Capt.  C.  E.  Dukes; 
Temp.  Capt.  (acting  Ma.j.)  J . G.  Duneanson  ; Temp.  Capt.  E.  C.  Dutton  ; 
Temp.  Capt.  H.  II.  Elliot,  M.C.;  Ma.j.  (acting  Lt.-Col.)  A.  C.  Elliott; 
Temp.  Capt.  C.  M.  G.  Elliott ; Capt.  (acting  Ma.j.)  R.  Ellis,  M.C.  ; Ma.j. 
(actitag . Lt.-Col.)  H.  U.  A.  Emerson,  D.S.O.:  Lt.-Col.  and  Bt.  Col. 
(temp.  Col.)  H.  Eosor,  C.M.G.,  D.S.O.  ; Lt.-Col.  (acting  Col.)  C.  R. 
Evans,  D.S.O.  ; Temp.  Capt.  M.  du  B.  Ferguson;  Ma.j.  (acting Lt.-Col.) 

E.  G.  Ffrench  ; Temp.  Capt.  G.  Fildes  ; Temp.  Hon.  Capt.  E.  S.  Fish  ; 
Temp.  Capt.  A.  Fleming  ; Capt.  (acting  Lt.-Col.)  .7.  H.  Fletcher,  D.S.O., 
M.C. ; Ma.j.  (acting  Lt  -Col.)  A.  D.  Fraser,  D.S.O.,  M.C.  ; Temp.  Capt. 
J.  E.  Frere  ; Temp.  Capt.  T.  F.  S.  Fulton  ; Temp.  Capt.  (acting  Ma.j.) 

H.  W.  Gabe;  Capt.  (acting  Lt.-Col.)  R.  VV.  Galloway ; Temp.  Capt.  G.  C. 
<Gell ; Temp.  Capt.  (acting  Maj.)  .VV.  E.  Gemmell ; Capt.  (acting  Ma.j.) 
<7.  de  VV.  Gibb;  Capt.  and  Bt.  Ma.j.  H.  G.  Gibson  : Temp.  Capt.  E.  C. 
Girling;  Temp.  Capt.  S.  R.  Gleed  (T.F);  Temp.  Capt.  (acting 
Ma.j.)  H.  Goodman  ; Lt.-Col.  (acting  Col.)  W.  R.  P.  Goodwin,  D.S.O. ; 
Temp.  Capt.  C.  B.  Goulden ; Ma  j.  (acting  Lt.-Col.)  A.  C.  H.  Gray ; 
Temp.  Maj.  K.  E.  L.  G.  Gunn;  Capt  (acting  Lt.-Col.)  II.  A.  Harbison, 
M.C. ; Temp.  Capt.  T.  H.  Harker  ; Temp.  Capt.  D.  T.  Harris  ; Temp. 
Capt.  J.  N.  J.  Hartley  ; Maj.  (acting  Lt.-Col.)  VV.  J.  S.  Harvey,  D.S.O.  ; 
Temp.  Capt.  T.  A.  Hawkesworth  ; Lt.-Col.  E.  C.  Hayes ; Temp.  Capt. 
E.  D.  F.  Hayes;  Ma.j.  (aiding  Lt.-Col.)  A.  F.  Heaton  (R.  of  0.) ; Temp. 
Capt.  A.  G.  Henderson  ; C*pt.  (acting  Maj  ) R.  A.  Hepple,  M.C. ; Temp. 
Capt.  VV.  Herbertson ; Temp.  Capt.  E.  Hesterlow ; Temp.  Cop*, 
(acting  Ma.j.)  T.  T.  Higgins;  Temo.  Capt.  R.  MeC.  Hill,  D S.O.  ; 
Temp.  Capt.  (acting  Lt.-uol.)  G.  D.  Hindley,  M.C.  ; Temp. 
Capt.  A.  N.  Hooper;  Temp.  Hon.  Maj.  C.  W.  M.  Hope;  Temp.  Capt. 

E.  I.Horsburg  ; Temp. Hon.  Maj.T.  Houston;  Capt. (acting Lt.-Col.)  I.  R. 
Huu.cc ton  ; Maj.  ann  Bt.  Lt.-Col.  (acting  Lt.-Col.)  G.  VV.  G Hughes, 
D.S  O.  ; Lt.-Col.  E.  T.  lnkson,  V.C.,  D.S.O.;  Temp.  Capt.  (acting 
Maj.)  J.  VV.  lnnes ; Temp.  Lt.-Col.  G.  S.  Jackson,  D.S.O.,  T.D.;  Temp. 
Capt.  C.  W.  VV.  James  ; Lt.-Col.  J.  C.  Jameson ; Temp.  Capt.  J.  G. 
Johnstone  ; Temp.  Capt.  (acting  Maj.)  A.  C.  Keep,  M.C.  ; Temp.  Hon. 
Maj.  R.  F.  Kennedy;  Capt.  (acting  Maj.)  G.  L.  Keynes;  Temp.  Capt.  C. 
King;  Temp.  Maj.  C.  F.  Knight,  D.S.O.;  Temp.  Hon.  Maj.  L.  F. 
Knutbsen  ; Capt.  (acting  Lt.-Col.)  E.  C.  Lang,  D.S.O.  ; Capt.  (acting 
Lt.-Col.)  II.  H.  Leeson,  M.C. ; Temp.  Capt.  T.  1’.  Lewis;  Temp.  Capt. 
(acting  Maj.)  S.  J.  L.  Lindeman,  M.C.  ; Temp.  Capt.  (acting  Maj.)  E.  C. 
Lindsay;  Temp.  Capt.  W.  S.  Lindsay;  Temp.  Capt.  F.  C.  Litchfield, 
M.C.  ; Temp.  Capt.  J.  S.  Lloyd;  Temp.  Capt.  (acting  Maj.)  A.  L. 
Lockwood,  D.S.O.,  M.C.  ; Temp.  Ma.j.  (acting  Lt  -Col.)  C.  E.  M.  Lowe; 
Temp.  Capt.  N.  P.  L.  Lumb ; Temp.  Capt.  F.  C.  MacDonald ; 
Maj.  (acting  Lt.-Col.)  W.  MacD.  Maedowall;  Temp.  Capt.  VV. 
Mat-Ewen;  Temp.  Capt.  (acting,  Maj.)  R.  B.  Maeiie ; Temp.  Capt. 
(acting  Maj.)  C.  Mackenzie;  Maj.  (acting  Lt.-Col.)  D.  F.  M-mkenzie, 
D.S.O.;  Temp.  Capt.  D.  Mackinnon;  Temp.  Capt,.  J.  VV.  MacLeod, 
D.B.E. ; Temp.  Capt.  A.  S.  L.  Malcolm;  Temp.  Capt.  E.  C.  Malden; 
Temp.  Capt.  A.  C.  Mann,  M.C. ; Temp.  Capt.  (acting  Maj.)  F.  E. 
Manser;  Maj.  (acting  Lt.-Col.)  P.  J.  Marett;  Temp.  Capt  O.  de  B. 
Marsh;  Temp.  Capt.  R.  P.  Marshall ; Temp.  Capt.  (acting  Maj.)  VV.  S. 
Martin,  M.C. ; Temp.  Capt.  (acting  Maj.)  R.  Massie ; Temp.  Capt. 
H.  N.  Matthews;  Temp.  Capt.  O.  S.  Maunsell ; Capt.  (acting  Maj.) 

C.  A.  R.  McCay;  Temp.  Lieut.  T.  McLaren;  Temp.  Capt.  G.  McLeod, 
M.C. ; Temp.  Capt.  D.  McNeill;  Temp.  Capt.  J.  P.  McVey.  M.C. ; 
Maj.  A.  A Mearten,  D S.O.;  Lt.-Col.  T.  I.  N.  Mears,  D.S.O.;  Temp. 
•Capt.  C.  H.  Medlock;  Temp.  Capt.  A.  U.  Millar,  M.C.  ; Temp.  Capt. 
H.C.D.  Miller;  Temp.  Capt. E.  T.  C.  Milligan  ; Temp.  Capt.  J.  H.  Moir, 

D. S.O.,  M.C.  ; Capt.  (acting Lt.-Col.)  H.  G.  Monteitb,  D.S.O.;  Temp. 
Capt.  A.  T.  Moon;  Maj.  E.  H.  M.  Moore,  D.S.O.;  Capt.  (acting  Maj.j 
J.  Y.  Moore  ; Temp.  Capt.  R.  F.  Moore ; Maj.  (acting  Lt.-Col.)  C.  R.  M. 
Morris,  D.S.O.  ; Temp.  Capt.  (acting  Maj.)  J.  Morrison  ; Temp.  Capt. 
J.  T.  Morrison;  Temp.  Capt.  H.  H.  P.  Morton  ; Temp.  Capt. (acting  Maj.) 

F.  H.  Moxon;  Capt.  W.  P.  Mulligan,  O.B.E.;  Lt.-Col.  C.  D.  Myles, 
<O.B.E.  ; Temp.  Capt.  F.  L.  Napier ; Temp.  Capt.  G.  L.  Neil;  Maj.  (acting 
Lt.-Col.)  R.  E.  U.  Newman,  M.C.  ; Capt.  (acting  Maj.)  C.  V.  Nicoll ; 
Temp.  Capt.  (acting  Maj.)  A.  A.  O'Connor;  Lt.-Col.  C.  J.  Ohorman, 
D.S.O.;  Maj.  (acting  Lt.-Col.)  D.  deC.  O'Grady  ; Temp.  Capt.  M.  VV.  B. 
Oliver;  Tepip.  Capt.  H.  B.  Owens;  Maj.  (acting  Lt.-Col.)  G.  R.  Painton, 
Temp.  Capt.  (acting  Maj.)  A.  C.  Palmer  ; Maj.  J.  S.  Pascoe,  D.S  O.  ; 
Temp.  Capt.  (acting  Maj.)  J.  A.  Paterson,  M.C.  ; Temp.  Capt.  E.  J.  Peili  ; 
Ma.j.  H.  M.  J.  Perry  ; Temp.  Capt.  (acting  Maj.)VV.  de  M.  Peyton;  Capt 
(acting  Lt.-Col.)  E.  Phillips.  M.C.;  Temp.  Capt.  S.  E.  Picken,  M.C.  ; 


Temp.  Capt.  (acting  Maj.)  B.  Bickering ; Temp.  Capt.  a.  10.  Pinnlger; 
Temp.  Capt.  (J.  Pirio;  (/apt.  (acting  Lt.  Col.)  A.  M.  Pollard,  D.S.O.  ; 
Temp.  Capt.  (acting  Maj.)  IL.  W.  Powell;  Temp.  Capt.  (acting  Maj . ) 
K.  G.  C.  Price;  Temp.  Capt.  J.  Pryce-Daview  ; Temo.  Capt.  (}.  It.  13. 
Puree,  M.U.  ; Temp.  Capt.  M.  H.  Rainey  ; Capt.  (acting  Lfc.-Col.)  II.  C.  I). 
Rankin;  Temp.  (’apt.  S.  I*.  Rea:  Temp.  Capt.  W.  A.  Rees  , Lt.-Col. 
(acting  Col.)  VV.  Riach,  C.M.G. ; Temp.  Capt.  .1.  10.  Richards;  Temp. 
Capt.  (acting  Maj.)  J.  10.  H Roberta;  Temp.  Capt.  It.  C.  Robertson; 
Temp.  Capt.  G.  It  olnson;  Tamo.  Capt.  W.  .1.  Ronan  ; Maj.  (acting  Lt. 
Col. i P.  E.  Itowiin- Robinson  ; Temp.  Lt.-Ool.  It.  J.  Rowlette;  MhJ. 
(acting  Lt.  -Col.)  G.  P Rudkin,  D.S.O. ; Temp  Capt.  (acting  Maj.)  J.  0. 
Sale,  D.S.O.,  M.C. ; Maj.  (temp.  Lt.-Col.)  P.  C.  Sampson,  D.S.O.;  Temp. 
Capt.  (acting  Maj.)  H.  H.  Sampson,  M C.  ; Temp.  Capt.  (acting  Maj.) 
H.  VV.  Scawin  ; Temp.  Capt.  A.  Scott;  Teinp. Capt.  (acting  Ma.j.)  10.  .J . 
Selby;  Temp.  Capt.  II.  P.  Shackleton  ; Temp.  Capt.  W.  Shanks;  Temp, 
lion.  Maj.  G.  C.  Shat- duck;  Temp.  Capt.  H.  L.  Shelton  ; Temp.  Capt. 
11.  J.  Shone;  Ma.j.  (acting  Lt.-Col.)  H.  C.  Sidgwick ; Lt.-Col.  (acting 
Col.)  II.  Simaon;  Temp.  Capt.  A.  P.  S.  SUdden;  Temp.  Capt.  J.  M. 
Smeaton;  Capt.  (acting Lt.-Col.)  J.  C.Sproule;  Temp.  Capt  . C.  M.Stallard; 
Temp.  Capt.  (acting  Maj.)  E.  G.  Stanley;  Temp.  Ma.j  F.  N.  G.  Starr; 
Temp.  Capt.  R.  S.  6 Stainam  ; Temp.  Capt.  VV.  Stirling;  Temp.  Capt. 
A.  Stokes,  D.S.O.;  Temp.  Capt.  (acting  Lt.-Col.)  H.  Stokes;  Temp. 
Capt.  C.  P.  A.  Scranaghan  ; Capt.  (acting  Lt.-Col.)  J.  VV.  C.  Stubbs, 
M.C.  ; Temp.  Capt.  E.  J.  Stuckey;  Temp.  Capt.  (acting  Maj.)  C. 
Sullivan;  Maj.  (acting  Lt.-Col.)  G.  G.  Tabiir,»-au,  D.S  O. ; Temp  Capt. 

R.  J.  Tait;  Temp.  Capr.  (acting  Maj.)  D.  C.  Taylor,  M.C.  ; Temp.  Maj. 

G.  Taylor;  Lt.-Col.  (temp.  Col.)  W.  Taylor;  Temp.  Capt.  L.  H.  Terry; 
Maj.  (acting  Lt.-Col.)  W.  I.  Tnompaon,  D.S.O.  ; Temp.  Capt.  (acting 
Lt  Col.)  F.  R.  Thornton,  M C. ; Temp.  Capt.  (acting  Maj.)  K.  Tinnall, 
M.C.  ; Temp.  Capt.  (acting  Maj.)  A.  T.  Todd;  Temp.  Capt.  R.  S. 
Topham  ; Temp.  Capt.  R.  H.  Tribe,  M.C.  ; Temp.  Cauc.  C.  N.  Vaisey  ; 
Capt.  (acting  Maj.)  B.  Varvill,  M.C.  Temp.  Capt.  (acting  Maj.)  P.  N. 
Vellacott  ; Temp  Capt.  (acting  Maj.)  H.  M.  Vickers;  Capt.  P.  S. 
Walker  ; Teinp.  Cai  t.  J.  C.  Walker  ; Temp.  Capt.  A.  B.  Waller  ; Temp. 
Capt.  (acting  Maj.)  H.  H.  Warren;  Maj.  (acting  Lt.-Col.)  W.  J.  Waters  ; 
Temp.  Capt.  E.  J.  M.  Watson  ; Temp.  Capt.  (acting  Maj.)  H.  C.  Watson, 
M.C.;  Capt.  (acting  Lt.-Col.)  L.  F.  K.  Way  ; Temp.  Capt.  P.  E.  Webb  ; 
Temp.  Capt.  (acting  xMaj.)  F.  W.  Wesley  ; Temp.  C»pt.  F.  Whitby  ; M*j. 
C.  P.  White;  Temp.  Capt.  M.  H.  Whiting;  Temn.  Capt.  A.  R. 
Wightman  ; Maj.  (temp.  Lt.-Col.)  A.  J.  Williamson;  Temp.  Capt.  J. 
Williamson;  Temp.  Capt.  G.  R.  Wilson;  Temp.  Capt.  J.  A.  Wilson; 
Temp.  Capt.  F.  A.  Winder;  Maj.  J.  L.  Wood;  Temp.  Capt.  (acting 
Maj.)  P.  R.  Woodbouse,  D.S.O.,  M.C. ; Temp.  Capt.  E.  VV.  N.  Wooler  ; 
Temp.  Capt.  H.  Yellowlees;  Temp.  Capt.  C.  R.  Young,  D.S.O.,  M.C. 

Royal  Army  Medical  Corps  ( S.R. ). — Capt.  (acting  Maj.)  S.  R. 
Armstrong  ; Capt.  (acting  Maj.)  R.  G.  Battersby  ; Cape.  H.  C.  Ba/.ett, 
M.C.  ; Capt.  E.  Braraley  ; Cape.  J.  L.  D.  Buxton;  Capt.  (acting  Maj.) 
T.  W.  Clarke,  xM.C. ; Capt.  W.  H.  Cornelius;  Capt.  W.  J.  F.  Craig; 
Capt.  F.  A.  Dutfield  ; Capt.  (acting  Maj.)  F.  G.  Foster;  Capt.  (acting 
Lt.-Col.)  W.  R.  Gardner,  D.S.O. ; Capt.  (acting  Maj.;  A.  J.  Gilchrist, 
M.C.;  Capt.  (acting  Maj.)  B.  Goldsmith;  Capt.  (acting  Lt.-Col.)  C.  N. 
Gover,  M.C.  ; Lt.  G.  N.  Groves;  Capo.  M.  St.  C.  Hamilton;  Capt. 
(acting  Maj.)  R.  L.  Horton;  Capt.  F.  Jefferson;  Capt.  J.  L.  Kilbride; 
Capt.  (acting  M<%j.)  D.  M.  Marr ; Capt.  (acting  Maj.)  G.  Marshall; 
Capt.  (acting  Lt.-Col.)  W.  H.  L.  McCarthy,  D.S.O.,  M.C. ; Capt.  D. 
Mitchell;  Capt  M.  K.  Nelson;  Capt.  (acting  Maj.)  fl.  D.  Rollinson  ; 
Capt.  (acting  Maj.)  A.  F.  L.  Shields;  Capt.  (acting  Maj.)  G.  H. 
Stevenson,  xM.C. ; Capt.  (acting  Maj.)  L.  S.  B.  Tasker.  M.C.  ; Capt. 
(acting  Maj.)  J.  Walker,  M.C.  ; Capt.  (acting  Maj.)  W.  J.  Webster, 
M.C. ; Capt.  (acting  Maj.)  A.  Wilson,  M.C.  ; Capt.  T.  Wilson. 

Royal  Army  Medical  Corps  (T.F.).—  Capt.  G.  W.  McB.  Andrew;  Maj. 
(acting  Lt.-Col.)  W.  Archibald;  uapt.  R.  A.  Adkins;  xMaj.  A.  Ayre- 
Smitti  ; Capt.  (acting  Maj.)  H.  T.  Bates  ; Capt.  (acting  Lt.-Col.)  A. 
Baxter;  Capt.  W.  F.  B.  Bensted-Smith  ; Maj.  (acting  Lt.-Col.)  G.  N. 
Biggs;  Capt.  (acting  Maj.)  E.  J.  Boome  ; Capt.  A.  M.  Brown  ; Qrm. 
and  Lt.  H.  M.  Browne  ; Capt.  (acting  Lt.-Col.)  J.  Bruce;  Cape,  (acting 
Lt.-Col.)  H.  N.  Burroughes;  Lt.-Col.  and  Bt.  Col.  J.  F.  Bush,  C.M.G.  ; 
Lt.-Col.  E.  xM.  Callender,  T.D.  ; Maj.  (acting  Lt.-Col.)  D.  G.  Campbell; 
Maj.  (acting  Lt.-Col.)  T.  M.  Carter;  Capt.  R.  C.  Clarke  ; Capt.  (acting 
Maj.)  T.  C.  Clarke,  M.C. ; Capt.  (acting  Maj.)  F.  Clayton;  Capt.  L. 
Colledge  ; Capt.  D.  R.  Cramb  ; Capt.  (acting  Maj.)  C.  H.  Crawshaw  ; 
Capt.  J.  D.  Davidson  ; Capt.  (acting  Maj.)  K.  G.  Dixon;  Capt.  (acting 
Ma.j.)  G.  W.  Deeping  ; Capt.  A.  D.  Downes  ; Et.-Col.  A.  D.  Ducat,  T.D.; 
Maj.  J.  M.  Duncan  ; Capt.  (acting  Lt.-Col.)  W.  Duncan  ; Capt. 
(acting  Maj.)  J.  F.  Edmiston ; Maj.  A.  Elliott;  Lt.-Col.  C.  I.  Ellis, 
C.M.G.;  Capt.  (acting  Maj.)  R.  Bilis,  M.C.  ; Capt.  (acting  Maj.)  J. 
Everidge  ; Maj.  A.  H.  Falkner  ; Capt.  H.  N.  Fletcher;  Capt.  C.  Forbes  ; 
Maj.  M.  G.  Foster;  Capt.  (acting  Maj.)  C.  J.  Fox;  Capt.  (acting 
Lt.-Col.)  J.  H.  F.  Fraser,  M.C.  ; xMaj.  VV.  H.  Galloway;  Capt.  (acting 
Maj.)  H.  J.  Gorrie ; Maj.  (acting  ljt. -Col.)  D.  J.  Graham;  Lt.-Col. 
A.  G.  Hamilton ; Capt.  F.  G.  Harper.  M.C.;  Lt.-Col.  J.  R Harper,  T.D.  ; 
Capt  L.  Hawkes  ; Capt.  VV.  R.  H Heddy  ; Capt.  (acting  xMaj.)  R.  Henry  ; 
Lt.-Col.  (acting  Col.)  F.  W.  Higgs ; Capt.  VV,  H.  Hill ; Capt.  ^acting  Maj.y 

S.  J.  C.  Holden  ; Capt.  (acting  xMaj.)  A.  J.  Jex-Blake;  xMaj.  (acting 
Lt.-Col.)  F.  W.  Johnson  ; Capt.  W.  Jobustone  ; Capt.  (acting  Lt.-Col.) 
E.  Knight;  Capt.  R.  A.  Lennie ; Capt.  (acting  Lt.-Ooi.)  A.  W.  B. 
Loudon;  Capt.  G.  E.  Loveday ; Capt.  (acting  Maj.)  H.  A.  Lucas;  Capt. 
(acting  Maj.)  A.  M.  Maekay  ; Capt.  (acting  Maj.)  H.  A.  Macmillan,  M.C.  ; 
Capt.  (act-mg  Maj  ) I.  C.  Marshall;  Maj.  C.  J.  Martin;  Capt.  G.  E. 
Martin  ; Maj.  S.  xMartyn  ; Capt.  E.  R.  Matthews  ; Capt.  (temp.  Lt.-Col.) 
G.  K.  Maurice,  M.C.  ; Capt.  (acting  Lt.-Col.)  A.  C.  H.  McUullugh; 
Capt.  (acting  Maj  ) W.  G.  McKenzie,  M.C. ; Capt.  J.  C.  W.  Methven  ; 
Capt.  (acting  Lt.-Col.)  J.  Miller,  M.C.  ; Capt.  (acting  Maj.)  J. 
Morham  ; Qrmr.  and  Lt.  F.  W.  Newboult;  Maj.  D.  C.  L.  Orton  ; Capt. 
(acting  Maj.)  VV.  K.  Pierce;  Capt.  E.  B.  Pike;  Maj.  (acting  Lt.-Col.) 
A.  J.  D.  Riddett ; Maj.  (acting  Lt.-Col.)  H.  B.  Roderick;  Capt.  (acting 
Lt.-Col.)  P.  T.  Rutherford  ; Capt.  (acting  Maj.)  C.  F.  M.  Saint  ; 
Capt.  (acting  Lt.-Col.)  D.  J.  Scott,  M.C.  ; Lt.-Col.  G.  C.  E. 
Simpson  ; Capt.  (acting  Lt.-Col.)  W.  Simpson  ; Capt.  T.  S.  Slessor  ; 
Capt.  T.  H.  Somervell;  Capt.  R.  W.  E.  Stickings;  Capt.  (acting  Maj.) 
W.  Sbobie  ; Capt.  lacting  xvlaj.)  R.  W.  S wayne  ; Capt.  (acting  Maj.) 
E.  S.  Taylor;  Capt.  (acting  Maj.)  A.  G.  G.  Thompson;  xvlaj.  (acting 
Lt.-Col.)  VV.  A.  Thompson;  Capt.  W.  S.  Tresawna  ; Capt.  (acting  Maj.) 
C.  A.  Webster;  Lt.-Col.  and  13c.  Col.  F.  H.  Westmacott;  Capt.  (acting 
Maj  ) K.  D.  Wilkinson  ; Capt.  (acting  Maj.)  F.  E.  Withers  ; Capt.  J.  M. 
Wyatt  ; Capt.  (acting  Maj.)  A.  L.  Yates,  M.C. 

Cmadian  Army  Medical  Corps.—  Capf.  W.  F.  Abbott.  M.C.  ; Capt. 
(acting  Maj  ) M.  H.  Allen;  Lt.-Col.  W.  H.  K.  Anderson,  D.S.O. 


THE  .SERVICES. 


[July  26,  1919 


178  Thb  Lancet.] 


Maj.  (acting  Lt.-Col.)  W.  A.  G.  Bauld.  D.S  0. ; Maj.  (acting 
Lt,  Col.)  A.  E.  H.  Bennett;  Capt.  II.  Black;  Lt.-Col.  G.  I.  Boyce, 

D. S.O. ; Capt.  K.  S.  R.  Carruthers ; Cant  U.  E.  Connolly;  Capr. 

C.  K Down  ti  ; Col.  L.  Drum;  Col.  J.  M.  Elder.  C.M.G.  ; Maj. 
A.  W.  M.  Ellis;  Capt.  J.  M.  Fowler;  Maj,  G.  W.  Hall.  D.S.O.  ; 
Maj.  (acting  Lt.-Col.)  It.  H.  M.  Hardisty,  M.C.  ; Lt.-Col.  K.  V.  Hogan  ; 
Maj.  K.  E.  Hollis;  Maj.  A.  L.  Jones,  M.C. ; Capt.  (acting  Maj.)  L.  F. 
Jones;  Lt.-Col.  D.  P.  Kappele,  D.S.O.;  Maj.  B.  E.  Kelly.  D.S.O.; 
Ja. -Col.  T.  M.  Leask,  D.S.O.;  Maj.  A.  F.  Macaulay;  Lt.-Col  R.  U. 
Macdonald,  M.C.  ; Maj.  J.  A.  MacMillan  ; Capt.  D.  C.  Malcolm, 
M.C. ; Capt.  J.  J'.  S.  Marshall,  M.C.  ; Capt.  H.  W.  Martin; 
'"’apt.  11.  B.  Mitchell;  Lt.-Col.  H.  K.  Mun»*oe.  O.B.E. ; Maj. 

E.  A.  Neff;  Capt.  J.  I.  O'Connell:  Capt.  G.  P.  Parker ; Maj.  S. 
Paulin,  D.S.O. ; Col.  C A.  Peters,  D.S.O. ; Maj.  (acting  Lt.-Col.)  G.  A. 
Platt;  Lt.-Col.  C.  II  Reason.  D.S.O.;  Capt.  J.  W.  RevnoHs;  Capt. 
W.  A.  Richardson;  Maj.  R.  B.  Robertson;  Brig. -Gen.  A.  E.  R »ss,  C.B.. 

C. M.G.  ; Maj.  (acting  Lt.-Col.)  E.  R.  Selby  ; Col.  R.  M.  Simpson. 

D. S.O. ; Maj.  P I).  Stewart:  Maj.  S J.  S reight ; Lt.-Col.  (acting  Col  ) 

C.  P.  Templeton,  D S.O.  ; Maj.  G W.  Treleaveu,  D.S.O.,  M C.  ; Capt. 
J.  C.  Tull;  Maj.  W.  II.  Tytler;  Capt.  ILL.  Walker;  Maj.  E.  L. 
Warner. 

A ustralian  Army  Medical  c orps . — Lt.-Col.  J.  K.  Adey,  O.B.E. ; Col. 
G.  W.  Barber,  C.M.G,  D.S.O.;  Capt.  B.  McN.  Beith  ; Capt.  (temp. 
Maj.)  G.  Bell;  Maj  J.  C.  Campbell,  D S.O. ; Maj.  L.  R.  Cook;  Mij. 

D.  D.  Coutts.  D.S.O.;  Maj  R.  s’.  Craig,  D.S  O ; M\j.  A.  S.. Curtin; 
Col.  M.  II.  Downey.  D.S.O.  ; Msj.  A.  P.  Drummond  ; Col.  T.  P. 
Dunhill;  Lt.-Col.  and  Bt.  Col.  W.  L'K.  Etmes,  C.B.  ; M*j.  J.  W. 
Parrar;  Lt.-Col.  P.  Fiaschi ; Capt.  H.  W.  Franklands ; Lt.-Col.  A.  H. 
Gibson;  Capt.  J.  W.  Grieve;  Maj.  (temp.  Lt.-Col.)  J.  A.  James  ; Maj. 
I),  ti.  B.  Lawton;  Lt.-Col.  H.  B Lewers,  O.B  E.  ; Capt.  E.  I. 
Littlejohn;  Col.  F.  A.  Maguire.  D.S.O.;  Col.  A.  H.  Marks,  D.S.O.; 
Maj.  L.  May,  D.S.O.,  M.C. ; Capt.  A.  L.  McLean.  M.C.  ; Capt.  F. 
Meldrum  : Maj.  (temp.  Lt.-Col.)  J.  R.  Muirheai ; Maj.  R.  B.  Norths; 
Capt.  P.  J.  F.  O Shea,  D.S.O  , M.O. ; Capt.  C.  A Oxiey;  Capt.  R.  L 
Park;  Col.  A.  E.  Shepherd,  D S.O.  ; Maj.  J.  S.  Smyth;  Maj.  M.  V. 
Southey;  Maj.  (temp.  Lt.-Col.)  V.  O.  Stacy;  Lt.-Col.  C.  W.  Tnompson  ; 
Capt.  W.  J.  Trewhella;  Maj.  C.  T.  Turner;  Maj  F.  T.  Wheatland; 
Maj.  K.  M.  Whiting:  Maj.  II.  H.  Willis:  Lt.-Col.  F.  C.  Wooster. 

New  Zealand  Medical  Corps.—  Capt.  P.  A.  Ardagb.  D.S  O.,  M.C.  ; 
Maj.  F.  T.  Bowerbank  ; Capt.  E.  M.  Finlayson;  Caot.  P.  G.  Horsburgh  ; 
Maj.  (temp.  Lt.-Col.)  P.  J.  Jory  ; Capt.  J.  Mitchell;  Lt.-Col.  J.  H. 
Neil.  D.S.O. 

South  African  Medical  Corps.— Capt.  J.  Drummond;  Capt.  W.  L. 
Gordon  ; Lt.-Col.  G.  R.  Thomson;  Lt.  Col.  G.  H.  Usmar. 

American  Expeditionary  Force  Medical  Corps.—  Capt.  G.  R.  Curl ; 
1st  Lt.  C.  E.  Hamilton ; 1st  Lt.  S.  B.  Hinton  ; Lt.  D.  W.  Kramer ; 
Capt.  L.  Little;  Lt  II.  W.  Mahon;  1st  Lt.  J.  McCall;  1st  Lt.  A.  W. 
Th  >mas  ; Lt.  J.  C.  Willis  ; Mr.  H.  W.  Marsh,  Harva-d  Unit. 

British  Red  Cross  Society. — Temp.  Hon.  Capt.  D.  H.  D.  Cran ; Dr. 
J.  Stew  art.. 

Civilian.— Dr.  A.  II.  Fardon. 


ROYAL  NAVAL  MEDICAL  SERVICE. 

Surg. 'Corner.  E.  A.  Shaw  (retired)  to  be  Surgeon  Captain  (retired)  in 
recognition  of  services  rendered  during  the  war. 

Surg.  Lieut. -Comdr.  F.  C.  Alton  is  placed  on  the  Retired  List. 

K Granger  to  be  temporary  Surgeon  Lieutenant. 

Temp.  Surg.  Lieut.  G.  Aubrey  is  transferred  to  permanent  list  of 
Surgeon  Lieutenants.  

ARMY  MEDICAL  SERVICE. 

Temp.  Major-Gen*  Sir  B.  E.  Daw'son,  G.C.V.O.,  C.B.  (Captain, 

R.A.M.C.,  T.F.).  relinquishes  his  temporary  commission  on  re-posting. 

Temp.  Cols.  J.  II.  Parsons.  C.B. E.,  and  R.  Davies-Colley  relinquish 
their  commission  and  retain  the  rank  of  Colonel. 

Col.  C.  C.  Reilly,  C.B.,  is  placed  on  retired  pay. 


ROYAL  ARMY  MEDICAL  CORPS. 

L eut.-Col.  FitzG.  G.  Fitzgerald,  D.S.O.,  relinquishes  the  acting  rank 
of  Colonel  on  re  posting. 

The  underment  ioned  relinquish  the  acting  rank  of  Lieutenant-Colonel 
on  ceasing  to  be  specially  employed:  Majors  J.  E.  Carter,  A.  E.  S. 
Irvine;  Temp.  Major  A.  F.  Hurst. 

Tne  undermentioned  to  he  acting  Lieutcnant-Colonels  whilst  specially 
employed  : Major  E.  C.  Phelan  ; Temp.  Major  C.  E.  Ligertwood  ; Capt. 
R.  M.  Dickson. 

The  undermentioned  relinquish  the  acting  rank  of  Ma  jor : Capts. 
C.  T.  V.  Benson,  E.  G.  H.  Cowen  ; Temp.  H<>n.  Capt.  O.  H.  Stansneld  ; 
Temp.  Capts.  C.  M.  Kennedy,  G.  R.  E.  Colquhoun,  A.  G.  McLpod, 
N.  M.  Grace,  P.  W.  Uove,  K.  M.  Fenn,  R.  Edwards,  W.  J.  D.  Bromley, 
W.  F.  Dunlop,  J.  E.  Power,  C.  Clvne,  P.  L.  Hope.  J.  W.  Applegate, 
G.  S.  Mill,  G.  J.  Arnold,  F.  J.  Thorne,  B.  Sweeten,  N.  F.  Norman, 

A.  C.  Parsons,  C.  C.  Lord,  R.  E.  F Pearse,  P.  A.  Leighton,  A.  E.  Seller, 
J.  V.  Bates,  It.  R.  Wallace,  H.  T.  Mant,  W.  T.  Hedlev.  M.  McLeod, 

B.  Hart,  F.  K.  Fielden,  A.  Dingwall-Fordyce,  G.  T.  Gifford,  G.  11. 
Darlington,  W.  A.  Wheeldon,  J.  F.  Venables,  J.  P.  Loweon,  A.  E. 
Marsaclt,  G.  A.  Skinner. 

To  he  acting  Majors  : Capt.  and  Bt.  Major  J.  D.  Kidd  ; Capt.  C.  E.  L. 
Harding;  Temp.  Capt-s.  II.  U.  Dummere,  A.  L.  Lockwood,  R.  K. 
Robertson,  W (J.  Sharpe,  A.  G'ant,  C.  B.  Tudehope. 

Officers  relinquishing  their  commissions  :— Temp.  Capt.  J.  G. 
Johnston  (granted  the  rank  of  Lieutenant-Colonel'.  Temporary 
Captains  granted  the  rank  of  Major  : J.  E.  Power,  R.  B.  Blair,  A.  Grant, 
J.  Alexander,  1{.  Felton,  N F.  Norman,  J.  E.  Davies,  P.  W.  Dove,  H.  B. 
Day.  Temporary  Captajns  retaining  the  rank  of  Captain  : W.  J. 
Nisbet.  J.  A.  Delmege,  T.  W.  Hey  wood.  T.  J.  Lyons,  S.  G.  Billington, 
J.  A.  MacLeod,  G.  N.  Montgomery,  C.  M.  Fonder.  K.  C.  Myott,  H. 
Cardin,  H.  Alnscow,  F.  W.  Daniels.  A.  Evans,  G.  B.  Cliarnock,  J.  H. 
McAllum,  J.  S.  Bookless,  D.  Fisher,  H.  C.  D.  Miller,  J.  P.  MacDonald, 
T.  R.  Phipps,  A.  C.  Major,  J.  B.  Fairclough,  W.  Leggett,  J.  A.  N.  Scott, 
J.  T.  Bowman.  A.  Davies.  J.  N.  L.  Thosehy,  T.  W.  R.  Strode,  L.  R. 
King,  H.  A.  Ronn,  E.  P.  H.  Vickery,  H.  Mohan.  B.  E.  A.  Batt,  S.  P. 
Bedson,  A.  G.  Winter.  P.  L.  T.  Bennett.  J.  B.  Hunter,  J.  S.  Coldwell, 
W.A  L.  Dunlop,  A. W. Gill,  F.  C.  Macdonald,  E.  L.  Steele.  M.J.  Macauley, 
II.  K.  M.  Bavlis.  M.  F.  Kmrys-Jones,  J.  MacKinnon.  A.  S.  Holden, 
G.  Fleming.  R.  Stipe.  J.  A.  R.  Wells,  J.  W.  Pell,  A.  C.  Parsons,  R.  L. 
Bell,  R.  M.  Rowe,  J.  E.  T.  Jones,  F.  Corner,  J.  W.  Coulter,  A.  Topping. 


I).  J.  Evans,  W.  F.  Dunlop,  F.  D.  Walker,  J.  P.  Brennan,  T.  C. 
Findlatcr,  F.  W.  Haves.  W.  M.  T.  Wilson,  S.  P.  Rea,  J.  G.  Willmore, 
W.  D Wilkins,  R.  W.  Russell-Jones,  W.  J.  Spearing,  J.  M.  Adams, 

S.  M Vassallo,  S.  D.  Adam,  R.  R.  Archibald.  C.  S.  Tennant,  F.  M. 
Gardner- Med  win,  D.  H.  Jones,  C.  D.  Kean,  C.  Harris,  B.  W.  Wibberley, 
R.  W.  L.  Wallace. 

Canadian  Army  Medical  Corps. 

Temp.  Major  W.  J.  McAlister,  M.O.,  to  be  acting  Lieutenant-Colonel 
while  employed  in  command  of  C.C.O.H.,  Matlock  Bath. 

Temp.  Capt.  (acting  Major)  J.  A.  M.  Hemmeon  retains  the  acting 
ra"k  of  Major. 

Temporary  Captains  (acting  M vjors)  relinquishing  the  acting  rank  ol 
Major  : J.  S.  Huls  m,  T.  W.  Sutherland. 

Temp.  Lieut.  L.  G.  Hillier  to  be  temporary  Captain. 

Canadian  Army  Dental  Corps. 

H.  Jackson,  Canadian  Forestry  Corps,  to  he  temporary  Lieutenant. 

SPECIAL  RESERVE  OF  OFFICERS. 

Capts.  C.  S.  Staddon  and  J.  D.  Dickson  relinquish  the  acting  rank  of 

Major. 

TERRITORIAL  FORCE. 

Major  (acting  Lieut.-Col.)  T.  A.  Barron  relinquishes  the  acting  rank 
of  Lieutenant-Colonel  on  ceasing  to  be  specially  employed. 

Captains  (acting  Lieutenant-Colonels)  relinquishing  the  acting  rank 
of  Lieutenant-Colonel  on  ceasing  to  be  employed:  G.  C.  E.  Simpson, 
R.  A.  Stark. 

Capt.  (acting  Major)  C.  B.  Baxter,  O.B.E.,  to  be  Major. 

Capt.  H.  J.  A.  L >ngmore  to  be  acting  Major  whilst  specially  employed. 

Captains  (acting  Majors)  relinquishing  the  acting  rauk  of  Major  on 
ceasing  to  he  specially  employed  : U J.  A.  Longmore,  C E.  W. 
McDonald,  H.  M.  Calder,  C.  Burrows,  W.  J.  Hirst.  T.  W.  H.  Downes. 

2nd  London  General  Hospital:  Lieut.-Col.  (Hon.  Major-Gen.)  Sir 
G.  H.  Makins,  G.C.M.G..C  B.,is  retired,  having  attainei  the  age  limit. 

2nd  Eastern  General  Hospital:  Capt.  H.  Gervis  is  restored  to  the 
establishment. 

1st  Southern  General  Hospital:  Lieut.-Col.  H.  G.  Barling,  C.B. , is 
restored  to  the  establishment  oa  ceasing  to  hold  a temporary  com- 
mission in  the  Army  Medical  Service.  Capt.  (acting  Major)  A.  R.  Bearn 
relinquishes  the  acting  ran*  of  Major  on  ceasing  to  be  specially  employed. 

2nd  Southern  General  Hospital:  Major  J.  Swain  is  restored  to  the 
establishment  on  ceasing  to  hold  a temporary  commission  in  the  Army 
Medical  Service. 

3rd  Scottish  General  Hospital : Lieut.-Col.  A.  G.  Hay  is  restored  to 
the  establishment.  

ROYAL  AIR  FORCE. 

Medical  Branch.— Major  F.  H.  Stephens  (Staff  Surgeon,  R.N.) 
relinquishes  his  commission  on  reverting  to  R.N.  Medical  Services. 

Tne  undermentioned  are  transferred  to  unemployed  list : Capt.  N.  F. 
Stallard  ; Lieuts.  E.  S.  Sharpe,  R.  W.  Stephenson,  N.  C.  Cooper. 

INDIAN  MEDICAL  SERVICE. 

Col  W.  E.  Jennings  to  be  Major-General. 

Temporary  Lieutenants  to  be  temporary  Captains  : E.  T.  N.  Taylor, 
Govind  Shivram  Mandlik.  Har  Gobind  Dayal  Mathur,  Ram  Xarain  Sud, 
Jehangir  Cursetji  Bharucba,  Sher  Singh,  Hirnaya  Kumar  Sen,  Shapoor 
Dinsha  Vania,  Peruvemba  Ayya-arai  Acyer  Karaanathan,  Kshetra 
Mohan  Ray,  Satindra  Chandra  Basu,  Btdhu  Bhushm  Chatterjee, 
Padmanabba  Kangapp*  Bbandarkar,  Raghupati  Bauerji,  Kaikhusroo 
Rust  >mji  Dalai,  Susauta  Kumar  Sen,  Kantilal  Kalynji  Mankodi.  Suresh 
Chandra  Sarkar,  Ainar  Nath  Madhok,  Hantwall  Shankar  Rau,  Gopal 
Krishna  Rainrao  Padoidri,  Paskal  De  Souza.  Jehangir  Hormasji  Clarke, 
Keralapuram  Sreenevasa  Subraraanyam,  Duriseti  Narayanarao. 

Indian  Defence  Force  ( Medical  Corps). 

Temporary  rank  has  been  granted  as  follows  : — To  he  Lieutenant- 
Colonel  : E.  A.  C.  Hindmarsh.  To  be  Captains  : J.  H.  Sheldon,  W.  R. 
Taylor.  To  be  Lieutenant : Satish  Chandra  Ghosh. 

Capt.  RadhaMadhab  Prasad  relinquishes  his  temporary  rank. 


BOOKS,  ETC.,  RECEIVED. 

Blackie  and  Son,  London. 

Life  and  its  Maintenance.  A Symposium  of  Biological  Problems  of 
tne  Day.  Pp.  297.  5s. 

Crystal  Press,  Ltd.,  91,  Regent-street,  London. 

Healing  by  the  Realisation  of  God  or  True  Prayer  for  Doctors.  By 

F.  L.  Uawson,  M.I.E.E.,  A.M.I.C.E.  Pp.  62.  Is. 

Headley  Bros.,  London. 

Practical  Butter-making.  By  C.  W.  Walker- Tisdale,  F.C.S.,  and 

T.  R.  Robinson,  F.S.I.  Pp.  144.  5s.  6d. 

Longmans,  Green,  and  Co.,  London. 

The  Metals  of  the  Rare  Earths.  By  J.  F.  Spencer,  D.Sc.  Pp.  280. 

12s.  6 d. 

Marci’s.  A.,  and  Weber,  E.,  Bonn. 

Die  Behandlung  der  Haut-und  Geschlechtskrankheiten.  Von  Dr. 
K.  Hoffmann.  Pp.  150.  M.5.60. 

Orphan-Apprentice  School,  40,  Rue  La  Fontaine,  Paris. 

De  1’Orthopedie  Instrumentale.  By  Dr.  G.  Bidou.  Pp.  132. 

Spun,  E..  and  F.  N.,  London. 

Induction  Coils  in  Theory  aud  Practice.  By  Profeisor  F.  E.  Austin* 

E.E..  U.S.A.  Pp.  64.  5s. 

William-*  and  Norgate.  London. 

Problems  of  Life.  By  Rev.  R.  J.  Campbell.  Pp.  217.  5s. 


Messrs.  H.  Iv.  Lewis  and  Co.,  Ltd.,  have  removed 
their  publishing,  wholesale,  and  advertisement  departments 
to  28,  Gower-place,  W.C.  1.  The  change  should  provide 
more  convenient  accommodation  for  publishing  work,  whrle 
the  space  vacated  in  the  old  premises  will  afford  additional 
room  for  the  library,  to  which  a new  reading  room  will  be 
added. 


The  Lanoet,] 


PARLIAMENTARY  INTELLIGENCE. 


[July  26,  1919  179 


^Parliamentary  |ntelligenre. 

HOUSE  OP  COMMONS. 

Tuesday,  July  15th. 

Public  Health  Propaganda. 

To  a written  question  it  he  would  appoint  a publicity 
committee  to  consider  how  best  by  posters,  leaflets,  lectures, 
and  other  means  to  educate  the  nation  in  the  principles 
of  health,  Major  Astor  (Parliamentary  Secretary  to  the 
Ministry  of  Health)  replied:  The  Minister  of  Health  has 
recently  appointed  a Committee  to  advise  him  on  the 
dissemination  of  information  in  regard  to  housing,  whether 
by  the  means  indicated  in  the  question  or  otherwise.  I will 
send  the  honourable  Member  the  names  of  the  Members  aud 
the  terms  of  reference  to  the  Committee.  My  right  honour- 
able friend  proposes  to  await  their  advice  before  proceeding 
to  consider  the  question  of  publicity  in  relation  to  other 
problems  affecting  health. 


Wednesday,  July  16th. 

Dental  Reform. 

Mr.  Jesson  asked  the  Minister  of  Health  whether  an 
amending  Bill  to  the  Dentists  Act,  1878,  was  in  course  of 
preparation ; if  so,  whether  this  Bill  would  appoint,  in 
accordance  with  the  recommendations  of  the  Departmental 
Committee  of  Dentistry,  an  ad  hoc  Committee  to  inquire 
into  the  eligibility  of  unregistered  dentists  for  registration  ; 
whether  the  personnel  of  this  ad  hoc  Committee  had  already 
been  decided  upon ; whether  the  Incorporated  Dental  Society, 
Ltd.,  would  have  representatives  upon  it,  and  how  many; 
and  whether  he  could  state  why  the  National  Dental  Asso- 
ciation, an  organisation  which  represented  at  the  present 
moment  over  800  unregistered  dental  practitioners,  who 
each,  by  the  terms  of  his  agreement  with  the  association 
on  assuming  membership,  undertook  not  to  canvass  or 
advertise  for  patients,  and  made  a declaration  that  he  had 
been  in  practice  for  a period  of  five  years  as  a dental 
assistant  or  practitioner  wholly  engaged  in  operations  on 
the  mouth  before  Feb.  5th,  1919,  had  not  been  accorded 
equality  of  treatment  with  the  Incorporated  Dental  Society, 
Ltd.— Dr.  Addison  replied  : No,  Sir;  most  of  the  proposals 
referred  to  in  the  Report  of  the  Committee  must  form  part 
of  the  general  scheme  for  improved  health  services  for  the 
nation  which  the  Ministry  of  Health  are  concerned  to  develop 
as  soon  as  possible,  but  there  has  not  yet  been  sufficient 
time  to  work  out  such  a scheme,  nor  to  consider  adequately 
the  various  recommendations  of  the  Committee  in  question 
as  regards  dental  registration.  The  other  points  in  the 
question,  therefore,  do  not  arise. 


Thursday,  July  17th. 

Paddington  Military  Hospital. 

Captain  Wedgwood  Benn  asked  the  Secretary  for  War 
whether  he  was  aware  that  upwards  of  500  wounded  men 
the  majority  of  whom  were  cases  that  had  lost  one  or  more 
limbs,  had  recently  been  transferred  from  various  military 
hospitals,  in  particular  from  the  King  George  Hospital,  to  the 
Haddington  Military  Hospital,  in  the  Harrow-road-  whether 
he  was  aware  that  the  Paddington  Military  Hospital,  a con- 
verted workhouse,  was  quite  unsuited  for  the  reception 
of  such  cases  both  by  construction  and  situation.— Mr. 
Churchill  replied:  Complaint  has  been  made,  especially 
regarding  the  situation  of  this  hospital,  and  for  sometime 
past  endeavours  have  been  made  to  obtain  another  suitable 
building,  but,  I regret  to  say,  so  far  without  success.  I hope 
however,  that  arrangements  may  be  made  to  enable  the 
hospital  to  be  vacated  within  the  next  few  weeks. 


Disturbance  of  Military  Patients. 

Major  Glyn  asked  the  Secretary  for  War  if  the  position 
of  those  officers  and  men  who  were  at  present  undergoing 
treatment  in  those  military  hospitals  that  were  to  be  taken 
over  by  the  Ministry  of  Pensions  on  August  1st  had  been 
fully  considered ; whether  it  was  proposed  that  patients 
were  to  be  removed  from  those  hospitals  to  others  remaining 
under  War  Office  control,  in  spite  of  the  fact  that  their 
treatment  was  liable  to  be  detrimentally  affected  if  such 
transfer  to  nurses,  doctors,  and  surgeons  who  had  not  super- 
vised  their  cases  from  the  first  was  carried  out;  and 
whether  it  was  possible  for  the  War  Office  and  the  Ministry  of 
Pensions  to  come  to  such  a financial  understanding  in  regard 
to  these  cases  that  would  permit  these  patients  to  remain 
undisturbed  and  to  continue  their  treatment  under  the 
existing  medical  and  nursing  staff.— Mr.  Forster  (Financial 
Secretary  to  the  War  Office)  replied:  No  transfer  will  take 
place  when  injury  to  the  patient’s  health  would  be  likely  to 
be  caused  thereby.  J 

Venereal  Disease. 

Mr.  Lunn  asked  the  Minister  of  Health  whether  inquests 
ere  required  to  be  held  after  all  cases  of  sudden  death  of 
persons  undergoing  treatment  for  venereal  disease ; and,  if 
not,  whether  he  would  issue  instructions  with  a view  to 


securing  that  inquests  should  lie  held  on  all  such  cases  in 
future. — Dr.  Addison  replied  : Section  2 of  the  Coroners  Act, 
1887,  requires  an  inquest  to  be  held  whenever  there  is  a 
violent  or  unnatural  death,  or  a sudden  death  of  which  the 
cause  is  unknown.  There  is  no  power  under  the  statute 
enabling  any  Minister  to  issue  instructions  that  inquests 
shall  be  held  in  any  cases  not  covered  by  the  section  to 
which  I have  referred. 

Monday,  July  21st. 

Invalided  Officer  : Statement  by  Pensions  Minister. 

Mr.  Bottomley  asked  the  Pensions  Minister  whether  he 
would  give  an  explanation  of  the  circumstances  in  which  a 
lieutenant  invalided  out  of  the  Army  suffering  from  neuras- 
thenia was  recently  directed  by  telegram,  sent  to  a hotel  at 
which  he  was  staying,  to  proceed  to  the  London  Lock 
Hospital,  Harrow-road,  which  was  an  institution  for  women 
suffering  from  venereal  disease;  whether,  having  been 
certified  by  two  medical  men  employed  at  his  own  expense 
as  free  from  such  disease  aud  having  protested  against  being 
sent  to  the  men’s  branch  of  the  Lock  Hospital,  situated  in 
Soho,  to  which  he  had  been  referred  from  the  women’s 
institution,  he  was  informed  by  the  Ministry  of  Pensions 
that  an  officer’s  unreasonable  refusal  to  undergo  treatment 
rendered  him  liable  to  have  his  pension  reduced  by  half; 
whether  he  would  say  who  was  responsible  for  this  course 
of  action ; and  what  reparation  was  being  made  to  the 
officer  in  question. — Sir  L.  Worthington-Evans  replied  : 
I am  glad  to  have  the  opportunity  of  expressing  publicly  my 
deep  regret  for  the  annoyance  and  trouble  given  to  this 
officer.  The  doctors  are  not  able  to  decide  affirmatively 
what  is  the  cause  of  his  illness.  He  was  sent  to  a tuber- 
culosis specialist  and  examined  by  him,  but  the  report 
was  negative  ; he  advised  that  the  officer  should  be  admitted 
to  hospital-  and  kept  under  medical  observation  in  case  the 
illness  was  occasioned  by  general  paralysis.  Arrangements 
were  made  fora  private  room  at  the  Lock  Hospital,  where  it 
was  intended  that  the  specialist  in  general  paralysis  should 
make  the  desired  observations  so  as  to  exclude  general 
paralysis,  as  tuberculosis  had  been  excluded,  if  such  turned 
out  to  be  the  case.  The  telegram  never  ought  to  have  been 
sent,  although  no  serious  consequence  would  have  arisen  if 
it  had  been  opened  by  the  officer.  It  was,  however,  opened 
at  his  request  and  read  to  him  on  the  telephone  by  someone 
at  his  hotel.  With  regard  to  the  letter  the  officer  came  to 
the  Ministry  after  the  letter  was  written  and  before  it  was 
delivered  and  saw  one  of  the  doctors.  The  doctor  heard 
his  explanation  and  withdrew  the  letter  and  apologised 
for  the  telegram.  The  letter  ought  not  to  have  been 
sent,  but  being  in  the  post  could  not  be  recalled. 
There  was  no  question  of  unreasonable  refusal  to 
undergo  treatment ; no  treatment  had  been  decided  upon. 
The  officer  was  asked  to  go  to  the  hospital  for  observation. 
Treatment  could  not  be  decided  upon  until  after  the  result 
of  the  observation  was  known.  The  officer  himself  has  since 
proved  that  there  is  not  the  slightest  reason  to  suppose  that 
he  is  suffering  from  general  paralysis  due  to  venereal  disease. 

I fully  accept  that  conclusion.  The  clerk  at  the  Ministry 
who  was  responsible  for  the  letter  will  not  in  future  be 
engaged  in  this  class  of  work,  and  steps  have  been  taken  to 
ensure  that  no  warnings  of  withdrawal  or  reduction  of 
pension  shall  be  made  until  the  case  has  been  considered  by 
a principal  medical  officer.  I have  myself  seen  this  officer 
when  he  called  at  the  Ministry.  I have  expressed  to  him  my 
deep  regret  for  both  the  telegram  and  the  letter,  and  I have 
offered  to  refund  to  him  the  expenses  to  which  he  has  been 
put  in  obtaining  the  medical  certificates  referred  to.  I 
explained  to  him  what  I have  now  told  the  House,  and  I 
trust  that  the  blunder  made  by  an  administrative  clerk  will 
not  discredit  the  really  excellent  and  efficient  work  done  for 
thousands  of  officers  aQd  men  by  the  medical  officers 
employed  at  the  Ministry. 

Tuesday,  July  22nd. 

Case  of  Paralysis  Agitans. 

Mr.  Raper  asked  the  Financial  Secretary  to  the  War  Office 
if  he  would  state  what  steps  were  being  taken  definitely  to 
settle  the  compensation  claim  of  Mr.  Thomas  Clark  Barcliff, 
in  view  of  the  fact  that  Mr.  Barcliff  had  been  discharged  as 
incurable  from  five  hospitals  and  had  also  been  declared  to 
be  suffering  from  paralysis  agitans  by  every  nerve  specialist 
who  had  examined  him. — Mr.  Forster  replied  : Mr.  Barcliff 
has  received  the  maximum  compensation  payable  under  the 
scheme  framed  under  the  Injuries  in  War  Compensation 
Act,  1914  (Section  2),  which  applies  to  his  case.  In  the 
opinion  of  the  Treasury  medical  referee  Mr.  Barcliff  would 
benefit  from  a course  of  special  treatment  suitable  for  the 
malady  from  which  he  is  suffering,  and  arrangements  are 
being  made  for  him  to  receive  such  treatment. 

National  Health  Insurance  Bill. 

The  House  considered  on  Report  the  National  Health 
Insurance  Bill,  which  had  passed  through  Standing  Com- 
mittee without  amendment.  The  Bill  was  read  a third 
time. 


180  The  Lancet,] 


MEDICAL  NEWS.— APPOINTMENTS. 


[July  26,  1919 


Utefrical  Stetos. 


University  of  Cambridge  : The  Psychological 

Laboratory.— It  haB  been  decided  by  the  managing  com- 
mittee lor  the  Cambridge  diploma  in  psychological  medicine 
to  recognise  12  months’  clinical  experience  in  a military 
neurological  hospital  as  qualifying  a candidate  do  enter  for 
Part  II.  of  the  examination  for  this  diploma.  Part  I.  is  open 
to  all  persons  whose  names  are  on  the  Medical  Register.  A 
course  in  preparation  for  these  examinations  will  be  held  at 
the  psychological  laboratory,  Cambridge,  during  August 
next,  information  may  be  obtained  by  writing  to  Dr.  J.  P. 
Lowson,  at  the  Psychological  Laboratory. 

Royal  College  of  Physicians  of  London. — An 

extraordinary  Comitia  of  the  Royal  College  of  Physicians  of 
London  was  held  on  July  17th,  Sir  Norman  Moore,  the 
President,  being  in  the  chair.  A letter  was  received  from 
the  Minister  of  Health,  (lated  July  4th,  inviting  the  College 
to  place  before  him  the  names  of  persons  who,|in  the  opinion 
of  the  College,  are  specially  suitable  to  serve  upon  the 
Consultative  Council  which  will  advise  'upon  “ Medical  and 
Allied  Services. ” A provisional  list  was  laid  before  the 
College  and  approved. 

London  University. — The  Senate  has  sanctioned 
the  granting  of  the  M.S.  degree  in  two  additional  branches— 
namely:  (1)  ophthalmology;  and  (2)  laryngology,  otology, 
and  rhinology;  and  the  regulations  have  been  modified  in 
accordance  with  this  decision. 

University  of  Edinburgh. — At  the  summer 
graduation  ceremonial  held  on  Thursday,  July  10th,  in  the 
M‘Ewan  Hall,  Edinburgh,  the  honorary  degree  of  Doctor  of 
Law  was  conferred  upon  Sir  Thomas  R.  Eraser,  F.R.S., 
emeritus  professor  of  materia  medica  in  the  University,  and 
upon  Mr.  Rutherford  Morison,  lately  professor  of  surgery 
in  the  University  of  Durham. 

The  following  degrees  in  Medicine  were  awarded  : — 

Doctor  or  Medicine. 

"Arthur  Cecil  Alport  (in  absentia),  (Robert  George  Archibald, 
"■Robert  George  Baunerman,  Frederick  Adolphus  Fleming 
Barnardo  (in  absentia),  (Edwin  Bramwell,  Frederick  Russell 
Bremner  (in  absentia).  Arihur  William  Treminheere  Buist 
(in  absentia).  fDuncan  Macuab  Callender  (in  absentia),  "Disney 
Hubert  Dusch  Chan.  "Gerald  Fitzgerald,  Walter  Benjamin  Harry, 
Kenneth  Goodall  Hearne,  James  Burnett  Hogarth.  Matthew  James 
Johnston,  "Robert  Lawson,  Edward  Loggie  Middleton.  Ronald 
Roderick  Murray  iin  absentia),  "William  Henry  Parkes  (in  absentia), 
Dhanavada  Samuel  Ramacbandra  Rao  (in  absentia).  Archibald 
Romanes.  Alan  William  Stuart  Sichel,  Robert  Scott  Stevenson, 
Samuel  Henry  Stewart,  and  "Edmund  Leigh  White. 

* Commended  for  thesis.  t Highly  commended  for  thesis. 
Master  of  Surgery. 

James  Methuen  Graham  (awarded  gold  medal  for  thesis). 

Bachelor  of  Medicine  and  Bachelor  of  Surgery. 

Henry  Morris  Anderson,  Adam  Armit,  Alfred  Badenoch,  Harry 
Berelowitz,  John  James  Rouse  Binnie.  Alice  Bloomfield  (first-class 
honours),  Charles  George  Booker,  Peter  Martin  Brodfe  (second- 
class  honours),  Cecil  Carron  Brown,  Robert  M'Cail,  Levbourne 
Stanley  Patrick  Davidson  (first-class  honours), Frederick  John  Deane, 
Arthur  Armstrong  Denham,  Robert  Light  body  Galloway,  Kurt 
Gillis,  Morris  Goldberg  (second-class  honours),  Arthur  Trevenning 
Harris,  Marjorie  Harris,  Cecil  Edith  Lyster  Hole,  Jiwanda  Ram 
Katarlya,  Marjorie  Hamilton  King.  Raymond  Leslie  Langley  (fir.t- 
class  honours),  Robert  Kho  Seng  Lim,  Harry  Stepbenson  Lucrafo 
(first-class  honours).  John  Charles  Macartney,  James  MTntyre, 
Elia  Grace  Florence  MacKenzie.  Ronald  Douglas  Mackenzie,  Robert 
Macnair.  Mona  Macnaughton.  Elizabeth  M‘Vieker,  Mabel  Stevenson, 
Martin,  George  Henry  Hope  Maxwell  (in  absentia),  Jacobus  Hugo 
Meiring.  Ahraham  Marais  Moll,  John  Oliver  Murray,  Arthur  Vincent 
Treadwell  Musto,  Edward  Paul  O’Dowd,  Aerath  Narayanan  Xanoo 
Panikker,  Clifford  William  Patterson,  John  Redwood  Payn,  Howard 
Sidney  Plowman,  Erie  Haldane  Ponder,  Mary  Simps««i  Poole  (nde 
Paterson),  William  Gordon  Robson  i second-class  honours),  Beatrice 
Annie  Sybil  Russell,  Richard  Sandilands,  Mahmoud  Zaky  Sheriff, 
Bertie  Soutar  Simpson,  William  Augustus  Slack,  Valentine 
Alexander  Stooks.  Arthur  Kinsey  Towers,  Maung  Sein  Tun, 
Petrus  Cornelius  Uvs.  Jakob  Rudolph  de  Vllliers,  George  Ronald 
Waller,  Robert  Boog  Watson.  Alfred  George  Norton  Weatherbead, 
John  Sinclair  Westwater.  James  Leslie  Wilson,  and  Duncan 
Ferguson  Yuille. 

Summer  School  of  Civics  and  Eugenics. — The 

second  Summer  School  of  Civics  aud  Eugenics,  organised  by 
the  Civil  and  Moral  Education  League  and  Che  Eugenics 
Education  Society,  will  be  held  at  Cambridge  during 
tne  fortnight  from  Saturday,  August  2nd  to  I6th.  The 
aim  of  the  school  is  to  give  teachers,  social  workers,  aud 
others  interested  in  educational  and  social  reconstruction 
opportunities  for  study  and  discussion.  The  fee  for  the 
fortnight’s  course  is  2 guineas.  Hoard-residence  varies  from 
£2  2s.  to  £3  3s.  The  committee  have  at  their  disposal  a 
small  bursary  fund,  which  is  to  he  used  to  cover  the  expenses 
of  such  people  as  find  themselves  unable  to  defray  the  whole 
cost  of  their  course  at  the  school.  Further  particulars  can 
be  obtained  from  the  Summer  School  Secretary,  II,  Lincoln’s 
Inn-fields,  London,  W.C.2. 


Queen's  University  of  Belfast. — The  Senate  of 
Queen's  University  of  Belfast  on  July  16th  appointed  Mr. 

A.  W.  Stewart,  D.Sc.,  professor  of  chemistry,  in  place  of  the 
late  Dr.  A.  Letts;  Dr.  Thomas  Walmsley  professor  of  |l 
anatomy,  in  place  of  Dr.  J.  Symington,  resigned;  and  Dr. 

J.  W.  C.  Gunn  lecturer  in  pharmacology,  in  the  vacancy 
created  by  the  retirement  of  Sir  William  Wbitla.  All 
these  new  teachers  come  from  Scotland,  the  first  two 
from  Glasgow'  University,  the  third  from  the  University  of 
Edinburgh.  Dr.  P.  T.  Crymble  has  been  reappointed 
lecturer  in  applied  anatomy.  It  was  announced  at  the 
meeting  that  a sum  of  £8000 ‘is  to  be  placed  by  the  Treasury 
at  the  disposal  of  Queen’s  University  for  expenditure  during 
the  current  financial  year  on  certain  pressing  wants  (salaries 
of  professors  and  lecturers,  urgent  improvements  in  various 
teaching  departments,  Ac.).  So  far,  it  was  said,  no  actual 
money  had  passed  from  the  Treasury  to  the  finance  com- 
mittee of  the  University. 

Devon  Red  Cross  and  Voluntary  Aid  Organi- 
sation.—During  the  late  war  this  association  was  responsible 
for  the  organisation  of  34  hospitals  aud  equipped  3905  beds, 
which  received  45,007  patients,  with  a staff  comprising  2735. 
The  funds  administered  amounted  to  £261,585,  the  cost  of 
administration  being  £1912. 

Bognor  War  Memorial  Cottage  Hospital. — 
The  Bognor  War  Memorial  Cottage  Hospital,  towards 
which  Mr.  James  Fleming  gave  £7000,  was  opened  on 
July  16th.  After  a short  dedication  service  Mrs.  Fleming 
was"  presented  with  a silver  key,  with  which  she  unlocked 
the  door  amid  an  enthusiastic  scene.  The  hospital  was 
formerly  a large  residence  situated  on  the  Chicbester-road, 
and  the  greater  part  of  the  £7000  has  been  spent  in  its  con- 
version into  a hospital  of  5 wards  and  15  beds,  with,  of 
course,  all  the  necessary  concomitants.  A roll  of  honour 
carved  in  oak,  which  will  bear  the  names  of  all  those  from 
Bognor  who  have  fallen  in  the  war,  has  been  placed  in  a 
conspicuous  position  in  the  entrance  ball. 

Dr.  C.  H.  Browning,  director  of  the  Bland-Suttou 
Institute  of  Pathology  at  the  Middlesex  Hospital,  has  been 
elected  to  the  Gardiner  Chair  of  Bacteriology  in  the 
University  of  Glasgow. 


Crownhill  Convalescent  Home,  near  Plymouth. 
—Tne  annual  meeting  of  the  friends  of  this  institution  was 
recently  held  under  the  presidency  of  Lord  Mount  Edgcumbei 
It  was  stated  that  during  the  past  year  149  patients  bad  been 
admitted,  about  half  the  number  in  pre-war  davs.  The 
financial  statement  was  satisfactory.  The  chairman  alluded 
to  the  excellent  work  of  the  home  and  reminded  the  sub- 
scribers that  the  charming  building  had  been  presented  by 
Dr.  C.  A.  Hingston. 

The  late  Dr.  B.  A.  Palmer. — The  death  is 
announced  of  Benjamin  A.  Palmer,  M.B.  Glasg.,  J.P.,  0: 
Millvale  House,  co.  Armagh,  in  the  Newry  Hospital.  Dr. 
Palmer,  an  Armagh  man,  was  born  on  March  30th,  1852 
He  studied  in  Glasgow,  where  he  graduated  M.B.  in  1880; 
and  became  also  L.R.C.S.  Edin.  In  the  same  year  he  wa 
appointed  dispensary  medical  officer  of  the  Crossmaglei 
District  of  the  Castleblaney  Union,  a position  he  occupies 
until  1890,  when  he  became  medical  officer  of  the  Mullaghglass 
Dispensary  District  of  the  Newry  Union,  an  office  he  held  a 
the  time  "of  his  decease.  For  over  33  years  he  was  f 
justice  of  the  peace  for  county  Armagh,  and  for  11  yean 
for  the  county  of  Down.  Dr.  Palmer  was  a well-known  an. 
much  respected  figure  in  the  life  of  Newry  and  the  surround 
ing  district,  and  a large  circle  of  friends  and  patients  nov 
mourn  his  loss.  He  leaves  a widow  and  three  daughters. 


appointments. 


Successful  applicants  tor  vacancies.  Secretaries  oj  Public  Institution* 
and  others  possessing  information  suitable  for  (his  column,  or 
invited  to  forward  to  The  Lancet  Office,  directed  to  the  Sul 
Editor,  not  later  than  9 o'clock  on  the  Thursday  wu  ruing  oj  eac 
week,  such  information  for  gratuitous  publicalion. 


Bamford,  Miss  A.,  has  been  appointed  House  Surgeon  to  the  Nort 
Devon  Infirmary.  Barnstaple. 

Off fi  n.  D.  H . M.B.,  B.S.Lond.,  Second  Assistant  Medical  Officer 1 
t lie  Marvlebine  Guardians.  . 

Glaistfr,  j . M.D.  Glasg..  one  of  the  Medical  Referees  under  tt) 
Workmen's  Compensation  Act  for  the  Sheriffdoms  of  Ayr,  Kentre 
and  Bute,  and  Stirling,  Dumbarton,  and  Clackmannan. 

Hallows,  Norman  F.,  M.D.  Oxon..  D.P.H.,  Medical  Officer 
Marlborough  College.  Wilts.  ... 

Wade,  It..  M H.C.S..  I.  U.C.P..  Assistant  Administrator  of  AnicsthetK 
to  St.  Bartbolomew.'s  Hospital. 

Certifying  Surgeons  under  tire  Factory  and  Workshop  Act. 
Roberts,  A.  H . M.K.O.S  . L.R.C.P.  Lond.  (Mailing);  Wai.kki 
W N M.B.,  Cb.B  Dubl.  (Manorcunnlngham  and  Letterkenuy 
Watson,  F.  H.,  M B.,  B.C.  Cantab.  (Sbeerness). 


I 


NOTES,  SHORT  COMMENTS,  AND  ANSWERS  TO  CORRESPONDENTS.  [July  26,  1919  181 


The  Lancet,] 


Uaranries. 


For  farther  information  refer  to  the  advertisement  columns. 
Bnrwley,  Beckett  Hospital.— First  ami  Second  Ren.  11  S.’s. 

| Bermondsey  Medical  Mission  fur  Women  and  Children.— Med.  Woman. 

I £150. 

Birmingham  City — Municipal  Bacteriologist..  £700. 

Birmingham  General  Hospital.— Asst.  V.  £60  Surgical  Registrar. 
£200  Two  Asst.  S.  £50.  Also  H.P..  H.S.,  Obstets.  H.S.,  H.S. 
to  the  Bar  and  Throat  and  Venereal  Dept.  £100. 

Birmingham.  Rubery  Hill  Asylam  and  Annexe  at  Hollymoor.— Med. 
If  Supt.  £1250. 

Bolton,  Townleys  Hospitals,  Farnworth,  near  Bolton.— Med.  Supt.  and 
Asst.  Med.  Supt. 

\ Bournemouth,  Royal  Victoria  and  West  Hants  Hospital.  Boscombe 
Branch.— Res.  M.O.  £250.  Also  Second  Res.  M.O.  £200. 

Cairo,  Egyptian  Government  School  of  Medicine. — Professors  and 
Lecturers.  £E.1000  and  £E.600.  Also  Ruliologist  and  Lect.  in 
Radiology,  £B.5X),  Anaesthetist  and  Lect.  in  Anaesthetics,  £E.500, 
and  Registrar  and  Tutor,  £E.600. 

i Canterbury,  Kent  and  Canterbury  Hospital.— Jun.  Res.  M.O.  £150. 
a Cape  Town  University,  Faculty  of  Medicine  —Profs,  of  Medicine,  Sur- 
gery, Obstetrics,  and  Gynaecology.  £1250. 

Cardiff,  Gian  Ely  Hospital.  — Asst.  Res.  M.O.  £3C0. 

Cheam,  Surrey,  St.  Anthony’s  Hospital.— Res.  M.O. 

Coventry  and  Warwickshire  Hospital.— Hon.  Surg.  Staff. 

Devon  and  Cornwall  Sanatorium  for  Consumptives,  Didworlhy , South 
Brent.— Female  Asst.  M.O.  £200. 

I Devonport,  Royal  Albert  Hospital. — Res.  H.S.  £200. 

Dorset  County  Council  — A«sa.  County  M.O.  £400.. 

Ely,  Isle  ot  Ely  County  Council.  — jvsst.  Tuberc.  O.,  M.O.H.,  and 
School'M.O.  £450.  • 

Great  Yarmouth  Hospital,— H.S.  £200.  g 

Huddersfield  County  Borough  Education  Authority. — Full-time  Sent. 
Surg.  £350. 

Hull  Education  Committee —Asst.  Sch.  M.O.  £450. 

' Hall  Royal  Infirmary. — Hon.  P.  and  Two  Hon.  S.’s. 

' Kingston-upon-Thames  Borough  Education  Committee. — School  M.O. 
£300. 

Leeds  Public  Dispensary,  North-street. — Res.  M.O.  £200. 

Leeds  University.— heat,  in  Expert.  Phys.  £500.  Demonstr.  in  Phys. 
£250.  Demonstr.  in  Hist.  £250. 

Leicester  Poor-law  Infirmary  —Res.  M.O.  £250.  Also  Sec.  Res.  M.O. 
Liverpool  School  of  Tropical  Medicine.—  Asst.  Lect.  in  Parasitology. 

: £250. 

Liverpool,  Stanley  Hospital. — H.P.  and  H.S. 

Liverpool  University. — Chair  of  Anatomy.  £800. 

Maidstone,  Kent  County  Asylum.— Jun.  Asst.  M.O.  £300. 

Manchester,  Ancoats  Hospital.  — H.P.  £150.  Also  Hon.  P.  and 
Radiologist. 

: National  Hospital  for  Diseases  of  the  Heart,  Westtnoreland-street,  W.— 
I Res.  M.O.  £100.  Also  Non-Res.  M.O.  £50. 

Newcastle-upon-Tyne,  Royal  Victoria  Infirmary.— Res.  Anaesth.  £120. 

i Also  Four  Non-Res.  Anaesth.  £50. 

Newcastle-upon-Tyne,  University  of  Durham  College  of  Medicine.— 
Demonstrators  of  Anatomyand  Physiology.  £350  to  £500  and  £300. 
Newport  Borough  Asylum,  Caerleon,  Mon.— Asst.  M.O.  £300 
Newport,  Mon.,  Royal  Gwent  Hospital. — Third  Res.  M.O.  £200. 

New  Zealand  —Path,  and  Bact.  for  Pub.  HealthDept.,  Auckland.  £700. 
Otago  University,  New  Zealand. — Prof,  of  Syst.  Med.,  Prof,  of  Clin. 
Med.  and  l'herap.,  and  Leet.  on  Clin.  Med.  £600,  £500,  and  £400 
respectively. 

ii  Queen  Mary’s  Hospital  for  the  East  End,  Stratford,  E.— Asst.  Hon.  P.’s., 

Hon.  Opbthal.  S , and  Hon.  Aural  S. 

St.  Helens  County  Borough.— Asst.  M.O.H.  £500. 

Seychelles  Government.— Asst.  M.O.  and  Visiting  Magistrate.  Rs.5000. 

I Sheffield  City  Education  Committee. — School  Dent.  Surgeons.  £350. 

I Sheffield  Royal  Infirmary. — Asst.  H.P.  £150. 

Smyrna  Mission  and  Beaconsfield,  Memorial  Hospital.  — Medical 
1 Missionary.  £250. 

Taunton  and  Somerset  Hospital. — Hnh.  S. 

Taunton,  Somerset  and  Bath  Asylum.  Cotford.— Asst.  M.O.  £300. 
TintiwaU.  Whiteness,  and  Weisdale  Dafish.— M.O.  and  Pub.  Vac.  £45. 
Twickenham,  St.  John's  Hospital. — Hon.  Con.  Surgeon. 

West  African  Medical  Staff. — Number  of  appointments.  £400. 

West  Riding  County  Council,  Treatment  of  Venereal  Diseases.—  Asst, 
i £550.  Also  Sch.  Oculist.  £450. 

[The  Chief  Inspector  of  Factories,  Home  Office,  S.W.,  gives  notice  of 
a vacancy  for  a Certifying  Surgeoh.  under  the  Factory  and  Workshop 
Acts  at  Soham  (Cambridge). 

r , 


Carriages,  attb  geittjjs. 


BIRTHS. 

Harnett. — On  July  16th,  at  Devon  House,  Barnet,  the  wife  of  W.  G. 
Harnett,  M.A.,  M.D.,  of  a son  (stillborn). 

MARRIAGES. 

Duncan— MCEwan.—  On  July  22nd,  at  St.  Wilfrid's  Church,  Harrogate, 
William  Henry  Duncan,  F.R.C.S.  Edih.,  to  Ida,  elder  daughter  of 
Mr.  and  Mrs.  J.  H.  McEwan,  Crimple  House,  Harrogate. 
Orr-Bwing — Ross.— On  July  16th,  at  Parbold,  Archibald  Orr-Ewing, 
M.B.,  B.C.  Cantab.,  to  Gladys  Mary,  second  daughter  of  Mr.  and 
Mrs.  Alex.  Ross,  of  Clifton,  Parbold. 

DEATHS. 

Peile.— On  July  14tb,  at  Phillimore,  Sidmouth,  William  Hall  Peile, 
M.D.,  aged  50. 

Randall.— At  Park-street,  Bridgend,  Wyndham  Randall,  L.R.O.P. 
, Edin.,  M.R.C.S.  Eng.,  in  his  73rd  year. 

N.B.—A  fee  of  5s.  is  charged  for  the  insertion  of  Notices  of  Births, 
Marriages,  and  Deaths. 


ftotes,  Sjiort'  Cfltnmcnts,  anb  Rasters 
ta  Camsponknts. 

THE  BATHS  OF  OLD  LONDON. 

By  Septimus  Sunderland,  M.D.  Brux. 

Part  iii. 

Spas,  )Vclls,  and  Springs. 

The  preceding  account  of  the  few  baths  of  Old  London,  the 
former  existence  of  which  I have  been  able  to  trace,  will  be 
sufficient  to  show  that  some  attempt  was  made  to  treat 
diseases  of  the  skin  by  balneo-therapeusis  in  London  during 
the  past  few  centuries.  Spas 

But  there  remains  something  to  be  said  about  the  spas  and 
wells  of  Old  London  in  connexion  with  bathing.  During  the 
time  when  existed  the  vogue  of  drinking  the  waters  at  the 
various  London  spas — roughly  speaking,, from  the  latter  half 
of  the  seventeeth  to  the  early  period  of  the  nineteenth 
century,  no  provision  was  made  for  bathing  at  these  spas 
with  the  exception  of  one  or  two  minor  ones  already  men- 
tioned ; although  in  many  instances,  no  doubt,  the  water 
was  used  locally  by  affusion.  Those  best  known  of  the  spas 
(the  waters  being  taken  internally)  were  : St.  Chad’s  for 
“ Scrofula  ” (near  the  preseut  King’s  Cross);  Pancras,  for 
“ obstinate  cases  of  scurvy,  king’s  evil,  leprosy,  and  all  other 
skin  diseases  ” ; Powis  Well  (near  the  Foundling  Hospital, 
Guilford-street),  for  “ sore  legs,  inflammation  of  the  eyes”; 
Sadler’s  Well  for  “scurvy  ’;  Sbadwel!  Spa  for  “scorbutic 
and  cutaneous  diseases’’  (by  drinking  or  bathing);  Hoxton 
Well  for  “ those  afflicted  with  wounds,  ulcers,  fistulas,  sores, 
scabs,  sore  eyes,  sore  legs,  leprosy,"  Ac. ; Marylebone  Spa 
for  “scorbutic  disorders";  The  Well  in  Restoration  Spring 
Gardens  (St.  George’s  Fields)  “ for  the  cure  of  all  cancerous 
and  scorbutic  tumours  ” ; Sc.  George’s  Spa,  Lambeth,  by 
Dr.  John  Fothergill  in  1695  for  “ most  cutaneous  disorders 
and  preventing  cancerous  affections”;  Biggin  Hill  Spring, 
Norwood,  for  “scrofulous  complaints."  Sydenham  Wells 
were  referred  to  by  Dr.  John  Peter  as -Lewisham  Well.  He  ’ 
wrote  : — 

“This  water  outwirdlv  used  is  very  gooi  for  most  cutaneous  dis- 
tempers ai  leprosy,  itch,  s:abs,  pimples,  ringworms,  scurvy.  It  also 
dissolves  turn  jurs,  and  cureth  old  ulcers  if  the  parts  ill-affected  be 
washed  or  bathed  therewith,  or  if  a curd  made  by  boyling  milk  there- 
with be  applied  ; and  I am  persuaded,  it  being  used  bv  wav  of  a warm 
bath,  it  would  be  of  grear  efficacy  to  consume  hydropic*!  tumours,  to 
ea  e or  cure  gouty  and  rheumatic  dolours,  an  1 far  more  effectual  also  in 
the  abovesaid  cutaneous  distempers.” 

Springs  and  Wells. 

Other  old  springs  and  wells  of  London  which  may  be 
mentioned  as  having  some  connexion  with  the  subject  of 
dermatology,  although  they  did  not  achieve  the  fame  of 
being  considered  ‘spas,"  or  even  “spurious  spas”  are  the 
following  : “ Crowder’s  Well  (Cripplegate)  “ for  sore  eyes  ” ; 
Highgate  Spring  “for  bathing  eyes”;  St.  Agnes  Well, 
Hyde  Park,  “ for  bathing  eyes”;  Vauxhali  Well  “for  eye 
troubles”;  Ladywell,  Lewisham,  “for  sore  eyes”;  East 
Sheen  Well  “ for  eye  troubles  and  for  bathing  ^he  legs." 

Holy  Wells. 

I will  not  weary  you  by  enumerating  the  names  of  the 
23  so-called  “Holy  Wells”  of  London,  about  which  I 
gathered  information  some  years  ago,  although,  of  course, 
all  the  “Holy  Wells”  were  attended  by  people  suffering 
from  skin  troubles  as  well  as  from  every  other  ailment. 

Conclusion. 

I do  not  know  to  what  extent  ordinary  bathing  and 
washing  may  prevent  the  acquirement  of  skin  diseases,  but 
assume  that  most  modern  dermatologists  agree  with 
Crocker’s  statement  in  the  1903  edition  of  his  book  that 
“ the  key-note  of  modern  dermo-therapeutics  is  anti- 
septicism.”  I imagine,  therefore,  that  skin  specialists 
approve  of  ordinary  bathing  and  washing  in  moderation 
for  people  with  healthy  skins,  with  the  hope  of  prevention 
of  some  at  least  of  the  various  cutaneous  disorders,  in  spite 
of  the  views  of  Dr.  Samuel  Johnson  and  of  the  apostle  of 
the  doctrine  of  vaccine  treatment.  Of  course,  everyone 
knows  that  bathing  to  excess  and  the  use  of  certain  soaps 
may  cause  skin  irritation. 

At  the  present  day  the  value  of  bath  treatment  in  phases 
of  certain  skin  diseases  is  recognised  and  is  recommended 
by  dermatologists,  but  not,  perhaps,  to  the  extent  that  it 
may  deserve.  It  is  possible  that  in  the  near  future,  when 
the  practice  of  hydrology  will  be  systematically  taught 
either  in  post-graduate  courses  or  as  part  of  the  medical 
student’s  curriculum,  that  the  attention  of  skin  specialists 
will  be  still  more  directed  to  the  subject,  and  that  hydro- 
logical  methods  of  treatment  may  be  elaborated  which  will 
be  even  more  beneficial  to  sufferers  from  skin  diseases  than 
those  practised  at  the  present  time. 


[July  26,  1919 


182  Thf.  Lancet,]  NOTES,  SHORT  COMMENTS,  AND  ANSWERS  TO  CORRESPONDENTS. 


In  conclusion,  I should  like  to  offer  the  suggestion  that  it 
might  be  advisable  that  a fuller  investigation  should  be 
made  by  dermatologists  on  the  effects  of  bath-treatment  in 
skin  diseases.  It  appears  to  me  that  its  value  may  not  be 
adequately  recognised,  that  its  possibilities  may  not  have 
been  sufficiently  explored,  and  that  no  very  earnest 
endeavours  have  been  made  of  late  years  to  attemnt 

further  progress.  

To  the  Editor  of  The  Lancet. 

Sir, — My  good  friend  Septimus  Sunderland,  in  his  excellent 
description  of  the  baths  of  Old  London,  refers  to  the  bath  in 
Strand  Lane  as  a “ Roman  bath.”  In  doing  this  he  is  only 
voicing  the  commonly  received  opinion.  There  is,  however, 
no  evidence  that  the  bath  dates  back  to  Roman  time.  It 
does  not  resemble  a Roman  bath,  which  was,  I believe, 
usually  a square  excavation  in  the  floor,  lined  with  tesselated 
pavement,  and  descended  into  by  one  or  more  steps ; whereas 
the  bath  in  Strand  Lane,  as  Dr.  Sunderland  points  out, 
resembles  the  ordinary  plunge  bath  of  modern  times,  but  of 
large  size.  Moreover,  it  is  very  strange,  as  pointed  out  by 
Besant  and  others,  that,  if  this  bath  is  Roman,  it  is  not 
mentioned  by  Stowd  and  other  antiquaries. 

I am,  Sir,  your  faithfully, 

S.  D.  Clippingdale. 

Holland  Park-avenue,  W.,  July  ?lst,  1919. 

HEALTH  OP  THE  GERMAN  NAVY  DURING  THE  WAR. 

With  a few  noteworthy  exceptions  German  ships  stayed 
in  port  during  the  war,  so  that  the  conditions  of  health 
obtaining  among  the  personnel  cannot  have  differed  greatly 
from  those  of  peace  times.  The  daily  ration  strength  of 
the  German  navy — the  number  of  men  in  that  navy — is  j 
calculated 1 to  have  been  in  the  first  year  of  the  war,  202,123  ; 
in  the  second,  235,267 ; in  the  third,  251,347 ; and  in  the 
fourth,  383,071  men.  Amongst  these  there  came  under 
treatment  in  each  year  (“  new  cases  ”)  per  1000,  first  year, 
472 ; second  year,  442 ; third  year,  441 ; and  fourth  year, 
497.  As  the  average  annual  number,  per  1000,  for  the  five 
years  before  the  war  was  525,  it  appears  that  fewer  men 
fell  sick  in  the  German  navy  in  war  than  in  peace.  The 
increase  in  the  figures  for  the  fourth  year  is  largely  due  to 
the  influenza  epidemic  (92  cases  per  1000).  Tuberculosis  of 
the  lungs  is  the  only  disease  quoted  as  more  prevalent 
during  the  war  (per  10t)0  before  the  war,  1-37  cases  annually, 
during  the  war  in  successive  years  1*45,  2-08,  2-81,  and  2 09), 
while  the  mortality,  too,  was  much  increased  (11 Y per  cent, 
in  the  first  year,  10'4  in  the  second,  13-6  in  the  third,  and 
18'4  in  the  fourth  year)  (August,  1917-August,  1918).  The 
number  of  men  killed  at  once,  without  medical  treatment,  is 
not  mentioned,  but  of  the  sick  and  wounded  who  were  seen 
by  doctors  4073  died ; also  5899  were  invalided  up  to 
August  1st,  1918. 

THE  GAZETTE  OF  THE  THIRD  LONDON  GENERAL 
HOSPITAL,  WANDSWORTH. 

Among  the  many  publications  which  the  various  war  hos- 
pitals have  issued  for  the  benefit  of  the  patients  and  the 
amusement  of  both  patients  and  public,  the  Gazette  of  the 
3rd  London  Hospital  holds  a prominent  place,  and  it  is  with 
feelings  of  regret  that  we  announce  its  forty-sixth  and 
last  number,  though  that  regret  is  tempered  by  the 
fact  that  the  signing  of  Peace  has  rendered  the  hos- 
pital no  longer  necessary.  The  hospital,  which  has  done 
most  excellent  service  for  the  wounded,  had  from  the 
first  a wealth  of  artistic  and  literary  talent  among 
its  staff  and  patients,  and  the  Gazette  has  borne  witness 
to  the  lavish  way  in  which  that  staff  has  placed  its 
talents  at  the  disposal  of  the  patients,  and  in  providing  for 
them  and  the  public,  under  the  past  and  present  editors, 
Corporal  Ward  Muir  and  Sergeant  Noel  Irving,  a magazine 
of  high  merit.  This  last  and  enlarged  number  maintains 
that  high  standard,  and  both  as  a souvenir  of  Peace  and 
an  entertaining  journal  is  more  than  worth  the  Is.  which 
is  charged  for  it.  Many  of  the  old  contributors  cater  for 
this  issue,  Corporal  J.  H.  Dowd  illustrating  among  other 
productions  the  emotions  of  a hospital  visitor  on  receiving 
final  instructions  from  a disabled  patient  as  to  the  writing 
of  a letter  : “ Love  to  yourself  and  Babs.  P.S.  Please  excuse 
the  scribble.” 

COLONIAL  HEALTH  REPORTS. 

Gilbert  and  Ellice  Islands. — According  to  the  official  report 
for  1917-18  there  were  during  the  year  in  12  of  the  islands  of 
the  Gilbert  Group,  having  a population  of  18,014,  579  births 
and  528  deaths.  In  two  of  the  islands  the  deaths  exceeded 
the  births,  there  being  64  deaths  to  44  births  in  Butaritari 
(population  1138)  and  63  deaths  to  25  births  in  Ocean 
Island  (population  1100).  In  the  latter  instance  the  high 
death-rate,  it  is  suggested,  is  largely  due  to  the  unnatural 
conditions  under  which  the  natives  live  and  to  the  use  of 
European  foodstuffs,  whilst  the  low  birth-rate  is  attributed 
to^'the  scarcity  of  wives  among  the  company’s  labourers." 


1 Aron.  f.  Sohiff-  und  Tropen-Hygleue,  xxiii.,  7,  p.  136. 


In  seven  islands  of  the  Ellice  Group  (population  3131) 
there  were  171  births  and  95  deaths.  Fanning  Island 
reported  17  births  and  only  3 deaths.  From  certain  other 
islands  returns  have  not  been  received.  The  erection 
of  the  Central  Leper  Asylum  on  the  island  of  Tarawa  has 
been  completed.  It  has  not  as  yet  been  found  possible  to 
collect  the  lepers  from  the  other  islands  owing  to  the  lack  of 
a Government  vessel.  Efforts  are  being  made  to  charter  a 
leper  vessel  from  Australia.  A suggestion  has  been  put 
forward  for  an  improved  Government  hospital  for  Ocean 
Island  and  for  a water-borne  drainage  system  for  the  native 
villages  and  Government  station.  The  continued  prevalence 
of  dysentery  on  Ocean  Island  is  causing  anxiety.  The  native 
death-rate  on  that  island  is  far  too  high,  especially  amongst 
the  resident  population  as  opposed  to  native  imported 
labour.  The  following  record  of  the  rainfall  at  Ocean 
Island  for  the  last  five  years  shows  the  remarkable  variation 
on  the  Line  Islands  : — 


Inches. 

1913- 14  131-05 

1914- 15  137-85 

1915- 16  18-41 


Inches. 

1916- 17 6-63 

1917- 18 26-62 


The  drought  broke  in  May,  1918,  and  in  the  last  two  months 
of  the  year  some  20  inches  were  recorded. 


THE  NATIONAL  COUNCIL  FOR  THE  UNMARRIED 
MOTHER  AND  HER  CHILD. 


The  annual  report  of  the  first  year’s  work  of  this  Council 
shows  useful  progress.  The  legal  recommendations  on 
the  preventive  side  of  the  work  as  laid  down  at  the  Mansion 
Hous*  Congress  in  1918  have  resulted  in  the  drafting  of  a 
Bill  which  is  likely  to  form  the  basis  of  legislation,  while  the 
provisions  of  the  Maternity  and  Child  Welfare  Act  open  up 
unlimited  opportunities  for  the  curative  side  of  the  work.  X 
Prejudice  remains  in  certain  quarters  against  helping  the 
unmarried  mother,  but  it  is  noteworthy  that  the  construe-  1 
tive  policy  of  the  Council  has  evoked  a large  measure  of 
sympathy  in  the  efforts  made  to  restore  the  mother  to  good  . 
citizenship,  and  to  make  effective  the  responsibilities  of 
the  father.  The  greater  activities  of  the  Council  depend  : 
upon  increased  financial  support,  but,  as  at  present  con- 
stituted, the  Council  has  no  reliable  source  of  income.  .' 
Since  its  inception  the  work  has  depended  very  largely  • 
on  the  generosity  of  the  honorary  treasurer,  Sir  Charles 
Wakefield,  but  if  the  work  is  to  continue  generous  financial 
help  must  be  given.  The  British  Red  Cross  Society  has,  ( 
we  are  glad  to  note,  accepted  an  invitation  to  join  the 
Central  Council  for  Infant  and  Child  Welfare,  of  which  the  ’ 
National  Council  for  the  Unmarried  Mother  is  a con- 
stituent part.  — 

J.  R.  L.  is  advised  to  take  counsel  with  one  or  two  pro- 
fessional colleagues  before  acting. 

Prevention  of  Hydrophobia. — A person  who  talks  of  the  . 
arguments  of  opponents  as  “ imbecilic  rot,”  and  who  states  ( 
that  “ Pastuerism  (sic)  has  been  proved  an  utter  imposture,” 
clearly  needs  no  reply. 


Communications,  Letters,  &c.,  to  the  Editor  have 
been  received  from— 


A. — Mr.  R.  J.  Albery,  Lond. 

B. — British  Dental  Association; 
Dr.  A.  Balfour,  Load.;  Sir  J. 
Barrett,  Melbourne ; Mr.  J.  B. 
Burke,  Lond. ; Board  of  Educa- 
tion, Sir  J.  W.  Byers,  Belfast; 
Dr.  A.  E.  Boycott,  Lond. ; Col. 

R.  J.  Blaekham,  I.M.S. ; British 
Fire  Prevent  ion  Committee;  Mr. 
I.  Back,  Lond-t  Dr.  Blonde!, 
Paris. 

C.  -Dr.  P.  J.  Cammidge,  Lond.; 
Dr.  F.  G.  Crookshank,  Loud.; 
Mr.  E.  M.  Cowell,  Croydon;  Dr. 

S.  D.  Clippingdale,  Lond. ; Tne 
Co-operative  Sanatoria.  Ltd., 
Billericay ; Dr.  J.  R.  Collins, 
Cheltenham ; Dr.  IV.  F.  Croll, 
Aberdeen ; Chief  Inspector  of 
Factories. 

E. — Dr.  R.  Eager,  Exminster, 
f. — Mr.  P.  J.  Franslin,  Lond.;  Dr. 
R.  Fielding-Ould,  Lond. 

G. — Mr.  B.  Ulendining,  Aspley 
Guise;  Mr.  H.  T.  Gray,  Lond.; 
Dr.  Ida  M.  Guillaume,  Torquay; 
Dr.  W.  K.  Gallie,  Lond. ; Dr.  E. 
Goodall,  Whitchurch. 

H.  — Home  Office;  Mr.  J.  H.  Hart, 
East  Molesey;  Lt.-Col.  A.  R. 
Henchley,  R.A.M.C. ; Prof.  I. 
Walker  Hall.  Bristol. 

J.— Mr.  H.  M.  Johnston,  Newcastle- 
on-Tyne. 


K.  — Dr.  B.  G.  Klein,  Chislehurst. 

L. — Dr.  A.  Levers,  Melbourne; 
London  War  Pensions  Commit- 
tee; Liverpool  Medical  Institu- 
tion, Sec.  oi;  Livingstone  College, 
Principal  of. 

M. — Dr.  J.  F.  D.  Macara,  Lairg; 
Medical  Guild,  Hon.  Sec.  of; 
Mrs.  M.  McConnel,  Petersfield  ; 
Ministry  of  Health,  Sec.  of;  Miss 
A.  R.  Martin,  Eastbourne. 

N.  — Mr.  L.  E.  C.  Norbury,  Lond. ; 
National  Council  for  the 
Unmarried  Mother,  Hon.  Secs, 
of. 

R.  —Royal  Fern  Company,  Florida; 
Dr.  W.  C.  Rivers.  Barnsley ; 
Registrar-General,  Edinburgh. 

S. — Dr.  S.  P.  Sunderland,  Lond.; 
Summer  School  of  Civics  aad 
Eugenics:  Societe  de-Biologie, 
Paris  ; Dr.  M.  B.  Shipsey, 
Birmingham;  “Sea- Pie,"  Puo- 
lishers  of ; Save  the  Children 
Fund,  Lond. ; Mr.  S.  Stephenson, 
Lond. ; South  London  Hospital 
for  Women,  Sec.  of;  Colonel 
A.  W.  Sheen,  A.M.S. 

T.  — Dr.  A.  H.  Thompson,  Lond.; 
Mr.  O.  P.  Turner,  Hastings; 
Mr.  L.  C.  Thorburn,  Lond. 

W. — Dr.  F.  P.  Weber.  Lond. ; Dr. 
L.  A Weatherly,  Bournemouth ; 
Dr.  F.  J.  Waldo,  Lond. 


Communications  relating  to  editorial  business  snould  be 
addressed  exclusively  to  the  Editor  of  The  Lancet, 
423,  Strand,  London,  vV.C.  2. 


THE  LANCET,  August  2,  1919. 


^11  Hbkrss 

ON 


X RAY  THERAPY. 


Delivered  before  the  Hampstead  Medical  Society 


The  tieissler  discharge  tube  known  as  tho  Pliicker  IliUorf 
or  Crookes  tube— the  former  beautiful  plaything  of  the 
scientist— has  proved  the  pioneer  of  some  of  the  most 
wonderful  discoveries  and  speculations  that  physical  science 
of  this  or  any  generation  has  known." 

That  is,  in  brief,  a summary  of  the  events  leading  up  to,  and 
including,  the  discovery  of  X rays.  These  have,  as  can 
readily  be  seen,  revolutionised  our  conception  of  the  atom. 


By  ROBERT  KNOX,  M.D.  Edin.,  M.R.C.S.,  L.R.C.P., 

CONSULTING  RADIOLOGIST,  GREAT  NORTHERN  CENTRAL  HOSPITAL; 
HONORARY  RADIOLOGIST,  KING'S  COLLEGE  HOSPITAL  ; DIRECTOR, 
ELECTRICAL  AND  KADIOTHERAPEUTIC  DEPARTMENT, 

CANCER  HOSPITAL  (FREE)  LONDON. 


Mr.  President  and  Gentlemen,— The  proper  apprecia- 
tion of  the  value  of  radiations  in  practical  therapeutics  is,  to 
those  unacquainted  with  the  subject,  very  difficult.  Opinions 
vary  amongst  surgical  and  medical  experts  to  an  astonishing 
degree.  Such  opinions  are  sometimes  expressed  on  scanty 
knowledge  of  the  matter,  especially  of  the  technique  and  the 
action  of  radiations  upon  the  tissues,  and  oftener  on  the 
results  obtained  in  the  treatment  of  quite  unsuitable  cases. 
Perhaps  a still  more  confusing  factor  is  presented  by  the 
conflicting  opinions  of  experienced  radiologists  who  may  be 
over-enthusiastic  in  their  claims  for  the  efficacy  of  the 
agents  they  employ,  and  who  may  not  have  had  a very 
extensive  clinical  knowledge  of  the  diseases  they  are  called 
upon  to  treat.  Lastly,  the  new  agents  were  quite  early  in 
their  history  called  upon  to  cure  diseases  which  had  com- 
pletely baffled  all  other  known  methods.  Little  wonder 
that  the  results  should  have  been  scanty,  and  that  so 
many  conflicting  opinions  on  value  have  been  formed  and 
expressed. 

In  this  paper  I shall  endeavour  to  give  a summary  of 
X ray  therapeutics  and  describe  the  technique  for  a number 
of  diseases  which  benefit  from  radiation  treatment.  It  will 
be  impossible  to  discuss  the  instrumentation  or  the  physics 
of  the  subject.  The  former  is  best  learned  by  a few  visits 
to  an  X ray  department.  The  latter  calls  for  an  extensive 
practical  knowledge  of  physics. 

The  X Rays  and  the  Structure  of  Matter. 

The  far-reaching  effects  of  the  discovery  of  X rays  and 
the  subsequent  isolation  of  radium  were  at  the  outset  hardly 
recognised.  Kaye,  in  his  introduction  to  his  admirable  book 
on  X rays,  says  : — 

“ In  the  early  nineties  it  was  not  infrequently  maintained 
that  the  science  of  physics  had  put  its  house  in  complete 
order,  and  that  any  future  advances  could  only  be  along  the 
lines  of  precision  measurement.  Such  pessimism  has  been 
utterly  confounded  by  a sequence  of  discoveries  since  1895 
unparalleled  in  their  fundamental  nature  and  promise.  Even 
many  not  specially  concerned  have  had  their  attention 
directed  to  the  recent  attempts  at  solving  the  riddle  which 
has  excited  interest  and  taxed  ingenuity  since  the  beginning 
of  civilisation— the  problem  of  the  ultimate  structure  of 
matter. 

The  chemist  and  physicist  have  long  built  upon  a theory 
of  atoms  and  molecules,  though  information  as  to  the  exist- 
ence and  behaviour  of  individual  atoms  was  only  based  on 
speculation,  however  justifiable. 

But  within  the  last  decade  we  have  not  only  isolated  the 
atom  but  we  have  learnt  a great  deal  about  its  internal 
structure.  Radio-activity  has,  for  example,  introduced  us 
to  an  electrically  charged  atom  of  helium  (the  a ray)  with 
characteristics  such  that  it  can,  in  spite  of  its  extreme  small- 
ness, make  individual  appeal  to  our  senses. 

The  speed  of  the  a rays  is  so  abnormally  high  that,  if,  for 
instance,  they  are  allowed  to  strike  a fluorescent  screen,  as 
in  the  spinthariscope  of  Sir  William  Crookes,  each  atom 
possesses  enough  energy  to  record  its  arrival  by  a single 
flash  of  light.  Rutherford  and  Geiger  have  actually  recorded 
the  arrival  of  atoms  by  means  of  a delicate  electrometer. 
C.  T.  R.  Wilson  has  succeeded  in  rendering  visible  and 
photographing  the  paths,  not  ODly  of  single  charged  atoms 
but  of  electrons  and  X rays  as  well. 

These  are  interesting  phenomena,  and  the  closer  study  of 
their  production  and  characteristics  led  to  the  further  dis- 
covery of  electrons  by  J.  J.  Thomson  and  of  the  X rays  by 
Routgen. 

Through  the  efforts  of  a band  of  workers  the  Rbntgen 
rays  have  thrown  a search-light  on  many  phases  of  atomic 
physics  not  susceptible  to  other  methods  of  attack.  Quite 
recently  X rays  have  come  to  the  aid  of  the  crystallograpber 
anddisplayed  inthe  hands  of  Laue,  Friedench  and  Knipping, 
Bragg,  and  others,  the  regular  grouping  of  the  atoms  in  a 
crystal. 

No.  5005 


Achievements  and  Possibilities  of  Radiations  in 
Medicine. 

The  great  advances  in  physics  rendered  possible  by  the 
accidental  discovery  of  X rays  by  Roentgen  have  their 
analogues  in  the  field  of  practical  and  experimental  medicine. 
The  immediate  adoption  of  X rays  all  over  the  world  by 
medical  men  working  with  physicists  soon  led  to  an 
appreciation  of  the  value  of  the  new  agent. 

No  one  at  the  outset  could  have  foretold  the  immense 
strides  the  new  agent  would  make  in  the  short  space  of  two 
decades.  The  use  of  Xrays  in  diagnosis  has  been  increased, 
and  many  important  advances  have  been  made  as  experience 
accumulated  and  apparatus  was  improved. 

Far  more  interesting  has  been  the  gradual  unfolding  of  the 
possibilities  of  radiations  in  therapeutics.  The  developments 
up  to  the  present  have  been  enormous.  Still  greater 
discoveries  may  lie  before  us,  especially  when,  as  a result  of 
more  extensive  and  intensive  research,  better  understanding 
of  the  method  of  action  of  radiations  in  their  application  to 
the  treatment  of  disease  is  arrived  at. 

It  is  necessary  to  indicate  the  ever-increasing  field  of 
activity  before  we  attempt  to  deal  with  the  technique  and 
description  of  cases  suitable  for  treatment.  X rays  when 
skilfully  used  can  influence  practically  all  the  tissues  which 
go  to  make  up  the  living  organism,  the  degree  of  action 
depending  so’ely  upon  the  quantity  of  radiation  used  and  the 
response  to  it  of  the  tissue  affected.  Here  we  have  the 
possibility  of  acting  upon  one  or  all  of  the  tissues  by  an 
agent  of  great  power.  Obviously  the  action  must  be  a 
general  one,  whose  activities  are  at  present  only  vaguely 
understood.  So  far  we  know  that  definite  results  follow  upon 
definite  doses  of  radiations,  and  if  this  fact  is  grasped  we  go 
a long  way  towards  a comprehension  of  the  governing 
principle  ef  radiation  therapeutics. 

Medicine,  however,  is  not  an  exact  science,  and  rules  or 
laws  which  have  a definite  value  in  physics  are  not  so 
readily  applied  to  the  practice  of  medicine.  So  far  the 
applications  of  radiations  in  medicine  are  more  or  less 

empirical.  . 

As  already  stated,  the  striking  discoveries  in  physics  have 
gone  a long  way  towards  explaining  problems  which  have 
perplexed  the  human  mind  since  the  dawn  of  early  civilisa- 
tion Possibly  when  our  knowledge  extends,  and  a thorough 
grasp  of  the  physics  of  these  agents  and  the  underlying 
principles  which  govern  their  action  has  been  obtained,  it 
will  lead  to  the  development  of  a thorough  technique  and 
to  a great  improvement  in  the  results  obtained  by  their 
application  to  morbid  conditions. 

The  developments  may  even  be  as  revolutionary  in  medi- 
cine as  they  have  been  in  physics.  It  may  be  even  that  the 
discovery  of  an  underlying  principle  in  cell  metabolism  may 
give  us  (by  the  aid  of  physics)  the  clue  to  the  causatic  n of 
certain  diseases  which  have  been  the  torment  of  many 
generations  of  medical  men.  Certainly  the  future  teaching 
in  the  medical  sciences  must  take  more  notice  of  physics. 
Medical  education  may  be  revolutionised  in  this  way,  and 
many  of  the  now  recognised  and  apparently  well-established 
laws  in  medicine  may,  in  the  light  of  further  research,  requiie 
to  be  reviewed  and  possibly  seriously  modified. 

Effects  of  Radiations  on  the  Living  Cell. 

A great  deal  of  valuable  work  has  already  been  done  in 
regard  to  the  behaviour  of  the  living  cell  when  exposed  to 
radiations.  Colwell  and  Russ  have  given  us  a valuable  work 
in  11  X rays,  Radium,  and  the  Living  Cell,”  which  clearly 
sets  forth  the  great  effect  which  can  be  produced  by  radia- 
tions on  cellular  structures. 

A thorough  appreciation  of  the  action  of  radiations  upon 
the  normaf  tissues  will  be  valuable  when  we  come  to  deal 
with  morbid  conditions.  What  we  know  now  is  very  limited, 
and  the  result  of  the  application  of  measured  doses.  Dealing 
with  the  subject  broadly,  it  may  be  stated  that  if  a particular 
cell  or  a group  of  cells  be  exposed  to  a beam  of  radiations 
E 


184  The  Lancet,] 


DR.  ROBERT  KNOX  : X RAY  THERAPY. 


[August  2, 1919 


from  any  source,  and  in  this  example  we  will  assume  that 
the  radiations  emanate  from  an  X ray  tube,  certain  events 
may  follow  : (a)  The  cell  may  be  stimulated  ; (i)  its  activities 
may  be  inhibited  ; (o)  the  cell  may  be  destroyed. 

The  determining  factor  in  the  production  of  any  of  these 
ends  so  far  as  the  radiations  are  concerned  is  the  intensity 
of  the  radiation  and  the  duration  of  the  exposure.  The 
former  is  governed  by  certain  physical  data  which  it  is 
unnecessary  to  enumerate  now. 

In  regard  to  the  cell,  the  determining  factor  will  be  the 
resistance  the  cell  possesses  to  external  stimuli.  Cells 
vary  enormously  in  this  respect,  and,  further,  individual 
cells  of  the  same  type  vary  in  a direct  ratio  to  the  stage  of 
activity  they  are  in  when  treated  by  the  radiations.  This  is, 
in  fact,  the  most  difficult  of  the  problems  one  encounters 
when  estimating  dosage. 

It  can  readily  be  seen  from  a consideration  of  these  facts 
how  many  and  varied  may  be  the  results  from  a single 
exposure  to  radiations.  It  also  indicates  that  treatment  by 
radiations  must  of  necessity  be  solely  in  the  hands  of  experts 
whose  training  will  enable  them  to  obtain  the  maximum  of 
good,  and,  what  is  of  equal  importance,  the  minimum  of 
harm  in  the  treatment  of  diseased  conditions. 

It  is  clearly  demonstrated  that  changes  can  be  induced  in 
cellular  structures,  and  these  might  be  described  as  the 
direct  effects.  There  are,  however,  indirect  effects  produced 
which  may  have  a far-reaching  influence  upon  the  metabolism 
of  the  organism.  The  human  frame  is  a complex  machine 
with  many  systems  in  full  activity,  each  acting  in  sympathy 
or  coordination  with  the  others.  Consequently  when  a 
particular  group  of  cells  which  go  to  make  up  the  area 
treated  is  acted  upon  by  a measured  dose  of  radiations 
various  effects  of  an  indirect  nature  are  induced.  If  the 
dose  is  excessive,  cell  activity  is  arrested  and  the  cellular 
structures  die.  The  destroyed  cells  are  absorbed  or  rendered 
inert  by  the  activity  of  the  surrounding  tissues.  When 
absorption  takes  place  the  products  of  disintegration  are 
carried  by  the  lymphatics  to  other  organs  in  the  body.  Far- 
reaching  effects  may  follow.  The  term  “ reaction  ” is  applied 
to  this  phenomenon.  The  reaction  may  be  severe  and  a rise 
of  temperature  lasting  for  several  days  may  occur.  This  is 
obviously  due  to  a powerful  action  upon  the  tissues. 
Products  of  disintegration  of  tissues  may  be  circulated  in 
the  blood  and  serum  and  produce  beneficial  or  harmful 
effects.  If  the  former,  the  tissues  are  toned  up  and  the 
patient  improves.  If  the  latter,  the  patient  may  be  reduced 
to  an  extreme  degree.  This  is  specially  liable  to  occur  in 
the  treatment  of  diseases  of  the  blood,  such  as  leukaemia, 
where,  if  care  is  not  exercised,  a rapid  fall  of  the  white  cells 
may  lead  to  a fatal  leucopenia. 

There  are  many  interesting  phenomena  induced  by  radia- 
tions which  could  be  discussed  at  great  length,  but  time 
forbids. 

In  dealing  with  a subject  of  such  scope  and  interest  it  is 
somewhat  difficult  in  a single  lecture  to  give  an  adequate 
description  of  all  the  points  of  interest,  and  much  of  value 
must  be  left  to  another  occasion.  What,  I imagine,  will  be 
of  the  greatest  value  will  be  a brief  consideration  of  the 
practical  application  of  radiations  to  the  treatment  of 
disease,  with  short  descriptions  of  technique  and  a summary 
of  the  value  of  the  radiations  in  their  application  to  particular 
diseases.  These  are  numerous,  since,  as  has  been  shown, 
X rays  may  influence  practically  all  the  tissues  which  go  to 
make  up  the  complex  mechanism  of  the  human  frame. 

The  Treatment  of  Diseases  of  the  Skin. 

The  diseases  of  the  skin  are  particularly  responsive  to 
regulated  doses  of  X rays.  The  proof  of  this  lies  in  the 
fact  that  many  skin  specialists  include  in  their  armamen- 
tarium an  X ray  outfit,  and,  judging  from  the  results  pro- 
duced by  its  use,  it  is  not  the  least  valuable  of  the  agents 
employed.  The  treatment  of  skin  diseases  by  X rays  has 
led  to  the  production  of  the  radio-dermatologist,  because  it 
is  evident  that  in  this  branch  of  medicine  there  is  ample 
room  for  another  specialist.  I shall,  therefore,  not  labour 
the  point. 

Suffice  it  to  state  that  in  the  treatment  of  ringworm  of  the 
scalp  X rays  are  very  valuable.  The  technique  has  to  be 
very  thorough  to  produce  accurate  results.  The  method  is 
not  free  from  danger.  Untoward  results  are  not  unknown. 
These  are  dermatitis  and  permanent  alopecia.  In  view  of 
the  possibility  of  such  results  it  is  well  to  caution  the 


parents  of  children  undergoing  X ray  treatment  that  there 
is  danger.  The  percentage  of  accident  is  small  but  it  does 
occur,  and  we  must  admit  the  possibility  of  such  regrettable 
consequences.  The  technique  is  readily  carried  out.  The 
following  diagram  illustrates  the  manner  in  which  the  treat- 
ment is  administered. 


Diagram  showing  centres  of  areas  to  be  rayed. 

Dr.  Adamson  is  responsible  for  the  introduction  into  this  | 
country  of  a method  of  exposure  which  in  skilled  hands 
yields  satisfactory  results.  It  consists  briefly  of  the  division  1 
of  the  scalp  into  five  areas,  each  of  which  gets  a measured  \ 
dose.  The  diagram  shows  four  of  the  areas  marked  on  the 
scalp  ; the  fifth  is  given  to  a corresponding  area  opposite.  I 

A number  of  other  diseases  of  the  skin  are  amenable  to 
skilfully  applied  doses  of  X rays. 

Rodent  ulcer  very  frequently  calls  for  X ray  treatment,  and  i 
the  results  are,  on  the  whole,  an  improvement  on  those 
obtained  by  other  methods.  Operation  offers  in  the  early 
case  a better  prospect  of  cure.  X rays,  however,  quickly  I 
heal  the  ulcer.  There  is  a tendency  to  recrudescence,  and  it 
is  not  at  all  uncommon  for  a case  to  require  treatment 
extending  over  several  years  at  intervals.  On  the  whole  it  is 
better  to  treat  rodent  ulcer  with  radium.  The  dosage  is 
more  accurately  controlled,  and  the  results  are  better  and  ji 
tend  to  be  more  permanent. 

Malignant  disease  of  the  skin. — The  technique  employed 
should  be  that  for  malignant  disease  generally,  though  in 
cases  of  superficial  epithelioma  and  a number  of  cases  of 
rodent  ulcer  unfiltered  radiations  may  be  used  for  the  earlier  I 
doses,  a gradual  increase  of  the  thickness  of  the  filter  being  I 
employed  to  ensure  the  adequate  irradiation  of  the  deeper  ; 
structures. 

Hyperidrosis. — This  troublesome  condition  readily  yields  I 
to  radiations.  It  should  be  more  widely  employed  than  it  is 
at  present.  The  result  can  be  obtained  by  one  or  two  large 
doses  at  an  interval  of  two  to  three  weeks  between  the 
exposures,  but  it  is  sound  policy  to  aim  at  a slower  production 
of  the  effect.  Three  or  four  exposures  of  each  axilla  at 
intervals  of  three  weeks  should  lead  to  an  arrest  of  the 
excessive  perspiration.  The  aim  should  always  be  to  control 
rather  than  to  suppress  the  secretion.  The  technique  is 
simple.  The  patient  lies  on  a couch  with  the  arm  extended 
over  the  head,  and  the  axilla  is  thoroughly  irradiated  with 
unfiltered  radiations.  Subsequent  doses  should  be  given 
through  an  aluminium  filter. 

The  Treatment  of  Enlarged  Lymphatic  Glands. 

The  growing  experience  in  the  treatment  of  enlarged 
glands  is  forcing  upon  us  the  conviction  that  in  X rays  we 
possess  a remedy  of  great  power.  During  the  course  of 
investigations,  extending  over  many  years,  into  the  action  of 
radiations  upon  tissues,  I have  found  that  the  behaviour  of 
the  enlarged  lymphatic  glands,  of  whatever  nature,  is  such 
as  to  indicate  unmistakably  that  the  effects  may  be  far- 
reaching.  X rays  and  radium  have  been  extensively  employed 
in  these  investigations.  Either  will  succeed  if  the  proper 


The  Lancet,] 


DR.  ROBERT  KNOX  : X RAY  THERAPY. 


[August  2, 1919  185 


dosage  is  administered.  The  response  in  a large  number  of 
cases  has  been  very  marked  and  almost  invariable,  the  chief 
matter  being  the  selection  of  the  suitable  radiation  for  each 
condition  dealt  with. 

Diagnostic  Value  of  X Rays  in  Enlarged  Glands. 

It  is  so  certain  that  several  types  of  enlarged  glands  will 
respond  to  radiations  that  we  might  employ  the  rays  in  a 
diagnostic  as  well  as  in  a therapeutic  sense.  It  has  been 
observed  that  enlarged  glands  respond  in  somewhat  like  the 
following  order  to  estimated  doses  of  radiations. 

1.  Enlarged  glands  due  to  simple  inflammatory  conditions 
give  a very  rapid  response  if  suppuration  has  not  set  in  and 
the  condition  is  becoming  chronic. 

2.  Lymphadenomatous  glands  give  a fairly  rapid  response, 
but  not  so  rapid  as  the  simple  inflammatory  ones. 

3.  Sarcomatous  and  lympho- sarcomatous  glands  give  a 
rapid  response  in  the  majority  of  cases  treated,  leading  to  a 
rapid  diminution  in  the  size,  but  the  effect  is  rarely  per- 
manent, there  being  a tendency  to  recurrence,  and  an 
ultimate  refusal  to  respond  to  further  treatment. 

4.  Tuberculous  glands  give  a slow  response  as  a rule. 
When  treated  early  enough  the  glands  become  quiescent 
and  slowly  subside,  but  if  not  completely  fibrosed  they  tend 
to  break  out  at  a later  period. 

5.  Carcinomatous  glands  give  a very  slow  response.  They 
hardly  ever  completely  disappear,  buc  they  may  be  arrested 
in  their  growth.  It  is,  then,  sound  practice  to  remove  the 
glands  surgically. 

6.  Enlarged  glands  due  to  a mixed  infection  are  fairly 
common.  For  example,  in  a patient  suffering  from 
carcinoma  in  an  adjoining  area  the  glands  may  enlarge  in 
groups  and  yet  no  secondary  cancer  be  present,  or  the 
glands  on  the  opposite  side  from  the  lesion  may  become 
enlarged.  These  will  quickly  subside  under  radiation  treat- 
ment. All,  or  nearly  all,  may  disappear,  or  one  or  more  in 
a group  of  enlarged  glands  may  persist.  These  may 
ultimately  be  found  to  have  invading  cancer  cells  in  their 
substance.  Only  a few  groups  of  cells  may  be  found,  the 
bulk  of  the  enlargement  being  due  to  inflammatory  reaction, 
and  there  may  be  a secondary  infection  due  to  other 
organisms.  The  same  condition  may  occur  in  tuberculosis. 
A group  of  glands  may  have  only  one  or  two  which  are 
actually  invaded  by  the  tubercle  bacillus.  In  both  of 
these  instances,  if  the  glands  are  treated  by  X rays,  a mixed 
response  is  obtained. 

From  a consideration  of  the  above  statements  it  is  obvious 
that  in  X rays  we  possess  a differential  diagnostic  test  which 
may  be  extremely  useful  when  we  are  in  doubt  regarding  the 
nature  of  the  causal  condition. 

Therapeutic  Radiation  of  Tuberculous  Glands. 

The  irradiation  of  enlarged  tuberculous  glands  is  useful  for 
other  purposes  than  that  of  the  glands  alone.  Coexistent  or 
chronic  tuberculosis  of  the  lungs  may  at  the  same  time 
receive  benefit  from  the  radiations,  and  it  is  a matter  for 
serious  consideration  whether  all  such  cases  should  not  have 
radiations  applied  as  a part  of  the  routine  treatment. 

A considerable  amount  of  this  class  of  work  is  being  done, 
and  it  will  be  interesting  to  have  later  a report  from 
sanatoriums  which  have  adopted  the  method.  The  general 
tonic  action  of  radiations  should  also  be  helpful  in  these 
cases. 

The  treatment  in  all  cases  of  enlarged  glands  must  be 
thorough.  In  sanatoriums  where  the  patient  is  at  rest 
and  under  observation  daily  doses  may  be  given,  a fresh 
area  being  selected  each  day  and  the  exposure  repeated  to 
the  same  area  not  oftener  than  once  in  14  days.  The  aim 
in  tuberculosis  cases  should  be  to  include  the  thoracic 
contents,  particularly  the  mediastinal  gland,  in  the  field  of 
irradiation,  so  that  all  deep  glands  may  receive  adequate 
exposures.  In  less  acute  cases  the  treatment  may  be  given 
once  or  twice  a week.  The  dose  at  each  visit  will  vary  with 
the  condition  requiring  treatment.  Tuberculous  glands 
require  to  be  treated  for  a lengthy  period  of  time  extending 
over  many  months 

Enlargement  of  the  Thyroid  and  Thymus  Glands. 

There  are  no  groups  of  clinical  symptoms,  such  as  occur  in 
exophthalmic  goitre  or  Basedow’s  disease,  which  call  for 
more  skilful  treatment  than  those  associated  with  disorders 
of  the  thyroid  and  thymus  glands.  The  combined  skill  of 
the  clinician  and  the  radiologist  is  necessary  to  combat 
successfully  the  complex  phenomena  exhibited  in  this 


disease.  There  can  be  no  question  that  a combined  attack, 
using  all  the  measures  available,  will  enable  us  to  check  the 
symptoms  and  ultimately  cure  the  disease  in  a number  of 
cases.  These  vary  in  the  degree  of  acuteness,  and  the  treat- 
ment will  require  to  be  varied  accordingly,  if  a successful 
issue  is  to  be  looked  for.  Sanatorium  treatment  combined 
with  medicinal  measures  and  radiations  affords  us  the  treat- 
ment par  excellence. 

The  very  acute  case  demands  absolute  rest  in  bed,  quiet, 
careful  diet,  fresh  air,  and  practically  a continuous  action 
from  radiation  treatment.  Small  doses  of  the  latter  daily 
may  be  required  over  several  weeks  before  any  sign  of 
improvement  shows  itself.  Later,  when  the  severity  of  the 
symptom  abates,  the  treatment  should  be  gradually 
diminished  in  intensity  and  frequency,  and  when  the 
metabolic  balance  is  gradually  restored  the  dosage  may  be 
reduced  to  three  times  a week,  and,  later,  given  at  longer 
intervals. 

X Ray  Treatment  in  Exophthalmic  Goitre. 

Three  areas  of  the  thyroid  gland  should  be  irradiated,  one 
on  the  right  side,  another  on  the  left,  and  a central  large 
area  should  include  the  isthmus  of  the  gland  and  the  upper 
thoracic  region,  the  object  being  to  include  the  thymus 
gland,  which  is  generally  enlarged  in  these  cases. 
Experience  has  shown  the  value  of  including  the  thymus  in 
the  irradiated  area.  It  is  well  to  use  filters  of  2 or  3 mm. 
of  aluminium,  and  in  addition  a secondary  filter  to  protect 
the  skin.  The  latter  should  always  be  carefully  protected 
from  over-dosage,  because  if  this  should  occur,  even  to  a 
slight  extent,  it  may  be  followed  later  by  teleangiectasis, 
which  is  a troublesome  complication. 

Treatment  should  be  continued  at  intervals  over  a long 
period  of  time  in  these  acute  cases.  Patients  complain  of 
a tendency  to  relapse  if  this  is  not  done,  and  it  is  quite 
possible  to  maintain  the  balance  of  activity  of  the  gland 
by  such  treatment. 

Fortunately  the  majority  of  cases  treated  do  not  require 
such  systematic  treatment.  There  are  many  patients  who 
are  not  acutely  ill,  and  though  these  would  improve  more 
rapidly  under  the  stricter  regime,  circumstances  may  not 
allow  of  such  vigorous  treatment  and  it  may  be  necessary  to 
treat  these  patients  at  an  out-patient  clinic.  Several  hundreds 
of  such  cases  have  been  treated  by  visits  of  once,  twice,  or 
three  times  a week.  The  dosage  is  similar  to  that  described 
for  the  more  acute  cases,  and  the  treatment  requires  to  be 
carried  on  over  many  months.  In  the  majority  of  cases  the 
progress  is  satisfactory,  there  being  a gradual  restoration  of 
balance  of  health,  a diminution  of  the  symptoms,  and  a slow 
but  steady  reduction  in  the  size  of  the  enlarged  gland. 

Better  results  in  the  more  chronic  cases  have  been  obtained 
by  the  administration  of  small  doses  at  frequent  intervals 
than  were  formerly  met  with  when  the  larger  doses  were 
given  at  intervals  of  three  to  four  weeks.  It  is  not  neces- 
sarily cases  of  very  large  thyroid  glands  which  respond  most 
readily.  The  aim  of  treatment  is  to  regulate  the  secretion 
from  the  gland,  and  a small  gland  may  be  very  active.  A 
regulating  dose  may  check  the  activity,  and  so  influence  the 
condition. 

Parenchymatous  Goitre  and  Other  Conditions. 

Another  form  of  enlarged  thyroid  met  with  is  the  parenchy- 
matous goitre,  where  the  chief  disturbance  is  due  to  the 
enlargement,  with  few  or  none  of  the  general  disturbances. 
These  cases  require  careful  treatment,  the  gland  being  very 
difficult  to  treat,  and  the  reduction  in  size  being  very  slight 
and  very  slowly  induced. 

A number  of  these  cases  appear  to  respond  more  rapidly 
when  radium  is  used.  Possibly  the  tissues  are  more  resistant 
because  the  enlargement  is  due  to  a general  increase  of  the 
structural  tissues  as  against  the  glandular  hyperpla'ia  with 
over-secretion  in  the  cases  of  exophthalmic  goitre.  In 
parenchymatous  goitre  the  claim  of  surgery  should  always 
come  first  in  treatment.. 

Malignant  disease  is  another  form  of  enlargement  of  the 
thyroid.  This  is  very  untractable  to  radiation  treatment. 
Operation,  if  possible,  offers  the  best  chance  of  cure  in  those 
cases.  Failing  this,  radium  should  be  used.  Large  quantities 
of  radium  are  required,  and  the  filtration  should  be  through 
3 mm.  or  4 mm.  of  lead  or  2 mm.  of  platinum,  and  long 
exposures  given.  X rays  of  a penetrating  type  may  also  be 
useful. 

Enlargement  of  the  thymus  in  children  frequently  requires 
treatment.  X rays  will  be  found  useful  in  these  cases. 


186  The  Lancet,] 


DR.  ROBERT  KNOX:  X RAY  THERARY. 


[August  2,  1919 


The  Treatment  of  Diseases  of  the  Blood  and 
Ductless  Glands. 

X rays  may  be  employed  in  the  treatment  of  a number  of 
these  conditions.  In  dealing  with  the  diseases  of  organs 
affected  by  morbid  growths  the  skin  receives  a large  per- 
centage of  the  radiation,  and  it  has  been  noted  that  in  this 
way  the  blood  while  circulating  in  the  tissues  receives  a dose 
which  may  exercise  an  influence  far-reaching  in  its  action 
not  only  upon  the  constituents  of  the  blood  but  on  the 
tissues  through  which  the  blood  circulates. 

It  is,  therefore,  a good  practice  to  irradiate  large  areas  of 
skin  surface  as  well  as  the  spleen  and  the  bone  marrow  when 
dealing  with  diseases  such  as  leukaemia.  When  it  is 
necessary  to  get  a rapid  action  the  greater  part  of  the  surface 
of  the  body  may  be  utilised  for  this  purpose.  Patients  who 
have  been  treated  for  other  diseases  show  upon  examination  a 
marked  improvement  in  the  blood.  This  is  known  by  an 
increase  in  the  percentage  of  haemoglobin  and  a raising  of 
the  crlour  index,  and  if  a blood  count  is  taken  it  may  show 
a marked  increase  in  the  percentage  of  the  red  blood 
corpuscles.  Patients  who  have  been  treated  by  X rays  for 
fibroid  of  the  uterus  frequently  show  this  marked  improve- 
ment in  the  condition  of  the  blood.  The  change  is,  how- 
ever, due  to  other  causes.  For  instance,  the  checking  of  the 
excessive  haemorrhage  induces  an  arrest  of  the  secondary 
anaemia  which  accompanies  it. 

Patients  treated  for  cancer  also  frequently  show  an 
improvement  in  the  blood  condition,  evidenced  by  an 
increase  in  the  number  of  red  cells  and  a nearly  normal 
colour  index.  These  improvements  undoubtedly  occur, 
though  they  may  be  only  temporary. 

Most  of  the  diseases  in  which  there  are  blood  changes 
have  been  subjected  to  radiations  in  the  hope  that  benefit 
might  accrue.  Evidence  exists  which  proves  that  it  is 
possible  to  exercise  a considerable  influence  upon  a number 
of  these  diseases.  Leukaemia  generally  responds  for  a 
time  at  least  to  radiations,  and  there  is  no  reason  to 
assume  that  the  improvement  is  only  a variation  in  the 
course  of  the  disease.  The  effects  are  too  marked  and 
exist  for  too  long  a period  for  this  to  be  so. 

Technique  for  Diseases  of  the  Blood  and  Ductless  Glands. 
This  will  vary  with  the  effects  we  wish  to  produce.  If 
a rapid  action  is  required  it  should  be  the  aim  to  induce 
a profound  effect  upon  the  blood  cells.  This  can  best  be 
done  by  irradiating  large  areas  of  the  skin  surface  with 
very  lightly  filtered  rays.  The  first  inch  of  tissues  below 
the  skin  absorbs  about  75  per  cent,  of  the  total  of  these  rays, 
and  consequently  if  the  blood-supply  is  up  to  the  normal  the 
percentage  of  radiation  absorbed  will  be  considerable.  When 
deeper  effects  are  likely  to  be  more  helpful  then  more  pene- 
trating radiations  may  be  employed.  A filter  should  be  used 
to  absorb  a percentage  of  the  softer  radiations. 

For  the  irradiation  of  the  spleen  and  other  deep  organs 
filtered  rays  are  employed,  the  filter  in  this  case  being  used 
to  protect  the  skin,  which  is  likely  to  receive  large  doses  of 
rays  if  repeated  applications  are  required. 

The  Treatment  of  Diseases  of  the  Pelvic  Organs. 
Early  in  its  history  the  extension  of  radiation  treatment 
took  in  the  diseases  of  the  uterus,  and  attention  was  par- 
ticularly directed  to  the  enlargement  of  the  uterus  arising 
from  fibromyoma.  The  effect  upon  these  structures  was  led 
up  to  by  experimental  work  carried  out  in  1905  by  Halber- 
stiidter,  who  first  noticed  atrophic  changes  in  the  ovaries  of 
rabbits  as  a sequel  to  irradiation  by  X rays. 

Similar  observations  were  made  by  BergoniG,  Tribondeau, 
and  Recamier.  Reifferscheid  described  changes  occurring  in 
the  human  ovary  as  a sequel  to  irradiation  by  X rays.  These 
effects  were  observed  in  cases  treated  by  X rays  and  subse- 
quently operated  upon.  Many  other  observers  have  recorded 
changes  produced  in  the  ovary  as  a result  of  prolonged 
X ray  treatment.  The  majority  of  the  results  given  are 
presumably  those  produced  by  relatively  small  doses  of 
X rays,  and  no  details  are  submitted  as  to  the  penetrative 
quality  of  the  ray  or  the  filtration  employed.  Albers 
Schonberg,  Henish  Bordier,  and  later  Gauss  and  Lembekte, 
give  results  obtained  by  the  more  intensive  form  of  treat- 
ment, the  latter  having  worked  out  a very  extensive 
technique,  using  filtered  rays  of  moderate  penetration,  and 
giving  results  showing  improvement  as  the  intensity  of  the 
dosage  increased. 


Later  work  in  America  and  England  on  intensive  lines  has 
given  improvement  in  results  altogether  greater  than  was  at 
one  time  thought  of.  The  advent  of  the  Coolidge  tube  and 
apparatus  capable  of  exciting  it  adequately  have  further 
improved  the  technique  and  put  within  our  reach  the 
possibility  of  administering  fairly  large  doses  at  a con- 
siderable depth  from  the  surface  of  the  body.  Further,  the 
introduction  of  many  ports  of  entry  and  the  angling  of  the 
tube  to  focus  the  beam  of  rays  upon  a given  part  have 
rendered  it  possible  to  increase  greatly  the  dose  at  a given 
spot.  The  ovary  on  either  side  is  taken  as  the  landmark 
upon  which  the  rays  should  be  focussed. 

Mode  of  Action  of  the  Radiation. 

The  action  of  the  rays  appears  to  be  primarily  exercised 
on  the  ovary  and  its  blood  supply,  suppression  of  function  . 
leading  to  atrophy  of  the  structure  and  cessation  of  the 
menstrual  haemorrhage.  The  latter  is  the  most  troublesome  i 
symptom  arising  from  fibromyoma.  The  improvement  in  I 
the  patient’s  health  may  in  fact  be  attributed  to  the  cessation 
of  the  haemorrhage.  The  atrophy  of  the  ovaries  is,  however,  I 
accompanied  in  a number  of  cases  by  a diminution  in  the 
size  of  the  tumour.  It  is  reasonable  to  assume  that  an 
action  is  exercised  on  the  tumour  itself.  It  is,  therefore,  I 
advisable  when  treating  the  ovarian  areas,  to  include  the 
tumour  as  well. 

The  anterior  abdominal  wall  is  mapped  out  into  a number 
of  areas.  The  tube  is  arranged  in  treating  each  area  so  that  : 
the  beam  of  rays  may  be  focussed  upon  a given  spot.  If  , 
eich  ovary  gets  the  maximum  effect  from  those  “ ports  of  i 
entry  ” on  the  side  in  which  it  lies,  the  tumour  also  receives 
a very  large  proportion  of  the  radiations  passing  through  it. 

A part  of  these  radiations  being  absorbed  by  the  tumours, 
changes  must  therefore  occur  in  its  structure  as  a result  of 
the  dosage  it  receives. 

Whatever  the  action  may  be  and  upon  whichever  structure 
the  rays  act  most,  there  is  no  doubt  whatever  that  in  the 
treatment  of  those  conditions  many  marked  beneficial  results 
can  be  obtained  by  carefully  applied  courses  of  radiations. 
It  will  therefore  be  necessary  to  describe  in  some  detail  the 
technique  now  employed,  the  type  of  case  likely  to  benefit, 
and  to  analyse  the  results  obtained. 

Technique  for  the  Treatment  of  Fibromyoma  of  the  Uterus  and\ 
Other  Co/  ditions  of  the  Pelvic  Organs. 

The  technique,  although  chiefly  employed  for  the  treat-  j 
ment  of  fibromyoma,  may  be  also  applicable  to  such  condi-  i 
tions  as  tumours  of  the  other  pelvic  organs,  the  ovary, 
malignant  disease  of  the  pelvic  organs,  and  in  the  prophy 
lactic  treatment  of  cases  of  new  growth  after  removal.  I' 
is  also  applicable  in  a modified  form  for  the  treatment  o- 
conditions  such  as  endometritis,  fibrosis  of  the  uterus,  anc  1 
for  the  production  of  sterility  in  conditions  requiring  sucl  j 
treatment. 

With  a modern  installation  .the  Coolidge  tube  offers 
advantages  over  any  other  tube  in  use.  By  using  a high 
tension  transformer  with  the  tube  a uniform  series  o 
exposures  can  be  readily  and  rapidly  carried  through.  Tbt; 
heating  current  is  adjusted  to  give  the  desired  penetratioi 
and  the  whole  series  of  irradiations  can  be  administerec 
under  precisely  the  same  conditions.  The  dose  should  b< 
measured  by  the  Sabouraud  and  Noir6  pastille,  or  by  ilj 
photographic  paper,  or  by  any  method  which  is  known  t<| 
be  reliable. 

A filter  of  at  least  3 mm.  of  aluminium  is  used,  and  i j 
should  be  placed,  if  possible,  midway  between  the  tube  ant 
the  patient’s  skin.  The  secondary  filter,  consisting  of  chamoi 
leather,  several  layers  of  thick  paper,  and  loofah  sponge 
enclosed  in  a linen  bag  for  convenience,  is  placed  upon  th 
skin  under  the  tube  box.  The  time  taken  to  produce  th 
tint  B varies  with  each  installation,  and  the  current  it  i 
capable  of  passing  through  the  tube.  An  average  of  abou 
five  minutes  to  each  dose  can  easily  be  obtained,  usin: 
2-3  ma.  in  the  coil  circuit.  If  the  current  is  increased  th 
time  will  be  shortened  proportionately  to  the  amount  of  th 
increase  in  the  intensity.  A “hard”  ray  is  necessary 
Between  8 and  9 on  the  Bauer  qualimeter  is  a usefv 
radiation  to  employ  in  these  pelvic  conditions. 

The  anterior  abdominal  wall  is  marked  out  into  a pre 
determined  number  of  areas,  the  landmarks  used  being  th 
level  of  the  umbilicus  and  the  pubic  arch.  As  many  as  2 
ports  of  entry  can  be  utilised  in  this  way.  In  addition,  th 
areas  may  be  extended  into  the  lateral  wall  of  the  abdome 


Thb  Lancet,] 


Dll.  ROBERT  KNOX  : X RAY  THERAPY. 


[August  2,  1919  187 


and  the  posterior  aspect.  These  extra  areas  are  useful  when 
it  is  necessary  to  get  in  a very  large  dose  quickly  in  acute 
cases.  Each  area  receives  the  same  dose  of  radiations. 

The  Question  of  Dosage. 

It  is  advisable  to  commence  the  treatment  just  after  the 
cessation  of  the  menstrual  period  in  cases  where  that  is 
possible.  The  whole  of  the  areas  may  be  treated  at  one 
seance  where  it  is  necessary  to  do  so,  but  from  experience 
it  has  been  found  that  it  is  better  to  divide  the  dose  into 
two  or  three  days.  This  diminishes  the  exhausting  action 
on  the  patient  arising  from  the  continuous  treatment  of 
one  or  two  hours  or  more,  and  lessens  the  after-effects 
upon  the  patient. 

The  aim  of  treatment  is  to  produce  the  result  gradually, 
so  it  is  necessary  to  give  three  or  more  seances  before  the 
patient  is  really  benefited.  It  is  quite  possible  to  produce 
a result  in  one  or  at  the  most  two  seances,  but  the  effect 
on  the  patient  is  often  very  injurious  for  a time,  as  serious 
reaction  may  be  induced  when  the  very  intensive  line  of 
treatment  is  adopted.  As  a rule,  in  the  average  case  a 
satisfactory  result  may  be  looked  for  in  from  3 to  6 seances, 
each  consisting  of  10  to  12  areas.  It  is  not  at  all  uncommon 
for  the  period  after  the  first  seance  to  be  more  excessive 
than  those  before  the  treatment,  so  it  is  necessary  to 
caution  the  patient  on  this  point  if  she  is  not  to  be 
discouraged  and  discontinue  the  treatment. 

The  improvement  is  gradual,  beginning,  as  a rule,  after  the 
second  series  of  treatment.  The  menstruation  or  haemorrhage 
generally  ceases  after  the  third  series  and  may  not  be 
seen  again.  It  is,  however,  advisable  to  administer  one  or 
two  further  series  in  order  to  keep  up  the  action. 

Immediate  and  Later  Effects. 

There  are  certain  conditions  produced  by  the  treatment  of 
which  the  practitioner  should  be  cognisant  if  he  is  to  be  in 
a position  to  advise  his  patients  on  these  and  other  points 
of  importance  arising  in  the  course  of  treatment.  Of  these 
the  most  important  is  the  so-called  reaction  induced  by  the 
effects  of  the  radiation.  These  may  be  divided  into 
(a)  immediate  effects,  (ff)  later  effects  (reaction,  &c.). 

Of  the  immediate  effects  nausea  is  most  common.  This  is 
probably  due  to  the  inhalation  of  highly  ionised  air  which 
is  invariably  found  in  the  vicinity  of  high-tension  electrical 
machinery  and  possibly  to  the  generation  of  ozone  in  the 
vicinity  of  the  active  X ray  tube.  Headache  is  often  met 
with  and  is  attributable  to  the  same  causes.  Giddiness  is  a 
common  symptom  and  may  be  directly  traced  to  change  of 
posture,  most  patients  suffering  temporarily  and  briefly  from 
this  when  they  arise  from  the  X ray  couch.  Patients 
frequently  go  to  sleep  while  being  treated.  This  is  possibly 
due  to  the  monotonous  hum  of  the  active  electrical 

apparatus.  

The  remedy  for  most  of  these  conditions  is  simple.  If  or 
faintness  a small  dose  of  sal  volatile  will  suffice.  Eau-de- 
Cologne  sprinkled  on  a towel  and  laid  over  the  patient’s  face 
will  serve  to  minimise  the  effects  of  the  ozone  and  ionised 
air.  An  electrical  fan  in  the  near  vicinity  of  the  tube  will 
quickly  change  the  air  and  carry  off  some  of  the  ionised  air. 
In  prolonged  treatments  a little  oxygen  in  an  inhaler  will 
revive  the  patient. 

The  later  effects  come  on  several  days  after  the  treatment, 
and  their  appearance  has  a direct  relationship  to  the  intensity 
of  the  dose.  In  large  doses  it  comes  on  earlier,  possibly  the 
next  day,  but  in  the  average  not  for  two  or  three  days.  In 
cases  where  the  dosage  has  been  very  heavy  intense  prostra- 
tion may  follow,  with  rapid  pulse,  raised  temperature,  and 
feelings  of  malaise.  The  temperature  may  rise  to  103°  and 
104°  and  remain  at  this  limit  for  some  time,  when  patients 
may  become  extremely  ill.  The  treatment  consists  of  rest 
in  bed  and  careful  attention  to  diet.  Medicinal  treatment 
should  be  used  as  the  symptoms  indicate. 

The  patient  generally  recovers  in  time  for  the  next  series 
of  treatment,  which  is  due,  as  a rule,  in  about  a month  from 
the  preceding  one.  Generally  a degree  of  tolerance  to  the 
treatment  develops  and  the  patient  shows  hardly  any  reaction 
to  subsequent  doses,  but  a number  of  patients  never  acquire 
this  tolerance  and  dread  the  repetition  of  the  treatment  on 
account  of  the  distressing  symptoms  it  produces.  In  these 
cases  it  is  probable  that  the  dosage  has  been  too  great  for 
the  patient’s  general  resistance.  The  after-effects  may  in 
these  cases  be  minimised  by  giving  the  treatment  at  longer 
intervals,  or  giving  smaller  doses  and  carrying  the  total 
amount  over  a longer  period. 


Type  of  Case  likely  to  Benefit  from  X Ray  Treatment. 
Although  it  may  be  assumed  that  tissue  changes  may  be 
induced  in  practically  any  form  of  pelvic  disease,  and  that  in 
a number  of  these  the  action  will  be  beneficial,  yet  for 
practical  guidance  it  is  necessary  to  survey  carefully  the  field  . 
of  usefulness  and  indicate  where  radiation  treatment  is  likely 
to  give  better  results  than  other  methods  such  as  the  opera- 
tive, where  it  is  likely  to  help  towards  a cure  when  combined 
with  the  operative  and  other  forms  of  treatment,  and  par- 
ticularly to  indicate  when  it  is  wise  to  hold  one’s  band  and 
decide  against  X ray  treatment.  This  involves  a resume  of 
the  conditions  met  with,  particularly  in  the  present  instance 
with  regard  to  fibro-myoma.  ' 

While  it  has  been  admitted  that  up  to  the  present  the 
interstitial  fibroid  is  the  most  suitable  for  radiation  treat- 
ment, several  writers  have  pointed  out  that  practically  all 
forms  of  fibroid  respond  favourably.  The  small  tumour  is 
more  likely  to  become  amenable  to  treatment  than  the  very 
large  tumour  which  fills  the  pelvis  and  the  greater  part  of  the 
abdomen.  It  is  also  worthy  of  note  that  the  majority  of  the 
patients  submitted  to  X ray  treatment  have  been  for  one 
reason  or  another  unsuitable  for  operation.  Hence  the 
results  secured  in  a number  of  cases  have  been  obtained  in 
patients  who  were  too  bad  for  operation,  and  therefore 
presumably  not  favourable  subjects  for  any  form  of  treatment 
from  the  curative  point  of  view. 

A typical  instance  of  this  is  found  in  the  case  of  a patient 
who  was  rapidly  sinking  from  profuse  haemorrhage,  and  who 
in  the  earlier  stage  of  her  malady  refused  to  submit  to 
operation.  Later,  when  she  was  willing  to  do  so  her  con- 
dition was  so  grave  that  the  surgeon  refused  to  operate.  As 
a last  resource  she  was  taken  to  an  X ray  department  in  an 
ambulance.  Treatment  was  pushed  vigorously  and  in  a 
short  time  the  patient  was  out  of  danger.  Later  she  made  a 
complete  recovery. 

Sir  John  Phillips  in  a valuable  paper  ' states  that  he  has 
used  X rays  in  nearly  all  forms  of  fibroid  with  beneficial 
results. 

Any  case  of  fibroid  tumour  will  be  benefited  by  radiation 
treatment  if  the  symptoms  are  not  urgent  enough  to  call  for 
immediate  operation.  The  need  for  operation  may  be 
determined  by  : 1.  The  amount  and  frequency  of  the  haemor- 
rhage and  the  secondary  effects  upon  the  patieDt.  2.  The 
size  of  the  tumour  and  rate  of  growth.  3.  The  pressure 
effects  upon  other  structures.  Even  in  this  class  of  case 
radiotherapy  may  achieve  results  if  the  patient  is  willing  to 
risk  the  effect  of  very  intensive  treatment  and  any  other 
danger  incident  to  its  use. 

There  are  other  factors,  such  as  the  age  of  the  patient, 
which  may  be  taken  as  a guide  to  the  practitioner  in  these 
cases  Till  recently  it  has  been  said  that  patients  under 
40  years  should  not  be  treated  by  X rays  or  radium.  More 
recently  it  has  been  found  that  at  any  age  the  patient  may 
be  beneficially  influenced,  and  that  if  modified  results  are  all 
that  are  required  it  is  possible  to  produce  them.  Instances 
of  this  kind  will  be  met  with  in  severe  dysmenorrhcea  asso- 
ciated with  an  infantile  type  of  uterus.  Such  patients  should 
be  warned  of  the  probable  complete  cessation  of  menstruation 
if  the  treatment  is  pushed  to  its  limit. 

There  are  other  conditions  than  fibroids,  such  as  menor- 
rhagia from  any  cause  and  endometritis,  which  may  be 
influenced  by  treatment. 

Put  briefly,  the  advantages  the  treatment  possesses  over 
other  forms  are  that  it  is  quite  painless,  and,  if  it 
fails,  operative  measures  may  be  employed  under  the  same 
conditions  as  before  or  even  under  improved  conditions  It 
is  not  accompanied  by  so  much  risk  as  the  operative,  and  the 
after-effects  are  not  so  disturbing  or  lasting.  _ Reaction  may, 
however,  in  a number  of  cases  be  rather  disturbing.  Ihe 
final  result  is  brought  about  gradually  and  the  patient  is 
not  so  seriously  affected  by  the  climacteric  symptoms 
induced  in  both  methods  of  treatment.  It  is  perhaps  obvious 
that  if  the  patient  has  the  whole  matter  put  clearly  before 
her  she  may  decide  upon  the  radiation  method  in  preference 
to  the  operative. 

The  Treatment  of  Malignant  Disease. 

The  treatment  of  malignant  disease  by  radiations,  as  has 
been  shown,  is  now  widely  recognised.  The  indiscriminate 
use  of  the  method  has  in  the  past  somewhat  detracted  from 
its  value.  In  the  earlier  days  X rays  were  tried  in  hopeless 

i The  Lancet,  1918,  i.,  427;  Archives  of  Radiology  and  Electro- 
therapy,  1918. 

E p 


188  The  Lancet,] 


DR.  ROBERT  KNOX  : X RAY  THERAPY. 


[August  Z,  1919 


cases.  Even  now  we  are  compelled  to  resort  to  their  use  in 
cases  which  we  recognise  as  beyond  the  reach  of  any 
therapeutic  agent  so  far  as  cure  is  concerned. 

Palliative  Treatment. 

This  leads  us  to  the  consideration  of  the  palliative  use  of 
X rays  in  cases  which  are  quite  hopeless.  Pain  may  be 
relieved,  tumours  are  reduced  in  size,  and  the  general  health 
of  the  patient  improves.  The  treatment  is  palliative  in 
another  sense,  because  it  must  be  recognised  that  in  bad 
cases  of  cancer,  where  it  is  known  that  the  patient  cannot 
be  cured,  the  mental  state  of  the  patient  has  to  be  con- 
sidered. Careful  use  of  X rays  in  these  cases  will  give  an 
amount  of  comfort  to  the  patient  which  is  altogether  out  of 
proportion  to  any  physical  benefit  received. 

It  is  pathetic  to  have  to  deal  with  these  patients.  The 
hope  of  benefit,  even  cure,  from,  to  them,  a wonderfully 
powerful  agent,  takes  possession  of  them  to  the  end.  Patients 
will  struggle  to  the  X ray  room  when  it  is  obvious  to  all  that 
they  cannot  possibly  be  relieved  of  their  troubles.  How  far 
it  is  justifiable  to  encourage  these  patients  I leave  to  the 
practitioner  to  decide.  It  is,  however,  noticeable  that  if 
nothing  at  all  is  done  to  help  these  victims  they  soon  lose 
hope,  become  depressed,  and  quickly  succumb  to  the  malady. 

In  this  relationship  it  is  remarkable  how  much  response 
may  be  obtained  in  extensive  superficial  carcinoma  involving 
the  skin  and  adjacent  structures.  I have  seen  extensive 
involvement  of  the  skin  clear  up  under  practically  continuous 
X ray  treatment.  By  this  is  meant  daily  doses  to  numerous 
areas  of  skin.  The  treatment  may  be  carried  on  for  several 
weeks  in  this  way. 

Possibility  of  Good  Results  in  Very  Grave  Cases. 

Cases  which  are  apparently  hopeless  respond  well  to  the 
radiations,  and  a period  of  good  health  results.  A striking 
instance  of  this  kind  may  be  quoted. 

A man  of  about  35  had  a sarcoma  of  the  right  testicle 
removed  by  operation.  I saw  him  about  two  years  after 
the  operation.  He  was  nearly  in  extremis,  the  abdomen 
was  enormously  distended,  and  there  was  serious  engorge- 
ment of  the  superficial  vessels  of  the  anterior  abdominal 
wall.  The  abdominal  cavity  was  filled  by  a large  mass  of 
new  growth,  this  being  nodular  and  very  hard.  The  legs 
were  oedematous,  and,  to  judge  from  the  physical  condition 
of  the  patient,  treatment  seemed  as  if  it  would  be  useless. 
However,  it  was  thought  advisable  to  attempt  to  help  the 
man.  Large  doses  of  X ravs  were  administered  to  several 
areas  of  the  abdomen— back,  front,  and  laterally — the  idea 
being  to  get  in  a large  dose  rapidly.  Improvement  soon 
set  in,  the  tumours  diminished,  and  the  swelling  of  the 
legs  subsided  slowly,  this  being  aided  by  regular  massage  to 
the  limbs. 

In  about  three  to  four  months  the  patient  was  able  to  walk. 
He  attended  as  an  out-patient  for  over  a year,  receiving  treat- 
ment at  intervals.  It  is  now  over  a year  since  treatment 
was  commenced.  The  patient  is  at  work  and  is  able  to 
carry  on,  the  condition  being  quiescent.  He  remained  well 
for  over  18  months,  when  he  returned  for  further  treatment. 

The  next  case,  although  not  one  of  malignant  disease, 
illustrates  the  degree  of  influence  which  can  be  exercised 
over  a very  large  tumour. 

A patient  attended  the  Great  Northern  Central  Hospital 
over  eight  years  ago  suffering  from  an  enormously  enlarged 
spleen,  the  organ  reaching  down  nearly  to  the  pubic  arch. 
He  was  anaemic  and  appeared  to  be  rapidly  going  down  hill. 
He  was  admitted  to  the  hospital  and  received  doses  of 
radiations  three  times  a week  for  a month.  At  the  end  of 
that  time  there  was  no  visible  improvement  and  the 
question  of  removal  of  the  spleen  was  discussed.  I asked 
that  a continuation  of  the  treatment  should  be  advised  after 
a short  interval.  This  was  done,  the  spleen  steadily  reduced 
in  size,  and  in  about  a year  had  returned  nearly  to  the 
normal.  Treatment  at  intervals  of  three  or  four  weeks  was 
administered.  When  last  heard  of  about  a year  ago  the 
patient  was  in  good  health  and  had  been  actively  engaged  in 
business  for  about  eight  years. 

These  cases  are,  I admit,  exceptionally  good  from  the 
point  of  view  of  treatment.  The  prognosis  in  both  was  as 
grave  as  it  could  be,  yet  both  responded  to  treatment  in  a 
remarkable  way.  I quote  them  in  support  of  the  treatment 
of  hopeless  cases  by  palliative  measures,  because  we  cannot 
say  when  a patient  will  not  respond  in  some  measure  to  the 
radiations. 

In  our  endeavour  to  obtain  results  in  these  cases  we  resort 
to  combined  treatment  by  X rays  or  radium  and  the  injection 
of  salts  of  metal  in  a colloidal  form.  Theoretically  the 
proposition  is  a sound  one,  since  it  is  possible  to  obtain 


secondary  radiation  effects  from  this  method.  I am  quite 
of  an  open  mind  in  regard  to  the  value  of  colloidal  salts 
of  metals.  I have  seen  good  results  obtained,  but,  on  the 
other  hand,  the  results  obtained  by  radiations  alone  are 
equally  good. 

I am  often  asked  about  the  value  of  potassium  and  magnesia 
salts  in  this  connexion.  No  objection  should  be  raised  to 
their  use,  since  theoretically,  if  we  can  saturate  the  tissues 
with  the  salts,  the  radiation  effects  may  be  enhanced.  The 
only  proviso  I make  is  that  they  should  be  discontinued  if 
the  patient’s  health  is  affected  by  their  use. 

Salvarsan  and  its  substitutes  may  be  used,  good  results 
being  sometimes  seen  when  it  is  combined  with  radiations. 

Prophylactic  Treatment. 

It  is  reasonable  to  assume  that  if  it  is  possible  to  bring 
about  the  disappearance  of  a small  superficial  nodule  of  new 
growth  by  X ray  treatment,  it  should  be  possible  to  effect 
a similar  change  in  structures  more  deeply  situated  in 
the  body. 

In  the  first  place,  after  an  operation  for  the  removal  of  a 
cancerous  growth  the  tissues  in  an  area  spreading  from  the 
seat  of  the  growth  are  damaged  by  the  manipulations  of  the 
surgeon,  and  therefore  more  prone  to  become  infected. 
Secondly,  the  fluid  from  the  growth  itself  may  contain 
cancer  cells  in  an  active  condition,  and  these,  if  squeezed 
into  the  tissues  along  with  the  lymph,  may  settle  on  damaged 
tissue,  and  so  at  a later  date  give  rise  to  what  is  known  as  a 
“recurrence.”  Thirdly,  the  lymphatics  spreading  out  from 
the  region  of  the  tumour  may  already  be  infected  or  deep- 
seated  glands  may  be  involved.  It  is  in  the  hope  of  checking 
the  development  of  one  or  other  of  the  above  complications 
that  we  resort  to  prophylactic  treatment. 

In  view  of  the  above  facts  it  is  logically  certain  that  the 
sooner  the  treatment  is  commenced  after  operation  the  more 
probable  is  it  that  a beneficial  influence  will  follow.  Indeed, 
several  authorities  advocate  the  pre-operative  treatment  in 
addition  to  the  post-operative.  A number  of  workers 
advocate  the  administration  of  the  first  treatment  at  the 
operation  when  the  tissues  are  fully  exposed.  The  only 
objection  to  doing  so  is  the  time  it  takes  thoroughly  to 
irradiate  the  whole  area  of  the  wound,  the  lymphatics  in  the 
axilla  and  superclavicular  areas  and  the  deep  mediastinal 
glands.  If  this  method  is  employed  the  {first  dose  should 
be  confined  to  the  open  wound.  Later,  in  a day  or  so,  the 
patient  will  be  able  to  submit  to  further  treatment  if  the 
apparatus  can  be  brought  to  the  bedside. 

In  whatever  way  the  treatment  is  commenced  it  must 
be  thoroughly  administered  so  as  to  cover  all  possible 
sites  of  recurrence,  and  the  treatment  should  be  kept  up 
for  about  one  year  or  longer  from  the  time  of  the  opera- 
tion. Opinions  differ  in  regard  to  the  frequency  of  the 
dosage.  Some  good  results  have  been  seen  in  patients  who 
have  had  many  weekly  doses,  followed  at  a later  date  by 
fortnightly  treatments.  The  dose  in  these  instances  has  to 
be  rather  smaller  at  each  seance  than  in  those  treated  at 
longer  intervals.  The  technique  should  be  similar  to  that 
described  for  the  treatment  of  uterine  diseases. 

It  may  be  asked  what  proof  have  we  that  prophylactic 
treatment  does  any  good  at  all,  and  the  question  is  a 
pertinent  one.  We  can  produce  no  proof  that  recrudescence 
is  actually  prevented,  but  we  know  that,  in  the  experience 
of  radiologists,  a result  of  the  treatment  is  that  the  per- 
centage of  superficial  recurrence  is  somewhat  smaller  in  the 
later  years  of  treatment  than  it  was  in  the  earlier  when  the 
technique  had  not  been  perfected.  Manifestations  still 
appear  in  the  deeper  structures — i.e.,  in  the  thoracic  walls 
and  glands  of  the  neck,  axilla,  and  mediastinum.  The  time 
has  not  yet  come  when  we  can  make  any  positive  statements 
on  this  point.  Years  may  elapse  before  we  can  prove  by 
statistics  that  any  good  is  being  done  in  the  way  of  preventing 
recrudescence,  but  in  the  meantime  we  can  definitely  state 
that  radiation  treatment  helps  the  patients  in  other  ways. 
A general  tonic  action  is  evident,  scar  tissue  is  rendered 
pliant,  the  recovery  of  limb  movements  is  facilitated,  and, 
lastly,  the  patient  is  encouraged  to  help  herself  and  is  sup- 
ported in  this  effort  by  the  fact  that  others  are  endeavouring 
to  help  her 

Curative  Treatment. 

The  last  and  not  the  least  important  of  the  uses  of  radia- 
tions in  dealing  with  malignant  disease  brings  us  to  a con- 
sideration of  the  value  of  these  in  an  attempt  at  the  cure  of 
a particular  case.  How  far  have  we  reached  towards  this 


The  Lancet,]  DR.  W.  MacADAM  : A BACILLUS  OF  GAERTNER-rARATYPHOID  GROUP.  [August  2,  1919  189 


end  ? Great  care  and  judgment  are  necessary  in  arriving  at 
a decision  to  rely  solely  on  either  X rays  or  radium  for  the 
cure  of  a new  growth. 

The  first  consideration  is  whether  there  is  any  prospect  of 
curing  an  early  case.  Undoubtedly  a number  of  cases  have 
been  cured  by  a thorough  exposure  to  X rays  or  radium. 
Such  cases  are  naturally  early  ones  where  the  lesion  is  super- 
ficial, and  therefore  readily  accessible  to  the  radiations. 
Rodent  ulcer  can  be  so  dealt  with,  and  superficial  epithelioma 
may  also  disappear  after  treatment  and  remain  cured  for 
lengthy  periods. 

Sarcoma  is  another  condition  in  which  success  may  be 
obtained. 

One  particular  case  occurs  to  me  in  which  a recurrent 
growth  on  the  face  was  completely  cured  by  a course  of 
radium  exposures.  The  original  growth  had  affected  the 
eyelid.  Recurrence  had  been  dealt  with  on  two  occasions 
by  operation,  as  had  also  the  primary  manifestation.  The 
glands  on  the  affected  side  in  the  cervical  region  had  become 
involved.  The  patient  was  treated  eight  years  ago  and,  so 
far  as  is  known,  remains  healed.  When  last  heard  of  about 
a year  ago  she  was  quite  well. 

The  final  judgment  is,  however,  in  favour  of  operation  in 
all  early  cases  of  cancer,  because  the  balance  of  opinion  is 
against  an  attempt  to  cure  by  radiations  when  an  operation 
can  so  easily  be  performed  and  a radical  excision  offers  the 
best  chance  of  cure.  Delay  in  these  cases  is  always  dangerous, 
because  it  is  not  yet  possible  to  be  certain  that  radiations 
will  invariably  yield  a successful  result,  and  surgery  may 
ultimately  have  to  be  employed  under  much  less  favourable 
conditions  if  we  fail  to  bring  about  a disappearance  of  the 
growth  by  X rays  and  radium. 


AN  ACCOUNT  OF 

AN  INFECTION  IN  MESOPOTAMIA  DUE  TO 
A BACILLUS  OF  THE  GAERTNER- 
PARATYPHOID  GROUP. 

By  WILLIAM  MacADAM,  M.A.,  M.D.,  M.R.C.P.  Lond., 

CAPTAIN,  R.A.M.C.  (T.C.)  I BACTERIOLOGIST  ATTACHED  TO 

BRITISH  STATIONARY  HOSPITAL,  MESOPOTAMIA 

EXPEDITIONARY  FORCE. 

( A Report  to  the  Medical  Research  Committee. ) 


A series  of  inagglutinable  organisms  culturally  and 
morphologically  indistinguishable  from  Bac.  para.  B have 
been  isolated  from  the  blood  stream  by  the  writer  in 
Bagdad  between  July  and  December,  1918,  and  it  is  learned 
that  similar  findings  have  been  recorded  in  a number  of 
cases  in  other  areas  of  Mesopotamia.  In  view  of  the  bacterio- 
logical results  obtained  and  pathological  lesions  revealed  at 
autopsy  in  three  fatal  cases  which  occurred,  an  account  of 
the  findings,  along  with  a note  on  the  clinical  history  of  the 
series  of  cases,  has  been  deemed  worthy  of  retord  to  draw 
attention  to  the  possibility  of  other  cases  of  fever  with  or 
without  marked  pulmonary  lesions  being  due  to  the  same 
organism,  as  well  as  to  raise  the  question  of  its  relationship 
to  the  infections  of  the  classical  “enterica”  group,  especially 
paratyphoid  B fever. 

Characters  of  the  Organism  Isolated  from  the  Blood  and  from 
the  Various  Organs. 

The  several  strains  of  the  organism  under  review  all  have 
the  cultural  and  morphological  characters  of  the  Gaertner- 
paratyphoid  group.  It  is  most  closely  related  to  Bac.  para.  B 
and,  as  will  be  shown,  it  does  not  appear  to  belong  to  the 
Bac.  aertrycke  type.  Up  to  the  present  the  organism  has 
been  obtained  from  nine  cases,  from  seven  of  which  it  was 
isolated  during  routine  blood-culture  investigation  of 
“P.U.O.’s.”  In  the  remaining  two  cases  it  was  isolated  at 
autopsy  from  the  lungs  and  spleen,  no  blood  culture  having 
been  carried  out  during  life.  The  organism  has  so  far  not 
been  isolated  from  the  urine  or  stools  in  spite  of  numerous 
examinations,  but  at  one  of  the  autopsies  it  was  obtained  in 
pure  culture  from  the  bile. 

All  the  strains  give  similar  microscopic  appearances — an 
actively  motile  short,  stout,  Gram- negative  bacillus  or  cocco- 
bacillus,  with  some  tendency  to  pleomorphic  formation. 
The  growth  on  agar  is  less  transparent  and  oily  in  appear- 
ance than  the  usual  paratyphoid  cultures,  and  is  usually 
more  profuse.  There  is  no  liquefaction  of  gelatin.  On 


MacOonkey’s  medium  the  colonies  are  indistinguishable  from 
the  paratyphoids.  Biochemically  the  organism  produces 
acid  and  gas  in  mannite,  glucose,  dulcite,  maltose,  galactose 
and  arabinose,  no  change  occurring  in  lactose,  saccharose, 
and  inulin.  Litmus  milk  becomes  at  first  slightly  acid, 
changing  to  alkalinity  on  the  fifth  to  seventh  day  ; there  is 
no  production  of  indol. 

Serologioal  Characters. 

On  isolation,  all  the  strains  were  inagglutinable  even  in 
low  dilutions  of  the  high-titre  sera  (Lister  Institute)  for 
B.  typhosus , B.  para.  A,  B para.  B,  and  B.  enteritidis 
(Gaertner).  After  eight  subculturings  in  broth  spread  over 
a fortnight,  all  the  strains  had  become  agglutinable  to 
para.  B serum  in  dilution  of  200  and  250  ; while  in  the  case 
of  four  of  the  strains,  each  of  which  was  subcultured  on 
30  occasions,  agglutination  was  obtained  in  considerably 
higher  serum  dilutions.  Fine  soft  flocculi  with  a distinctly 
opalescent  supernatant  fluid  were  present  in  dilutions 
ranging  up  to  1000  and  2000  (titre  of  the  para.  B serum 
6000),  but  marked  sedimentation  was  never  present  in 
dilutions  higher  than  200  or  250.  In  none  of  the  tests  with 
para.  B serum  did  I obtain  the  clear  supernatant  fluid  which 
usually  results  in  similar  tests  with  Bac.  para.  B.  Consistently 
negative  results  were  obtained  in  the  agglutination  tests  with 
all  other  high-titre  sera  (Dreyer’s  method  slightly  modified 
being  the  technique  adopted). 

Specific  sera  for  three  of  the  strains  have  been  obtained 
by  the  immunisation  of  rabbits,  a titre  of  6000  to  10,000 
being  reached  without  any  difficulty.  All  the  nine  strains 
were  agglutinated  to  practically  the  full  titre,  whereas  two 
stock  strains  of  Bac.  para.  B never  showed  any  signs  of 
clumping  in  higher  dilution  than  1 in  250.  For  example, 
strain  No.  6,  which  was  obtained  in  pure  culture  from  the 
lungs  at  autopsy  by  plating  the  lung  juice  on  MacConkey’s 
medium  (as  also  from  the  heart  blood  and  spleen),  was 
agglutinated  immediately  after  isolation  by  the  rabbit 
immune  sera  for  the  strains  No.  3 and  4 in  dilutions  of  8000 
and  10,000  respectively,  while  para.  B.  sera  (Lister  Institute, 
titre  6000)  failed  to  produce  any  reaction  with  this  strain  in 
dilution  1 in  50.  “Zones  of  inhibition”  were  occasionally 
met  with  in  the  agglutination  experiments  both  with  the 
specific  para.  B serum,  as  well  as  with  the  sera  obtained 
from  the  immunised  rabbits,  but  no  reference  need  be  made 
to  them  in  the  present  connexion. 

It  has  unfortunately  not  been  possible  to  obtain  from 
England  subcultures  of  recognised  B.  aertryche  strains,  but 
through  the  kindness  of  Lieutenant-Colonel  Ledingbam, 
R.A.M.C.,  I was  enabled  to  compare  the  reactions  of  a strain 
of  presumed  Bac.  aertrycke  isolated  from  an  epizootic  among 
guinea  pigs  by  Major  Gloster,  I.M.S.,  at  Amara.  The 
behaviour  of  this  bacillus  with  the  sera  produced  from  the 
immunised  rabbits  was  very  different  from  that  of  all  the 
nine  strains  of  the  organism  under  review.  Agglutination 
with  sedimentation  was  present  up  to  the  250  dilution,  while 
the  same  indeterminate  type  of  clumping  associated  with  the 
the  fine  soft  flocculi  as  was  obtained  with  the  stock 
B.  para.  B was  present  up  to  a dilution  of  1 in  1000.  Nor 
did  this  B.  aertrycke  strain  become  more  agglutinable  after 
repeated  subculturings,  while  it  maybe  noted  that  it  clumped 
with  the  Lister  para.  B serum  practically  up  to  titre.  Thus 
it  appears  infjprobable  that  the  series  of  organisms  under 
investigation  belong  to  the  B.  aertrycke  group,  although  the 
evidence  is  meantime  incomplete  in  the  absence  of  experi- 
ments with  specific  B.  aertrycke  sera. 

Agglutination  of  organism  with  patient's  serum. — One  case 
— No.  1 — is  of  special  interest,  in  that  it  was  possible  to 


Dilutions  of  Serum  oj  Case  Nq.  1. 


— 

25 

50 

100 

200 

250 

500 

No.  1 

+ + 

+ + 

+ + 

± 

± 

- 

No.  2 

+ 

+ 

+ 

— 

— 

— 

No.  3 

+ + 

+ + 

+ 

+ 

± 

— 

No.  4 

+ + 

+ + 

+ 

+ 

— 

No.  5 

+ + 

+ 

+ 

— 

~ 

— 

Stock  B.  para.  B 

+ 

+ 

— 

— 

~ 

Stock  B.  para.  A 

+ 

— 

— 

— 

Stock  B.  typhosus 

+ 

+ 

carry  out  agglutination  tests  with  two  lots  of  this  man  s 
serum  against  his  own  organism  as  well  as  against  the  others 
cf  the  series.  Unfortunately  no  serum  was  obtained  before 
the  twenty-fourth  day  of  illness.  On  this  occasion  the 


190  The  Lanoet,]  DK.  W.  MacADAM  : A BACILLUS  OF  GAERTNER-PARATYPHOID  GROUP.  [August  2,  1919 


serum  gave  negative  results.  On  Oct.  28th,  1918 — i.e.,  the 
forty-second  day  from  the  onset  of  No.  l’s  illness — blood  was 
again  obtained,  and  the  following  results  were  obtained  in 
macroscopic  agglutination  tests  with  the  serum  against  five 
of  the  strains  and  against  our  stock  T.A.B.  emulsions.  This 
patient  has  been  inoculated  with  T.A.B.  vaccine  in 
November,  1916,  and  again  in  February,  1918. 

Absorption  tests. — Although  it  was  not  to  be  expected  that 
much  information  was  to  be  gained  from  absorption  tests 
when  the  I’ara.  B agglutinogens  of  all  the  strains  of  the 
organism  are  relatively  slight  in  character  and  produce  such 
atypical  flocculi  as  compared  with  those  of  the  homologous 
organism,  yet  a number  of  such  tests  have  been  carried  out. 
Out  of  six  experiments  with  Strain  No.  4 immune  serum  the 
following  result  was  recorded  in  two  instances 


Strain  No.  4 rabbit  immune  serum  (titre  6000).  Titre  before  and 
after  absorption  with  (A)  Bac.  paid,  li  and  with  (B)  Strain  No.  3 


(A) 

<B) 

Original 

titre. 

After 

absorption 

Original 

titre. 

After 

absorption. 

li.  para.  B 

250 

<50 

250 

. <50 

Strain  No.  4 

6000 

6000 

6000 

500 

Strain  No.  3 

6000 

5000 

6000 

j > 500 
1 <1000 

It  is  seen  that  Bao.  para.  B removed  all  the  para.  B 
co-agglutinins  from  the  rabbit  immune  serum,  but  did  not 
touch  the  agglutinins  for  the  homologous  or  similar  organism, 
whereas  after  absorption  with  a presumably  similar  bacillus 
(Strain  No.  3)  more  than  five-sixths  of  the  agglutinins  for 
the  homologous  organism  were  removed,  as  also  were  all  the 
para.  B co-agglutinins.  In  the  other  four  tests  such  removal 
of  the  para.  B co-agglutinins,  by  the  strain  presumably 
similar  to  the  homologous  organism,  did  not  occur.  This 
may  have  been  due  to  the  use  of  an  insufficiency  of  organisms 
in  the  saturation  of  the  serum,  although  from  the  extent  of 
the  removal  of  the  homologous  agglutinins  this  does  not 
appear  probable.  The  atypical  character  of  the  flocculi 
present  in  the  ordinary  agglutination  tests  and  the  incom- 
pleteness of  the  reaction,  as  shown  by  the  persistent 
opalescence  in  the  supernatant  fluid,  may  throw  some  light 
on  the  inconstant  results  obtained,  and  further  investigation 
in  this  direction  is  required. 

In  four  experiments  in  which  para.  B.  high-titre  serum 
was  saturated  with  strains  No.  1 and  4 there  was  no  absorp- 
tion of  the  agglutinins  for  those  organisms  or  for  the 
homologous  organism  B.  para.  B.  It  is  very  probable, 
therefore,  that  we  are  dealing  with  a specific  organism  the 
serological  characters  of  which  are  quite  distinct  from  those 
of  B.  para.  B. 

Pathogenioity  to  Animals. 

No  special  experiments  to  test  pathogenicity  have  been 
carried  out  owing  to  the  small  number  of  experimental 
animals  available.  Some  observations  were  made,  however, 
during  the  course  of  preparation  of  immune  sera  in  rabbits. 
One  animal,  which  had  previously  received  two  intravenous 
injections  of  225  and  900  million  of  dead  bacilli,  was  found 
dead  on  the  third  morning  after  an  intravenous  dose  of  500 
million  living  organisms  ; while  another  rabbit  died  after 
300  million  live  bacilli  following  on  three  doses  of  300,  1200, 
and  3000  millions  respectively  of  killed  organisms,  all  given 
intravenously. 

Post-mortem  examination  showed  that  both  animals  had 
died  of  a haemorrhagic  septicaemia.  Petechial  haemorrhages 
were  present  on  the  pleural  surfaces,  as  well  as  in  the 
substance  of  the  lungs.  Some  were  larger  than  petechias, 
and  in  the  case  of  the  second  rabbit  one  extensive  hxmor- 
rliage  involved  a third  of  the  right  lower  lobe.  Small 
haemorrhages  were  present  in  both  spleen  and  kidneys. 

The  intestinal  tract  also  showed  lesions  of  considerable 
interest.  Discrete  haemorrhagic  areas  ranging  in  size  from 
a pinhead  to  a millet  seed  were  to  be  seen  in  the  lower  part 
of  the  duodenum,  while  in  the  jejunum  and  ileum  they  were 
well  marked  over  a length  of  three  inches,  and  extending  in 
less  degree  for  nine  inches  below.  There  was  some  associated 
oedema  of  the  mucous  membrane,  but  there  was  no  naked - 
eye  involvement  of  the  lower  part  of  the  ileum  or  of  the 
appendix.  The  great  intestine  appeared  normal. 


The  Clinical  Aspects  of  the  Infection  with  Some  Notes  on  the 
Morbid,  Anatomy. 

The  clinical  history,  &c.,  along  with  the  post-mortem 
findings  in  the  three  fatal  cases,  is  as  follows  : — 

Case  3. — Pte.  W.,  aged  30,  was  admitted  to  hospital  at 
Bagdad  on  Sept.  16th,  1918,  with  a fever,  the  temperature 
curve  being  suggestive  of  malaria,  and  the  clinical  symptoms 
of  “ influenza,”  of  which  there  was  an  epidemic  in  Bagdad 
at  the  time.  The  man  had  been  transferred  from  a con- 
valescent camp,  having  been  invalided  from  Persia  for 
debility  following  clinical  malaria.  No  malaria  parasites 
had  been  found  previous  to  admission,  nor  were  any  detected 
during  several  examinations  while  the  patient  was  in 
hospital.  After  five  days’  intermittent  temperature  (98°  to 
104°)  (see  Chart  1)  there  appeared  definite  signs  of  a right 


Chabt  1. 


basal  pneumonia,  spleen  being  palpable  on  deep  inspiration. 
Condition  became  very  critical  and  six  days  later  patient 
died.  There  was  no  paratyphoid  eruption.  Leucocyte 
count  on  day  before  death  12,000  per  c.mm. 

Autopsy  (10  hours  after  death).  Lungs:  Right  middle  and 
lower  lobes  in  state  of  grey  hepatisation.  Upper  lobe  acute 
congestion.  Left  lung  normal.  Pleura;  Right  cavity 
contains  8 ounces  clear  serous  fluid  with  a recent  exudate 
of  lymph  over  the  affected  lobes.  Heart : Signs  of  dilata- 
tion. Myocardium  soft  and  friable.  Spleen:  Twice  the 
normal  size,  soft  and  diffluent.  No  pigment  deposit  to  be 
seen  by  the  naked  eye  or  in  smears.  No  malarial  parasites 
detected.  Intestines : Peyer’s  patches  apparently  perfectly  j 
healthy.  Nothing  abnormal  seen  in  any  part  of  the 
alimentary  canal. 

Bacteriology. — Cultures  from  the  spleen  and  consolidated 
lung  made  direct  on  to  MacConkey’s  medium  gave  a pure 
culture  of  the  cocco-bacillus  described  above.  This  organism 
was  agglutinated  by  its  homologous  serum  obtained  from 
an  immunised  rabbit  in  1 in  6000  dilution.  Originally 
inagglutinable  to  all  the  specific  sera,  after  numerous  sub- 
culturings,  it  reacted  with  para.  B serum  (titre  6000)  as 
follows  : Dilution  1 in  1000  + ; 1 in  2000  ±. 


Case  4. — Sgt.  G.,  aged  40,  had  been  12  days  in  hospital 
suffering  from  vague  nervous  symptoms,  having  suffered 
from  shell  shock  in  France  in  1915,  from  which  he  had 
never  completely  recovered.  Patient  appeared  to  be  doing 
well  during  his  12  days’  residence,  when  his  temperature 
suddenly  shot  up  to  102°  (Chart  2)  and  there  developed 
symptoms  of  bronchitis  and  rhinitis.  On  the  third  dav  of 
fever  signs  of  a right  apical  pneumonia  developed.  Five 
days  later  the  right  lower  lobe  and  also  the  left  apex  showed 
signs  of  involvement.  No  suggestive  rose  spots  were  seen. 
Restlessness  and  delirium  latterly  became  a marked 
feature,  the  patient  dying  on  the  fifteenth  day  of  illness. 

Autopsy  (14  hours  after  death).— Emaciation  slight  with 
moderate  hypostatic  lividity.  Pleura  : Right  sac  contains 
8 oz.  blood-stained  fluid.  No  adhesions  or  lymph  exudation. 
Left  sac  normal.  Lungs:  Consolidation  of  greater  part  of 
right  lung— viz.,  whole  of  lower  lobe,  middle  lobe,  and 
posterior  portion  of  upper  lobe.  In  section  the  colour  was 
yellowish  grey,  the  consistence  distinctly  friable,  with  a 
suggestion  of  softening,  while  there  was  a purulent  exudate 
on  squeezing  the  consolidated  areas.  Left  lung  healthy 
except  for  marked  congestion,  especially  of  upper  lobe. 


The  Lancet,]  OB.  W.  MacADAM  : A BACILLUS  OF  GAERTNER-PARATYPHOID  GROUP.  [August  2,  1919  191 


Heart:  Showed  dilatation  of  the  left  ventricle  with  a large 
antemortem  clot  in  the  corresponding  auricle.  Myocardium 
pale,  flabby,  and  easily  friable.  Spleen:  Slightly  enlarged, 
sottish.  Stomach  and  intestines  (great  and  small)  : Normal 
in  appearance  except  for  a pink  oodematous  condition  of  the 
jejunum  and  upper  part  of  the  ileum.  This  may  have  been 
associated  with  the  presence  of  several  ascarides  in  the 
small  intestine.  Kidneys:  Marked  cloudy  swelling  with 

some  fatty  changes. 

Bacteriology.— Three  blood  examinations  for  malaria 
during  life  were  all  negative.  Blood  culture  on  the  ninth 
day  of  illness  gave  a pure  culture  of  a Gram-negative  cocco- 
bacillus  with  the  characters  above  described,  while  at 
autopsy  the  same  organism  was  obtained  from  spleen,  lung, 
and  contents  of  gall-bladder.  Although  originally  inagglutin- 
able,  all  four  strains  after  a week’s  subculturing  were 
agglutinated  by  para.  B serum  in  1 : 2000  dilution,  tests  with 
the  other  specific  sera  being  negative.  The  serum  of  the 
animal  immunised  with  this  strain  easily  reached  a titre  of 
10,000.  Smears  from  the  sputum  during  life,  as  well  as  from 
the  lung  juice  at  autopsy,  showed  some  Gram-positive  cocci 
in  addition  to  numerous  Gram-negative  bacilli,  but  no 
organism  morphologically  resembling  the  pneumococcus 
was  seen. 

Chart  2. 


Case  6. — Pte.  D.,  aged  32,  admitted  to  hospital  on  Nov.  20th, 
1918,  as  suffering  from  anaemia,  thought  to  be  due  to  bleed- 
ing haemorrhoids,  gave  a recent  history  of  diarrhoea  and 
colicy  pains  for  the  preceding  12  days.  History  of  inter- 
mittent bleeding  from  the  bowel  during  the  previous  two 
months  was  elicited,  blood  with  clots  being  passed  along 
with  formed  stool,  while  the  occasional  occurrence  of 
prolapse  on  defalcation  was  reported.  Four  days  after 
admission  patient  developed  a condition  which  was  diagnosed 
as  acute  bacillary  dysentery.  Fever  asserted  itself  so  that 
the  patient’s  temperature  reached  102°  (Chart  3),  while  4-6 
non-fasculent  motions  were  passed  daily  consisting  chiefly 
of  bright  red  blood  associated  with  blood  clots  and  a 
little  mucus  in  the  form  of  sago-like  granules.  Their 
appearance  was  altogether  much  more  suggestive  of 
intestinal  haemorrhage  than  of  the  usual  acute  dysenteric 
“B.  and  M”  stool.  On  microscopical  examination  the 
cytology  did  not  suggest  bacillary  dysentery,  very  few 
cellular  elements  being  present  apart  from  blood  cells. 
No  entamoebas  were  seen  while  on  cultivation  on 
MacConkey’s  medium  on  three  occasions,  no  non-lactose 
fermenters  were  in  evidence.  Blood  films  failed  to  reveal 
the  presence  of  any  malarial  parasites.  The  blood  picture 
did  not  suggest  a primary  blood  disease.  The  only  striking 
feature  was  the  pallor  and  distortion  of  the  red  cells,  but  no 
megalocytes  or  nucleated  red  cells  were  seen. 

At  first  the  sigmoid  felt  definitely  thickened  and  was 
acutely  tender,  but  after  several  days  this  feature  completely 
disappeared.  The  patient’s  general  condition  suggested 
marked  toxaemia.  He  was  treated  with  antidysentery  serum, 
but  no  improvement  ensued.  On  Nov.  28th — i.e.,  the  twenty- 
first  day  of  fever— severe  watery  diarrhoea  set  in,  the  stools 
being  pea-soup  like  with  flecks  of  blood.  On  Dec.  4th  the 
temperature  fell,  collapse  set  in,  patient  falling  into  a 
comatose  condition,  and  death  took  place  on  Dec.  6th. 

Autopsy  (performed  20  hours  after  death). — Body  con- 
siderably emaciated ; blood  watery.  Respiratory  system 
normal.  Cardio-vascular  system  : Pericardium  normal ; 
dilatation  of  right  ventricle.  Myocardium  pale  and  fatty 


Nothing  else  of  note.  Alimentary  tract : Stomach  : Small 
erosions  in  the  mucosa.  Lower  part  of  duodenum  and  upper 
part  of  jejunum— mucous  membrane  oedematous  with  signs 
of  acute  congestion.  Scattered  petechial  hcomorrbages  but 
no  erosions.  Ileum  normal.  Large  intestine  : Congestion  of 
transverse  and  descending  colon  with  numerous  small 

Chart  3. 


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erosions  and  haemorrhages  in  the  mucosa.  No  marked 
ulceration  and  no  thickening  present.  Liver  and  kidneys  : 
Marked  cloudy  swelling  with  fatty  changes.  Spleen:  Normal 
in  size,  soft  and  diffluent.  Suprarenals  and  thyroid  normal. 
Red  marrow  of  sternum  and  ribs — no  marked  hyperplasia. 

Bacteriology. — A bacillus  with  the  morphology  and  cultural 
characters  of  the  other  organisms  of  the  present  series  was 
obtained  in  pure  culture  from  the  spleen  and  heart  blood. 
In  the  first  agglutination  tests  with  this  organism  after 
isolation  the  findings  were : Against  immune  serum  of 

strain  4,  +-f  1 in  5000,  + 1 in  10,000.  Against  Lister  Institute 
para.  B serum  (titre  6000),  nil  1 in  50. 

Summary  of  Chief  Symptoms. 

As  for  the  cases  in  general,  seme  of  the  clinical  data  have 
been  tabulated  in  Table  A,  while  a summary  of  the  notes  on 
the  chief  symptoms  observed  is  given  below.  No  special 
stress  can  be  laid  on  any  clinical  feature  which  may  not 
occur  in  the  course  of  enteric  group  infections,  although  the 
prominence  of  respiratory  symptoms  has  been  somewhat 
striking  in  the  present  series  of  cases. 

Course  of  the  fever. — The  fever,  which  was  in  most 
instances  of  sudden  onset,  appears  to  be  of  variable  duration , 
depending  partly  on  the  relative  severity  of  the  infection, 
partly  on  the  extent  of  involvement  of  the  respiratory 
tract.  The  milder  cases  lasted  5-7  days  on  the  average. 
Two  patients  (Nos.  1 and  7)  each  ran  an  11-days’  fever,  at 
first  intermittent  and  latterly  of  the  continued  type  (see 
Chart  4).  Of  the  fatal  cases  one  of  the  pneumonias 
(No.  4)  ran  a continued  fever  during  the  whole  15  days' 
illness.  The  other  (No.  3)  showed  a markedly  inter- 
mittent course  for  ten  days,  becoming  of  the  continued 
high  type  on  the  onset  of  extensive  lung  consolidation  four 
days  before  death.  The  fatal  “ haemorrhagic  ” case  (No.  6) 
ran  a 28- days’ pyrexia,  and  was  of  the  continued  type  during 
the  14  days  he  was  under  observation. 

As  regards  relapses,  none  occurred  while  the  patients 
were  convalescing  in  hospital  or  subsequent  to  discharge,  as 
far  as  could  be  learned  from  their  after  history. 

Respiratory  system. — Marked  involvement  of  the  respira- 
tory tract  was  a feature  of  all  the  cases  except  three.  Thus 
in  four  instances  in  which  this  inagglutinable  paratyphoid- 
like organism  was  obtained  by  blood  culture,  the  infections 
were  of  a mild  character  and  of  short  duration,  while 
bronchial  catarrh  was  so  prominent  a feature  that  all  four 
cases  had  been  labelled  “bronchitis”  or  “influenza  with 
bronchitis.”  As  already  described,  two  of  the  fatal  infections 
appeared  clinically  to  be  suffering  from  lobar  pneumonia,  as 
was  subsequently  proved  at  autopsy  (Cases  3 and  4).  Of  the 
three  cases  with  no  respiratory  symptoms  two  of  them  had 
been  considered  enteric  infections,  while  the  third  was 


192  The  Lancet,]  DR.  W.  MacADAM  : A BACILLUS  OF  GAERTNER-PAKATYPHOID  GROUP.  [August  2,  1919 


regarded  as  a markedly  toxic  type  of  bacillary  dysentery. 
Smears  and  cultures  of  throat  swabs  from  a number  of  the 
patients  gave  nothing  of  pathogenic  importance. 


Alimentary  system. — Gastric  and  intestinal  symptoms  were 
in  most  instances  inconspicuous.  Vomiting,  except  in  case 
No.  6,  was  absent,  while  constipation  was  the  rule.  Case 
No.  5,  considered  clinically  an  “ enterica  ” infection,  suffered 
from  diarrhoea  in  the  early  period  of  the  illness,  while  in  the 
fatal  “ pneumonias  ” (Nos.  3 and  4)  there  was  no  lesion  of 
the  intestinal  tract  except  that  one  showed  a pink  cedematous 
condition  of  the  jejunum  and  upper  part  of  the  ileum.  The 
Peyer’s  patches  and  solitary  glands  appeared  quite  normal. 


albuminuria  was  present  in  the  cases  examined.  The 
presence  of  pus  cells  or  other  cellular  elements  was  not 
observed. 

Discussion. 

The  question  as  to  whether  this  bacillus  found  associated 
with  the  present  series  of  cases  is  an  aberrant  type  of 
Bac.  paratyphosus  B or  whether  it  is  an  undescribed  organism 
(which  for  convenience  may  be  called  Bac.  paratyphosus  U)  ' 
belonging  to  the  Gaertner-paratyphoid  group  is  a matter  for 
discussion.  The  fact  that,  after  as  many  as  30  subculturings, 
none  of  the  strains  of  the  organisms  are  agglutinated  by 
specific  para.  B serum  (Lister  Institute)  in  any  dilution  at  all 
approaching  its  maximum  titre  is  important,  especially  when 
it  is  remembered  that  the  isolation  of  readily  agglutinable 
para.  B bacilli  during  the  course  of  routine  blood- culture 
work  in  Bagdad  has  been  far  from  uncommon.  Considera- 
tion must  also  be  taken  of  the  unusual  nature  of  such 
agglutination  as  was  obtainable  with  high-titre  para.  B 
serum — viz.,  the  very  fine  soft  flocculi  which  seldom 
produced  much  sedimentation  and  which  never  left  a clear 
supernatant  fluid.  Nor  do  the  serological  observations, 
described  above,  point  to  the  organism  having  closer 
affinities  to  the  Bac.  aertryche  group,  although  it  has  to  be 
noted  that  unfortunately  it  has  not  yet  been  possible  to 
obtain  from  Europe  any  of  the  recognised  high-titre 
B.  aertryche  sera. 

Clinically,  although  it  is  well  recognised  that  marked 
respiratory  symptoms  may  be  a common  accompaniment  of 
paratyphoid  B infections  and,  indeed,  have  been  the  chief 
feature  of  certain  enteric  epidemics,  yet  the  local  microbic 
infection  in  these  cases  is  still  a matter  of  dispute.  Bacilli 
of  the  Gaertner-paratyphoid  group  have  been  reported  on 
various  occasions  as  having  been  isolated  from  the  sputa,  but 
as  to  whether  they  were  originally  present  or  were  merely 
secondary  invaders  does  not  appear  to  have  been  conclusively 
settled.  It  has  not  been  possible  to  consult  the  literature 
on  the  subject,  but  Miller,1  in  his  recent  Goulstonian 
lectures  (1917)  on  Paratyphoid  Infections,  says 

“The  paratyphoid  bacilli  apparently  do  not  attack  the 
lungs  and  pleura  themselves.  Labbe,  however,  mentions 


Table  A. — Statement  of  Clinical  Data. 


No. 

Clinical  diagnosis  of  case. 

Duration 

of 

fever. 

Day  of  disease 
of  positive 
blood  culture. 

Isolation  of 
organilm  from 
other  sources. 

Probable 
place  of 
infection. 

Character  of  infection. 

1 

Bronchitis  (N.Y.D.  enteric 
group). 

11  days. 

9th  day. 

— 

Bagdad. 

A somewhat  severe  attack,  the  course  suggest- 
ing an  enteric  infection. 

2 

Influenza  with  bronchitis. 

6 „ 

3rd  ,, 

— 

,, 

A short  but  Very  acute  fever. 

3 

"Clinical  malaria”  followed 
by  lobar  pneumonia. 

14  „ 

No  culture 
made. 

Lungs,  spleen, 
heart  blood. 

Kermanshah. 

( Both  very  severe  and  fatal  infections  with  all 

4 

Bronchitis  followed  by  lobar 
pneumonia. 

15  „ 

9th  day. 

Lungs,  spleen, 
bile. 

Bagdad. 

j the  signs  of  lobar  pneumonia.* 

5 

Bronchitis. 

7 „ 

4th  „ 

— 

Kifri. 

A mild  infection. 

6 

Acute  dysentery  (bacillary  ?). 

28  „(?) 

No  culture 
made. 

Spleen,  heart 
blood . 

Tekrit. 

A very  severe  toxic  infection,  with  a haemor- 
rhagic colitis  ending  fatally.t 

7 

Bronchitis  (N.Y.D.  enteric 
group). 

11  „ 

9th  day. 

— 

Bagdad. 

Nothing  of  special  note.  Clinically  very  sus- 
picious of  an  enteric  infection. 

8 

Bronchitis. 

5 ,. 

4 th  „ 

— 

n 

j-  Both  mild  short  fevers. 

9 

•• 

7 „ 

4 th  ,, 

- 

•’ 

* See  p.m.  notes.  t See  detailed  notes  on  clinical  history  and  autopsy. 


The  third  fatal  case  (No.  6),  however,  showed  distinct 
intestinal  lesions,  which  have  been  described  above.  This 
patient  had  complained  of  marked  hypogastric  tenderness  in 
the  early  days  of  his  fever.  Otherwise  abdominal  distension 
or  tenderness  was  not  a feature  of  the  cases. 

Nervous  system. — There  was  no  nervous  symptom  of  special 
note.  Delirium  was  present  towards  the  end  in.  the  two  fatal 
cases  of  pneumonia,  while  No.  6 sank  into  the  typhoid  state 
before  death. 

Skin. — Nothing  suggestive  of  rose  spots  or  of  an  eruption 
of  any  kind  was  seen  in  any  of  the  series. 

Abdominal  organs. — Spleen. — Its  size  varied  considerably 
in  the  different  cases.  Some  of  the  notes  report  the  organ 
as  being  slightly  or  distinctly  palpable  on  deep  inspiration. 
In  one  fatal  case  it  was  two  fingers-breadth  below  the  costal 
margin,  while  at  the  other  two  autopsies  the  organ  showed 
nothing  of  special  note.  Malarial  parasites  or  pigment  was 
not  seen  in  any  smears  of  the  splenic  pulp.  Liver,  kidneys, 
and  bladder : Nothing  of  special  note.  The  usual  febrile 


a case  of  abscess  of  the  lung  from  the  pus  of  which 
B.  para.  B was  isolated.  Apart  from  this  rather  special 
case,  I cannot  find  a recorded  instance  of  paratyphoid  bacilli 
being  found  in  the  pleural  fluid  ante  mortem  nor  in  the 
lungs  post  mortem.  I can  only  think  that  if  these  organisms 
do  attack  the  lungs  and  pleura  it  must  be  but  rarely.” 

In  the  two  cases  of  the  present  series  which  showed 
extensive  pneumonic  consolidation  the  organism  was 
isolated  from  the  lung  juice  in  pure  culture  on  MacConkey’s 
bile  medium,  while,  except  for  a few  scattered  diplococci 
which  did  not  resemble  the  pneumococcus,  it  alone  was 
seen  in  stained  lung  smears. 

The  duration  of  the  bacilhemia  is  so  far  undetermined,  as 
positive  blood  cultures  weie  obtained  from  the  third  to  the 
ninth  days  inclusive  in  the  various  cases.  Marked  involve- 
ment of  the  intestinal  tract,  except  where  the  infection 
assumed  the  character  of  a haemorrhagic  septicaemia,  was 
uncommon,  and  the  absence  of  any  lesion  of  Peyer’s  patches, 


1 Miller:  The  Lancet  1917, 1.,  831. 


The  Lancet,]  DR.  A.  CARVER  : COMMOTIONAL  FACTOR  IN  ETIOLOGY  OF  SHELL  SHOCK.  [August 2, 1919  1 93 


or  of  the  solitary  glands,  may  be  of  importance  as  a 
differential  feature. 

My  attention  has  recently  been  drawn  to  an  account  by 
Neukirch  2 of  an  epidemic  which  occurred  between  March, 
1915,  and  the  early  part  of  1917  in  Anatolia  and  Turkey 
from  the  cases  of  which  an  organism  called  Bao.  Erzindjan 
was  isolated.  This  organism,  the  author  concludes,  is 
closely  related  culturally  to  Bao.  para.  B and  the  suipesti/er 
group,  but  it  can  be  differentiated  by  serological  tests.  From 
the  title  of  his  p^per  Neukirch  is  inclined  to  identify  the 
organism  with  the  Gliisser-Voldagsen  group,  placing  his 
reliance  on  the  agglutination  test.  Yet  he  states  that  all 
the  strains  of  Bao.  Erzindjan — like  those  isolated  from  the 
present  series  of  cases — produced  acid  at  first  in  litmus 
milk,  followed  later  by  alkali  production,  except  one  which 
showed  no  initial  acidity.  On  the  other  hand,  all  the 
Gliisser-Voldagsen  strains  tested  produced  acidity  and 
remained  acid  until  the  end  of  the  ten  days  recorded.  It 
seems  difficult  to  accept  the  serological  similarity  and  ignore 
this  constant  biochemical  difference  between  the  organism 
under  review  and  the  Gliisser-Voldagsen  group.  The  cultural 
characters  of  Bao.  Erzindjan  cannot  be  compared  with  our 
Bao.  para  C,  as  Neukirch  has  so  far  described  its  action  on 
glucose  and  lactose  only. 

This  worker  distinguishes  two  main  clinical  groups  of 
cases  from  which  the  Bao.  Erzindjan  was  obtained  in  pure 
culture:  (1)  the  “ typho-septic  ” type,  with  a mortality  of 
46  per  cent.  ; (2)  the  dysenteric  type,  with  a much  smaller 
mortality  of  6 7 per  cent.  For  comparison  he  quotes  a 
5 per  cent,  mortality  rate  as  having  occurred  among  the 
infections  of  the  “ enterica  ” group.  Two  other  groups  are 
also  mentioned — viz. , four  cases  of  slight  general  infection 
and  a solitary  case  of  pyelonephritis.  Neukirch  draws 
special  attention  to  the  very  variable  clinical  picture  met 
with,  and  to  the  difficulties  of  distinguishing  these  cases 
from  those  of  typhoid,  paratyphoid,  and  dysentery,  apart 
from  a bacteriological  diagnosis.  I have  not  had  access  to 
the  original  article  to  ascertain  what  types  of  infection  are 
included  in  the  group  called  “ typho-septic,”  but  it  appears 
very  probable  that  the  causative  organism  in  the  present 
series  of  cases  of  infection  among  British  troops  is  the  same 
as  that  described  as  Bao.  Erzindjan. 

Most  of  the  cases  which  are  the  subject  of  this  paper 
appear  to  have  been  infected  in  the  Bagdad  area,  although 
in  three  instances  the  evidence  available  pointed  to  the  place 
of  infection  being  much  farther  up  the  line — viz.,  at  such 
widely  separated  places  as  Kermanshah,  Tekrit,  and  Kifri. 
For  the  present  it  is  impossible  to  say  anything  about  the 
epidemiology.  The  probable  prevalence  of  the  infection 
among  the  native  population  requires  investigation,  while  it 
would  be  of  considerable  interest  to  learn  whether  a similar 
para.  C-like  organism  has  been  among  the  bacteriological 
findings  in  Palestine  and  in  other  areas  of  military  operations 
in  the  Near  East. 

Summary. 

1.  A series  of  inagglutinable  organisms  culturally  and 
morphologically  indistinguishable  from  Bac.  para  B have 
been  isolated  by  blood  culture  in  Bagdad  during  the  latter 
half  of  1918,  and  it  is  learned  that  similar  findings  have  been 
reported  in  other  areas  of  Mesopotamia. 

2.  Of  the  three  patients  suffering  from  the  infection  who 
died,  two  of  them  were  clinically  regarded  as  cases  of  lobar 
pneumonia.  At  autopsy  the  same  cocco-bacillus  was  isolated 
from  the  lungs  and  spleen,  and  in  one  instance  from  the 
gall-bladder  also.  Respiratory  symptoms  were  a prominent 
feature  of  most  of  the  cases,  while  the  symptomatology  and 
course  of  the  fever  were  usually  not  suggestive  of  an  enteric 
group  infection. 

3.  Serologically  all  the  strains  on  isolation  were  in- 
agglutinable to  the  “enterica”  high-titre  sera  (Lister 
Institute).  After  30  subculturings  of  the  organism  agglutina- 
tion of  an  atypical  character  was  present  in  dilutions  up  to 
1 in  1000  of  specific  para  B.  serum  (Lister),  while  in  com- 
parison a 1 in  10,000  dilution  of  the  same  serum  led  to  marked 
clumping  with  two  stock  strains  of  B.  pan-a  B.  Absorption 
tests  tended  to  confirm  those  serological  differences.  The 
sera  obtained  from  three  rabbits  immunised  with  different 
strains  of  the  bacillus  readily  agglutinated  the  whole  series 
of  organisms  in  dilutions  of  1 in  5000  to  1 in  10,000 ; whereas 
no  reaction  resulted  with  the  stock  Bao.  para  B in  dilutions 

2 Neukirch,  1918,  Ztechr.  f.  Hyg.  u.  Infektionskrankh.  Ixxxv.,  103. 


higher  than  1 in  250.  Equivocal  findings  were  also  recorded 
in  tests  with  a strain  of  presumed  Bao.  aertryolie. 

4.  The  real  identity  of  the  organism  is  so  far  undecided. 
In  its  behaviour  with  specific  sera  it  is  distinguishable  from 
both  Bac.  para.  B and  Bao.  aertryolie , although  closely  related 
to  both.  It  has  b n learned  with  interest  that  an  epidemic 
in  Turkey  and  A itolia  has  been  described  as  due  to  a 
paratyphoid-like  oi  anism  with  similarly  atypical  serological 
characters.  If  the  b;  cillus  should  eventually  be  proved  not  to  be 
a specific  organism  Lut  to  be  simply  a variety  of  Bao.  para.  B , 
the  practical  importance  of  its  recognition  seems  to  lie  in  the 
fact  that  the  recognised  high-titre  para.  B sera  fail  altogether 
to  agglutinate  it  on  isolation,  and  after  numerous  sub- 
culturings they  react  with  it,  to  only  a limited  extent,  while 
a special  immune  serum  is  necessary  for  its  ready  identifica- 
tion. Many  of  the  organisms  which  have  been  from  time 
to  time  reported  as  non-agglutinable  or  ‘ ‘ temporarily 
inagglutinable  ” para.  B bacilli  may  belong  to  this  para. 
C-like  group. 

It  is  with  pleasure  that  I acknowledge  my  indebtedness  to 
Lieutenant-Colonel  J.  C.  G.  Ledingham,  C.M.G.,  R.A.M.C., 
consultant  bacteriologist  to  the  Mesopotamian  Expeditionary 
Force,  for  his  great  assistance  and  helpful  criticism  ; while 
I desire  to  express  my  thanks  to  Lieutenant- Colonel  H.  J. 
Crossley,  R.A.M.C.,  O.C.  — Stationary  Hospital,  Bagdad,  for 
access  to  and  the  use  of  the  clinical  records  of  the  described 
cases. 

Bagdad,  January,  1919. 


SOME  OBSERVATIONS  BEARING  UPON 
THE  COMMOTIONAL  FACTOR  IN  THE 
AETIOLOGY  OF  SHELL  SHOCK. 

By  ALFRED  CARVER,  M.D.  Camb., 

LATE  CAPTAIN,  R.A.M.C.(T.C.)  ; DIRECTOR  OF  THE  BIRMINGHAM 
PSYCHONECROSIS  CLINIC. 


In  The  Lancet  of  Jan.  11th,  1919,  Dr.  C.  S.  Myers 
raises  three  important  questions  relating  to  the  problem  of 
“ shell  shock.”  The  first  is  as  to  “ the  existence  of  distinct 
commotional  and  emotional  syndromes.”  I believe  that  the 
following  experiments,  carried  out  with  the  assistance  of 
Lieutenant  A.  Dinsley,  R.A.O.C.,  prior  to  the  appearance  of 
Dr.  Myers’s  article,  will  prove  of  interest  as  bearing  upon 
this  point.  The  conditions  under  which  “ shell  shock  ” arises 
in  man  render  accurate  observations  so  difficult  that  experi- 
ments upon  animals  seemed  advisable  carried  out  so  that  the 
weight  of  explosive  used  could  be  kept  constant,  its  nature 
and  composition  known  but  varied  at  will,  and  the  actual 
distance  of  the  animals  from  the  centre  of  detonation 
measured. 

Effects  of  High  Explosives. 

When  a high  explosive  is  detonated  there  arises  first  a 
sudden  terrific  blow  which  exerts  a compressing  and 
shattering  force  upon  its  surroundings  in  every  direction. 
This  is  instantaneous  and  is  followed  immediately  by  an 
equally  sudden  decompression,  thirdly  rapid  oscillatory  or 
vibrating  movements  are  set  up,  which  die  down  only 
gradually.  Each  of  the  three  results  requires  analysis 
when  considering  the  effects  upon  living  organisms.  A 
further  effect  is  the  purely  demoralising  effect  produced  by 
the  vibrations  outside  the  sphere  within  which  any  demon- 
strable physical  destruction  or  injuries  occur.  Evidence 
will  be  adduced  to  show  that  the  Germans  arranged  their 
shell-fillings  so  as  to  enhance  this  peculiar  effect.  This, 
fully  in  keeping  with  other  of  their  methods,  might  be 
described  as  “ frightfulness  by  detonation.” 

If  a high  explosive  be  detonated  at  a point  X three  zones 
may  roughly  be  mapped  out  around  it,  their  radii  depending, 
amongst  other  things,  upon  the  weight  of  explosive. 

Zone  A is  delimited  by  the  extent  of  obvious  gross  dis- 
ruption, and  may  be  termed  “ the  zone  of  brisance  ” ; within 
it  a crater  is  formed,  barbed  wire  and  other  obstacles 
are  blown  aside,  broken  and  distorted  ; animals  are  killed 
and  usually  lacerated  ; other  high  explosives  immediately 
detonated. 

Outside  this  is  a second  zone,  B,  which  may  be  termed 
the  “ zone  of  decompression,”  for  the  disturbances  within  it 
seem  mainly  attributable  to  this  factor,  though  coarse 
shaking  movements  also  play  their  part.  In  zone  B the 


194  The  Lancet,]  DR  A.  CARVER  : COMMOTIONAL  FACTOR  IN  AETIOLOGY  OF  SHELL  SHOCK.  [Augcst2,  1919 


gross  effects  of  shattering  and  disruption  are  no  longer 
evident  ; animals  placed  in  it  and  protected  from  flying 
fragments  rarely  show  external  signs  of  injury ; only 
sensitive  explosives,  whose  tonal  standard  is  somewhat 
similar  to  that  of  the  primary  explosive,  detonate. 

Beyond  this  can  be  named  a zone,  C,  : n which  the  effects 
of  detonation  are  modified  further.  The  fleets  upon  animals 
in  zone  C vary  considerably,  but  as  a r lea  short  transitory 
state  of  stupor  is  followed  by  a stage  of  jxcitement. 

Experiments  on  Fish. 

Experiments  were  first  carried  out  in  water,  the  test 
animals  being  fish  (perch)  ; a depth  charge  of  6 oz.  of 
gelignite  was  used. 

Fish  in  zone  A became  obviously  “hors  de  combat,1’ 
showed  gross  lacerations,  and  were  sometimes  torn  in  pieces. 

Fish  in  zone  B after  the  detonation  floated  in  an  almost 
vertical  position,  but  slightly  inclined  with  their  ventral 
surfaces  uppermost,  their  mouths  just  protruding  above  the 
surface.  At  this  early  stage  the  whole  of  their  bodies  were 
rigid,  and  if  the  fish  were  pushed  down  to  a depth  of  about 
two  feet  they  sank  slowly  to  the  bottom  of  the  tank  and 
there  remained.  The  earliest  sign  of  animation  was  violent 
and  irregular  spasmodic  movement  of  the  opercula  and 
gills.  The  first  reflex  which  could  be  elicited  from  such  fish 
was  erection  of  the  dorsal  fin  upon  stimulation  of  the  skin 
to  either  side  of  it.  At  the  end  of  about  half  an  hour  those 
fish  which  eventually  recovered  began  to  swim  when  the 
abdomen  was  stroked  with  a piece  of  stick,  but  these  first 
swimming  movements  carried  the  fish  only  forward  in  a 
straight  line,  and  no  turns  were  made  even  when  an  obstruc- 
tion was  met.  The  movements  were  made  with  the  ventral 
surface  uppermost  and  almost  flush  with  the  surface  of  the 
water.  At  this  stage,  then,  the  fish  had  lost  their  power  of 
equilibration,  and  with  this  the  whole  of  their  orientation  in 
life. 

The  majority  of  those  which  attained  the  stage  of  swim- 
ming in  this  way  gradually  became  more  active,  and 
eventually,  after  passing  through  a side-uppermost  posture, 
began  to  swim  about  in  a natural  manner.  In  about  12  hours 
after  the  detonation  all  those  fish  which  had  not  succumbed 
were,  to  all  appearances,  completely  normal. 

Dissection  of  the  dead  one  showed  definite  congestion  of 
the  foreparts  of  the  brain,  haemorrhagic  points  in  the  mid- 
brain and  basal  gangliar  region,  and  generally  haemorrhage 
in  the  upper  region  of  the  spinal  cord  and  medulla.  The 
gills  and  other  viscera,  also  the  muscles  attached  to  the 
vertebral  column,  frequently  showed  areas  of  haemorrhage. 
Dissection  of  perch  taken  at  random  immediately  after  the 
detonation  either  revealed  varying  degrees  of  the  above- 
described  changes  or  else,  at  macroscopic  examination, 
nothing  abnormal  was  discovered. 

Towards  the  outer  margin  of  B zone  and  the  inner  region 
of  C zone  the  effects  upon  fish  could  not  be  sharply 
differentiated,  the  severity  of  the  symptoms  and  the 
anatomical  findings  gradually  diminishing  with  the  distance 
of  the  creature  from  X. 

Fish  well  out  in  C zone  dashed  about  vigorously  in  a 
disturbed  and  excited  manner,  but  though  their  movements 
were  wild  and  apparently  haphazard  they  generally  made 
away  from  X.  A few  came  to  the  surface  and  splashed 
about,  but  when  netted  no  physical  abnormality  could  be 
demonstrated,  and  those  returned  to  the  water  soon  behaved 
in  a completely  normal  manner. 

In  considering  the  effect  upon  fish  of  vibrations  set  up  in 
water  one  should  bear  in  mind  the  great  development  in 
these  creatures  of  special  sense  organs  directly  susceptible  to 
stimulation  from  such.  It  is  conceivable  that  the  effects  of 
the  violent  vibrations  just  described  are  in  part  due  to 
excessive  stimulation  of  these  special  sense  organs.  If  this 
be  so,  the  shock,  though  still  physical,  might  be  more 
accurately  described  as  of  neurogenic  than  of  commotional 
origin.  It  is  well  known  that  in  man  unconsciousness  can 
be  produced  by  purely  reflex  stimulation,  the  whole  ego  beiDg 
swamped  by  an  excessive  flood  of  afferent  impulses  which 
gives  rise  to  a condition  of  neurogenic  shock  ; there  being 
no  “ commotio.”  As  1 have  no  evidence  which  leads  me  to 
think  that  neurogenic  shock  of  this  type  plays  any  appreciable 
r61e  in  the  production  of  the  war  neuroses  I shall  not  refer 
to  this  aspect  of  the  subject  any  further. 

Experiments  on  Mammals. 

Experiments  with  mammals  (rats  and  mice)  were  carried 
out  on  land.  Perforated  zinc  cages  were  used,  partly  to  fix 


the  position  of  the  animals  and  partly  to  protect  them  from 
flying  fragments.  These  cages  were  distributed  at  measured 
distances  around  X.  The  charge  was  standardised  to  3 oz. 
of  explosive. 

In  zone  A cages  in  and  immediately  outside  the  crater 
formation  were  simply  blown  away  and  distorted,  the 
animals  being  killed  or  severely  wounded  by  direct  violence  ; 
their  eyes  were  bloodshot,  and  there  was  often  external 
haemorrhage  from  the  ear,  nose,  or  mouth.  On  dissection 
the  alveoli  of  the  lungs  were  found  to  be  ruptured,  and  to  a 
variable  extent  the  contral  nervous  system  and  other  viscera 
showed  haemorrhagic  areas.  With  the  effect  in  A zone  we 
are  not  further  concerned  ; the  changes  would  seem  to  be 
due  to  the  direct  blow  of  displaced  air,  which  strikes  like  a 
solid  substance,  and  to  the  effect  of  the  exceedingly  rapid 
decompression  succeeding  this. 

Along  the  inner  part  of  zone  B the  findings,  though 
similar  to  the  above,  were  much  less  in  degree.  Animals 
were  invariably  rendered  unconscious  irrespective  of  the 
extent  or  nature  of  the  lesions  demonstrable,  and  occa- 
sionally were  found  to  be  dead,  even  though  no  external 
injury  was  present  ; upon  dissection  the  only  abnormal 
finding,  to  coarse  examination,  was  general  capillary  engorge- 
ment, especially  noticeable  in  the  central  nervous  system  and 
meninges.  Whether  this  indicates  that  vaso-motor  changes 
play  any  part  in  the  associated  phenomena  I am  not  pre- 
pared to  say. 

Further  out  in  zone  B a state  of  stupor  or  transitory  loss 
of  consciousness,  of  much  shorter  duration  than  in  zone  A 
animals,  was  an  almost  constant  result.  During  the  stage 
of  recovery  twitching 'movements  of  the  limbs  were  often 
present,  and  then  the  animals,  if  stimulated  by  appropriate 
physical  agents,  showed  massive  and  exaggerated  reflex 
reactions.  For  example,  the  application  of  a pin- prick  to 
one  hinder  extremity  might  be  followed  either  by  bilateral 
contraction  of  the  hinder  extremities  or  even  by  a generalised 
convulsion.  There  was  frequently  considerable  difference 
in  the  activity  of  the  reflexes  on  the  two  sides  of  the  body — 
a hemiplegic  distribution— but,  as  a rule,  the  fore-limbs 
were  more  severely  affected  than  the  hind  and  showed  weak- 
ness and  dragging  after  the  latter  had  recovered  normal 
movements.  Reflex  responses,  though  vigorous,  died  away 
quickly,  but  were  often  succeeded  by  a weaker  repetition 
even  when  no  fresh  stimulus  was  given.  Rapid  fatigue  of 
the  response  on  repeated  stimulation  was  a noticeable 
feature.  By  dissection  no  gross  macroscopical  evidence  of 
internal  injury  to  such  animals  was  revealed,  but  capillary 
engorgement,  as  in  animals  nearer  X,  was  generally 
demonstrable. 

Animals  left  alone  after  this  stage  had  been  reached 
gradually  began  to  behave  in  a more  normal  manner,  though 
for  a considerable  time  their  conduct,  postures,  and  gaits 
were  awkward.  The  severity  of  these  disorders  varied 
greatly  from  animal  to  animal,  which  rendered  it  impossible 
to  deliminate,  from  biological  observations,  the  precise 
boundaries  of  the  several  zones.  Speaking  generally,  the 
effect  diminished  gradually  in  proportion  to  the  distance  of 
the  animal  from  X. 

For  some  distance  beyond  what  I have  termed  the  C 
zone,  animals  crouched  down  and  huddled  themselves 
together  whenever  a detonation  took  place  ; after  this  state 
of  diminished  activity  a state  of  apparent  excitement  with 
increased  restlessness  was  the  rule.  Animals  left  exposed 
in  this  position  during  a series  of  experiments  invariably 
crouched  down  as  flat  as  possible  and  seemed  to  be  in  an 
absolutely  stuporose  condition.  When  liberated  they  made 
no  effort  to  run  away  but  remained  for  a long  time  in  a 
huddled-np  posture.  The  interpretation  of  these  latter 
peculiarities  of  behaviour  is  difficult.  Should  fear  be 
allowed  as  the  cause  or  are  other  more  material  factors  also 
at  work  ? 

If  instead  of  employing  a single  explosive  at  X one 
detonated  a composite  charge  all  the  above  phenomena 
became  more  pronounced,  but  the  increased  effect  was 
particularly  noticeable  in  zone  C and  its  immediate 
surroundings. 

Observations  on  Soldiers. 

In  this  connexion  it  is  of  interest  to  record  some  observa- 
tions carried  out  upon  physically  and  mentally  fit  men  of  an 
“Ammunition  Proof  and  Demolition  Section  ” during  the 
ordinary  course  of  their  duties.  The  staff,  drawn  from 
infantry-men  with  some  technical  knowledge,  was  sheltered 
in  a well-protected  dug-out  about  100  yards  from  X,  the 


ThhLanoht,]  DR.  A.  OARVEll : COMMOTIONAL  FACTOR  IN  iETIOLOGY  OF  SHBLL  SHOCK.  [August  2, 1919  1 95 


centre  of  detonation.  In  this  case  X was  a large  crater 
formed  in  the  centre  of  the  demolition  ground,  and  contained 
the  official  maximum  weight  for  each  single  destruction — 
viz.,  200  lb. 

Although  the  men  had  some  technical  knowledge  they  did 
not  know  the  nature  of  the  explosive  fillings  which  were  to 
be  destroyed  on  any  given  occasion,  and  it  was  interesting  to 
study  the  differing  effects  of  these  upon  them.  Simple  single 
fillings,  such  as  T.N  T.,  picric  acid,  and  tetryl,  rarely  caused 
any  of  the  men  discomfort  under  the  conditions  described, 
yet  when  mixtures  such  as  ammonal  (British),  amatol 
(British  and  German),  donarit  and  gliickauf  (German)  were 
detonated  many  of  the  men  complained  of  unpleasant  sensa- 
tions— e.g.,  “ catching  in  the  throat,”  “ peculiar  feelings  in 
the  chest,”  “ creepy  feelings  down  the  spine,”  or  “ weakness 
of  the  legs  others  were  seen  to  shake  violently  and  the 
rate  of  their  pulse  and  respiration  increased. 

When  separated  or  layered  fillings  of  different  explosives 
having  widely  differing  velocities  of  detonation  were  de- 
molished the  effects  became  greater  and  several  of  the  men 
passed  into  a stuporose  condition,  followed  in  some  instances 
by  violent  shaking  and  twitching,  and  in  one  case  by 
vomiting. 

Men  thus  affected  were  not  fit  for  duty  for  the  next  two  or 
three  days,  and  even  then,  although  fully  aware  that  no  real 
danger  attended  the  demolitions,  they  seemed  to  be  in  a 
state  of  mental  anxiety  and  were  more  readily  affected  by 
detonations  than  previously. 

Effects  of  Detonations  of  Shells  with  Layered  Fillings. 

Examination  of  German  shells  shows  that  in  certain  of 
them  layered  fillings  were  deliberately  employed,  although 
involving  more  time  and  labour.  Captured  German  docu- 
ments reveal  the  fact  that  this  type  of  shell  was  intended 
for  use  immediately  prior  to  an  attack,  and  in  sectors  where 
the  opposing  troops  were  well  entrenched.  Hence  we  must 
infer  that  the  Germans  were  aware  of  the  peculiar 
demoralising  effects  which  attend  the  detonation  of  these 
mixed  and  layered  fillings. 

Most  of  those  who  have  been  through  a severe  German 
bombardment  bear  witness  to  the  demoralising  effect  it  had 
upon  them,  and  state  how  this  was  succeeded,  owing  to 
summation  of  effect  as  the  bombardment  continued,  by  a 
sort  of  “fixed  glassy  feeling  ” even  when  the  shell  did  not 
detonate  particularly  close  to  them.  In  order  to  eliminate 
as  far  as  possible,  if  not  entirely,  the  psychic  factor  which  in 
such  cases  plays  its  part  it  is  instructive  to  study  cases  in 
which  the  detonation  fell  like  a “bolt  from  the  blue  ” upon 
individuals  who  were  not  in  a state  of  tense  expectation  or 
fatigue  at  the  moment  of  the  incident. 

At  the  same  time  one  cannot  ignore  the  importance  of  the 
predisposing  factors,  which  are  highly  complex.  There  is, 
however,  nothing  distinctive  about  them  as  regards  the  type 
of  neurosis  developed.  So  far  as  my  observations  go  the 
most  important  of  them — viz.,  fatigue  both  physical  and 
mental — seem  to  operate  in  a general  way  by  lowering  the 
resistance  of  the  individual  to  all  forms  of  shock,  though 
naturally  the  individual  of  poor  make-up  is  more  profoundly 
affected  than  the  robust  type. 

Commotion  from  11  Direct  Concussion." 

First  to  deal  with  the  syndrome  in  cases  where  commotion 
resulting  from  “direct  concussion”  without  wounding,  as 
in  animals  exposed  in  the  B zone,  is  the  primary  causal 
facte  r. 

The  initial  symptom  is  unconsciousness,  often  of  several 
hours’  duration  and  possibly  persisting  for  days.  Conscious- 
ness when  first  recovered  does  not  remain  clear,  but  the 
patient  passes  through  a stage  of  variable  duration  during 
which  he  loses  and  regains  it — the  so-called  “dipping  of 
consciousness.”  Some  degree  of  aphasia  and  sphincter 
troubles  are  common  at  this  stage,  which  is  frequently 
associated  with  an  active  delirium  in  which  the  patient 
re-enacts  episodes  of  his  military  service. 

At  this  time  the  general  condition  is  one  of  extreme 
exhaustion  ; all  mental  operations  are  sluggish  and  there  is 
great  difficulty  of  concentration.  Amnesia  both  for  imme- 
diate and  remote  past  is  a common  occurrence.  The  voice 
is  often  altered,  becoming  slow,  monotonous,  and  higher 
pitched  than  normally.  In  severe  cases  these  symptoms  tend 
to  persist  for  many  months  and  relapses  are  easily  induced 
by  any  form  of  fatigue. 


Clinically  the  importance  of  recognising  these  symptoms 
is  that  the  prognosis  in  such  cases  is  much  graver  than  in 
those  giving  an  exaggerated  account  of  events  after  they  had 
been  thrown  down  or  partially  buried.  In  cases  exhibiting 
the  above  symptoms  prolonged  rest,  with  freedom  from  strain 
of  all  sorts,  is  essential.  Psycho-therapeutic  treatment  is 
of  little  avail  except  in  so  far  as  fixation  of  symptoms  may 
have  occurred  in  the  later  stages. 

'■'Indirect  Concussion." 

Cases  of  “indirect  concussion”  corresponding  to  animals 
on  the  borders  of  the  B and  C zones  demand  more  careful 
discrimination.  The  history  is  complicated  by  the  fact  that 
there  is  a tendency  on  the  part  of  the  patient  to  exaggerate, 
but  careful  questioning  will  overcome  this  difficulty. 

Unconsciousness  or  stupor  of  comparatively  brief  duration 
is  the  rule,  and  the  phenomenon  of  “dipping  of  conscious- 
ness” is  not  observed.  Active  delirium  is  rare,  and  is  not  of 
the  occupational  type.  Amnesia  though  frequently  present 
is  only  retrograde,  is  less  extensive,  and  more  readily 
recovered  than  in  the  type  of  case  previously  described. 

The  severity  of  the  symptoms,  as  well  as  their  duration, 
is  also  less,  but  there  is  a greater  tendency  to  the  super- 
imposition of  functional  troubles  such  as  paralyses  and 
algesias  ; these  may  supervene  immediately  but,  more  com- 
monly, they  develop  later  in  the  course  of  the  disease  when 
the  symptoms  of  commotional  origin  are  recovering.  If  they 
are  removed  by  appropriate  treatment  the  patient,  after  a 
few  weeks’  complete  rest,  generally  feels  as  well  as  ever. 
Easy  fatigability  and  diminished  power  to  concentrate  the 
attention  are  apt  to  be  more  persistent  symptoms,  and 
although  the  patient  declares  himself  “quite  fit,”  it  is 
advisable  to  insist  upon  a more  prolonged  period  of  rest. 

“ The  Last  Straw." 

Cases  in  which  the  neurosis  arose  as  the  result  of  exposure 
to  shell  fire  in  what  I have  referred  to  as  the  C zone  are 
naturally  much  more  difficult  to  differentiate  from  those  of 
purely  psychogenic  origin,  and  it  cannot  be  said  that  they 
are  recognisable  by  a distinctive  syndrome.  The  description 
already  given  of  men  so  exposed  in  the  “Ammunition  Proof 
and  Demolition  Ground  ’’  affords  a better  picture  of  the  onset 
of  the  neurosis  than  can  be  got  from  an  analysis  of  the 
more  complicated  conditions  arising  during  trench  warfare. 

In  a rather  disparaging  way  any  shell  detonating  outside 
the  A zone  is  commonly  referred  to  as  merely  “thfe  last 
straw,”  its  influence  being  thus  tacitly  attributed  to  purely 
emotional  factors.  It  is,  nevertheless,  a last  straw  which 
cannot  be  lightly  disregarded,  and  one  is  justified  in  main- 
taining that  a sufficient  number  of  such  “ straws  ” will  cause 
the  downfall  even  of  the  most  robust. 

It  should  be  remembered  that  the  stability  of  any  explo- 
sive is  under  these  conditions  diminished,  and  its  sensitive- 
ness so  raised  that  it  may  eventually  detonate.  There  is  no 
difficulty,  then,  in  conceiving  that  physical  processes,  which 
cause  alterations  in  the  direction  of  instability  in  a relatively 
simple  chemical  compound  such  as  an  explosive,  may,  in  a 
similar  way,  affect  the  far  more  delicate  colloidal  solutions 
contained  in  the  central  nervous  system. 

Combination  of  Physical  and  Emotional  Cateses. 

With  cases  of  purely  psychogenic  origin,  many  of  whom 
never  reach  the  danger  zone,  it  is  not  my  purpose  to  deal. 
The  syndrome  closely  resembles  that  with  which  we  are 
familiar  in  civil  life,  though  the  “current  conflict”  is 
usually  of  a different  nature.  Psychological  analysis  reveals 
the  repression  and  the  conflict  which  is  being  shirked. 

The  point  which  seems  to  have  been  universally  overlooked 
is  that  under  the  conditions  of  modern  warfare  the  soldier 
is  constantly  subjected  both  to  physical  and  emotional  causes 
of  shock,  and  that  the  two  factors  operate  in  conjunction. 
Also  whichever  factor  be  in  any  given  case  the  primary  one 
the  individual,  once  sensitised  by  either,  remains  for  a long 
time,  perhaps  always,  hypersensitive  to  both  forms  of 
stimulation,  and  a vicious  circle  is  thus  established. 

Although  one  not  infrequently  meets  with  cases  in  which 
apparently  a single  factor  has  been  operative,  a careful  study 
of  histories  in  the  special  military  neurological  hospitals  has 
led  me  to  conclude  that  the  combined  action  of  the  two 
etiological  factors  is  much  the  more  common  event.  If  this 
be  so,  it  is  not  surprising  that  those  who  expect  to  find  either 
definite  commotional  or  emotional  syndromes  in  the  bulk  of 
their  patients  are  generally  disappointed. 


196  The  Lancet,] 


MR.  R.  E.  SMITH  : INTRACRANIAL  LESIONS. 


[August  2,  1919 


Conclusion. 

I have  tried  with  the  aid  of  the  experiments,  here  briefly 
set  forth,  to  give  a picture  of  the  early  syndrome  which  dis- 
tinguishes the  more  severe  cases  of  commotional  shock,  but 
as  the  experiments  themselves  no  less  than  clinical  experi- 
ence indicates,  the  symptoms  in  slighter  cases  become  almost 
inextricably  blended  with  others  which  appear  identical  with 
those  resulting  from  emotional  shock.  Hence,  tnough  at 
the  two  extremes  one  may  with  ease  deduce  the  nature  of 
the  primary  pathogenic  factor  from  a study  of  the  syndrome 
exhibited,  this  becomes  increasingly  difficult  as  one 
approaches  the  intermediate  members  of  the  series,  and 
one’s  judgment  is  largely  determined  by  the  aspect  from 
which  one  approaches  the  problem. 


INTRACRANIAL  LESIONS: 

THREE  INTERESTING  CASES. 

By  R.  ECCLES  SMITH,  M.B.  Leeds,  F.R.C.S.  Edin., 

SURGEON  TO  THE  SURGICAI.  HOSPITAL,  BARRY,  WALES. 


These  cases,  each  differing  widely  from  one  another,  but 
each  having  in  common  a hemiplegia,  are  recorded  together, 
the  first  on  account  of  its  rarity,  the  second  for  its  interest- 
ing obscurity  and  want  of  a true  diagnosis,  and  the  third 
merely  as  a reminder  of  what  one  must  be  prepared  for  as  an 
aftermath  of  the  war. 

Cavernous  Sinus  ; Thrombosis  ; Hemiplegia,  ; Pyorrhoea 
Alveolaris. 

Patient,  a man,  aged  28,  was  admitted  to  hospital  on 
March  7th,  1918;  long  history  of  pyorrhoea  alveolaris.  On 
Feb.  20th  seven  teeth  were  extracted  from  right  upper  and 
lower  jaws.  He  developed  an  alveolar  abscess  in  the  right 
lower  jaw  with  cervical  suppuration,  requiring  incision.  On 
Feb.  27th  temperature  104°;  repeated  rigors  and  symptoms 
of  septicfemia.  The  chest  was  involved  in  an  early  broncho- 
pneumonia of  a septic  type.  Loss  of  power  on  left  side  of 
body. 

On  admission  patient  was  extremely  ill.  His  mouth  was 
foul.  There  was  marked  necrosis  of  the  lower  jaw  all  along 
the  right  alveolar  margin,  with  sloughing  of  the  gums.  Both 
antra  were  apparently  not  involved  when  searched  by  trans- 
illumination. The  right  lung  showed  signs  of  broncho- 
pneumonia, with  some  pleural  effusion ; sputum  full  of 
streptococci ; blood  culture  sterile.  Intense  proptoses  of 
right  eye,  with  oedema  of  lids ; marked  chemosis  and 
paralysis  of  sixth  nerve.  The  fundi  were  normal  except 
for  tortuosity  and  enlargement  of  retinal  veins  on  right  side. 
There  was  a little  oedema  over  right  mastoid  region  due  to 
back-pressure  in  the  petrosal  sinuses.  He  was  quite  con- 
scious, but  was  almost  completely  paralysed  in  face,  arm, 
and  leg  on  leftside.  Reflexes  abolished  ; no  sensory  changes; 
incontinence  of  urine  and  fteces. 

Intravenous  eusol  1 per  cent,  was  given  daily  for  seven 
days;  initial  dose  100  c.cm.,  rapidly  increasing  to  250  c.cm. 
Temperature  of.  septic  type,  103-5°-I04°  ; respirations,  30-35 ; 
pulse,  120-130.  After  the  second  injection  of  eusol  the 
symptoms  improved.  On  the  third  day  the  proptosis  was 
a little  less ; sixth  nerve  began  to  recover.  On  the  fourth 
day  the  paralysis  of  the  arm  was  not  so  complete  ; on  fifth 
day  improvement  in  leg.  The  paralysis  was  never  absent, 
but  improved  until  he  could  partly  move  arm  and  leg.  By 
the  seventh  day  the  sphincters  were  normal.  The  proptosis 
decreased  up  to  a certain  point  and  signs  of  chronic  back- 
pressure began  to  show  in  the  veins  of  the  lids  and  in  a solid 
unaltering  cedema  of  the  conjunctiva.  The  right  fundus 
remained  as  first  noted.  The  chest  lesion  began  to  dominate 
the  scene  on  March  14th;  increasing  respirations  and 
gradual  deterioration  ; duct  parotitis  which  did  not 
suppurate.  By  March  16th  he  was  profoundly  toxiemic ; 
death  on  March  23rd  from  septic  broncho-pneumonia  and 
septiciemia. 

The  points  of  interest  are  : 1.  The  infection  and  thrombosis 
of  the  cavernous  sinus  by  septic  absorption  from  pyorrhoea 
alveolaris  via  the  pterygoid  plexus  of  veins,  through  the 
ophthalmic  veins  into  the  sinus.  2.  The  hemiplegia  due  to 
pressure  by  direct  swelling  of,  or  added  tissue  oedema  about, 
the  sinus,  on  that  part  of  the  right  crus  cerebri  containing 
the  motor  fibres  of  the  face,  arm,  and  leg  of  the  left  side, 
where  it  is  in  relationship  with  the  cavernous  sinus.  And 
of  the  sixth  nerve  as  it  lies  intimately  related  to  the  outer 
wall  of  the  sinus.  3.  The  improvement  in  the  hemiplegia 
and  squint  and  proptosis  suggesting  organisation  of  the 


clot  and  absorption  of  surrounding  oedema  and  establish- 
ment of  collateral  circulation.  4.  Recovery  might  possibly 
have  been  hoped  for  had  not  septicaemia  and  broncho- 
pneumonia led  on  to  death. 

A Case  for  Diagnosis  ; Cerebral  Decompression  ; Recovery. 

Patient,  a man,  aged  43,  apparently  perfectly  healthy,  and 
walking  in  the  street,  suddenly  gave  an  articulate  cry  and 
fell  down  in  a fit.  Syphilis  20  years  ago  ; teetotaller  13  years. 
On  admission  to  hospital  on  August  8th,  4 P.M.,  he  presented 
a further  fit.  Twitching  and  fine  tremors  started  in  the  left 
hand,  passing  up  the  arm,  involving  face  on  left  side,  and 
ending  in  left  lower  extremity  ; great  distress.  His  tongue 
was  bitten  before  a gag  could  be  obtained.  Pupils  dilated 
and  fixed ; eyes  turned  to  the  left.  Consciousness  during 
jactitations  and  intervals.  Reflexes  were  absent  on  left  side  ; 
Babinski’s  sign  negative.  Total  flaccid  paralysis  of  the  left 
side  of  face,  arm,  and  leg.  No  alteration  of  sensation.  Urine 
normal  except  for  a slight  trace  of  albumin.  Distinct  cedema 
of  discs,  especially  on  right  side.  Pulse  120,  full,  and 
bounding.  B.P.  : systolic  130  mm.,  diastilic  100  mm. 
Lumbar  puncture,  fluid  under  pressure ; 20  C.cm.  clear  fluid 
withdrawn. 

At  8 p.m.  patient  was  deeply  comatOss  and  cyanosed, 
respirations  slow,  and  breathing  stertorous.  Pulse-rate  had 
fallen  to  56,  full,  and  thudding.  Pupils  equal,  semi-dilated, 
and  reacting  slightly,  and  fully  dilated  in  a fit.  Complete 
paralysis  as  above,  but  with  total  loss  of  all  reflexes, 
including  sphincters.  Every  few  minutes  patient,  although 
unconscious,  was  thrown  into  most  violent  left-sided  jactita- 
tion, beginning  in  face  and  ending  in  lower  extremity,  and 
lasting  30  to  40  seconds.  No  external  injury  was  present. 

Having  diagnosed  compression  due  to  a pathological 
rather  than  a traumatic  lesion  with  a localising  site  in 
the  right  cerebral  hemisphere,  I advised  decompression. 
In  cerebro-spinal  fluid  only  an  excess  of  small  lymphocytes ; 
cells  of  any  kind  scanty.  This  is  of  extreme  importance 
in  later  developments. 

Operation  was  carried  out  at  10  p.m.  under  chloroform. 
A large  semilunar  flap  was  turned  down  on  right  side  of 
skull  over  motor  area  and  middle  meningeal  artery.  The 
brain  was  exposed  over  area  of  2 square  inches,  including 
precentral  gyrus.  No  extradural  haemorrhage ; middle 
meningeal  artery  intact.  A normal  dura  mater  bulged  ; loss 
of  brain  pulsation.  No  subdural  haemorrhage  observed,  so 
whole  of  dura  in  decompression  area  was  turned  down.  The 
brain  bulged  out  rapidly,  assuming  size  of  duck’s  egg ; 
meninges  apparently  normal ; no  cedema  or  suggestion  of 
thrombosis.  The  skin  and  fascial  flap  was  then  sutured 
completely.  Breathing  and  pulse-rate  immediately  improved 
and  he  was  returned  to  ward. 

On  August  9th  in  the  morning  there  was  complete 
recovery  of  consciousness  and  ability  to  talk.  Paralysis- 
remained  and  reflexes  absent;  no  sensory  changes.  On 
the  10th  conversation  sensible.  Partial  recovery  of  lower 
limb ; face  and  arm  paralysed ; control  of  sphincters.  On 
the  11th  further  recovery  of  leg  with  sluggish  knee-jerk, 
arm  could  be  moved,  no  fine  movements  possible.  On  the 
12th  Wassermann  reported  strongly  positive.  On  the  13th 
power  in  arm  and  leg  increased ; facial  paralysis  almost 
stationary.  Coordination  was  defective.  Steady  improve- 
ment continued,  even  in  the  face,  until  August  18th. 

On  the  18th  he  suddenly  had  a coarse  tremor  of  the  left 
arm,  lasting  a few  seconds,  repeated  several  times  daily ; 
over  25  tremors  recorded  in  a week;  otherwise  patient  is 
making  a good  recovery.  On  the  28th  sudden  return  of 
violent  jactitations  affecting  arm  and  then  leg,  but  not  face  ; 
24  violent  fits  in  12  hours.  No  loss  of  consciousness  in 
convulsions.  Brain  at  site  of  decompression  very  tense 
and  enlarged.  Lumbar  puncture  removed  40  c.cm.  of  clear 
fluid  under  great  pressure  ; fluid  similar  to  last.  Complete 
paralysis  of  leg  and  arm  followed  and  lasted  two  days 
before  return  of  slight  movement  in  the  leg.  During  this 
time  slight  athetoid  movements  continued  in  the  arm  and 
leg. 

From  August  30th  no  further  tremors ; steady  return  of 
power,  chiefly  to  leg,  continued.  The  reflexes  were  now 
exaggerated  on  that  side ; Babinski’s  sign  negative.  On 
Sept.  20th  he  could  walk  with  some  spasticity  of  the  left  leg ; 
arm  be  raised  with  difficulty  and  hand  placed  on  head ; grip 
good.  The  eyelids  could  close  ; lower  supply  of  facial  nerve 
not  recovered ; fundi  completely  recovered.  Antispecific 
treatment  with  iodides  has  been  steadily  carried  out  as  far 
as  the  stomach  will  allow. 

From  this  point  up  to  his  discharge  on  Oct.  27th  a change 
was  seen  in  his  mental  attitude,  which  had  been  quite 
rational.  He  has  been  emotional  and  childish  and  a little 
verbose;  general  health  good;  able  to  carry  on  light 
work  in  civil  life.  He  was  last  seen  in  February,  1919 
(seven  months  after  admission).  The  mental  attitude 
remained  the  same;  slight  improvement  in  gait  and  arm 
power.  Tremor  of  tongue  and  slight  tremor  of  hands  had. 
appeared. 


The  Lancet,] 


MR.  JAMES  TAYLOR  : COLECTOMY. 


[August  2,  1919  197 


Points  of  Interest  and  Discussion. 

A man  with  a strong  positive  Wassermann  is  brought  in 
■with  a left-sided  hemiplegia,  left-sided  Jacksonian  epilepsy, 
and  cerebral  compression.  Where  and  what  is  the  lesion  ? 

A.  At  the  time  of  onset  of  the  symptoms  the  strongest 
feature  was  increasing  intracranial  compression  with 
coincident  hemiplegia  on  the  left  side,  denoting  haemor- 
rhage in  the  region  of  the  basal  ganglia  from  the  lenticulo 
striate  branch  of  the  middle  cerebral  artery.  This  would  not 
account  for  the  localised  and  definite  convulsions  which 
essentially  belong  to  a cortical  lesion,  the  two  conditions 
remain  uncorrelated. 

B.  Syphilitic  thrombosis  of  the  cortical  vessels  over  the 
right  motor  area,  with  a syphilitic  meningitis,  might  explain 
both  the  palsy  and  the  epilepsy.  But  it  does  not  explain 
the  excessive  intracranial  pressure  leading  to  profound 
coma,  nor  does  the  normal  condition  of  the  meninges  and 
vessels  found  allow  of  such  a theory. 

0.  Haemorrhage  into  a cyst  or  a softened  gumma  in  the 
region  of  the  basal  ganglia  can  only  explain  the  hemiplegia 
and  compression,  but  not  the  cortical  symptoms.  The 
recurrence  of  convulsions  21  days  after  decompression, 
relieved  by  lumbar  puncture,  tends  to  strengthen  the  view 
of  further  haemorrhage  into  such  cyst. 

D.  The  abundance  of  small  lymphocytes  in  the  spinal  fluid 
in  the  early  stage,  with  the  onset  of  changes  in  the  mental 
attitude  later,  strongly  suggest  early  general  paralysis  of  the 
insane  which,  as  is  well  known,  may  be  ushered  in  by  con- 
vulsions and  even  transient  hemiplegia.  But  this  fails  to 
supply  the  explanation  of  severe  compression  sufficient  to 
have  been  fatal  without  surgical  interference. 

My  own  opinion  now  is  that  a combination  of  (C)  and  (D) 
is  the  only  means  of  correlating  the  antagonistic  symptoms. 

A photograph  showed  the  site  of  decompression  and 
protruded  brain  on  the  right  side,  unfortunately  almost 
obscured  by  his  hair.  The  position  of  the  leg  is  voluntary. 
The  arm  will  be  noticed  to  be  still  lacking  power,  and  the 
facial  muscles  are  not  controlled. 

Latent  Meningitis  lolloning  Gunshot  Wound  of  the  Skull. 

Patient,  aged  34,  sustained  in  November,  1916,  a severe 
wound  by  shrapnel  of  left  frontal  bone  above  air  sinus. 
Both  tables  were  carried  away,  leaving  a semilunar  opening 
in  the  bone  2J  inches  long  by  | inch  wide.  Laceration  of 
frontal  lobe.  From  the  injury  up  to  Feb.  1st,  1919,  he  had 
recurring  headaches  with  from  time  to  time  vertigo.  The 
fundi  did  not  denote  any  intracranial  pressure. 

On  Feb.  1st,  1919,  he  was  admitted  to  hospital,  having 
suddenly  had  four  very  severe  generalised  fits  with  cyanosis 
and  vomiting ; semi-coma  between  convulsions.  He  was 
unconscious  to  his  surroundings  on  arrival.  The  fits  had  no 
localising  features,  but  were  very  violent  generalised  clonic 
convulsions.  In  the  period  of  quiet  a violent  fit  could  be 
elicited  by  firm  pressure  on  the  scar.  Fundi  normal.  All 
reflexes  present,  but  sluggish.  The  scar  was  very  thick, 
and  firmly  adherent  all  round  hiatus  in  bone.  The  tissues 
about  the  scar  were  slightly  oedematous,  simulating  the 
puffy  tumour  of  Pott.  The  convulsions  continued  frequent 
and  violent.  The  diagnosis  acute  spreading  oedema  of  the 
meninges  was  made,  and  operative  measures  advised. 

Operation. — Under  chloroform  the  old  scar  was  rapidly 
excised  and  site  of  fracture  exposed,  well  in  front  of  motor 
area.  The  hiatus  in  the  frontal  bone  was  filled  up  with 
dense  scar  tissue,  consisting  of  brain  tissue,  organised  blood 
clot,  and  the  remains  of  the  meninges.  The  whole  was 
markedly  cedematous;  cerebro-spinal  fluid  more  abundant 
than  usual.  A trephine  disc  was  removed  from  the  sound 
bone  just  behind  the  fracture  and  the  tissues  adherent  to  the 
ragged  bone  carefully  separated  until  the  brain  and  meninges 
were  free  from  the  skull.  Bone  was  then  removed  until  a 
decompression  over  2 inches  square  had  been  effected.  The 
organised  clot  and  scar  tissue  were  carefully  excised  from 
the  frontal  lobe,  hot  saline  freely  used,  and  the  wound  closed 
except  for  drainage. 

On  recovery  from  the  ansesthetic  two  hours  later  patient 
had  a violent  convulsion,  followed  by  a state  of  acute  cerebral 
irritation,  which  was  continuous  and  had  to  be  controlled  by 
chloroform  ansesthesia.  This  stage  in  about  ten  hours  gave 
place  to  intervals  of  lethargy  alternating  with  violent  fits. 
Twenty-four  hours  later  compression  symptoms  came  on 
and  patient  developed  hemiplegia  of  the  whole  of  the  right 
side.  Coma  and  death  ensued  48  hours  after  admission. 

Post  mortem. — The  frontal  lobe  on  the  left  side  showed 
marked  destruction  of  old  standing,  with  a dry  cavity  in  the 
deeper  portion  suggesting  the  site  of  an  old  abscess  which 
had  undergone  absorption.  On  the  left  side  of  the  brain 
there  was  a marked  basal  meningitis.  The  meninges  were 
in  a state  of  acute  oedema,  especially  marked  on  the  left  side. 


No  undue  localising  pressure  was  noted  on  the  left  motor 
area  to  account  for  the  increasing  paralysis  on  the  right 
side. 

This  case  illustrates  the  guarded  prognosis  necessary  in 
war  wounds  of  the  skull.  In  brief,  the  majority  of  such 
wounds  are  fatal  on  the  field.  Those  brought  under  the 
surgeon’s  care  either  remain  clean  and  recover  or  become 
septic  and  die  within  a fortnight  from  suppurative  lepto- 
meningitis or  encephalitis  or  end  with  a hernia  cerebri, 
which  remains  a menace  for  all  time.  This  man  had 
apparently  completely  recovered,  with  no  hernia  cerebri  or 
bulging  of  the  brain  tissue.  Yet  over  two  years  elapsed 
before  the  latent  infection  flashed  up,  ending  fatally  in  an 
acute  generalised  oedema  of  the  meninges  and  a definite 
localised  basal  meningitis. 

Plymouth.  

COLECTOMY. 

By  JAMES  TAYLOR,  F.R.C.S.  Edin., 

MAJOR,  R.A.M.C.  ; DISTRICT  CONSULTING  SURGEON,  ALDERSHOT 
COMMAND. 

V 

At  present  the  question  of  intestinal  stasis  is  much  before 
the  profession.  The  medical  journals  constantly  refer  to  it, 
and  even  the  public  press  has  articles  on  this  subject.  We 
are  recognising  more  and  more  that  a great  many  ailments 
have  their  origin  in  the  intestine.  In  many  cases  diseases 
are  the  direct  mechanical  result  of  the  delayed  passage  of 
food,  but  much  more  suffering,  and  a much  greater  variety 
of  sickness,  is  produced  by  toxins  from  fermentive  pro- 
cesses among  the  accumulated  intestinal  contents.  Other 
diseases  are  produced  by  germs  directly  attacking  organs 
after  their  resistance  has  been  lowered  by  intestinal  toxaemia. 
The  mechanical  and  fermentive  processes  are  always  more 
or  less  associated.  They  act  and  react  on  one  another,  but 
sometimes  one  and  sometimes  the  other  is  the  dominant 
factor  in  the  production  of  any  particular  disease. 

The  treatment  of  intestinal  stasis  rests  with  the  physician, 
but  a fairly  large  proportion  of  cases  get  beyond  his  control 
and  can  only  be  relieved  by  surgical  measures.  Many  cases 
only  reach  this  stage  because  all  treatment  has  been  neglected 
until  serious  mechanical  obstructions  and  marked  toxic 
changes  have  taken  place. 

The  most  striking  results  of  surgical  treatment  are  seen 
in  the  toxsemic  cases.  Nothing  is  more  impressive  than  to 
see  a large  thyroid  shrivel  to  normal  dimensions,  or  a Bright’s 
disease  entirely  clear  up  after  removal  of  the  colon.  Six 
years  ago  after  performing  an  ileo-sigmoidostomy  on  a woman 
with  inveterate  constipation  the  feeling  of  well-being  which 
followed  was  surprising.  Within  24  hours  she  felt  entirely 
different,  and  the  change  was  obvious  to  the  observer.  Before 
the  operation  the  odour  of  her  breath  made  it  unpleasant  to 
be  near  her,  in  spite  of  the  utmost  care  of  her  mouth  by  the 
nurses.  Within  a day  from  the  operation  this  had  entirely  dis- 
appeared, and  her  muddy  complexion  became  clear  incredibly 
soon.  The  removal  of  a controlling  appendix  or  the  division 
of  a controlling  band  will  often  produce  remarkable  improve- 
ment, but  the  results  which  impress  one  most  occur  after  the 
more  radical  operations,  and  one  sees  the  most  wonderful 
recoveries  after  the  removal  of  the  large  bowel. 

Illustrative  Cases. 

In  this  paper  I propose  to  describe  some  cases  in  which 
the  changes  in  the  colon  itself,  resulting  from  stasis,  were 
such  as  to  demand  its  removal.  They  illustrate  the  effect  of 
the  irritating  contents  on  the  bowel. 

Case  1.— The  colon  was  not  actually  diseased,  but,  being 
overloaded,  had  sunk  down  till  almost  all  Jhe  ascending, 
transverse,  and  descending  portions  were  in  the  pelvis.  The 
patient,  aged  30,  came  under  my  care  suffering  from  severe 
indigestion.  Constant  pain  and  vomiting  after  food  ; bowels 
always  constipated.  The  symptoms  were  those  of  gastric 
ulcer  ;<  physical  examination  confirmed  this.  When  the 
abdomen  was  opened  an  old  healed  ulcer  was  found  at  the 
pylorus;  obstruction  not  very  great.  The  colon  was  as 
described,  and  obviously  was  the  essential  cause  of  the 
trouble.  The  large  bowel  from  csecum  to  lower  part  of 
pelvic  colon  was  removed,  and  the  end  of  the  ileum  joined 
to  the  end  of  the  divided  sigmoid. 

Case  2.— A boy,  aged  18,  complaining  of  abdominal  pain 
for  three  months.  Pain  in  spasms;  during  spasms  a con- 
siderable swelling  appeared  in  right  side  of  abdomen,  just 


1<j8  The  Lancet,] 


MR.  JAMES  TAYLOR  : COLECTOMY. 


[August  2,  1919 


below  umbilicus.  It  was  movable  and  tympanitic,  and  only 
slightly  tender.  At  times  it  would  disappear  altogether,  and 
the  pain  would  pass  off.  He  was  constipated ; occasional 
attacks  of  vomiting ; slight  distension  of  whole  abdomen. 
A diagnosis  of  chronic  obstruction  was  made,  and  I thought 
he  had  probably  a tuberculous  caecum.  When  the  abdomen 
was  opened  the  end  of  the  ileum  was  dilated  to  the  size  of 
a normal  stomach  ; walls  greatly  hypertrophied.  In  caecum 
and  beginning  of  ascending  colon  was  a firm  elastic 
swelling  resembling  chronic  intussusception.  The  dilated 
end  of  the  ileum  and  the  whole  colon  round  to  its  pelvic 
portion  were  excised,  and  an  end-to-end  anastomosis  between 
ileum  and  sigmoid  made.  On  examination  of  the  specimen 
the  lumen  of  the  caecum  and  lower  ascending  colon  was 
so  narrowed  that  a finger  passed  with  difficulty.  The  sub- 
serous  and  submucous  coats  were  greatly  thickened  and 
the  mucous  membrane  was  thrown  into  folds,  which  gave 
the  appearance  of  a large-celled  honeycomb.  Professor  S.  G. 
Shattock  very  kindly  examined  the  specimen  and  pronounced 
it  to  be  a case  of  colitis  polyposa. 

Case  3. — Six  years  before  coming  under  my  care  patient 
suffered  from  constipation  ; appendix  removed  ; condition 
did  not  alter  during  next  .four  years.  Then  pain  began  on 
right  side  of  abdomen ; blood  in  stools.  A few  weeks  later 
diarrhoea  began  to  be  troublesome;  much  blood  and  mucus 
passed.  He  was  in  hospital  at  various  times  during  the 
next  two  years,  once  for  five  months.  When  I saw  him  first 
he  had  been  under  treatment  for  six  weeks  without  improve- 
ment, and  I was  asked  by  the  physician  to  perform  a 
csecdstomy.  Diarrhoea  was  constant,  as  many  as  12  motions 
a day  ; patient  extremely  thin  and  weak.  The  caecum  was 
opened  and  irrigation  started.  He  improved  up  to  a point, 
but  relapsed  when  caecostomy  opening  was  allowed  to  close. 
More  radical  treatment  was  decided  upon.  The  whole  colon 
down  to  within  a few  inches  of  the  rectum  was  excised. 
The  patient  stood  the  operation  well,  and  gradually 
improved.  A certain  amount  of  diarrhoea  still  resulted 
from  diseased  condition  of  rectum.  Cultures  were  made 
from  the  stools,  and  a streptococcal  vaccine  was  given ; 
this  with  protargol  injections  hastened  recovery.  He  was 
discharged  from  the  Service  fit  for  light  employment. 

Case  4. — Patient,  a woman  aged  53 ; intestinal  obstruc- 
tion for  ten  days.  There  had  been  much  abdominal  pain, 
occasional  vomiting,  and  repeated  enemata  had  only  resulted 
in  a very  little  flatus  being  passed.  The  abdomen  was 
enormously  distended  and  somewhat  tender.  On  laparotomy 
there  was  an  escape  of  free  gas  from  the  peritoneal  cavity  ; 
free  fluid  was  present  in  pelvis.  The  large  and  small 
intestines  were  greatly  distended,  and  a malignant  growth 
was  found  in  middle  of  pelvic  colon.  Several  stercoral 
ulcers  in  caecum ; one  had  perforated.  The  caecum  was 
brought  out  of  the  wound,  perforation  closed,  and  a Paul's 
tube  tied  into  the  most  healthy  part.  A large  rubber  drain 
was  then  passed  down  to  the  bottom  of  the  pelvis,  to  be  left 
in  for  several  days. 

The  patient  was  very  ill  for  about  a week  ; distended  bowel 
very  slowly  recovered  tone,  and  expelled  its  contents.  After 
three  weeks  the  abdomen  was  quite  flat ; bowels  moving 
freely  through  artificial  anus.  Under  stovaine  and  ether 
anaesthesia  an  incision  was  made  round  the  caecostomy 
opening,  two  narrow  flaps  of  skin  turned  up  and  stitched 
together  face  to  face  so  as  temporarily  to  close  the  opening. 
The  field  of  operation  was  then  again  thoroughly  cleansed, 
and  the  abdominal  cavity  freely  opened.  The  whole  colon, 
except  a few  inches  of  pelvic  portion,  was  resected,  with 
about  4 ft.  of  lower  ileum  hopelessly  matted  together  as  a 
result  of  the  perforative  peritonitis.  An  end-to-end  anasto- 
mosis was  made,  and  a tube  passed  up  through  the  rectum 
to  a little  above  the  line  of  intestinal  suture.  Most  excellent 
recovery  ; healing  by  first  intention. 

Eighteen  months  afterwards  the  patient  is  in  better  health 
than  she  has  enjoyed  for  years,  the  bowels  move  easily  twice 
a day,  and  she  can  lead  a normal  active  life,  including  horse- 
riding.  There  is  no  evidence  of  recurrence. 

Case  5. — This  is  a similar  case,  a malignant  growth  in  the 
same  situation  causing  acute  obstruction,  which  had  to  be 
relieved  in  the  same  way  with  colectomy  a fortnight  later. 
No  perforation  ; only  about  8 in.  of  small  intestine  sacrificed. 
Recovery  excellent,  but  it  is  too  soon  to  say  whether  any 
recurrence  is  going  to  take  place. 

Case  6. — A patient  had  had  a transverse  colotomy  for  gun- 
shot wound  of  pelvis  involving  rectum.  When  the  rectum 
had  healed  the  colotomy  opening  had  to  be  closed.  So  jpuch 
of  the  transverse  colon  was  damaged  that  it  was  going  to  be 
difficult  to  bring  the  ends  together  after  removal  of  injured 
portion.  The  ascending  and  descending  colon  were  removed 
as  well  and  an  end-to-end  anastomosis  made  between  the 
ileum  and  the  pelvic  colon.  Recovery  excellent. 

These  six  cases  are  the  only  complete  colectomies  I have 
had  the  opportunity  of  performing.  I was  surprised  at  the 
way  the  patients  stood  the  operation,  especially  in  the  two 
cases  in  which  so  much  delay  was  caused  by  the  precautions  to 


avoid  contamination  of  the  wound  from  the  cclotomy  opening. 
The  rapid  improvement  in  general  health  was  also  striking. 
I have  seen  four  of  these  cases  recently  and,  except  the  case 
with  the  ulcerative  condition  of  the  rectum,  there  was  no 
trouble  with  diarrhoea,  the  bowels  only  moving  about  twice  a 
day.  One  hears  that  these  patients  are  always  troubled  with 
looseness  of  the  bowels,  but  that  has  not  been  my  experience. 
Even  the  patient  who  lost  4 ft.  of  ileum  as  well  as  the 
whole  colon  has  had  no  trouble  of  this  kind.  Yet  another 
patient  in  whom  I removed  about  the  same  length  of  intes- 
tine— 8 ft.  of  small  intestine,  caecum,  and  ascending  colon — 
has  suffered  from  troublesome  diarrhoea  since.  This  seems 
to  indicate  loss  of  small  intestine  as  more  likely  to  cause 
frequent  motions  than  loss  of  colon. 

Sir  Arbuthnot  Lane  is  most  emphatic  that  in  cases  of 
obstruction  from  a growth  in  the  colon  the  whole  large 
bowel,  including  the  tumour,  should  be  removed  at  the 
primary  operation.  The  tube  which  is  then  passed  up 
through  the  rectum  into  the  end  of  the  ileum  drains  the 
small  intestine  directly  and  at  once.  It  seems  the  ideal 
method,  but  I think  could  only  be  done  by  a surgeon  of  his 
skill  and  experience.  In  my  two  cases  I felt  that  the  patients 
would  not  stand  more  than  I did  at  the  first  operation,  and  I 
also  anticipated  having  great  trouble  in  making  my  anasto- 
mosis tight  when  the  ileum  was  so  much  distended.  On  the 
other  hand,  I almost  lost  my  first  patient  from  toxic  absorp- 
tion from  the  colon,  for  it  took  nearly  a week  to  empty  itself 
through  the  colotomy  opening,  and  the  difficulty  of  doing 
the  radical  operation  afterwards  was  greatly  increased  by 
the  presence  of  a faecal  fistula. 

Partial  Operations. 

Attempts  to  relieve  patients  by  partial  operations  are  not 
very  successful.  Two  recent  cases  bear  this  out,  and  are 
rather  instructive. 

Case  A.— I saw  this  patient,  aged  38,  in  consultation  in 
the  country.  She  had  been  an  invalid  for  many  years,  much 
troubled  with  indigestion,  and  not  able  to  do  more  than 
move  about  quietly  in  her  garden.  Thirty-six  hours 
before  I saw  her  she  was  seized  with  sudden  severe 
abdominal  pain  and  vomiting.  When  seen  by  her  doctor 
there  was  no  marked  tenderness  or  rigidity,  but  enemata 
failed  to  produce  any  result;  nothing  had  passed 
by  bowel  since  onset  of  pain.  I found  the  abdomen 
much  distended  and  somewhat  tender  in  its  lower  part. 
Pulse  weak  but  not  rapid.  Immediate  laparotomy  was 
decided  on.  The  abdomen  was  open'  d in  the  middle  line 
and  a large  gangrenous  caecum  prescutea  in  the  wound. 
Examination  showed  extreme  visceroptosis,  and  a volvulus 
of  an  extremely  mobile  caecum  hail  taken  place.  This 
portion  of  bowel  was  greyish  black  in  colour,  had  lost  its 
lustre,  and  rupture  seemed  imminent.  I first  incised  the 
caecum  and  cleared  out  the  contents ; the  torsion  was  then 
easily  uncoiled.  I had  to  remove  the  colon  round  to  the 
middle  of  its  transverse  portion  before  a moderately  healthy 
part  was  reached.  I was  much  in  doubt  as  to  whether  I should 
resect  the  whole  large  bowel,  but  decided  it  was  better  not 
to  have  any  raw  surfaces  on  the  left  side  of  the  abdomen,  as 
the  peritoneum  was  somewhat  infected  from  the  gangrenous 
gut.  An  end-to-end  junction  was  made  therefore  between 
the  ileum  and  the  transverse  colon.  Patient  made  a good 
recovery,  but  she  has  not  put  on  any  more  weight,  and  does 
not  seem  to  have  improved  in  general  health,  as  I should 
have  expected  had  the  ileum  been  drained  directly  into  the 
pelvic  colon. 

Case  B. — This  is  a very  instructive  case,  the  notes  on 
which  Sir  Arbuthnot  Lane  has  very  kindly  allowed  me  to 
publish.  The  patient,  aged  36,  had  suffered  from  constipa- 
tion for  many  years,  and  about  four  years  before  she  came 
to  me  began  to  have  considerable  abdominal  discomfort. 
She  was  supposed  to  have  appendicitis  and  had  this  organ 
removed  ; it  was  noticed  that  the  colon  was  badly  prolapsed. 
She  was  no  better  after  this  treatment  and  three  months 
later  laparotomy  was  performed  by  another  surgeon,  and 
the  caecum,  ascending  and  beginning  of  the  transverse  colon 
resected.  She  was  fairly  comfortable  for  the  next  18  months, 
when  constipation  again  became  very  troublesome,  and  after 
various  kinds  of  medical  treatment,  the  abdomen  was  opened 
for  the  third  time.  Some  adhesions  were  separated,  and  a 
loop  of  small  intestine,  which  had  been  acutely  bent  on  itself, 
was  sutured  to  the  abdominal  wall.  She  nearly  died  of  ileus, 
and  such  was  her  suffering  during  the  next  month  that 
operation  was  decided  on  again.  On  this  occasion  a lateral 
anastomosis  between  the  ileum  and  pelvic  colon  was  per- 
formed, and  the  patient  was  told  that  when  she  had  recovered 
sufficiently  the  segregated  loop  would  be  removed.  However, 
at  the  end  of  another  year  the  operator  refused  to  do  this,  as 
adhesions  had  made  the  operation  too  difficult. 


The  Lancet,]  DR.  C.  WILSON  : ANEURYSM  OF  THE  HEART  WITHOUT  SYMPTOMS.  [August  2,  1919  199 


At  this  stage  I saw  her  for  the  first  time.  She  was 
leading  a miserable  existence.  Large  doses  of  aperients 
were  necessary  every  day,  and  often  enemata  as  well.  She 
was  in  almost  constant  pain.  At  times  a distended  loop  of 
bowel  could  be  seen  standing  out  with  Waves  of  peristalsis 
passing  along  it.  Opaque  meal  examination  showed  very 
marked  delay  in  the  small  intestihe.  Most  of  the  contents 
passed  slowly  through  the  ileo-sigmoidostomy  opening,  but 
a small  quantity  travelled  through  the  side-to-side  anasto- 
mosis made  between  the  end  of  the  ileum  and  the  end  of 
the  transverse  colon.  By  this  means  it  reached  the  splenic 
flexure,  and  was  held  up  here  for  about  48  hours.  Although 
she  was  taking  aperients,  it  was  hot  till  the  fourth  day  that 
the  opaque  meal  reached  the  rectum.  A barium  enema 
showed  a very  long  and  distended  pelvic  colon,  and  the 
fluid  could  not  be  forced  beyond  the  splenic  flexure.  It 
was  obvious  that  she  was  suffering  from  chronic  obstruc- 
tion, which  might  become  acute  at  any  moment.  As  a 
radical  operation  was  going  to  be  extremely  difficult,  I 
advised  her  to  have  it  done  by  Sir  Arbuthnot  Lane,  and  I 
had  the  privilege  of  assisting  him  with  it.  After  carefully 
separating  the  adhesions,  the  very  long  pelvic  colon  was 
divided  near  its  lower  end.  The  bowel  was  freed  and 
removed  from  below,  upwards,  until  the  ileum  above  the 
higher  anastomosis  was  reached.  An  end-to-end  anasto- 
mosis between  the  ileum  and  the  pelvic  colon  was  then 
made. 

The  patient  had  a much  happier  convalescence  after  this 
operation  than  after  any  of  her  previous  ones,  and  her 
pain  was  entirely  relieved.  She  is  now  steadily  recovering 
her  strength.  Had  a complete  colectomy  been  done  in  the 
first  instance  she  would  have  been  saved  much  suffering  and 
four  years  of  invalidism. 

Conclusion - 

Although  my  experience  of  colectomies  has  been  some- 
what limited,  I feel  it  is  worth  while  publishing  notes  on  the 
few  cases  done  because  there  is  a very  general  belief  that 
many  patients  do  not  recover  from  the  operation,  and  that 
those  who  do  are  no  longer  capable  of  leading  an  active  life. 
Operation  deaths  do  occur,  but  usually  because  the  patient 
is  suffering  from  a serious  organic  lesion,  and  an  operation  is 
being  done  that  one  may  give  him  the  only  chance  of 
recovery.  One  must  expect  misfortunes  sometimes  when 
patients  with  serious  kidney  disease  are  submitted  to  opera- 
tion, but  the  fact  that  my  first  six  cases  of  colectomy  were 
recoveries  seems  to  show  that  the  risk  is  not  very  great  when 
no  very  vital  organ  is  seriously  involved. 

I feel  assured  that  improving  the  drainage  system  pro- 
duces wonderful  results,  and  often  efficient  drainage  cannot 
be  obtained  without  removal  of  the  large  bowel.  One  sees 
the  effect  of  improved  drainage  in  those  patients  with 
peptic  ulcer  who  have  had  a gastro-enterostomy  performed, 
and  their  ileal  control  freed.  The  complexion  clears,  the 
tongue  becomes  clean,  and  the  excretion  of  foul-smelling 
toxins  by  the  sweat  glands  no  longer  takes  place,  and  yet  in 
these  cases  only  slight  relief  has  been  given  to  the  obstructed 
alimentary  tract.  I feel  sure  that  the  great  improvement  in 
health  often  following  appendicectomy  is  not  due  to  the 
removal  of  a diseased  organ,  but  to  the  excision  of  an 
appendix  which  has  been  controlling  the  end  of  the  ileum . 


ANEURYSM  OF  THE  HEART  WITHOUT 
SYMPTOMS. 

By  CLAUDE  WILSON,  M.D.  Edin. 

Aneurysmal  dilatation  of  the  cardiac  wall  is  rare,  though, 
perhaps,  not  so  rare  as  supposed,  for  in  many  cases  of  sudden 
death  from  heart  failure  no  autopsy  is  made.  The  condition 
cannot  be  diagnosed  during  life,  and  in  very  few  cases  has  it 
ever  been  suspected.  It  has  been  found  as  a solitary  lesion 
in  an  otherwise  healthy  heart,  but  is  commonly  associated 
with  widespread  changes — syphilitic,  sclerotic,  or  fatty. 
The  immediate  cause  is  probably  in  all  cases  the  blocking 
of  a branch  of  the  coronary  artery,  leading  to  atrophy  of  a 
limited  area  of  the  heart  wall. 

Occasional  cases  have  been  published  in  the  medical  litera- 
ture of  many  nations.  In  English  there  are  two  well-known 
monographs  on  the  subject  : by  Dr.  Wickham  Legg 1 and 
Dr.  D.  G.  Hall.2  In  neither  of  these  is  the  clinical  history 


1 The  Bradshaw  Lectures,  1883  (Med.  Times  and  Gazette,  1883,  ii.,  199). 

3 Edinburgh  Medical  Journal,  1903,  p.  322. 


dealt  with  very  fully  ; but  it  may  be  stated  generally  that  in 
the  great  majority  of  cases  the  usual  signs  and  symptoms 
of  cardiac  enfeeblement  have  been  present,  while  angina  is 
a fairly  common  symptom.  But  in  a certain  proportion  of 
cases  the  severer  symptoms  of  cardiac  weakness  have  been 
singularly  wanting,  and  I have  traced  one  case,  recorded  by 
Dr.  F.  M.  Hughes  3 — in  addition  to  my  own — in  which  there 
were  no  symptoms  at  all. 

The  patient,  a dock  labourer  who  bad  never  bad  any 
cardiac  symptoms,  had  worked  hard  all  his  life,  and  had 
several  times  been  passed  as  fit  for  work  by  doctors.  He  had 
had  no  occasion  for  medical  treatment  of  any  kind  during 
the  last  15  years  of  his  life  ; he  walked  six  miles  to  his  work 
two  days  before  his  death,  and  was  able  to  continue  his 
arduous  labours  after  his  first  slight  feelings  of  distress, 
until  on  the  third  day  he  suddenly  dropped  dead  at  the  age 
of  49.  At  the  autopsy  the  pericardium  was  found  full  of 
blood  clot,  and  in  the  anterior  wall  of  the  left  ventricle — 
near  the  apex — was  an  aneurysm  the  size  of  a walnut,  which 
had  ruptured.  The  valves  and  aorta  were  healthy,  but  the 
microscope  showed  degeneration  of  the  myocardium  in  the 
area  of  the  aneurysm  and  fatty  degeneration  of  the  whole 
heart  wall.  The  other  organs  were  healthy,  and  there  was 
no  evidence  of  syphilis. 

Account  of  a Case. 

The  case  under  my  care  is  not  less  remarkable. 

The  patient,  aged 60,  was  married  at  36 ; three  children,  all 
grown  up.  Pale  complexion  which  made  her  look  somewhat 
fragile,  but  with  a wonderful  record  of  health  ; could  not 
remember  ever  having  been  ill.  Cheerful  disposition.  Very 
active  worker  at  home  and  abroad.  Good  walker:  could 
take  a 20-mile  walk,  and  go  up  the  hills  as  fast  as  her 
daughters.  This  record  ceased  on  Sunday  morning,  Sept.  8th, 
1918,  when  after  breakfast,  for  the  first  time  in  her  life,  she 
felt  somewhat  sick.  However,  she  went  to  church — a mile 
walk,  mostly  uphill— and  ate  the  usual  substantial  meal  on 
her  return.  At  2 p.m.  some  visitors  turned  up.  She  enter- 
tained them,  but  was  glad  when  they  departed  at  3.30  a3  she 
then  felt  sick  and  ill  and  said  she  would  go  to  bed.  At  3.45  I 
received  a message  from  her  husband  asking  me  to  see  her 
at  once,  and  I went  at  once. 

I found  her  sitting  up  in  bed,  complaining  of  a pain 
behind  the  sternum,  and  of  nausea.  Almost  immediately 
she  was  violently  sick  and  vomited  her  undigested  meal. 
She  then  said  she  felt  better  and  laid  down,  but  the  nausea 
continued  and  she  still  felt  some  pain.  Her  pulse  was 
regular — about  75 — and  the  heart  sounds  normal.  I con- 
cluded it  was  a gastric  attack,  and  that  she  must  have 
eaten  something  that  had  disagreed.  At  7 p.m.  I telephoned 
and  heard  that  she  was  better,  but  still  retching  from  time 
to  time.  Later  she  told  her  husband,  who  is  a somewhat 
restless  sleeper,  that  she  thought  she  would  sleep  better 
alone.  He  consequently  leftherat  about  11  p.m.  and  sleptin 
the  adjoining  room.  At  4.30  he  awoke  and  heard  her 
“coughing.”  He  went  into  her  room  and  found  her  sitting 
up  in  bed,  with  a basin  in  her  hands,  endeavouring  to  vomit. 
Hardly  had  he  reached  her  side  when  she  gave  a gasp  and 
fell  back  dead.  At  4.45  a.m.  (Monday,  Sept.  9th)  my  tele- 
phone woke  me  up,  and  I was  informed  that  she  was  dead. 
I was  at  the  house  before  5.30,  when  I learned  the  history  of 
the  night,  and  made  sure  that  life  was  extinct. 

Necropsy.— In  the  afternoon  of  the  same  day  I made  a 
post-mortem  examination.  The  abdominal  contents  were 
normal,  and  in  the  thorax  attention  was  immediately  centred 
on  the  bulging  pericardium.  On  puncturing  it  blood  gushed 
out,  and  the  sac  was  found  to  be  full  of  blood,  partly  liquid 
and  partly  clotted.  The  heart  itself  was  small, and  the  walls 
rather  thin  and  pale.  On  the  surface  of  the  left  ventricle, 
about  an  inch  above  the  apex,  was  a dark  circular  patch 
rather  'smaller  than  a shilling,  with  a small  rent  in  the 
centre.  On  section,  the  patch  proved  to  be  a collapsed 
aneurysmal  dilatation ; the  central  portion,  where  the 
rupture  had  taken  place,  was  hardly  thicker  than  brown 
paper.  The  obvious  difference  in  colour  and  texture  of  the 
aneurysm  from  that  of  the  rest  of  the  ventricular  wall 
seemed  conclusive  evidence  that  the  lesion  was  one  of  old 
standing.  In  other  respects  the  heart  appeared  normal.  No 
microscopical  examination  was  made. 

I presume  that  what  occurred  on  the  Sunday  was  a pin- 
hole perforation,  allowing  of  the  oozing  of  droplets  of  blood 
into  the  pericardium,  thus  occasioning  widespread  vagal 
disturbance,  and  that  the  larger  rent  took  place  just  before 
death. 

The  occurrence  of  such  cases  is  valuable  evidence  of  the 
astonishing  capacity  of  some  badly  damaged  hearts,  and  it 
is  surely  fortunate  that  these  conditions  cannot  be  diagnosed. 
Both  of  these  patients  lived  useful  lives  to  the  very  end.  As 


3 The  Lancet,  1914,  i.,  533. 


200  Thb  Lancet,] 


MR.  H.  W.  TURNER  : FLAVINE  IN  JAW  FRACTURES,  ETO. 


[August  2,  1919 


the  lesion  could  not  have  been  cured,  any  extra  lease  of  life 
secured  by  rigid  limitation  of  effort  would  have  been  dearly 
purchased  at  the  price  of  invalidism,  coupled  by  continual 
apprehension. 

Tunbridge  Wells. 


FLAVINE  IN  THE  TREATMENT  OF  COM- 
MINUTED FRACTURES  OF  THE  JAWS 
AND  ACUTE  SEPTIC  STOMATITIS. 

By  H.  WATSON  TURNER,  M.R  C.S.,  L.D.S., 

DENTAL  SURGEON  TO  THE  MIDDLESEX  HOSPITAL. 


The  treatment  of  fractures  of  the  jaws  due  to  shrapnel  or 
gunshot  presents  a complicated  problem,  special  difficulties 
being  extensive  comminution  of  bone  and  laceration  of  soft 
tissues,  and  the  high  degree  of  septic  infection.  Provided 
the  patients  came  under  treatment  before  extensive  necrosis 
of  bone  had  occurred — i.e.,  not  later  than  seven  to  ten  days 
after  injury— the  results  have  been  highly  favourable  in  many 
cases  with  very  severe  damage  and  infection.  I attribute 
my  success  in  great  part  to  the  use  of  flavine,  which  has 
been  shown  to  possess  powerful  antiseptic  action  in  dilutions 
relatively  harmless  to  tissue  elements. 

Method  of  Treatment. 

The  following  method  was  adopted  as  a general  practice. 
After  the  patient  had  been  anassthetised  a tube  was  passed 
into  the  larynx  and  the  anaesthetic  administered  by  means  of 
it ; the  throat  being  plugged  with  gauze  there  was  no  possi- 
bility of  foreign  bodies  passing  downward.  Teeth  in  the 
lines  of  fracture  were  removed  wherever  possible,  and  also 
every  septic  tooth  and  root.  In  dealing  with  fractured  bone 
where  comminution  was  extensive,  it  was  impossible  to  decide 
which  fragments  were  viable  and  which  were  necrotic. 
Accordingly  I made  a rule  to  leave  all  bony  fragments 
undisturbed  and  to  bathe  and  soak  the  whole  fractured  area 
for  five  to  ten  minutes  with  1 : 1000  flavine  solution,  disturb- 
ing the  parts  as  little  as  possible,  so  as  to  avoid  mechanical 
injury  to  tissues  already  devitalised.  The  external  wound 
was  cleansed  with  flavine  solution  and  dressed  with  gauze 
soakei  in  flavine,  which  was  also  used  to  pack  lightly  any 
sinuses.  In  fractured  mandible  the  jaw  was  supported  with 
a knitted  chin  support.  Subsequent  to  this  the  treatment 
followed  on  the  usual  lines  ; cap-splints  were  fitted  to  maxilla 
and  mandible  and  were  wired  together.  Cleanliness  of  the 
mouth  was  ensured  by  frequent  syringing. 

I am  convinced  that  the  favourable  results  were  largely 
due  to  the  early  treatment  with  flavine,  which,  hastening 
the  extinction  of  septic  infection,  yet  left  unimpaired  the 
vitality  of  the  osteogenetic  tissue.  Had  the  living  bone  been 
destroyed  in  the  course  of  treatment  such  complete  bony 
union  as  occurred  in  these  cases  could  not  have  been 
obtained. 

Illustrative  Cases. 

The  following  notes  indicate  the  results  in  two  particularly 
severe  cases  : — 

Case  1. — -Pte.,  admitted  Sept.  3rd,  1918.  The  X ray  photo- 
graph showed  very  extensive  comminution  of  bone;  there 
was  much  destruction  of  soft  tissues  and  profuse  suppura- 
tion. After  treatment  on  the  lines  described  there  was 
practically  reconstruction  of  the  mandible,  as  shown  in  a 
photograph  taken  on  March  25th,  1919. 

Case  2. — Australian  Lt.  There  was  a fracture  of  the  right 
maxilla  with  involvement  of  the  antrum,  which  was  filled 
with  pus.  The  soft  palate  was  badly  lacerated,  and  the  hard 
palate  extensively  comminuted;  the  mouth  was  very  foul. 
The  parts  were  cleansed  with  flavine  and  the  antrum  washed 
out  with  the  solution,  then  all  the  soft  tissues  were  soaked 
with  flavine  ; all  broken  teeth  were  removed.  At  the  close 
of  the  operation  the  soft  palate  was  stitched  up.  It  is  to  be 
specially  noted  that  although  the  wound  was  completely 
closed,  and  no  provision  was  made  for  drainage,  the  parts 
healed  excellently  and  there  was  no  recrudescence  of  sepsis. 

Acute  Stomatitis. 

The  frequency  of  acute  stomatitis  of  all  degrees  up  to 
actual  gangrene  has  been  a striking  feature  among  soldiers. 
These  acute  infections  were  usually  superadded  on  a chronic 
septic  condition  of  the  mouth.  When  such  cases  first  come 
under  observation  the  gums  are  exceedingly  tender  and 
painful,  and  there  is  often  extensive  sloughing  and  an 
exceedingly  foul  odour.  It  is  essential  to  get  rid  of  the 


acute  inflammation  before  instituting  thorough  operative 
measures. 

The  following  method  of  preliminary  treatment  has  yielded 
excellent  and  rapid  results : — The  mouth  is  syringed  out 
with  flavine  1 : 1000,  special  attention  beiDg  paid  to  all 
pockets.  Then  gauze  soaked  with  flavine  solution  is  lightly 
packed  into  the  angle  of  the  cheek  and  all  round  the  gums, 
and  is  retained  in  the  mouth  for  20  to  30  minutes.  This 
procedure  is  repeated  thrice  daily. 

As  regards  the  results,  not  merely  is  the  application  pain- 
less, but  it  leads  quickly  to  relief  of  pain  and  to  subsidence 
of  the  acute  inflammatory  condition.  Further,  in  several 
cases  where  the  mouth  was  so  foul  that  one  could  readily 
detect  the  bad  odour  at  a distance  of  several  yards,  24  hours 
after  commencing  treatment  with  flavine  the  breath  has 
become  quite  free  from  smell. 


Clinical  Itotcs: 

MEDICAL,  SURGICAL,  OBSTETRICAL,  AND 
THERAPEUTICAL. 

« 

THE  USE  OF  BISMUTH  AND  IODOFORM  IN 
THE  TREATMENT  OF  CHRONIC  SUPPURA- 
TIVE OTITIS  MEDIA. 

By  Feed.  Stoker,  M.B.  Durh.,  F.R.C.S.  Edin., 

AURAL  SURGEON  TO  THE  NATIONAL  INSTITUTE  FOR  THE  BLIND,  AND  TO 
THE  ACTON  EDUCATION  COMMITTEE;  REGISTRAR.  HOSPITAL  FOR 
DISEASES  OF  THE  THROAT,  GOLDEN-SQUARE. 


Early  in  1916  I was  introduced  to  the  merits  of  bipp1 
by  its  inventor,  Professor  Rutherford  Morison.  The  results 
he  was  attaining  by  its  use  in  bone  surgery  impressed  me  very 
greatly,  and  I put  into  operation  his  suggestion  of  using  it  in 
mastoid  work.  The  sequel  more  than  j ustified  our  expecta- 
tions, and  encouraged  me  to  use  a powder  of  bismuth  and 
iodoform  in  the  same  proportions  as  in  bipp  in  certain 
cases  of  chronic  ear  suppuration. 

Types. — Chronic  ear  suppuration  may  be  divided  roughly 
into  the  following  types  : 1.  Those  in  which  the  suppuration 
is  not  confined  to  the  tympanum,  but  has  extended  to  the 
mastoid  or  the  labyrinth.  Although  in  acute  suppuration 
the  whole  middle  ear  cleft  is  generally  involved,  this  by  no 
means  holds  good  in  the  chronic  stage.  It  is  a common 
experience  to  observe  the  relief  of  mastoid  pain  and  tender- 
ness after  tympanic  drainage  is  established  in  acute  cases, 
and  it  is  equally  common  to  open  a healthy  mastoid  antrum 
when  operating  for  the  cure  of  chronic  suppuration. 
2.  Cases  in  which  naso-pharyngeal  or  tubal  sepsis  is 
responsible  for  the  continuance  of  the  suppuration.  3.  Those 
in  which  the  bony  tympanum  is  carious.  4.  Those  in  which 
the  suppuration  is  limited  to  the  mucous  tympanum. 

It  is  only  in  cases  belonging  to  the  last  group  that  cure 
may  be  hoped  for  by  local  conservative  measures,  but  such 
cases  are  extremely  common.  The  usual  method  of  treating 
them  with  syringing,  mopping,  “ drops, ”&c. , is  discouraging. 
One  is  so  completely  at  the  mercy  of  the  patient’s  attendants, 
and  the  eSect  of  the  “ drops,”  even  when  they  are  correctly 
instilled,  is  so  transitory,  that  it  is  difficult  to  expect  a cure. 
The  use  of  “ bip  ” 2 to  a great  measure  removes  these 
handicaps. 

Technique. — 1.  Establishment  and  maintenance  of  thorough 
drainage.  In  the  generality  of  cases  that  is  already  present, 
very  many  “ chronic  ears  ” presenting  but  a rim  of  membrane 
or  even  none  at  all.  2.  Removal  of  crusts,  dead  epithelium, 
and  all  morbid  material  with  hydrogen  peroxide.  3.  Thorough 
cleansing  of  meatus  and  tympanum  with  spirit,  applied  on  a 
wool-carrying  applicator,  and  allowing  to  dry.  4.  Covering 
the  tympanum  with  bip.  The  powder  is  blown  in  with  a 
fine-pointed,  slightly  curved,  powder-blower  through  a large 
speculum.  In  cases  with  profuse  suppuration  I have  not 
found  that  more  than  three  applications  a week  are 
necessary,  and  in  milder  ones  a weekly  application  fulfils 


1 Bismuth,  iodoform,  and  paraffin  paste,  containing  bismuth  and 
iodoform  in  the  proportions  of  1 of  bismuth  to  2 of  iodoform. 

- Bismuth  and  iodoform  powder. 


The  Lancet,] 


CLINICAL  NOTES. 


[August  2, 1919  201 


requirements.  As  the  suppuration  lessens  the  need  for 
frequent  sittings  diminishes,  of  course. 

Results. — I have  treated  well  over  200  cases  on  these  lines, 
and  while  100  per  cent,  of  cures  cannot  be  claimed,  the 
results  have,  in  the  great  majority  of  cases,  been  so  satis- 
factory as  to  justify  my  recommending  the  method.  The 
curative  effects  may  be  attributed  to  two  causes : 1.  The 

continual  antiseptic  action  of  the  nascent  iodine,  which  is 
being  constantly  formed  from  the  iodoform.  2.  The  preven- 
tion of  putrefaction  in  accumulated  secretions  by  the  same 
agency.  The  factor  of  putrefaction  is  an  extremely  important 
one  in  chronic  suppuration. 

Long  duration  of  the  condition  is  no  bar  to  success. 
Many  of  the  cases  successfully  treated  have  suffered  seven 
and  eight  years.  The  presence  of  a polypus  need  not  always 
cause  dismay  ; it  is  not  conclusive  evidence  of  bone  disease, 
but  its  removal  is  necessary  before  thorough  treatment  can 
commence. 

Queen  Anne- street,  W. 

A NOTE  ON 

DUPLICATION  IN  HUMAN  SPERMATOZOA. 

By  S.  R.  Tattersall,  M.R.C.S.,  L.R.C.P. 

In  spermatozoa  from  certain  of  the  lower  animals  partial 
doubling  of  the  tail  has  been  described  as  an  occasional 
occurrence  ; but  similar  observations  in  the  human  subject 
seem  to  be  at  present  wanting.  In  the  case  to  which  this 
note  refers,  the  patient  was  a man,  25  years  of  age,  suffering 
from  spermatorrhoea.  The  microscopic  examination  was  made 
upon  films  fixed  by  heat  and  stained  for  ten  minutes  in  hot 
carbol-fuchsin.  This  was  found  to  stain  the  tails  of  the 
spermatozoa  extremely  well,  but  at  the  expense  of  some 
detail  in  the  head  and  middle  part. 

The  greater  number  of  the  spermatozoa  are  normal,  but  in 
a few  instances  one  head  is  furnished  with  two  distinct  tails. 
The  tails  are  quite  separate  and  distinct  as  far  forwards  as 
the  posterior  end  of  the  middle  part,  with  which  they  join. 
The  position  of  the  two  tails  varies  widely.  Some  lie  close 
together,  while  others  diverge  at  varying  angles.  The 


I 


Human  spermatozoa,  showing  two-headed  and  two-tailed  varieties. 

1/12  in.  oil-immersion.  (Figure  reduced.) 

possibility  of  two  heads  and  middle  parts  overlying  each 
other  has  to  be  excluded,  but  the  head-cap  of  the  two- 
tailed  forms  is  not  less  translucent  than  the  head-cap  of 
normal  sperms.  In  each  case  the  middle-piece  is  not 
increased  in  thickness.  The  tails  have  been  of  equal 
length  with  the  exception  of  one  sperm,  where  they  differ 
markedly.  The  proportion  of  two-tailed  to  normal  sperms  is 
estimated  at  about  1 : 750.  Those  sperms  which  have  been 
observed  have  all  been  in  thin  parts  of  the  film  where  con- 
fusion with  the  tails  of  neighbouring  spermatozoa  may  be 
with  certainty  excluded. 

A second  type  of  abnormality  was  also  observed.  One 
or  two  spermatozoa  were  furnished  with  two  heads  and 
one  tail.  The  angle  made  by  the  axes  of  the  heads  varied 
from  about  60°  to  about  170°.  They  are  much  less 


frequent  than  the  first  type  described,  the  estimated  ratio 
to  normal  spermatozoa  being  about  1 : 5000.  In  a few  of 
these  two-headed  spermatozoa  the  middle  part  appears  of 
normal  thickness,  but  in  many  it  is  slightly  thicker,  though 
not  denser  than  that  of  the  normal  spermatozoon.  The 
genuineness  of  this  type  is,  however,  not  indisputable. 
Several  instances  have  been  observed  where  with  divergent 
ljeads,  the  middle  parts  and  tails  have  adhered  very  closely, 
indeed  diverging  only  for  about  the  last  eighth  of  their 
length.  Although  these  latter  are  probably  spermatozoa 
adherent  to  one  another,  the  possibility  of  their  being  fused 
by  the  middle  part  may  be  borne  in  mind. 

No  abnormality  has  been  found  in  the  sexual  history 
of  the  man’s  family.  There  has  not  been  a marked 
preponderance  of  one  sex  among  the  children  born,  nor  has 
there  been  an  instance  of  twins  or  abnormal  children  for 
two  generations  back.  The  drawings  were  made  under 
Professor  Shattock’s  supervision,  and  he  informs  me  that  the 
occurrence  of  two-headed  spermatozoa  in  the  seminal  fluid 
of  man  was  recorded  by  Major  F.  Smith  in  the  Journal  of 
the  Royal  Army  Medical  Corps  (Vol.  XI.,  1908),  though 
without  either  particulars  or  drawings : the  individual  is 
stated  to  have  regularly  procreated  twins. 

Schafer  1 states  that  in  animals  the  extremity  of  the  tail 
may  be  split  into  two  or  three  fibrils,  which  can  sometimes 
be  traced  along  the  whole  length  of  the  tail.  The  drawings 
accompanying  this  communication  were  made  with  a 1/12  in. 
oil-immersion  objective,  and  a 10  x eyepiece. 

Since  the  above  observation  was  made  I have  found  similar 
two-tailed  forms  in  the  fluid  from  a spermatocele.  The 
opalescent  fluid,  which  contained  great  numbers  of  sperma- 
tozoa, was  diluted  from  normal  saline,  and  from  this 
preparations  were  made  as  above  described. 

St.  Thomas's  Hospital. 


CASE  OF  SMALL  POX  SIMULATING  ACUTE 
APPENDICITIS. 

By  J.  K.  Haworth,  M.D.,  B.S.  Durh., 

CAPTAIN,  R.A.M.C.  (S.R.)  ; SURGICAL  SPECIALIST,  8TH  LUCKNOW 
DIVISION. 


The  following  case  of  small-pox  appears  to  illustrate  the 
difficulties  of  diagnosis  in  acute  appendicitis. 

Mrs. was  admitted  at  10.30  p.m.  to  Family  Hospital, 

Lucknow,  complaining  of  acute  pain  in  her  right  side,  with 
vomiting  and  fever — the  Murphy  sequence.  Her  history 
was  that  she  had  been  unwell  for  three  days,  but  only  on  the 
day  of  admission  had  she  thought  it  necessary  to  call  in 
medical  advice.  On  admission  she  was  in  great  pain, 
temperature  104-6°  F.,  pulse  100,  with  vomitiDg.  The  rate  of 
breathing  was  slightly  increased.  Her  abdomen  was  not 
distended  ; she  was  very  tender  over  the  appendix  area,  with 
only  slight  rigidity.  Chest  normal.  The  case  at  first  appeared 
one  of  acute  appendicitis,  but  it  was  decided,  not  without 
considerable  anxiety,  to  delay  operation  till  next  morning,  as 
her  general  condition  and  abdominal  signs  did  not  seem 
quite  to  agree.  Next  morning  she  developed  a typical  small- 
pox rash  with  some  haemorrhagic  spots.  Her  temperature 
dropped.  The  pain  disappeared  and  the  course  of  disease 
was  uneventful  to  recovery. 

In  striking  contrast  to  this  case  on  the  next  day  a patient 
in  hospital  developed  almost  exactly  similar  symptoms  and 
was  operated  on  in  less  than  12  hours  from  his  first  attack  of 
pain,  and  a black  gangrenous  appendix  was  removed. 


1 Essentials  of  Histology,  1914,  p.  389. 


A Psychiatric  Clinic  for  Cardiff. — A con- 
ference was  recently  held  at  the  City  Hall,  Cardiff,  attended 
by  Sir  William  Byrne  and  Dr.  C.  H.  Bond,  on  behalf  of  the 
Board  of  Control,  at  which  the  setting  up  of  an  in-  and  out- 
patient department  for  early  mental  cases  in  connexion  with 
King  Edward  VII. ’s  Hospital  was  fully  discussed.  The 
proposal  is,  in  the  first  instance,  for  a psychiatric  clinic  of 
50  beds  within  convenient  reach  of  the  infirmary,  with 
facilities  for  special  examination  and  psychotherapy,  as  well 
as  lecture  rooms  and  laboratories.  The  out-patient  depart- 
ment, it  is  expected,  will  be  located  at  the  King  Edward  VII. ’s 
Hospital.  Sir  William  Byrne,  in  expressing  the  sympathy  of 
the  Board  of  Control  with  the  scheme,  outlined  the  main 
features  of  the  amending  Bill  to  the  Lunacy  Acts,  the  draft 
of  which  is  now  being  considered  by  the  Government. 


‘202  The  Lancet,] 


REVIEWS  AND  NOTICES  OF  BOOKS. 


[August  2,  1919 


ait&  Dtoticw  at  ^oofes. 


The  Story  of  English  Public  Health.  By  Sir  Malcolm 
Morris,  K.O.V.O.  Pp.  166.  Infant  and,  Young  Child 
Welfare.  By  Harold  Scurfield,  M.D.  Edin.,  D.P.H. 
Camb.  Pp.  166.  Food  and  Public  Health.  By  William 
G.  Savage,  B.Sc.,  M.D.  Lond.,  D.P.H.  Pp.  156. 
Housing  and  Public  Health.  By  John  Robertson, 
C.M.G.,  O.B.E  , M.D.,  B.Sc.  Pp.  159.  The  Welfare  of 
the  Exoeotant  Mother.  By  Mary  Scharlieb,  C.B.E., 
M.D.,M.S.  Pp.  152.  (English  Public  Health  Series,  edited 
by  Sir  Malcolm  Morris.)  London:  Cassell  and  Co., 
Ltd.  5s.  each  volume. 

The  editor  and  the  publishers  are  to  be  congratulated 
upon  the  timely  appearance  of  this  series  of  books  dealing 
with  the  present  problems  of  public  health.  It  is  designed 
especially  to  meet  the  needs  of  members  of  local  authorities, 
district  nurses,  health  visitors,  and  the  lay  public  generally 
in  so  far  as  this  public  is  interested  in  its  own  welfare.  We 
hipe  that  where  that  interest  is  lacking  these  b >oks  will  do 
much  to  supply  the  want,  for  legislation  can  never  be  effec- 
tive in  public  health  unless  it  is  supported  by  an  intelligent 
body  of  opinion. 

Sir  Malcolm  Morris,  who  also  edits  the  series,  is  responsible 
for  the  first  volume— a short  history  of  the  growth  of  the 
public  health  movement  from  the  work  of  Edwin  Chadwick, 
which  culminated  in  the  passing  of  the  Public  Health  Act  of 
1848  down  to  the  establishment  of  the  Ministry  of  Health. 
The  functions  of  the  principal  central  health  authorities  in  the 
old  regime  are  dealt  with  serially  ; two  chapters  are  devoted 
to  the  questions  opened  up  in  recent  years  by  discoveries  of 
the  nature  of  the  infections  and  the  spread  of  venereal  disease, 
and  finally  the  Ministry  of  Health  is  invoked  to  embrace 
all  the  measures  taken  by  old  authorities  as  well  as  to  deal 
with  the  new  problems  as  they  arise. 

The  welfare  of  the  infant  is  viewed  by  Dr.  Scurfield  from 
a very  broad  standpoint,  and  is  exactly  the  kind  of  writing 
which  is  most  needed.  In  his  introduction  he  reviews  the 
doctrine  of  the  survival  of  the  fittest  as  becomes  a disciple 
of  Benjamin  Kidd,  and  wonders  how  many  useful  citizens 
the  Spartan  Council  of  Elders  ordered  to  be  thrown  down 
the  cavern  of  Mount  Taygetus.  If  we  are  to  assist  in  the 
survival  of  the  fittest  it  must  not  be  by  neglecting  the  weak, 
but  rather  by  paying  attention  to  eugenics.  Dr.  Scurfield 
recognises  the  limitations  necessary  to  the  application  of 
this  science,  but  does  powerfully  plead  for  some  endeavour 
to  prevent  the  marriages  of  syphilitics,  epileptics,  alcoholics, 
mental  defectives,  and  persons  suffering  from  an  infectious 
stage  of  tuberculosis.  From  its  heritage  the  writer  passes 
to  a consideration  of  the  baby’s  environment,  and  thence  to 
a very  practical  review  of  the  details  which  make  its  life  worth 
living.  This  is  a volume  which  every  mother  and  every 
intending  mother  ought  to  study. 

When  the  second  edition  of  “ Food'  and  the  Public 
Health  ” comes  to  be  published  it  is  reasonable  to  suppose 
that  a great  deal  of  new  matter  will  have  to  be  introduced 
into  the  first  chapter.  In  the  present  edition  the  food 
constituents  are  classified  and  the  common  foods  are  con- 
sidered as  regards  their  caloric  value  and  digestibility.  But 
the  newer  knowledge  acquired  during  the  war  of  the  effects 
of  certain  foods  in  counteracting  fatigue  and  the  results  of  the 
deprivation  of  others  through  war  conditions — all  this  is 
perhaps  not  yet  sufficiently  crystallised  to  find  expression  in 
popular  language.  The  remaining  chapters  deal  mainly  with 
the  adulteration  and  infection  of  food,  and  are  illustrated 
by  half-tone  plates. 

Dr.  John  Robertson  writes  as  one  having  authority,  for  he 
depends  mainly  upon  his  own  experience  as  a medical  officer 
of  health  in  one  of  our  most  crowded  cities,  and  quotes  but 
seldom  from  the  works  of  others,  though  a useful  little 
bibliography  is  apoended.  The  bad  housing  of  the  past  was 
due  to  poverty.  Never  again,  says  Dr.  Robertson,  must  the 
labourer  be  allowed  to  suit  the  house  to  his  wage.  Public 
attention  has  already  been  closely  focussed  upon  the  evils 
attendant  on  bad  housing,  and  it  is  a relief,  therefore,  to 
find  that  the  scope  of  this  book  is  almost  entirely  con- 
structive. The  minimal  standard  for  a dwelling-house  as 
laid  down  by  the  author  is  certainly  not  too  high,  he  writes 
as  a practical  man  rather  than  as  a seer,  and  in  our  opinion 
his  plea  for  the  use  of  electrical  labour-saving  devices  is 
almost  too  apologe1  ic. 


The  welfare  both  of  the  expectant  mother  and  of  her  child 
depends  to  a very  great  extent  upon  the  care  devoted  to 
them  in  the  antenatal  period,  and  the  first  step  towards  or 
diminution  of  the  risks  incurred  by  both  is,  as  Dr.  Scharlieb 
says,  in  the  direction  of  popular  education.  Dr.  Scharlieb 
has  long  practised  what  she  preaches,  and  the  gravamen  of 
this  book  has  formed  the  substance  of  her  writings  and 
lectures  for  many  years.  All  the  popular  aspects  of 
pregnancy,  with  its  demands  and  its  dangers,  are  dealt  with 
in  her  usual  incisive  style.  She  pleads  for  a larger  number 
of  midwives,  increased  hospital  accommodation,  and  the 
multiplication  of  welfare  centres,  and  recommends  that 
facilities  be  increased  for  the  investigation  of  the  causes 
leading  to  antenatal  death.  A scheme  for  the  endowment 
of  motherhood  is  also  on  her  list  of  desirable  reforms. 

We  have  said  that  these  books  are  intended  for  lay  readers, 
but  there  is  no  doubt  that  they  will  also  prove  of  interest  to 
many  medical  men. 

Anaphylaxis  and  Anti- anaphylaxis.  By  A.  Besredka.  With 
a preface  by  E.  Roux.  English  edition  by  S.  Roodhouse 
Gloyne.  M.  D.  London  : W.  Heinemann.  1919. 

Pp.  143.  6s. 

If  any  reader  considers  anaphylaxis  to  be  a dull  topic  he 
should  read  this  gay  account  by  one  who  has  been  in  the 
thick  of  its  experimental  investigation  almost  from  the  first. 
And  anyone  who  thinks  it  a difficult  subject  may  do  the 
same,  for  the  exposition  is  forcible  and  for  the  most  part 
clear  enough,  the  whole  finding  an  admirable  summary  in  the 
preface  by  Roux.  It  is  some  17  years  since  Richet  had  the 
idle  curiosity  to  call  in  the  dog  Neptune  to  help  with  the 
poisonousness  of  his  extracts  of  sea-anemones,  and — which 
is  the  basis  of  most  great  discoveries — the  wit  to  see  that  he 
had  found  out  something  more  than  that  experiments  do  not 
always  come  off.  Arthus  made  further  progress,  though  it 
was  not  till  Rosenau  and  Anderson  brought  “ Richet’s 
phenomenon  ” into  the  restricted  field  of  pathological 
vision  by  using  the  familiar  serum-guinea-pig  apparatus 
that  the  stream  of  inquiry  fairly  began  to  flow,  and 
finally  almost  flooded  us  out.  Besredka  takes  the 
phenomena  seen  with  egg-white,  serum,  &c.,  and  the  guinea- 
pig  as  typical,  and  describes  in  order  the  circumstances  of 
sensitisation  by  a first  injection,  of  exciting  anaphylactic 
shock  by  a second  injection,  of  desensitisation  by  a vaccinat- 
ing or  anti-anaphylactic  injection,  and  finally  discusses  the 
theory  of  the  whole  business.  The  view  he  takes  is  that 
now  pretty  generally  admitted : the  first  injection  of  a 
proteid  causes  the  production  by  the  recipient  aninul  of  an 
antibody,  which  he  frankly  assumes  without  clear  evidence 
to  be  a special  “anaphylactic  antibody.”  The  second 
injection,  given  after  an  interval  in  which  this  “ sensibilisin  ” t 
accumulates,  either  in  large  amount,  or  in  curious  places,  or 
in  both,  reacts  as  any  antigen  will  with  its  antibody,  and, 
either  by  the  violence  of  this  reaction  or  on  account  of  the 
place  where  it  occurs,  general  symptoms  of  greater  or  less 
severity  ensue.  These  symptoms  may  be  avoided  if,  quite 
shortly  before  the  second  injection,  a small  dose  of  the  antigen 
is  given,  and  Besredka  points  out  at  some  length  how  easily 
the  anaphylactic  troubles  of  serum  therapy  may  be  minimised 
by  his  method  of  small  preparatory  injections  of  serum 
preceding  the  main  therapeutic  dose  by  10  minutes  to  3 or  4 
hours,  according  to  the  route  of  administration.  The  | 
method  seems  to  deserve  special  consideration  now  that,  e.g., 
meningitis  and  pneumonia  are  being  treated  with  doses  of  j 
serum  undreamed  of  a few  years  ago. 

With  regard  to  the  mechanism  of  production  of  anaphy- 
lactic shock,  the  author  will  have  none  of  Friedberger  and 
the  anaphylotoxin  he  has  so  profusely  propagated.  He  says, 
indeed,  bluntly  that  there  is  no  anaphylactic  poison  ; that 
the  union  of  antigen  and  antibody  results  in  a harmless  i 
complex,  and  that  the  disturbance  is  produced  by  the  anti-  I 
body  becoming  attached  to,  and  so  enabling  the  antigeD  to  ! 
penetrate,  certain  nerve  cells.  Here  he  is  vague.  The 
question  at  issue  seems  to  be  not  whether  there  is  a poison 
or  not — unless  the  cellular  injury  which  objectively  occurs  is 
mechanical  in  origin  there  must  be  something  somewhere  I 
which  might  be  called  a poison — but  whether  the  reaction 
which  results  in  the  shock  takes  place  in  the  fluids  of  the 
body  or  inside  the  cells.  Friedberger  would  say  that  the  { 
combination  of  antigen  and  antibody  in  humore  gives  a 
poison,  Besredka  that  it  upsets  cells  because  it  takes  place 
inside  them.  The  two  views  are  not  necessarily  mutually 
exclusive  ; both  parties  are.  as  usual,  probably  more  or  less 


The  Lancet,] 


REVIEWS  AND  NOTICES  OF  BOOKS. 


[August  2,  1919  203 


right,  and  likely  the  truth  is  that  the  reaction  takes  place 
inside  cells,  and  on  thataccount  liberates  poisonous  substances 
which  may  act  generally  as  well  as  locally. 

A good  many  details  are  naturally,  and  commendably, 
left  unnoticed  ; some  of  the  more  important  recent  advances 
are  described  in  a supplementary  chapter  by  Dr.  S.  R. 
Gloyne.  The  enthusiasm  of  the  narrative  leads  to  a few 
statements  which  can  hardly  be  taken  at  their  face  value 
— e.g.,  that  passive  anaphylaxis  takes  place  “instan- 
taneously.” There  is  a sad  misprint  on  p.  18,  where,  at  its 
definition,  sensibilisin  is  called  sensibiligen.  Neither  the 
title-page  nor  prelace  is  dated. 

Mammalian  Physiology : A Course  of  Practical  Exercises. 

By  0.  S.  Sherrington,  M.D.,  D.Sc.,  F.R.S.,  Waynflete 

Professor  of  Physiology  in  the  University  of  Oxford. 

Oxford  : At  the  Clarendon  Press.  1919.  Pp.  156. 

Professor  Sherrington,  recognising  the  fact  that  a certain 
broadening  of  scope  of  the  practical  work  customary  for 
students  in  animal  physiology  is  desirable,  has  in  this 
manual  given  an  admirable  response  to  this  desire.  The 
work  is  correctly  described  as  a course  of  practical  exercises 
in  mammalian  physiology,  the  emphasis  being  on  the  word 
mammalian.  In  most  medical  schools  what  is  called 
“experimental  physiology,”  as  carried  out  by  the  students 
themselves,  is  usually  confined  to  muscle-nerve  preparations 
and  the  cardiac  and  spinal  physiology  of  the  frog,  and  but 
rarely  does  the  student  make  experiments  on  a mammal — 
save  on  himself.  Professor  Sherrington  does  not  propose 
to  do  away  with  laboratory  experiments  on  the  frog. 
But  he  sees  that  there  are  other  facts  of  great  value 
and  interest,  especially  to  the  future  practitioner  of 
medicine,  which  can  be  better  displayed  and  more 
easily  obtained  in  the  mammalian  preparation,  and  thus, 
with  elaborate  detail,  describes  how  in  Oxford  for  some 
time  he  has  met  this  proposition.  Building  on  the  fact  that 
in  a decerebrate  or  decapitate  “carcase” — e.g.,  rabbit  or 
cat — the  circulatory,  glandular,  muscular,  and  simpler 
nervous  activities  remain  for  some  considerable  time,  a 
scheme  whereby  the  student  can  observe,  study,  or  record,  if 
need  be,  these  activities  became  possible  ; but  in  this  course 
the  great  fact  is  that  the  student  does  the  work  himself — it 
is  not  a question  of  a mere  demonstration  by  the  teacher — 
so  that  by  the  actual  performance  of  these  main  experiments 
he  gets  a genuine  insight  into  their  general  significance 
and  into  the  problems  they  touch.  Moreover,  the  systematic 
knowledge  acquired  from  text-books  is  vivified  as  well  as 
vitalised,  and  the  interest  in  their  studies  intensified  and 
thereby  made  a living  and  abiding  possession  of  -great 
practical  value  where  practical  work  has  actually  been  done. 

The  course  comprises  21  lessons,  each  consisting  of  some- 
what less  than  three  hours’  work.  In  each  lesson  certain 
“observations”  have  to  be  made,  and  full  details  for  these 
are  given,  the  instruction  being  greatly  aided  by  anatomical 
and  other  notes  set  forth  in  nine  plates  in  colour  admirably 
drawn  by  the  author  himself,  diagrams  of  apparatus,  and 
graphic  records  in  the  text,  reproduced  from  the  tracings 
obtained  by  the  class  students  themselves.  To  each  exercise 
is  subjoined  a short  annotation  concerning  the  source  and 
bearings  of  some  of  the  more  salient  observations  included 
in  the  exercise.  Their  trend  is  often  historical,  and  many 
references  are  given  to  publications  in  which  additional 
details  are  to  be  found.  By  way  of  showing  how  all 
these  observations  can  be  carried  out  on  the  “carcase,” 
and  how  they  can  be  so  arranged  as  to  obtain  the  maximum 
profit  from  each  animal  utilised,  an  appendix  is  added 
at  the  end  of  the  volume.  There  is  an  index  of  the  names 
of  authors  referred  to  in  the  text,  but  with  rare  modesty  the 
author  omits  his  own  name,  though  there  is  scarcely  an 
exercise  to  which  he  himself  has  not  made  some  original 
contribution. 

Ninety-five  “observations”  are  comprised  in  the  21 
“exercises.”  The  idea  of  the  extraordinary  scope  of 
the  work  done  in  about  60  hours  can  be  best  grasped 
by  a limited  epitome  of  the  main  experiments.  Given  a 
“decerebrate”  or  “ decapitate  ” carcass  of  rabbit  or  cat- 
no  dogs  are  used — the  first  exercise  comprises  the  study  and 
recording  of  intestinal  movement  and  tone,  with  the  action 
of  adrenal  extract  on  these  and  qn  the  excised  spleen 
and  arterial  wall.  The  circulation  next  is  taken  in 
hand,  comprising  revival  of  the  excised  heart  by 
coronary  perfusion  ; the  influence  of  temperature,  adrenalin, 
and  chloroform  on  the  excised  heart ; inspection  of  the  lungs, 


great  vessels,  and  the  heart  beating  in  situ  ; vagus  inhibition, 
and  effect  of  raising  the  intra-pericardial  pressure.  Then 
follow  graphic  records  of  arterial  pressure  by  the  kymograph, 
and  the  effect  on  heart  and  blood  pressure  of  stimulation  of 
the  vagus  and  spinal  cord  and  splanchnic  nerve  ; “ vagus 
escape”;  the  action  of  atropine,  adrenalin,  amyl  nitrite, 
pituitary  extract  ; asphyxia  ; artificial  aortic  stenosis  and 
insufficiency  ; time  of  the  lesser  circulation,  action  of  the 
accelerans  on  heart  rate,  and  other  cardiac  phenomena. 
Itenal  secretion,  hydrsemic  plethora,  diuresis  by  caffeine 
citrate,  effect  of  pituitary  extract,  perfusion  of  the  kidney 
with  normal  saline,  and  the  action  of  adrenal  extract  and 
amyl  nitrite  with  cognate  subjects  occupy  two  exercises. 
Next  salivary  secretion — corda  stimulation — and  the  action 
of  pilocarpine  and  atropine  are  studied.  Then  follow 
observations  on  respiratory  movement  and  allied  pheno- 
mena ; respiratory  rhythm  and  the  effect  of  nerves 
thereon  ; air-embolism,  pneumothorax,  respiratory  undula- 
tions of  blood  pressure,  and  the  various  reflexes  connected 
with  the  glottis,  and  swallowing  in  its  various  aspects. 

Pressor  and  depressor  phenomena  are  then  dealt  with,  and 
so  are  other  reflexes.  This  leads  up  to  knee-jerk  functions  of 
the  spinal  roots  and  other  spinal  phenomena,  cervical  sym- 
pathetic action,  proprioceptive  reflexes,  measurements  of 
reflex  and  twitch,  postural  tone,  and  reflex  inhibition  of 
posture  and  contracture.  Haemorrhage  and  arterial  pressure 
and  restoration  of  the  latter  by  gum-saline  injection, 
clotting,  and  fibrinogen  are  all  described.  One  exercise  is 
given  to  “washed  leucocytes,”  phagocytosis,  and  opsonic 
power  of  serum,  and  another  to  preparation  of  secretin, 
pancreatic  secretion,  and  bladder-bile.  Fortunate  indeed 
are  the  students  who  obtain  such  a compendious,  practical, 
and  vivifying  course  of  instruction  in  applied  physiol  gy. 
We  most  cordially  endorse  the  view  of  Sir  George  Newman 
that  these  exercises  are  an  illustration  of  the  kind  of 
applied  physiology  which  should  be  taught  in  all  schools  of 
physiology. 

As  was  to  be  expected,  Professor  Sherrington  has  done  his 
work  with  a master  hand.  If  we  compare  the  operative 
training  and  the  vast  amount  of  knowledge  directly  and 
personally  acquired  during  60  or  70  hours  spent  in  a well- 
equipped  physiological  laboratory  with  the  modicum  of 
anatomical  detail  acquired  during  the  same  time  in  the 
dissecting  room,  there  seems  to  us  to  be  no  doubt  as  to 
where  and  how  the  medical  student  can  most  profitably 
spend  what  after  all  represents  less  than  three  full  days 
of  his  academic  time. 

Modern  Medicine  and  Some  Modern  Remedies : Practical 

Notes  for  the  General  Practitioner.  By  Thomas  Bodley 

Scott,  M.R.C.S.  Eng.,  L.R.C.P.  Edin.  Second  edition. 

London  : H.  K.  Lewis  and  Co.,  Ltd.  1919.  Pp.  xvi. 

+ 198.  6s.  6 d. 

These  essays  were  first  reviewed  in  our  columns  in 
September,  1916.  It  is  no  surprise  to  us  that  a second 
edition  should  have  been  called  for.  Dr.  Scott  writes  in  a 
style  that  is  at  once  pleasant  to  read  and  that  carries  with 
it  the  confidence  of  the  reader,  who  feels  instinctively  that 
the  author  has  used  his  observation  not  only  at  the  bedside 
but  also  in  the  laboratory,  and  that  he  has  used  it  with  a 
shrewd  discrimination.  In  dealing  with  such  ailments  as 
heart  disease  and  chronic  bronchitis  the  general  practitioner 
learns  much  that  was  never  taught  to  him  as  a medical 
student,  and  many  who  are  setting  up  in  practice  at  the 
present  time  will  be  the  wiser  by  borrowing  from  Dr.  Scott’s 
well-stocked  store  of  common-sense. 


JOURNALS. 

Quarterly  Journal  of  Experimental  Physiology.  Editors: 
E.  Sharpey  - Schafer,  w.  D.  Halliburton,  C.  S. 
Sherrington,  E.  H.  Starling,  A.  D.  Waller.  Vol.  XII., 
No. 2.  London:  Charles  Griffin  and  Co.  1919.  Pp.  97-198. 
7s.  6 d. — Carbohydrate  Metabolism  in  Relation  to  the  Thyroid 
Gland  (IV.):  The  Effect  of  Thyroid  Feeding  on  the  Gaseous 
Metabolism  of  Thyroidectomised  Rats,  by  W.  Cramer  and 
R.  McCall.  Such  animals  react  to  thyroid  feeding  by  an 
increased  metabolism,  but  this  experimental  hypothyroidism 
shows  two  stages.  In  the  early  stage  in  which  the  meta- 
bolism is  reduced  if  thyroid  gland  is  administered  the 
metabolism  is  brought  back  to  that  of  the  normal  animal  ; 
in  this  respect  it  is  similar  to  pathological  hypothyroidism. 
In  the  later  stage  the  metabolism  is  similar  to  that  pro- 
duced in  a normal  animal  by  thyroid  feeding.  This 
result  seems  to  be  due  to  a compensatory  mechanism, 
and  does  not  really  represent  a condition  of  true  hypo- 


204  TheLavcet,] 


REVIEWS  AND  NOTICES  OF  BOOKS.— NEW  INVENTIONS. 


[August  2,  1919 


thyroidism.  The  increased  metabolism  due  to  thyroid 
feeding  occurs  also  in  the  absence  of  preformed 
carbohydrate  in  the  food.  It  appears  that  all  changes 
in  metabolism  can  be  explained  as  being  the 

result  of  disturbance  of  the  glycogenic  function.  It  is 
suggested  that  in  Graves’s  disease  a diet  rich  in  carbo- 
hydrates is  indicated  to  counteract  the  loss  of  flesh  which  is 
one  of  the  features  of  the  disease. — The  Action  of  the  Blood- 
serum  of  the  Dog  in  a Condition  of  Tetania  Parathyreopriva 
on  Voluntary  Muscular  Tissue  compared  with  that  of 
Normal  Serum,  by  B.  A.  Houssay.  Neither  of  these 
serums  causes  tremors  in  the  muscles  of  the  South  American 
frog  ( Leptodactylus  ocellatus).  Five  out  of  six  samples  of 
tetania  serum  produced  tremors  in  the  muscles  of  a toad 
(Bufo  marinus),  while  four  samples  from  normal  dogs  pro- 
duced tremors.  On  the  other  hand,  four  other  samples 
from  normal  dogs  produced  no  effect. — The  Adrenalin 
Content  of  the  Suprarenals  of  the  Female  White  Rat  and 
the  Changes  Brought  about  by  Thyroid  Feeding  and  other 
Conditions,  by  P.  T.  Herring. ' The  suprarenals  of  young 
female  white  rats  are  normally  40  per  cent,  heavier  than  the 
suprarenals  of  the  male  [animals  of  the  same  weight,  while 
the  adrenalin  content  of  the  suprarenals  of  the  female  is 
twice  as  large  as  that  in  the  male  of  the  same  size — e.g., 
average  adrenalin  in  female  0-073  mg.,  in  male  0’034  mg. 
These  differences  are  associated  with  sex  differences  in  the 
other  endocrine  glands  and  organs  of  the  body.  The  adrenalin 
content  is  increased  during  pregnancy,  but  is  not  per- 
manently altered  by  the  occurrence  of  this  condition.  The 
female  white  rat  is  less  tolerant  of  thyroid  feeding  than  the 
male;  a daily  dose  of  0-2  g.  fresh  thyroid  if  continued  is  too 
high  and  checks  the  rate  of  growth  of  the  animal.  Thyroid 
feeding  causes  a rapid  increase  in  the  weight  of  the  supra- 
renals, but  more  so  in  the  male.  The  chromaphil  tissue  of 
the  female  rat  normally  contains  a much  higher  level  of 
adrenalin  production  than  it  does  in  the  male.  The  increased 
size  of  the  suprarenals  following  on  thyroid  feeding  is 
mainly  due  to  hypertrophy  of  the  cortex.  The  percentage 
amount  of  adrenalin  is  always  diminished  by  thyroid 
feeding. — The  Effect  of  Phloridzin  on  the  Permeability  to 
Glucose  of  the  Frog’s  Glomerular  Membrane,  by  R. 
Brinkman.  The  surviving  kidneys  of  the  frog  were  perfused 
with  certain  solutions  of  known  composition — e.g.,  Ringer’s 
fluid — and  the  result  showed  that  frog’s  glomerular 
membrane  is,  under  normal  conditions,  impermeable  to 
physiological  quantities  of  glucose.  The  “urine”  obtained 
was  compared  with  the  fluid  perfused.  The  rate  of 
diuresis  had  no  influence  on  the  results.  So  far  as  glucose 
was  concerned — the  urine  obtained  always  contained  the 
percentages  of  glucose  (0-05-0T  per  cent.)  in  the  perfusing 
liquid.  Further  experiments  showed  that  the  permeability 
of  the  glomerular  membrane  is  dependent  on  the  composi- 
tion of  the  perfusing  fluid— the  concentration  of  the  free 
Ca-ions  is  the  factor  of  greatest  importance  in  this  connexion. 
If  the  Ca-ions  have  a certain  concentration  the  membrane 
shows  itself  impermeable  to  physiological  quantities 
(0-06  per  cent.)  of  glucose.  If  the  concentration  exceeded 
0 003  per  cent.  CaCD  the  membrane  became  permeable 
to  glucose.  A second  factor  is  the  preservation  of 
the  normal  slight  alkaline  reaction  of  the  perfusing 
liquid  (=  0-285  per  cent.  NaHCos)  = to  that  of  frog’s 
serum.  As  to  the  action  of  phloridzin,  it  is  known 
that  phloridzin-glycosuria  is  a renal  process,  most  investiga- 
tions finding  that  blood-sugar  is  not  increased,  it  may 
even  be  decreased — i.e.,  hvpoglyciemia.  Many  suppose 
that  this  drug  causes  the  tubuli  to  secrete  glucose.  It  was 
found  that  the  addition  of  0 0004  per  cent,  of  phloridzin  to 
the  solution  already  described  is  sufficient  to  make  the 
otherwise  impermeable  membrane  wholly  permeable  to 
physiological  quantities  of  glucose,  though  the  membrane 
is  not  influenced  by  many  other  drugs — e.g.,  atropin, 
pilocarpin,  nicotin,  narcotics.  The  concentrations  of  the 
glucose  in  the  urine  closely  follow  those  in  the  corresponding 
serums.  Phloridzinised  frogs  show  well-marked  hyper- 
glycaemia.  Phloridzin  promptly  makes  the  glomerular 
membrane  permeable  to  glucose.  In  higher  animals 
secretion  of  glucose  by  the  tubuli  is  the  dominating 
phenomenon.  — A Convenient  Method  of  Recording 
Pulmonary  Blood  Pressure,  by  Sir  Edward  Sharpey 
Schafer.  The  method  was  used  in  some  of  the  experi- 
ments described  in  the  Effects  of  Adrenalin  on  the 
Pulmonary  Circulation,  by  Sir  Edward  Sharpey  Schafer 
and  R.  K.  S.  Lim.  The  intravascular  administration 
may  produce  effects  on  the  pulmonary  circulation  by 

(1)  an  effect  on  the  pulmonary  arterioles,  causing  con- 
striction, or  in  some  cases  dilatation  of  these  vessels, 
resulting  in  a diminution  or  increase  of  the  flow  and 
a rise  or  fall  of  the  pressure  in  the  pulmonary  system  ; 

(2)  on  the  musculature  of  the  heart  through  the  sympathetic 
nerve  and  coronary  vessels  ; (3)  on  the  conducting  (Purkinje) 
fibres  under  the  endocardium ; and  (4)  indirectly  as  a con- 
sequence of  constriction  of  the  systemic  arterioles  and  great 
rise  of  the  aortic  pressure.  The  effects  produced  upon  the 
aortic  system  can  be  similarly  caused  in  four  ways.  First 
the  effects  of  perfusing  adrenalin  through  the  surviving  lung 


were  studied.  The  results  of  previous  observers  are  not  in 
accord.  In  the  rabbit  adrenalin  in  moderate  doses  injected 
into  the  jugular  vein  usually  at  first  causes  a rise  of 
pulmonary  blood  pressure,  owing  to  constriction  of  the 
jmlmonary  arterioles,  or  shows  no  effect  on  this  system. 
If  there  is  great  constriction  any  rise  in  the  pulmonary 
system  is  soon  converted  into  a fall,  gradual  recovery 
following  as  the  constriction  passes  off.  The  effects 
are  similar  when  it  is  injected  into  the  aorta  through 
the  carotid,  but  the  preliminary  rise  is  absent.  In  the 
cat  the  usual  result  is  a sharp,  well-marked  rise  in 
both  pulmonary  and  aortic  pressures — and  usually  with 
parallelism  in'  both  systems— which  must  be  of  cardiac 
origin.  In  the  dog  there  is  a great  rise  in  both  systems, 
sometimes  running  almost  parallel.  The  rise  in  the 
pulmonary  system  is  not  due  to  “ back  action  ” propagated 
from  the  aortic  system.  There  may  be  no  rise  at  all  in  the 
pulmonary,  with  great  rise  in  the  aortic  systems,  even  when 
the  aortic  pressure  is  raised  by  compression  of  the  aorta  and 
in  other  ways.  In  rabbits  the  chief  effects  of  adrenalin  upon 
both  pulmonary  and  aortic  pressures  are  produced  upon  the 
blood-vessels,  but  in  most  cats  and  dogs  the  chief  effects  are 
produced  by  the  drug  upon  the  cardiac  musculature.  The 
musculature  of  the  two  sides  of  the  heart  may  be  differently 
affected  by  adrenalin,  which  may  be  due  to  its  action  on  the 
Purkinje  network  of  the  ventricles. — The  Effect  of  Adrenalin 
on  Muscular  Fatigue  in  Leptodactylus  ocellatus  and  in 
Bufo  marinus.  By  John  Guglielmetti.  Subcutaneous  or  intra- 
venous injection  or  perfusion  produces  recovery  of  muscular 
contractions  which  have  been  abolished  by  previous  fatigue. 
Given  sufficient  doses  recovery  may  be  obtained  in  muscles 
which  have  been  wholly  exhausted.  Recovery  is  more 
usually  obtained  when  the  adrenalin  is  made  to  act  early 
upon  the  preparation. — Note  on  Strychnine  Tetanus.  By 
Arthur  R.  Cushny.  The  author’s  experiments  lead  him  to 
conclude  that  it  is  unnecessary  to  assume,  as  as  been  done, 
that  strychnine  changes  the  ordinary  coordinated  reflex, 
not  only  in  quantity,  but  also  qualitatively,  by  inducing  a 
reversal  of  inhibition  into  contraction.  Strychnine  tetanus 
is  merely  a quantitative  change  of  the  “start”  reflex  which 
occurs  under  normal  conditions. 


Itefo  Intentions. 


A VENTILATING  ETHER  BAG  MOUNT. 


The  accompanying  illustration  shows  a bag  mount  designed 
to  afford  an  inhalation  as  “open”  or  “closed,”  as  the 
administrator  may  wish.  A fits  Hewitt’s  wide-bore  inhaler 
and  face-piece.  An  Ormsby  (or  paper)  bag  is  attached  over 
the  cage  c by  a thick  rubber  band,  b opens  a window, 
simultaneously  cutting  out  the  bag  to  any  desired  extent. 
T admits  gas,  oxygen,  or  ethyl  chloride  to  the  bag,  whatever 
the  position  of  B,  and  is  removable  for  cleansing  purposes. 
r,  fixed  to  T,  is  pushed  home  into  A for  use.  Gases  can  be 
retained  in  the  bag  by  opening  B and  closing  T by  the 
stopcock  s.  This  affords  a convenient  means  of  giving 
ethyl  chloride  either  alone,  or  before  ether,  the  bag  being 


charged  before  applying  the  face-piece  and  gradually  opened 
as  the  window  at  b is  being  closed.  For  the  gas-ether 
sequence  a little  hot  water  can  be  poured  into  the  Ormsby 
through  A.  With  less  than  two  ounces  of  ether  anaesthesia 
can  then  be  induced  in  about  three  minutes,  usually 
without  appreciable  coughing  or  struggling.  Daring  the 
operation  b is  always  more  or  less  open,  so  that  with 
every  breath  the  patient  gets  some  fresh  air,  as  warm 
and  moist  as  the  anaesthetist  may  desire.  The  hot  water 
in  the  bag  can  be  easily  renewed  or  the  bag  may  float  in 
a bowl  of  hot  water.  The  mount  (and  bag)  can  be  boiled, 
there  are  no  valves  to  get  out  of  order.  By  means  of  an 
“adapter”  the  mount  may  be  adjusted  to  an  ordinary 
“Clover”  or  face-piece.  I have  used  this  apparatus  for 
brain  cases  and  abdominal  operations  of  every  kind  during 
the  last  five  years.  It  is  made  by  Messrs.  Barth. 

Beresford  Kixgsford,  M.D.  Durh., 
Anaesthetist.  University  College  Hospital,  4c. 


The  Lancet,] 


SCIENCE  AND  UNREST.  PSYCHIATRIC  CLINICS. 


[August  2,  1919  205 


THE  LANCET. 


LONDON:  SATURDAY , AUGUST  2.  1019. 


Science  and  Unrest. 

Truly  these  are  progressive  times,  when  we  find 
labour  organisations  demanding  State  aid  for 
scientific  research  on  the  ground  that  the  value 
of  scientific  advancement  to  the  welfare  of  the 
nation  is  many  times  greater  than  the  cost  of  the 
necessary  laboratory  quest.  Public  recognition  of 
this  fact  will  mean  the  era  of  a great  movement 
of  the  utmost  social  and  economical  - importance. 
When  it  is  realised  that  increased  productivity  of 
industry  results  from  scientific  research,  a powerful 
aid  will  appear  to  those  involved  in  an  ever 
increasing  struggle  to  raise  their  standard  of 
living.  In  applied  science  there  lies  a possible 
solution  of  many  disastrous  labour  problems,  and 
none  too  soon  those  who  labour  are  perceiving  it. 
Have  they  not  seen  the  truth  before  their  organisers 
or  their  employers  ? 

In  a remarkable  manifesto  on  scientific  research 
recently  drawn  up  by  the  American  Federation  of 
Labour  it  is  maintained  that  the  importance  of 
scientific  applications  in  industry  must  steadily 
increase,  since  there  is  a limit  beyond  which  the 
average  standard  of  living  of  the  whole  population 
cannot  progress  by  the  usual  methods  of  readjust- 
ment, a limit  which  can  only  be  raised,  it  is  claimed, 
by  research  in  industry.  The  wise  solution  of  the 
numerous  important  and  pressing  problems  of 
administration  and  regulation  now  facing  almost 
all  Governments  of  the  world  depends,  it  is 
suggested,  upon  scientific  and  technical  research. 
It  would  be  a remarkable  consummation  in  the 
history  of  the  world,  as  is  here  hinted,  should 
science  ultimately  prove  to  be  the  palliative  of 
unrest.  And  it  seems  probable,  if  we  accept  the 
application  of  science  to  mean  increased  production 
and  output  of  what  is  essential  to  the  existence 
and  welfare  of  both  workers  and  community.  This 
may  be  a truism  and  altruism  well  worth  the 
serious  thought  of  our  counsellors.  The  com- 
munity has  its  claims  on  medical  science 
also  for  maintaining  the  health  and  well- 
being not  only  of  the  workers  but  of  the  whole 
population,  which  is  thus  dependent  upon  scien- 
tific advances  in  medicine  and  sanitation.  Without 
research  progressive  medicine  is,  of  course,  impos- 
sible, and  medical  science  could  not  have  reached 
its  advanced  stages  without  intensive  studies  along 
all  sorts  of  ancillary  lines  ; and  similarly  progressive 
industry  and  output  must  be  dependent  upon  deeply 
searching  and  minutely  inquisitorial  work.  The 
war  has  brought  home  to  us  the  fact  that  the  world 
has  ignored  a great  asset  brought  into  valuation  by 
the  pursuit  of  knowledge ; the  war  was  largely  won 
by  applied  science,  and  it  is  to  science  properly 
applied  that  the  world  looks  for  regeneration.  The 
British  Labour  Party  has  recognised  this,  and  its 
advisory  committee  on  public  health  has  urged  on 
the  Ministry  of  Health  as  one  of  its  main  duties  the 
direct  prosecution  of  medical  research  and  its 
encouragement  in  universities  and  elsewhere. 

Here  is  a concrete  example  to  which  we  referred 
last  week — namely,  the  encouragement  of  research 
work  in  drugs  by  the  State,  which  resulted  in  great 


advantages  to  the  country.  At  the  outbreak  of  the 
war  there  was  a threatened  famine  in  essential 
drugs,  the  supply  and  preparation  of  which 
had  hitherto  been  left  entirely  to  enemy  sources. 
The  National  Health  Insurance  Commission  were 
fully  alive  to  this  fact  and  to  the  possibility 
of  disaster  looming  ahead  on  this  account  ; 
but  with  the  assistance  of  the  Royal  Society  and 
various  State  departments  scientific  workers  and 
manufacturers  were  brought  into  touch  with  each 
other.  The  result  was  that  there  was  no  drug  famine, 
no  really  important  medicine  was  lacking  for  essen- 
tial purposes,  and  at  no  time  did  the  public  health 
suffer  from  a lack  of  medical  and  surgical  material. 
What  was  done  by  the  State  in  encouragement  of 
one  particular  and  important  industry  in  a time  of 
emergency  should  obviously  be  continued  with 
benefit  to  all  the  economic  and  industrial  resources 
of  the  country  now  that  the  war  is  over. 


Psychiatric  Clinics. 

The  essential  mystery  of  mental  disease  baffles  us 
now  as  it  did  a century  ago,  and  Dr.  Bedford  Pierce, 
in  his  presidential  address  to  the  summer  meeting 
of  the  Medico-Psychological  Association,  queries 
whether  the  recovery  rate  has  increased  during 
that  time.  But  signs  are  not  wanting  of  encourage- 
ment. During  the  past  year  several  medico-psycho- 
logists have  been  earnestly  engaged  in  framing 
recommendations  for  the  more  rational  treatment 
of  patients  suffering  from  incipient  mental  disease. 
It  is  satisfactory  to  note  that  the  result  of  their 
labours  is  likely  to  bear  fruit  in  the  near  future. 
The  experience  gained  in  the  special  hospitals  for 
similar  cases  under  military  organisation  has  served 
to  bring  to  a focus  what  has  long  been  held 
to  be  desirable  in  civilian  practice.  But  to  attain 
this  objective  no  proper  provision  exists,  as  is  well 
known,  neither  is  there  legal  sanction.  The  pre- 
vention of  disease  is  as  much  the  role  of  the  practi- 
tioner as  is  the  cure  and  care  of  patients.  To  this 
end  the  sooner  a case  of  threatening  mental  break- 
down can  be  dealt  with  the  better  should  be  the 
result  secured ; and  it  is  not  too  much  to  hope 
that  insanity  may  yet  be  nipped  in  the  bud  to  no 
small  extent.  The  extension  of  the  voluntary 
boarder  principle  to  the  county  and  borough 
asylums,  which  is  being  promoted,  is  a step  in  the 
right  direction,  but  there  is  a large  class  for 
which  other  facilities  for  early  treatment  must  be 
devised.  The  establishment  of  recognised  homes 
for  incipient  or  border-line  cases,  advocated  by  Dr. 
L.  A.  Weatherly  last  week,  is,  we  think,  generally 
approved,  subject  to  notification  to  some  public 
authority  competent  to  exercise  supervision.  Such 
homes  would  apply  to  private  patients  in  a position 
to  defray  the  expenses  incurred.  But  for  the  person 
of  slender  means  the  demand  for  psychiatric  clinics 
seems  to  be  imperative  in  order  to  keep  abreast  of 
the  times. 

Several  of  the  voluntary  hospitals,  in  response  to 
appeals, have  institutedout-patient  clinicsfor  mental 
cases,  but  apparently  they  hesitate  to  allocate  beds 
for  them.  No  doubt  this  would  entail  the 
building  of  an  annexe,  or,  at  any  rate,  the  provision 
of  a special  ward  with  suitable  arrangements,  and 
the  services  of  nurses  with  asylum  training.  It  is 
quite  possible  that  the  overcrowded  state  of  the 
hospitals  militates  against  a departure  which 
involves  increased  responsibilities  and  expense.  Yet 
the  advantages  which  should  accrue  are  manifest 


206  The  Lancet,] 


MEDICAL  TRADE-UNIONISM. 


[August  2,  1919 


in  bringing  mental  diseases  into  closer  alliance 
with  other  diseases,  and  the  consultations  between 
the  various  departments  would  be  of  the  utmost 
value.  Moreover,  the  class-rooms  and  laboratories 
would  be  at  hand,  and  there  would  be  increased 
opportunities  for  the  scientific  teaching  of  psycho- 
logical medicine.  The  finances  of  such  a scheme 
for  mental  clinics  might  very  fairly  be  met  by 
contributions  from  the  local  authority  or  central 
exchequer,  and  this,  we  take  it,  is  provided  for  in 
the  legislation  proposed  by  the  Board  of  Control. 
The  union  infirmaries,  to  which  the  poorer  classes 
of  mentally  affected  patients  in  the  first  instance 
have  access  on  certain  conditions,  can  scarcely  be 
held  efficient  under  the  present  regime.  The 
medical  and  surgical  staffs  are  inadequate,  there  is 
a need  for  workers  in  pathology,  and  their  status 
would  be  improved  by  the  appointment  of  a 
recognised  authority  on  psychiatry  to  direct 
the  treatment  of  mental  cases.  In  the  interests 
of  public  health  mental  patients  should  be  able 
to  obtain  early  treatment  without  the  formalities 
of  the  three-day  order  and  certification,  which, 
with  the  added  stigma  of  pauperism,  have  such  a 
baneful  influence  on  persons  in  the  incipient  stage 
of  insanity.  Reform  can  only  be  achieved  by 
dissociating  the  management  entirely  from  the 
Poor-law  in  name  as  well  as  in  fact.  Were  this 
accomplished,  it  is  more  than  probable  that  many 
existing  buildings  could  be  remodelled  and  adapted 
for  the  formation  of  psychiatric  clinics,  in  addition 
to  those  which  the  voluntary  hospitals  may  in  time 
provide,  and  where  medical  schools  exist  in  the 
vicinity  they  should  be  affiliated  to  the  clinics  for 
the  purposes  of  teaching  and  research. 

But  besides  these  problematical  innovations 
there  is  yet  another  method  to  deal  with  the 
situation,  which  has  already  been  initiated,  and 
that  is  to  build  hospitals  for  incipient  nervous 
and  mental  diseases  analogous  to  the  special  hos- 
pitals that  exist  for  other  diseases.  There  is  much 
to  be  said  for  this  movement,  and  it  might  save  the 
cost  of  the  continual  additions  to  the  asylums  of 
the  country.  These  hospitals  should  constitute 
thoroughly  up-to-date  psychiatric  clinics  with 
every  means  for  scientific  investigation;  care 
should  be  taken  that  they  are  bereft  of  any 
tinge  of  asylum  atmosphere,  or  they  might 
defeat  the  object  in  view.  The  Maudsley  Hospital, 
which  is  equipped  with  modern  laboratories,  already 
exists  owing  to  the  foresight  of  its  munificent  donor, 
and  it  is  to  be  hoped  that  no  time  will  be  lost  in 
admitting  suitable  patients  on  a voluntary  basis 
when  the  military  authorities  have  evacuated  it. 
The  meetings  of  delegates  of  the  various  asylums’ 
committees  of  the  country  which  took  place 
at  the  Guildhall  this  year  on  the  problem 
at  issue  have  resulted  in  good  work,  and  we  observe 
with  satisfaction  that  it  is  proposed  to  institute  a 
psychiatric  clinic  at  Cardiff,  to  which  allusion  is 
made  in  our  news  columns.  By  such  means  we 
may,  as  Dr.  Edwin  Goodall  suggests  in  his  letter, 
remove  the  reproach  at  present  resting  on  psych- 
iatry in  this  country.  For  the  moment,  however, 
there  is  this  difficulty  to  be  faced.  The  functions 
of  these  clinics,  and  more  especially  of  approved 
homes,  can  scarcely  be  performed  without  risk  in 
the  present  state  of  the  lunacy  laws.  These  and 
other  cognate  matters  have  received  the  careful 
attention  of  the  Board  of  Control,  whose  recom- 
mendations are  in  close  accord  with  those  contained 
in  the  report  of  the  Lunacy  Legislation  Committee 
of  the  Medico-Psychological  Association.  An 
amending  Bill  drafted  by  the  Board  of  Control  has 


been,  we  understand,  in  the  hands  of  the  Government 
for  some  time,  and  it  is  regrettable  that  this  measure 
has  not  been  brought  forward  this  session  in  con- 
nexion with  the  Ministry  of  Health.  The  position  of 
the  various  administrative  departments  of  health 
will  require  rearrangement  under  the  new  Ministry, 
and  it  would  seem  feasible  for  lunacy  to  come 
within  its  province,  a course  rendered  possible  by 
an  Order  in  Council.  The  transfer,  if  effected,  should 
not  interfere  with  the  duties  of  the  Board  of  Control, 
whose  work  in  administering  the  present  Acts  is  fully 
appreciated,  and  we  are  glad  to  find  that  the  Board 
is  in  sympathy  with  the  new  aspirations  for  more 
rational  means  of  treating  the  early  stages  of 
mental  disease. 


Medical  Trade-Unionism. 

The  Annual  Representative  Meeting  of  the  British 
Medical  Association  was  held  last  week  under  the 
presidency  of  Dr.  T.  W.  H.  Garstang,  the  Chairman 
of  the  Representatives,  and,  as  might  have  been 
expected,  having  consideration  to  the  times  in 
which  we  live,  the  trade-union  question  in  refer- 
ence to  the  medical  profession  was  treated  as  an 
important  issue.  A recommendation  was  received 
from  a large  provincial  branch  that  the  British 
Medical  Association  should  not  endeavour  to 
prevent  its  members  from  joining  any  other 
organisation  which  was  attempting  to  combine 
the  profession  on  trade-union  lines,  the  reference 
clearly  being  to  the  Medico-Political  Union,  a 
body  which  is  frankly  committed  to  trade-union 
principles.  Speeches  were  made  by  some  who  had 
already  given  in  their  adherence  to  the  Medico- 
Political  Union,  and  although  their  arguments  were 
not  perhaps  conclusively  dealt  with,  the  vote 
showed  that  the  British  Medical  Association, 
through  its  Representatives,  disagrees  in  great 
majority  with  any  attempt  to  convert  the  profession 
of  medicine  into  a trade-union.  It  is  no  reproach 
to  clear  thinking,  or  to  the  debating  powers  of  either 
side  in  the  controversy,  that  nothing  was  said 
proving  the  one  side  to  be  wholly  right  or  the  other 
side  to  be  wholly  wrong ; the  arguments  for  the 
introduction  into  medical  practice  of  trade-union 
principles  are  very  strong,  but  the  arguments 
which  can  be  employed  in  opposition  are  at  least 
equally  strong ; and  it  is  a great  error  on  the  part 
of  those  who  see  salvation  in  the  formation  of  a 
trade-union  to  insist  that  those  who  dissent  from 
them  are  influenced  only  by  motives  of  obsolete 
snobbery. 

That  a trade-union  may  be  an  effective  weapon 
capable  of  good  use  and  capable  of  gross  abuse  we 
all  know  at  the  present  day,  but  its  virtues  and  its 
defaults  have  been  displayed  in  association  with 
callings  which  cannot  be  compared  with  the  calling 
of  medicine.  The  analogies  usually  employed  in  this 
controversy  are  imperfect.  A trade-union  must  be 
substantially  a union  of  those  employed  in  the  trade, 
though  no  doubt  every  trade-union  has  among  its 
supporters  dissentients  who  now  and  again  form  a 
considerable  body  of  opinion.  None  the  less,  the 
members  have  a common  policy,  and  by  effective 
weapons  which  are  within  their  reach  can  stimulate 
political  activity  along  the  desired  lines.  The 
medical  profession  cannot  have  a common  policy 
except  in  the  carrying  out  of  the  grand  ideal  to 
serve  humanity.  Certainly  in  the  pursuit  of  this 
ideal  medical  practitioners  have  the  right  to 
formulate  a common  demand  for  proper  remunera- 
tion, and  this  demand  depends  for  its  real  force 
upon  no  vaporous  or  sentimental  claim  to  the 


The  Lancet,] 


THE  FUTURE  OF  HOSPITALS  IN  IRELAND. 


[August  2,  1919  207 


gratitude  of  the  public,  but  upon  the  undeniable 
argument  that  good  service  can  only  be  rendered 
by  men  who  are  placed  in  a proper  position  to  do 
good  work.  Where  that  work  is  multifarious  it  is 
exceedingly  difficult  to  devise  a plan  to  insure  that 
along  each  and  all  the  lines  justice  is  being  done. 
Clearly  no  single  rate  of  wages,  with  which  a trade- 
union  is  so  well  able  to  deal,  would  meet  the  case.  It 
is  generally  admitted  that  the  most  ardent  advocates 
of  medical  trade-unionism  have  no  intention  of 
using  the  last  weapon  of  the  trade-union — namely, 
the  strike  ; but  a proposal  to  substitute  for  the 
strike  against  individuals  a strike  against  Govern- 
ment regulations  may  be  a distinction  without  a 
difference.  A recent  memorandum  by  the  Medico- 
Political  Union  states  that  panel  practitioners  are 
the  only  citizens  in  this  country  who  are,  at  the 
present  time,  outside  the  protection  of  the  law,  the 
statement  deliberately  excluding  the  position  of 
the  Civil  Servant.  It  is  conceivable,  and  indeed 
conceded,  that  a large  body  of  the  medical  pro- 
fession, being  engaged  in  homogeneous  work  by 
a common  employer,  form  typical  material  for  a 
trade-union,  and  in  this  sense  is  doubtless  to  be 
construed  the  National  Insurance  Defence  Trust  to 
be  administered  by  the  British  Medical  Association. 
But  what  is  to  be  the  attitude  of  other  members  of 
the  medical  profession  not  in  the  same  position  ? 
They  cannot  be  forced  into  a trade-union,  and 
their  scientific  and  humanitarian  services  must  be 
available  for  the  benefit  of  medicine  as  a whole, 
within  and  without  its  sections. 

It  was  to  assist  in  the  solution  of  such’questions 
that  the  Medical  Parliamentary  Committee  was 
formed,  and  if  in  its  present  shape  as  a British 
Federation  of  Medical  and  Allied  Societies  it  should 
become  representative,  the  medical  man  through 
any  body,  association,  or  group  with  which  he  is 
affiliated,  would  give  a vote  on  these  great  questions 
and  inaugurate  a policy  of  strength  and  of  concilia- 
tion.. But  it  is  understood  that  the  British 
Medical  Association,  within  whose  ranks  a difference 
of  opinion  on  the  trade-union  question  has  become 
manifest,  will  not  revise  its  opinion  that  this 
Federation  has  no  reason  for  its  existence.  The 
British  Medical  Association  is  the  elaborate  work  of 
men  devoted  to  the  interests  of  the  medical  pro- 
fession, and  every  respect  must  be  paid  to  their 
decision  ; but  here  is  a question  of  vital  importance 
upon  which  apparently  members  of  the  Association 
do  not  think  alike.  If  the  trusted  leaders  of  the 
Association  would  debate  this  and  cognate  questions 
with  a real  federation  of  medical  and  allied  bodies 
good  would  emerge. 


The  Government’s  intention  to  regulate  the 
sale  of  products  which  in  the  past  were  limited 
by  patent  was  made  by  Sir  Auckland  Geddes, 
President  of  the  Board  of  Trade,  in  the  House 
of  Commons  on  July  28th,  on  the  occasion  of 
his  moving  the  second  reading  of  the  Trades  Marks 
Bill.  In  what  he  said  he  was  guided  probably  by 
the  recommendations  of  the  Select  Committee  on 
Patent  Medicines,  the  report  of  which  was  ordered 
by  the  House  of  Commons  to  be  printed  August  4th, 
1914.  This  Committee  proposed  that  fancy  names 
for  recognised  drugs  should  be  subject  to  regula- 
tion, and  that  the  period  of  validity  of  a name  used 
as  a trade  mark  for  a drug  should  be  limited, 
as  is  already  the  case  with  patents  and  copyrights. 
We  anticipate  that  legislation  will  follow  in  this 
direction. 


^itnotaiians. 

“ Ne  quid  nlmls.” 


THE  FUTURE  OF  HOSPITALS  IN  IRELAND. 

An  Irish  correspondent  writes : “ There  is  no 
more  urgent  medical  question  in  Ireland  at  present 
than  the  future  of  the  voluntary  hospitals.  In 
Dublin,  the  Richmond,  the  Whitworth,  and  the 
Hardwicke  Hospitals  are  controlled  by  a common 
board  of  governors,  and  since  1856  have  enjoyed 
a Government  subsidy  of  £7600  per  annum. 
They  have  no  other  funds,  and  as  the  cost 
of  maintenance  has  risen  from  a pre-war  figure 
of  £64  per  bed  to  a present  sum  of  £119  per  bed, 
they  are  in  serious  plight.  All  the  governors  have 
tendered  their  resignation  to  the  Lord-Lieutenant, 
the  hospitals  being  now  without  funds  to  pay 
tradesmen’s  bills.  The  Whitworth  Hospital  is 
definitely  closed.  For  some  time  the  Treasury 
grant  has  been  held  by  the  bank  and  devoted  to 
the  reduction  of  the  overdraft.  The  Irish  Govern- 
ment has  now  expressed  its  inability  to  come  to  the 
relief  of  the  hospitals  in  their  present  crisis,  and 
if  this  course  is  persisted  in  the  only  chance  is 
for  the  Dublin  Corporation  to  act,  but  the  rates 
are  so  terribly  high  in  that  city  that  little  hope 
is  felt  in  such  a relief.  In  Belfast — with  a popula- 
tion much  larger  than  Dublin — the  Government 
has  never  contributed  a halfpenny  to  the  hospitals, 
but  it  is  plain  that  hospitals  there  cannot  go  on 
unless  the  working-classes  themselves — with  their 
present  high  wages — give  more  to  the  places  to 
which  their  debt  is  so  huge.  At  the  Royal  Victoria 
Hospital  an  arrangement  is  in  force  by  which,  for  a 
penny  a week  contribution,  a working  man  and  his 
wife  and  family  are  treated  at  the  hospital — as 
extern  or  intern  patients — except  for  the  zymotic 
fevers  and  tuberculosis.  This  plan,  which  was  made 
about  a quarter  of  a century  ago,1  is  utterly  out  of 
date  now,  and  the  contribution  should  be  raised  to 
at  least  sixpence  weekly  or  even  more.  Middle- 
class  people  who  formerly  subscribed  to  the  hos- 
pitals can  do  so  no  longer,  as  owing  to  the 
diminished  purchasing  value  of  the  sovereign 
and  the  heavy  taxation  they  are  greatly  crippled 
financially.”  

THE  COMMOTIONAL  FACTOR  IN  THE  /ETIOLOGY 
OF  SHELL  SHOCK. 

In  our  present  issue  Dr.  Alfred  Carver  records  in 
some  detail  a series  of  experiments  on  animals 
which  has  a direct  bearing  on  the  problem  of  the 
aetiology  and  symptomatology  of  so-called  shell 
shock.  Dr.  Carver  describes  in  a lucid  way  the 
three  zones  produced  round  a point  of  detonation, 
and  brings  forward  evidence  to  show  the  different 
physical  effects  in  these  three  zones.  In  the  first, 
the  zone  of  “ brisance,”  objects  are  shattered  by  the 
sudden  terrific  compression ; in  the  second,  the 
zone  of  “ decompression,”  there  is  very  much  less 
evidence  of  actual  destruction  or  distortion  of 
objects  ; in  the  third,  outer  zone,  physical  effects 
are  modified  still  further.  Some  significance  is 
attached  to  the  fact  that  in  the  central  zone  other 
high  explosives  will,  under  the  influence  of  the 
original  detonation,  themselves  spontaneously 
detonate,  as  will,  in  the  intermediate  zone,  those 
whose  tonal  standard  is  somewhat  similar  to  that 
of  the  primary  explosive.  Corresponding  to  these 
physical  changes  are  the  effects  produced  on 


208  Thb  Lanobt,] 


IMPERIAL  CANCER  RESEARCH  FUND. 


[August  2,  1919 


animals  finding  themselves  within  the  various 
zones ; thus  in  the  innermost  zone  animal  life  is 
destroyed,  with  laceration  of  the  body  structures  ; 
in  the  intermediate  animals  are  rendered  uncon- 
scious, often  with  no  sign  of  external  injury ; in  the 
outer  a state  of  diminished  activity  is  followed  by 
a period  of  excitement  and  restlessness.  Patho- 
logical evidence  reveals  numerous  haemorrhages  in 
the  zone  A animals,  and  capillary  engorgement  in 
such  zone  B animals  as  are  killed.  There  is, 
perhaps,  something  of  the  artificial  and  the 
schematic  in  these  experiments,  and  some  psycho- 
logists may  be  inclined  to  minimise  their  import- 
ance, as  regards  human  beings,  in  judging  of  the 
effects  of  shell  concussion  not  merely  in  the  physical 
atmosphere  but  also  in  the  mental.  Dr.  Carver’s 
experiments,  however,  are  supplemented  by  valuable 
observations  on  the  effect  of  high-explosive  detona- 
tions on  a more  or  less  picked  set  of  men  belonging 
to  an  “ ammunition  proof  and  demolition  section,” 
according  to  which  definite  physical  and  mental  sym- 
ptoms supervene  on  shell  explosions  even  where  the 
“psychic  factor”  can  almost  certainly  be  elimi- 
nated. Again,  evidence  is  adduced  of  the  peculiarly 
“ demoralising  ” effect  of  shells  with  fillings  layered 
in  a special  fashion,  as  though  an  unusual  physical 
effect  is  somehow  transformed  into  an  unusual 
psychical  disturbance.  We  feel  that  Dr.  Carver  is 
justified  in  his  contention  that  both  physical  and 
psychical  factors  operate  in  the  production  of  shell 
shock,  and  that  differentiation  of  their  respective 
actions  is  a matter  of  considerable  difficulty.  In 
any  case,  to  ignore  the  physical  element  is  unwise, 
and  to  restrict  psychical  phenomena  to  a 
psychical  aetiology  is  unscientific.  Our  experience 
of  shell-shock  cases  over  the  five  years  of  war  is  in 
the  main  that  the  physical  factor  predominates  in 
the  originating  of  shell  shock ; that  thereafter  sub- 
conscious or  unconscious  “ rumination  ” takes  its 
place  in  the  continuing  of  the  symptoms ; that  the 
first  two  years  saw  more  severe  and  protracted 
and  inveterate  cases  of  the  condition  than  the  last 
two — a fact  which  may  be  taken  to  suggest  that  in 
the  perpetuation  of  symptoms  the  psychogenic 
element  is  much  the  more  important.  The 
commotionne  becomes  an  emotionne  in  many 
instances  ; clear-cut  examples  of  the  two  syndromes, 
we  agree  with  Dr.  Carver,  are  the  exception  and 
not  the  rule. 


IMPERIAL  CANCER  RESEARCH  FUND. 

The  seventeenth  annual  report  of  this  Fund, 
dealing  with  the  year  1918-19,  has  just  been 
issued,  and  consists  of  statements  by  the  secretary, 
the  director,  and  the  honorary  treasurer,  together 
with  a list  of  the  year’s  subscriptions  (£956  Os.  4 d., 
making  with  amounts  acknowledged  in  previous 
years  £174,112  2s.  5 d.),  and  a statement  of  accounts. 
Mr.  F.  G.  Hallett,  the  secretary,  points  out  that 
now  it  is  becoming  possible  to  resume  systematic 
investigations  in  the  laboratories  the  foresight 
shown  by  expending  time  and  labour  in  maintaining 
the  various  tumour  strains  in  mice  is  justified,  for 
already  material  for  research  purposes  has  been 
supplied  to  Professor  Borrel’s  Laboratory  and  the 
Institut  Pasteur,  Paris,  and  to  Dr.  J.  Shaw 
Mackenzie  at  King’s  College.  The  report  of  the 
director,  Dr.  J.  A.  Murray,  shows  that  during  the 
war,  while  the  working  organisation  has  been 
maintained,  the  main  efforts  of  the  staff  have 
been  concentrated  on  war  problems,  the  results 
of  which  work  will  shortly  be  published  in 
the  Sixth  Scientific  Report.  This,  for  the  most 


part,  will  deal  with  the  investigations  of  Messrs. 
W.  E.  Bullock  and  W.  Cramer  on  new  factors  in 
bacterial  infections,  and  by  Dr.  Murray  on  cellular 
changes  on  cartilage  grafts.  The  report  of  Sir 
W.  Watson  Cheyne,  the  honorary  treasurer,  records 
the  gratifying  fact  that  the  loan  from  the  bankers 
has  been  reduced  by  £1700,  leaving  only  £500  still 
to  be  cleared  off.  As  the  scientific  staff,  depleted 
owing  to  the  war,  is  now  nearly  at  full  strength, 
researches  will  be  energetically  resumed  with  a 
necessarily  increased  expenditure,  and  an  earnest 
appeal  is  made  to  all  who  are  interested  in  cancer 
research  to  support  the  Fund  themselves  and  to 
induce  others  to  do  likewise.  “ Looking  to  the 
heavy  death-rate  from  malignant  disease,”  says  Sir 
Watson  Cheyne,  “ it  must  surely  be  to  the  interest 
of  the  community  that  this  Fund  should  not  be 
starved  in  its  efforts.” 


TRAUMATIC  PSORIASIS. 

Fkom  a recent  article  on  this  subject  byDollner,1 
of  Duisburg,  it  appears  that  Kobner  in  1872  was  the 
first  to  describe  this  form  of  the  disease.  Another 
case  was  published  in  the  Lyon  Medical  in  1895,  in 
which  psoriasis  followed  vaccination  in  a man, 
aged  22,  who  was  alcoholic  himself  and  belonged  to  an 
alcoholic  family.  Otherwise,  apart  from  a case  pub- 
lished by  Becker  in  1906,  Dollner  has  not  been  able 
to  find  any  example  of  traumatic  psoriasis  on  record. 
He  has  lately  observed  two  examples  himself  in 
soldiers  who  developed  psoriasis  after  gunshot 
wounds,  in  one  case  of  the  tibia  and  fibula,  where 
the  psoriasis  appeared  on  the  injured  leg  but  not  at 
the  site  of  the  wound,  and  in  the  otlfer  at  the 
actual  site  of  the  wound  in  the  tibia.  The  last 
case  was,  further,  of  interest  in  that  it  proved  to  : 
be  infectious.  Six  months  after  his  discharge  from 
hospital  the  patient’s  wife,  who  had  recently 
recovered  from  scarlet  fever  and  still  had  a trace 
of  albumin  in  the  urine,  developed  psoriasis, 
which  extended  over  both  knees  and  the  middle 
line  of  the  back.  In  another  two  months  her 
mother  also  contracted  psoriasis.  In  a postscript 
Dollner  relates  the  case  of  a stretcher-bearer  who 
was  wounded  while  carrying  another  wounded  man, 
the  subject  of  psoriasis,  and  developed  the  skin 
disease  a fortnight  later  on  his  face,  knees,  and 
back.  


THE  PLIGHT  OF  VIENNA  HOSPITALS. 

The  prestige  of  the  Vienna  Medical  School  has 
for  long  been  high  in  this  country  as  anyone  may 
see  for  himself  by  turning  over  the  pages  of  the 
Medical  Directory  and  noting  the  names  of  dis- 
tinguished British  surgeons  and  specialists  who 
took  post-graduate  study  there.  The  number  of  its 
students  was  never  greater  than  was  the  case  in 
1914  on  the  eve  of  the  war.  The  contrast  between 
its  situation  then  and  the  situation  of  the  school 
to-day  is  startling  and  tragic.  The  hospitals,  at 
first  overwhelmed  with  wounded  men  and  later 
with  the  victims  of  epidemic  disease,  are  now  filled 
with  enfeebled  and  semi-starved  patients,  while 
lacking  the  food  and  equipment  necessary  to 
minister  to  their  needs.  Tuberculosis  has  developed 
into  a deadly  and  acute  disease.  Nephritis  has 
taken  vast  toll.  Continuous  underfeeding  with  its 
results  seen  as  hunger-dropsy,  rickets,  scurvy, 
and  Barlow’s  disease,  provide  the  major  part  of  the 
clinical  material.  In  one  clinic  alone  there  were 
recently  to  be  seen  18  cases  of  spontaneous  fracture 

i Arzt.  Sachverst.  Ztg.,  1919,  sir.,  64-5. 


The  Lancet,] 


TRAUMATIC  ANEURYSM  OF  THE  RIGHT  VENTRICLE. 


[August  2,  1919  209 


in  adults  due  to  inanition.  In  consultation  with 
Professor  Tandler,  Austrian  Minister  of  Health,  an 
effective  organisation  for  the  distribution  of  relief 
to  the  hospitals  and  kindred  institutions  has  been 
brought  into  being.  This  is  known  as  the  Inter- 
national Spitalhilfsaktion,  which  has  its  offices  at 
the  Albrecht  Palace,  and  its  own  private  store 
houses.  It  is  independent  of  other  Government 
departments  and  is  controlled  by  an  international 
committee,  of  which  Professor  Wenckebach  is 
chairman.  An  appeal  to  provide  the  urgent  means 
of  relief  for  this  excellent  organisation  to  distribute 
has  been  issued  by  Frau  Dr.  Biene,  Frau  Hofrath 
Lecher,  Mr.  C.  K.  Butler,  chief  of  the  British 
Mission,  Mr.  Halstead,  chief  of  the  American 
Mission,  Mr.  Karpeles,  of  Schenker  and  Co.,  and  Dr. 
Hector  Munro  representing  the  Save  the  Children 
Fund.  The  most  urgent  need  exists  for  extra  rations 
to  give  to  these  hospital  patients.  The  foodstuffs 
required  are  enumerated  as  fats  (margarine,  butter, 
cod-liver  oil),  sugar,  eggs,  meats,  milk,  and  flour — 
the  list  suggesting,  what  we  believe  to  be  the 
fact,  that  the  present  diet  of  hospital  inmates 
consists  principally  of  broth  and  tea.  46,000  gallons 
of  milk  (of  which  11,000  turned  sour  owing  to 
difficulty  of  transport)  are  stated  to  have  been  the 
total  supply  for  a population  of  over  two  millions 
during  three  recent  days.  Those  to  whom  Vienna 
is  a pleasant  memory  of  student  days  will  interest 
themselves  in  bringing  the  needs  home  to  those 
who  can  supply  them.  The  address  of  the  Save  the 
Children  Fund  is  329,  High  Holborn,  London,  W.C.  1. 


TRAUMATIC  ANEURYSM  OF  THE  RIGHT  VENTRICLE. 

Spontaneous  aneurysm  of  the  heart  is  rare 
enough ; Dr.  Claude  Wilson,  in  recounting  an 
interesting  case,  indicates  how  easily  the  condition 
may  be  overlooked.  Traumatic  cardiac  aneurysm  is 
rarer  still,  although  less  likely  to  elude  diagnosis 
during  life.  In  the  Journal  of  the  American  Medical 
Association  of  June  7th  Dr.  G.  H.  Curfman 
and  Dr.  C.  R.  duller  have  recorded  a case.  On 
July  19th,  1917,  a youth,  aged  18  years,  complained 
of  the  effects  of  a kick  in  the  epigastrium  by  a mule. 
Since  the  injury  he  noticed  difficulty  in  breathing, 
which  steadily  increased.  There  was  persistent 
cough,  accompanied  by  expectoration,  the  sputum 
consisting  of  frothy  mucus  tinged  with  bright  blood. 
During  the  previous  month  the  abdomen,  ankles, 
and  legs  had  become  greatly  enlarged.  On 
examination  the  face  was  swollen,  with  marked 
puffiness  under  the  eyes.  The  lips  and  tongue  were 
very  cyanotic.  There  was  pronounced  pulsation  of 
the  jugular  veins.  On  lying  down  the  whole  face 
became  extremely  cyanotic.  The  cardiac  impulse 
was  heaving  and  could  be  seen  to  extend  from  the 
seventh  interspace,  about  11  in.  to  the  left  of  the 
middle  line  over  the  entire  cardiac  area.  Cardiac 
dullness  was  greatly  increased  both  to  the  right 
of  the  sternum  and  to  the  left  of  the  mid -clavicular 
line.  There  was  a loud  systolic  murmur  most 
audible  at  the  apex  and  transmitted  over  the  whole 
cardiac  area.  At  the  end  of  systole  the  murmur 
became  “ whistling  ” and  then  faded  into  a faint 
blowing  sound.  The  second  pulmonic  sound  was 
accentuated.  The  abdomen  was  distended  with 
fluid  and  there  was  marked  tenderness,  most 
noticeable  in  the  epigastrium.  The  liver  extended 
three  fingers-breadth  below  the  ribs  and  was  tender 
on  pressure.  The  lower  limbs,  from  the  ankles 
to  above  the  knees,  were  swollen  and  oedematous. 
He  gradually  became  worse  ; the  cyanosis  deepened 
and  the  abdomen  became  more  distended  with 


fluid.  The  pulse  became  weak  and  irregular.  On 
Feb.  27th,  1918,  he  passed  into  mumbling  delirium 
and  died.  The  necropsy  revealed  a greatly 
thickened  pericardium  containing  about  a litre  of 
light  amber-coloured  fluid.  The  heart  was  enlarged 
and  weighed  723  g.  At  the  apex  of  the  right 
ventricle  was  an  irregular  tumour  about  the  size 
of  half  a lemon,  which  proved  to  be  a sacculated 
aneurysm  connected  with  the  ventricle  by  an  open- 
ing which  admitted  the  index  finger.  The  right 
ventricle  was  greatly  hypertrophied  and  there  was 
relative  insufficiency  of  the  tricuspid  valve.  The 
abdomen  was  normal  except  for  a large  amount  of 
ascitic  fluid. 


THE  HANDICAP  OF  DISABLEMENT. 

The  Central  Hall,  Westminster,  on  July  24th  was 
crowded  from  floor  to  ceiling  with  men  who  had 
lost  their  limbs  in  the  Great  War.  The  sight  while 
the  hall  was  being  filled  was  one  which  at  first 
could  only  engender  feelings  of  despair,  some  of  the 
men  being  so  helpless  that  they  had  to  be  carried, 
others  legless,  shuffling  along  the  floor  by  the  aid 
of  their  arms  only ; but  before  the  end  of  the 
meeting  that  feeling  gave  way  to  conviction  that 
the  awful  pageant  presented  by  the  tragedy  of 
war  had  its  hopeful  side.  Under  the  auspices 
of  the  London  War  Pensions  Committee  and 
the  British  Red  Cross  Society  the  meeting 
was  convened  with  the  object  of  demonstrating 
to  disabled  soldiers  and  sailors  the  possibilities  of 
success  in  life  which  lay  before  them,  and  with  this 
purpose  in  view  two  American  gentlemen,  Judge 
Corley  and  Mr.  Michael  Dowling,  who  had  been 
crippled  in  youth,  but  in  spite  of  their  disabilities 
had  risen  to  positions  of  honour  and  trust,  prac- 
tically by  their  own  efforts,  gave  their  experiences. 
Sir  Laming  Worthington-Evans,  Minister  of 
Pensions,  who  presided,  in  introducing  the  speakers, 
said — and  the  attitude  of  the  meeting  proved  his 
words — that  if  one  really  wanted  to  get  among 
people  who  were  stout-hearted  and  cheerful  it  was 
necessary  to  go  among  limbless  men.  He  desired 
to  see  these  men  put  in  the  service  of  the  country, 
and  into  as  good  a position  as  possible  by  providing 
them  with  artificial  limbs,  but  the  cooperation  of 
the  men  themselves  was  also  necessary.  Each 
man’s  case  was  a separate  case,  and  after  the  skill 
of  the  surgeon,  who  was  doing  his  very  best,  had 
been  requisitioned,  there  was  need  for  the 
individual  who  used  the  artificial  limbs  to  select 
and  learn  to  use  properly  the  instrument  which  was 
best  adapted  to  his  purpose.  Judge  Corley,  who 
had  no  arms,  then  gave  a demonstration  of  the 
instrument  which  he  had  invented  and  perfected, 
and  which  enabled  him  to  perform  all  the  necessary 
actions  of  daily  life.  The  main  principle  of  the 
apparatus  was  that  of  the  working  of  a pair  of 
forceps,  with  various  attachments  for  eating, 
drinking,  performing  the  daily  toilet,  and  even 
paring  the  toe-nails.  As  he  explained,  he  could 
drive  a motor-car,  shave,  play  games — in  fact,  enter 
into  life  with  the  same  enjoyment  as  a man  with 
both  his  hands  and  feet.  “ And  I get  my  full  share 
of  that  enjoyment,”  he  exclaimed  with  conviction. 
Warning  his  hearers  against  the  danger  of  allowing 
the  natural  sympathy  of  the  public  towards  them 
to  lead  to  apathy,  he  concluded  by  exhorting  the 
disabled  to  endeavour  to  do  for  themselves  every- 
thing it  was  possible  to  do.  Prince  Albert,  who 
was  present,  in  the  course  of  a short  speech  said : 

“ We  all  know  what  you  did  in  the  war  and  what 
you  have  suffered,  and  it  is  now  up  to  us  to  make 


210  The  Lancet,] 


PLAGUE  AT  AVONMOUTH.— GOVERNMENT  SALARIES. 


[August  2,  1919 


things  as  easy  for  you  as  possible.  And  only  right 
that  we  should.”  The  Prince  then  made  an  inspection 
of  the  exhibits  of  the  work  done  by  limbless  men 
at  the  various  training  centres,  which  included 
many  of  the  arts  and  trades  of  the  country.  After 
a cinematograph  display  showing  Mr.  Dowling  as 
an  expert  motorist,  the  subject  of  the  pictures 
himself  gave  a stirring  address,  the  keynote  of 
which  was  “ grit.”  The  knowing  man,  he  Baid,  did 
not  pick  out  the  winner  by  listening  to  the  tales  of 
tipsters  or  stableboys,  but  by  noting  the  handicap 
and  record  of  the  horse.  The  greater  the  handicap 
the  more  certain  it  was  that  the  horse  had  got  the 
stuff  in  him  if  he  won  the  race.  And  the  man  who 
had  lost  a limb  in  the  war  was  likely  to  have  the 
stuff  to  win.  Mr.  Dowling,  who  has  lost  both  legs, 
half  his  left  arm,  and  half  his  right  hand,  has 
risen  in  life  from  a state  of  poverty  to  that  of 
president  of  the  largest  bank  in  Minnesota,  and 
boasts  that  he  can  do  everything  in  life  except 
tie  a bow-knot  in  his  tie.  In  spite  of  his  disabilities 
he  won  his  bride  against  two  whole-limb  com- 
petitors, and  is  the  father  of  healthy  children. 


PLAGUE  AT  LIVERPOOL  AND  AVONMOUTH. 

The  Ministry  of  Health  announces  a fatal  case 
of  plague  in  Liverpool,  in  a bargeman.  From  the 
same  source  we  learn  that  on  the  arrival  of  the 
s.s.  Framlirujton  Court  at  Avonmouth  from  Montreal 
on  July  22nd,  one  of  her  officers,  who  was  ill,  was 
removed  to  the  isolation  hospital  suffering  from 
bubonic  plague.  Another  officer,  we  are  informed, 
having  suspicious  symptoms,  was  taken  to  hospital 
the  following  day  and  has  been  found  also  to  be 
suffering  from  the  disease.  The  vessel  came  from 
Alexandria  to  Montreal  and  called  at  Sydney,  Nova 
Scotia,  on  her  voyage  to  Avonmouth.  She  is  being 
detained  by  the  Bristol  Port  Sanitary  Authority. 
All  the  accepted  precautions  have  been  taken, 
while  the  circumstances  are  being  investigated. 


GOVERNMENT  SALARIES. 

A vacancy  is  announced  for  a medical  inspector 
of  factories  who  will  be  required  to  undertake 
medical  inspection,  under  the  direction  of  the 
senior  medical  inspector,  in  factories,  workshops, 
and  other  places  under  the  Factory  Acts.  The 
salary  offered  is  £500  per  annum,  rising  by  annual 
increments  of  £20  to  a maximum  of  £700  per 
annum,  these  figures  being  exclusive  of  war  bonus  ; 
and  the  appointment  is  subject  to  the  usual  Civil 
Service  regulations  as  to  retirement  and  pension. 
The  scale  of  salary  will  certainly  be  criticised 
at  the  present  moment,  when  the  salaries 
to  be  obtained  in  so  many  directions  are 
considered,  as  well  as  the  diminished  and 
diminishing  purchasing  power  of  the  sovereign. 
■\Ve  may,  however,  remind  intending  candidates 
that  the  war  bonus  to  be  added  to  the  salaries  will 
be  equivalent  to  an  additional  one-third,  making, 
roughly  speaking,  the  salaries  nearly  £700  and  over 
£900  respectively.  These,  also,  are  not  generous 
figures,  but  if  the  pay  is  maintained  at  that  rate, 
and  if  proper  account  is  given  to  the  value  of 
the  pension,  the  salaries  are  not  distinctly 
lower  than  those  attached  to  many  Civil  Service 
appointments.  It  will,  of  course,  be  remembered 
that  a war  bonus  is  a distinctly  conditional  sum, 
and  with  a fall  in  prices  might  be  arbitrarily 
withdrawn.  We  cannot  attempt  to  estimate  the 


measure  of  this  risk.  But  the  Home  Office  must  be 
served,  and  therefore  it  must  pay  salaries  com- 
parable to  those  paid  by  other  departments. 
Having  regard  to  the  sums  mentioned  in  connexion 
with  posts  in  certain  of  the  new  bureaux,  we  feel 
that  if  the  Home  Office  should  later  attempt  to 
reduce  the  salaries  which  it  is  now  offering  it 
would  be  involved  in  a difficult  struggle.  Moreover, 
we  should  expect  the  salaries  of  medical  inspectors 
of  factories  not  to  come  down,  but  to  go  up  in 
response  to  the  increasing  knowledge  of  the  nation 
that  on  trade  production  depends  our  very  life, 
while  on  healthy  workers  depends  our  trade  pro- 
duction. 


THE  MENTAL  NURSE’S  WORKING  DAY. 

In  a recent  number  of  The  Lancet  (July  19th) 
we  referred  at  some  length  to  the  conditions  of 
asylum  service  in  so  far  as  these  affected  medical 
officers.  The  head  of  a large  establishment  dealing 
with  one  group  of  the  mentally  infirm  calls  our 
attention  to  another  aspect  of  the  matter — namely, 
that  of  the  nursing  of  these  patients.  This  ques- 
tion of  mental  nursing  has  been  under  considera- 
tion lately  by  the  various  authorities,  with  whom 
rests  the  responsibility  of  making  suitable  pro- 
vision ; and  the  two  especially  concerned  with 
London,  its  County  Council  and  the  Metropolitan 
Asylums  Board,  have  now  adopted  proposals  for 
reducing  considerably  the  hours  of  duty  of  the  staff 
employed  in  their  institutions.  There  is,  of  course, 
no  parallel  between  ordinary  industrial  conditions 
and  those  of  nursing,  and  many  difficulties  arise 
from  the  inability  of  certain  workers  to  appreciate 
this  fact.  It  is,  therefore,  not  surprising  that  the 
two  bodies  just  mentioned  are  experimenting  on 
different  lines,  and  it  will  be  interesting  to  see 
which  solution  of  the  problem  is  found  the  more 
satisfactory.  The  County  Council  has  adopted  a 
three-shift  system,  each  shift  averaging  eight  hours 
on  each  of  six  days  a week,  while. annual  leave  of 
14  days  is  granted.  In  the  institutions  controlled 
by  the  Metropolitan  Asylums  Board  the  weekly 
total  of  hours  worked  is  to  be  50,  spread  over  five 
days  in  each  week,  while  four  weeks  of  annual 
leave  are  to  be  given.  The  total  number  of  hours 
on  duty  is  the  same  under  both  arrangements 
— i.e.,  2400  per  annum.  Both  methods  have 

their  own  drawbacks,  and  other  schemes  drawn 
up  by  other  authorities  are  open  to  objections 
probably  of  equal  weight.  The  chief  requirements 
are  to  have  a sufficient  staff  on  duty  at  all  times 
without  having  a superfluity  at  particular  hours, 
and  to  provide  that  every  ward  shall  have  a 
responsible  officer  in  charge  of  its  equipment 
without  its  being  necessary  to  check  the  stock 
twice  a day  or  oftener  as  the  change  over  is  made. 
Since  the  working  day,  as  distinct  from  the  bedtime 
of  the  patients,  must  ordinarily  extend  over  14 
hours — that  is  to  say,  98  hours  per  week — it  will  be 
seen  what  a gap  has  to  be  filled  when  a charge 
nurse  or  attendant  is  only  on  duty  for  48  or  50 
hours.  To  keep  patients  in  bed  12  hours  out  of  the 
24  is  feasible  in  some  instances,  but  can  hardly  be 
regarded  as  a good  arrangement  for  young  and 
active  persons.  Much  will  turn  upon  the  spirit  in 
which  the  staff  take  advantage  of  their  extended 
freedom,  but  if  the  concessions  made  now  are 
merely  to  serve  as  the  basis  for  further  demands 
the  public  practice  of  charity  towards  the 
weaker  brethren  is  likely  to  prove  an  expensive 
luxury. 


Thh  Lanokt,] 


DR.  B.  PIERCE:  PSYCHIATRY  A HUNDRED  YEARS  AGO. 


[August  2,  1919  211 


PSYCHIATRY  A HUNDRED  YEARS  AGO, 

WITH  SOME  COMMENTS  ON  THE  PROBLEMS 
OF  TO-DAY.' 

By  Bedford  Bierce,  M.D.  Lond.,  F.R.C.P.  Bond., 

MEDICAL  SUPERINTENDENT,  THE  RETREAT,  • YORK. 


In  the  latter  part  of  the  reign  of  George  III.  many 
treatises  on  insanity  were  published,  many  of  them 
possessing  much  literary  grace.  They  abound  in  details  of 
clinical  cases,  including  frequently  the  appearance  on  post- 
mortem examination.  Probably  the  public  interest  taken 
in  the  King’s  illness  helped  to  stimulate  this  remarkable 
output.  The  volumes  are  full  of  interest,  containing  much 
that  is  wonderfully  modern,  yet  it  is  not  easy  to  enter  into 
the  spirit  of  the  age,  which  was  one  of  conflicting  doctrines, 
old  and  new. 

Blistering  and  Blood-letting . 

During  the  early  part  of  this  period  medical  treatment 
was  based  on  the  hypothesis  that  acute  insanity  was  due  to 
inflammation  of  the  brain  and  its  membranes  ; and  it  was 
considered  necessary,  by  whatever  method,  to  reduce  the 
supply  of  blood  to  the  brain.  This  can  be  illustrated  by  the 
treatment  of  George  III.  himself.  It  appears  that  his 
physicians  were  unanimous  only  on  one  occasion,  when  they 
decided  to  blister  the  King’s  legs  to  relieve  his  acute  excite- 
ment ! We  are  told  that  no  beneficial  result  seemed  to 
follow  this  operation. 

Similarly,  the  practice  of  blood-letting  was  considered  of 
great  value.  In  1811  Crowther,  the  surgeon  to  Bethlem, 
claimed  to  have  bled  150  patients  at  one  time,  without 
untoward  result.  He  also  recommended  emetics,  quoting  a 
case  of  hypochondriacal  melancholia  relieved  entirely  by 
their  use.  The  patient  took  61  vomits  in  the  course  of  six 
months,  and  for  18  nights  one  every  evening,  yet  made  a 
perfect  recovery  1 This  view  of  the  pathology  of  mania  was 
supported  by  the  post-mortem  findings,  which  frequently 
described  haemorrhagic  points  in  the  substance  of  the  brain 
The  Treatment  of  Insanity. 

The  treatment  of  insanity  was  founded  on  the  anti- 
phlogistic theory,  which  at  that  time  was  generally  held,  and 
we  must  not  pass  hasty  judgment  on  those  who  con- 
scientiously accepted  it.  In  our  own  times  theoretical 
considerations  have  suggested  methods  of  treatment  that 
may  be  criticised  adversely  by  our  successors.  For  instance, 
since  convalescents  frequently  possess  an  increased  number 
of  white  blood-cells,  it  has  been  suggested  that  an  artificial 
leucocytosis  might  promote  recovery,  and  turpentine  has 
been  injected  in  order  to  produce  an  abscess.  This  line 
of  treatment  is  founded  on  the  gratuitous  assumption  that 
the  leucocytosis  in  the  two  cases  is  similar  in  nature. 
The  underlying  thought  is  akin  to  that  of  Dr.  Joseph 
Mason  Cox,  who  recommended  inoculation  with  small-pox, 
or  the  itch,  and  who  said  in  his  “ Practical  Observations  on 
Insanity,”  published  in  1804  : — 

“Certain  it  is  that  if  any  considerable  commotion,  any  violent  new 
action,  can  he  excited  in  maniacal  complaints,  by  whatever  means,  the 
mental  derangement  is  often  permanently  improved.” 

This  little  book  formulates  the  teachings  of  the  whole  school 
very  concisely.  It  professes  to  state  rules  which  will  lead 
to  “a  more  humane  and  successful  method  of  cure,”  yet  it 
offends  the  modern  reader  from  start  to  finish.  We  are  told 
that  it  is  essential,  in  management,  to  procure  the  con- 
fidence of  the  patient,  or  to  excite  his  fear.  Pious  frauds 
are  recommended,  and  the  case  is  recorded  of  a gentleman 
who  imagined  that  his  housekeeper  had  tried  to  murder  him 
by  means  of  poison  in  his  shirts.  It  was  arranged  that  she 
should  be  arrested,  and  dragged  away  in  his  presence  ; a 
bogus  analysis  of  his  shirts  was  made,  which  confirmed  his 
suspicions  ; antidotes  were  prescribed,  and  he  recovered  in  a 
few  weeks. 

Still  more  objectionable  is  the  next  method,  which  Cox 
strongly  recommend^*— the  use  of  a circular  swing,  invented 
by  Dr.  Erasmus  Darwin,  by  means  of  which  a patient,  firmly 
strapped  down  on  a chair  or  a bed,  could  be  made  to  rotate 
round  a central  beam  at  any  desired  pace.  It  is  only  fair  to 

1 Abstract  of  the  Presidential  Address  to  the  annual  meeting  of  the 
Medico-Psychological  Association  of  Great  Britain  and  Ireland,  held  in 
York,  July  22nd,  1919. 


say  that  Cox  gives  most  impressive  instances  of  the  mar- 
vellous cures  accomplished,  apparently,  by  the  swing.  It 
was  recommended  by  many  other  physicians  of  experience, 
and  in  Morrison’s  lectures,  published  in  1828,  an  illustration 
of  it  was  given,  that  every  private  asylum  might  be  properly 
equipped. 

The  striking  change  in  the  treatment  of  the  insane  which 
began  in  the  eighteenth  century  can  be  traced  to  three 
causes.  First,  there  was  the  great  humanitarian  move- 
ment, which  awakened  sympathy  with  all  human  suffering  ; 
secondly,  there  was  the  gospel  of  liberty,  equality,  and 
fraternity  preached  in  France,  which  penetrated  even  to  the 
prison  asylums  of  Paris  ; and,  thirdly,  there  was  a gradual 
enlightenment  of  medical  opinion.  So  far  as  I can  ascertain, 
actual  priority  in  asylum  reform  belongs  to  Italy,  where, 
between  1774  and  1778,  Vincenzo  Chiarugi,  assisted  by 
Daquin  of  Chambery,  introduced  new  methods  in  Florence. 

But  the  premier  place  in  reform  belongs  to  Philippe  Pinel, 
who  not  only  transformed  the  conditions  at  the  Bicetre 
and  Saltpetrilre  in  Paris,  but  convinced  the  world  by  his 
writings  that  the  old  methods  were  wrong  and  futile.  His 
work  on  Mental  Alienation,  published  in  1801,  constituted 
a fresh  departure.  He  was  the  hero  of  a wonderful  chapter 
in  the  history  of  medicine,  especially  as  his  reforms  were 
carried  out  during  the  darkest  hours  of  the  French 
Revolution.  It  was  to  the  terrorist  Couthon,  who  sus- 
pected him  of  harbouring  aristocrats,  that  he  made  the 
remark  which  stands  true  for  all  time:  “Citizens,  I have 
a conviction  that  the  insane  are  only  intractable  because 
they  are  deprived  of  air  and  liberty  1 ” The  same  day  he 
removed  the  chains  from  50  of  his  patients. 

“ The  Retreat ,”  York. 

To  pass  to  our  own  country,  the  Retreat,  in  York,  was 
opened  in  1796,  long  before  Pinel's  work  was  known  here, 
through  the  united  efforts  of  William  Tuke  and  Lindley 
Murray,  both  members  of  the  Society  of  Friends.  The  latter 
contributed  much,  in  a quiet  way,  to  the  project  ; but  the 
energetic,  strong-minded  William  Tuke  actually  carried  it 
through  at  the  age  of  60,  and  in  spite  of  much  misunder- 
standing and  opposition.  Even  his  wife  is  reported  to  have 
said,  “ Thou  hast  had  many  children  of  thy  brain,  William, 
but  this  last  one  will  be  an  idiot  1 ” In  1812  his  grandson, 
Samuel  Tuke,  published  “ The  Description  of  the  Retreat,” 
and  Sydney  Smith  drew  attention  to  it  in  a delightful  essay, 
“ Mad  Quakers,”  which  appeared  in  the  Edinburgh  Review. 

The  Retreat  was  fortunate  in  its  first  physician,  Dr. 
Thomas  Fowler,  a man  of  keen  scientific  spirit,  devoted  to 
experimental  research.  He  introduced  the  solution  of 
arsenic  known  everywhere  as  Fowler’s  solution.  He  left  in 
manuscript  notes  of1  6000  cases,  recited  concisely  and 
without  bias,  both  failures  and  successes.  Any  drug  or 
therapeutic  agent  which  he  investigated  was  administered 
singly,  under  conditions  as  similar  as  possible,  but,  to 
quote  Tuke’s  description,  he  was  “led  to  the  painful  con- 
clusion, painful  alike  to  our  pride  and  to  our  humanity,  that 
medicine  as  yet  possesses  very  inadequate  means  to  relieve 
the  most  grievous  of  human  diseases.”  That  conclusion,  I 
fear,  still  holds  good. 

I should  not  like  to  convey  the  false  impression  that  the 
Retreat  was  the  only  institution  in  England  conducted  on 
humane  and  enlightened  principles  ; the  report  to  the  House 
of  Commons  in  1815  gives  a very  favourable  account  of 
Laverstock  House,  Salisbury,  and  Brislington  House,  Bristol. 
Both  Pinel  and  Tuke  stood  for  a complete  change  of 
outlook,  involving  not  merely  the  abandonment  of  brutal 
methods  of  coercion,  but  the  application  of  a new  principle, 
which  they  called  “ moral  treatment.”  By  this  they  claimed 
that  more  could  be  done  for  the  insane  than  by  drugs  and 
discipline.  They  asserted  that  the  psychical  environment  of 
a patient  was  no  less  important  than  his  physical  condition. 

Problems  of  To-day. 

To  come  to  some  of  the  problems  that  still  vex  us  to-day. 
A hundred  years  ago  only  three  sedative  drugs  were  in  use — 
opium,  hemlock,  and  henbane,  and  opinion  was  greatly 
divided  as  to  their  value.  Haslam  strongly  condemned 
opium,  while  Pinel  suggested  that  experiments  should  be 
made  in  the  use  of  various  drugs,  with  proper  attention  to 
the  specific  distinctions  of  insanity.  At  present  more  than  a 
hundred  sedatives  are  advocated  for  sleeplessness  or  mental 
excitement,  and  the  problem  of  their  use  is  more  complex 
than  ever  before.  It  is,  of  course,  recognised  that  chemical 


212  Thb  Lanoht,] 


PARIS. 


[August  2,  1919 


restraint  is  generally  hurtful,  that  drug  habits  are  easily 
acquired,  and  that  sedatives  dull  the  faculties  and  mask 
symptoms.  Moreover,  all  physicians  in  hospitals  for  the 
insane  know  that  many  newly  admitted  patients  will  not 
recover  until  the  hypnotics  given  before  admission  are 
withheld.  Yet,  even  now,  we  have  no  clear  and  satis- 
factory data.  The  extreme  opinion  of  Haslam  is  shared 
by  many  present-day  physicians.  Prominent  among  these 
is  Dr.  C.  K.  Hitchcock,  formerly  the  medical  super- 
intendent of  Bootham  Park,  York,  who,  in  1900,  pub- 
lished a striking  article  in  the  Journal  of  Mental  Science, 
summarising  the  results  of  treating  206  cases  of  acute  mania 
with  no  sedatives  whatever.  During  the  period  in  which  he 
refrained  from  their  use  the  rate  of  recovery  was  a high  cne. 

At  the  Retreat  we  only  use  narcotics  when  ordinary 
measures  have  long  been  persevered  with  and  have  failed. 
It  is  only  fair  to  say  that  in  some  exceptional  cases  great 
benefit  has  seemed  to  follow.  Sometimes  the  intensity  of 
mental  suffering  calls  for  immediate  relief,  even  if  only 
temporary.  The  problem  is  to  find  out  the  value  and  the 
limitations  of  sedative  drugs.  I think  that  members  of  our 
association  could  investigate  this  problem  to  good  purpose. 
Our  patients  live  under  very  uniform  conditions ; in  the 
nursing  staff  we  have  trained  observers,  and  the  inquiries 
could  be  conducted  on  a sufficiently  large  scale  to  eliminate 
many  disturbing  factors.  At  the  outset  it  would  seem 
advisable  to  limit  the  inquiry  to  groups  of  cases  in  which 
psychical  factors  in  aetiology  are  of  secondary  importance, 
such  as  acute  delirium,  the  nocturnal  excitement  in  senile 
insanity,  or  the  agitated  melancholia  of  the  climacteric.  Two 
such  groups  might  be  compared,  one  taking  no  drug,  the 
other  any  drug  that  might  be  selected.  I am  sure  that 
results  thus  obtained  would  be  of  greater  value  than  the 
individual  opinions  of  even  the  most  observant  people. 

The  Drink  Question. 

Another  problem  which  confronted  physicians  at  the 
beginning  of  the  nineteenth  century  is  still  painfully 
present  with  us.  It  is  the  alcohol  problem.  The  wastage 
from  intemperance  is  incalculable,  yet  we  face  increasing 
industrial  competition  with  nations  such  as  the  United 
States,  which  are  relatively  abstemious.  The  word  inebriate 
is  unfortunate,  as  it  suggests  actual  drunkenness,  whereas 
there  may  be  dangerous  alcoholic  addiction  without  gross 
signs  of  intemperance.  This  morbid  condition,  of  course,  is 
essentially  the  concern  of  psychiatry.  It  is  virtually  a 
disease,  although  when  the  exciting  cause  is  removed  no 
symptoms  may  be  discovered. 

Experience  tells  us  that  the  potential  inebriate  should  be 
treated  early,  or  there  will  be  no  hope  of  preventing  con- 
firmed addiction.  But  the  Inebriate  Acts  are  practically 
useless  in  the  first  stages  of  the  disorder.  If  early  treatment 
is  to  be  obtained  it  must  clearly  be  on  a voluntary  basis 
and  in  strict  privacy,  for  no  one  can  afford  to  be  branded 
as  an  alcoholic. 

If  the  suggestion  of  Mr.  Theodore  Neild,  of  Leominster, 
were  adopted,  and  a consultation  bureau  were  established  in 
every  large  centre,  much  might  be  done. 

Clinics  for  Early  Treatment  of  Mental  Cases. 

But  inebriety  and  drug  addiction  should  not  be  considered 
apart  from  other  forms  of  mental  instability.  The  legis- 
lature is  taking  up  the  subject  of  the  establishment  of 
clinics  or  hospitals  which  will  provide  early  treatment  for 
unconfirmed  mental  trouble  ; and  the  proposed  consultation 
bureaus  might  be  affiliated  with  these  new  clinics  or  form  a 
special  department  of  them. 

Unfortunately,  many  patients  decline  all  treatment  and 
refuse  any  advice.  For  these  some  form  of  compulsion 
should  be  possible.  I suggest  that  any  new  laws  relating  to 
inebriety  might  provide  three  separate  procedures  in  dealing 
with  such  patients.  First,  a judicial  warning,  which  might 
be  given  privately,  when  the  justice  has  satisfied  himself 
that  the  patient  is  in  grave  danger  of  alcoholic  or  drug 
addiction.  Secondly,  if  warning  and  advice  failed,  the 
appointment  of  a guardian,  who  would  be  legally  authorised 
to  stop  supplies,  to  forbid  the  sale  of  liquor  to  the  patients, 
and  to  restrict  his  liberty  within  prescribed  limits.  Thirdly, 
internment  in  a farm  colony  or  other  approved  home. 

Progress  of  Psyohiatry. 

In  comparing  the  psychiatry  of  120  years  ago  with  that  of 
to-day  it  would  be  easy  to  show  that  progress  has  been  slow 


and  disappointing.  No  specific  treatment  of  mental  disease 
has  been  discovered,  save  in  the  case  of  that  arising  from 
thyroid  insufficiency ; and  it  is  doubtful  whether  the 
recovery  rate  has  improved.  It  is  probable  that,  a century 
since,  the  condition  of  patients  in  the  more  enlightened 
institutions  did  not  greatly  differ  from  their  condition 
to-day. 

The  medical  literature  of  that  period,  moreover,  contains 
much  that  anticipates  modern  teaching.  Haslam,  for 
instance,  describes  both  dementia  prsecox  and  general 
paralysis.  The  essential  mystery  of  mental  disease  baffles 
us  now  as  it  did  then.  Nevertheless,  we  have  achieved 
a great  deal.  A vast  amount  of  progress  has  been  made  in 
the  anatomy  and  physiology  of  the  nervous  system,  in  patho- 
logy, bio-chemistry,  and  in  many  departments  of  science 
which  intimately  affect  our  subject. 

War  Neuroses. 

The  war  has  thrown  some  light  upon  one  aspect  of  it. 
We  have  learned  that  symptoms  formerly  termed  hysterical 
or  functional  are  not  peculiar  to  the  frail  or  sensitive,  but 
occur  in  strong  men,  that  they  continue  long  after  any 
recognised  exciting  cause  has  ceased  to  operate,  and  that 
they  frequently  disappear  suddenly  as  if  charmed  away. 
Unfortunately,  we  cannot  analyse  the  causes  of  their  dis- 
appearance, which  is  ascribed  to  multifarious  agencies, 
suggestion,  psycho-analysis,  faith-healing,  hypnotism,  and 
ordinary  hygienic  measures.  There  is  no  organic  lesion, 
and  the  illness,  though  often  accompanied  by  physical 
disability,  is  clearly  a disorder  of  the  mind  rather  than  the 
body.  There  is  urgent  need  to  establish  a scientific  therapy, 
that  appropriate  treatment  may  be  selected  with  confidence. 

We  have  learned,  too,  that  the  functional  element  in 
definite  organic  maladies  must  not  be  overlooked.  Patients 
with  certain  diseases,  such  as  disseminated  sclerosis,  fre- 
quently present  symptoms  that  do  not  correspond  to  the  [ 
extent  of  the  organic  lesion. 

Conclusions. 

These  observations  may  throw  some  light  on  various 
problems  of  psychiatry.  Do  not  many  of  our  sudden 
recoveries  correspond  to  the  recoveries  in  the  psycho-  j 
neuroses  ? Are  not  many  of  our  chronic  cases  akin  to  that 
of  the  confirmed  neurotic,  with  this  difference,  that  in  the 
one,  the  disordered  function  affects  intelligence  and 
emotion,  and  in  the  other  some  lower  nervous  mechanism 
such  as  vision  and  muscular  coordination  1 This  thought,  of 
course,  does  not  carry  us  far,  but  it  suggests  that  the  study 
of  hysterical  phenomena  may  help  us  greatly,  and  it  reminds 
us  to  lay  due  stress  on  psychical,  as  well  as  physical,  factors,  , 
in  the  aetiology  of  mental  disease,  the  attempt  to  separate 
mental  and  bodily  factors  must  inevitably  lead  to  error,  ‘ 1 
since  they  constantly  react  on  one  another. 

Be  this  as  it  may,  we  have,  at  any  rate,  left  behind  the 
doctrine  expressed  in  the  dictum:  “All  insanity  is  either 
toxic  or  traumatic.”  Just  as  Tuke  and  Pinel  considered 
moral  treatment  of  paramount  importance  in  promoting  ] 
recovery,  so  we  recognise  the  profound  importance  of  mental 
strain  in  the  causation  and  development  of  certain  forms  of  ! 
mental  disorder. 


PARIS. 

(From  oxjr  own  Correspondent.) 

Mobilised  Students  and  their  Medical  Studies. 

War  has  left  cruel  gaps  in  the  student  ranks  of  all 
professions,  especially  perhaps  of  medicine,  for  all  young 
robust  medical  students  were  sent  to  the  very  front, 
whether  to  the  aid-posts  or  among  the  squads  of  stretcher 
bearers.  The  survivors  are,  on  account  of  their  age,  still 
mobilised  for  one  or  two  years,  since  the  term  of  compulsory 
service  is  three  years.  A large  number  of  older  students 
due  for  more  or  less  immediate  demobilisation  are  kept, 
since  the  armistice,  by  the  Army  of  Occupation  in  Germany. 
The  War  Minister,  at  the  request  of  the  heads  of  the  medical 
profession,  has  repeatedly  taken  steps  to  ensure  the  return 
of  these  students  and  the  completion  of  their  term  of  service 
in  a town  with  a medical  school.  In  December,  1918,  he 
gave  instructions  for  the  recall  of  all  students  mobilised 
54  months — i.e. , already  in  military  service  before  the  war — 
and  of  others  mobilised  51-53  months  who  had  served 


The  Lancet,] 


WOMAN  IN  INDUSTRY. 


[August  2,  1919  213 


32  months  or  more  in  a company  of  infantry  or  a squad 
of  stretcher  bearers,  or  had  been  wounded  short  of  being 
invalided  out.  Unfortunately,  these  limited  measures  affect 
only  a handful  of  individual  students.  The  Ministry  of  War  is, 
in  fact,  placing  great  obstacles  in  the  way  of  their  repatriation. 
A recent  decision,  ostensibly  an  improvement  on  the  earlier, 
introduces  only  nominal  alterations.  It  adds  to  the 
categories  already  cited  medical  students  of  any  age 
posted  to  other  duties  than  those  of  the  Service  de  Santo 
— students,  that  is,  who  preferred  to  enter  the  infantry, 
artillery,  or  air  force  to  making  use  of  their  medical  training 
— a very  limited  number  in  all.  The  medical  societies  and 
faculties  have  resolved  that  all  medical  students  without 
exception  shall  be  recalled  to  continue  their  medical  service 
at  some  town  containing  a medical  faculty,  where  they  can 
pursue  their  studies  and  still  perform  garrison  duty. 

Requisition  of  Civil  Doctors. 

To  ensure  medical  care  in  regions  deprived  of  doctors  by 
mobilisation  the  Ministry  of  War  during  the  two  years  pre- 
ceding the  armistice  had  charged  with  this  service  mobilised 
medical  men  of  the  later  age-groups.  These  men  are  now 
almost  all  demobilised,  and  in  order  to  supply  their  place  in 
localities  where  the  population  is  scanty  or  largely  indigent 
the  Minister  has  decided  to  avail  himself  of  the  service  of 
civil  volunteers,  offering  them  a monthly  stipend  of  300  fr., 
capable  of  increase  in  exceptional  cases. 

Acoustic  Troubles  in  Musicians. 

Dr.  Castex  has . published  an  intriguing  study  of  the 
auditory  disturbances  found  in  musicians.  These  are  not 
infrequent,  but  the  author  has  failed  to  determine  whether 
the  practice  of  the  musician  constitutes  an  actual  pre- 
disposition in  comparison  with  other  occupations.  He 
recognises  that  the  hearing  of  musicians  acquires  a special 
acuity,  a fact  sufficient  perhaps  to  explain  its  fragility. 
Certain  musicians,  for  example,  perceive  at  the  same  time 
as  the  note  struck  the  whole  gamut  of  natural  overtones. 
Among  the  disturbances  noted  by  M.  Castex,  some  concern 
the  timbre,  others  the  pitch,  and  others  again  the  intensity 
of  the  sound.  Sometimes  a slight  degree  of  sclerosis  only 
allows  of  the  perception  of  shrill  notes  or  of  the  deep  tones 
of  the  brasses.  In  other  cases  there  is  double  audition,  the 
two  ears  perceiving  a different  note,  the  interval  between 
them  varying  from  a semitone  to  an  octave.  Others  are 
victims  of  persistence  of  the  notes,  as  though  the  loud  pedal 
of  the  piano  is  depressed.  Modifications  of  timbre  make 
the  tone  metallic  or  nasal  in  quality.  Painful  increase  in 
audition  is  not  uncommon  an  ong  deaf  musicians.  They  may 
fall  in  a faint  as  a result  of  intensely  loud  notes  (organ, 
fanfare  of  trumpets),  when  the  ear  has  lost  its  damping 
mechanism.  The  prognosis  of  these  affections  depends  on 
the  fleeting  character  or  otherwise  of  the  auditory  affection, 
but  it  is  to  be  noted  that  incomplete  deafness  does  not 
prevent  a good  musician  from  appreciating  the  diverse  turns 
and  qualities  of  notes.  On  the  deafness  of  celebrated 
musicians,  Jean  Jacques,  Schumann  (obsessed  by  a fa), 
Beethoven  himself,  it  is  difficult  to  express  an  opinion  in 
the  absence  of  a technical  examination,  but— and  therein  is 
well  seen  the  secondary  role  in  music  of  the  sense  of  hearing 
— the  finest  works  of  the  master  were  written  after  he  had 
become  finally  deaf,  when  (as  he  wrote  himself)  “ he  knew 
the  divine  hour  in  which  the  composer  hears  nought  but  his 
musical  inspirations.” 


„ Death:  of  the  Hon.  Taraveth  Madavan  Nair, 
M.D.  Edin  — Dr.  Taraveth  Nair,  who  died  in  London  recently, 
was  prominent  in  Madras  both  as  a medical  man  and  a 
political  thinker.  Educated  at  the  University  of  Edinburgh 
he  graduated  M.B.,  C.M.,  in  1894,  and  was  for  some  time 
house  surgeon  at  the  Sussex  Throat  and  Ear  Hospital, 
Brighton.  In  1896  he  proceeded  to  the  M.D.  and  C M 
degrees  of  his  university,  and  on  his  return  to  India  he 
became  a political  leader  with  no  little  influence.  He 
in  London  a few  weeks  ago  in  a serious  condition  of 
aealth,  and  succumbed  to  diabetes,  a disease  on  which  as 
recently  as  1914  he  had  published.  This  book  is  a con- 
scientious  and  careful  summary  of  our  present  knowledge 
ana  theories.  In  consequence  of  the  frequency  of  diabetes 
m India  Dr.  Nair  was  of  the  opinion  that  organised  research 
'-nto i the  aetiology  and  pathology  of  the  disease  ought  to  be 
conducted  in  that  country  on  the  lines  of  the  anti- 
tuberculosis campaign  in  England. 


WOMAN  IN  INDUSTRY. 

(Concluded  from  ]>.  Wit.) 


Last  week  we  summarised  the  memorandum  by  Dr.  Janet 
Campbell  on  the  Health  of  Women  in  Industry,  forming  part 
of  the  comprehensive  Report  of  the  War  Cabinet  Committee 
on  Women  in  Industry  (Cmd.  135,  price  1*.  6 d.),  dealing 
then  with  the  effect  of  industrial  employment,  first,  on  the 
personal  health  of  the  woman  worker  and,  secondly,  on  the 
function  of  motherhood.  There  remains  for  notice  the 
important  section  of  the  memorandum  bearing  on  the  means 
for  mitigating  the  admitted  evils,  and  here,  as  before,  we 
follow  closely  the  actual  words  of  Dr.  Campbell’s  very  clear 
exposition. 

IV.  Safeguards  and  Remedies. 

During  the  war  the  employment  of  women  has  been 
greatly  modified.  The  number  of  employed  women  has 
increased,  they  have  been  employed  as  substitutes  for  men 
in  men’s  work,  restrictions  with  regard  to  hours  have  been 
removed — overtime  being  general  at  the  beginning  of  the 
war  and  night-shifts  usual  throughout— and  wages  have 
increased  to  subsistence  level  in  almost  all  cases  and  in 
excess  of  this  in  some.  The  result  of  these  changes  on  the 
health  of  women  workers  has  been  summed  up  in  a number 
of  memoranda  and  reports  which  have  been  issued  by  the 
Health  of  Munition  Workers  Committee.  An  examination 
was  undertaken  by  this  committee  of  2500  munition  workers 
with  a view  to  ascertaining  the  effects  of  employment  on 
their  health.  The  actual  findings  were  summed  up  as 
follows  : — 

(1)  That  there  is  a definite  burden  of  fatigue  which,  though 
relatively  small  in  amount  as  regards  severe  fatigue,  is  con- 
siderable as  regards  that  of  a less  severe  character. 

(2)  That  the  fatigue  and  ill-health  are  less  than  might  have 
been  anticipated,  having  regard  to  the  hours  of  work  and  the 
nature  of  the  employment,  and  that  this  is  due,  broadly 
speaking,  to  the  greatly  improved  attention  to  the  health 
and  welfare  of  the  workers. 

(3)  That  fatigue  and  sickness  are  greatest  where  heavy 
work  is  combined  with  long  hours  at  the  factory  and  asso- 
ciated with  onerous  domestic  duties  after  factory  hours. 

(4)  That  unless  brought  under  control  the  considerable 
amount  of  moderate  weariness  and  ill-health  now  present 
is  likely  to  reduce  immediate  efficiency,  and  also  exercise, 
in  many  cases,  an  injurious  effect  on  subsequent  health  and 
on  capacity  for  maternity. 

Dr.  Campbell’s  comment  on  these  findings  is  as  follows  : — 

1 ‘ The  fact  that  the  women  were  able  to  stand  the  work  as  well 
as  they  did  was  attributed  (a)  to  good  wages,  enabling  them 
to  feed  and  clothe  themselves  -properly  ; (b)  to  healthy  con- 
ditions in  the  factories ; and  (c)  to  welfare  and  health 
supervision,  including  the  provision  of  protective  clothing,- 
canteens,  rest-rooms,  surgeries  and  medical  advice.  It  may 
confidently  be  asserted  that  if  similar  demands  had  been 
made  upon  women  working  under  pre-war  factory  con- 
ditions they  could  not  have  been  met  to  the  same  extent, 
if,  indeed,  they  were  met  at  all,  without  causing  an 
immensely  greater  amount  of  fatigue  and  permanent  injury 
to  the  health  of  women  and  girl  workers.  As  it  was,  most 
women  enjoyed  the  more  interesting,  active  and  arduous 
occupations,  and  in  many  cases  their  health  improved 
rather  than  deteriorated.  Medical  officers  of  factories  and 
welfare  supervisors  have  pointed  out  the  beneficial  effects 
of  open-air  conditions  (yard  work,  trucking  in  filling  factories, 
&c.)  on  the  general  health,  and  the  success  with  which 
properly  selected  women  have  undertaken  work  involving 
the  lifting  of  weights,  heavy  machine  work,  and  even  forge 
and  foundry  work,  without  untoward  physical  consequences. 
The  whole  experience  tends  to  show  that  light  sedentary 
work  is  not  by  any  means  always  the  most  suitable  for 
women,  that  operations  involving  a change  of  posture  are 
preferable,  and  that,  given  adequate  nutrition,  many  women 
would  have  better  health  and  greater  physical  vigour  if  they 
followed  more  active  occupations.” 

Restrictions  on  Women's  Labour. 

The  question  of  restrictions  on  women’s  labour  then  claims 
attention.  The  Health  of  Munition  Workers  Committee 
examined  a number  of  witnesses  on  this  point. 

Various  of  these  witnesses,  Dr.  Campbell  tells  us,  urged  the 
abolition  of  all  special  protective  legislation  for  women  after 


214  The  Lancet,] 


WOMAN  IN  INDUSTRY. 


[August  2,  1919 


the  war.  They  consider  that  women  ought  not  to  be  prevented 
on  physical  grounds  from  entering  any  trades  open  to  men 
(unless  sex  injury  can  be  proved,  as  in  the  case  of  lead  poison- 
ing), or  from  working  similar  hours  to  men,  or  from  engaging 
in  night-work.  It  is  suggested  that  the  conditions  of  employ- 
ment should  be  improved  for  men  and  women  equally  and 
that  it  is  unfair  to  handicap  a woman  economically  by 
restricting  the  conditions  under  which  she  may  work.  There 
is  some  truth  in  these  arguments,  but,  on  the  other  hand,  it 
should  be  remembered  that  women  as  a class  are  still,  unfor- 
tunately, unorganised  and  therefore  in  a far  more  helpless 
position  than  men  in  the  face  of  unreasonable  demands  on 
the  part  of  unscrupulous  employers  ; to  abandon  all  restric- 
tive legislation  might  still  lead  to  the  exploiting  of  women 
and  the  return  of  some  of  the  abuses  which  this  legislation 
was  designed  to  remove.  The  women  factory  inspectors 
examined  were  unanimous  in  desiring  the  re-imposition  of 
some  restriction  of  women’s  labour,  though  it  was  considered 
that  a revision  of  the  Factory  Acts  was  desirable. 

Shorter  Hours. 

The  general  opinion  of  the  witnesses  examined  appeared 
to  be  that  a 44-hour  week  was  advisable  for  women,  with  a 
Saturday  half-holiday.  Attention  was  called  to  the  advantage 
of  a short  break  in  the  morning  spell,  especially  when  work 
begins  early  and  where  there  is  no  breakfast  interval,  as 
workers  often  have  no  time  for  a proper  meal  before  leaving 
home.  In  the  Report  of  the  Chief  Inspector  of  Factories 
and  Workshops  for  1917,  which  Dr.  Campbell  quotes,  Mr. 
Bellhouse  discusses  the  advisability  of  commencing  work 
after  instead  of  before  breakfast,  and  sets  out  the  following 
results  of  the  experiment  at  Paisley,  which  are  typical  of 
the  findings  elsewhere  : — 

(1)  Bad  time-keeping  in  the  morning  has  almost  dis- 
appeared. 

(2)  Sickness  amongst  the  girls  in  the  first  hours  of  the 
morning,  which  was  common  when  work  started  at  6 A.M., 
has  largely  ceased. 

(3)  Reduction  in  output  is  hardly  noticeable  in  depart- 
ments where  it  depends  on  the  activity  of  the  worker,  and 
not  in  proportion  to  the  drop  of  one  hour  per  day,  even  in 
departments  where  output  depends  chiefly  upon  machine 
hours. 

(4)  Better  work  is  secured  and  maintained. 

The  conclusion  drawn  is  the  eminently  reasonable  one  that 
shorter  hours  would  result  in  better  time-keeping,  especially 
where  married  women  are  concerned,  and  that  in  most  trades 
and  processes  output  would  not  suffer  and  might  even 
improve. 

Night  Work. 

Night- work,  also,  comes  in  for  its  share  of  condemnation  in 
Dr.  Campbell’s  memorandum.  The  conclusion  arrived  at  from 
the  examination  of  competent  witnesses  was  that  it  should 
not  be  permitted  to  women  after  the  war,  and,  in  the  case  of 
men,  it  might  also  be  injurious  and  should  never  be  resorted 
to  except  in  case  of  necessity.  Night-shifts,  and  especially 
permanent  night-shifts,  Miss  Martindale  pointed  out,  were 
particularly  harmful  to  women  with  domestic  responsibilities, 
as  it  was  more  difficult  for  them  to  obtain  adequate  sleep  ; 
they  invariably  did  their  own  house  work  during  the  day  and 
their  rest  was  subject  to  continued  interruption ; their 
work  became  inferior  in  quality  and  their  health  suffered. 
Evidence  showed  that  overtime  had  an  injurious  effect  on 
workers,  and,  if  continued  for  a long  period,  reduced  rather 
than  increased  the  output.  It  was  particularly  injurious  to 
girls  of  14  to  16  years  of  age  and  to  women  between  30 
and  40. 

Although  some  regulation  of  women’s  labour  is  thus  likely 
to  be  continued  after  the  war,  Dr.  Campbell  foresees  the 
time  when  the  need  for  special  protection  for  women  and 
girls  will  disappear  in  large  measure,  a revision  of  the 
existing  Factory  Acts  leading  to  a levelling-up  of  the  con- 
ditions under  which  men  work  to  the  standard  which  is  now 
considered  desirable  for  women. 

Medical  Supervision. 

The  whole  position  in  regard  to  medical  supervision  is  then 
surveyed.  Provision  for  medical  inspection  and  supervision 
has  already  been  made  by  the  local  education  authority  for 
persons  up  to  18  years  of  age.  It  is  presumed  that  every 
boy  and  girl  will  have  been  under  regular  medical  care  and 
supervision  during  the  whole  of  school  life  and  will  have 
received  treatment  for  such  physical  defects  as  have  revealed 


themselves.  With  regard  to  industrial  workers  direct  super- 
vision was  almost  non-existent  before  the  war.  Experience 
of  war  conditions  has  emphasised  the  need  for  more  effective 
supervision  and  for  energetic  research  into  the  causes  of 
industrial  fatigue  and  the  methods  of  preventing  disease 
directly  or  indirectly  due  to  occupation.  Factory  hygiene 
must,  indeed,  become  an  integral  part  of  the  general  system 
of  preventive  medicine,  which  is  likely  to  be  the  most 
important  branch  of  medicine  of  the  future.  For  this 
purpose  an  adequate  service  of  factory  medical  officers  is 
needed,  having  no  duties  of  treatment,  but  charged  with  the 
general  oversight  of  factory  conditions,  hygiene,  and  health. 
With  this  may  be  associated  the  “welfare”  service  in 
individual  factories,  responsible  to  the  factory  management, 
and  partly  occupied  in  carrying  out  recommendations  made 
in  regard  to  the  health  of  the  workers. 

The  duties  of  the  factory  medical  officers,  as  sketched 
out  in  the  memorandum,  comprise  the  supervision  of 
(a)  the  general  hygiene  of  the  factory,  including  sanitation, 
ventilation,  lighting,®  heating,  fcc.  ; (b)  the  particular 

hygiene  of  processes  likely  to  involve  hazard,  discomfort, 
or  injury  to  workers ; (e)  the  maintenance  of  surgeries, 
first-aid  equipment,  rest-rooms,  &c  ; and  (d)  the  general 
health  and  welfare  of  the  workers,  men,  women,  and  young 
people,  with  particular  regard  to  the  conditions  under  which 
women  and  young  people  are  employed.  Further,  it  should 
be  the  duty  of  the  factory  doctors  to  investigate  and  report 
upon  any  trades,  processes,  or  forms  of  work  which  appear  to 
lead  to  general  or  specific  ill-health  or  to  shorten  unduly  the 
lives  of  workers  employed  therein.  They  should  act  in  an 
advisory  capacity  only,  and  should  not  undertake  the  treat- 
ment of  disease  in  any  form. 

As  to  the  administration  of  factory  supervision  Dr. 
Campbell  writes : — 

‘ ‘ Such  a service  might  conceivably  be  established  centrally 
under  the  Home  Office,  and  locally  under  the  sanitary 
authority.  This  would  presumably  entail  the  formation  of 
a strong  central  Medical  Department  at  the  Home  Office, 
staffed  by  men  and  women  doctors,  and  the  appointment  of 
a considerable  number  of  medical  officers  (women  as  well  as 
men)  to  act  as  local  medical  inspectors  of  factories.  The 
nucleus  of  such  a service  might  possibly  be  drawn  from  the 
ranks  of  the  certifying  factory  surgeons,  whose  present 
duties  would  obviously  be  superseded  in  one  direction  by  the 
school  medical  officers,  and  in  the  other  by  the  factory 
medical  inspectors.  The  suggested  means  of  providing  for 
the  medical  inspection  of  factories  would  make  it  necessary 
to  enlarge  the  powers  and  duties  of  the  medical  officer  of 
health  in  connexion  with  factories  and  to  provide  him  with  a 
sufficient  staff  to  undertake  their  adequate  inspection  and 
supervision,  this  branch  of  his  work  being  under  the  general 
control  of  the  Home  Office  in  much  the  same  way  as  the 
medical  officer  of  health  in  his  capacity  of  school  medical 
officer  is  under  the  supervision  of  the  Board  of  Education. 
Such  an  arrangement  would  have  the  obvious  advantage  of 
combining  in  one  local  administration  the  whole  of  the 
powers  and  duties  relating  to  health  in  any  one  area,  of 
preventing  overlapping  of  function,  and  of  promoting  smooth 
and  rapid  action.” 

Concerning  ante-natal  and  post-natal  employment,  such 
evidence  as  there  is  suggests  that  suitable  employment  under 
reasonably  good  conditions  is  beneficial  rather  than  harmful. 

As  the  result  of  an  investigation  undertaken  by  the 
Women's  Industrial  Council  into  the  “ quality  of  maternity  ” 
in  relation  to  industrial  occupation,  it  was  stated  that  there 
was  practically  nothing  to  choose  in  quality  of  maternity  | 
between  those  who  went  to  work  and  those  who  stayed  at 
home.  Medical  witnesses  agreed  that  light  factory  work 
was  not  in  itself  objectionable,  and  that  it  was  better  for  a 
woman  to  work  than  to  be  under-fed. 

For  the  sake  of  the  mother  and  the  child  it  is  clearly 
desirable,  the  Memorandum  states,  that  the  mother  should 
have  not  less  than  one  month  of  ease  and  comfort  in  order 
to  complete  her  own  recovery,  and  that  she  should  be  in  a 
position  to  nurse  her  child  for  the  normal  period.  No  | 
extension  of  Section  61  of  the  Factory  and  Workshop  Act  of 
1901  will  in  itself  secure  this  unless  at  the  same  time 
financial  assistance  is  given  to  the  mother  to  enable  her  to 
remain  at  home  without  anxiety. 

Grants  in  Aid  of  Maternal  and  Infant  Welfare. 

In  order  that  women  might  be  enabled  to  refrain  from  work 
at  least  sufficiently  long  after  their  confinements  as  to  ensure 


The  Lancet,] 


URBAN  VITAL  STATISTICS. 


[August  2,  1919  215 


the  proper  care  of  their  infants,  it  was  suggested,  in  the 
■evidence  taken  by  the  Health  of  Munition  Workers  Com- 
mittee, that  the  desired  end  could  be  reached  by  means  of 
adequate  grants  in  aid. made  to  the  mother  at  the  time  of  and 
subsequent  to  her  confinement.  It  was  the  general  opinion 
that  these  grants  should  be  non-contributory,  that  they 
should  be  available  for  all  women  below  the  income-tax 
limit  (some  witnesses  preferred  to  impose  no  limit),  that 
they  should  preferably  cover  a period  of  nine  months  after 
confinement  and  perhaps  one  or  two  months  before,  but  if 
the  cost  of  this  was  prohibitive,  that  they  should  be  for 
periods  of  six  or  three  months  after  confinement,  the  three 
months  after  being  regarded  as  the  most  vital  period.  It  was 
recommended  that  a mother  in  receipt  of  grants  should  be 
prohibited  from  seeking  employment  away  from  home. 

The  probable  expenditure  involved  in  several  alternative 
schemes  was  estimated.  If  grants  were  given  it  was  con- 
sidered that  they  should  be  available  for  all  women  now 
entitled  to  maternity  benefit,  and  to  these  should  be  added 
the  wives  of  men  who  were  excepted  from  insurance  under 
the  Act,  as  there  would  be  no  logical  reason  for  excluding 
them,  and  their  need  was  often  great.  This  would  cost  the 
Exchequer  between  5 and  6 millions  a year  if  the  benefit 
was  available  for  a period  of  six  weeks,  and  between  11 
and  13  millions  a year  if  it  was  available  for  13  weeks.  It 
should  not  be  forgotten  that  these  grants  would  necessarily 
be  supplementary  to  the  existing  benefits  under  the  National 
Insurance  Act. 

The  specific  objects  of  the  proposed  grants  would  be,  in 
Dr.  Campbell’s  words 

(a)  To  ensure  efficient  midwifery  and  nursing  at  the  time 
of  the  confinement,  and  thus  to  prevent  avoidable  injury  to 
the  mother’s  own  health  or  to  the  infant. 

(i b ) To  enable  the  mother  to  secure  adequate  nutrition 
and  to  obtain  the  period  of  rest  necessary  for  complete 
recovery  after  confinement. 

(c)  To  reduce  infant  mortality  by  ensuring  as  far  as 
possible  regular  breast-feeding  and  the  personal  care  of  the 
mother. 

The  Memorandum  does  not  rashly  assume  that  the  grants 
would  have  these  desirable  effects.  If  the  professional 
fee  were  increased  it  does  not  follow  that  more  efficient 
treatment  would  be  obtained,  and  money  spent  on  the 
untrained  nurse  or  handy-woman  is  useless  if  the  intention 
of  the  grant  is  to  ensure  skilled  nursing.  It  is  also  doubtful 
whether  grants  would  make  a substantial  difference  on  the 
infant  mortality  rate  apart  from  improvements  in  domestic 
hygiene,  housing,  and  environment. 

What  actual  difficulties  might  arise  in  practice  the  Memo- 
randum frankly  discusses,  and  with  a transcript  of  these 
passages  we  close  our  survey  : — 

“ The  administration  of  such  grants  would  be  difficult  and 
costly.  At  present  there  is  no  machinery  for  this  purpose, 
though  a nucleus  might  be  found  in  the  staff  of  the  local 
sanitary  authority.  Presumably  the  grants  would  depend 
on  the  continued  breast-feeding  of  the  infants,  a matter  not 
easy  to  prove.  Visits  of  inspectors  (possibly  health  visitors) 
to  the  home,  or  of  the  mother  to  the  maternity  or  infant 
welfare  centres  would  be  necessary,  but  even  so,  little 
control  could  be  exercised  over  the  spending  of  the  money, 
especially  in  the  later  months.  If  the  grants  covered  a period 
of  six  months  or  longer  no  mother  could  be  expected  to  spend 
the  money  on  herself  or  on  her  own  food,  it  would  almost 
necessarily  be  merged  into  the  family  income.  The  family, 
as  a whole,  would  gain  in  consequence,  but  though  this 
would  be  a valuable  result  as  far  as  it  went,  it  would  not  be 
fulfilling  the  express  purpose  of  the  grants  and  might  be 
obtained  more  satisfactorily  in  other  ways. 

“ On  the  whole,  the  precise  effect  it  is  desired  to  obtain 
would  either  not  be  obtained  or  would  be  obtained  only  in 
part,  while  the  cost  of  the  improvement  made  in  maternal 
health  and  infant  welfare  would  probably  be  out  of  all 
proportion  to  the  results. 

“The  main  criticisms  in  regard  to  maternity  benefit  are 
that  it  is  an  ad  hoc  unsupervised  grant,  entirely  unrelated  to 
municipal  provision  for  maternal  welfare  and  not  available 
for  a certain  number  of  women  who  are  perhaps  particularly 
in  need  of  it.  Further,  it  is  administered  under  the  Insur- 
ance Act  by  Approved  Societies  and  not  by  the  sanitary 
authority.  Instead  of  setting  up  a new  system  of  maternity 
grants  overlapping  the  existing  maternity  benefit  and 
administered  by  another  Department  of  State,  maternity 


benefit  should  be  transferred  to  the  sanitary  authority  ; it 
should  be  placed  on  a non-contributory  basis,  made  avail- 
able for  all  women  under  the  income-tax  limit  and  increased 
to  at  least  the  60s.  now  paid  to  the  employed  wives  of  insured 
men. 

“ It  is  idle  to  expect  much  improvement  in  the  professional 
care  of  the  mother  and  child  until  we  have  wholly  efficient 
medical  and  midwifery  services,  in  addition  to  a more  just 
and  equitable  distribution  of  maternity  benefit.  Such 
services  could  only  be  organised  under  a competent  health 
authority.  It  is  essential  that  the  mother  should  be  able  to 
secure  a doctor  or  midwife,  whichever  she  prefers,  whose 
qualifications  in  this  respect  are  beyond  dispute.  Further, 
there  should  be  a full  exercise  by  the  sanitary  authority  of 
the  powers  which  already  exist  for  the  provision  of  food  and 
milk,  advice  and  treatment  for  mother  and  child,  health 
supervision,  &c.,  and  their  extension  as  and  when  found 
necessary. 

“It  is  submitted  that  the  provision  of  large  grants  in  aid, 
with  no  assurance  that  they  will  be  applied  to  the  specific 
purposes  for  which  they  were  awarded,  is  an  unscientific 
method  of  dealing  with  the  problem  of  maternal  and  infant 
welfare,  and  that  in  any  case  to  give  such  grants  before 
securing  an  adequate  health  and  medical  service  is  unsound 
administration.  If  grants  or  pensions  in  addition  to  a 
revised  maternity  benefit  prove  to  be  necessary,  it  would  be 
suitable  to  entrust  the  administration  of  such  grants  to  the 
central  and  local  health  authorities  responsible  for  the  public 
health  service.” 

In  this  short  account  of  the  Memorandum  many  inter- 
esting and  instructive  details  have  had  to  be  omitted. 
Anyone  interested  in  the  subject  would  be  well  repaid  for 
the  time  spent  in  the  perusal  of  the  whole  Memorandum — • 
indeed,  of  the  whole  Report. 


UEBAN  VITAL  STATISTICS. 

(Week  ended  July  26th,  1919.) 

English  and  Welsh  Towns. — In  the  96  English  and  Welsh  towns, 
with  an  aggregate  civil  population  estimated  at  16,500,000  persons, 
the  annual  rate  of  mortality,  which  had  been  10  0,  10T,  and  9'0  in 
the  three  preceding  weeks,  rose  to  10  3 per  1000.  In  London,  with 
a population  slightly  exceeding  4,000,000  persons,  the  annual  rate 
was  10'5.  or  1'3  per  1000  above  that  recorded  in  the  previous  week, 
while  among  the  remaining  towns  it  ranged  from  3 0 in  SwindoD, 
3'8  in  Gloucester,  and  4'4  in  Lincoln,  to  151  in  Bootle  and 
in  Bury,  15  5 in  Darlington,  and  19  7 in  Carlisle.  The  prin- 
cipal epidemic  diseases  caused  134  deaths,  which  corresponded  to 
an  annual  rate  of  0'4  per  1000,  and  included  54  from  infantile  diarrhoea, 
33  from  diphtheria,  22  from  measles,  12  from  whooping-cough,  11  from 
scarlet  fever,  and  2 from  enteric  fever.  Measles  caused  a death-rate 
of  T2  in  Newcastle-on-Tyne,  16  in  West  Bromwich,  and  2 2 in  Barnsley. 
There  were  2 cases  of  small-pox,  1526  of  scarlet  fever,  and  1140  of 
diphtheria  under  treatment  in  ,the  Metropolitan  Asylums  Hospitals 
and  the  London  Fever  Hospital,  against  5,  1438,  and  1100  respectively 
at  the  end  of  the  previous  week.  The  causes  of  21  deaths  in  the 
96  towns  were  uncertified,  of  which  5 were  registered  in  Birmingham, 
4 in  Gateshead,  and  2 in  Liverpool. 

Scotch  Towns. — In  the  16  largest  Scotch  towns,  with  an  aggregate 
population  estimated  at  nearly  2,500,000  persons,  the  annual  rate  of 
mortality,  which  had  been  9 9,  110,  and  10'6  in  the  three  preceding 
weeks,  rose  to  11 '1  per  1000.  The  222  deaths  in  Glasgow  corresponded 
to  an  annual  rate  of  10  3 per  1000,  and  included  5 from  whooping- 
cough,  4 from  measles,  and  2 from  infantile  diarrhoea.  The  82  deaths  in 
Edinburgh  were  equal  to  a rate  of  12  7 per  1000.  and  included  3 from 
diphtheria,  2 from  measles,  and  1 from  infantile  diarrhoea. 

Irish  Towns. — The  89  deaths  in  Dublin  corresponded  to  an  annual 
rate  of  11'5,  or  2 5 per  1000  above  that  recorded  in  the  previous 
week,  and  included  2 each  from  diphtheria  and  infantile  diarrhoea. 
The  92  deaths  in  Belfast  were  equal  to  a rate  of  12  0 per  1000.  and 
included  2 from  scarlet  fever  and  1 from  infantile  diarrhoea. 


National  League  for  Health,  Maternity  and 
Child  Welfare.— The  following  resolution  was  passed 
unanimously  by  the  League  at  its  last  meeting  : — 

“That  this  League  calls  upon  the  Government  to  continue  some 
reasonable  control  of  the  liquor  traffic  in  the  interest  of  the  health  and 
welfare  of  the  mothers  and  infants  of  the  nation.” 

The  National  Association  for  the  Prevention  of  Infant 
Mortality,  a constituent  section  of  the  League,  has  passed  a 
resolution  dealing  with  the  milk-supply 
“ That  this  Association  calls  the  attention  of  the  Government  to  the 
urgent  necessity  for  reconstruction  of  the  milk-supply  throughout  the 
country,  with  regard  to  (1)  Its  greater  purity,  (2)  freedom  from 
infection,  and  (3)  its  seriously  diminishing  volume.  This  Association 
would  remind  the  Government  that  both  the  quality  and  quantity  of 
the  milk-supply  of  the  United  Kingdom  are  at  present  in  a deplorable 
state,  and  that  the  earliest  attention  to  the  problem  is  vital  to  the 
babies  and  children  of  to-day,  who  will  bear  the  burden  of  Empire  in 
the  future.” 


216  The  Lanobt,]  COORDINATION  OF  CLINIOAL  RESEARCH:  POSITION  OF  PSYCHIATRY.  [August  2,  1919 


Comspnbme. 

“ Audi  alteram  partem.” 


THE  COORDINATION  OF  CLINICAL  RESEARCH: 
THE  POSITION  OF  PSYCHIATRY. 

To  the  Editor  of  The  Lancet. 

Sir, — In  The  Lancet  of  June  21st  a letter  appeared  from 
me  under  the  above  heading,  in  the  course  of  which  I 
expressed  the  view  that  the  time  was  ripe  for  a conference 
between  local  authorities  responsible  for  the  care  of  the 
insane,  the  governing  authorities  of  the  local  university,  and 
of  the  infirmary,  and  representatives  of  the  Board  of  Control, 
with  a view  to  the  establishment  of  a clinic  in  psychiatry. 
Since  that  date  such  a conference  has  taken  place  in  Cardiff, 
at  which  the  main  features  of  the  proposed  amending  Bill  to 
the  Lunacy  Laws  (which  will  allow  of  treatment  in  early 
cases  of  insanity  without  orders  and  certificates — in  fact,  will 
permit  of  the  establishment  of  these  clinics)  were  outlined, 
and  the  lines  upon  which  the  clinic  could  best  be  developed 
in  Cardiff  were  sketched.  I understand  that  similar  con- 
ferences have  been  held  at  Newcastle  and  at  Oxford,  and 
I believe  will  be  held  at  other  university  centres.  The 
proposed  amending  Bill  has  not  yet  been  adopted  by  the 
Government.  It  may  be  expected  that  the  proposition 
will  be  that  the  Government  should  find,  say,  50  per  cent,  of 
the  cost  of  maintenance,  and  perhaps  as  much  of  the  annual 
charges  for  liquidation  of  the  capital  expenditure,  the  local 
authority  finding  the  balance.  The  answer  to  the  question, 
Who  is  to  find  the  money  for  site  and  erection  of  the 
buildings  1 is  not  forthcoming  that  I know  of.  I cite  from 
the  Western  Mail  of  July  18th  as  follows,  in  regard  to  the 
Cardiff  conference  : — 

The  conference  was  unanimous  in  the  view  that  a clinic  in  psychiatry 
was  ab60'utely  necessary,  alike  in  the  interests  of  all  sections  of  the 
community, *anrt  of  teaching  ; and  it  was  resolved  that  a committee  of 
the  authorities  represented  be  formed,  to  act  with  the  advice  and 
cooperation  of  the  Board  of  Control,  to  promote  the  object  in  view. 

It  is  obvious  that  the  development  above  outlined  is  one  of  the  first 
importance  to  the  community  at  large,  aiming,  as  it  does,  at  the 
prevention  of  what  is  probably  the  most  terrible  of  the  ills  to  which  the 
flesh  is  heir.  In  the  erection  of  these  clinics,  each  locality  concerned 
must,  in  the  main,  bear  its  own  burden  ; and  there  is,  therefore,  scope 
for  the  exercise  of  that  spirit  of  munificence  on  the  part  of  private 
individuals  which  has  never  failed  to  manifest  itself  in  South  Wales 
when  an  appeal  has  been  made  on  behalf  of  suffering  humanity. 

Some  account  in  due  course  will  be  given  of  the  experience 
gained  in  treating  some  1700  cases  of  mental  disorder  amongst 
troops  at  the  Cardiff  City  Mental  Hospital  in  its  capacity  as 
the  Welsh  Metropolitan  War  Hospital  (Mental  Division). 
These  cases  have  been  admitted  and  detained  on  the  authority 
of  Army  Council  Instructions  (“  for  observation  and  dis- 
posal ”),  but  without  any  orders  or  certificates  or  formalities 
of  any  kind.  I wish  I could  convey  some  idea  of  the 
gratitude  and  relief  which  the  relatives  of  these  men  have 
experienced  and  expressed  for  this  blessed  immunity.  Yet 
very  large  numbers  of  these  patients,  had  they  not  been 
serving  soldiers,  would  have  been  placed  under  orders  and 
certificates  and  have  gone  through  the  channel  of  the  Poor- 
law.  Allow  me  the  following  citation  from  a letter  just 
received  from  a distinguished  American  psychiatrist,  to 
whom  I complained  of  the  woeful  backwardness  of  this 
country  in  psychiatry  : — 

“ Perhaps,  aB  a native  of  England,  I may  agree  with  you,  without 
offending  taste,  that  British  psychiatry  is  behind  the  times  in  many 
respects.  The  Phipps  Clinic  at  Johns  Hopkins  and  the  Psychiatric 
Hospital  in  Boston  have  both  been  stimulating  factors  in  advance,  not 
to  mention  several  other  like  institutions.” 

Are  we  to  understand  that  this  (still  great)  country  will 
continue,  either  through  poverty  of  ideals  or  poverty  of 
purse,  or  both,  to  remain  passive  in  this  matter,  and  recog- 
nise no  obligation  as  a State  in  regard  to  the  actual  finding 
of  money  for  the  erection  of  these  clinics,  but  relegate  this 
responsibility  to  the  local  authority,  or  trust  to  the  generosity 
of  those  to  whom  the  war  has  brought  wealth  ? I fear  the 
amending  Bill  referred  to  will  not  be  dealt  with  by  the 
Government  this  year  unless  it  judges  the  force  of  opinion  to 
be  such  that  to  ignore  it  would  be  inexpedient. 

I am,  Sir,  yours  faithfully, 

Edwin  Goodai.l. 

Cardiff  City  Mental  Hospital,  Cardiff,  July  28th,  1919. 


NATIONAL  HEALTH  INSURANCE  AND  THE 
MEDICAL  GUILD. 

To  the  Editor  of  The  Lancet. 

Sir, — Dr.  Frederick  Porter’s  letter  in  your  issue  of  to-day. 
containing  the  suggestions  of  the  Scottish  Medical  Guild 
with  regard  to  National  Health  Insurance,  is  a timely  one. 
The  bulk  of  non-panel  practitioners  are  determined  not  to 
sell  their  freedom  by  entering  into  contractual  relations  with 
Insurance  Committees.  They  consider  that  their  fees,  their 
times  and  methods  of  attendance,  and  so  on,  are  private 
matters  for  mutual  arrangement  between  themselves  and 
their  individual  patients,  and  that  at  any  time,  if  the  patient 
or  doctor  be  dissatisfied,  either  party  should  be  able  to 
bring  the  professional  relationship  to  an  end  at  once,  without 
any  recriminations  or  charges  one  against  the  other.  It  is 
this  freedom  of  choice  and  power  to  change  which  gives 
adequate  protection  to  the  interests  of  both  parties.  The 
question  of  the  freedom  of  the  medical  profession  and  the 
public  in  their  mutual  relations  is  the  root  issue  in  this 
matter. 

The  scandal  to  which  Dr.  Porter  alludes  in  the  latter  part 
of  his  letter  should  certainly  be  brought  to  an  end.  It  is 
grossly  unfair  that  insured  persons,  who  in  large  numbers 
prefer  and  are  prepared  to  pay  for  private  medical  attend- 
ance, should  in  effect  be  subjected  to  a money  fine  which  is 
distributed  gratuitously  amongst  panel  practitioners  who 
have  done  nothing  to  earn  it.  Another  way  of  bringing 
this  scandal  to  an  end  would  be  to  permit  every  insured 
person  who  preferred  obtaining  and  paying  for  medical  attend- 
ance himself  to  renounce  altogether  the  “medical  benefit” 
portion  of  the  Act,  and  in  consideration  of  the  money  loss 
thereby  incurred  by  him  to  have  his  “sickness  benefit” 
(i.e.,  sick  pay  while  he  is  prevented  by  illness  from  following 
his  occupation)  proportionately  increased. 

It  is  this  sick  pay  that  is  the  most  useful  and  desirable 
part  of  the  Act  for  many  insured  persons.  Those  who  pre- 
ferred to  continue  obtaining  “ medical  benefit”  on  the  panel 
system  would,  of  course,  be  free  to  do  so,  and  their  sick  pay 
would  remain  as  before. 

I am,  Sir,  yours  faithfully, 

Hampstead,  N.W.,  July  26th,  1919.  HENRY  SHARMAN. 


THE  ORIGIN  OF  LIFE:  THE  WORK  OF  THE 
LATE  CHARLTON  BASTIAN. 

To  the  Editor  of  The  Lancet. 

Sir, — Taking  note  of  a letter,  published  in  your  issue  of 
May  29th,  from  the  son  of  the  late  Dr.  H.  Charlton  Bastian, 
and  of  another  in  the  same  number  from  Sir  Ronald  Ross, 
referring  to  the  brave  battle  for  the  proper  discussion  of  the 
question  of  spontaneous  generation  carried  on  all  his  life  by 
Dr.  Bastian,  I venture  to  add  my  tribute  to  his  memory  in 
appreciation  of  that  long  life  of  persistence  in  the  advocacy 
of  a conviction  at  variance  with  that  of  the  scientific  men  of 
his  day. 

In  the  flush  of  a newly  born  activity  in  the  field  of  biology, 
in  the  rise  of  the  great  science  of  bacteriology,  the  illogical 
deductions  made  from  the  facts  set  forth  by  Pasteur  and 
Tyndall  passed  current  as  a valid  and  conclusive  negation  of 
the  reality  of  abiogenesis.  But  according  to  the  professions  of 
modern  methods  in  science  you  can  affirm  a fact  by  demon- 
stration, but  to  deny  and  disprove  an  asserted  fact  is  a very 
different  proposition.  Pasteur  and  his  followers  proved  to 
the  hilt  that  they  could  destroy  life  in  certain  fluids  and 
preventits  resurrection,  but  that  this  disproved  the  possibility 
of  the  birth  of  life  in  any  kind  of  media  in  any  combination 
of  chemical  elements  by  no  means  followed.  Yet  bacterio- 
logists behaved  for  a generation  after  Pasteur  as  though  be 
and  his  followers  had  established  this  position.  In  the  last 
one  or  two  decades  a change  has  set  in  and  very  few  men  of 
science  make  any  such  claims  ; a very  large  number  cannot 
accept  the  continuity  of  cosmic  processes  as  proven  unless 
they  accept  the  birth  of  the  organic  from  the  non-organic 
and  the  birth  of  life  from  the  lifeless. 

Dr.  Bastian  some  years  before  his  death  sent  me  some 
salts  and  solutions,  which,  combined  according  to  his 
directions,  examined  microscopically  and  by  culture  to  my 
satisfaction  and  sterilised  by  heat  under  pressure  in  closed 
tubes,  exhibited  after  varying  periods  of  time  various  forms 
indistinguishable  under  the  microscope  from  spores  and 


The  Lancet,] 


EDINBURGH  UNIVERSITY  ROLL  OK  HONOUR. 


[August  2,  1919  217 


bacilli.  These  were  not  present  before  the  tubes  were 
sealed.  They  took  various  stains,  some  not  so  deeply,  but  on 
the  whole  offering  little  ground  for  discrimination  between 
them  and  bacteria.  They,  however,  with  the  culture  media 
at  the  command  of  a fairly  well-equipped  laboratory 
presented  no  evidence  of  growth. 

I had  no  explanation  to  give  other  than  that  advanced  by 
Dr.  Bastian,  but  inasmuch  as  we  were  unable  to  get  a 
culture  and  because  the  simple  chemical  constitution  of  the 
fluids  in  which  they  appeared  was  not  in  accord  with  what 
I have  been  accustomed  to  associate  with  the  manifestations 
of  life,  I was  unable  to  agree  to  Dr.  Bastian’s  conclusion 
that  these  were  not  merely  simulacra  of  life,  but  life  itself. 

He  had,  as  I look  at  it,  the  best  of  the  argument  on 
orthodox  scientific  grounds.  I could  not  explain  the  results, 
and  insufficient  as  I regarded  the  evidence  to  be  I could  only 
oppose  to  it  a disbelief  founded  on  a theoretical  objection, 
the  commonly  accepted  view  of  life  as  being  made  up  of 
complex  molecules  interacting  upon  one  another  and  on  their 
environment  in  such  a way  as  to  exhibit  continuous  orderly 
proliferation  which  we  designate  by  the  term  “ reproduction.” 
A current  number  of  Science  (June  27th,  1919,  N.S.,  xlix., 
1278)  contains  a paper  by  Dr.  MacDougal  which  deals  with 
the  nature  of  these  molecules.  Incomplete  as  was  Dr. 
Bastian’s  own  experimental  evidence  and  that  of  the  work 
carried  out  under  my  own  supervision  by  those  skilled  and  of 
long  experience  in  bacteriological  technique,  1 was,  under  the 
circumstances,  able  to  offer  only  a still  more  unsatisfactory 
report.  Full  reports  of  the  work  of  myself  and  colleagues 
were  made  to  Dr.  Bastian,  and  doubtless  his  son  can  find  them 
among  his  papers.  The  conception  of  the  chemical  com- 
position of  living  matter  is  largely  hypothetical,  and  the 
utilisation  of  all  known  culture  media  and  devices  was  not 
performed.  I consider  Dr.  Bastian  offered  to  the  world 
sufficient  evidence  to  make  further  investigation  an  impera- 
tive duty  on  those  having  the  requisite  skill  and  the 
opportunity  to  continue  the  work.  His  conclusions  have 
never  been  answered  in  a way  to  reflect  credit  on  men  of 
science.  I am,  Sir,  yours  faithfully, 

Jonathan  Wright. 

Pleasantville,  Westchester  County,  New  York,  July  7th,  1919. 


To  the  Editor  of  The  Lancet. 

Sir, — With  reference  to  the  recent  letters  in  your  columns 
on  the  subject  of  the  Origin  of  Life,  I would  like  to  thank 
all  those  who  have  kindly  contributed  to  the  discussion  and 
have  themselves  repeated  certain  experiments.  It  would 
take  up  too  much  of  your  space  to  reply  in  detail  to  all  your 
correspondents.  May  I point  out,  however,  that  Professor 
W.  D.  Halliburton  is  mistaken  in  supposing  that  I am  not 
fully  acquainted  with  most,  if  not  all,  of  the  published 
reports  to  which  he  refers.  The  whole  literature  of  the 
subject  is  very  familiar  to  me,  not  only  on  account  of  my 
father’s  work,  but  because  I have  always  taken  an  interest  in 
the  subject  myself,  and,  I hope,  without  prejudice.  Given  a 
primary  creation  of  living  organisms,  by  whatsoever  means 
this  may  have  been  brought  about  in  the  long-ago  past,  we  are 
faced  with  the  difficulty  of  believing  that  existing  micro- 
organisms are  in  every  case  the  lineal  descendants  thereof . 
It  seems,  in  fact,  not  unreasonable  to  suppose  that  this  same 
genesis  of  living  matter  may  be  constantly  occurring  to-day 
under  suitable  conditions  of  radiant  energy,  temperature, 
season  of  the  year,  and  suitable  combination  of  the  necessary 
constituents  of  protoplasm  ; though,  of  course,  the  earliest 
stages  of  such  a process  would  necessarily  take  place  beyond 
our  ken  in  Nature’s  laboratory,  and  would  be  quite  invisible 
even  with  the  aid  of  the  most  powerful  microscope  now 
available. 

With  regard  to  the  negative  results  of  the  Hon.  H.  Onslow’s 
lesearches,  referred  to  by  Professor  Halliburton,  when  he 
says,  “This  work  settles  the  question  of  spontaneous 
generation  (in  Dr.  Bastian’s  sense)  once  and  for  all,”  it  is  a 
significant  fact  that  my  father  was  quite  familiar  with  such 
simulacra  and  pseudo-organisms  as  are  described  by  Mr. 
Onslow,  Prof.  Benjamin  Moore,  F.R.S.,  Mr.  Sydney  G.  Paine, 
and  others.  He  frequently  found  these  and  nothing  else  in 
whole  series  of  his  experimental  tubes,  and  recognised  them 
as  such.  But  he  did  not  find  that  these  pseudo-organisms 
multiplied  under  the  cover  glass  or  in  nutrient  media  after 
the  manner  of  bacteria  and  fungi.  Moreover,  I suggest  that 
Mr.  Onslow  kept  some  of  his  “ white  solution  ” tubes  far  too 
long — three  years  in  some  cases — before  finally  opening  them 


and  examining  their  contents.  Is  it  surprising,  therefore, 
that  no  living  organisms  were  found,  but  only  dead  ones  ? 
For  bacteria  in  a non-nulrient  medium  cannot  subsist  and 
flourish  indefinitely  by  living  on  one  another. 

On  referring  again  to  Mr.  Onslow's  detailed  account  of 
his  experiments,  as  published  in  Proceedings  of  Royal 
Society  (B.,  vol.  xc.,  p.  266),  I notice  that  his  “yellow 
solution”  was  composed  of  dilute  sodium  silicate  and 
pernitrate  of  iron  in  addition  to  the  other  ingredients  as 
contained  in  the  “white  solution.”  This  may  very  well 
account  for  his  failure  to  confirm  my  father’s  results  as 
described  in  “The  Origin  of  Life.”  Professor  Hewlett’s 
results,  to  which  Professor  Halliburton  also  refers,  if  they 
did  not  go  so  far  as  to  prove  the  truth  of  archebiosis, 
certainly  do  not  disprove  it,  as  he  himself  says  in  Nature  of 
Jan.  22nd,  1914,  p.  579.  On  the  other  hand,  we  have  the 
testimony  very  largely  in  favour  of  my  father’s  doctrines 
from  M.  Albert  Mary,  of  Paris,  in  his  letter  published  in 
your  issue  of  June  28th. 

I am,  indeed,  grateful  for  the  great  amount  of  time  and 
trouble  taken  by  the  various  observers  who  have  been  good 
enough  to  investigate  these  matters  for  themselves.  In 
view  of  the  importance  of  the  subject,  however,  it  is 
sincerely  to  be  hoped  that  experiments  on  somewhat  more 
extensive  lines  may  now  be  carried  out  and  that  some  of  the 
funds  from  which  we  hope  so  much  for  scientific  research 
may  be  devoted  to  this  object,  so  all-important  from  many 
points  of  view,  but  particularly  so  from  the  point  of  view  of 
medical  science.  — I am,  Sir,  yours  faithfully, 

W.  Bastian, 

Cheiham  Bols,  Bucks,  July  26th.  Surgeon  Commander,  R.N. 


EDINBURGH  UNIVERSITY  ROLL  OF  HONOUR, 

To  the  Editor  of  The  Lancet. 

Sir, — It  is  proposed  to  publish  a roll  of  honour  and  war 
record  of  the  University  of  Edinburgh,  and  a letter  asking 
for  information  as  to  war  service,  promotions,  honours,  &c.. 
with  dates,  is  being  sent  to  all  graduates  and  to  the  relatives 
of  the  fallen  whose  addresses  are  known.  The  number  of 
medical  graduates  who  have  given  their  lives  is  large,  and  it 
has  been  found  difficult  to  obtain  the  addresses  of  their 
relatives.  Will  those  interested  in  the  forthcoming  publica- 
tion communicate  particulars  to  the  undersigned  ? 

I am,  Sir,  yours  faithfully, 

John  E.  Mackenzie,  Major, 

Editor  of  the  Boll  of  Honour. 

University  of  Edinburgh,  July  15tb,  1919. 

THE  REMUNERATION  OF  MEDICAL  MEN 
SERVING  ON  PENSIONS  BOARDS. 

To  the  Editor  ot  The  Lancet. 

Sir,— In  a recent  issue  of  The  Lancet  there  was  a letter 
stating  that  the  Cheltenham  practitioners  had  held  a meeting 
and  formulated  the  terms  under  which  they  were  willing  to 
serve  on  Pensions  Boards.  The  majority  of  us  now 
serving  as  members  on  Pensions  Boards  feel  that  the  present 
fee  of  £1  Is.  per  session  of  two  and  a half  hours  and  often 
longer  is  quite  inadequate  payment  for  the  work  done.  The 
cases,  especially  those  of  suspected  tuberculosis,  require 
most  careful  examination  and  consideration.  There  is  a 
feeling  amongst  us  that  a good  deal  of  the  clerical  work  of 
a non-medical  character  should  be  done  by  a clerk.  Every 
few  days  more  clerical  work  is  thrust  upon  us,  but  the  fees 
are  not  raised,  although  we  now  have  to  spend  a good  deal  of 
extra  time  in  each  case.  Many  of  us  are  demobilised  from 
the  R.A  M C.  and  while  on  the  look-out  for  permanent  work 
we  are  trying  to  keep  the  wolf  from  the  door  by  doing  part- 
time  work.  The  present  remuneration  is  not  enough  to  meet 
the  increased  cost  of  living.— I am.  Sir,  yours  faithfully, 

July  28th,  1919.  MEMBER  OF  THE  BcTARD. 

ACUTE  OEDEMA  OF  THE  FACE  DUE  TO 
POTASSIUM  IODIDE. 

To  the  Editor  of  The  Lancet. 

Sir, — The  occurrence  of  acute  and  marked  oedema  of  the 
face,  arising  during  a course  of  treatment  by  potassium 
iodide,  is,  I think,  sufficiently  rare  to  be  of  interest. 

The  patient,  a man  aged  65,  consulted  me  on  account  of 
attacks  of  giddiness,  from  which  he  had  been  suffering  lately, 
and  he  also  gave  a typical  history  of  attacks  of  angina.  His 
radial  and  temporal  arteries  were  considerably  thickened, 
cardiac  dullness  extended  beyond  the  nipple  line,  the  first 


218  This  Lancet,]  ARMY  SURGEONS  AND  THE  F.R  O.S.  EXAMINATION.— MEDICAL  NEWS.  [August  2,  1919 


apical  sound  was  prolonged  and  the  second  aortic  sound 
accentuated.  The  urine  contained  neither  albumin  nor 
sugar.  The  patient  was  advised  as  to  a limitation  of  diet, 
given  a prescription  for  (1)  some  tabella  trinitrini,  and 
(2)  pot.  iod.  gr.  v.,  t.d.s.  He  returned  five  days  later  suffer- 
ing from  considerable  oedema  of  both  upper  and  lower 
eyelids  and  face.  There  was  no  oedema  anywhere  else  in  his 
body,  nor  was  there  a history  of  previous  attacks  of  oedema 
or  a family  history  of  angioneurotic  oedema.  He  also  com- 
plained of  frontal  headache  and  sorethroat.  It  became 
necessary  to  discontinue  the  iodides,  as  even  with  increased 
doses  the  symptoms  persisted. 

Having  failed  to  discover  any  other  cause  for  this  (edema, 
I believe  it  to  have  been  due  to  the  administration  of  the 
iodides,  possibly  aggravated  by  the  simultaneous  administra- 
tion of  nitrites. — I am,  Sir,  yours  faithfully, 

Sidney  S.  Lindsay,  L.R.C.P.  Lond.,  MR.CS. 

West  End-lane,  West  Hampstead,  July  8th,  1919. 

ARMY  SURGEONS  AND  THE  F.R.C.S. 
EXAMINATION. 

To  the  Editor  of  The  Lancet. 

Sir, — Some  time  ago  the  Royal  College  of  Surgeons  of 
England  announced  that  “ surgeons  who  hold,  or  have  held, 
commissions  in  H.M.  Forces  during  the  war  and  who  have 
done  commendable  surgical  work  during  such  service,  may  be 
admitted  to  the  First  Examination  for  the  diploma  of  Fellow 
on  special  conditions.”  It  is  unnecessary  for  me  to  repeat 
these  conditions,  as  your  readers  must  have  seen  them. 
They  were  also  issued  to  units.  Nevertheless  I do  not  think 
anyone  has  drawn  attention  to  the  anomaly  of  the  conditions 
or  to  the  unfairness  with  which  they  operate.  One  would 
have  thought  that  if  facilities  were  to  be  given  at  all  they 
would  have  been  in  respect  of  the  subject  in  which  special 
experience  might  have  been  gained  when  on  service — viz. , 
operative  surgery.  That  would  have  been  the  only  legitimate 
reason  for  creating  short  cuts  to  the  F.R.C.S.  Even 
then,  the  granting  of  these  facilities  to  a few  would  not  have 
been  fair,  because  one  cannot  control  one’s  postings  and 
their  resultant  opportunities  in  the  Army.  The  relief  pro- 
vided, however,  refers  to  embryology  and  physiology — two 
subjects  of  which  no  one  by  his  Army  service  can  have 
possibly  gained  any  experience.  This  makes  the  conditions 
still  more  unfair.  I submit  that  if  facilities  are  to  be  given 
— and  those  in  respect  of  ancillary  studies  difficult  for  a 
service  man  to  return  to — all  who  joined  voluntarily  should 
be  given  them.  It  is  quite  bad  enough  that  these  higher 
examinations  were  held  at  all  during  the  war,  thus  giving 
opportunities  to  the  stay-at-homes,  but  it  is  worse  to  reward 
only  some  of  those  who  freely  and  unsparingly  gave  them- 
selves and  jeopardised  their  prospects. 

I am,  Sir,  yours  faithfully, 

July  25th,  1919.  Late  R.A.M.C.  and  Ineligible. 

THE  PAY  OF  TERRITORIAL  MEDICAL 
OFFICERS. 

To  the  Editor  of  The  Lancet. 

Sir,- — I gather  that  the  response  of  medical  men  to  the 
War  Office  appeal  for  doctors  has  not  been  satisfactory. 
Perhaps  the  authorities  have  no  idea  how  bitter  still  is  the 
feeling  among  Territorial  and  Special  Reserve  medical  officers 
at  the  difference  in  treatment  recently  meted  out  to  them  as 
compared  with  the  temporary  R.A.M.C.  medical  officer. 
Letters  have  appeared,  representations  made,  but  all  to  no 
purpose. 

If  the  War  Office  were  to  supplement  gratuities  of  all 
Territorial  and  S.R.  medical  officers  (and  so  compensate 
them  for  the  monetary  loss  they  have  suffered  by  being  a 
Territorial  or  S.R.  instead  of  a temporary  R.A.M.C.  officer), 
making  their  gratuities  up  to  a total  of,  say,  £500  for  four 
years'  embodied  service  (the  same  exactly  as  a naval  medical 
officer  is  offered  in  peace-time  after  the  same  length  of 
service,  at  which  rate,  too,  a regular  R.A.M.C.  officer's 
gratuity  after  eight  years’  service  is  calculated),  it  would 
help  to  mitigate  some  of  that  soreness  still  so  prevalent. 
The  Territorial  and  S.R.  medical  officer  is  paid  at  the  same 
rate  as  the  regular : why,  then,  should  not  his  gratuity  be 
■worked  out  at  the  same  rate—  namely,  £125  a year  for  each 
year  of  embodied  service,  or  Is.  a day  pay  ! The  temporary 
R.A.M.C.  officer  gets,  after  all,  the  equivalent  of  this  in 
increased  pay  daily. — I am.  Sir,  yours  faithfully. 

Captain,  It  A M.C  (T.), 

July  38th,  1919.  late  Surgeon,  R.N. 


Utefcal 


Grants  for  Medical  Education. — We  learn  that 
certain  London  medical  schools,  which  have  prepared 
schemes  for  the  reconstruction  of  their  clinical  teaching, 
have  been  officially  informed  that  they  can  count  upon 
financial  assistance  from  the  State  based  upon  the  approved 
expenditure  incurred  in  carrying  out  those  schemes. 

Examining  Board  in  England  by  the  Royal 
Colleges  of  Physicians  of  London  and  Surgeons  of 
England.— At  the  Final  Examination,  held  from  July  l9t  to 
17th,  the  following  candidates  were  approved  in  the  under- 
mentioned subjects,  but  are  not  eligible  for  diplomas,  viz: — 
Medicine.— W . J.  McB.  Allan,  Guy’s  ; F.  T.  Allen,  St.  Thomas's  ; H.  E. 
Archer,  St.  Bart.'s;  S.  T.  Barrett.  B. A.  Cantab.,  Cambridge  and 
Guy’s;  G.  F.  Baxter,  Westminster; Grace  Mary  Beaven.L.M.S.S.A., 
St.  George’s;  Julia  Bell,  Royal  Free  and  St  Mary's;  W.  H. 
Bennett,  L.R.C.P.  A S.  Edin.,  L.F.P.  & S.  Glasg.,  Manchester;  P.C. 
Brett  and  J.  D.  M.  Cardell,  St.  Thomas’B ; Marjorie  Carnsew 
Chappel,  Royal  Free;  B.  H.  Cole,  Cambridge  and  St.  Bart.’s; 
Alison  Margaret  Collie,  St.  Mary’s;  R.  G.  Dansie,  King’s  College; 
Sarah  Helen  Davies,  Royal  Free;  K.  A.  Denholm,  Queen  Univ., 
Canada;  H.  Donovan,  Birmingham;  T.  Draper,  Edinburgh;  A.  J. 
Fenn,  King’s  College ; P.  0.  C.  Fenwick,  L.  M.S.S. A.,  St.  Thomas’s ; 
I.  Frost,  St.  Bart  's;  A.  E.  Gravelle,  L. .M.S.S. A.,  King’s  College; 

E.  C.  Grey,  D.Sc.  Lond.,  F.I.C.,  Guy’s;  H.  M.  Guggenheim,  M.D. 
Paris,  Paris;  H.  W.  Hardy,  L.D.S.Eng.,  Charing  Cross;  E.  P. 
Hicks,  Cambridge  and  St.  Bart.'s;  T.  R.  E.  Hiilier,  Middlesex; 
Mabel  Marian  Ingram,  Royal  Free  and  Lon  ion;  C.  A.  Kirton, 
University  College;  J.  V.  Landau,  St.  Bart.'s;  F.  G.  Lewtas, 
Cambridge  and  St.  George's;  R.  T.  McRae,  London;  Margaret 
Ombler  Meek,  Cambridge  and  Charing  Cross  ; G.  E Morgan,  Oxford 
and  London;  W.  P.  Newman  aud  C.  Nicory,  6t.  Thomas’s ; Sibyl 
Gertrude  Overton,  St.  Mary's  ; G.  Packham,  L.D.S.  Eng., and  W.  W. 
Payne,  Guy’s  ; J.  Posner,  Dublin  ; Eleanor  Margaret  Reece,  Royal 
Free;  H.  N.  Schapiro.  Guy’s;  Ruth  Mary  Scutt,  St.  Mary’s;  J.  T. 
Short,  M.D.  Penn.,  Pennsylvania;  J.  Y.  A.  Simpson.  Middlesex ; 
W.  A.  M.  Smart,  B.  Sc.  Lond.,  London;  H.  E.  Smith,  Sheffield ; 

G.  M.  Trist,  Charing  Cross  : W.  A.  Turner.  Guy’s  ; G.  van  Acker, 
Oxford  and  Birmingham ; A.  D.  Weeden.  Middlesex;  Effie  Adeli 
Wharton,  St  George's;  J.  S.  White,  St.  Bart.'s;  Octavia  Margaret 
Wilberforce,  Koval  Free  and  St.  Mary’s ; Katoleen  Mary  Wiikinson 
and  Margaret  Aileen  Williams.  Birmingham ; T.  Williams,  Middle- 
sex ; W.  K.  Williams,  Liverpool ; C.  Young,  Middlesex;  and  T.  F. 
Zerolo,  Sr.  Bart.’s. 

Midwifery. — F.  F.  Abdullah,  St.  Mary’s;  W.  G.  Barnard,  London; 

H.  Boger,  University  College  ; T.  L.  Bonar.  St.  George’s  ; J.  Bonfield, 

M. 3.  Kingston,  Queen's  Univ..  Ont. ; C.  H.  Bulcock,  St.  Bart.’s; 
G.  F.  Burnell,  Charing  Cross;  J.  W.  Chadwick,  Manchester; 

F.  Christian,  University  College  ; O.  T.  J.  C.de  H.  Clay  re,  Sr.  Bart.’s; 

G.  L.  Clements,  Birmingham  ; H.  Cohen,  Westminster  ; M.  Cohen, 
Guy’s;  J.  C.  Copp,  M.B. Tor.,  Toronto;  F.  C.  Cozens,  Cambridge 
and  St.  Bart.'s;  A.  R.  Crane.  London;  J.  J.  da  Gama  Machado, 
St.  Bart.’s;  R.  W.  M.  Dendy,  Cambridge  and  St.  George’s;  K.  A. 
Denholm,  M.D.  Queen’s  Univ.,  King-ton:  C.  J.  C.  de  Silva, 
Middlesex;  T.  Draper,  Edinburgh;  D.  G.  Garnett,  Cambridge  and 
St.  Thomas’s;  W.  Girgis,  St.  Mary’s;  A.  E.  Qravelle,  L. M.S.S.  A., 
King's  College  ; E.  C.  Grey.  D.Sc. Lond.,  F.I.C.,  Guy's;  F.  B.  Hobbs, 
Cambridge  and  St.  Thomas's:  F.  James,  Charing  Cross;  O.  E. 
Kennedy,  M.B.  Queen’s  Univ.,  Kingston  ; J.  V.  Landau.  St.  Bart.’s ; 
F.  F.  Langridpe,  London  ; T.  J.  Lesser,  Royal  Free ; H.  T.  Ls  Vieux. 
Guy’s ; F.  C.  Lewis,  Liverpool ; P.  T.  Liang,  Cambridge  and  St. 
Thomas's;  W.  A.  Low.  St.  Thomas's;  P.  T.  Mcllrov,  M.B.  Queen's 
Univ.,  Kingston;  S.  F.  Mahmod,  St.  Bart.’s;  C.  G.  Martin,  Cam- 
bridge and  St.  Bart.’s;  D.  J.  Millar,  M.B.  Queen’s  Univ., 
Kingston;  L.  Moss,  Guy’s;  G.  G.  Newman.  London;  Olga 
Grace  Mary  Payne,  M.Sc.,  M B.,  Ch.B.  Manch..  Manchester; 

N.  A.  M.  Petersen.  London  ; J.  A.  M.Ross.  St.  Bart.’s;  M.  Sawhney, 
Cambridge  and  Middlesex;  J.  T.  Short.  M.D.  Penn.,  Penn- 
sylvania; C.  J.  Slim,  Birmingham  ; W.  A.  M.  Smart,  B.Sc.  Lond., 
London;  F.  D.  Spencer.  Birmingham  ; B.  W.  Taompson.  St.  Bart.'s; 
B.  M.  Tonkin.  Guy’s  ; D L.  Tucker,  Cambridge  and  Edinburgh; 
W.  G.  D.  H.  Urwick,  St.  Bart.’s;  G.  v.  L.  van  Acker.  Oxford  and 
Birmingham  ; N.  V.  Wadsworth,  Guy’s  ; Mary  Howarth  Wild,  M.B., 
Ch.B.  Liverp  , Liverpool ; Kathleen  Mary  Wilkinson  and  Margaret 
Aileen  Williams,  Birmingham;  W.  R.  Williams,  Liverpool ; Grace 
Elizabeth  Winn,  Royal  Free  and  St.  Mary's;  Jane  Edith  Wood, 
Leeds;  C.  Woode,  Charing  Cross;  and  F.  B.  Yonge,  L.D.S.Eng., 
Middlesex. 

Surgery.— C.  M.  Billington,  Cambridge  and  St.  Thomas's;  M.  R. 
Boe,  M.D.,  C.M.,  Queen's  Univ.,  Kingston  ; H.  Brockman.  Middle- 
sex ; G.  P.  Evans,  St.  Mary's ; L.  P.  Garrod  and  N.  J.  Macdonald, 
Cambridge  and  St.  Bart.’s  ; T.  Mensa- Annan,  Cambridge  and  King's 
College;  Sibyl  Gertrude  Overton,  St.  Mary's;  Olga  Grace  Mary 
Pavne.  Manchester;  H.  W.  Pigeon,  M.D..  C.M.  McGill,  McGill; 
K.  E.  R.  Sanderson,  Cambridge  and  St.  Bart.'s;  E.  R.  Sarra,  Cam- 
brilgeand  London;  Ruth  Marv  Scutt,  St.  Mary's ; S.  D.  Sturton, 
Cambridge  and  St.  Bart.'s;  W.  S Ii.  Thomas,  Cambridge  and  Guy's  ; 
li.Tbur.-z,  King's  College ; D.  L.  Tucker,  Cambridge  and  Edinburgh; 
Kathleen  Suzanne  Vine,  L. M.S.S.  A . Royal  Free  ; W.  Walaham,  St. 
Mary's;  and  M.  L.  Young.  Cambridge  and  St.  Thomas's. 

Royal  College  of  Surgeons  of  England.— An 
ordinary  meeting  of  the  Council  was  held  on  July  24th,  Sir 
Henry  Makins.  the  President,  being  in  the  chair. — The 
President  reported  that  H.R.H.,  the  Prince  of  Wales  had 
consented  to  become  an  Honorary  Fellow  of  the  College 
The  votes  of  the  Council  were  taken  in  accordance  with  the 
requirements  of  the  Charter  of  1899,  and  the  President 
declared  His  Royal  Highness  to  be  duly  and  unanimously 
elected  an  Honorary  Fellow.  The  President  stated  that 


The  Lancet,] 


MEDICAL  NEWS. 


[August  2, 1919  210 


the  Prince  of  Wales  hoped  on  his  return  from  Canada 
towards  the  end  of  the  year  to  attend  at  the  College  to 
receive  his  diploma.  The  President  reported  that  H.R.II. 
the  Duke  of  Connaught  (Colonel-in-Chief  of  the  R.A.M.C.), 
had  also  consented  to  become  an  Honorary  Fellow  of  the 
College.  Whereupon  the  votes  of  the  Council  were  taken 
and  His  Royal  Highness  was  duly  and  unanimously  elected 
an  Honorary  Fellow.  The  Secretary  laid  before  the  Council 
a balance  sheet  dated  June  24th,  and  a statement  of  the 
receipts  and  expenditure  of  the  College  for  the  year  ending 
on  that  date,  with  the  certificates  of  the  auditors  attached 
thereto,  together  with  a list  of  the  investments,  showing 
their  value  on  that  date.  The  balance  sheet  and  the  state- 
ments as  to  receipts  and  expenditure  were  approved  and 
adopted,  and  it  was  resolved  to  publish  them  in  the  College 
calendar  and  in  the  annual  report  of  the  Council  to  the 
Fellows  and  Members.  It  was  decided  that  the  annual 
meeting  of  the  Fellows  and  Members  should  be  held  on 
Thursday,  Nov.  27th,  at  3 p.m. 

University  of  London. — At  examinations  for 
internal  and  external  students  held  recently  the  following 
candidates  were  successful : — 

M.D.  Examination. 

Branch  I.,  Medicine. — Frank  Cyril  Harvie  Bennett,  B.S.,  St.  Mary’s 
Hosp. ; Dorah  Challis  Colebrook,  B.S.,  London  School  of  Medicine 
for  Women;  Clement  Cooke,  B.S.,  St.  Bartholomew’s  Hosp.; 
Annie  Mary  Forster,  B.S.,  London  School  of  Medicine  for  Women  ; 
George  Edward  Genge-Andrews,  B.S  , Guy’s  Hosp. ; “Mary  Esther 
Harding,  B.S.,  London  School  of  Medicine  for  Women  ; John 
Stephen  Herbert  Lewis,  B.S.,  University  College  Hosp.  ; Harold 
Arundel  Moody,  B.S.,  King’s  College  Hosp. ; and  John  Alfred 
Ryle,  B S.  (University  medal).  Guy’s  Hosp. 

Branch  II.,  Pathology.— Graham  Selby  Wilson,  B.S. , Charing  Cross 
Hosp. 

Branch  III.,  Mental  Diseases. — Millais  Culpin,  B.3..  London  Hosp.  ; 
Charles  We6ley  Forsyth,  Victoria  University  of  Manchester  and 
University  College  Hosp. ; and  Thomas  Chivers  Graves,  B.S., 
B.Sc.  (Vet.  Sci.),  Universitv  College  Hosp. 

Branch  IV.,  Midwifery  and  Diseases  of  Women. — Joseph  Anthony 
Ferridre,  B.S.,  University  College;  Jerusha  Jacob  Jhirad,  B.S., 
London  School  of  Medicine  for  Women ; Martin  Herbert  Oldershaw, 
B.S.,  and  Victor  Jorge  E.  C.  del  S.  Perez  y Marzan,  B S.,  Uni- 
versity College  Hosp. ; and  Cecil  George  Richardson,  B.S.,  West- 
minster Hosp. 

“ Obtained  the  number  of  marks  qualifying  for  the  University  medal. 
M.S.  Examination. 

Branch  I.,  Surgery. — William  Bashall  Gabriel  and  Leonard  George 
Phillips,  B.Sc.,  Middlesex  Hosp. 

N.B. — This  list,  published  for  the  convenience  of  candidates,  is  issued 
subject  to  its  approval  by  the  Senate. 

University  of  Oxford. — At  examinations  held 
recently  for  the  Diploma  in  Ophthalmology  the  following 
satisfied  the  examiners 

Herbert  William  Archer-Hall,  Ernest  Milne  Eaton,  Vernon  O’Hea 
Cussen,  Walter  Herman  Kiep,  and  William  Clark  Souter. 

University  of  Sheffield. — At  examinations 
held  recently  the  following  candidates  were  successful : — 
M.B.,  Ch.B.  Degrees. 

Final  Examination. — William  Collins,  Raymond  E.  Ford,  Robert  H. 
Greaves,  Dorothy  E.  Matbews,  Reginald  E.  Pleasance,  Frederick 
Roper,  Lazarus  Samuels,  Frederick  L.  Smith,  and  Alice  White. 
Third  Examination. — May  T.  Bassett,  Constance  M.  Chappell,  and 
Raymond  E.  Ford. 

Second  Examination. — Edgar  S.  Clayton,  Robert  Platt,  and  Elsa  F. 
Faige. 

First  Examination. — George  R.  Bailey,  Oswald  H.  Billington, 
Clifford  S.  Dunbar.  Camille  Francotte,  Rene  Fraucotte,  John  E. 
Tannian,  William  H.  Harding  (with  distinction  in  Physics),  Sidney 
G.  Meanley,  James  B.  Schofield,  and  Francis  A.  Wrench. 

London  School  of  Tropical  Medicine. — The 
following  are  the  results  for  the  examination  held  at  the  end 
of  the  sixtieth  session  (May-July,  1919) 

*W.  H.  W.  Cheyne  (Duncan  and  Lalcaca  medals),  ifJ.  I.  Connor, 
*G.  S.  Glass,  *R.  D.  FitzGerald  (Straits  Settlements  Medical 
Service),  *Surg.  Lieut. -Cmdr.  T.  C.  Patterson,  R.N  , Capt.  W.  C. 
Spackman,  I.M.S.,  P.  A.  Dalai,  A.  C.  Price,  Capt.  H.  N.  Stafford, 
K.A.M.C.,  J.  T.  Smeall,  Miss  Y.  H.  Hoashoo,  Miss  S.  A.  Finch,  Miss 
A.  Bramsen,  N.  B.  Watch,  H.  C.  Gilmore,  S.  Foskett,  J.  W.  Scharff, 
J.  P.  Tibbies,  Miss  E.  Warren,  B.  Mountain,  B.  B.  Jareja,  C.  Farre’l, 
A.  R.  Neckles,  and  J.  A.  Liley. 

* With  distinction. 

Central  Midwives  Board. — A meeting  of  the 
Central  Midwives  Board  was  held  at  Queen  Anne’s  Gate 
Buildings,  Westminster,  on  July  24th,  with  Sir  Francis  H. 
Champneys  in  the  chair.  A letter  was  considered  from  the 
medical  officer  of  health  forWinchester,  inquiring  (a)  whether 
the  rules  of  the  Board  deal  with  the  question  of  practice  by 
a midwife  supposed  to  be  a chronic  carrier  of  disease ; 
(o)  whether  such  a woman,  if  suspended  from  practice  in 
order  to  prevent  the  spread  of  infection,  would  be  entitled 
to  compensation  from  the  Board,  or  from  the  local  super- 
vising authority  which  has  suspended  her.  The  Board 
directed  that  the  replies  be  (a)  that  the  question  of  practice 
by  a midwife  liable  to  be  a source  of  infection  is  dealt  with 


in  Rule  E.6;  (6)  that  by  Section  6 (2)  of  the  Midwives  Act, 
1918,  where  “a  midwife  has  been  suspended  from  practice  in 
order  to  prevent  the  spread  of  infection  the  Board,  or  the 
local  supervising  authority  by  whom  she  was  suspended, 
may,  if  they  think  fit,  pay  her  such  reasonable  compensation 
for  loss  of  practice  as  under  the  circumstances  may  seem 
just.”— The  secretary  tendered  his  resignation,  which  was 
received  by  the  Board  with  much  regret,  and  it  was  decided 
that,  subject  to  the  approval  of  the  Ministry  of  Health,  Mr. 
Herbert  George  Westley,  M.A.,  LL.B.  Cantab.,  be  appointed 
secretary. 

A special  meeting  was  held  on  the  same  day  when  four 
midwives  were  struck  off  the  Roll,  the  following  charges, 
amongst  others,  having  been  brought  forward  : — 

A child  suffering  from  inflammation  and  discharge  from  the  eyes  the 
midwife  did  not  explain  that  the  case  was  one  in  which  the  attendance 
of  a registered  medical  practitioner  was  required,  as  provided  by 
Rule  E.  21  (5).  Medical  aid  having  been  sought  for  a child  the  midwife 
neglected  to  notify  the  local  supervising  authority  thereof,  as  required 
by  Rule  E.  22(1)  (a).  The  midwife  not  being  scrupulously  clean  In 
every  way,  as  required  by  Rule  E.  2 ; when  attending  patients  she  did 
not  wear  a clean  dress  of  washable  material  that  can  be  boiled,  as 
required  by  Rule  E.  2,  and  when  called  toaconlinementshedid  not  take 
with  her  the  appliances  required  by  Rule  E.  3.  1 he  midwife  did  not  take 
and  record  the  pulse  and  temperature  of  her  patients  at  each  visit, 
as  required  by  Rule  E.14  ; she  did  not  enter  her  records  of  pulse  and 
temperature  in  a notebook  or  on  a chart  carefully  preserved,  as  required 
by  Rule  E.14,  and  she  did  not  keep  her  register  of  cases  as  required  by 
Rule  E.24.  When  called  to  a confinement  the  midwife  neglected  to  take 
with  her  in  a metal  case  or  bag  or  basket,  kept  for  that  purpose  only 
and  furnished  with  a removable  lining  which  can  bo  disinfected,  the 
appliances  and  antiseptics  required  by  Rule  E.3;  she  neglected  to 
disinfect  her  hands  and  forearms  before  touching  the  generative  organs 
or  their  neighbourhood,  as  required  by  Rule  E.4  ; she  neglected  to 
wash  the  patient's  external  parts  with  soap  and  water  and  to  swab 
them  with  an  efficient  antiseptic  solution,  as  required  by  Rule  E.S ; 
she  neglected  to  remove  soiled  linen,  placenta,  and  membranes  from 
the  patient’s  neighbourhood  and  from  the  lying-in  room  before 
leaving  the  patient's  house,  as  required  by  Rule  E.ll,  and  she 
neglected  to  give  the  necessary  directions  for  securing  the  cleanli 
ness,  comfort,  and  proper  dieting  of  the  mother  and  child  during 
the  lying-in  period,  as  required  by  Rule  E.12.  Medical  aid 
having  been  sought  for  a patient  the  midwife  neglected  to 
notify  the  local  supervising  authority  thereof,  as  required  by 
Rule  E.22  (1)  (a).  A child  suffering  from  imperforate  urethra  the 
midwife  did  not  explain  that  the  ease  was  one  in  which  the  attendance 
of  a registered  medical  practitioner  was  required,  as  provided  by 
Rule  E.21  (5).  A patient  suffering  from  rigor  with  raised  temperature, 
and  on  subsequent  days  fri  in  other  illness,  the  midwife  did  not  explain 
tbat  the  case  was  one  in  which  the  attendance  of  a registered  medical 
practitioner  was  required,  as  provided  by  Rules  E.20  and  21  (4i.  A 
patient  suffering  from  puerperal  fever,  and  the  midwife  being  herself 
liable  to  be  a source  of  infection,  6he  negl-cted  to  notify  tbe  local 
supervising  authority,  as  required  by  Rule  E 6. 

Lieutenant-Colonel  J.  F.  Donegan,  R.A.M.C.,  has 
been  awarded  the  honorary  degree  of  LL.D.  by  the  National 
Universitv  of  Ireland. 

Dr.  H.  Beecher  Jackson  has  been  appointed 

coroner  for  Croydon. 

Seaton  V.A.  Hospital. — This  hospital,  which  was 
recently  closed,  was  one  of  the  two  most  economically 
worked  in  Devonshire.  There  was  a balance  in  hand  of  £1088. 
£161  were  given  to  tbe  Royal  Devon  and  Exeter  Hospital 
and  the  balance  divided  amongst  the  parishes  which  had 
subscribed  to  the  hospital. 

London  Hospital  Medical  College. — A course 
of  clinical  lectures  for  advanced  students  on  “ Intermittent 
Blood  Infections  and  their  Relation  to  Certain  Common 
Diseases  of  the  Kidney,  Prostate,  Testicle,  and  other 
Organs”  will  be  delivered  by  Mr.  Frank  Kidd,  surgeon  in 
charge  of  the  Genito-Urinary  Department,  in  the  Clinical 
Theatre  of  the  Hospital,  on  four  successive  Wednesdays 
beginning  August  6th,  at  4.15  p.m.  A special  coarse  of 
instruction  in  the  surgical  dyspepsias  is  being  repeated  on 
Mondays  and  Fridays,  commencing  on  August  1st,  by  Mr. 
A.  J.  Walton,  assistant  surgeon  to  the  hospital.  The  lectures 
will  be  continued  till  Oct.  27th.  Members  of  the  medical 
profession  will  be  admitted  to  all  these  lectures  on  presenta- 
tion of  their  cards. 

London  Hospital  : Award  of  Prizes. — At  a 
recent  meeting  of  the  College  Board  of  tpe  Loudon  Hospital 
the  following  prizes  were  presented  : — “ Price  ” and  entrance 
scholarships  in  Science,  (1)  £100,  (2)  £50,  Messrs.  G.  N. 
Golden,  J.  A.  H.  Andre,  K.  W.  Todd  (equal,  scholarships 
divided) ; Epsom  scholarship  (for  students  of  Epsom 
College),  Mr.  G.  L.  Peskett ; prize  in  Clinical  Medicine  (£20), 
Mr.  A.  B.  K.  Watkins;  prize  in  Clinical  Surgery  (£20), 
Messrs.  E.  L.  Sergeant  and  A.  B.  K.  Watkins  (equal,  prize 
divided) ; prize  in  Clinical  Obstetrics  and  Gynaecology  (£20), 
Mr.  M.  W.  B.  Bulman ; “Duckworth  Nelson”  prize  in 
Practical  Medicine  and  Surgery  (£10),  Mr.  A.  B.  K.  Watkins ; 
“ Letheby  ” prizes  in  Elementary  Clinical  Surgery,  Messrs. 
J.  E.  Zeitlin,  F.  H.  W.  Tozer,  and  Miss  O.  G.  Potter; 
“ Anderson  ” prizes  in  Elementary  Clinical  Medicine,  Miss 
M.  E.  Kennedy,  Miss  D.  W.  Roughton,  Mr,  D.  C.  Williams. 


220  The  Lancet,] 


MEDICAL  NEWS.— THE  SERVICES. 


[August  2,  1919 


Post-Graduate  Medical  Teaching  in  Glasgow. 
— Under  the  joint  auspices  of  the  Faculty  of  Medicine, 
Glasgow  University,  and  the  General  Committee  for  Post- 
Graduate  Medical*  Teaching  in  Glasgow  a successful 
emergency  course  of  post-graduate  medical  study  in  various 
institutions  in  Glasgow  has  just  drawn  to  a conclusion.  The 
course  was  arranged  to  meet  the  needs  of  graduates  who  had 
been  on  Service  and  were  returning  to  take  up  civilian 
duties.  The  facilities  offered  were  taken  advantage  of  by 
doctors  from  places  as  far  away  as  America  and  China, 
India  and  the  West  Indies,  and  Basutuland,  and  while 
the  majority  of  the  graduates  who  attended  the  course 
were  officers  or  ex-officers  of  the  Navv  or  Army  a few 
local  practitioners  also  availed  themselves  of  the  oppor- 
tunities offered.  A further  course  has  been  arranged  to  be 
held  during  September  and  October  in  Glasgow,  and  this  is 
to  be  essentially  a practitioners’  course.  The  classes  will  be 
clinical  and  practical,  and  specially  designed  to  meet  the 
needs  of  those  who  have  been  on  Service  and  are  entering  or 
re-entering  general  practice.  In  addition  to  the  usual  classes 
in  medicine,  surgery,  and  obstetrics  a special  course  on  tuber- 
culosis has  been  arranged  at  the  Consumption  Sanatoria, 
Bridge  of  Weir,  and  at  the  tuberculosis  dispensary  in 
Glasgow.  In  gynaecology  and  obstetrics  exceptional  oppor- 
tunities are  available.  Special  evening  demonstrations  have 
been  arranged  in  diseases  of  the  throat,  nose,  and  ear.  The 
syllabus  may  be  obtained  from  the  acting  secretary,  Dr. 
A.  M.  Kennedy,  Pathological  Institute,  Royal  Infirmary, 
Glasgow. 

SociETE  de  Biologie,  Paris.— T wo  recent  meet- 
ings of  this  society — June  14th  and  21st — were  devoted  to  a 
consideration  of  the  physiology  and  pathology  of  aviation. 
Among  the  16  papers  read  were  the  following : — 

Ferry,  A. — Flying  Sickness  and  its  Sequelse. 

Elies  permettent : lu  De  rapproeher  des  manifestations  azotem'ques 
et  uremig&nes  de  la  sclerose  rdnale,  de  certains  troubles  accuses  par 
les  aviateurs.  2°  De  rattacher  ces  troubles  <fe  l’influence  surrenale. 
A,  Inlluencedu  repos  sur  la  tension  sanguine  de  l’aviateur  : 11  supprime 
l’bypertension  de  I'intervalle  des  vols,  reduit  l’hypertension  con- 
secutive au  vol.  B,  Signe9  premonitolres  de  l’astbenie  des  aviateurs. 
C,  Rechercher  surtout  le  dedoublement  tr6s  precoce  du  2e  bruit, 
4 1'exaraen  du  coeur. 

Guillain,  G.,  et  Ambard,  L. — Reaction-time  and  Flying 
Aptitude. 

La  determination  des  temps  de  reaction  elementaire  chez  les  can 
didats  a l'aviation  est  utile  au  point  de  vue  dncumentaire  ; mais  qu’il 
ne  faut  en  tirer  que  des  conclusions  tr6s  prudentes. 

Tara.— Blood  Pressure  Measurements. 

Les  mesuies  ont  abouti  aux  resultats  suivants  : 1°  Au  fur  et  a mesure 
que  l’altitude  croit.les  cbiffres  des  maxima  et  minima  baissent,  mais  pas 
aussi  vite  que  la  pression  atmosphdrique.  2°  A pi  res  grands  vols  aux 
hautes  altitudes  11  persists  de  I’hypotensioa  surtout  aux  maxima. 

Josue,  M.  O. — The  Airman’s  Asthenia. 

En  general  la  pression  maxima  est  basse.  La  pression  minima  est 
normale.  Aprils  repos  la  pression  revient  ft  la  normals.  Quand  on  a 
une  maxima  trfts  basse  et  qui  se  maintient  telle,  il  y a lieu  de  redouter 
l'apparition  de  l'asthenie  des  aviateurs. 

C'est  une  variate  partieuliere  d'insuffisance  surrenale.  Les  signes 
sont:  1°  Asthenie  avec  perte  de  la  maitrise  de  soi.  tendance  syncopale, 
quelquefois  phenomenes  neurasthenlques.  2°  Hypotension  arterielle 
portant  sur  la  maxima,  quelquefois  sur  la  minima.  3°  Ligne  blanche 
surrenale  de  Sergent.  Duree : un  mols  1/2  a 3 mois  et  plus.  Traite- 
ment : repos  absolu  et  l’opothdrapie  surrenale. 


®bc  ^erbiers. 

G 

THE  HONOURS  LIST. 

The  following  awards  to  medical  officers  are  announced • 
Bar  to  Military  Cross—  Capt.  F.  G.  Flood,  M.C.,  R.A.M.C.  (Spec. 
Res.).  During  operations  at  Vigozero  and  Petrovski  Yam  on  March  18th. 
1919.  he  dressed  wounded  under  heavy  machine-gun  and  rifle  fire,  and 
under  most  trying  conditions  saved  many  lives.  After  the  action  he 
successfully  evacuated  all  the  wounded  over  60  versts  of  most  difficult 
country  without  losing  a case.  He  showed  great  gallantry  and  marked 
ability  and  devotion  to  duty. 

C.B.F.— Surg.  Cdr.  R.  J.  MacKeown,  R.N.,  Surg.  Cdr.  H.  B 
Marriott,  R.N.,  Surg.  Lt.-Cdr.  E.  A.  G.  Wi.kinson,  R.N  , for  valuable 
services  in  the  First  Battle  Squadron. 

Foreign  Decorations. 

Legion  d'Honneur  (french).— Olficier:  Maj.-Gen.  M.  W.  O'Keefe. 
K.C.M.G.,  C.B.  Chevalier:  Temp.  Capt.  (acting  Maj.)  L.  D.  Woods, 

R.A.M.C. ; Temp.  Capt.  M.  S.  Bryce,  M.C.,  R.A.M.C.  Croix  de  Guerre  : 
Maj.-Gen.  H.  N.  Thompson,  C.B.,  C.M.G.,  D S.O. ; Temp.  Capt.  P.  B. 
Belanger,  M.C..  R.A.M.C.;  Maj.  J.  M.  Bowie,  R.A.M.C.  ; Temp.  Capt. 
(acting  Maj.)  D.  Cowin,  R.A.M.C.; Temp.  Capt. (acting  Maj.)  A.  R.  Green. 
R.A.M.C;  Temp.  Capt.  A.  A.  Greenwood,  R.A.M.C.;  Capt.  (acting 
Lt.-Col.)  H.  A.  Harblson,  M.C.,  R.A.M.C.  ; Temp.  Capt.  (acting  Maj.) 
E.  E.  Herga,  M.C.,  R.A.M.C. ; Maj.  (temp.  Col.)  T.  Kay,  D.S.O  , 
R.A.M.C.;  Maj.  B.  E.  Kelly,  Canadian  A.M.C. ; Temp.  Capt.  H. 
Meame,  R.A.M.C.;  Capt.  C.  L.  Franklin,  M.C.,  R.A.M.C.;  Capt. 
(acting  Maj.)  N.  V.  Lothian,  M.C..  R.A.M.C.  Palmes  Academii/ues : 
Maj.  (temp.  Lt.-Col.)  W.  D.  C.  Kelly,  D S.O.,  R.A.M.C. ; Temp.  Capt. 
(acting  Maj.)  T.  C.  Ritchie,  O.B.E.,  R A.M.C. ; Temp.  Cant.  H.  T. 
Retallack-Moloney,  R.A.M.C.  Ordre  de  I’Etoile  Noire : Maj.  (acting 
Lt.  Co'.)  T.  B.  Morlarty,  D.S.O. , R A M.C. 


Order  of  the  Redeemer  (Hellenes).— Chevalier  : Temp.  Capt.  J. Wats  on 

R. A.M.C.  OrderoJ  George  I.  — Officer : Surg. -Cdr.  K.  C.  Sawdy,  R.N. 
Military  Order  of  Avis  ( Portuguese ) —Grand  officer:  Maj  -Gen.  H. 

Carr,  C B.,  A.M.S  ; Maj.-Gen.  R H.  S.  Sawyer,  C.B  , C M G.  (ret  pay), 
late  A.M.S.  Commander  : Maj.  (temp.  Lt.-Col.)  G.  N.  Biggs,  R.A  M.C. ; 
Lt.-Col.  (temp.  Col.)  J.  H.  Campbell,  D.S.O.,  R.A.M.C. ; Col.  H E.  Cree 
(ret.  pay),  late  A.M.S  ; Brev.-Col.  W.  L'E.  E ones. C.B. , R.A  M.C.  ; Col. 
J.  M.  Elder.  C.M.G..  Canadian  A M.C. ; Lt.-Col.  J.  R.  Harper,  R.A.M  C., 
Col.  E.  M.  Hassard.  A.M.S. ; Col.  R.  H.  Penton.  D.S  O , A.M.S. ; Lt.-CM. 

S.  J.C.P.  Perry,  R.A.M.C. ; Lt.-Col.  (acting  Col  ) W.  L Steele,  C.M.G., 
R.A.M.C.;  Col.  H.  S.  Thurston,  C.B.,  C.M.G.,  R.A.M.C.;  Col.  A.  H. 
Waring,  D S.O. , R.A.M.C.;  Maj.  M.  C.  Wetherell,  R.A.M.C.  ('avaleiro  : 
Temp.  Capt.  M.  du  B.  Ferguson,  R.A  M.O. ; Capt  (acting  Maj.)  A.  D. 
Slirling,  D.S.O  , R.A.  M.C. ; Maj.  J.  L.  Wool.  R.A.M  C. 

Distinguished  service  Medd  (Ame  lean).— Maj  -Gen.  (temp.  Lt  - 
Gen.)  Sir  C.  H.  Burtehaell,  K.C.B.,  C M.G..  K.HS;  Lt -Gen.  Sir 

T.  H.  J.  C.  Goodwin.  K.C.B.,  C.  M.G.,  D.S.O.,  K H.3. 

Croix,  de  Guerre  (Be'glan).— Capt.  D.  L.  Stevenson,  M B E. 

Men  ioned  in,  D:spatches. 

In  a despatch  received  from  the  Commander-in-Chief  in  India  ;he 
names  of  the  following  medical  officers  and  others  are  mentioned  : Maj. 
F.  A.  H.  Clarke,  R.A.M.C.;  Capt.  F.  G.  Cross,  R.A.M.C.;  Maj  A.  L 
Davies,  Hon.  Supt.,  Red  Cross  Dtp..  Bombay;  Maj.  (temp.  Lt.-Col.) 
P.  Dwyer,  M.C.,  R.A.M.C.;  Maj  W.  F.  Harvey.  I.M  S..  Director, 
Central  Research  Institute.  Kasauli ; Maj.-Gen.  P.  Hehtr,  C.B  ,C.M.G., 
C.I.E.,  I.M.S.;  Lt.-Col.  K.  V.  Kuklay,  I.M. 8 ; Dr.  S.  K.  M dlick, 

C.  B.  K.,  Calcutta  ; Lt.-Gen.  Sir  T.  J.  O'Donnell.  K.C.I.E.,  C.B..  D.t.O., 
A M S.,  D..M.S.  in  India;  Dr.  S.  P Sarhadhikari,  C.l  E.,  C.lcutta; 
Capt.  A.  G.Tressider.  I.M.S. ; Maj.  G.  S.  Wallace,  R.A.M.C.  ; Lt.-Col. 
H.  E.  Winter,  R A.M.C. 

Brought  to  Notice. 

The  names  of  Surg.-Lt.  E.  St.  G.  S.  Goodwin.  R N.,  and  of  Surg.-Lt. 
L.  Moss,  R.N.,  have  been  b ought  to  the  notice  of  the  Admiralty  for 
valuable  services  in  the  prosecution  of  the  war. 

ROYAL  NAVAL  MEDICAL  SERVICE. 

Temp.  Surg.  Lieut.  K.  McFadyean,  who  has  been  Invalided  on 
account  of  ill-health  contracted  in  the  Service,  to  retain  his  rank. 

To  be  Surgeon  Lieutenants  : R.  P.  Ninnis,  E.  Hefferman. 

Temp.  Surg.  Lieut.  R.  A.  Brown  is  transferred  to  Permanent  List  of 
Surgeon  Lieutenants. 

, ROYAL  NAVAL  VOLUNTEER  RESERVE. 

To  be  temporary  Surgeon  Lieutenant : E.  L.  AdendorfT. 

ARMY  MEDICAL  SERVICE. 

Col.  (temp.  Maj.  Gen  ) Sir  Samuel  Hickson,  K.B.E  . C.B.,  is  granted 
the  honorary  rank  of  Major-General  on  ceasing  to  be  employed. 

Col.  Albert  L.  F.  Bate,  C.M.G.,  retires  on  retired  pay. 

Col.  W.  H.  Grattan.  C.B.E.,  D.S  0.,  to  be  D puty  Director  of 
Hygiene  at  the  War  Office. 

Temp.  Col.  Sir  T.  Myles,  C.B.,  relinquishes  his  commission  and 
retains  the  rank  of  Colonel.  

ROYAL  ARMY  MEDICAL  CORPS. 

Lieut.-Col.  J.  C.  Jameson  retires  on  retired  p\y. 

Major  H.  W.  Farebrother  relinquishes  the  acting  rank  of  Lieutenaut- 
Colonel  on  re-posting. 

The  undermentioned  relinquish  the  acting  rank  of  Major:  Capt.  and 
Brevet  Major  F.  C.  Cowtan;  Capts.  C.  Russell,  R.  A.  Hepple,  K.  B. 
Marsh,  R.  131118,  A.  P.  O'Connor,  N.  Cantlie,  F.  R.  H.  Mollan;  Temp. 
Capts.  C.  A.  R.  McCay,  W.  C.  Douglass,  T.  Bragg,  H.  B.  D .y.  J.  S. 
Djyle.  A.  P.  Saint,  J.  W.  Tocher,  J.  G.  Ackland,  A.  W.  D.  Coventon, 
J.  R.  Collins,  G.  Rankine,  B.  W.  Armstrong,  H.  F.  Warwick,  A.  Levland 
Robinson,  C.  A.  Weller,  J.  E.  G.  Calverley,  A.  Poole,  T.  Kelly,  E.  G.  D. 
Pineo,  A.  Feiling. 

To  be  acting  Majors : Capt.  A.  L.  Stevenson ; Temp.  Capts.  J. 
Buchanan,  W.  D.  Cruickshank,  A.  Mathleson,  A K.  H.  Pollock. 

D.  Cowin,  J.  V.  Grant,  T.  V.  Somerville.  E.  G.  D.  Pineo,  A.  H.  Mackltn 
Capt.  F.  W.  M.  Cunningham  retires,  receiving  a gratuity. 

Capts.  St.  J.  D.  Buxton  and  H.  A.  Harbison  resign  their  commissions. 
To  be  Captains  : Capts.  F.  K.  Tomlinson  (frjm  T.F.),  H.  S.  Griffith 
(from  Spec.  Res  ),  K.  O’Kelly  (from  Spec.  Res.),  T.  Young  (from 
Spec.  Res). 

To  be  Temporary  Captains:  C.  L.  G.  Powell,  L A.  J.  Graham, 
W.  G.  D.  McCall,  J.  M.  Ryaa. 

Captains  from  Special  Reserve  to  be  Lieutenants  and  to  be  temoorary 
Captains : D.  R.  Hennessy,  T.  Parr,  J.  D’Arcy  Champney,  J.  W.  Hyatt. 

Temp.  Capt.  J.  K.  Holland  to  be  Lieutenant  and  to  be  temporary 
Captain. 

Temp.  Lieut.  T.  C.  Hughes  to  be  temporary  Captain. 

Officers  relinquishing  their  commissions:  Temp.  Lieut.-Col.  G B. 
Price  (retains  the  rank  of  Lieutenant-Cjlonel).  Temp.  Hon.  Lieut-Col. 
W.  J.  R chard  (retains  the  honorary  rank  of  Lieutenant-Colonel  I. 
The  notification  of  the  relinquishment  of  the  acting  rank  ot 
Lieutenant-Colonel  by  Major  P.  T.  C.  Davy  is  cancelled.  Tem- 
porary Majors  retaining  the  rank  of  Major:  C.  DO.  Grange,  d. 
Irving,  E.  R.  Fothergill.  Temporary  Captains  granted  the  rank 
of  Major  : W.  K.  McIntyre,  A.  T.  Todd,  F.  J.  O.  Kiug,  A.  C.  Renton, 
W.  H.  Bryce,  J.  H.  Legge,  R.  R.  Wallace.  T.  W.  Buckley.  R. 
Millar,  J.  B.  Alexander,  G.  Rankine,  T.  Biagg.  S.  Brown. 
Temporary  Captains  retaining  rank  of  Captain  : W.  A.  Wilson-Smitb. 
A.  J.  D.  Cameron.  R.  Vincent.  E.  A.  0.  Travers.  O.  A.  Beaumont,  G.  C. 
Wells-Cole,  G.  H.  Urquhart.  P.  A.  Serjeant.  W.  A.  Wheeldon,  A. 
Brownlie,  D.  Kelly,  J.  Stephenson,  J.  M.  Biggs,  M.  A.  C.  Buckell, 
J.  A.  Dickson,  T.  L.  Fleming,  E.  T.  C.  Hughes,  G.  F.  Rlgden.  J.  D. 
Lyle,  A.  V.  Craig,  O.  J.  W.  Adamson,  F.  H.  Mosse,  J.  C.  Neil.  W.  F. 
Hare,  W.  P.  Philip,  P.  B.  Belanger.  M.  C.  R.  Grabame,  J.  F.  C O'Meara, 
W.  H.  Gibson,  R.  G.  Gordon,  R.  M.  Paterson,  V.  G.  Ward,  J.  Cross,  J.  G. 
Lee,  P.  W.  L.  Andrew,  N.  J.  Newbould.S.  W.  Fisk,  H.  S.  Metcalfe,  G.  W. 
Pope,  W.  H.  Duncan,  P.  G.  Leeman,  P.  Ashe.  K.  0.  Marks,  C.  Garner, 
C.  R.  Young,  G.  Macdonald,  A.  N.  Fell,  E.  S.  Johnson,  F.  H.  Y'oung, 
H.  L Burton.  J.  Ross.  L.  L.  Cassidy.  A.  Vella,  T.  A.  Davidson,  F.  R 
Dougan,  H.  T.  Retallack-Moloney.  T.  C.  Harte.  J.  A.  H.  Telfer,  O R.  M. 
Kelly,  C.  I.  Ilderton,  F.  V.  Hanratty,  C.  H.  G.  Gostwyck,  R.  Lewis 
J.  F.  Venables,  T.  S.  Reeves,  H.  j.  Rawson,  J.  D.  C.  Swan,  G;  E. 
Charters,  J.  M.  Richey,  S.  H.  Kingston,  I.  D.  Ramsay,  H.  C.  Weit, 


Thb  Lancet,] 


MONTHLY  RECORD  OF  ATMOSPHERIC  POLLUTION. 


[August  2,  1919  221 


M.  Gross,  J.  A.  Wood  (late  tomp.  Capt.,  is  granted  the  rank  of  Captain) ; 
Temp.  Hon.  Capt.  D.  E.  Carter  (retains  tlio  hon.  rank  of  Certain)  ; 
Temp.  Lleuts.  U.  M.  Halsall,  W.  Hickey,  W.  K.  Thompson,  W.  Napier, 
J.  K.  G.  Calverley,  E.  B.  Bate,  F.  Aitken  (retain  the  rank  of  Lieutenant). 

Canadian  Army  Medical  Corps. 

Temp.  Lieut. -Col.  (acting  Col.)  K.  St.  J.  MacDonald  relinquishes  the 
acting  rank  of  Colonel. 

The  undermentioned  temporary  Majors  (acting  Lieutenant-Colonels) 
relinquish  the  acting  rank  of  Lieutenant-Colonel : S.  L.  Walker, 
W.  H.  Lowry. 

The  undermentioned  temporary  Captains  (acting  Majors)  to  be 
temporary  Majors : J.  H.  Slayter,  C.  T.  Wallbridge,  C.  A.  Davies. 

Temporary  Captains  (acting  Majors)  relinquishing  the  acting  raDk  of 
Major  -.  C.  B.  Kidd,  II.  B.  Van  Wyck,  It.  F.  Slater,  A.  Sterling,  H.  G. 
Murray,  G.  S.  Murray,  G.  S.  Gordon,  E.  P.  Lewis,  L.  F.  Jones,  D.  G.  K. 
Turnbull. 

The  undermentioned  temporary  Lieutenants  to  be  temporary 
Captains:  J.  E.  Wadsworth,  M.  A.  Wittick. 

The  undermentioned  retire  in  the  British  Isles : Temp.  Major  G.  J. 
Gillam  ; Hon.  Major  F.  Lessore  ; Temp.  Capts.  D.  G.  K.  Turnbull,  G.  J. 
Preston,  A.  B.  Roberts,  E.  H.  Fisher,  It.  D.  Cowan,  A.  Keay,  G.  More; 
Hon.  Capt.  F.  White. 

Canadian  Army  Denial  Corps. 

Temp.  Major  (acting  Lieut.-Col.)  B.  L.  Neiley  to  be  temporary 
Lieutenant-Colonel. 

The  undermentioned  retire  in  the  British  Isles  : Temp.  Major  L.  N. 
Trudeau  ; Temp.  Capt.  W.  Kennedy. 

GENERAL  RESERVE  OF  OFFICERS. 

H.  A.  Harbison  and  S.  J.  D.  Buxton,  late  Captains,  R.A.M.C.,  to  be 
Captains. 

SPECIAL  RESERVE  OF  OFFICERS. 

Captains  relinquishing  the  acting  rank  of  Major : H.  T.  Chatfield, 
J.  W.  Malcolm,  T.  F.  Corkill,  F.  Cook,  J.  W.  Cannon. 

Capt.  F.  G.  Flood,  M.C.,  to  be  acting  Major. 

Lieuienants  to  be  Captains:  B.  G.  Derry,  J.  C.  McGregor,  J.  K.  T. 
Mills. 

TERRITORIAL  FORCE. 

Lieut.-Col.  (acting  Col.)  J.  Mackinnon,  D.S.O.,  relinquishes  the 
acting  rank  of  Colonel  on  ceasing  to  be  specially  employed. 

Major  R.  B.  Purves  to  be  acting  Lieutenant-Colonel  whilst  specially 
employed. 

- Capts.  (acting  Lieut.-Col.)  J.  Bruce  to  be  Major,  and  to  retain  the 
acting  rank  of  Lieutenant-Colonel. 

Captains  (acting  Lieutenant-Colonels)  relinquishing  the  acting  rank 
of  Lieutenant-Colonel  on  ceasing  to  be  specially  employed  : P.  Moxey, 
W.  B.  Keitb,  T.  H.  Richmond,  T.  A.  Green. 


Captains  (acting  Majors)  relinquishing  the  acting  rank  of  Major  on 
ceasing  to  be  specially  employed:  T.  C.  Britton,  A.  C.  Tibbits,  H. 
Foxton,  D.  It.  Kilpatrick,  H.  J.  Blackler,  T.  G.  Buchanan,  G.  B. 
Buchanan. 

Capt.  (acting  Major)  A.  Leggat  relinquishes  the  acting  rank  of  Major 
on  vacating  the  appointment  as  Deputy  Assistant  Director  of  Medical 
Services. 

Capt.  M.  S.  Doubble  to  be  a Deputy  Assistant  Director  of  Medical 
Services,  and  to  be  acting  Major  whilst  so  employed. 

Captains  to  be  acting  Majors  whilst  specially  employed  : M.  Brannan, 
J.  P.  Milton,  G.  Davidson,  J.  Muir,  A.  W,  Paterson. 

2nd  Scottish  General  Hospital  : Capt.  (acting  Major)  A.  A.  S.  Skirving 
relinquishes  the  acting  rank  of  Major  on  ceasing  to  be  specially 
emploved. 

1st  Southern  General  Hospital:  Lieut.-Col.  F.  W.  Ellis  is  seconded 
for  duty  with  the  2/lst  Southern  General  Hospital. 

2nd  Southern  General  Hospital:  Major  (Bt.  Lieut.-Col.)  (acting 
Lieut.-Col.)  A.  B.  Prowse  and  Major  J.  Swain  to  be  Lieutenant-Colonels. 
Majors  (acting  Lieut.-Coh.)  G.  Parker  and  R.  G.  P.  Lansdown  relin- 
quish the  acting  rank  of  Lieutenant-Colonel  on  ceasing  to  be  specially 
employed.  Capt.  (acting  Major)  J.  L.  Firth  relinquishes  the  acting 
rank  of  Major  on  ceasing  to  be  specially  employed. 

3rd  Southern  General  Hospital : Capt.  N.  B.  Clowes  is  restored  to 
the  establishment. 

4th  London  General  Hospital : Major  (acting  Lieut.-Col.)  W.  G. 
SpeDcer  relinquish! s the  acting  rank  of  Lieutenant-Colonel  on  ceasing 
to  be  specially  employed.  Capt.  (acting  Major)  C.  Gibbs  relinquishes 
the  acting  rank  of  Major  on  ceasing  to  be  specially  employed.  Capt.  W. 
Turner  to  be  acting  Major  whilst  specially  employed. 

1st  Northern  General  Hospital:  Major  T.  M.  Allison  is  restored  to 
the  establishment. 

1st  Western  General  Hospital : Major  (acting  Lieut.-Col.)  R.  W.  Murray 
relinquishes  the  acting  rank  of  Lieutenant-Colonel  on  ceasing  to  be 
specially  employed. 

1st  London  Sanitary  Company  : Lieut.  R.  Wood  to  be  Captain. 

2nd  Loudon  Sanitary  Company  -.  Lieut.  S.  G.  Reed  to  be  Captain. 

ROYAL  AIR  FORCE. 

Medical  Branch.— Major  E.  M.  W.  Hearn  (Staff  Surgeon,  R.N.) 
relinquishes  his  commission  on  ceasing  to  be  employed. 

Capt.  R.  L.  Roe  to  be  acting  Major  whilst  employed  as  Major. 

T.  C.  Backhouse  (Captain,  A.A.M.C.)  is  granted  a temporary  com- 
mission as  Captain. 

The  undermentioned  are  transferred  to  unemployed  list : Major  H. 
Pritchard;  Capts.  N.  R.  Williamson,  I.  L.  Waddell;  Lieuts.  L.  C. 
Broughton-Head,  C.  H.  Vernon,  P.  E.  Williams. 

Dental  Branch. — Lieut.  P.  J.  Proud  is  transferred  to  unemployed  list. 


A MONTHLY  RECORD  OF  ATMOSPHERIC  POLLUTION. 


Meteorological  Office  : Advisory  Committee  on  Atmospheric  Rollution  : Summary  of  Reports  for  the  Months 

ending 

June  30th , 1918.  July  31st,  1918. 


Metric  tons  of  deposit  per  square  kilometre. 


Place. 

.2  S 
13  g 

Insoluble  matter. 

Soluble 

matter. 

3 

Included 
in  soluble 
matter. 

5 8 

in 

•— • 

Insoluble  matter. 

Soluble 

matter. 

2 

Included 
in  soluble 
matter. 

si 

* s 

Tar. 

Carbon- 
aceous 
other 
than  tar 

Ash. 

Loss  on 
ignition. 

S3 

< 

o 

CO 

13 

"o 

H 

Sulphate 
as  (S03). 

Chlorine 

(Cl). 

5 

gffi 

a5 

Place. 

Jj 

aS  ^ 

Tar. 

Carbon- 
aceous 
other 
than  tar 

Ash. 

Loss  on 
ignition. 

Ash. 

o 

S Q 

'3 

O 

EH 

Sulphate 
as  (SO3). 

Chlorine 

(Cl). 

*2 

|n 

a 5. 

<4 

England. 
London — 

Meteorological 
Office  

32 

0'04 

0-97 

1-66 

0-76 

1-67 

5T0 

0-57 

0-40 

0-C6 

England. 
London — 

M e t e o r o logical 
Office 

154 

0-07 

1-54 

2-32 

3-08 

8-00 

15-01 

2-92 

0-87 

0-38 

Embankment 
Gardens  

18 

0-04 

0-76 

0-58 

1-80 

3-68 

6-86 

1 60 

0-51 

0 08 

Embankment 
Gardens* 

_ 

_ 

_ 











Finsbury  Park  ... 

31 

0'03 

0-56 

311 

0-78 

1-85 

6-32 

0-80 

0-20 

0-C6 

Finsbury  Park  ... 

ill 

0-02 

1-44 

3-55 

4-53 

4-53 

14-07 

2-90 

0-68 

0-08 

Ravenscourt  Park 

25 

0'02 

0-69 

1-80 

1-02 

1-93 

6-45 

0-86 

0-59 

0-11 

Ravenscourt  Park 

114 

o-io 

277 

7-06 

3-42 

6-84 

20-19 

2-74 

0-68 

J 34 

Southwark  Park 

14 

0-05 

1-01 

3-25 

1-51 

3T1 

893 

1-60 

0-38 

0-07 

Southwark  Park... 

56 

0-24 

2-06 

9-07 

3-89 

2-77 

18-02 

1-50 

0-44 

0-03 

Victoria  Park*  ... 

— 

— 

— 

— 

— 

— 



Victoria  Park 

39 

0-17 

213 

7-98 

2-13 

1-75 

14-15 

0-93 

0-23 

0-08 

Wandsworth  Com. 

12 

0-02 

0-44 

1-18 

0-72 

1-50 

3-85 

0-57 

0-24 

0-03 

Wandsworth  Com. 

13 

— 

o-oi 

o-oo 

0-58 

0-91 

1-51 

0-36 

0-14 

004 

Golden  Lane 

26 

0-05 

1-58 

2-22 

1-12 

2-35 

7-33 

1-18 

0-69 

0-15 

Golden  Lane 

120 

0-08 

2-48 

4-20 

1-92 

4-31 

1298 

2 34 

0-72 

0-30 

Malvern*- 

— 

— 

— 

— 

— 











Malvern* 





— 

— 

— 

— 

— 

— 

— 

— 

Manchester — 
Whitworth  Street 
(garden) 

41 

12-50 

Manchester — 
Whitworth  Street 
(garden) 

1C6 

14-30 

,,  (roof  of 
College)* 









,,  (roof  of 

College)* 













Newcastle  - on-Tyne 

14 

o-ll 

112 

2-43 

097 

1-92 

6-55 

0-94 

0-26 

0-02 

Newcastle-on-Tyne 

93 

0-16 

5-24 

7-35 

3-63 

11-21 

27-61 

4-16 

0-92 

0-14 

Rochdale 

— 

— 

— 

— 

— 

— 

34-80 





Rochdale  





— 

— 

— 

— 

32-88 

— 

— 

A=> 

St.  Helens  

56 

0-23 

352 

9-82 

2-92 

4-58 

21-08 

2-50 

1-28 

0-36 

St.  Helens  

83 

0 21 

1-92 

3-44 

2-27 

4-96 

12-80 

1-99 

1-16 

0-16 

Southport — 
Hesketh  Park  ... 

43 

o-oi 

0-22 

0-32 

0-63 

3-46 

4-64 

1-32 

0-51 

0-03 

Southport— 
Hesketh  Park  ... 

103 

0 02 

0-35 

0-47 

0-76 

507 

6-67 

1-83 

0-32 

0-C6 

Woodvale  Moss... 

35 

— 

— 

— 

— 

— 

4-36 

— 



96 



— 

— 

— 

7 22 

— 

— 



Scotland. 

Coatbridge  

Glasgow — 

31 

o-io 

1-45 

5-43 

1-22 

3T8 

11-38 

1-71 

0-19 

0-14 

Scotland. 

Coatbridge  

Glasgow — 

65 

0-13 

1-63 

6-27 

2-42 

4-95 

15-40 

2 60 

0-30 

0-21 

Alexandra  Park... 

18 

0-24 

104 

2-95 

o-so 

1-80 

6-83 

0-76 

0-06 

0-03 

Alexandra  Park... 

72 

0-12 

6-58 

3-43 

1-09 

3T3 

14-35 

1-83 

0-24 

0-18 

Bellahouston  Park 

27 

0'23 

1-29 

4-18 

0-56 

2-42 

8-68 

1 09 

0-14 

0-04 

Bellahouston  Park 

76 

0-08 

2-09 

4-31 

0-70 

2-10 

9-28 

1-71 

0-12 

0'01 

Blythswood-sq.  ... 

26 

0-16 

1-09 

2-82 

1*16 

0-90 

6-13 

0-65 

0-12 

0-05 

Blvthswood-sq. ... 

50 

0-09 

1-23 

3-00 

0-52 

1-20 

6-04 

1-11 

0-13 

0*12 

Botanic  Gardens 

26 

0‘ 32 

1-42 

4-35 

0-46 

1-85 

8-40 

0-82 

0-13 

0-04 

Botanic  Gardens 

93 

0-06 

1 71 

3-59 

1-31 

5-59 

12-26 

2-59 

0-22 

0-05 

Richmond  Park ... 

26 

0T9 

1-32 

3-05 

1-78 

2-24 

8-58 

1-27 

0-13 

0-05 

Richmond  Park... 

73 

0-19 

1-64 

5-82 

1-62 

2-97 

12-24 

2-OS 

0-51 

0'22 

Ruchill  Park 

26 

0-23 

1-27 

3-03 

0-81 

2-29 

7-63 

1-21 

0-11 

0 02 

Ruchill  Park 

53 

0 08 

1-17 

3-53 

0-39 

1-26 

6-43 

0-99 

0-09 

0'C6 

South  Side  Park. 

27 

0T8 

0-77 

3'24 

0-57 

2-69 

7-45 

1-03 

0-22  0-02 

South  Side  Park.. 

77 

0-05 

0-71 

2-14 

3-67 

4-50 

11-07 

1-94 

0-14 

0'07 

Tollcross  Park  ... 

27 

0-29 

1-70 

4-11 

1-27 

2-54 

9-91 

1-31 

0-22  0-04 

Tollcross  Park  ... 

72 

0-08 

1-45 

5-58 

5-12 

4-47 

16-70 

2-32 

0-14 

o-ii 

Victoria  Park  ... 

27 

0-29 

1-29 

3-88 

0-71 

1 69 

7-86 

0-93 

0-11  0 03 

Victoria  Park  ... 

95 

008 

1-79 

3-92 

1-58 

2-87 

10-24 

2-39 

0-33 

0-12 

Metric  tons  of  deposit  per  square  kilometre. 


. * No  returns. 

iar  ,,lnc  , a"  u™.  ef  ,lsolul>le  -n  water  but  soluble  in  Cs2-  ' caroonaceous  ” includes  all  combustible  matter  insoluhle  in  water  and 
In  Co  j.  Insoluble  ash  includes  all  earthy  matter,  fuel,  ash.  &c.  One  metric  ton  per  sq.  kilometre  is  equivalent  to:  la)  Approx.  9)b  tier 
acre;  (6)  2‘56  English  tons  per  sq.  mile;  (c)  l g.  per  sq.  metre;  (d)  1/1000  mm.  of  rainfall. 

The  personnel  of  public  health  authorities  concerned  in  the  supervision  of  these  examinations  and  of  the  analytical  work  involved  r<  mains  the 
The*!,  an  ckt  Labor  at  o ryr  6 " ° U S ta^*es'  analyses  of  the  rain  and  deposit  caught  in  the  gauge  at  the  Meteorological  Office  are  made  in 


222  The  Lancet,] 


PARLIAMENTARY  INTELLIGENCE. 


[August  2,  1919 


l^diameutarg  Intelligence. 


HOUSE  OF  LORDS. 

Monday,  July  28th. 

Ministry  of  Health  : Consultative  Councils. 

On  the  motion  that  the  House  approve  of  the  Ministry  of 
Health  (Consultative  Councils)  Order,  1919,  and  the  Ministry 
of  Health  (Welsh  Consultative  Council)  Order,  1919, 

Lord  Downham  expressed  the  opinion  that  the  setting  up 
of  the  proposed  four  consultative  councils  was  a costly  and 
cumbersome  experiment  in  government,  and  one  which 
struck  at  the  root  of  Ministerial  responsibility.  There  was 
no  precedent  for  it  whatever.  If  the  Ministry  of  Health  was 
to  set  up  these  councils  with  a large  amount  of  machinery, 
why  should  not  it  be  permitted  to  10  or  12  other  great 
Departments  of  State  also  to  do  so?  He  wished  to  know 
if  any  estimate  had  been  formed  of  the  cost  of  setting  up 
these  four  councils.  He  moved  an  amendment  to  limit  the 
number  of  councils  to  two,  one  for  medical  services  and  the 
other  for  national  health  insurance,  and  to  strike  out  the 
proposed  councils  for  local  health  administration  and 
general  health  questions  respectively,  on  the  ground  that 
they  were  uncalled  for,  as  the  Minister  could  obtain  all  the 
advice  he  required  for  the  numerous  bodies  who  were 
engaged  day  by  day  in  the  administration  of  sanitary  law. 

Viscount  Sandhurst  (Lord  Chamberlain)  said  he  had  done 
his  best  on  a former  occasion  to  show  why,  in  the  opinion  of 
the  Government,  the  proposed  consultative  councils  ought 
to  form  a most  important  part  of  the  Ministry  of  Health  Act. 
He  was  not  prepared  with  any  estimate  of  the  cost,  but  it 
was  only  proposed  to  have  one  secretary  and  one  staff,  and 
to  use  the  present  health  offices.  The  idea  behind  these 
consultative  councils  was  that  everything  should  not  be  done 
from  Whitehall.  The  council  on  the  general  health 
question  was  hardly  less  important  than  the  other  three 
councils,  and  he  believed  the  other  three  to  be  most 
important.  To  make  the  Ministry  of  Health  Act  a success 
they  must  endeavour  to  get  the  confidence  of  the  people,  and 
having  got  it,  they  must  enlist  the  most  sympathetic  health 
knowledge  and  cooperation  of  all.  He  submitted  that  these 
councils  would  supply  that,  and  he  appealed  to  the  House  to 
support  the  Orders  now  before  them. 

On  a division  the  amendment  was  lost  by  31  votes  to  23, 
and  the  motion  was  then  agreed  to. 

HOUSE  OF  COMMONS. 

Wednesday,  July  23rd. 

Medical  Advice  for  Officers  on  Leave. 

Colonel  Yate  asked  the  Secretary  for  India  whether  he 
was  aware  of  the  expenses  involved  in  obtaining  medical 
advice  in  London  for  officers  on  leave  from  India ; and 
whether  he  could  do  anything  to  assist  these  officers  in  that 
respect. — Mr.  Montagu  replied:  All  Indian  Army  officers 
on  sick  leave  in  this  country  during  the  war  have  been 
admitted  to  the  same  medical  treatment  in  hospitals  or  by 
private  practitioners  as  British  Service  officers.  Through 
the  generous  aid  of  the  London  School  of  Tropical  Medicine 
it  has  also  been  possible  to  arrange  to  send  civil  and  military 
officers  suffering  from  tropical  diseases  to  the  School  hospital 
at  the  Albert  Docks  for  diagnosis  and  preliminary  treatment. 
I hope  it  may  be  possible  to  continue  this  arrangement.  It 
secures  to  the  officer  the  best  advice  on  his  case  and  as  to 
its  treatment.  The  hospital  charges  in  these  cases  are  borne 
by  the  revenues  of  India. 

Service  Disability  Pensions. 

Sir  B.  Falle  asked  the  Secretary  to  the  Admiralty  if  he 
could  make  any  statement  as  to  the  service  pensions  of  men 
invalided,  apart  from  any  award  in  respect  of  disability. — Dr. 
Macnamara  replied:  Under  present  regulations  only  a man 
with  fourteen  years’  service  is  entitled  to  a life  pension  on  the 
service  disability  scale  in  addition  'to  any  award  from  the 
Ministry  of  Pensions  in  respect  of  permanent  disablement. 
The  whole  question  of  the  service  disability  side  of  the  award 
made  to  the  men  invalided  is  now  being  considered. 

Sir  B.  Falle  : Is  it  on  the  new  basis?— Dr.  Macnamara: 
That  is  the  point,  whether  the  service  disability  side  shall 
be  reassessed  to  an  amount  proportionate  to  the  new  soale 
basis,  but  as  to  that  I can  give  no  undertaking  at  the 
moment. 

Welsh  Hoard  of  Health. 

Sir  David  Davies  asked  the  Minister  of  Health  when  he 
proposed  to  appoint  the  remaining  members  of  the  Welsh 
Board  of  Health;  whether  he  proposed  to  give  definite 
powers  and  duties  to  the  Welsh  Board  as  a corporate  body  ; 
and  whether  he  would  give  an  assurance  that  the  organisa- 
tion of  his  department  in  Wales  would  not  be  proceeded 
with  until  the  Welsh  Board  had  been  fully  constituted  ? — 


Major  Astor  (Parliamentary  Secretary  to  the  Ministry  of 
Health)  replied:  My  right  honourable  friend  cannot  yet 
say  how  soon  any  further  members  will  be  appointed  nor 
when  the  whole  Board  will  have  been  completed.  Such 
powers  and  duties  as  may  be  exercised  in  Cardiff  under 
Section  5 of  the  Act  will  be  exercised  in  manner  provided 
by  that  Section.  The  organisation  in  Cardiff  will  be 
developed  from  time|  to  time  in  whatever  manner  the 
circumstances  may  render  expedient.  It  would  be  pre- 
mature for  me  to  make  any  forecast  in  this  respect  to-day. 

Thursday,  July  24th. 

Artificial  Limbs  for  Officers. 

Major  Cohen  asked  the  Pensions  Minister  if  he  would  say 
whether  officers  who,  as  the  result  of  their  war  service, 
required  to  wear  artificial  appliances  were  required  to  bear 
the  cost  of  repair  and  renewal  of  these  appliances  them- 
selves, although  in  the  case  of  the  sailor  or  soldier  the  cost 
was  borne  by  the  State.— Sir  L.  Worthington-Evans 
replied  : I am  glad  to  be  able  to  announce  that  the  cost  of 
repairs  and  renewals  of  artificial  limbs  and  other  appliances 
will  in  future  for  officers,  as  for  men,  be  borne  by  the  State. 
The  decision  which  was  some  time  ago  arrived  at  in  regard 
to  artificial  limbs  has  already  been  announced,  and  it  has 
now  been  extended  to  artificial  appliances  other  than  limbs. 
The  serving  officer  must  bear  the  cost  of  renewals  and 
repairs  until  retired,  but  on  his  retirement  my  department 
will  undertake  such  expenses  when  necessary  from  fair 
wear  and  tear. 

Dental  Register  in  Isle  of  Man. 

Mr.  Seddon  asked  the  Minister  of  Health  whether  he  was 
aware  that  dental  practitioners  in  the  Isle  of  Man  were  on  a 
register  separate  from  that  of  Great  Britain ; whether  he 
was  aware  that  gentlemen  whose  names  were  on  the  British 
register  could  practise  in  the  Isle  of  Man  but  not  vice  versa  : 
and  whether  the  coming  amending  Bill  to  The  Dentists  Act, 
1878,  would  take  cognisance  of  this  position  and  confer  the 
benefit  of  registration  in  Great  Britain  on  men  on  the 
register  of  the  Isle  of  Man,  in  order  to  give  them  equal  status 
to  gentlemen  on  the  British  register.— Commander  Eyres- 
Monsell  (Treasurer  of  the  Household)  replied : The 
Dentists’  Register  is  now  common  to  the  United  Kingdom 
and  the  Isle  of  Man.  By  the  Isle  of  Man  Dental  Act,  1908, 
provision  was  also  made  for  a “supplemental  register”  of 
persons  in  practice  in  the  island  on  Jan.  1st,  1908,  and  such 
persons  can  only  practise  locally.  As  regards  the  latter  part 
of  the  honourable  Member’s  question  it  is  premature  to  say 
what  will  happen  to  persons  so  situated,  but  the  recom- 
mendations on  the  point  contained  in  the  Report  of  the 
Dentists’  Committee  suggesting  machinery  through  which 
claims  might  be  considered  will  be  carefully  considered. 

Monday,  July  28th. 

Dental  Caries  in  Children. 

Mr.  Sugden  asked  the  Minister  of  Health  if  he  would 
state  what  steps  he  was  taking  to  prevent  dental  carie3  in 
children  under  school  attendance  age,  children  in  attend- 
ance at  school,  and  adults,  respectively;  and,  in  view  of  the 
prevalence  of  dental  caries,  as  revealed  by  recruit  examina-  _ 
tions,  in  adult  males,  whether  he  would  issue  instructions  to  " 
local  authorities  to  institute  inquiries  and  forward  recom- 
mendations thereon  for  its  elimination. — Dr.  Addison 
replied : Adequate  provision  of  dental  treatment  for  the 
whole  population  as  suggested  in  the  honourable  Member’s 
question  can  only  properly  be  produced  as  an  integral  part 
of  that  complete  scheme’of  national  health  services  which 
will  be  amongst  the  earliest  matters  to  be  considered  by  the 
Ministry  with  the  advice  of  the  consultative  councils.  A 
prime  necessity,  however,  must  be  certain  improvements  in 
the  existing  arrangements  for  dentistry  suggested  in  the 
Report  of  the  Departmental  Committee,  which  will  require 
legislation  in  certain  respects.  In  the  meantime  the  pro- 
vision of  dental  treatment  for  mothers  and  children  is  being 
developed  bv  several  local  authorities  under  the  Regulations 
of  the  Ministry  of  Health  and  by  help  of  its  grants;  in 
several  school  clinics  by  and  of  the  Board  of  Education ; and 
in  some  areas  in  connexion  with  Health  Insurance.  The 
importance  of  the  matter  is  emphasised  in  all  suitable 
communications  from  the  Ministry  to  local  bodies. 

Medical  Benent  under  National  Insurance. 

Mr.  Newbould  asked  the  Minister  of  Health  if  he  could  ' 
state  the  number  of  invalided  seamen,  marines,  and  soldiers 
entitled  to  medical  benefit  under  the  National  Insurance 
Acts  in  England,  Scotland,  and  Wales  respectively. — Dr. 
Addison  replied  : In  September.  1917,  special  arrangements 
were  made  as  to  the  provision  of  medical  benefit  for  men 
invalided  from  war  services.  The  approximate  number  of 
men  admitted  to  this  benefit  under  these  arrangements  is  j 
318,000,  being  270,000  in  England.  28,000  in  Scotland,  20,000  [ 
in  Wales.  But  there  is  an  additional  number  of  such  men 
who,  having  commenced  to  be  eligible  for  medical  benefit 
before  September,  1917,  are  not  included  in  these  figures ; 
the  number  of  these  is  not  known,  as  they  are  merged  in  the 
civil  population. 


The  Lancet,] 


MEDICAL  DIARY.— APPOINTMENTS. — VACANCIES. 


[August  2,  1919  223 


The  Physical  Condition  of  Recruits. 

Major  Farquhakson  asked  the  Pensions  Minister  if  it  was 
the  case  that  all  the  scientific  data  and  documents  collected 
by  the  Ministry  of  National  Service  in  regard  to  the  physical 
condition  of  recruits  of  His  Majesty’s  Army  had  now  passed 
into  the  possession  and  custody  of  his  department ; and,  if 
woinu  he  forthwith  transfer  these  documents  to  the 
Ministry  of  Health.  — Sir  James  Craig  (Parliamentary 
Secretary  to  the  Ministry  of  Pensions)  replied:  The  whole 
of  the  meuical  and  statistical  staff  of  the  Ministry  of  National 
Service  were  tranferred  to  the  Ministry  of  Pensions  on 
April  1st  last.  Part  of  the  staff  had  been  for  some  time 
engagen  on  the  work  of  collating  and  analysing  the  scientific 
data  and  documents  to  which  the  honourable  Member  refers 
and  it  was  considered  advisable  that  they  should  bring  the 
work  with  them  and  complete  it.  My  right  honourable 
friend  the  Minister  of  Health  has  throughout  approved  of 
this  course  of  action.  It  is  hoped  that  the  results  of  this 
work  will  be  published  in  the  autumn.  In  the  meantime 
any  information  is  at  the  service  of  the  Ministry  of  Health. 

Vaccination  in  the  Royal  Navy. 

Mr.  John  Davison  asked  the  First  Lord  of  the  Admiralty 
whether  he  was  aware  that  Stoker  P.  O.  Arthur  Simmons 
and  other  men  serving  on  H.M.S.  Culypos  in  the  Black  Sea 
had  been  confined  to  the  ship  for  three  months  because  of 
ieir  refusal  to  be  vaccinated ; whether  he  was  aware  that 
^ , aArea<?y  .been  vaccinated  three  times  whilst  in 
the  Navy ; whether  this  punishment  was  in  accordance  with 
slfr  atl?,us  > and  whether  he  would  have  inquiry  made 
ffti  A ,¥ACNAMara  (Parliamentary  Secretary 
? l e Admiralty)  replied  : The  Admiralty  has  no  informa 
*.°  td®  Particular  case  quoted,  but  the  circumstances 
related  in  the  question  are  in  accordance  with  the  regula- 
wpra  w’t h provide  that  persons  who  decline  revaccination 
yieie  not  to  land  in  ports  where  there  is  danger  of  contract- 

th!  Bl^v  S0X‘  mhVlruIe?‘  tyP®  of  small-pox  is  endemic  in 
the  Black  Rea.  The  confinement  to  the  ship  in  such  cases 

bnth°ihanPUniRhlA  e'r  ’ but  a necessary  precaution  to  protect 
both  those  who  decline  revaccmation  and  their  shipmates.’ 

Trade  Marks  and  Patent  Drugs. 

Sir  Auckland  Geddes  (President  of  the  Board  of  Trade) 
g sico.nd  reading  of  the  Trade  Marks  Bill,  said 
that  under  the  first  part  of  the  Bill  it  was  intended  to  have  a 

ixitst0/nrfiglSTter  °f  trade  mSrks  which  had  Common  Law 
existence  It  was  proposed  to  have  a part  “-B  ” of  the 

trad?  *?arks’  and  it  would  be  much  easier  for 
to  nsrt  ’^B-18thed  t0  r?gister  aooh  marks  to  get  them  on 
, ? than  on  to  Part  “A.”  The  second  cart  of 
lh®Bl”  had  very  considerable  practical  importance.  ^There 
as  a gre&t  abuse  at  the  present  time  in  connexion  with  the 
riR°fr/id^aS  Remarks,  and  it  was  to  deal  with  that 
abuse  that  the  second  part  of  the  Bill  was  designed.  They 
ka,d’  f°r  ®xa“PIe’  the  case  of  drugs  which  in  the  past  were 

lame  iiad”  Wrnn»rf^  the  peri°d  of  their  existence  the 
®a*?e  iTad  ,Pecome  the  one  practical  description  of  them 
and  when  the  name  became  a trade  mark  they  had  got  a 
STT®*  contlEUation  of  the  patent  protection.  There 
Imnwn°^nStafUCe’  .a.monS  chemical  substances  the  well- 
known  case  of  aspirin.  It  was  to  deal  with  the  difficulties 
from  tJie  use  of  such  names  as  absolutely  blocking 
names  upon  other  manufacturers  of  the  same'  chemical 
substance  that  the  second  part  of  the  Bill  was  brought 
forward.  The  second  reading  of  the  Bill  was  agreed  to?  g 

Tuesday,  July  29th. 

Medical  Officers  Serving  in  India. 

4al  Army  Med Mal^C or  ps*  officers  inlndia  wKontmSd 
whilst'other  SdSf^cefs 

^diprAeftl^SS^^^S  feSfK 

lnTu-SI0^ed  °®cers  who  are  serving  there. 

Pe«njo,A1R'  as,ked  the  Secretary  of  State  for  War  whether 
retained  Ra0fyai  Al'my  ,M®dlcal  c°rPs  officers  were  being 
1 home  ■ statl°us  whilst  doctors  who  took 
el^lmrary  commissions  were  being  detained  in  India  and 
CiiURCHiLi^eDlied?  offirS0Ilal  aDd  fluancial  sacrifice.— Mr. 


ilttoitl  $iitri  for  % instting  ®«h. 

LECTURES,  ADDRESSES,  DEMONSTRATIONS,  &r. 

LolHieHo“iuLITAfj  MEDICAL  COLLEGE,  in  the  Clinical  Theatre 
A Course  of  Clinical  Lectures  for  Advanced  Students  on  Intermittent 
d th«  rlitl0“8i)nd  [h.eir  Relation  to  Certain  Common  Diseases 
dehvcred  byMD  P®?-  ‘°  6’  an<1  °ther  0rgaua  wlu  ba 

Wednesday,  August  6th.- 4.15  p.m..  Lecture  I :-Iufectij4  of  (lie 

guosis?  T«atment.hrlt19  Cliuical 

A SKby°MMA?jSK?“  ^ the  SUrgiCaI  DJ!SPeP8f^  will  be 
IL:-Tbe  Clinical  History  Taking  of 


Successful  applicants  for  vacancies , Secretaries  oj  Public  Institutions 
and  others  possessing  information  suitable  for  this  column  are 
invited  to  forward  to  The  Lancet  Office  directed  to  the 
Editor,  not  letter  than  9 o'clock  on  the  'Thursday  morning  of  each 

week,  such  information  for  gratuitous  publication.  0 n 

DUL,BrE5-6’,J[“’  M D- Wurzburg,  L.S.A.,  has  been  appointed  a 

^IC^*^0f?a^fmen'S  C0mpeilSati°n  A<*  ^ 
P'R'°-S-  Bng-  CoDSulting  S™ 

“Treat  S'rmoifd-stfeft';  W t0  th8  H°Sf>ital  for  Sick  Ch“- 

°0nSU,ting  PhjSiCia“  to 
County  “ 0ffic-  or 

St.  Bartholomew’s  Hospital  and  College:  Ball,  W.  G.  FSCS  and 
Roberts,  J.  E.  H„  M B.,  F.R.O?S.,  Demonstrators  of  Practical 
Surgery;  Watson,  Sir  Charles  G„  F.R.C  S.,  Demonstrator  of 
Operative  Surgery  ; Donaldson,  M.,  M.B.,  P.R.C.S..  Demons  r.rato/ 
of  Midwifery;  Cunnington,  W.  A.,  Demonstrator  of  Biologv  • 
Johnston,  J H M.Sc  Demonstrator  of  Chemistry;  Hop  wood', 
M BIj'rhDitVSC«  D0“0j.trat°r  °f  Physics;  Shellshear,  J.  L, 
S^-Sydn||,  S<>nlor  Demonstrator  of  Anatomy;  Ramsay 
M Griffiths,  H.  E M.B.,  B.S.,  and  Hume,  J.  B.] 

o.P.,  Demonstrators  of  Anatony  ; Trevan,  J..  M B 
B b.,  S ©ill or  Demonstrator  of  Physiology  ; Dreyer.  N.  B , and 
Hilton,  R.,  Demonstrators  of  Physiology;  Can't!  R G M B 
B.C.,  Joekes,  T.,  M.B.,  and  Murray,  E.  G D Denlst^t,  itii 
Pathology;  and  Shore,  T.  H.  G„  M.D. 

General  Infirmary,  Leeds : Watson,  George  W M D Prop 
Honorary  Physician  ; Braitewaite,  L.  R„  M.B  Ch  b’  F p V s" 
|u^°“  i?  Charge  of  Out-patients;  Lee,  Harry,  M.B.,  B.C.',’ 
oi  d ' n Honorary  Ophthalmic  Surgeon ; Burrow,  J.  Le  F MB 
Cb.B  , Honorary  Assistant  Physician.  1 ' *’ 

LOnaM°AUR<YKOP1  MPR  HDPJtali  Sefh'’01  ot.  Medicine  for  Women  : Keene, 
Mary  L„  M.B  , B.S.,  Lecturer  m Anatomy  and  Head  of  the 
Anatomy  Department;  Kbden,  J.  W„  M.B.,  B.S.,  Abel  L MB 
B S.,  Hounseield  Mary,  M.B.,  B.S.,  and  Joll.  Mary,  M d’  BS" 
Demonstrators  of  Anatomy;  Spilsbury,  B H MB  Yh  r" 

LLEAUNr0R  inMB°renB  I Mf|lleiDe  an,d  T?«»ol«8y ; Scarborough; 
LLEA»,  M.B  , B.S.,  Demppstrator  in  Pharmacology;  Ross- 
Johnson,  M , Nat  Sci.  Tnpos,  Camb.,  and  Woodman,  D B Sc 
Demonstrators  of  Physiology.  ou' 

Miller  General  Hospital,  Greenwich  : Joll,  C.  A.  MS  B Sc  Fnnri 

ISvPSS:  HINE’  M'  L"  M'D' Ljnd-  F-R-c-s.Eng:;  ophtLTmic 

Vlct  .ria  Hnspital  for  Children:  Ev bridge,  J„  F.R.C.S..  Joll,  C A. 

GoR'?dfn  acdBMAi.aHH'A'Lq  ’ O SllrSeons  tr  Out-patients  ;’ 

goulden,  C.  B , I. R....S.,  Ophthalmic  Surgeon  ; Kay,  Val  LDS 
Dental  burgeon.  * 

Certifying  Surgeons  under  the  Factory  and  Workshop  Acts  ■ 

R.  J.  Bruce,  M.B.,  Ch.B.  Aherd.  (Turriff)-  Malonfy  T \ 
(Churchill);  Davies,  H.  C„  M.B..  Oh.B. GHsf^ WE&Jlkiri’. 
Griffiths,  D.  H„  M.H.C.S.,  L.R.C.P.  Lend.  (CroBs  Hand|  8) ' 


Surgeon  Alfred  J.  Corrie,  BN  has  keen 
elected  a governor  of  St.  Bartholomew’s  Hospital  London 


For  further  information  refer  to  the  advertisement  columns. 
Bedfordshire  Education  Committee.  - School  Dentist.  £400 
Birmingham  City.— Municipal  Bacteriologist.  £700. 

Birnrinfdiam  municipal  Antituberculosis  Centre.— Sen.  Asst.  Tuberc.  0 

Birimnghav^Rubery  Hill  Asylum  and  Annexe  at  Hollymoor.— Med 

Brighton.  Royal  Sussex  County  Hospital.— Sen  H S £140 
Cairo,  Egyptian  Government  School  of  Medicine.— Professors  and 
Lecturers.  £E.1000  and  £E.600.  Also  Radiologist  and  I pet  in 
Radiology,  £B.500,  Anaesthetist  and  Lect.  in  Anesthetics  fi^'hntl 
and  Registrar  and  Tutor,  £E,600.  Anesthetics,  i.B.500, 

Carmarthen  Mental  Hospital.— Second  Asst.  M O £250 
Croydon  County  Borough. — M.O.  £400. 

Devouport,  Royal  Albert  Hospital.— Res'.  H S £200 

^OrDenfek|£350.  Ed^U<-n  Committee- School 

Downpatrick,  Down  District  Asylum— Asst.  M O.  £250. 

1 1 1}^  County  Borough  Education  Committee.  -Scbool  Dentist  £400 
y,S^ool  MH?  £450?-  Tuberc.  0„  M.O.H.,  and 


224  The  Lancet,]  BIRTHS,  MARRIAGES,  AND  DEATHS. — BOOKS  RECEDED. 


[August  2,  1919 


Fulham  Infirmary,  St.  Dunstan'  s-road,  IF. — Tnree  Asst.  M.O.  s.  £350 
and  £300.  „ 

George  Town  Municipality,  Penang.  Straits  Settlements.— Asst.  M.O.H. 
84200. 

Gravesend  Hospital.— H. S.  £2  0. 

Great  Northern  Central  Hospital,  Hol'oway,  London,  A7.— H.P.  £150. 

Home  Office,  Whitehdl,  S.  — Med.  Inspecto-  o'  Factories.  £o00. 

Hong  Kong  Government.— Baet..  ami  Path  £600. 

Huddersfield,  Bradley  Won d Sanatorium  for  Pulmonary  and  Surgical 
Tuberculosis. — lies.  M.O.  £500. 

Huddersfield  County  Borough  Education  Authority.— Full-time  Dent. 
Sure.  £350. 

Hull  Education  Committee  — Asst.  Seh.  M.O.  £150. 

Kettering  and  District  General  Hospital.-V.es.  M.O.  £200. 

Khartoum,  Wellcome  Tropical  Hesearch  Laboratories.— Asst.  B icteno- 
logist.  £E.600. 

Lancaster  County  Asylum.—' Temp.  Asst.  M.O.  7 guineas  per  week. 

Leeds  Public  Dispensary,  North-street.— Kes.  M.O.  £200. 

Liverpool,  Samaritan  Hospital  for  Women,  Upper  Parliament-street.— 
Asst.  S.'s.  _ , 

Liverpool  School  of  Tropical  Medicine.— Asst.  Lect.  in  Parasitology. 
£250. 

Liverpool  University.— Chair  of  Anatomy.  £800. 

Macclesfield,  Cheshire  County  Asylum,  Parkside.— Locum  Tenens. 
£7  78.  per  week. 

Maidstone.  West  Kent  General  Hospital—  Jun.  II  S.  £125. 

Manchester,  Baguley  Sanatorium  .for  Tuberculosis  —First,  Second,  and 
Third  Asst.  M.O. 's.  £400,  £350.  and  £300  respectively. 

Manchester  Royal  Infirmary.— U.S.'s.  £25  for  first  six  months,  £50  for 
second  six  months. 

Newark  Hospital  and  Dispensary.— Ups.  H.S. 

Newcastle-upon-Tyne,  University  of  Durham  College  of  Medicine.— 
Demonstrator's  of  Anatomy  and  Physiology.  £350  to  £500  and  £300. 

Newport.  Borough  Asylum,  Caerleon.  Mon.— Asst.  M.O.  £300. 

Northampton  County  Borough  Education  Committee.— Female  Asst. 
School  M.O.  £350. 

Nottingham,  Notts  Education  Committee  —Asst,  .school  M.O.  £425. 

Peckham  House,  112,  Peckham-road,  S.E.— Sen.  Asst.  M.O.  £400. 

Poplar  Hospital  for  Accidents,  Poplar,  E.— Sen.  lies.  M.O.  £200. 

Rain  hill,  near  Liverpool,  County  Asylum.— Temp.  Asst.  M.O.  7 gsp.w. 

Rochester,  Kent  St.  Bartholomew's  Hospital.—  J un.  Res.  M.O.  £150. 

Royal  Chesl  Hospital.  City-road,  E.C.—Ves.  M.O.  £200. 

St.  Mary’s  Hospital  Medical  School,  Paddington,  IF.— Lecturer  on 
Chemistry.  £300.  _ _ „„ 

St.  Mary’s  Hospital  for  Women  and  Children,  Plaistow,  E.— Dent.  S.  £50. 

St.  Marylebone  Infirmary.  Rackham-street,  IF.— Third. Asst.  M.O.  £200. 

Salford  Royal  Hospital— Boa.  P.  and  Hon.  Asst.  P. 

Serbia  Hospital  —Surgeon. 

Seychelles  Government.— AsSt.  M.O.  and  Visiting  Magistrate.  Rs.5000. 

Sheffield  Royal  Infirmary.— Asst.  H.P.  £150. 

Taunton,  Somerset  and  Bath  Asylum,  Cotford.— Asst.  M.O.  £300. 

West  African  Medical  Staff.— Number  of  appointments.  £400. 

Westminster  Hospital.  Broad  Sanctuary.  S.  W .—  H.S. 

Weymouth,  Princess  Christian  Hospital.— H.S.  £200. 

Wigan  Infirmary. — Jun.  H.S.  £225. 

Willesden  Urban  District  Council.— Asst.  M.O.'s.  £550  to  £650. 

Tse  Chief  Inspector  of  Factories,  Home  Office,  S.W.,  gives  notice  of 
vacancies  for  Certifying  Surgeons  under  the  Factory  and  Workshop 
Acts  at  Beith  and  Crosshills. 

Ihrriages,  anil  geaijjs. 

BIRTHS. 

Anderson.— On  July  23rd,  at  Yealm  Cottage,  Loughton,  Essex,  the  wife 
of  Dr.  A.  W.  Anderson,  Ogmore  Vale,  Glam.,  of  a daughter. 

Cowan  —On  July  24th,  at  Thetford,  the  wife  of  Geoffrey  Cowan,  M.D., 
of  a daughter. 

Downs.-  On  July  22nd,  at  “ Palmers,”  Great  Marlow,  Bucks,  the  wife 
of  Dr.  G.  E.  Downs,  of  a son. 

Dunlop.— On  July  22nd,  at  Conyers  House.  Newcastle-on-Tyne,  the 
wife  of  E.  Craig  Dunlop,  M.B.,  B.S.,of  a daughter. 

Kemp.— On  July  24th,  at  Caversbam,  Lemsford-road,  St.  Albans, 
the  wife  of  C.  Gordon  Kemp,  M.D.,  of  a daughter. 

Willan.  — On  July  25th,  1919,  at  23,  Claremont.-place,  Newcastle-upon- 
Tyne,  to  Dorothy  (nfie  Shawyer),  wife  of  K.  J.  Willan,  M.V.O., 

F.R.C.S.,  a daughter. 

MARRIAGES. 

Batten— Turnbull.—  On  July  23rd,  at  Essex  Church,  Notting-hill 
Gate,  W.,  Captain  Lindsey  Willett  Batten,  R.A.M.C.,  to  Ellen 
Mary,  elder  daughter  of  Dr.  and  Mrs.  G.  Lindsay  Turnbull,  of 
Ladbroke-square,  W. 

Edwards— Bird.— On  June  11th,  at  All  Saints'  Church,  Srinagar, 
Kashmir,  the  Hon.  Major-General  W.  R.  Edwards,  C.B.,  C.M.G., 
K.H.P.,  I.M.S.,  Director-General,  Indian  Medical  Service,  to  Nell, 
widow  of  Lieutenant-Colonel  R.  Bird,  C.I.E.,  M.V.O.,  I.M.S.,  and 
daughter  of  the  late  Lieutenant-'  olonel  R.  Dewar,  R A. 

Farquharson— Banes.— On  July  16th,  at  the  Churen  of  St.  Michael 
and  All  Angels.  Southampton.  Donald  Charles  Farauharson, 
M.R.C.S.,  L.R.C.P.,  to  Lovedav  S.  Banes,  M.B.,  B S.  Lond. 

WOODHOUSE—  Ferguson.— On  July  24th,  at  St.  Peter's,  CrAnley- 
gardens,  Kensington,  Sydney  C.  Woodhouse,  M.B.  Lond.,  M.lt.C.S. 
Eng.,  Temporary  Surgeon  Lieutenant,  R.N.,  to  Erica,  younger 
daughter  o'  the  late  Donald  and  of  Mrs.  Ferguson,  of  Croydon, 
formerly  of  Colombo,  Ceylon. 

DEATHS. 

Hi’ heard. — On  July  23rd,  in  London,  Daniel  Lovett  Hubbard,  M B., 
B.S.,  of  Bordighera,  aged  59  years. 

Pocock.— On  July  23rd,  at  Oxford-gardens,  Frederick  Ernest  Pocock, 
M.D.,  M.K.C.S.,  late  of  "The  Limes,"  St.  Mark's-road,  North 
Kensington,  aged  67. 

Read.— On  July  23rd.  at  Downsbire-hill,  Hampstead,  Charles  Read, 
M.D.  Lond  , aged  81. 

Youngeir.— On  July  24th,  at  2,  Mecklenburgh-square,  W.C.  1,  Edward 
George  Younger,  M.D.,  M.  R.C.P.,  aged  69  years. 

N.B.—A  jet  of  6s.  is  charged  for  the  insertion  of  Notices  of  Births, 
Marriages,  and  Deaths. 


BOOKS,  ETC.,  RECEIVED. 

Arnold,  Edward,  London. 

Diseases  of  Women.  By  Ten  Teachers  under  the  direction  of  Comyns 
Berkeley,  M.C.  Cantab.  Pp.  650.  30s. 

Baillierk,  Tindall,  and  Cox,  London. 

Aids  to  Ophthalmology.  By  N.  Bishop  Harman,  M B.,  F.R.C.S. 

6th  ed.  Pp.  226.  3s.  6d. 

Manual  of  Anatomy.  By  the  late  A.  M.  Buchanan,  M.D.  Edited 
by  a Committee  of  Anatomists  In  London.  4th  ed.  Pp.  xli.  + 1743. 
30s. 

Balk,  John,  Sons,  and  Danielsson,  London. 

Toe  Urethroscope  in  the  Diagnosis  and  Treatment  of  Urethritis.  By 
Major  N.  P.  L.  Lumb,  R.A.M.C.  (T.C.).  Pp  52.  10s.  6 d. 

Eugenics  and  Environment.  By  Prof.  C.  Lloyd  Morgan,  F.R.S. 

Pp.  82.  2s. 

The  Problem  of  Sex  Diseases.  By  A.  Corbett-Smith.  2nd  ed. 
Pp.  108.  2s.  6 d. 

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(19181.  Pp.  480. 

Transactions  of  the  Southern  Surgical  Association.  Vol.  XXX. 
(1917).  Edited  by  H.  A.  Royster,  M.D.  Pp.  404. 

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Browning.  M.D..  and  David  Watson.  M.B.  With  introduction  by 
Sir  John  Bland-Sutton.  Pp.  336.  16s. 

Gale  and  Polden,  London. 

Ten  Lectures  on  Field  Sanitation.  By  C.  B.  Moss  Blundell,  M.D. 
Pp.  134.  5s. 

Heinkmann,  W.,  London. 

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Lea  and  Febioer,  Philadelphia  and  New  York. 

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Lewis,  H.  K.,  London. 

Auto-Erotic  Phenomena  in  Adolescence.  By  K.  Menzies.  With  a 
foreword  by  Dr.  Ernest  Jones.  Pp.  88.  4s.  6 d. 

Notes  on  Galvanism  and  Faradism.  By  E.  M.  Magill.  2nd  ed. 
Pp.  224.  6*. 

Longmans,  Green,  and  Co.,  London  and  Uaiver=ity  Press,  Manchester. 
Shell  Shock  and  its  Lessons.  By  Prof.  G.  K.  Smith.  M D.,  and  T.  H. 
Pear,  B.Sc.  2nd  ed.  Pp.  135.  Cheap  edition,  Is.  6 d. 

Communications,  Letters,  &c.,  to  the  Editor  have 
been  received  from— 

A.— Mr.  W.  Applevard,  Bradford.  H.— Nursing  Times.  Lond.,  Editor 

B — Baby  Saving  League  of  British  of;  Miss  O.  Nethersole,  Lond.; 

Guiana;  Dr.  B G.  M.  Baskett,  Dr.  A J.  Nvulasy.  Perth; 

Rayleigh ; Mr.  G.  Buckle.  Elin-  National  Food  Reform  Associa- 
burgh  ; Surg.-Comdr.  W.  Bastian,  tion.  Lond.;  National  League  for 

R.N.:  Dr.  W.  Langdon  Brown,  Health,  Maternity,  and  Child 

Loud.  Welfare,  Lond.;  Dr.  B.  H. 

C.— Dr.  E.  F.  Cyriax,  Lond.;  Dr.  Norman,  Harpenden. 

K.  H.  Cole.  Lond.;  Mr.  W.  P'-Dr'  B' 4Pl®r“e'  Y°rkj  CokA'  ?' 
Cowdery,  Lond.;  Dr.  M.  Cos-  Phe,ar',,  L°nd':  Dr'  S' 

grave.  Dublin ; Fleet-Surg.  A.  T.  Porterfield,  Widnes. 

Corrie,  R.N.;  Colonial  Office,  R.— Dr.  J.  D.  Rolleston,  Lond.: 
Lond  Rockefeller  Institute  for  Medical 

D — Lieut.-Col.  J.  F.  Donegan.  Research.  Lond.;  Royal  Faculty 

C.B.,  Lond.;  Mr.  L.  J.  Devota,  % Physicians  and  Surgeons, 

Kota  Bliaru,  Kelantan : Mr.  H.  Glasgow,  Dr.  W.  C.  Risers, 

Dickinson,  Lond.;  Dr.  V.  Dickin-  AIJon:.  . , , . „ . 

son  Lond.  S.— Sociele  de  Biologie,  Pans^  Mr. 

E.— Dr.  W.  A.  Evans,  Keighley.  B-  Smith-  Ba[ry  • 

* _ „ • tv-  Sherlock,  Lond.:  Summer  Schoil 

p~ Dr  C.  Flandin,  laris;  Dr.  Qf  Qjviea  and  Eugenics,  Lond.; 

■J,  N.  : F.  Fergusson,  Brighton  ; Save  the  Children  Fund.  Lond.; 

Mr  p-  Pr??k,m'  Dond..  Mr.  F.  B.  Shawe,  Boxmoor;  Prof, 

tones,  Chief  Inspector  of,  Lond.  w St.irlingi  Manchester ; Dr.  H. 

G.  — Mr.  J.  J.  Grace.  Lond.;  Dr.  Sharman,  Lond.  ; Selbome 

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Lieut.-Col.  E.  Goodall,  R.A.M.C.;  Mr.  F.  St.  J.  Steadman.  Lond.; 

Dr.  A.  G.  Gibson,  Oxford.  Dr.  A.  G.  Shera,  Eastbourne; 

H. — Dr.  H.  Head,  Lond.;  Lieut.-  Dr.  D.  M.  Shaw,  Lond. 

Col.  C.  L.  Hunter;  Mr.  R.  W.  t. — Dr.  H.  H Thomson,  Hertfo  d ; 
Hatt,  Bath.  Dr.  A.  H.  Thompson,  Lond.:  Dr. 

I. — Insurance  Committee  for  the  a.  H.  Turner,  Meols  ; Dr.  H.  H. 

County  of  London;  Industrial  Tooth,  C.B.,  C.M.G.,  Lond. 

Fatigue  Research  Board,  Lond.  U. -University  of  London.  Sec  to 

J.  — Dr.  F.  Wood  Jones,  Lond.  the  Senate;  University  of  Shef- 

K. — Dr.  A.  M.  Kennedy.  Glasgow.  field.  Registrar  of. 

L.  — London  Hospital  Medical  Col-  w. — Dr.  J.  D.  Wynne,  Norwich: 

lege,  Sec.  of ; Miss  M.  M.  Lee,  Mrs.  M.  White,  Banteer ; Mr.  J. 
Lond.:  London  School  of  Tropical  Wright,  Pieasantville  ; Dr.  G. 
Medicine,  Sec.  of.  Ward,  Sevenoaks ; Wellcome 

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Mrs.  M MeConnel,  Petersfield  ; Lond.;  Dr.  A.  C.  Wilson,  Lond.; 

" Member  of  Board";  Ministry  Dr.  S.  A K.  Wilson,  Lond. 

of  Health.  Lond.  Z —Dr.  S.  C.  Zavitzianos,  Corfu. 

Communications  relating  to  editorial  business  should  be 
addressed  exclusively  to  the  Editor  of  The  Lancet, 
423,  Strand,  London,  W.C.  2. 


Dr.  MacDowel  Cosgrave,  5,  Gardiner-row,  Dublin,  will  be 
grateful  for  book-plates  of  medical  men,  and  will  gladly  seac 
bis  own  in  exchange.  i 


The  Lancet,]  NOTES,  SHORT  COMMENTS,  AND  ANSWERS  TO  CORRESPONDENTS.  [August  2,  1919  225 


Jtato,  SJrarl  fitommettto,  atto  Rasters 
to  forespttoento* 

MUSCLE  TRAINING  IN  RECLAIMING  CRIPPLES. 
By  James  Patterson,  M.D., 

CAPTAIN,  CANADIAN  ARMY  MEDICAL  CORPS;  OFFICER  IN  CHARGE, 
MASSAGE,  HYDRO-  AND  ELECTRO  THERAPY,  AND  REMEDIAL 
GYMNASIUM,  GRANVILLE  CANADIAN  SPECIAL  HOSPITAL, 

BUXTON,  DERBYSHIRE. 


The  ideas  underlying  this  paper  may  be  expressed  thus  : 
success  in  restoring  function  demands  a common-sense 
application  of  a simple  knowledge  of  physics,  anatomy,  and 
psychology.  Given  that,  and  sufficient  help,  muscle  training 
will  play  an  increasingly  satisfactory  role  in  the  reclaiming 
of  crippled  men.  And  the  greatest  efficiency  will  be 
attained  under  unity  of  direction.  The  hydro-therapy, 
massage,  electro-therapy,  gymnasium  games  and  remedial 
workshops  must  form  one  department  with  coordinate 
effort  to  that  end. 

Physical  Remedies. 

Heat,  whether  in  the  form  of  the  eau  courante  baths, 
whirlpool  baths,  hot  packs,  or  the  radiant-heat  box,  makes 
possible  a greater  range  of  motion,  either  passively  or 
voluntarily.  Next  comes  massage  and  passive  movement, 
the  application  of  which  is  universally  conceded  to  be 
efficacious.  Great  care  is  necessary  in  applying  this 
remedial  agent.  It  must  be  done  without  pain  until  the 
operator  has  the  absolute  psychic  and  muscular  cooperation 
of  the  patients.  Then  it  is  possible,  and  often  desirable,  to 
push  passive  movements  to  the  point  of  causing  distress. 
But  unless  this  happy  coordinate  effort  between  masseur 
and  patient  obtains,  we  find  that  although  the  patient  may 
be  willing  to  suffer  pain  in  order  to  secure  movement,  the 
muscles  controlling  the  part  affected  are  in  a state  of 
rebellion,  the  one  set  acting  absolutely  independently  of  his 
consciousness  against  the  set  from  which  we  desire  to 
obtain  action.  But  with  massage  properly  given  this  muscle 
terror  is  entirely  overcome. 

As  to  electro-therapy  the  galvanic  current  has  a use  in 
helping  to  maintain  function  in  muscles  to  which  the  nerve- 
supply  is  destroyed.  The  faradic  current  has  tremendous 
helpful  influence  in  building  up  weakened  muscles  that 
have  been  out  of  use  for  a period,  from  any  cause  whatever, 
but  to  which  the  nerve  is  intact.  And  we  cannot  neglect 
what  may  be  termed  a psychic  lameness — that  is,  a habit  of 
thought  that  the  affected  part  is  not  usable. 

In  muscle  training  itself  two  elementary  facts  must  be 
noted.  The  first  is,  we  must  put  the  muscle  group  we  are 
working  on  in  such  a position  that  it  does  not  contend 
against  the  force  of  gravity.  The  other  is  that  a most  useful 
aid  comes  by  having  the  patient  perform  the  motion  with 
the  good  limb  that  he  is  being  taught  to  perform  with  the 
crippled  one. 

Our  method  of  attack,  then,  entails  a knowledge  of  the 
subjects  mentioned.  The  war  has  forced  on  the  profession 
the  value  of  all  these  physical  remedies,  and  each  one  has 
its  use,  its  limit,  and  its  definite  place.  To  secure  the  best 
results  the  hospital  should  have  a department  of  physical 
remedies  under  one  head,  and  with  plenty  of  help,  alike  of 
fully  trained  medical  officers,  competent  masseurs,  and 
remedial  instructors.  These  medical  officers  and  trained 
assistants  must  know  not  only  massage,  but  hydro-  and 
electro-therapy  and  physical  training,  because  only  by  the 
most  close  cooperation  between  the  workers  in  these  very 
closely  allied  lines  can  we  hope  to  obtair  rapid  and  effective 
results.  The  sooner  expert  treatment  of  this  sort  is 
established  the  better,  thus  preventing  adhesions  forming. 
However,  we  must  at  present  deal  with  the  cases 
that  come  to  us,  where  there  may  be  more  or  less 
firm  fixation  between  muscle  planes,  tendons,  and  tendon 
sheaths,  and  deformities  due  to  contractures.  [A  rough 
ground-plan  of  a treatment  department,  suitable  to  take 
the  cases  from  a hospital  of  about  1400  beds,  was  here  put 
forward,  showing  a logical  arrangement  of  heat,  massage, 
and  electro  therapy.]  Continuous  with  this  should  be  the 
gymnasium,  into  which  the  patient  may  be  at  once  taken  to 
carry  on  his  treatment,  or  from  which  he  may  be  sent  after 
his  efforts  there.  The  building  should  be  large  enough,  light 
enough,  and  warm  enough  to  be  comfortable,  with  little  and 
simple  apparatus,  and  plenty  of  room  for  games. 

Metatarsalgia. 

We  now  come  to  some  special  problems.  The  first  of  these 
forms  too  large  a percentage  of  disabilities,  and  is  prevent- 
able—namely,  metatarsalgia.  Primarily  the  term  refers  to 
the  condition  known  as  Morton’s  disease,  but  here  we  must 
group  not  only  the  metatarsalgias,  but  also  the  deformities 
of  the  anterior  part  of  the  foot,  bunions,  hammer  toes,  and 

law  feet.  These  conditions  have,  as  a most  notable  contri- 


butory cause,  the  wearing  of  hoots  too  short  and  improperly 
shaped.  The  hampering  of  the  toes  causes  a distortion  of 
their  joints,  particularly  a partial  luxation  of  the  proximal 
phalanges  on  the  metatarsals. 

For  cure  we  must  have  first  of  all  boots  of  the  proper  size, 
which  is  three  sizes  longer  than  the  foot.  The  foot  being 
measured  for  a boot  is  lifted  from  the  ground.  When  a 
person  puts  his  full  weight  on  his  foot  it  spreads  antero- 
posteriorly  from  one  to  two  shoe  lengths,  sometimes  more. 
Again,  we  are  placing  two  curved  surfaces  together ; when 
the  foot  bends  in  the  boot  it  is  the  inner  of  the  two  curved 
surfaces.  The  sole  of  the  boot  must  be  sufficiently  long  to 
allow  of  this  curving  of  the  foot  without  distorting  the  inner 
curve.  A man  working  in  this  department  must  provide 
himself  with  a shoemaker’s  foot  measure,  and  be  ready  to 
explain  why  such  a sized  boot  is  worn.  A size  is  three- 
eighths  of  an  inch.  But  how  much  better  it  would  be  if  each 
non-commissioned  officer  in  charge  of  the  boot  stores  had 
such  an  instrument  and  issued  proper  sized  boots  to  each 
soldier. 

Next  to  consider  is  the  shape  of  the  boot.  It  must  he  wide 
at  the  toe  to  allow  the  toes  to  come  straight  from  their 
respective  metatarsal  bones,  and  the  cap  must  be  firm  and 
extend  sufficiently  far  back  to  prevent  wrinkling  of  the  upper 
from  pressing  on  the  already  deformed  toes.  Besides  that  it 
must  have  a snug-fitting  heel  seat,  and  grasp  the  waist  of  the 
foot  firmly,  widening  forward  to  allow  the  metatarsals  to- 
spread  and  the  toes  to  come  straight.  Given  this,  a bar  put 
across  the  sole,  as  recommended  by  Sir  Robert  Jones,  is  of 
inestimable  value.  Other  men  have  used  successfully  an 
adhesive  strap  around  the  foot,  with  or  without  a pad  of  felt 
to  lift  the  transverse  arch,  and  Goldthwaite’s  figure-of-S 
strap  has  its  sphere  of  usefulness.  For  the  more  stubborn 
cases  a sandal,  cut  to  allow  of  the  toes  assuming  their 
correct  position,  with  a bar  behind  the  metatarsal  heads 
and  with  adjustable  straps  or  tapes  to  pull  the  deformed 
toes  into  their  proper  places,  has  been  most  effective. 

These  things  are  palliative,  and  we  must  not  only  use 
them  but  re-educate  the  intrinsic  muscles  of  the  feet  so  as 
to  obtain  full  and  strong  action  at  the  metatarso  phalangeal 
joints.  The  set  of  drills  adopted  for  this  purpose  can  be 
drawn  up  by  anyone  with  a knowledge  of  the  muscles 
involved.  A bar  of  wood  works  well,  curved  to  lift  the 
transverse  arch,  and  perforated  for  a strap  or  a heavy  cord, 
so  that  when  the  patient  adjusts  this  behind  the  metatarsal 
heads  and  pulls  on  the  cord  he  has  a counter  force  on  which 
to  work  at  obtaining  flexion  at  the  metatarsal  phalangeal 
joints.  The  difficulty  that  patients  tend  to  flex  the  inter- 
phalangeal  joints  must  be  overcome  by  supervision.  Other 
exercises  are  drills  in  abduction  and  adduction  of  the  toes, 
and  here,  again,  the  game  idea  is  the  most  satisfactory  aid. 
Patients  can  early  begin  to  pick  up  marbles  and  golf  balls 
and  regain  prehensile  power ; after  that  games  can  be 
devised. 

Flat-foot. 

In  flat  feet  the  longitudinal  outer  arch  rarely  gives 
trouble,  but  the  inner,  longer,  and  more  springy  arch 
frequently  results  in  casualties,  and  it  is  mainly  the  tarsal 
bones  and  the  muscles  and  ligaments  that  hold  them  in  place 
with  which  we  have  to  deal.  It  is  on  the  tibialis  posterior 
that  we  mainly  depend  for  cure.  The  symptoms  of  flat-foot 
are  numerous,  and  the  examination  is  not  always  satis- 
factory. One  gets  all  the  grades  from  the  beginning  with 
only  vagne  pains,  to  the  most  pronounced  luxation  of  the 
tarsus,  with  marked  deformity  and  absolute  rigidity. 
In  the  early  stages  we  can  be  pretty  sure  of  our  ground  if 
we  keep  in  mind  the  position  of  attachment  of  the  tibialis 
muscle,  its  action,  and  the  relief  or  increase  of  pain  on 
pressure  along  it,  and  along  the  inner  longitudinal  arch 
when  we  invert  or  evert  the  foot.  One  very  characteristic 
place  for  pain  to  be  obtained  by  this  manoeuvre  is  where  the 
belly  of  the  muscle  changes  to  the  tendon. 

Any  of  the  various  methods  of  treatment  succeeded  more 
or  less  : moulding  over  a triangular  block  followed  by  plaster- 
of-Paris  fixation  ; plates;  alteration  of  the  boots  by  advancing 
the  inner  side  of  the  heel ; and  raising  the  inner  side  of  the 
heel  and  sole.  Relief  may  also  be  obtained  by  use  of  adhesive 
plaster  strapping  and  corrected  boots.  But  unless  we 
develop  and  strengthen  the  tibialis  posterior  muscle  we  do 
not  obtain  a permanent  cure.  The  first  thing  to  recognise 
in  weakness  of  the  tibial  muscles  is  the  concomitant 
contracture  of  theft:  opponents,  the  peroneals  ; and  with  the 
weakening  of  the  ligaments  on  the  inner  side  there  is  a 
corresponding  contracture  of  the  ligaments  and  fibrous 
tissues  on  the  outer  side  of  the  tarsus.  In  order  to  get  a 
coordinate  relaxation  of-  the  muscles  in  question  it  is 
necessary  to  re-establish  tone  in  the  muscles  that  have  lost 
their  power.  One  very  effective  means  that  we  use  is  having 
the  patients  walk  on  an  angled  board,  the  two  boards  being 
joined  at  an  angle  of  45°.  With  that  we  have  a series  of 
drills  in  ankle  rocking,  also  some  steps  of  the  sailor’s 
hornpipe.  Other  dances  can  be  used  as  strength  increases. 
When  one  considers  the  attachments  of  the  muscles  one  can 
devise  a variety  of  movements. 


226  The  Lancet,]  NOTES,  SHORT  COMMENTS,  AND  ANSWERS  TO  CORRESPONDENTS.  t August  2,  1919 


It  is  essential  that  the  patient  stand  and  walk,  and  do  all 
his  exercises  with  the  feet  parallel  and  5 inches  apart.  This 
gives  an  even  pull  for  all  the  muscles,  and  if  persisted  in 
will,  with  other  measures,  cure  any  case  of  acquired  flat- 
foot.  The  usual  position  of  attention,  with  the  feet  at  an 
angle  of  45\  gives  the  peroneal  group  advantage  over  the 
tibial  group  and  tends  to  produce  flat-foot. 

Internal  Derangements  of  the  Knee. 

Another  special  problem  is  the  internal  derangements  of 
the  knee,  of  the  internal  lateral  ligaments,  and  dislocation 
of  the  internal  semilunar  cartilage  ; they  are  most  unsatis- 
factory, causing  recurring  disability  to  the  patient  and  an 
enormous  loss  of  time  to  the  army.  These  injuries  alwavs 
occur  as  the  result  of  an  inward  twist  to  the  knee  when  it  is 
partially  flexed  and  the  foot  turned  out.  When  we  consider 
the  anatomy  of  the  knee-joint  it  is  not  strange  that  the 
majority  of  our  injuries  are  to  the  inner  lateral  ligaments 
and  the  inner  semilunar  cartilages.  It  is  the  weaker  part  of 
the  joint. 

On  examining  a knee  of  this  sort  we  observe,  whether 
there  be  swelling  or  not,  tremendous  atrophy  of  the  vastus 
internus.  In  the  early  stages  heat  and  massage  play  a part 
in  relieving  pain  and  swelling,  but  perhaps  faradic  stimula- 
tion to  the  vastus  internus  is  the  most  important  physical 
remedy  in  restoring  tone.  However,  unless  this  electric 
treatment  is  followed  by  muscle  training  we  do  not  attain 
our  end.  With  the  intelligent  cooperation  of  the  patient  it 
is  possible  to  get  results  without  either  massage  or  electrical 
treatment.  A combination  of  all,  however,  gives  best  results. 

One  of  the  earliest  exercises  to  develop  this  muscle  may 
be  termed  “ knee-rolling.”  This  can  be  done  in  the  early 
stage  when  it  is  not  advisable  to  have  the  patient  bear 
weight  on  the  joint,  by  having  him  sit  so  that  the  heel 
touches  the  floor,  and  with  the  hip  of  the  affected  side 
nearly  free  from  the  bench.  Here  he  begins  describing 
circles  with  the  knee,  either  inward  or  outward,  and  the 
instructor  sees  that  he  gets  the  proper  contracture  of  the 
•vastus  internus  muscle.  The  straighter  the  leg  the  more 
action  is  got  in  that  muscle,  but  long  before  he  can  get 
complete  extension  contractions  occur. 

But  knee-rolling  is  not  sufficient  in  itself.  Frequentlv  a 
lift  on  the  inner  side  of  the  heel  and  sole  is  of  decided 
advantage.  Far  beyond  the  need  of  this,  however,  is  the 
insistent  observance  of  the  placing  of  the  feet  parallel 
and  5 inches  apart  in  all  walking,  standing,  or  drilling. 
The  double  knee  bend  is  bad  in  internal  derangement  of 
the  knee,  and  has  resulted  more  than  once  in  dislocation 
of  the  semilunar  cartilage.  The  stronger  position  of  the 
knee  with  the  feet  parallel  and  5 inches  apart  over  that  of 
the  usual  position  of  attention  can  easily  be  felt  in  one’s 
own  joints.  For  these  reasons  and  because  of  the  very 
notable  improvement  and  not  infrequent  cures  obtained, 
we  consider  it  essential  in  all  remedial  muscle  training  that 
patients  stand  and  move  with  the  feet  parallel  and 
5 inches  apart.  Were  this  adopted  universally  in  the 
physical  training,  both  in  the  army  and  in  schools,  it 
would  very  much  reduce  the  casualties  from  sprained 
knees  and  also  flat  feet. 

Of  great  importance  is  the  manner  in  which  the  exercises 
are  given.  Individual  drill  is  impracticable,  so  cases  are 
arranged  in  classes,  which  will  as  nearly  as  possible  group 
similar  disabilities.  These  classes  are  named  from  the  parts 
to  which  most  of  our  effort  is  directed — i.e.,  shoulder,  elbow, 
wrist  and  hand,  thigh,  leg,  foot,  back,  special,  and  general 
or  Swedish  drill.  The  leg  class  includes  flat-foot  cases. 
The  special  class  is  devoted  to  cases  that  do  not  fit  in  the 
others,  or  need  iudividual  attention,  and  also  to  stump  cases 
learning  to  walk  on  peg  legs.  To  these  classes  the  patient  is 
sent,  as  his  progress  in  the  massage  and  electro-therapy 
departments  indicates. 

Psychic  lameness  is  a tremendous  factor.  The  closer  one 
is  to  the  bed  the  more  simple  and  gentle  must  the  commands 
for  exercises  be  in  order  to  restore  coordinate  movement. 
The  reason  is  obvious.  When  function  has  been  eliminated 
for  any  period  of  time  it  takes  some  mental  training  before 
the  patient  can  hope  to  get  any  muscular  action,  conse- 
quently the  commands  given  should  be  given  distinctly,  and 
should  call  for  very  simple  movements.  In  a hospital  where 
the  patients  come  almost  directly  from  the  bed  sharp  com- 
mands and  complicated  movements  have  a distinctly 
deleterious  effect,  and  this  is  particularly  true  in  neuras- 
thenics, hysterics,  aud  shell  shock  cases. 

When  the  [patient  is  advauced  to  a reasonable  stage  the 
next  step  is  to  introduce  him  to  outdoor  games.  Any  game  ! 
with  a bail  seems  to  take  with  the  Anglo-Saxon,  and  the  ! 
element  of  competition  leads  to  many  involuntary  efforts,  i 
often  with  surpi isingly  beneficial  results.  As  ‘soon  ss  ! 
possible  one  must  getaway  from  treating  the  injured  part, 
aud  make  the  patient  feel  that  he  need  no  longer  focus  his 
attention  on  his  disability.  For  example,  much  can  be  done 
for  upper  extremity  injuries  by  skipping-rope  dances. 

Vocational  training  has  its  sphere,  but  that  is  not  in  our 
province  to  discuss  now.  Workshops  have  a potent  part  to 
play.  The  effectiveness  of  that  part,  however,  depends  on  the 


creative  interest  evoked  in  the  patient  by  the  work  he  chooses, 
and  can  in  no  way  be  measured  by  marketable  value  or  useful- 
ness. If  the  result  of  the  patient’s  activity  be  useable  or  sale- 
able so  much  the  better.  That  idea  can  often  be  instilled  to 
incite  interest.  The  workshops  should  be  equipped  simply, 
with  reasonable  expenditure,  as  to  material  and  tools — all 
hand  and  foot  power — and  should  offer  as  varied  activities  as 
can  be  arranged.  An  effort  to  combine  the  treatment  shops 
with  splint  or  hospital  requisite  factories  is  futile,  a failure 
either  way. 

For  measuring  progress,  complicated  apparatus  is  a 
distinct  disadvantage  in  dealing  with  large  numbers.  With 
the  simplest  goniometer  one  can  get  a very  satisfactory  idea 
of  progress  in  the  movement  of  joints.  ‘ A statement  of 
how  far  the  patient  can  travel  on  a Ling  beam  or  parallel 
bars,  or  how  often  he  can  “ chin  himself,”  is  an  accurate 
enough  index  of  the  strength  in  arm  cases ; while  a march 
over  a measured  route,  with  notations  of  where  the  patients 
drop  out,  serves  in  leg  cases.  And  in  order  to  co-relate  the 
work  done  in  hospitals  with  later  progress  a note  of  weekly 
examinations  should  be  made  by  the  medical  officer  in 
charge  of  the  treatment  department — i.e.,  massage,  electro- 
therapy, and  gymnasium — as  to  improvement  or  lack  of 
improvement.  This  record  should  follow  the  patient  up,  so 
as  to  save  duplication  of  effort. 


THE  CONVERTED  ARMY  HUT. 

The  Disposal  Board  of  the  Ministry  of  Munitions  have 
erected  on  the  Horse  Guards  Farade,  St.  James  Park, 
London,  S.W.,  a 60  ft.  x 15  ft.  army  hut  which  has  been 
converted  into  a bungalow.  As  remodelled,  the  hut  com- 
prises a living-room  20  ft.  x 15  ft.;  three  bedrooms,  one 
15  ft.  x 10  ft.,  and  two  others  10  ft.  by  10  ft.,  the  height  of  the 
rooms  being  about  7 ft.  9 in.  There  are  also  a scullery, 
larder,  bath,  w.c.,  and  coal  house.  The  hut  is  lined  with 
asbestos  filled  in  with  coke  breeze.  A cooking  range,  stoves 
for  the  bedrooms,  and  an  18-gallon  farm  boiler  are  provided. 
The  price  of  the  hut  unconverted  is  £100,  the  cost  of  turning  ' 
itintoadwelling  being  approximately £300,  whilst  thefurnish- 
ing,  as  carried  out  by  Messrs.  Heal  and  Sons,  of  Tottenham 
Court-road,  which  includes  furniture,  linoleum,  rush  mats, 
curtains,  toilet  ware,  table  ware  for  six  people,  fireproof 
kitchen  ware,  and  bedding  costs  about  £32t>.  The  life  of  a ' 
hut  is  estimated  at  from  15  to  20  years.  The  lighting  and 
ventilating  arrangements  are  good,  the  upper  halves  of  the  12 
windows  being  arranged  as  fanlights.  The  conversion  of  \ 
these  huts  may  help  towards  the  solution  of  the  house  ; 
famine,  though  the  price,  reasonable  enough,  is  none  the 
less  too  high  for  the  small  man  desiring  to  own  his  home. 
Moreover,  while  the  life  of  the  hut  is  stated  to  be  15  years 
or  more— and  this  need  not  be  challenged— the  premises 
are  liable  to  supervision  by  local  authorities  at  the  expira- 
tion of  a five  years’  licence. 

TRAVELLING  HEALTH  EXHIBITIONS. 

The  National  Union  of  Women  has  long  made  the  travelling  J 
child  welfare  exhibition  into  a fine  art  as  a method  of  public  i 
instruction,  and  the  National  Association  for  Combating  ' 
Tuberculosis  has  made  similar  if  sporadic  efforts  in  popu-  * 
larising  its  own  activities.  At  a recent  meeting  of  the 
Medical  Council  of  the  People’s  League  of  Health,  held  1 
under  the  chairmanship  of  Sir  G.  Sims  Woodhead,  the 
honorary  organiser,  Miss  Olga  Nethersole,  outlined  her 
scheme  for  public  travelling  exhibitions  as  one  channel 
to  be  employed  by  the  League  for  the  -dissemination  of 
knowledge  regarding  health.  The  exhibitions  would  cover 
the  whole  field  of  physical,  mental,  and  moral  health,  with 
sections,  such  as  tuberculosis,  food,  housing,  waste,  teeth, 
eyes,  parentage,  hygiene  and  respiration,  child  welfare, 
venereal  disease,  crime,  alcohol,  physical  education  and 
gymnastics.  The  scheme  was  adopted  on  the  understanding 
that  other  associations  should  be  invited  to  cooperate  with 
the  League  of  Health  in  the  arrangement  of  the  exhibitions. 


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THE  LANCET,  August  9,  1919. 


J'likstipfioiis 


ON 

THE  NORMAL  VITAL  CAPACITY  IN  MAN 
AND  ITS  RELATION  TO  THE  SIZE 
OF  THE  BODY. 

THE  IMPORTANCE  OP  THIS  MEASUREMENT  AS  A 
GUIDE  TO  PHYSICAL  FITNESS  UNDER  DIFFERENT 
CONDITIONS  AND  IN  DIFFERENT  CLASSES 
OF  INDIVIDUALS.1 

By  GEORGES  DREYER,  M.A.,  M.D., 

PROFESSOR  OF  PATHOLOGY,  UNIVERSITY  OF  OXFORD. 

(From  the  Department  of  Pathology,  University  of  Oxford.) 

During  the  last  few  years  questions  relating  to  the  vital 
capacity  of  man  have  acquired  prominent  importance,  since 
this  measurement  has  been  a decisive  factor  in  the  selection 
or  exclusion  of  candidates  for  our  Flying  Service.  A definite 
minimum  standard  of  “ vital  capacity ’’was  fixed,  more  or 
mss  arbitrarily,  for  the  admission  of  cadets  to  the  Royal  Air 
Force,  and  standards  were  also  decided  upon  for  the  grading 
of  flying  oflicers  for  different  types  of  service.  In  laying 
down  rules  in  this  connexion,  the  question  of  the  size  of  the 
man  was  entirely  disregarded  as  though  of  no  consequence 
and  the  standards  were  arrived  at  simply  as  the  result  of 
examining  a number  of  successful  pilots,  and  determining 
their  average  vital  capacity.  e 

Pioneer  Work  of  John  Hutchinson. 
Justification  for  this  arbitrary  course  was  possibly  found  in 
the  fact  that  no  definite  relationship  between  vital  capacity 
and  size  was  believed  to  exist,  and  that  vital  capacity  was 
regarded  as  an  extremely  variable  measure  in  different 
individuals,  although  the  question  of  its  relation  to  size  had 
been  approached  in  the  remarkable  and  fundamental  work  of 
John  Hutchinson  as  long  ago  as  1846.  He  claimed  that 
vital  capacity  increases  in  a simple  arithmetical  progression 
with  increasing  height,  and  believed  that  he  had  disproved 
the  existence  of  any  definite  relationship  between  vital 

S°™t.  “ b0dr  ,elght'  Stem  '“sth’  » ch“* 

,hlSVork  stands  °ut  as  a pioneer  achievement  by 
one  who  realised,  as  none  before  or  since  has  done  the  vast 
importance  and  wide  scope  of  the  problem  which  he  attacked 
and  forms  a model  of  careful  and  accurate  observation  and 
measurement  yet,  as  will  be  shown  in  this  paper  Us 
mathematical  analysis  of  his  results  failed  to  reveal  the  true 
relationship  which  vital  capacity  bears  to  certain  other body 

Sllows6— 6ntS‘  The  COnclusiorls  at  which  he  arrives  are  as 

1.  That  there  exists  a definite  relatinnchir* 

standing  height  and  vital  capacity,  and  he  llvs  down  the 
rule  ‘ that  for  every  inch  of  height  (from  5 ft  tn  fi  n 
8 additional  cubic  inches  of  air  at  60°  are  eiv^n  onf  k 
forced  expiration.”  glven  out  bV  a 

2.  That,  as  regards  the  influence  of  weiaht  on  vital 
capacity,  the  vital  capacity  increases  from  the7  7st  men  to 
the  12  st.  men  and  then  becomes  more  or  less  irreenlnr 
Purther,  that  it  may  be  said  that  the  vital  capacitv  innrit  ar‘ 
nearly  ln  the  ratio  of  1 cubic  inch  per  pouni  Horn  105 fb  to 
155  lb.,  and  that  from  1551b.  to  200  lb.  this  increase  rwi 

of°  weight.4  th6re  iS  a 1083  °f  39-5  cubic  inches  a*  the  effect 

estimating  the  vital  capacity.”  *’  ready  guide  to 

In  referring  to  these  remarkable  observations  of  Hutchinson 

scilntffb.  b express  the  greatest  admiration  for  the 
scientific  manner  in  which  they  are  collected.  The  fact 

that  the  conclusions  which  I,  drawing  upon  his  material  as 
wen  „ hav«  reacbed  in 


and  various  body  measurements  differ  from  his  on  practically 
every  single  point,  cannot  affect  my  profound  admiration  for 
this  quite  unusual  piece  of  pioneer  work— an  admiration  to 
which  I cannot  better  testify  than  by  quoting  the  fine 
sentences  with  which  he  ends  his  exhaustive  and  excellent 
treatise  on  the  Respiratory  Functions  : 

“ The  matter  of  this  communication  is  founded  upon  a 
vast  number  of  facts— immutable  truths,  which  are  infinitely 
beyond  my  comprehension.  The  deductions,  however,  which 
I have  ventured  to  draw  therefrom,  I wish  to  advance  with 
modesty,  because  Time,  with  its  mutations,  may  so  unfold 
science  as  to  crush  these  deductions,  and  demonstrate  them 
&s  unsound. 

Nevertheless,  the  facts  themselves  can  never  alter,  nor 
deviate  in  their  bearing  upon  respiration— one  of  the  most 
important  functions  in  the  animal  economy.” 

The  Author’s  Results. 

Before  entering  into  detailed  discussion  of  my  results,  it 
would  be  well  to  state  here  that  the  result  of  my  investiga- 
tions has  enabled  me  to  establish  definite  relationships 
between  vital  capacity  and  body  surface,  body  weight,  stem 
length  and  chest  measurement,  and  to  show  that  vital 
capacity  is  not  a simple  function  of  height,  as  Hutchinson 
claimed.  In  order  of  importance  the  relations  are  as 
follows  : — 

1.  The  vital  capacity  is  a function  of  the  weight.  This 
can  be  expressed  in  the  formula  K,  where  W is  the 

net  weight  of  the  body  expressed  in  grammes,  VC.  the 
vital  capacity  expressed  in  cubic  centimetres,  and  the 
power  n is  approximately  f,  though  more  accurately  0 72, 
Kl  1S  a constant-  As  it;  is  already  established  that 
wbere  W = net  weight,  S = body  surface,  and  the 

f°"°r  n i«  approximately  f though  more  accurately  0 72, 
o f that  the  Vllal  oapaoity  is  a simple  function  of  the 
body  surface.  In  other  words,  that  the  smaller  and  lighter 
individual,  with  his  relatively  larger  surface,  has  a greater 

IndtviduafClty  ^ Umt  °f  b°dy  W6ight  than  the  larger 

2.  The  relation  between  the  vital  capacity  and  stem 
length  can  correctly  be  expressed  by  the  formula  X°  = K3 
where  X = stem  length  in  centimetres,  V.C.  = vital  canacitv 

k"?“b‘««srtr“',h8  pow“  - ” 

3.  The  relation  between  vital  capacity  and  circumference 
of  chest  can  be  expressed  by  the  formula  = where 

Vhr  =JirZmferenC!  °f  Ch6St  ^pressed  'in  ' centimetres, 
V.C.  - vital  capacity  expressed  in  cubic  centimetres  the 
pover  n ,s  approximately  2,  and  K4  is  a constant  ’ 
n -i-i  X X Ch. 

ma  y’  V.C.  ~ wbere  ^ — stem  length  in  centi- 
V o'"-’  CirCUmfArence  of  chest  in  centimetres, 

a constant  y “ CUblC  centimet«*.  and  K,  is 

I shall  now  proceed  to  prove  the  existence  of  the  above- 
mentioned  relationships.  In  order  to  do  so  I will  dell  firlt 
with  my  own  observations  and  subsequently  with  those  of 
Hutchinson  and  other  observers. 

The  Author’s  Observations. 

The  data  given  in  the  following  tables  was  obtained  from 

16  men  and  boys  who  were  carefully  selected  on  account  of 

in  wXhhtS1V,al  T’  and  covered  ^ widely  different  a range 
in  weight,  height,  &c.,  as  possible. 

The  weight  varied  from  29  8 kg.  to  88  8 kg  • the  standi™ 
o30,Cm-  t0  186  Cm  J tb«  stem' 

67-5  cm'  t1°9fi81  5 Cm‘  : circumference  of  chest  from 

aho„t  %n  961  n7uan,d  the  Vltal  caPacitv  ranged  from 
about  2300  c.cm.  in  the  lightest  to  about  5100  c cm  in  the 

52ayelS.  ' The  ag6S  raDged  from  13  to  about 

this  paper  all  measures  are  expressed  in  grammes 
centimetres,  and  cubic  centimetres  unless  otherwise  stated’ 
The  weight  is  net  weight,  without  clothing  - the  standing 
height  in  stockinged  feet  is  taken  in  the  usua  manner  th? 
circumference  of  chest  was  measured  by  t^pe  measure 

fine06  Whii?bei0nngthe  ^ ^ CbeSt  juSt  on  the  niPP>« 

line.  hile  being  measured  the  subject  was  made  to  stand 


228  The  Lancet,]  PKOF.  G.  DREYER  : THE  NORMAL  VITAL  CAPACITY  IN  MAN. 


[August  9, 1919 


with  his  arms  hanging  loosely  down  at  his  sides,  breathing 
normally.  This  method  of  measurement  was  chosen  because 
it  was  found  to  yield  more  regular  results  for  comparison  than 
measurements  taken  during  extreme  inspiration  and  expira- 
tion. The  subject  should  be  encouraged  to  talk  whilst  being 
measured,  as  the  muscles  are  then  more  or  less  perfectly 
relaxed.  The  stem  length  was  obtained  by  seating  the 
subject  on  the  floor  or  a board,  with  his  back  against  a 
perpendicular  triangular  projection,  to  which  the  scale  is 
fixed.  To  secure  accurate  measurement  it  is  necessary  for 
him  to  place  his  hands  on  the  floor  or  board,  close  to 
his  body,  and,  drawing  up  his  knees,  to  raise  himself  for  a 
moment  and  press  his  os  sacrum  as  close  as  possible  against 
the  scale.  It  will  be  found  that  different  persons  bend  the 
knees  to  different  degrees  when  attempting  to  achieve  this 
result.  In  such  a position  a constant  measurement  of  stem 
length  is  provided  from  the  top  of  the  head  to  the  ischial 
tuberosities,  and  one  that  does  not  vary  in  repeated  measure- 
ments of  the  same  individual.  On  account  of  the  influence 
of  the  muscles  the  stem  length  taken  when  the  subject  is 
seated  on  a chair  does  not  afford  a constant  measure  of  an 
individual,  nor  a measure  which  lends  itself  to  accurate 
comparison  of  one  individual  with  another — a point  to  which 
Walker  has  also  drawn  attention.  The  measurements  taken 
by  this  latter  method  have  been  found  to  be  about  3 per 
cent,  greater  than  those  obtained  by  the  methods  used  in 
this  paper. 

For  the  measurements  of  vital  capacity  a spirometer  of 
the  dry  type,  made  by  Boullite,  of  Paris,  was  selected,  as  it 
offers  a minimum  resistance  to  expiration.  The  measure- 
ments were  taken  while  the  subject  was  sitting  on  a high 
stool  with  his  back  straight.  He  was  always  first  shown 
carefully  how  to  proceed,  and  then  five  measurements  were 
taken.  The  subject  was  kept  in  ignorance  of  the  readings 
while  being  examined,  as  it  was  found  that  any  such 
knowledge  tended  to  interfere  with  the  accuracy  of  the 
results.  The  highest  reading  of  the  five  measurements  is 
the  figure  recorded  in  the  tables.  In  a large  number  of 
observations  the  highest  reading  was  found  to  be  about 
5 per  cent,  greater  than  the  mean  of  the  five  observations. 
The  measures  are  all  reduced  to  room  temperature  (15°  C.) 
and  760  mm.  pressure. 

In  Table  I.  are  given  the  details  of  the  16  persons  as 
regards  age,  weight,  standing  height,  stem  length,  circum- 
ference of  chest,  and  vital  capacity.  It  is  seen  from  this 


Table  I. 


(A)  Body  weight  (g.).  (D)  Circumference  of  chest  (cm.). 

(Bi  Standing  height  (cm.'.  (E)  Vital  capacity  (c.cm). 

(C)  “Stein  length  " (cm.). 


6 

fc 

ai 

bfl 

(A) 

(B) 

tC) 

<D( 

(E) 

o 

z; 

© 

b£ 

-< 

(A) 

(B) 

(C) 

(D) 

(E) 

16 

121? 

29,800 

1400 

71-5 

67.5 

2330 

9 

25 

63,500 

171  0 

88-0 

85-2 

4160 

15 

13  ft 

38,900 

156-0 

74  0 

73-3 

2840 

11 

22 

66,900 

179-6 

91-0 

86-0 

4400 

14 

14,*, 

41,200 

150-0 

77-5 

76-7 

3030 

5 

43  j-\ 

69,100 

164-2 

86-0 

91-3 

4400 

10 

18ft 

55,300 

160-5 

87  0 

87  4 

3830 

3 

31ft 

74,600 

184-5 

95-2 

932 

4660 

13 

18ft 

58,600 

168-8 

83-5 

79-6 

3300 

7 

35  ft 

77,400 

1725 

91-5 

964 

4800 

4 

27)  i 

63,500 

172  0 

850 

88-8 

4200 

8 

25 

81,000 

184-0 

95-4 

92-2 

4890 

6 

31ft 

63,500 

171-0 

90-2 

92-2 

4200 

12 

24 

81,100 

178-0 

90-0 

95-2 

5140 

35ft 

63,500 

172  0 

92-0 

S5-2 

4440 

1 

51}V 

88,800 

186-0 

98-5 

96-1 

5130 

g.,  grammes,  cm.,  centimetres,  c.cm.,  cubic  centimetres. 


table  that  there  is  an  almost  steady  increase  of  vital 
capacity  with  increasing  weight,  while  this  regularity  is 
but  poorly  maintained  with  increase  in  standing  height. 


The  Relation  between  Vital  Capacity,  Body  Surface,  an 
Body  Weight. 

In  attempting  to  find  the  best  mathematical  expressio 
for  the  relationship  between  body  weight  and  vital  capacit 
it  was  found  that  the  body  weight  to  the  nth  power,  divide 
by  the  vital  capacity,  gives  a constant,  and  it  will  be  furthe 
seen  that  the  power  n is  approximately  $,  though  mor 
accurately  0 72.  But  since  it  has  already  been  shown  tha 
W" 

g — K where  W = net  weight  in  grammes,  S.  = surface  i 


square  centimetres,  and  the  power  n is  approximately  f,  but 
more  accurately  0 72,  it  follows  that  the  vital  capacity  is  a 
simple  function  of  the  body  surface. 


In  Table  II.  is  calculated  the  “ vital  ^capacity  constant” 

W °-72 

from  the  formula  K = y p as  well  as  the  vital  capacity 

expressed  in  percentage  of  the  body  weight  in  grammes.*;  In 
comparing  these  two  columns  it  is  obvious  that  there  is'an 
almost  regular  decrease  in  the  percentage  of  vital  capacity 

Table  II. 

(A)  Body  weight  (g.). 

(B)  Vital  capacity  observed  (c.cm.). 

W»?2 

C)  Vital  capacity  constant : K = y — 

W 0-72 

(D)  Vital  capacity  calculated  : V.C.  = — 

(B)  Difference  between  vital  capacity  calculated  and  observed? 
(per  cent.j. 

(F)  Vital  capacity  as  percentage  of  body  weight. 

(G)  Vital  capacity  calculated  as  percent.  (6  626)  of  body  weight. 

(H)  Difference  between  vital  capacity  calculated  and  observed 
(per  cent.). 


No. 

(A) 

< B) 

(C) 

(D) 

(E) 

(F) 

(Q) 

<H) 

16 

29,800 

2330 

0 714 

2410 

3 32 

7-819 

1975 

17  97 

15 

38,900 

2840 

0 710 

2922 

2 81 

7-301 

2577 

10-21 

11 

41,200 

3030 

0-693 

3041 

0-46 

7 354 

2730 

10-99 

10 

56,300 

3830 

0-638 

3812 

0-47 

6 802 

3730 

2 68 

13 

58,600 

3800 

0 712 

3922 

311 

6-485 

3883 

214 

4 

63,500 

4200 

0 683 

4160 

0-96 

6-614 

4207 

017 

6 

63,500 

4200 

0 683 

4160 

0-96 

6614 

4207 

017 

2 

63,500 

4441 

0-646 

4160 

6-73 

6-992 

4207 

554 

9 

63,500 

4160 

0-691 

4160 

000 

6-552 

4207 

112 

11 

66,900 

4400 

0-677 

4315 

1-97 

6-577 

4433 

0-74 

5 

63,100 

4400 

0-693 

4419 

0-43 

6 368 

4578 

3-89 

3 

74,600 

4S60 

0-691 

4668 

017 

6247 

4943 

6-73 

7 

77.400 

4800 

0-689 

4793 

015 

6"292 

5130 

6-43 

8 

81,000 

4890 

0-699 

4954 

1-29 

6037 

5367 

8 89 

12 

81,100 

5140 

0-656 

4958 

3-67 

6 338 

5374 

4-35 

1 

88,800 

5130 

0-713 

5293 

3-08 

5-777 

5884 

12-82 

Average 

0-690 

1-85 

6 626 

687 

as  the  individuals  increase  in  weight,  while  the  “ vital 
capacity  constant  ” does  not  show  any  periodical  change 
with  the  increase  iD  weight,  the  variations  only  being  such 
as  depend  on  slight  individual  differences.  It  is  further 
seen  that  the  mean  vital  capacity  constant  is  0 69  and  that 
the  average  figure  representing  the  vital  capacity  as  a 
percentage  of  the  body  weight  is  6 626. 

In  the  same  table  is  also  calculated  the  vital  capacity  from 
W»« 

the  formula  V.C.  = ■— -by.-  (i.e.,  as  a function  of  the 
u 09 

surface),  and  from  the  average  vital  capacity  percentage, 
6 626,  as  well  as  the  percentage  differences  between  the 
observed  figures  and  those  calculated  under  the  two  pro- 
cedures. In  the  first  case  the  greatest  individual  devia- 
tions of  the  observed  from  the  calculated  figures  are 
4-  6 73  per  cent,  and  — 3 -32  per  cent.,  while  the  average 
deviation  is  only  185  per  cent.  If,  on  the  other  hand,  the 
vital  capacity  is  calculated  as  a percentage  of  the  body 
weight,  the  greatest  individual  deviations  become  as  much  as 
+ 12  82  per  cent,  and  — 17  97  per  cent.,  the  average 
deviation  being  5 87  per  cent.,  or  about  three  times  as  large 
as  in  the  former  case.  From  this  there  is  no  doubt  that  the 
formula  expressing  the  vital  capacity  as  a function  of  the 
body  surface  represents  the  experimental  data  in  a highly 
satisfactory  manner,  while  the  same  data  cannot  rightly  be 
expressed  in  percentage  of  body  weight. 

In  Table  III.  the  observations  are  arranged  in  eight 
groups,  by  grouping  together  the  individuals  of  approximately 
the  same  weight  and  averaging  their  vital  capacity.  The 
vital  capacity  constant  and  the  vital  capacity  expressed  as 
percentage  of  the  body  weight  are  then  calculated.  It  is 
again  seen  that  the  percentage  of  vital  capacity  decreases 
with  almost  absolute  regularity  from  7 819  per  cent,  in  the 
lightest  group  to  5 77  per  cent,  in  the  heaviest  group,  while 
the  vital  capacity  constant  shows  no  periodic  deviation. 

In  the  same  table  are  calculated  the  vital  capacity  as  a 
function  of  the  surface,  and  also  as  a simple  function  of  the 
weight.  In  the  former  case  the  percentage  deviation  is  only 
1-57,  while  in  the  latter  it  is  5-23,  taking  into  consideration 
the  number  of  individuals  in  each  group,  or  more  than  three 


Thb  Lanobt,] 


PROP.  G.  DUBVRR:  THB  NORMAL  VITAL  CAPACITY  IN  MAN.  [August  9,  1919  229 


times  as  great..  It  is  obvious  that  the  greater  the  range  of 
weight  covered  by  the  observations  the  greater  must  be  the 
difference  in  the  results  arrived  at  by  the  two  methods  of 
calculation. 

If,  instead  of  making  use  Of  the  best  value  for  n (0  72)  in 
the  formula  one  uses,  for  the  sake  of  convenience,  the 
power  J,  the  average  K for  the  16  observations  is  0 380,  and 

Table  III. 

<A)  Numbers  from  Table  I.  forming  groups. 

'(B)  Number  in  group. 

■(C)  Average  body  weight  (g  ). 

<D)  Average  vital  capacity  observed  (c.cm.) 

\yo-72 

•(E)  Vital  capacity  constant : K = ~y~C — 

WQ-72 

(F)  Vital  capacity  calculated  : V.C.  = 


between  vital 


0-691. 
capacity  calculated 


and  observed 


<G)  Difference 
(per  cent.). 

(H)  Vital  capacity  as  percentage  of  body  weight. 

(I)  Vital  capacity  calculated  as  per  cent.  (6-643)  of  body  weight. 

(J)  Difference  between  vital  capacity  calculated’  and  observed 
(per  cent.). 


(A) 

(B> 

(C> 

(D) 

(B) 

(F) 

(G) 

(H) 

a) 

(J) 

16 

1 

29,800 

2330 

0-714 

2407 

3 20 

7-819 

1979 

17-74 

15,14 

2 

40,050 

2935 

0-702 

2981 

1-54 

7-329 

2690 

911 

10, 13 

2 

57,450 

3815 

0 700 

3867 

1-34 

6-640 

3816 

0-03 

4,  6,  2,  9 

4 

63,500 

4250 

0-616 

4156 

2-26 

6-693 

4218 

0-76 

11,  5 

2 

68,000 

44C0 

0-685 

4363 

0 85 

6-471 

4517 

2-59 

3,7 

2 

76,000 

4730 

0-691 

4730 

o-oo 

6-223 

5049 

6-32 

8, 12 

2 

81,0.=0 

5015 

0-682 

4952 

1-27 

6-188 

5384 

6 85 

1 

J- 

88  800 

5130 

0713 

5285 

2-93 

5-777 

5898 

13-02 

Average 

0-691 

1 57 

6*643 

... 

5-23 

the  percentage  difference  between  observation  and  calcula- 
tion increases  from  158  in  the  case  of  the  best  n (0  72)  to 
246,  taking  n as  §.  Whenever  a great  range  of  weight  is 
covered  by  the  observations  it  becomes  imperative  to  make 
use  of  the  best  n (0'72)  in  the  formula,  while  this  is  of  less 
importance  when  only  a relatively  small  range  of  weight  is 
covered. 

In  Table  IY.  are  calculated  my  own  observations  on  vital 
capacity,  according  to  Hutchinson’s  idea  that  it  increases  in 
a simple  arithmetical  progression  with  increasing  height.  By 
applying  this  method  it  was  ascertained  that  the  best 
approximation  to  be  found  was  that  for  each  1 cm. 
increase  in  height  there  is  an  increase  of  65  c.cm.  in  vital 
capacity.  In  this  table  the  greatest  individual  differences 
between  the  calculated  and  observed  figures  are  seen  to  be 
+ 15  39  per  cent,  and  - 1342  per  cent.,  while  the  average 
difference  between  calculation  and  observation  is  6-02  per 
: cent.— more  than  three  times  greater  than  the  deviation 
found  if  the  vital  capacity  be  calculated  as  a function 

of  the  body  surface  by  means  of  the  formula  V.C.  = , 

K 

where  the  percentage  devialion  is  found  to  be  as  little 
as  1-85. 

It  is  further  of  interest  to  note  that  if  the  vital  capacity 
be  calculated  as  a simple  function  of  the  height  the  per- 
centage deviation  is  even  larger  than  if  the  vital  capacity 
be  calculated  as  a simple  function  of  the  body  weight — a 
procedure  which  has  already  been  proven  to  be  entirely 
fallacious. 

Both  from  this  table  and  from  Table  I.  it  will  also  appear 
that  the  vital  capacity  of  man  is  not  (as  claimed  by  Hutchinson) 
a simple  function  of  the  height , since  it  does  not  increase  at  a 
fixed  rate  with  each  unit  increase  in  height,  but  irregularly, 
and  in  the  following  manner.  From  a certain  point  the  rate 
of  increment  of  vital  capacity  per  unit  increase  of  height  at 
first  quickens,  but  presently  a maximum  is  reached  at  a 
certain  body  height,  and  thereafter  the  rate  of  increment 
of  vital  capacity  diminishes  for  a period  before  it  again 
increases. 

The  Relation  between  Vital  Capacity  amd  Stem  Length. 

1 In  Table  V.  the  16  observations  are  arranged  accord- 
ing to  their  stem  length.  It  iS  seen  that,  with  increase 
in  stem  length  there  is  also  a more  or  less  regular  increase 
in  vital  capacity,  though  the  regularity  is  very  much  less 
pronounced  than  was  the  case  when  the  same  observations 
were  arranged  by  weight.  The  mathematical  relationship 


between  stem  length  and  vital  capacity  was  found  to  be 
\ » 

y - — K where  the  power  n is  approximately  2.  In 
Table  Y.  this  constant  is  calculated,  as  well  as  that  of  the 

vital  capacity  from  the  formula  V.C.  = Looking  at  the 

1 9 

column  where  the  constants  are  given  it  will  be  found  that, 
though  they  exhibit  considerable  individual  variations,  there 
is  no  evidence  of  periodicity.  By  applying  the  formula  it 


Table  FVY 

(A)  Standing  height  (cm.). 

(B)  Vital  capacity  observed  (c.cm.). 

(C)  Vital  capacity  calculated 
from  height  (Hutchinson's 
method). 

(D)  Difference  between  vital 
c -.pacify  calculated  and  observed 
(per  cent.). 


Table  V, 

(A)  Stem  length  (\)  (cm.). 

(B)  Vital  capacity  observed  (c.cm.) 

(C)  Constant : K :=  h . 

V.C. 

(D)  Vital  capacity  calculated  : 

v.c. = r 

1 o 

(E)  Difference  between  vital  capa- 
city calculated  and  observed 
(per  cent.). 


No. 

(A) 

(B) 

(0) 

(D) 

No. 

(A) 

(B) 

(C) 

(D)  : (E) 

16 

140-0 

2330 

2240 

4-02 

16 

71-5 

2330 

2-20 

2690  13-38 

14 

150-0 

3030 

2890 

4-84 

15 

74-0 

2840 

1 83 

2880  1-39 

15 

156-0 

2840 

3280 

13  42 

14 

77-5 

3030 

1 98 

3160  4-11 

10 

160-5 

3830 

3702 

3-46 

4 

85-0 

4200 

Y72 

3810  10-24 

5 

164-2 

4400 

3813 

15-39 

5 

86-0 

4400 

1-68 

3900  12-82 

13 

168-8 

3800 

4092 

7-14 

10 

87-0 

3830 

1-98 

3930  4-01 

6 

1710 

4200 

4255 

1-29 

9 

88-0 

4160 

1-86 

4080  1 96 

9 

171-0 

4160 

4255 

2-23 

13 

88-5 

3800 

2 06 

4125  7-85 

4 

172-0 

4200 

4320 

2-78 

12 

90-0 

5140 

1-68 

4280  ; 20  09 

2 

172-0 

4440 

4320 

1-39 

6 

90  2 

4200 

1-94 

4282  1-92 

7 

172-5 

4800 

4352 

10  29 

11 

91-0 

4400 

1 98 

4370  0-69 

12 

178-0 

5140 

4710 

9-13 

7 

91-5 

4800 

1 75 

4420  8-60 

11 

179-6  1 

4400 

4814 

8 60 

2 

92-0 

4440 

1-91 

4460  0-45 

8 

184-0 

4890 

5100 

4-12 

3 

95  2 

4660 

1-95 

4780  2-51 

3 

184-5 

4660 

5132 

9 20 

8 

95-4 

4890 

1-86 

4800  1-88 

186-0  f 

5130 

5230 

1-91 

1 

98-5 ! 

5130 

1-89 

5115  0-29 

Average  ... 

6-C2 

Average  ... 

1-90 

...  5-76 

is  made  clear  that  there  is  an  average  percentage  deviation 
of  observation  from  calculation  of  5 76.  This  percentage 
deviation  is  nearly  three  times  as  great  as  in  the  case  where 
the  vital  capacity  is  calculated  as  a function  of  the  surface, 
and  only  slightly  smaller  than  if  it  be  calculated  as  a simple 
function  of  the  weight.  Such  a considerable  percentage 
deviation  of  observation  from  calculation  is  caused  by  the 
fact  that  the  stem  length  in  individuals  of  the  same  weight 
varies  considerably.  That  this  interpretation  is  true  becomes 
patent  when  we  arrange  the  observations  in  five  groups 
according  to  their  stem  lengths  and  average  their  vital 
capacities,  as  done  in  Table  VI.  In  this  case  the  percentage 
deviation  of  observation  from  calculation  of  the  vital 

A 2 

capacity,  using  the  formula  V.C.  = — , is  only  3 54,  white 

the  percentage  deviation  found  if  the  vital  capacity  be 
calculated  as  a simple  function  of  the  body  weight  hardly 
diminishes  by  grouping  but  remains  more  or  less  unchanged. 

If  we  consider  for  a moment  the  significance  of  this 
relationship  which  has  been  found  to  exist  between  stem 
length  and  vital  capacity,  it  is  easy  to  demonstrate  that  it 
is  entirely  rational  and  must  exist  in  view  of  the  relationship 
which  has  been  shown  to  hold  between  weight  and  stem 
length.  The  same  considerations  will  make  it  clear  that 
there  exists  no  definite  relationship  between  standing  height 
and  vital  capacity. 

In  an  unpublished  analysis  which  I made  nearly  ten  years 
ago  of  a number  of  existing  observations  of  standing  height 
and  body  weight  in  man  I f<  und  it  was  impossible  to 
demonstrate  any  simple  regular  relationship  between  these 
two  measurements.  On  the  other  hand,  in  different  animals 
a definite  relationship  between  stem  length  and  weight  was 
to  be  traced.  This  relationship  could  be  expressed  by  the 

formula  — = K and  the  power  n is  approximately  equal 

to  It  was  therefore  probable  by  analogy  that  a similar 
relationship  between  stem  length  and  weight  would  exist  in 


230  The  Lancet,]  PROF.  G.  DREYER:  THE  NORMAL  VITAL  CAPACITY  IN  MAN.  [August  9, 1919 


man.  This  point  was  cleared  up,  at  my  suggestion,  by  Dr. 
Ainley  Walker.  The  results  of  his  investigations  have 
already  been  published,  and  proof  given  that  the  relation- 
ships between  stem  length  and  body  weight  can  be 


Table  VI. 

(A)  Numbers  from  Table  I.  form- 
ing groups. 

(B)  Number  tn  group. 

(C)  Average  stem  length. 

(D)  Average  vital  capacity 
observed  (c.cm.). 

(K)  Vital  capacity  calculated  : 

X2 

V.C.  = ^ 

(P)  Difference  between  vital 
capacity  calculated  and 
observed  (per  cent.). 


Table  VIII. 


(A)  Numbers  from  Table  I.  form- 
ing groups. 

(B)  Number  in  group. 

(C)  Average  circumference  of 
chest  (cm.). 

(D)  Average  vital  capacity 
observed  (c.cm.). 

(E)  Vital  capacity  calculated : 

v.c.  = °JL2 
1-82 

(F)  Difference  between  vital 
capacity  calculated  and 
observed  (percent.). 


(A) 

(B 

(C) 

(D) 

(E) 

(F) 

(A)  . 

(B) 

(C) 

(D)  (B) 

(F) 

16,  15, 14 

3 

74-3 

2733 

2910 

6-08 

16,  15,  14 

3 

72-5 

2733  2890 

5-43 

4,  5,  10 

3 

86-0 

4143 

3900 

6-  23 

13,  2,  9 

3 

83-3 

425?  3815 

11-48 

9, 13,  12,  6 

4 

89-2 

4325 

4200 

2-98 

11,  10,4,5 

4 

88-4 

4208,  4300 

214 

11,  7,  2 

3 

91-5 

4413 

4405 

0- 18 

6,  8,  3 

3 

92-5 

4583  4700 

2-49 

3,  8,  1 

3 

96-4 

4890 

4900 

020 

12,  1,  7 

3 

95-6 

5023  5050 

0 54 

Average  . . 

312 

Average 

4-27 

expressed  by  the  same  formula  in  animals  and  man,  and 
wn 

that  the  formula  — — - = K,  where  the  power  n is  approxi 


mately  i,  holds  good. 

As  we  have  just  seen  that 


w3 

= K,  and  also  that 

V.C. 


i \ 2 

W - K,  it  follows  directly  that  = K,  which  exactly 
X V-L. 

represents  the  formula  which  was  deduced  from  the  expert 
mental  data. 


In  Table  VII.  the  observations  are  arranged  according  to 
the  chest  measurements.  It  is  seen  that  with  increase  in 
chest  measurement  there  is  also  a more  or  less  regular 
increase  in  vital  capacity,  though  exhibiting  similar  irregu- 
larities as  in  the  case  of  the  stem  length,  the  individual 
variations  here  also  being  much  more  marked  than  if  they  were: 
arranged  according  to  weight.  In  the  same  table  are  also 
given  the  individual  constants  calculated  from  the  formula 

Ch2.  _ g as  wen  as  the  vital  capacity  calculated  from 
V.C.  ’ rh  2 

the  formula  V.C.  = • Here,  again,  it  will  be  observed 

that  there  is  no  periodic  variation  in  the  size  of  the 
constant,  the  variations  being  caused  only  by  individual 
differences.  The  percentage  deviation  of  observation  from 
calculation  is  found  to  be  5‘8-a  deviation  practically 
identical  with  that  found  if  the  vital  capacity  be  calculated 

as  a function  of  the  stem  length  by  the  formula  V.C.  = g’ 

while  it  is  about  three  times  as  great  as  when  the  vital 
capacity  is  calculated  as  a function  of  the  body  surface  by 
the  usual  formula.  If  these  observations  are  arranged  in 
five  groups  according  to  the  chest  measurement  and  the 
vital  capacity  averaged  (as  done  in  Table  X III.)  the 
percentage  deviation  of  calculation  from  observation  is 
reduced  to  4 27,  or  a difference  somewhat  larger  than  the 
deviation  found  if  the  vital  capacity  is  calculated  by  the 
stem  length  by  means  of  the  proper  formula.  _ 

The  above-mentioned  relationship  between  vital  capacity 
and  chest  measurement  having  been  established,  it  became  a 
mathematical  necessity  that  a relationship  similar  to  that 
which  has  already  been  shown  between  stem  length  and 
weight  should  exist  between  weight  and  circumference  of 
Wn 

chest ; in  other  words,  that  = K,  and  the  power  n is 

the  existence  of  such 


The  Relationship  between  Circumference  ot  Chest  and  Vital 
Capacity. 

In  examining  the  relationship  between  the  circumference 
of  the  chest  and  the  vital  capacity  during  normal  breathing 
it  was  found  that  this  relationship  could  be  expressed  by 

the  formula  = K,  and  the  power  n was  again  found 

v.c. 

to  be  approximately  2. 


Table  VII. 

(A)  Circumference  of  chest  (Ch.) 
(cm  ) 

(B)  Vital  capacity  observed 
(c.cm.). 

Ch.2 

(C)  Constant : K=  y.C. 

(D)  Vital  capacity  calculated 

Ch.2 
V.C.  - v8ii_ 

(E)  Difference  between  vital  capa- 
city calculated  and  observed 
(\>er  cent.). 


Ch. 

approximately  i-  The  proof  of 
relationship  will  be  given  below. 

Relationship  Between  Circumference  of  Chest  and  Body 
Weight. 

In  Table  IX.  are  given  the  weights  of  the  16  persons  and 
the  corresponding  chest  measurements.  There  is  also 

to  be  found  the  constant  K = — . as  well  as  the  chest 


measurement  calculated 


Ch. 
from  the 


formula  Ch.  = 


W 


Table  IX. 

(A)  Body  weight  (g.). 

(B)  Circumference  of  chest  (cm.). 

y/!s 

(C)  Constant : K = ^ 

(D)  Circumference  , of  chest 

W3 

calculated:  Ch.  = Q.^^ 

(E)  Difference  between  circum- 
ference of  chest  calculated  and 
observed  (per  cent.). 


No. 

(A) 

1 B) 

(C)  1 

(D) 

(E) 

No.* 1 

(A) 

(B) 

(C) 

(D) 

(B) 

16 

67-5 

2330 

1-96 

2505 

6 99 

16 

29,800 

67-5 

0-459 

67-8 

0-44 

15 

733 

2840 

1-89 

2955 

3-89 

15 

38,900 

73  3 

0-462 

741 

1-08 

14 

76-7 

3C30 

1-94 

3240 

6 48 

14 

41,200 

76-7 

0-450 

75-5 

1-59 

13 

79-6 

3800 

1-67 

3495 

8-73 

10 

56,300 

87-4 

0 438 

83  8 1 

4-30 

2 

85-2 

4440 

1-64 

3995 

11-14 

13 

58,600 

796 

0-488 

84-9 

6-24 

9 

85-2 

4160 

1-74 

3995 

4-13 

4 

63,500 

88-8 

0-449 

87-2 

1-83 

11 

86-0 

4400 

1-68 

4070 

811 

6 

63,500 

92-2 

0-432 

87-2 

5-73 

10 

87-4 

3830 

1-99 

4200 

8-81 

2 

63.500 

85-2 

0-468 

87-2 

2-29 

4 

88-8 

4200 

1-88 

4340 

323 

9 

63.500 

85-2 

0-468 

87-2 

2 29 

5 

91-3 

4400 

1-89 

4595 

4-24 

11 

66,900 

86-0 

0-472 

88-8 

3-15 

6 

92-2 

4200 

2 02 

4680 

10-26 

5 

69,100 

91-3 

0-449 

89  8 

1-67 

8 

92-2 

4890 

1-74 

' 4680 

4-49 

3 

74.600 

93-2 

0-451 

92-1 

119 

3 

93-2 

4660 

1-86 

4780 

2-51 

7 

77,400 

96-4 

0-442 

932 

3-43 

12 

95  2 

5140 

1-76 

4990 

301 

8 

81,000 

92-2 

0-469 

! 94  6 

4 65 

1 

961 

5130 

1-80 

1 5090 

0-79 

12 

81,100 

95-2 

0-454 

94-7 

0-53 

7 

96  4 

4800 

1-94 

5110 

6-07 

1 

1 88,800 

96-1 

0-464 

97-6 

1-54 

Avera 

ige  .. 

1-84 

5-80 

Average  ... 

0-457 

1 - 

2-62 

0-457. 

0-457  is  the  average  constant  for  the  16  individual  observa- 
tions. The  percentage  deviations  of  the  observed  from  the 
calculated  circumference  of  chest  are  also  given. 

It  is  clear  that  the  chest  constant  shows  no  periodic 
variations,  but  only  such  irregularities  as  depend  on  indi- 
vidual differences.  The  average  percentage  deviation  of 
observation  from  calculation  is  only  2 -62 -a  difference  some- 
what smaller  than  that  found  by  Walker  in  calculating  the 
stem  length  from  the  weight.  The  mean  deviation  of 
observation  from  calculation,  as  determined  by  the  method 
of  least  squares,  is  found  to  be  3 25,  which  indicates  that  if 
an  individual  be  found  to  differ  by  about  6 per  cent,  from 
the  normal  chest  measure  for  his  weight  he  is  probably 
abnormal  in  this  respect  ; and  if  he  exhibit  a chest  measure- 
ment 12  per  cent,  smaller  or  larger  than  the  theoretical  he  is 
almost  certainly  abnormal.  Hence  it  follows  that  the  formula 

— K where  the  power  n is  approximately  j,  expresses  the 
Ch.  ' 

relationship  between  body  weight  and  circumference  of  chest 
in  an  extremely  satisfactory  manner. 

If  from  the  data  given  in  Table  I.  we  calculate  the  average 
constant  for  stem  length  and  weight  by  means  of  the  formula 

W*|  _ K it  is  found  to  be  0 449.  If  we  use  this  constant 

inX  calculating  the  stem  length  from  the  weight  by  the 

formula  X = the  average  percentage  deviation  of 

observation  from  calculation  is  2 58,  while  the  mean  per- 
centage deviation  by  the  method  of  least  squares  is  3 21— or 
practically  identical  with  those  deviations  aoove  mentioned 
where  the  chest  measurement  was  calculated  from  tbe 

^From  the  constants  found  in  the  two  cases- viz..  0 457  (in 
case  of  the  chest  measurement)  and  0 449  (in  case  of  th 


The  Lancet,] 


PROK.  G.  DRBYER  : TIIE  NORMAL  VITAL  CAPACITY  IN  MAN.  [Augusi  9,  1919  231 


stem  length) — it  follows  that  in  the  normal  healthy  man  the 
circumference  of  chest  is,  on  an  average,  about  15  per  cent, 
smaller  than  the  stem  length,  though  in  a fair  number  of  the 
individual  cases  the  chest  measurement  may  be  greater  than 
the  stem  length. 


The  Relationship  between  Stem  Length , Ciroumferenoe  of 
Chest , and  Vital  Capacity. 

From  what  has  been  said  above  with  regard  to  the  relation- 
ships of  the  vital  capacity  to  stem  length  and  chest  measure- 
ment, and  their  relationships  to  body  weight,  it  follows  that 


X |=  k.  In  Table  X. 

Table  X. 

(A)  Vital  capacity  observed 
(o.cm.). 

(B)  Constant : K = 

(C)  Vital  capacity  calculated  : 


(D)  Difference  between  vital 
capacity  calculated  and 
. observed  (per  cent.). 


this  constant  is  calculated  from 

Table  XI. 

(A)  Body  weight  (g.). 

(B)  A x Cb.  observed.  , 

W 9 

(C)  Constant : K = - 

\ X Ch. 

(D)  A x Ch.  calculated  : , 

TO3 

A x Ch-  = 0 21 

(E)  Difference  between  A x Ch. 
calculated  and  observed  (per 
cent.). 


No. 

(A) 

<B) 

(C) 

(D) 

No. 

(A) 

(B) 

(C) 

(D) 

(E) 

16 

2330 

2-07 

2610 

10-75 

16 

29,800 

4826 

0-199 

4579 

5-40 

15 

2840 

1-91 

2930 

5-07 

15 

38,900 

5438 

0-211 

5467 

0-53 

14 

3030 

1-96 

3215 

5-75 

14 

41,200 

5944 

0-201 

5677 

4-70 

10 

3830 

1-99 

4110 

6-81 

10 

56,300 

7604 

0-193 

7329 

3 75 

13 

3800 

1-86 

3815 

0-39 

13 

58,600 

7044 

0-214 

7186 

1-98 

4 

4200 

1-80 

4080 

2-94 

4 

63,500 

7548 

0-211 

7582 

0-45 

6 

4200 

1-98 

4500 

6-67 

6 

63,500 

8316 

0 191 

7582 

9-68 

2 

4440 

1-77 

4240 

3'77 

2 

63,500 

7838 

0-203 

7582 

3-24 

9 

4160 

1-80 

4050 

2-72 

9 

63,500 

7497 

0-212 

7582 

112 

11 

4400 

1-73 

4110 

7-06 

11 

66,900 

7826 

0-211 

7849 

029 

5 

44C0 

1-79 

4245 

3-65 

5 

69,100 

7852 

0-215 

8020 

2-09 

3 

4660 

1-90 

4800 

2-92 

3 

74,600 

8872 

0-200 

8439 

5-13 

7 

4800 

1-84 

4770 

0-63 

7 

77,400 

8821 

0 206 

8649 

1-99 

8 

4890 

1-80 

4750 

2-95 

8 

81,000 

8796 

0-213 

8916 

1-35 

12 

5140 

1-67 

4630 

11-01 

12 

81,100 

8568 

0-219 

8925 

4-00 

1 

5130 

1-85 

5130 

o-oo 

1 

88,800 

9465 

0210 

9477 

0-13 

Average... 

1-85 

4-44 

Average  ... 

0-210 

2-74 

the  individual  data  given  in  Table  I.  The  average  constant 
is  1 85,  and  by  means  of  this  constant  the  vital  capacity  is 

calculated  from  the  formula  V.C.  = * _ ' , as  well  as  the 


percentage  deviation  of  observed  from  calculated  figures. 
The  average  percentage  deviation  is  found  to  be  only  4 44, 
as  compared  with  5-76  and  5 80  if  the  vital  capacity  were 
calculated  from  the  stem  length  and  the  circumference  of 
chest  respectively. 

That  the  agreement  between  observation  and  calculation 
is  improved  by  taking  into  account  both  stem  length  and 
chest  measurement  was  a priori  to  be  expected,  as  we  are 
making  use  of  two  dimensions  instead  of  one.  Moreover, 
the  two  measures  often  tend  to  correct  each  other,  If,  for 
instance,  a person  is  found  to  have  too  big  a stem 
length  in  proportion  to  his  weight,  the  circumference  of 
chest  is  usually  too  small  in  proportion  to  weight.  We  see, 
therefore,  that  the  errors  thus  introduced  will  be  partly,  and 
sometimes  entirely,  eliminated  by  taking  both  measurements 
into  account. 

From*  the  various  formulas  already  given,  it  follows 


directly  that 


W» 


= K where  the  power  n is  approxi- 


A X Ch. 

mately  §.  That  this  is  the  case  will  be  seen  from 

W* 

as  calculated 


Table  XI.  where  the  constant  K — 

A x Ch. 

from  the  data  in  Table  I.  Ax  Ch.  is  also  here  calculated 

WS 


from  the  formula  A x Ch.  = 


0-21 


-,  as  well  as  the  per- 


centage difference  between  A X Ch.  observed  and  A X Ch. 
calculated.  The  percentage  deviation  of  observation  from 
calculation  is  found  to  be  2-74— or  only  slightly  greater 
than  when  the  stem  length  or  the  chest  measurement 
individually  are  calculated  from  the  body  weight. 


Though  the  relationships  here  shown  to  exist  in  normal  man 
between  vital  capacity,  body  weight,  stem  length,  and  chest 
measurement  are  all  rational  relationships,  there  can  be  no 
question  that  the  most  aeourate  manner  in  which  to  express  the 
vital  capacity  is  as  a function  of  the  body  surface , by  means  of 


the  formula 


Wn 

VC. 


— K,  where  n is  approximately  J,  or , more 


accurately , 0 72. 

The  importance  and  utility  of  the  other  relationships  at 
once  become  obvious  when  one  begins  to  deal  with  indi- 
viduals whose  weight  has  become  abnormal  as  a result  of 
disease — as,  for  example,  in  the  study  of  the  effect  of  pul- 
monary tuberculosis  and  other  diseases  definitely  resulting 
in  emaciation  on  vital  capacity.  For  it  is  evident  that  with 
loss  of  weight  a vital  capacity  which  was  definitely  abnormal 
when  calculated  in  relation  to  the  normal  weight  of  the 
person  might  appear  normal  if  calculated  in  relation  to  the 
reduced  weight  found  during  disease,  whereas  no  such  inter- 
ference with  the  size  of  the  constant  would  take  place  if  the 
vital  capacity  were  calculated  in  relation  to  stem  length,  and 
only  to  a small  extent  if  calculated  in  relation  to  circum- 
ference of  chest. 

By  taking  all  three  relationships  into  account  information 
is  therefore  gained  not  only  as  regards  the  vital  capacity, 
but  also  as  regards  the  condition  of  weight,  whether  it  be 
increased  or  decreased  beyond  the  normal  measure. 


Hutchinson’s  Observations  Compared  with  the 
Foregoing  Results. 


Before  dealing  any  further  with  my  own  observations, 
which  have  led  to  conclusions  so  contrary  to  those  of 
Hutchinson,  it  is  important  to  consider  his  observations,  as 
well  as  those  of  others,  in  the  light  of  what  has  been  said 
above.  I have  already  given  in  a previous  paragraph  the 
conclusions  at  which  Hutchinson  arrived.  I shall  now 
proceed  to  show  not  only  that  his  observations  entirely 
bear  out  my  own  results,  but  also  to  point  out  why  he  arrived 
at  some  of  his  own  erroneous  conclusions. 

Table  XII.  is  a reprint  of  Table  E (p.  163)  in  Hutchinson’s 
paper,  where  the  results  of  his  observations  on  the  vital 
capacity  of  1285  men  are  arranged,  the  grouping  being 
according  to  weight,  but  at  the  same  time  keeping  the  height 
in  view.  It  is  at  once  seen  that  the  vital  capacity  seems  to 
increase  to  a maximum  at  the  weight  of  1501b.,  and  then  to 
become  stationary,  or  even  decrease.  He  concludes  himself  : 
"It  seems  the  vital  capacity  increases  42  cubic  inches  with 
the  weight  from  100  to  155  lb.,  and  from  155  to  200  lb.,  the 
effect  is  balanced  by  minus  5 and  plus  5 cubic  inches.” 

It  was  of  interest  and  importance  to  examine  this  marked 
discrepancy  between  the  results  obtained  in  my  own  observa- 
tions, and  the  mean  of  results  obtained  by  Hutchinson  in 
observing  such  a large  number  of  people,  and  to  find  out 
whether  the  discrepancy  was  real  or  only  apparent.  By 
analysis  of  the  data  given  in  Table  D (p.  162)  in 
Hutchinson’s  paper,  from  which  he  himself  had  constructed 
the  table  reprinted  above,  it  soon  became  evident  that  the 
reason  why  he  reached  results  so  absolutely  contrary  to  those 
which  I have  obtained  was  the  manner  in  which  he  arrived 
at  his  average  vital  capacity  for  each  given  weight.  The 
fact  is  that  he  entirely  disregarded  the  number  of  individuals 
in  each  of  the  series  from  which  he  was  making  up  his 
groups  ; in  other  words,  in  arriving  at  the  average  vital 
capacity  for  the  group,  if  he  has  a single  case  with  a very 
small  vital  capacity,  he  gives  the  same  value  to  this  as  to  50 
or  more  cases  which  have  a large  vital  capacity,  or  vice  versa. 
Such  a procedure  naturally  leads  not  only  to  marked 
irregularities,  but  to  definite  errors  in  the  estimation  of  the 
proper  relationship  between  vital  capacity  and  body  weight. 

To  prove  this  point,  Table  XIII.  has  been  constructed  . 
from  Hutchinson’s  Table  D (p.  163),  and  here  due  considera- 
tion has  been  given  to  the  number  of  cases  in  each  series  in 
arriving  at  the  average  vital  capacity  for  each  group.  In 
the  same  table  are  also  given  the  values  for  the  constant  K 


■w 


in  the  formula  y-jj  = K,  as  well  as  the  vital  capacity 


expressed  in  percentage  of  body  weight. 

It  is  seen  that  the  vital  capacity  increases  gradually 
and  steadily  from  the  lowest  to  the  highest  weight.  There 
i»,  in  fact,  no  evidence  whatever  that  from  a weight  of 
150  lb.  upwards  the  vital  capacity  becomes  stationary  or 
decreases,  as  appears  to  be  the  case  from  Hutchinson’s 


232  LAVOBT,]  I’R9F  G.  DREYER:  THU  NORMAL  VITAL  CAPACITY  IN  MAN. 


f Auoijst  P,  1919 


Table  XII.  abjve.  It  is  therefore  ouvmus  tint  his  oOserva- 
tions  are  so  far  entirely  in  agreement  with  my  own.  From 
Table  XIII.  it  is  also  seen  that  if  the  vital  capacity  be 
expressed  in  percentage  of  body  weight,  there  is  a steady 
and  regular  decrease  in  the  percentage  as  the  weight 
increases,?  falling  from  1 63  per  cent,  in  the  lightest,  to 

Table  XIII. 

(A'  Number  of  individuals  in  group. 

( B)  Body  weight  db.). 

(C)  Vital  capacity  observed  (cubic  inches). 

(D)  Constant : K = 


V.C. 


yfl 


Table  XU. 

(A)  Body  weight 
(Ih.j 

(B)  Vital  oapv 
city  (cubic 
inches). 


(B)  Vital  capacity  calculated  : V.C.  = — - ■ 

0 1 jO 

(Fj  Difference  between  vital  capacity  calculated 
and  observed  (per  cent.). 

(G)  Vitil  capacity  as  percentage  of  body  weight. 

(G)  Vital  capacity  calculated  as  per  cent.  ( 1 *47 > of 
body  weight. 

(I)  DilTa'ence  between  vital  capacity  calculated  and 
oa^erved  (per  cent.). 


(A) 

(B) 

(A) 

(B) 

(C) 

(D) 

(B) 

(F) 

<G) 

(H) 

(I) 

no 

181 

63 

no 

179  5 

0-128 

1794 

0 06 

1-63 

161  7 

11-01 

no 

199 

318 

130 

200-0 

0-128 

200-5 

0-25 

1-54 

1911 

4-64 

504 

150 

211  6 

0 127 

220-6 

0-45 

1-48 

220-5 

C-50 

150 

223 

301 

170 

238  6 

0-124 

239-7 

0-46 

1-40 

219-9 

4-52 

170 

218 

9! 

190 

245-6 

0135 

253-3 

4-92 

1-29 

279  3 

1207 

190 

223 

128a 

Average ... 

0 128 

0-72 

1-47 

3-86 

1 29  per  cent,  in  the  heaviest,  group  ; while  if  it  be  expressed 
in  relation  to  the  body  weight  to  the  § power,  the  relation- 
ship is  constant.  Thus  in  Hutchinson' s observations  also  we 
find  thatthe  vital  capacity  is  a function  of  the  surface  of  the  body, 

W» 

correctly  expressed  by  the  formula  y--—  = K,  where  the 

power  n is  approximately  J,  so  proving  from  his  own  data 
and  observations  how  erroneous  was  his  conclusion  that  no 
definite  relationbhip  between  vital  capacity  and  body  weight 
could  exist. 

Furthermore,  in  Table  XIII.  the  vital  capacity  is  calculated 
as  a function  of  the  body  surface  by  means  of  the  formula 

W ‘ 

V.C.  = Q-j— j and  also  as  a simple  function  of  the  body 

weight  from  the  formula  V.C.  = W x 147,  as  well  as  the 
percentage  .difference  between  observation  and  calculation 
by  these  two  procedures.  In  the  first  case  the  average 
percentage  deviation  is  only  0 72,  taking  the  numbers  in  the 
groups  into  consideiation,  while  in  the  latter  case  the 
average  deviation  is  as  much  as  3 86  or  about  five  times  as 
great  as  in  the  former. 

To  take  the  matter  a step  further,  we  will  now  test  the 
validity  of  Hutchinson’s  statement  that  there  exists  a simple 
relationship  between  the  height  of  the  individual  and  his 
vital  capacity.  In  Table  XIV.  are  given  the  average  vital 

Table  XIV. 

(A)  Number  of  individuals  in  group. 

(B)  Standing  height  (inches). 

(C)  Vital  capacity  ob?>erved  ?.s  tabulated  by  Hutchinson  (cubic  inches). 

(D)  Vital  capacity  observed  correctly  tabulated  (cubic  inches). 
tE)  Vital  capacity  calculated  from  height  by  Hutchinson. 

(F)  Difference  between  vital  capacity  calculated  and  observed 
(per  cent.). 


(A) 

(B) 

(C) 

(D) 

(E) 

. (F) 

36 

61 

176  0 

171-7 

174 

1-32 

99 

63 

191-0 

185  6 

190 

2-32 

239 

65 

207  0 

200-2 

206 

282 

697 

67 

2280 

232-2 

222 

4-59 

530 

69 

2410 

238  4 

238 

017 

226 

71 

258  0 

255-0 

254 

0-39 

1827 

Average 

2-37 

capacities  for  Hutchinson’s  observations,  detailed  in  Table  A 
(p.  156),  as  tabulated  by  him  for  heights  ranging  from  5 ft. 
to  6 ft.  inclusive  ; also  the  average  vital  capacities  for  the 
corresponding  heights  arrived  at  by  ray  calculation,  which 
takes  into  account  the  number  of  individuals  in  each  series 
forming  the  groups,  as  should  obviously  be  done.  There  is 


also  given  the  series  ot  vital  capacities  in  arltmuetical 
progression  as  calculated  by  Hutchinson  : and,  finally,  the 
percentage  deviation  of  observation  from  calculation.  It  is 
seen  that,  considering  the  number  of  individuals  in  each 
group,  this  deviation  is  as  much  as  2 37  per  cent.,  which  is 
an  error  more  than  three  times  as  great  as  the  percentage 
difference  found  above  between  observation  and  calculation  ; 
for  when  the  same  data  was  expressed  as  a function  of  the 
body  surface  the  deviation  was  only  0 72  per  cent.  Thus  it 
is  evident  from  Hutchinson’s  observations,  as  well  as  from 
my  own,  that  the  vital  capacity  of  man  is  not  a simple 
function  of  the  body  height,  as  he  contended,  since  it 
increases  in  an  irregular  manner  and  not  at  a fixed  rate  with 
each  unit  increase  in  height. 


The  Variations  of  Vital  Capacity  in  Normal  Individuals. 

Having  once  established  the  actual  existing  relationships 
between  vital  capacity  and  different  body  measurements,  it 
is  necessary  to  determine  the  magnitude  of  the  deviations 
from  the  average  met  with  in  normal  and  healthy  individuals, 
as  it  is  otherwise  impossible  to  decide  whether  the  vital 
capacity  found  in  aoy  given  person  should  be  considered  as 
normal  or  abnormal. 

In  the  case  of  the  16  persons  examined,  the  average 
W» 

constant  in  the  formula  ^ — = K,  was  found  to  be  0 380  if 
1 .o. 


the  power  n he  taken  as  J and  0 690  if  the  best  power,  0 72, 
be  used.  The  mean  deviation  of  observation  from  calculation, 
employing  the  method  of  least  squares,  was  found  in  the  two 
cases  to  be  3 56  and  2 64  per  cent,  respectively,  or  distinctly 
greater  if  the  power  § is  used.  This  indicates  that  if  a 
person  is  found  to  have  a vital  capacity  6 per  cent,  smaller 
or  larger  than  that  calculated  from  his  surface  by  means  of 

the  formula  g-  K,  where  n is  0 72,  it  is  probable  that 


he  has  an  abnormal  vital  capacity,  and  if  the  vital  capacity 
is  10  per  cent,  above  or  below  the  normal  it  is  almost  certain 
that  he  is  abnormal  in  this  respect. 

If  we  deal  with  the  material  of  Haldane  and  FitzGerald  on 
11  men  in  a similar  manner  we  find  that  if  the  vital  capacity 
be  calculated  as  a function  of  the  surface  the  mean  deviation 
by  the  method  of  least  squares  for  the  individual  observa- 
tions are  as  much  as  15  8 per  cent.,  or  a mean  deviation  five 
times  greater  than  that  found  in  my  own  observations.  The 
explanation  of  this  enormous  difference  is  most  likely  to  be 
found  in  the  fact  that  their  observations  have  been  carried 
out  on  a highly  mixed  material,  and  therefore  necessarily 
exhibit  great  individual  variations.  The  existence  of  such 
individual  differences  and  their  causes  is  a factor  of  the 
utmost  importance  in  attempting  to  fix  definite  standard 
limits  of  vital  capacity  in  normal  persons,  as  will  be  shown 
in  the  following  paragraph. 


Variations  of  Vital  Capacity  in  Normal  Individuals  of 
Different  Classes  and  Occupations. 

In  the  course  of  further  observations  on  the  vital  capacity 
in  apparently  normal  persons  of  various  classes  and  positions 
it  became  evident  that  a distinct  variation  was  found  in  the 
vital  capacity  constant,  resulting  upon  the  varying  nature  of 
the  life  and  habits  of  the  indiv  iduals  in  question.  It  was 
therefore  obvious  that  unless  due  attention  were  paid  to 
these  influences  any  fixed  standard  would  become  vitiated 
by  them.  Fortunately,  we  possess  in  Hutchinson’s  carefnl 
observations  a material  which,  when  properly  used,  gives 
us  important  information  with  regard  to  the  value  of  the 
vital  capacity  in  judging  the  physical  fitness  and  develop- 
ment of  different  classes  of  the  population. 

To  demonstrate  this  fact  I have  compiled  and  calculated 
some  1900  cases  from  Hutchinson's  recorded  observations. 
I have  classified  these  men  according  to  their  occupation, 
and  calculated  the  vital  capacity  constant  from  the  formula 


\V: 

— T = K.  The  results  of  the  calculation  are  given 

v . C. 

Table  XV.  Before  calculation  Hutchinson’s  observations, 
recorded  in  pounds  and  cubic  inches,  were  reduced  to 
grammes  and  cubic  centimetres,  the  weight  of  the  body 
being  the  net  weight  without  clothing.  From  the  construc- 
tion of  the  formula  it  is  obvious  that  the  larger  the  constant 
the  smaller  the  vital  capacity  for  any  given  weight.  The 
classes  are  arranged  according  to  vital  capacity,  that  with 
the  highest  vital  capacity  heading  the  list,  and  the  remainder 
being  graded  in  order  of  decreasing  rate. 


Thu  Lancet,] 


PROF.  G DRKYEB:  THE  NOKM  VL  VITAL  CAPACITY  IN  MAN.  [August  9,  1919  23:3 


Table  XV. 


A)  Number  of  Individuals  In  group,  o 
W5 

(B)  Vital  capacity  constant : K = y ,7 
(0)  Physical  titnoss  (per  cent.). 


(A) 

Occupation. 

(B) 

(C) 

(A) 

Occupation. 

(B) 

(C) 

172 

Chatham  recruits. 

0-412 

100-0 

69 

Grenadier  Guards. 

0-441 

93-4 

27 

Pugilists. 

0 420 

98  1 

20 

Draymen. 

0-413 

93  0 

563 

Woolwich  marines. 

0-425 

96-9 

23 

Pressmen. 

0-450 

91  5 

119 

Seamen. 

0-426 

96-7 

168 

Mixed  classes. 

0-455 

90  4 

74 

Thames  police. 

0-427 

96  4 

82 

Miscellaneous. 

0-458 

899 

30 

Horse  Guards. 

0-433 

95-1 

47 

Compositors. 

0-467 

88-1 

130 

Metropolitan 

police. 

0-434 

94  8 

101 

Gentlemen. 

0-488 

84-3 

92 

Fire  brigade. 

0 439 

93-7 

116 

Paupers. 

0-499 

825 

It  is  seen  that  Hutchinson’s  “Chatham  Recruits” 
represent  the  best  class,  and  it  is  interesting  to  note  that 
he  himself  characterises  these  individuals  as  “a  remarkably 
fine  body  of  young  men.”  Taking  the  constant  calculated 
from  this  group  of  men  as  representing  100  per  cent,  of 
physical  fitness,  the  fitness  of  the  other  classes  appears  in 
the  table  in  percentage  of  this  class.  It  is  noted  that  the 
percentage  falls  steadily  from  100  per  cent,  in  the  best  class 
in  a way  that  might  be  expected  from  the  nature  of  the 
occupations  of  the  different  groups,  until  we  come  to  paupers, 
with  about  20  per  cent,  less  vital  capacity  than  the  best 
group.  It  will  be  observed,  probably  with  some  astonish- 
ment, how  very  low  is  the  position  taken  in  this  respect  by 
the  cla-s  of  gentlemen  in  1846 — a fact  doubtless  connected 
with  the  life  and  habits  of  gentlemen  in  London  at  that 
date. 

Table  XV.  indicates  that  it  would  appear  promising  to 
make  use  of  the  vital  capacity  in  its  proper  relation  to  the 
size  of  the  body  to  obtain  important  knowledge  regarding 
the  physical  condition  of  the  various  classes  of  the  popula- 
tion, and  to  express  this  in  relation  to  the  standard  of 
perfect  health. 

In  Table  XVI.  I hive  arranged  my  own  observations  of  a 
few  classes  of  the  people  of  the  present  day.  Here  al-o  the 


constant  is  calculated  from  the  formula 


W® 

-TT7Y  = K,  the 

V .C. 


weight  is  net  weight  in  grammes,  without  clothing,  and  the 
vital  capacity  expressed  in  cubic  centimetres.  The  constants 


Table  XVI. 


A)  Numbers  of  individuals  in  g 
(B)  Vital  capacity  constant : K 


Ws 

"vTcT 


(C)  Physical  fitness  (per  cent.). 


(A) 

Occupation. 

(B) 

(C) 

16 

vien  and  adolescents  selected  for  physical 
fitness S 

0 380 

1083 

14 

Oxford  undergraduates  (own). 

0-380 

10S-3 

959 

„ ,,  (Schustei’s). 

0-381 

108  1 

7 

Boy  Seouts. 

0-390 

105-7 

12 

Men  (mixed  upper  elass). 

0-416 

990 

12 

,,  ( ,,  lower  .,,  ). 

0-445 

92-6 

12 

Females  (mixed  classes). 

0-493 

83-6 

are  therefore  directly  comparable  with  those  in  the  above 
table,  and  the  percentages  were  expressed  in  percentages  of 
Hutchinson’s  “ Chatham  Recruits,”  equalling  100  percent, 
of  fitness. 

It  is  most  interesting  to  observe  from  this  table  ho  w the 
active,  athletic  class  of  gentlemen  of  the  present  day  heads 
the  group  of  my  own  observations  with  actually  9 per  cent, 
more  relative  fitness  than  the  above-mentioned  “ remarkably 
fine  holy  of  young  men.” 

From  observations  that  I have  made  it  seems  clear  that 
the  difference  in  vital  capacity  exhibited  by  different  classes 
has  nothing  to  do  with  fundamental  bodily  deficiencies,  but  is 
simply  a result  of  conditions  depending  upon  occupation  and 
mode  of  life.  Taking,  for  example,  two  sets  of  boys  from 
the  same  elementary  school,  from  similar  homes  and  living 
uuder  similar  conditions — -with  the  exception,  however, 
that  one  of  the  two  sets  of  boys  were  Boy  Scouts— it  was 


found  that  the  latter  had,  on  an  average,  a vital  capacity 
constant  approaching  the  magnitude  of  that  found  in  Oxford 
undergraduates,  and  exhibited  a vital  capacity  of  about 
15  per  cent,  greater  than  that  of  the  lads  who  were 
not  Boy  Scouts.  The  army  training  has  brought  out, 
in  those  who  have  undergone  it,  the  same  marked 
increase  in  vital  capacity  when  they  are  compared  with 
similar  classes  of  the  population  who  have  not  had  this 
physical  training. 


The  Fixing  of  Standards  of  Normal  Vital  Capacity. 

From  a comparison  of  the  results  obtained  on  the  limited 
number  of  individuals  hitherto  examined  sufficient  informa- 
tion has  been  gathered  to  make  it  clear  that  it  would  not  be 
justifiable  to  employ  the  data  collected  by  Hntchinson  for 
the  fixing  of  standards  for  the  different  classes  of  the  popu- 
lation at  the  ])  'esent  date.  Before  definite  and  vadd 
standards  can  be  arrived  at  it  is  inevitable  that  a relatively 
large  number  of  subjects  drawn  from  the  different  classes 
and  trades  of  the  population  must  ue  examined  in  regard  to 
vital  capacity  and  various  body  measurements.  To  help  to 
carry  out  this  extensive  scheme  the  Medical  Research 
Committee  have  already  undertaken  to  give  financial 
aid,  and  it  is  hoped  that  this  inquiry  may  take  its 
place  in  a larger  scheme  for  the  study  of  anthropometric 
standards. 

At  the  present  moment  I can  only  consider  the  standard 
fixed  from  the  examination  of  Oxford  undergraduates  as  an 
accurate  standard  for  this  particular  class  of" population.  The 
average  constants  arrived  at  from  my  own  observations  upon 

W0'72 

14  Oxford  undergraduates  were  as  follows  : — — — = 0 69  ; 


A2 

v.o. 


19 ; 


Ch.2 

V7c. 


1-82. 


Before  accepting  these  constants,  obtained  from  a very 
limited  number  of  observations,  as  valid  standards  it 
became  important  to  see  how  they  would  compare  with  the 
constants  that  could  be  obtained  from  calculation  of 
Schuster’s  extensive  series  of  measurements  of  vital  capacity 
in  959  Oxford  undergraduates.  In  Table  XVII.  I have 


(cL)  Number  of 
group. 

(B)  Bidy  weight  (g.). 

(C)  Stem  length  (cm.). 
(U;  Vital  capacity  (c.em.). 


(E)  Constant : K = y jj 

yyii-72 

(F)  Constant : K = y ^ 

\2 

(G)  Constant:  K =.  y 77 


Table  XVII. 

individuals 


(A) 

Age. 

(B) 

(C) 

(D) 

(E). 

(F) 

(S) 

129 

18 

64,210 

88-5 

4184 

0383 

0-691 

1-87 

29 

20 

66,100 

90-4 

4268 

0-383 

0 691 

1 91 

59 

23 

66,100 

90-4 

44.8 

0370 

0 669 

1-85 

330 

19 

66.240 

90-5 

4278 

• 0-383 

0-691 

1 92 

95 

22 

66,480 

90-4 

4301 

0-381 

0-689 

1-90 

137 

21 

68,000 

911 

4438 

0-375 

0-679 

1-87 

Average  

0-381 

0-690 

1-90 

made  an  abstract  from  Schuster’s  data.  The  weights  are 
net  weights  in  grammes,  arrived  at  by  the  subtraction  of 
the  weight  of  clothing,  using  the  proper  reduction  factor  ; 
the  stem  lengths  in  centimetres  are  the  stem  lengths 
recorded  by  Schuster,  reduced  by  3 per  eent.  This  reduc- 
tion is  necessary  to  make  the  measurements  comparable 
with  my  own  observations,  for  it  was  found,  as  previously 
stated,  that  the  measurement  obtained  by  seating  a person 
on  a chair  is  about  3 per  cent,  greater  than  that  obtained 
by  measuring  the  stem  length  in  the  manner  used  in  my 
own  observations.  The  vital  capacities  are  given  in  cubic 
centimetres. 

In  this  table  is  calculated  the  constant  K,  by  means  of 


W n • i 

the  formula  CF-  = K,  both  when  the  power  n is  taken  as 
§ and  when  the  best  n (0  72)  is  used,  as  well  as  the  K 
for  the  formula  = K.  The  constants  found  are 

I 0~i 

= 0 381 ; W_!H'  — 0-690  ; = 190.  It  is  striking 

V.C.  V.O.  VO. 

to  see  that  the  constants  arrived  at  by  an  analysis  of  this 


234  The  Lancet,] 


DR.  G.  E.  BEAUMONT:  THE  ETIOLOGY  OF  INFLUENZA. 


[August  9,  1919 


extensive  series  of  careful  observations  of  959  Oxford  under- 
graduates are  absolutely  identical  with  those  found  in  my 
own  very  limited  number,  and  also  the  same  as  those 
obtained  in  the  16  observations  on  persons  selected  for  their 
physical  fitness.  In  view  of  this  fact,  therefore,  it  seems 
entirely  justifiable  to  accept  these  standards  as  true 
standards  for  the  measurement  of  a condition  of  the  most 
perfect  health  and  fitness  at  the  present  time. 

Vital  Ca, parity  in  Relation  to  Diagnosis  of  Disease. 

Since  the  vital  capacity  has  been  shown  to  exhibit  such 
marked  variations  in  the  different  classes  of  the  population, 
depending  upon  their  mode  of  life,  and  has  also  been  shown 
during  the  war  to  be  influenced  by  the  strain  on  flying  men 
(continued  flying  in  high  altitudes  resulting  in  a temporary 
diminution  of  vital  capacity),  it  is  likely  that  various  forms 
of  fatigue  would  be  found  to  influence  it  in  the  same  manner. 
If  this  be  the  case  it  is  probable  that  certain  diseased*fcon- 
ditions,  more  particularly  of  the  respiratory  and  circulatory 
organs,  would  lead  to  a distinct  diminution  in  the  vital 
capacity.  One’s  mind  naturally  turns  at  once  to  the 
question  of  the  effect  of  pulmonary  tuberculosis  on  vital 
capacity.  This  application  is  not  novel,  as  already  in  1846 
Hutchinson  had  made  use  of  the  study  of  vital  capacity  as  a 
help  in  diagnosis  of  diseases  of  the  lungs — more  particularly 
tuberculosis.  He  showed  that  cases  of  pulmonary  tubercu- 
losis exhibited  a vital  capacity  distinctly  inferior  to  what 
he  considered  normal,  judging  from  the  height  of  the 
individual. 

From  what  has  already  been  said  it  is  self-evident  that  it 
is  impossible  to  deduce  valuable  conclusions  regarding  the 
effect  of  disease  on  vital  capacity  before  definite  standards 
have  been  worked  out  for  the  various  classes  of  the  normal 
population.  By  means,  however,  of  a few  undoubtedly  fairly 
accurate  standards  so  far  arrived  at  it  has  been  possible  to 
approach  the  study  of  the  effect  of  pulmonary  tuberculosis 
on  vital  capacity.  And  although  it  would  be  premature  at 
the  present  moment  to  express  a final  opinion  as  regards  the 
value  of  this  method,  it  can  already  be  stated  that  it  has 
yielded  very  promising  results  in  the  examination  of  about 
150  cases  of  pulmonary  tuberculosis  which  I myself  have  dealt 
with  in  collaboration  with  Dr.  L.  S.T.  Burrell,  of  the  Brompton 
Hospital.  The  particulars  of  the  results  obtained  will  be 
published  in  detail  when  sufficient  material  has  been  collected 
and  analysed.  At  the  present  moment  I can  only  state  the 
following  : that  I have  been  able,  without  seeing  the  cases 
or  knowing  anything  about  the  diagnosis,  but  simply  from 
measurements  (recorded  and  sent  to  me  by  Dr.  Burrell)  of 
the  vital  capacity  and  the  various  body  measurements  men- 
tioned above  and  by  subsequent  calculation,  to  classify  these 
persons  as  normal  individuals,  or  as  examples  of  mild,  of 
moderate,  or  of  severe  pulmonary  tuberculosis,  in  practically 
absolute  agreement,  as  afterwards  appeared,  with  the  clinical 
diagnosis  and  classification  made  at  the  time  at  the  Brompton 
Hospital. 

From  the  experience  already  gained  it  seems  likely  that  the 
careful  study  of  the  vital  capacity  in  its  proper  relationship 
to  body  size  will  give  important  information  as  to  the  bene- 
ficial effects  derived  from  sanatorium  treatment  of  pulmonary 
tuberculosis,  and  also  enable  us  to  distinguish  between  those 
cases  likely  to  benefit  from  continued  treatment  and  those  for 
whom  it  would  be  of  no  further  profit. 

Conclusion. 

From  a consideration  of  the  results  arrived  at  in  the 
present  communication  it  seems  likely  that  systematic 
measurement  of  the  “vital  capacity”  and  various  body 
measures  indicated  above,  in  adults  and  adolescents  in 
different  trades  and  occupations,  and  in  different  ranks  of 
life,  will  afford  most  important  information  from  the  point  of 
view  of  national  health,  and  will  throw  light  upon  the  value 
of  such  measures  as  may  be  contemplated  for  the  improve- 
ment of  the  general  health  and  well-being  of  the  people  of 
this  and  other  countries. 

References. 

1.  Hutchinson,  John  : On  the  Capacity  of  the  Lungs  and  on  the 
Respiratory  Functions.  Ac.,  Medico-Chlrurgical  Transactions,  xxlx., 
1846,  London,  p.  137.  Tint  Lancet,  vol.  i.,  1846,  p.  630. 

2.  Walker,  Ainley  E.  W.  : The  Growth  of  the  Body  in  Man.  the 
Kelatlonship  between  the  Body  Weight  and  the  Body  Length  (Stem 
Length),  Proc.  Roy.  Soc.,  R.,  vol.  lxxxix.,  1915,  p.  157 

3.  Fitzgerald,  Purefoy  M.,  and  Haldane.  J.  S.  : The  Normal  Alveolar 
Carbonic  Acid  Pressure  in  Man,  Journal  of  Physiology,  vol.  xxxli., 
1905,  p.  486. 

4.  Schuster,  E. : First  Results  from  the  Oxford  Anthropometric 
Laboratory,  Biometrika,  vol.  viii..  Nos.  1 and  2,  1911,  p.  40. 


THE  /ETIOLOGY  OF  INFLUENZA. 

By  G.  E.  BEAUMONT,  M.A.,  B.M.  Oxon.,  M.R.C.P., 
D.P.H.  Lond., 

TEMPORARY  ASSISTANT  PHYSICIAN,  METROPOLITAN  HOSPITAL,  E.  ; 
RAPCLIFFE  TRAVELLING  FELLOW,  UNIVERSITY  OF  OXFORD; 
TEMPORARY  CAPTAIN,  R.A.M.C. 


The  following  is  a section  of  a longer  article  dealing  with 
influenza  from  the  point  of  view  of  clinical  signs  and 
symptoms,  and  describing  the  results  obtained  by  various 
therapeutic  methods. 

VEtiology  of  the  Disease. 

The  cause  of  the  disease  will  be  discovered  in  the 
laboratory.  Clinical  observations  enable  one  to  diagnose  it 
in  the  great  majority  of  instances,  but  until  the  infective 
agent  is  described  and  uncontrovertibly  recognised  as  such, 
diagnosis  of  obscure  cases  will  Femain  doubtful. 

In  respect  of  influenza,  bacteriologists  are  divisible  into 
two  classes — those  who  believe  in  the  Pfeiffer  concept,  and 
the  rest.  At  the  commencement  of  this  epidemic  the 
generally  accepted  view  was  that  Pfeiffer’s  bacillus  is  the 
cause  of  influenza,  and  it  is  interesting  to  see  what  has 
arisen  to  shake  one’s  confidence  in  this  orthodoxy. 

Pfeiffer,1  in  January,  1892,  described  a bacillus  as  occurring 
in  the  sputum  of  acute  cases  of  influenza.  These  organisms, 
he  stated,  were  constantly  present,  but  do  not  occur  in  the 
bronchial  secretion  of  other  bronchial  or  pulmonary  affec- 
tions. The  bacillus  has  the  following  characteristics : It  is 
very  minute,  about  half  the  length,  and  the  same  thickness 
as  the  bacilli  of  Koch’s  mouse  septicaemia.  It  is  non-motile. 
It  stains  with  difficulty  with  the  aniline  dyes,  but  when 
stained  shows  a granule  at  each  end  retaining  the  stain  and 
a central  unstained  portion,  showing  only  the  outline  of  the 
sheath.  The  bacillus  thus  looks  like  a diplococcus,  and 
where  two  such  bacilli  are  placed  end  to  end  they  look  like 
a chain  of  four  spherical  cocci. 

Kitasato  in  the  same  paper  describes  the  cultural  charac- 
teristics of  the  bacillus.  It  does  not  grow  below  28=  C.  It 
grows  well  in  broth  and  on  glycerine  agar  at  37°  C.  The 
growth  in  broth  appears  as  whitish  small  granules  or 
flocculi,  and  the  broth  does  not  become  turbid.  The  cultures 
soon  die  out — stained  specimens  from  the  cultures  show  the 
same  bi-polar  staining. 

Pfeiffer  later  showed  that  the  addition  of  blood  to  the 
culture  medium  greatly  enhances  the  growth  of  the  bacillus 
— especially  on  subcultures,  and  for  this  purpose  smeared 
blood  over  the  surface  of  the  agar  medium. 

Klein  2 examined  films  of  sputum  in  20  cases  of  influenza, 
during  February  and  March,  1892.  and  found  the  bacillus  of 
Pfeiffer  present  in  every  case.  The  films  were  stained  with 
carbol  methyl  blue.  The  organism  was  a minute  bacillus 
(0*4  /a  x 0*8  /a ) , with  rounded  ends  and  bi-polar  staining. 
From  washed  sputum  pure  cultures  were  obtained  in  broth, 
and  if  subcultures  were  made  every  two  or  three  days,  the 
growth  could  apparently  be  carried  on  indefinitely.  Growth 
was  also  obtained  on  ordinary  agar,  and  subcultures  for  as 
many  as  20  generations  obtained. 

Films  made  from  the  cultures  showed  the  bacilli  growing 
in  long  twisted  threals  or  chains,  the  bacilli  being  placed 
end  to  end  and  enclosed  in  a continuous  sheath.  In  all 
specimens,  no  matter  how  recent,  spherical  or  oval  bulli 
appear,  many  times  thicker  than  the  typical  bacillus.  The 
number  of  these  spheres  is  greater  in  later  than  in  recent 
cultures  and  the  largest  of  them  often  show  a vacuole  in 
their  centre  or  at  one  side.  . 

Canon,  at  the  same  time  as  Pfeiffer  and  Kitasato  and  in 
the  same  paper  (vide  Pfeiffer1),  stated  that  he  examined 
influenzal  blood  by  making  cover-slip  films.  The  films  were 
dried,  fixed  in  absolute  alcohol,  and  stained  in  methyl  blue 
eosin  for  several  hours  at  37®  C.  He  states  that  in  every  case 
he  saw  5 to  20  bacilli  in  each  cover-slip  film,  and  these  bacilli 
■were  definite  and  pathognomonic  of  the  disease.  Further, 
he  states  that  by  using  8 to  12  drops  of  blood  he  succeeded  in 
everv  case  in  growing  the  bacillus  on  sugar  agar. 

Klein  2 examined  43  cases,  and  only  found  bacilli  in  cover- 
glass  blood  films  in  six  of  these.  The  bacilli  had  the  charac- 
teristics of  Pfeiffer’s  bacillus,  but  in  no  case  was  a growth 
obtained  on  subculture.  He  concludes  that  “any  bacilli  of 
influenza  that  may  gain  access  to  the  circulation  lose  here 
their  vitality  and  are  present  in  the  blood  only  as  dead 
bacilli.” 

Klein  also  performed  animal  inoculation  experiments, 
using  sputum  containing  Pfeiffer’s  bacilli,  and  broth  cultures 
of  the  bacilli  as  the  inoculum.  Rabbits  and  monkeys  were 
injected,  but  although  the  subcutaneous,  intravenous,  and 
intratracheal  routes  were  employed,  in  no  case  was  the 
disease  reproduced.  The  position  at  the  commencement 
of  the  present  epidemic  was  therefore  this— a bacillus 


The  Lanoet,] 


DR.  G.  E.  BEAUMONT  : THE  7ETIOLOGY  OF  INFLUENZA. 


[August  9,  1919  2.35 


was  described  which  was  found  in  the  sputum  in  overy 
acute  case  of  influenza ; it  was  also  seen  in  the  blood 
in  a certain  number  of  cases.  Attempts  to  reproduce  the 
disease  in  animals  by  injecting  the  bacillus  had  failed.  It 
was  generally  considered  that  the  bacillus  was  only  seen  in 
material  obtained  from  patients  suffering  from  influenza. 

Now  one  may  say  that  there  is  considerable  doubt  as  to 
whether  Pfeiffer’s  bacillus  is  the  cause  of  influenza.  Many 
papers  have  been  published  by  workers  in  Europe  on  the 
bacteriology  of  influenza  during  the  present  epidemic,  and 
their  results  are  by  no  means  concordant.  The  examinations 
comprise  those  of  posterior  nasal  swabs,  sputum,  pleural 
effusions,  blood,  and  post-mortem  materials — chiefly  lungs 
and  lymphatic  glands.  The  results  of  these  investigations 
are  shown  below. 

Posterior  Nasal  Swabs. 

In  the  following  table  (I.)  accounts  of  the  experiments  of 
eight  different  observers  have  been  noted,  and  from  the 
results  shown  it  will  be  seen  that  Pfeiffer’s  bacillus  or  a 
diplococcus  has  been  obtained. 


Table  I. 


Observer. 

No.  of 
cases. 

Pfeiffer’s 

bacillus 

found. 

Cocci. 

Abrahams,  Hallows,  and  French  3 ... 

10 

Per  cent. 
50 

Per  cent. 
100 

Whittingham  and  Sims4  

£0 

38 

100 

Braxton  Hicks  and  Gray  5 

p 

80 

100 

Little,  Garofalo,  and  Williams6 

20 

0 

100 

Averil,  Young,  and  Griffiths7  

16 

0 

100 

Matthews  8 

12 

100 

100 

McIntosh  9 

12 

66 '8 

100 

Fildes,  Biker,  and  Thompson  10 

15 

80 

100 

The  net  result  of  these  various  investigations  is  that 
Pfeiffer's  bacillus  has  been  found  in  51-8  per  cent,  of  cases  of 
naso-pharvngeal  swabs  taken  from  influenzal  patients,  cocci 
being  also  found  in  every  cass. 

Sputum. 

The  result  of  the  observations  shown  in  Table  II.  is  that 
Pfeiffer’s  bacillus  has  been  found  in  the  sputum  in  42  per 
cent,  of  cases. 

Table  II. 


Observer. 

No.  of 
cases. 

Pfeiffer’s 

bacillus 

found. 

Observer. 

No.  of 
cases. 

Pfeiffer’s 

bacillus 

found. 

Gotch  and  Whit- 

Per  cent. 

Per  cent. 

tingham  u 

50 

8 

McIntosh  9 

25 

84 

Braxton  Hicks 
and  Gray  6 

9 

75 

Fildes 10  

106 

43 

Little,  Garofalo, 

Leichentritt 1:1  ... 

72 

60 

and  Williams  6 
Averil,  Y ung. 

20 

0 

Lowenfeld14 

55 

71 

and  Griffiths  7 

41 

78 

Graetz  

182 

1-5 

Seller 12  

33 

0 

As  regards  other  organisms,  Gotch  and  Whittingham  11 
found  a Gram-negative  micrococcus  resembling  Micrococcus 
catarrhalis  in  100  per  cept.  of  cases  during  the  first  wave  of 
the  epidemic.  Little,  Garofalo,  and  Williams  found  a Gram- 
positive diplococcus  with  flattened  adjacent  sides  in  100  per 
cent,  of  cases,  whereas  Bernhardt11'  describes  a Gram-positive 
diplococcus  ( Diplococcus  epidemicus)  as  occurring  in  all 
cases. 

Pleural  Effusions. 

Netter 17  examined  12  cases  (all  purulent)  and  found 
Pfeiffer’s  bacillus  in  8 per  cent.  Braxton  Hicks  and  Gray  5 
found  Pieiffer’s  bacillus  on  two  occasions  in  pleural  exudate, 
in  addition  to  a diplostreptococcus.  This  latter  organism 
was  allied  to,  if  not  identical  with,  the  Streptococcus  mucosus 
(of  Stephan ls),  and  was  found  in  every  case  of  pleural 
effusion,  but  the  number  of  cases  examined  is  not  given. 

Blood  cultures. — These  have  either  proved  sterile,  yielded 
Pfeiffer’s  bacillus  or  a coccus  (of  different  varieties)  in  the 
proportions  shown  in  Table  III. 

The  resultant  of  this  series  is  that  82  8 per  cent,  of  blood 
cultures  have  proved  sterile,  7 '8  have  yielded  Pfeiffer’s 
bacillus,  and  9 4 per  cent,  cocci  of  different  varieties.  The 


cocci  which  Whittingham  and  Sims  1 found  in  their  blood 
cultures  were  of  different  varieties — a streptococcus,  a 
pneumococcus,  and  a Diplocnoous  mucosus  (Stephan  l8)-in  the 
relative  proportions  of  5,  1,  and  1.  This  Diplococcus  mucosus 

Table  III. 


Observer. 

No.  of 
cases. 

Sterile. 

Pfeiffer’s 

bacillus 

found. 

Cocci 

found. 

Percent. 

Percent. 

Per  cent. 

Abrahams,  Hallows,  and  { 
French  :t f 

10 

90 

— 

10 

Whittingham  and  Sims4  ... 

50 

86 

— 

14 

Braxton  Hicks  and  Gray  ■>  ... 
Little,  Garofalo,  and( 

20 

50 

100 

- 

60 

Williams6  f 

Averil,  Young,  and  Griffiths  7 

9 

100 

— 

— 

Gotch  and  Whittingham  1 1 ... 

? 

100 

— 

— 

Netter17  

12 

83-4 

16  6 

— 

McIntosh  9 

Fildes,  Baker,  andl 

Thompson  10 [ 

10 

80 

100 

- 

20 

Orticom  and  Barbie  19  

62 

39 

61 

Yes. 

* ? How  much. 

was  described  by  Stephan  18  at  the  end  of  the  year  1916.  He 
isolated  it  in  an  extensive  outbreak  of  influenza  in  Strumpell’s 
clinic  at  Leipsic,  and  obtained  it  both  from  blood  and 
sputum.  The  cultural  characteristics  of  this  organism  are 
described  later.  Post  mortem  Segale 20  obtained  another 
coccus  from  heart  blood.  He  called  it  the  Streptococcus 
pandemicus , and  finding  it  also  in  spinal  fluid  and  lymphatic 
ganglia  had  55  per  cent,  positive  results  in  a series  of 
54  cases. 

Post-mortem  Material : Lungs  and  Lymph  Glands. 

In  the  post-mortem  examination  shown  in  Table  IV. 
Pfeiffer’s  bacillus  was  found  in  38  3 per  cent,  of  cases,  and 
cocci  of  different  varieties  in  47 -5  per  cent,  of  cases. 


Table  IV. 


Observer. 

No.  o 
cases. 

Pfeiffer’s 

bacillus 

found. 

Cocci. 

Other 

organisms 

Per  cent. 

Per  cent. 

Per  cent. 

Abrahams,  Hallows,  and  ( 
French  3 ( 

28 

25 

96 

- 

Braxton  Hicks  and  Gray  5 ... 

? 

0 

' ? 

— 

Fletcher  21 

36 

30-5 

44-3 

— 

Netter 17  

7 

71 

? 

— 

Harris22  

2 

0 

0 

100* 

Segale 20  

? 

0 

50 

— 

Leichentritt 13 

6 

100 

— 

— 

Lowenfeld 14  

45 

80 

— 

— 

* An  organism  resembling  B.  pestis. 


Thus  Abrahams,  Hallows,  and  French3  found  a Strepto- 
coccus longus  in  36  per  cent,  of  cases,  a diplostreptococcus 
in  36  per  cent,  of  cases,  and  a pneumococcus  in  26  per  cent, 
of  cases.  Fletcher21  found  a meningococcus  in  30  5 per  cent, 
of  cases,  a pneumococcus  in  8 3 per  cent,  of  cases,  and  a 
streptococcus  in  5 5 per  cent,  of  cases.  The  organism 
found  by  Segale  20  was  his  Streptococcus  pandemicus. 

From  the  publications  during  the  present  epidemic,  which 
have  been  quoted  above,  we  see  that  Pfeiffer's  bacillus  has 
been  isolated  from — 

Naso  pharyngeal  swabs  in  51‘8  per  cent,  of  cases. 
Sputum  ,,  42  ,,  ,, 

Pleural  fluids  ,,  8 ,,  ,, 

Blood  ,,  7-8  ,,  ,, 

Lungsand  lymph  glands  ,,  38  3 ,,  ,, 

During  the  epidemic  various  media  have  been  devised 
which  have  been  considered  to  have  a specially  Selective 
action  favouring  the  growth  of  Pfeiffer’s  bacillus.  These 
are  blood  media  in  which  the  blood  has  been  subjected  to 
the  action  of  trypsin,  as  in  Matthews’s  medium,8  or  boiled  as 
in  Levinthal’s  medium.23  Thus,  Fildes 10  states  “the 

classical  blood-agar  medium  has  been  practically  useless 
under  the  conditions  met  with,”  but  using  Levinthal’s 
medium  he  recovered  Pfeiffer’s  bacillus  in  a high  percentage 
of  cases.  Fleming 21  stated  that  if  blood  is  boiled  with 
f 2 


236  Thf  Lancet,] 


DR.  G.  E.  BEAUMONT  : THE  ETIOLOGY  OF  INFLUENZA. 


[August  9,  1919 


water,  and  only  the  clear  filtrate  added  to  agar,  an  efficient 
medium  for  growing  influenza  bacilli  is  obtained,  and  I 
suggest  that  it  is  possible  that  the  essential  element  is  iron 
which  is  liberated  from  the  haemoglobin  by  boiling  and 
present  in  the  filtrate. 

On  the  other  side  we  have  the  records  of  observers  who 
have  examined  large  numbers  of  cases  and  used  the  very 
latest  and  most  fashionable  media,  and  yet  failed  to  obtain 
Pfeiffer’s  bacillus  in  more  than  an  inconsiderable  percentage 
of  cases,  and  we  must  remember  that  the  bacillus  was  first 
isolated  without  the  use  even  of  the  simplest  form  of  blood 
medium,  and  was  stated  to  grow  in  broth  cultures. 

The  case  for  Pfeiffer’s  bacillus  is  still  further  weakened  by 
the  fact  that  it  has  been  found  in  cases  which  are  not 
influenzal  in  nature.  Thus,  Fildes 10  examined  71  naso- 
pharyngeal swabs  from  healthy  individuals  and  found 
Pfeiffer’s  bacillus  in  21  per  cent.  Fleischmann  23  has  shown 
that  Pfeiffer’s  bacillus  may  be  found  in  healthy  tonsils,  and 
in  the  tonsils  in  diphtheria  and  scarlet  fever ; also  in 
broncho-pneumonia  occurring  as  a complication  of  measles, 
and  in  tuberculous  cavities  in  lungs,  and  in  bronchiectasis. 

The  organism  does  not,  therefore,  fulfil  even  the  first 
postulate  of  Koch  for  specificity— which  states  that  it  shall 
be  found  in  every  case  in  lesions  typical  of  the  disease,  and 
there  alone.  It  has  not  been  shown  to  be  pathogenic  to 
animals,  and  it  only  produces  slight  serological  reactions  in 
man  during  infection. 

Ford  Robertson,20  a staunch  supporter  of  the  Pfeiffer 
school,  states  that  by  injection  into  man  of  a killed  culture 
of  Pfeiffer’s  bacilli  he  can  at  will  produce  a “controlled 
attack  of  influenza.”  How  he  can  prove  that  the  reaction 
following  the  giving  of  the  vaccine  differs  in  any  way  from 
that  following  the  injection  of  any  other  vaccine  he  does  not 
state ; but  to  assert  that  an  attack  of  the  specific  disease 
influenza  is  produced  requires  some  evidence  to  support  it, 
and  that  is  not  given. 

If  Pfeiffer’s  bacillus  is  not  considered  to  be  the  cause  of 
influenza,  what  alternatives  are  left  ? 

First  of  all,  the  infective  agent  may  be  of  small  size  and 
belong  to  the  class  of  filter-passers.  Nicolle  and  Lebailly  27 
showed  in  October,  1918,  that  filtered  sputum  of  influenzal 
cases  reproduced  the  disease  in  man  when  inoculated  by  the 
subcutaneous  route  ; further,  he  used  unfiltered  sputum  and 
injected  it  by  the  subconjunctival  and  nasal  routes  in 
monkeys,  and  produced  a disease  resembling  influenza.  Since 
then  Gibson,  Bowman  and  Connor,28  and  Rose  Bradford, 
Bashford  and  Wilson,20  working  independently,  have  published 
results  showing  that  a filtrable  virus  exists  in  material 
obtained  from  influenza  patients  (sputum,  blood,  pleural 
fluid).  This  virus,  when  injected  into  animals— monkeys 
and  guinea-pigs— produces  in  some  cases  death,  in  others 
illness.  Post  mortem  the  lesions  found  in  the  lungs,  trachea, 
pleura,  and  heart  muscle  resemble  those  seen  post  mortem  in 
man  in  influenza.  From  this  material  the  virus  is  recover- 
able, and  by  animal  passage  increases  in  virulence.  It  is 
anaerobic  and  can  be  grown  by  the  Noguchi  method. 

It  is  thus  demonstrated  that  a virus  which  is  a filter-passer 
can  be  obtained  from  influenzal  material  ; but  whether  the 
disease  produced  in  the  animals  is  influenza  still  requires 
proof.  Leschke,30  working  with  the  filtrate  obtained  from 
an  influenzal  lung,  sprayed  man  and  produced  typical 
attacks  of  influenza.  In  one  instance  two  people  who  nursed 
the  sprayed  individual  developed  the  disease. 

Although  the  amount  of  work  which  has  been  done  on 
filter-passing  organisms  in  influenza  is  small,  yet  the  evidence 
is  weighty  as  regards  the  presence  of  a filtrable  virus,  but  yet 
insufficient  to  prove  that  it  is  the  actual  causative  agent 
either  in  toto  or  merely  as  a stage  in  the  life- history  of  a 
larger  organism. 

The  cocci.  — Authors  who  have  been  unsuccessful  in  their 
search  for  Pfeiffer  s bacillus,  and  who  have  not  experimented 
with  the  filter-candle,  have  described  cocci  and  put  forward 
the  suggestion  that  here  we  have  the  actual  ciuse  of  the 
disease.  Gotch  and  Whittingham 11  described  a Gram- 
negative micrococcus  occurring  in  all  cases  in  the  sputum 
and  naso-pharyngeal  swab  cultures  as  the  predominating 
organism.  They  inoculated  it  on  the  naso-pharynx  of  two 
healthy  individuals  and  “ produced  the  disease  in  a typical 
form.  ’ They  therefore  conclude  that  this  micrococcus  is 
probably  the  specific  organism,  either  alone  or  in  conjunction 
with  B.  influenza  (Pfeiffer).  The  cultural  characteristics  of 
this  organism  are  not  described. 


Whittingham  and  Sims 4 obtained  from  blood  cultures 
streptococci,  pneumococci,  and  an  organism  resembling 
the  Diplococcus  mucosus  of  Stephan.18  When  first  isolated 
it  is  Gram-negative,  but  on  subculture  not  only  does  its 
staining  by  Gram  become  variable,  but  it  assumes  a pleo- 
morphic form — oval  diplococci  and  bacillary  forms  appearing. 
These  bacillary  forms  are  always  Gram- negative,  stain 
readily  with  dilute  carbol  fuchsin  and  grow  on  ordinary 
agar.  They  occur  mixed  with  the  cocci  in  individual  plate 
colonies. 

Donaldson 31  has  published  some  most  suggestive  notes  on 
his  bacteriological  findings.  In  the  first  place  he  failed  to 
find  Pfeiffer’s  bacillus  in  every  case  examined,  but  he  found 
constantly  an  organism  previously  undescribed.  This  is  a 
coccus  which  he  calls  the  organism  “ D.”  It  is  characterised 
by  its  remarkable  pleomorphism. 

“It  may  grow  in  the  form  of  enormous  bacilli,  or  as 
extremely  long  chains  of  giant  cocci,  or  cocci  alternating 
with  giant  bacilli  of  all  shapes.  Later  on  it  loses  this 
pleomorphism  and  comes  to  resemble  a staphylococcus,  and 
finally  assumes  the  form  of  large  deeply  Gram-positive 
tetrads.  The  cultural  characters  vary  with  the  different 
morphological  phases,  and  it  shows  an  extraordinary  varia- 
bility towards  Gram’s  stain.” 

Donaldson  also  suggests  that  there  may  be  a filter-passing 
stage  to  this  organism.  Rosenow  32  has  described  a similar 
pleomorphic  coccus  in  acute  epidemic  poliomyelitis.  Crook- 
shank  33  has  pointed  out  the  resemblance  between  Rosenow’s 
coccus,  the  organism  found  by  Rajchman  in  encephalitis 
lethargica,  and  Donaldson’s  organism.  Further,  he  points 
out  that  Rajchman  from  his  pure  cultures  of  “Rosenow” 
produced  under  strict  anaerobiasis  a free  growth  of  minute 
bodies  resembling  Flexner’s  “globoid  bodies”  and  also 
those  obtained  by  Rose  Bradford,  Bashford  and  Wilson29 
from  the  filtrable  virus  in  influenza. 

The  sugar  reactions  of  various  cocci  isolated  in  influenza 
are  given  in  Table  Y. 

Table  V. 


Organisms. 

Morphology. 

Glucose. 

Lactose. 

© 

o g 
« 2 

“ 1 
5 a 

GO 

Mannite. 

6 

O 

J 1 

Donaldson’s  “ D ” 

Pleomorphic  coccal 

A. 

A. 

A.  A. 



— A. 

organism. 

and  bacillary  forms. 

Diplococcus  muco- 

,, 

A. 

— 

A.  A. 

— 

— A.C 

sus  (Stephan). 

Dip'ococcits  pan- 

Gram  4-  pairs  and 

A. 

A. 

— A. 

— 



demicus  (Segale). 

short  chains  of  cocci 

A.  = Acid.  A.C  = Acid  clot. 


The  result  of  these  investigations  is  that  it  has  been 
demonstrated  that  in  this  epidemic  a diplococcus,  often 
growing  in  chains,  has  been  present  very  constantly  in  the 
sputum,  occasionally  in  blood,  naso-pharyngeal  swabs,  and 
post-mortem  material.  The  coccus  is  pleomorphic  and 
variable  in  Gram  staining,  and  possibly  also  in  its  sugar 
reactions. 

Evidence  that  this  pleomorphic  coccus  is  the  actual 
causative  agent  in  influenza  is  at  present  incomplete. 

Bacteriologica  l Investigations . 

I did  not  begin  active  laboratory *work  in  connexion  with 
influenza  until  the  commencement  of  January,  1919.  At 
that  period  I was  impressed  by  two  facts — the  relative 
infrequency  with  which  Pfeiffer’s  bacillus  was  being  found, 
and  the  significance  of  the  observations  of  Donaldson  31  on 
his  pleomorphic  organism  “ D ” and  its  possible  relation  to 
the  filtrable  virus  obtained  by  Nicolle27  and  Gibson. 29 
Further,  Captain  H.  J.  B Fry,  R.A.M.C.  (T.),  pathologist  at 
No.  — General  Hospital,  had  obtained  results  which  sug- 
gested the  occurrence  of  two  other  stages  in  the  life-history 
of  the  parasite — a large  spore  stage  and  a hyphal  stage. 
The  results  I am  about  to  describe  are  those  of  my  own 
experiments  conducted  in  the  laboratory  of  No.  — General 
Hospital,  which  was  then  in  the  charge  of  Captain  Fry. 
Much  work  has  been  done  by  Captain  Fry  alone,  both  before 
and  after  I commenced  my  investigations,  and  he  has  already 
sent  in  for  publication  a preliminary  note  on  his  findings.  I 
therefore  make  no  claim  for  originality,  and  the  deductions 
drawn  are  merely  the  sequence  of  the  deductions  of  previous 
observers. 


Taa  Lavoet,] 


DR.  G.  E.  BEAUMONT:  THE  7ETIOLOGY  OF  INFLUENZA. 


[August  9,  1919  237 


Examination  of  sputum. — Sputum  was  collected  in  sterile 
Petri  dishes  and  examined  shortly  after  expectoration.  Films 
were  made  and  stained  by  Gram’s  method,  carbol-fuchsin 
being  used  as  a counter  stain.  In  certain  cases  the  sputum 
was  examined  daily  throughout  the  disease  ; in  others  only 
one  examination  was  made.  A large  number  of  sputa  have 
thus  been  looked  at.  Examination  of  these  films  shows  the 
presence  of  a variety  of  organisms,  and  it  is  suggested  that 
certain  of  these  are  stages  in  the  life-history  of  a mycotic 
parasite — that,  in  other  words,  influenza  is  a mycosis. 

The  evidence  that  is  forthcoming  to  support  this  view  will 
be  detailed  below,  but  a preliminary  statement  will  help  to 
unify  the  bacteriological  findings  and  enable  them  to  be 
considered  in  what  is  believed  to  be  their  true  relations  one 
to  another. 

Film  preparations  made  from  material  from  two  sources 
show  most,  if  not  all,  the  different  stages  of  the  parasite  ; 
these  sources  are  the  lungs  and  the  intestines.  Thus  sputum 
in  cases  of  influenzal  bronchitis  or  broncho-pneumonia,  and 
feces  in  cases  of  influenzal  enteritis,  yield  films  which  when 
stained  by  Gram’s  method  show  the  following  forms  : — 

1.  Ryphte,  septate  and  branching. — In  their  substance 
large  round  or  oval  spores  4 to  5 u in  diameter  may  be 
formed,  or  smaller  spores  or  smaller  coccal  bodies  which 
occur  in  diplococcal  and  streptococcal  forms.  Further  small 
exospores  may  be  seen  attached  to  and  shed  from  their 
exterior.  The  finer  filaments  may  septate  into  bacillary 
forms. 

2.  Larqe  spores  may  occur  singly  or  in  groups.  They  may 
be  round,  oval,  or  elongated,  and  shaped  like  Zeppelins  or 
spindles.  Generally  retaining  Gram’s  stain  with  avidity,  in 
some  cases  they  are  Gram-negative,  or  have  a Gram-positive 
centre  with  a Gram-negative  periphery.  Further,  they  may 
be  frankly  Gram-negative,  and  contain  Gram-positive 
granules.  When  seen  unstained  in  hanging  drop  prepara- 
tion they  appear  to  have  a smaller  circular  body  inside  the 
main  body.  Their  size  is  about  5/*  in  diameter. 


1>  Hyphae  ; 2,  large  spores ; 3,  coccal  clusters ; 4,  small  spores  ; 5,  tetrads  ; 6,  mulberry 
masses ; 7,  chains  of  cocci  in  hyphae ; 8,  bacilli. 

3.  Coccal  clusters. — These  consist  of  aggregations  of  small 
cocci,  0 5 to  l/x  in  diameter,  in  circular  masses.  Generally 
they  are  Gram-negative,  and  contain  towards  the  centre  one 
or  more  larger  Gram-positive  coccal  forms.  They  are  believed 
to  be  derived  from  the  large  spores. 

4.  Small  spores. — These  are  circular  Gram-positive  or 
negative  bodies,  about  2/u  in  diameter.  They  may  divide 
and  form — ■ 

5.  Tetrads,  which  are  almost  invariably  intensely  Gram- 
positive, or 

6.  Mulberry  masses,  which  are  knobby  agglomerations  of 
Gram-positive  bodies,  formed  by  incomplete  fission  of  the 
small  spores. 

7.  Chains  of  cocci. — These  are  often  diplococci  or  diplo- 
etreptococci,  and  may  be  small  with  flattened  opposed  sur- 
faces, and  variable  in  Gram  staining.  Four,  six,  eight,  or 
ten  occur  in  a chain,  or  they  may  be  larger  and  ovoid,  form- 
ing a Streptococcus  maximus,  and  not  then  tending  to  vary 
in  Gram’s  stain,  all  the  elements  being  Gram-positive. 

8.  Bacilli. — Large  Gram-positive  or  Gram-negative  rods, 

2 to  3p  in  length  and  0 5 p.  in  breadth.  Smaller  Gram- 
positive or  negative  bacilli,  down  to  minute  Gram  negative 
bacilli,  morphologically  resembling  that  of  Pfeiffer  : inter- 
mediate cocco- bacillary  forms  also  occur. 

The  connexion  between  these 


diagrammatically  (as  shown  above). 


stages  is  put  forward 


Returning  now  to  the  actual  examination,  and  dealing  first 
with  sputum  ; in  all  cases  in  which  films  were  made  from 
cases  of  influenza  a large  number  of  the  above  stages  were 
seen,  the  commonest  being  coccal  clusters,  hyphsc,  large 
spores,  and  diplostreptococci.  Pfeiffer-like  bacilli  were  not 
often  noticed. 

Dealing  now  with  special  cases,  that  of  Case  124,  which 
proved  fatal  on  the  sixteenth  day  of  the  disease,  showed  on 
the  eighth  day  bright  green  purulent  sputum.  This  contained 
groups  of  Gram-positive  and  Gram-negative  large  spores  in 
great  numbers,  the  only  other  organism  being  small  Gram- 
negative bacilli  in  chains,  and  Gram-positive  and  Gram- 
negative minute  cocci  in  clusters.  (Fig.  1a.)  The  sputum  of 
the  next  day  showed  many  large  Gram-negative  spores,  many 
minute  Gram-negative  cocci,  and  a few  Gram-negative 
hyphal  threads.  This  was  cultured  on  to  trypsinised  serum- 
glucose  agar  and  showed  an  apparently  pure  growth  in 
18  hours  of  minute  circular,  slightly  raised,  transparent 
colonies — a little  iridescent  by  transmitted  light,  and  about 
0 5 mm.  in  diameter. 

Examination  of  a film  made  from  a single  colony  showed 
small  Gram-positive  cocci  and  a few  Gram-negative  bacilli, 
and  Gram-negative  large  spores  with  Gram-positive  cocci 
attached  to  their  periphery.  This  culture  was  kept  3 days 
at  37°  C.  and  13  days  at  room  temperature,  and  then  showed 
a thick,  uniform,  diffuse,  white  heaped-up  growth,  glistening 
strongly  by  reflected  light.  A film  showed  this  to  be  an 
almost  pure  culture  of  Gram-positive  large  spores,  together 
with  some  Gram-negative  large  spores  containing  Gram- 
positive granules — the  other  elements  being  scanty  and  con- 
sisting of  some  small  Gram-positive  and  negative  cocci,  and 
a Gram-negative  filament  with  Gram-positive  exospores. 
(Fig.  1b.)  Subculture  on  agar  for  20  hours  yielded  a diffuse 
growth  of  minute  pin-point  grey  translucent  colonies, 
becoming  confluent.  Single  colony  examinations  showed 
many  Gram-positive  large  spores  of  varying  shapes,  a few 
small  Gram-positive  cocci,  and  one  or 
two  Gram-negative  bacilli. 

On  further  subculture  the  large  spores 
were  obtained  practically  pure,  and  on 
hanging  drop  in  2 per  cent,  glucose 
broth  grew  out  at  37°  C.  in  16  days  into 
branching  filaments,  containing  and 
shedding  the  small  coccal  forms  and 
having  a variable  Gram  reaction. 

A further  10  cultures  were  made  from 
sputum  ; they  were  planted  either  with 
or  without  preliminary  washing  in  sterile 
saline  on  the  following  media : (1) 

Matthews’s  medium 3 4 5 6 7 8 ; (2)  Levinthal’s 
medium  23 ; (3)  Loffler’s  serum  medium  ; 
(4)  trypsinised  serum-glucose  agar ; (5) 
agar  ; (6)  1/500,000  brilliant  green  agar. 

Now,  although  Matthews’s  medium 
and  Levinthal’s  medium  are  described  as 
being  especially  suitable  for  the  isola- 
tion of  Pfeiffer’s  bacillus,  in  no  case 
could  I isolate  it.  I obtained  single 
colonies  which  showed  minute  polar- 
staining,  non-motile,  Gram-negative  bacilli,  growing  in 
chains  and  resembling  Pfeiffer,  but  the  colonies  individually 
were  never  pure.  They  contained  one  or  two  Gram-positive 
coccal  elements,  and  would  grow  on  subculture  on  agar. 
Further,  on  subculture  the  Pfeiffer-like  bacilli  would  often 
disappear — even  when  the  subculture  was  made  in  Matthews’s 
medium,  and  Gram-positive  and  negative  coccal  forms  grow. 

In  another  instance,  in  a case  of  broncho-pneumonia,  with 
typical  blood-stained  sputum,  the  washed  sputum  was 
planted  on  Matthews’s  medium.  After  24  hours’  incubation 
at  37°  C.  a growth  showing  some  minute  colonies  resembling 
those  described  for  Pfeiffer  was  seen. 

Examination  of  three  of  these  showed  in  each  case  a 
mixture  of  Gram-positive  cocci  and  a few  Gram-negative 
bacilli,  but  no  Pfeiffer’s  colonies  were  obtained.  Case  90, 
which  proved  fatal  on  the  fourteenth  day  of  illness,  showed 
on  the  eleventh  day  sputum  thick,  green,  and  purulent. 

In  films  only  Gram-negative,  Pfeiffer-like  bacilli  were  seen 
in  enormous  numbers,  together  with  a few  Gram-negative 
coccal  clusters.  It  was  planted  on  Matthews’s  medium  and 
on  trypsinised  serum-glucose  agar.  After  incubation  at 
37°  C.  for  24  hours,  examination  of  individual  colonies  showed 
no  Pfeiffer  or  even  Pfeiffer-like  bacilli — thus  one  single 
colony  contained  Gram-positive  diplostreptococci,  Gram- 


238  - The  Lancet,] 


DR.  G.  E.  BEAUMONT  : THE  ETIOLOGY  OF  INFLUENZA. 


[August  9, 1919 


negative  cocci,  Gram-positive  large  spores,  and  minute  Gram- 
positive cocci. 

The  results  of  the  sputum  examinations  were  therefore  as 
follows  : — 

Films  showed  organisms  which  appeared  diagnostic  of 
influenza — namely,  hyphae,  large  spores,  small  spores,  coccal 
clusters  and  mulberry  masses,  diplostreptococci. 

Cultures  in  no  case  yielded  Pfeiffer’s  bacillus.  A pure 
culture  of  large  spores  was  obtained,  which  grew  out  into 
hyphae,  small  spores,  and  coccal  forms.  Single  colonies, 
even  on  subculture,  were  not  pure,  in  that  they  did  not 
contain  only  one  organism. 

An  endeavour  was  then  made  to  determine  whether  these 
organisms,  as  seen  in  the  sputum  in  every  case  of  influenza, 
occur  in  other  respiratory  diseases.  Three  cases  of  pul- 
monary tuberculosis  with  tubercle  bacilli  in  the  sputum, 
when  stained  by  Gram’s  method,  showed  none  of  these 
forms. 

Two  or  three  cases  of  post-anaesthetic  bronchitis  have  been 
examined  with  negative  results,  but  the  material  from  a 
sufficient  number  of  definitely  non-influenzal  cases  has  not 
been  available  to  make  a certain  statement  on  this  point, 
which  appears  to  be  of  considerable  importance. 

Examination  of  faces. — Six  cases  of  influenza  that  had 
attacks  of  acute  enteritis  during  their  illness  were  examined 
bacteriologically.  They  were  passing  liquid  motions  con- 
taining bright  red  blood.  Specimens  were  collected  on 
sterile  swabs,  and  direct  films  stained  by  Gram’s  method. 
In  all  cases  large  spores,  Gram-positive  and  Gram-negative, 
were  seen.  In  addition  there  were  coccal  clusters  of  Gram- 
negative and  Gram-positive  elements,  hyphal  filaments, 


emulsion  of  the  agar  slope  culture  was  made  and  found 
to  give  no  agglutination  in  dilutions  of  1/25  to  1 250 
of  the  patient’s  serum  taken  during  convalescence  on  the 
twelfth  day  of  illness. 

The  organism  appears  to  resemble  closely  the  pneumo- 
bacillus of  Friedliiuder,  but  did  not  form  a nail-headed 
growth  in  slab  cultures  in  gelatin.  Further,  it  appeared 
pleomorphic,  for  on  incubating  the  broth  culture  for  20 
days  at  37°  C.  Gram-positive  large  spores,  small  Gram- 
positive  cocci,  and  minute  Gram-negative  cocci  were 
found. 

Urine  cultures. — It  is  a comparatively  common  occurrence 
to  find  albumin,  blood  cells,  or  even  casts  present  for  a few 
days  in  the  urine  during  an  attack  of  influenza,  but  I have 
not  seen  any  publication  which  describes  positive  results  in 
urine  cultures  during  the  disease. 

In  my  series  seven  cases  of  influenza  were  examined  for  the 
presence  of  organisms  in  the  urine,  and  of  these  six  were 
positive,  giving  a percentage  of  86  per  cent,  positive 
results. 

I perforrhed  these  experiments  at  the  suggestion  of 
Captain  Fry,  who  had  previously  obtained  positive  results 
in  some  cases.  In  every  case  the  urine  was  drawn 
off  under  the  most  rigidly  aseptic  conditions  by  catheter 
into  a sterile  test-tube.  5 c.cm.  were  transferred  to  a 
sterile  centrifuge  tube  and  centrifugalised  at  high  speed  for 
10  to  15  minutes.  By  means  of  a sterile  pipette  films  were 
made  from  the  deposit,  and  a broth  tube  and  agar  slope  or 
Loffler  slope  were  also  inoculated.  The  urine  and  the 
cultures  were  then  incubated  at  37°  C. 

The  results  obtained  may  be  expressed  in  Table  VI. 


Table  VI. 


No.  of 
case. 

Day  of  disease, 
temperature,  and 
nature  of  case. 

Urine  deposit. 

Duration  of  incubation  of 
urine  necessary  before 
obtaining  growth  on 
subculture. 

Primary  subculture. 

1 

Later  subcultures. 

81 

5th  day.  T.  98°  to 
99°  F.  Bronchitis. 

No  albumin,  no  cells,  no  casts.  G.  — 
bacilli  with  G.  4-  tips;  G.  + cocci. 

72  hours  (Loffler). 

G.  + cocco- bacilli;  G.  + 
cocci ; G.  - threads. 

Pfeiffer-like  bacilli.  G.  + 
cocci;  G.  + large  spores. 
Mucin. 

83 

4th  day.  T.  100°  F. 
Bronchitis. 

No  albumin,  a few  epithelial  cells. 
G.  + cocco  bacilli. 

Sterile. 

Sterile. 

Sterile. 

85 

5th  day.  T.  102°  F. 
Bronchitis. 

Trace  of  albumin,  one  or  two  red  and 
white  blood  cells,  one  cast.  G.  — 
cocci ; G.  - bacilli. 

48  hours  (agar  and 
Loffler). 

G.  + cocci : G.  — cocci ; 
G.  - bacilli. 

G.  + cocci ; G.  + diplo- 
cocci ; G.4-  large  spores. 
Mucin. 

87 

7th  day.  T.99°F. 
Bronchitis. 

No  albumin,  no  cells  or  casts.  G.  + 
diplococci;  few  G.  — diDlococci. 

24  hours  (agar  and 
Loffler). 

G.  + diplococci ; G.  + 
tetrads ; G.  — bacilli. 

G.  4-  cocci  4-  small 
spores. 

130 

8th  day.  T.  100° 
to  101°  F.  Severe 
bronchitis. 

Albumin  present,  no  cells  or  casts. 
G.  -f  small  spores  ; G.  - bacilli ; G.  - 
bacilli  with  G.  -f  tips  ; G.  - filaments. 

18  hours  (broth);  '40 
hours  (agar). 

G.  4-  cocci ; G.  - small 
spores. 

G.  + diplostreptococci. 

159 

6th  day.  T.  100°F. 
Severe  bronchitis. 

No  albumin,  no  cells.  G.  4-  large 
spores;  G.  - small  spores. 

Direct  (broth). 

G.  + ovoid  diplococcus; 
G.  - hyphae  contain- 
ing small  spores;  G.  + 
filaments. 

G.  4-  ovoid  diplostrepto- 
coccus. 

170 

10th  day.  T.100°F. 
Bronchitis. 

Much  albumin,  many  red  cells,  few 
white  cells.  ? G.  negative,  large 
spores. 

Direct  (broth) ; 18  hours 
(agar). 

1 

G.  4-  small  spores ; 
minute  G.  4-  diplo- 
cocci;  G.  — large 
spores. 

* 

G.  + diplostrepto- 
coccus.  Few  G.  - 
cocci. 

G.  + = Gram  + . G.  — = Gram  — . 


diplostreptococci,  mulberry  masses,  and  bacilli.  In  one 
case  (No.  87)  a 1/500,000  brilliant  green  agar  plate  was 
inoculated  from  a saline  emulsion  of  the  fasces.  After 
24  hours’  incubation  at  37°  C.  small  raised,  rounded, 
whitish  pin-point  colonies  were  seen. 

A film  made  from  one  of  these  showed  Gram-negative 
bacilli  of  varying  lengths  and  Gram-negative  filaments, 
and  one  of  the  filaments  contained  a Gram-positive  spore 
in  its  substance.  A subculture  from  this  colony  on  Loffler’s 
serum  medium  produced  in  24  hours  at  37°  C.  a pure 
culture  of  Gram-negative  bacilli  of  varying  lengths  and  a 
few  filamentous  forms,  the  culture  being  a uniform,  raised 
glistening  growth,  whitish  in  colour,  composed  of  minute 
cilonies.  This  was  subcultured  in  broth  for  24  hours  at 
37°  C.,  and  produced  a uniform  turbidity  of  the  medium. 
A film  showed  Gram-negative,  short,  rather  plump  bacilli, 
and  no  filamentous  forms.  An  agar  slope  was  inoculated  ; 
after  24  hours  at  37°  C.  the  colonies  were  circular,  about 
2 mm.  in  diameter,  opaque,  and  grey. 

The  sugar  reactions  of  this  organism  were  as  follows  : 
Acid  and  gas  were  produced  in  lactose,  glucose,  mannite, 
and  cane  sugar.  Milk  became  acid  the  first  day,  and 
remained  acid  with  clot  the  second  day.  Gelatin  was 
not  liquefied.  It  was  very  slightly  motile.  A saline 


Thus,  whereas  six  out  of  seven  urines  gave  a positive 
culture,  not  one  gave  a positive  culture  when  placed  direct 
(without  previous  incubation  of  the  urine)  on  to  a solid 
medium  ; but  if  the  urine  were  incubated  at  37°  C.  for  from 
18  to  72  hours  subcultures  were  obtained  in  six  cases.  The 
two  urines  which  were  also  put  direct  into  broth  gave  a 
direct  growth,  but  in  these  cases  also  the  urine  had  to  be 
incubated  before  a growth  could  be  obtained  on  subculture 
on  a solid  medium.  Further,  it  will  be  seen  that  from  urines 
the  following  stages  have  been  obtained : hyphae,  large 
spores,  small  spores,  coccal  clusters,  tetrads,  mulberry 
masses,  diplostreptococci,  and  Gram-negative  bacilli. 

The  sugar  reactions  of  the  cocci  obtained  from  Cases  130, 
159,  and  170  were  determined,  and  are  shown  in  Table  VII. 

A control  specimen  of  urine,  removed  with  similar  pre- 
cautions from  a healthy  individual  by  catheter,  remained 
sterile  during  incubation  for  a week,  and  would  not  grow  on 
subculture. 

Blood  cultures. — These  were  made  in  13  cases,  and  in  one 
case  a positive  result  was  obtained,  which  is  equivalent  to 
7 -7  per  cent,  positive  results.  In  each  case  the  blood  was 
removed  bv  venipuncture,  and  received  direct  through  a 
sterile  needle  with  short  rubber  tube  attached  into  the  tubes 
containing  the  medium. 


The  Lancet,] 


DR.  G.  E.  BEAUMONT:  THE  AETIOLOGY  OF  INFLUENZA. 


[August  9,  1919  239 


1.  Large  spores 

In  A,  sputum  film  ; B,  sputum  culture  ; C,  blood  culture  ; D,  urino  ; E,  faeces. 

2.  Hyphse  : — 

In  A,  sputum  film  ; B,  f;cces  ; C,  culture  from  large  spores. 

3.  Coccal  clusters  and  mulberry  masses  : — 

In  A,  sputum  film ; B,  faeces ; C,  urine. 

4.  Tetrads,  cocci,  bacilli 

In  A,  sputum  film;  B,  sputum  culture;  C,  faeces  • D,  urite  film;  E,  urine 
culture  ; P,  blood  culture. 


4 F 


240  The  Lancet,]  DR.  E.  E.  PREST  : SANATORIUM  TREATMENT  & MILITARY  SERVICE.  [August  9,  1919 


Table  VII. 


No.  of 
case. 

Glucose. 

Lactose. 

Maltose. 

Mannite. 

Cane 

sugar. 

Salicin. 

Milk. 

Gelatin. 

130 

159 

170 

Acid. 

Acid. 

Acid. 

( 

” 1 

Nil. 

Acid. 

Acid 

(late). 

Nil. 

Nil.  4 
Acid. 
Nil. 

Acid  and  1 
clot.  ) 

Aik. 

Not  liquefied. 

Liquefied. 
Not  liquefied. 

The  media  employed  were  : (1)  Broth  ; (2)  2 per  cent, 
glucose  broth  ; (3)  4 per  cent,  maltose  broth  ; (4)  citrated 
broth;  (5)  sterile  urine.  The  tubes  contained  5 c.  cm.  of  the 
medium,  and  an  equal  volume  of  blood  was  added  to  each. 
In  two  cases  the  blood  was  in  addition  received  direct  in  a 
sterile  tube  before  subcultures  were  made,  and  in  one  of  these 
there  was  a positive  result,  the  growth  being  obtained  on 
serum-glucose  agar  from  the  broth  subculture  which  had 
been  incubated  six  days.  Although  in  the  other  cases  sub- 
cultures from  the  primary  culture  remained  sterile,  yet  in  11 
out  of  the  12  cases  organisms  were  seen  in  the  primary 
cultures  after  incubating  for  periods  varying  from  4 to  24 
hours.  The  results  are  shown  in  Table  VIII.  : — 


Table  VIII.— Blood  Cultures. 


1 No  of  , 

I case. 

1 Day  of 
| disease. 

Tempera- 

ture 

(Fah.). 

Primary  culture. 

Subculture. 

82 

6th 

99°- 

ino° 

G.  - rods  with  G.  + tips  (broth). 

Nil. 

83 

3rd 

ioi°- 

G.  + granular  bacilli  ; G.  - bacilli 

83a 

4th 

102° 

101° 

(broth). 
Nil  (broth). 

84 

5th 

99° 

G.  - bacilli,  G.  + cocci  (citrated  broth) ; 

88 

8th 

103°- 

G.  + small  spores  (urine). 

G.  + small  spores  ; G.  + cocco-bacilli  and 

89 

9th 

104° 

103° 

filaments  ; minute  G.  + coccal  bodies 
(broth  and  glucose  broth). 

Large  G.  + spores  and  hyphse  (glucose 

90 

101°- 

lf)2o 

broth). 

G.  + cocci  (glucose  broth). 

* 

92 

6th 

100-8° 

G.  - large  spores  and  hypha-  (glucose 

96 

9th 

101° 

broth). 

G.  4-  diplococci ; G.  - bacilli ; G.  + 

126 

8th 

103° 

small  spores  (glucose  broth). 

G.  - cocci  and  bacilli ; G.  — large  spore9 

135 

7th 

101°- 

(glucose  broth). 

G.  - large  spores  with  G.  + centre 

G.  + diplo- 

181 

4th 

102° 

103° 

(incubated  blood,  glucose  broth). 
G.  -f  large  spores  and  G.  + cocci. 

cocci 

in  chains,  t 
Nil. 

197 

9th 

105° 

G.  - large  spores. 

- 

* But  grew  from  blood  later,  when  patient  was  bled, 
t Agar  and  serum-glucose  agar. 


The  subcultures  from  Case  135  grew  equally  well  on  agar 
and  serum-glucose  agar,  in  minute  transparent  dew-drop 
colonies,  tending  to  become  confluent. 

The  sugar  reactions  were  as  follows  : Glucose,  acid  ; 
lactose,  acid  ; maltose,  acid  ; mannite,  nil  ; cane  sugar,  nil  ; 
salicin,  nil ; milk,  alkaline  ; gelatin,  not  liquefied. 

It  therefore  resembles  very  closely  the  coccus  isolated 
from  the  urine  in  Case  170  ; the  only  difference  being 
the  late  change  produced  in  mannite  in  the  urine  coccus. 

Primary  cultures  of  blood  show  the  following  stages : 
Large  spores,  small  spores,  hyphas,  cocci  in  clusters,  pairs 
and  diplostreptococcal  form,  Gram-negative  bacilli  and 
Gram-negative  bacilli  with  Gram-positive  tips  ; and  minute 
coccal  forms  which  appear  to  be  liberated  from  large  spores, 
and  which  are  approaching  the  limits  of  microscopic 
visibility. 

There  is  difficulty  in  obtaining  growth  on  subculture,  but 
in  one  case  the  coccal  form  grew  out,  and  had  the  same 
morphological  appearance  as  that  seen  in  urine  and  sputum, 
although  the  sugar  reactions  varied  slightly. 

Pleural  Effusions.  ' 

Six  cases  were  examined  bacteriologically.  Cells  were 
scanty,  a few  small  lymphocytes  and  polymorphonuclears 
being  found  in  the  deposit  after  centrifugalisation.  Direct 
films  showed  a few  Gram-negative  bacilli,  and  in  one  case 


a pleomorphic  variably  Gram-staining  organism  of  diplo- 
streptococcal type.  In  no  case  was  growth  obtained  on  sub- 
culture. The  organisms  described  above  are  illustrated  in 
the  accompanying  figures. 

1.  Large  spores. — In  A,  sputum  film;  B,  sputum  culture; 
C,  blood  culture;  D,  urine;  E,  faeces. 

2.  Hyphce. — In  A,  sputum  film;  B,  faeces  ; C,  culture  from 
large  spores. 

3.  Coccal  clusters  and  mulberry  masses.— In  A,  sputum  film  ; 
B,  faeces  ; C,  urine. 

4.  Tetrads  : cocci,  bacilli. — In  A,  sputum  film ; B,  sputum 
culture;  C,  fasces;  D,  urine  film  ; E,  urine  culture  ; F,  blood 
culture. 

Conclusions  from  Bacteriological  Examinations. 
Examination  of  material  obtained  from  patients  suffering 
from  influenza  has  shown  the  presence  of  a mycotic  organism. 

It  is  possible  that  the  disease  is  a mycosis — not 
necessarily  in  all  cases  a bronchomycosis,  but  perhaps  in 
some  an  enteromycosis. 

The  originality  of  these  findings  belongs  to  Captain  Fry, 
with  whom  I have  performed  experiments  on  animal  inocula- 
tion and  examination  of  material  obtained  post  mortem 
in  man. 

Although  the  results  obtained  do  not  justify  an  assertion 
that  influenza  is  a mycotic  infection,  they  appear  to  demon- 
strate the  fact  that  such  an  organism  is  present  during  the 
disease,  and  afford  a means  of  unifying  the  seemingly 
discordant  results  that  have  been  obtained  by  other  workers. 

Bibliography.— 1.  Pfeiffer:  Deutsche  Med.  Wchnsch.,  No.  2.  1892. 
2.  Klein  : Loc.  Gov.  Board  Report.  C,  7051, 1893.  3.  Abrahams,  Hallows, 
and  French  : The  Lancet,  Jan  4th,  1919.  4.  Whittingbam  and  Sims  : 
The  Lancet,  Dec.  28th,  1918.  5.  Braxton  Hicks  and  Gray:  The  Lancet, 
March  15th,  1919.  6.  Little,  Garofalo,  and  Williams : The  Lancet, 
July  13th,  1918.  7.  Averi),  Young,  and  Griffiths  : Brit.  Med.  Jour., 
August  3rd,  1918.  8.  Matthews:  The  Lancet,  July  27th,  1918.  9. 

McIntosh:  The  Lancet,  Nov.  23rd.  1918.  10.  Fildes.  Baker,  and 

Thompson  : The  Lancet  Nov.  23rd.  1918.  11.  Gotch  and  Whittingham  ■. 
Brit.  Med.  Jour.,  July  27th,  1918  12.  Selter  : Deutsche  Med.  Wchnsch., 
Berl.  u.  Leipz.,  1917,  xliii.,  1005.  13.  Leichentritt -.  Deutsche  Med. 

Wchnsch.,  Berl.  u.  Leipz.,  1918.  xliv.,  1919-22.  14.  Lowenfeld : Wien, 
klin.  Wchnsch.,  1918,  xxxi.,  1274-5.  15.  Graetz : B»rl.  klin.  Wchnsch., 
1919,  lvi.,  46.  16.  Bernhardt : Med.  klin.  Berl.  u.  Wien.,  1918,  xtv.,  683. 
17.  Netter  : Bull.  Acad,  de  Med.,  Par.,  1918  3e  ser..  lxxx..  275-86.  18. 
Stephan  : Munch,  med.  Wchnsch.,  1917,  lxiv.,  257.  19.  Orticoni  and 
Barbie  : Bull,  et  mem.  soe.  med.  d.  hop  de  Par.,  1918, 3e  ser.  xlii.,  959-61. 
20.  Segale  : Patholog.  Genova,  1918,  xi.,  1.  21.  Fletcher:  The  Lancet, 
Jan.  18th,  1919.  22.  Harris : The  Lancet,  Dec.  28th,  1918.  23. 

Levinthal  : Ztschrift.  f.  Hyg.  und  Infekt.,  Krankh.,  Jena,  1918,  861. 
24.  Fleming:  The  Lancet.  Jan.  25th,  1919.  25.  Fleischmann:  Ztschr. 
f.  arztl.  Fortbild.,  Jena,  1918,  xv.,  425-31.  26.  Ford  Robertson:  Brit. 
Med.  Jour.,  Dec.  21st,  1918.  27.  Nicolle  and  Lebailly  : C.  R.  Acad. 

Sci.,  607.  28.  Gibson,  Bowman,  and  Connor:  Brit.  Med.  Jour., 

Dee.  14th.  1918,  March  22nd,  1919.  29  Rose  Bradford,  Bashford,  and 
Wilson:  Brit.  Med.  Jour.,  Feb.  1st,  1919.  30.  Leschke  : Berl.  klin. 

Wchnsch.,  1918,  lvi.,  11.  31.  Donaldson:  The  Lancet,  Nov.  23rd, 

1918  ; Brit.  Med.  Jour.,  Dec.  21st,  1918.  and  Feb.  15th,  1919. 

32.  Rosenow  : J.  of  Infect.  Dis..  Chicago,  xxvii..  No.  4,  pp.  281,  et  seq. 

33.  Crookshank  : The  Lancet,  Feb.  22nd,  1919. 


SANATORIUM  TREATMENT  AND  MILITARY 
SERVICE  : 

AN  ANALYSIS  OF  47  CASES. 

By  EDWARD  E.  PREST,  M.A.,  M.D.  Cantab., 

MEDICAL  SUPERINTENDENT.  AYRSHIRE  SANATORIUM  ; CONSULTING 
PHYSICIAN,  AYRSHIRE  COUNTY  TUBERCULOSIS  COMMITTEE. 


The  following  account  of  the  adventures  of  a number  of 
patients  who  had  served  in  the  various  services  during  the 
war,  after  being  treated  in  a sanatorium,  may  be  of  interest 
at  the  present  time.  It  must  not  be  supposed  that  this 
is  the  best  which  might  be  expected  if  the  cases  had  been 
treated  at  an  earlier  date,  for  many  of  these  cases  were  not 
very  favourable,  and  in  many  symptoms  had  existed  for  pro- 
longed periods  before  undergoing  treatment,  and  the  stage 
stated  does  not  indicate  necessarily  the  duration  of  sym- 
ptoms, as  some  cases  advance  rapidly  in  a short  time, 
whilst  others  go  on  for  long  periods  before  much 
apparent  destruction  has  taken  place.  Most  of  these 
cases  were  volunteers  in  the  true  sense,  for  most  of  them 
could  have  procured  exemption  by  obtaining  a certificate. 
They  did  not  ask  my  advice  before  enlisting  ; in  some 
cases  I should  have  attempted  to  dissuade  them, 

and  a number  ought  certainly  to  have  been  rejected. 

I think,  however,  it  goes  to  show  that  were  cases  treated 
at  sanatoriums  as  soon  as  symptoms  became  recognisable 
and  were  persistent,  it  would  become  unnecessary  to  reject 


The  Lancet,]  DR.  E.  E,  PREST  : SANATORIUM  TREATMENT  & MILITARY  SERVICE.  [August  9,  1919  241 


Pr.  or  Ab.  = Presence  ( + ) or  absence  (-)  of  tubercle  bacilli : (1)  on 
admission ; (2)  on  dischargo. 


| Stage. 

Year  of 
admis- 
sion. 

Pr.  or 
Ab. 

Progress  and  particulars. 

1907 

u) 

(2) 

1 

1st 

“ 

Enlisted  1915;  4 years  France;  demob.,  well  and 
working  at  his  trade. 

2 

1st 

19C9 

Severely  wounded,  left  to  die;  almost  complete 
recovery  from  wounds,  working  at  his  old  trade 
for  two  years. 

3 

2nd 

1909 

+ 

— 

Still  in  the  Army.  well. 

4 

1st 

1909 

— 

Untraced ; probably  should  not  have  been  taken. 

5 

2ud 

1909 

+ 

+ 

Engineer,  Mercantile  Marine ; torpedoed  Feb., 
' 1917, 350  miles  from  land.  15  hrs.  in  open  boat, 
no  worse  ; Killed  by  torpedo,  April.  1917. 

6 

1st* 

1910 

— 

Should  not  have  been  enlisted  ; demob.;  working 
at  his  old  trade. 

7 

2nd 

1910 

+ 

— 

Three  years  France,  sergeant;  demob.,  well, 
working  at  his  old  trade. 

8 

1st 

1910 

“ 

Served  in  Salonika  and  India ; demob.  ; working 
at  his  old  trade. 

9 

2nd 

1910 

+ 

“ 

Two  years  in  Army;  demob.,  well,  returned  to 
his  old  trade. 

10 

1st 

1910 

+ 

“ 

Enlisted  at  latter  end  of  war;  demob,  against  his 
will,  working  at  his  old  trade. 

11 

2nd 

1910 

(a) 

Served  in  France  until  very  severely  gassed; 
readmitted;  well,  working  at  his  old  trade. 

12 

1st* 

1910 

Served  from  1914  in  Egypt  and  France,  wounded; 
demob.,  working  at  bis  old  trade. 

13 

1st 

1911 

“ 

Enlisted  under  age;  discharged,  working  at  his 
old  trade. 

14 

2nd 

1911 

+ 

(fc) 

Another  affection  whilst  in  sanatorium,  kept  him 
in  bed  for  weeks ; served  through  war  till  severely 
wounded ; well. 

15 

2nd 

1911 

+ 

Served  some  years  in  France ; sergeant ; read- 
mitted ; well. 

16 

2nd 

1911 

_ 

Served  in  Egypt ; demob.,  well. 

17 

1st 

1911 

Served  lour  years  on  home  service  ; demob.,  well, 
and  working  at  his  old  trade. 

18 

2nd 

1911 

En  isted  1914.  Very  severe  y wounded  in  France  ; 
well  except  for  results  of  injuries. 

19 

1st 

1912 

_ 

Served  from  beginning  of  war,  wounded  twice, 
Egypt  and  France;  well. 

20 

2nd 

1912 

+ 

- 

Enlisted  1914.  Wounded  in  France.  Readmitted 
1917 ; died  in  a few  days  from  influenza. 

21 

2nd 

1912 

+ 

Enlisted  1914,  served  in  Egypt,  broke  down  after 
2 years’  service ; readmitted,  worked  for  a time  ; 
died  from  acute  tuberculosis  after  short  illness. 

22 

1st 

1912 

_ 

Still  in  Army,  well. 

23 

1st 

1913 

+ 

Reservist,  compelled  to  go  to  France  ; broke  down. 
At  present  working. 

24 

1st 

1913 

+ 

(6) 

Served  throughout  war  in  Navy.  Torpedoed, 
1917 ; 4 days  in  op°n  boat.  Malaria  whilst  in 
Red  Sea.  Jan.,  1919,  still  in  Navy  and  quite  well. 

25 

1st 

1913 

- 

Enlisted  1915 ; l.-corp-iral ; at  present  demob., 
well,  and  working  at  his  old  trade. 

26 

1st 

1913 

- 

Served  in  Eg\  pt,  Dardanelles,  and  France  ; 
demob.,  well,  working  at  his  old  trade. 

27 

1st 

1913 

(c) 

Enlisted  earlv  in  war,  corporal,  gassed  and  badly 
wounded  ; demob.,  well  but  for  wound  trouble. 

28 

1st 

1913 

— 

Served  at  home ; demob.,  working  at  his  old  trade. 

29 

2nd 

1914 

- 

Fought  through  earlier  part  of  war  in  France, 
last  heard  of  in  military  hospital. 

30 

2nd 

1914 

— 

Enlisted  1916,  still  in  France,  well. 

31 

3rd 

lyi4 

Fought  in  France,  broke  down  ; in  1917  sent  to 
Egypt,  ship  torpedoed,  4 hours  in  open  boat ; 
demob.,  well,  aud  working  at  his  old  trade. 

32 

1st 

1914 

_ 

Still  in  Army,  well. 

33 

3rd 

1914 

Enlisted  April,  1916;  blown  up  and  buried; 
readmitted  1917 ; died  from  puim.  tuberculosis 
two  days  after  leaving  sanatorium 

34 

1st 

1914 

Enlisted  1917,  corporal ; served  in  France. 
Demob.  Jan.,  1919.  In  excellent  health. 

35 

2nd 

1914 

Served  four  years  in  Army;  demob.,  well,  and 
working  at  his  old  trade. 

36 

2nd 

1914 

Enlisted  when  not  feeling  well ; died  after  two 
operations  in  military  hospital.  Advised  to 
return  to  sanatorium  instead  of  going  into  Army. 

37 

2nd 

1914 

Enlisted  1914 ; for  14  months  in  thickest  of 
fighting  in  France  ; died  of  wounds  in  1916. 

38 

2nd 

1914 

Enlisted  1915,  corporal , after  much  fighting  in 
France  very  severely  wounded ; now  demob, 
and  working  at  his  old  trade. 

39 

1st 

1914 

— 

Enlisted  at  18,  served  in  Egypt  and  France  ; well. 

40 

2nd 

1914 

Enlisted  in  1915,  was  five  months  in  Army, 
discharged  for  other  illness;  working  at  his  old 
trade  ever  since. 

41 

1st 

1915 

Remained  in  sanatorium  a short  time,  returned 
to  Army,  soon  after  discharged  ; unsatisfactory 
ca^e.  Working  when  last  heard  of. 

42 

2nd 

1915 

+ 

+ 

Killed  in  France,  1917. 

43 

2nd 

1915 

Conscripted,  should  not  have  been  taken  ; soon 
aiterwards  discharged,  now  labouring. 

44 

3rdf 

1916 

+ 

+ 

Conscripted,  should  not  have  been  taken.  Died 
in  Army  from  influenza  (?)  1918. 

45 

2nd 

1916 

... 

Conscripted  ; keen  to  go,  should  not  have  been 
taken  ; served  successfully  for  some  months  ; 
broke  down  after  influenza;  readmitted. 

46 

2nd 

1917 

Only  in  Army  a short  time  ; readmitted  and  is 
now  well ; he  could  only  be  treated  for  3 
months  when  first  in  sanatorium. 

47 

1st 

1915 

Enlisted  1917  ; gasspd  in  France  ; in  hospital  some 
months;  quite  well,  working  at  his  old  trade. 

* Acute.  T Laryngeal.  (a)  Present  beiore  admission.  (6)  No 
sputum  on  discharge,  (c)  Reacted  to  tuberculin  under  treatment. 


men  on  the  ground  that  they  had  been  in  a sanatorium,  and 
it  follows  from  this  that  under  ordinary  peace  conditions 
such  patients  would  return  to  their  former  manner  of  life  and 
old  avocations.  It  should,  of  course,  be  understood  that  if 
passed  as  medically  fit  the  country  would  have  to  take 
complete  responsibility  for  their  condition  if  they  sub- 
sequently broke  down.  Had  all  sanatoriums  spent  their 
energies  from  their  inception  in  treating  early  cases 
they  might  easily  have  produced  a division  of  excellent 
soldiers  ; as  it  is,  the  majority  of  the  patients  treated  in 
sanatoriums  are  either  dead  or  hopelessly  unfit,  and  are 
requiring  after-care. 

Analysis  of  Cases. 

Except  in  certain  cases  which  should  not  have  been 
enlisted,  it  will  be  seen  that  the  expense  of  treating  these 
men  for  tuberculosis  has  not  been  excessive.  All  these 
cases  were  treated  in  the  Ayrshire  Sanatorium.  I have  only 
come  across  one  case  treated  in  the  Ayrshire  hospitals  for 
advanced  cases  who  enlisted,  and  he  apparently  made  a bet 
that  he  would  be  taken,  and  he  was  passed  Grade  I.  and  saw 
some  years’  service  in  the  East  ; he  was  finally  invalided  out 
of  the  Army  with  tuberculosis,  and  at  the  present  time  he  is 
in  fair  condition. 

The  occupations  of  the  above  when  admitted  to  the 
sanatorium  were  as  follows  : Coal-miners,  14  ; labourers,  6 ; 

schoolboys,  5 ; engineers,  shop  assistants,  painters,  iron 
moulders,  and  railway  clerks,  2 of  each  ; groom,  bleacher, 
cabinet  maker,  iron  turner,  brass  finisher,  iron-stone  miner, 
surfaceman,  gardener,  blacksmith,  French  polisher,  mason, 
and  agricultural  labourer,  1 of  each.  One  of  these  patients 
became  a professional  athlete  after  leaving  the  sanatorium, 
and  is  so  engaged  at  the  present  time.  One  held  a com- 
mission, another  was  offered  a commission,  1 won  the 
military  medal,  1 was  promoted  on  the  field  for  valour, 
2 were  sergeants,  and  3 were  corporals.  Three  lost  their 
lives  in  their  country’s  service,  8 were  wounded,  3 gassed, 
and  1 buried  alive.  One  was  discharged  from  the  Army 
because  be  was  said  to  be  suffering  from  valvular  disease  of 
the  heart ; he  really  had  heart  failure  due  to  excessive 
fibrosis,  and  should  not  have  been  taken.  Another  had 
suffered  from  caries  in  the  spine  ; this  man  did  home 
service  right  through  the  war,  and  is  at  present 
working  at  a laborious  occupation.  One  man  was 
discharged  after  an  anti-enteric  inoculation,  and  he 
has  been  working  ever  since.  One  was  in  hospital  for 
some  months,  supposed  to  have  pneumonia,  but  from  the 
account  he  gave  of  himself  he  had  evidently  been  suffering 
from  an  acute  attack  of  tubercle  ; this  is  a mistake  which  is 
constantly  being  made,  and  is  the  cause  of  not  a few 
incorrect  death  certificates.  This  man  is  now  at  his  old 
work  after  seeing  a good  deal  more  of  service.  It  will  be 
noted  that  14  had  tubercle  bacilli  in  their  sputum,  one 
reacted  to  tnberculin,  and  of  those  in  whom  bacilli  were 
not  found  12  were  in  the  second  stage  and  two  in  the 
third. 

In  closing  I may  remark  that  28  had  been  in  the  sana- 
torium in  1913  or  previous  years,  and  had  been  engaged  in 
their  ordinary  occupations  for  some  time  before  war  broke 
out.  Finally,  I would  remark  that  the  sacrifices  of  these 
men  will  not  have  been  made  in  vain  if  they  teach  us  that 
those  who  have  had  the  misfortune  to  contract  tuber- 
culosis may  be  worthy  of  a better  fate  than  to  be 
segregated,  but  let  it  be  understood  there  can  be  no 
worse  place  for  an  uncured  tuberculous  patient  in  war 
time  than  the  Army. 


London  Hospital  : Old  Students’  Dinner.— 
The  old  students’  dinner  will  be  held  on  Thursday,  Oct.  2nd, 
at  Princes’  Restaurant.  Sir  Bertrand  Dawson  will  preside. 
This  will  be  the  first  reunion  of  old  students  since  the  out- 
break of  the  war.  Application  for  tickets  should  be  made  to 
one  of  the  honorary  secretaries,  Mr.  Hunter  Tod,  11,  Upper 
Wimpole-street,  W.  1,  or  Dr.  Charles  H.  Miller,  32,  Devon 
shire-place,  W.  1. 

King’s  College  Hospital  Medical  School 
(University  of  London).— The  following  elections  to 
scholarships  have  been  made: — Burney  Yeo  scholarships: 
J.  W.  Hirst,  Gonville  and  Caius  College,  Cambridge  ; C.  F.  T. 
East,  New  College,  Oxford.  Senior  Scholarship  and  Todd 
prize:  E.  A.  L.  Cricblow,  M.R.C.S.,  L.R.C.P.  Jelf  medal: 
H.  Kamal,  M.B.,  B.S.,  M.R.C.S.,  L.R.C.P.  Tanner  prize  : 
Miss  D.  E.  P.  Jolly. 


242  The  Lanoet,]  DBS.  ELKINS  & THOMSON  : TUBERCULOSIS  IN  ASYLUM  PATIENTS.  [August  9.  1919 


THE  INCIDENCE  OF  TUBERCULOSIS 
AMONGST  ASYLUM  PATIENTS. 

By  FRANK  ASHBY  ELKINS,  M.D.  Edin., 

MEDICAL  SUPERINTENDENT,  METROPOLITAN  ASYLUM,  LEAVESDEN  ; 
AND 

H.  HYSLOP  THOMSON,  M.D.Glasg.,  D.P.H., 

COUNTY  MEDICAL  OFFICER  OF  HEALTH  AND  COUNTY  TUBERCULOSIS 
OFFICER  FOR  HERTFORDSHIRE. 


Since  tlie  commencement  of  the  war  there  has  been  a 
marked  increase  in  the  prevalence  of,  and  death-rate  from, 
pulmonary  tuberculosis.  During  1917  the  crude  death-rate 
from  this  disease  in  England  and  Wales  amongst  civilians 
was  1250  per  million  population,  compared  with  1178  for  1916 
and  1034  for  1912-14.  The  cause  of  this  increase  is  to  be 
attributed  to  the  existence  of  conditions  directly  arising 
from  the  war  which  have  impaired  our  resistance  to  attacks 
by  the  tubercle  bacillus  and  which  have  favoured  the  spread 
of  infection.  Such  conditions  are  to  be  found  in  prolonged 
mental  anxiety  and  worry,  physical  exhaustion,  depletion  of 
the  normal  dietary,  increase  of  the  ratio  of  population  per 
house,  and  departure  generally  from  the  normal  pre-war 
standard  of  living.  This  increase  in  the  incidence  of 
pulmonary  tuberculosis  provides  one  significant  lesson.  It 
emphasises  the  fact  that  even  under  pre-war  conditions  the 
national  reserve  of  resistance  to  attack  by  the  tubercle 
bacillus  was  small  and  that  any  degree  of  security  and  the 
prospect  of  finally  controlling  tuberculosis  can  never  be 
attained  until  the  national  reserve  of  resistance  has  been 
materially  increased. 

The  increase  in  the  incidence  of  pulmonary  tuberculosis, 
which  has  been  a feature  of  the  last  four  years,  is  especially 
characteristic  of  the  mentally  abnormal  population.  Since 
1914  there  has  been  an  increase  of  41  per  cent,  in  the  deaths 
from  tuberculosis  in  lunatic  asylums.  One  of  us  has  had  the 
opportunity  of  studying  tuberculosis  amongst  the  insane  for 
a period  of  over  30  years,  and  the  marked  increase  in  the 
death-rate  from  this  disease  since  the  commencement  of  the 
war  amongst  the  inmates  of  a large  asylum  has  been  a cause 
of  much  thought  and  anxiety.  It  is  obvious  that  the  reserve 
of  resistance  to  tuberculous  infection  in  the  insane  and  low- 
grade  mentally  defective  person  reaches  a very  low  standard. 
In  the  following  table  are  given  the  death-rates  from  tuber- 
culosis during  the  last  20  years  amongst  the  inmates  of  a 
large  metropolitan  asylum. 


Death-rates  from  Tuberculosis  during  the  last  20  years  amongst 
the  Inmates  of  a Metropolitan  Asylum. 


Year. 

Average 

No. 

patients 

resident. 

Deaths 
from  all 
eauses. 

Mortality  from 
tubercle— 

Year. 

Average 

No. 

patients 

resident. 

Deaths 
from  all 
causes. 

Mortality  from 
tubercle— 

Deaths. 

Hate 
per  1000 

Deaths 

Rate 
per  1000 

1898 

1986 

194 

55 

276 

1909 

2069 

210 

70 

338 

1899 

1952 

250 

73 

37-4 

1910 

1911 

120 

31 

16-2 

1900 

1905 

310 

104 

54-6 

1911 

2049 

144 

38 

185 

1901 

1772 

164 

67 

37-8 

1912 

2068 

129 

41 

19-8 

1902 

1768 

134 

43 

23-8 

1913 

2051 

197 

59 

29-0 

1903 

1752 

131 

34 

19-4 

1914 

2099 

172 

42 

20-0 

1901 

1751 

158 

53 

30-2 

1915 

2045 

240 

70 

34'2 

1905 

1776 

126 

44 

24-7 

1916 

2041 

283 

102 

49'9 

1906 

1782 

127 

40 

22-4 

1917 

1941 

459 

141 

72'6 

1907 

1819 

151 

37 

20-3 

1918 

1769 

542 

208 

117-6 

1908 

1920 

156 

39 

20-3 

Note. — Pram  the  year  1900  onwards  t lie  diagnosis  has  been  assured  by 
post-mortem  examination  in  more  than  90  per  cent,  of  cases. 


From  this  table  it  will  be  seen  that  the  death-rate  from 
tuberculosis  in  1914  was  20  per  1000,  and  that  the  rate  has 
risen  since  that  year  to  117  6 per  1000  for  1918.  The 
increase  in  the  death-rate  from  tuberculosis  amongst  the 
inmates  of  asylums  since  the  commencement  of  the  war  is 
remarkable,  and  is  referred  to  by  the  Registrar-General  in 
his  annual  report  for  1917.  In  that  report  it  is  stated  that 
12  out  of  97  county  and  county  borough  asylums  were 
evacuated  during  the  war  in  order  that  they  might  be 
devoted  to  military  purposes,  and  this  is  stated  by  the  Board 


of  Control  to  have  led  to  some  degree  of  overcrowding. 
But,  as  is  pointed  out  by  the  Registrar-General,  this  had 
much  abated  in  1917  from  what  it  was  in  1915,  when  the 
deaths  from  tuberculosis  were  far  fewer.  This  fact  is  borne 
out  by  the  table  given  above,  for  in  1914,  when  the  average 
number  of  patients  was  2099,  the  number  of  deaths  from 
tuberculosis  was  only  42,  whereas  in  1918,  when  the  average 
number  of  patients  was  only  1769,  the  number  oL  deaths 
from  this  cause  was  208. 

Clinical  Features. 

One  of  the  features  of  pulmonary  tuberculosis  is  the 
variation  in  type  which  it  presents,  and  the  disease  as  it  is 
found  amongst  the  mentally  abnormal  population  is  a type 
by  itself.  In  the  great  majority  of  cases  the  classical  sym- 
ptoms of  the  disease  are  absent.  In  walking  through  a ward 
reserved  for  the  tuberculous  insane  one  is  at  once  struck  by 
the  almost  entire  absence  of  coughing.  The  same  applies 
to  sputum  ; the  tuberculous  insane  patient  has  little  or  no 
expectoration  for  the  twofold  reason  that  the  amount  of 
sputum  actually  produced  is  less  than  in  normal  cases,  and 
that  any  sputum  which  may  exist  is  swallowed.  Haemoptysis 
is  a rare  symptom.  The  temperature  shows  very  consider- 
able variation.  In  certain  cases  the  temperature  during  the 
latter  stages  of  the  disease  presents  the  usual  tuberculous 
type,  but  in  many  cases  it  is  subnormal,  even  when 
marked  pulmonary  disease  exists,  and  it  is  therefore 
not  to  be  relied  upon  as  a guide  to  diagnosis.  In 
the  non-tuberculous  demented  type  of  patient  it  is  quite 
usual  to  have  a subnormal  temperature  which  rises  to  normal 
when  tuberculosis  develops.  The  most  significant  feature 
of  pulmonary  tuberculosis  as  it  exists  amongst  the  insane 
and  mentally  defective  is  the  frequency  with  which  gross 
pulmonary  lesions  exist  without  any  corresponding  physical 
signs  to  suggest  the  existence  of  such  changes.  This  fact 
seriously  complicates  the  question  of  diagnosis  and  provides 
room  for  doubt  as  to  the  accuracy  of  the  statistical  evidence 
of  the  incidence  of  tuberculosis  in  asylums,  unless  such 
evidence  is  based  on  post-mortem  findings.  The  figures  1 
given  in  the  present  article  are,  for  the  most  part,  based 
on  post-mortem  evidence  and,  therefore,  may  be  accepted  as 
accurately  representing  the  upward  trend  of  asylum  tuber-  j 
culosis  since  the  outbreak  of  war.  The  clinical  picture  of  i 
asylum  tuberculosis  may  be  briefly  described  as  loss  of  flesh 
with  progressive  muscular  wasting  and  weakness,  and  the 
onset  of  diarrhoea  due  to  abdominal  tuberculosis  in  a large 
percentage  of  cases. 

JEtiological  Factors. 

The  high  attack-rate  and  death-rate  from  tuberculosis 
amongst  the  insane  are  due  to  fairly  well-defined  causes, 
some  of  which  are  preventable,  others  of  which  it  is  1 
impossible  to  control.  The  first  root  cause  is  the  lowered 
tissue  resistance  to  attacks  by  the  tubercle  bacillus,  which  is 
characteristic  of  mentally  abnormal  persons,  more  especially 
the  lower  grade  type  such  as  idiots,  imbeciles,  and  the 
demented.  In  the  Leavesden  Asylum  the  death-rate  from 
tuberculosis  has  always  been  high,  and  one  explanation  of 
this  high  rate  is  the  fertility  of  the  existing  soil  owing  to  the 
low  grade  and  hopeless  type  of  patient  which  is  admitted. 

The  large  majority  of  patients  admitted  are  in  weak  or 
very  weak  bodily  health,  and  it  has  been  rare  to  admit  a man 
or  woman  capable  of  doing  work.  Thetype  of  case  admitted  I 
may  be  gauged  from  the  fact  that  it  includes  broken  down  ; 
senile  cases,  epileptics,  demented  general  paralytics,  I 
demented  drunkards,  mental  defectives,  chiefly  idiots  and 
imbeciles  and  patients  with  advanced  bodily  disease  or  with  1 
serious  physical  defects.  Patients  of  this  type  are  unable  to 
work  or  even  to  walk  about.  Their  life  is  spent  in  bed  or  in 
sitting  on  a chair  in  the  ward,  with  the  result  that  they  have 
shallow  respiratory  movements  and  sluggish  circulation. 
This  leads  to  imperfect  lymphatic  drainage  of  the  lungs  and 
predisposes  to  tuberculosis. 

With  reference  to  the  relationship  between  the  mental 
phase  and  tuberculosis  it  is  apparent  that  certain  types  of 
mental  abnormality  exercise  a greater  influence  in  impairing 
the  resistaice  to  tuberculosis  than  others.  A certain  ! 
percentage  of  senile  cases  have  become  tuberculous  in  the  I 
asylum,  although  this  is  of  rare  recurrence  outside.  Thus 
of  326  senile  rases  which  died  during  the  five  years  ending 
Dec.  31st,  1918,  9 were  found  to  be  tuberculosis.  According 
to  Clouston,  general  paralytics  never  develop  tuberculosis, 
but  this  has  not  been  the  experience  at  the  Leavesden 


The  Lancet,]  DRS.  ELKINS  & THOMSON  : TUBERCULOSIS  IN  ASYLUM  PATIENTS.  [August  9,  1919  243 


Asylum.  It  should  be  mentioned,  however,  that  all  the 
general  paralytics  admitted  to  Leavesden  Asylum  are 
abnormal  and  most  of  them  are  of  the  demented  type.  Of 
52  general  paralytics  dying  during  the  five  years  ending 
Dec.  31st,  1918,  16  were  found  to  be  suffering  from  tuber- 
culosis. Clouston  also  taught  that  patients  with  fixed 
delusions  of  suspicion  and  unseen  agency  always  died  of 
tuberculosis,  while  persons  with  grandiose  delusions  never 
died  from  this  cause.  The  experience  at  Leavesden  Asylum 
shows  this  to  be  wonderfully  true.  This  fact  is  of  interest 
and  importance,  as  it  sheds  a suggestive  light  upon  the 
possible  setiological  relationship  between  the  mental  standard 
and  capacity  for  muscular  movement  and  tuberculosis. 

The  second  important  setiological  factor  in  the  high 
death-rate  from  tuberculosis  amongst  the  insane  is  contact 
infection.  All  the  available  clinical  evidence  is  in  favour 
of  contact  infection.  It  is  true  that  insane  tuberculous 
patients  have  rarely  any  expectoration,  and  therefore  the 
medium  of  infection  is  obviously  not  sputum.  The  frequency 
of  intestinal  disease  and  the  extent  to  which  the  hands, 
clothes,  bed  clothes,  &c. , are  contaminated  by  f:ccal  matter 
point  to  the  disease  being  conveyed  through  the  medium  of 
infected  excreta.  The  following  facts  clearly  indicate  that 
many  of  the  patients  dying  from  tuberculosis  have  con- 
tracted the  disease  while  resident  in  the  asylum  : — 


Male. 

Patients  found  suffering  from  tuberculosis  on 
admission  during  five  years  ending  1918  ...  31 

Female. 
..  12  .. 

Total. 

43 

Length  of  residence  of  patients  dying  from  tuber- 
culosis during  1918: — Under  1 year 

18 

...  8 .. 

26 

„ 5 years  

58 

...  11  .. 

69 

,.  10  

45 

...  13  .. 

58 

„ 20  

30 

...  6 .. 

36 

Over  20  ,,  

17 

...  2 .. 

19 

Deaths  from  tuberculosis  during  1918 : — 

Tuberculosis  (primary) 

150 

...  36  .. 

186 

,,  (secondary)  

18 

...  4 .. 

. 22 

168 

40 

208 

Closely  connected  with  the  two  primary  setiological  factors 
is  the  question  of  the  ventilation  and  heating  of  the  wards. 
Generally  speaking,  the  ventilation  and  air  space  provided 
are  not  sufficient  to  exercise  any  favourable  influence  in  com- 
bating the  marked  predisposition  on  the  part  of  mentally 
abnormal  persons  to  the  development  of  tuberculosis.  While 
an  abnormally  low  tissue  resistance  and  the  existence  of 
contact  infection  are  to  be  regarded  as  the  primary  causes  of 
the  high  incidence  of  tuberculosis  amongst  the  inmates  of 
asylums  compared  with  the  mentally  normal  population, 
other  factors  have  to  be  considered  which  are  responsible  for 
the  marked  increase  which  has  resulted  since  the  outbreak 
of  war.  The  first  and  most  important  of  these  was  the 
interference  with  the  standard  of  feeding,  more  especially 
with  regard  to  the  amount  of  fats  and  sugar.  Insane 
people  require  a diet  rich  in  fats  if  their  resistance  to 
tuberculosis  is  to  be  maintained  at  a satisfactory  level. 
Other  contributory  causes  are  the  occurrence  of  outbreaks  of 
influenza  and  pneumonia  during  1917,  and  more  especially  in 
1918,  the  weaker  state  of  the  patients  admitted  during  the 
period  referred  to,  the  serious  depletion  of  the  skilled  staff 
experienced  in  the  management  of  the  insane  sick  and  the 
methods  of  prevention  of  disease,  and  the  difficulty  expe- 
rienced in  maintaining  the  cleanliness  of  the  wards  by 
painting  and  other  means.  The  experience  of  the  past  four 
years  has  emphasised  how  extremely  sensitive  is  the  tuber- 
culous index  of  the  insane  to  unfavourable  conditions. 

The  Diagnosis  of  Tuberculosis  amongst  the  Insane. 

The  control  of  tuberculosis  depends  upon  early  recognition 
of  the  disease.  The  diagnosis  of  pulmonary  tuberculosis  as 
it  is  to  be  found  amongst  insane  persons  is  a clinical  problem 
of  peculiar  difficulty.  In  the  majority  of  cases  the  disease 
develops  and  progresses  without  presenting  any  definite 
symptoms  or  physical  signs,  and  it  is  not  until  the  condition 
is  revealed  by  post-mortem  examination  that  the  diagnosis  of 
tuberculosis  can  be  accurately  made.  As  has  been  previously 
stated,  the  figures  given  in  the  present  paper  are  based  on 
post-mortem  findings,  and  they  may  therefore  be  accepted  as 
accurately  representing  the  increase  in  the  death-rate  from 
tuberculosis  in  the  lower  grade  of  the  mentally  abnormal 
population  during  the  war. 


The  most  frequent  and  reliable  indication  of  tuberculosis 
in  the  insane  is  progressive  loss  of  weight  with  progressive 
muscular  asthenia.  The  downward  trend  will,  therefore, 
be  speedily  observed  if  all  patients  in  asylums  are  carefully 
and  regularly  weighed.  The  next  important  indication  is 
the  onset  of  chronic  diarrhoea,  more  especially  if  this 
follows  a period  of  falling  weight  and  failing  strength. 
Conclusive  evidence  will  be  obtained  by  the  bacteriological 
examination  and  the  finding  of  the  tubercle  bacillus. 
Indeed,  the  more  frequent  examination  of  the  excreta  for 
tubercle  bacilli  would  be  a great  aid  to  diagnosis  and 
would,  undoubtedly,  reveal  the  fact  that  amongst  the 
tuberculous  insane  the  presence  of  the  bacillus  in  the 
excreta  is  high  compared  with  that  in  the  tuberculous 
sane.  The  X ray  examination  of  the  chest  would  be  of 
value  in  clearing  up  the  diagnosis  in  certain  types  of 
cases,  although  its  application  might  not  always  be  an  easy 
matter.  The  extent  to  which  the  various  grades  of  tuberculous 
insane  patients  react  to  tuberculin,  especially  the  cuti- 
reaction,  is  worthy  of  further  investigation,  but  without  such 
investigation  it  cannot  be  relied  upon  as  of  any  assistance  in 
confirming  the  diagnosis  of  tuberculosis.  The  question  of 
diagnosis  may  be  summed  up  by  the  statement  that  the 
majority  of  low-grade  insane  patients  who  die  from  wasting 
or  chronic  diarrhoea  will  be  found  on  post-mortem  examina- 
tion to  have  been  suffering  from  tuberculosis. 

Prevention  and  Treatment. 

in  considering  the  measures  to  be  adopted  to  prevent  the 
spread  of  tuberculosis  amongst  the  insane  consideration  at 
the  onset  must  be  given  to  the  fact  that  we  are  dealing 
with  a type  of  individual  peculiarly  susceptible  to  the 
development  of  the  disease.  It  is  necessary,  therefore, 
that  prophylactic  measures  should  be  directed  towards 
maintaining  the  resistance  of  the  insane  patients  to 
tuberculosis  at  as  high  a level  as  possible,  and,  secondly, 
to  securing  the  segregation  of  tuberculous  cases  or  of  sus- 
pected tuberculous  cases  as  early  as  is  practicable  so 
as  to  prevent  the  spread  of  infection.  The  resistance 
of  the  insane  person  to  tuberculosis  during  residence  in 
an  asylum  chiefly  depends  upon  four  factors— viz. , exercise, 
ventilation,  warmth,  and  the  quantity  and  character  of 
the  diet.  Physical  exercise,  or  rather  the  lack  of  it,  has  a 
direct  influence  on  the  capacity  of  the  body  to  resist  tuber- 
culosis, but  the  physical  condition  of  many  insane  patients 
of  the  low-grade  type  precludes  the  possibility  of  any  regular 
form  of  physical  exercise.  The  amount  of  air  space  per 
non-tuberculous  patient  is  laid  down  by  the  Local  Govern- 
ment Board  or  the  Board  of  Control,  but  it  is  obvious  that, 
in  view  of  the  striking  proclivity  of  the  insane  person  to 
develop  tuberculosis  under  certain  conditions  of  asylum  life, 
the  amount  of  air  space,  and  especially  the  extent  of  floor 
space,  should  be  increased.  Efficient  ventilation  with  uniform 
efficient  heating,  conforming  to  some  extent  to  a modified 
open-air  regime,  would  appear  to  be  necessary.  The  insane 
person,  especially  of  the  lower  grade,  is  very  sensitive  to 
changes  of  temperature  and  has  generally  a poor  circulation, 
and  while  a frequent  change  of  air  is  essential  a sus- 
tained uniform  temperature  is  also  necessary.  A generous 
dietary  with  a liberal  allowance  of  fats  and  sugar  is 
of  primary  importance  in  raising  resistance  to  tuberculosis. 
In  common  with  the  rest  of  the  population  the  inmates  of 
asylums  have  suffered  during  1918  from  interference  with 
the  normal  scale  of  diet,  and  the  adverse  influence  of  the 
conditions  arising  from  war  would  undoubtedly  show  itself 
earlier  amongst  persons  of  a mentally  abnormal  type. 

With  regard  to  treatment  this  consists  for  the  most  part 
of  segregation  in  sanatorium  blocks  with  a view  to  pro- 
phylaxis. It  is  extremely  doubtful  if  the  onward  progress  of 
tuberculosis  to  a fatal  termination  can  be  definitely  arrested 
in  a hopelessly  insane  or  mentally  defective  person,  although 
the  progress  of  the  disease  may  be  very  slow.  Two  special 
types  of  sanatorium  wards  should  be  provided,  one  for  early 
cases  immediately  the  disease  is  diagnosed  and  for  suspected 
cases,  and  the  other  for  advanced  cases,  especially  those 
cases  with  evidence  of  intestinal  tuberculosis.  Cod-liver  oil 
or  one  of  its  preparations  in  combination  with  creosote 
should  be  administered  as  a method  of  routine  treatment. 
The  development  of  tuberculosis  in  an  insane  person  presents 
a tragic  picture,  and  to  visit  a tuberculosis  ward  in  a large 
asylum  is  an  experience  not  easily  forgotten.  The  question 
may,  no  doubt,  be  asked  if  it  serves  any  useful  or  even 


244  The  Lancet,]  PROF.  K.  PETREN : PRIMARY  TOXIC  EFFECT  OF  NEOSALVARSAN.  [August  9.  1919 


humanitarian  purpose  to  endeavour  to  prolong  the  life  of  the 
tuberculous  insane  person.  If  this  question  were  truthfully 
answered  from  the  point  of  view  of  the  economic  value  of 
the  tuberculous  insane,  it  would  be  answered  in  the  negative, 
but  as  the  aim  of  all  medical  effort  is  to  relieve  suffering  and 
prolong  life  the  insane  person  who  develops  tuberculosis 
must  receive  his  due  share  of  care  and  treatment. 

Conclusions. 

The  conclusions  to  be  drawn  from  a study  of  the  inci- 
dence of  tuberculosis  amongst  asylum  patients  are  as 
follows : — 

1.  That  the  mentally  abnormal  person  is,  generally  speak- 
ing, more  liable  to  develop  tuberculosis  than  the  individual 
who  is  mentally  normal. 

2.  That  this  liability  is  primarily  due  to  predisposition 
dependent  upon  the  mental  condition. 

3.  That  the  determining  factor  in  the  spread  of  tuber- 
culosis amongst  the  asylum  patients  is  contact  infection. 

4.  That  contact  infection  amongst  the  mentally  abnormal 
is  frequently  due  to  infected  excreta. 

5.  That  the  increase  in  the  prevalence  of  tuberculosis 
amongst  asylum  patients  since  the  commencement  of  the 
war  is  due  to  the  influence  of  a number  of  well-recognised 
factors  arising  from  the  war. 

6.  That  in  view  of  the  extreme  susceptibility  on  the  part 
of  asylum  patients  to  develop  tuberculosis  it  is  essential  that 
increased  efforts  should  be  made  to  provide  such  conditions 
of  asylum  life  as  will  tend  to  counteract  such  susceptibility. 


THE  PRIMARY  TOXIC  EFFECT  OF 
NEOSALVARSAN. 

By  Professor  K.  PETREN. 

( From  the  Intern  Clinic  of  the  University  of  Lund , Sweden. ) 

It  has  been  difficult  from  clinical  observations  to  decide 
the  question,  what  toxic  effects  salvarsan  produces.  We 
know  well  that  a very  great  number  of  observations  have 
been  published  in  which  morbid  symptoms  have  occurred 
after  the  injection  of  salvarsan  ; these  symptoms  have  often 
been  of  a very  serious  character,  and  Matzenauer  reported  in 
1916  that  about  200  fatal  cases  of  intoxication  by  salvarsan 
have  been  published.  The  symptoms  which  have  been 
observed  as  a consequence  of  the  injection  of  salvarsan  have 
been  very  various  in  the  different  cases  : one  can,  however, 
say  that  they  all  are  localised  to  the  nervous  system,  but 
otherwise  they  are  described  as  very  different. 

A “Toxic  Storm." 

As  regards  the  causes  of  the  morbid  symptoms  from  the 
nervous  system  which  we  can  observe  after  injection  of 
salvarsan,  it  is  generally  recognised  that  one  must  always 
take  into  consideration  the  possibility  that  they  may  be  a 
consequence  of  the  biological  interaction  between  the  human 
organism  and  the  micro-organisms  of  syphilis — as  the  expe- 
rience of  the  effects  of  salvarsan  has  almost  exclusively  been 
obtained  from  observations  of  patients  suffering  from  syphilis. 
Many  authors  have  accepted  the  suggestion  that  these 
symptoms  from  the  nervous  system,  to  a very  great  extent, 
are  due  to  a “ toxic  storm  ” — that  is  to  say,  that  they  suppose 
a very  great  number  of  the  micro-organisms  of  syphilis  have 
been  suddenly  killed  through  the  effects  of  salvarsan,  which 
has  resulted  in  a large  amount  of  toxin  suddenly  becoming 
free  in  the  blood. 

The  grounds  which  speak  for  such  an  interpretation  of  the 
salvarsan  poisoning  are,  indeed,  very  strong.  As  a con- 
sequence, we  can  never  come  to  very  definite  conclusions  as 
to  what  are  the  real  toxic  effects  of  salvarsan  itself,  so  long 
as  our  experience  is  confined  to  patients  suffering  from 
syphilis. 

Neosalvarsan  in  Influenza-pneumonia. 

During  the  great  epidemic  of  influenza  from  which  every 
country  in  the  world  has  suffered  during  the  last  year  I have 
had  the  opportunity  of  observing  the  effects  of  the  injection 
of  salvarsan  in  individuals  not  suffering  from  syphilis,  as  I 
have  tried  to  treat  the  influenza-pneumonia  with  neosalvarsan. 
In  this  paper  I shall  not  enter  upon  the  question  as  to  the 
effects  of  this  treatment  on  the  pneumonia  itself.  (I  hope 
that  I shall  find  occasion  shortly  in  another  medical  paper  in 
the  English  language  to  treat  of  this  question  among  a 


number  of  others  relating  to  my  experience  of  influeDza- 
pneumonia.)  Here  I will  only  speak  of  the  toxic  effect 
which  I have  observed  as  a consequence  of  the  injection  of 
(neo)  salvarsan. 

In  a great  number  of  cases  of  influenza-pneumonia 
(about  140)  we  have  given  injections  of  neosalvarsan.  In 
almost  every  case  we  injected  0 60  g.  (in  my  first  cases  only 
we  tried  a smaller  dose),  but  having  seen  no  harmful  effect 
follow  these  smaller  doses-we  had  at  once  progressed  to  the 
doses  of  0-60,  and  thereafter  regularly  continued  with  the 
large  doses. 

In  by  far  the  greater  number  of  cases  we  have  not  seen 
any  toxic  effect  whatever.  In  some  few  cases,  however,  we 
have  seen  a special  effect  of  the  injection,  inasmuch  as  the 
injection  has  been  followed  by  vomiting.  In  some  of  these 
cases  the  vomiting  occurred  only  once  ; in  other  cases  two 
or  three  times,  or  perhaps  sometimes  even  oftener.  This 
pathological  occurrence  has  quite  regularly  shown  the 
following  characters.  The  vomiting  has  appeared  during 
the  first  24  hours  following  the  injection — only  during  this 
period  and  never  later.  The  patients  have  not  shown 
any  other  signs  of  dyspeptic  troubles.  After  the  lapse  of 
24  hours  no  disturbance  of  the  stomach  has  occurred.  Practi- 
cally all  the  patients  suffering  from  influenza-pneumonia 
— and  I lay  special  stress  upon  this — have  been  treated  with 
digitalis,  either  with  drug  or  with  digitotal  (a  preparation 
which  approximately  corresponds  to  digalen).  When  I first 
saw  these  cases  of  vomiting  I did  not  venture  to  give  them 
digitalis  for  the  next  few  days,  but  after  having  found  that 
the  patients  to  whom  I had  given  digitalis  after  two  or  three 
days  tolerated  it  with  no  more  difficulty  than  other  patients, 

I began  later  to  give  even  these  patients  digitalis  in  the  cases 
with  vomiting,  when  the  first  day  had  passed,  in  other  cases 
also  during  the  first  24  hours  after  the  injection. 

Vomiting  after  the  injection  of  salvarsan  we  have  seen  in 
a great  number  of  cases  of  pneumonia  among  women.  For 
a time  I did  not  observe  the  occurrence  among  men,  but  later 
I saw  it  in  four  cases  of  men  ; for  three  of  these  cases  , 
the  body  weight  was  determined  53  kg.  (19  years),  53  5 kg. 
(28  years),  and  57  kg.  (17  years)  ; the  fourth  patient  was  a 
man  of  24  years  and  was  not  a person  of  great  weight,  j 
Otherwise  we  have  not  seen  the  least  toxic  trouble  after  the 
injection  of  neosalvarsan.  We  have  never  seen  albuminuria 
when  the  patients  had  not  shown  it  before  the  injection,  and 
in  those  cases  where  they  had  albuminuria  before  the  injec- 
tion we  have  never  observed  that  it  had  increased  as  a 
consequence  of  the  injection.  Also  the  microscopical 
examination  of  the  urine  has  never  shown  an  increase  of 
the  sediment  as  a consequence  of  the  injection.  We  have 
never  seen  headache,  vertigo,  or  other  symptoms  from  the 
nervous  system — with  exception  of  the  vomiting — after  the  ' 
injection. 

Conclusions. 

From  the  foregoing  description  we  find  that  the  toxic 
effect  after  the  injection  of  salvarsan  was  quite  mono- 
symptomatic,  and  that  the  only  toxic  effect,  when  it  occurred 
at  all,  followed  fixed  laws,  as  its  occurrence  was  limited  to  a 
fixed  period  after  the  injection  and  was  also  to  a certain  degree 
dependent  on  the  weight  of  the  individual  that  had  received 
the  injection. 

When  we  take  these  circumstances  into  consideration  it 
seems  unnecessary  to  discuss  the  question  where  the  injected 
salvarsan  exercises  its  effects,  as  it  is  quite  manifest  that  a 
morbid  phenomenon  of  this  regular  character  and  of  this 
short  duration  (with  no  exception  from  the  rule  that  the 
vomiting  occurs  only  during  the  first  24  hours  after  the 
injection)  cannot  be  the  consequence  of  a local  effect  exer- 
cised on  the  stomach  wall,  but  must  be  the  effect  of  the  poison 
on  the  centre  of  vomiting  in  the  bulb. 

In  consequence,  thanks  to  the  circumstance  that  my 
observations  on  the  effect  of  the  injection  of  sal var-an  are 
uncomplicated,  in  the  sense  that  they  are  free  from  the  dis- 
turbing influence  of  the  biological  effect  exercised  by 
salvarsan  on  the  micro-organism  of  syphilis,  and  thanks  to  : 
the  fact  that  these  observations  are  of  sufficiently  great 
number  to  lead  to  the  deduction  that  the  phenomena  produced 
are  governed  by  certain  laws,  we  come  to  the  conclusion  that 
the  first  toxic  effect  of  salvarsan  (neosalvarsan)  on  man  can 
be  demonstrated  with  the  certainty  of  an  experiment  on 
animals,  and  that  this  toxic  effect  consists  in  a strictly  elec- 
tive effect  produced  exclusively  on  the  centre  of  vomiting  in 
the  medulla  oblongata. 


THE  Lancet,]  MR.  J.  J.  GRACE:  TREATMENT  OF  SCIATICA  BY  RADIANT  HEAT,  ETC.  [August  9,  1919  245 


FURTHER  REPORT  ON  THE 

TREATMENT  OF  SCIATICA 

BY  RADIANT  HEAT  AND  STATIC  WAVES. 

By  JOHN  J.  GRACE,  F.R.C.S.  Eng., 

LATE  MEDICAL  OFFICER  Ilf  CHARGE  OF  THE  EI.ECTRO-THKRAPEUTIC 
DEPARTMENT,  MANOR  HOUSE  ORTHOPAEDIC  HOSPITAL. 


Some  years  ago  I published 1 a short  report  on  the  treat- 
ment of  sciatica  by  radiant  heat  and  the  static  wave  current. 
In  the  interval  I have  treated  some  70  cases,  and  the  results 
obtained  are  instructive. 

So  far  as  has  been  possible  I have  differentiated  between 
sciatica  and  pain  in  the  sciatic  distribution  due  to  osteo- 
arthritis of  the  hip-joint,  or  of  the  sacro-iliac-joint,  but  this 
distinction  is  not  always  possible,  and  perhaps  some  of  the 


unrelieved  cases  are  of  this  nature.  Of  the  70  treated,  59 
were  cured  or  relieved  of  the  pain  to  such  a degree  that  they 
could  pursue  their  usual  avocations  in  comfort.  If  it  be 
taken  into  consideration  that  I do  not  see  mild  or  early  cases 
of  sciatica,  practically  all  being  referred  cases  in  which  other 
forms  of  treatment  have  failed,  I think  the  results  shown  in 
the  table  are  very  good.  The  term  recovery  as  used  in  the 
table  means  complete  recovery,  and  “no  improvement  ” is 
the  expression  of  my  opinion.  The  other  terms  are  taken 
from  the  patients. 

The  treatment  is  painless,  except  to  those  few  people  to 
whom  all  electricity  is  painful.  One  of  these  patients  is 
included  in  the  above  list,  and  though  she  hated  the  treat- 
ment she  persisted  to  a triumphant,  though  belated,  con- 
clusion. No  exposure  is  involved,  though  the  electrode  must 
be  applied  to  the  bare  skin,  and  finally  no  harm  is  done  in 
the  event  of  failure. 


No.  of 
Case. 

Sex. 

Age. 

Duration. 

No.  of 
treatments. 

Result. 

| No.  of 
Case. 

Sex. 

Age. 

Duration. 

No,  of 

treatments. 

Resul^. 

1 

M. 

19 

4 ra. 

ii 

Recovery. 

36 

F. 

58 

5 d. 

N.r. 

Recovery. 

2 

M. 

32 

3 w. 

_ 

37 

M. 

58 

N.r. 

4 

Very  much  better. 

3 

M. 

34 

i y- 

( 12  S.w.;  ^ 
7 6 X-ray.  ) 
13 

No  improvement. 

38 

M. 

59 

(see  belowt) 

13 

Not  mnch  better. 

4 

M. 

34 

6 w. 

Recovery. 

39 

M. 

60 

i y- 

— 

No  improvement. 

5 

F. 

35 

4 y- 

19 

40 

M. 

62 

4 ra. 

15 

Very  much  better. 

6 

M. 

35 

ll.m. 

N.r. 

Improvement  (could  play  golf). 

41 

M. 

62 

2 w. 

12 

7 

M. 

35 

3 w. 

26 

Almost  well,  a little  stiff. 

42 

M. 

70 

2 w. 

21 

Recovery. 

8 

M. 

36 

4 w . 

N.r. 

Recovery. 

43 

F. 

70 

2 m. 

8 

Great  improvement. 

9 

F. 

36 

4 m. 

,, 

44 

M. 

71 

2d. 

12 

Recovery. 

10 

M. 

36 

4 w. 

11 

45 

M. 

75 

N.r. 

N.r. 

Very  much  better. 

11 

M. 

37 

9 ra. 

- 

No  improvement. 

46 

M. 

77 

4 m. 

” 

Improved. 

12 

M. 

37 

2 m. 

12 

Much  better. 

47 

M. 

88 

5 m. 

4 

Very  much  better. 

13 

M. 

38 

i y- 

16 

Very  much  better. 

48 

M. 

N.r. 

Some  w. 

N.r. 

Recovery. 

14 

M. 

40 

5 d. 

4 

Recovery. 

49 

M. 

1 w. 

8 

Much  better. 

15 

M. 

41 

6 ra. 

12 

,, 

50 

F 

5m.  on  & off. 

5 

16 

M. 

44 

4y- 

4 

51 

M. 

Few  m. 

8 

Almost  well. 

17 

M. 

45 

1 m. 

10 

n 

52 

M. 

,, 

3 m. 

12 

Recovery. 

18 

M. 

46 

5 m. 

— 

|f 

53 

F. 

5 ra. 

24 

19 

M. 

47 

6 m. 

- 

No  improvement. 

54 

M. 

3 w. 

4 

.. 

20 

M. 

47 

2 w. 

6 X-ray. 

Very  much  better. 

55 

F. 

.. 

3 m. 

10 

” 

21 

M. 

48 

5 ra. 

12 

Complete  recovery. 

56 

F. 

4 w. 

11 

» » 

22 

M. 

49 

1 w. 

10 

Recovery. 

57 

F. 

.. 

6 w. 

6 

» > 

23 

M. 

50 

14  w. 

14 

58 

F. 

,, 

2 y- 

6 

.. 

24 

M. 

50 

(see  below*) 

10 

„ 

59 

F. 

iy- 

N.r. 

Practically  well. 

25 

M. 

50 

1 w. 

N.r. 

60 

F. 

,, 

About  2 w. 

9 

Recovery. 

26 

M. 

50 

5 m. 

89 

Jf 

61 

F. 

• » 

2d. 

2 

** 

27 

M. 

52 

1 d. 

7 

,, 

62 

M. 

,, 

3 m. 

N.r. 

No  improvement. 

28 

M. 

53 

10  d. 

N.r. 

,, 

63 

F. 

6 m. 

12 

.. 

29 

M. 

53 

14  y. 

10 

No  improvement. 

64 

F. 

M 

5 ra. 

9 

30 

M. 

53 

2y. 

25 

Recovery. 

65 

M. 

- 

10  m. 

S.w..  n.r., 
13  X-ray. 
9 

Improved,  but  not  well. 

31 

M 

54 

6 ra. 

N.r. 

,1 

66 

F. 

10  m. 

No  improvement. 

32 

M. 

55 

2 w. 

4 

,, 

67 

M. 

.. 

11  m. 

14 

,, 

33 

M. 

56 

N.r. 

8 

.. 

68 

F. 

i y- 

N.r. 

Recovery. 

34 

M. 

57 

4 m. 

18 

.. 

69 

M. 

„ 

9 ra. 

10 

Practically  well. 

35 

M. 

57 

1 ra. 

N.r. 

•• 

70 

F. 

•• 

iy. 

6 

Very  much  better. 

* An  attack  every  3 years  for  11  years,  t 10  years’  history  of  pain  in  legs  ; doubtful  osteo-arthritis.  N.r.,  not  recorded  ; 
S.w.,  static  wave ; d.,  days  ; w.,  weeks  ; m.,  months ; y.,  years. 

Remarks. 


Case  3.— Relapse  during  military  service. 

Case  5. — Had  spent  8 months  in  bed. 

Case  7. — This  case  was  remarkable  for  its  severity,  and  though  the 
present  attack  was  of  short  duration  he  had  had  a previous  severe  and 
prolonged  attack.  The  usual  treatment  by  the  static  wave  with  an 
electrode  6"  X 4''  applied  over  the  gluteal  region  from  behind  the 
trochanter  up  towards  the  sacrum  having  failed  to  relieve,  I examined 
the  prostate,  which  was  enlarged  and  tender.  Treatment  of  this  with 
a rectal  electrode  produced  almost  immediate  relief  of  the  sciatica 
and  markedly  reduced  the  size  of  the  prostate. 

Cask  10. — Much  better  after  five,  then  relapse,  and  bed  for  a week. 
Then  six  more  treatments. 

Cask  13. — This  man  was  buried  by  a shell  explosion  in  1914.  When 
dug  out  his  thigh  was  bent  back  so  that  his  heel  was  against  his  back. 
Pain  in  the  sciatic  distribution  was  constant.  He  left  much  improved 
and  free  from  pain  after  16  treatments.  The  peroneal  group  of  muscles 
were  partially  paralysed. 

Case  15. — Was  blown  up  by  a shell,  and  sciatica  started  imme- 
diately. Had  had  various  treatments  by  electricity  and  massage  before 
he  came  to  me. 

Case  16. — Had  been  prisoner  of  war  and  had  had  no  treatment. 

Case  18. — Present  attack  had  lasted  five  months.  When  first  seen 
he  had  marked  scoliosis.  He  walked  with  great  difficulty,  with  the  aid 
of  a Btick,  on  the  toes  of  his  left  foot.  Could  bear  no  weight  at  all  on 


1 The  Lancet,  Jan.  10th,  1914. 


the  leg.  Pain  very  severe  and  continuous.  In  six  weeks  the  pain  was 
slight,  but  the  scoliosis  remained.  Two  months  later  he  was  quite 
straight  and  could  walk  well. 

Case  20.  — Was  treated  with  the  X ray  only,  as  the  static  wave 
current  did  not  appear  to  benefit  him. 

Case  21. — This  patient’s  sciatica  was  relieved  after  12  treatments. 
Attention  was  then  directed  to  lumbago,  from  which  he  had  suffered 
for  eight  years.  This,  too,  got  quite  well. 

Case  23. — This  patient  improved  steadily  for  ten  treatments ; then 
improvement  ceased.  The  prostate  was  examined  and  found  slightly 
enlarged.  After  four  treatments  to  this  he  got  quite  well. 

Case  29. — Patient  discontinued  treatment. 

Case  31.— Returned  2 years  later  with  recurrence  which  got  well,  and 
again  1 year  later. 

Case  37. — Had  to  return  to  trenches  (very  pleased).  • 

Case  43.— High  blood  pressure  210  mm.  reduced  to  165  by  auto- 
condensation . 

Case  47. — Discontinued  owing  to  gout  in  knee. 

Case  49. — Had  to  stop  treatment.  Was  a soldier  under  orders. 

Cases  60  and  61. — Same  patient,  different  attacks  and  sides. 

Case  62. — Got  practically  well.  Went  for  a long  walk,  relapse i , and 
did  not  again  improve. 

Case  63.  - Recovered  after  operation  for  piles. 

Case  67.— Sciatica  followed  wound  of  thigh. 

Case  70. — Discontinued  owing  to  death  in  family. 

Welbeck-street,  W. 


246  The  Lancet,]  DR.  F.  E.  TAYLOR:  INJECTIONS  OF  ANTIMONIUM  TARTARATUM. 


[August  9,  1919 


INTRAVENOUS  INJECTIONS  OF  ANTI- 
MONIUM TARTARATUM  (TARTAR 
EMETIC)  IN  BILHARZIASIS. 

By  FRANK  E.  TAYLOR,  M.D.,  M.Sc.,  F.R.C.S.,  D.P.H., 

LECTURER  ON  BACTERIOLOGY,  UNIVERSITY  OF  LONDON,  KING'S  COLLEGE; 
1'ATHOLOGIST  AND  UAC I'ERIOlOGIST  TO  THE  BERMONDSEY 
MILITARY  HOSPITAL. 


Owing  to  the  recent  important  advances  in  our  knowledge 
of  bilharziasis  much  attention  has  been  attracted  to  this  con- 
dition. These  advances  are  chiefly  due  to  the  work  of 
Leiper,  Fairley,  and  Christopherson. 

Summary  of  Recent  Advances. 

In  1915  Leiper 1 worked  out  the  complete  cycle  of  develop- 
ment of  the  bilharzial  worms,  giving  a connected  story 
of  their  life-history.  He  found  the  non-eyed,  bifid-tailed 
cercarim  characteristic  of  the  genus  in  two  genera  of  snails, 
Rullinus  contortus  and  Planorbis  boissyi.  These  snails  were 
shown  to  harbour  two  different  species  —Bilharzia  hcematobia, 
characterised  by  a terminal-spined  ovum,  and  Bilbarzia 
mansoni,  characterised  by  a lateral-spined  ovum. 

Fairley’s*  3 work  demonstrated  how  bilharzial  parasites  and 
their  ova  exert  a deleterious  influence  on  the  tissues  of  their 
definitive  host,  man,  mainly  by  the  production  of  toxins,  and 
not  merely  mechanically.  These  toxins  call  into  action 
cellulo-humeral  responses  which  neutralise  or  limit  their 
activity.  As  a result  immune  bodies,  including  complement- 
fixing substances,  are  produced,  and  a complement-fixation 
test  for  bilharziasis  has  been  devised  by  Fairley  comparable 
to  the  Wassermann  test  for  syphilis.  As  antigen  an  alcoholic 
extract  of  the  infected  livers  of  snails  (P.  boissyi)  was 
employed.  Positive  complement-fixation  was  obtained  in  a 
high  percentage  of  cases  in  man  as  well  as  in  experimentally 
infected  monkeys.  The  practical  application  of  this  test, 
Fairley  considers,  will  facilitate  the  diagnosis  of  bilharziasis 
in  the  early  stages  of  the  disease  before  localising  symptoms 
have  developed,  and  also  in  estimating  the  effect  of  the  intra- 
venous administration  of  drugs  on  the  adult  parasites. 

Christopherson4  5 introduced,  or  independently  re-intro- 
duced, the  administration  of  intravenous  injections  of  solutions 
of  tartarated  antimony  (tartar  emetic)  with  success,  and  claims 
that  this  method  constitutes  a specific  cure  for  the  disease. 
It  was  the  satisfactory  results  obtained  by  himself  and  others 
by  this  method  in  Oriental  sore,  internal  leishmaniasis,  and 
naso-oral  leishmaniasis  (espundia)  as  found  in  the  Sudan 
which  induced  Christopherson  to  apply  it  in  bilharziasis, 
vesical  and  rectal.  This  method  was  commenced  by  him  in 
the  Khartoum  Civil  Hospital  in  May,  1917.  In  September, 
1918,  he  recorded  13  cases  of  Schistosomum  bcematobium 
treated  by  this  method  with  apparently  complete  cure  in  all 
the  cases,  but  with  relapses  in  from  one  to  eight  months  in 
three  cases.  As  the  result  of  his  experience  he  considers 
that  there  is  no  doubt  that  antimony  given  as  intravenous 
injections  of  tartar  emetic  considerably  interferes  with  the 
bilharzia  and  suspends  its  activities,  even  when  it  does  not 
actually  kill.  His  own  opinion,  based  on  the  cases  treated 
during  the  last  year,  is  that  antimony  (antimony  tartrate)  is 
a definite  cure  for  bilharziasis,  and  that  intravenous  injections 
of  tartar  emetic  kill  the  Schistosomum  bcematobium  in  the 
blood  and  render  it  harmless. 

Christopherson’s  method  consisted  in  giving  a course  of 
injections  on  alternate  days  for  a period  of  15  to  30  days, 
commencing  with  4 gr.  dissolved  in  6 c.cm.  of  distilled  water 
and  increasing  by  ^ gr.  up  to  2 gr.  until  a total  of  30  gr. 
have  been  injected.  This  amount  he  considers  to  be  the 
required  killing  dose,  notwithstanding  that  all  the  symptoms 
of  the  disease  often  completely  disappear  after  the  first  or 
second  injection. 

Series  of  Cases. 

The  following  ten  cases  of  vesical  bilharziasis  have  recently 
been  treated  by  this  method  at  the  Bermondsey  Military 
Hospital : — 

Case  1. — Pte.  C.  Admitted  to  the  Bermondsey  Military 
Hospital  on  Sept.  21st,  1918,  having  been  transferred  to 
England  from  Egypt  for  bilharziasis.  Blood  first  noticed  in 
urine  in  August,  1916.  Much  blood  and  many  terminal- 
spined  bilbarzia  ova  found  in  urine.  Had  17  injections  of 
tartar  emetic  intravenously,  291  gr.  being  given.  Stiffness  of 
neck  and  shoulder  muscles  after  injection.  Discharged  well 
Dec.  12th,  1918. 


Case  2. — Pte.  T.,  aged  27.  Admitted  Sept.  21st,  1918. 
Transferred  to  England  from  Egypt  for  bilharziasis.  Com- 
plained of  hmmaturia  and  abdominal  pain  in  July,  1918, 
having  been  stationed  in  thePayoum  District  for  13  months. 
Albumin,  blood,  and  terminal-spined  bilharzia  ova  found  in 
urine.  Ten  intravenous  injections  with  a total  of  2\l  gr.  of 
tartar  emetic.  No  further  blood  or  ova  in  urine.  Discharged 
well  Jan.  20th,  1919. 

Case  3. — Cpl.  B.,  aged  29.  Admitted  Sept.  21st,  1918, 

having  been  transferred  to  England  from  Egypt  for 
bilharziasis.  Was  in  the  Fayoum  District  in  1915-16, 
where  he  developed  baematuria  with  dysuria  and  hypo- 
gastric pain.  Albumin,  blood,  and  terminal-spined  bilharzia 
ova  found  in  urine.  27|  gr.  tartar  emetic  injected  intra- 
venously. Cough  and  irritation  of  the  throat  after  each 
injection,  and  vomiting  after  one  injection.  Blood  and  ova 
not  again  found  in  urine.  Discharged  well  Dec.  18th,  1918. 

Case  4. — Spr.  S.,  aged  39.  Admitted  Sept.  21st,  1918. 
Went  to  Egypt  December,  1915.  Began  to  pass  blood  and 
clots  in  urine  in  November,  1916.  Complained  of  haematuria 
and  burning  sensation  at  end  of  micturition  with  general 
weakness,  wasting,  and  anmmia.  Weight  had  fallen  from 
14  st.  to  10  st.  7 lb.  Terminal-spined  bilharzia  ova,  red  blood 
cells,  and  a little  albumin  in  urine.  27J  gr.  tartar  emetic 
given  intravenously  in  17  injections.  Complained  after 
various  injections  of  irritation  in  the  throat,  with  tickling 
cough,  nausea,  vomiting,  diarrhoea,  and  stiffness  of  muscles 
of  neck  and  shoulders.  Blood  and  ova  not  again  found  in 
urine.  Discharged  well  Dec.  4th,  1918. 

Case  5. — Pte.  L.,  aged  22.  Admitted  Sept.  8th,  1918.  Had 
been  in  Egypt  since  April,  1916.  Haematuria  commenced  in 
January,  1917.  Bilharzia  ova  found  in  urine  in  Egypt,  but 
not  in  England,  though  albumin  and  blood  were  present. 

22A  gr.  tartar  emetic  injected.  Rigor,  pyrexia  (103°),  nausea, 
vomiting,  and  pain  in  the  body  after  injections.  Discharged 
fairly  fit  and  free  from  bladder  symptoms  Dec.  19th,  1918. 

Case  6.— Pte.  M.,  aged  21.  Admitted  Sept  21st,  1918.  Sent 
direct  from  Egypt,  where  he  had  been  since'  December, 
1915.  Haematuria  commenced  May,  1916.  Urine  showed  a 
trace  of  albumin  and  abundance  of  red  blood  cells  and 
terminal-spined  bilharzia  ova.  301  gr.  tartar  emetic  injected. 
Symptoms  produced  were  immediate  cough,  giddiness, 
vomiting,  slight  diarrhiea,  and  stiffness  in  shoulder  muscles.  1, 
Blood  and  ova  not  found  again.  Discharged  well  Dec.  19th,  % 
1918. 

Case  7.— Lcpl.  D.,  aged  22.  Admitted  Sept.  9th,  1918.  1 
Went  to  Egypt  November,  1915.  Haematuria  first  observed 
at  Fayoum  October,  1916.  Urine  contained  terminal-spined 
bilharzia  ova,  red  blood  cells,  and  a trace  of  albumin,  j 
Sixteen  injections  (29  gr.)  tartar  emetic.  No  ova  after 
completion  of  injections.  Weight  increased  from  10  st.  7 lb.  4 
to  li  st.  41  lb.  Discharged  well,  except  for  a little  weakness.  ! 

Case  8. — Pte.  G.,  aged  25.  Admitted  Jan.  17th,  1919.  Sent 
direct  from  Egypt  for  bilharziasis.  Was  infected  in  the  < 
Fayoum  District  1915-16.  Blood  cells  and  terminal-spined 
bilharzia  ova  abundant  in  urine.  31J  gr.  tartar  emetic 
injected.  Pyrexia  (100°)  and  general  pruritus  occurred  after 
two  injections.  No  further  blood  or  ova.  Discharged  well. 

Case9. — Cpl.  M.,  aged  30.  Admitted  Oct.  12th,  1918.  Sent 
direct  from  Egypt  for  bilharziasis.  Blood  and  terminal-  * 
spined  bilharzia  ova  found  in  urine.  30  gr.  tartar  emetic 
injected.  Irritative  cough  and  headache  after  injections. 

No  more  blood  or  ova  in  urine.  Discharged  free  from 
bladder  symptoms,  though  still  has  slight  dull  pain  in  small 
of  back,  and  patient  considers  he  is  weaker  and  more  easily 
tired  than  before  injections. 

Case  10.— Pte.  C..  aged  25.  Admitted  Nov.  12th,  1918.  Was 
perfectly  fit  until  sent  to  Egypt  in  September,  1915.  Was 
stationed  in  the  Fayoum  Province  until  November,  1916, 
when  he  was  sent  to  Palestine,  where  the  haematuria  com- 
menced. Bilharzia  ova  found  in  urine.  301  gr.  tartar 
emetic  injected.  At  the  end  of  the  course  of  injections  the 
urine  was  free  from  ova,  blood,  and  albumin,  but  patient 
still  complained  of  pains  in  the  back  and  over  the  bladder. 
During  the  following  week  there  was  a recurrence  of  the 
haematuria,  with  headache  and  more  pain  on  micturition. 
The  urine  contained  red  blood  cells  and  granular  epithelial 
cells,  but  no  ova  were  found.  Patient  was  transferred  to  the 
4th  London  General  Hospital. 

Results. 

In  all  these  cases  the  solutions  used  were  made  by 
dissolving  the  tartar  emetic  in  freshly  distilled  sterile  water, 

1 gr.  in  6 c.cm.,  and  then  sterilised  by  autoclaving  for  one 
hour.  At  first  the  injections  w^ere  administered  every  two 
days,  with  a maximum  dose  of  2 gr.,  whilst  on  the  later 
cases  I worked  up  to  doses  of  3 gr.  twice  a week.  No  serious 
drawback,  no  marked  toxic  manifestations,  and  no  severe 
reactions  followed  the  injections.  With  one  exception  all 


The  Lancet,]  DR.  F.  E.  TAYLOR:  INJECTIONS  OF  ANTIMONIUM  TARTARATUM.  [August  9.  1919  247 


the  patients  were  troubled  with  irritation  of  the  pharynx  and 
a spasmodic  outburst  of  coughing  either  during  or  after  the 
injections,  usually  just  at  the  end  of  administration.  In  four 
cases  stiffness  and  cramp  of  the  muscles  of  the  neck  and 
shoulder  girdle  were  complained  of.  Gastro-intestinal  sym- 
ptoms were  fairly  frequent,  comprising  nausea  in  3 cases, 
vomiting  (usually  once  only)  in  4 cases,  and  slight  diarrhoea 
in  3 cases.  Headache  was  noted  in  2 oases.  There  was 

induration  at  the  seat  of  injection  in  2 cases.  Pyrexia  (to 

103°  F.),  slight  giddiness,  pains  in  the  body,  general 
pruritus,  and  loss  of  weight  were  noticed  in  1 case  each. 


Untoward  Effects  of  the  Injections. 


Cases. 


Cough  and  pharyngeal  irrita- 
tion   9 

Stiffness  of  neck  and  shoulder 

muscles  4 

Nausea 3 

Vomiting  (slight)  4 

Diarrhoea  (slight)  3 

Headache  2 


Induration 

Pyrexia(to  103°  P.) 

Giddiness  (slight)  

Pains  in  the  body  

General  pruritus  

Loss  of  weight 

Relapse  of  hsematuria  .. 


Cases. 
...  2 
...  1 
...  1 
...  1 
...  1 
...  1 
...  1 


The  immediate  results  were  very  striking  and  comprised  a 
rapid  disappearance  of  the  blood  and  ova  from  the  urine, 
disappearance  or  mitigation  of  the  hypogastric  and  perineal 
pains  and  pain  in  micturition,  improvement  in  anaemia,  gain 
of  weight,  and  a quite  striking  improvement  in  general 
appearance  and  feeling  of  well-being.  The  remote  results  I 
am  unable  to  discuss  owing  to  the  short  time  elapsed  and  to 
the  fact  that  all  the  patients  have  left  the  hospital.  As  far 
as  is  known  all  the  cases  have  remained  free  from  symptoms 
except  Case  10,  who  developed  a smart  htematuria  within  a 
week  of  completing  the  course  of  injections  ; no  ova  could  be 
discovered  on  microscopic  examination  of  his  urine. 

Case  3 was  so  pleased  that  he  writes  from  the  country 
under  date  Dec.  22nd,  1918 

“ The  haemorrhage  has  completely  stopped,  and  bar  a little 
pain  in  the  affected  region  I am  practically  fit  ” (although 
he  states  elsewhere  his  duties  are  not  of  a very  light 
character).  “There  are  one  or  two  fellows  here  who  are 
discharged  with  bilharziaand  have  had  no  treatment  what- 
ever. They  are  naturally  anxious  to  undergo  this  particular 
treatment.  I should  be  greatly  obliged  if  you  could  inform 
me  as  to  the  course  they  should  adopt  to  obtain  it.” 

That  tartar  emetic  injected  intravenously  exerts  a strikingly 
beneficial  effect  on  vesical  bilharziasis  is  amply  demonstrated 
by  the  cases  here  recorded,  but  how  this  effect  is  produced  is 
not  so  evident.  That  the  drug  kills  or  inhibits  the  activity 
of  the  parasite  appears  the  most  reasonable  suggestion.  At 
what  stage  in  the  life  history  of  the  parasite  this  occurs, 
whether  ovum,  miracidium,  or  adult  worm,  or  all  three,  has 
not  yet  been  demonstrated.  Christopherson  claims  that  the 
tartar  emetic  exerts  a direct  helminthicidal  action  on  the 
adult  worm.  Direct  experimental  proof  on  this  point  is  still 
lacking,  though  Archibald  and  Innes’s  case,  the  only  one  so 
far  submitted  to  post-mortem  examination,  provides  some 
support  for  this  view. 

The  Toxicity  of  Tartar  Emetic. 

The  high  toxicity  of  tartar  emetic  has  always  been  a 
matter  of  serious  concern  to  those  employing  it  in  intra- 
venous injections,  especially  in  the  intensive  manner  now 
prevailing  for  the  treatment  of  bilharziasis,  trypanosomiasis, 
and  leishmaniasis.  That  such  injections  are  not  free  from 
risk  is  shown  by  Knowles6  and  by  Archibald  and  Innes.7 
The  former  recorded  5 deaths  out  of  20  cases  of  kala-azar 
treated  by  tartar  emetic,  whilst  the  latter  record  a fatal  case 
of  bilharzia  so  treated. 

The  case  of  Archibald  and  Innes  was  a strong  Egyptian 
soldier  suffering  from  hsematuria,  whose  urine  showed  a 
heavy  infection  with  terminal-spined  ova  of  bilharzia. 
The  solution  employed  for  intravenous  injection  contained 
1 gr.  of  the  drug  dissolved  in  2 c.cm.  of  sterile  water, 
being  mixed  immediately  before  use  with  an  equal  amount 
of  sterile  normal  saline  solution.  The  initial  dose  was 
i gr.,  gradually  increasing  to  a maximum  of  2 gr.,  until  a 
total  of  33  gr.  were  given,  the  injections  being  given  every 
second  day.  At  the  end  of  the  treatment  the  urine  con- 
tained blood,  but  no  ova.  The  patient  then  developed 
influenza,  and  died  on  the  fourth  day  of  the  illness  from 
broncho-pneumonia.  At  the  autopsy  no  adult  worms  could 
be  found,  though  the  congested  mucous  membrane  of  the 
bladder  contained  large  numbers  of  bilharzial  ova.  The 
liver  and  kidney  cells  and  the  tunica  intima  of  the 
inferior  vena  cava  showed  fatty  degeneration  and  fatty 


infiltration,  changes  which  were  attributed  to  the  action  of 
tartar  emetic,  and  were  not  sequels  of4bilharzia,, influenza, 
or  a previous  malarial  infection. 

This  opinion  of  Archibald  and  Innes  appears  correct,  as 
somewhat  similar  changes  are  found  in  the  liver  in  certain 
toxic  conditions,  especially  in  the  closely  allied  conditions  of 
arsenic  and  phosphorus  poisoning,  and  as  was  found  by 
Gregorsonand  Taylor"  in  trinitrotoluol  poisoning.  The  toxins 
attributed  to  the  ova  and  miracidia  of  bilharzia  by  two 
Japanese  observers,  Kiyono  and  Murakami,"  do  not  appear  to 
produce  fatty  changes  in  the  liver,  but  lead  to  a cirrhotic 
condition  of  that  organ. 

Although  in  Archibald  and  Innes's  case  the  cause  of  death 
appears  to  have  been  influenzal  broncho-pneumonia  the 
degenerative  changes  in  the  liver  and  kidneys  may  have 
been  recoverable,  or  may  have  been  due  to  undue  suscepti- 
bility of  the  patient  to  antimony.  That  very  much  larger 
doses  of  tartar  emetic  can  be  given  intravenously  with 
perfect  safety  is  evident  by  a case  under  the  care  of  Dr.  C.  W. 
Daniels,  treated  by  Dr.  H.  B.  Newham,  C.M.G.,10  at  the 
Seamen’s  Branch  Hospital  attached  to  the  London  School  of 
Tropical  Medicine. 

This  was  a patient  infected  with  Trypanosome  rhodesiense, 
who  received  236  bi-weekly  intravenous  injections  of  tartar 
emetic  in  the  course  of  two  and  a half  years.  The  maximum 
dose  was  2)  gr.,and  the  total  quantity  administered  amounted 
to  the  enormous  total  of  550  gr.  The  patience  of  the  physician 
and  the  fortitude  of  the  patient  were  finally  rewarded  by  the 
complete  recovery  of  the  patient  from  the  most  virulent  of 
all  the  forms  of  trypanosomiasis,  and  the  patient  remains 
free  from  symptoms  both  of  the  disease  and  of  antimony 
poisoning  until  the  present  day. 

less  Toxic  Compounds  of  Antimony. 

Since  the  risks  of  antimony  poisoning  as  the  result  of 
intravenous  injections,  though  apparently  not  very  great, 
cannot  be  ignored,  other  forms  of  antimony  should  be  sought 
combining  equal  therapeutic  effects  with  diminished  toxicity. 
Antimony  and  arsenic  are  so  closely  allied  in  their  chemical 
characters  that  this  condition  would  probably  be  brought 
about  by  the  production  of  organic  compounds  of  antimony. 
Since  antimony  and  arsenic  are  so  closely  allied  in  their 
chemical  characters  and  the  toxicity  of  arsenic  has  been 
greatly  reduced  without  diminishing  its  therapeutic  action 
by  introducing  arsenic  in  organic  combinations  in  such  drugs 
as  salvarsan  and  its  substitutes,  it  would  appear  highly 
probable  that  similar  organic  compounds  of  antimony  could 
be  produced  and  that  the  effects  of  the  antimony  would  be 
similarly  influenced. 

In  view  of  the  prevalence  of  trypanosomiasis,  leishmaniasis, 
and  bilharziasis  in  various  parts  of  the  world  and  the 
undoubted  beneficial  action  of  antimony  compounds  on  these 
diseases,  the  production  or  thorough  investigation  of  such 
organic  compounds  of  antimony  is  one  of  the  pressing  problems 
of  the  day  in  tropical  medicine. 

Meanwhile  Sir  Leonard  Rogers11  has  drawn  attention  to 
the  occasional  danger  from  the  toxicity  of  tartar  emetic 
intravenously,  and  has  done  the  pioneer  work  in  searching 
for  equally  efficient  but  less  toxic  forms  of  antimony.  In 
1916  he  recommended  sodium  antimony  tartrate,  Plimmer’s 
salt.  More  recently  he  has  employed  colloid  antimony 
sulphide  intravenously  in  kala-azar.  He  found  it  effective 
in  smaller  doses,  being  retained  in  the  blood  longer  than  the 
soluble  tartrates  of  antimony,  and  concludes  that  colloid 
antimony  sulphide  appears  a distinct  advance  on  soluble 
antimony  tartrates.  It  is  evident  that  colloid  antimony 
sulphide  given  intravenously  would  be  well  woith  trying  in 
bilharziasis. 

I am  indebted  to  Lieutenant-Colonel  Marett  Tims, 
R.A.M.C.,  Officer  Commanding  the  Bermondsey  Military 
Hospital,  for  permission  to  publish  these  cases,  and  to 
Captain  F.  Talbot,  R.A.M.C.,  and  Drs.  R.  H.  Townend, 
J.  Howard  Cook,  A.  M.  Cato,  and  A.  E.  Wilson,  for 
permission  to  use  the  cases  under  their  care. 

References.— 1.  Leiper : Report  on  the  Results  of  the  Bilharzia  Mission 
to  Egypt,  Journal  of  the  Royal  Army  Medical  Corps,  July-Sep* ember, 
1915.  2.  Fairley:  The  Discovery  of  a Specific  Complement-Fixation 

Test  for  Bilharziasis  and  its  Practical  Application  to  Clinical  Medicine, 
Journal  of  the  Royal  Army  Medical  Corps,  June,  1919,  449.  3.  Fairley  : 
Bilharziasis:  Some  Recent  Advances  in  Our  Knowledge,  The  Lancet, 
1919,  i.,  1016.  4.  Christopherson:  The  Successful  Use  of  Antimony  in 
Bilharziasis,  administered  as  Intravenous  Injections  of  Antimonium 
Tartaratum,  The  Lancet,  1918,  ii.,  325.  5.  Christopherson:  Antimony 
Tartrate  for  Bilharziasis:  a Specific  Cure.  The  Lancet,  1919,  i.,  1021. 

6.  Knowles : Notes  on  Some  Results  in  Kala-azar,  Indian  Journal  of 
(Continued  at  foot  of  next  page.) 


248  The  Lancet,]  MEDICO-PSYCHOLOGICAL  ASSOCIATION  OF  GREAT  BRITAIN  & IRELAND.  [August9,  1919 


SUPPLEMENTARY  NOTE  ON 

JAUNDICE  AMONG  THE  BRITISH  TROOPS 
IN  NORTHERN  ITALY. 


The  following  is  an  addendum  to  the  article  under  the 
above  heading  by  Dr.  H.  H.  Tooth  and  Dr.  E.  G.  Pringle 
which  appeared  in  The  Lancet  of  July  26th,  1919  : — 
Addendum. 

Lieut. -Colonel  A.  E.  Gates,  consulting  physician  at  the 
forward  area  at  the  time  when  our  cases  were  recorded,  has 
kindly  allowed  us  to  include  abstracts  of  notes  of  four  cases, 
two  of  which  were  fatal  but  presented  no  evidence  of 
spirochsetosis.  But  the  blood  of  the  two  that  recovered 
grew  spirochaetes  in  guinea-pigs.  The  cases  were  briefly  as 
follows  : — 

1.  Pte.  B.  Onset  sudden,  Sept.  2nd,  1918,  with  headache 
and  general  illness.  On  the  6th,  vomiting;  7th,  admitted  to 
hospital.  Marked  jaundice,  conjunctivae  injected.  8th, 
impaired  resonance  and  moist  sounds  in  right  lung 
posteriorly.  10th,  copious  pasty  motions  with  much  blood 
clot.  13th,  died.  Low  grade  of  fever  99°-100 ',  rising  to  102° 
on  day  of  death.  Sputum,  no  influenza  bacilli,  predominant 
organisms  pneumococci.  Post-mortem  : Confluent  broncho- 
pneumonia lower  lobe  of  right  lung,  discrete  and  haemor- 
rhagic of  left.  Gall-bladder  distended  with  thick  dark  bile, 
common  duct  occluded  by  blood  clot.  Punctiform  sub- 
mucous haemorrhages  in  stomach  and  intestines.  Micro- 
scopic examination  by  Professor  Bonome,  of  Padua : Left 
lung  multiple  foci  of  acute  haemorrhagic  broncho-pneumonia, 
no  Gram-staining  micro-organisms  or  spirochastes.  Liver, 
slight  grade  of  acute  atrophy,  and  slight  small-celled  infiltra- 
tion of  bile  passages.  Spleen  congested,  numerous  small 
haemorrhages  in  pulp. 

2.  Pte.  N.  D.  Admitted  August  28th,  1918,  as  a case  of 
pneumonia.  Jaundice  developed  on  sixth  day  of  illness, 
faeces  clay-coloured,  bile  and  albumin  in  urine.  Tempera- 
ture for  first  six  days  about  102°,  fell  to  subnormal  on  appear- 
ance of  jaundice,  when  pulse  rose  to  160,  with  delirium, 
epistaxis,  and  haematemesis,  and  purpuric  eruption  on  the 
buttocks.  Died  on  Sept.  1st.  Guinea-pig  inoculated  with 
blood  12  hours  before  death  with  no  result.  Post  mortem  : 
lungs  congested,  many  small  haemorrhages.  Liver,  no 
abnormality.  Gall-bladder  contained  a small  quantity  of 
bile.  Common  duct  patent.  Spleen  enlarged.  Kidney, 
capsule  strips  with  difficulty,  multiple  punctiform  haemor- 
rhages. Stomach  and  jejunum,  small  submucous  haemor- 
rhages. Microscopic  examination  by  Professor  Bonome  : 
Liver,  slight  grade  of  acute  atrophy  of  hepatic  cells,  dilata- 
tion of  intralobular  bile  canaliculae,  with  small-celled  infil- 
tration of  the  connective  tissue ; no  Gram-staining  micro- 
organisms, no  spirochaetes.  Kidneys,  acute  nephritis,  chiefly 
glomerular  and  interstitial.  Spleen,  small  disseminated 
haemorrhages. 

3.  Qm.  S.  C.  Sudden  onset  Sept.  4th,  1918,  with  head- 
ache and  general  illness.  Temperature  103-6°,  and  raised 
until  ninth  day  of  disease.  Jaundice  and  herpes  labialis 
on  the  fourth  day.  Slight  purpuric  rash  on  sixth  day. 
Photophobia.  Urine  contained  bile,  albumin,  and  casts. 
Blood  culture  negative,  "but  inoculated  guinea-pig  died 
with  a few  spirochaetes." 

4.  Driver  F.  Admitted  Sept.  16th,  1918.  Onset  sudden 
three  days  before,  with  headache  and  general  illness. 
Jaundice  on  the  third  day.  Temperature  103°,  falling  to 
subnormal  on  the  seventh  day  for  a period  of  eight  days, 
after  which  a daily  variation  from  97;  to  101°  or  102°  for  l4 
days  or  more,  when  he  was  transferred  to  the  base.  Urine 
examined  for  spirochaetes  on  the  eleventh  and  thirteenth 
days  with  negative  results.  A guinea-pig  inoculated  with 
the  blood  of  the  sixth  day  died,  and  spirochastes  were  found 
in  its  liver. 

The  two  cases  of  ascertained  spirochastosis  seem  to  weaken 
the  suggestion,  in  the  concluding  remarks  of  the  article,  that 
another  infective  virus  was  possible,  but  the  question  whether 
two  positives  are  to  be  accepted  as  invalidating  so  many 
negatives  must  be  left  to  the  judgment  of  the  reader. 


( Continued  from  preceding  page.) 

Medicvl  Research,  1918.  548.  7.  Archibald  and  Innes : Clinical  and 
Rathologlcal  Notes  of  a Fatal  Case  of  Bilharzia  treated  by  Tartar  Emetic. 
.11.  Trop  Med.  and  Hyg.,  1919,  53.  8 Gregorson  and  Taylor : On 
Trinitrotoluol  Poisoning,  with  Records  of  Five  Cases,  Glasgow  Medical 
Journal,  1918,  65.  9.  lviyono  and  Murakami : Uber  die  Toxinproduction 
der  Schistosomum-Eier  und  ihre  Bez.iehung  rur  Entstehung  der 
Leherzirrhose  bel  der  Schistosomum-lvrankheit,  Verliandl  der  Japan. 
Path.  Gesellsch.  10.  Newham:  Private  communication.  June,  1919. 
11.  Rogers:  Colloid  Antimony  Sulphide  in  Kala-azar,  Thk  Lancet, 
1919, i„  505. 


Stoical  Societies. 


MEDICO-PSYCHOLOGICAL  ASSOCIATION 
OF  GREAT  BRITAIN  AND  IRELAND: 
THE  ANNUAL  MEETING. 

The  seventy-eighth  annual  meeting  was  held  at  York  on 
July  22nd  and  23rd,  under  the  presidency  of  Lieutenant- 
Colonel  J.  Keay  and,  later,  that  of  Dr.  Bedford  Pierce. 

Coordination  in  the  Asylum  Services. 

Dr.  J.  G.  Soutar  moved  the  following  resolution  : — 

“ That  a deputation  be  appointed  to  place  before  the 
Minister  of  Health  the  opinion  of  the  Medico-Psychological 
Association  that  all  matters  concerning  the  care  of  the 
insane  in  England  and  Wales  should  as  soon  as  possible  be 
brought  within  the  authority  of  the  Ministry  of  Health  ; and 
that  the  Board  of  Control,  whose  sympathetic  experience 
and  encouragement  in  all  matters  concerning  the  welfare  of 
the  insane  has  been  so  valuable,  be  maintained  for  the 
department.” 

Dr.  Soutar  said  they  all  recognised  that  coordination  ought 
to  exist  in  what  they  might  call  the  asylum  services  generally. 
They  felt  it  was  preferable  that  the  coordinating  body  should 
be  within  a Government  department  specially  constituted 
to  deal  with  the  health  of  the  whole  community,  rather  than 
left  to  some  self-appointed  body  which  was  inclined  to 
consider  asylum  administration  from  a lay  point  of  view  and 
to  eliminate  the  medical  element.  All  who  had  had  expe- 
rience had  seen  for  a long  time  that  the  Board  of  Control 
had  maintained  a most  sympathetic  attitude  towards  ideas  of 
progress  and  advancement  in  matters  of  the  insane.  That 
was  becoming  more  and  more  a medical,  and  less  and  less  a 
legal,  matter.  The  experience  of  the  members  of  the  Board 
of  Control  was  vast ; it  would  be  a disaster  if  that  sym- 
pathetic body  should  be  scrapped  and  some  new  body 
established  when  the  administration  of  lunacy  passed  into 
the  hands  of  the  Ministry  of  Health. 

Dr.  Shaw  Bolton  said  it  was  not  fully  realised  how 
much  it  was  desired  by  some  members  of  asylum  com- 
mittees to  eliminate  the  Board  of  Control.  The  object  of 
the  National  Federation  was  to  establish  mental  hospitals 
free  from  the  Board  of  Control.  He  was  strongly  in  favour 
of  Dr.  Soutar’s  resolution. 

Dr.  C.  F.  Fothergill  asked  if  it  would  include  borderline 
conditions. 

Dr.  Soutar  said  they  would  rather  not  include  them. 

The  resolution  was  carried  unanimously,  and  it  was  agreed 
to  send  a copy  of  it  to  Dr.  Addison,  the  Minister  of  Health, 
with  a request  that  he  would  receive  a deputation. 

Training  of  Mental  Nurses. 

Dr.  G.  M.  Robertson  said  what  was  required  in  mental 
cases  was  two  different  qualifications.  In  the  first  place, 
the  person  must  be  a skilled  nurse  who  knew  how  to  care 
for  sick  people  and  look  after  the  mentally  deranged  people. 
In  the  second  place,  it  was  important  that  he  or  she  should 
be  a person  of  good  character  upon  whom  they  could  rely. 
He  ventured  to  say  the  character  of  a mental  nurse  was 
more  important  than  the  technical  training.  He  moved  : — 

“That  in  future  the  three  years’  course  of  training  for 
nurses  applying  for  a certificate  shall  be  taken  in  one  mental 
hospital  in  place  of  not  more  than  two  hospitals.  ” 

Dr.  W.  F.  Menzies  opposed  the  proposal.  He  thought  that 
if  the  superintendent  could  not  judge  in  six  or  nine  months 
of  the  character  of  a nurse  then  he  was  not  able  to  give  any 
certificate  of  character  at  all. 

Dr.  Shaw  Bolton  said  that  ever  since  he  had  been  a 
superintendent  he  had  systematically  refused  to  take  nurses 
from  other  institutions  because  they  had  so  much  to  unlearn. 
He  would  like  to  see  the  question  of  training  pressed  to  the 
fore. 

The  President  put  the  motion,  and  Dr.  Robertson’s 
resolution  was  declared  carried  by  a majority. 

Hypnotic  Suggestion. 

Dr.  G.  R Jeffrey  read  notes  on  a case  treated  by  hypnotic 
suggestion.  He  referred  to  the  great  difficulty  in  the  treat- 
. ment  of  mental  illnesses,  and  brought  before  the  meeting  notes 


The  Lancet,]  MEDICO-PSYCHOLOGICAL  ASSOCIATION 


of  a case  which  was  treated  by  hypnosis  and  suggestion.  He 
further  suggested  that  even  in  advanced  mental  disease  this 
method  of  treatment  was,  in  suitable  cases,  always  worthy 
of  consideration.  Dr.  Jeffrey,  in  a few  words,  referred  to 
the  value  of  this  method  of  treatment  during  the  recent  war 
in  dealing  with  all  sorts  of  so-called  functional  diseases  of 
the  nervous  system.  The  case  which  formed  the  basis  of  this 
paper  was  that  of  a young  woman  who,  after  several  months 
of  very  indifferent  mental  health,  became  distinctly  worse 
after  a dream,  in  which  she  dreamt  that  the  sun  and  the  moon 
had  come  into  collision,  with  the  result  that  the  world  was 
submerged  in  blood.  She  awoke  from  her  dream  in  a state 
of  terror,  dazed  and  confused,  and  finally  sought  admission 
to  Bootham  Park  Mental  Hospital  as  a voluntary  boarder. 
Under  the  influence  of  light  hypnosis  her  illness  was 
explained  to  her,  and  suggestion  treatment  generally  was 
employed.  She  awoke  next  morning  quite  well,  and  left  the 
hospital  completely  recovered  after  five  days’  residence. 

Dr.  Robertson  said  he  found  in  all  cases  in  which  he 
attempted  hypnotism  those  suffering  from  melancholia  were 
most  difficult  to  deal  with,  whilst  those  with  acute  mania 
were  extremely  suggestible  and  easily  hypnotised.  Dr. 
Jeffrey  had  pointed  out  that  the  symptoms  did  not  resemble 
those  of  ordinary  melancholia ; it  was  probably  a case  of 
what  was  known  as  anxiety  neurosis.  He  (Dr.  Robertson) 
thought  that  the  dream  which  was  related  showed  a decided 
sexual  element. 

Dr.  R.  M.  Ladell  agreed  that  melancholic  patients  were 
practically  impossible  to  hypnotise.  He  wondered  if  it 
would  be  wise  to  drug  patients  sufficiently  to  get  them 
quieter  and  then  to  superimpose  hypnotism. 

Dr.  H.  M.  Eustace  congratulated  Dr.  Jeffrey  on  being  able 
to  induce  hypnosis.  They  realised  personal  magnetism  was 
needed  to  induce  it,  and  all  had  not  the  power. 

Dr.  Jeffrey  agreed  that  it  was  a case  of  aoxiety  neurosis. 
He  entirely  disagreed  with  the  sexual  explanation.  He  gave 
particular  care  to  try  to  find  out  if  there  was  any  sexual 
point,  and  there  was  none.  He  induced  hypnosis  in  the 
usual  way. 

A Representative  from  Paris. 

The  President  said  that  at  this  annual  meeting  they  were 
honoured  by  the  presence  of  a representative  of  the  Medico- 
Psychological  Society  of  Paris,  Dr.  Henri  Colin,  its  honorary 
secretary.  To  our  distinguished  guest  they  extended  a warm 
greeting  and  a hearty  welcome,  not  only  on  account  of  his 
eminence  as  an  alienist,  and  of  the  fact  that  he  represents 
the  sister  society  at  our  meeting,  to  which  we  are  united  by 
bonds  of  growing  esteem  and  affection,  but,  if  possible,  even 
more  so  because  he  stands  for  closer  union  in  all  things  with 
our  brave  and  glorious  ally,  the  heroic  and  immortal  France. 

Members  Entertained. 

Members  were  entertained  to  luncheon  at  the  Retreat,  Mr. 
Yeomans,  chairman  of  the  Committee  of  Management, 
presiding. 

The  President,  in  thanking  the  committee  for  their 
hospitality,  explained  that  the  Association  was  practically  an 
Irish  association,  and  between  Irishmen  and  Yorkshiremen 
were  many  points  of  similarity.  They  therefore  expected  to 
receive  the  kind  of  hospitality  they  had,  and  they  showed  it 
by  coming  to  the  Retreat  for  their  new  President.  They  had 
admired  the  committee’s  splendid  hospital  with  its  historic 
associations  and  its  world-wide  reputation  for  all  that  was 
good. 

The  Chairman  said  the  committee  appreciated  the  kind 
words  which  had  been  said.  It  was  not  the  first  time  the 
Association  had  visited  York.  He  remembered  that  his  pre- 
decessor, the  then  chairman,  took  the  opportunity  of  urging 
improvements  in  the  education  and  status  of  nurses  and 
encouraging  a higher  type  of  woman  to  engage  in  the 
nursing  of  the  insane.  He  believed  that  idea  had  per- 
meated the  asylum  world,  and  though  they  still  had  a nursing 
question  it  was  of  a very  different  character.  They  bad 
endeavoured  to  preserve  the  homely  character  and  domesticity 
of  the  institution,  which  had  always  been  a feature  of  the 
Retreat.  It  was  founded  by  William  Tuke  in  1796  and  was 
the  first  asylum  in  England  established  on  humane  lines. 
Members  subsequently  inspected  the  buildings,  and  viewed 
with  great  interest  the  archives  and  other  historic  treasures 
of  the  committee. 

The  Afternoon  Session. 

At  the  afternoon  session  Dr.  Percy  Smith  proposed  a 
vote  of  thanks  to  the  retiring  President  and  officers  of  the 


OF  GREAT  BRITAIN  & IRELAND.  [August  9, 1919  249 


Association.  Colonel  Keay  had  occupied  the  presidential 
chair  for  a year  in  addition  to  carrying  on  military  duties, 
and  they  offered  their  hearty  thanks  to  him.  Dr.  Smith 
added  that  it  was  a pleasure  to  him  that  Colonel  Keay  was 
to  be  succeeded  by  one  of  his  (Dr.  Smith’s)  old  assistants  at 
Bethlem  Hospital  in  1891,  he  meant  Dr.  Bedford  Pierce. 
He  went  on  to  say  that  but  for  the  work  of  the  permanent 
officers  the  Association  could  not  go  on  every  year.  He  thought 
special  thanks  were  due  to  Dr.  R.  II.  Steen,  the  secretary 
(recently  succeeded  by  Major  It.  Worth)  ; to  Dr.  J.  Chambers, 
the  treasurer  ; the  editors  of  the  journal,  who  had  had  a very 
difficult  and  arduous  task  during  the  war  ; and  the  registrar. 
Also  to  the  secretaries  of  the  various  divisions,  who  had 
accomplished  most  useful  work. 

Dr.  C.  C.  Easterbrook  seconded  the  motion,  which  was 
unanimously  agreed  to. 

The  President  returned  thanks  on  behalf  of  his 
colleagues  and  himself.  He  had  great  pleasure  in  handing 
over  to  Dr.  Bedford  Pierce  the  direction  of  affairs  and 
ornamenting  him  with  the  badge  of  office. 

Dr.  Pierce  said  he  was  very  proud  to  wear  the  blue 
riband  of  the  Association.  He  did  not  know  that  there 
was  anything  more  pleasing  in  this  world  than  to  win  the 
goodwill  and  appreciation  of  one’s  friends  and  colleagues. 
He  had  always  been  an  ardent  believer  in  the  Association, 
and  it  would  be  a pleasure  to  him  to  do  what  he  could  to  pilot 
it  this  next  year. 

The  President  announced  that  the  Gaskell  prize  and  gold 
medal  had  been  awarded  to  Dr.  James  Walker  and  the 
bronze  medal  to  Dr.  R.  Eiger.  There  had  been  no  divisional 
prizes.  He  believed  the  papers  sent  in  had  been  of  exceptional 
excellence. 

Presidential  Address. 

The  President  then  delivered  his  address  on  “ Psychiatry 
— a Hundred  Years  Ago,”  an  abstract  of  which  appeared  in 
The  Lancet  of  August  2nd.  Before  doing  so  he  referred  to 
the  death  of  one  of  the  late  presidents,  Dr.  Joseph 
Wiglesworth,  a distinguished  and  able  man.  In  1883,  while 
superintendent  at  Rainhill,  where  he  spent  nearly  all  his 
professional  life,  Dr.  Wiglesworth  won  the  prize  for  an 
essay  in  which  he  dealt  with  certain  states  of  melancholia 
attonita,  or  acute  dementia,  showing  the  inflammatory- 
changes  in  motor  cells. 

Dr.  D.  G.  Thomson,  in  moving  a vote  of  thanks,  said  he 
looked  back  historically  to  the  problems  of  years  ago.  He 
brought  out  the  fact  that  we  were  asked  to-day  much  the  same 
problems  as  those  of  3000  years  ago.  He,  with  Dr.  Pierce,  was 
hopeful  of  the  ultimate  solution  of  many  of  them,  and  we 
should  not  sink  into  the  feeling  that  the  questions  of  insanity 
were  unknown  and  unknowable. 

Dr.  Soutar,  in  seconding,  said  that  the  illnesses  with 
which  we  had  to  deal  were  often  due  to  social  conditions 
over  which  we  must  exercise  control  if  we  were  to  stem  the 
tide  of  mental  disease.  The  next  step  was  to  deal  with 
incipient  cases. 

In  the  afternoon,  the  committee  of  the  Retreat  gave  a 
garden  party  to  the  members  and  their  friends,  a large 
number  of  guests  attending. 

Morning  Session , July  23rd. 

At  this  session,  with  Dr.  Bedford  Pierce,  the  President, 
in  the  chair,  Dr.  G.  L.  Brunton  read  his  , 

Notes  on  the  Cytology  of  the  Certbro-  spinal  Fluid , 
based  on  the  examination  of  100  cases  of  mental  disease  by 
Alzheimer’s  method.  This  method  has  the  great  advantage 
that  cells  in  a fluid  can  be  treated  and  stained  similar  to  the 
methods  employed  in  the  histo- pathology  of  the  tissues.  He 
concluded  that  the  cells  of  the  greatest  diagnostic  importance 
are  the  plasma  cell,  the  phagocytic  endothelial  cell,  and  the 
lymphocyte  in  excess  ; and  that  a high  cell-count  with  an 
excess  of  lymphocytes,  together  with  the  plasma  cells,  is 
strong  evidence  of  a parasyphilitic  lesion.  A number  of 
excellent  coloured  diagrams  were  exhibited  to  illustrate  the 
paper. 

An  interesting  discussion  followed,  in  which  Dr.  G.  M. 
Robertson,  Captain  Oliver  Latham  (Australia),  and  Dr. 
F.  H.  Edwards  took  part. 

Captain  Latham  said  it  was  the  custom  in  New  South 
Wales  to  examine  cases  (of  general  paralysis)  by  Wasser- 
mann  reaction  ; if  no  result,  the  cerebro-spinal  fluid  was 
examined  by  the  method  used  for  counting  white  blood 
corpuscles.  They  found  this  worked  very  well.  Captain 


250  The  Lancet,] 


REVIEWS  AND  NOTICES  OF  BOOKS. 


[August  9,  1919 


Latham  described  at  length  cases  of  insanity  frequent 
among  children  in  Brisbane  due  to  lead  poisoning  caused  by 
scraping  powder-paint  from  the  verandahs. 

The  President  contrasted  the  coordination  in  patho- 
logical work  between  asylums  in  N.S.  Wales  and  those  in 
this  country,  where  every  institution  had  to  do  what  it 
could  by  itself. 

Dr.  J.  E.  Middlemiss  read  a paper  on 

An  Analysis  of  200  Cases  of  Mental  Defeat. 

The  cases  dealt  with  were  analysed  in  tabular  form  from 
various  aspects.  The  number  of  cases  comprised  under  the 
four  types  recognised  under  the  Mental  Deficiency  Act  (1913) 
was  given,  as  well  as  the  number  coming  under  the  recognised 
clinical  groups.  The  cases  were  further  tabulated  from  the 
point  of  view  of  the  different  aetiological  or  associated 
factors.  Reasons  were  adduced  for  regarding  the  customary 
division  into  primary  and  secondary  groups  as  unsatis- 
factory. It  was  pointed  out  that  on  investigation  cases 
of  ementia  presented  every  degree  and  variety  of  com- 
bination of  the  primary  and  secondary  factors,  so  that  it  was 
frequently  impossible  to  classify  them  on  these  lines. 
Instead,  a broad  division  into  two  main  types  was  advocated 
according  to  the  presence  or  absence  of  a decided  neuro- 
pathic strain  as  shown  in  the  family  history.  Attention  was 
drawn  to  two  varieties  of  stigmata  of  degeneration  not 
usually  emphasised  in  the  literature.  1.  Variations  in  the 
actual  as  well  as  the  relative  lengths  of  the  digits  of  both 
upper  and  lower  extremities,  but  particularly  the  former. 
2.  Variations  in  the  superficial  reflexes.  These  were  shown 
to  be  frequently  modified  in  the  direction  of  hyper-  or  hypo- 
acuity,  there  being  no  constant  relationship  in  the  degree 
of  response  in  the  reflexes  examined  in  each  individual  case. 

Colonel  W.  R.  Dawson  and  Dr.  Edwards  contributed  to 
the  discussion  on  this  paper. 

Dr.  Henri  Colin  (Paris)  contributed  a paper  on 

The  Influence  of  War  Fatigue  on  General  Paralysis. 

Dr.  Colin  said  that  the  influence  of  the  war  was  much 
greater  than  at  first  supposed.  He  drew  attention  to  the 
fact  that  the  emotions,  the  result  of  the  war,  were  a very 
strong  causative  factor  in  general  paralysis.  He  also  drew 
attention  to  the  very  great  acceleration  of  symptoms  and  the 
rapidity  with  which  general  paralysis  developed  following 
the  shocks  and  general  emotional  state  of  those  who  had 
served  in  the  trenches.  In  the  case  of  many  prisoners  of 
war  who  had  developed  syphilis  it  was  only  a few  months 
after  the  infection  that  symptoms  of  general  paralysis 
supervened  and  death  followed  within  a few  months. 

The  President  said  the  paper  raised  many  questions  of 
serious  importance.  Service  members  could  speak  to  the 
acceleration  of  general  paralysis  due  to  war  conditions. 
The  whole  question  (of  general  paralysis)  was  in  a very 
unsatisfactory  position.  He  was  much  struck  by  the  facts 
Dr.  Colin  brought  out  as  to  the  effect  of  emotion,  accident, 
&c. , on  the  course  of  general  paralysis. 

Colonel  Dawson  wished  to  know  if  alcoholism  played  a 
leading  part  in  Dr.  Colin’s  case. 

Dr.  Robertson  confirmed  the  rapid  course  of  general 
paralysis  during  the  war  from  observations  at  Morningside. 
He  agreed  with  the  statement,  “ No  syphilis,  no  general 
paralysis,”  as  true. 

Dr.  M.  Ross  related  his  experiences  in  a military  hospital 
during  the  latter  part  of  the  war.  There  were  a large 
nBmber  of  young  men  there,  many  with  recent  syphilis.  Of 
these  a large  number  died  within  a short  time  or  became 
moribund.  Dr.  Ross  said  that  a lot  of  the  repatriated 
prisoners  had  turned  out  to  have  general  paralysis.  These 
men  had  been  exposed  to  all  sorts  of  privation,  and  most 
had  a history  of  brutality  as  well. 

Captain  Latham  described  the  treatment  of  general 
paralysis  with  salvarsanised  serum  in  temporary  hospitals  in 
Australia.  He  said  general  paralysis  was  very  serious  in 
Sydney  and  one  of  the  most  important  causes  of  death  in 
New  South  Wales. 

Dr.  Colin,  replying,  said  they  were  agreed  that  alcohol, 
besides  syphilis,  must  be  a factor  of  general  paralysis.  He 
agreed  with  Dr.  Robertson  that  syphilis  was  the  primary 
factor,  but,  though  the  primary  cause,  there  were  many  other 
contributory  ones.  There  was  a general  lack  of  recognition 
of  paralysis  both  here  and  in  France,  where  many  paralytics 
had  been  swept  into  the  army.  The  knowledge  of  mental 
diseases  was  backward  in  every  country. 


anb  Itotfos  d $0olts. 


Geriatrics : the  Diseases  of  Old  Age  and  their  Treatment , 
including  Physiological  Old  Age , Home  and  Institutional 
Care , and  Medico-Legal  Relations.  By  I.  L Nascher, 
M.D.,  Chief  of  Clinic  Department  of  Internal  Medicine, 
Mount  Sinai  Hospital  Dispensary,  New  York,  &.C.  With 
an  Introduction  by  A.  Jacobi,  M.D.  Second  edition, 
revised.  50  plates,  containing  81  illustrations.  London  : 
Kegan  Paul,  Trench,  Triibner,  and  Co.  1919. 
Pp.  xx.  + 527.  21*. 

This  book  is  not  a treatise  on  how  to  prolong  life,  but 
rather  a text-book  of  diseases  and  morbid  conditions — as 
they  present  themselves  to  medical  practitioners  in  their 
treatment  of  aged  patients — giving  rise  to  what  the  author 
terms  pathologioal  old  age.  Old  age  in  itself  is  not  patho- 
logical, and  normal  old  age,  to  which  the  author  devotes  a 
first  portion  of  the  book,  cannot  be  remedied.  He  dis- 
cusses the  anatomical  and  functional  changes  connected  with 
the  physiological  state  of  senility,  and  shortly  reviews  the 
theories  of  the  causation  of  ageing.  But  the  bulk  of  the 
book  is  given  up  to  a methodical  account  of  the  diseases 
and  morbid  conditions  of  old  age,  in  which  senile  diseases 
are  considered  as  (1)  primary,  (2)  secondary,  (3)  pre- 
ferential, and  (4)  modified,  the  latter  dealing  with  such 
diseases  as  asthma  and  pneumonia  when  complicated  by 
senility. 

Following  all  this  a considerable  portion  of  the  book  is 
given  up  to  the  long  series  of  diseases  which  are  relatively 
uninfluenced  by  old  age,  such  as  many  acute  infectious 
diseases,  leukaemia,  muscular  rheumatism,  &c.  The  11  pages 
on  Surgical  Procedure  in  Senile  Cases — a fresh  chapter 
introduced  into  the  second  edition — are  based  “upon  the 
views  and  experiences  of  surgeons  who  have  had  an  extensive 
practice  in  senile  cases.”  The  author  says  that,  in  spite  of  a 
few  optimistic  sentiments  that  have  been  expressed  on  the 
subject,  surgeons  generally  never  operate  upon  a senile  case 
if  operation  is  avoidable.  He  holds  that  the  saying,  “Age 
is  no  bar  to  surgical  operations,”  should  be  accepted  “ only 
if  the  infirmities  and  debilities,  the  degenerations  and 
pathological  conditions  to  which  the  aged  are  particularly 
liable,  are  kept  in  mind  at  every  stage  through  the  pre- 
operative period  to  complete  convalescence.  ” 

Very  important  is  the  final  section  of  the  book  on  the 
Hygiene  of  the  Aged  (Home  Care  and  Institutional  Care)  ' 
and  the  Medico-Legal  Relations  of  Old  Age,  including  such 
subjects  as  Sir  George  H.  Savage  recently  and  ably  dealt  with  , 
in  his  post-graduate  lecture  on  “Mental  Disorders  Associated 
with  Old  Age.” 1 We  do  not  believe  that  it  is  human  nature 
in  most  parts  of  the  world  to  give  less  attention  to  the  wants 
of  the  aged  members  than  of  the  infantile  members  of  the 
family  (and  in  this  respect  the  diUiful  sons  and  daughters  of 
Hebrew  families  in  the  East  End  of  London  may  specially  be 
referred  to).  The  reverse  seems  rather  to  be  the  case,  and 
the  fact  that  the  present  large  work  has  already  reached  the 
stage  of  a second  edition  seems  to  support  our  view.  We 
feel  tempted  to  prophecy  that  there  will  be  a growing  demand 
for  this  kind  of  book. 

In  regard  to  treatment,  as  already  stated,  the  author  does 
not  seek  to  remove  the  normal  infirmities  of  old  age — what 
he  wishes  to  help  in  is  to  convert  a pathological  old  age  into  a 
physiological  one.  The  subject  is  a very  complicated  one  on 
which  much  remains  to  be  studied  and  discussed.  On  p.  17 
the  author  writes:  “The  popular  conception  of  old  age  is 
based  upon  the  appearance  of  the  individual.  It  is  not 
unusual,  however,  to  find  apparently  decrepit  individuals 
regain  strength,  mental  activity,  cheerfulness  and  a more  i 
buoyant  spirit,  as  well  as  a more  youthful  appearance  when  ' 
freed  from  care  and  the  necessity  to  work.  This  is  a common 
observation  in  inmates  of  homes  for  the  aged  shortly  after 
their  admission.”  But  is  not  this  partly  due  to  a kind  of 
reawakening  of  the  mind  by  the  altered,  and  doubtless  i 
improved,  social  surroundings  ? Freedom  from  care  and  ! 
from  work  may  have  a quite  different  effect,  according  to 
what  is  observed  in  the  upper  and  middle  classes,  when  a 
man  retires  from  his  profession  or  business,  and  is  without 
sufficient  interests,  including  “hobbies,”  to  keep  his  mind 


1 Thb  Lancet,  June  14th,  1919. 


The  Lancet,] 


REVIEWS  AND  NOTICES  OF  BOOKS. 


[August  9,  1919  251 


exercised  as  well  as  his  body.  Exercise  for  the  body  and  occupa- 
tion of  some  kind  for  the  mind  are  as  necessary  in  old  age  as 
at  any  other  period  of  life — if  not  more  so  ! Without  them  the 
Dody  soon  loses  in  vigour  and  in  resistance  towards  disease, 
whilst  the  mind  more  rapidly  degenerates  and  more  readily 
falls  a victim  to  morbid  “growths,”  which  arise  like  tares 
in  neglected  soil — “mental  growths,”  which  not  only  prey 
upon  the  mental  faculties,  but  indirectly  involve  and  play 
havoc  with  the  functions  of  other  organs  besides  the  brain. 


On  Longevity  and  Means  for  the  Prolongation  of  Life.  By 
SirHERM ann  Weber,  M D.,  F.R.C  P.  London  : Macmillan 
and  Co.,  Ltd.  Fifth  edition.  1919.  Pp.  292.  12s. 

Not  many  authors  have  so  soundly  justified  the  principles 
which  they  laid  down  for  the  pursuit  of  a certain  course  as 
did  Sir  Hermann  Weber  in  this  treatise  on  the  prolongation 
of  life,  for  he  died  in  his  ninety-fifth  year.  The  edition  now 
before  us,  the  fifth,  was  in  type  at  the  time  of  his  death, 
and  is  issued  under  the  editorship  of  his  son,  Dr.  F.  Parkes 
Weber.  The  book  is  an  expansion  of  a lecture  delivered 
before  the  Royal  College  of  Physicians  of  London  in  1903, 
when  the  author  had  already  attained  the  respectable  age  of 
80  years.  The  book  is  full  of  sound  sense,  and  is  founded 
upon  a belief  in  exercise,  fresh  air,  moderation,  cleanliness, 
and  cheerfulness.  This  is  a following  of  the  old  Salernitan 
dictum  : — 

Si  tibi  deficiant  medici,  medici  tibi  liant, 

Haec  tria,  mens  hilaris,  requies  moderata,  diaeta. 

We  are  glad  to  see  that  Sir  Hermann  Weber  speaks  in 
praise  of  gardening,  for  it  is  an  admirable  and  useful  occupa- 
tion for  those  getting  on  in  years,  though  we  rather  demur 
to  his  description  of  weeding  as  a “light”  occupation. 
Gardening  certainly  conduces  to  sound  wholesome  sleep  at 
night  and  is  a means  for  keeping  a man  out  in  the  air, 
especially  those — and  tljey  are  many — to  whom  walking  is 
anathema.  Sir  Hermann  Weber’s  remarks  upon  diet  are  in 
general  thoroughly  commendable,  but  we  think  that  he  is  a 
little  too  sweeping  in  his  condemnation  of  wine.  Many 
elderly  persons  find  that,  say,  a pint  of  really  sound  light 
claret  in  the  24  hours  has  no  harmful  effect,  but  rather  the 
contrary,  in  that  it  aids  digestion.  At  the  time  of  the  death 
of  Sir  Moses  Montefiore,  who  died  in  his  hundredth  year,  it 
was  currently  reported  that  he  had  drunk  a bottle  of  port 
every  day  of  his  life  since  he  grew  up.  His  is  not  an 
example  to  be  followed,  for  the  ordinary  man  is  better 
without  alcohol  except  in  a really  moderate  amount  and  in 
the  shape  of  a wine  of  good  quality. 


The  Diagnosis  and  Treatment  of  Heart  Disease.  By  E.  M. 

Brockbank,  M.D.  Viet.,  F.R.C.P.  Fourth  edition. 

With  illustrations.  London  : H.  K.  Lewis  and  Co.,  Ltd. 

1919.  Pp.  158.  5s. 

In  its  rapid  passage  through  three  editions  this  little 
collection  of  practical  points  for  students  and  practitioners 
has  not  had  an  opportunity  to  get  out  of  date.  Several 
alterations  and  some  additions  have,  however,  been  made  to 
the  third  edition,  and  the  text  is  practical  and  reliable  as 
ever.  Students  who  think  that  they  know  all  about  the 
auscultation  of  the  heart  will  do  well  to  read  it  through 
before  their  final  examination. 


Instrumental  Orthopcedics  (Dc  V Orthopedie  Instrumental). 
By  Dr.  Gabriel  Bidou.  May,  1919.  Twenty  plates. 
Iraprimerie  des  Orphelins-Apprentis  d’Auteuil,  40,  rue  La 
Fontaine,  Paris.  Pp.  132. 

This  little  book,  which  deals  chiefly  with  the  instrumental 
treatment  of  paraplegia,  discusses  at  some  length  the 
principles  on  which  apparatus  should  be  constructed.  The 
author  advocates  celluloid  in  place  of  leather,  and  has 
adopted  the  principle  of  active  control  which  is  so  well 
known  in  the  American  type  of  artificial  leg.  He  also 
employs  indiarubber  springs,  and  in  certain  cases  multiplies 
the  range  of  movement  by  the  use  of  pulleys  and  levers. 


The  Great  War  Brings  it  Home.  By  John  Hargrave. 
London  : Constable  and  Co.  1919.  Pp.  367.  10s.  6 d. 

The  argument  of  this  book  is  an  essay  in  sociology.  The 
present  state  of  civilisation  is  considered  to  result  from  an 
unhealthy,  because  restricted,  development  of  the  individual. 
We  are  living  by  purpose  instead  of  by  impulse,  and  so  are 


losing  in  vitality  and  suffering  from  the  effects  of  repressed 
instinct.  The  Great  War  has  awakened  us  to  the  fact  that 
we  are  moving  along  a false  trail.  The  right  way  is  the 
natural  way  : the  normal  instincts  if  allowed  freedom  to 
develop  from  an  early  age  will  produce,  according  to  the 
author’s  view,  a higher  type  of  creature.  The  argument  is 
profusely  illustrated  from  a wide  knowledge  of  primitive  life 
and  customs.  The  careful  reader  will  find  many  criticisms 
to  make,  and  though  he  may  not  be  convinced  by  the 
argument  he  cannot  fail  to  be  interested  by  the  illustrative 
detail. 


Induction  Coils  in  Theory  and  Practice.  By  Professor  F.  E. 

Austen,  E.E.,  U.S.A.  London  : Messrs.  E.  and  F.  N. 

Spon,  Ltd.  1919.  Pp.  64.  5s.  net. 

It  is  difficult  to  conceive  of  any  class  of  student  to  whom 
this  book  could  be  recommended.  It  is  of  the  “ potted  ” 
order,  being  divided  into  245  numbered  paragraphs,  ranging 
from  a definition  of  the  term  “ equation  ” to  an  explanation 
of  the  exponential  function.  There  are  occasional  excursions 
into  the  Calculus,  and  the  amount  of  logic  in  the  arrangement 
may  be  estimated  from  the  fact  that  para.  110  contains  a 
differential  equation,  and  para.  235  deals  with  the  theorem 
of  Pythagoras.  The  subject-matter  is  the  result,  so  we  are 
told  in  the  preface,  of  the  author’s  experience  in  directing 
courses  in  the  American  Army.  We  must  suppose  that  the 
luckless  students  had  to  face  these  245  paragraphs  much 
as  they  might  have  to  face  the  Chinese  characters.  No 
explanation  is  given  of  the  almost  uni-directional  character 
of  the  secondary  discharge  or  of  the  effect  of  the  condenser. 
There  are  two  graphs  in  the  book,  on  one  of  which  the 
coordinate  units  are  not  even  indicated. 

Some  of  the  diagrammatic  representations  of  apparatus 
are  good,  and  the  specifications  of  different  types  of  coil  are 
of  value  to  those  who  wish  to  build  up  coils  of  their  own, 
though  the  same  information  could  probably  be  obtained 
from  a shilling  manual. 


JOURNALS. 

Mental  Hygiene.  Vol.  III.  No.  1.  January,  1919. — This 
number  contains  several  articles  by  some  of  the  leading 
psychiatrists  of  America,  who  have  succeeded  in  writing  in 
an  entirely  popular  style  in  order  that  the  journal  may 
appeal  to  the  lav  mind.  While  this  is  a leat  of  no  small 
merit  in  itself  it  does  inevitably  result  in  certain  limitations. 
There  is,  for  instance,  a tendency  to  multiply  words  and 
examples  as  well  as  a striking  absence  of  references.  The 
organisation  of  the  neurological  department  of  the  American 
medical  service  in  the  late  war  is  the  subject  of  an  editorial 
article.  Profiting  by  the  experience  gained  during  the 
earlier  part  of  the  war  in  the  French  and  British 
Armies,  the  Americans  attached  to  each  division  a 
neuropsychiatrist,  who  was  stationed  in  the  most  advanced 
field  hospital.  This  arrangement  proved  the  value  of 
early  treatment  in  war  neuroses.  Only  1 per  cent,  of 
-the  cases  presenting  themselves  at  the  advanced  hospital 
were  ultimately  invalided  to  America. — Dr.  Macfie 
Campbell  has  contributed  an  interesting  paper  on  Nervous 
Children  and  their  Training.  He  attributes  to  errors  in 
home  education  at  an  early  age  many  of  those  untoward 
and  “ irregular”  symptoms  which  cause  so  much  trouble  in 
later  life.  A number  of  cases  are  quoted  to  illustrate  the 
harmful  results  of  indulging  the  caprices  of  sensitive 
children  instead  of  helping  them  to  adapt  themselves  to  their 
environment.  The  physician  in  these  cases  has  to  treat  the 
nervous  child  by  educating  the  parents.  He  has,  in  short, 
to  treat  not  a symptom  but  a situation. — Dr.  Adolph  Meyer 
discusses  the  Right  to  Marry.  Excluding  “imbeciles  and 
many  psychopaths,”  and  granting  the  possibility  of  a healthy 
environment  for  the  future  children,  he  believes  that  an  indi- 
vidual of  “tainted  stock  ” should  be  allowed  to  marry  another 
whose  ancestry  shows  only  normal  individuals.  Marriages 
cannot  be  controlled  by  law,  nor  are  intentionally  childless 
marriages  to  be  encouraged.  A propaganda  of  tire  laws  of 
heredity,  so  that  marriage  shall  not  be  undertaken  without  a 
clear  understanding  on  the  part  of  both  contracting  parties, 
is  advocated  as  the  better  way.  Runaway  marriages  should 
be  made  a legal  impossibility,  as  they  are  in  Switzerland. — 
The  annual  census  of  the  insane  is  considered  statistically 
by  H.  M.  Pollock,  Ph.D.,  and  E.  M.  Furbush,  A.B.,  B.S. — 
There  are  articles  also  of  interest  to  the  sociologist  and 
educationalist,  as  well  as  abstracts  of  reviews  of  English  and 
American  literature. 

In  the  Military  Surgeon  (Washington,  D.C.,  U.S.A.)  for 
May  Professor  Theodore  Tuffier,  consulting  surgeon  to  the 
French  Army,  gives  an  account  of  the  transport  service  for 


252  The  Lancet,] 


NEW  INVENTIONS. 


[August  9,  1919 


wounded  by  aeroplane  as  it  was  extemporised  in  the  Sahara 
with  its  wide  spaces,  turbulent  tribes,  and  military  posts, 
hardly  accessible  except  by  air.  A general  officer,  wounded 
in  the  chest  at  Tafilalet  in  South  Morocco,  had  to  be  carried 
26  miles  by  bearers  to  Ksar-es-Souk.  A major  of  the  French 
Medical  Service  was  sent  to  him  by  aeroplane,  200  miles 
over  the  mountains  and  into  the  desert.  The  patient  was 
found  to  require  an  X ray  examination,  which  would  only  be 
given  at  Bou-Denib,  60  miles  away  and  isolated  by  enemy 
forces.  There  was  nothing  for  it  but  to  transport  the 
patient  thither  by  aeroplane,  which  was  done  in  an  hour 
by  a Farman  aeroplane,  and  the  subsequent  operation 
was  now  carried  out  with  knowledge,  and,  happily, 
with  success.  Professor  Tuffier  goes  on  to  say  that  an 
aero-ambulance  service  is  in  organised  existence  in  the 
South  of  Algeria  (Sahara)  and  in  Tunis.  Patients  are  carried 
about  100  miles  a day,  generally  in  Farman  aeroplanes,  and 
they  should  be  sent  in  the  early  morniDg.  It  is,  however, 
impossible  to  send  them  during  a Scirocco  wind,  which 
shrouds  the  desert  in  a high,  dense  dust-cloud  and  prevents 
the  pilot  from  finding  his  way  and  makes  landing  impossible. 
—Major  M.  C.  Winternitz,  U.S.M.C.,  details  the  damage 
done  to  the  lungs  of  dogs  by  irritating  poison  shell  gases,  and 
shows  that  the  ultimate  effects  closely  resemble  those  of 
influenzal-pneumonia,  the  pathology  being  similar.  In  each 
the  epithelium  of  the  air-passages  is  destroyed,  the  lung  thus 
loses  its  protection  and  is  exposed  to  infection  from  the  bacilli 
of  the  mouth,  which  rapidly  spread  through  the  extensively 
cedematous  pulmonary  tissue.  It  will  be  recalled  that  in  the 
April  number  of  this  magazine  Major  Dodge  mentioned 
that  a 1 in  10,000  quinine  sulphate  gargle  seemed  to  protect 
influenza  cases  from  pneumonia.1  Mustard  gas  sets  up 
a spasm  of  the  bronchioles  which  keeps  it  out  of  the  air 
vesicles,  but  where  it  does  reach  the  lung  it  causes  necrosis. 
(The  worst  examples  of  necrosis  of  epithelium  in  larynx 
and  bronchi  in  the  College  of  Surgeons  War  Museum  are 
ascribed  to  mustard  gas.)  Chlorine  and  phosgene  have 
similar  actions,  but  chlorine  acts  more  on  the  upper  air 
passages,  phosgene  on  the  vesicles,  in  which  it  breaks  up, 
forming  nascent  chlorine.  The  paper,  which  is  the  outcome 
of  experiments  on  some  1500  subjects,  should  be  read.— 
Lieutenant-Colonel  W.  B.  Cannon  tells  of  his  researches  on 
wound  shock,  which  is,  he  urges,  a toxaemia  due  to  absorp- 
tion of  poisons  from  dead  or  dying  cells.  These  poisons 
cause  great  outflow  from  the  blood-vessels  into  lymph 
spaces  with  resultant  halving  of  the  blood  pressure. 
Thus  he  accounts  for  the  sweating  and  chilliness 
of  the  patient  and  the  poor  circulation  with  accumula- 
tion of  red  blood  cells  in  the  peripheral  vessels,  conse- 
quently poor  aeration  of  the  tissues,  and  in  the  advanced 
stages  air  hunger.  He  recommends,  as  the  first  treatment, 
warmth.  If  the  patient  is  on  a stretcher  he  should 
have  blankets  below  him  as  well  as  above  ; rectal  or  intra- 
venous saline  injections  or  gum-salt  solution  injections 
should  ring  the  changes  with  transfusion.  Tourniquets  are 
not  to  be  lightly  removed  from  shattered  limbs;  they 
prevent  the  shock-toxins  becoming  diffused  through  the 
body,  and  shock  has  often  appeared  for  the  first  time  just 
after  a tourniquet  has  been  removed.  The  only  anaesthetic 
to  be  used  in  shock  is  nitrous  oxide  and  oxygen.  Thus  he 
upholds  the  conclusion  of  Mr.  Cowell  in  his  Arris  and  Gale 
lecture.1 — Major  J.  Bayard  Clark  reports  on  what  he  saw  of 
the  treatment  of  venereal  disease  in  England  in  1918.  He 
paid  many  surprise  visits  to  military  hospitals,  which  he 
always  found  clean  and  well  managed,  well  equipped,  and 
with  a sufficient  staff.  He  professes  himself  satisfied  with 
us  and  notes  that  “ the  percentage  of  complications  in  all 
hospitals  was  very  small.” 


THE  ENHAM  VILLAGE  CENTRE  FOR  THE 
RE-EDUCATION  OF  MEN  DISABLED 
IN  THE  WAR. 


The  first  annual  meeting  of  the  Village  Centres  Council 
was  held  recently  at  the  house  of  the  chairman,  Lord  Henry 
Cavendish  Bentinck,  M.P.,  Sir  George  Makins,  Vice-Pre- 
sident, in  the  chair,  when  the  administrator,  Major  Garth- 
waite,  reported  that  the  Enham  Village  Centre,  opened 
for  ex  Service  men  on  May  31st,  had  30  men  in  resiuence 
receiving  medical  treatment  and  undergoing  training,  mainly 
in  horticulture,  agriculture,  and  forestry.  Workshops  for 
basket-making,  electrical  fitting,  and  carpentry  had  also 
been  opened,  and  in  other  directions  the  re-education  of  men 
disabled  in  the  war  was  being  undertaken. 

Dr.  Fortescue  Fox,  the  medical  director,  said  that  the 
interval  between  a man’s  discharge  from  the  army  and  his 
reception  at  Enham  varied  from  1 to  43  months^  with  an 
average  period  of  12  months  in  their  own  homes.  Nineteen 
out  of  the  total  of  30  had  not  done  any  work  during 
this  time,  and  ten  had  attempted  to  return  to  work  and 


1 The  Lancet,  July  26th,  1919. 


had  broken  down.  All  of  them  were  now  doing  some 
work  at  Enham,  under  medical  supervision,  from  * two 
to  six  hours  daily.  Many  kinds  of  physical  and  mental 
disability  were  represented.  Nearly  half  the  cases  were 
definitely  neurological,  and  under  the  care  of  Captain  Douglas- 
Morris,  R.A.M.C.,  the  neurologist,  who  often  made  use  of 
mental  treatment  with  advantage.  Several  men  had  come 
with  paresis,  after  fracture  of  the  skull,  and  all  of  these 
were  quite  unfitted  for  the  nervous  strain  and  noise  of  town 
life,  and  had  improved  in  the  country.  Cases  of  old  wounds 
of  the  arm,  with  stiffness  and  wasting,  were  put  to  light 
curative  work,  such  as  thinning  grapes,  clipping  hedges, 
sawing,  or  wood-cutting.  Sensation  as  well  as  movement 
could  be  re-educated  by  appropriate  work,  such  as  planting 
seedlings  or  picking  fruit.  Games  like  bowls  were  very 
helpful.  Whatever  label  was  attached  to  the  disability  all 
the  men  should  be  regarded  as  neurasthenic.  A large  pro- 
portion— perhaps  the  greater  number — would  never  be  able  to 
compete  with  able-bodied  men  in  industry ; therefore,  looking 
ahead,  it  seemed  likely  that  the  Village  Centre  would  become 
not  only  a centre  for  treatment  and  training,  but  a centre  for 
providing  special  industries  for  permanently  subnormal 
men,  for  whom  there  would  always  be  needed  a measure  of 
protection.  The  process  of  re-education  and  the  choice  of 
their  occupations  required  far  more  care  than  had  hitherto 
been  bestowed  upon  them,  and  should  be  based  upon  exact 
measurement  of  each  man’s  physical  and  mental  capabilities, 
with  special  regard  to  individual  tastes  as  well  as  pre-war 
occupation,  family  circumstances,  and  the  condition  of  the 
labour  market.  It  was  not  sufficiently  realised  that  the 
industry  of  the  disabled,  if  properly  guided,  was  capable  of 
making  a very  large  addition  to  the  production  of  the 
country. 

Mr.  Rowntree,  architect  to  the  council,  gave  particulars 
of  the  housing  scheme  of  the  council.  The  Chairman 
and  Sir  R.  Godlee  expressed  the  hope  that  types  of  disable- 
ment would  be  selected  for  Enham  which  were  capable  of 
being  effectually  treated,  so  that  a considerable  number  .of 
cases  could  be  passed  rapidly  through  the  centre. 


|tefo  Jfntettbns. 


IMPROVED  FORCEPS. 

For  the  last  four  years  all  my  artery  and  tissue  forceps 
have  been  made  with  a bowed  lock  at  the  end  as  part  of  the 
circular  finger  ring.  The  illustration  shows  this  lock 
applied  to  towel  clips,  to  the  Mayo-Ochsner  angular  forceps 
(open),  and  to  mosquito  forceps  (closed).  The  advantages 


of  the  attachment  are  greater  resiliency  and  increased 
leverage  in  locking,  more  facile  opening  and  closing,  and — 
one  great  convenience— sutures  are  no  longer  liable  to 
become  caught  up  between  the  finger  rings  as  with  the 
ordinary  forcep  lock. 

Messrs.  Charles  F.  Thackray,  Great  George-street,  Leeds, 
are  the  manufacturers. 

Aspley  Guise,  Beds.  BRtDEN  GLENDINING,  M.S.,  F.R.C.S. 


The  Lancet,] 


AN  ANTHROPOMETRIC  INDEX  OK  PHYSICAL  FITNESS. 


[August  9,  1919  253 


THE  EANCET. 


LONDON:  SATURDAY,  AUGUST 9,  1919. 


An  Anthropometric  Index  of 
Physical  Fitness. 

That  little  children  are  more  apt  than  adults  to 
suffer  ill-effects  from  remaining  uncovered  in  a 
cool  atmosphere  is  a fact  that  is  known  to  every 
mother,  and  all  surgeons  recognise  the  import- 
ance of  keeping  children  warm  when  prolonged 
exposure  on  the  operating  table  is  necessary.  The 
reason  for  this  is  that  the  surface  area  of  the  child’s 
body  bears  a higher  proportion  to  the  body  volume 
than  is  present  in  the  larger  body  of  the  adult, 
since  increase  of  volume  outruns  increase  of  surface 
with  general  growth  of  the  body.  We  may  say  that 
body  surface  represents  the  area  of  heat  loss,  while, 
in  great  part,  body  volume  represents  the  area  of 
heat  production.  Considered  in  this  simple  way  we 
would  naturally  be  prepared  to  find  that  the 
expression  of  internal  heat  production  should  be  “ a 
simple  function  of  the  body  surface,’’  as  in  another 
column  of  The  Lancet  Professor  Georges  Dreyer 
has  shown  it  to  be,  rather  than  “ a simple  function 
of  height,  as  Hutchinson  claimed.”  But  Professor 
Dreyer’s  important  researches  have  proved  much 
more  than  this.  They  not  only  show  that  the 
smaller  and  lighter  individual,  with  his  relatively 
larger  surface,  has  a greater  vital  capacity 
per  unit  of  body  weight  than  the  larger 
individual,  but  they  also  seem  to  prove  quite 
definitely  that  no  anthropometrical  standard  of 
health  that  has  so  far  been  suggested  is  so  true 
an  index  of  fitness  as  is  the  vital  capacity  when 
this  factor  is  considered  in  its  proper  relations. 
Mere  measurements  of  height,  weight,  girth,  or 
proportions  become  insignificant  as  clues  to  physical 
fitness  when  they  are  compared  with  the  vital 
capacity  constant  of  Professor  Dreyer. 

Professor  Dreyer’s  reference  to  Hutchinson 
recalls,  and  rightly,  to  the  memory  of  medical  men 
one  whose  painstaking  and  somewhat  neglected 
work,  given  to  the  world  over  70  years  ago, 
seems  now  to  be  coming  to  its  full  apprecia- 
tion. If  the  most  recent  research  has  shown 
that  he  was  but  a poor  mathematician  it  has 
increased  our  admiration  of  him  as  a true 
pioneer  possessed  of  accurate  scientific  insight. 
On  April  28th,  1846,  before  the  Royal  Medical  and 
Chirurgical  Society,  John  Hutchinson  read  a 
paper  with  the  following  title,  “ On  the  Capacity  of 
the  Lungs  and  on  the  Respiratory  Movements,  with 
the  view  of  establishing  a precise  and  easy  method 
of  detecting  the  disease  by  the  spirometer.” 1 In 
this  paper,  after  describing  the  movements  of 
respiration,  he  divided  air  into  (1)  residual  air; 
(2)  reserve  air  ; (3)  breathing  air ; (4)  complemental 
air ; and  (5)  vital  capacity.  His  definitions  seem  to 
have  been  original  in  many  ways,  but  were  at  once 
accepted,  and  for  that  matter  most  of  his  com- 
munication was  perfectly  sound.  He  narrated 
results  which  he  had  found  in  2000  cases  and 
showed  the  effects  upon  what  he  termed  “vital 
capacity” — namely,  “the  greatest  voluntary  expira- 
tion following  the  deepest  inspiration,”  which  were 
produced  by  height,  weight,  age,  and  sickness.  At 

1 The  Lancet,  vol  i.,  1846,  p.  630. 


the  same  time  he  exhibited  an  instrument  which  he 
called  a spirometer,  and  which  was  devised  to 
record  the  respiratory  movements  in  health  and 
disease.  Mr.  Hutchinson’s  audience  were  obviously 
impressed  by  the  industry  and  ingenuity  which  he 
had  displayed  throughout  laborious  investigations, 
and  they  appear  to  have  accepted  as  a reasonable 
discovery  his  dictum  that  if  the  height  of  the 
individual  be  known,  the  number  of  cubic  inches 
of  air  which  he  is  able  to  expire  in  the  healthy 
state  can  be  calculated  with  tolerable  accuracy. 
As  Professor  Drey'ER  shows,  this  was  an  un- 
warranted deduction,  but  the  value  of  the  early 
researches  remains. 

The  fixing  of  standards  of  vital  capacity  for  the 
different  elements  of  the  population  is  a work  of 
national  importance,  for  by  this  means  better  than 
by  any  other  shall  we  arrive  at  a true  index  of 
fitness  from  which  the  individual  may  be  judged. 
Those  upon  whom  the  responsibility  for  the 
national  health  and  national  welfare  will  devolve 
should  note  the  interesting  fact  that  the  Boy  Scout 
possesses  a vital  capacity  about  15  per  cent,  greater 
than  the  boy  who  is  not  a scout.  Croakers  about 
racial  degeneration  would  do  well  to  compare  the 
vital  capacities  of  the  gentleman  of  to-day  and  of 
John  Hutchinson’s  gentleman  of  the  “ forties.” 
But  the  most  important  result  which  we  expect 
from  Professor  Dreyer’s  work  is  a definite  under- 
standing, first  among  medical  men,  and  secondly 
among  the  public,  as  to  what  significance  is  to  be 
attached  to  the  phrase  “ good  physique.”  What 
does  “good  physique”  mean?  Vaguely  we  all 
know  the  kind  of  well-set-up  individual  implied, 
but  when  we  go  to  see  Mr.  James  Wilde  fight  do 
we  use  this  phrase  about  him?  We  do  not,  but 
clearly  his  physical  fitness  is  colossal,  though  his 
frame  is  small.  It  is  absolutely  necessary  that  wo 
should  not  be  misled  in  the  future  by  vague  termin- 
ology, but  should  arrive  at  standards  whereby 
physical  fitness  can  be  determined.  The  Medical 
Research  Committee,  whose  assistance  to  Professor 
Dreyer  in  his  researches  has  been  openhanded,  is 
engaged  at  the  moment  in  obtaining  facts  along 
similar  lines,  with  the  assistance  of  the  heads  of 
certain  Government  Departments.  The  results  of 
these  researches,  when  added  to  Professor  Dreyer’s 
results,  will  supply  a really  important  body  of 
evidence  upon  which  it  should  become  easier  to 
evaluate  the  normal  criterions  of  health ; we  trust 
therefore  that  there  may  be  no  long  tarrying. 


The  Tuberculosis  Curve. 

The  ominous  reports  on  the  increasing  prevalence 
of  tuberculosis  in  many  European  countries  have 
inevitably  provoked  criticism  of  anti-tuberculosis 
measures  which  a few  years  ago  were  almost 
tacitly  accepted  as  sound  and  satisfactory.  It  was 
hoped  of  the  Insurance  Act,  for  example,  that, 
framed  as  it  was  in  many  respects  with  special 
reference  to  tuberculosis,  it  would  soon  justify  its 
existence  by  an  appreciable  fall  in  the  death-rate 
from  this  disease.  This  hope  has  not  been  realised. 
But  is  this  failure  traceable  to  factors  which  the 
Insurance  Act  cannot,  in  common  fairness,  be  ex- 
pected to  control,  or  is  the  Act  directly  to  blame  for 
the  present  state  of  affairs  ? Dr.  B.  G.  M.  Baskett, 
of  Rayleigh,  appears,  in  an  interesting  communica- 
tion he  has  addressed  to  us,  to  take  the  latter  view. 
The  economic  factor  is,  in  his  opinion,  the  only 
one  which  explains  all  the  phenomena  of  the 


254  The  Lancet,] 


THE  HOLDING  OF  INQUESTS  IN  CAMERA. 


[August  9,  1919 


tuberculosis  death-rate  in  this  country;  and  he  sees 
in  the  Insurance  Act,  or  rather  in  the  policy  of  which 
the  Act  is  the  supreme  expression,  the  cause  of  the 
conversion  of  a falling  to  a rising  tuberculosis 
curve.  His  words  are  so  much  to  the  point  that 
we  reproduce  them  exactly: — 

“Briefly,  from  1840-1915  we  have  (1)  a period  of  laissez- 
faire,  with  no  public  arrangements  for  treatment  of  disease 
and  medical  skill  at  its  lowest — sequel,  a huge  drop  ; (2)  a 
period  of  tempered  laissez-faire— sequel,  a slightly  lower 
but  very  satisfactory  continuation  of  the  fall  ; (3)  a period 
of  municipal  and  State  benevolence  ever  growing  more 
intense — sequel  (a)  a slackened  drop,  and  (A)  an  actual  rise, 
after  the  largest  measure  of  paternalism  in  English  history. 
How  are  we  to  explain  the  brilliant  success  of  laissez-faire, 
with  medical  knowledge  at  its  lowest  and  no  public  means 
of  treatment,  and  the  dismal  failure  of  State  collectivism 
with  indefinitely  increased  medical  knowledge,  and  * all  the 
means  and  appliances  to  boot  ’ ? Why  should  we  have 
maintained  almost  constantly  for  56  years  a decrease  of 
about  200  per  million  in  the  mortality  in  each  five  years, 
and  have  made  less  progress  in  the  last  20  years  than  in  any 
previous  five,  except  two  very  early  in  the  period  ? Why 
should  we  have  been  able  justifiably  to  talk  in  the  nineties 
of  the  approaching  extinction  of  tuberculosis,  when  in  1918 
the  Registrar’s  officer  of  statistics  gravely  suggests  that  it 
may  be  possible  to  revert  to  old  conditions  ? I submit  that 
there  is  only  one  facter  which  explains  all  the  phenomena, 
the  economic.” 

No  doubt  the  economic  factor  plays  a very  im- 
portant part  in  tuberculosis.  It  is,  in  innumerable 
cases,  the  disease  to  which  the  poor  man  succumbs, 
and  from  which  the  rich  man  recovers.  A balance 
at  the  bank,  with  balance  of  mind,  is  the  best 
preventive  of  tuberculosis  yet  discovered.  And 
the  economic  policy  which  secures  the  greatest 
prosperity  for  the  working  classes  must,  other 
things  being  equal,  be  the  policy  calculated  to 
lower  the  tuberculosis  rate  most  effectively.  So 
far  we  agree  with  Dr.  Baskett,  though  we  are 
not  prepared  at  this  juncture  to  discuss  the 
respective  merits  of  a laissez-faire  or  a paternal 
policy.  Nor  do  we  believe  that  sufficient  data  are 
yet  available  for  forming  a correct  estimate  of  the 
effect,  good  or  bad,  of  the  Insurance  Acts  on  the 
incidence  of  tuberculosis.  The  war  alone  has 
obscured  the  issues  far  too  effectively  for  such  a 
balance  of  accounts  to  be  attempted  at  present. 
In  regard  to  the  influence  of  the  war  itself  on  the 
development  of  tuberculosis  we  think  that  some 
confusion  has  arisen  from  a failure  to  analyse 
carefully  the  factors  concerned.  It  is  evident  that 
the  fighting  man  in  general,  while  exposed  to 
horror  and  hardship,  was  obliged  to  live  an  active 
out-of-door  existence,  with  the  opportunity  of  an 
abundant  diet  and  under  the  close  supervision  of  a 
trained  sanitary  personnel.  Even  in  countries 
where  famine  threatened  every  nerve  was  strained 
to  keep  up  the  physique  of  the  men  at  the  front. 
Undoubtedly  these  men  have  broken  down  with 
active  tuberculosis  in  considerable  numbers,  but 
military  service  has  not  necessarily  been  attended 
with  catastrophe  in  ex- sanatorium  patients.  How 
many  compositors,  shop-assistants,  and  brewers’ 
draymen,  on  the  other  hand,  were  prevented  from 
becoming  frankly  tuberculous  by  their  change  of 
environment  cannot,  of  course,  be  stated.  But 
the  number  is  large,  even  as  numbers  go  in 
wartime. 

A group  of  totally  different  factors  was  concerned 
in  bringing  about  increased  tuberculosis  in  civilian 
circles  during  the  war.  Here  all  the  normal  pre- 
disposing factors  were  present  and  accentuated, 
and  on  them  were  superimposed  the  limitation  in 
diet — to  put  it  mildly — and  the  hindrance  to  free 


ventilation  entailed  by  the  light-screening  regula- 
tions. It  is  therefore  demonstrably  absurd  to 
suggest  that  the  economic  factor  explains  all  the 
phenomena  of  the  tuberculosis  curve  in  this 
country.  This  curve  is  criticised  because  its  steep 
decline  is  not  maintained  ; it  flattens  out  and 
then  begins  to  rise.  Setting  aside  this  rise,  which 
is  largely,  if  not  wholly,  due  to  the  war,  even  if 
influenced,  as  Dr.  F.  A.  Elkins  and  Dr.  H.  H. 
Thomson  show  in  an  article  appearing  in  our 
columns,  by  such  a factor  as  overcrowding  in 
asylums,  we  get  a curve  such  as  is  obtained 
by  emptying  a viscid  fluid  out  of  a vessel  where 
the  emptying  becomes  progressively  slower.  Can 
the  stamping  out  of  a disease,  the  germs  of 
which  exist  in  over  90  per  cent,  of  the  adult 
inhabitants  of  civilised  communities,  follow  any 
but  a “ viscid  ” curve  ’?  Leprosy  was,  no  doubt, 
quickly  stamped  out  in  Norway  by  effective  isolation 
measures,  but,  in  spite  of  the  close  morphological 
relations  of  the  two  bacilli,  leprosy  and  tuberculosis 
differ  so  fundamentally  that  this  comparison  is  apt 
to  be  misleading.  Isolation  of  the  advanced  con- 
sumptive— the  prevention  of  massive  infection — 
may  be  beneficial  to  the  rest  of  the  community,  and 
it  was  suggested  by  Koch  that  the  abrupt  fall  in 
the  tuberculosis  death-rate  in  England  in  the  middle 
of  last  century  was  to  be  traced  to  the  segregation 
of  dying  consumptives  under  the  Poor-law.  But 
this  same  abrupt  fall  has  also  been  correlated  with 
the  conversion  of  this  country  to  an  industrial  life, 
which,  it  is  argued,  affords  many  opportunities  for 
frequent  accidental  inoculation  of  small  quantities 
of  the  tubercle  bacillus — a beneficial  process.  Again, 
in  the  “ sixties,”  far-reaching  sanitary  reforms  in 
certain  English  towns  coincided  with  a remarkable 
drop  in  the  tuberculosis  death-rate;  in  Newport 
and  Leicester  it  fell  32  per  cent.,  in  Salisbury  49  per 
cent.  If  we  are  to  be  perfectly  candid,  we  must 
confess  to  considerable  ignorance  of  the  factors 
influencing  the  form  of  the  tuberculosis  curve 
during  recent  years.  Dr.  Baskett’s  questions, 
which  pursue  a frequent  line  of  criticism,  will  be 
valuable  if  they  stimulate  research  into  the 
general  conditions. 

♦ 

The  Holding  of  Inquests  in 
Camera. 

At  two  recent  inquests  held  by  Dr.  F.  J.  Waldo 
the  cases  have  been  of  alleged  suicide  by  the 
deceased  throwing  themselves  in  front  of  trains, 
and  the  coincidence  led  the  coroner  to  offer  sugges- 
tions as  to  the  publicity  now  given  to  the  por- 
ceedings  at  inquests.  The  juries  endorsed  his 
words,  disclosing  thereby  what  appears  to  be  public 
opinion.  Dr.  Waldo’s  view,  which  was  to  some 
extent  supported  by  witnesses  whom  he  questioned 
during  the  two  sets  of  proceedings,  is  that  the 
publication  of  the  details  of  an  inquest  upon  an 
apparent  suicide  has  not  infrequently  put  the  idea 
of  self-destruction  into  the  minds  of  others.  These 
persons  may  possibly  be  weak  of  intellect,  or 
broken  down  by  distress,  or  racked  with  appre- 
hension ; but  though,  for  this  reason  or  that, 
inclined  to  take  their  lives,  the  fatal  determination 
dates  from  the  moment  when  they  read  that  fellow 
creatures  have  succumbed  to  the  impulse.  Having 
got  thus  far  down  the  path  to  death,  it  may  be  that 
the  details  of  suicides,  as  reported  in  the  papers, 
will  advise  them  of  simple  means  for  ending  their 
lives.  It  may  be  said  that  the  opportunities  for 


The  Lancet,] 


THE  AETIOLOGY  OF  INFLUENZA. 


[August  9,  1919  255 


suicide  offered  by  a passing  train,  an  open  gas- 
tube,  or  a silent  pool  need  no  writing  up  to 
bring  them  to  notice,  but  none  the  less  the  printed 
accounts  of  such  cases  do  serve  as  an  actual 
stimulus.  It  is  impossible  not  to  ascribe  to  some 
extent  the  frequent  recurrence  of  certain  methods 
of  suicide  to  the  suggestion  afforded  by  example 
and  by  printed  record.  The  fact  that  a man  or  a 
woman  has  committed  suicide  in  a certain  way  is 
likely  to  be  known  without  newspaper  reports  in 
the  immediate  circle  of  the  event,  but  it  is  not  here 
that  the  sinister  influence  of  example  is  felt.  The 
evil  grows  as  the  influence  spreads  to  a wider 
population  which  includes  among  it  a large  number 
of  susceptible  subjects. 

As  far  as  neighbours  are  concerned  nothing  would 
be  gained  by  suppressing  the  evidence  at  the 
inquest.  On  the  other  hand,  rumour  often  makes  a 
suicide  out  of  an  occurrence  which  really  was  an 
accident,  and  in  this  event  it  may  be  very 
desirable  that  not  only  the  verdict  but  the 
evidence  leading  up  to  it  should  be  known. 
The  possibility  that  the  public  trial  of  shop-lifters 
and  burglars,  to  say  nothing  of  other  criminals, 
may  suggest  a life  of  profitable  adventure  to 
unscrupulous  persons  has  never  caused  anyone  to 
suggest  trying  such  rogues  in  camera,  or  dispensing 
with  the  deterrent  advantages  attached  to  punish- 
ment publicly  imposed.  We  pride  ourselves,  on  the 
contrary,  upon  the  publicity  given,  whether  to  their 
conviction  or  their  acquittal,  as  maintaining  the 
national  confidence  in  our  courts  of  criminal 
justice.  The  medical  profession  is  interested  in 
the  question  of  wide  publicity,  chiefly  because 
its  members  appear  as  witnesses  at  practically  every 
inquest  that  is  held,  as  well  as  in  very  many  trials 
arising  out  of  criminal  offences.  Publicity  tends 
in  their  case  to  secure  the  giving  of  full  weight 
to  their  evidence  by  those  before  whom  it  is  laid, 
for  a vital  witness  can  much  more  easily  be  ignored 
if  no  public  opinion  is  there  to  criticise  the  pro- 
ceedings. Publicity  also  means  for  medical  men 
the  appreciation  of  their  testimony  by  all  members 
of  their  profession  who  may  chance  to  read  it.  It 
helps  moreover  to  exclude  from  the  witness-box 
persons  who  might  otherwise  endeavour  to  pass 
themselves  off  as  medical  witnesses.  An  unqualified 
quack  would  have  a much  better  chance  of  escaping 
undetected  in  camera  than  he  has  in  a public  trial, 
followed  by  the  publication  of  his  evidence  and  of 
the  name  and  address  under  which  he  tendered  it. 

'We  do  not  suggest  that  the  publication  of  columns 
of  scandalous  detail  not  directly  bearing  upon  the 
cause  of  death,  such  as  has  recently  taken  place 
in  the  case  of  two  women,  is  of  any  value  to  the 
community.  But  while  we  admit  the  force 
of  the  contention  that  the  inquest  held  in 
camera  could  never  become  an  inducement  to 
suicide,  we  still  think  that  society  at  large  is  better 
served  by  the  existing  publicity. 


With  reference  to  the  increased  subscription  to 
Fellows  of  the  Royal  Society  of  Medicine  living 
within  a mile  of  the  Society’s  House,  the  Treasurers 
of  the  Society  make  the  following  announcement : — 
Bv  resolution  of  a special  general  meeting  of  the  Fellows, 
this  increase  is  n t to  apply  to  Fellows  who  have  served 
abroad  for  24  months  or  more,  or  have  been  unable  to 
practise  on  account  of  war  service,  until  Oct.  1st,  1920. 

Fellows  who  desire  to  take  advantage  of  this 
privilege  should  send  necessary  particulars  to  the 
secretary  as  soon  as  possible. 


^nnoidians. 


" Ne  quid  nlmls.” 


THE  /ETIOLOGY  OF  INFLUENZA. 

The  recent  pandemic  of  influenza  has  afforded  an 
opportunity  to  bacteriologists  to  review  the  aetiology 
of  this  disease  and  to  investigate  it  further,  an 
opportunity  of  which  advantage  has  been  largely 
taken,  as  a review  of  our  columns  in  recent  months 
will  show.  The  result  is  somewhat  surprising, 
since  the  outcome  has  been  seriously  to  assail  the 
position  previously  accorded  to  the  Pfeiffer  bacillus, 
isolated  in  1892,  as  the  cause  of  the  disease,  and  to 
bring  the  whole  question  into  the  arena  of  con- 
troversy. The  Pfeiffer  ba'cillus  is  still  regarded  by 
some  authorities  as  the  infective  agent,  and  it  is 
claimed  by  them  that  with  improved  methods  it 
can  be  found  in  a very  large  percentage  of  cases  of 
the  disease.  Others  again,  while  accepting  its 
presence  in  many  cases  of  influenza,  assign  to  it 
a secondary  role  as  contributing  to  the  clinical 
manifestations  or  complications  of  the  disease, 
much  in  the  same  way  as  the  pneumococcus  and 
streptococcus  are  believed  to  do ; and  on  this 
view  its  inclusion  in  the  triple  vaccine 
employed  as  a prophylactic  is  justified,  even 
though  it  is  not  regarded  as  the  actual  exciting 
cause.  One  fact  seemed  early  to  emerge  from  the 
controversy — namely,  that  in  the  minds  of  highly 
competent  bacteriologists  there  was  room  for 
scepticism  in  regard  to  the  aetiological  role  of  the 
Pfeiffer  bacillus,  and  that  at  best  the  critical  verdict 
regarding  it  must  be  one  of  not  proven.  It  was 
natural,  therefore,  that  research  should  be  more 
especially  directed  to  two  points — one  the  further 
investigation  of  the  Pfeiffer  bacillus,  the  other  a 
search  for  other  organisms.  A plentiful  crop  of 
possible  causative  agents  has  resulted,  varying 
from  ultra-microscopic  filter  passers  to  pleio- 
morphic  cocci.  The  result  at  present  can  be  nearly 
described  as  confusion,  from  which,  however,  we 
may  hope  to  see  some  definite  results. 

An  interesting  and  suggestive  contribution  to 
the  subject  is  afforded  by  a paper  which  we  publish 
in  another  part  of  our  present  issue  by  Dr.  G.  E. 
Beaumont.  He  states  that  he  was  impressed  by  the 
comparative  infrequency  of  the  Pfeiffer  bacillus  and 
by  the  pleiomorphism  of  the  organism  separated  by 
Donaldson  with  its  possible  relation  to  one  of  the 
filter-passing  organisms  described  by  other  observers. 
He  now  records  some  observations  suggesting  that 
influenza  is  in  reality  a mycosis,  sometimes  bronchial, 
sometimes  intestinal,  due  to  a mycotic  parasite 
with  several  stages  in  its  life-history  ; and  he  offers 
the  suggestion  that  the  discordant  results  of  other 
observers  may  find  their  eventual  explanation  in 
the  pleiomorphic  character  of  the  parasite  he 
describes.  He  is  careful  to  disclaim  priority  or 
originality  for  his  observations,  pointing  out  that 
they  are  an  extension  of  those  of  Captain  H.  J.  B. 
Fry,  who  described  a large  spore  stage  and  a 
hyphal  stage  in  the  parasite  he  isolated  from  cases 
of  influenza.  Dr.  Beaumont  describes  eight  forms 
in  the  life-history  of  this  parasite — namely,  liyphae, 
large  spores,  coccal  clusters,  small  spores,  tetrads, 
mulberry  masses,  chains  of  cocci,  and  bacilli. 
These  forms  he  has  found  in  varying  com- 
binations in  films  made  from  the  sputum  in 
cases  of  influenzal  bronchitis  and  broncho-pneu- 
monia, and  in  the  faeces  of  cases  of  influenzal 


256  The  Lancet,] 


PRACTICAL  ISSUES  OF  THE  ALCOHOL  QUESTION. 


[August  9, 1919 


enteritis.  The  reactions  to  the  Gram-stain- 
ing method  of  these  various  forms  appear  to  be 
very  variable,  and  this  peculiarity  was  also  to  be 
observed  in  the  cultures  made  on  various  media 
from  the  sputum.  These  cultures  also  gave 
interesting  and  suggestive  results  when  examined 
under  the  microscope,  as  they,  too,  showed  pleio- 
morphic  characters.  Although  Dr.  Beaumont  used 
the  various  media  suggested  as  specially  adapted  to 
the  growth  of  the  Pfeiffer  bacillus,  he  was  not  able 
to  isolate  it.  He  sometimes  obtained  single  colonies 
which  showed  characters  resembling  the  Pfeiffer 
organism,  but  they  were  never  pure  and  often  con- 
tained Gram-positive  coccal  elements ; moreover 
the  Pfeiffer-like  organisms  would  often  disappear 
in  subculture.  Dr.  Beaumont  has  in  addition 
made  a few  observations  on  the  urine  and  blood 
in  cases  of  influenza,  and  in  the  former  he  has 
obtained  all  the  stages  of  the  parasite  he  describes. 
In  the  blood  in  primary  cultures  he  has  recovered 
several  of  the  stages  or  forms,  but  only  in  one 
case  was  he  able  to  obtain  growths  in  subculture. 

Dr.  Beaumont’s  observations  are  admittedly 
incomplete,  but  they  are  sufficiently  striking 
and  suggestive  to  require  further  examination 
at  the  hands  of  other  workers.  If  his  results  are 
confirmed  and  the  organism  is  submitted  to  and 
fulfils  the  full  tests  of  the  Koch  postulates,  then 
the  relation  of  the  various  forms  of  the  parasite  to 
one  another  and  to  the  different  organisms  found  in 
this  disease  by  other  observers  will  afford  interest- 
ing matters  for  investigation  and  possibly  serve,  as 
Dr.  Beaumont  suggests,  to  clear  up  the  confusion 
at  present  existing  by  explaining  the  discrepancies 
and  coordinating  the  divergent  views. 


PRACTICAL  ISSUES  OF  THE  ALCOHOL  QUESTION. 

The  Medical  Besearch  Committee  have  issued  a 
further  report1  on  the  alcohol  question,  in  which  the 
main  results  on  manual  work  and  on  the  coordina- 
tion of  fine  muscular  movements  agree  well  with 
those  reported  previously  by  Dr.  Mellanby.  Dr. 
Mellanby’s  report  (No.  31  of  the  series)  was  dealt 
with  in  our  issue  of  July  19th  in  an  annotation 
under  the  above  title.  The  present  investigation 
was  undertaken  by  Dr.  M.  H.  Vernon,  who  was 
assisted  by  Dr.  W.  C.  Sullivan,  Captain  M. 
Greenwood,  R.A.M.C.,  and  N.  B.  Dreyer.  Both 
reports  show  the  important  differences  between 
the  effects  produced  by  alcohol  when  taken  with  or 
without  food,  a question  which  we  have  pointed 
out  again  and  again  has  a practical  bearing,  and 
which,  Dr.  Vernon  now  remarks,  has  been  curiously 
ignored  by  most  previous  investigators.  The 
Medical  Research  Committee  agrees  that  the  rela- 
tions between  the  consumption  of  food  and  the 
physiological  effects  of  absorbed  alcohol  are  so 
important  (as  these  recent  studies  show)  that  much 
previous  work  upon  the  effects  of  alcohol  is  now 
seen  to  have  been  impaired  in  value  by  dis- 
regard of  the  presence  or  absence  of  food  in  the 
stomach  during  the  experiments.  The  influence  of 
alcohol  on  manual  work  and  on  neuro  muscular 
coordination  was  investigated  in  eight  men  and  five 
women.  In  seven  of  the  subjects  observations  were 
made  on  the  accuracy  and  speed  of  typewriting,  in 
three  on  the  accuracy  and  speed  of  working  an 
adding  machine,  and  in  six  on  the  accuracy  with 

1 Special  Report  Series,  No.  34.  National  Health  Insurance.  Medical 
Research  Committee:  The  Influence  of  Alcohol  on  Manual  Work  and 
Neuro-muscular  Coordination.  London:  Published  by  His  Majesty's 
Stationery  Office. 


which  a target  could  be  pricked.  The  administra- 
tion of  alcohol  produced  some  effect  in  all  of  the  in- 
dividuals tested  by  the  typing  and  adding-machine 
methods,  the  degree  of  effect  depending  largely  on 
whether  the  alcohol  was  taken  on  an  empty  stomach 
or  with  food.  On  an  average  it  was  about  twice  as 
toxic  under  the  former  conditions  as  under  the 
latter.  In  the  foodless  experiments  one  subject 
made  88  per  cent,  more  typing  mistakes  after  she 
drank  11‘2  c.cm.  of  alcohol.  Another  subject 
increased  his  adding  machine  mistakes  74  per 
cent,  after  taking  claret  containing  19'4  c.cm.  of 
alcohol ; another  increased  her  typing  mistakes 
156  per  cent,  after  drinking  sherry  containing 
22  c.cm.  of  alcohol.  In  some  subjects,  however, 
a moderate  dose  of  alcoholic  liquid  taken  with  food 
produced  no  measureable  reaction.  Such  a non- 
reactive dose  amounted  to  one  glass  of  port  in  a male 
subject  and  to  4 oz.  of  port  in  a female  subject.  One 
subject  who  a year  before  had  been  rather  a heavy 
drinker  showed  little,  if  any,  reaction,  even  after 
drinking  whisky  containing  45  or  60  c.cm.  of  alcohol. 
He  was  tested  by  the  target  method  and  took  the 
whisky  three  hours  after  food.  In  the  target  method,  /" 
rows  of  dots,  made  on  squared  paper  fixed  vertically 
at  arm’s  length,  were  pricked  at  three-minute 
intervals  before  and  after  the  alcohol.  The  average 
distance  of  a puncture  made  from  the  centre 
was  about  1'8  mm.,  hut  after  taking  30  c.cm. 
of  alcohol  the  target-pricking  error  increased 
12  per  cent.;  after  taking  37'5  c.cm.  it  increased 
43  per  cent.,  and  it  continued  to  increase  in 
arithmetical  progression  with  the  dose  of  alcohol 
till  it  was  132  per  cent,  above  the  normal 
when  60  c.cm.  were  taken.  To  sum  up,  this  inquiry 
would  seem  to  endorse  by  scientific  measurement 
what  has  been  recognised  for  a long  time  in 
practice.  The  creature  of  addiction,  or  one  who 
has  acquired  the  habit  of  moderate  alcohol 
consumption,  shows  a negligible  result  to  moderate 
doses  of  alcohol  according  to  the  tests  here  applied.  . 
In  other  words,  the  body  has  a remarkable  power  of 
adapting  itself  to  acquired  habit.  Then,  again, 
according  to  these  experiments,  alcohol  taken  on 
an  empty  stomach  proves  to  be  twice  as  toxic  as  ; 
when  taken  with  food.  Alcohol  consumers  found 
this  out  long  ago,  for  the  munching  of  a biscuit 
with  a glass  of  wine  between  meals  is  a very  old 
and  familiar  practice.  Man  seems  to  have 

discovered  instinctively  that  food  tempers  the 
action  of  the  spirit.  

GONOCOCCUS  PNEUMONIA. 

Dr.  Martin  Ross,1  of  New  York,  records  the 
following  case,  which  he  regards  as  one  of  gono- 
coccus pneumonia.  The  patient  was  a girl,  aged  16, 
suffering  from  an  acute  exacerbation  of  an  old 
gonorrhoeal  infection  superimposed  upon  a dys- 
menorrhoea.  Lobar  pneumonia  developed  and 
followed  an  atypical  course.  The  sputum  was 
scanty  and  milky  white  in  colour,  with  no  trace 
of  blood  in  it  at  any  time.  Pure  cultures  of 
Gram-negative,  biscuit-shaped  diplococci  were  I 
obtained  from  the  sputum,  the  blood,  and  the 
lung.  Post  mortem  both  lungs  were  found  riddled 
with  minute  abscesses,  there  was  consolidation  j 
of  the  upper  left  lobe ; in  the  lower  lobe  of  the  i 
right  lung  there  was  a large  abscess  cavity  and  a I 
smaller  abscess  in  the  right  upper  lobe.  The 
occurrence  of  gonococcus  septicaemia  in  this 
case  was  probably  due  to  the  presence  of 

1 Medical  Record,  1919.  xcv.,  950-2. 


The  Lancet,] 


THE  CASK  OF  BUBONIC  PLAGUE  IN  LIVERPOOL. 


[August  9, 1919  257 


dysmenorrhoea  with  the  damming  up  of  the 
menstrual  flow.  In  spite  of  the  relative 
frequency  of  gonococcus  septicasmia  with  meta- 
stases,  ltoss  could  only  find  one  other  case  on 
record  of  gonococcus  pneumonia,  which  was 
reported  by  von  der  Bressel  in  the  Munchener 
niedizinische  Wochenschrift  in  1903.  The  patient, 
a man  aged  32,  while  under  treatment  for  gonor- 
rhoea developed  signs  of  lobar  pneumonia  with 
scanty,  milky  white,  bloodless  sputum.  Pure 
cultures  of  Gram-negative  diplococci  were  obtained 
from  the  blood  and  sputum.  In  a week's  time  the 
temperature  fell  by  lysis,  and  complete  resolution 
took  place  on  the  eighteenth  day. 


THE  CASE  OF  BUBONIC  PLAGUE  IN  LIVERPOOL. 

The  Ministry  of  Health  make  the  following 
announcement  concerning  the  fatal  case  of  bubonic 
plague  in  Liverpool  to  which  reference  was  made 
in  our  last  week’s  issue.  The  patient,  a master 
stevedore  and  bargeman,  was  removed  to  the 
isolation  hospital  on  July  11th  and  died  on 
July  19th,  but  bacteriological  confirmation  of  the 
fact  that  he  was  suffering  from  plague  was  not 
obtained  until  July  26th.  No  further  cases  have 
occurred.  Dead  rats  have  been  discovered  in  the 
patient’s  office  and  in  the  adjacent  premises,  but  on 
examination  none  were  ascertained  to  have  plague. 
A mouse  found  dead  has  been  proved  by  bacterio- 
logical examination  to  have  suffered  from  plague. 
The  corporation  have  undertaken  the  disinfection 
of  the  premises  and  the  destruction  and  examina- 
tion of  rodents  found  in  them.  One  of  the  medical 
officers  of  the  Ministry  is  engaged  on  a detailed 
investigation  of  all  the  circumstances  of  the  case. 


THE  NEW  PUBLIC  HEALTH  ACT  IN  SOUTH 
AFRICA:  CONSCIENCE  CLAUSE  ABOLISHED. 

The  new  Public  Health  Act,  No.  36,  1919,  of  the 
Union  of  South  Africa,  was  recently  promulgated 
at  Capetown.  The  Governor-General  has,  under 
the  Act,  appointed  Sir  Thomas  Watt,  K.C.M.G., 
Minister  of  the  Interior,  to  hold  the  portfolio  and 
administer  the  Department  of  Public  Health  in 
addition  to  the  Department  of  the  Interior  and  the 
Public  Works  Department.  It  is  also  announced 
that  from  July  1st,  and  until  further  notice,  the 
Department  of  Public  Health  established  under 
Section  2 of  the  Act  administers  all  matters 
relating  to  (a)  public  health,  (b)  adulteration 
of  food  and  drugs,  (c)  district  surgeons,  and 
(d)  medical  councils  and  pharmacy  boards,  instead 
of,  as  heretofore,  the  Department  of  the  Interior. 
The  Public  Health  Bill  in  its  passage  through  the 
Senate  was  subjected  to  one  radical  alteration — the 
deletion  of  the  antivaccination  conscience  clause — 
and  this  alteration  was  accepted  by  the  Assembly 
and  has  become  law.  Sir  Thomas  Watt  submitted 
to  the  Senate,  when  the  conscience  clause  was 
under  consideration  on  June  2nd,  that  a reason- 
able case  had  been  made  out  for  such  a clause,  but 
the  Senate  deleted  the  clause  by  13  votes  to  8. 
Eight  days  later  the  Assembly  accepted  the  deletion 
of  the  conscience  clause  by  48  to  26,  although  it 
had  been  originally  carried  by  the  popular  House 
by  61  votes  to  19.  One  argument  that  evidently 
weighed  with  the  Assembly  was  that  under  a 
conscience  clause  there  would  be  nothing  to 
prevent  whole  tribes  of  natives  or  coloured  people 
raising  objections  to  vaccination.  Sir  Thomas 
Watt  also  ,stated  that  in  the  six  years  before 


the  war  there  were  only  four  cases  of  small  pox  in 
Germany,  where  vaccination  was  compulsory  “ even 
in  the  case  of  people  with  a conscience.”  According 
to  Dr.  John  Hewat’s  statement  in  the  Senate, 
40  per  cent,  of  the  people  in  the  Orange  Free  State 
are  unvaccinated,  and  the  senior  elected  member  of 
the  Colonial  Medical  Council  is  not  likely  to  make 
loose  assertions  on  such  a matter.  The  Act  also 
provides  for  a refund  by  the  Government  of 
50  per  cent,  of  all  expenditure  on  public  health 
incurred  by  municipalities,  a clause  with  obvious 
bearing  upon  the  State  treatment  of  tuberculosis. 
While  the  measure  was  in  the  Senate  Dr.  Hewat 
urged  the  Government  to  deal  with  tuberculosis 
sanatoria  from  a national  point  of  view,  instead  of 
leaving  it  to  the  municipalities  to  contribute  half 
of  the  cost.  Sir  Thomas  Watt  claimed  that  the 
measure  went  a long  way  towards  the  nationalisa- 
tion of  the  care  of  public  health.  It  had  been 
asserted  that  the  Government  spent  more  money 
on  dealing  with  diseases  of  stock  than  on  public 
health,  but  the  Minister  declared,  on  the  contrary, 
that  the  Government  spent  £10  on  public  health  as 
compared  with  £1  spent  on  animals.  Dr.  Hewat  said 
that  the  cost  of  the  measure  was  not  going  to  be  great 
— only  £80,000  or  £100,000  per  annum — and  appealed 
to  the  Government  to  increase  the  refund  of 
50  per  cent,  on  expenditure  made  by  municipalities 
in  connexion  with  public  health.  This  request 
being  declined  by  the  Minister,  Dr.  Hewat  said 
he  deplored  the  decision  of  the  Government, 
especially  in  reference  to  the  need  for  tuberculosis 
sanatoria.  


RESECTION  OF  ANKYLOSED  FINGERS. 

In  the  Journal  de  Medecine  de  Bordeaux  M.  H. 
Lefevre  has  called  attention  to  an  improved  method 
of  treating  ankylosed  fingers,  such  as  follow  bullet 
wounds,  which  should  prove  useful,  especially  at 
the  present  time.  These  wounds,  if  they  do  not 
lead  to  immediate  amputation,  terminate  in  anky- 
losis, usually  in  extension,  frequently  with 
the  ankylosed  finger  overriding  its  neighbour.  The 
overriding  is  due  to  partial  loss  of  articular 
surface,  whether  condyle  or  socket.  Such  ankylosed 
fingers  are  useless,  subject  to  numerous  injuries, 
and  interfere  with  the  function  of  the  next  fingers. 
The  usual  treatment  is  amputation.  One  day,  after 
amputation  of  an  ankylosed  finger,  which  he  con- 
sidered useless,  M.  Lefevre  asked  himself,  Can 
nothing  better  be  done  ? On  dissection  he  found 
the  flexor  tendons  intact,  the  extensors  adherent  to 
the  skin  and  the  bones  but  without  solution  of 
continuity.  They  had  been  divided  by  a shell  frag- 
ment, but  the  ends  were  united  by  fibrous  tissue. 
Having  broken  down  the  ankylosis  involving  the 
first  interphalangeal  joint  and  freed  the  tendons,  he 
could,  by  traction  on  them,  flex  and  extend  the 
phalanges  on  one  another.  He  therefore  decided  to 
resect  the  next  ankylosed  finger  that  he  encountered 
with  the  tendons  intact.  But  in  three  cases  in 
which  he  operated  he  could  obtain  no  indica- 
tion on  this  point  beforehand.  Only  the  operation 
gave  this.  Wound  of  finger-joint  is  frequently 
accompanied  by  articular  fracture  and  suppuration, 
and  the  resulting  ankylosis  by  peri-articular  lesions. 
In  the  end  the  tendons  and  soft  parts  are  more  or 
less  altered,  if  they  are  not  initially.  Whatever  the 
degree  of  disability,  it  is  the  condition  of  the 
tendons  that  matters.  Whether  they  are  ruptured 
or  adherent  the  result  is  the  same — complete 
immobility  of  the  phalanges  on  one  another  or  on 
the  metacarpal  bone.  Before  sacrificing  such  a 


258  The  Lancet,] 


SCIENCE  AS  MADE  IN  GERMANY. 


[August  9,  1919 


finger  M.  Lefevre  thinks  that  the  surgeon  should 
make  sure  by  exploratory  incision  of  the  state  of 
the  tendons  and  not  amputate  unless  they  are 
irreparable.  He  relates  three  cases  in  which  he 
resected  the  finger  with  success.  The  following 
may  be  taken  as  an  illustration.  A man,  aged  32 
years,  was  wounded  on  Jan.  17th,  1915.  He  was 
admitted  to  hospital  on  the  20th  with  a sloughing 
wound  of  the  first  interphalangeal  joint  of  the  right 
index.  At  the  end  of  February  cicatrisation  was 
complete.  In  April  he  came  under  the  care  of 
M.  Lefevre.  The  joint  was  ankylosed  in  extension 
and  the  index  overrode  the  middle  finger.  Radio- 
scopy showed  that  this  was  due  to  loss  of  the 
internal  condyle  of  the  first  phalanx.  On  the  dorsal 
and  internal  surface  of  the  finger  there  was  adherent 
scar.  The  palmar  surface  of  the  second  and  third 
phalanges  rested  on  the  dorsal  surface  of  the 
middle  finger.  The  patient  could  not  effect  any 
movement  of  flexion  of  the  phalanges  on  one 
another,  or  any  movement  of  flexion  or  extension 
on  the  metacarpal  bone.  He  therefore  asked  for 
amputation.  On  April  8th  a longitudinal  incision 
down  to  the  bone  was  made  on  the  external  surface 
of  the  finger.  With  a rugine  the  soft  parts  were 
raised  from  the  dorsal  and  from  the  palmar  surface. 
The  fibrous  and  osseous  tissues  constituting  the 
ankylosis  were  divided.  The  cartilaginous  surfaces 
had  disappeared.  In  the  centre  of  the  glenoid 
cavity  of  the  second  phalanx  was  a little  focus  of 
osteitis  with  granulations.  Curetting  was  performed 
and  a new  cavity  was  modelled.  The  external 
condyle  was  resected  so  as  to  level  the  end  of  the 
bone.  With  a gouge  a new  head  was  modelled. 
Two  sutures  were  inserted  in  the  fibrous  tissues. 
Adhesions  between  the  skin  and  the  fibrous  tissue, 
which  surrounded  the  extensor  tendon,  were  broken 
down.  The  cutaneous  wound  was  sutured.  Next 
day  passive  movements  were  begun.  On  June  26th 
the  patient  could  completely  extend  and  almost 
completely  flex  the  finger.  He  could  roll  a cigarette 
and  button  his  clothes.  The  finger  was  simply  a 
little  shortened.  When  seen  again  in  February, 
1917,  he  had  good  use  of  the  finger. 


SCIENCE  AS  MADE  IN  GERMANY. 

Even  in  the  days  when  it  was  customary  to  take 
German  scientists  at  their  own  valuation  doubt 
would  at  times  arise  as  to  whether  or  not  these 
gentlemen  were  quite  so  altruistic  and  so  devoted 
to  the  cult  of  philosophy  for  its  own  sake  as  they 
held  themselves  out  to  be.  A wise  commentary 
on  their  attitude  is  contained  in  an  excellent 
series  of  articles  on  the  Pan-German  Internationale 
by  Mr.  Adolphe  Smith,  which  appeared  in  the 
Times  at  the  end  of  July.  Mr.  Smith,  whose 
forcible  writing  on  many  subjects  of  vital  import- 
ance to  medicine  is  familiar  to  all  readers  of 
The  Lancet,  writes  as  follows  : — 

“ The  danger  or  otherwise  of  consuming  tuberculous  meat 
was  of  very  material  importance  to  the  German  Agrarian 
Party,  for  a large  proportion  of  German  cattle  was  known  to 
be  tuberculous.  This  party  held  office  when  at  a great 
international  scientific  congress  it  was  my  good  fortune  to 
discover  and  to  denounce  intrigues  that  had'  for  their  purpose 
the  adoption  of  a resolution  exonerating  the  specific  germ  of 
bovine  tuberculosis.  This  manoeuvre  had  been  promoted  by 
the  German  delegation  and  the  official  representatives  of  the 
German  Government.” 

The  accuracy  of  the  statement  emerges  from  the 
report  to  The  Lancet  of  the  International  Congress 
on  Tuberculosis  held  in  1908  at  Washington,  and  it 
brings  to  light  an  aspect  of  German  duplicity  for  I 


which,  even  after  the  experience  of  the  past  five 
years,  we  confess  that  we  were  unprepared.  Mr. 
Smith’s  protest  against  German  methods  at  this 
Congress  was  printed  in  very  similar  words  in  our 
own  columns  11  years  ago.  Those  whose  memories 
carry  them  back  to  the  year  1901  will  recall  the 
profound  sensation  caused  by  the  statement  made 
by  Koch  before  the  British  Congress  on  Tuberculosis 
in  reference  to  this  same  topic. 

“ The  infection  of  human  beings  (by  bovine  tuberculosis) 
is  a very  rare  occurrence.  I should  estimate  the  extent  of 
infection  by  the  milk  and  flesh  of  tuberculous  cattle,  and  the 
butter  made  from  their  milk,  as  hardly  greater  than  that  of 
hereditary  transmission,  and  I therefore  do  not  deem  it 
advisable  to  take  any  measures  against  it.” 

It  was  charitably  supposed  that  the  distinguished 
scientist  had  slipped  into  error.  No  doubt  he  had, 
but  we  may  perhaps  be  forgiven  for  wondering  if 
the  exact  nature  of  the  error  was  correctly 
diagnosed  at  the  time. 


HEREDITY  AND  MENDELISM  IN  PTOSIS. 

A remarkable  family  has  been  discovered  in 
America  in  which  the  inheritance  of  ptosis  can  be 
traced  through  six  generations.1  Living  in  a 
sparsely  settled  country,  this  family,  though  seldom 
intermarrying,  have  remained  in  the  same  district 
for  a century  and  a quarter.  The  recorder,  Dr. 
Briggs,  of  Asheville,  North  Carolina,  gives  statistics 
of  128  members  of  23  families  (or  “ sibships,”  to  use 
Nettleship’s  term),  all  descended  from  one  Martin 
Maney,  an  emigrant  from  Dublin  and  a veteran 
of  the  Revolutionary  War.  In  each  of  these  23 
sibships  one  or  more  members  were  affected  with 
ptosis,  and,  taking  them  all  together,  the  numbers  of 
the  affected  and  unaffected  were  exactly  equal,  64  of 
each.  The  evidence  in  most  cases  rested  on  hearsay 
and  family  tradition,  but  the  condition  was  seen 
and  photographed  in  six  members  of  the  last  three 
generations,  and  with  regard  to  the  others,  in  the 
case  of  such  an  obvious  defect,  family  tradition  can 
probably  be  trusted.  The  equality  in  numbers 
between  the  affected  and  unaffected  points  strongly 
to  the  inheritance  being  in  accord  with  the 
Mendelian  theory,  although  the  precise  equality  in 
this  case  must  be  accidental,  for  the  theory 
postulates  equality  not  between  the  number  of 
affected  and  unaffected  developed  individuals,  but 
between  the  number  of  potential  individuals 
contained  in  all  the  germs,  both  developed  and 
undeveloped,  originally  possessed  by  the  members 
of  the  affected  sibships.  Perhaps  even  more  striking 
than  the  equality  in  numbers  is  the  fact  of  the  in- 
heritance being  continuous  in  every  case  but  one — 
i.e., there  was  noaffected  individual  with  both  parents 
normal,  and  in  every  case  (but  one)  of  both  parents 
being  normal  none  of  the  progeny  were  affected. 
We  may,  perhaps,  suppose  that  in  the  exceptional 
case  a slight  degree  of  ptosis  had  been  overlooked 
by  the  family ; at  any  rate  thisis  what  the  recorder 
suggests  (though  in  that  case  the  equality  before 
mentioned  would  no  longer  be  exact).  To  explain 
the  facts  on  the  Mendelian  theory  it  must  be 
assumed  that  the  character  of  ptosis  is  a dominant 
one  in  relation  to  the  normal  character,  which  is 
recessive.  The  ancestor  of  the  first  generation  was 
an  impure  dominant — i.e.,  he  was  affected  himself 
with  ptosis,  but  while  one-half  of  his  germ  cells 
contained  the  ptosis  factor  the  other  half  did  not. 
The  result  would  be  that  of  his  children  roughly 
one-half  would  be  affected  with  ptosis,  while  the 


1 American  Journal  of  Ophthalmology,  June,  1919. 


Thh  Lancet,] 


A CONFERENCE  ON  PEDIATRICS. 


[August  9,  1919  259 


other  half,  developed  from  germs  completely  free 
from  the  ptosis  character,  would  be  normal. 
Every  affected  member  of  the  genealogy  would 
be  like  the  ancestor  of  the  first  generation,  an 
impure  dominant,  and,  as  the  result  of  a marriage 
with  a normal  partner,  would  transmit  the  character 
of  ptosis  to,  roughly,  one-half  of  his  or  her  children, 
while  unaffected  members  of  the  genealogy  would 
transmit  no  taint.  This  is  what  happened  in 
the  family  in  question,  so  far  as  we  can  tell 
from  the  not  very  full  data  supplied.  The 
record  is  one  of  extreme  interest,  and  should 
be  compared  with  the  work  of  the  late  Mr. 
Nettleship,  whose  observations  on  the  bearing 
of  the  Mendelian  theory  on  various  eye  diseases 
are  summed  up  in  his  Bowman  lecture  for  1909.a 
It  is  here  shown  that  while  the  facts  of  some 
hereditary  conditions  in  humans  cannot  be  inter- 
preted on  the  Mendelian  theory  except  by  the 
assumption  of  various  modifying  influences  there 
are  other  hereditary  conditions  in  which  they  can. 
The  best  example  of  the  latter  is  found  in 
hereditary  forms  of  cataract,  whether  noticed  first 
at  birth  or  in  later  life.  Most  cases  of  senile 
cataract  occur  apart  from  heredity,  but  there  are 
some  families  in  which  there  is  no  doubt  that  the 
liability  to  the  disease  is  inherited,  and  in  these  it 
is  very  rare  to  find  an  affected  member  one  of 
whose  parents  was  not  also  affected.  In  the  case 
of  congenital  cataract  the  inheritance  is  practically 
always  of  the  continuous  type,  and  in  affected 
families  (sibships)  a rough  approach  to  equality 
between  affected  and  non-affected  members  will  be 
found  on  the  average.  The  factor  causing  cataract, 
therefore,  behaves  as  a dominant  towards  the 
normal,  and  we  may  predict  with  some  confidence  of 
an  affected  member  of  such  a family  that  in  the 
case  of  children  being  born  to  him  or  her  the 
chance  of  their  inheriting  the  disease  will  be  an 
even  one,  while  in  the  case  of  a non-affected 
member  of  the  same  family,  provided  that  the 
second  parent  is  normal,  the  chance  of  inheritance 
is  practically  nil.  Several  pedigrees  of  families 
with  retinitis  pigmentosa  have  also  been  put  on 
record,  and  in  the  majority  of  them  the  inheritance 
is  continuous,  the  disease  factor  behaving  as  a 
dominant;  but  in  some  of  these  pedigrees  the 
inheritance  is  discontinuous — i.e.,  interrupted  by 
a healthy  generation,  and  it  is  possible  that  in 
these  pedigrees  the  disease  behaves  as  a recessive. 
In  the  case  of  some  other  diseases— e.g.,  Leber’s 
hereditary  optic  atrophy — the  interpretation  of  the 
facts  is  complicated  by  a new  factor — sex  limita- 
tion. It  is  only  when  there  are  no  complicating 
factors  that  we  can  expect  to  find  the  Mendelian 
theory  illustrated,  but  the  instances  where  this  has 
already  been  done  to  some  extent  are  sufficiently 
numerous  to  encourage  those  interested  in  the 
subject  who  have  the  opportunity  of  collecting 
pedigrees  bearing  on  the  point  to  persevere. 

2 Trans.  Ophthalmologica!  Society,  vol.  xxix. 


The  Potassium  Compounds  Order. — By  an 

Order  issued  by  tbe  Minister  of  Munitions  dated  July  31st, 
1919,  the  operation  of  the  Potassium  Compounds  Order, 
1917,  as  modified  by  an  Order  (Partial  Suspension) 
issued  in  1919,  is  suspended  on  and  after  August  1st,  1919 
until  further  notice.  The  original  Order  set  forth  that  no 
person  may  offer  to  purchase  or  take  delivery  of  certain 
potassium  compounds  except  in  accordance  with  the  terms 
of  a licence  restricting  the  quantities  permitted  to  be  dealt 
with.  Shorn  of  legal  verbiage,  the  new  Order  means  that 
the  restrictions  then  indicated  are  now  removed,  and  it  is 
cited  as  the  Potassium  Compounds  (Complete  Suspension) 
Order,  1919. 


A CONFERENCE  ON  PEDIATRICS. 


I.— The  Medical  Aspect. 

For  some  time  past  the  subject  of  pediatrics  has  been 
occupying  the  minds  of  those  who  have  at  heart  the  health 
and  welfare  of  infants  and  young  children.  More  especially 
have  they  been  concerned  with  the  question  of  the  teaching 
of  the  normal  physiology  as  well  as  the  pathological  con- 
ditions of  childhood  to  medical  students,  for  it  is  said  that 
the  newly  qualified  practitioner  is  turned  out  with  some 
knowledge  of  disease  as  it  occurs  in  children,  none  of  the 
healthy  child,  and  the  haziest  notions  about  the  feeding  of 
infants. 

An  informal  conference  was  held  last  spring  to  consider 
generally  the  subject  of  pediatrics,  under  the  chairmanship 
of  Sir  George  Newman,  K.C.B.  Advantage  was  taken  of 
the  presence  in  this  country  of  specialists  from  America  and 
the  colonies  to  ascertain  the  results  of  their  experience  of 
maternity  and  child  welfare  in  relation  to  the  medical 
curriculum.  The  conference  did  not  receive  at  the  time 
the  attention  that  it  deserved. 

Dr.  W.  R.  Ramsey,  associate  professor  of  diseases  of 
children,  University  of  Minnesota,  described 

The  Position  of  Pediatrics  at  the  University  of  Minnesota. 

Here  there  is  a separate  department  with  30  beds,  a 
whole-time  professor  at  the  head,  and  an  associate  pro- 
fessor and  staff  of  clinical  assistants,  most  of  whom 
are  half-time  men.  Until  four  or  five  years  ago  pediatrics 
was  a separate  professorship,- but  was  under  the  department 
of  medicine.  It  was  soon  realised  that  the  subject  must  be 
taught  intensively,  and  that  to  teach  a subject  intensively 
there  must  be  a separate  department.  In  Minnesota  there  is 
very  close  cooperation  between  pediatrics  and  obstetrics. 
Both  departments  are  on  the  same  floor,  and  as  soon  as  the 
cord  is  tied  the  child  is  passed  over  directly  to  the  depart- 
ment of  pediatrics.  The  normal  infant  is  regarded  as  of 
vital  importance  in  the  teaching  of  the  student,  for  it  is 
realised  that  if  he  knows  the  normal  infant  thoroughly  he 
quickly  recognises  the  abnormal  one.  Dr.  Ramsey  mentions 
three  fallacies  which  are  still  prevalent  amongst  medical 
men  : (1)  that  the  baby  must  be  bathed  immediately  after 
birth  ; (2)  that  the  baby’s  mouth  must  be  swabbed  out  daily  ; 
and  (3)  that  a dose  of  castor-oil  should  be  given  on  the  third 
day.  Dr.  Ramsey  also  remarked  on  the  many  and  various 
opinions  which  were  rife  on  the  subjects  of  infant  feeding 
and  hygiene.  In  the  United  States  it  was  found  necessary 
to  appoint  a commission  of  representative  pediatricians  to 
formulate  a scheme  to  which  all  might  subscribe.  As  the 
result  a pamphlet  was  drawn  up  and  issued  by  the  Govern- 
ment in  many  hundreds  of  thousands.  The  findings  of  these 
men  are  now  accepted  as  the  basis  for  a uniform  propaganda 
for  child  feeding  and  general  hygiene  to  be  applied  to 
children. 

The  Teaching  of  Pediatrics  in  Canada. 

Dr.  G.  S.  Strathy  (Lieutenant-Colonel,  C.A.M.C.), 
assistant  physician,  Hospital  for  Sick  Children,  Toronto, 
described  the  condition  of  affairs  in  that  city  as  it  was  when 
he  was  there  four  years  ago.  The  teaching  of  pediatrics, 
he  said,  had  changed  considerably  in  Toronto  in  the  last 
decade. 

About  ten  years  ago  the  teaching  of  this  subject  was 
put  in  special  hands  and  taken  up  from  two  points  of 
view — the  teaching  of  medical  people  and  the  teaching  of 
the  public.  The  former  is  divided  into  two  parts — the 
teaching  of  the  medical  student  and  the  teaching  of  the 
practitioner.  The  student  has  had  to  undergo  a five  years’ 
training,  but  this  is  now  to  be  increased  to  six  years.  In 
the  fifth  year  there  are  practically  no  lectures  to  attend,  all 
the  time  being  spent  in  the  wards  and  laboratories.  Each 
student  gave  three  months  to  specialities,  six  weeks  of 
which  was  given  to  pediatrics.  He  attended  for  two  hours 
a day  on  three  days  a week.  The  Children’s  Hospital  in 
Toronto  contains  150  beds,  50  of  them  being  devoted  to 
children  under  a year.  Some  of  tbe  students  live  in  the 
hospital  and  assist  the  house  staff  in  their  work  ; all  attend 
the  out-patient  clinic,  weighing  the  babies  week  by  week 
and,  if  necessary,  following  them  up  in  their  own  homes. 
At  the  Hospital  for  Sick  Children  the  pediatrics  division  is 
responsible  for  the  children  from  birth  to  18  months,  the 


■260  The  Lancet,] 


A CONFERENCE  ON  PEDIATRICS. 


[August  9.  1919 


medical  division  from  18  months  to  14  years.  The  education 
of  the  .practitioners  is  largely  done  in  association  with  the 
municipal  authorities. 

Dr.  J.  G Adami,  professor  of  pathology,  McGill  Univer- 
sity, Montreal,  gave  an  account  of  Canadian  provisions  in 
general,  Canada,  as  he  said,  holding  a half-way  position 
through  having  partly  British  and  partly  United  States 
influences  acting  upon  it,  and  being  sensitive  to  both.  Ever 
since  the  McGill  University  was  opened  in  1824  the  medical 
school  has  followed  the  British  system  of  having  the  free 
entry  of  the  students  into  the  wards,  bedside  teaching  in 
maternity  work,  as  well  as  in  medicine  and  surgery,  being  a 
striking  characteristic.  In  pediatrics  there  is  a professor, 
•three  lecturers,  and  two  demonstrators,  the  size  of  the 
staff  being  due  to  the  fact  that  there  are  out-patient 
clinics  for  children  at  both  of  the  two  main  hospitals 
attached  to  the  University,  the  Royal  Victoria  and  the 
Montreal  General  Hospitals,  as  well  as  at  the  Maternity 
Hospital.  In  all  these  pediatrics  is  taught.  An  extra  year 
is  now  being  added  to  the  curriculum,  and  still  more  work 
on  this  subject  will  be  done.  According  to  the  McGill 
Calendar  for  the  1916-17  session — 

A didactic  course  on  the  diseases  of  infancy  and  childhood,  including 
the  feeding  of  infants,  is  given  during  the  session  to  students  of  the 
fourth  year.  Clinical  and  didactic  lectures  are  given  on  diseases  of  the 
newborn  at  the  Montreal  Vlaernity  Hosp  tai.  In  the  Montreal 
General  and  Royal  Victoria  Hospitals  weekly  clinical  lectures  and  ward 
demonstrations  on  diseases  of  childhood  will  be  given  to  students  of  the 
fifth  year,  and  groups  of  stuients  in  rotaiion  will  be  as-igned  w .rk  in 
connexion  with  the  out-patient  children’s  departments  of  both  hospitals. 
The  new  Foundling  and  Baby  Hospital,  which  has  recen'ly  been 
opened,  with  a capacity  of  100  beds,  will  be  utilised  during  the  session 
for  a series  of  demonstrations  in  infant  feeding.” 

An  extraordinarily  strong  point  is  made  of  infant  feeding. 
In  the  Maternity  Hospital  the  children  are  taken  away 
from  their  mothers  as  soon  as  they  are  born,  and  those 
infants  are  looked  after  mainly  by  the  pediatricians,  so 
much  so  that  one  of  the  leading  obstetricians  absolutely 
refuses  to  see  the  child.  He  adopts  the  “by-product” 
idea,  and  says  that  his  whole  concern  is  with  the  mother, 
to  see  that  she  is  well  through  maternity,  and  that  the 
child  should  be,  from  the  first  moment  of  its  life,  in  the 
hands  of  the  physician  who  is  going  to  look  after  it  during 
the  next  two  or  three  years. 

A Children's  Department  at  Guy's  Hospital. 

Dr.  H.  C.  Cameron  described  the  scheme  for  a complete 
children’s  department  as  accepted  by  the  governors  of  Guy’s 
Hospital  and  now  in  process  of  completion.  It  is  best 
described  in  his  own  words  : — 

The  chi  clren's  wards,  containing  about  50  cots,  will  be  in  close 
proximity  to  a lying-in  ward  of  20  beds.  The  infants  born  in  the  lying-in 
ward  will  be  under  the  care  of  an  assistant,  who  will  act  under  the  joint 
control  of  the  obstetric  surgeons  and  myself  The  Salomon's  Centre  for 
Infant  Welfare  is  housed  in  a building  adjoining  the  hospital,  and  is 
approaching  completion  It  will  be  conducted  by  assistants  acting 
under  my  control.  The  centre  will  undertake  the  antenatal  care  of  the 
two  to  three  thousand  expectant  mothers  who  apply  e>ch  year  to  the 
hospital  lor  assistance  in  cbildoirth.  These  birth  are  attended  in  part 
by  the  students  of  Guy's  Hospital,  and  In  part  by  the  pupil-mid  wives  of 
the  midwifery  school  attached  to  the  hospital,  in  ea  h case  under  the 
necessary  supervision.  The  mothers  all  live  in  an  area  which  is  situated 
in  the  borou.hs  of  Bermondsey,  Southwark  and  Lambeth,  and  our 
arrangements  have  the  approval  of  the  medical  officers  of  health  con- 
cerned. In  this  area  there  are  some  12  other  infant  centres  at  work, 
aiil  the  Salomon's  centre  has  entered  into  arrangement  with  these 
centres  to  cover  the  whole  area  completely,  so  that  every  child  is  sent 
to  the  centre  which  is  m ist  conveniently  situated  to  its  home.  The 
Salomon's  centre,  therefo  e,  although  it  conducts  the  an' e-natal  work 
for  the  whole  area,  restricts  its  cost  natal  work  to  a small  district  in 
the  immediate  neighbourhood  of  the  hospital. 

The  out  patient  children’s  deuartment  has  made  arrangements  to 
place  the  resources  of  Ihe  hospital  bo  h for  diagnosis  and  treatment  at 
the  disposal  of  all  these  centres  In  tbe  Salotn  n's  centre  there  will  be 
a resident  superintendent  and  six  resident  health  visitors.  They  will 
be  assisted  in  the  work  by  the  pupil-rnidwives,  and  ultimately,  it  is 
hoped,  by  students  working  for  a diploma  in  infant  welfare.  The 
medical  students  of  Guv’s  Hospital  will  have  opportunities  of  studying 
the  work  and  appreciating  its  methods  and  objects.  An  arrangement 
has  just,  been  made  hy  which  all  students  will  spend  three  mouths  in 
the  children’s  department,  passing  into  it  immediately  a'ter  three 
months  spent  in  the  special  study  of  midwifery  and  the  diseases  of 
women,  and  I feel  that  with  these  arrangements  it  will  be  possible  to 
make  the  instruction  sufficiently  comprehensive  so  tnat  it  may 
include  Ihe  study  ot  the  newly  born  and  of  tue  normal  child  as  well  as 
the  study  of  sick  children. 

Pediatrics  in  the  Medical  Curt  ionium. 

Dr.  Cameron  points  out  that  one  of  the  difficulties  which 
beset  the  teacher  in  his  endeavour  to  give  the  student  a 
sufficient  training  in  pediatrics  is  that  the  subject  is  a 
voluntary  one,  and  there  is  no  set  examination  of  his  know- 
ledge as  part  of  the  final  examination.  The  training  should 
be  compulsory,  and  an  examination  must  be  held  which  will 


demand  that  the  student  shows  the  same  knowledge  of 
infant  management  and  hygiene  as  is  expected  of  him  in 
his  answers  on  morbid  anatomy  and  clinical  symptoms.  In 
order  to  afford  time  for  the  amount  of  study  necessary  Dr. 
Cameron  suggested  that  the  curriculum  should  be  relieved 
on  the  anatomical  detail  side  and  on  the  surgical  assistance 
side.  Something  might  also  be  done  in  cutting  out  a good 
deal  of  bacteriological  technique.  He  urged  that  the  Uni- 
versity of  London  should  grant  an  M.D.  degree  in  pediatrics, 
as  is  done  now  in  midwifery  and  diseases  of  women. 

As  the  Chairman  said  concisely,  Dr.  Cameron  suggests 
(1)  that  a pediatric  department  is  necessary  in  every  medical 
school ; (2)  in  this  department  every  student  shall  be  taught 
compulsorily  for  three  months  ; and  (3)  every  student  shall 
have  a special  and  separate  examination  in  pediatrics. 

Dr.  J.  S.  Fairbairn  pointed  out  that  any  suggestions 
with  regard  to  examinations,  in  order  to  be  effective,  must 
come  from  the  General  Medical  Council.  The  examination 
system  should  be  arranged  to  meet  the  new  conditions  of 
things  ; every  medical  school  should  have  a complete  centre; 
the  student  should  take  the  midwifery  course  and,  if  possible, 
go  straight  on  from  midwifery  into  pediatrics,  watch  the  life 
and  health  of  the  infant  whose  intra-uterine  development 
and  birth  have  hitherto  been  his  care,  through  its  breast- 
feeding and  weaning.  If  the  student  does  that  he  gets  a 
complete  picture  of  the  whole  thing  from  the  preventive 
medicine  point  of  view.  It  is  the  normal  infant  that  should 
be  taught  to  the  student.  The  pediatrician  should  approach 
the  subject  from  the  standpoint  of  physiology  rather  than  of 
pathology. 

Dr.  Eardley  Holland  was  strongly  in  favour  of  the 
infant  being  handed  over  to  the  pediatrician  for  the  purpose 
of  teaching  and  research  in  the  hospitals  and  medical 
schools.  If  the  obstetrician  has  to  look  after  the  infant  and 
to  study  it  intensively,  he  must  give  up  gynaecology  ; he 
cannot  do  both.  He  must  either  be  an  obstetrician  and 
pediatrician,  or  he  must  be  an  obstetrician  and  gynaecologist. 
But  obstetrics  ought  not  to  be  separated  from  gynaecology. 
It  is  agreed  that  they  are  inseparable  subjects.  Dr.  Holland 
considers  that,  except  in  a few  chosen  places,  the  teaching  of 
obstetrics  is  exceedingly  badly  done.  As  he  says  : — 

Nearly  all  the  lying  in  beds  for  teaching  are  allocated  to  the  teaching 
of  the  midwife,  and  the  student  is  left  out  in  the  cold.  It  is  absolutely 
essential  that  lying-in  beds  in  the  general  hospitals  should  he  estab- 
lished, and  that  it  should  be  made  obligatory  upon  the  student  to  do 
lying  in  work  in  a ward.  I mention  this  because  it  is  closely  connected 
witn  pediatrics  ; for  it  means  the  study  of  the  fcet.us,  the  causes  of 
foetal  death,  the  relation  of  the  foetus  to  the  Infant,  injuries  received  by 
the  foetus,  and  the  diseases  transmitted  to  the  foetus  during  pregnaney. 
I feel  that  as  obstetricians  we  have  very  little  mure  interest  in  the 
infant  than  is  included  in  the  focal  stage.  The  part  that  should  be 
played  by  the  obstetrician  in  infant  welfare  is  to  look  after  the  foetus ; 
to  preserve  it  during  pregnincy  from  transmitted  nisease.  and  to 
preserve  it  during  labour  from  the  injuries  it  may  receive  during  its 
passage  through  the  birth-canal.  As  soon  as  the  establishment  of 
pulmonary  respira  ion  has  announced  the  fact  that  the  m-tamorphosis 
from  foetus  'o  infant  is  complete,  he  will  hand  over  the  intant  to  his 
pediatric  colleague,  asking  the  latter  to  note  that  it  has  been  delivered 
to  him  in  good  condition. 

It  has  only  been  possible,  so  far,  to  consider  the  opinions 
which  were  brought  forward  by  some  of  the  members  of  the 
Conference  on  the  teaching  of  the  medical  student.  The 
following  is  an  account  of  the  discussion  of  the  social  aspect. 

II.— The  Social  Aspect. 

The  Importance  of  Breast  Feeding. 

Dr.  \V.  R.  Ramsey  laid  stress  on  the  importance  of  breast 
feeding,  and  described  the  change  which  had  lately  taken 
place  in  American  opinion,  both  lay  and  medical.  A few 
years  ago,  he  said,  not  more  than  30  to  40  per  cent,  of 
American  women  nursed  their  children.  Tbe  country  was 
flooded  with  literature  on  patent  foods,  which  was  sent  to 
women  not  only  afcer  the  baby  was  born,  but  loDg  before, 
pointing  out  the  simplicity  of  artificial  feeding.  Doctors  and 
nurses  became  imbued  with  the  same  opinion,  and  as  a result 
the  public  thought  that  breast  feeding  was  practically  an 
impossible  thing.  At  the  present  time  in  many  communities 
75  to  80  per  cent,  of  even  well-to-do  women  nurse  their 
babies  and  are  proud  of  it,  instead  of  regarding  it  as  a 
disgrace.  As  he  puts  it,  “they  discuss  it  at  their  circles 
and  their  card  parties,  and  go  home  piomptly  to  nurse  their 
babies.”  In  order  to  eradicate  the  heresies  which  have  been 
handed  down  from  time  immemorial  we  must  first  educate 
*the  doctors  and  nurses,  and  then  the  public  will  become 
educated  ; or  else  we  must  educate  the  public  first,  and  the 
doctors  will  be  compelled  to  follow  suit. 


The  Lancet,] 


A CONFERENCE  ON  PEDIATRICS. 


[August  9,  1919  261 


Infant  Welfare  in  Toronto. 

Lieutenant-Colonel  Strathy  described  the  state  of  affairs 
in  Toronto.  The  healthy  babies  are  looked  after  at  milk 
depots,  each  serving  a district,  of  which  there  are  16  in 
Toronto,  for  which  the  municipality  is  responsible.  To 
each  of  these  depots  a practitioner  is  attached,  who  attends 
twice  a week.  The  city  authorities  supply  the  premises 
for  the  clinics,  and  the  nurses  who  attend  there  and  who 
follow  up  the  children.  Within  10  days  of  the  birth  of 
the  baby,  whether  the  family  be  wealthy  or  poor,  the  nurse 
from  the  City  Hall  calls  at  the  house  to  offer  help  or 
advice  to  the  mother.  In  the  poorer  districts  she  is 
usually  welcomed  and  asked  to  call  again.  The  mother  is 
encouraged  to  go  to  the  depot  and  have  the  baby 
weighed  each  week,  and  it  is  found  now  that  she 
can  do  this  without  hurting  the  feelings  of  the 
practitioner  who  is  looking  after  that  baby,  though  at 
first  they  had  to  be  careful  not  to  tread  on  the  toes  of 
local  practitioners.  As  long  as  the  baby  is  healthy  and 
advice  is  needed  only  in  the  matter  of  feeding,  it  is  treated  at 
the  depot,  but  sick  babies  are  sent  to  the  children’s  hospital 
with  a card.  A card  index  is  kept  for  all  babies,  and  after 
treatment  at  the  out-patient  department  of  the  hospital  the 
baby  is  sent  back  to  the  depot,  together  with  its  card,  show- 
ing all  the  treatment  it  has  had.  A nurse  is  always  present 
with  the  doctor  who  holds  the  clinic,  and  will  always  supply 
a report  of  the  home  conditions  when  required.  For  those 
who  attend  the  out-patient  clinic  any  home  treatment,  such 
as  washing  out  the  stomach,  can  be  carried  out  by  the 
nurse  ; instructions  go  to  the  City  Hall  to  the  head  nurse, 
and  a nurse  is  instructed  to  go  and  do  it.  There  are 
about  150  nurses  carrying  on  this  work  who  have  graduated 
at  the  children’s  hospital. 

Infantile  Tuberculosis  in  Italy. 

Captain  R.  A.  Bolt  gave  a brief  outline  of  some  of  the 
findings  of  a Commission  which  was  sent  to  look  into  the 
tuberculosis  situation  in  Italy,  and  which  was  part  of  the 
American  Red  Cross  in  Italy.  It  was  found  that  tuberculosis 
was  very  closely  related  to  other  problems,  and  the  report 
which  they  issued,  which  was  drawn  up  by  Captain  Knud 
Stonman,  statistician  of  the  Commission,  is  chiefly  concerned 
with  infantile  mortality  in  Italy  duriDg  the  war  and  with 
the  child-welfare  aspect  of  the  problem.  In  Italy,  prior  to 
the  war,  the  infant  mortality  rate  was  gradually  being 
lowered  as  industrial  prosperity  increased,  especially  in  those 
places  where  serious  efforts  in  child  welfare  had  been  made. 
The  Italians  had  developed  a system  of  institutions  through 
their  pediatricians  which  in  most  places  met  the  immediate 
needs  of  sick  children,  had  recognised  the  need  for  a good 
milk-supply  for  growing  children,  and,  through  a system  of 
marine  and  mountain  colonies,  had  provided  recreation  and 
outdoor  life  for  those  who  were  weak  and  predisposed  to 
tuberculosis.  In  a number  of  medical  centres  of  Italy,  prior 
to  the  war,  special  instruction  was  given  in  pediatric  clinics, 
but  only  in  a few  was  the  socio-economic  side  of  child-welfare 
work  emphasised  and  opportunity  given  to  the  students  to  do 
practical  work  in  milk  stations,  consultations,  and  infant 
welfare  centres.  In  Italy  breast  feeding  of  infants  has 
always  been  in  favour,  and  in  the  north  from  85  to  90  per 
cent,  of  the  children  are  breast-fed  for  one  year  at  least,  and 
in  the  south  from  90  to  95  per  cent.  The  midwife  service  is 
satisfactory,  mid  wives  being  required  to  take  a two  years’ 
course  of  training  in  medical  centres,  after  which  they 
take  their  diploma.  In  Italy  the  incidence  of  puerperal 
infection  is  comparatively  small,  and  the  amount  of 
ophthalmia  neonatorum  relatively  so.  On  the  outbreak  of 
war  some  of  the  obstetricians  and  pediatricians  were  drafted 
into  war  service  and  a number  of  children’s  hospitals  were 
utilised  for  war  purposes.  The  birth-rate  increased  up  to 
about  nine  months  after  mobilisation,  and  since  that  time 
there  has  been  a steady  and,  in  some  places,  an  alarming 
decrease,  the  national  birth-rate  falling  from  about  30-5  per 
1000  at  the  outbreak  of  war  to  something  like  18  or  16.  With 
this  decrease  in  the  birth-rate  there  has  been  an  increase  in 
infant  mortality,  especially  during  the  winter  and  summer, 
most  marked  in  January,  February,  and  March,  and  in  June, 
July,  and  August.  The  death-rate  of  children  from  1 to  5 
years  has  increased  much  more  rapidly,  which  has  been 
attributed  to  the  unsuitable  food  given  to  young  children 
after  weaning  owing  to  the  difficulty  of  procuring  suitable 
food  because  of  the  high  prices.  The  death-rate  from 


influenza  was  particularly  high  amongst  babies  and  young 
children,  young  women  between  20  and  30  years  of  age,  and 
pregnant  women.  Abortion  occurred  very  readily. 

In  the  North  of  Italy  considerable  progress  has  been  made 
in  the  organisation  of  infant  welfare  work*  and  although  the 
birth-rate  is  lower  than  that  of  the  Adriatic  coast  and  in  the 
south,  they  have  managed  in  the  large  centres  to  reduce  the 
infant  mortality  rate,  so  that  there  the  actual  saving  in  life 
has  probably  been  greater.  The  smaller  towns  along  the 
Adriatic  have  suffered  severely  from  the  cutting  off  of  trade 
and  Ashing,  and  of  the  influx  of  the  rural  population  into 
the  cities.  Women  were  drawn  into  the  various  industries, 
and  often  left  their  children  to  be  looked  after  by  those  who 
did  not  know  how  to  direct  the  feeding  properly.  There  has 
been,  in  consequence,  a considerable  increase  in  deaths  from 
gastro-intestinal  diseases  in  the  provinces  along  the  Adriatic 
coast  from  Rimini  to  Lecce.  During  the  war  there  has  also 
been  a considerable  increase  in  the  number  of  deaths  from 
tuberculosis,  and  tuberculosis  among  children  under  10  years 
of  age  is  also  on  the  increase.  The  increased  cost  has 
prohibited  the  middle  classes  from  procuring  wet  nurses. 
The  death-rate  among  the  wet  nurses’  own  babies  has  also 
been  high.  There  has,  apparently,  been  no  increase  in  the 
number  of  foundling  asylums  and  illegitimate  babies.  The 
mortality,  however,  among  the  illegitimate  babies  has  been 
about  twice  that  among  the  legitimate  children,  and  under 
the  best  conditions  in  the  foundling  asylums  the  mortality 
has  been  greater.  In  order  to  meet  all  these  problems  milk- 
distributing  stations  and  economic  kitchens  have  been  estab- 
lished in  every  large  centre,  and  considerable  amounts  of 
condensed  milk  have  been  distributed  by  the  Red  Cross. 
Clothes  and  institutional  care  have  also  been  provided,  but 
there  has  never  been  in  Italy  any  enthusiasm  for  health 
visitors,  and  up  to  the  present  time  the  people  neither 
understand  nor  appreciate  the  importance  of  trained  health 
visitors.  During  the  war  a considerable  number  of  intelligent, 
well-to-do  women  entered  the  nursiDg  service  in  the  Army 
with  the  Italian  and  American  Red  Cross,  and  have  had 
their  eyes  opened  to  the  needs  of  the  civil  population, 
especially  to  the  care  of  the  babies.  From  this 
group  of  women  it  is  hoped  to  gather  nuclei  here  and 
there  for  instruction  in  public  health  nursing.  The  coordina- 
tion of  all  the  child-welfare  activities  in  various  centres 
must  also  take  place,  and  in  order  to  become  effective  a 
national  organisation,  with  an  executive  committee  repre- 
senting various  types  of  work  for  children,  should  be 
organised.  In  Italy  there  is  growing  a healthy  idealism  for 
maternity  and  child  welfare.  The  men  and  women  with 
children  are  looked  upon  as  having  real  assets,  economic, 
social,  and  religious.  The  committee  has  been  able  to 
supply  nurses  to  give  secretarial  help  and  to  help  with  regard 
to  publicity. 

The  Position  in  England. 

Speaking  of  the  situation  in  England,  Captain  Bolt  con- 
sidered that  three  things  would  have  to  be  done.  The  most 
important  was  the  education  of  the  medical  student  to  the 
needs  of  infant- welfare  work  through  the  pediatric  depart- 
ments. The  next  was  the  training  of  health  visitors  along 
broad  social,  economic,  and  nursing  lines,  though  not  neces- 
sarily very  intensive.  Thirdly,  there  was  the  need  of 
educating  the  growing  generation  of  mothers  to  the  necessity 
for  this  type  of  work,  which  could  most  easily  be  done 
in  the  upper  grades  of  the  schools.  In  Cleveland  a 
scheme  was  introduced  whereby  elementary  courses  on 
infant  hyaiene  were  given,  school  nurses  taking  one 
course  and  domestic  science  teachers  the  other.  Mother- 
craft  in  schools  should  be  taught  not  by  regular  day 
school  teachers,  but  by  those  who  are  specially  familiar 
with  the  health  side  of  child  problems.  ’The  health  visitor 
can  teach  the  importance  of  proper  feeding  and  the  proper 
care  of  milk,  can  impress  upon  the  school  children  why 
the  babies  are  dying,  and  can  urge  the  necessity  for  breast 
feeding.  Teaching  should  be  given  to  children  between 
the  ages  of  12  and  14,  and  should  be  compulsory.  The 
health  visitor  should  have  a thorough  training  in  general 
nurdng  before  she  takes  up  her  public  health  duties.  In 
Cleveland  all  the  nurses  connected  with  the  health  depart- 
ment have  had  a general  hospital  training,  a special 
training  in  tuberculosis  dispensaries,  sanatoriums,  &c.,  or  in 
infant  welfare  centres,  children’s  hospitals,  and  dispensaries. 
From  an  infant- welfare  point  of  view,  social  service  should 
receive  more  stress  than  long  preliminary  hospital  training. 


262  The  Lancet,] 


ROYAL  COLLEGE  OF  PHYSICIANS  OF  LONDON. 


[August  9,  1919 


A Baby  Hospital  in  Nerv  Zeala  nd. 

Dr.  Truby  King  described  what  had  been  done  in  New 
Zealand.  A small  hospital  was  established  solely  as  a baby 
hospital,  and  nurses  were  trained  to  fit  them  for  teaching 
and  for  the  care  of  the  mother  and  child  throughout  the 
whole  country.  The  Society  for  the  Health  of  Women  and 
Children  was  started  as  a purely  voluntary  organisation  ; 
monthly  reports  are  issued  to  the  Public  Health  Depart- 
ment, and  the  society  has  worked  in  loyal  cooperation  with 
them.  There  has  been  a growing  recognition  upon  the  part 
of  the  public  authority.  At  first  there  was  no  grant  towards 
the  voluntary  funds  of  the  society,  but  now  the  Government 
contributes  24. s',  for  every  pound  raised  voluntarily  for  the 
salaries  of  mothercraft  nurses,  and  grants  generous  annual 
subsidies  towards  the  support  of  the  hospitals  established  by 
the  organisation.  The  nurses  are  allowed  to  travel  free  of 
cost  over  the  State-owned  railways,  and  the  municipalities 
give  them  free  travelling  over  the  municipal  tramways. 

Resolutions  Approved. 

The  following  important  resolutions  were  unanimously 
passed : — 

(1)  That  every  effort  should  be  made  to  impress  on  the  whole  com- 
munity the  supreme  importance  of  breast  feeding,  for  the  sake  of  both 
mother  and  child  ; that  at  present  over-feeding  of  the  baby,  especially 
in  the  first  fortnight  of  life,  is  one  of  the  commonest  and  most  serious 
mistakes  of  nursing  mothers,  often  upsetting  the  child  and  leading  to 
the  early  abandonment  of  suckling.  (2)  This  tendency  can  be  best 
counteracted  by  a general  recognition  of  the  benefit  of  greater  regularity 
and  lessened  frequency  of  feeding  than  is  customary.  (3)  With  very  few 
exceptions  nursing  only  every  four  hours  from  birth  is  best  for  mother 
and  child,  though  in  a few  cases  more  frequent  feeding  may  be  desirable. 

(4)  That  in  general  there  should  be  an  interval  of  seven  or  eight  hours 
between  the  last  feeding  at  night  and  the  first  feeding  in  the  morning. 

(5)  That  every  medical  student  preparing  for  a registrable  qualification 
shall  receive  adequate  teaching  in  the  subjects  of  infancy  and  child- 
hood in  health  and  disease;  that  attendance  in  a department  where 
instruction  is  given  in  these  subjects  should  be  compulsory  for  a period 
of  not  less  than  three  months  and  that  some  special  part  of  the  final 
examination  in  medicine  should  be  devoted  to  these  subjects.  (6)  That, 
as  far  as  practicable,  this  study  shall  follow  upon,  and  be  coordinated 
with,  a satisfactory  course  in  obstetrics  and  gynecology,  and  should 
be  made  available  for  post-graduate  students;  that  the  present 
training  in  obstetrics  leaves  much  to  be  desired,  especially  in 
regard  to  the  lack  of  facilities  for  bedside  teaching  in  midwifery. 
(7)  Great  public  advantage  would  result  from  a larger  measure  of 
uniformity  in  the  advice  given  by  public  authorities  and  others  In 
respect  of  maternity,  infant,  and  child  welfare  ; the  only  way  in  which 
we  think  this  can  be  secured  is  by  obtaining  a written  statement  from  a 
body  of  experts.  (8)  Both  practical  and  theoretical  instruction  in 
infant  hygiene  should  form  a part  of  the  training  of  midwives  and  of 
all  persons  engaged  by  public  authorities  in  infant  welfare  work. 
(9)  That  maternity  nursing  should  only  be  undertaken  by  competent 
and  adequately  trained  persons,  preferably  by  qualified  midwives. 


URBAN  VITAL  STATISTICS. 

(Week  ended  August  2nd,  1919.) 

English  and  Welsh  Towns.— In  the  96  English  and  Welsh  towns, 
with  an  aggregate  civil  population  estimated  at  16,500,000  persons, 
the  annual  rate  of  mortality,  which  had  been  101,  9‘0,  and  10  3 in 
the  three  preceding  weeks,  fell  to  9 7 per  1000.  In  London,  with 
a population  slightly  exceeding  4,000,000  persons,  the  annual  rate 
was  9’5,  or  l'O  per  1000  below  that  recorded  in  the  previous  week, 
while  among  the  remaining  towns  it  ranged  from  2'7  in  Acton.  2 9 
in  Carlisle,  and  4 0 in  Rotherham,  to  15  5 in  Stockton-on-Tees,  16  3 in 
Southport,  and  17  2 in  Exeter.  The  principal  epidemic  diseases 
caused  154  deaths,  which  corresponded  to  an  annual  rate  of  0’5  per 
1000,  and  included  69  from  infantile  diarrhcea,  45  from  diphtheria,  20 
from  measles,  10  from  whooping-cough,  6 from  enteric  fever,  and  4 
from  scarlet  fever.  Measles  caused  a death-rate  of  12  in  Newcastle- 
upon-Tyne.  There  were  2 cases  of  small-pox,  1538  of  scarlet  fever, 
and  1117  of  diphtheria  under  treatment  in  the  Metropolitan  Asylums 
Hospitals  and  the  London  Fever  Hospital,  against  2,  1526,  and  1140 
respectively  at  the  end  of  the  previous  week.  The  causes  of  31 
deaths  in  the  96  towns  were  uncertified,  of  which  5 were  registered 
in  Birmingham,  4 each  in  Liverpool  and  South  Shields,  and  3 each  in 
London  and  Manchester. 

Scotch  Towns.— In  the  16  largest  Scotch  towns,  with  an  aggregate 
population  estimated  at  nearly  2.500,000  persona,  the  annual  rate  of 
mortality,  which  had  been  110.  10'6,  andllT  in  the  three  preceding 
weeks,  fell  to  10  6 per  1000.  The  227  deaths  in  Glasgow  corresponded 
to  an  annual  rate  of  10  6 per  1000,  and  included  6 from  measles,  5 
from  infantile  diarrhcea,  2 from  whooping-cough,  and  1 each  from 
enteric  fever  and  diphtheria.  The  72  deaths  in  Edinburgh  were  equal 
to  a rate  of  11 '2  per  1000,  and  included  4 from  measles  and  1 each  from 
scarlet  fever,  whooping-cough,  and  diphtheria. 

Irish  Towns. — The  92  deaths  in  Dublin  corresponded  to  an  annual 
rate  of  11  8,  or  0 3 per  1000  above  that  recorded  in  the  previous 
week,  and  included  4 from  infantile  diarrhcea.  The  79  deaths  in 
Belfast  were  equal  to  a rate  of  10  3 per  1000,  and  included  2 from 
infantile  diarrhoea  and  1 from  diphtheria. 


The  King  lias  approved  the  retirement  of  Lieut.- 
Col.  F.  P.  Maynard  and  Lieut.-Col.  S.  H.  Henderson  from 
the  Indian  Medical  Service. 


ROYAL  COLLEGE  OF  PHYSICIANS  OF 
LONDON. 


Comitia  of  the  College. 

An  ordinary  Comitia  of  the  College  was  held  on  July  31str 
Sir  Norman  Moore,  the  President,  being  in  the  chair. 

On  the  report  of  the  Censor’s  Board  it  was  resolved — 

"That  Arthur  Edward  Gladstone  be  declared  to  be  no  longer  a 
Licentiate  of  the  College,  that  he  forfeit  all  rights  and  privileges  of  a 
Licentiate,  and  that  his  name  be  removed  from  the  List  of  Licentiates 
during  the  pleasure  of  the  College.” 

Dr.  Frederic  Percival  Mackie  was  admitted  to  the  Fellow- 
ship of  the  College. 

The  following,  having  passed  the  required  examination, 
were  admitted  as  Members : — 

Thomas  Beaton,  M.D.  Lond.,  L.R.C.P. ; Cecil  Clinton  Birchard1 
M.B.  Toronto;  Reginald  St.  George  S.  Bond,  M.B.  Eiin.;  Maurice 
Davidson,  M.D.  Oxf.,  L.R.C.P.;  Alan  Worsley  Holmes  a Court,  M.B. 
Sydney;  Arthur  Edwin  Horn,  M.D.  Lond. .L.R.C.P. ; Sydney  Fancourt 
McDonald,  M.D.  Melt.;  Douglas  Murray  McWhae,  M.D.  Melb. ; 
Thomas  Archibald  Malloch,  M.D.  McGill;  Ludlow  Murcott  Moody, 
M.B.  Lond.,  L.R.C.P.;  Julian  Lionel  Preston,  MB.  Lond.,  L.R.C.P.; 
Archibald  Cathcart  Roxburgh,  M B.  Camb.,  L.R.C.P. ; Joseph  Wilkie 
Scott,  M.D.Glasg. ; Frank  Shufilebotham,  M.D.  Camb. ; Eric  Clarence 
Spaar,  M.D.  Lond. ; Robert  Maxwell  Trotter,  M.D.  Aberd. ; William 
Balcombe  Winton,  M.D.  Camb. 

Licences  to  practise  physic  were  granted  to  78  candidates 
who,  having  conformed  to  the  by-laws  and  regulations,  had 
passed  the  required  examinations.  Diplomas  in  Public 
Health  were  granted,  in  conjunction  with  the  Royal  College 
of  Physicians,  to  the  following  candidates  who  were  found  by 
the  Examiners  to  be  qualified  : — 

Lionel  Danyers  Bailey,  L.R.C.P.,  M.R.C.S.,  St.  George’s ; Malcolm 
Barker,  L.R.C.P.,  M.R.C.S.,  King’s  College;  Cyril  Douglas  Day, 
L M.S.S.A.  Lond.,  Cambridge  and  St.  Bart.’s ; Herman  Falk  (Major, 
I.M.S.),  L.R.C  P.,  M.R.C.S.,  M.B.,  B.C.  Cantab.,  Cambridge  and  St. 
Thomas’s;  Walter  Henry  Grace,  MB.,  B.S.Lond.,  M.K.C.P.,  M R.C.S., 
Guy’s ; Mervyn  John  Holmes,  M.B.,  B.S.  (Melbourne,  Australia), 
University  College;  Tam  Legge,  L.R.C.P.,  M.R.C.S.,  University 
College;  Richard  Douglas  Passey,  M.C.,  M.B.,  B.S. Lond.,  Guy’s ; Eva 
Louise  Cairns  Roberts,  M.B.,  Cb.B.  Manch.,  Manchester  and  King's 
College;  William  Leslie  Webb,  M.B.,  B.S.Lond.,  L.R.C.P.,  M.R.C.S., 
Guy’s;  Harold  Edward  Whittingham.  M.B  , Ch.B.GIasg.,  Glasgow  and 
University  College;  John  Pryce  Williams,  L.R.C.P.,  M.R.C.S.,  St. 
Mary  ’s  and  King’s  College. 

The  following  appointments  were  made,  and  the  newly 
elected  officers  gave  their  faith  to  the  College  : — 

Censors.— Sir  Wilmot  P.  Herringham,  Sir  Humphry  D.  Rolleston. 
Dr.  Raymond  H.  P.  Crawfurd,  Sir  John  Rose  Bradford. 

Treasurer. — Sir  Dyce  Duckworth. 

Registrar.— Dr.  Joseph  Arderne  Ormerod. 

Harveian  Librarian.— Dr . T.  H.  Arnold  Chaplin. 

Members  of  the  Library  Committee.— Dr.  Hector  W.  G.  Mackenzie, 
Dr.  Dawson  Williams,  Dr.  Arthur  Francis  Voelcker,  Dr.  Herbert  Ritchie 
Spencer. 

Curators  o)  the  Museum. — Dr.  John  Mitchell  Bruce,  Sir  Seymour 
John  Sharkey,  Dr.  Frederick  William  Andrewes,  Dr.  William  Hunter. 

Finance  Committee.— Dr.  Sidney  Philip  Phillips,  Dr.  Arthur  Templer 
Davies,  Dr.  Herbert  Ritchie  Spencer. 

Examiners.— Chemistry  : Mr.  William  Holdsworth  Hurtley,  Mr. 
Ileurv  Rondel  Le  Sueur.  Physics  : Mr.  James  Hancock  Brinkworth, 
Mr.  Alfred  Henry  Fison.  Practical  Pharmacy : Dr.  Robert  Arthur 
Young.  Dr.  David  Forsyth,  Dr.  William  Mitchell  Stevens,  Dr.  James 
Andrew  Gunn,  Dr.  Edward  Mellanby.  Physiology  : Dr.  David 
Henriques  de  Souza,  Mr.  John  Smyth  Macdonald.  Anatomy;  Dr. 
Edward  Barclay-Smith.  Metical  Anatomy  and  Principles  and  Practice 
of  Medicine : Dr.  James  Calvert,  Dr.  William  Hunter,  Dr.  William 
Aldren  Turner,  Dr.  Horace  George  Turney,  Dr.  John  Walter  Carr,  Dr. 
John  Fawcett,  Dr.  James  Stansfield  Collier,  Dr.  Robert  Hutchison,  Dr. 
Frederick  John  Poynton,  Dr.  Arthur  John  Hall.  Midwifery  and 
Diseases  peculiar  to  Women  : Dr.  George  Francis  Blacker,  Dr.  Henry 
Russell  Andrews,  Dr.  Hugh  J.  M.  Playfair,  Dr.  William  F.  Victor 
Bonnev,  Mr.  Harold  Chappie. 

Public  Health.— Part  I. : Mr.  John  Henry  Ryffel.  Part  II. : Dr. 
Edward  William  Hope. 

Tropical  Medicine. — Dr.  John  C.  Grant  Ledingham,  Dr.  John  Brian 
Christopherson. 

Murchison  Scholarship.— Dr.  John  Fawcett,  Dr.  Alfred  Ernest 
Russell. 

Communications  were  received  from  (1)  the  secretary  of 
the  Royal  College  of  Surgeons  reporting  proceedings  of  the 
Council  of  that  College  upon  May  8th,  June  12th,  and 
July  11th  last,  respectively ; (2)  Dr.  E.  A.  Gates  asking  to 
be  allowed  to  resign  temporarily  hisDiploma  of  Membership 
—this  was  agreed  ; (3)  Lady  Allchin  offering  to  the  College 
a portrait  of  the  late  Sir  William  Allcbin,  by  Sir  Luke 
Fildes.  R.A.— the  thanks  of  the  College  were  accorded  to 
Ladv  Allchin.  On  the  recommendation  of  the  Council  the 
Balv  medal  was  awarded  to  Dr.  Leonard  Hill,  F.R.S.  The 
report  of  the  Imperial  Cancer  Research  Fund  was  received. 
Dr.  F.  W.  Andrewes  was  re-elected  a member  of  the 
Executive  Committee  of  the  Imperial  Cancer  Research  Fund. 
Sir  William  Church  and  Sir  Thomas  Barlow  were  reappointed 
members  of  the  Executive  Committee  of  the  Imperial  Cancer 
Research  Fund,  on  the  recommendation  of  the  General 
Committee  of  the  Fund.  The  President  informed  the  College 
that  the  Executive  Committee  of  the  Streatfeild  Scholarship 


The  Lancet,] 


ROYAL  COLLEGE  OF  PHYSICIANS  OF  LONDON.— THE  SERVICES.  [August9,  1919  263 


have  awarded  the  scholarship  to  Dr.  F.  G.  Cawston,of  Durban > 
Natal.  Reports  were  received  from  the  representative  of  the 
College  on  the  General  Medical  Council  and  from  Sir  George 
Savage  on  the  Chelsea  Physic  Garden. 

Reports  from  the  Committee  of  Management  of  the  Conjoint 
Examining  Board. 

The  report  of  the  Committee  of  Management,  dated 
June  3rd  last,  contained  the  following  recommendations: — 

1.  The  Committee  recommend  that  the  following  schools  be  added 
to  the  list  of  institutions  recognised  by  the  Board  for  instruction  in 
Chemistry  and  Physics— namely,  the  Central  Secondary  School, 
Sheffield,  and  the  Grammar  School,  Barnstaple. 

2.  The  Committee  recommend  that  the  following  school  he  recognised 
for  instruction  in  Chemistry,  Physics,  and  Biology— namely,  St.  Paul’s 
School  for  Girls,  West  Kensington. 

3.  The  Committee  recommend  that  the  following  institution,  which 
is  already  recognised  for  instruction  in  Chemistry  and  Physics,  he  also 
recognised  for  instruction  in  Biology — namely,  Municipal  College, 
Grimsby. 

A report  of  the  Committee  of  Management,  dated  July  8th, 
was  also  received  dealing  with — 

J . The  report  of  the  Council  of  British  Ophthalmologists. 

2.  The  substitution  of  an  examination  in  Materia  Medica  and  Phar- 
macology for  the  present  examination  in  Practical  Pharmacy. 

3.  The  recognition  of  schools  for  instruction  in  Chemistry  and 
Physics. 

4.  The  recognition  'of  the  course  of  instruction  in  Pharmacology  at 
the  University  of  Cape  Town. 

1.  The  report  of  the  Council  of  the  British  Ophthalmo- 
logists on  the  teaching  and  examination  of  medical  students 
in  ophthalmology  concludes  with  the  following  recom- 
mendations : — 

(1)  No  student  shall  be  admitted  to  the  Final  Examination  qualifying 
to  practise  medicine  unless  he  hss  attended  an  ophthalmic  clinic  for  not 
less  than  six  hours  a week  during  a period  of  three  months,  and  has 
attended  a course  of  systematic  instruction  in  ophthalmology.  (2)  No 
student  shall  be  considered  to  have  passed  the  qualifying  examina- 
tion unless  he  has  shown  a sound  knowledge  of  practical  ophthalmology 
in  an  examination  conducted  by  ophthalmic  surgeons. 

In  referring  this  report  to  the  Committee  the  Council  of 
the  Royal  College  of  Surgeons  of  England  also  forwarded  a 
resolution  stating  that  in  their  opinion  it  is  not  desirable  to 
institute  a special  examination  in  ophthalmology  conducted 
by  ophthalmic  surgeons.  The  Committee  of  Management 
agree  with  this  resolution,  and  have  therefore  considered 
whether  any  alteration  in  the  Regulation  relating  to  instruc- 
tion in  ophthalmology  is  desirable.  In  connexion  with  this 
subject  the  following  resolution,  adopted  by  the  General 
Medical  Council  on  May  31st,  1919,  was  also  considered  : — 

“That  every  student  should  be  required  to  attend  a course  of 
practical  instruction  in  ophthalmology  of  not  less  than  ten  weeks’ 
duration,  and  that  no  student  should  be  admitted  to  the  Final  Exami- 
nation unless  he  presents  a certificate  to  the  effect  that  he  has 
attended  such  a course  regularly,  and  that  his  work  in  connexion 
therewith  has  reached  a satisfactory  standard." 

The  present  Regulation  of  the  Conjoint  Board,  Section  II. 
XXI.  6,  requires  a certificate— 

“ Of  having  attended  clinical  instruction  in  ophthalmic  surgery  in 
the  ophthalmic  department  of  a recognised  general  hospital,  or  at  an 
ophthalmic  hospital  recognised  for  the  purpose  by  the  Examining 
Board  in  England,  during  not  less  than  three  months." 

The  Committee  of  Management  of  the  Royal  College  of 
Physicians  of  London  are  of  opinion — 

That  the  present  Regulation  Section  II.  XXI.  6 covers  the  resolution 
of  the  General  Medical  Council,  and  that  this  Regulation  requires  a 
sufficient  period  of  special  instruction  in  ophthalmology ; that  the 
provisions  of  the  Regulations  Section  I.,  paragraphs  VIII.  and  IX., 
enable  the  teachers  of  ophthalmology  in  the  medical  schools  and  hos- 
pitals to  hold  class  examinations  and  to  institute  such  conditions  for 
attendance  on  the  course  as  they  consider  desirable  before  certificates  of 
attendance  are  granted  by  them. 

For  these  reasons  the  Committee  recommend  that  no 
alteration  be  made  in  the  present  Regulation  relating  to 
instruction  and  examination  in  ophthalmology. 

2.  In  the  year  1915  the  Royal  Colleges  decided  to  substitute 
an  “examination  in  Materia  Medica  and  Pharmacology”  for 
the  present  examination  in  Practical  Pharmacy,  but  agreed 
that  the  new  examination  should  not  come  into  force  until 
January,  1918,  and  then  only  if  the  war  be  ended.  The 
Committee  of  Management  are  of  opinion  that  the  time  has 
now  arrived  when  this  new  examination  should  be  instituted, 
and  they  have  accordingly  adopted  the  following  recom- 
mendations to  the  Royal  Colleges,  viz. : — 

1.  That  notice  be  given  to  the  medical  schools  and  by  advertisement 
in  the  medical  journals  that  an  examination  in  Materia  Medica  and 
Pharmacology  will  be  substituted  for  the  examination  in  Practical 
Pharmacy.  2.  That  the  examination  in  Materia  Medica  and  Pharma- 
cology be  taken  by  all  candidates  who  have  not  completed  the  First 
Examination,  including  Practical  Pharmacy,  by  May  1st,  1920.  3.  That 
no  alteration  in  the  fees  payable  on  the  first  admission  to  the  First 
and  Second  Examinations  is  necessary.  4.  That  the  fee  for  re- 
examination in  Materia  Medica  and  Pharmacology  be  3 guineas. 

5.  Tuat  the  capitation  fee  paid  to  the  examiners  be  raised 
from  10s.  to  16s.  (It  is  estimated  that  each  examiner  will  receive 
at  least  £40  a year.)  6.  That  the  revised  Regulations,  with  the  new 
synopsis  already  authorised  by  the  Royal  Colleges,  be  issued. 


7.  That  in  addition  to  the  revision  In  the  Regulations  already 
authorised,  paragraphs  II.,  III.,  and  IV.  of  Section  III.  of  the  Regu- 
lations relating  to  the  conditions  of  admission  to  examination  "f 
members  of  English.  Scottish,  Colonial  I>  dlan,  and  foreign  Univer- 
sities bo  modified  so  as  to  admit  of  such  students  presenting  themselves 
for  the  Final  Examination  at  the  expiration  of  two  years  from  the  dale 
of  passing  in  anatomy  and  physiology  at  their  Universities,  provided 
the  curriculum  of  professional  study  has  been  completed,  notwith- 
standing that  the  corresponding  examination  at  their  Universities  in 
pharmacology  and  materia  medica  may  have  been  passed  in  the  third 
or  fourf  h year. 

3.  The  Committee  recommend  that  the  following  schools 
be  added  to  the  list  of  institutions  recognised  by  the  Board 
for  instruction  in  chemistry  and  physics — namely  : King’s 
School,  Rochester;  the  Grammar  School,  Normanton. 

4.  The  Committee  recommend  that  the  course  of  instruc- 
tion in  pharmacology  and  practical  pharmacology  in  the 
Medical  Department  of  the  University  of  Cape  Town  be 
recognised  by  the  Board. 


Kk  Vertices. 


ARMY  MEDICAL  SERVICE. 

Major-General  Sir  Menus  W.  O’Keefe,  K.C.M.G.,  C.B.,  retires  on 
retired  pay. 

Major-General  Sir  M.  P.  C.  Holt.  K.C.B.,  K.C.M.G.,  D.S.O.,  is 
appointed  Honorary  Surgeon  to  the  King,  vice  Major-General  (temp. 
Lieut. -General)  Sir  W.  Babtie,  V.C.,  K.C.M.G.,  C.B.,  K.H.S. 

ROYAL  ARMY  MEDICAL  CORPS. 

Lieut.-Cols.  L.  F.  F.  Winslow  and  R.  C.  Lewis  retire  on  retired  pay. 

Major  and  Bt.  Lieut.-Col.  C.  R.  Sylvester -Bradley  and  Capt.  A.  C. 
Hammond-Searle  relinquish  the  acting  rank  of  Lieutenant-Colonel  on 
re-posting. 

Major  A.  E.  Smithson  is  placed  on  retired  pay. 

Captains  to  be  Majors  : A.  W.  Howlett,  G.  F.  Dawson,  H.  S.  Dickson, 
W.  A.  Spong,  H.  P.  Hart,  J.  C.  L.  Hingst-m,  A.  Hendry.  R.  E. 
Todd,  G.  Petit,  and  W.  R.  O'Farrell ; (acting  Majors)  J.  A.  Renshaw, 
D.  B.  McGrigor,  R.  F.  O’T.  Dickinson,  A.  E.  B.  Jones,  J.  R.  Lloyd,  J.  F. 
Grant,  and  C.  Kelly ; (acting  Lieut.-Cols.)  R.  G S.  Gregg  and  B.  A. 
Odium  ; (Bt.  Major)  F.  T.  Dowling 

Temporary  Captains  relinquishing  the  acting  rank  of  Major  : R.  S. 
Dickie  (on  re-posting\  T.  E.  R.  Branch. 

Capt.  D Forsyth  Panton,  from  Special  Reserve,  to  be  Lieutenant  and 
to  be  Temporary  Captain. 

Temp.  Capt.  A.  E S.  Pringle- Pattison  to  be  Captain. 

Capt.  II.  G.  Trayer  resigns  his  commission. 

Officers  relinquishing  their  commissions  Temp.  Lieut.-Col.  H.  L. 
Eason  retains  rank  of  Lieutenant-Colonel.  Temporary  Majors  retain- 
ing the  rank  of  Major:  C.  S.  Read,  J.  Phillips,  T.  M.  Frood,  W.  H 
Thompson.  Temporary  Captains  granted  rank  of  Major  : A.  T.  Edwards, 
A.  C.  S.  Courts,  W.  H.  Welsh,  J.  A.  Doull,  J.  S.  Stewart,  A.  C.  Bryson. 
Temporary  Captains  retaining  rank  cf  Captain:  G.  S.  Banks,  J.  V. 
Grant,  J.  W.  N.  Roberts,  V.  T.  P.  Webster,  H.  M.  Brown,  J.  F.  Smith, 
A.  S.  Richmond,  P.  A.  B.  Clark,  S.  F.  Cheesman,  J.  H Glover,  J.  M. 
Johns’one,  W.  G.  Fee,  R.  W.  T.  Clampett,  L.  W.  Batten,  H.  F.  Briee- 
Smith,  F.  P.  Hearder,  G.  Rcbimon.  A.  C.  Profeit,  T.  L.  Butler,  M.  W. 
Shutte,  J.  B.  Lester,  A.  G.  Payne,  J.  F.  Sheppard,  W.  H.  W.  C.  Carden, 
D.  A.  Farquharson.  Temporary  Lieutenants  retaining  the  rank  of 
Lieutenant : W.  P.  McCowan,  W.  A.  S.  Magrath,  W.  E.  Martin,  R.  R. 
MacGregor,  H.  E.  Thompson. 

SPECIAL  RESERVE  OF  OFFICERS. 

The  undermentioned  Captains  to  be  acting  Majors  whilst  specially 
employed  : M.  Stewart,  R.  D.  Cameron. 

TERRITORIAL  FORCE. 

Lieut.-Col.  Sir  Wilmot  P.  Herringham  is  retired  on  attaining  the  age 
limit,  and  is  granted  the  honorary  rank  of  Major-General. 

Capt.  (acting  Lieut.-Col.)  G.  R Rickett,  relinquishes  the  acting  rank 
of  Lieutenant-Colonel  on  ceasing  to  be  specially  employed. 

Capts.  (acting  Majors)  W.  Scott,  A.  B.  Mackenzie,  and  L.  M.  V. 
Mitchell  relinquish  the  acting  rank  of  Ma  jor  on  ceasing  to  be  specially 
employed. 

1st  Eastern  General  Hospital : Capts.  (acting  Majors)  G.  S.  Haynes 
and  .1.  C.  W.  Graham  relinquish  the  acting  rank  of  Major  on  oeasiDg  to 
be  specially  employed. 

3rd  Northern  General  Hospital : Major  H.  R.  Dean  is  restored  to  the 
establishment. 

TERRITORIAL  FORCE  RESERVE. 

Capt.  Sir  James  P.  Stewart,  from  4th  London  General  Hospital,  to  be 
Colonel. 

Capt.  M.  W.  K.  Bird  relinquishes  his  commission  on  account  of  ill- 
health  contracted  on  active  service,  and  retains  the  rank  of  Captain. 

ROYAL  AIR  FORCE. 

Medical  Branch. — Major  A.  Fairley  (Surgeon  Lieut. -Comdr.,  R.N.) 
relinquishes  his  commission  on  ceasing  to  be  employed. 

The  undermentioned  are  transferren  to  unemployed  list:  Lieut.-Col. 
T.  Philp ; Capts.  J.  Freeman,  C.  C.  O’Malley,  (Hon.  Major)  D.  Wilson, 
A.  Sutcliffe,  J.  L.  Whatley,  H.  M.  Holt ; Lieut.  A.  J.  Swanton. 

DEATHS  IN  THE  SERVICES. 

Captain  George  Thomas  Whyte,  F.R.C.S.  Irel.,  D.P  H.,  R.A.M.C., 
who  died  at  the  Militarv  Hospital,  Spike  Island,  Queenstown,  on 
June  9th,  qualified  in  1892  and  took  the  F.R.C.S.  Irel,  in  1901.  He 
served  as  civil  medical  officer  to  the  Field  Force  during  the  South 
African  War,  and  after  obtaining  a public  health  diploma  returned 
to  his  post  on  the  We9t  African  Medical  Staff  in  Northern  Nigeria. 
He  had  served  18  months  in  France  during  the  war  that  is  past,  and 
died  after  a brief  illness  of  four  days.  He  leaves  a widow  and  a little 
girl,  aged  2 years. 


264  The  Lancet,]  THE  PENSIONS  PROBLEM.— INCIPIENT  MENTAL  DISEASES. 


[August  9,  1919 


®0mspnbme. 

" Audi  alteram  partem.” 


THE  PENSIONS  PROBLEM. 

To  the  Editor  of  The  Lancet. 

Sir, — In  connexion  with  the  assessment  of  the  pensions  to 
be  allotted  to  partially  disabled  officers  and  men,  the  power 
of  prognosis  of  the  medical  profession  is  in  many  cases  being 
submitted  to  a test  that  it  cannot  sustain.  It  is  possible  to 
estimate  with  some  measure  of  accuracy  the  degree  of  future 
disability  of  a man  who  after  an  injury  has  had  a limb  or 
portion  of  a limb  amputated.  For  these  and  some  other 
similar  cases  a partial  pension  can  be  more  or  less  fairly 
assessed.  It  is  quite  impossible  to  forecast  with  any 
approach  to  certainty  the  future  average  employability 
and  proportionate  earning  capacity  of  a man  who  has  sus- 
tained a gunshot  wound  of  a viscus  or  has  suffered  from 
tuberculous  or  malarial  infection.  For  these  and  very  many 
similar  cases  no  fair  individual  assessment  can  be  made. 
Such  cases  could  be  put  in  groups  according  to  their  history 
and  present  condition,  and  a rough  calculation  made  as  to 
the  average  incidence  of  future  disability  amongst  all  the 
members  in  each  group ; just  in  the  manner  in  which 
impaired  lives  seeking  life  insurance  are  dealt  with.  Prob- 
ably something  of  this  sort  is  being  done  now  in  allotting 
partial  pensions.  But  what  will  be  the  result  ? Those  with 
partial  pensions  who  do  not  subsequently  break  down  will  be 
heard  of  no  more,  but  the  minority  who,  according  to  the  law 
of  averages,  will  break  down  badly  will  find  their  small 
pensions  altogether  inadequate,  their  hardships  will  quite 
rightly  come  under  public  notice,  and  the  profession  will  be 
blamed  for  not  having  made  for  them  adequate  provision. 

It  would  be  well,  therefore,  for  the  profession  at  once  to 
make  clear  to  the  public  that  it  is  quite  impossible  for  science 
to  provide  the  data  on  which  a fair  pension  can  be  assessed 
in  the  case  of  large  numbers  of  partially  disabled  men. 
Since,  however,  the  number  of  such  men — some  not  yet 
demobilised,  others  demobilised  but  still  on  temporary 
pensions — is  very  great,  some  provision  must  be  made  to 
meet  their  special  risk  of  disability.  For  a considerable 
number  of  cases  the  most  suitable  way  of  meeting  the  risk 
would  be  the  issue  of  a sickness  insurance  policy  guaranteeing 
in  the  event  of  a breakdown  in  the  future  the  periodical 
payment  by  the  Government  of  a sum  to  meet  the  then 
ascertained  degree  of  disability  so  far  as  it  is  not  met  by 
any  other  national  insurance.  In  some  cases  such  a policy 
would  take  the  place  of  a partial  pension,  in  others  it  would 
be  additional  to  it.  The  task  of  dealing  with  many  cases, 
which  now  present  an  insoluble  problem,  would  at  once 
become  simple.  It  would  only  be  necessary  at  the  outset  to 
earmark  certain  cases  as  having  been  rendered  by  injury  or 
disease  resulting  from  war  service  specially  liable  to  relapses 
of  disability,  and  later  on  to  determine  the  fact  of  disability 
should  it  occur.  The  Ministry  of  Pensions  must  naturally  look 
to  the  medical  profession  for  advice  as  to  fair  and  proper  ways 
of  dealing  with  all  the  various  types  of  cases  amongst  those 
whose  health  has  suffered  from  war  service.  Those  medical 
men  who  are  in  a position  to  offer  such  advice  should  lose  no 
time  in  pointing  out  that  there  is  a large  proportion  of  cases 
whose  special  claim  upon  the  nation  cannot  be  met  by  the 
old-fashioned  method  of  a pension  assessed  according  to  the 
demonstrable  degree  of  disability,  but  can  be  quite  satis- 
factorily dealt  with  by  a well-considered  scheme  of  sickness 
insurance.  Such  a scheme  could  be  easily  devised  and  at 
once  put  in  force.  Those  who  ought  to  come  under  it  are, 
as  things  stand  at  present,  either  not  having  their  claims 
met  or  are  being  dealt  with  in  a manner  which  will 
ultimately  prove  unfair  to  them  or  to  the  State. 

I am,  Sir,  yours  faithfully, 

August  4tb,  1919.  LAURISTON  E.  SHAW. 


INCIPIENT  MENTAL  DISEASES. 

To  the  Editor  of  The  Lancet. 

Sir, — In  vour  issue  of  July  26th  is  published  a letter  by 
Dr.  L.  A.  Weatherly  on  the  treatment  of  cases  of  incipient 
mental  disease,  and  while  fully  agreeing  with  most  of  his 
statements  I do  not  think  too  strong  a protest  should  be 
made  against  the  proposed  limitation  of  sojourn  for  such 


cases  to  six  months.  I quite  agree  with  Dr.  Weatherly  that 
under  such  a regulation  a certain  number  of  patients  may 
be  found  nearly  well  at  the  time  they  have  to  leave  the 
institution  ; but  I would  rather  this  happen  than  have  in 
any  way  retarded  the  facilities  for  early  treatment  that  are 
apparently  rapidly  materialising. 

In  dealing  with  many  thousands  of  cases  of  acute  mental 
disorder  in  the  early  stages  during  the  war  in  a military 
hospital  I found  that  three  months  was  an  average  period 
of  residence.  Out  of  1000  cases  in  hospital  at  the  end  of  a 
two  years’  period  of  admissions  only  200  were  found  to  have 
been  resident  six  months  or  over,  and  '/O  per  cent,  of  these 
were  looked  upon  as  unlikely  to  make  an  early  recovery. 
At  the  time  I refer  to  it  was  the  custom  to  keep  such  cases 
for  nine  months  prior  to  certification,  but  from  my  previous 
experience  I consider  that  any  retention  of  chronic  cases  in 
a hospital  intended  for  treatment  of  early  cases  is  to  be 
condemned  in  the  strongest  possible  terms. 

An  atmosphere  of  cure  is  what  is  wanted  above  all  things 
in  such  an  institution,  and  for  this  reason  I would  support 
the  limitation  to  six  months,  but  would  suggest  that  the 
words  “provided  that  the  patient  is  not  making  obvious 
improvement”  be  added,  as  a means  of  overcoming  the 
difficulty  referred  to. — I am,  Sir,  yours  faithfully, 

Richard  Eager,  M.D. 

Devon  Mental  Hospital,  Exminster,  July  30th,  1919. 


THE  COORDINATION  OF  CLINICAL  RESEARCH 
AND  PSYCHOLOGICAL  MEDICINE. 

To  the  Editor  of  The  Lancet. 

Sir, — In  The  Lancet  of  August  2nd  there  appeared  an 
article  by  Dr.  Bedford  Pierce  on  ‘ • Psychiatry  a Hundred 
Years  Ago,”  also  a letter  from  Dr.  E.  Goodall  setting  out 
what  Cardiff  is  about  to  do  in  the  present.  I should  like  to 
draw  attention  to  the  fact  that  Birmingham  already  has  a 
special  hospital  for  the  treatment  of  nervous  diseases,  the 
largest  department  of  which  is  a “psychoneurosis  clinic.” 
The  hospital  was  founded  in  1913,  but  before  beds  could  be 
provided  in  a suitable,  quiet  locality  the  war  broke  out.  The 
governors,  therefore,  deemed  it  wise  to  postpone  the  opening 
of  the  in-patient  department  for  mental  cases  until  after  the  j 
war.  Immediately  upon  the  cessation  of  hostilities  they 
acquired  a very  suitable  property  with  large  grounds 
attached,  and  this  will  be  ready  for  the  reception  of  patients 
by  the  end  of  next  month. 

I wish  to  emphasise,  in  this  connexion,  two  or  three  points 
which  seem  to  me  to  have  been  passed  over  by  the  writers 
referred  to  above.  The  first  point — mentioned  in  your  leading 
article  but  not  sufficiently  stressed — is  the  necessity  of 
separating  early  borderline  and  psychogenic  from  certifiable 
cases.  If  the  public  even  suspect  that  they  or  their  friends 
are  being  invited  to  attend  an  institution  in  any  way 
associated  with  an  asylum  the  early  cases,  in  which  treat- 
ment is  most  likely  to  be  effectual,  will  not  present 
themselves.  For  this  reason  it  seems  to  me  essential 
that  the  special  clinics  now  springing  up  should  be  kept 
free  from  any  taint  of  the  asylum.  The  term  “hospital 
for  nervous  diseases  ” or  disorders  seems  acceptable  to  the 
general  public,  and  I suggest  that  its  adoption  would  avoid 
the  danger  under  discussion.  There  is  another  advantage 
to  be  gained  by  working  the  new  clinics  from  a special  hos- 
pital for  “ nervous  diseases  ” — viz.,  the  well-recognised  fact 
that  even  in  cases  in  which  the  primary  causal  factor  is 
indisputable  of  organic  origin,  it  is  nevertheless  the  super- 
added  functional  or  psychogenic  symptoms  which  cause 
most  trouble,  though  they  are  also  the  most  amenable  to 
suitable  treatment.  Such  cases  willingly  attend  a hospital 
for  nervous  diseases  where  both  elements  of  their  trouble 
can  be  tackled,  but  they  would  merely  be  offended  were 
they  asked  to  attend  a psychiatric  clinic.  Again,  although 
borderline  and  psychogenic  cases  should  be  separated  from 
advanced  and  hopeless  cases  of  insanity,  it  will,  from  the 
research  point  of  view,  be  a great  advance  if  all  diseases 
with  a pronounced  psychogenic  element  can  be  grouped  and 
observed  together  with  ordinary  neurological  cases  instead 
of  being  dealt  with  by  the  more  or  less  logic-tight-  i 
compartment  methods  hitherto  in  vogpe. 

My  last  point  concerns  the  desirability,  in  large  towns  at  | 
any  rate,  of  separating  the  out-  from  the  in-patient  depart-  j 
ment.  The  former  must  be  in  a central  situation,  which  ' 
implies  a small  and  noisy  site,  whereas  the  latter  ought  to  ! 


The  Lancet,]  THE  ORIGIN  OK  LIFE  : THE  WORK  OK  THE  LATE  CHARLTON  BASTIAN.  [August  9,  1919  265 


be  in  a quiet  locality  and  have  large  grounds  and  work- 
shops attached,  so  that  occupation  and  recreation  may  be 
available  for  the  patients.  During  the  year  1918  the  out- 
patient attendances  at  the  Birmingham  Nerve  Hospital 
totalled  17,246,  while  the  beds  provided  at  present  are  for 
30  patients  only.  It  would  he  unwise  to  attempt  to  divert  so 
many  out-patients  from  a conveniently  situated  central 
institution,  and  impracticable  to  provide  adequate  accommo- 
dation for  this  special  type  of  in-patient  upon  a centrally 
situated  site.  The  governors,  therefore,  have  located  their 
new  in-patient  department  for  functional  and  borderline 
cases  at  some  distance  from  the  original  institution,  although 
this  involves  an  increase  in  the  expenses  of  management. 

My  plea,  then,  is  that  the  basis  of  the  new  clinics  be 
broadened  and  that  at  the  same  time  everything  reasonable 
be  done  to  secure  the  confidence  of  those  whom  we  are 
seeking  to  benefit. — I am,  Sir,  yours  faithfully, 

Alfred  Carver. 

Birmingham  and  Midland  Hospital  for  Diseases  of  the 
Nervous  System,  Birmingham,  August  4th,  1919. 


THE  ORIGIN  OF  LIFE:  THE  WORK  OF  THE 
LATE  CHARLTON  BASTIAN. 

To  the  Editor  of  The  Lancet. 

Monsieur, — Je  n’airais  eu,  pour  le  moment,  que  peu  de 
chose  4 aj outer  A ma  lettre  parue  dans  vos  colonnes  le 
28  Juiu  dernier,  si  ^intervention  de  M.  John  Butler  Burke 
{The  Lancet,  26  Juillet)n'efcait  venue  introduire  de  nouvelles 
hypotheses  dans  l’interpretation  des  experiences  du  Dr. 
Bastian  et  autres  essais  du  meme  genre.  Je  dois  pleinement 
reconnaitre  le  tres  grand  interet  des  Radiobes  de  M.  Burke, 
dont  les  proprietes  biotiques  sont  saisissantes  ; mais  Raphael 
Dubois  (avant  M.  Burke)  et  Martin  Kuckuck  (apres  lui),  ont 
obtenu  des  resultats  exactement  semblables  en  utilisant  des 
sels  non  radioactifs  de  baryum,  strontium,  &c.  Comme  les 
radiobes  de  M.  Burke,  les  miorobiu'ides  de  Dubois  et  les 
baryumcytoden  de  Kuckuck  grossissent,  se  meuvent,  se 
xeproduisent  par  bipartition,  semblent  parfois  se  conjuguer  ;1 
la  maniere  de  certaines  algues  monocellulaires  : ce  qui  ne  les 
empfiche  nullement  de  passer,  en  vieillissant,  & l’etat  de 
cristaux  polyedriques  inertes.  II  semble  difficile  de  voir  dans 
ces  corpuscules  autre  chose  que  de  tres  petits  cristaux 
imparfaits  dont  le  stade  precristallin  se  trouve  considerable- 
ment  prolonge  par  l’ambience  colloidale  ; d’ailleurs,  tous  les 
cristaux  en  voie  de  formation,  surtout  dans  des  milieux 
tres  visqueux,  se  comportent  temporairement,  au  point  de  vue 
structural  et  dynamique,  comme  des  6tres  vivants.  A l’appui 
de  ce  que  j’avance,  je  mentionnerai  les  Protohies  de  A.  L. 
Herrera  (cristaux  imparfaits  en  milieux  siliciques)  et  nos 
propres  experiences  sur  la  formation  des  cristaux.1  La 
radioactivity  me  semble,  en  toute  sincerity  absolument 
etrangere  4 de  telles  questions.  Quant  au  role  de  la  diffusion 
et  de  la  pression  osmotique  dans  l’apparition  des  bacteries 
minerales  de  Bastian  et  Mary,  il  doit  etre  inexistant.  Sans 
doute,  mon  eminent  ami  Stephane  Leduc  a produit,  par 
osmose,  et  aussi  par  diffusion  de  cristalloides  dans  les  gels 
■colloidaux,  une  profusion  de  formes  et  de  structures 
artificielles  de  nature  d,  nous  renseigner  sur  l’intervention 
des  forces  capillaires  dans  la  determination  des  caracteres 
morphologiques  et  physiologiques  geueraux  des  organismes. 
Mais  les  croissances  osmotiques,  que  nous  avons  aussi 
■etudiyes  depuis  1908,  sont  des  vesicules,  et  les  figures  de 
•diffusion  dans  les  gels  n’ont  pas  d’existence  en-dehors  de 
leur  substratum  colloidal.  Les  corpuscules  syntbetiques  de 
Bastian  sont  forays  par  les  colloides  eux-metnes,  et  ne  sont 
pas  vysiculaires.  Pour  expliquer  le  mecanisme  physique  de 
leur  dyveloppement,  c’est  exclusivement  & la  physico-chimie 
■colloidale  qu’il  faut  faire  appel,  et  tout  l’interet  du  probleme 
tient  precisement  & ce  fait  qu’il  n’y  a qu 'une  physico-chimie 
colloidale,  embrassant  dans  des  lois  communes  l’organique 
«t  le  mineral. — Je  suis,  Monsieur,  tres  sincyrement  votre, 

Albert  Mary. 

Jnstitut  de  Biophysique,  Paris,  30  Juillet,  1919. 

To  the  Editor  of  The  Lancet. 

Mr.  S.  G.  Paine,  writing  some  time  ago  in  your 
columns  on  the  “ Origin  of  Life,”  in  particular  connexion 
with  the  work  of  Charlton  Bastian,  mentioned  that  the  sand 
of  the  Egyptian  desert,  which  is  subjected  to  a considerable 
heat,  contains  living  protozoa.  I do  not  know  what  temperature 


these  organisms  can  withstand,  but  it  should  be  remembered 
that  under  those  conditions  the  heat  will  be  dry.  The  following 
facts,  however,  show  that  the  limits  of  resistance  of  certain 
organisms,  even  to  moist  heat,  are  greater  than  was  sus- 
pected. M.  Paul  Portier,  professeur  l’lnstitut  Oc6ano- 
graphique,  in  his  recent  work  entitled  “Les  Symbiotes” 
(Masson  et  Cie,  1918),  describes  certain  symbiotic  micro- 
organisms, isolated  from  both  vertebrates  and  insects,  which 
are  extraordinarily  resistant  to  physical  and  chemical 
agents.  When  freshly  isolated  they  are  killed  by  a tempera- 
ture of  100°  C.,  but  after  a few  subcultivations  the 
temperature  must  be  raised  to  115°  C.,  moist  heat.  In  a 
dry  atmosphere  they  can  resist  a temperature  of  140°  C., 
and  are  only  just  killed  by  a temperature  of  150°  C.,  main- 
tained for  half  an  hour.  Further,  these  organisms  may  be 
boiled  in  absolute  alcohol,  chloroform,  or  acetone,  and 
yet  remain  capable  of  cultivation.  In  one  set  of  experi- 
ments, indeed,  they  withstood  heating  in  acetone  in  sealed 
tubes  at  a temperature  of  100°  C.  to  120°  C. 

In  connexion  with  this  subject  it  may  be  mentioned  that 
certain  enzymes,  as,  for  instance,  ptyalin,  which  begin  to 
decompose  at  a temperature  of  60°  C.  and  are  completely 
destroyed  by  temperatures  of  less  than  100°  C.,  can,  when 
dialysed  free  from  all  traces  of  electrolytes,  be  boiled 
without  losing  all  activity,  which  returns  on  the  readdition 
of  a little  salt.  In  view  of  such  facts,  experiments  similar 
to  Dr.  Bastian’s  must  be  carried  out  with  the  greatest 
possible  precautions  as  to  technique  and  sterilisation.  It  is 
true  that  the  interesting  experiments  of  Dr.  Mary  were  carried 
out  at  a temperature  which  should  kill  any  organisms  at 
present  known.  Dr.  Mary,  however,  admits  that  the  bodies 
found  in  his  solutions  do  not  contain  any  protein  and  are 
incapable  of  cultivation,  even  on  the  simple  solutions  which 
are  supposed  to  generate  them — that  is  to  say,  they  are  not 
living  matter  in  any  ordinarily  accepted  use  of  that  term. 

Since  writing  the  above,  I have  seen  Commander  Bastian’s 
letter  of  July  26th.  I gather  the  objections  he  raises  to  my 
experiments1  are  two.  (a)  That  the  “yellow  solution” 
contained  ammonium  phosphate  and  phosphoric  acid  in 
addition  to  the  proper  ingredients,  and  ( b ) that  the  tubes  were 
kept  for  too  long  a period,  during  which  the  “organisms,” 
which  were  supposed  to  have  developed,  died.  In  the  first 
place,  I must  thank  Commander  Bastian  for  pointing  out  my 
error.  I cannot  excuse  such  carelessless,  my  only  explana- 
tion is  that  when  writing  up  the  account  of  the  experiments 
during  the  war  and  several  years  after  the  solutions  were 
made  up,  I foolishly  referred  to  Dr.  Bastian’s  “ Origin  of 
Life,”  instead  of  to  my  own  notes,  in  order  to  ascertain  the 
composition  of  the  solutions,  which  being  quite  arbitrary,  I 
had  not  unnaturally  forgotten.  Though  there  is  no  doubt  as 
to  Dr.  Bastian’s  meaning  when  carefully  read,  anyone  who 
will  take  the  trouble  to  look  up  the  reference  (p.  30)  will  see 
that  the  words,  “the  proportion  of  the  other  ingredients 
remaining  always  the  same,”  might  be  misleading  in  the 
hurry  of  the  moment.  I have  now  looked  up  my  original 
notes,  and  I beg  leave  to  correct  the  error  by  making  the 
following  quotation  from  my  note-book  : — 

“ On  Sunday,  August  10th  (1913)  test-tubes  of  hard 

white  German  glass  5 in.  x J in were  charged  half 

full  with  Dr.  Bastian’s  ‘ yellow  solution,’  consisting  of 
8 drops  of  liquor  ferri  pernitratis  and  3 drops  of  dilute 
sodium  silicate  (from  A and  H’s  sample  reserved  for  Dr. 

Bastian)  to  each  oz.  of  distilled  water,  these  proportions 

gave  the  port- wine  colour  recommended  by  Dr.  Bastian  with 
a minimum  amount  of  sediment.” 

Oq  the  next  page  the  correct  formula  for  both  solutions 
are  written  in  a tabular  form  above  the  two  series  of  tubes. 
I trust  that  Commander  Bastian  will  accept  this  evidence. 
With  regard  to  his  second  criticism,  I think  Commander 
Bastian  makes  a misrepresentation.  He  implies  that  the 
tubes  j of  the  “white  solution”  were  kept  for  38  months 
before  being  opened,  whereas  the  truth  is  that  the  tubes  of 
both  series  were  opened  at  varying  periods  from  l£  months  to 
38  months  (at  intervals  of  about  3 months):  The  period  of 
38  months  was  only  the  maximum  duration  of  the  experi- 
ment. I believe  the  longest  that  Dr.  Bastian  kept  his  tubes 
was  two  years.  When  planning  the  experiments  I therefore 
considered  that  if  I kept  some  of  the  tubes  for  three  years 
I could  not  be  accused  of  impatience.  I must  apologise  for 
taking  up  so  much  of  your  valuable  space,  and  beg  to 
remain,  Yours  faithfully, 

The  Biochemical  Laboratory,  Cambridge,  H.  ONSLOW. 

August  2nd,  1919. 


i Voir  L’ Actuality  ScienUfique,  Paris,  Mai,  1919. 


Proc.  Roy.  Soc.,  B,  vol.  xc  , p.  266. 


266  Thb  Lancet,] 


A CRITICISM  OF  THE  MEMORANDUM  ON  MALARIA. 


[August  9. 1919 


A CRITICISM  OF 

THE  MEMORANDUM  ON  MALARIA. 

To  the  Editor  of  The  Lancet. 

Sir, — I must  protest  against  the  pernicious  and  dangerous 
advice  given  by  Dr.  Gordon  Ward  in  his  criticism  of  the 
Memorandum  on  Malaria  in  your  issue  of  Julyl9oh.  He 
say 8 : — 

“ The  most  important  principle  in  the  treatment  of 
malaria  in  pensioners  is  the  improvement  of  the  natural 
resistance  of  the  body  with  the  aid  of  as  little  quinine  as 
possible.” 

It  is  just  such  treatment  that  is  filling  the  wards  in  our 
hospitals  with  pensioners  and  demobilised  men.  They  all 
come  in  with  the  same  st  ory.  Since  they  left  the  Army  they 
have  had  recurrent  attacks  of  fever,  been  treated  by  civil 
practitioners  with  totally  inadequate  doses  of  quinine,  which 
have  had  no  effect  on  their  ma’aria,  and  finally  have  to  come 
into  hospital.  There  they  are  put  on  10-gr.  doses  of  quinine 
sulphate  in  solution,  three  times  a day,  and  they  very  rarely 
have  more  that  one  rigor  after  the  treatment  has  begun.  It 
is  a great  relief  to  the  men  to  find  they  are  rid  of  their  fever 
in  48  hours,  after  recurrent  attacks  ; in  one  case  for  five 
weeks  on  minimum  doses  of  quinine.  It  may  now  be 
regarded  as  established  beyond  a doubt  that  the  optimum 
dose  of  quinine  during  the  attack  is  that  stated  in  the 
Memorandum — viz.,  10  gr.  of  sulphate  or  hydrochloride  in 
solution  three  times  a day;  whilst  the  experience  at  con- 
centration centres  has  proved  that  10  gr.  a day  is  a valuable 
anti-relapse  precaution.  If  this  be  carried  out  regularly 
over  a prolonged  period,  say,  three  months,  and  relapses 
prevented,  the  natural  resistance  of  the  body  will  assert 
itself  and  justify  Osier’s  dictum,  that  the  proper  treatment 
of  malaria  is  “ quinine  and  time,  both  in  divided  doses.” 

The  danger  we  have  to  fight  against  is  the  fear  of  the  civil 
practitioner  to  give  adequate  duses  for  a sufficiently  long 
period,  and  we  are  not  helped  by  such  advice  as  Dr.  Ward 
gives.  Dr.  Ward’s  picture  of  the  man  with  chronic  tachy- 
cardia and  effort  syndrome  is  in  most  cases  the  result  of 
inadequate  doses  of  quinine  for  a short  period,  allowing 
frequent  relapses  and  general  deterioration  of  health.  If 
Dr.  Ward  will  re  read  the  Memorandum  carefully  he  will  find 
that  the  intramuscular  method  of  administration  is  recom- 
mended only  when  vomiting  is  so  persistent  that  quinine 
cannot  be  given  by  the  mouth,  or  in  pernicious  attacks,  when 
no  time  must  be  lost.  It  is  not  advocated  in  simple  attacks 
without  complications. 

Twenty  months  in  the  malaria  section  of  a military  hospital 
in  England  have  only  confirmed  what  20  years’  experience  in 
the  tropics  had  already  taught  me,  that  the  intramuscular 
giving  of  quinine  is  a most  valuable  method  in  urgent  cases, 
and  that  by  using  quinine  bi-hydrochloride,  being  careful 
about  sterilising  the  solution,  and  all  the  apparatus,  and 
making  the  injection  actually  into  the  muscle  and  not  sub- 
cutaneously, the  risk  of  causing  abscess  is  small,  whilst  a 
very  elementary  knowledge  of  anatomy  will  enable  one  not 
to  inject  in  the  close  proximity  of  an  important  nerve  trunk. 
In  about  2000  cases  I have  had  through  my  hands  in  this 
country  I have  seen  only  one  partially  paralysed  arm  as  the 
result  of  an  injection,  and  in  that  case  the  needle  had  been 
inserted  directly  over  the  musculo-spiral  nerve.  Pernicious 
attacks  in  this  country  fortunately  are  rare,  but  in  such  cases 
the  intramuscular  route  is  pre-eminently  the  safest  for  the 
civil  practitioner  to  follow. 

I am,  Sir,  yours  faithfully, 

T.  H.  Jamieson,  M.D.,  M.R.C.P.  Edin., 

London,  July  31st,  1919.  D.T.M  H.,  D.P.H. 


DUPLICATION  IN  HUMAN  SPERMATOZOA. 

To  the  Editor  of  The  Lancet. 

Sir, — If  Mr.  S.  R.  Tattersall,  who  communicated  to 
The  Lancet  of  August  2nd  on  the  above  subject,  would 
look  up  Broman's  “Normale  und  Abnorme  Eatwicklung 
des  Menschen,”  p.  18  et  seq.,  he  will  find  the  conditions  he 
has  described  as  well  as  excellent  photographs  of  the 
specimens.  He  will  further  find  an  interesting  discussion  of 
the  whole  question  of  abnormal  spermatozoa,  by  one  who 
has  done  much  work  on  the  subject,  but  whose  magnificent 
book  seems  to  be  little  known. 

I am,  Sir,  yours  faithfully, 

Edward  Fawcett, 

August  2nd,  1919.  Professor  of  Anatomy,  University  of  Bristol. 


THE  RESULTS  OF  COMPLETE  COLECTOMY. 

To  the  Editor  of  The  Lancet. 

Sir, — Major  James  Taylor  is  quite  correct  in  stating,  in 
your  issue  of  August  2nd,  that  there  is  a very  general  belief 
that  many  patients  do  not  recover  from  the  operation  (of 
complete  colectomy),  and  that  those  who  do  are  no  longer 
capable  of  leading  an  active  life.  This  general  impression 
is  not  likely  to  be  changed  in  any  way  by  a perusal  of  Major 
Taylor’s  paper.  His  small  series  of  cases  is  of  undoubted 
interest,  but  it  is  to  be  regretted  that  he  does  not  give  any 
information  of  the  after-progress  of  Cases  1 and  2 and  a full 
description  of  the  “diseased  condition  of  the  rectum  ” held 
responsible  for  the  imperfect  recovery  of  Case  3.  The  opera- 
tion of  complete  colectomy  for  intestinal  stasis  will  remain 
under  a cloud  so  long  as  those  surgeons  who  perform  it  are 
content  to  support  their  views  by  the  publication  of  their 
cases  in  this  imperfect  manner. 

I am,  Sir,  yours  faithfully, 

Leeds,  August  2nd,  1919.  J.  F.  DOBSON. 


SHELL  SHOCK  IN  FISHES. 

To  the  Editor  of  The  Lancet. 

Sir, — Dr.  Alfred  Carver  narrates  in  your  columns  last 
week  certain  experiments  on  fishes;  these  were  made  only 
on  perches.  D.\  Carver  will  be  interested  to  hear  that 
Dr.  A.  G.  Mayer  1 found  that  when  a halt  stick  of  dynamite 
was  exploded  within  3 ft.  of  a^small  shark  (Carver’s  zone  A 
with  a vengeance)  no  apparent  injury  was  produced  ; the 
same  thing  applied  in  a lesser  degree  to  such  teleosts  as 
lack  swim-bladders.  When  swim-bladder  fishes  were  killed 
by  the  explosion  their  swim-bladder  burst,  the  tissues  were 
crushed,  and  the  vertebral  column  was  often  broken.  Mayer 
attributes  the  injurious  effects  of  explosives  in  fishes,  when 
present,  to  mechanical  laceration  of  tissues,  and  especially 
the  crushing  inward  of  air-filled  cavities.  A full  abstract 
of  Mayer’s  paper  appears  over  mv  signature  in  the  Renew 
of  Neurology  and  Psychiatry , 1917,  xv.,  p.  335. 

I am,  Sir,  yours  faithfully, 

London,  N.W.,  August  1st,  1919.  LEONARD  J.  KlDD. 


HOME  HOSPITAL  ESTABLISHMENTS  AND  THE 
WAR  MEDALS. 

To  the  Editor  of  The  Lancet. 

Sir, — I wish  to  call  attention  to  the  gross  unfairness  of 
laying  down  a geographical  qualification  for  the  1914-15  Star, 
General  Service,  and  Victory  Medals,  at  all  events  as  regards 
the  medical  establishments.  Elderly  medical  men  in  the 
R A.M.C.,  whether  Reserve,  Special  Reserve,  or  Territorial, 
were  called  up  at  the  outbreak  of  the  war  in  August,  1914. 
Often  this  entailed  the  abandonment  of  our  private  practices, 
our  means  of  livelihood,  and  serious  financial  loss.  We  have 
been  in  charge  of,  or  performing  important  services  in,  large 
general  hospitals  and  their  auxiliaries,  or  in  the  military 
hospitals  and  training  camps  ; and  we  have  been  kept  in 
this  country  because  we  could  not  be  replaced.  We  have 
been  overwhelmed  with  work  which  has  been  absolutely 
essential,  yet  we  have  not  been  considered  to  be  entitled  to 
the  medals  issued  to  commemorate  this,  the  greatest  of  all 
wars,  because,  forsooth,  we  have  not  crossed  the  Channel  1 

This  decision  is  contrary  to  precedent.  It  has  always 
previously  been  recognised  that  the  medical  establishment 
had  a special  claim  to  medals  issued  to  commemorate  a 
campaign  in  view  of  their  special  work  of  dealing  with  the 
wounded.  The  hospitals  in  this  country  have  equally  with 
those  in  France  been  associated  with  the  fighting  forces. 
They  have  taken  wounded  practically  direct  from  the  battle- 
fields, Americans,  Belgians,  Chinese,  French,  Serbians, 
besides  the  British  and  Dominion  troops ; yet,  having  per- 
formed these  services  to  our  Allies,  we  alone  of  all  the  Allied 
forces  are  not  to  have  the  Allies  Medal ! It  is  sought  to 
justify  this  discrimination  by  excluding  this  country  from 
the  list  of  “ war  areas.”  But  we  who,  by  the  exigencies  of 
the  service,  were  retained  here,  have  been  declared  to  be 
serving  “on  Active  Service”  and  have  drawn  “Field 
Allowances.  ” Hitherto  the  necessary  corollary  to  such  con- 
ditions has  been  the  issue  of  the  medal  granted  for  the 
campaign. 

What  makes  this  discrimination  more  remarkable  is  that 
it  does  not  apply  to  Dominion  troops.  They  receive  not 

1 Proc.  National  Acad.  Sciences  of  U.S.A.,  1917,  iii.,  p.  597. 


The  Lancet,] 


PARLIAMENTARY  INTELLIGENCE. 


[August  9,  1919  267 


anly  the  war  medals,  but  also  the  chevrons,  without  the 
aeoessity  of  crossing  the  Channel.  Hence,  in  their  case,  it 
follows  that  they  are  given,  not  according  to  the  precise 
ocality  in  which  the  war  service  was  rendered,  but  merely 
’rom  the  place  of  residence  before  the  war.  Surely  a 
i “reductio  ad  absurdum.”  Another  precedent  for  the 
ssue  of  a war  medal  without  actually  entering  a “ war  area  ” 
,vas  the  issue  of  the  South  African  Medal,  without  clasps,  to 

t he  Militia  Garrisons  in  the  Mediterranean. 

It  is  suggested  that  hospital  and  medical  services  rendered 
n this  country  should  be  recognised  by  the  issue  of  the 
General  Service  Medal,  without  the  clasps,  which  will,  no 
loubt,  later  be  granted  for  service  in  particular  battles  or 
war  areas  ; and  that  the  Victory  Medal  should  be  given  with 
late  clasps.  Any  other  distribution  is  most  unfair  to  those 
vho  have  formed  the  personnel  of  the  hospitals  and  medical 
’stablishments  in  this  country.  The  Royal  Red  Cross  has 
ieen  given  to  a small  percentage  of  the  nursing  staffs,  and 
io  one  has  ventured  to  deny  the  justice  of  the  award  ; but 
tospitals  are  not  run  by  nurses  alone.  With  the  exception 
)f  a few  commandants,  the  V.A.D.  workers  have  been 
gnored 

Practically  all  of  us  are  now  returning  to  civil  life,  with 
ibsolutely  nothing  to  indicate  that  our  services  have  been 
ippreciated,  cr  that  we  have  done  our  duty  in  accordance 
vith  the  orders  of  the  higher  authorities  ; but  I am  confident 
hat  I speak  for  my  medical  colleagues  when  I say  that  we 
lesire  no  decorations  which  are  not  shared  by  the  whole 
nale  and  female  personnel  who  have  so  nobly  sacrificed 
hemselves  to  tend  and  succour  the  sick  and  wounded  in  the 
lospitals  of  this  country,  services  which  have  been  absolutely 
ndispensable  to  the  victory  of  the  Allies,  and  which  are 
miversally  recognised  as  reflecting  the  utmost  credit  and 
tonour  upon  all  concerned. 

I am,  Sir,  yours  faithfully, 

August  5th,  1919.  Ignored. 

i THE  MARRIAGE  OF  ASSISTANT  MEDICAL 
OFFICERS  AT  ASYLUMS. 

To  the  Editor  of  The  Lancet 
Sir, — I read  with  great  interest  in  The  Lancet  of 
uly  19th  the  article  setting  forth  the  new  conditions  laid 
town  for  assistant  medical  officers  in  the  London  County 
.sylums.  In  the  issue  for  July  26th  there  is  an  advertise- 
oent  for  an  assistant  medical  officer  at  a borough  asylum, 
nd  it  may  interest  you  to  know  how  the  vacancy  has  arisen, 
n April,  1907,  I became  assistant  medical  officer  at  a 
iorough  asylum,  and  continued  to  hold  that  post  till  I joined 
ip  in  July,  1917;  but  I still  remained  technically  assistant 
nedical  officer,  and  my  post  was  open  for  me  when  I left  the 
trmy.  In  February  of  this  year  I married,  and  shortly  after 
was  asked  by  my  committee  to  resign  ; this  I refused  to  do, 
.3  I had  not  done  anything  wrong.  They  then  gave  me 
lotice  of  dismissal  on  the  ground  that  there  was  no  accom- 
aodation  for  a married  A.M.O.  I replied  to  that  by  saying 
hat  I did  not  ask  for  extra  accommodation,  and  that  I was 
filling  to  go  back  and  live  as  a single  man  as  I did  previously, 
ay  wife  living  elsewhere.  Their  reply  was  simply  to  dismiss 
ae  because  I had  married. 

It  is  surely  cruel  and  unjust  to  penalise  marriage  so  very 
leavily,  and  to  dismiss  a man— after  ten  years’  service— just 
■ecause  he  has  married.  The  committee  expressed  them- 
elves  as  being  quite  satisfied  with  my  services,  and  allege 
io  reason  for  dismissing  me  but  the  fact  that  I have  married. 

have  been  turned  out  of  my  post,  at  45  years  of  age, 
fithout  pension  or  compensation  of  any  kind,  and  with 
iractically  no  chance,  by  reason  of  age,  of  getting  another 
isylum  post,  the  work  to  which  I devoted  all  my  professional 
ife.  I am  still  serving  in  the  Army,  so  the  action  of  the 
:ommittee  is  at  least  premature.  I think  such  action  by  a 
cmmittee  ought  to  be  made  widely  known,  and  I shall  be 
;lad  to  hear  the  views  of  others. 

I am,  Sir,  yours  faithfully, 

Ju!y  30th,  1919.  DISMISSED. 


The  Committee  of  the  Territorial  Force  Medical 

tDcers  Ass°ciati°n  are  making  arrangements  for  a dinner 
n October  next  for  Territorial  medical  officers.  Any  medical 
'nicer  who  wishes  to  be  present  should  send  his  name  to 
Jieutenant-Colonel  D.  L.  Hamilton,  R.A.M.C.,  T.F.R., 
, Russell-square,  London,  W.C.,  who  is  actiDg  as  honorary 
ecretary  for  the  dinner. 


JJarliamnitarg  Jntdligenu. 

NOTES  ON  CURRENT  TOPICS. 

Pensions  Reorganisation. 

Changes  in  Medical  Arrangements. — Increases  in  Personnel. 

The  Uouse  of  Commons  went  into  Committee  of  Supply 
on  Thursdays  July  31st,  on  the  Supplementary  Vote  of 
£45,855,000  for  the  salaries  and  expenses  of  the  Ministry  of 
Pensions. 

Sir  L.  Wortiiington-Evans  (Minister  of  Pensions)  stated 
that  the  decisions  of  the  Government  upon  the  recom- 
mendations mode  in  the  interim  report  of  the  Select  Com- 
mittee on  Pensions  would  call  for  an  extra  expenditure  for 
the  remainder  of  this  year  of  about  £11  000,000,  so  that  the 
estimates  should  be  treated  as  £86,000,000,  and  not  as  just 
under  £73,000,000  as  presented.  For  a full  year,  as  long  as 
the  number  of  pensioners  remained  at  or  near  the  maximum, 
the  rate  would  be  about  £96,000,000.  Dealing  with  the  new 
scheme  of  decentralisation,  the  right  honourable  gentleman 
said  that  all  medical  boards  and  arrangements  for  medical 
treatment  would  be  dealt  with  by  the  regional  medical 
officer.  Proceeding  to  speak  of  the  medical  services  of  the 
Ministry,  the  Minister  said  :— 

“I  have  been  fortunate  in  securing  as  Chief  Medical 
Officer  Colonel  Webb.  During  the  war  be  held  an 
important  position  in  t lie  medical  service  of  the  War  Office, 
and  he  brings  a very  special  knowledge  of  the  requirements 
of  the  serving  man  who  is  now  a pensioner  to  the  service  of 
the  pensioners.  The  work  of  this  division  is  probably  the 
most  important  of  any  of  the  divisions  of  the  Ministry.  It 
deals  with  that  primary  necessity  of  the  disabled  man — 
namely,  the  provision  of  medical  treatment  both  in  hospitals 
and  clinics  and  convalescent  centres.  When  the  bulk  of  the 
men  were  in  the  Army,  the  Army  did  the  work,  but 
demobilisation  has  transferred  the  necessity  for  providing 
hospitals  and  clinics  from  the  "War  Office  to  the  Ministry  of 
Pensions.  We  have  already  taken  over  from  the  War 
Office  two  hospitals,  and  arrangements  are  practically  com- 
plete for  the  transfer  of  others.  The  Red  Cross  are  assisting 
the  Pensions  Ministry  as  they  assisted  the  War  Office. 

Nursing  Service. 

“As  we  take  over  hospitals  we  are  bound  to  provide  a 
nursing  service,  and  I am  glad  to  say  that  Queen  Alexandra 
has  graciously  consented  to  be  president  of  the  Pensions 
Nursing  Ser\  ice.  I have  been  fortunate  to-secure  as  matron- 
in-chief  Miss  M.  E.  Davies,  R.R.O.,  who  will  be  assisted  by 
an  advisory  committee.  I am  also  hoping  to  have  ready 
very  shortly  certain  convalescent  centres  at  Blackpool, 
Epsom,  and  elsewhere,  in  which  men  who,  while  suffering 
from  disabilities  which  require  more  or  less  prolonged  out- 
patient treatment,  will  be  able  to  employ  their  time  to  their 
own  advantage  by  receiving  preliminary  training  to  fit  them 
for  their  after-life.  I have  been  impressed  by  the  large 
number  of  out-patients  attending  hospitals  for  perhaps  half 
an  hour  a day,  upon  whose  hands  time  hangs  heavily.  I 
believe  that  if  such  men  as  these  are  admitted  to  con- 
valescent centres  they  will,  while  receiving  treatment,  be 
capable  of  much  useful  training  during  their  convalescent 
stage,  and  more  rapidly  benefit  by  the  industrial  training 
thereafter  given  them  under  the  Ministry  of  Labour.  More- 
over, experience  shows  that  many  men,'  attracted  no  doubt 
by  the  high  wages  and  the  demand  for  labour  during  the 
latter  stages  of  the  war,  who  went  into  industrial  life,  are 
likely  to  break  down  and  require  more  or  less  prolonged 
convalescent  treatment.  For  these,  also,  the  convalescent 
centres  are  likely  to  prove  of  great  use. 

Medical  Boards. 

“Until  recently  the  boarding  of  the  men  applying  for 
pensions  and  the  re-boarding  of  men  on  renewal  of  pensions 
was  performed  by  the  Ministry  of  National  Service,  but  on 
April  1st  last  the  central  and  regional  staff  of  the  Ministry 
of  National  Service  was  transferred  to  the  Ministry  of 
Pensions,  and  we  became  directly  responsible  for  the 
boarding  of  all  men.  On  August  4th  we  are  taking  over 
from  the  War  Office  the  Re-survey  Boarding  of  Officers.  To 
give  the  Committee  some  idea  of  the  extent  of  the  increase 
of  the  work  of  medical  boards,  I may  inform  them  that 
229,697  men  were  examined  by  medical  boards  in  the  six 
months  ending  June  last.  There  has  been  a steady  and  rapid 
increase  in  the  number  of  men  boarded  owing  to  demobili- 
sation, and  in  June  last  45,000  men  were  boarded. 

Medical  Appeal  Boards. 

“The  Committee  may  be  aware  that  under  the  system 
hitherto  prevailing  the  medical  officers  at  the  headquarters 
of  the  Ministry  reviewed  the  decisions  of  these  boards  and  a 
medical  officer  was  authorised  to  alter  the  amount  of  a man’s 
assessment  bya  board  without  himself  re-examining  the  man. 
Many  complaints  of  this  system  have  been  brought  to  my 


268  The  Lancet,] 


PARLIAMENTARY  INTELLIGENCE. 


[August  9,  1919 


notice,  ami  the  Select  Committee  has  recently  called  special 
attention  to  this  system,  and  has  recommended  that  any 
case  of  doubt  should  be  sene  for  re-hearing  by  the  same  or 
by  a second  board,  who  in  every  case  should"  examine  the 
man  in  person.  I entirely  agree  with  this  recommendation. 
Indeed,  I informed  the  "Select  Committee  when  I gave 
evidence  before  it,  that  I intended  to  alter  the  system  as 
soon  as  the  decentralised  regions  were  set  up.  While  it  was 
probably  impossible  to  arrange  for  Appeal  Boards  before  the 
Ministry  of  Pensions  had  its  own  medical  personnel 
available  to  sit  on  boards  and  specialists,  both  surgical 
and  medical,  at  its  hospitals  and  clinics  to  constitute  the 
boards,  it  will  be  possible  to  set  up  the  Appeal  Boards  as 
soon  as  the  medical  personnel  in  the  regions  has  been 
completed.  Thereafter,  a definite  procedure  will  be  laid 
down,  which  will  be  followed  in  all  cases — namely,  that  if 
the  Medical  Assessor,  on  scrutinising  the  report  of  the  board, 
is  not  satisfied  that  substantial  justice  has  been  done  either 
to  the  pensioner  or  to  the  taxpayer,  he  is  not  to  alter 
the  assessment,  but  he  is  to  refer  the  case  either  to 
the  same  board  or  to  an  Appeal  Medical  Board  for 
a re-examination  of  the  man — and  similarly,  if  the 
pensioner  himself  is  not  satisfied  that  his  degree  of 
disability  has  teen  correctly  assessed — that  is  to  say,  if 
he  is  not  satisfied  with  the  amount  of  his  pension,  he 
will  have  the  right  to  appeal  himself  to  a Medical  Appeal 
Board,  whose  decision  in  the  case  has  to  be  treated  as  final, 
subject  to  this  proviso,  which  is  in  the  man’s  interest,  that  if 
he  gets  seriously  worse  during  the  period  for  which  the 
assessment  has  been  made,  he  may  go  to  a medical  referee 
who  may  give  him  temporarily  a higher  allowance  pending 
the  reconsideration  of  his  case  by  the  board.  This  arrange- 
ment of  Appeal  Boards,  while,  I believe,  absolutely  necessary 
in  the  interests  of  justice  and  to  give  the  pensioner  a 
reasonable  assurance  that  his  case  is  properly  considered, 
will  entail  a large  increase  in  the  medical  personnel,  which 
can  only  be  supplied  if  not  only  the  permanent  medical  staff 
of  the  region  is  available  for  boards,  but  also  the  specialists 
attached  to  the  hospitals  and  clinics,  and  probably  in  some 
cases  the  medical  referees. 

Artificial  Limbs. 

“As  regards  the  provision  of  artificial  limbs,  soon  after  I 
became  Minister  I wanted  to  be  satisfied  that  the  provision 
of  artificial  limbs  for  both  officers  and  men  was  sufficient, 
and  that  the  best  limbs  were  being  supplied.  I accordingly 
set  up  a very  strong  Committee,  upon  which  several 
Members  of  the  House  kindly  served,  and  they  have  recently 
reported.  On  the  whole  their  report  shows  that  the  position 
is  satisfactory.  They  have  made  several  recommendations 
which  are  in  the  course  of  being  carried  out.  Perhaps  the 
most  important  is  that  an  expert  Committee  should  be  set 
up  to  review  all  the  various  forms  of  artificial  limbs  at 
present  made  with  a view  to  standardisation,  by  selecting  the 
best  from  each  limb.  It  is  proposed  that  fitting  centres 
shall  be  established  in  connexion  with  orthopaedic  hospitals 
spread  throughout  the  country,  and  that  in  addition  repair 
depots  shall  be  opened  in  populous  centres,  so  that  minor 
repairs  can  be  made  in  a short  time.  I have  also  referred  to 
the  Committee  the  extent  to  which  fibre  pylons  should  be 
supplied  and  used  by  men  with  artificial  limbs.  I fancy  that 
fibre  pylons  will  take  their  place  alongside  artificial  limbs 
much  as  a slipper  does  to  a boot,  and  that  a man  with  an 
art'ficial  limb  coming  home  from  his  daily  occupation  will 
be  glad  to  change  it  for  a light  fibre  pylon.  "However,  that  is 
primarily  a surgical  question,  and  1 have  therefore  referred 
it  to  the  "surgeons  for  advice. 

Tuberculosis. 

“ I was  also  not  satisfied  that  the  provision  made  for  the 
pensioner  suffering  from  tuberculosis  was  sufficient,  and 
in  agreement  with  the  Minister  of  Health  we  appointed  a 
Joint  Committee  for  the  purpose  of  thoroughly  investigating 
this  question.  The  Joint  Committee  has  now  reported,  and 
immediate  consideration  will  be  given  to  the  report. 

Independent  Tribunals. 

“The  Government  is  prepared  to  accept  the  recom- 
mendation of  the  Select  Committee  that  the  appeal  tribunals 
shall  be  set  up  under  an  authority  independent  of  the 
Ministry  of  Pensions,  and  a Bill  will  be  introduced  as  soon 
as  possible  to  empower  the  Lord  Chancellor  to  set  up  appeal 
tribunals  and  to  make  the  necessary  regulations  in  respect 
to  the  procedure.  The  tribunals  will  consist  of  one  legal 
representative,  either  a barrister  or  solicitor,  who  will  be 
chairman  of  the  tribunal,  and  a disabled  officer  in  officers’ 
cases  and  a disabled  man  in  men’s  cases  with  a duly 
qualified  medical  practitioner.  Any  refusal  on  the  part  of 
the  Ministry  to  a claim  for  pension  on  the  ground  that  the 
disability  is  not  attributable  to,  or  aggravated  by,  military 
service,  or  is  due  to  serious  negligence  or  misconduct  of  the 
claimant,  will  be  subject  to  appeal  by  the  claimant  to  this 
independent  tribunal.  Similarly,  a widow  or  a motherless 
child  whose  claim  to  pension  is  rejected  on  the  ground  that 
the  death  of  the  officer  or  man  was  not  due  to  military 


service  will  be  subject  to  appeal.  In  this  way  there  will  be 
granted  a statutory  right  to  assert  a claim  to  pension  and  a 
statutory  court,  independent  entirely  of  the  Ministry,  will 
be  the  sole  and  final  judge  of  whether  the  right  exists  in  a 
particular  case. 

Appeals  on  Amount  of  Pension. 

“ It  is  suggested  by  the  Select  Committee  that  there 
should  be  a lay  ex-service  element  on  the  tribunal,  but  a3 
the  assessment  questions  are  mainly  medical  questions  the 
medical  element  should  have  a majority,  and  they  advise 
that  this  medical  element  should  comprise  senior  surgeons 
and  specialists  in  the  diseases  or  injuries  causing  the  dis- 
abilities under  consideration.  This  recommendation  appears 
to  me  to  be  entirely  impracticable.  During  the  last  six 
months  920,439  awards  have  been  made,  or,  if  I deduct  from 
this  total  awards  to  widows,  children,  and  dependents, 
nearly  700,000  awards  have  been  made  either  for  the  first 
time  or  on  renewal  to  men.  These  awards  are  made  for 
varying  periods  for  from  six  to  12  months.  The  Select 
Committee  recognises  that  an  appeal  would  be  of  no  use 
unless  the  medical  men  upon  the  appeal  tribunal  were  more 
authoritative  than  the  medical  men  who  made  the  original 
assessment.  If  even  1 in  10  men  appealed  we  should  have 
something  like  70,000  appeals  in  six  months,  and  the  delays 
would  be  so  great  that  the  appeals  could  not  be  heard  before 
the  pension  had  expired.  Moreover,  it  would  be  im- 
possible to  get  the  authoritative  consultants  and  specialists 
iu  sufficient  numbers  to  form  the  appeal  tribunals. 

I do  not  believe  that  a reform  is  possible  upon  these  lines. 
Ido,  however,  agree  that  it  is  quite  wrong  for  any  medical 
assessor  who  has  not  seen  a man  to  alter  an  assessment 
made  by  a board  who  has  seen  the  man,  and  as  soon  as  the 
regional  organisation  is  complete  Medical  Appeal  Boards 
will  be  set  up  to  which  either  the  man  or  the  department 
can  appeal  in  the  event  of  the  assessment  being  challenged. 

I ask  the  Committee  to  believe  me  that  this  is  the  practical 
way  of  curing  the  evil  which  the  Select  Committee  has 
pointed  out.  Any  outside  tribunal  dealing  with  these 
assessments  would  icause  so  much  delay  as  to  actually 
deprive  the  man  of  the  benefits  which  the  Select  Committee 
desires  him  to  obtain.” 

Tuberculosis  Committee's  Report. 

Sir  Montague  Barlow  (chairman  of  the  Select  Committee 
on  Pensions  and  deputy  chairman  of  the  Committee  on 
Tuberculosis),  alluding  to  the  report  of  the  latter  committee, 
which  the  Government  are  still  considering,  said  that, 
roughly  speaking,  the  Committee  found  that  there  were 
some  30,000  or  40,000  tuberculous  discharged  soldiers.  The 
first  point  the  Committee  desired  to  make  was  that  the 
tuberculous  soldier  was  only  one  part  of  the  general  problem 
of  tuberculosis  throughout  the  country.  In  the  early  stages, 
at  any  rate,  the  tuberculous  soldier  must  fit  into  the  ordinary 
machinery  of  tuberculous  treatment  throughout  the  country. . 
In  the  next  place,  the  Committee  had  found  that  the  accom- 
modation with  regard  to  sanatoriums  and  hospitals  was 
unsatisfactory  and  insufficient.  The  requirement  of  addi- 
tional sanatoriums  had  got  to  be  dealt  with  as  it  was  very 
urgent. 

Captain  Loseby  said  the  Select  Committee  had  made 
definite  recommendations  in  regard  to  the  constitution  of 
the  medical  boards  and  the  constitution  of  the  appeal  board.  J 
He  urged  the  Minister  to  throw  these  recommendations 
overboard.  He  could  find  a simpler  method  of  putting  tip 
medical  boards  which  would  enable  him  to  give  the  right  of 
appeal  to  which  every  man  who  had  been  tried  for  his  life 
had  a right.  Perhaps  he  would  consider  the  proposition 
that  a medical  board  might  be  equally  competent  as  now  if 
there  was  only  one  medical  man  upon  it  and  two  laymen. 
He  would  thus  get  over  his  difficulty  of  medical  personnel. 

Mr.  Leonard  Lyle  said  many  of  the  medical  boards 
looked  upon  their  job  in  the  same  way  as  a big  insurance 
company  doctor  looked  at  his  job.  The’point  of  view  of  the 
insurance  doctor  was  to  see  how  little  he  could  give  the  men. 

It  was  his  job  to  try  to  make  a total  disablement  into  a two- 
thirds  disablement",  and  a two-thirds  disablement  into  a half 
disablement.  Medical  men  were  just  as  humane  as  anyone 
else,  but  they  had  got  it  into  their  heads  that  if  there  was  a 
doubt  the  benefit  of  the  doubt  must  not  go  to  the  man. 
but  to  the  other  side.'  New  ideas  should  be  put  into  the 
heads  of  these  medical  boards.  Some  of  the  questions  were 
inquisitorial  to  say  the  least.  Men  had  been  asked  by  a 
medical  board  what  wages  they  had  been  earning. 

Sir  L.  Worthington-Evans  : The  honourable  Member 
knows  that  that  question  has  been  withdrawn.  The  men 
were  always  told  that  they  need  not  answer  it  unless  they 
liked,  but  "now  no  one  has  any  right  to  ask  the  question. 

Mr.  Lyle  said  he  was  glad  to  hear  it,  and  it  would  do  good 
that  such  a statement  had  been  made.  Sometimes  doctors 
did  ask  this  question,  although  they  were  not  entitled  to 
do  so. 

Dr.  Murray  : Were  they  not  originally  ordered  to  ask  the 
question? 


The  Lancet,] 


PARLIAMENTARY  INTELLIGENCE. 


[August  9,  1919  269 


Mr.  Lyle  said  if  it  was  not  to  be  asked  $n'y  more  he  was 
pleased  to  bear  it. 

Dr.  Murray  said  that  one  of  the  most  cruel  duties  that 
could  be  placed  on  medical  boards  was  that  they  should  be 
asked  to  say  whether  a certain  disease  was  caused  by,  or  had 
been  aggravated  by,  service  in  the  war.  It  was  not  a question 
that  should  be  put  to  a medical  board.  He  quite  admitted 
that  the  doctors  might  be  wrong,  and  in  such  a case  the 
benefit  should  be  given  to  the  man.  The  position  at  present 
was  illogical  and  unscientific,  and  might  without  difficulty 
be  accounted  an  injustice.  Medical  reports  were  certainly 
not  perfect,  but  it  must  be  remembered  after  all  that  it  was 
a new  work  to  medical  men.  The  doctors  on  these  boards 
did  not  act  on  their  own  unaided  intelligence,  but  got  their 
orders  from  above. 

The  vote  was  agreed  to.  

HOUSE  OF  COMMONS. 

Wednesday  July  30th. 

Medical  Treatment  tor  Officers  from  India. 

Colonel  Yate  asked  the  Secretary  for  India  whether, 
considering  the  importance  of  the  generous  arrangement 
made  bv  him  for  the  treatment  of  civil  and  military  officers 
from  India  suffering  from  tropical  diseases  at  the  hospital 
of  the  London  School  of  Tropical  Medicine,  he  would  take 
steps  to  have  his  recent  announcement  on  the  subject 
published  in  India  for  the  information  of  all  concerned.— 
Mr.  Montagu  replied  : Yes,  sir. 

The  Use  of  Opium,  Morphine,  and  Cocaine. 

Sir  James  Agg-Gardner  asked  the  Home  Secretary 
whether  Regulations  40  and  40b  under  the  Defence  of  the 
Realm  Act,  restricting  the  use  of  opium,  morphine,  and 
cocaine,  would  cease  to  be  operative  before  the  projected 
pharmacy  legislation  to  give  effect  to  the  provisions  of  the 
International  Opium  Convention,  1912,  had  been  enacted. — 
Mr.  Shortt  replied  : I hope  Parliament  will  agree  to  keeping 
Regulation  40b  in  force  long  enough  to  allow  legislation  to 
be  passed  to  give  effect  to  the  International  Convention. 

Tl’ar  Gratuities  for  Naval  Nurses. 

Major  Sir  Bertram  Falle  asked  the  Secretary  to  the 
Admiralty  if  he  would  state  if  any  increase  of  pay.  gratuity, 
or  war  gratuity  had  been,  or  was  to  be,  given  to  the  naval 
nursing  sisters  for  their  work.— Dr.  Macnamara  replied:  I 
presume  that  my  honourable  and  gallant  friend’s  question 
refers  to  nursing  sisters  and  reserve  nursing  sisters  of 
Queen  Alexandra’s  Royal  Naval  Nursing  Service,  and 
not  to  Y.A.D.  nursing'  members  or  British  Red  Cross 
Association  nurses  employed  in  naval  hospitals.  The  rates 
of  pay  of  reserve  nursiDg  sisters  were  revised  in 
September,  1918.  The  rates  of  pay  for  nursing  sisters 
(active  service)  is  at  present  under  consideration.  We  are 
at  present  m correspondence  with  the  War  Office  on  this 
point,  and  that  department  hopes  to  be  able  to  give  its 
observations  shortly.  No  war  bonus  is  payable  to  nurses, 
as  they  are  in  receipt  of  free  victualling  and  the  larger  part 
of  their  uniform  is  provided  at  public  expense.  It  has  been 
decided  to  extend  the  War  Office  scheme  of  war  gratuities 
for  nurses  to  the  naval  nursing  staff,  and  it  is  hoped  to 
publish  full  details  in  the  press  at  an  early  date. 

Thursday,  July  31st. 

Royal  Army  Medical  Corps  Appointments. 

Mr.  Leonard  Lyle  asked  the  Secretary  for  War  if  he 
would  say  on  whose  recommendation  senior  appointments 
were  made  in  the  Royal  Army  Medical  Corps,  and  whether 
an  advisory  committee  was  appointed  for  this  purpose. — 
Captain  Guest  (Joint  Patronage  Secretary  to  the  Treasury) 
replied  : The  promotion  of  officers  to  the  senior  ranks  of  the 
Army  Medical  Service  is  made  by  the  Army  Council  on  the 
recommendation  of  a Selection  Beard  composed  of  Major- 
Generals  of  the  Army  Medical  Service. 

Monday,  August  4th. 

Royal  Army  Medical  Corps  in  Egypt. 

Viscount  Wolmer  asked  the  Secretary  for  War  if  he  would 
say  how  many  units  of  the  Royal  Army  Medical  Corps  were 
being  retained  in  Egypt : and  whether  it  was  proposed  to 
send  any  of  these  home  at  an  early  date. — Mr.  Churchill 
replied:  There  are  51  units  of  the  Royal  Army  Medical 
Corps  in  Egypt,  including  field  ambulances,  hospitals, 
sanitary  sections,  depots,  Ac.  As  these  units  become  surplus 
to  requirements  they  are  disbanded  in  Egypt,  and  the 
personnel,  if  available  for  demobilisation,  is  sent  to  this 
country  for  dispersal.  Those  who  are  not  eligible  for 
demobilisation  are  utilised  for  reinforcements. 

Ex-Service  Men  and  Tuberculosis. 

Lieutenant-Colonel  Raw  asked  the  Minister  of  Health 
whether  he  had  considered  the  Report  of  the  Special  Com- 
mittee on  Tnberculous  ex-Service  Men,  and  when  it  would 
be  made  public,  as  the  matter  was  one  of  great  urgency. — 
Mr.  Parker  replied  : My  right  honourable  friend  has  only 


received  the  Report  of  the  Committee  within  the  last  few 
davs.  He  will  consider  it  at  once  and  discuss  the  matter 
with  the  Minister  of  Pensions,  who,  jointly  with  himself, 
appointed  the  Committee. 

Tuesday,  August  5th. 

Treatment  of  Uncertijiable  Mental  Cases. 

Colonel  Wedgwood  asked  the  Minister  of  Health  if  he 
would  state  what  steps  he  was  taking  with  a view  to  pro- 
viding in  all  areas  convalescent  homes  for  the  benefit  of 
early  uncertifiable  mental  cases,  so  as  to  prevent  their 
growing  worse  and  becoming  certifiable  and  a burdeD  on  the 
State ; and,  in  order  that  such  homes  should  not  be 
regarded  as  half-way  houses  to  asylums,  would  he 
ensure  that  intending  patients  should  enter  voluntarily 
and  without  compulsion  in  the  same  way  as  they 
would  enter  a hospital,  and  that  the  homes  so  provided 
should  have  no  connexion  with  lunacy  administration. — 
Major  Astor  (Parliamentary  Secretary  to  the  Ministry  of 
Health)  replied:  The  proposal  in  the  first  part  of  the  ques- 
tion, with  which  I am  in  full  sympathy,  would  require 
legislation  for  it  to  be  effectively  carried  out.  This  matter, 
together  with  the  important  points  referred  to  in  the  rest  of 
the  question,  with  which  I am  also  in  sympathy,  are  having 
very  careful  consideration  between  my  right  honourable 
friend  the  Minister  of  Health  and  my  right  honourable 
friend  the  Home  Secretary,  and  it  is  hoped  that  suitable 
legislation  for  the  purpose  in  view  may  shortly  be  introduced. 

State  Medical  Service. 

Mr.  Leonard  Lyle  asked  the  Minister  of  Health  whether 
any  representations  had  been  made  to  him  with  regard  to 
the  establishment  of  a State  Medical  Service  ; and  whether, 
in  that  case,  he  would  indicate  their  nature  and  state 
whether  the  Ministry  had  considered  them,  and  with  what 
result. — Major  Astor  : Several  different  proposals  have 
reached  my  right  honourable  friend  from  time  to  time  as  to 
new  schemes  for  public  medical  services.  I am  sending  the 
honourable  Member  a copy  of  the  reply  which  my  right 
honourable  friend  gave  on  May  28th  to  a question  on  this 
subject  from  the  honourable  and  gallant  Member  for  Leeds, 
from  which  he  will  see  that  the  development  of  local  medical 
services  of  various  kinds  is  certainly  contemplated  by  the 
Ministry  of  Health  ; but  the  opinions  of  the  consultative 
councils  will  be  sought  before  any  substantial  steps  on  these 
lines  will  be  decided  upon. 

Cholera  Outbreak  in  Lidia. 

Viscount  Wolmer  asked  the  Secretary  for  India  whether 
he  was  aware  that  there  had  recently  been  a serious  out- 
break of  cholera  amongthe  troops  of  the  6th  Indian  Brigade 
at  Ali  Masjid  on  the  North-West  Frontier,  and  that  in  the 
brigade  about  400  cases  and  over  100  deaths  had  occurred ; 
that  the  medical  personnel  attached  to  the  brigade  was  not 
up  to  the  establishment  strength  and  was  quite  inadequate 
to  deal  with  the  outbreak  : that  there  was  a breakdown  in 
the  medical  arrapgements ; that  insufficient  anti-cholera- 
vaccine  was  available  : and  that  the  supply  of  saline  tabloids 
was  inadequate  ; and  whether  he  would  cause  an  inquiry  to 
be  made  into  the  matter. — Mr.  Montagu  : An  outbreak  of 
cholera  in  the  Rhyber  Pass  has  been  reported,  but  the 
number  of  cases  in  the  6th  Indian  Brigade  was  not  stated. 
As  regards  the  remainder  of  the  noble  Lord's  question  I 
have  telegraphed  for  information. 

Health  of  the  Troops  in  India. 

Replying  to  Colonel  Yate,  Mr.  Montagu  stated  that  he  had 
received  a telegraphic  report  from  India  to  the  effect  that  orders 
had  been  issued  to  all  generals  in  command  that  medical 
officers  were  to  ask  for  whatever  they  deemed  necessary 
for  the  comfort  of  the  sick  and  wounded'  in  their  charge  and 
that  their  demands  were  to  be  met  at  once.  Additional 
hospitals  for  4000  British  and  8000  Indian  troops  had  been 
established  in  specially  fitted  barracks  in  proximity  to  the 
frontier,  and  electric  lighting  and  fans  where  none'already 
existed  were  being  supplied  to  the  former.  Convalescent 
depots  for  officers  and  soldiers  had  in  addition  been  formed, 
mainly  in  the  Murree  Hills.  Special  arrangements  had 
been  made  for  the  supply  of  fresh  milk  to  the  sick  in  the 
hospital,  and  cows  for  this  purpose  had  beeD  placed  so  far  at 
the  front  as  Dakka,  Bannu,  and  Tank.  Scale  of  equipment 
of  Indian  general  hospitals  had  been  reviewed  and  arrange- 
ments for  providing  additional  equipment  were  in  progress. 


Necessitous  Ladies'  Holiday  Fund. — The  war 

has  reduced  the  income  of  many  superannuated  governesses, 
hospital  nurses,  literary  ladies,  companions,  painters, 
musicians,  actresses,  and,  indeed,  all  those  disqualified 
from  engaging  in  other  lucrative  work.  A letter  signed 
by  the  treasurer,  Miss  Constance  Beerbohm.  appeals  for 
support  in  order  to  make  a holiday  possible  for  ladies 
unable  to  earn  in  the  summer  months.  For  those  to  whom 
a holiday  is  out  of  the  question  relief  is  supplied  in  the  form 
of  food,  medicine,  and  clothing.  The  address  of  the  treasurer 
is  48,  Upper  Berkeley-street.  London.  W.  1. 


270  The  Lancet,]  MEDICAL  NEWS.— MEDICAL  DIARY.— APPOINTMENTS.— VACANCIES.  [August  9,  1919 


Stoical  |t efes. 


Medical  Instruments  for  Serbia  : An  Appeal. 
— The  urgent  need  for  every  description  of  instrument  and 
hospital  equipment  prompts  this  appeal  to  the  medical 
profession.  The  Hon.  Mrs.  Haverfield  is  returning  imme- 
diately to  Serbia  to  dispense  the  Fund  for  Disabled  Serbian 
Soldiers,  and  will  be  deeply  grateful  to  any  medical  men 
who  will  send  to  her  at  9,  Ennismore  Gardens,  S.W.,  any 
material  of  the  indicated  description. 

Royal  Colleges  of  Physicians  of  London  and 
Surgeons  of  England. — At  a meeting  of  the  Council  of  the 
Royal  College  of  Surgeons  on  July  24th  and  of  the  Comitra  of 
the  Royal  College  of  Physicians  on  July  31st  Diplomas  of 
M.R.C.S.  and  L.R.C.P.  were  respectively  conferred  upon  78 
candidates  (including  13  women)  who  have  passed  the  Final 
Examination  in  Medicine,  Surgery,  and  Midwifery  of  the 
Conjoint  Board,  and  have  complied  with  the  necessary 
by-laws.  The  following  are  the  names  and  medical  schools 
of  the  successful  candidates : — 

William  Stirk  Adams  and  Robert  Geoffrey  Addenbrooke,  Birmingham 
Univ. ; Reginald  John  Allison.  Manchester  Univ. ; James  Colling- 
wood  Andrews,  Cambridge  Univ.  and  London  IIosp. ; Maurice 
Aronsobn,  London  ; George  Arthur  Emmanuel  Barnes,  University 
College  Hosp. ; Cecil  Bluett,  L M.S.S.A.,  Sydney  Univ.  and  London 
Hosp. ; Thomas  George  Doughty  Bonar,  Guy’s  ; Hilda  Crichton 
Bowser,  B.Sc.  Lond.,  and  Sarah  Aiteen  Florence  Boyd-Mackay, 
Royal  Free;  William  Edelsten  Bracey,  L.R.C.P.  & S.  Edin., 
Birmingham  Univ.  ; Gerald  Arthur  Augustine  Bradnack,  Guy's  ; 
Ella  Mariauue  Britten,  St.  George’s  ; Anna  Bridget  Broman,  Royal 
Free  and  St.  Mary's;  Harold  Mallows  Brown,  Guy’s;  Nai  Cheua 
and  Benjamin  Yroung  Harper  Chri&tmas,  Middlesex  ; Simeon  Moses 
Cohen  and  Peroival  Charles  Collyns,  St.  Bart.’s  ; Allred  Innes  Cox, 

L. D.S.  Eng.,  Middlesex;  Ursula  Beatrice  Cox,  Royal  Free  and 
St.  Mary's ; Egbert  Aubrey  Lennox  Crichlow,  King's  College  Hosp.  ; 
Ignatius  Joseph  Cruchley,  London  ; Herbert  Ernest  Cumming, 

M. D.,  C.M.,  McGill  Univ.  ; George  Lambert  Cutts,  L.D.S.  Eng., 
Guy’s;  Jenner  Conway  Davies,  Cambridge  Univ.  and  St.  Bart.’s ; 
Henry  Dryerre,  Edinburgh  Univ. ; Clement  Dunscombe,  Cambridge 
Univ.  and  St.  Bart.’s ; Tyrrell  George  Evans,  St.  Bart.’s ; 
Thomas  Fernandez.  Cambridge  Univ.  and  Guy’s  Hosp.  ; Kathleen 
Field.  St.  Mary’s  ; Frederic  Lionel  Fonseka,  Ceylon  Medical  College 
and  St.  Mar>'s  ; Herman  Meyer  Gerspn  and  Frederick  John  Good, 
London;  Harold  Hyman  Goodman,  Leeds  Univ. ; Dorothy  Margaret 
Greig,  Royal  Free  and  St.  Mary’s  ; Oscar  Stanley  Hillman, 
Middlesex;  Aga  Mohamed  Kazim,  Madras  and  University  College 
Hosp. ; Herbert  Wilfred  Kerloot,  M.D.,  C M.  McGill,  McGill  Univ. ; 
Vasant  Ramji  Khanokar,  B.Sc.  Lond  , University  College  Hosp.; 
Hyman  Jacob  Levy,  St.  Bart.’s  ; David  Livingston,  Durham  Univ. ; 
Eric  Sbaw  Longton,  Liverpool  Univ.  ; Aziz  Abd  El  Sayed  Mansour, 
Charing  Cross;  Maurice  Marcus,  London;  Alfred  Marsh,  Liverpool 
Univ.  ; Alfred  Yaphet  Massouda,  Guy’s  ; Kathleen  Harding 
Matthews,  St.  Mary’s;  Charles  Moffatt,  Guy’s;  Vasant  Ganesh 
Mohile,  M.B.,  B.S.  Bombay,  Bombay  Univ. ; Frewen  Moor,  Cam- 
bridge Univ.  and  St.  Thomas’s ; Farid  Moroos,  St.  Mary’s;  John 
Edward  Blackburn  Morton.  Ox'ord  Univ.  and  King's  College  Hosp.; 
Vernon  Arthur  Newton,  Birmingham  Univ.  ; John  Gough  Nolan, 
Manchester  Univ.;  Arthur  Gordon  Ord,  Guy’s;  Edwin  Ronald 
Ormerod,  Manchester  Univ. ; Arthur  Arnold  Osman,  Guy’s;  Sigrid 
Letitia  Sharpe  Pearson,  Royal  Free;  Geraint  Arthur  Penoant, 
Cardiff  and  Bristol  Univ.;  George  Stuart  Bain  Philip,  Charing 
Cross  ; Thomas  Henry  Algernon  Pinniger,  Bristol  Univ.;  Hugh  Reid, 
Liverpool  Univ.;  Benn  Roland  Reynolds, Bristol  Univ.  and  St. Bart.’s; 
Charles  Herbert  St.  John,  Guy’s  ; Olive  Ballance  Sharp,  Royal  Free 
and  St.  Mary’s ; George  John  Sophianopoulos,  St.  Bart.’s;  Frederick 
Gordon  Spear,  Cambridge  Univ.  and  St.  Thomas's;  Mary  Sylvia 
Stocks,  Royal  Free  and  St.  Mary’s;  James  Grant  Sera  ban, 
M.B.  Ter.,  Toronto  Univ.;  Sonia  Straschun,  St.  Mary’s;  Stanley 
Roy  Tatter9all,  St.  Thomas’s;  Beriah  Melbourne  Gwynne  Thomas, 
Cardiff  and  St.  Bart.’s;  Desmond  Villiers  Townshend,  Birmingham 
Univ. ; Alfred  Basil  Keith  Watkins,  Loudon ; Frederic  Francis 
Wheeler,  St.  Mary’s;  Ang-  s Hedley  Whyte,  Durham  Univ.;  and 
Gladys  Mar3T  Thurlow  Williams,  Birmingham  Univ. 

Diplomas  in  Public  Health  were  also  conferred  upon  the 
following  12  candidates  (including  one  woman),  viz. : — 

L.  D.  Bailey,  L.R.C.P.,  M.R.C.S.,  St.  George’s;  M.  Barker,  L.R.C.P., 
M.R.C.S.,  King's  College ; C.  D.  Day,  L.M.S.S.A.  Lond.,  Cambridgo 
Univ.  and  St.  Bart.’s;  H.  Falk,  L.R.C.P.,  M.R.C.S.,  M.B., 
B.C  Cantab  , Cambridge  Univ.  and  St.  Thomas’s;  W.  H.  Grace, 
M.B.,  B.S.  Lond.,  M.R.C.P.,  M.R.C.S  , Guy’s;  M.  J.  Holmes,  M.B., 
B.S.  Melb.,  Melbourne  Univ.  and  University  College ; T.  Legge, 
L.R.C.P.,  M.R.C.S.,  University  College;  R.  D.  Passey,  M.B., 

B. S.  Lond.,  Guy’s;  Eva  Louise  Cairns  Roberts,  M.B.,  Ch.B.  Manch., 
Manchester  Univ.  and  King’s  College;  W.  L.  Webb,  M.B.,  B.S. 
Lond,  LR.C.P..  M.R.C.S.,  Guy’s;  H.  E.  Whittingham,  M.B., 
Ch.B.  Glasg.,  Glasgow  Univ.  and  University  College;  and  J.  P. 
Williams,  L.R.C.P.,  M.R.C.S.,  St.  Mary's  and  KiDg's  College. 

The  Royal  Society  op  Medicine  : A War 
Section. — Tiie  proposed  new  section  for  dealing  with  all 
questions  affecting  medicine  and  surgery  in  the  Navy,  the 
Army,  and  the  Air  Force,  has  been  established  under  the 
name  of  “ War  Section.”  The  officers  and  council  elected 
are  as  follows  : — 

President.— Sure.  Rear-Admiral  Sir  Robert  Hill,  K.C.M.G.,  O.B., 

C. V.O.,  R.N. 

Vice-Presidents.— Navy : Surg.-Capt.  P.  W.  Bassett-Smith,  C.B., 
C.M.O.,  K N.  Army : Major-Geneial  S.  Guise  Moores,  C.B., 


C.MG..AM.S.  Air:  Bdg.-General  Fell,  C.M.O.,  R.A.F.  India: 
Sir  Havelock  Charles,  G.C.V.O.  Naval  and  Military  Auxiliary 
Services:  Col.  William  Pasteur,  C.B.,  C.M  G. 

Honorary  Secretaries. — Navy:  Surg.  Lieut.-Cmdr.  H.  B.  Hill,  R N. 
Army:  Col.  Oliver  Robinson,  C.  M.G.,  A.M.S.  Air:  Lieut. -Col. 

J.  McIntyre,  M.C..  R.A.F. 

Representative  on  Editorial  Committee. — Col.  S.  L.  Cummins,  C.M.G., 
A.M  S. 

Represmtative  on  Library  Committee.— Surg.-Capt.  P.  W.  Bassett- 
Smiih,  C.B.,  C.M.G.,  R.N. 

Other  Members  of  Council.  — Navy  : Surg.-Cmdr.  R.  Bankart,  C.V.O., 
R.N. ; Surg.-Cmdr.  R.  A.  Ross,  R.N.  Army  (Regular) : Col.  K.  M. 
Pilcher,  C.B..  C.M.G.,  A.M.S. ; Col.  Sir  Eiwatd  Worthington, 

K. C.V.O.,  C.B.,  C.M.G.,  R.A  M.C.  (Special  Reserve):  Capt. 

C.  Max  Page,  D S O..  R.A.  M.C.  (S.R.).  Air  Force:  Lieut.-Col. 
Henry  Cooper,  D.S  O. ; Major  A.  P.  Biwdler.  Naval  and 
Military  Auxiliary  Services:  Major  E.  B.  Waggett,  D.S.O., 

R.A. M.C.  ( T. F.).  India:  Lieut.-Col.  C.  Tilson  Hudson,  C.M.G., 
I.M.S.  (ret.);  Co).  G.  Irvine,  C.B.,  I.M.3.  (ret.).  Canada: 
Col.  H.  A.  Chisholm,  C.A.M.C.  Australia:  Lieut.-Col.  J.  H. 
Anderson,  A.i.F.  New  Zealand:  Lieut.-Col.  Bernard  Myers, 

C.M.G.,  N.Z  B.F.  South  Africa:  Col.  P.  G.  Stock,  S.A.M.C. 
Colonial  Office  : Dr.  A.  E.  Horn. 

These  will  serve  until  Sept.  30th,  1920.  The  first  meeting  of 
the  section  will  be  held  on  Monday,  Nov.  10th,  at  5.30,  when 
a paper  will  be  read  by  the  President  of  the  Section,  and  it 
is  hoped  that  the  opening  meeting  will  be  well  attended. 
Members,  of  course,  are  at  liberty  to  introduce  friends. 


itebiral  for  % ensuing  Week. 

LECTURES,  ADDRESSES,  DEMONSTRATIONS,  &c 

LONDON  HOSPITAL  MEDICAL  COLLEGE,  in  the  Clinical  Theatre 
of  the  Hospital.  . 

A Special  Course  of  Instruction  in  the  Surgical  Dyspepsias  will  be 
given  by  Mr.  A.  J.  Walton  : — 

Monday,  August  11th.— 1 p.m.,  Lecture  III.:— Dr.  G.  Scott:  Radio- 
logical Examination  of  Upper  Abdominal  Lesions.  Value  of 
Opaque  Meals. 

Friday.— 4 30p.m..  Lecture  I V::-Dr.  Panton : Test  Meals.  Technique 
for  Acidity.  Value  of  Results.  Technique  for  Motor  Power. 
Examination  of  Faeces. 

A Course  of  Clinical  Lectures  for  Advanced  Students  on  Intermittent 
Blood  Infections  and  their  Relation  to  Certain  Common  Diseases 
of  the  Kidney,  Prostate,  Testicle,  and  other  Organs  will  be 
delivered  by  Mr.  F.  Kidd: — 

Wednesday.— 4.15  p.m..  Lecture  II. :— Hatmatogenous  Infections  of 
the  Prostate.  Clinical  Course ; Diagnosis;  Treatment. 


^pwntments. 

Successful  applicants  for  vacancies.  Secretaries  of  Public  Institutions, 
and  others  possessing  information  suitable  for  this  column,  are 
invited  to  forward  to  The  Lancet  Office,  directed  to  the  Sub- 
Editor,  not  later  than  9 o'clock  on  the  Thursday  morning  of  each 
week,  such  information  for  gratuitous  publication. 

Coombs,  II  M.  McC.,  M.R.C.S.,  L.R.C.P.  Lond.,  has  been  appointed 
Certifying  Surgeon  under  the  Factory  and  Workshop  Acts  for  the 
Bedford  District  of  the  county  of  Bedford. 

Lightbody,  J.  H.,  M.D.Vict.,  Permanent  School  Medical  Inspector 
for  the  Honiton  District  under  the  Devon  County  Council. 

Raeburn  J.  A.,  M.D.,  Ch.B.  Edin.,  D.P.H.,  to  take  Charge  of  the 
Whole  Svstem  of  Anti-tubercular  Institutions  Organised  for  the 

Roy^DV  B.C.  Cantab.,  Assistant  Obstetric  Physician  to 

St  George’s  Hospital. 

Simmies,  a.  G.,  M.B.  Lond.,  L.R.C.P.,  Medical  Registrar  to  West- 
minster Hospital.  , 

Woodman,  M , M S.  Lond.,  F.R  C.S.  Eng,  Honorary  Aural  Surgeon  and 
Laryngologist,  General  Hospital.  Birmingham. 

Roval  Free  Hospital:  Blare,  Miss  Aldrich.  M S.  Lond.,  Consulting 
Surgeon,  with  Care  of  Patients  ; Davis.  H.,  M.B.  Oxon.,  F.R.C  S . 
Dermatologist.  _ _ — - , „ 

Salford  Royal  Hospital:  Jeeferson,  G..  M.S..  M.B.  Lond.,  Honorary 
Assistant  Surgeon;  White,  II.  V.,  M.D.,  Ch.B.  Manch.,  Honorary 
Ophthalmic  Surgeon  ; Smalley,  A.  A..  M.B.,  Cb.B.  \ ict..  Honorary 
Surgeon  for  Diseases  of  the  Bar,  Nose,  and  Throat. 


Vacancies. 


For  further  information  refer  to  the  advertisement  columns, 
delaide  University.— Prof . of  Path,  and  Bact. 
ntrim  County  Council. — Chief  Tuberc.  M.O.  £500. 
ath  City  Council. — M.O.H.  and  Sch.  M.O.  £700  • 

'•enenden,  Kent,  national  Sanatonum  -ksst.  Med  Supt.  £173. 
'irkenhead  County  Borough.-ksst.  M.O.H.  and  Clin.  Tuberc.  O.  £500. 
'irmingham  City. — Municipal  Bacteriologist.  £/00. 

’■irmingham  General  Hospital.—  Two  Assist.  S s.  £50- 
'irmingham  Municipal  Antituberculosis  Centre.—  Seu.  Asst.  Tuberc.  O. 
£600  * 
Urmingham,  Rubery  Hill  Asylum  and  Annexe  at  Holly  moor. -Med. 
Supt.  £1250. 

Irad ford  Royal  Infirmary-Res.  Surg, ;0.  £250. 

Innhton  Education  Committee. -Sen.  bob.  Doctor.  £600. 

Irighton,  Royal  Sussex  County  Hospital. -pen.  H.S.  £140. 

'.aerleon,  Mon.,  Xeu-port.  Royal  Infirm  ary.— Asst.  M.O.  £300. 


The  Lanobt,]  BIRTHS,  MARRIAGES  & DEATHS.— NOTES,  SHORT  COMMENTS,  ETC.  [August  9,  1919  271 


Cairo , Egyptian  Government  School  of  Medicine.— Profersors  and 
Lecturers.  £E.1000  and  £E.600.  Also  Radiologist,  and  Lcct.  in 
Radiology,  £B.500,  Ana-si hetlst.  and  Lect.  in  Anaesthetics,  £E.500, 
and  Registrar  and  Tutor,  £10.600. 

Carmarthen  Mental  Hospital.  — Second  Asst.  M.O.  £250. 

Chartham,  near  Canterbury,  Kent  County  Asylum  — Jun.  Asst.  M.O. 
£300. 

Chesterfield  and  North  Derbyshire  Royal  Hospital.— lies.  Sure.  O.  £350. 
Also  Jun.  H. 8.  £250. 

City  of  London  Maternity  HospHal,  City-road.  E G'.— Surg.  for  Venereal 
Diseases.  Also  Physician,  Chi  d Welfare  Department. 

Croydon  County  Borough.— M.O.  £40u. 

Derby,  County  Borough  Education  Committee.—  Asst.  Seh.  M.O.  £500. 
i Derbyshire  Roy  U Infirmary.— ()ph.  H.S.  £200. 

Devnnpnrt.  Royal  Albert  Hospital.— H»b.  H.S.  £200. 

Durham  Couti  y Council.  Asst.  Welfare  M.O.  £500.  Also  District 
Tuberc.  M.O.’s.  £600. 

I East  Ham  County  Borough  Education  Committee.— School  Dentist.  £400. 
East  London  Hospital  for  Children,  Shadwell,  E.— Cas.  O.  £120. 

Eccles  and  Patrieroft  Hospital.— lies.  H.S.  £200. 

Exeter  City. — Asst  M.O.H.  and  Asst.  Sci.  M.O.  £400. 

Oeorge  Town  Municipality,  Penang,  Straits  Settlements.— Asst.  M O H 
.$4200. 

Glamorgan  County  Asylum,  Bridgend.— Yo urth  Asst.  M.O.  £400. 
Greenwich  Union  Infirmary,  East  Greenwich,  S.E.— Dep.  Med.  Supt. 
£400. 

Hong  Kong  Government.— Burt,  and  Path.  £600. 

Huddersfield.  Bradley  Wood  Sanatorium  for  Pulmonary  and  Surgical 
Tuberculosis.— Kes.  M.O.  £500. 

KKrloum,  Wellcome  Tropical  Research  Laboratories.— Asst.  Bacterio- 
logist. £E,600. 

Leeds  Public  Dispensary,  NnrtKstreet.—Res.  M.O.  £200. 

Liverpool,  David  Lewis  Norlhem  Hospital.— Three  S.'s  and  Two  P.'s. 

£150. 

Liverpool  Hospital  for  Consumption,  Ac.— Hon.  M.O.'s. 

Liverpool  School  of  Tropical  Medicine.— Tropical  Research,  Brazil. 

Liverpool.  West  Derby  Union — Asst.  Res.  M.O.  £393. 

London  University  .—‘William  Julius  Mickle  Fellowship.  £200.  . 

Maidstone,  West  Kent  General  Hospital.— Jun.  H S.  £125. 

Manchester  Royal  Infirmary.— H.S. 's.  £25  for  first  six  months,  £50  for 

I second  six  months. 

Manchester,  St.  Mary’s  Hospitals  for  Women  and  Children.— Res. 

Obst.  S.  Also  Res.  Surg.  O.  £250. 

Newark  Hospital  and  Dispensary  —Res.  H.S. 

Newcastle  upon-Tyne,  Hospital,  for  Sick  Children.— Sen.  Res.  M.O.  £200. 

'j  Newcastle  upon-Tyne,  University  of  Durham  College  of  Medicine.— 
Demonstrators  of  Anatomy  ant  Physiology.  £350  to  £500  and  £300. 
Norfolk  Education  Committee.— Sen.  Asst.  Seh.  M O.  £500. 

! Northampton  County  Borough  Education  Committee.— Female  Asst. 
School  M.O.  £350. 

Nottingham,  Notts  Education  Committee  —Asst.  School  M.O.  £425. 
Peckham  House. lit.  Peckham-roacl,  S.E.—  Sen.  Asst.  M.O.  £400. 

Putney  Hospital,  S-  II'.— Res.  M.O.  £ 50. 

Queen  Mary’s  Hospital  for  the  East  End,  Stratford,  E.— H.S. 

Rochdale  Infirmary  and  Dispensary  —Sen  H.S.  £200. 

Royal  Chest  Hospital,  City-road,  li.C.— Res.  M.O.  £200. 

Royal  College  Of  Surgeons  in  Ireland.- Sen.  Asst.  (Anatomy). 

St.  Bartholomew’s  Hospital. -Phy .,  Surg.,  Asst.  Surg.,  and  Asst.  Phy.- 
Accoucheur. 

tit.  George's  Hospital,  S.  W.~~ Two  Cao  Officers.  £100. 

St.  Mary's  Hospital  for  Women  and  Children,  Plaistow,  E.— Dent.  S.  £50. 
Salford.  Royal  Hospital —Hon.  P.  and  Son.  Asst.  P. 

Shrffiel  i Royal  Infirmary.— H.S.  £150. 

Swansea  General  and  Eye  Hospital—  Res.  M.O.  £200. 

Taunton  and  Somerset  HospitaL—lies.  Asst.  H..S.  £80." 

Torquay  Education  Authority.— Asst.  Sch.  M.O.  and  Dept.  M.O.H. 
£350. 

University  College  Hospital.  Gower-street,  W.C.—  Asst.  S. 

West  African  Medical  Staff.—  Number  of  appointments.  £400. 

Willesclen  Urban  District  Council— Asst.  M.O.'s.  £550  to  £650 
Wolverhampton  and  Staffordshire  General  Hospital.— M.O.  for  Venereal 
Clinic.  £800. 

Yorks,  West  Riding  County  Council.  -District  Tuberc.  O.’s.  £500. 

The  Chief  Inspector  of  Factories,  Home  Office,  S.W.,  gives  notice  of 
a vacancy  for  Certifying  Surgeons  under  the  Faotory  and  Workshop 
Acts  at  Thorne.  1 


Jjftitrriiip,  anil  ftatfcs. 


BIRTHS. 

Carlisle.  On  August  1st,  at  “Ardlair,”  Heswall,  Cheshire,  the  wife 
of  Captain  H.  G.  Carlisle.  R.A.M.C.,  of  a daughter. 

MacCallan.  On  July  30th,  at  Mandeville- place,  W.,  the  wife  of  Arthur 
Ferguson  MacCallan.  F.K.C.S.,  of  a daughter. 


marriages. 

Elliot— Greene. — On  July  31st,  at  St.  Margaret’s,  Westminster, 
Lieutenant  Colonel  Henry  Charles  S.  Elliot,  O.B.E  , C. A.  M.U.,  to 
Margaret  Kathleen  Mary,  daughter  of  the  late  Charles  Temple 
Greene. 

Greenish  Wright.— On  J uly  29th,  at  All  Saints  Church,  Warlingham, 
Surrey,  F.  Harold  S.  Greenish,  M.A.,  M.R.C.S.,  L R.C.P..  to  Edith 
Marjorie,  only  daughter  of  Mr.  and  Mrs.  Duncan  Wright,  of 
“Sldbury,”  Warliugham.  

DEATHS. 

®UR^rE^L*  30th,  at  Kew  Gardens-road,  Kew,  Lionel  Burrell, 

M.D.,  aged  80. 

August  1st,  at  College  Court,  Shrewsbury,  Paul 
Mathews,  M.D  , aged  39. 

Weekes.— On  July  3lst,  at  Malvern,  Francis  Henry  Weekes,  F.Ii.C.S. 
Eng.,  M.D.  Durh.,  aged  65. 

N.B,  A fee  of  5s.  is  charged  for  the  insertion  of  Notices  of  Births , 
Marriages , and  Deaths. 


Hates,  JSJjoit  (torntta,  aite 
to  Carmpitkitis. 

AN  EMERGENCY  CASES  HOSPITAL  IN  THE 
MEUSE.1 

By  J.  A.  Cairns  Forsyth,  M.Sc.,  M.B.,  F.R.C.S., 

SURGEON  TO  THE  FRENCH  HOSPITAL. 


Offered  to,  and  accepted  by  the  French  Army,  in 
December,  1914,  our  unit  did  not  leave  England  until  the 
following  March,  for  the  hospital  was  independent  of  any 
Red  Cross  organisation  as  regards  funds,  and  it  took  some 
time  before  the  means  necessary  to  equip  and  maintain  the 
formation  for  any  length  of  time  were  obtained. 

We  went  out  with  the  intention  of  doing  urgent  surgery, 
but  when  we  arrived  at  Bar-le-Duc,  our  destination,  we 
found  that  for  that  olass  of  work  we  were  both  unnecessary 
and  unsuitable.  We  were  a little  disappointed  at  first,  but 
we  talked  things  over  among  ourselves,  and  decided  that  we 
could  still  do  good  work  in  the  treatment  of  fractures,  a 
department  of  surgery  that  was  then  making  rapid  progress. 

Early  Days  in  Bar-le-Duc. 

At  Bar-le  Due  we  were  given  a wing  of  a caserne  for  our 
hospital,  and  it  was  easily  adapted  to  our  needs.  The  con- 
crete barrack  rooms  made  excellent  wards,  and  I am  afraid 
we  scandalised  the  French  by  the  open-air  treatment  that 
we  gave  our  wounded. 

We  were  fortunate  in  having  for  our  surgeon-general  the 
M6decin  Inspecteur  Mignon,  a former  director  of  the  Val-de- 
Grace.  When  the  hospital  was  offered  to  the  French  Army 
as  a whole  General  Mignon  asked  for  it  to  be  attached  to  his 
command,  as  he  had  a profound  respect  for  English  nursing. 
He  was  a man  of  deep  human  feeling,  a great  organiser,  and, 
at  the  same  time,  a fine  clinician.  He  quickly  arranged  that 
we  should  receive  our  wounded  direct  from  the  front,  and 
8dvised  the  medecins  chefs  of  the  field  hospitals  to  reserve 
the  fracture  cases  for  us.  The  system  worked  well.  When- 
ever there  was  fighting  in  the  Argonne  we  were  informed  at 
once,  and  our  cars  went  up  and  brought  down  the  wounded 
straight  away. 

We  soon  made  friends  with  the  staffs  of  the  field 
ambulances,  and  they  took  great  interest  in  our  hospital, 
visiting  it  whenever  they  came  to  Bar-le-Duc.  They  were 
naturally  rather  envious  of  our  fine  equipment,  for  the 
French  Medical  Service  is  the  Cinderella  of  all  the  Army 
Services.  In  order  to  be  a successful  medecin  chef,  you 
must  have  the  gift  of  being  able  to  make  bricks  without 
straw.  Many  of  these  men  possessed  that  gift,  and  I have 
often  been  astounded  at  the  ingenuity  they  displayed  in 
making  something  out  of  nothing. 

Visits  to  the  Argonne  front. 

One  road  along  which  we  often  travelled  led  us  to 
Clermont.  Clermont  is  built  on  a bluff  in  the  Argonne,  and 
must  have  been  a very  beautiful  spot  once,  before  it  was 
burned  out  by  the  Germans.  Its  staircase  street  is  rather 
quaint,  winding  up  the  side  of  the  bluff  to  the  church, 
which  has  been  quite  destroyed. 

The  local  hospital  fortunately  was  saved  from  destruction 
by  the  energies  of  a very  brave  nun,  the  Sister  Gabrielle. 
She  drove  out  the  Germans  when  they  entered  the  building 
to  set  it  on  fire,  and  rumour  had  it  that  she  even  had  a 
few  words  of  wisdom  for  the  Crown  Prince. 

From  Clermont,  the  Paris-Metz  road  ran  west  to  east, 
and  along  this  road  were  the  towns  and  villages  of  Dombasle, 
Les  Islettes,  Ste.  Menehould,  and  Braux  Ste.  Cohiere.  In 
each  of  these  were  field  hospitals,  and  at  Braux  there  was 
one  of  the  first  motor  hospitals,  or  “ auto-ebirs,”  as  they 
were  called,  costly  formations,  but  very  mobile.  Beyond 
this  line  were  the  smaller  advanced  hospitals,  scattered 
throughout  the  Argonne,  for  at  this  time  the  French  were 
doing  a deal  of  urgent  surgery  close  to  the  lines,  as  the 
Argonne  roads  were  very  bad.  In  one  village,  which  was 
only  800  yards  from  the  lines,  they  had  an  advanced  operating 
centre  installed  in  two  houses.  Here  I saw  head  cases, 
chest  cases,  and  abdominal  cases  that  had  been  operated  on, 
lying  on  the  straw  and  doing  well. 

The  great  majority  of  the  wounds  from  the  Argonne  were 
produced  by  bombs.  It  was  the  era  of  the  jam-tin  bomb,  the 
“ tourterelle,”  the  “ crapouillot,”  the  “ minenwerfer,”  and 
such  barbarous  engines  of  trench  warfare.  Gas  gangrene, 
on  the  whole,  was  not  common,  but  we  saw  enough  of  it  to 
be  always  on  guard. 


1 An  address  given  at  the  last  Social  Evening  of  the  Royal  Society  of 
Medicine  and  here  published  in  an  abridged  form. 


272  The  Lancet,]  NOTES,  SHORT  COMMENTS,  AND  ANSWERS  TO  CORRESPONDENTS.  [August  9,  1919 


The  Real  Frenchman. 

By  this  time  we  had  got  to  know  our  soldier  patients  very 
well,  and  had  acquired  the  greatest  respect  for  them. 
Most  of  us  had  gone  to  France  with  only  the  conception  of 
French  character  such  as  one  sees  on  the  stage,  and  we 
wore  agreeably  surprised  to  find  that  the  French  soldier 
was  a totally  different  beiDg,  a really  very  great  man.  At 
heart  a child,  he  resembled  a child  in  that  he  could  find  his 
own  amusement  and  required  no  entertaining.  The  poilus 
were  very  skilled  in  handicrafts,  and  excelled  in  metal  work 
and  woodwork,  and  as  soon  as  they  were  strong  enough  and 
able  to  use  their  hands  they  took  to  fashioning  things  out  of 
bits  of  aluminium  and  shell  cases.  With  a few  simple  tools 
they  turned  out  beautiful  rings  and  automatic  lighters. 
Later  on,  when  we  moved  to  Faux  Miroir,  they  specialised 
in  the  making  of  walking-sticks. 

At  Colonel  Hunter’s  lecture  I referred  to  their  personal 
cleanliness,  and  certainly  it  was  remarkable  how  they 
managed  to  keep  their  bodies  free  from  lice.  My  own 
opinion,  if  I may  give  it  again,  is  that  it  was  largely  due  to 
the  fact  that  the  French  soldier  is  provided  with  a uniform 
that  will  wash  and  which  he  is  made  to  wash,  and,  in 
addition,  be  wears  cotton  shirts  and  underclothing  instead 
of  woollen.  He  washes  his  body  daily — there  is  no  false 
modesty  among  the  French  soldiers  on  that  point — and  he 
does  not  require  a bath  for  his  ablutions.  Whatever  the 
reasons  were,  we  found  that  parasitic  diseases  were  con- 
spicuous by  their  absence,  and  trench  fever  was  unknown. 

The  Hospital  at  Faux  Miroir. 

In  August,  1915,  we  were  asked  to  move  to  Faux  Miroir,  a 
chateau  near  Revigny,  nine  miles  to  the  west  of  Bar-le-Duc. 
Now  this  chateau  of  Faux  Miroir,  which,  by  the  way,  was 
more  like  a Swiss  hotel  than  a chateau,  proved  to  be  an 
interesting  place,  for  it  had  been  a German  ambulance  for 
two  days  during  the  battle  of  the  Marne.  The  verandah  had 
served  as  the  operating  theatre,  and  limbs,  as  they  were 
amputated,  were  simply  thrown  over  the  parapet  into  the 
little  plantation  adjoining.  The  chateau  was  frequently 
visited  by  the  Crown  Prince  during  the  battle,  as  there  was 
a staff  headquarters  in  the  laundry.  In  a flower  bed  in  front 

of  the  verandah  was  the  grave  of  Hauptmann  von  G -, 

one  of  the  Crown  Prince’s  intimate  friends,  who  was  mor- 
tally wounded  at  the  gate  of  the  chateau  and  died  in  the 
salon. 

All  round  Faux  Miroir  were  signs  of  the  fighting  at  the 
Marne.  Three  parallel  rows  of  trenches  crossed  the  park 
immediately  in  front  of  the  chateau.  In  the  fields,  woods, 
and  by  the  roadsides  were  many  graves.  Revigny  itself, 
3 kilometres  away,  on  the  railway  from  Paris  to  Nancy,  had 
been  much  destroyed,  partly  by  shells,  partly  by  paraffin, 
for  the  Germans,  before  they  retreated,  set  the  town  on  fire. 
The  Crown  Prince  is  said  to  have  viewed  the  bombardment 
and  burning  of  Revigny  from  a dug-out  at  Yillers-aux-Vents. 
It  was  a very  palatial  dug-out,  for  it  was  lined  with  fine  old 
oak  doors  taken  from  the  neighbouring  cottages. 

Close  to  the  chateau,  in  the  lee  of  a small  wood,  we  built 
our  hospital.  It  was  hard  work,  as  we  were  on  60  feet  of 
clay,  but  by  putting  down  over  200  tons  of  stones,  slag,  and 
gravel  we  made  the  surface  sufficiently  porous  and  dry  to 
withstand  the  damp  of  the  Meuse  winters.  The  wards  were 
the  usual  Bessanot  huts,  double  walled,  with  swinging  side 
partitions  that  opened  outwards,  so  that  there  was  abund- 
ance of  air  in  warm  weather.  Each  of  the  six  wards 
accommodated  20  patients.  The  private  chapel  made  an 
excellent  operating  theatre,  as  it  was  well  lit  and  easily 
cleaned.  The  sacristy  adjoining  was  converted  into  a 
preparation  and  sterilising  room.  We  soon  got  the  local 
ironmonger  quite  enthusiastic  in  the  making  of  Blake 
splints,  and  we  were  able  to  employ  them  during  that 
autumn  and  winter  and  find  out  their  many  advantages. 

Life  at  Faux  Miroir  was  much  more  pleasant  than  at 
Bar-le-Duc,  and  the  change  from  town  to  country  was 
greatly  appreciated  by  both  patients  and  staff.  We  had  600 
acres  of  wood  and  park  where  the  convalescents  could  roam 
about,  and  we  gave  them  plenty  of  liberty,  which  I am 
proud  to  say  they  never  abused".  The  winters  were  very 
severe,  and  for  weeks  the  whole  country  lay  deep  in  snow. 
Transport  of  the  wounded  to  and  from  the  station  was  then 
very  difficult,  as  a high  and  steep  hill  lay  between  us  and 
Revigny.  In  our  off  times  during  the  winter  we  hunted  the 
mighty  boar  that  came  down  in  bands  from  the  Argonne. 
The  larger  ones  we  shot  and  ate  with  great  relish,  the  little 
ones  we  tried  to  catch  alive  with  the  dogs,  as  they  made  most 
lovable  pets.  (To  be  concluded.) 

THE  PNEUMAMETER. 

Described  as  a new  portable  spirometer,  this  apparatus 
is  simple  enough  in  detail,  and  after  a little  practice  the 
results  obtained  appear  concordant  and  relatively  instruc- 
tive. The  principle  is  that  of  the  diving  bell  with  a small 
escape  at  the  top,  the  bell  being  kept  poised  by  the  expired 
air  of  the  operator,  and  releasing  a scale  which  descends 


uniformly  by  its  own  weight  and  registers  the  duration  of 
expiration  and  therewith  its  actual  volume  on  an  empirical 
scale.  To  use  the  apparatus  water  is  placed  in  the  outer 
cylinder,  the  inner  cylinder  being  removed  for  that  purpose. 
The  inner  cylinder  is  then  replaced,  the  scale  which  passes 
through  aD  aperture  at  the  top  being  brought  upwards  to 
the  zero  mark.  A pair  of  levers  each  side  of  the  scale  keeps 
it  in  position  and  these  are  released  as  soon  as  the  pressure 
of  expired  air  raises  the  cylinder.  When  the  operator  can 
no  longer  maintain  the  expiratory  pressure  the  inner 
cylinder  falls  and  the  descending  scale  is  caught  by  the 
pointers  or  levers  and  held  there  when  the  reading 
can  be  taken.  The  breath  enters  by  a pipe  in  the  outer 
cylinder  bent  upwards  and  projecting  into  the  inner 
cylinder.  A rubber  tube  is  attached  with  a glass  mouth- 
piece, so  designed  as  to  prevent  condensed  water  from  the 
expired  air  reaching  the  mouth  again.  The  glass  month- 
piece,  of  course,  can  be  sterilised. 

The  instrument  was  submitted  to  us  by  the  Oliver-Pell 
Electric  and  Manufacturing  Co.,  Ltd.,  of  Granville  House, 
Arundel-street,  London,  W.C.2. 

SMALL  HOLDINGS  AND  THE  RETURNED  SOLDIER. 

A new  addition  to  the  excellent  series  of  guide  books  for 
ex  Service  men  and  others,  some  of  which  we  noticed  in 
The  Lancet  of  May  24th,  p.  922,  has  just  been  made  by  the 
Board  of  Agriculture  and  Fisheries — namely,  “ Dairy  Farming 
Under  Small  Holding  Conditions.”  In  it  the  choice  and 
management  of  a holding,  the  relative  advantages  of  milk- 
selling, cheese-making,  and.  butter-making  are  discussed, 
together  with  methods  of  production.  The  pamphlet  can  be 
obtained  for  2d.,  post  free,  by  the  general  public,  and  by 
ex-Service  men  free  of  charge  and  post  free,  from 
3,  St.  James’s-square,  S. W.  1.  The  Board  of  Agriculture  and 
Fisheries  have  also  issued  a pamphlet,  which  can  be  obtained 
post  free  from  the  same  address,  on  “ Apple  Aphides.”  This  is 
an  abridgment  of  an  article  which  recently  appeared  in  the 
Journal  of  the  Board  of  Agriculture  from  the  pen  of  Mr.  F.  V. 
Theobald  and  deals  with  the  life  histories  and  the  methods 
of  destruction  of  some  of  the  aphides  which  infe3t  apple 
trees. 

AN  IMPROVEMENT  IN  THE  GALYANOSET 
APPARATUS. 

An  improvement  of  some  importance  in  the  rheostat, 
known  as  the  Galvanoset,  is  announced  by  the  Medical 
Supply  Association  of  167-185,  Gray’s  Inn-road,  London, 
W.C.  1.  The  four  conducting  elements  were  formerly  made 
of  carbon,  but  the  positive  element  of  this  material  tended 
to  crumble  and  discolour  the  water,  which  necessitated 
frequent  changing  of  the  water  and  replacing  the  carbon. 
This  disadvantage  is  entirely  removed  by  adopting  a positive 
element  of  platinum.  The  improvement  is  an  obvious  one, 
and  those  who  have  been  using  the  Galvanoset  apparatus 
may  be  glad  to  know  that  this  change  can  readily  be  made, 
and  what  was  a source  of  inconvenience  can  be  avoided  by 
this  simple  adjustment. 


Communications,  Letters,  &c.,  to  the  Editor  have 
been  received  from— 


A.  — Agricultural  Costings  Com- 
mittee ; Mrs.  V.  B.  Alvarez,  New 
York  ; Sir  R.  Armstrong-Jones, 
Lond. 

B. — Dr.  E.  A.  Barton,  Lond.;  Mr. 

J.  S.  Buckle,  Lond.;  Dr.  J.  Blom- 
field,  O.B.E.;  Mr.  W.  G.  Ball, 
Lond.;  Board  of  Agriculture  and 
Fisheiies,  Lond.;  Dr.  G.  Bous- 
field,  Lond.;  Dr.  N.  Bradly, 
Crowborough ; Mr.  W.  E.  Brown, 
Uxbridge ; Mr.  J.  B.  Burke, 
Kingston  Hill. 

C.  — Colonial  Office,  Lond.;  Dr.  A. 
Carver,  Birmingham  ; Dr.  T.  F. 
Cotton,  Lond. 

D. — Mr.  J.  D.  Driberg,  Lond.; 
Capt.  R.  Datta,  I.M.S. 

E. — Dr.  R.  Eager,  Exminster. 

F. — Dr.  W.  G.  Forde,  Cloyne ; Dr. 
R.  F.  Fox,  Enham  ; Pte.  W.  Foss, 
R.A.M.C.;  Factories,  Chief  In- 
spector of,  Lond. 

G — Dr.  H.  L.  Gordon,  Lond.;  Dr. 

W.  E.  Gye,  Lond. 

H. — Capt.  J.  K.  Haworth,  R.  A.M.C. 
(S.R.i 

J.  — Dr.  T.  H.  Jamieson,  Lond.; 
Prof.  F.  Wood  Jones.  Lond. 

K.  — Dr.  L.  J.  Kidd,  Lond  ; King's 
College  Hospital  Medical  School, 
Lond.,  Seo.  of ; Lieut.-Col.  J.  W. 
Kynaston,  R. A.M.C. 

L.  — Dr.  R.  B.  Low,  Lond.;  Dr.  O. 
Langmead,  Lond.;  Dr.  H.  A. 


Lediard,  Carlisle;  Dr.  E.  G. 
Little,  Lond.;  Mr.  J.  H.  Lloyd, 
Leighton. 

M. — Ministry  of  Health,  Lond.; 
Capt.  H.  C.  Martin,  R.A.M.C.; 
Mr.  W.  Y.  McNae,  Lond.;  Dr.  A. 
Mary,  Paris ; Dr.  B.  Moore, 
Lond.;  Mr.  J.  Y.  W.  MacAlister, 
Lond.;  Dr.  C.  S.  Myers,  Cam- 
bridge; Mr.  E.  Mulligan,  Swin- 
ford ; Messrs.  Masson  et  Cie, 
Paris. 

N. — National  Council  for  the  Un- 
married Mother  and  her  Child. 
Lond. 

P.— Dr.  S.  Porterfield,  Widnes; 
Major  J.  Porter,  R.A.M.C. 

R. — Dr.  W.  C.  Rivers,  Alton ; Royal 
Society  of  Medicine,  Lond.;  Royal 
Sanitary  Institute,  Lond. 

S.  — Dr.  A.  G.  Shera,  Eastbourne  ; 
Salford  Royal  Hospital,  General 
Supt.  and  Sec.  of ; Prof.  W. 
Stirling,  Manchester ; Mr.  E.  S. 
Servetopoulos,  Cairo ; Mr.  F.  B. 
Shawe. 

T. — Dr.  H.  H.  Tooth,  C.B.,  C.M.G., 
Lond.;  Territorial  Force  Medical 
Officers  Association,  Lond.,  Hon. 
Sec.  of. 

W.— Dr.  C.  Walker,  Birmingham; 
Dr.  F.  J.  Wethered,  Falmouth ; 
Dr.  L.  A.  Weatherly,  Bourne- 
mouth ; Mr.  M.  Woodman,  Bir- 
mingham. 


Communications  relating  to  editorial  business  should  be 
addressed  exclusively  to  the  Editor  of  The  Lancet, 
423,  Strand,  London,  W.C.  2. 


THE  LANCET,  August  16,  1919. 


Clinical  (Dbstrimtwns 

IN 

INDIA  DURING  THE  WAR. 

By  A.  W.  SHEEN,  C.B.E.,  M.S.,  M.D.,  F.R.C.S., 

COLONEL,  A.M.S.  (T.F.)  ; FORMERLY  O.C.  NO.  34  (WELSH)  GENERAL 
HOSPITAL,  INDIA,  AND  CONSULTING  SURGEON,  WAR  HOSPITALS, 
INDIA  ; CONSULTING  SURGEON,  KING  EDWARD  VII. 
HOSPITAL,  CARDIFF. 


The  following  are  brief  observations  which  seem  of 
interest,  made  during  nearly  three  years  in  India.  They 
are  not  meant  to  be  exhaustive  and  I have  confined  myself 
to  conditions  peculiar  to  the  tropics  and  mainly  to  India. 

War  wounds — The  gunshot  wounds  coming  back  from 
Mesopotamia  did  not  suppurate  either  so  often  or  so  freely 
as  those  sustained  in  France.  Many  presented  the  clean 
“in  and  out”  character  of  the  South  African  war  wounds. 
This  is  probably  because  the  soil  of  Mesopotamia  is  not  so 
infective  as  the  highly  manured  soil  of  densely  populated  and 
elaborately  cultivated  countiies  like  Belgium  and  Northern 
France.  Tetanus  and  gas  gangrene  were  infrequent,  almost 
the  only  cases  that  I saw  in  India  being  in  wounded  Turkish 
prisoners,  who  had,  before  coming  into  British  hands,  been 
— perhaps  unavoidably — inadequately  treated. 

Anesthetics. — I am  convinced  that  ether  can  be  given  in 
India.  In  1916,  on  arrival,  I was  fortunate  in  having 
under  me  officers  who  could  give  “open  ether,”  and  it 
became  the  routine  anaesthetic.  Later  the  details  of  an 
“ open  ether”  series  of  cases  were  carefully  recorded  at  one 
of  the  Bombay  war  hospitals.  The  operations  were  in  May 
and  June,  the  hottest  time  of  the  year,  with  the  temperature 
between  90°  and  100°  F.  Scopomorphine  sometimes,  but 
not  always,  preceded.  The  majority  of  the  operations  were 
abdominal.  No  difficulties  were  experienced  in  any  case  ; 
the  amount  of  ether  given  was  not  excessive.  In  India  with 
ordinary  precautions  there  is  no  difficulty  in  keeping  ether. 
It  could  be  manufactured  there  with  a little  enterprise. 

Operating  and  operation  theatres  in  hot  climates. — To 
prevent  sweat  dropping  on  to  the  wound  area  special 
assistants  dab  the  faces  of  those  concerned  in  the  operation 
with  the  ends  of  rolled  towels  or  with  mops  on  handles. 
A small  mouth  mask  should  be  worn.  Through  a large-type 
face  mask  one  perspires  and  cannot  be  mopped.  Bacterio- 
logical investigation  of  the  sweat  on  several  occasions 
universally  gave  a pure  culture  of  Staphylococcus  albus. 
The  following  is  probably  a case  of  sweat  wound  infection. 

On  a hot  day  the  femur  was  plated  with  two  heavy  plates 
in  a simple  fracture  ; skin  was  carefully  excluded.  There 
was  a slight  evening  rise  of  temperature,  usually  99'2°. 
Except  for  this  all  went  apparently  well  until  between  five  to 
six  weeks  after  the  operation,  when  a point  of  sero-purulent 
oozing  appeared  in  the  wound  line  ; this  gave  a pure  cultiva- 
tion of  Staphylococcus  albus.  Later,  after  bone  union,  the 
plates  were  removed  and  every  one  of  the  screw-holes  tested 
gave  a similar  cultivation.  Cases  such  as  bone-plating 
should  be  removed  to  a cool  place  for  operation. 

A fan  in  the  theatre  is  unobjectionable  ; the  air  near  it 
showed  no  more  organisms  than  in  other  parts  of  the  theatre. 
A case  of  neck  suppuration  led  me  to  advise  that  the  long- 
haired, full-bearded  Sikhs  should  wear  sterile  linen  fitted 
covers  for  head  and  beard  during  operations  on  them.  A roof 
light  is  not  usually  found  in  Indian  theatres.  Sterile  topses 
for  all  concerned  would  be  a ludicrous  addition  to  the  equip- 
ment ! There  is  no  objection,  however,  to  a sloping  north 
roof  light  of  the  long  and  narrow  type  continuous  with  a 
narrow  north  window.  Too  big  a north  window  is  to  be 
avoided.  I know  of  one  “war”  theatre  where  practically 
the  whole  north  wall  is  glass,  making  it  a veritable  hot 
house.  The  room  where  the  sterilisers  are  should  not  be 
continuous  with  the  theatre,  but  cut  off  by  an  open  corridor 
— i.e.,  one  with  a roof  but  no  sides. 

Orthopedics. — The  principles  of  military  orthopaedics  have 
been  so  often  and  so  well  enunciated  that  I will  not  give 
more  than  the  briefest  summary  of  my  views.  They  are 
embodied  at  length  in  the  Indian  Medical  Gazette!  The 
treatment  of  these  cases  should  be  preventive  from  the 

1 11  The  Principles  of  Military  Orthopaedics,  with  Notes  on  the 
Constitution  of  an  Orthopaedic  Hospital,”  Indian  Medical  Gazette, 
vol.  liii.,  No.  9,  September,  1918. 

No.  5007. 


beginning  ; it  is  necessary  that  there  should  be  quick  return 
from  the  active  war  areas  and  segregation  in  a few  large 
special  hospitals  where  all  the  necessary  specialists  and  the 
special  treatment  materials  are  assembled.  I had  to  combat 
the  idea  that  British  “ orthopaedics  ” could  wait  until  they 
got  to  England  to  be  treated.  Many  could  be  cured  and 
sent  back  to  duty.  For  those — a minority — who  had  to  go 
home  I recommended  “orthopaedic”  equipment  on  the 
hospital  ships. 

The  cases  in  Indians  presented  some  special  features.  A 
number  were  largely  functional,  and  amongst  some  of  these 
patients— as  those  who  know  the  country  will  realise— a 
disability  is  regarded  as  an  asset.  Particularly  it  was  found 
that  special  physical  drill  was  very  valuable  in  curing 
functional  deformities,  and  on  the  parade  ground  the 
motionless  arms  or  legs  would  gradually  be  seen  to  move 
more  and  more  in  concert  with  the  limbs  of  the  others 
exercising.  In  this  connexion  it  is  interesting  to  call  atten- 
tion to  the  great  use  the  Germans  have  made  of  this  form  of 
treatment. 

Head  cases. — A number  of  cases  of  head  wounds  which 
had  gone  to  England  and,  being  apparently  well,  had  been 
sent  back  to  Mesopotamia  came  under  my  notice  in  that, 
having  been  a very  short  time  in  Mesopotamia,  they  were 
invalided  to  India  with  headache  or  other  symptoms.  My 
conclusion  was  that  head  wounds  should  not  be  returned  to  a 
hot  climate.  I saw  my  colleague  Major  L.  B.  Rawling’s  cases 
of  decompression  for  epileptiform  attacks  following  heat- 
stroke, and  can  testify  to  the  benefits  of  the  operation. 

Oriental  sore. — This  cutaneous  or  subcutaneous  malady, 
due  to  the  infection  of  the  tissues  with  Letshmania  tropioa, 
is  of  great  interest.  Its  names  are  protean  : Delhi  boil, 
Bagdad  boil,  Aleppo  boil  are  some  of  many.  The  cases 
which  I saw  all  came  from  Mesopotamia.  Sand-flies  have 
been  suggested  as  a possible  source  of  infection.  In  typical 
cases  the  diagnosis  is  easy— a more  or  less  scabbed,  sloughy, 
often  circular  ulcer,  usually  on  exposed  parts  of  the  body. 
Diagnosis  is  confirmed  by  finding  the  typical  parasite  in 
scrapings  or,  better,  by  puncture  of  the  edge.  The  sub- 
cutaneous form  is  often  most  puzzling,  la  a case  shown  by 
Lieutenant-Colonel  R.  Row,  I.M.S.,  to  the  Bombay  War 
Hospitals  Medical  Society  there  was  a group  of  keloidal 
swellings,  each  about  the  size  of  an  almond,  over  the  left 
scapula  ; in  a nursing  sister,  whom  I saw  with  Captain  H. 
Weir,  R.A.M.C.,  there  was  a bluntly  pedunculated  sphere  on 
the  lower  lip  the  size  of  a large  marble,  pale,  shiny, 
cedematous-looking,  of  six  months’  duration.  Diagnosis  in 
these  two  cases  would  have  been  impossible  without  the  aid 
of  puncture.  I saw  many  cases  in  British  soldiers  and  several 
in  nurses. 

As  with  many  diseases  which  spontaneously  tend  to  get 
well,  numerous  forms  of  treatment  have  been  credited  with 
success.  Colonel  Row  gave  a vaccine  prepared  from  the 
parasite  and  dressed  the  sores  with  salol  in  oil.  I have  seen 
good  results  from  salvarsan  and  from  X rays.  Other 
measures,  such  as  scraping,  ionisation,  and  the  application 
of  antiseptics  or  caustics,  sometimes  apparently  cure  but  are 
followed  by  recurrence.  Intravenous  injection  of  antimony 
tartrate  is  usually  successful.  A good  treatment  for  small 
sores  suitably  situated  is  complete  excision.  Microscopical 
examination  of  the  excised  sore  shows  down-growing  columns 
of  bells  with  cell-nests  indistinguishable  from  epithelioma. 
This  has  an  interesting  bearing  on  the  aetiology  of  cancer, 
and  it  is  to  be  remembered  that  the  South  American  naso- 
pharyngeal form  of  the  disease  is  known  as  “ Leishman 
cancer.” 

Regarding  infection,  Colonel  Row  cilled  my  attention  to 
a flagellate  found  in  the  latex  of  plant  juice  (Euphorbia) 
which  strongly  resembles,  morphologically  and  culturally, 
the  flagellate  form  of  the  Leishman  body.  As  the  incuba- 
tion period  of  oriental  sore  may  be  prolonged  to  five  or  six 
months,  and  as  apparently  healed  cases  may  recur,  the 
disease  should  be  borne  in  mind  in  the  home  country. 

Kangri  cancer.— A visit  to  Srinagar  in  Kashmir  gave  me 
an  opportunity,  through  the  kindness  of  Dr.  Ernest  Neve,  of 
visiting  the  excellent  mission  hospital  there  and  learning 
something  about  this  disease.  The  Kashmiri  keep  them- 
selves warm  during  their  very  cold  winters  by  hugging  to  the 
abdomen  under  the  clothing  a kangri,  which  is  an  earthen- 
ware receptacle  about  4 inches  across  enclosed  in  basket 
work,  this  being  continued  into  a curved-over  handle..  In  it 
is  kept  glowing  wood  ash.  Minor  skin  irritation,  staining,  or 
G 


274  Thf  Lanoht,] 


COL.  A.  W.  SHEEN  : CLINICAL  OBSERVATIONS  IN  INDIA. 


[August  16,  1919 


ulceration  are  common  results  and  sometimes  cutaneous 
cancer  develops.  I saw  Dr.  Neve  operate  on  one  case.  The 
patient,  a man,  aged  60,  had  a large  circular  median  growth 
below  and  including  the  umbilicus  ; it  was  removed  with 
muscle  and  a portion  of  peritoneum.  In  this  case  the  growth 
was  recurrent,  the  original  operation  having  been  done  six 
months  previously.  For  the  following  facts  I am  indebted 
to  Dr.  Neve.  The  cancer  occurs  in  skin  irritated  or  actually 
burnt  from  kangris.  As  well  as  the  abdomen,  the  fronts  of 
the  thighs  are  afffected  from  squatting.  Though  this  growth 
is  below  the  umbilicus  the  glands  in  the  axillte  must  be 
examinee},  as  they  may  be  affected.  It  is  best  to  remove  the 
groin  glands  when  operating,  even  if  these  are  not  obviously 
affected.  The  disease  is  more  frequent  in  people  who  have 
warts  or  moles  about  them.  The  man  whom  I saw  operated 
on  had  a pigmented  mole  on  his  forehead.  Dr.  Neve  had 
never  seen  a case  under  30. 

Guinea  worm. — It  would  puzzle  anyone  unacquainted  with 
this  infection  to  know  the  meaning  of  an  earthenware 
receptacle  of  water  suspended  some  feet  above  the  leg  of  a 
patient,  while  from  a small  hole  in  its  bottom  water  drips  on 
to  an  opening  in  the  patient’s  leg,  from  which  a whitish 
thread  protrudes.  This  is  a method  of  coaxing  out  the  worm. 
The  worm — always  a female — lies  under  the  epidermis.  It 
tends  to  emerge,  and  this  may  be  hastened  by  injection  of 
various  antiseptics.  When,  as  occasionally,  closely  coiled 
the  worm  can  be  excised  in  toto  ; rarely  it  protrudes  as  a 
loop.  The  native  method  of  abstracting  it  is  by  twisting  the 
protruding  portion  round  a stick,  giving  a turn  or  two  daily. 
Castellani  suggests  that  the  worm  is  the  fiery  serpent  of 
Moses;  if  this  is  so,  the  badge  of  the  R.A.M.C.  shows  this 
method  of  abstraction  1 The  worm  should  never  be  pulled 
upon,  for  if  it  bretks  in  the  tissues  it  sets  up  an  intense 
gangrenous  cellulitis,  often  fatal ; I saw  two  cases  of  this 
kind  which  died.  The  worm  is  mostly  uterus,  and  the 
uterine  contents  appear  to  be  intensely  irritating  to  the 
tissues.  The  method  of  treatment  is,  of  course,  alluded  to 
in  some  text-books.' 

Inguinal  bubo. — I saw  quite  a series  of  cases  in  which  no 
source  of  infection  was  demonstrable,  the  majority  being 
in  Colabi  War  Hospital  under  the  care  of  Captain  G.  W. 
Bury,  R A.M.C.  The  patients  were  British,  the  greater 
number  being  sailors.  The  glands  enlarge  and  soften  and 
excision  shows  broken  down  gland  tissue  and  sero-purulent 
material.  Cultivations  were  invariably  reported  sterile. 
The  wounds  often  broke  down  aseptically  and  were  slow  in 
healing.  I understand  that  cases  of  “Oriental  bubo”  are 
common  amongst  natives  in  the  Madras  district.  The  occur- 
rence in  sailors  suggests  infection  through  the  bare  feet,  but 
no  evidence  was  found  in  support  of  this. 

leprosy. — Of  very  great  interest  was  a visit  which  I,  in 
common  with  a number  of  other  medical  officers,  paid  to  the 
leper  asylum  at  Matunga,  Bombay,  on  the  kind  invitation 
of  t)r.  Arthur  Powell.  The  patients  were  mostly  Hindoos, 
and  the  majoritj  had  lived  near  the  sea.  Dr.  Powell  pointed 
out,  the  roughened,  wrinkled,  reddened  skin  like  an  orange  ; 
frequent  enlargement  of  the  nipples,  constrictions  round  the 
fingers  like  ainhum,  depressed  nose  bridges,  hoarse  voices 
from  nodules  on  the  laryngeal  cartilages,  mixed  cases — i.e., 
both  nodular  and  amesthetic,  the  light-coloured  anaesthetic 
areas,  cases  showing  ulnar  griffe  ; others,  weakness  of  the 
anterior  tibial  muscles.  “ Nastin  ” and  other  remedies  had 
been  tried  without  success.  The  bacillus  is  not  pyogenic. 
It  can  be  got  from  the  liver  and  spleen.  The  patients  die  of 
tuberculosis  or  other  intercurrent  disease. 

In  the  visitors'  book  we  saw  the  signature  of  Jonathan 
Hlitchinson  in  1903  and  his  written  expression  of  opinion 
that  no  harm  would  come  from  selling  flowers  gathered  by 
t he  lepers  in  their  gardens,  but  that  other  people  should  not 
eat  food  prepared  by  lepers’  hands. 

Cholera. — Nothing  struck  me  more  about  cholera  than  the 
urgency  necessary  for  its  treatment.  To  get  cases  early  and 
to  treat  them  early  is  to  save  their  lives.  The  cholera  outfit 
should  be  as  ready  and  as  handy  as  the  tracheotomy  box. 
The  copious  hypertonic  saline  intravenous  infusions  and  the 
free  oral  administration  of  permanganate  of  potash  are — as 
discovered  and  so  ablv  advocated  by  Sir  Leonard  Rogers — 
truly  life-saving  procedures.  I was  glad  to  hear  the 
presidential  address  of  Sir  Leonard  Rogers  to  the  Indian 
Science  Congress  at  Bombay  in  January  of  this  year,  when 
he  told  us  that  his  latest  results  showed  a mortality  of  only 
14  9 per  cent. 


Plague. — It  is  aitliculo  to  oelieve  that  this — perhaps  the 
greatest  scourge  of  India — only  last  invaded  the  country  in 
1896.  Besides  the  rat,  a little  squirrel,  known  as  the  tree- 
rat,  almost  universal  in  India,  can  become  infected.  It 
seems  to  me  that  what  is  wanted  in' India  is  not  so  much 
laboratory  research  in  plague  as  sending  out  amongst  the 
people  “ missionaries”  of  their  own  race  and  class  to  teach 
them  what  to  do  to  avoid  plague  and  how  to  act  if  it  occurs. 

Malaria. — Of  the  numerous  malaria  patients  a certain 
proportion  come  under  surgical  attention  for  this  or  that 
reason.  I saw  three  cases  of  musculo-spiral  paralysis 
following  intramuscular  quinine  injections  into  the  upper 
arm  ; in  two  of  these  the  nerve  had  been  freed  from  fibrous 
tissue  and  they  were  recovering.  My  experience  is  that 
aseptic  operations  do  not  set  up  an  attack  of  malaria  in 
patiepts  who  have  parasites  in  their  blood  but  no  active 
symptoms.  The  patients  were  usually  taking  quinine  at  the 
times  cf  the  operations.  I saw  arthritis  attributed  to 
malaria. 

I saw  also  sufferers  from  dysentery,  scurvy,  the  typljpid 
group,  influenza,  and  tuberculosis. 

Dysentery. — I saw  thickened  transverse  colon,  cases  of 
general  tumidity  of  the  abdomen,  arthritis  of  knees  and  of 
ankles,  and  rectal  ulcer  which  had  been  diagnosed  as  cancer. 
With  regard  to  carriers,  my  colleague,  Captain  W.  MacAdam, 
R.A.M.C.,  found  proportionately  more  amongst  the  general 
hospital  population  than  amongst  the  cases  labelled  dysentery. 

Scurvy. — There  were  at  one  time  many  cases  in  Indians, 
and  I am  afraid  the  lime  juice  issued  was  not  always  a 
prophylactic.  A series  of  leg  sores,  many  apparently 
resulting  from  slight  injuries,  yielded  readily  to  anti- 
scorbutic treatment,  Dakin's  fluid  proving  the  best  dressing 
for  the  ulcers.  The  hsematoma  in  the  calf  or  elsewhere 
resulting  from  scurvy  is  puzzling  to  diagnose  if  one  is  not  on 
the  look  out  for  the  disease. 

Typhoid  group. — Amongst  the  complications  I saw 
phlebitis  with  leg  ulcer ; osteitis  of  tibia,  humerus,  and 
metacarpals  ; paralysis  of  deltoid  with  pectoralis  major  ; a 
case  under  Lieutenant-Colonel  T.  S.  Novis,  I.M.S.,  where 
the  muco-pus  from  the  gall-bladder  gave  a pure  cultivation 
of  paratyphoid  A ; another  case,  on  which  I operated,  a 
long-standing  carrier,  in  which  the  gall-bladder  contents 
were  sterile.  I wish  that  the  surgeon  had  been  called  upon 
to  drain  the  gall-bladder  and  the  bacteriologist  to  investi- 
gate its  contents  in  more  of  these  carrier  cases.  A curious 
case  of  bilateral  swellings  in  the  posterior  knee  region 
following  typhoid  showed  nothing  but  muscle  on  incision. 
A B.  coli  infection  of  the  urine  occurred  occasionally  after 
typhoid  ; the  patients  had  puffy,  pasty  faces.  An  autogenous 
vaccine  usually,  but  not  always,  cured. 

Influenza.  — Amongst  the  surgical  complications  I noted 
two  cases  of  suppurative  parotitis,  one  bilateral.  From  the 
pus  of  the  latter  pneumococcus  was  obtained  in  pure  culture. 

Tuberculosis. — There  seemed  an  unusual  incidence  of 
surgical  tuberculosis  of  bones,  joints,  glands,  and  abdomen 
in  Indians  who  had  been  in  France.  Special  institutions  are 
badly  needed  for  the  treatment  of  these  cases. 

Snakes. — Cobras  and  kraits  were  a bete  noir  in  my  hospital 
area,  and  one  walked  about  at  night  with  a lantern.  The 
antivenine  and  other  necessary  equipment  for  treating  snake- 
bite were  always  kept  ready  in  the  emergency  receiving 
room.  Antivenine  is  useless  for  krait- bite.  It  was  interesting 
at  the  Bombay  Bacteriological  Laboratory  to  see  the  snakes 
handled.  They  bit  into  material  stretched  tightly  over  the 
top  of  a wineglass,  the  venom  being  milked  out  of  their 
glands  into  the  glass.  Then  they  were  fed  with  a milk 
preparation  through  a funnel.  The  Russell's  viper  was  the 
fiercest  of  all.  The  man  who  handled  the  snakes  was 
rumoured  to  get  the  munificent  sum  of  10-15  rupees  a 
month  ! 

Ulcers  — Bites  of  mosquitoes  and  other  insects  sometimes 
develop  into  ulcers  which  were  slow  in  healing.  At 
Secunderabad  I saw  a case  of  ulcer  of  the  ankle  which 
had  given  a pure  cultivation  of  a diphtheroid  bacillus,  and  I 
was  told  that  there  had  been  a regular  epidemic  of  similar 
cases  elsewhere. 

Madura  foot. — I saw  one  case  of  this  in  an  Indian.  It  had 
started  three  months  previously  at  Samara,  and  was  attributed 
to  the  kick  of  a mule.  There  was  a large  puffy  swelling 
over  the  inner  ankle  in  which  were  several  sinuses  from 
which  pus  could  be  squeezed  showing  the  characteristic 
yellow  granules. 


The  Lancet,] 


SIR  JOHN  PHILLIPS  : MATERNAL  MORTALITY  IN  CHILD-BED.  [AUGUST  16,  1919  275 


Bilha*ziasis. — This  I saw  successfully  treated  by  Captain 
; T.  B.  Heaton,  R A.M.C.,  with  intravenous  injections  of 
antimony  tartrate. 

Bugs. — These  are  the  plague  of  Indian  barracks  and  most 
difficult  to  get  rid  of.  To  deprive  them  of  their  proper 
nutriment  by  emptying  the  barrack  of  its  human  inhabitants 
is  not  much  good,  as  one  realises  by  recalling  Shipley’s 
Statement  that  a bug  can  live  for  a year  without  nourish- 
ment, although  at  the  end  of  that  time  it  is  so  thin  that 
you  can  read  print  through  it.  We  had  most  success  by 
generating  HCN  and  letting  it  into  the  barrack,  emptied 
except  for  its  furniture  and  bedding.  The  louvred  roofs  of 
the  barracks  are,  however,  difficult  to  seal.  The  HCN 
machines  are  used  by  railway  companies  in  India  for  their 
carriages.  The  smell  of  prussic  acid  wafted  over  the  barracks 
of  a 3000-bedded  hospital  is  most  impressive 

For  bedsteads  total  immersion  in  a special  tank  of  boiling 
water  is,  of  course,  effective.  This  method  I saw  in  use  at 
Secunderabad.  Wooden  bedsteads  and  wooden  mosquito 
poles  are  to  be  avoided  ; the  bugs  get  into  all  the  cracks. 
Apart  from  the  above,  painstaking  cleaning  of  bedsteads  and 
furniture  and  sterilisation  of  bedding  and  clothing  are  the 
best  remedies. 

Conclusion. 

In  conclusion,  let  me  say  how  fresh  and  varied  in  medical 
experience  is  India  to  the  newcomer,  and  I hope  that  these 
random  notes  will  do  something  to  convey  this  interest 
to  others.  I trust  that  the  Medical  Service  of  India, 
remodelled  as  it  should  be.  with  its  manifold  opportunities 
for  interesting  practice  and  its  general  attractiveness,  will 
never  cease  to  command  the  best  trained  members  of  the 
| profession. 

MATERNAL  MORTALITY  IN  CHILD-BED. 

By  Sir  JOHN  PHILLIPS,  M.A.,  M.D.  Cantab.,  F.R.C.P., 

HONORARY  PHYSICIAN  TO  HER  MAJESTY  QUEEN  MARY  ; CON- 
SULTIN&  OBSTETRIC  PHYSICIAN  TO  KING'S  COLLEGE 
HOSPITAL  ; AND  EMERITUS  PROFESSOR  OF  OBSTETRICS 
IN  KING'S  COLLEGE. 


Can  material  mortality  in  childbirth  be  further  reduced  ? 

At  the  present  time,  when  most  medical  men  interested  in 
obstetrics  are  studying  eugenics  and  antenatal  pathology,  it 
behoves  one  to  produce  all  possible  evidence  in  the  hope  of 
arriving  at  improved  results  and  diminished  maternal  mor- 
tality. I have  thought  it  might  be  of  interest,  and  possibly 
helpful,  to  give  an  abstract  of  35  years  of  midwifery  in 
private  practice.  No  record  of  a large  number  of  cases  under 
these  circumstances  has  recently  been  published,  and  a com- 
parison between  the  results  obtained  in  private  practice  and 
in  public  institutions  may  lead  to  useful  conclusions.  I have 
looked  up  the  notes  of  all  the  cases  of  pregnancy  and  labour 
for  which  I have  been  personally  responsible  during  35  years 
and  1 find  that  in  round  numbers  the  to^al  is  2100.  I met, 
unfortunately,  with  seven  maternal  deaths,  of  which  I give 
abstract  notes  below,  taken  from  full  records  made  at  the 
time. 

Reduction  of  Septic  Mortality  and  Morbidity  in  Special 
Hospitals. 

The  great  risk  of  labour  in  the  “seventies. ’’and  previously, 
was  puerperal  fever.  The  records  of  special  hospitals  and 
lying-in  wards  at  that  time  make  dismal  reading,  for  they 
speak  only  of  repeated  outbursts  of  what  is  now  known  as 
Btreptococcic  infection  and  the  usual  heavy  toll  of  deaths, 
with  consequent  closing  down  of  the  wards. 

The  introduction  of  antiseptics  in  the  late  “seventies” 
gradually  changed  all  this,  and  although  the  first  attempts 
at  grappling  with  the  germ  were  not  very  successful,  still, 
by  continued  effort,  such  an  improvement  resulted  that  for 
some  years  now  streptococcic  infection  may  be  said  to  have 
been  practically  banished  from  lying-in  hospitals  and  the 
obstetric  wards  of  general  hospitals',  although  occasional 
outbursts  are  from  time  to  time  reported  in  outlying  districts. 

As  an  obstetric  clerk  I remember  officiating  at  several 
labours  under  the  carbolic  spray  ; nothing  could  be  more 
disagreeable  for  patient  and  attendant,  and  the  absorption 
of  the  carbolic  acid  occasionally  produced  carboluria  and 
pneumonia.  Anyone  interested  in  the  subject  has  only  to 
refer  to  the  late  Dr.  Robert  Boxall’s  interesting  and 


exhaustive  paper  on  “ Fever  in  Child-bed,”1  read  before  the 
Obstetrical  Society,  in  which  he  showed  from  the  statistics 
of  tile  General  Lying-in  Hospital  how  by  gradual  experi- 
ments in  various  antiseptics,  beginning  with  permanganate 
of  potash,  followed  by  carbolic  acid,  and,  lastly,  by  mercury, 
septic  mortality  and  morbidity  was  steadily  reduced. 

During  the  last  few  yiars  asepsis  has  somewhat  replaced 
antisepsis  ; by  that  I mean  sterilised  dressings  and  gloves 
being  used  in  place  of  strong  antiseptic  solutions.  I must 
confess,  however,  that  I know  of  nothing  .safer  than  the  spirit 
solution  of  1 in  1000  bydrarg.  biniodide. 

Care  of  Mother  in  Pregnancy  and  Puerpe.rium. 

Although  streptococcic  infection  may  be  said  to  be  a pre- 
ventable accident,  another  formidable  infection  exists  in 
Bacterium  coli , the  ravages  of  which  are  nob  yet  fully 
grasped.  The  frequently  depreciated  health  in  pregnancy, 
especially  among  the  poorer  and  ill-fed  classes,  is  a fertile 
cause  of  this  bacillus  over-riding  its  natural  barriers  and 
infecting  outside  organs,  especially  the  bladder,  liver,  and 
kidneys.  In  a recent  paper  I have  endeavoured  to  show  that 
very  grave  and  even  fatal  results  may  occur  from  infection 
of  the  bile  ducts  by  this  organism.2  The  gonococcus,  it  need 
hardly  be  stated,  is  a formidable  complication  of  the 
pregnant  condition  and  may  lead  to  a permanent  disablement 
from  infection  of  the  tubes. 

Pregnahcy  and  labour  are  still  looked  upon  by  a large 
number  of  the  laity  as  perfectly  normal  processes,  but  my 
experience,  and  I think  that  of  hundreds  of  others,  is  that 
with  our  present  conditions  of  life  such  is  not  the  case. 

I have  always  advocated  the  regular  pelvic  examinatioh 
of  women  during  the  whole  of  pregnancy  and  the  puerperiura, 
in  addition  to  a careful  pathological  examination  of  the 
excreta.  When  a patient  misses  a period  and  presumes 
herself  pregnant  a pelvic  examination  will  reveal  the 
possible  presence  of  an  ovarian  dermoid  cyst  or  uterine 
fibroid  or  other  pathological  condition  which  could  be  satis- 
factorily treated  at  the  time.  Examination  at  intervals 
should  show  a steady  increase  in  the  size  of  the  uterus  and 
an  absence  of  any  pathological  products  from  the  urine  or 
faeces.  • Pelvic  measurements  are  of  gfeat  importance,  and 
should  there  be  the  slightest  suspicion  of  diminution  or  dis- 
proportion in  any  of  the  diameters  of  the  pelvis  the  patient 
should  be  examined  at  fortnightly  intervals,  from  the 
thirtieth  week  onward  to  term.  Any  deposit  in  the  mine 
not  clearing  up  by  boiling  should  aroufe  a strong  suspicion 
of  bacillnria,  and  the  practitioner  should  riot  be  content  with 
an  ordinary  tCst-tuhe  examination. 

It  has  also  been  my  custom  during  the  lying-in  period  to 
measure  the  level  of  the  uterus  daily  tor  the  first  week,  and 
to  examine  the  pelvis  internally  at  the  end  of  a fortnight, 
and  again  at  the  end  of  three  weeks,  when  the  patient  rises 
from  her  bed  ; subinvolution  and  retroversion  of  the  uterus 
and  unhealed  lacerations  are  in  this  way  detected. 

Abstract  of  Fatal  Cases. 

I now  append  a short  abstract  of  each  of  the  seven  fatal 
cases. 

Acute  Peritonitis. 

Case  1. — Aged  35,  a 5-para,  all  at  term.  Pains  began  a 
month  prematurely,  vertex  presentation,  the  labour  lasted 
nine  hours  and  delivery  was  natural  and  easy,  a male  being 
born  alive.  At  the  last  labour,  two  years  before,  she  had  au 
acute  attack  of  pain  in  the  right  iliac  fossa,  with  tempera- 
ture ; this  subsided  and  she  remained  quite  well  until  a few 
days  before  the  onset  of  the  present  labour  ; she  then  had 
several  severe  attacks  of  pain  in  the  right  iliac  fossa,  with 
temperature  ; labour  came  on  prematurely  during  one  of 
these  attacks  and  continued  after  the  labour.  The  patient 
died  of  acute  peritonitis  after  36  hours’  illness  ; she  was  very 
weak  and  ill  during  the  labour,  with  a rapid  pulse  and  a hot, 
dry  skin.  A post-mortem  was  obtained,  which  showed 
general  peritonitis  over  the  lower  abdomen,  its  focus  being 
a gangrenous  appendix  lying  in  a cavity  of  putrid  pus,  the 
size  of  an  orange. 

It  must  be  noted  that  this  case  occurred  in  1883,  at  which 
period  the  pathology  and  treatment  by  operation  of  disease 
of  the  appendix  was  not  sufficiently  recognised  ; had  I seen 
this  case  at  the  present  time  no  doubt  the  proper  course 
would  have  been  to  open  the  abdomen  before  labour  com- 
menced, and  a satisfactory  issue  might  have  resulted. 


1 Obstetrical  Transactions  of  London,  1889,  xxxii..  215,  275. 

2 Hepatic  Toxaemia,  Royal  Society  of  Medicine,  Obstetrical  and 
Gynaecological  Section,  1916,  115. 


276  The  Lanoet,]  SIR  JOHN  PHILLIPS  : MATERNAL  MORTALITY  IN  CHILD-BED. 


[August  16,  1919 


I have  contributed  a short  paper  on  this  subject  entitled 
“Acute  Peritonitis  (without  Discovered  Cause)  Complicating 
Pregnancy  and  Labour.”  3 

In  this  is  related  the  case  of  a woman,  nearly  seven  months 
pregnant  and  in  good  health,  who  fell  over  a chair-back  on 
her  left  side.  Much  pain  and  persistent  vomiting  followed. 
She  was  found  in  a very  serious  condition,  her  abdomen  dis- 
tended, pulse  120,  temperature  103°  F.,  and  respirations  48. 
Though  no  proper  pains  could  be  distinguished,  labour 
came  on  and  terminated  very  quickly.  Her  condition  became 
rapidly  worse,  her  abdomen  was  opened  and  general  peri- 
tonitis found,  but  no  apparent  cause.  Free  drainage  was 
carried  out,  but  the  patient  died  in  the  course  of  a few 
hours. 

Cases  of  a similar  nature  described  by  Simpson  and  Gow 
are  too  sparse  in  their  details  to  draw  any  satisfactory 
conclusion  from. 

“ Russian  ” Influenza. 


This  is  quite  a characteristic  case  of  concealed  accidental 
haemorrhage.  The  cardiac  complication  was  most  un- 
fortunate. I treated  her  on  the  lines  generally  laid  down 
in  my  article  on  “ Pregnancy  and  Cardiac  Disease.  ” 4 It  is 
difficult  to  decide  to  what  exactly  to  ascribe  the  patient’s 
death.  In  two  similar  cases  of  concealed  accidental 
hfemorrhage  which  I have  encountered,  a larger  amount  of 
blood  was  lost  without  producing  more  than  an  ordinary 
amount  of  temporary  shock,  and  in  both  cases  the  child  was 
alive,  though  in  each  case  resuscitation  was  difficult.  She 
had  been  warned  against  pregnancy  by  more  than  one 
authority  on  heart  disease,  so  that  apparently  the  extra 
strain  of  pregnancy  and  then  the  haemorrhage  were  sufficient 
to  produce  what  must  be  termed  “shock.”  Quite  possibly 
had  the  drug  pituitrin  been  in  existence  it  might  have  done 
something  towards  saving  her  life.  If  the  cardiac  condition 
had  been  more  sound,  I think  Caesarean  section  would  have 


I believe  this  to  have  been  one  of  the  earliest  cases  of  what 
was  then  called  “ Russian  ” influenza.  I was  attacked  with 
the  same  malady  within  24-  hours. 

Case  2.— Aged  27,  seven  children.  When  8*  months 
pregnant  she  was  seized  with  a sharp  rigor  and  all  the 
symptoms  of  the  disease  we  now  call  epidemic  influenza. 
Bronchial  catarrh  rapidly  ensued,  with  distressing  dyspnoea 
and  blueness  of  the  face.  There  was  a large  amount  of 
liquor  amnii  present,  and,  as  the  cervix  was  thin  and  soft 
and  admitted  three  fingers,  in  order  to  relieve  her  distress 
the  membranes  were  punctured.  Temporary  relief  to  the 
dyspnoea  was  given,  labour  came  on  rapidly,  and  a living 
child  was  born,  followed  by  a short  amelioration  of  the 
symptoms,  but  the  bronchial  affection  rapidly  increased  and 
she  died  in  great  dyspnoea  within  24  hours  of  the  labour 
starting. 

This  case  fully  bears  out  the  experience  of  the  epidemic  of 
1918,  where  advanced  pregnancy  complicated  by  this  disease 
was  in  a large  proportion  of  cases  fatal  in  a few  days  from 
septic  pneumonia,  no  remedy  appearing  to  have  any  power 
to  check  its  progress. 

Hcemorrhage. 

Case  3. — The  patient,  a 2-para,  whom  I had  attended 
three  years  before  with  a somewhat  difficult  labour,  was 
again  38  weeks  pregnant.  She  was  then  in  the  country,  and 
without  any  warning  she  was  seized  with  severe  haemorrhage. 
As  soon  as  she  had  sufficiently  recovered  from  this  she  was 
driven  up  to  London,  and,  unfortunately,  during  the  journey 
she  passed  over  a level  railway  crossing  at  somewhat  high 
speed.  She  was  badly  jolted,  and  a return  of  the  haemor- 
rhage took  place  before  reaching  her  journey’s  end.  When 
I reached  her  I found  her  almost  pulseless,  with  the  cervix 
two-thirds  dilated  and  the  edge  of  the  placenta  presenting 
posteriorly.  I therefore  ruptured  the  membranes  und 
proceeded  to  endeavour  to  restore  her  by  venesection  and 
saline  injections.  She  did  not  respond  very  well  to  this 
treatment.  In  the  meantime  the  haemorrhage  all  ceased, 
labour  pains  came  on,  and  the  head  descended  into  the  pelvis. 
Immediately  on  full  dilatation  of  the  cervix  1 applied  the 
forceps  without  an  anaesthetic  and  lifted  the  child  out  quite 
easily;  it  was  stillborn.  For  an  hour  she  tended  to  improve 
under  the  action  of  the  usual  restoratives,  but  after  that  she 
rapidly  sank  without  any  further  haemorrhage. 

Had  I seen  this  case  during  the  first  haemorrhage  the 
obvious  treatment  would  have  been  a Caesarean  section,  but 
her  condition  after  the  second  haemorrhage  was  so  grave  that 
no  possible  attempt  at  operation  could  be  made. 

Conoealed  Accidental  Hcemorrhage. 

Case  4.— This  patient,  a 2-para,  was  at  full  term  and  was 
suffering  from  cardiac  trouble,  namely,  pericarditis  with 
aortic  stenosis.  She  remained  fairly  well  until  the  day  of  the 
labour.  1 had  previously  ascertained  that  the  presentation 
was  a vertex  and  the  pelvic  condition  normal.  Her  pulse, 
however,  was  small  and  quick,  much  accelerated  by  any 
exertion;  there  was  no  albumin  or  swelling  of  the'  feet. 
She  was  suddenly  seized  with  abdominal  pain  while  at 
lunch  on  the  day  of  her  labour.  On  seeing  her  about  an 
hour  afterwards  I found  her  in  a collapsed  condition,  the 
uterus  being  hard  and  tender.  Labour  pains  were  slight, 
but  the  cervix  was  slowly  dilating.  All  attention  was 
therefore  directed  to  her  general  condition,  oxygen  was 
given  to  inhale,  salines  were  injected  with  strychnine  and 
musk  subcutaneously,  but  none  of  these  remedies  appeared 
to  produce  any  improvement  in  her  pulse.  When  the 
os  uteri  was  fully  dilated  I applied  the  forceps  and  delivered 
easily  without  an  anaesthetic ; the  child  was  stillborn. 
Immediately  on  delivery  two  measured  pints  of  recent  blood 
clot  escaped.  She  slowly  sank,  and  died  in  about  au  hour. 

3  Obstetrical  Transactions  of  London,  xli.,  389. 


been  indicated.  ..  Hepatic  Toxcemia." 

Case  5. — This  case  is  described  under  “ Hepatic  Toxaemia  ” 
(Case  l)5.  The  patient  was  a primigravida,  with  well- 
marked  pelvic  contraction,  for  which  induction  of  labour 
was  carried  out.  For  some  weeks  before  labour  sickness  and 
prostration  had  been  observed.  Labour  was  quite  easy  and 
delivery  natural,  and  there  was  no  apparent  reason  for  the 
child’s  stillbirth.  The  progress  of  the  case  immediately 
after  labour  was  most  unsatisfactory,  the  vomiting  continued 
and  shortly  afterwards  contained  altered  blood.  Jaundice 
supervened  and  the  patient  died  in  48  hours,  with  a tem- 
perature of  110°.  A post  mortem  was  obtained  and  a differ- 
ence of  opinion  occurred  as  to  the  exact  cause  of  death,  one 
of  the  pathologists  considering  it  a case  of  acute  yellow 
atrophy  of  the  liver,  and  another,  hepatic  toxaemia. 

Assuming  that  this  was  a case  of  acute  yellow  atrophy  of 
the  liver,  it  is  the  only  one  of  the  kind  that  I have  ever 
encountered.  1 believe  that  such  cases  are  uniformly, 
rapidly,  and  progressively  fatal,  no  remedy  having,  so  far, 
been  discovered. 


Pregnancy  following  Abdominal  Uterine  Fixation. 

Case  6. — This  patient,  a 6-para,  had  not  been  pregnant 
for  seven  years.  She  had  had  uterine  fixation  for  prolapsus, 
which  had  improved  her  health  very  much.  I did  not  see 
her  until  the  thirty-eighth  week,  when  a very  serious  condi- 
tion of  things  was  present.  The  foetus  was  lying  transversely 
in  the  abdomen  in  a bi-lobed  swelling,  the  narrow  portion 
of  which  was  produced  by  adhesions  from  the  old  operation. 
The  head  lay  in  one  dilatation,  the  buttocks  in  another.  At 
a consultation  the  question  of  Caesarean  section  or  immediate 
induction  was  discussed,  and  the  latter  decided  on.  The 
labour  proceeded  quite  quietly  until  dilatation  of  the  cervix 
was  sufficient  to  bring  down  a leg.  I carefully  turned  and 
was  surprised  how  easily  it  was  brought  about.  Labour 
terminated  rapidly,  a living  child  being  born  ; the  placenta 
was  expressed  in  the  ordinary  course  and  the  patient 
appeared  quite  well  for  an  hour.  She  then  became  faint, 
and,  although  there  was  no  hemorrhage  and  I had  explored 
the  uterine  cavity  to  eliminate  any  question  of  rupture  of 
the  uterus,  she  died  in  spite  of  all  attempts  to  restore  her. 

It  appeared  that  on  two  other  occasions  at  her  labours 
she  had  nearly  succumbed  from  heart  failure  without  any 
apparent  reason,  and  it  is  quite  probable  that  the  stretching 
of  the  adhesions  between  the  uterus  and  the  abdominal  wall 
during  labour  produced  reflex  inhibition  of  the  cardiac 
apparatus.  This  case  was  an  instance  of  the  risk  that 
attends  pregnancy  following  an  abdominal  uterine  fixation. 
In  the  old  operation  the  sutures  were  passed  through  the 
fundus  uteri,  which  prevented  dilatation  as  the  pregnancy 
advanced.  In  the  more  modern  operation  the  sutures  are 
passed  low  down,  thus  allowing  dilatation  of  the  fundus 
without  producing  either  a miscarriage  or  difficulty  at  labour. 


Secondary  Post-partum  Hcemorrhage. 

Case  7. — This  patient,  a primigravida,  was  at  full  term. 
The  labour  was  a long  and  lingering  one  owing  to  slow 
dilatation  of  the  cervix  and  an  occipito-posterior  presenta- 
tion. The  cervix  was  finally  manually  dilated,  the  bead  was 
rotated  with  the  forceps,  and  delivery  carried  out.  No  com-  I 
plications  followed,  the  placenta  being  easily  expressed,  and 
no  haemorrhage  occurred.  Forty-eight  hours  after  labour  s 
her  child  had  a slight  convulsion,  and  an  unwise  relative  | 
walked  hurriedly  into  the  room  and  told  her  of  it.  I had 
seen  both  mother  and  child  about  two  hours  before  and  both  J 
were  doing  well.  Almost  immediately  on  receiving  the  news 
she  had  a violent  secondary  post-partum  hsemorrnage  and 


4 Practitioner,  JuDe,  1895,  "The  Management  of  the  Pregnant, 
Parturient  and  Lying-in  Woman  Suffering  from  Cardiac  Disease." 

5 Eoyal  Society  of  Medicine,  Obstetrical  and  Gynaecological  Section, 

1916,  p.  115. 


ThbLanokt,]  DR.  J.  H.  E.  BROCK:  CONDUCT  OF  LABOUR  AND  PUERPERAL  SEPSIS.  [August  16,  1919  27  7 


died  within  an  hour,  despite  uterine  plugging  and  the  usual 
restoratives.  I might  add,  however,  that  she  was  one  of  the 
most  nervous  and  apprehensive  patients  I have  ever  attended. 

Statistical  Data. 

The  question  to  consider  is,  Can  the  present  percentage  of 
maternal  mortality  in  child-bed  be  further  reduced  ? This 
mortality  may  vary  very  much  according  to  whether  the 
labour  takes  place  in  a special  ward,  in  private  practice,  or 
in  outdoor  maternity  practice. 

For  instance,  in  1916,  in  the  outdoor  department  of  the 
Ladies  Lying-in  Charity,  Liverpool,  1086  cases  were  attended 
by  midwives,  with  2 deaths  (0T8  per  cent.). 

At  the  General  Lying-in  Hospital  in  1917,  870  cases  were 
attended,  with  5 deaths  (0’5  per  cent.),  and  in  1918,  914  cases, 
with  6 deaths  (0  6 per  cent.). 

My  own  experience  in  special  practice  amounts  to  2100 
cases,  with  7 deaths  (0  3 per  cent.).  At  a home  for  officers’ 
wives,  where  labours  are  carried  out  under  the  best  possible 
conditions  and  where  all  the  patients  are  examined  and 
reported  on  beforehand  by  myself,  240  were  attended  in 
20  months,  with  1 death  (0  4 per  cent.).  This  death  occurred 
a few  daysaftera  normal  labour  owing  to  a severe  abdominal 
operation  for  old-standing  intestinal  obstruction,  a condition 
which  had  arisen  independently  of  the  pregnancy. 

The  mortality  of  every  variety  of  practice  thus  varies  from 
0T8  per  cent,  to  0 6 per  cent.  These  divergencies  of  results 
may  be  accounted  for  in  many  ways.  At  a lying-in  hospital 
all  the  serious  cases  are  admitted,  some  of  them  in  a state  of 
acute  sepsis,  others  moribund  from  delay  in  delivery  ; and, 

I think,  the  statistics  of  the  General  Lying-in  Hospital  may 
be  considered  a very  fair  indication  of  the  results  obtained  in 
the  class  of  cases  admitted  to  such  an  institution.  There  is 
also  the  element  of  what  can  be  called  “chance” — for 
instance,  my  first  two  cases  occurred  in  a short  run  of  40 
labours ; then  followed  an  unbroken  series  of  636  cases 
without  a death. 

In  private  practice  the  patients  are  generally  well-to-do, 
in  healthy  surroundings,  and  under  the  care  of  the  family 
doctor.  This  class  should  be  more  likely  to  produce  a low 
percentage  of  mortality  than  a lying-in  hospital,  where  the 
patients  have  often  been  ill- fed,  have  lived  in  filthy  surround- 
ings, and  may  be  admitted  in  an  already  infected  condition. 

Prospect  of  Reduced  Mortality. 

In  studying  the  cases  of  death  in  my  practice  we  have  to 
consider  whether  any  different  treatment  would  possibly  have 
saved  any  of  the  seven  cases.  The  chief  advance  resulting 
from  the  antiseptic  system  is,  no  doubt,  the  perfection  of 
Caesarean  section.  This  operation  is  now  applied  with  the 
greatest  success  in  a much  extended  class  of  case,  more 
especially  in  placenta  praevia  occurring  in  primigravidse  and 
in  selected  cases  in  multipart,  in  concealed  accidental 
haemorrhage,  and  in  most  cases  of  puerperal  convulsions  in 
first  labours.  Thus  it  is  quite  possible  that  Cases  3 and  4 
might  have  been  saved  by  a prompt  Caesarean  section.  Case  1, 
under  modern  treatment,,  would  also  in  all  probability  have 
been  saved.  Were  I to  meet  a case  similar  to  No.  6 again  I 
should  be  inclined  strongly  to  advise  Caesarean  section  in 
place  of  induction.  If  Case  5 was  acute  yellow  atrophy, 
then  it  was  practically  hopeless  from  the  onset  of  the  disease, 
as  I know  of  no  case  of  recovery  under  those  conditions. 
Finally,  the  last  case,  No.  7,  was  one  of  those  accidents  out- 
side the  control  of  the  medical  practitioner,  but  it  serves  as 
a warning  to  those  who 'think  that  excitement  is  not  harmful 
to  the  lying-in  woman.  Although  Caesarean  section  can  be 
properly  applied  more  extensively,  I feel  that  the  tendency 
is  for  the  pendulum  to  swing  in  a somewhat  extreme 
direction,  and  that  in  many  cases  of  slight  pelvic  contrac- 
tion, in  which  Caesarean  section  is  resorted  to,  an  equally 
good  result  might  be  obtained  by  induction  of  labour. 

From  these  statistics  it  is  clear  that  maternal  mortality  in 
child-bed  is  certainly  in  process  of  being  reduced,  and  the 
question  now  is  whether  we  have  at  our  disposal  any  means 
to  reduce  this  mortality  further. 

Another  important  complication  of  pregnancy — namely, 
what  iscdled  “ pregnancy  kidney” — may,  I trust,  ultimately 
be  treated  successfully  when  the  physiological  chemist  has 
discovered  its  cause.  Vaccine  treatment  may  also  be 
expected  to  be  much  in  evidence,  especially  against  toxins 
and  Bacterium  ooli. 

With  regard  to  the  use  of  scopolamine  morphine  (twilight 
sleep),  my  own  experience  is  that,  although  in  some  cases 
it  acts  like  a charm,  its  results  are  not  sufficiently  reliable, 
and  it  certainly  is  not  free  from  risk  to  both  mother  and  child. 


THE  CONDUCT  OF  LABOUR  AND 
PUERPERAL  SEPSIS. 

By  J.  H.  E.  BROCK,  M.D.,  B.S.  Lond.,  D.P.H., 
F.R.O.S.  Eng., 

LATE  HONORARY  PHYSICIAN  TO  THE  WESTMINSTER  GENERAL  DISPENSARY 

From  that  large  majority  of  general  practitioners  who 
accept  midwifery  as  part  of  their  usual  work,  the  dread  of 
puerperal  sepsis  is  never  absent.  When  looking  back  nearly 
40  years  one  contrasts  the  methods  of  that  day  with  the 
present  technique  the  enormous  improvement  is  borne  in 
upon  one.  To  gauge  results  by  hard  figures  is  to  admit, 
however,  the  comparatively  small  reduction  in  the  mortality 
rate  from  puerperal  sepsis.  Indeed,  the  returns  for  the  last 
70  years  prove  that,  for  some  of  the  earlier  years,  the  death- 
rate  was  almost  identical  with  some  quite  recent  ones.  Dr. 
Victor  Bonney,1  in  his  admirable  address  on  the  Continued 
High  Maternal  Mortality  of  Childbearing,  the  Reason  and 
the  Remedy,  deplores  that,  while  in  every  other  domain  of 
surgery  death  from  sepsis  has  almost  been  abolished,  in 
midwifery  it  has  hardly  diminished. 

Some  points  bearing  on  the  question  have  not,  in  my 
opinion,  been  sufficiently  brought  into  the  light  of  day,  or 
made  to  bear  the  responsibility  rightly  belonging  to  them. 
I believe  the  reason  for  the  high  death-rate  from  puerperal 
sepsis  resides  in  these  facts  ; and  not  until  their  proper 
importance  in  the  conduct  of  labour  is  accorded  to  them 
can  we  hope  to  attain  asepsis. 

A Vindication  of  Nature. 

I take  it  that  Dr.  Bonney  is  inclined  to  attribute  a part 
of  the  blame  to  a faulty  surgical  technique  on  the  part  of 
doctors  and  midwives,  and  partly  to  the  difficulty  of 
sterilising  the  “area  of  operation,”  owing  to  the  position  of 
the  vagina.  He  considers  this  to  have  been  a blunder  of 
Fature.  If  so,  she  has  persisted  in  repeating  it  in  a very 
wilful  way  almost  throughout  the  mammalia.  And,  as  if  to 
emphasise  her  cynical  disregard  for  the  end  of  the  genital 
canal,  she  has  gone  out  of  her  way  further  to  outrage 
surgical  propriety  by  causing  the  sexually  mature  woman  to 
produce  an  abundant  growth  of  coarse  hair  almost  com- 
pletely encircling  the  vulva,  and  practically  incapable  of 
sterilisation.  Now,  the  first  duty  of  Nature  is  to  preserve  the 
race,  and  to  do  so  she  would  scarcely  be  furthering  her  ends 
by  introducing  two  death-traps  in  close  proximity  to  the 
vagina. 

I have  no  doubt  that,  in  determining  the  plan  of  the 
human  body,  Nature  thought  of  healthy  bodies  ; a physio- 
logical process  for  delivery  ; and  the  practice  of  sexual  inter- 
course merely  for  the  propagation  of  the  species,  and  not  as  a 
pastime.  As  a determining  factor  in  sepsis  at  the  time  of 
labour,  provided  there  has  been  no  interference  and  no 
examination  on  the  part  of  the  medical  man  or  midwife,  I am 
of  opinion  that  the  “ external  ” area  of  operation — viz.,  vulva 
and  perineum — plays  an  insignificant  part.  For  some 
excellent  observations  on  this  point  I would  refer  readers  to 
Dr.  Routh’s  remarks  at  the  reading  of  Dr.  Bonney 's  paper.2 

I do  not  wish  it  to  be  understood  that  I minimise  the 
importance  of  sterilising  this  area  as  far  as  possible.  But  I 
believe  that  the  real  danger  zone  begins  inside  the  vulva  and 
increases  in  danger  the  nearer  we  approach  the  placental 
site.  If  the  presenting  part  could  reach  the  perineum 
through  a sterile  canal  I do  not  think  the  external  area  of 
operation  would  be  a serious  menace  to  the  patient.  It  is 
precisely  on  this  external  area  that  most  of  the  surgical  care 
has  been  lavished  with  such  disappointing  results  ; while  the 
sterility  or  otherwise  of  the  far  more  dangerous  zone  from 
within  the  vulva  to  the  placental  site — the  real  operation  area 
— has  been  passed  over  in  silence  and  that  area  assumed  to 
be  surgically  clean.  I am  of  opinion  that  the  reason  why 
there  is  such  a large  amount  of  sepsis  still  rampant  in 
parturition  is  that  the  woman  begins  her  labour  with  the  vaginal 
canal , and  sometimes  the  uterine  canal , surgically  nnolean. 
Some  Personal  Reminiscences. 

Before  I adduce  the  reasons  which  lead  me  to  hold  this 
view  and  put  forward  the  well-known  clinical  fact  that 
proves  it  conclusively,  I will  recall  the  conditions  under 


1 The  Lancet.  1919,  i.,  775. 

2 The  Lancet.  1919,  i.,  796. 

G 2 


278  Thb  Lanoht,]  DR.  J.  H.  E.  BROCK : CONDUCT  OF  LABOUR  AND  PUERPERAL  SEPSIS.  [August  16,  1919 


which  midwifery  was  practised  when  I was  a student,  so  as 
to  show  that,  in  spite  of  the  uncleanliness  of  the  patients 
and  the  appalling  conditions  under  which  the  majority  of 
them  lived,  our  results,  though  not  quite  so  good  as  at  the 
present  day,  were  not  so  many  points  behind.  It  will  help 
to  show  that,  in  spite  of  the  vast  improvements  in  housing 
and  external  cleanliness  of  the  patient,  and  the  scrupulous 
care  that  the  doctor  now  takes  to  make  himself  and  keep 
himself  surgically  clean  during  the  conduct  of  labour,  we 
have  not  succeeded  in  abolishing  sepsis,  but  only  in  reducing 
it  moderately.  Such  improvements  apparently  do  not  give 
the  complete  key  to  the  conquest  of  puerperal  sepsis. 

Just  36  years  ago  I attended  my  first  case  of  labour,  in  a 
mews  off  Gower-street.  Students  carried  a midwifery  bag, 
and  in  it  were  about  half  a dozen  bottles,  containing  ergot, 
opium,  chloral,  sp.  am.  aromat.,  pure  liquid  carbolic  acid, 
and  perchloride  of  iron.  A pot  of  carbolised  vaseline,  a 
Higginson’s  syringe,  a perineum  needle,  and  silver  wire  com- 
pleted the  equipment.  Our  district  included  some  of  the 
worst  slums  in  London,  and  only  those  who  lived  and 
worked  in  them  at  that  time  can  form  any  idea  of  what  they 
were  like. 

The  patient  was  prepared  for 'the  labour  by  having  her 
clothes  removed  above  the  waist  and  her  nightdress  slipped 
on  and  tied  up  below  the  arms.  Below  the  waist  she  very  often 
retained  her  dress  and  petticoat.  The  bedspread  consisted 
of  an  old  blanket  folded  on  brown  paper,  and  the  baby  was 
usually  wrapped  in  a petticoat  when  it  arrived.  Before 
examining  the  patient  we  removed  our  coats,  washed  our 
hands,  and  then  rinsed  them  in  1 in  40  carbolic.  The  finger 
was  anointed  either  with  carbolised  vaseline  or  with  carbolic 
oil.  The  perineum  and  vulva  were  never  cleansed  before 
examination.  The  patient,  as  a rule,  perambulated  the 
room  until  the  head  came  on  to  the  perineum.  Dress  and 
petticoat  were  then  loosened  from  the  waist,  and  she  got  on 
to  the  bed.  The  dress  and  petticoat  were  drawn  out 
of  the  way  and  the  delivery  took  place.  After  the  placenta 
had  been  expressed  the  nurse  washed  up  the  patient,  and 
the  soiled  garments  were  pulled  off.  Those  were  the  days  of 
douches  ; and  usually  an  antiseptic  douche  was  given  before 
we  left.  As  a rule,  the  patient  had  douches  for  the  first  few 
days  after  labour. 

A Puzzling  Result. 

Worse  conditions  for  the  patient  can  hardly  be  imagined  ; 
and  the  medical  attendant  was  certainly  neither  aseptic  nor 
rigorously  antiseptic  in  his  methods.  In  spite  of  this,  no 
case  of  puerperal  septicsemia  occurred  amongst  the  cases  of 
the  six  men  “ on  the  list  ” for  the  month  ; nor  did  any  case 
occur  during  my  tenure  of  office  as  obstetric  assistant.  Of 
what  we  used  to  call  saprsemia  we  had  an  abundance.  The 
majority  got  well  with  vaginal  douches,  while  a few  required 
intra-uterine  irrigation.  Of  deaths  from  puerperal  sepsis, 
I am  certain  there  were  none,  either  while  I was  on  the 
student  midwifery  list,  or  when  I was  in  charge  of  the 
extern  midwifery  department.  Of  ophthalmia,  we  had 
plenty  of  examples  ; for  we  did  not,  at  that  time,  wash  out 
the  eyes  immediately  after  birth  nor  instil  anything  into 
them. 

This  is  a puzzling  result,  if  puerperal  sepsis  is  invariably 
carried  to  the  patient  either  by  doctor  or  midwife,  through 
carelessness  in  asepsis  or  antisepsis,  or  contracted  through 
an  uncleanly  environment.  These  women  ought  to  have 
died  like  flies,  but  they  did  not  1 They  all  made  excellent 
recoveries.  Far  be  it  from  me  to  underrate  the  urgent 
importance  of  surgical  cleanliness  for  the  successful  conduct 
of  labour  and  the  safety  of  the  patient.  I only  wish  to 
throw  up  into  relief  the  fact  that  it  is  precisely  these  condi- 
tions which  have  undergone  such  steady  and  vast  improve- 
ment during  the  last  30  years  with  such  disappointing  results. 
They  quite  patently  do  not  give  the  complete  answer  to  the 
question  that  we  are  trying  to  solve  ; and  we  must  therefore 
look  around  for  some  other  clue.  Dr.  Bonney  himself  refers 
to  the  disappointment  of  the  high  hopes  that  were  raised 
upon  the  introduction  of  trained  midwives  into  obstetric 
practice.  Some  slight  reduction  of  the  mortality  rate  from 
sepsis  followed  ; but  once  more  the  old  experience  reasserted 
itself,  and  the  decline  has  not  continued. 

Condition  of  Maternal  Passages. 

Why  has  it  come  to  a standstill  ? Why  does  sepsis 
continue  to  claim  its  yearly  toll  of  victims  amongst 
parturient  women  ? The  reason,  I believe,  is  that  the 


maternal  passage — the  “internal  area  of  operation” — 
nearly  always  contains  the  germs  of  sepsis  within  itself,  at 
the  time  of  labour.  The  route  along  which  the  foetus  will 
have  to  travel,  before  it  reaches  the  world,  is  practically 
never  sterile. 

On  what  do  I base  this  assumption  ? Simply  on  the 
notorious  clinical  fact  of  the  prevalence  of  ophthalmia  and 
conjunctivitis  among  children,  within  the  first  week  of  birth. 

We  have  succeeded  to  a large  extent  in  suppressing  the 
evidence  of  the  existence  of  the  infection  by  immediately 
washing  out  the  baby’s  eyes  with  an  antiseptic  ; but  that 
does  not  alter  the  fact  that  the  infection  is  there  all  the  same 
in  the  maternal  passage,  and  would  have  claimed  its  victim 
if  we  had  not  promptly  intervened  and  destroyed  it.  Only 
let  the  nurse  be  careless  in  performing  this  duty  and  we 
shall  not  long  be  left  in  doubt  about  the  reality  of  its 
existence. 

Some  dissentient  may  say : ‘ ‘ What  proof  is  there  that 
this  also  is  not  an  extraneous  infection  carried  into  the 
mother  ? ” The  proof  consists  in  the  fact  that  it  may,  and 
does,  occur  when  there  has  been  no  interference  in  labour  ; 
and  also,  that  the  organism  which  produces  the  most  virulent 
type  of  infection  is  the  gonococcus.  Most  medical  men 
would  repudiate  the  suggestion  that  they  possessed  such  a 
frequent  and  intimate  association  with  this  unpleasant 
invader  as  this  hypothesis  demands. 

Now,  what  are  the  organisms  that  produce  puerperal 
sepsis  ? They  are  varieties  of  streptococci,  staphylococci, 
gonococci,  and,  as  Dr.  Bonney  claims,  also  Bacillus  coli. 

What  organisms  cause  ophthalmia  ? We  know  that  the 
most  virulent  infection  is  due  to  the  gonococcus,  in  which 
the  conjunctival  sacs  become  converted  into  bags  of  pus  and 
sight  is  imperilled,  unless  the  infection  is  promptly  and 
vigorously  dealt  with.  But  not  all  cases  of  conjunctival 
infection  after  birth  are  due  to  this  destructive  organism. 
Everybody  knows  that  there  are  all  gradations  of  con- 
junctival inflammation  after  birth,  varying  from  slight 
redness  of  the  conjunctiva  or  inflammation  with  a minute 
drop  of  pus  at  the  inner  canthus  occasionally  during  the  day  ; 
or  congestion,  with  thin  muco-purulent  discharge  from  the 
lids  ; or  cases  with  a very  small  amount  of  discharge  that 
dries  on  the  ciliary  margins  and  forms  a powdery  deposit. 
These  cases  are  not  ophthalmia  neonatorum,  but  they  are 
evidences  of  conjunctival  infection  by  organisms  in  the 
vagina.  Streptococci,  staphylococci,  and  Bacillus  coli  may 
all  produce  conjunctivitis. 

II ore  the  Infection  is  Carried. 

Now,  supposing  that  all  these  organisms  do  cause  con- 
junctival infection  of  varying  degree — and  they  most 
certainly  can — what  evidence  is  there  that  they  are  present 
in  the  vagina  before  labour  ? The  evidence  only  requires 
that  I shall  produce  proof  either  that  they  can  be  carried 
into  the  vagina  by  someone  already  infected,  and  acting  as  a 
carrier,  or  that  they  are  transported  either  by  the  penis 
itself  or  from  the  area  immediately  adjacent  to  the  vulva 
as  it  enters  the  genital  canal  for  intercourse. 

Of  all  venereal  diseases  gonorrhoea  is  the  most  prevalent, 
and  it  is  one  that  in  the  majority  of  cases  is  incompletely 
cured.  It  is  often  associated  with  a secondary  streptococcal 
infection  ; and  it  is  now  known  that  these  organisms  may 
persist  for  very  long  periods,  either  in'the  urethra  or  in  the 
prostate  or  vesicular,  long  after  all  external  evidence  of  the 
disease  has  ceased  and  the  patient  believes  himself  cured. 
He  is  not  well,  and  may  infect  his  wife  and  child  with  the 
organisms  of  which  he  is  a carrier.  I do  not  know  what 
proportion  of  the  male  population,  at  some  period  or  other  of 
their  lives,  suffer  from  gonorrhoea ; but,  judging  from 
medical  histories  gleaned  in  the  course  of  ordinary  clinical 
examinations,  it  must  be  pretty  heavy. 

The  transportation  of  streptococci,  staphylococci,  and 
Bacillus  coli  into  the  vagina  is  very  easy.  The  skin  of  the 
penis  and  that  of  the  vulva  and  female  perineum  are 
probably  the  most  heavily  infected  cutaneous  surfaces  in  the 
body.  The  penis  is  grasped  with  unwashed  arid  soiled 
hands,  and  must  receive  many  and  various  organisms, 
including  streptococci,  staphylococci,  and  B.  coli.  The 
organ  is  within  trousers  of  varying  age,  which  in  most  men 
have  a flora  of  their  own.  When  we  turn  to  the  lady 
conditions  are  present  for  supplying  the  organisms,  as  the 
average  vulva  and  perineum  must  be  suitable  culture 
beds. 


Thb  Lancet,]  DR.  J.  H.  E.  BROOK  : CONDUCT  OF  LABOUR  AND  PUERPERAL  SEPSIS.  [AUGUST  16,  1919  279 


Should  any  be  still  doubtful  as  to  the  possibility  of 
Baoillus  ooli  and  streptococci  being  introduced  into  the 
vagina  from  without  they  will  do  well  to  ponder  also  the 
question  of  their  invasion  of  the  vagina  from  within  the 
body.  With  intestinal  stasis  and  oral  sepsis  of  common 
occurrence  amongst  women,  the  invasion  of  the  bowel  wall 
by  these  organisms  is  frequent,  whence  excursions  to  other 
and  various  parts  of  the  body  result.  We  know  that  both 
these  organisms  attack  the  kidney  and  bladder  from  the 
bowel,  whence  they  are  excreted  in  the  urine  and  pass 
through  the  meatus  urinarius.  Once  at  the  meatus,  are  they 
not  within  the  portals  of  the  vagina?  What  these  organisms 
can  accomplish  via  the  urine  they  can  also  probably 
accomplish  by  direct  attack  on  uterus  and  vagina  in  condi- 
tions of  intestinal  sepsis.  In  fact,  I think  the  day  may 
come  when  some  portion  of  the  cases  of  puerperal  septicaemia 
may  be  traced  either  to  intestinal  stasis  or  oral  sepsis. 

Evidence  of  Sepsis  of  the  Vagina. 

There  is  no  gainsaying  the  fact  that  sexual  intercourse  is 
practised  by  most  people  without  the  smallest  attention  to 
the  cleanliness  of  the  organs  concerned.  It  is  quite  clear 
that  in  this  way  organisms  must  be  introduced  into  the 
vagina,  and  as  Bacillus  eoli,  streptococci,  and  staphylococci 
abound  in  the  organs  they  must  be  introduced  into  the  vagina 
during  intercourse.  Add  to  this  the  frequency  of  latent 
gonorrhoeal  and  streptococcal  infection  of  the  male  urethra, 
and  the  evidence  of  sepsis  of  the  vagina  becomes  complete. 

All  this  would  be  bad  enough  if  it  only  occurred  once 
during  gestation.  From  inquiries  made  I am  positive  that 
the  nauseous  habit  of  sexual  intercourse  during  pregnancy  is 
the  rule  and  not  the  exception,  and  that  it  is  continued  some- 
times far  on  in  gestation — at  times,  in  fact,  as  long  as 
mechanical  conditions  will  allow.  What  would  any  surgeon 
say  if  he  were  asked  to  operate  in  an  area  that  received  the 
amount  of  soiling  that  is  but  the  too  common  fate  of  the 
vagina  ? Yet  this  is  what  falls  to  the  lot  of  the  medical 
attendant  at  a confinement  1 I contend  that,  with  our 
present  methods  of  conducting  labour,  it  is  small  wonder 
that  disaster  sometimes  follows.  The  marvel  is  that  accidents 
are  not  more  frequent. 

Some  years  ago  I had  a very  conclusive  proof  of  the 
capability  of  the  uncleansed,  but  otherwise  healthy,  penis  of 
causing  puerperal  sepsis.  I attended  a patient  who  had  a 
perfectly  normal  labour.  Until  the  morning  of  the  eighth 
day  recovery  was  uneventful  and  the  temperature  normal. 
On  that  day  I was  surprised  to  find  the  temperature  between 
100°  and  101°.  The  vagina  was  washed  out ; on  the  ninth 
day  the  temperature  was  normal.  On  the  tenth  day  it  had 
again  risen,  and  again  the  vagina  was  washed  out.  The 
temperature  came  down  to  normal,  and  remained  so  for  two 
days,  when  it  rose  again.  I was  completely  at  a loss  for  an 
explanation  of  these  fitful  rises  of  temperature  coming  on 
after  a period  when  the  risk  of  puerperal  sepsis  was  usually 
at  an  end.  While  debating  these  facts  in  my  mind  in  the 
patient’s  bedroom  I became  aware  that  I was  looking  fixedly 
at  a second  pillow  in  line  with  her  own.  Without  more  ado 
I asked  her  if  her  husband  had  been  occupying  her  bed  since 
the  end  of  the  first  week.  I extorted  a confession  not  only 
of  that  fact,  but  also  that  sexual  intercourse  had  taken  place 
on  the  nights  preceding  the  morning  rise  of  temperature.  I 
had  my  little  say  and  with  it  the  trouble  vanished. 

The  Conduct  of  Labour. 

The  problem,  therefore,  that  the  medical  attendant  has  to 
solve  is  to  deliver  the  child  through  a septic  maternal  passage, 
with  a vulva  and  perineum  also  heavily  infected.  A portion 
of  the  problem  has  been  already  solved  and  has  resulted  in 
wiping  off  some  part  of  the  death-rate  from  sepsis,  but  part 
remains  to  answer  still. 

Concerning  the  surgical  preparation  of  patient  and 
attendant  Dr.  Bonney  has  dealt  completely.  One  point  as 
regards  the  toilet  of  the  patient  might  be  added — that  the 
vulva  should  be  shaved  as  for  any  other  surgical  operation. 
No  doubt  it  would  be  a good  deal  opposed  by  patients,  but 
I think  it  very  important,  in  view  of  the  impossibility  of 
sterilising  hair  and  the  great  danger  of  introducing  septic 
organisms  into  the  vagina,  should  interference  be  imperative. 
Should  interference  not  be  necessary  this  could  be  dispensed 
with. 

What  should  be  our  attitude  towards  the  vagina  during 
the  conduct  of  labour  ? Most  certainly  by  every  possible 
means  we  should  avoid  the  necessity  for  internal  examina- 


tions. I’arturition  is  a physiological  process,  and  in  quite 
95  per  cent,  of  cases  the  patient  is  capable  of  delivering 
herself.  No  doubt  when  Nature  placed  the  vagina  in  front 
of  the  anus  and  surrounded  the  vulva  with  hair  she  hoped  that 
this  fact  would  be  recognised,  and  that  no  unnecessary  inter- 
ference with  the  genital  passage  would  become  the  fashion 
during  the  performance  of  this  physiological  act.  Labour  is  a 
reflex  act,  and  can  be  successfully  conducted,  not  only 
without  medical  assistance,  but  also  independently  of  the 
volition  of  the  patient.  Several  cases  are  on  record  where 
pregnant  women  with  complete  transverse  lesions  of  the 
cord  have  successfully  accomplished  it.  Dr.  Amand  Routh 
reported  such  a case  some  years  ago,  and  quite  recently  Dr. 
Drummond  Robinson  reported  another. 

Avoidance  of  Internal  Examinations. 

It  is  well  known  that  women  who  have  delivered  them- 
selves before  the  arrival  of  the  medical  attendant  very 
rarely  come  to  any  harm.  This  was  in  my  mind  when 
making  the  assertion  above  that — provided  there  had  been 
no  interference — the  perineum  and  vulva  play  but  a small 
part  in  the  causation  of  sepsis.  The  rule  in  the  conduct  of 
labour  ought  to  be  to  avoid  interfering  with  the  genital 
passage  wherever  possible.  It  matters  not  whether  the 
perineum  and  vulva  be  made  as  far  as  possible  aseptic,  and 
the  medical  attendant’s  technique  be  also  rigorously  aseptic, 
if  he  is  going  to  conduct  the  labour  by  frequent  examina- 
tions carried  up  as  far  as  the  cervix,  through  a vagina  which, 
in  the  majority  of  cases,  is  contaminated  with  a variety  of 
organisms.  The  perfectly  aseptic  gloved  finger,  if  the  vagina 
is  septic,  is  capable  of  carrying  up  organisms  from  its  walls, 
and  smearing  them  on  the  inside  of  the  cervix,  and  thus 
bringing  them  within  reach  of  the  most  dangerous  zone  of 
the  operation  area — the  placental  site.  If  my  contention  is 
correct  that  conjunctival  infection  of  the  child  is  proof  of 
sepsis  of  the  maternal  passage,  then  it  becomes  evident  that 
to  introduce  even  an  aseptic  finger  into  the  vagina  and  carry 
it  up  to  the  inside  of  the  cervix  is  fraught  with  considerable 
risk  and  should  only  be  done  if  unavoidable. 

The  anxiety  in  the  minds  of  medical  men  as  to  the  state  of 
the  os  is  deep-rooted  and  genuine  ; and  no  wonder,  since 
from  hospital  days  they  have  always  been  exhorted  to  pay 
attention  to  it,  and  examine  its  size,  consistence,  dilatability, 
&c. , when  called  to  a case  of  labour.  I have  known  this 
anxiety  spread  even  to  a patient,  who  informed  me  on 
entering  the  room  that  I should  find  “the  hoss  riggid”! 
After  looking  at  the  anus  and  perineum,  I was  able  to  assure 
her  that  this  time  the  “ ’oss  was  a’doin’  ’is  best,”  and  she 
need  not  worry.  I know  nothing  of  the  routine  now  followed 
by  lying-in  hospitals  during  the  course  of  labour ; but  I 
suspect  that  no  inconsiderable  part  of  their  success  in 
reducing  sepsis  is  due,  not  merely  to  rigorous  asepsis  of 
patient  and  attendant,  but  also  to  the  avoidance  of  internal 
examinations. 

As  far  back  as  1885,  when  I was  a resident  student  at  the 
Rotunda  Hospital,  Dublin,  no  patient  was  allowed  to  be 
examined  more  than  once  during  the  course  of  labour  ; and 
then  only  after  thorough  preparation  of  hands  and  forearms 
with  soap  and  water  and  nailbrush,  followed  by  soaking  the 
hands  in  perchloride  of  mercury  solution  for  three  minutes. 
I have  no  doubt  our  patients  on  the  midwifery  list,  when  we 
were  students,  escaped  septicaemia  because  they  usually 
summoned  us  late  in  the  course  of  labour,  when  the  head  or 
presenting  part  was  in  the  middle  or  lower  part  of  the  cavity 
of  the  pelvis  and  fairly  through  the  os  ; when  danger  of 
inoculating  the  cervix  by  examination  was  over  ; or, 
frequently,  the  child  was  born  before  our  arrival.  It  was 
also  the  time  of  douches ; and  usually  the  vagina  was 
washed  out  after  labour. 

Nature's  Method  of  Sterilising  the  Vagina. 

I have  tried  to  show  the  undesirability  of  vaginal 
examinations  during  labour,  on  account  of  the  undeniable 
fact  of  sepsis  in  the  maternal  passage  : as  evidenced  by 
conjunctival  infection  in  the  newly-born  child.  It  can  be 
shown  also  that,  in  making  such  examinations,  we  are 
reversing  and  largely  annulling  the  methods  that  nature 
brings  into  play  to  sterilise  the  vagina  and  wash  out  intruding 
organisms. 

One  of  the  earliest  changes  in  the  uterus,  on  conception, 
is  cedema  of  the  cervix,  which  steadily  progresses  throughout 
gestation.  I do  not  think  this  phenomenon  is  the  result  of 
pressure,  because  it  starts  almost  with  impregnation.  What- 


280  THE  Lancet,]  MR.  M.  FITZMAURIGE-KELLY  : KINEPLA8TIO  AMPUTATIONS. 


[August  16,  1919 


ever  its  cause,  my  opinion  is  that  it  subserves  a purpose  over 
and  above  that  of  increasing  the  dilatability  of  the  cervix. 
With  the  progress  of  the  presenting  part  the  cervix  becomes 
gradually  dilated  and  subjected  to  an  increasing  pressure. 
As  a result  vessels  are  ruptured,  and  tears  small  or  large 
occur.  The  torn  vessels  are  sealed,  and  from  them  exudes 
a copious  flow  of  serum  mixed  with  extravasated  blood.  The 
purpose  of  this  serous  exudation  is,  doubtless,  physiological, 
and  it  is  in  all  probability  bactericidal,  resembling  the  flow 
of  lymph  after  wounds  in  other  parts.  Its  role  is  probably 
partly  to  cleanse  the  vagina  and  partly  bactericidal  to 
retained  organisms.  It  is  tempting  to  suggest  that,  when 
impregnation  occurs,  there  is  a local  retention  of  salt  in  the 
tissues  of  the  cervix,  which  attracts  fluid  to  itself  and  stores 
up  a lymphagogue,  to  be  put  to  practical  use  during  labour. 

While  all  this  is  a physiological  process  and  wholly 
beneficial  to  the  patient,  it  becomes  far  otherwise  if  vaginal 
examinations  are  made  the  rule  in  labour.  Instead  of  a pro- 
tection, it  may  be  a menace  to  life.  Granting  that  the 
vagina  must,  in  most  cases,  be  a canal  harbouring  noxious 
organisms  at  the  time  of  labour,  the  danger  of  introducing  a 
finger  and  carrying  it  up  to  a wounded  cervix  is  apparent. 
If  the  finger  is  also  introduced  inside  the  cervix  and  swept 
round  between  the  bag  of  membranes  and  the  uterine  wall, 
we  may  be  simply  implanting  colonies  of  organisms  on  the 
uterine  wall,  and  with  nothing  between  them  and  the  uterine 
sinuses.  Now,  the  organisms  which  we  have  shown  reason 
to  believe  most  likely  to  gain  entrance  to  the  vaginal  canal 
are  gonococci,  streptococci,  staphylococci,  and  Bacillus  ooli. 
Of  these  four  the  one  with  the  power  of  causing  a specific 
effect  is  the  gonococcus  ; but  it  shares  with  the  others  the 
ability  of  producing  non-specific  inflammations  in  other  parts 
of  the  body.  All  of  them  may  enter  the  blood  stream,  and, 
by  causing  bacteriascnia,  set  up  inflammatory  foci  in  various 
tissues.  How  careful,  then,  ought  we  to  be  to  avoid  bringing 
them  into  contact  with  wounded  surfaces.  Of  all  possible 
channels  for  the  entry  of  organisms  vascular  lymphatics  are 
easily  the  first. 

Some  Guiding  Rules. 

If  the  facts  that  I have  endeavoured  to  make  plain  are 
true,  what  should  be  our  method  in  the  conduct  of  a case  of 
pregnancy  and  labour  1 In  my  opinion  it  should  be  as 
follows  : — 

1.  The  patient  should  have  a general  physical  examination, 
and  the  state  of  her  health  should  be  accurately  gauged. 

2.  At  the  time  of  examination  the  urine  should  be 
examined,  and  the  examination  should  be  repeated  at 
intervals  of  two  months. 

3.  The  external  diameters  and  circumference  of  the 
pelvis  should  be  taken  ; also  indications  of  marked  lateral 
curvature,  old  angular  curvature,  and  past  rickets  should 
be  looked  for. 

4.  A careful  abdominal  examination  should  be  made 
between  the  seventh  and  eighth  months,  or  later  if  the  pelvic 
measurements  are  normal,  to  ascertain  the  position  of  uterus 
and  contained  foetus.  By  training  this  method  yields 
accurate  results,  and  the  presentation  can  be  determined 
with  practical  certainty.  The  position  of  the  foetal  heart 
sounds  in  this  connexion  is  of  great  importance  and  should 
be  always  noted. 

5.  If  the  patient  is  a multipara  the  history  of  previous 
confinements  should  be  obtained. 

Armed  with  this  knowledge  it  will  be  possible  to  conduct 
the  vast  majority  of  labour  cases  without  vaginal  examination. 

Up  to  the  present  it  has  been  too  much  the  fashion  to 
recognise  only  external  sources  of  infection  and  the  methods 
by  which  they  may  gain  entrance  to  the  maternal  passages 
during  labour.  The  equally  important  fact  that  vaginal 
sepsis  is  already  present  when  labour  starts,  as  proved  by 
conjunctival  infection  in  the  newly-born  child,  has  been 
waived  as  absurd  and  this  important  clinical  fact  not 
rated  at  its  proper  significance  and  gravity.  A few  will 
grudgingly  admit  that  on  rare  occasions  autoinfection  may 
occur.  Not  on  rare  occasions,  I submit,  but  on  every 
occasion,  should  the  possibility  be  held  in  mind,  and  a 
septic  canal  be  as  seldom  interfered  with  as  the  safety  of  the 
patient  will  allow. 


Dr.  William  Ewart  Gye  announces  that  he  has 
formally  relinquished  the  surname  of  Bullock  and  assumed 
the  name  of  Gye.  His  address  remains  as  in  the  Medical 
Register,  1919. 


KINEPLASTIC  AMPUTATIONS. 

By  M.  FITZMAURICE-KELLY,  F.R.C.S.  Eng., 

ACTING  MAJOB,  B.A.M.C. 


The  object  of  this  paper,  which  is  a preliminary  com- 
munication, is  to  present  briefly  the  methods  employed, 
and  the  results  obtained,  in  a series  of  kineplastic 
amputations  recently  performed  at  the  Pavilion  Hospital, 
Brighton.  The  subject  has,  so  far  as  I am  aware,  found 
a very  small  place  hitherto  in  British— or  French — 
surgical  literature  and  practice  ; but  the  pitiable  plight  of 
men  who  have  lost  an  arm  seems  to  call  for  a very  thorough 
trial  of  any  method  which  holds  out  the  hope  of  better 
things,  while  the  results  so  far  obtained  justify  the  expecta- 
tion that  the  method  may  be  found  of  great  value. 


Selected  Cases. 

The  cases  selected  for  trial  were,  in  the  first  instance, 
those  with  amputation  stumps  which  were  unsuitable  for  the 
fitting  of  an  artificial  limb  ; short  forearm  stumps — two  to 
three  inches  below  the  elbow,  measured  from  the  tip  of  the 
olecranon  process — or  stumps  a little  longer,  with  partial  and 
incurable  limitation  of  movement  in  the  elbow-joint.  Later, 
in  longer  forearm  stumps,  tunnelisation  of  the  muscles  was 
tried,  and  finally  amputations  through  the  elbow-  and  wrist- 
joints  were  operated  upon  by  a method  arising  out  of 
previous  experience.  It  is  not  my  present  intention  to  lay 
down  definite  indications  for  kineplastic  amputation ; I 
think  it  may  fairly  be  claimed  that  the  cases  so  far  selected 
had  nothing  to  lose  by  the  operation  and  much  to  gain  in  the 
event  of  success.  And  there  now  seems  ground  for  hope 
that  the  advantages  will  be  great  enough  to  justify  the 
sacrifice  in  length  in  stumps  hitherto  rated  as  useful. 

Literature. 


In  starting  this  series,  which  at  the  time  of  writing 
includes  13  cases  operated  on  in  the  last  eight  weeks,  I found 
considerable  difficulty  in  getting  much  light  and  leading  from 
the  literature  at  my  command.  By  far  the  most  valuable 
paper  was  Vanghetti’s1  on  General  Principles;  Pellegrini’s1 
contribution  contained  useful  suggestions  on  the  technique 
of  tunnelisation,  while  critical  abstracts  from  German 
surgical  literature  in  the  Medical  Supplements  issued  by  the 
Medical  Research  Committee  gave  valuable  hints,  chiefly  on 
methods  which  it  seemed  desirable  to  avoid.  For  the  rest— 
and  I imagine  it  will  be  the  case  with  most  surgeons — I had 
to  devise  my  own  technique  and  modify  it  as  the  particular 
cases  demanded. 

Plastic  Motors  : Technique. 

The  forms  of  plastic  motors  attempted  have  been  two : 
club-shaped  motors,  built  up  of  muscles  with  their  bony 
insertion,  or  an  adventitious  bony  attachment,  and  loop 
motors,  made  by  constructing  a canal  or  tunnel  lined  with 
skin  and  surrounded  with  muscle  or  tendons.  Of  the  13 
cases  operated  on,  in  4 club-shaped  motors  alone  have  been 
made  (two  each  in  3 cases  and  three  in  the  fourth)  ; in  3 
cases  skin  tunnels  only  have  been  constructed  (one  in  each 
case),  while  in  the  remaining  6 cases,  two  club-shaped  motors 
and  one  tunnel  have  been  made  in  each  case.  In  describing 
the  technique,  it  will  be  simplest  to  deal  first  with  the 
tunnelisation  method,  and  then  to  give  the  various  methods 
used  to  make  the  club  motors. 


Loop  motors.— In  making  the  skin  canals,  the  double- 
pedicle method  suggested  by  Pellegrini  has,  in  the  main, 
been  followed.  The  length  of  the  canal  required  will  vary 
according  as  muscle  or  tendon  is  to  be  used  for  the  loop  ; but 
there  is  an  advantage  in  makiDg  it  short  and  wide,  as  the 
blood-  and  nerve-supply  is  better,  and  the  tendency  to 
excoriation  less.  Two  incisions  are  made  of  the  length 
required,  parallel  with  one  another,  and  2 inches  apart.  From 
the  ends  of  each  cut  oblique  diverging  incisions  are  made  in 
a proximal  direction.  The  lower  end  of  the  area  so  marked  ont 
is  dissected  up,  with  the  subcutaneous  tissue  down  to  the  deep 
fascia,  and  the  upper  edge  is  freed  until  the  skin  can  be  rolled 
up  to  form  a canal  by  union  of  the  edges  of  the  two  original 
incisions.  These  edges  are  then  united  with  a subcuticular 
suture  of  fine  silkworm  gut  and  reinforced  with  a few  points 
of  catgut  in  the  subcutaneous  tissue.  The  subcuticular 
suture  gives  accurate  apposition  and  is  easily  removed. 

Gainer  thns  formed,  the  deep  fascia  is  opened 


i Archive,  Medicales  Beiges.  June,  1918,  p.  653. 
- Ibid.,  p.  675. 


The  Lanoet,] 


MR.  M.  FITZM  AURIC  E-KELLY  : KINE PLASTIC  AMPUTATIONS.  [August  16,  1919  281 


above  and  below,  the  muscle  or  tendons  whioh  it  is  pro- 
posed to  place  superficial  to  it  selected,  brought  over,  and 
sutured  to  the  deeper  parts  on  the  distal  side  of  the  canal. 
It  is  important  that  both  the  superficial  and  deep  tendons  or 
muscles  should  be  liberated  from  attachments  or  adhesions 
below  and  the  canal  itself  freed  from  attachment  to  the 
deep  fascia,  in  order  to  obtain  the  greatest  possible  freedom 
of  movement  and  the  widest  excursion.  The  motor  so 
formed  is  then  covered  in  by  a plastic  operation,  gliding 
flaps  from  above  and  below,  and  a piece  of  gauze  packing 
passed  through  the  canal. 

Club  motors. — The  making  of  the  club  motors  is  more 
difficult,  and  can  perhaps  be  most  easily  described  as  done 
at  the  elbow,  where  powerful  muscles  with  their  bony 
insertions  are  available.  In  a typical  case,  where  it  is 
intended  to  use  the  triceps  and  the  brachialis  anticus,  the 
operation  is  best  performed  from  behind  forwards,  as  this 
mode  of  access  keeps  the  structures  it  is  intended  to  preserve 
out  of  harm’s  way  until  the  latest  possible  moment.  A 
tourniquet  is  applied,  and  a posterior  flap  is  first  marked 
out  with  its  base  equal  to  half  the  diameter  of  the  limb 
opposite  the  condyles,  and  including  all  the  available 
skin  on  the  back  of  the  stump.  The  incisions  will 
probably  need  to  be  prolonged  upwards  at  a later  stage. 
This  flap  is  dissected  back  to  the  base  of  the  olecranon 
process ; the  latter  is  sawn  through  and  the  joint  so 
opened  from  behind.  The  lateral  attachments  of  the 
olecranon  are  severed,  the  posterior  capsule  divided,  and 
the  triceps  dissected  up  from  the  back  of  the  humerus  to  a 
distance  of  about  3|  inches  above  the  condyles.  The 
skin  covering  the  superficial  aspect  of  the  muscle  is 
left  undisturbed.  The  muscle  and  its  attachment,  thus 
Isolated,  are  wrapped  in  gauze.  The  coronoid  process  is 
•then  detached  by  a saw-cut  carried  downwards  and  forwards 
from  the  interior  of  the  joint,  and  the  brachialis  anticus 
carefully  isolated  from  the  structures  on  either  side.  The 
biceps  tendon,  if  it  has  not  already  been  utilised  to  build 
another  motor,  is  then  divided,  and  the  remaining  structures 
— supinator  longus  and  the  muscles  arising  from  the 
■condyles — dissected  away,  all.the  skin  on  the  anterior  surface 
of  the  stump  being  preserved.  The  brachialis  anticus  is 
then  separated  from  the  humerus  to  the  same  level  as  the 
triceps  and  the  humerus  then  sawn  across.  The  tourniquet 
is  removed,  all  bleeding  vessels  tied,  and  all  nerves 
shortened.  The  biceps,  if  available,  is  stitched  to  the 
'brachialis  anticus,  and  the  two  motors  thus  formed  are 
clothed  with  skin.  In  doing  this  two  points  need  careful 
attention  : one  is  to  place  the  skin  stitches  very  accurately 
around  the  neck  of  the  motor,  where  pressure  will 
ultimately  be  taken,  and  the  other  is  to  fix  the  bony 
insertion  firmly  to  the  skin  to  prevent  retraction.  The 
■best  method  of  doing  this  is  by  an  anchor  stitch  of  stout 
silkworm  gut,  which  transfixes  the  tendon  close  to  its  inser- 
tion and  the  connective  tissue  on  either  side  of  the  bone; 
the  two  ends  issue  through  the  skin  close  to  the  apex  of  the 
motor,  about  three-quarters  of  an  inch  apart,  and  are  tied  on 
a piece  of  drainage-tube  threaded  on  to  one  end.  These 
■should  not  be  tied  tightly  and  should  be  retained,  if  possible, 
for  10  or  12  days. 

A certain  amount  of  oozing  is  inevitable  from  the  large 
wound  involved  in  this  operation  ; the  method  of  drainage 
employed  is  by  strands  of  silkworm  gut.  About  six  strands 
-are  knotted  together,  and  three  or  four  of  these  are  passed 
in  various  directions,  one  from  base  to  apex  of  each  motor. 
These  are  removed  after  48  hours,  and  the  wound  is  not 
dressed  again  until  the  tenth  day,  when  the  stitches  are 
removed.  yy(tf  Tno  Methods  Combined. 

The  methods  above  described — tunnelisation  and  club 
motors — have  been  combined  in  six  of  my  cases. 

First,  a skin  tunnel  was  made  in  front  of  the  arm,  just 
above  the  bend  of  the  elbow.  The  biceps  tendon  was  split 
after  being  divided  low  in  the  wound,  and  the  superficial 
half  brought  in  front  of  the  tunnel  and  sutured  to  the  deep 
part.  Then  motors  of  the  club  type  were  made  of  the 
triceps  and  brachialis  anticus,  the  plastic  operation  to  cover 
thfe  canal  being  left  to  the  end,  when  it  was  made  easy  by 
taking  up  the  slack  skin  from  the  end  of  the  stump.  The 
■object  is  to  use  the  biceps  as  a supinator  of  the  artificial 
hand,  but  none  of  the  cases  are  sufficiently  advanced  yet  for 
a definite  opinion  to  be  expressed  as  to  whether  the  motor 
will  develop  sufficient  power  or  independence  of  action  to  be 
effective,  and  in  my  most  recent  case  I made  a third  club 
motor  by  turning  up  a U-shaped  flap  from  the  front  of  the 
elbow,  detaching  the  tubercle  of  the  radius  and  shortening 
the  biceps  tendon  by  folding  it  in  a Z upon  itself. 

Another  Modification  in  Technique. 

Yet  another  modification  in  the  technique,  which  seems 
full  of  promise  and  of  very  wide  application. 

In  two  cases,  amputations  through  the  elbow- and  wrist- 
joints  respectively,  the  adventitious  adhesions  of  the 
muscles  were  used  to  make  club  motors.  In  the  first,  pieces 
of  the  lower  end  of  the  humerus,  with  the  cut  ends  of  the 


brachialis  anticus  and  triceps  still  adherent  to  them,  were 
ohiselled  off  the  anterior  and  posterior  surfaces  of  the  end  of 
the  bone;  the  muscles  were  then  dissected  up  as  before, 
and  the  shaft  sawn  through  at  a higher  level.  In  the  latter, 
pieces  of  the  lower  end  of  the  radius  were  similarly  pre- 
served with  the  flexors  and  extensors  of  the  fingers  attached, 
and  the  overlying  skin  undisturbed.  Both  healed  well  and 
show  movement,  but  are  not  yet  sound  enough  to  take  a 
load. 

Review  of  the  Methods  Adopted. 

Reviewing  the  cases,  as  far  as  I have  gone,  I am  not 
favourably  impressed  with  the  possibilities  of  the  skin 
tunnels.  Others  who  have  used  the  method— notably 
Sauerbruch,  Driiner,  and  other  German  surgeons,  using  a 
technique  similar  to  Rochet’s  urethroplasty — have  had 
trouble  from  excoriation  of  the  canals,  and  though  this 
risk  is  diminished  by  making  short  wide  tunnels  with  a good 
blood-  and  nerve-supply,  it  still  exists.  More  important  is 
their  limited  range  and  limited  power,  as  compared  with  the 
club  motors,  and  I am  inclined  to  doubt  whether  they  will 
take  a permanent  place  in  kineplastic  surgery. 

On  the  other  hand,  there  seems  good  reason  to  hope  much 
from  the  club  motors,  especially  when  multiple,  and  in- 
cluding a pair  of  antagonistic  action.  The  motor  being 
wholly  exteriorised,  the  covering  remains  healthy  and  able  to 
bear  pressure,  and  about  the  power  developed  there  is, 
happily,  no  doubt.  That  is,  after  all,  as  one  would  have 
guessed,  as  the  preservation  of  the  bony  insertion  of  a muscle 
means  the  concentration  of  the  force  it  exerts  in  one  available 
point.  And,  as  far  as  I have  tested  them,  they  bear  pressure 
well,  even  within  a few  weeks  of  the  operation.  One  of  my 
early  cases  is  now  on  a temporary  training  apparatus  made 
out  of  a Thomas  arm-splint,  working  the  muscles  against 
an  elastic  resistance,  and,  tested  with  a steelyard  inserted 
in  place  of  the  indiarubber  tubing,  he  registered  15  lb.  with 
one  motor  and  21  lb.  with  the  other  at  the  first  attempt. 
The  arm  still  appears  quite  wasted,  and  is,  I.  am  sure, 
capable  of  much  greater  development.  And  several  of 
the  later  cases  are  much  more  promising — the  motors  have 
been  made  longer,  and  I propose,  in  one  or  two  of  the  early 
cases,  to  remove  an  inch  more  of  the  humerus  to  increase 
the  range  of  the  motors. 

The  apparatus  used  to  attach  the  motors  is  a metal  collar 
with  hinge  and  screw  adjustment,  similar  to  Putti’s.  They 
are  made  for  me  in  the  temporary  limb  department  of  the 
Pavilion  Hospital,  and  coated  with  vulcanite  by  a dental 
mechanic.  I have  found  that  it  is  best  that  they  should 
not  fit  accurately,  as  if  they  do  marked  congestion  of  the 
motor  is  caused,  and  I am  now  having  them  made  circular 
for  motors  which  are  oval  in  section,  and  vice  versa.  The 
motor  then  keeps  its  colour  perfectly,  and  the  patient  is 
more  comfortable. 

All  the  cases  in  the  present  series  are  arm  amputations, 
but  though  the  much  more  satisfactory  prostheses  available 
make  the  problem  less  urgent  in  the  lower  limb,  I think 
there  are  certain  cases  in  which  it  is  worth  while.  I refer 
to  the  group  of  short  and  unsatisfactory  stumps  below  the 
knee.  Some  of  these,  owing  to  deficient  movement,  cannot 
be  fitted  with  a limb ; others  with  very  short  stumps,  after 
trying  a kneeling  leg  and  finding  it  unsatisfactory,  return 
for  re-amputation  above  the  knee.  In  some  of  these  cases, 
which  I now  have  under  my  care,  I propose  to  build 
motors  of  the  quadriceps  and  hamstrings,  so  as  to  give  the 
patient  voluntary  control  of  the  knee-joint.  It  should  be 
easier  to  do,  and  easier  to  fit,  than  the  operations  in  the 
region  of  the  elbow. 

I regret,  and  apologise  for,  the  incomplete  state  in  which 
this  work  is  presented,  but  judging  from  the  difficulty  in 
coming  at  any  records  in  English  surgical  literature,  the 
number  of  cases  on  which  these  observations  are  based 
constitutes  an  exceptional  experience.  And  already  I feel 
very  strongly  that  the  club-motor  method — and  especially 
its  extension  by  the  use  of  adventitious  bony  attachments 
— is  that  which  holds  out  hope  for  the  future,  and  it  is  in 
the  hope  that  English  surgeons  will  give  the  method  a more 
extended  trial  that  I present  my  conclusions  in  their  p esent 
form.  I hope,  later  in  the  year,  to  bring  forward  a more 
complete  record,  and  to  show  cases. 

I have  to  acknowledge  my  deep  indebtedness  to  Mr. 
Muirhead  Little,  on  whose  representations  this  work  was 
undertaken,  and  whose  advice  and  help  in  the  selection  of 
cases,  and  in  unearthing  literature,  have  been  invaluable. 
Also,  to  my  colleagues  at  the  Pavilion  Hospital,  Brighton, 
for  much  encouragement  and  help. 


282  Thb  Lancet,]  DR.  W.  E.  GALLIE  : LENGTHENING  OF  AMPUTATION  STUMPS. 


[August  16,  1919 


OBSERVATIONS  ON 

LENGTHENING  OF  AMPUTATION  STUMPS. 

By  W.  E.  GALLIE,  M.B.,  F.R.C  S., 

MAJOR,  CANADIAN  ARMY  MEDICAL  CORPS. 

Amputations  in  which  the  femur  is  sectioned  less  than 
three  inches  below  the  lesser  trochanter  are  most  unsatis- 
factory for  fitting  with  artificial  legs.  The  various  sugges- 
tions made  for  overcoming  the  difficulties  have  not  been  very 
successful.  As  far  as  I know,  no  surgeon  has  hitherto 
attempted  to  lengthen  the  stump.  The  following  case  shows 
that  such  a procedure  is  possible. 

Account  of  Case. 

Pte.  B.  was  admitted  to  the  Granville  Canadian  Special 
Hospital,  Buxton,  on  April  15th,  1918,  with  amputation  of 
thigh  at  about  junction  of  upper  and  middle  thirds.  The 
amputation  had  been  performed  with  equal  anterior  and 
posterior  flaps;  wound  had  healed,  except  in  centre,  where  a 
discharging  sinus  led  to  dead  bone.  On  May  3rd,  1918, 
operation  for  the  osteomyelitis ; the  terminal  inch  of  the 
femur  was  necrotic  and  had  to  be  removed,  thus  the  bone 
extended  only  two  and  a quarter  inches  below  lesser 
trochanter.  The  flaps  were  sutured  back  in  position  ; wound 
healed  in  two  months.  Patient  was  then  fitted  with  a 
temporary  artificial  limb,  but  the  femur  was  so  short  that 
when  he  flexed  the  hip  the  end  of  the  bone  slipped  forward 
over  the  top  of  the  socket.  We  were  confronted  with  the 
necessity  of  fitting  him  with  the  tilting-table  leg  or  of 
lengthening  the  femur. 

On  Feb.  27th,  1919,  he  was  operated  upon  again.  The 
flaps  were  reflected  as  before  and  the  incision  continued  up 
the  outer  side  of  the  thigh  as  far  as  the  great  trochanter 
and  deepened  until  the  bone  was  exposed.  The  muscles 
were  then  reflected  until  the  outer  half  of  the  femur  was 
laid  bare.  With  an  osteotome  applied  in  the  sagittal  plane 
a half  of  the  terminal  three  and  a half  inches  of  the  shaft  of 
the  bone  was  cut  free.  This  piece  of  bone  was  slid  down- 
wards so  as  to  lengthen  the  femur  by  two  and  a half  inches, 
and  was  then  fastened  by  two  long  screws  of  beef-bone.1  The 
flaps  were  then  dissected  up  sufficiently  far  to  allow  them 
to  be  drawn  down  and  closed  over  the  end  of  the  bone.  The 
wound  healed  by  primary  union,  except  for  a hsematoma, 
which  opened  spontaneously  and  disappeared  without 
infection,  otherwise  recovery  uneventful. 

Two  months  later  the  fragments  were  solidly  united  and 
the  patient  commenced  active  exercise  of  the  stump  to 
increase  the  density  of  the  bone.  He  is  now  wearing  the 
ordinary  artificial  limb  and  has  a very  satisfactory  stump. 

Remarks. 

This  case  resulted  in  several  observations.  Owing  to 
osteoporosis  the  fixation  was  none  too  good.  As  solid 
fixation  oE  the  fragments  is  imperative,  it  would  be  wise  to 
convert  the  screws  into  bolts  by  small  nuts  made  of  beef- 
bone.  Heavy  silver  wire,  or  the  brass  ribbon  used  by  Putti, 
or  even  metal  bolts  would  serve,  but  the  beef-bone  has  the 
advantage 2 of  uniting  rapidly  to  the  living  bone  and  of 
undergoing  absorption  and  replacement,  as  does  an  ordinary 
autogenous  graft. 

The  extensive  splitting  of  the  bone  led  to  rather  profuse 
hemorrhage.  This  could  be  avoided  by  substituting  for  the 
method  described  an  ordinary  inlay  bone-graft  or  a graft 
driven  into  the  medullary  cavity.  We  have  one  case  of 
amputation  of  the  leg  in  which  the  fibula  will  be  used  after 
splitting  it  into  two  halves  to  allow  the  endosteal  osteoblasts 
to  be  bathed  in  lymph,  either  as  an  inlay  or  as  a medullary 
graft,  lengthening  the  stump  an  inch  and  a quarter.  In  this 
case  the  flaps  are  sufficiently  long  and  the  fibula  is  much 
longer  than  the  tibia  which  was  sectioned  just  below  the 
tubercle. 

The  bone  in  the  stump  may  be  too  short  to  allow  an 
operation  as  such  described,  and  it  may  not  be  wise  to 
remove  a graft  from  the  other  leg.  In  such  a case  a suit- 
able graft  might  be  obtained  from  a recently  amputated 
limb.  We  have  satisfied  ourselves  that  bone  transplanted 
from  one  animal  to  another  of  the  same  species — at  any  rale, 
in  dogs — retains  vitality  in  the  same  sense  as  does  an 
ordinary  autogenous  graft— that  is,  those  cells  which  are 
exposed  on  the  surfaces  to  a supply  of  lymph  survive  and 
proliferate,  and  ultimately  accomplish  the  absorption  and 
replacement  of  the  graft.  It  would  be  well,  in  trans- 
planting bone  from  another  patient  or  from  a recently 

i Canadian  Medical  Journal  of  Medicine  and  Surgery,  May,  1916 

2 Journal  A.M.A.,  April  20th,  1918,  lxx.,  1134-40. 


amputated  limb,  to  make  sure  that  the  cells  of  the  one 
patient  are  capable  of  living  in  the  lymph  of  the  other,  as 
indicated  by  the  testing  of  their  bloods  for  haemolysis  and 
agglutination.  A recent  paper  by  Masson  indicates  that 
Thiersch  skin-grafts  from  a donor  whose  blood  is  not 
compatible  with  that  of  the  patient  do  not  live ; if  the 
bloods  are  compatible  the  transplantation  is  successful. 

Up  to  now  the  operation  described  appears  successful, 
but  failure  is  still  possible  owing  to  absorption  of  the  graft. 
Only  time  can  show,  and  this  paper  is  but  a preliminary 
report.  There  is  reason  to  believe,  however,  that  such 
grafts  will  not  disappear.  When  autogenous  bone  is  trans- 
planted into  the  muscles  of  the  back  in  animals  the  bone 
ultimately  disappears.  But  if  such  grafts  are  so  placed  that 
they  have  work  to  perform,  as  when  used  to  bridge  gaps  in 
the  long  bones,  they  ultimately  increase  in  thickness  until 
the  bone  is  restored  to  approximately  its  normal  outline. 
Evidently  the  fate  of  such  transplants  is  dependent  upon 
the  work  performed.  Up  to  the  present  the  X ray  shows  no 
evidence  of  disappearance  of  the  graft,  and  a mass  of  new 
bone  has  restored  the  normal  thickness  of  the  shaft  where 
the  graft  was  removed,  and  has  also  increased  the  thickness 
of  the  graft  itself. 

Among  our  wounded  are  many  who  could  have  such  an 
operation  done,  for  we  have  seen  men  passing  through  this 
hospital  who  had  very  short  bones  in  their  stumps  and  yet 
ample  flaps  of  skin  to  allow  bone-lengthening.  It  has  been 
the  practice  to  remove  these  redundant  flaps  by  re-amputa- 
tion. Again,  if  a successful  lengthening  of  the  bone  can  be 
looked  forward  to,  the  method  of  primary  amputation,  when 
short  bones  are  inevitable,  should  be  changed.  The  skin-flaps 
should  be  left  very  long,  so  that  later  sufficient  skin  will  be 
available  to  cover  the  graft  properly.  This  would  also  apply 
in  civil  practice. 


A CASE  OF 

CARCINOMA  OF  THE  PELVIC  COLON 

TREATED  BY  EXCISION  AND  ANASTOMOSIS. 

By  CLAUDE  FRANKAU,  C.B.E.,  D.S.O.,  F.R.C.S.  EXG., 

SENIOR  ASSISTANT  SURGEON  TO  ST.  GEORGE’S  HOSPITAL. 


The  following  case  of  apparent  cure  following  excision  of 
a carcinomatous  stricture  of  the  pelvic  colon  may  be  of 
interest  inasmuch  as  there  is  no  evidence  of^recurrence  after  1 
six  years. 

The  Case  Described. 

A man,  aged  47,  was  admitted  into  St.  George’s  Hospital  : I 
on  July  4th,  1913,  for  intestinal  obstruction.  He  had  ■ I 
apparently  been  absolutely  well  until  four  days  previously ; ■ I 
he  then  noticed  a certain  amount  of  colicky  pain  and  had  I 
absolute  constipation,  which  was  not  relieved  by  drugs  or  I 
enemata.  On  examination  he  did  not  look  ill.  Pulse  88,  I 
temperature  normal.  Tongue  slightly  furred.  The  abdomen  I 
was  enormously  distended  and  was  tympanitic  all  over.  I 
Rectal  examination  was  negative.  An  attempt  was  made 
by  means  of  further  enemata  to  open  the  bowels  but  I 
without  result,  and  it  was  clear  that  the  obstruction  was  I 
complete.  The  same  evening  I opened  the  abdomen  in  | 
the  middle  line  ; all  the  intestines  were  greatly  distended, 
the  caecum  being  enormous  and  showing  commencing 
splitting  of  the  serous  coat.  The  cause  of  the  obstruction 
was  an  annular  stricture  of  the  pelvic  colon  just  above  the 
pelvic  floor;  the  growth  was  movable  and  there  appeared. to 
be  a prospect  of  excising  it  with  good  results  if  the  man  - 
recovered  from  the  intestinal  distension.  The  mid-line 
incision  was  therefore  closed  and  a second  muscle-splitting 
incision  made  over  the  caecum  ; as  soon  as  the  peritoneum 
had  been  incised  the  caecum  bulged  out  and  burst  partly 
externally  and  partly  intraperitoneally ; a Paul’s  tube  was 
sewn  into  the  tear  in  the  caecum  and  the  peritoneal  cavity 
was  cleansed  locally  as  far  as  possible.  In  spite  of  the 
enormous  distension  present  before  the  operation  and  ! 
the  peritoneal  infection  he  rapidly  improved,  so  that 1 
three  weeks  later  a second  laparotomy  was  performed 
with  the  idea  of  excising  the  growth.  On  examina- 
tion the  growth,  which  resembled  a tight  ligature  j 
round  the  gut,  was  found  to  be  quite  freely  movable,  and 
there  appeared  to  be  no  glandular  involvement.  It  wasj 
situated  so  near  the  pelvic  floor  that  the  feasibility  of  an 
anastomosis  seemed  doubtful.  However,  after  clamping 
and  dividing  the  gut  above  the  growth  and  dividing  the 
mesentery,  it  was  found  possible  to  draw  the  growth  and  the 
distal  part  of  the  gut  up  and  divide  it  about  three-quarters  of 
an  inch  above  the  pelvic  floor.  An  end-to-end  anastomosis | 


Thb  Lancet,]  DR.  ABRAM  & PROF.  GLYNN  : PARATYPHOID  INFECTIONS  OF  PLEURA.  [AUGUST  16, 1919  283 


was  then  performed  by  means  of  a double  layer  of  interrupted 
stitches.  This  proved  to  be  a matter  of  very  great  difficulty 
and  could  only  be  effected  by  the  use  of  the  high 
Trendelenburg  position  and  after  partial  division  of  the  left 
rectus  abdominis  muscle  to  allow  of  easier  access.  Owing 
to  the  likelihood  of  leakage  from  the  suture  line,  a rubber 
drain  was  left  in  for  the  first  three  days.  Enemata  were 
commenced  on  the  eighth  day  after  operation,  and  small 
actions  were  obtained  every  other  day.  On  the  twenty- 
fourth  day  after  the  excision  the  cmcostomy  was  closed  by 
operation,  and  normal  actions  of  the  bowels  followed.  The 
growth  proved  to  be  a columnar-celled  carcinoma  ; some 
small  glands  in  the  mesentery  were  not  involved. 

No  Evidence  of  Recurrence. 

I saw  the  patient  every  few  months  up  to  the  summer  of 
1914.  Owing  to  the  war  I was  unable  to  see  him  again  until 
May,  1919,  when  he  was  in  very  good  health  and  had  no 
intestinal  symptoms  of  any  sort.  Abdominal  examination 
was  negative,  and  there  was  no  local  evidence  of  recurrence. 

In  this  case  the  absence  of  prodromal  symptoms  before  the 
obstruction  became  absolute  is  remarkable,  and  the  man 
must  be  regarded  as  extremely  fortunate  to  have  survived 
the  enormous  distension  found  at  the  first  operation  and  the 
effects  of  the  rupture  of  the  caecum. 


A NOTE  ON 

SEGMENTAL  HYPERALGESIA  IN  MALARIA. 


lumbars  in  malaria,  and  the  consequent  reduction  in  the 
number  of  cases  of  complete  distribution. 

The  middle  group  shows  a few  minor  differences  ; in 
trench  fever  it  is  rare  to  find  anything  but  D.7  or  D.7  and  8 
involved,  but  in  the  malarial  cases  D.  6 was  found  once,  D.  8 
17  times,  and  D.  9 once,  also  in  nine  cases  the  hyperalgesia 
was  unilateral,  which  was  hardly  ever  found  in  trench  fever. 

Conclusion. 

The  similarity  between  the  signs  as  found  in  the  two 
disorders  remains  very  striking  and  adds  one  more  to  the 
many  likenesses  between  them  : one  being  mosquito-borne 
and  the  other  louse-borne  ; one  admittedly  protozoal,  and  the 
latter  probably  so  from  its  cyclic  character  and  its  capacity 
for  lying  latent ; both  associated  with  enlargement  of  the 
spleen. 

It  is  necessary,  however,  for  either  disease  to  be  excluded 
before  the  presence  of  such  segmental  hyperalgesia  can  be 
allowed  weight  in  the  diagnosis  of  the  other. 


PARATYPHOID  INFECTIONS  OF  THE 
PLEURA. 

By  J.  HILL  ABRAM,  F.R.C.P., 

HONORARY  PHYSICIAN,  ROYAL  INFIRMARY,  LIVERPOOL ; LATELY  ACTIN' G- 
PHYSICIAN,  NORTHERN  HOSPITAL,  LIVERPOOL  ; 

AND 


By  D.  W.  CARMALT  JONES,  M.D.,  F.R.C.P., 

LATE  TEMPORARY  COLONEL,  A.M.S.,  AND  CONSULTING  PHYSICIAN,  E.E.F. 


In  the  course  of  1918  I made  a series  of  observations 
on  segmental  hyperalgesia  in  trench  fever,  which  were 
embodied  in  a paper  published  in  The  Lancet.1  The 
substance  of  them  was  briefly  as  follows  : — 

If  a series  of  light  pin-pricks  are  made  on  the  skin  in  a 
direction  which  crosses  a large  number  of  areas  of  segmental 
nerve  distribution,  it  will  be  found  in  patients  suffering 
from  trench  fever  that  three  groups  of  areas  are  unusually 
sensitive,  particularly  as  to  their  borders.  The  groups  are 
an  upper  one  containing  the  eignth  cervical  and  first  dorsal 
areas,  a middle  one  containing  the  seventh  dorsal  area, 
and  a lower  one  containing  all  the  lumbar  areas.  The  areas 
are  not  found  in  every  case,  and  in  positive  cases  only  parts 
of  these  groups  may  be  hyperalgesic,  but  something  of  the 
kind  is  present  in  the  great  majority. 

I noted  in  this  paper  that  in  18  cases  of  malaria  which 
had  been  examined  similar  areas  were  found.  I have  since 
had  the  opportunity  of  examining  patients  suffering  from 
malaria  in  very  large  numbers,  both  at  a camp  in  France, 
where  patients  were  treated  who  had  been  infected  in  other 
theatres  of  war,  and  also  in  Egypt  and  Palestine,  where 
malaria  was  incomparably  the  highest  cause  of  sickness 
during  my  service  there.  I was  able  to  find  the  same  areas 
of  hyperalgesia  in  the  great  majority  of  cases,  and  they  differ 
in  no  important  particular  from  those  found  in  trench  fever, 
and  such  minor  variations  as  were  present  are  stated  below. 


Analysis  of  Results. 

The  following  is  an  analysis  of  the  results  found  in 
120  cases  examined  consecutively  for  this  sign. 

Cases  examined,  120.  Positive  83  (70  per  cent.).  Negative 
37  (30  per  cent.).  This  is  a lower  incidence  than  in  trench 
fever,  where  I found  only  five  negative  in  73  cases,  but 
malaria  is  capable  of  far  more  certain  recognition,  and  I 
came  to  rely  on  the  presence  of  these  areas  for  the  differential 
diagnosis  of  trench  fever. 

The  areas  found  hyperalgesic  in  the  malarial  cases  were 
these  : 


Upper  group  ...  ] p j 

Middle  group  ...  D.  7 or  8 


Lowergroup  ...  -!  *}’ 

“ 1 L (meomph 

Full  distribution  C.  8,  D.  1 ; I 
positive  eases. 


9 ) 

35  ^-44  = 50%  of  positive  eases. 

...  83  = 100% 

4y|-49  = 59% 

L.  1,  2,  3,  4,  5,  8 eases  = 10%  of 


It  was  remarked  that  these  areas  could  never  be  demon- 
strated while  a rigor  was  in  progress. 

In  68  positive  cases  of  trench  fever  the  results  were  these  : 
Lpper  group  ...  39  = 57%  I Lowergroup  ...  67  = 99% 
Middle  group  ...  68  = 100%  | Full  distribution  24  = 35% 
The  only  differences  are  the  more  frequent  escape  of  the 


1 An  Address  on  Sensory  Changes  in  the  Diagnosis  of  Trench  Fever, 
The  Lancet,  Oct.  5th,  1918. 


ERNEST  GLYNN,  F.R.C.P., 

PROFESSOR  OF  PATHOLOGY,  UNIVERSITY  OF  LIVERPOOL  ; 
CAPTAIN,  R. A.M.C.T. 

(From  the  Thompson  Tates  Laboratory .) 


Pneumonia,  and  especially  bronchitis,  is  not  an  un- 
common complication  of  paratyphoid  fever 1 ; but  sero- 
fibrinous or  purulent  pleurisy  due  to  infection  with  the  para- 
typhoid bacilli  is  apparently  so  rare  that  the  following  cases 
deserve  recording. 

Case  1.— F.  L.,  a man  aged  38,  was  admitted  to  the  David 
Lewis  Northern  Hospital,  Liverpool,  on  Feb.  12th,  1918. 
after  being  crushed  between  a wagon  and  a wall.  The  left 
side  was  strapped.  During  the  11  days  he  was  in  the 
surgical  ward  he  had  some  diarrhoea,  and  typhoid  was 
suspected.  He  was  then  transferred  to  a medical  ward  with 
signs  of  consolidation  at  the  left  base.  As  the  breath  sounds 
were  very  feeble,  although  there  was  no  displacement  of  the 
heart,  a needle  was  inserted  into  the  pleura  and  5 c.cm. 
slightly  turbid  fluid  were  obtained. 

On  bacteriological  examination  a motile  Gram-negative, 
indol-negative  organism  was  present  in  pure  culture,  which 
gave  the  characteristic  reactions  of  paratyphoid  B in  lactose, 
glucose,  maltose,  mannite,  and  saccharose.  It  agglutinated 
with  the  Lister  Institute  paratyphoid  B serum  1 - 6500,  but 
not  with  the  paratyphoid  A or  typhoid  serum. 

Th.e  patient’s  serum  agglutinated  his  own  organism 
1 — 1250,  and  the  results  with  the  Oxford  standard  emulsions 
were  : typhoid  — 1 — 25,  paratyphoid  A — 1 — 25,  para- 
typhoid B + 1 - 1250.  The  fieces  were  not  examined. 

' Throughout  his  stay  in  the  medical  ward  the  temperature 
never  rose  above  100’4°  F.  and  the  respirations  above  30,  but 
the  pnlse  averaged  about  100.  Treated  on  general  lines  he 
made  an  uninterrupted  recovery  without  any  further 
operative  treatment. 

Case  2. — M.  W.,  a woman  aged  24,  was  admitted  to  the 
David  Lewis  Northern  Hospital,  Liverpool,  on  July  22nd, 
1918.  She  stated  that  three  months  previously  she  suffered 
from  “ influenza,”  and  recently  had  pain  in  the  left  side. 
There  were  obvious  signs  of  pleural  effusion,  her  tempera- 
ture was  104°  F.,  pulse  124,  respirations  44.  On  July  23rd 
2§  pints  of  clear  fluid  were  removed  by  aspiration.  On 
August  1st  the  chest  was  again  explored,  and  as  pus  was 
found  the  empyema  was  opened ; the  patient  made  an 
uninterrupted  recovery.  The  fluid  was  examined  after 
aspiration  and  twice  subsequently  when  the  chest  had  been 
opened.  It  always  contained  a streptococcus  longus  and  a 
bacillus  which  gave  the  characteristic  cultural  tests  of  para- 
typhoid B,  it  agglutinated  with  the  Oxford  paratyphoid 
serum  up  to  1 — 40,  titre  1 — 100. 

The  patient’s  serum  agglutinated  her  own  organism 
1 — 96,  and  the  results  with  the  Oxford  standard  emulsions 
were  : typhoid!-  1 — 25,  paratyphoid  A - 1 — 25,  paratyphoid 
B + 1 - 50.  The  faeces  were  examined  with  negative  results. 

Cases  Reported  by  Other  Observers. 

Lenhartz  (1910)  published  the  first  case  of  pleurisy  in 
paratyphoid  fever ; here  the  effusion  was  serous  and  contained 
paratyphoid  B bacilli  in  pure  culture. 


1 Dawson  and  Whittington,  1916  ; Willcox,  1916 ; Hurst,  1917. 


284  Thb  Lanoht,]  MR.  W.  McC.  WANKLYN  : SMALL-POX  NOTES  FOR  PRACTITIONERS.  [August  16;  1919 


Costa  and  Clavelin  (1911)  described  the  case  of  a man  who 
developed  empyema  due  to  paratyphoid  B five  weeks  after 
the  Onset  of  the  fever.  They  also  mention  two  of  serous 
effusion  described  by  R.  Schmidt  and  Sacqu6p6e  and  Chevrel 
respectively — here  the  type  of  paratyphoid  bacillus  is  not 
stated,  but  it  is  almost  certainly  B. 

According  to  Schottmiiller  (1911)  pleurisy  is  often  met 
with  in  paratyphoid  fever,  and  even  when  suppurating  will 
clear  up  with  repeated  aspirations.  He  alludes  to  a case  by 
Lorey  where  the  effusion  occurred  during  a “long-drawn-out” 
attack  of  paratyphoid  B fever. 

War  Cases. 

Several  others  have  been  recorded  during  the  war,  notably 
by  the  French  authors. 

Joltrain  and  Petitjean  noted  that  during  the  1915-16 
epidemic  of  enteric  in  the  French  Army  pleural  complica- 
tion were  rare  amongst  the  typhoid  cases— viz.,  2-4  per 
cent.,  but  common  amongst  the  paratyphoid  cases — viz., 
19  cases  in  310— i.e.,  6 per  cent.  In  the  latter  pleurisy  was 
purulent  in  2 per  cent.,  dry  in  2 per  cent.,  and  sero-fibrinous 
in  the  rest.  Paratyphoid  B was  isolated — apparently  from 
the  blood— in  all  the  cases  except  one,  where  paratyphoid  A 
was  found.  The  pleurisy  usually  developed  in  cases  of 
atypical  or  latent  paratyphoid  ; it  was  sometimes  the  first 
symptom.  The  exudate  in  the  sero-fibrinous  cases  con- 
tained a preponderance  of  lymphocytes  and  endothelial 
plates. 

Jean  Minet  (1915)  carefully  described  8 cases  of  para- 
typhoid infection  with  complications  in  the  “lung  and 
pleura”;  the  complication  was  usually  bronchitis.  In  two, 
viz.,  Nos.  6 and  7,  there  were  definite  signs  of  effusion.  In 
No.  7,  some  drops  of  citron  colour  liquid  removed  by  aspira- 
tion were  sterile.  In  No.  8 paratyphoid  B bacilli  were 
isolated  from  the  sputum  and  from  the  blood. 

Florenzano  (1916)  reports  a case  of  pleurisy  with  effusion 
of  clear  yellow  fluid  which  gave  a positive  agglutination  to 
paratyphoid  B.  The  patient  later  developed  symptoms  of 
typhoid. 

Two  other  observers  have  noted  paratyphoid  A infections. 
(1)  Giroux  (1915).  Here  the  patient  developed  pleurisy  in 
the  third  week  of  paratyphoid  ; the  fluid  was  first  serous, 
then  haemorrhagic,  and  finally  purulent  ; the  bacilli  were 
isolated  from  the  empyema,  but  two  blood  cultures  were 
negative.  (2)  Weeks  (1916).  Here  the  patient,  who  was 
also  a soldier,  “ had  diarrhoea  for  a fortnight  and  was 
apparently  well,  when  two  weeks  before  admission  to 
hospital  he  was  seized  with  acute  pain  in  the  back.”  He 
subsequently  developed  empyema,  which  was  opened,  and 
finally  recovered. 

A case  of  pleurisy  due  to  an  “ inagglutinable  para- 
typhoid B ” bacillus  is  worth  alluding  to. 

Pte.  W.  received  a gunshot  wound  in  the  region  of  the  left 
rib  on  Nov.  17th,  1916,  after  which  he  lay  for  24  hours  in 
water.  He  was  transferred  to  Toxteth  Military  Hospital, 
Liverpool,  under  the  care  of  Captain  J.  R.  Logan.  The  bullet 
was  removed  at  Toxteth  in  January,  1917  ; it  had  apparently 
damaged  the  pleura,  but  not  the  lung.  An  empyema 
developed,  which  was  aspirated  on  three  occasions  in  two 
months,  after  which  he  recovered.  Each  sample  of  pus 
contained  in  pure  culture  a persistently  “ inagglutinable 
paratyphoid  B”  organism  ; it  did  not  absorb  paratyphoid 
agglutinins  ; the  patient’s  serum  agglutinated  it  up  to  1-128. 
The  same  organism  was  isolated  from  the  urine  once. 
Further  particulars  regarding  it  are  given  elsewhere.2 

Civilian  Cases. 

In  conclusion,  it  is  noteworthy  that  both  our  cases  of 
typical  paratyphoid  B pleurisy  occurred  in  civilians. 

During  the  years  February,  1917,  to  February,  1919,  the 
sera  of  about  40  civilian  patients,  excluding  sailors,  with 
enteric-like  symptoms  were  tested  in  this  laboratory  with 
the  Oxford  standard  emulsions.  The  patients  were  in  the 
Liverpool  Royal  Infirmary  and  the  Northern  Hospital ; none 
had  been  inoculated  with  T.  orT.A.B.  vaccine.  Twenty— 
i.e.,  8 men,  10  women,  and  2 children — agglutinated  typhoid 
only,  the  lowest  titres  being  1—25  one  case,  1 - 50  two  cases, 
while  the  rest  ranged  from  1 - 250  to  1—5000.  On  the  other 
hand,  five  cases  agglutinated  paratyphoid  B.  only — viz., 
W. , adult  male  4-  1 - 50  ; M.,  adult  male,  hospital  dispenser, 
+ 1 - 1000  ; W.,  boy,  + 1 - 50  ; E.,  boy,  + 1 - 500  ; M.,  adult 
female  -f-  1-25+.  The  rest  were  negative  to  all  three 
emulsions.  Including  the  two  pleurisy  cases,  27  patients 
gave  some  agglutination  either  to  typhoid  or  paratyphoid. 

2 Glynn,  A.  L.  Robinson,  Ac.,  1917. 


Excluding  the  two  casesj  with  titres  of  + 1 — 25  (typhoid) 
and  + 1 - 25  + (paratyphoid  B),  the  clinical  history  and 
agglutination  results  indicate  that  19  were  almost  certainly 
typhoid  and  six  almost  certainly  paratyphoid  B.  These 
statistics  are  obviously  based  on  too  few  cases  to  afford  more 
than  a very  rough  indication  of  incidence,  but  a proportion  of 
approximately  1 of  paratyphoid  to  4 of  typhoid  is  higher 
than  most  medical  men  or  public  health  authorities  would 
expect. 

Nevertheless,  there  has  undoubtedly  been  a relative  increase 
in  the  number  of  cases  of  enteric  3 diagnosed  as  paratyphoid 
amongst  the  civilian  population,  since  the  outbreak  of  war. 
This  increase  is  probably  partly  real , and  due  to  the  presence 
of  soldiers  or  sailors  with  paratyphoid,  most  probably 
carriers  who  have  escaped  detection  by  the  routine  bacterio- 
logical examinations  before  discharge  from  hospital.  The 
paratyphoid  outbreak  at  Reading  amongst  civilians  was 
probably  due  to  infected  soldiers  (Donaldson,  1916).  The 
increase  is  also  partly  apparent  and  due  to  improved  sero- 
logical and  bacteriological  technique,  especially  the  former. 

Dr.  E.  W.  Hope,  medical  officer  of  health  for  the  city  of 
Liverpool,  kindly  informed  us  that  during  the  years  1907-08, 
929  civilians  were  notified  as  suffering  from  enteric  or 
typhoid,  and  none  from  paratyphoid,  while  during  1917-18, 

91  civilians  were  notified  as  suffering  from  enteric  or 
typhoid  and  four  from  paratyphoid.  Thus  the  number  of 
paratyphoid  cases  notified  in  the  whole  city  of  Liverpool  is, 
two,  if  not  three,  less  in  approximately  the  same  period  than 
those  diagnosed  serologically  or  bacteriologically  in  two  hos- 
pitals where  there  were  only  19  or  20  cases  of  typhoid.  This 
discrepancy  is  undoubtedly  explained  by  the  fact  that  the 
medical  man  usually  diagnoses  his  patient  on  clinical 
grounds  only,  and  hastens  to  notify  him  as  enteric  or  typhoid 
before  a proper  bacteriological  investigation.  If  the  patient 
is  subsequently  proved  to  be  paratyphoid,  the  original 
notification  is  usually  not  corrected. 

Thus  the  official  figures  of  the  relative  number  of  typhoid 
and  paratyphoid  cases  among  civilians  will  be  misleading 
until  they  are  invariably  controlled  by  the  bacteriologist. 

We  are  indebted  to  Mr.  Hugh  Smith  for  assistance  in  the 
bacteriological  work. 

For  an  interesting  review  of  Typhoid  Infections  of  the 
Pleura  see  a recent  annotation  in  The  Lancet. 

References. — CoBta,  S.,  and  Clavelin,  Ch. : Coropt.  Kend.  Soc.  Biol., 
1911,  70—71.  816.  Dawson,  B..  and  Whittington,  T.  H.  : Quart  Journ. 
Med.,  1916,  ix.,  96.  Donaldson,  K. : The  Lancet,  1916,  i.,  429. 
Florenzano,  A. : Gazz.  degli.  Osp.  e delle  Clin..  1916.  37, 1553  (quoted 
from  Review  Bacteriology,  1917,  vii.,  38).  Giroux:  Soc.  Med.  Hop  de 
Paris,  1915.  39,  1102.  Glynn,  E.  E.,  Robinson,  A.  L.,  and  oth-rs:  Med. 
Res.  Committee  Special  Hep.,  Ser.  No.  7,  1918,  66.  Hurst,  A.  F. : Med. 
Diseases  of  the  War,  1917,  94,  Arnold,  London.  Joltrain,  E.,  end  ‘ 
Petitjean.  G. : Archiv.  Med.  Pharmacie  Militaires,  1916,  lxvi.,  4,  518. 

Le  Progres  Medicate,  1916,  22,  221.  Lenhartz,  H.  : Microscopie  und 
Chemie  und  Kranbenbett.  Sechste  Auflage,  Berl.,  1910,  58.  Minet,  J.:  ‘ 
Bull.  Soc.  Med.  H6p.  de  Paris.  1915,  37-38.  1106.  Schottmiiller.  H. : 
Hanbuch  der  Inneren  medizin,  1911,  Erster  Band,  544,  Springer. 
Weeks,  C.  C. : The  Lancet,  1916  ii..  433.  Willcox,  W.  H. : The  Lancet, 
1916,  i.,  454.  Annotation  on  Pleuro-Typhoid,  The  Lancet,  June  7th, 
1919,  p.  990.  


SMALL-POX  NOTES  FOR  PRACTITIONERS. 

By  W.  McCONNEL  WANKLYN,  B. A.  Cantab., 
M.R.C.S.,  L R.C.P.,  D.P.H., 

AUTHOR  OF  ‘‘HOW  TO  D11GNOSE  SMALL-POX,"  ‘‘ILLUSTRATIVE 
CASES  IN  THE  DIAGNOSIS  OF  SMALL-POX,”  “ THE 
ADMINISTRATIVE  CONTROL  OF  SMALL- POX,”  ETC. 


It  may  be  a service  to  colleagues  in  practice  who  have 
been  unable  to  keep  in  touch  with  the  subject  to  note  how 
small-pox  stands  at  present,  and  give  some  brief  notes  on 
diagnosis.  A list  of  sources  of  further  information  is  added. 

This  year  there  have  been  cases  of  small-pox  in  London. 
Liverpool,  Bootle,  Bebington,  South  Shields,  Hartlepool,  | 
Middlesbrough,  Lincoln,  Wisbech,  Ilford,  DarliDgton,  I 
Pontefract,  Featherstone,  Bracebridge,  Bury  St.  Edmunds,  | 
Herefordshire,  Amersham,  Chorley  Wood,  Bishops  Stortford, 
East  Ham.  Southampton,  Weymouth,  Jarrow,  Barnard  I 
Castle,  Hull,  Derby,  Plymouth,  Cowes,  Strood,  Mitcham,  i 
Penge,  Southend,  Gravesend.  There  has  been  an  unusual 
pie  valence.  Previous  Epidemics. 

Small-pox  was  last  widely  prevalent  in  England  about  the 
year  1902,  when  there  were  about  8,000  cases  in  London.  It 

3 “Enteric  Fever Varieties  : (a)  Typhoid  Fever;  (6)  Paratyphoid 
Fever.”  See  1916  edition  Nomenclature  and  Classification  of  Diseases, 
Royal  College  of  Physicians.  The  Lancet,  1916,  i.,  887. 


The  Lancet,]  DR.  J.  R.  GOODALL  : VACCINATION  BY  SUBCUTANEOUS  INJECTION.  [August  16, 1919  285 


died  down  through  1903  and  1904,  and  has  been  almost 
quiescent  until  now.  Previously  to  that  there  was  a 
moderate  outburst  of  it  in  1893,  about  2400  cases  in  London. 
Previously  to  that  again,  it  was  severe  in  1885  and  1884,  in 
each  of  which  years  there  were  about  6000  cases.  In  1881 
there  were  6000  cases  in  London  ; prior  to  1885  in  London 
it  was  constantly  prevalent,  often  in  the  thousands  per 
annum  for  years  together.  In  1871,  a very  heavy  year, 
there  were  13,000  cases  in  London. 

There  has  never  been  recorded  before  a period  of  small- 
pox quiescence  so  long  as  from  1903  to  1919,  i.e.  16  years. 
The  previous  longest  quiet  interval  was  about  8 years. 
Prophecy  of  when  small-pox  will  be  epidemic  again  is  futile  ; 
the  practical  thing  is  to  be  prepared  for  whatever  may  come. 
All  that  can  be  said  is  that  it  is  more  prevalent  than  usual 
this  year. 

Importations  from  Abroad. 

At  present,  as  often  as  it  occurs  in  our  country,  so  often 
it  is  extinguished  ; infection  appears  neither  to  remain  nor 
seriously  to  spread.  But  it  is  being  continually  reintroduced 
from  abroad,  from  ports  such  as  Oporto,  Lisbon,  Bombay, 
Salonica,  Alexandria,  Naples.  Many  of  the  recent  importa- 
tions have  been  from  European  and  nearer  Eastern  ports. 
Soldiers  and  sailors  have  been  importers  of  infection.  Many 
of  these  have  been  stopped  at  the  ports.  Others,  however, 
and  the  most  dangerous,  are  those  who  come  through  in  the 
incubation  stage,  and  are  settled  at  home  by  the  time  the 
disease  declares  itself. 

A Pertinent  Question. 

In  keeping  on  the  lookout  for  small-pox  by  far  the  most 
useful  practice  is  to  carry  continually  the  question  in  one’s 
mind,  “Can  this  case  be  small-pox?”  This  is  a question 
which  can  be  usefully  applied  as  a touchstone  to  every  case 
in  practice  the  diagnosis  of  which  is  not  clear.  Overlooking 
small-pox  is  mainly  due  to  the  possibilities  of  small-pox 
never  having  crossed  the  mind.  It  is  a disease  of  extra- 
ordinarily deceptive  qualities.  Take  its  stages  from  the 
beginning.  Onset  simulating  rheumatism,  lumbago,  influenza, 
to  mention  only  a few.  Prodromal  rash  simulating  measles, 
scarlet  fever,  urticaria,  for  instance.  Haemorrhagic  small-pox 
simulating  meningitis,  ulcerative  endocarditis,  septicaemia, 
among  others.  Severe  confluent  small-pox  resembling 
measles,  perhaps,  or  showing  little  sign  of  illness  at  all, 
because  there  are  no  spots,  but  only  one  spot ; the  skin  of 
the  face  slowly  rising  (till  early  death)  in  one  vesicle.  Then 
there  is  the  rash  proper  of  a moderate  case  with  a host  of 
disguises  : chicken-pox,  syphilis,  dermatitis,  pustular  eczema, 
scabies,  impetigo,  acne,  and  many  more.  These  are  not 
fancied,  but  are  very  close  resemblances,  as  the  rash  passes 
through  its  various  stages  of  papule,  vesicle,  pustule,  ulcer, 
scab.  Then  there  is  the  last  stage  of  all,  when  scabs  under 
the  hard  skin  of  the  feet  and  the  reddish  scars  elsewhere 
may  be  the  only,  but  yet  unmistakable,  mark  of  small- pox. 

Value  of  a Second  Opinion. 

Directly  suspicion  is  aroused  it  is  well  at  once  to  certify 
and  get  removal,  or  to  get  a second  opinion.  I recall  very 
well  a case  where  an  action  was  brought  for  damages  caused 
by  an  error  in  diagnosis.  As  soon  as  the  jury  were  shown 
that  the  medical  attendant  had  used  all  his  skill  and  care 
and  had  also  called  a second  opinion,  they  stopped  the  case 
and  found  for  the  defendant.  Had  this  not  been  done,  he 
would  probably  have  had  to  pay  heavy  damages. 

Diagnosis. 

As  to  clinical  details  of  diagnosis,  reference  is  suggested 
to  the  various  sources  mentioned  below.  As  I was  a pupil 
of  the  late  Dr.  T.  F.  Ricketts  and  have  worked  by  his 
methods  for  22  years  I naturally  prefer  them.  They  are  set 
out  in  his  “ Diagnosis,”  with  Dr.  J.  B.  Byles’s  superb  photo- 
graphs ; in  my  “ Diagnosis,”  “ Illustrative  Cases,”  and  “ Dif- 
ferential Diagnosis  between  Small-pox  and  Chicken-pox.” 

For  one  faced  with  a suspected  case  it  is  best  to  take 
first  the  pathological  features,  especially  the  rash  of  the 
case,  the  history  last,  and  to  weigh  all  the  evidence  as  a 
whole.  The  surest  single  guide  is  the  distribution  or  arrange- 
ment of  the  rash  on  the  skin.  The  key  to  that  is  that 
the  rash  of  small-pox  especially  favours  skin  which  is 
vascularised  by  irritation  or  exposure.  May  I also  add 
this?  Withhold  an  opinion  in  a doubiful  light.  Get  the 
very  best  light  possible.  See  the  whole  of  the  skin  and  as 
much  as  possible  in  one  view.  The  sitting-up  posture  in 


bed,  the  patient  stripped  to  the  waist  and  his  arms  crossed 
in  front,  is  very  useful. 

The  quickest  and  soundest  method  of  learning  the  rudi- 
ments of  diagnosis,  apart  from  seeing  actual  cases,  is  to 
spend  an  hour  with  a stereoscope  and  some  good  stereo- 
scopic photographs,  with  a small-pox  date  card  and  some 
explanation. 

I acts  for  Antivaooinators. 

With  antivaccinators  I have  usually  found  most  good  can 
be  done  by  setting  out  the  facts  when  temperately  asked  for 
and  by  avoiding  argument.  I say  that  I am  as  much 
entitled  to  my  opinion  as  they  to  theirs.  When  small-pox 
threatens  it  is  worth  while  asking  the  question,  What  are 
you  going  to  do  about  it  ? Are  you  going  to  gamble  on  the 
risk  of  taking  small-pox,  or  make  a certainty,  at  considerable 
present  inconvenience,  of  safety  ? I found  this  kind  of 
reasoning  effective  during  the  war  with  convinced  anti- 
vaccinators, and  learnt  from  many  of  them  with  whom  I 
served  that  much  opposition  to  vaccination  comes  from  the 
facts  never  having  been  put  to  them.  Further  information 
on  this  point  is  in  my  “Lecture  to  Soldiers  on  Small-pox 
and  Vaccination.” 

It  is  worth  noting  that  successful  vaccination  within  the 
first  48  hours  of  the  incubation  period  of  small-pox  prevents 
an  attack  ; vaccination  can  be  performed  later,  but  then  it 
has  little  or  no  protective  effect. 

Books. 

The  Diagnosis  of  Small-pox,  Ricketts  and  Byles,  Cassell  and  Co.,  21«. 

Article,  Small-pox,  by  John  MauCombie,  M.D.,  in  System  of 
Medicine,  vol.  ii.,  part  1,  infectious  Diseases. 

Article,  Small-pox,  by  E.  \V.  Hope,  M.D..  D. Sc.,  Medical  Officer  of 
Health,  Liverpool,  Encyclopedia  Medica,  1902. 

Chapter,  Small  pox,  in  Manual  of  Infectious  Diseases,  by  Goodall  and 
Washbourn,  1908. 

Chapter  iv..  Small-pox,  in  Acute  Contagious  Diseases,  Welch  and 
Schamberg,  1905,  price  25s. 

Article,  Small-pox,  by  John  William  Moore,  M.D.,  M.Ch.,  F.R.C.P.I., 
Dublin,  in  Twentieth  Century  Practice  of  Medicine,  vol.  xiii.,  1898. 

Article,  Small-pox.  by  William  T.  Councilman.  M.D.,  in  System  of 
Medicine,  Osier  and  Macrae,  vol.  ii.,  Infectious  Diseases.  1907. 

The  Vaccination  Question,  C.  Killick  Millard,  M.D.,  1914. 

Article,  Variole,  by  B.  Auche,  in  Flbvres  ISruptives,  Paris,  1905. 

Wanklyn : How  to  Diagnose  Small-pox,  1912,  John  Murray, 
Albemarle- street,  London,  3s.  6 d.  The  Administrai ive  Control  of 
Small-pox,  1913.  Longmans,  Green,  and  Co.,  Paternoster-row,  E.C., 
3s.  6 d.  The  Differential  Diagnosis  between  Chicken-pox  and  Small  pox, 
Jenner  Mem  trial  Number  of  the  British  Medical  Journal,  19J2.  Cases 
illustrating  Points  in  Small  pox  Diagnosis,  1914,  6 d.  Lecture  to 
Soldiers  on  Small  pox,  1915,  Is.  A Short  History  of  Vaccination,  1911. 
A Small-pox  Date  Card,  1919,  showing  the  main  dates  associated  with  a 
case.  The  Medical  Officer  Weekly  Journal,  36,  Whitefriars-street,  B.C 


VACCINATION  BY  SUBCUTANEOUS 
INJECTION. 

By  J.  R.  GOODALL,  O.B.E.,  B.A.,  M.D.,  C.M.,  D.Sc. 
(McGill  Univ.),  F.A.S.G., 

MAJOR,  C.A.M.C.  ; ASSISTANT  PROFESSOR  OF  GYNECOLOGY,  MCGILL 
UNIVERSITY,  MONTREAL. 


In  the  spring  of  1915,  while  attached  to  the  Canadian 
Mounted  Rifles  as  medical  officer,  I came  frequently  in 
contact  with  Dr.  George  Hume,  of  Sherbrooke.  We  dis- 
cussed the  question  of  vaccination  of  troops  by  subcutaneous 
injection.  He  had  done  a few  cases  in  this  way,  and  before 
inflicting  this  method  upon  the  men  of  my  unit  I had 
myself  vaccinated  by  Dr.  Hume.  I had  been  vaccinated  ten 
times  previously  without  success.  Within  three  days  my 
arm  was  sore,  and  I went  through  all  the  general  symptoms 
of  successful  vaccination. 

Since  then  I have  vaccinated  hypodermically  approxi- 
mately 6000  men  and  quite  a number  of  officers’  children. 

Method  of  Preparing  Vaccine. 

It  was  impossible  to  procure  vaccine  in  bulk,  so  vaccine 
put  up  in  the  small  capillary  glass  tubes  was  used  in  the 
majority  of  cases. 

These  vaccine  tubes  were  first  placed  in  methylated  spirit 
for  a few  minutes,  then  withdrawn  singly  by  surgically  clean 
or  gloved  hands,  the  excess  alcohol  wiped  off  with  sterile 
absorbent  cotton,  the  ends  broken  off,  and,  lastly,  the  sterile 
rubber  bulb  fixed  to  one  end  of  tube  to  blow  out  the  vaccine 
into  a sterile  beaker.  The  vaccine  generally  shoots  out  of 
the  tube  into  the  beaker  in  the  form  of  a small  cylinder. 

When  the  vaccine  available  was  in  small  wax  tubes  the 
extreme  end  was  first  punctured  with  a sterile  needle  and 
the  vaccine  squeezed  out  bycompressing  thecontainer.  From 


286  The  Lancet,] 


REVIEWS  AND  NOTICES  OF  BOOKS. 


[August  16, 1919 


one-half  to  three-quarters  of  a tube  of  vaccine  was  used  per 
individual.  Sufficient  sterile  water  was  then  added  to  the 

vaccine  to  make  each  injection  equal  to  l c.cm. 

In  private  practice,  or  where  one  or  two  only  are  to  be 
vaccinated,  the  vaccine  may  be  prepared  as  an  ordinary 
hypodermic  injection,  using  vaccine  instead  of  a drug. 

Patients  can  be  vaccinated  with  great  rapidity.  After 
preparation  of  the  vaccine  four  medical  officers  vaccinated 
1100  in  two  and  a half  hours  by  using  20-c.cm.  Record 
syringes  and  injecting  1 c.cm.  into  20  consecutive  men, 
changing  the  needle  after  each  injection. 


Technique  of  Injection. 

The  arm  was  sterilised  with  iodine  and  the  vaccine 
injected  diagonally  with  a fine  hypodermic  needle  and 
svringe  into  the  subcutaneous  tissues.  In  a few  cases  by 
mistake  the  vaccine  was  injected  intracutaneously. 

Everything  should  be  done  with  surgical  cleanliness. 

After-effects. 

The  local  reaction  sets  in  usually  between  two  and  four 
days  but  in  a few  cases  the  reaction  is  considerably  delayed, 
and  in  one  colonel’s  family  three  children  were  vaccinated, 
and  reaction  did  not  appear  until  12,  13,  and  15  days 
respectively.  The  local  reaction  is  much  like  that  following 
antityphoid  inoculation  and  just  as  variable  in  intensity. 
About  8 per  cent,  proved  ineffective,  showing  but  slight 
local  reaction,  not  more  than  perhaps  could  have  been 
accounted  for  by  the  iodine  applied  to  the  skin  ; in  70  per 
cent,  (approximate  only)  there  was  a reaction  similar  to  the 
usual  reaction  after  antityphoid  inoculation  i.e.,  local 
swelling,  heat,  tenderness,  slight  pain,  and  redness.  In  a 
small  percentage  of  cases  the  reaction  was  marked,  causing 
swelling  and  oedema  of  the  elbow,  and  in  a few  cedema 

involving  the  whole  arm  and  hand. 

In  every  one  of  the  6000  cases  vaccinated  hypodermically 
by  myself  or  under  my  supervision  (for  all  of  whom  I myself 
prepared  the  vaccine  for  injection)  the  local  condition 
subsided  without  any  signs  other  than  those  of  excessive 

local  reaction.  ...  , 

After  the  seventh  or  tenth  day  the  local  swelling  and 
induration  subside,  leaving  a hard  nodule  in  the  subcutaneous 
tissues,  usually  ill-defined  at  first,  becoming  later  well 
circumscribed  and  lasting  for  about  one  month.  This  is 
quite  painless  after  the  first  acute  reaction.  The  process 
differs  in  no  respect  from  that  of  an  antityphoid  reaction, 
except  that  the  onset  is  slower  and  the  reaction  spreads  itself 

over  several  days.  . 

The  general  symptoms  vary  in  intensity  ana  do  not  diiier 
from  those  of  ordinary  vaccination. 


|Uiriefos  anb  Itotiees  of  ‘goohs. 


Infection. 

In  the  6000  cases  quoted  there  was  not  one  case  of  infec 
tion  This  can  be  stated  without  question  of  doubt.  The 
men  were  all  soldiers  who  came  directly  under  me  and  my 
medical  officers  for  observation  and  for  sick  parade.  They 
were  all  seen  several  times  afterwards,  and  in  about  50  per 
cent  of  cases  the  vaccination  was  done  at  the  same  time  or 
between  the  regular  antityphoid  inoculations.  I saw  one 
case  of  infection  in  another  brigade  ; this  was  brought  to 
my  attention,  and  on  close  questioning  it  was  found  that 
there  had  been  faulty  technique.  There  was  a punched-out 
ulcer,  about  the  size  of  a halfpenny,  exposing  the  fascia.  The 
ulcer  healed  without  untoward  result. 

None  of  the  6000  required  dressings,  and  the  men  were 
not  exempted  from  anything  but  physical  training  and  rifle 
drill.  A percentage  were  given  light  duty,  and  a very  small 
percentage  were  excused  duty  for  a few  days,  owing  to 
excessive  local  or  general  reaction.  There  were  no  hospital 
admissions.  In  a few  cases  (about  10  altogether)  the  vaccine 
was  injected  intradermically,  and  about  four  or  five  days 
later  there  developed  the  typical  vesicular  and  pustular 
stages  of  ordinary  vaccination,  quite  uncomplicated. 

Advantages  of  the  Method. 

1.  This  is  a clean  surgical  operation.  If  untoward  results 
develop  they  are  due  to  faulty  technique.  2.  There  is  no 
open  wound,  and  therefore  dressings  are  not  required. 

3.  Dangers  of  secondary  infection  are  practically  eliminated. 

4.  The  percentage  of  positive  reactions  is  very  high.  5.  In 
only  a small  percentage  of  cases  the  local  and  general 
symptoms  caused  complete  incapacity.  6.  It  is  painless  as 
compared  with  scarification.  7.  Children  undergo  the 
hypodermic  vaccination  without  any  difficulty,  owing  to  the 
rapidity  with  which  the  injection  is  carried  out. 


William  Howard  Lister.  By  Walter  Seton.  With  a 
.Foreword  by  Lieutenant-General  Sir  Ivor  Maxse, 
K.C.B.,  C.V.O.,  D.S.O.  Printed  for  private  circulation 
by  Philip  Lee  Warner,  Publisher  to  the  Medici  Society, 
Ltd.,  Grafton-street,  London,  W.  1919. 

The  Life  of  William  Howard  Lister,  Captain,  R.A.M.C., 
by  Walter  W.  Seton,  LL.D.,  will  interest  a wider  circle  than 
that  of  the  University  College  men  for  whom  it  is  primarily 
intended.  Senators  of  the  University  of  London  might  read  it 
with  advantage,  and  the  general  public  will  find  the  incidents 
of  this  short  life  to  be  of  thrilling  interest.  Though  of  Quaker 
stock,  and  educated  at  a Quaker  school,  he  was  eminently  a 
fighter  ; not,  however,  for  fighting’s  sake,  but  as  a champion 
of  good  causes.  Three  or  four  such  contests  are  a 
good  record  for  one  who  had  only  reached  the  age  of  31. 
He  entered  heart  and  soul,  from  the  student’s  point 
of  view,  into  the  vain  struggle  to  make  the  University  into  a 
real  University  of  London  ; and  in  an  unobtrusive  way  he 
was  the  instigator  and  leader  of  some  of  the  more  active 
movements  of  the  London  students  of  his  day.  Amongst 
these  was  the  incident  of  the  “Brown  Dog  at  Battersea, 
which  is  graphically  described.  The  reader  will  see  that  it 
was  not,  as  some  thought,  a mere  piece  of  rowdyism,  but  a 
fight  for  a principle  which  was  backed  up  by  newspaper 
articles  and  debating  society  discussion.  It  was  an  easier  task 
to  cultivate  the  spirit  of  comradeship  amongst  his  fellow 
students  than  to  start  such  a spirit  amongst  the  students  of 
the  University.  His  untiring  efforts  in  this  direction  had 
much  to  do  with  the  successful  origin  of  University 
College  Hall.  . 

But  the  real  spirit  which  inspired  him  is  most  clearly, 
though  all  too  briefly,  shown  in  the  account  of  his  service 
during  the  war.  He  was  one  of  the  first  dozen  qualified  men 
to  obtain  a commission  in  the  R.A.M.C.  and  was  in  time  to 
take  part  in  the  battles  of  the  Marne  and  of  the  Aisne,  and  ' 
except  for  sick  leave,  he  was  continuously  with  the  Army  till 
he  was  killed  on  the  Italian  front  in  August,  1918.  He  was 
not  one  of  those  who  do  not  know  what  bodily  fear  is,  and 
the  excitement  of  battle  had  no  attraction  for  him.  He  was 
always  anxious  lest  his  courage  should  fail,  but  when  the 
time  came  nothing  could  keep  him  from  the  place  of  danger. 
In  a letter  to  a personal  friend,  dated  B.E.F.,  France,  March, 
1918,  he  said : 

“ We  are  all  of  us  a little  grave  and  anxious  out  here,  waiting 
in  this  quiet  before  the  storm,  not  about  the  ultimate  result, 
of  course,  for  of  that  there  can  be  no  doubt.  But  there  a 
going  to  be  deadly  work  this  year,  and  with  so  many  splendid 
fellows  round  one,  one  wonders  more  than  ever  at  the 
wickedness  and  beastliness  of  it  all.  The  people  I am  with 
now  are  the  most  charming  I have  yet  met,  and  I only  pray  1 
may  be  able  to  do  my  full  duty  by  them. 

His  power  of  organising  was  great,  and  everywhere  he 
inspired  enthusiasm.  Sir  Ivor  Maxse,  in  a foreword,  says  : 

■ In  fact,  his  eager  temperament  and  immovable  standard 
of  duty  made  him  indispensable  to  the  troops  whenever 
fighting  was  on,  and  we  all  recognised  his  value  from  the 
last  recruit  to  the  divisional  commander.’’ 

Dr.  Seton  tells  the  story  very  simply,  clearly,  brightly,  and 
without  redundancy.  There  is  not  a dull  page  in  the  book. 
He  is  fortunate  in  having  almost  equally  acceptable  writers 
in  the  two  friends  who  have  supplied  the  longest  quotations. 
It  is  a good  testimonial  for  the  author  that  one  closes  the 
hook  with  regret  and  wishes  that  it  had  been  longer.  It  is 
beautifully  produced,  and  those  who  desire  copies  can  obtain 
them  from  the  senior  clerk,  University  College,  London, 
Gower-street,  W.C.  


Practical  Vaccine  Treatment  for  the  General  Practitioner. 
Bv  R.  W.  Allen,  M.A.,  M.D.,  B.S.,  late  Captain, 
N.Z.M.C.  London  : H.  K.  Lewis  and  Co.  1919. 
Pp.  308  + ix.  7 s.  6 d.  net. 

This  little  volume  contains  a fund  of  useful  information 
on  the  subject  with  which  it  deals.  After  an  autobio- 
graphical introduction,  in  which  the  author  claims  that 
never  in  the  past  12  years  has  he  misled  his  readers  on 
the  subject  of  vaccine  treatment,  he  passes  on  to  explain 
the  rationale  of  vaccine  therapy  in  its  varied  forms.  He  is 
impatient  of  those  who  cannot  distinguish  between  vaccine 


The  Lancet,] 


REVIEWS  AND  NOTICES  OF  BOOKS. 


[August  16,  1919  287 


and  serum.  He  holds — and  we  think  rightly — that  every 
case  undergoing  vaccine  treatment  is  “ a law  unto  itself,” 
and  therefore  it  is  illogical  to  lay  down  beforehand  any 
hard-and-fast  scheme  of  dosage.  The  inference  is  that 
the  clinical  pathologist  should  give  his  own  vaccines ; but 
whereas  it  may  conceivably  be  true,  as  Dr.  Allen  contends, 
that  no  dermatologist  is  a sound  bacteriologist,  it  does  not 
necessarily  follow  that  every  clinical  pathologist  is  a sound 
physician. 

The  author’s  ruling  principle  in  the  administration  of 
vaccine  is  to  give  the  smallest  dose  which  suits  the  patient, 
and  he  gives  some  sound  advice  on  technique — e.g.,  “ Use 
good  tools  and  get  it  over  and  done  with  as  quickly  as 
possible.”  To  this  axiom  we  should  add  the  rider:  “See 
that  in  your  haste  you  have  not  injected  vaccine  into  a vein 
unless  you  wish  to  do  so.”  He  deprecates  the  employment 
of  detoxicated  vaccines  as  being  unsound  in  principle.  He 
is  aware  of  the  bearing  on  success  of  the  barriers  to  the 
action  of  vaccine  occasioned  by  want  of  access,  as  from 
fibrin  in  pneumonia  and  scar-tissue  in  wounds,  and  he 
illuminates  this  pitfall  for  the  unwary.  A novel  and  useful 
feature  for  the  inquiring  mind  is  the  appendix  of  questions 
and  answers  as  regards  vaccines. 

We  find  the  author’s  experience  entertaining,  but  we  should 
like  to  know  more  of  his  failures  in  order  that  others  may 
learn  to  share  his  successes.  He  is  not  always  consistent. 
On  one  page  we  read  that  the  staphylococcus  forms  endotoxin 
and  endotoxin  alone,  and  on  the  same  page,  a few  lines 
further  down,  we  are  told  that  the  staphylococcus  forms 
one  endotoxin  and  two  exotoxins.  Whereas  it  is  twice 
stated  that  the  author  has  never  lost  a case  of  septicaemia, 
we  read  that  in  relation  to  infective  endocarditis  of  a strepto- 
coccal nature  (and  is  not  this  septicaemia  ?)  a few  successes 
(the  italics  are  ours)  are  on  record  ! 

The  author  has  many  lances  to  tilt,  mostly  “agin  the 
Government,”  and  has  apparently  been  “ laughed  to  scorn  ” 
quite  a number  of  times.  Referring  to  pensioners  or  other 
discharged  soldiers  who  may  be  dysentery  carriers  he  writes : 

“ what  steps  the  Army  or  Government  will  take  once 

they  have  been  discharged,  Heaven  only  knows,”  a surmise 
which  may  be  true,  but  does  not  presage  well  for  a judicial 
survey  of  a difficult  subject. 

If  he  does  not  surrender  his  own  judgment,  the  practi- 
tioner will  find  Dr.  Allen’s  book  useful  to  him. 


The  Newer  Knowledge  of  Nutrition : the  Use  of  Food  for  the 
Preservation  of  Vitality  and  Health.  By  E.  V.  McCollum, 
School  of  Hygiene  and  Public  Health,  the  Johns  Hopkins 
University.  Illustrated.  New  York  : The  Macmillan 
Company.  1919.  Pp.  200.  6s.  6d. 

Regardless  of  the  outcome  of  future  studies  relating 
to  the  importance  of  diet  in  the  aetiology  of  such  diseases 
as  pellagra,  tuberculosis,  and  allied  disorders,  the  author 
essays  to  give  a non-technical  presentation  of  the  kinds  of 
combinations  of  our  natural  foods  which  induce  good  or 
faulty  nutrition  in  animals.  This  should  be  of  service  in 
showing  the  inadequacy  of  the  practice,  which  is  still  in 
vogue,  of  regarding  calories  as  the  only  factor  of  import- 
ance in  the  planning  of  the  diet.  It  is  neither  necessary 
nor  desirable  to  abandon  the  customary  classification  of  food- 
stuffs. The  author’s  great  point  is  that  a chemical  analysis 
of  a foodstuff  may  throw  no  light  whatever  upon  certain 
aspects  of  its  dietary  properties,  and  that  only  by  biological 
methods  can  we  arrive  at  principles  which  can  serve  as  a safe 
guide  to  the  planning  of  a safe  dietary. 

The  biological  method  for  the  analysis  of  a foodstuff  is  first 
dealt  with.  Over  3000  feeding  experiments,  most  on 
domestic  rats,  and  some  on  farm  pigs,  cattle,  chickens,  and 
guinea-pigs,  were  made,  and  in  the  result  it  is  found  that 
“the  chemical  requirements  of  these  different  types  of 
animals  are  essentially  the  same.”  It  was  only  in  1897  that 
the  first  fertile  suggestion  was  made  by  Eijkmann  as  to  the 
dietary  fault  causing  beri-beri.  The  various  feeding  experi- 
ments by  other  observers  with  purified  proteins,  amino  acids, 
&c.,  are  explained,  as  well  as  how  it  comes  about  that  under 
certain  conditions  neither  maintenance  of  body  weight  nor 
growth  could  be  secured  with  such  diets,  and  why  the  addi- 
tion of  certain  unidentified  food  substances  restored  the 
balance.  The  relation  of  a diet  of  polished  rice  to  experi- 
mental beri-beri  and  the  “ vitamine  ” hypothesis  of 
Funk  led  up  to  the  discovery  of  two  classes  of  unidentified 


substances  as  necessary  constituents  of  a normal  diet  to 
which  the  terms  fat-soluble  A and  water-soluble  B were 
given.  We  need  hardly  refer  readers  of  The  Lancet 
to  the  large  literature  on  these  points.  A most  interest- 
ing chapter  is  devoted  to  experimental  scurvy  and  the 
dietary  properties  of  vegetables.  Guinea-pigs  restricted  to 
a diet  of  oats  develop  scurvy  in  a few  weeks.  All  the 
“ seeds  ” — wheat,  oats,  rye,  barley,  &c. — examined  resemble 
each  other  very  closely  in  their  dietary  properties,  and  all 
have  important  dietary  faults,  so  that  it  is  not  possible  to 
secure  appreciable  growth  in  young  animals  fed  exclusively 
upon  seed  products  as  the  sole  source  of  nutriment.  There 
seems  to  be  no  species  of  the  omnivora  which  subsists  entirely 
upon  seeds.  Appropriate  mixtures  of  leaf  and  seed  make  fairly 
satisfactory  food  mixtures,  and  the  author  gives  his  reasons 
why  the  leaf  should  show  such  decided  dietary  differences  as 
contrasted  with  the  seed.  The  tubers  and  roots  employed 
and  their  characteristics,  more  especially  as  regards  the 
solubles  A and  B,  are  passed  in  review.  The  short  chapter 
on  the  Vegetarian  Diet  is  most  suggestive,  and  so  is  the  next 
on  Foods  of  Animal  Origin.  Milk  is  our  most  important 
foodstuff,  for  in  addition  to  the  extraordinary  value  of  its 
protein,  when  used  in  combination  with  the  foodstuffs  of 
either  animal  or  vegetable  origin,  it  corrects  their  dietary 
deficiencies.  Milk  and  leafy  vegetables  and  eggs  are 
regarded  as  protective  foods.  The  author  is  loud  in  his 
praises  of  milk  ; indeed,  according  to  him  mankind  can  be 
classified  into  two  groups.  Both  groups  have  derived  the 
greater  part  of  their  food-supply  from  seeds,  tubers,  roots, 
and  meats,  but  differ  in  the  character  of  the  remainder  of 
their  diet.  Those  peoples — Europeans  and  North  Americans 
who  have  made  liberal  use  of  milk  as  a food,  in  contrast 
with  those  peoples — Chinese,  Japanese,  and  people  of  the 
tropics  generally — who  have  made  use  of  the  leaf  as  their 
sole  protective  food,  in  the  words  of  the  author  - 
“ have  attained  greater  size,  greater  longevity,  and  have 
been  much  more  successful  in  rearing  their  young.  They 
have  been  more  aggressive  than  the  non-milk  using  peoples, 
and  have  achieved  greater  advancement  in  literature,  science, 
and  art.  They  have  developed  in  a higher  degree  educa- 
tional and  political  systems  which  offer  the  greatest  oppor- 
tunity for  the  individual  to  develop  his  powers.  Such 
development  has  a physiological  basis,  and  there  seems 
every  reason  to  believe  that  it  is  fundamentally  related  to 
nutrition.” 

In  the  United  States  15-25  per  cent,  of  the  total  food-supply 
is  from  the  products  of  the  dairy.  Milk  is  the  greatest  factor 
of  safety  of  our  nutrition.  Its  value  cannot  be  estimated  on 
the  basis  of  its  content  of  protein  and  energy.  It  has  a 
value  as  a protective  food,  improving  the  quality  of  the  diet, 
which  can  be  estimated  only  in  terms  of  health  and  efficiency. 
The  last  chapter  deals  with  the  nursing  mother  as  a factor  of 
safety  in  the  nutrition  of  the  suckling. 

This  is  a record  of  laborious  and  painstaking  work  on  an 
important  and  urgent  subject,  illuminated  by  penetrating 
criticism  and  suggestive  practical  applications.  It  largely 
modernises  and  fructifies  our  ideas  of  the  importance  of 
food  and  feeding,  while  demonstrating  how  little  we  know 
as  yet  of  the  intimate  factors  of  nutrition.  Altogether  a 
wonderfully  suggestive  contribution  to  the  elucidation  of 
some  of  the  obscure  phenomena  of  the  physiology  of 
metabolism  in  its  widest  sense. 


Health  Resorts  of  the  British  Isles.  Edited  by  Neville 
Wood,  M.D.  Second  edition.  London  : University  of 
London  Press,  Ltd.  1919.  Pp.  254.  6s. 

The  present  is  an  auspicious  time  for  the  publication  of 
a second  edition  of  this  book.  For  one  reason  or  another 
many  patients  will  be  prevented  for  many  years  to  come  from 
visiting  the  famous  centres  of  hydrology  on  the  continent. 
At  the  same  time,  owing  to  the  efforts  of  a few  English 
physicians,  the  importance  of  hydrology  is  at  leDgth  being 
realised  in  this  country,  and  there  are  prospects  of  a 
scientific  development  of  our  own  not  inconsiderable 
resources.  As  Dr.  Wood  points  out,  there  are  important 
mineral  springs  scattered  throughout  the  Empire,  and  it  is 
unfortunate  that  the  medical  men  coming  from  our  own 
overseas  dominions  should  have  to  seek  on  the  continent 
that  post-graduate  instruction  in  hydrology  which  we  are 
at  present  unable  to  provide. 

The  lesser  as  well  as  the  better  known  British  watering- 
places  are  all  noticed  in  this  book,  and  their  virtues, 
whether  for  baths,  climate,  or  sunshine,  are  duly  recorded. 


288  The  Lancet,] 


A MONTHLY  RECORD  OF  ATMOSPHERIC  POLLUTION. 


[August  16,  1919 


There  are  numerous  illustrations,  many  of  which  are  already 
well  known  to  those  who  travel.  More  important,  perhaps, 
are  the  analytical  tables  which  are  given  from  time  to  time, 
and  of  which  there  might  be  even  more  with  advantage  to 
the  medical  reader.  Some  districts  are  necessarily  better 
reported  than  others.  The  accounts  furnished  by  medical 
committees  and  societies  are  obviously  the  best,  and  an 
increasing  interest  on  the  part  of  medical  men  in  their  own 
districts  will  doubtless  lead  to  a continued  improvement  of 
this  useful  volume. 


JOURNALS. 

In  the  Military  Surgeon  for  June  Colonel  H.  L.  Gilchrist 
describes  the  “ mobile  degassing  station”  devised  by  him- 
self as  Medical  Director  of  the  Chemical  Warfare  Service  of 
the  American  Expeditionary  Force.  They  were  required  to 
deal  with  damage  to  the  mucous  membranes  by  acid  and 
chlorine  and  with  damage  to  the  skin  by  mustard  gas.  They 
bad  a blue  flag  by  day,  a blue  lantern  by  night.  When  the 
men  arrived  any  who  showed  gas  symptoms  were  at  once 
treated  and  sent  on  to  hospital,  the  others  were  divided  into 
groups  of  24  for  bathing  and  re-clothing.  These  last,  after 
laying  down  arms  and  loose  equipment,  neutralised  their 
hands  and  shoes  with  dry  lime,  and  their  helmets  with  lime 
water,  the  helmets  being  hung  on  numbered  shelves.  The 
men  then  undressed,  stepped  under  the  showers,  sprayed 
themselves  with  liquid  soap,  the  hot  showers  were  turned  on 
for  15  seconds,  45  seconds  were  allowed  for  washing,  and  the 
showers  were  then  turned  on  again  for  30  seconds  to  remove 
the  soap.  Each  man  had  a clean  towel.  Eyes,  noses,  and 
throats  were  then  sprayed  with  5 per  cent,  solutionof  sodium 
bicarbonate,  the  men  were  inspected  naked  by  medical 
officers,  were  served  out  with  fresh  uniform  and  under- 
clothes, and  returned  to  their  units.  The  degassing  unit  was 
essentially  a motor  truck  carrying  a 1200-gallon  tank,  a 
rotary  pump,  and  a device  for  heating  the  water  ; a portable 


shower  apparatus  with  24  shower-heads  like  a pergola  made 
of  2-inch  tubing  with  sliding  joints  and  standing  7 ft.  6 in. 
above  ground ; a hospital  ward  tent  used  as  a bathing  and 
dressing  tent;  and  wagons  to  carry  the  stores  and 
clothing.  The  baths  could  thus  be  taken  to  the  troops, 
the  showers  could  be  erected  in  two  minutes,  the 
whole  outfit  in  17  minutes,  and  packed  up  again  in 
nine.  160  outfits  were  ordered  by  the  Army. 

In  the  same  issue  Brigadier-General  F.  Winter,  Medical 
Corps,  U.8.  Army,  recounts  the  trials  and  triumphs  of  the 
Medical  Corps,  starting  from  crowded  St.  Nazaire,  where 
surgical  specialists  helped  the  needed  hospital  outfit  from 
the  ships  to  the  cars,  through  the  difficulties  of  sanitation  in 
France  when  deficiency  of  tonnage  kept  appliances  short, 
and  the  early  discomfort  of  hospitals  when  cargoes  of 
linoleum  were  sunk  by  submarines,  and  Carrel-Dakin  solu- 
tion froze  in  the  wards,  and  lice  had  not  yet  been  mastered. 
It  was  enthusiasm  for  General  Pershing  and  his  leadership, 
General  Winter  thinks,  that  inspired  all  ranks  to  make  the 
war  machine  work  to  best  advantage ; everyone  helped, 
doctors,  nurses,  and  orderlies.  He  claims  great  results  for 
preventive  medicine  : 45,000  deaths  from  wounds,  22,000  from 
disease,  including  pneumonia,  which,  by  the  way,  attacked 
least  of  all  the  1st  Army  Corps  in  bivouac.  He  believes  it 
was  loyalty  to  their  families  that  kept  the  U.S.  soldiers  off 
alcohol,  and  here  they  were  greatly  assisted  by  the  Y.M.C.A. 
He  pays  a generous  tribute  to  the  work  of  the  Red  Cross, 
which  was  not  only  always  friendly  and  open-handed  with 
stores,  but,  looking  ahead,  published  for  the  young  army  a 
book  of  the  splints  they  might  best  use,  and  set  up  a factory 
in  France  to  make  them.  He  proudly  quotes  from  Sir 
Arthur  Stanley  that  the  people  of  the  United  States  raised 
more  than  five  times  as  much  for  the  Red  Cross  as  was 
raised  in  England,  but  we  must  remember  that  the  United 
States  have  had  nothing  like  our  war  taxation.  All  American 
officers,  speaking  in  the  United  States,  give  most  cordial 
thanks  to  the  French  and  ourselves  for  our  sympathetic 
cooperation. 


A MONTHLY  RECORD  OF  ATMOSPHERIC  POLLUTION. 


Meteorological  Office  : Advisory  Committee  on  Atmospheric  pollution  : Summary  of  Reports  for  the  Months 

ENDING 

August  31st,  1918.  Sept.  30th,  1918. 


Metric  tons  of  deposit  per  square  kilometre. 


Place. 

r co 
SZ  © 

Insoluble  matter. 

Soluble 

matter. 

BO 

2 

Included 
in  soluble 
matter. 

Ij 

Tar. 

Carbon- 
aceous 
other 
than  tar 

Ash. 

5 a 

o o 
Ofi 

J u 

i 

o 

CO 

* 

O 

H 

Sulphate 
as  (S03). 

Chlorine 

(Cl). 

2 

O * 

gK 

Enuland. 
London — 

M e t e o r o 1 ogical 
Office  

37 

010 

099 

1-93 

1-18 

0‘59 

479 

0-74 

0-31 

0-04 

Embankment 
Gardens  

32 

0-07 

1-53 

2-52 

1-48 

2-62 

8-21 

1-21 

0-35 

0 07 

Finsbury  Park  ... 

36 

0-04 

116 

5'72 

1 04 

2-81  10-77 

1-18 

0-24 

006 

Ravenscourt  Park 

22 

0-02 

0-27 

0 76 

0'93 

2'34 

4-32 

0-94 

0-20 

o-io 

Southwark  Park 

32 

0-06 

0-97 

2-21 

2-09 

322 

8 54 

1-29 

0-46 

0-11 

Victoria  Park 

12 

0 02 

103 

5'32 

0'64 

1-27 

8 27 

0-3* 

0 10 

0-03 

Wandsworth  Com. 

50 

001 

o-oi 

010 

1-49 

3-27 

4-88 

1-23 

0-42 

o-oi 

Golden  Lane 

41 

0-05 

1-93 

3-02 

0'66 

3-63 

9-34 

1-44 

0-45 

0-15 

Malveru* 

— 

— 

— 

— 

— 

— 

— 

— 

— 

— 

Manchester— 
Whitworth  Street 
(garden) 

63 

12-20 

,,  (roof  of 
College) 

64 

_ 

_ 

- 



12-00 

_ 



_ 

Newcastle  - on-Ty  ne 

31 

016 

316 

7 80 

1‘43 

324 

15-77 

1-50 

0-30 

0-07 

Rochdale 

— 

- 

— 

— 

— 

— 

32-88 

— 

— 

— 

St.  Helens  

79 

017 

1-28 

337 

2 77 

6-42 

14-01 

2-01 

1-43 

0-12 

Southport— 

Hesketh  Park  ... 

67 

002 

0 30 

033 

1-00 

4-36 

6 01 

119 

0 21 

0-07 

Woodvale  Moss  .. 

62 

— 

— 

— 

— 

— 

5 51 

— 

— 

— 

Scotland. 
Coatbridge  

85 

0'28 

624 

9-44 

3-86 

61525-97 

3-00 

0-31 

0-25 

Glasgow — 

Alexandra  Park... 

73 

0-13 

1 23 

3‘82 

0-96 

3 48 

9-62 

2-05 

0-32,0-16 

Bellahouston  Park 

81 

008 

1-02 

3-03 

2‘67 

377  10-57 

1 88 

0-32 

0 08 

Blythswood-sq.  ... 

bS 

013 

214 

4-24 

1-56 

3-2511-32 

2-08 

0-31 

0-18 

Botanic  Gardens 

71 

0-09 

214 

4-08 

2-35 

4-80  13-46 

1-98 

0-31 

o-os 

Richmond  Park... 

85 

010 

1‘61 

516 

4 36 

5-72  16-95 

2-87 

0-44 

0-14 

Ruchill  Park 

79 

010 

1-55 

3 93 

3-40 

357  12-56 

2-30 

0-26 

0 06 

South  Side  Park. 

l 70 

o-os 

1-56 

293 

2-70 

4-3811  70 

1-81 

0 44 

0-08 

Tollcross  Park  ... 

! 80 

Oil 

2-20 

5‘79 

1-28 

4-78  14-60 

2-41 

0-28 

0-08 

Victoria  Park  ... 

100 

•01? 

1-97 

3 79 

2-71 

3 80  12-39 

216 

0 62 

0 18 

Place. 


England. 
London — 
Meteorological 

Office 1 

Embankment 

Gardens  

Finsbury  Park*... 
Ravenscourt  Park 
Southwark  Park... 
Victoria  Park  ... 
Wandsworth  Com. 
Golden  Lane 

Malvern* 

Manchester— 
Whitworth  Street 
(garden) 
,,  (roof  of 

College)  

Newcastle-on-Tvne 

Rochdale  

St.  Helens  

Southport  - 
Hesketh  Park  ... 
Woodvale  Moss... 
Scotland. 

Coatbridge  

Glasgow— 
Alexandra  Park... 
BellahoustonPark* 
Blvthswood-sq. ... 
Botanic  Gardens 
Richmond  Park* 
Ruchill  Park 
South  Side  Park.. 
Tollcross  Park*  ... 
Victoria  Park*  ... 


* No  returns.  1 Excessive  rainfall,  bottle  overflowed. 


Metric  tons  of  deposit  per  square  kilometre. 


1 

*3  © 

Insoluble  matter. 

Soluble 

matter. 

CD 

2 

included 
in  soluble 
matter 

is 

os  S 
65  £ 

Tar 

Carbon- 
aceous 
other 
than  tar 

Ash. 

si 

it 

A 

a 

< 

o 

CD 

s 

© 

© ^ 
a 3 
sz  C 

3 ^ 

SO  ofi 

Chlorine 

(Cl). 

Ammonia 
1 (NH,). 

60 

0-16 

1-76 

2-21 

3-89 

1218 

20-20 

4-85 

1-31 

Oil 

121 

0-03 

1-53 

5-67 

2-42 

2-39 

1204 

1-35 

0-46 

0 21 

59 

Tr. 

4-34 

11-21 

3-72 

4-46 

23-73 

311 

0-59 

0-37 

40 

o-oo 

1-38 

3-27 

0-71 

1-57 

695 

1-50 

0-21 

006 

18 

0-05 

0-87 

4-66 

058 

1-26 

7-42 

0-44 

012 

0-04 

130 

0-04 

1-80 

2-73 

1-56 

6-24 

12-37 

2 95 

097 

0-39 

— 

— 

— 

— 

. 

249 

— 

— 

— 

— 

— 

24  90 

— 

— 

— 

227 











26-10 



_ 



112 

o-io 

2-86 

4-33 

2-23 

4-46 

13-99 

2-45 

0-91 

028 





— 

— 

— 

— 

32-88 

— 

— 



201 

0-43 

318 

6-92 

4-02 

654 

2109 

4-43 

2-98 

0-07 

223 

0 04 

0-67 

048 

4 99 

5 61 

11-80 12-96 

2-45 

0-20 

187 

- 

— 

— 

— 

— 

9 35 

— 

— 

— 

130 

0-14 

1-94 

6-44 

416 

7-30 

19  98 

2 96 

0-65 

0-26 

121 

0-06 

1-29 

2-53 

213 

4-66 

10-67 

2-44 

0-34 

0-23 

154 

0-04 

1-33 

1-62 

2-38 

6-33 

11-70 

338 

0-37 

0-34 

170 

0-06 

1-65 

219 

3-22 

8-65 

15-77 

3-55 

0-34 

017 

140 

002 

114 

203 

2-38 

6 47 

12-04 

3-21 

0-25 

014 

167 

0-01 

0-75 

1-60 

1-47 

7 03 

10-86 

2 51 

0-33 

018 

— 

— 

— 

— 

— 

— 

— 

— 

- 

- 

' — 

— 

— 

— 

— 

— 

— 

— 

Tr.  = trace. 


‘•Tar"  includes  all  matter  insoluble  in  water  but  soluble  in  CSj.  “Carbonaceous"  includes  ail  combustible  matter  insoluble  in  water  and 
in  CS  j.  “Insoluble  ash"  includes  all  earthy  matter,  fuel,  ash,  Ac.  One  metric  ton  per  sq.  kilometre  is  equivalent  to:  (a)  Approx.  91b.  per 
acre : (6)  2‘b6  English  tons  per  sq.  mile ; (c)  1 g.  per  sq.  metre ; ( d ) 1/1000  mm.  of  rainfall. 

The  personnel  of  public  health  authorities  concerned  in  the  supervision  of  these  examinations  and  of  the  analytical  work  Involved  remains  the 
same  as  nubUshpd  in  nrevious  tables.  The  analvses  of  the  rain  and  deposit  caught  in  the  gauge  at  the  Meteorological  Office  are  made  in 
The  Lancet  Laboratory. 


The  Lancet,] 


THE  REORGANISATION  OF  PENSIONS. 


[August  16,  1919  289 


THE  LANCET. 


LONDON:  SATURDAY,  AUGUST  16,  1919. 


The  Reorganisation  of  Pensions. 

The  speech  of  Sir  Laming  Worthington 
Evans,  the  Minister  of  Pensions,  in  asking  the 
House  of  Commons,  sitting  as  Committee  of 
Supply,1  to  agree  to  the  supplementary  vote 
of  £45,855,000  for  the  Ministry  of  Pensions,  has 
helped  the  nation  to  realise  the  responsibility 
imposed  by  the  care  of  its  injured  sailors  and 
soldiers.  A nation  yet  unborn  will  gather  the 
aftermath  of  the  world- war  and  see  the  last  maimed 
pensioner  carried  to  the  grave  from  which  the 
surgery  of  this  generation  saved  him.  It  is  with 
the  sailor  or  soldier  disabled  by  his  service  that  our 
profession  is  chiefly  concerned  ; it  is  here  our  assist- 
ance is  indispensable  to  the  carrying  out  of  the 
work  of  the  Ministry.  The  granting  of  pensions  to 
the  widows  and  dependents  of  the  dead  is  another 
branch  of  pensions  work,  for  which  medical  advice 
is  essential,  being  invoked  chiefly  when  there  is 
doubt  whether  death  by  disease  should  be  attributed 
to  war  service.  The  figures  relating  to  pensions 
are  instructive,  and  may  do  something  towards 
explaining  the  occurrence  of  delays  and  mistakes 
in  a department  newly  organised  in  the  midst  of 
war,  of  whose  duties  the  granting  of  pensions 
to  the  injured  and  to  dependents  forms  only  one 
part.  Pensions,  gratuities,  and  final  allowances 
during  the  past  12  months  have  been  considered 
in  respect  of  more  than  two  and  a quarter  million 
persons,  including  officers,  nurses,  and  men,  with 
their  widows,  their  children,  and  their  other 
dependents.  The  annual  payment  at  present 
comes  to  near  £100,000,000,  though  this  sum  is 
subject  to  reduction  in  the  future,  not  only  by  the 
deaths  of  pensioners,  but  by  the  cessation  of 
gratuities  that  will  not  have  to  be  repeated. 
Moreover,  no  pensioner,  wounded  or  invalided  at 
any  date  in  the  war,  will  leave  the  protection  of  the 
Pensions  Ministry  save  under  proper  medical  certi- 
fication that  he  is  fit  to  undertake  the  training 
proposed  for  him  by  the  Ministry  of  Labour. 

The  part  to  be  played  by  medical  men  in 
future  pension  administration  was  considerably 
insisted  upon  by  the  Minister  of  Pensions,  who 
described  the  procedure  in  detail.  The  medical 
boards  for  men  applying  for  pensions,  or  for  the 
renewal  of  them,  passed  on  April  1st  out  of  the 
hands  of  the  Ministry  .of  National  Service  into  those 
of  the  Ministry  of  Pensions,  which  department 
took  over  on  August  4th  from  the  War  Office 
responsibility  for  the  Re-survey  Boarding  of 
Officers.  This  is  a task  which  demobilisation  has 
rendered  very  heavy,  and  during  the  six  months 
ending  with  last  June  medical  boards  were  held 
upon  229,697  men.  At  the  same  time,  and  owing  to 
the  process  of  demobilisation,  there  has  come  under 
the  jurisdiction  of  the  Ministry  the  care  of  the 
disabled,  including  their  treatment  in  hospitals, 
clinics,  and  convalescent  centres.  Colonel  Webb 
will  be  the  chief  medical  officer,  under  whom  a 
medical,  surgical,  and  nursing  staff  will  carry  out 
the  duties  assigned  to  them  by  the  Ministry,  among 
which  will  be  the  provision  of  artificial  limbs  and 
their  repair.  These  increases  in  the  sphere  of  the 

1 The  LiNCET,  August  9th,  p.  267. 


activities  of  the  Ministry  of  Pensions  will,  however, 
be  of  less  interest  to  the  public  than  the  steps 
which  are  promised  for  reorganisation  of  the 
work  of  the  department.  There  has  been  public 
expression  of  dissatisfaction,  which  may  have 
been  exaggerated  but  has  not  been  altogether 
baseless, and  the  existence  of  which  cannot  be  denied. 
A system  by  which  medical  officers  at  the  head- 
quarters of  the  Ministry  were  empowered  to  review 
the  decision  of  a medical  board,  and  by  which  a 
medical  officer  was  authorised  to  alter  the  amount 
of  a man’s  assessment,  though  made  by  a board, 
without  himself  re-examining  the  case,  was  one 
which,  in  popular  phraseology,  “ asked  for  trouble.” 
There  are  now  to  be  Medical  Appeal  Boards  to  which 
the  medical  assessor  of  the  Ministry  may  refer  a 
case,  if  not  satisfied,  on  the  perusal  of  the  papers  in 
it,  that  substantial  justice  has  been  done  to  the 
pensioner  or  to  the  taxpayer.  For  the  taxpayer 
must  be  protected.  To  these  boards  the  pensioner 
himself  will  have  a right  to  appeal,  if  not  satisfied 
with  the  amount  awarded  him,  and  such  re- 
examination should  do  much  to  justify  the  finality 
assigned  to  the  decision  which  will  then  follow. 
In  a question  of  incapacity  the  body  of  the  man 
concerned  supplies  an  essential  part  of  the  material 
required  for  the  consideration  of  his  case,  and  a 
summary  or  statement  of  the  observations  and  con- 
clusions of  others,  whether  medical  men  or  not, 
cannot  satisfactorily  be  substituted  for  it. 

In  addition  to  the  Medical  Appeal  Boards 
there  will  be,  we  understand,  other  new  tribunals 
set  up  as  the  result  of  the  report  of  the  Select 
Committee  recently  published,  and  these  will  be 
independent  of  the  Ministry  of  Pensions,  and 
appointed  by  the  Lord  Chancellor  when  a Bill 
for  that  purpose  has  been  duly  passed.  Their 
functions  will  be  to  consider  appeals  by  a claimant 
of  a pension  in  cases  of  its  refusal  either  on  the 
ground  that  the  disability  was  not  attributable 
to,  or  not  aggravated  by,  military  service,  or 
on  the  ground  that  the  disability  was  due  to 
serious  negligence  or  misconduct  of  the  claimant. 
They  will  also  review  refusals  of  pension  to  a 
widow  or  dependents  on  the  ground  that  the  sailor 
or  soldier’s  death  has  not  been  due  to  military 
service.  These  tribunals  will  be  composed  of  a 
barrister  or  solicitor  as  chairman,  a medical  prac- 
titioner, and  a disabled  officer  or  disabled  man, 
according  to  whether  the  case  to  be  considered  is 
that  of  an  officer  or  of  one  not  holding  a 
commission.  Thus  a statutory  right  will  be 
granted,  as  distinct  from  one  arising  out  of  a 
Royal  Warrant,  to  claim  a pension  before  an 
independent  statutory  count,  whose  decision  will 
be  final.  This  court  will  have  to  decide,  we  may 
add,  one  of  the  most  difficult  of  the  many  complex 
questions  that  arise  in  the  granting  of  war  pensions. 
A man  may  have  entered  the  Army  an  apparently 
healthy  man,  or  with  an  admitted  unsoundness. 
He  may  have  faced  the  rigours  of  one  or 
more  winters  in  the  trenches  and  returned  to 
develop  disease,  ending  in  death  or  disability,  in 
the  healthy  surroundings  of  his  home  or  of  a well- 
ordered  camp  in  the  United  Kingdom.  Naturally, 
to  him  or  to  his  surviving  relatives  it  is  clear 
beyond  demonstration  that  his  war  service  is  the 
responsible  cause  of  a result  which  otherwise 
would  never  have  supervened,  and  yet  it  may 
not  be  so.  We  urge  in  such  a case  a liberal 
consideration  of  the  facts,  medical  and  otherwise, 
with  the  benefit  for  the  claimant  of  such  doubt  as 
science  may  not  be  able  to  clear  up.  We  are  not, 
however,  altogether  in  accord  with  the  observations 


290  The  Lancet,] 


ERNST  HAECKEL. 


[August  16, 1919 


of  Dr.  D.  Murray  in  the  House  of  Commons 
when  he  said  that  this  question  of  the  attribution 
of  disease  to  war  service  should  not  be  put  to  a 
medical  board  at  all.  We  agree  with  him  that  it  is 
a cruel  duty,  and  one  the  perfect  fulfilment 
of  which  is  wellnigh  impossible.  We  regard 
the  matter,  however,  as  one  essentially  for 
medical  decision,  and  we  are  inclined  to  ask  our- 
selves whether  an  appeal  tribunal  with  a majority 
of  laymen  upon  it  can  really  do  more  than  relieve 
a medical  board  of  a painful  responsibility. 
Whether  it  supports  or  overrules  a medical 
hoard’s  decision,  it  can  hardly  add  weight  to  it. 
It  is  our  fervent  hope  that  the  changes  intro- 
duced by  the  present  Minister  of  Pensions  may 
result  in  his  department  combining  justice  with 
generosity,  and  giving  that  degree  of  public  satis- 
faction which  is  essential  to  the  smooth  working  of 
the  affairs  of  the  State.  It  has  to  create  its  own 
standards  and  to  live  up  to  them.  The  standards  of 
pension  administration  created  by  previous  wars 
are  not  merely  obsolete  ; they  were  never  altogether 
worthy  of  the  occasions  which  called  them  into 
being. 

♦ ■"  - 

Ernst  Haeckel.  v 

The  death  is  announced  at  the  age  of  85  of 
Professor  Ernst  Haeckel,  who  attained  world- 
wide reputation  as  a biologist,  a zoologist,  and 
an  apostle  of  Darwinism  in  Germany ; later  he 
secured  notoriety  as  an  expounder  of  a theory 
of  the  universe  by  which  he  settled,  according  to 
his  own  satisfaction,  such  problems  as  the  exist- 
ence of  God,  the  freedom  of  the  will,  and  the 
immortality  of  the  soul.  In  addition  to  these 
labours  he  travelled  widely  in  the  East,  and  during 
the  war  was  an  embittered  opponent  of  Great 
Britain  and  an  ardent  upholder  of  the  German 
cause.  He  was  a skilled  artist  both  with  the  brush 
and  the  lead,  and  his  books  of  travel  were  illustrated 
with  his  own  hand,  while  many  of  his  biological  and 
zoological  works  were  also  embellished  by  him  with 
magnificent  drawings,  both  coloured  and  uncoloured. 
Haeckel’s  chief  claim  to  fame  is  that  when  quite 
a young  man  at  the  very  beginning  of  his 
scientific  career,  apart  from  medicine,  he  read 
and  at  once  accepted  Darwin’s  thesis  as  laid 
down  in  The  Origin  of  Species.”  He  was  the  first 
German  biologist  to  do  so,  and  he  maintained  his 
position  in  opposition  to  many  of  the  foremost 
thinkers  in  Germany,  among  whom  the  most 
prominent  was  \ irchow.  Before  very  long,  as 
every  one  knows,  Darwin’s  doctrine  of  evolution 
was  accepted  in  scientific  circles  in  Germany  as 
well  as  elsewhere.  Haeckel’s  mind,  however, 
worked  on  different  lines  from  that  of  Darwin, 
who  was  eminently  cautious  and  who  worked  by 
amassing  particulars  and  from  them  formulating 
a general  rule.  Haeckel  considered  that  the 
doctrine  of  evolution  could  be  applied  to  the 
solution  of  all  problems  wherein  men  or  animals 
are  concerned  with  almost  the  certainty  of 
mathematical  laws,  and  in  upholding  this  thesis  he 
was  as  bitter  and  dogmatic  as  any  of  the  clericals 
against  whom  he  so  often  tilted.  Thus,  we  find 
him  saying  in  “ The  Riddle  of  the  Universe  ” (we 
quote  from  the  shilling  edition  of  1913),  on  p.  12 

“ In  the  famous  speech  which  Emil  du  Bois-Reymond 
delivered  in  1880  in  the  Leibnitz  session  of  the  Berlin 
Academy  of  Sciences  he  distinguished  seven  world  enigmas, 
which  he  enumerated  as  follows  : (1)  The  nature  of  matter 
and  force  ; (2)  the  origin  of  motion  ; (3)  the  origin  of  life  ; 
(4)  the  (apparently  pre-ordained)  orderly  arrangement  of 


nature  ; (5)  the  origin  of  simple  sensation  and  consciousness  ; 
(6)  rational  thought  and  the  origin  of  the  cognate  faculty, 
speech  ; (7)  the  question  of  the  freedom  of  the  will.” 

Haeckel  goes  on  to  say  that  du  Bois-Reymond 
considered  three  of  these  problems  entirely  trans- 
cendental and  insoluble — namely,  problems  1,  2, 
and  5 ; three  others,  problems  3,  4,  6,  capable  of 
solution  though  difficult ; while  as  to  problem  7 he 
remained  undecided.  Haeckel  sweeps  all  doubts 
away  as  follows  : — 

“ In  my  opinion  the  three  transcendental  problems  (1,  2, 
and  5)  are  settled  by  our  conception  of  substance ; the 
three  which  he  considers  difficult  though  soluble  (3,  4,  and  6) 
are  decisively  answered  by  our  modem  theory  of  evolution  ; 
the  seventh  and  last,  the  freedom  of  the  will,  is  not  an 
object  for  critical,  scientific  inquiry  at  all,  for  it  is  a pure 
dogma,  based  on  an  illusion,  and  has  no  real  existence.” 

Haeckel’s  “ law  of  substance  ” is  the  combina- 
tion of  the  fundamental  chemical  law  of  the  con- 
stancy of  matter  with  the  fundamental  physical 
law  of  the  conservation  of  energy,  and  according 
to  him  it  definitely  rules  out  the  three  central 
dogmas  of  metaphysics — God,  freedom,  and  immor- 
tality. We  can  expand  this  doctrine  in  the  words 
of  Mr.  Joseph  McCabe,  who  is  Haeckel’s  warmest 
supporter  in  this  country,  by  the  following  quota- 
tion from  his  “ Haeckel’s  Critics  Answered,”  where 
he  says  that  Haeckel  concludes — 

“ That  the  thinking  and  willing  force  in  man — what  we 
call  his  mind  or  spirit — is  identical  with  the  force  that 
reveals  itself  in  light  and  heat.  In  other  words,  he  is  forced 
to  think  that  spirit  and  energy  are  one  and  the  same  thing, 
and  so  he  uses  the  names  indiscriminately.  But  he  is  further 

convinced  that  matter  and  spirit  (or  force)  are  not  two 

distinct  entities  or  natures,  but  two  forms  or  two  aspects  of 
one  single  reality,  which  he  calls  the  fundamental  substance. 
This  one  entity  with  the  two  attributes — this  matter-force 
substance — is  the  sole  reality  that  exists.  ” 

Belief  in  God  is  not  the  exploded  idea  that 
Haeckel  seemed  to  consider  it,  nor  can  we  see 
how  belief  in  the  two  cardinal  doctrines  of  the 
conservation  of  matter  and  energy  necessarily 
rules  out  belief  in  God.  But  here  Haeckel  showed 
the  typical  psychology  of  the  Prussian.  Just  as 
the  pan- German — i.e.,  Prussian — ideal  was  that  the 
whole  world  should  be  ruled  and  governed  by  i 
Prussian  kultur,  that  phase  of  psychology  being 
the  one  and  only  mental  attitude  which  possessed 
any  real  good,  so  Haeckel  held  that  belief  in  the 
law  of  substance  explained  all  the  problems  which 
have  exercised  the  mind  of  man  for  centuries, 
whence  it  followed  for  him  that  anyone  who  did 
not  hold  with  his  ideas  was  a gross  obscurantist. 

We  turn  with  relief  from  Haeckel  the  Monist 
philosopher  to  Haeckel  the  biologist.  In  that  field 
he  undoubtedly  did  excellent  work  ; his  champion- 
ship of  Darwin  at  a time  when  that  great  observer’s 
views  were  generally  looked  upon  with  disfavour 
is  greatly  to  his  credit,  and  the  biological  museum 
which  he  gradually  formed  at  Jena  is  comparable 
to  the  immortal  Hunter’s  museum  in  London.  His 
“ General  Morphology  ” was  highly  praised  by 
Huxley,  while  Darwin  gave  similar  praise  to  his 
“ History  of  Creation.”  As  to  his  views  on  the 
war,  which,  when  they  were  published  in  October, 
1914,  rightly  aroused  indignation,  we  can,  now  that 
their  author  is  dead,  feel  nothing  but  pity  that  one 
of  such  intellectual  gifts  should  have  associated 
himself  with  92  other  professors  in  glorifying  the 
atrocities  in  Belgium  and  the  German  doctrine  of 
kultur  and  militarism.  His  work  as  a biologist 
will  stand  as  a whole,  although  it  was  undoubtedly 
defective  in  part ; his  philosophical  and  political 
views  will  be  buried  in  oblivion. 


Thb  Lanoht,] 


THE  BIRTHDAY  HONOURS.— EXPERIMENTS  ON  OUTPUT.  [August  16,  1919  2!)1 


Annotations. 

••  Ne  quid  nlmls.” 

THE  BIRTHDAY  HONOURS. 

On  the  occasion  of  the  celebration  of  His 
Majesty’s  birthday  the  King  has  conferred 
honours  upon  three  members  of  the  medical  pro- 
fession— namely,  Lieutenant-Colonel  Harry  Gilbert 
Barling,  Dr.  Robert  Charles  Brown,  and  Mr. 
William  Ireland  de  Courcy  Wheeler.  Lieutenant- 
Colonel  Harry  Gilbert  Barling,  who  becomes  a 
baronet,  is  the  Vice-Chancellor  of  Birmingham 
University,  where  he  has  been  Ingleby  lecturer  and 
dean  of  the  medical  faculty ; he  has  also  been  exa- 
miner in  surgery  at  the  University  of  Cambridge. 
His  public  services  during  the  war  were  of  the  first 
importance.  Dr.  Robert  Charles  Brown,  who 
becomes  a knight,  is  consulting  medical  officer 
of  Preston  Royal  Infirmary  and  the  founder 
of  a scholarship  for  research  at  Cambridge.  His 
work  in  connexion  with  the  promotion  of  infant 
welfare  has  been  indefatigable.  Sir  W.  I.  de  Courcy 
Wheeler  has  rendered  valuable  scientific  and 
organising  service  during  the  war,  and  is  a member 
of  the  Consultative  Committee  of  the  War  Office. 
Sir  J.  Y.  W.  MacAlister,  secretary  of  the  Royal  Society 
of  Medicine  and  its  parent  society  for  32  years, 
is  President  of  the  Library  Association,  started 
and  acted  as  secretary  of  the  War  Office  Surgical 
Advisory  Committee,  and  organised  the  Royal  Army 
Medical  Corps  Bureau  and  an  Emergency  Surgical 
Aid  Corps  for  the  Admiralty,  the  War  Office,  and 
Metropolitan  Police  during  the  air  raids.  To  these 
.gentlemen,  in  the  name  of  the  medical  profession, 
we  heartily  tender  congratulations  for  well-deserved 
honours,  and  while  doing  so  include  the  name  of 
Mr.  Laurence  Richard  Philipps,  the  founder  of  the 
Paraplegic  Hospital  in  Wales,  who  becomes  a 
baronet,  and  of  Sir  Henry  Francis  New,  the  mayor 
of  Marylebone,  and  vice-president  of  Marylebone 
War  Supply  Hospital,  whose  knighthood  has  been 
thoroughly  earned.  

EXPERIMENTS  ON  OUTPUT.1 

The  first  two  publications  of  the  Industrial 
Fatigue  Research  Board  are  a good  augury  of  the 
high  standard  of  future  issues  to  be  expected 
from  this  recently  established  board.  They  deal 
with  subjects  of  paramount  importance  in  the 
present  industrial  unrest.  Miss  Ethel  E. 'Osborne’s 
report  is  based  on  the  hourly  output  of  43 
women  in  a National  Ordnance  factory,  who 
were  employed  on  a particularly  heavy  and 
rapid  operation  in  the  turning  of  six-inch  shells. 
Data  from  two  shops  were  obtained  of  the  hourly 
output  for  all  operators  for  a whole  week  during 
two  shifts,  day  and  night,  of  12  hours  each,  before 
hours  were  readjusted  so  as  to  replace  those  two 
shifts  by  three  shifts  of  eight  hours  each ; where- 
upon, after  the  lapse  of  five  months  so  as  to  allow 
of  adaptation  to  the  new  conditions,  a fresh  series 
of  data  was  collected  under  precisely  comparable 
conditions,  the  only  variable  factor  being  the 
alteration  in  the  hours  of  work.  The  resulting 
relatively  small  increase  in  hourly  output  under 

1 The  Output  of  Women  Workers  in  Relation  to  Hours  of  Work  in 
Shell-Making.  By  Ethel  E.  Oshorne,  M.Sc.  A Study  of  Improved 
Methods  in  an  Iron  Foundry.  By  Charles  S.  Myers,  M.D.,  Sc.D.,  F R.S. 
Reports  No.  2 (price  6 d.  net)  and  No.  3 (price  2 d.  net)  of  the  Industrial 
Fatigue  Research  Board,  appointed  by  the  Medical  Research  Committee 
and  the  Department  of  Scientific  and  Industrial  Research.  Published 
by  H.M.  Stationery  Office,  1919. 


the  short  shift  system  depended  on  the  large  pro- 
portion of  the  working  time  which  was  absorbed  by 
automatic  machinery  operations,  the  speed  of  which 
was  constant  and  beyond  the  workers’  control.  But 
in  the  work  of  fixing  and  removing  the  shells, 
over  the  speed  of  which  alone  the  operator  has 
control,  the  time  required  for  a fixed  amount  of 
work  shows  a decrease  of  19’5  per  cent,  in  favour  of 
the  shorter  shift.  (In  the  shorter  shifts  the  average 
worker’s  hours  in  the  factory  seem  to  have  been 
about  15  per  cent,  less  than  in  the  longer  shifts.) 
Miss  Osborne  also  shows  that  there  was  a drop  in 
possible  output  of  3’43  per  cent,  for  the  long  shift 
as  compared  with  a drop  of  only  0'58  per  cent,  for 
the  short  shift — i.e.,  the  machinery  became  more 
efficient  and  there  was  less  idle  time  in  the  short 
shift.  Moreover,  during  the  last  hour  of  each  shift 
the  12-hour  shift  showed  a constant,  well-marked 
diminution  in  output,  whereas  no  such  uniformity 
exists  in  the  case  of  the  short  shifts  ; on  the 
contrary,  several  sets  of  curves  exhibit  no  falling 
off.  The  curves  of  output  for  the  short  shifts  give 
evidence  of  the  possibility  of  running  at  full  output 
right  to  the  end  of  the  shift ; but  the  curves  for  the 
long  shifts  give  no  such  evidence. 

Dr.  Charles  S.  Myers’s  report  describes  the 
remarkable  effects  of  movement  study,  reduced 
hours  of  work,  and  an  improved  system  of  payment 
on  output  at  the  Derwent  Foundry  Company,  Ltd., 
Derby.  The  workers  were  voluntarily  trained  in 
the  best  methods  of  casting,  moulding,  &c.  Their 
hours  were  reduced  from  54  to  48  per  week.  As 
soon  as  a worker  reached  60  per  cent,  of 
“ standard  output  ” he  began  to  receive  a 
bonus  on  his  piece-rate  earnings,  which  was 
so  contrived  that  the  price  paid  per  piece 
rose  automatically  with  increasing  output.  Under 
this  scheme  the  increase  in  hourly  earnings 
amounted  to  about  200  per  cent,  in  one  instance 
examined.  The  output  increased  by  more  than 
300  per  cent.  No  evidence  of  increased  fatigue 
was  found,  save,  perhaps,  in  the  case  of  two  workers 
who  had  enormously  increased  their  output  and 
were  producing  far  above  “standard  output.”  There 
was  no  complaint  of  increased  monotony  under  the 
new  system,  and  the  workers  were  unanimous  in 
their  preference  for  it.  The  value  of  such  a report 
as  this  needs  no  emphasis  in  the  present  industrial 
crisis. 


MORAL  IMBECILITY. 

In  the  case  of  a man  named  Edward  Noel  Craven, 
convicted  at  the  Central  Criminal  Court  of  obtain- 
ing property  by  false  pretences,  it  was  urged  at  his 
trial  that  he  ought  to  be  dealt  with  as  a moral 
imbecile  under  the  Mental  Deficiency  Act,  1913. 
He  was,  however,  convicted,  as  stated,  and  sentenced 
to  three  years’  penal  servitude.  From  this  he 
appealed  to  the  Court  of  Criminal  Appeal.  He  was 
a man  able  to  earn  a living  as  an  engineer,  but 
had  committed  many  offences  of  dishonesty,  and 
had  been  in  a home  under  the  Act  of  1913. 
At  the  trial  of  Craven  a medical  witness  from 
that  home  expressed  the  opinion  that  he  was  a 
moral  imbecile  and  should  be  treated  as  such,  but 
the  Lord  Chief  Justice  in  giving  judgment  in  the 
Court  of  Criminal  Appeal  held  that  the  judge  at 
the  trial  did  not  see  his  way  to  make  use  of  the 
Act,  and  that  he  (the  Lord  Chief  Justice)  saw  no 
reason  for  interfering  with  his  discretion.  The 
Home  Secretary,  he  said,  might  order  the  examina- 
tion of  the  prisoner  when  he  was  in  prison  and  his 
removal  to  a home.  An  observation  of  Mr.  Justice 


292  The  Lancet,] 


DEATHS  FROM  MALARIA  IN  ENGLAND. 


[August  16,  1919 


Shearman  at  an  earlier  6tage  of  the  appeal  may  be 
noted.  It  was  to  the  effect  that  the  Mental 
Deficiency  Act  of  1913  contemplates  the  existence  of 
homes  for  persons  committed  under  it,  but  that 
there  is  usually  no  such  home  available,  and  that 
this  had  been  his  lordship’s  experience  when  trying 
such  cases  on  circuit.  He  added  that  it  was  very 
difficult  for  a judge  at  the  trial  of  a charge  to 
investigate  satisfactorily  the  mental  condition  of 
the  prisoner.  The  proper  deduction  would  seem 
to  be  that  the  Mental  Deficiency  Act  is,  in  respect 
of  such  matters  as  those  referred  to,  in  danger  of 
becoming  a dead  letter — first,  because  sufficient 
homes  for  moral  imbeciles  with  criminal  tendencies 
are  not  provided  by  the  State,  upon  which  the  duty 
of  providing  them  should  fall ; and,  secondly, 
because  the  State  does  not  supply  for  the  guidance 
of  judges  the  medical  expert  evidence  which 
usually  must  be  beyond  the  reach  of  the  accused. 


DEATHS  FROM  MALARIA  IN  ENGLAND. 

The  Ministry  of  Health  are  frequently  asked  to 
assist  in  ascertaining  the  nature  of  obscure  cases  of 
illness  in  which  a fatal  issue  has  occurred.  In  two 
recent  instances  the  post-mortem  inquiries  made 
for  this  purpose  by  medical  officers  of  the  Ministry 
have  shown  that  the  fatal  issue  was  due  to  malaria. 
The  Ministry  are  advised  that  in  this  country  a 
death  from  acute  malaria  would  be  an  exceedingly 
rare  event  if  all  medical  practitioners  adopted  the 
diagnostic  rule  that  in  every  case  of  obscure  illness 
in  a demobilised  soldier,  or  other  person  who  has 
served  overseas,  a blood  film  taken  early  in  the 
illness  should  be  examined.  The  Ministry  have 
made  arrangements  by  which  such  blood  specimens 
sent  to  them  for  the  diagnosis  of  malaria  will  be 
examined  and  reported  on  free  of  charge.  The 
method  of  taking  the  specimen  is  described  on  p.  11 
of  the  Memorandum,  “ Suggestions  for  the  Care  of 
Malaria  Patients,”  of  which  a copy  has  been  supplied 
to  all  registered  medical  practitioners  in  England 
and  Wales.  The  specimens  should  be  addressed 
to  the  Ministry  of  Health,  Whitehall,  S.W.  1,  accom- 
panied by  the  patient’s  name  and  the  name  and 
address  of  the  sender.  The  cover  should  be 
marked  “ Malaria  Specimen  : Urgent.” 

Sir  George  Newman.  Chief  Medical  Officer  to  the 
Ministry,  takes  this  opportunity  to  add  that  during 
the  present  hot  weather  there  is  a possibility  that, 
as  regards  cases  of  illness  in  demobilised  soldiers, 
symptoms  which  appear  to  be  due  to  “ heatstroke  ” 
or  other  effects  of  the  sun  may  in  reality  be  due  to 
malaria.  Medical  practitioners  are  reminded  that 
in  accordance  with  the  provisions  of  the  Public 
Health  (Pneumonia,  Malaria,  Dysentery,  &c.) 
Regulations,  1919,  it  is  incumbent  upon  them  to 
notify  cases  of  malaria  to  the  medical  officer  of 
health  for  the  district. 

INFLUENZAL  OTITIS. 

The  tendency  to  aural  complications  in  influenza 
varies  considerably  in  different  epidemics.  In  the 
winter  of  1889-90  and  in  the  following  years 
influenzal  otitis  was  very  frequent.  In  the  1918 
epidemic,  on  the  other  hand,  it  was  decidedly  less 
common.  Farner,1  assistant  at  the  Zurich  clinique 
for  diseases  of  the  ear,  nose,  and  throat,  states 
that  from  the  beginning  of  July  to  the  end  of 
December  1918,  only  85  ear  cases  visited  the 
clinique,  and  in  another  hospital  at  Zurich  only 
30  ear  cases  occurred  among  861  influenza  patients. 

1 Correspondenzblatt  f.  Sehweizer  Aerzte,  1919,  xlix.,  356-9. 


Of  the  115  cases,  71  were  males  and  44  females, 
90  were  between  the  ages  of  16  and  35,  12  were 
younger,  and  13  older.  In  49  the  otitis  was  of  the 
acute  catarrhal  variety  (in  40  unilateral,  in  9 
bilateral),  and  in  56  suppurative  (in  47  unilateral 
and  in  9 bilateral).  The  otitis  began  on  the  first 
day  of  the  disease  in  23  cases,  on  the  second  day  in 
7,  on  the  third  to  the  seventh  day  in  45,  in  the 
second  week  in  24,  in  the  third  week  in  4,  and  in  12 
the  date  of  onset  could  not  be  determined.  Haemor- 
rhagic vesicles  on  the  tympanic  membrane  and 
sanguineo-purulent  secretion  in  the  tympanic 
cavity  were  seen  in  31  cases.  In  13  paracentesis 
was  performed.  Mastoid  irritation  was  observed  in 
17  cases  and  mastoid  abscess  in  12,  in  1 case  on 
both  sides.  The  following  organisms  were  found 
in  the  pus : pneumococcus  in  5,  streptococcus 
pyogenes  in  3,  streptococcus  mucosus,  diplostrepto- 
coccus,  pneumococcus  and  diplococcus  in  1 each ; 
in  1 the  pus  was  sterile.  The  course  of  influenzal 
otitis,  apart  from  the  cases  complicated  by  mastoid 
abscess,  was  rapid  and  favourable,  and  purely 
nervous  symptoms  such  as  neuralgia  and  “ nervous  ” 
deafness  were  much  less  frequent  and  pronounced 
thap  was  formerly  the  case. 


POOR-LAW  MEDICAL  INSTITUTIONS  AND  LAY 
SUPERINTENDENCE. 

Seizing  the  opportunity  afforded  by  the  re- 
arrangement of  certain  Government  departments, 
the  National  Association  of  Masters  and  Matrons 
of  Poor-law  Institutions  is  attempting  to  revive  an 
old  controversy  by  addressing  to  the  Minister  of 
Health  and  to  the  public  generally  a statement  in 
support  of  the  lay  administration  of  hospitals.  If 
this  document  sets  forth  the  best  case  which  can  be 
made  for  a departure  from  established  principles,  < 
it  does  not'  appear  that  the  medical  men  aimed  at  ' 
have  much  cause  for  alarm.  The  Council  of  the  t 
Association  claims  for  its  members  “probity  of  E 
conduct,  continuity  of  work,  sympathy,  considera-  I 
tion,  and  a fair  holding  of  the  scales  between  all 
the  interests  concerned.”  It  does  not  state  that  I- 
these  qualities  are  lacking  among  the  medical  men 
who  undertake  administrative  work,  though  unless  ,1 
that  implication  is  intended  to  be  conveyed  the  j 
argument  has  no  weight.  Accepting,  however,  the  l 
criteria  proposed,  we  think  that  any  unbiassed  I 
person  would  admit  that  they  are  most  likely  to  be  p 
efficiently  presented  by  professional  men  with  fc 
higher  education,  more  profound  knowledge  of  e 
human  nature,  and  wider  experience  of  public  El 
affairs  than  is  characteristic  of  the  class,  however 
morally  worthy  it  may  be,  from  which  masters  and 
matrons  in  the  Poor-law  Service  are  drawn.  Those  ? 
who  have  seen  the  experiment  tried  know  that  lay  I: 
superintendence  means  divided  control  and  conse-  - 
quent  friction — friction  which  impedes  the  running  , 
of  the  administrative  machine  and  may  bring 
it  to  a standstill.  There  must,  in  practice,  be  one 
head,  and  as  between  the  qualifications  of  medical 
men  and  workhouse  masters  to  manage  institutions 
for  the  sick  the  choice  is  not  difficult.  And  the, 
question  of  choice  is  clearly  raised,  for  in  the ' 
opinion  of  the  Council  “ many  of  our  Poor-law 
institutions  are  bound  to  become  more  and  more 
of  the  nature  of  State  hospitals.”  Nor  is  the  matter  j 
merely  one  affecting  medical  officers.  In  the  Poor-j 
law  Service  the  term  “ matron  ” has  not  the  same 
connotation  as  in  ordinary  hospital  practice.  It  is 
not  to  be  expected  that  trained  nurses  will  submit 
to  continual  interference  by  a superior  officer  who 
is  incompetent  to  judge  their  work  aright  and  who, 


Thk  Lancet,]  INTERNATIONAL  HEALTH  AND  LEAGUE  OF  RED  CROSS  SOCIETIES.  [August  16,  1919  29:5 


lias  not  the  technical  knowledge  which  would 
enable  her  to  be  appealed  to  in  case  of  need.  No 
sane  person,  so  far  as  we  know,  has  suggested 
that  military  hospitals  should  be  placed  under 
the  charge  of  the  Army  Service  Corps,  but  the 
plan  would  have  quite  as  much  to  recommend  it 
as  could  be  said  for  the  proposals  of  the  National 
Association  of  Masters  and  Matrons  of  Poor-law 
Institutions.  The  practice  of  appointing  medical 
men  as  heads  of  institutions  has  stood  the  test  of 
time,  and  any  drawbacks  which  attach  to  it  are  not 
to  be  overcome  by  substituting  for  a fully  qualified 
officer;  one  ignorant  of  the  most  important  part  of 
the  duties  required. 

INTERNATIONAL  HEALTH  AND  THE  LEAGUE  OF 
RED  CROSS  SOCIETIES. 

With  the  approval  of  the  Ministry  of  Health,  Dr. 
G.  S.  Buchanan  proceeded  at  the  beginning  of  the 
week  to  Poland  to  make  one  of  a small  International 
Committee  formed  at  the  instance  of  the  new 
League  of  Bed  Cross  Societies.  This  league  has 
been  requested  by  the  Polish  Government  to  aid 
in  devising  a public  health  organisation  for  that 
sorely  tried  country  in  face  of  the  devastating 
attack  of  typhus  which  it  has  recently  experienced, 
and  of  other  epidemics  which  are  threatened.  Dr. 
Buchanan’s  collaborators  are  Professor  Castellani 
(Italy),  Professor  Dopter  (France),  and  Colonel 
Hugh  Gumming  (United  States  of  America),  so  that 
each  and  all  of  the  Committee  will  be  able  to  advise 
from  close  personal  experience  on  the  practical  ways 
of  preventing  and  of  combating  epidemic  disease. 
A great  promise  may  lie  behind  this  announcement, 
though  more  that  this  cannot  be  said  until  the 
League  of  Bed  Cross  Societies  has  received  the 
report  of  the  International  Committee ; for 
obviously  when  a country  in  the  special  condition 
of  Poland  is  concerned  it  may  be  impossible  for  the 
Committee  to  suggest  practical  measures ; or  it 
may  be  easy  to  suggest  the  measures  that  should 
be  taken  while  impossible  to  give  any  assur- 
ance that  public  health  organisation,  however  well 
defined,  can  live  in  so  distressed  an  environment. 
Looking,  however,  on  the  brighter  possibilities,  we 
see  in  the  appointment  of  this  International  Com- 
mittee, with  a mandate  to  give  considered  counsel 
to  the  League  of  Bed  Cross  Societies,  a prevision  of 
what  may  be  done  in  the  future  by  the  League  of 
Nations,  a grand  part  of  whose  programme  is 
maintenence  of  world  health  by  inter-State 
support.  It  seems  to  us  that  the  League  of  Bed 
Cross  Societies  may  be  a very  valuable  pioneer  in 
those  territories  of  international  hygiene  which 
the  League  of  Nations  will  have  to  take  over. 


AMPUTATION  STUMPS. 

Many  accepted  principles  of  surgery  remain 
unchanged  by  the  lessons  of  the  war.  For  instance, 
despite  all  the  experience  of  the  last  four  years, 
the  routine  treatment  of  amputation  stumps  and 
the  methods  of  prosthesis  remain  essentially  the 
same  in  principle  as  they  were  before  the  war, 
though  they  have  been  much  improved  in  details. 
No  doubt  during  the  times  of  stress  the  claims 
of  urgent  surgical  procedures  were  so  over- 
whelming that  no  leisure  was  left  for  the  trial 
of  methods  of  which  the  practical  value  was  not  yet 
established,  such  as  the  operations  advocated  some 
years  ago  by  Dr.  Yanghetti.  Now,  however,  we  may 
hope  that  surgeons  will  be  able  to  devise  new 
methods  of  treatment,  and  that  mechanicians  may 
be  successful  in  constructing  suitable  apparatus 


for  the  improved  amputation  stump.  Two  papers 
which  we  print  in  this  issue  of  The  Lancet  are 
doubtless  only  an  earnest  of  the  developments  to 
come.  Major  Fit/.maurice-Kelly’s  paper  contains 
nothing,  perhaps,  startling  in  its  novelty,  but  it 
offers  what  is  just  now  much  wanted — namely, 
a valuable  contribution  to  the  technique  of  the 
operation  for  forming  plastic  motors.  In  the  Pavilion 
Hospital  at  Brighton  there  is  a plentiful  supply  of 
material,  probably  unrivalled  in  the  Empire,  of 
which  Major  Fitzmaurice-Kelly  has  availed  him- 
self, so  that  he  has  been  able  to  perform  what  is 
perhaps  a greater  number  of  kinematic  operations 
than  any  other  British  surgeon  has  yet  published. 
At  the  present  moment  most  surgeons  are  sceptical 
of  the  practical  value  of  Vanghetti’s  methods,  but 
the  next  few  months  should  see  the  improved  plastic 
motors  fitted  with  suitable  artificial  limbs  and  their 
value  established  or  disproved.  The  paper  by  Major 
W.  E.  Gallie,  of  the  Canadian  Army  Medical  Corps, 
records  an  attempt  to  lengthen  an  amputation 
stump  which  is  too  short  to  be  useful,  by  means  of 
an  osteoplastic  operation.  If  sufficient  muscular 
attachments  and  muscular  control  can  be  secured 
there  seems  no  reason  to  doubt  that  this  pro- 
cedure may  be  of  value.  As  in  both  Major  Fitz- 
maurice-Kelly’s  and  in  Major  Gallie’s  operations  the 
risk  of  leaving  the  patient  worse  off  than  before  is 
negligible,  there  seems  no  reason  why  these  opera- 
tions should  not  be  repeated  until  an  agreed 
technique  is  arrived  at. 

MARINE  HYGIENE. 

At  the  Congress  of  the  Boyal  Sanitary  Institute, 
held  at  Newcastle-upon-Tyne  from  July  28th  to 
August  2nd,  Surgeon  Bear- Admiral  Sir  Bobert  Hill, 
Director-General  of  the  Medical  Department  of  the 
Navy,  read  an  excellent  paper  upon  Marine  Hygiene. 
After  pointing  out  to  his  audience  that  much  of 
the  organisation  of  sanitation  afloat  was  similar 
to  that  required  upon  land,  he  emphasised  the 
fact  that  marine  hygiene  necessarily  differed 
in  one  important  particular  from  land  hygiene 
— only  a limited  allowance  of  sleeping  and 
working  space  is  available  in  a ship.  The 
ventilation  of  ships,  especially  fighting  ships,  is 
a difficult  problem,  for  armoured  sides,  decks,  and 
bulkheads  must  be  kept  intact  as  far  as  possible, 
main  watertight  bulkheads  must  not  be  pierced 
below  the  main  deck,  and  ventilation  outlets  or 
inlets,  on  or  above  the  upper  deck,  must  not  interfere 
with  the  working  of  the  guns,  nor  be  placed  within 
the  area  of  their  blast.  The  technical  and  construc- 
tional difficulties  of  the  naval  architect  are  there- 
fore many  when  merely  ventilation  is  in  question. 
Three  systems  are  employed  in  the  Navy : (1)  the 
Plenum  system  in  which  fresh  air  is  forced  into  the 
space  to  be  ventilated,  thus  driving  out  the  foul  air ; 
(2)  the  exhaust  system  in  which  foul  air  is  drawn 
out,  thus  sucking  in  fresh  air ; (3)  the  com- 
bined system,  consisting  of  both  artificial  supply 
and  exhaust.  At  present  the  Plenum  system  is 
generally  used  for  living  spaces,  but  the  exhaust 
system  for  spaces  in  which  are  generated  great 
heat,  disagreeable  odours,  water  vapour,  or  dan- 
gerous gases.  The  combined  system  is  used  for 
medical  dressing  stations  and  operating  rooms. 
Means  are  provided  for  preventing  draughts  and 
for  distributing  air  and  warmth  evenly.  Air  is 
warmed  by  passing  between  tubes  heated  by  steam 
and  a temperature  of  from  55-60°  F.  is  aimed  at. 
Speaking  of  the  water-supply  on  board  ship,  Sir 
Bobert  Hill  said  that  it  had  to  be  most  strictly 
guarded, distilled wateronlybeingused when  the  ship 


294  The  Lancet,] 


HOUSING  SCHEMES. 


[August  16, 1919 


is  at  sea  ; when  lying  in  harbour  or  in  rivers  ships 
are  supplied  by  water-boats  from  the  shore,  which 
are  designed  and  handled  so  as  to  reduce  the  possi- 
bility of  pollution  to  a minimum.  All  water,  more- 
over, supplied  from  the  shore  is  treated  with  chloride 
of  lime  in  the  proportion  of  30  gr.  to  100  gallons. 
For  ventilation  and  disinfection  of  ships  formal- 
dehyde vapour  is  used  and  also  sulphurous  acid. 
The  former  disinfectant  was  found  of  great  service 
during  the  influenza  epidemic  of  1918.  As  to  the 
health  of  the  Grand  Fleet  during  the  war  it  was 
eminently  satisfactory  as  regards  pneumonia, 
enteric  fever,  and  preventable  diseases  generally. 
The  only  serious  epidemics  were  the  two  of 
influenza  in  the  spring  and  autumn  of  1918 ; in  the 
former  of  these  the  death-rate  was  0 03  per  cent., 
in  the  latter  2'8  per  cent.,  owing  to  the  prevalence 
of  broncho  pneumonia  as  a complication.  We 
commend  a study  of  this  paper  to  our  readers,  for 
they  will  there  learn  to  estimate  aright  the  never 
ceasing  watch  which  is  kept  by  the  Naval  Medical 
Department  over  the  health  of  its  charges. 


HOUSING  SCHEMES. 

We  learn  that  sites  have  been  selected  for  the 
400,000  houses  which  are  to  be  built  at  some  time 
or  another  to  provide  for  the  needs  of  .the  popula- 
tion, and  the  Ministry  of  Health  is  urging,  in  its 
magazine  Housing,  the  necessity  for  speeding  up. 
It  is  implied  that  local  authorities  are  responsible 
for  the  delay,  but  we  can  imagine  that  local  autho- 
rities are  naturally  chary  about  entering  on 
schemes  which  must  involve  the  spending  of 
large  sums  of  money.  Economy  appears  to  be 
the  watchword  of  the  Prime  Minister  and  the 
Chancellor  of  the  Exchequer,  but  we  doubt  whether 
economy  will  be  realised  in  Government  house- 
building after  reading  an  article  in  Housing  headed 
the  Production  Department.  From  this  we  learn 
that  there  are  three  problems  in  the  production  of 
a house : materials,  labour,  and  transport.  To 
manage  these  there  is  to  be  a production  officer 
who  will  work  in  liaison  with  officials  from  the 
Ministry  of  Munitions  for  materials,  the  Ministry  of 
Labour  for  labour,  and  the  Ministry  of  Ways  and  Com- 
munications for  transport.  There  will  also  be  a 
regional  advisory  committee.  We  are  not  told  whence 
the  money  is  to  come  which  all  these  bodies  will 
assuredly  demand,  but  we  doubt  whether  local 
bodies  will  speed  themselves  up  to  get  into  liaison 
with  this  army  of  officials.  In  the  meantime  it  is 
very  desirable  that  the  taxpayers,  on  whose  pocket 
the  cost  of  the  housing  is  sure  to  fall,  should  be 
enlightened  as  to  the  manner  in  which  the  Govern- 
ment houses  are  to  be  built.  For  instance,  we 
should  like  to  know  whether  the  water  pipes  will 
be  run  as  much  as  possible  away  from  the  outer 
walls,  or  carefully  packed  if  run  down  them, 
so  as  not  to  freeze  in  cold  weather.  Again, 
will  the  cut-off  taps  (if  such  are  supplied, 
as  they  should  be)  be  in  a place  where 
the  tenant  can  get  at  them  without  risking : 
(a)  setting  the  house  on  fire,  (b)  spoiling  his 
clothes,  (c)  breaking  his  leg  by  having  to  scramble 
into  mainly  inaccessible  places  in  a dark  loft. 
Again,  if  there  are  electric  bells  will  the  cells  be 
put  where  they  can  be  seen  and  also  easily  reached. 
The  members  of  the  Housing  Department  of  the 
Ministry  of  Health  do  live  in  houses,  and  have 
some  idea  as  to  what  constitutes  comfort  and 
freedom  from  worry  in  a house  be  it  ever  so  small. 
We  should  like  to  know  that  in  the  projected 
buildings  all  these  things  are  being  thought  out, 


for  they  are  of  immense  medical  importance.  The 
medical  interest  in  housing  does  not  cease  when 
ordinary  questions  as  to  site,  aspect,  and  drainage 
have  been  satisfactorily  answered. 


THE  ACTION  OF  ULTRA-VIOLET  RAYS  ON  THE 
ACCESSORY  FOOD  FACTORS. 

An  interesting  differentiation  of  the  accessory 
food  factors  appears  in  a paper  by  S.  S.  Zilva, 
published  in  the  July  number  of  the  Bio-Chemical 
Journal.  This  investigation  showed  that  the 
exposure  of  treated  lemon  juice  to  ultra- violet  rays  in 
neutral  condition  does  not  influence  its  antiscorbutic 
activity.  Similarly  the  exposure  of  autolysed 
yeast  juice  for  the  same  length  of  time  does  not 
impair  its  antineuritic  potency ; but  butter  exposed 
for  eight  hours  to  ultra-violet  light  undergoes  a 
very  noticeable  change,  and  the  fat- soluble  A factor 
in  it  becomes  inactivated.  The  moral  of  this  is 
that  butter  should  be  kept  in  the  dark,  and  it  is 
well  known  also  that  light  is  a contributory  factor 
in  rendering  butter  rancid. 


ANDREW  CARNEGIE. 

By  the  death  of  Andrew  Carnegie,  in  his  eighty- 
fourth  year,  a conspicuous  figure  passes  from  the 
ken  of  this  world.  Born  of  comparatively  poor 
parents,  who  were  in  his  childhood  ruined  by  the 
introduction  of  the  power  loom  in  displacement  of 
the  hand  loom,  he  arrived  in  America  with  his 
family  in  1848.  After  passing  through  the  stages 
of  bobbin-boy  in  a cotton-mill,  furnace-boy  in  a 
factory,  telegraph  operator,  and  various  posts 
in  the  Pennsylvania  Railway  Company,  he  became, 
in  1863,  superintendent  of  the  line.  He  had 
both  made  money  and  acquired  experience,  and 
the  enormous  development  of  the  iron  industry 
which  began  after  the  American  Civil  War  gave 
him  his  opportunity.  He  possessed  to  the  full  the 
faculty  of  using  men,  and  though  naturally  kind-  | 
hearted  and  generous,  business  always  came  first. 
In  1873  he  put  £50.000  into  an  iron  and  steel 
company ; 26  years  later  the  business  was  sold  for 
something  over  £90,000,000,  Carnegie’s  share  being 
more  than  a half.  Although  relentless  in  his 
methods  of  making  money  he  gave  away  enormous 
sums,  his  total  benefactions  by  1908  being  estimated 
at  about  £85,000,000,  and  most  of  this  was  devoted 
to  organs,  education,  peace  propaganda,  and  the 
Hero  Fund.  If  his  benefactions  did  not  bring 
about  all  the  benefits  that  he  desired  it  was  not  for 
want  of  will,  and  his  gift  of  £2,000,000  to  Scottish 
universities  is  an  example  to  be  followed,  for 
all  the  criticisms  which  have  been  showered  on 
it.  It  is  because  of  this  gift  that  he  may  be 
regarded  as  a supporter  of  the  cause  of  science. 
His  mentality  was  curious,  his  gospel  of  wealth  laid 
down  strict  theories  as  to  the  duties  of  wealth, 
yet,  as  the  great  Homestead  strike  showed  in 
1892,  he  was  a bitter,  even  venomous,  opponent 
of  organised  labour.  If  he  did  not  live  to 
see  one  of  his  ideals  realised — namely,  the 
union  of  Great  Britain  with  the  United  States 
— yet  he  at  least  saw  the  two  nations  brought  into 
more  intimate  relations  than  ever  before.  His 
other  ideal,  the  abolition  of  war,  received  a rude 
shock  in  1914,  and  while  the  conflict  was  being 
fought  out  he  relapsed  into  complete  seclusion. 
On  the  whole  it  may  be  said  of  him,  that  other 
men  laboured  and  he  entered  into  their  labours, 
yet  he  tried  his  best  to  do  good  with  wealth  which 
in  some  ways  had  ominous  origin. 


The  Lancet  ] 


REGISTRAR-GENERAL'S  DECENNIAL  SUPPLEMENT  (1901  1910).  [August  16,  1919  295 


REGISTRAR-GENERAL’S  DECENNIAL 
SUPPLEMENT  (1901-1910). 


I. 

In  Part  III.  of  the  recently  issued  supplement  to  his 
seventy-fifth  annual  report  Sir  Bernard  Mallet  contributes  a 
volume  which  will  certainly  be  welcomed  by  students  of 
statistical  science.  This  volume  contains  detailed  statistics 
of  natality  as  well  as  mortality  in  England  and  Wales  during 
the  ten  years  1901-10,  and  forms  part  of  a series  of 
decennial  reviews  of  which  the  first,  published  in  1864, 
related  to  the  period  1851-60. 

Although  in  some  earlier  years  summaries  of  recent 
mortality  had  been  issued  from  the  General  Register  Office, 
Dr.  William  Farr  decided  in  1864  to  inaugurate  a regular 
system  of  decennial  reviews  in  which  the  proportions,  resting 
on  the  experience  of  a sufficient  number  of  years,  should 
deserve  the  confidence  of  statisticians.  At  the  close  of  each 
subsequent  decennium  similar  supplements  have  been  issued, 
retaining  to  a large  extent  the  essential  features  of  the 
original  volume.  In  this  report  the  Registrar-General 
presents  an  interesting  review  of  the  whole  series  from 
1851-60  onwards.  He  expresses  regret  at  the  late  appearance 
of  the  work,  but  attributes  the  delay  to  the  war,  which  has 
entailed  depletion  of  the  staff  and  imposed  new  and  urgent 
duties  upon  those  responsible  for  the  production  of  this 
volume.  The  present  supplement,  like  its  several  pre- 
decessors, deals  with  registration  areas,  which,  except  in 
the  case  of  counties,  are  not  coextensive  with  any  territories 
used  for  public  health  or  other  administrative  purposes.  It  is 
the  last  of  its  kind,  the  scheme  designed  for  the  next  supple- 
ment being  based  on  administrative  in  place  of  registration 
districts  as  the  local  units  for  tabulation. 

Natality , Legitimate  and  Illegitimate. 

The  births  in  England  and  Wales  during  the  ten  years 
ended  in  1910  numbered  9,298,209,  of  which  370,418  were 
born  out  of  wedlock.  There  has  been  a creditable  decrease 
of  illegitimacy  between  1871-80  and  1901-10,  a decrease 
which  is  the  more  remarkable  as  it  commenced  whilst  the 
legitimate  birth-rate  was  still  rising.  Stated  in  terms  of  the 
living  at  all  ages,  the  decennial  birth-rate  in  the  course  of 
the  last  six  decennia  has  varied  from  35  4 in  1871-80  to 
272  in  1901-10 ; but,  calculated  as  it  ought  to  be,  in  pro- 
portion to  the  numbers  of  women  of  child-bearing  ages — i.e., 
from  15  to  45 — the  birth-rate  shows  a greater  fall  than  when 
calculated  on  the  aggregate  population. 

Natural  Increase  of  Population  in  Recent  Decennia. 

The  mean  populations  employed  in  this  volume  were 
calculated  by  the  method  described  in  the  annual  report  for 
1907,  which  is  a modification  of  that  used  for  the  decennial 
supplement  of  1891-1900.  The  results  obtained  by  the  two 
methods  differ  very  slightly,  the  main  principles  in  both 
cases  being  identical.  The  estimated  mean  population  of 
England  and  Wales  in  the  latest  decennium  was  34,180,202 
persons,  among  whom  females  were  in  excess  by  more  than  a 
million. 

The  natural  increase  of  the  population  by  excess  of  births 
over  deaths  in  each  of  the  last  six  decennia  is  shown  by  a 
table  from  which  it  appears  that  the  fall  in  the  death-rate 
had  almost  exactly  compensated  for  the  fall  in  the  birth-rate 
throughout  the  period  from  1851-60  to  1901-10.  But,  during 
the  latest  decennium  this  balance  has  been  upset,  the  further 
decline  in  the  death-rate  being  insufficient  to  compensate  for 
the  fall  in  the  birth-rate,  even  before  the  war.  Dr.  T.  H.  C. 
Stevenson  gives  reasons  for  believing  that  “ these  excesses  of 
crude  birth-rate  over  crude  death-rate  (which  are  of  practical 
importance  as  measuring  the  rate  of  increase  actually 
occurring)  are  the  result,  in  each  case  of  two  factors,  the 
tendency  towards  reproduction  or  death,  and  the  opportunities 
afforded  by  each  population  for  the  display  of  these 
tendencies.” 

* Deaths  and  Standardisation  of  Death-rates. 

The  deaths  registered  in  England  and  Wales  during  the 
decennium  1901-10  numbered  5,248,774,  corresponding  to  a 
crude  rate  of  15  4 per  1000  living,  which  is  the  lowest 
recorded  since  the  establishment  of  civil  registration.  From 
a table  of  male  and  female  death-rates  in  the  respective 
decennia  it  appears  that  mortality  has  fallen  by  30  per  cent, 
in  the  course  of  the  last  60  years,  the  fall  in  1901-10  being 


much  more  rapid  than  in  any  previous  decennium.  For  com- 
parative purposes  it  has  long  been  the  Registrar-General's 
practice  to  express  mortality  in  the  form  of  “ corrected 
death-rates  ” — i.e.,  rates  “ weighted  ” to  allow  for  differences 
of  sex  and  age  in  the  population  experiencing  the  observed 
mortality.  These  ratesarenow  referred  to  as  “ standardised,” 
the  reasons  for  this  change  having  been  explained  in  the 
annual  report  for  1911.  The  enumerated  population  of 
England  and  Wales  in  1901  has  been  retained  as  the  standard 
in  the  present  volume,  and  all  standardised  rates  incidental 
to  earlier  decennia  have  been  recalculated  accordingly. 
From  a useful  table  we  learn  that  during  the  last 
half  century  a much  greater  decline  has  occurred  in 
the  mortality  of  females  than  in  that  of  males  at  all  ages 
from  15  upwards.  This  has  had  the  effect  of  increasing  the 
excess  of  mortality  in  the  male  sex  which  has  been  manifest 
at  all  adult  ages  from  the  earliest  periods  for  which  records 
are  accessible.  This  excess  has  long  been,  and  still  is,  very 
marked  at  age  45-55,  when  it  amounts  fo  30  per  cent.  But 
the  changes  at  some  other  ages  are  even  more  noteworthy. 
Thus,  equality  of  mortality  between  the  sexes  at  age  35-45 
in  1841  50  has  been  converted  into  a male  excess  of  22  per 
cent,  in  1901-10,  and  a female  excess  mortality  of  about 
6 per  cent,  at  ages  25-35  in  1841-50  has  gradually  been 
changed  into  a male  excess  of  17  per  cent,  in  1901-10.  It 
is  notorious  that  the  number  of  females  aged  20-25  has 
been  overstated  in  the  Census  returns.  And  if  such  mis- 
statement at  this  period  did  not  apply  equally  to  the  returns 
of  age  at  death,  it  would  have  the  effect  of  reducing  the 
recorded  mortality  of  females  at  this  age,  and  so,  possibly, 
of  converting  a real  deficiency  into  an  apparent  excess  of 
male  mortality.  Nevertheless,  there  can  be  no  doubt  of  the 
male  excess  in  1901-10.  when  it  amounted  to  not  less  than 
19  per  cent.  At  ages  15-20  the  pre-existiDg  excess  of  female 
has  during  the  last  two  decennia  been  converted  into  an 
excess  of  male  mortality. 

At  age  5-10,  on  the  other  hand,  female  excess  has  during 
the  same  period  replaced  a pre-existing  excess  of  male 
mortality.  This  is  the  only  age- period  at  which  the  mortality 
of  females  has  increased  relatively  to  that  of  males.  At 
age  10-15  the  death-rate  of  females  has  been  in  excess 
throughout  the  seven  decennia,  though  in  1871-80  practical 
equality  was  attained.  It  is  particularly  noteworthy  that  at 
every  age-period  from  5 to  25  years  among  males  and  from 
5 to  35  years  among  females  the  mortality  in  1901-10  was 
less  than  half  that  recorded  50  years  previously — viz.,  in 
1851-60.  The  decline  in  mortality  in  1901-10  from  that  in 
the  preceding  decennium  was  shared  by  each  sex  at  every 
age-group,  the  slight  increase  among  young  children 
experienced  in  1891-1900  having  given  place  to  a decrease 
in  1901-10  amounting  to  20  per  cent. 

Mortality  in  Infancy  and  Early  Childhood. 

An  outstanding  feature  of  the  decennium  under  review  is 
the  substantial  diminution  in  loss  of  life  among  young 
children,  especially  infants.  The  mortality  of  infants  in 
their  first  year  was  equal  to  128  per  1000  births,  while  that 
of  children  under  5 years  was  equal  to  46  per  1000  living  at 
that  age.  Both  of  these  rates  are  the  lowest  recorded  in 
any  previous  decennium.  The  fall  in  the  mortality  of  the 
first  year  of  life  started  about  the  beginning  of  this  century. 
Infant  mortality  in  the  last  quinquennium  of  the  nineteenth 
century  was  as  high  as  it  had  ever  been  since  1837,  and  had 
been  slowly  rising  for  15  years.  The  remarkable  fall  since 
experienced  commenced  with  the  year  1902.  The  death-rate 
in  the  first  five  years  of  life,  which  had  been  stationary  in 
the  last  three  quinquennia  of  the  nineteenth  century,  began 
to  fall  again  with  the  first  year  of  the  new  century.  It  has 
since  maintained  an  almost  parallel  course  with  that  of 
infant  mortality,  of  which,  naturally,  it  is  largely  composed. 

It  is  noteworthy  how  closely  the  relative  position  of  the 
English  counties,  as  regards  mortality  in  early  life,  corre- 
sponds to  that  of  subsequent  ages  in  the  aggregate.  The 
six  counties  with  highest  total  mortality — viz.,  Stafford, 
West  Riding,  Glamorgan,  Northumberland,  Durham,  and 
Lancaster — return  also  the  highest  mortality  at  ages  under 
5 years,  almost  in  the  same  order,  as  well  as  furnishing 
five  out  of  the  six  highest  places  in  infant  mortality. 
Evidently  the  environment  which  weeds  out  most  of  the 
weeklings  in  early  life  is  also  the  most  prejudicial  to 
survival  at  later  ages.  A similar  conclusion  would  be  reached 
if  comparison  were  made  between  countries  instead  of 
counties  as  above,  and  it  seems  to  follow  that  measures 


296  The  Lancet,] 


THE  PUBLIC  SUPPLY  OF  VACCINE  LYMPH. 


[August  16,  1919 


which  preserve  the  lives  of  young  children  must  generally 
promote  the  vitality  of  survivors  likewise. 

The  distribution  of  mortality  over  each  of  the  first  five 
years  of  life  is  here  discussed,  both  for  the  country  at  large 
and  for  the  urban  and  rural  groups  of  counties.  The  differ- 
ence between  urban  and  rural  environment  appears  to 
influence  the  death-rate  considerably  more  in  the  second  and 
each  of  the  three  succeeding  years  of  life  than  in  the  first. 
The  urban  excess,  which  is  30  per  cent,  in  the  first  year  after 
birth,  grows  to  not  less  than  96  per  cent,  in  the  second  and 
third  years,  after  which  it  declines  to  56  per  cent,  in  the 
fifth  year.  This  excess  is  at  all  ages  much  less  due  to  the 
extent  by  which  the  urban  rates  exceed  the  average, 
than  to  that  by  which  the  rural  rates  fall  below  it ; this, 
indeed,  is  natural,  in  view  of  the  relative  populations  of 
the  two  groups.  Among  girls  the  favourable  effect  of 
rural  environment  is  more  perceptible  than  among  boys 
at  the  earlier  ages,  but  after  the  second  year  there  is 
scarcely  any  difference  in  this  respect.  The  death-rate 
of  females,  which  is  much  below  that  of  males  in  the  first 
year  after  birth,  gradually  approximates  to  it  in  the  next 
three  years,  and  in  the  fifth  year  even  slightly  exceeds  it,  as 
it  tends  to  do  also  in  the  two  subsequent  quinquennia  of  age. 
So  considerable  is  the  influence  of  environment  on  life 
and  health  during  the  second  and  third  years  of  life  that 
whilst  in  1901-10  the  mortality  of  the  urban  group  of 
counties  in  the  third  year  was  practically  identical  with 
that  at  all  ages  together,  that  of  the  rural  group  was  only 
two-thirds  of  the  corresponding  figure  for  that  group  at  all 
ages.  In  childhood  the  difference  between  urban  and  rural 
mortality  may  be  regarded  as  a rough  indication  of  the 
comparative  extent  to  which  mortality  generally  is  pre- 
ventable. And  thus  the  extreme  importanoe  is  emphasised 
of  safeguarding  the  health  of  children  in  the  years  inter- 
vening between  infancy  and  compulsory  school  attendance — 
a matter  which  is  now  happily  receiving  the  public  attention 
which  it  deserves. 


THE  PUBLIC  SUPPLY  OF  VACCINE 
LYMPH. 


A Memorandum  has  been  prepared  by  the  Ministry  of 
Health,  for  the  use  of  the  medical  officer  of  health,  in  con- 
nexion with  the  supply  and  use  of  vaccine  lymph  for  the 
vaccination  or  revaccination  of  persons  who  may  have  been 
exposed  to  small-pox  infection.  The  Memorandum  has  been 
prepared  for  convenience  of  reference  in  consequence  of  a 
number  of  small  outbreaks  of  small-pox  that  have  occurred 
during  recent  months  in  which  it  was  evident  that  the  pro- 
cedure to  obtain  vaccine  lymph  is  not  always  fully  under- 
stood. The  Memorandum  runs  as  follows  : — 

1.  The  importance  of  obtaining  the  prompt  vaccination  of 
persons  who  have  been  exposed  to  small-pox  infection  needs 
to  be  emphasised,  as  cases  have  recently  occurred  in  which 
known  contacts  of  small-pox  cases  have  not  been  offered 
vaccination  promptly  and  subsequently  have  developed 
small-pox. 

2.  It  is  the  duty  of  the  public  vaccinator  to  vaccinate  or 
revaccinate  at  the  public  expense  persons  in  his  district 
who  apply  to  him  for  the  purpose,  and  who  have  not  pre- 
viously been  vaccinated  or  revaccinated  within  a period  of 
ten  years.  Vaccination  of  small-pox  contacts  by  the  public 
vaccinator  should  therefore  be  regarded  as  the  ordinary  pro- 
cedure when  this  can  be  arranged  without  causing  delay. 
In  this  connexion  it  should  be  remembered  that  public 
vaccinators  frequently  have  in  their  possession  a recent 
supply  of  vaccine  lymph  ready  for  use.  In  any  case,  the 
medical  officer  of  health  is  requested  immediately  to 
acquaint  the  public  vaccinator  and  vaccination  officer  con- 
cerned when  cases  of  small-pox  come  to  his  notice. 

3.  Vaccination  of  small-pox  contacts  may  also  be  carried 
out  by  the  medical  officer  of  health  without  reference  to  the 
public  vaccinator,  and  sometimes  it  is  obviously  the  best 
course  that  these  contacts  should  be  vaccinated'by  him  at 
once  when  the  fact  of  exposure  to  infection  has  been 
discovered.  The  Local  Government  Board  issued  in  1917 
the  “Public  Health  (Small-pox  Prevention)  Regulations,” 
which  provided  that : “ The  medical  officer  of  health  of  any 
local  authority  may,  on  the  occurrence  of  any  case  of  small- 
pox and  where  the  circumstances,  in  his  opinion,  so  require 
and  permit,  perform  vaccination  or  revaccination  on  any 
person  who  has  come  in  contact  with  the  infection  and  is 
willing  to  be  vaccinated,  and  without  charge  to  the  said 
person." 


4.  Vaccine  lymph  from  the  Government  Lymph  Estab- 
lishment will  be  supplied  for  this  purpose  to  medical  officers 
of  health  cn  application  by  letter,  telegram,  or  telephone  to 
the  Government  Lymph  Establishment,  Colindale  Avenue, 
The  Hyde,  London,  N.W.  9.  Telegraphic  address : 
“ Defender,”  Hyde,  London.”  Telephone  No. : Kingsbury  41 
(London  District). 

The  next  three  sections  of  the  Memorandum  contain 
important  counsel  and  information.  The  Government 
Lymph  Establishment  advise  that  lymph  sent  out  by  them 
should  be  used  within  a week  of  its  receipt  as  an  obvious 
precaution  against  unnecessary  storing.  An  exception  can 
be  made  in  the  case  of  ports  in  frequent  communication  with 
the  continent  if  the  medical  officers  of  health  of  such  ports 
communicate  with  the  Establishment.  It  is  also  stated  that 
lymph  supplied  to  medical  officers  of  health  is  for  vaccina- 
tions performed  by  them,  their  assistants,  or  deputies,  while 
arrangements  for  facilitating  public  vaccination  in  an 
affected  district  will  continue  to  rest  with  the  boards  of 
guardians  and  public  vaccinators.  Medical  officers  of 
health,  in  vaccinating  contacts,  are  enjoined  to  keep  a 
dated  record  of  vaccination,  revaccination,  and  their  results, 
with  name,  age,  and  address  of  the  subject.  Where  Govern- 
ment lymph  is  employed  the  official  reference  number 
should  be  recorded,  and  lymph  from  supplies  where  no 
information  concerning  source  is  kept  should  not  be  employed. 

The  Memorandum  quotes  from  a circular  of  the  Local 
Government  Board  of  Feb.  13th,  1917,  the  regulations 
referred  to  in  its  third  paragraph,  which  run  as  follows  : — 

(а)  Vaccination  should  at  every  stage  be  carried  out  with 
aseptic  precautions,  which  should  include  the  cleansing  of 
the  surface  of  the  skin  before  vaccination,  the  use  of 
sterilised  instruments,  and  the  protection  of  the  vaccinated 
surface  against  extraneous  infection  both  on  the  perform- 
ance of  the  operation  and  on  inspection  of  the  results. 
Advice  as  to  the  precautions  to  be  taken  in  this  respect  until 
the  scabs  have  fallen  and  the  arm  has  healed  should  always 
be  given  to  the  person  vaccinated  or.  in  the  case  of  the 
vaccination  of  a child  not  more  than  14  years  of  age,  to  the 
parent  or  other  person  having  the  custody  of  the  child. 

(б)  In  all  ordinary  cases  of  primary  vaccination  the 
vaccinator  should  aim  at  producing  four  separate  good-sized 
vesicles  or  group  of  vesicles  not  less  that  half  an  inch  from 
one  another.  The  total  area  of  vesiculation  resulting  from 
the  vaccination  should  not  be  less  than  half  a square  inch. 

(c)  If  any  person  vaccinated  or  revaccinated  requires 
medical  treatment  in  consequence  of  the  vaccination  or 
revaccination,  the  local  authority  should  offer  to  provide 
such  medical  treatment  as  may  be  required. 

(d)  The  local  authority  should  arrange  to  pay  to  the 
medical  officer  of  health  such  sum  as  is  reasonable  in  respect 
of  the  extra  work  which  he  undertakes  in  pursuance  of  these 
regulations.  For  their  guidance  the  Board  may  state  that  in 
their  view  the  payment  should  be  not  less  than  2s.  6 d.  for 
every  vaccination  or  revaccination  performed. 

When  a medical  officer  of  health  reports  to  the  Ministry  of 
Health  a case  of  small-pox  in  his  district  (Article  XIX.  of 
the  Local  Government  Board’s  General  Order  of  Dec.  13th, 
1910),  it  is  desirable  that  he  should  add  a note  regarding  the 
steps  taken  to  secure  the  vaccination  of  contacts.  Recent 
experience  shows  that  it  is  important  to  bear  in  mind  that 
inspectors  or  others  concerned  with  the  removal  of  small-pox 
cases  or  the  disinfection  of  their  clothing,  and  members  of 
hospital  staffs  who  at  any  time  are  likely  to  come  into 
contact  with  a small-pox  case,  should  at  all  times  be  well 
protected  by  revaccination,  and  should  not  take  the  risk  of 
waiting  to  be  vaccinated  until  exposure  to  infection  has 
occurred. 


Drought  in  Belfast. — Like  many  other  places 
in  the  United  Kingdom  Belfast  is  now  feeling  the  effects  of 
the  continued  drought.  July  is  usually  a wet  month,  but 
during  July  of  1919  rain  to  the  extent'of  only  0 68  in.  fell 
in  nine  days,  the  average  for  the  previous  44'  years  being 
2-80  in.  during  that  month.  Indeed,  for  the  whole  of  the 
year  1919,  up  to  July,  the  rainfall  has  been  only  15T5  in., 
while  the  average  is  20-51  in.  All  over  Ulster  the  weather 
has  been. very  dry;  for  example,  in  Warrenpoint,  at  the 
head  of  Carlingford  Lough,  there  were  only  four  days  in  July, 
during  which  rain  fell  to  the  extent  of  0 54  in.,  while  in  the 
same  month  of  1918  rain  fell  to  the  extent  of  5T1  in.  in 
18  days.  As  a result  farmers  and  water  commissioners  are 
becoming  uneasy.  In  Belfast  the  water  in  store  on  July  31st 
was  reduced  to’ 1461  million  gallons— that  is,  340  million 
gallons  less  than  at  a corresponding  date  in  last  year.  The 
supply  has  been  already  reduced,  and  it  is  announced  that,  if 
the  weather  continues,  a still  further  reduction  will  be  made. 


The  Lancet,] 


PARIS.— AUSTRALIA. 


[August  16,  1919  297 


PARIS. 

(From  our  own  Correspondent.) 

The  Prevalence  of  Raines  in  Paris  and  in  the  Department 
of  the  Seine  and  Oise. 

The  annals  of  the  Pasteur  Institute  contain  the  annual 
report  for  1918  of  the  Institute  with  respect  to  the  treat- 
ment of  rabies  for  the  year.  The  tables  affixed  to  the 
report  make  very  instructive  reading,  for  they  display  a 
great  progression  of  cases  of  rabies  observed  and  treated. 
The  number  of  these  cases  amounts  to  1803  for  the  year 
1918,  while  the  information  collected  by  the  antirabic 
service  allows  us  to  foresee  that  for  1919  the  total  will  be 
still  higher.  In  1914  only  373  cases  came  under  treatment. 
It  is  in  the  Department  of  the  Seine  and  Oise  that  increase 
has  been  particularly  marked.  Before  the  war  from  this 
department  only  30  cases  of  rabies  came  to  the  cognisance 
of  the  Institute  each  year.  In  1918  there  were  193  cases. 

Boric  Acid  in  the  Preservation  of  Food. 

The  report  by  M.  Lindet  to  a committee  of  the  Health  and 
Hygiene  Department  of  the  Seine  calls  attention  to  the 
increased  employment  of  boric  acid  in  connexion  with  food- 
stuffs, and  dwells  on  the  dangers  which  emerge  for  public 
health.  Before  the  war  such  employment  of  boric  acid  was  inter- 
dicted where  not  limited  to  small  percentages  in  case  of 
certain  products.  Severe  proceedings  have  been  taken 
against  the  manufacturers  of  soft  cheese,  who  employ  for 
preservative  purposes  a German  speciality  containing  boric 
acid  to  a degree  which  renders  the  food  dangerous  to 
habitual  consumers.  The  war  suppressed  the  importation  of 
this  stuff  and  the  cheeses  grew  better,  but  to-day  there  is  a 
renewed  danger,  the  incriminated  substances,  no  doubt, 
coming  into  France  by  devious  routes.  Moreover,  there  is  a 
sale  now  for  the  yelks  of  eggs,  rare  and  costly  delicacies, 
which  have  been  preserved  by  boric  acid,  while  butchers  use 
borates  to  retard  putrefaction  of  their  wares,  and  so  do  those 
who  sell  fish  and  butter.  Evidently  the  use  of  boric  acid  is 
not  being  controlled  owing  to  the  urgent  food  difficulties 
of  the  war.  M.  Lindet’s  report  concludes  with  a demand 
for  the  return  to  the  legal  repression  of  these  dangerous 
procedures. 

u. Esthetic  Surgery. 

^Esthetic  surgery,  or,  as  you  call  it,  cosmetic  surgery,  con- 
tinues to  develop  its  territory.  Two  communications  have 
already  been  received  at  the  Academy  of  Medicine  upon  the 
correction  of  nasal  deformities  by  surgical  intervention 
within  the  nostrils  and  under  the  skin,  the  sections  and 
sutures  being  carried  on  without  any  cicatricial  result  which 
is  visible  from  without.  More  recently  Dr.  Passot  has 
undertaken  the  cure  of  wrinkles.  He  had  observed  that 
when  the  skin  in  front  and  above  the  ear  was  pulled  upon 
obliquely  from  below  upwards  and  backwards  effacement  of 
many  wrinkles  took  place,  while  folds  due  to  laxity  of  the 
integument  disappeared.  His  technique  for  obtaining  these 
results  consists  of  a little  cutaneous  resection  under  local 
anaesthesia  at  a site  preferentially  covered  by  the  hair. 
The  scalp  is  shaved  before  the  operation,  and  cicatrices 
will  be  hidden  by  the  growing  hair.  The  operation,  made 
with  full  aseptic  precautions  and  followed  by  minute 
suturing,  gives,  he  considers,  excellent  results,  no  trace  of 
the  proceeding  remaining.  For  wrinkles  on  the  forehead  a 
similar  operation  is  practised  in  the  temporal  region.  The 
hair  having  been  shaved  previously,  the  cuts  here  are 
spindle-shaped.  These  little  operations  appear  to  have  been 
followed  with  considerable  success,  particularly  among 
women. 

Venous  Tension  and  Varicose  Veins. 

Dr.  Mabille  has  made  important  advance  in  the  diagnosis 
and  treatment  of  varicose  veins  in  employing  the  sphygmo- 
meter and  the  viscometer,  in  order  to  measure  the  blood- 
tension  in  venous  system.  This  examination  is  made  in 
the  recumbent  position,  the  leg  being  first  horizontal  and 
then  vertical ; then  in  the  sitting  position,  the  legs  hanging 
down  ; and  finally,  in  the  standing  position.  The  observa- 
tion of  the  differential  pressure  measuring  the  deviation 
between  the  maximum  and  minimum  pressures,  and  of  the 
oscillometric  index,  allow  venous  troubles  to  be  classified  in 
three  groups  : — (1)  Venous  erethism,  temporary  troubles  due 
to  fatigue  or  to  the  great  iDgestion  of  liquid ; (2)  valvular 


insufficiency  ; and  (3)  endocrine  troubles.  Each  of  these 
has  its  different  characteristics.  This  procedure  allows 
the  fixing  of  rules  for  treatment : to  the  first  category  of 
cases  massage  is  assigned,  to  the  second  surgical  inter- 
vention with  resection  of  the  femoral  vein,  and  to  the  third 
treatment  by  medicaments. 

August  11th. 

AUSTRALIA. 

(From  our  own  Correspondent.) 

The  Influenza  Epidemic. 

For  the  last  two  months  the  feature  of  the  epidemic  in 
Victoria  has  been  the  steady  level  of  morbidity  and  mortality. 
From  10  to  12  deaths  daily  occur  for  the  whole  State.  The 
number  of  hospital  patients  is  gradually  diminishing. 
There  are  at  present  about  750  in  public  hospitals.  In 
New  South  Wales  the  lifting  of  the  restrictions  soon 
after  Easter  was  followed  by  an  immediate,  though  not 
explosive,  spread,  just  as  happened  in  Victoria.  During  the 
past  month  in  Sydney  the  spread  has  been  very  acute,  and 
the  death-rate  has  become  very  serious,  although  it  is  difficult 
to  say  what  ratio  it  bears  to  the  actual  number  of  cases. 
Banks  and  public  offices  have  been  partly  closed  owing  to 
shortage  of  staffs.  There  are  at  present  2000  hospital 
cases,  and  fear  is  expressed  that  further  accommodation  will 
have  to  be  provided.  The  Government  have  not  reapplied 
the  restrictions  as  to  masks  or  public  assemblies,  and  the 
chief  health  officer  for  Sydney  has  expressed  the'  opinion 
that  no  measures  of  public  health  are  likely  to  be  of  any 
avail.  In  Brisbane  the  disease  has  appeared  in  epidemic 
form,  but  has  never  reached  alarming  proportions,  although 
the  death-roll  already  numbers  some  hundreds.  In  South 
Australia  it  appears  to  be  smouldering.  Tasmania  still 
remains  free,  and  owing  to  the  shipping  strike  has  practically 
been  cut  off  completely  from  the  mainland  for  the  last 
month.  Lord  Jellicoe  visited  several  Tasmanian  harbours, 
but  no  communication  was  allowed  with  the  shore. 

Returning  Troops. 

Practically  the  last  of  the  hospital  cases  from  overseas 
have  arrived  in  the  hospital  ship  Karoola.  The  system  of 
dealing  with  returning  men  in  Victoria,  or,  as  it  is  called, 
“finalising”  them,  has  been  brought  to  very  smooth 
working.  The  men  are  brought  straight  from  the  transport 
to  a depot  where  a number  of  medical  boards  are  in  waiting. 
The  medical  officers  sit  in  groups  of  two  and  mark  the  men 
in  three  divisions.  Those  who  have  suffered  no  disability 
and  are  well  are  classed  A and  discharged  forthwith.  Those 
who  have  suffered  disability  but  do  not  need  treatment  are 
B and  are  awarded  a pension  on  the  spot,  which  is  subject 
to  review  in  six  months.  Those  who  need  treatment  in  hos- 
pital are  sent  to  Caulfield  Military  Hospital ; those  who 
need  out-patient  attention  or  require  a special  examination 
to  assess  their  pension  rights,  are  referred  to  No.  5 A.  G.  H., 
now  used  only  for  out-patient  cases.  As  many  as  500  men 
are  handled  in  an  hour  and  a half  by  seven  boards,  and  the 
system  is  popular  with  the  men.  The  scene  outside  the 
depot  where  the  relatives  of  the  men  are  in  waiting  is  one 
of  considerable  animation,  and  everyone  inside  works  their 
hardest  to  pass  the  men  out  as  rapidly  as  possible.  Every 
man  is  examined  by  a dentist  and  given  the  right  to  six 
months’  dental  attention  if  needed,  whether  discharged  or 
not.  The  Red  Cross  officials  also  give  each  man  a parcel  of 
underclothing. 

A Question  of  Ethics. 

An  ethical  question  is  attracting  attention  in  Sydney. 
Professor  D.  A.  Welsh,  who  occupies  the  chair  of  pathology 
in  the  University,  recently  wrote  several  articles  over  his 
own  name  in  the  Sun,  a Sydney  daily  newspaper,  on  the 
subject  of  influenza.  This  constitutes  a breach  of  the 
by-laws  of  the  New  South  Wales  branch  of  the  British 
Medical  Association,  and  the  matter  was  brought  to  the 
notice  of  the  local  council.  Professor  Welsh  wrote  intimating 
that  he  would  resign  his  membership  of  the  branch,  but 
the  council  replied  that  he  could  not  do  so  unless  he  also 
resigned  his  membership  of  the  British  Medical  Association. 
There  the  matter  stands  at  present.  Professor  Welsh  is  one 
of  the  three  members  of  the  consultative  council  on  influenza 
appointed  by  the  Government  in  New  South  Wales. 


298  Thh  Lancet,] 


NOTES  FROM  INDIA.— URBAN  VITAL  STATISTICS. 


[August  16,  1919 


Medical  Honours. 

Several  well-known  practitioners  have  received  distinctions 
in  the  Birthday  Honours.  Sir  J.  C.  Verco  has  been  a leader 
in  Adelaide  for  many  years,  and  has  held  almost  every 
position  of  professional  distinction  as  a practitioner  and 
teacher.  Surgeon-General  C.  S.  Ryan,  of  Melbourne,  has 
received  the  honour  of  C.B.E.  Dr.  T.  P.  Dunhill  receives  a 
C.M.G. 

Eliza  Hall  Institute. 

The  position  of  director  of  the  Eliza  Hall  Institute  of 
Research,  which  been  established  at  the  Melbourne  Hospital 
by  an  endowment  for  that  purpose,  has  been  given  to  Dr. 
S.  W.  Patterson,  who  is  a graduate  of  the  Melbourne  Uni- 
versity, but  has  been  for  some  years  engaged  in  special 
study  in  London.  Dr.  Patterson  served  during  the  war  with 
the  rank  of  major  in  the  R.A.M.C. 

June  26th. 

NOTES  FROM  INDIA. 

(From  our  own  Correspondent.) 

The  Soldier’s  Life  in  India. 

Referring  to  the  relief  of  the  Territorials  which  is  now 
proceeding,  a leading  Indian  journal  3ays  : “Apart  from 
their  military  services,  one  of  the  most  important  achieve- 
ments of  the  Territorial  in  India  has  been  his  success  in 
obtaining  better  conditions  for  soldiers  in  garrison.  The  old 
regular  who  happens  to  be  in  India  to-day  will  admit  the 
amenities  of  his  life  have  been  enormously  increased.  For 
much  of  this  the  new  units  will  have  to  thank  the  Territorial 
officers  and  men  who,  having  a ‘divine  discontent,’  made  it 
felt  to  good  effect.” 

Red  Cross  Work  for  the  A fghan  War. 

The  Indian  branch  of  the  Joint  War  Committee  of  St.  John 
and  the  Red  Cross  telegraphed  within  24  hours  of  the  out- 
break of  hostilities  for  supplies  to  be  sent  up  to  the  front 
from  the  main  depot  at  Bombay.  Shortly  afterwards  the 
five  Assistant  Red  Cross  Commissioners,  whose  services  had 
been  obtained  from  the  Commander-in-Chief,  arrived  at  their 
bases  at  Rawal  Pindi,  Peshawar,  Kohat,  Bannu,  and  Quetta. 
Since  then  the  committee  have  been  receiving  indents  from 
them  almost  daily  and  have  already  sent  up  supplies  valued 
at  five  lakhs  of  rupees  (£33,000  sterling). 

Women's  Medical  Service. 

The  Central  Committee  of  the  Countess  of  Dufierin’s  Fund 
for  the  junior  branch  of  the  Women’s  Medical  Service  for 
India  announces  that  in  selected  cases  promotion  will  be 
made  from  the  junior  to  the  senior  branch  of  the  Women’s 
Medical  Service.  Such  selection  will  be  made  from  any 
grade,  even  the  lowest,  when  the  Selection  Committee  is 
convinced  that  promotion  is  deserved  and  a vacancy  has 
occurred.  Should  the  Central  Committee  consider  that  it 
would  be  in  the  interests  of  any  of  the  members  recommended 
for  selection  to  proceed  to  Europe  for  post-graduate  study 
financial  assistance  will  be  given  to  deserving  members  in 
their  own  and  the  public  interest.  In  such  cases  definite 
courses  of  study  will  be  laid  down  such  as  may  from  time  to 
time  be  found  suited  to  the  requirements  of  India.  It  must, 
however,  be  understood  that  the  number  of  vacancies  in  the 
senior  Women’s  Medical  Service  is  at  present  small,  although 
it  is  hoped  that  the  service  may  in  the  near  future  be 
augmented. 

Calcutta  Ophthalmic  Hospital. 

The  absence  of  an  efficient  ophthalmic  hospital  in  Calcutta 
has  long  been  a reproach  to  Bengal.  The  existing  hospital 
is  inadequate  and  ill-equipped,  and  it  has  to  serve  not  only 
the  requirements  of  Bengal  but  of  areas  outside  that  pro- 
vince, patients  coming  from  great  distances  to  be  treated. 
Just  before  the  war  the  Government  is  understood  to  have 
purchased  a site  for  a new  hospital.  The  Indian  press  has 
been  commenting  on  the  subject  in  strong  terms,  and  it 
suggests  that  what  is  wanting  is  a larger  conception  of  the 
whole  situation  regarding  the  treatment  of  eye  diseases  in 
India  and  a more  statesmanlike  way  of  dealing  with  it. 

Beggars  in  Madras. 

An  agitation  is  on  foot  in  Madras  to  do  something  to 
control  the  large  number  of  diseased  beggars  who  infest  the 


streets.  The  Governor  has  just  issued  an  appeal  on  behalf 
of  the  lepers,  for  whose  suffering  thousands  much  more 
ought  to  be  done  than  has  been  achieved  in  the  past  ; but 
until  it  is  recognised  as  an  offence  instead  of  a legitimate 
profession  to  beg  from  every  possible  victim,  the  large  army 
of  those  who  exist  by  this  means  will  prefer  to  pick  up  their 
living  as  hitherto. 

I.M.S.  Officers  from  Ceylon. 

In  response  to  the  appeal  recently  made  for  recruits  from 
Ceylon,  upwards  of  50  applications  have  been  received  from 
Ceylon  doctors  desirous  of  joining  the  Indian  Medical 
Service.  The  number  of  Ceylon  Government  medical 
officers  allowed  to  join  the  Indian  service  has  not  yet  been 
decided  on. 

Pilgrimage  Sanitation. 

The  Government  of  Bihar  and  Orissa  have  submitted  to 
the  Government  of  India  a Bill  to  make  better  provision  for 
the  control  and  sanitation  of  places  of  pilgrimage  in  the 
province. 

Bombay  Water-supply . 

A recent  official  report  by  the  municipal  hydraulic  engineer 
stated  that  “if  two  consequent  failures  of  the  monsoon 
should  occur  before  the  water-supply  is  again  increased,  it  will 
be  absolutely  necessary  to  stop  all  water  supplied  for  trade 
purposes.”  The  daily  amount  available  for  domestic  supply 
during  the  last  nine  months  has  been  only  22  gallons  a head 
of  the  population. 

July  20th. 


URBAN  VITAL  STATISTICS. 

(Week  ended  August  9th,  1919.) 

English  and  Welsh  Towns. — In  the  96  English  and  Welsh  towns, 
with  an  aggregate  civil  population  estimated  at  16,500.000  persons, 
the  annual  rate  of  mortality,  which  had  been  9 0,  10'3,  and  9 7 in 
the  three  preceding  weeks,  was  again  9’7  per  1000.  In  London,  with 
a population  slightly  exceeding  4.000,000  persons,  the  annual  rate 
waB  95  per  1000,  and  coincided  with  that  in  the  previous 
week,  while  among  the  remaining  towns  the  rates  ranged 
from  29  in  Wimbledon,  30  in  Willesden,  and  3’5  In  Ilford, 
to  15'5  in  S'.  Helens,  162  in  South  Shields,  and  16'5 
in  Stockton-on-Tees.  The  principal  epidemic  diseases  caused 
131  deaths,  which  corresponded  to  an  annual  rate  of  0 4 per 
1000,  and  Included  53  from  infantile  diarrhoea,  36  from  diphtheria,  21 
from  measles,  11  from  whooping-cough,  7 from  scarlet  fever,  and  3 
from  enteric  fever.  Diphtheria  caused  a death-rate  of  10  in  Bolton, 
IT  in  Portsmouth,  and  12  in  St.  Helens.  There  were  1547  cases  of 
scarlet  fever,  1092  of  diphtheria,  and  1 of  small-pox  under  treatment  in 
the  Metropolitan  Asylums  Hospitals  and  the  London  Fever  Hospital, 
against  1538, 1117,  and  2 respectively  at  the  end  of  the  previous  week, 
i he  causes  of  25  deaths  in  the  96  towns  were  uncertified,  of  which 
5 were  registered  in  Liverpool,  4 In  London,  and  3 In  Gateshead. 

Scotch  Towns. — In  the  16  largest  Scotch  towns,  with  an  aggregate 
population  estimated  at  nearly  2.500,000  persons,  the  annual  rate  of 
mortalltv,  which  had  been  10‘6,  11T,  and  10  6 in  the  three  preceding 
weeks,  further  declined  to  10  0 per  1000.  The  224  deaths  in  Glasgow 
corresponded  to  an  annual  rate  of  10  4 per  1000,  and  Included  9 from 
infantile  diarrhoea,  4 from  diphtheria,  3 from  enteric  fever,  and  2 each 
from  measles  and  whooping-cough.  The  62  deaths  in  Edinburgh  were 
equal  tea  rate  of  9 6 per  1000,  and  included  1 each  from  whooping-cough 
and  diphtheria. 

Irish  Towns. — The  99  deaths  In  Dublin  corresponded  to  an  annual 
rate  of  12'7,  or  0 9 per  1000  above  that  recorded  in  the  previous, 
week,  and  included  12  from  infantile  diarrhoea  and  1 each  from  enteric 
fever  and  measles.  The  73  deaths  Id  Belfast  were  equal  to  a rate  of 
9 5 oer  1000,  and  included  2 from  infantile  diarrhoea  and  1 from 
scarlet  fever. 


Donations  and  Bequests. — By  the  will  of  the 

late  Sir  Archibald  Davis  Dawnay,  of  Cedars-road,  Clapham 
Common,  Mayor  of  Wandsworth",  the  testator  has  left,  among 
other  bequests,  5000  £1  shares  in  Messrs.  Dawnay  and  Sons, 
Ltd.,  each  to  King  Edward’s  Hospital  (Cardiff  Infirmary) and 
the  Putney  Hospital,  Lower  Common,  Putney ; 500  shares 
to  the  Royal  Hospital  for  Incurables ; his  premises  known 
as  Eddington,  Barnet  Wood-laDe,  Ashtead,  to  the  Putney 
Hospital ; and  No.  108,  Penylan-road,  Cardiff,  to  King 
Edward’s  Hospital  (Cardiff  Infirmary). 

Fatality  from  Carrying  Loose  Matches. — At 
an  inquest  held  by  Mr.  Inglebv  Oddie  on  August  5th  at 
Lambeth  on  the  body  of  David  Rothery,  aged  17,  employed 
by  the  Nugget  Polish  Company,  a witness  stated  that  he  j 
saw  Rothery  with  his  clothing  alight.  He  turned  the  hose 
on  him  and  put  the  flames  out.  Rothery’s  clothes  were 
saturated  with  turpentine,  and  before  his"  removal  to  the 
hospital  he  stated  that  he  had  stumbled  over  a barrel,  when 
some  loose  matches  in  his  pocket  caught  fire.  A verdict  of 
“ Accidental  death  ” was  returned. 


The  lancet,]  INTRAVENOUS  INJECTIONS  OF  ANTIMONY  TARTRATE  IN  B1LHARZIASIS.  [August  16,  1919  299 


dffmspnknn. 

" Audi  alteram  partem.” 

INTRAVENOUS  INJECTIONS  OF  ANTIMONY 
TARTRATE  IN  BILHARZIASIS. 

To  the  Editor  of  The  Lancet. 

Sir, — Dr.  Frank  E.  Taylor’s  series  of  ten  cases  of  vesical 
bilharziasis  treated  successfully  by  antimony  tartrate,  as 
recorded  in  The  Lancet  of  August  9th,  are  very  interesting 
because  they  are  all  British  soldiers  who  contracted  the 
disease  in  Egypt  during  the  recent  war.  There  must  be 
hundreds  of  soldiers  in  this  country  similarly  infected,  and, 
in  view  of  the  fact  that  such  cases  if  not  cured  will  demand 
and  receive  pensions,  it  is  of  importance  that  this  treatment 
should  become  known  and  scientifically  carried  out  by  keen 
and  able  observers.  The  treatment  needs  care  and  skill  and 
some  tenacity  of  purpose,  for  it  demands,  to  ensure  success, 
that  the  urine  shall  be  examined  microscopically  every  day 
of  injection.  But  care,  skill,  and  tenacity  of  purpose 
expended  are  amply  repaid  by  the  great  interest  of  the 
developments  which  result  and  by  the  certainty  of  the 
cure. 

Mr.  J.  R.  Newlove  and  I reported  at  length  1 details  of  the 
treatment  as  carried  out  at  the  Khartoum  Civil  Hospital 
during  the  last  two  and  a half  years.  Over  70  cases  were 
included  in  that  paper  and  we  have  watched  the  result  of 
treatment  in  some  cases  for  a period  of  over  two  years.  The 
result  has  conclusively  demonstrated  the  permanency  of  the 
cures. 

With  regard  to  the  series  of  cases  reported  by  Dr.  Taylor  I 
shall  not  be  surprised  if,  in  every  case,  ova  reappear  in  the 
urine  and  with  the  ova  hasmaturia  (microscopic  blood  only 
perhaps)  and  some  albuminuria.  But  supposing,  as  is  most 
likely,  ova  do  appear  again  in  the  urine  of  these  cases  this 
will  not  mean  that  the  treatment  has  not  been  successful, 
for  the  ova  are  those  already  deposited  by  the  worms  before 
the  course  of  treatment.  They,  naturally,  are  eliminated  as 
foreign  bodies,  even  after  the  death  of  the  worms.  In  some 
of  our  cases  dead  ova  were  eliminated  for  two  years  after 
the  course  of  injection.  Further,  if  the  ova  which  are 
eliminated  after  a total  of  10  or  15  gr.  of  antimony  tartrate 
have  been  injected  be  microscopically  examined  it  will  be 
found  that  they  are  small , shrivelled , black,  and  have  lost 
their  double  contour,  and  that  their  contents  are  granular 
and  do  not  show  the  outline  of  primitive  organs.  They  are, 
in  fact,  dead,  sterile,  and  incapable  of  harm. 

Antimony  tartrate  not  only  kills  tne  bilharzia  worms  in 
the  portal  circulation  ; it  also  acts  directly  on  the  ova 
already  deposited  in  the  bladder  and  rectum,  and  these  ova, 
although  they  are  eliminated  in  due  course,  are  sterile — in 
fact,  the  patient  has  ceased  to  be  a carrier  of  bilharzia 
disease.  That  the  ova  are  sterilised  by  antimony  tartrate  is 
a fact  more  important  than  that  the  worms  are  killed. 
Prophylaxis  is  more  important  than  the  individual  cure. 

The  case  reported  by  Major  R.  G.  Archibald  and  Major 
.Arthur  Innes  2 should  never  have  been  reported  as  a case  of 
death  from  the  treatment.  He  died  of  influenzal  pneumonia, 
as  was  shown  by  the  post-mortem  examination.  I have  written 
fully  in  reply  to  this  paper.3  Any  fatty  degeneration  found 
by  the  authors  in  the  organs  was  probably  due  to  other 
causes — intestinal  parasites,  ankylostomum,  tasnia  nana,  or 
to  bilharzia  itself  (it  is  a mistake  to  think  that  bilharzia  acts 
as  a mere  mechanical  agent  and  that  the  only  effect  is  the 
physical  one,  the  ova  acting  merely  as  foreign  bodies  ; 
Ferguson  and  Fairley  have  both  shown  that  bilharzia  is  more 
far-reaching  in  its  effects).  It  has  yet  to  be  proved  that 
antimony  tartrate,  given  in  doses  necessary  to  cure  bilharzia 
(25-30  gr.),  gives  rise  to  fatty  degeneration,  or,  in  fact,  that 
its  causes  fatty  degeneration  at  all.  Other  workers  have 
recorded  cases  of  bilharzia  where  37  and  even  67  gr.  have 
been  given,  and,  as  Dr.  Taylor  states,  very  much  larger 
doses  have  been  given  for  trypanosomiasis  and,  I may  add, 
for  kala-azar,  without  any  untoward  result. 

The  suggestion  of  Major  Archibald  that  the  deaths  which 
have  occurred  in  cases  of  kala-azar  where  antimony  tartrate 

1  Journal  of  Tropical  Medicine  and  Hvgiene,  July  16th,  1919. 

2  Ibid.,  April  1st,  1919. 

3  Ibid.,  June  14th,  1919. 


has  been  used  are  due  to  fat  embolism  needs  a rather  serious 
call  on  the  imagination,  for  it  is  difficult  to  believe  that 
microscopic  fat,  deposited  in  the  cells  of  an  organ,  becomes 
dislodged  and  finds  its  way  into  the  blood-vessels  and  so  to 
the  heart  to  form  the  embolus.  So  far  as  my  experience 
goes,  these  cases  of  death  in  kala-azar  are  due  to  heart 
failure — e.g.,  an  emaciated  kala-azar  patient  after  an 
injection  tries  to  sit  up  in  bed,  or  perhaps  gets  out  of  bed 
to  urinate  or  defaecate  in  the  absence  of  the  attendant, 
and  the  resulting  heart-strain  is  in  itself  sufficient  to  produce 
the  fatal  result  in  the  later  stages  of  the  disease.  In  bilharzia 
the  patient  is  not  as  a rule  weak  and  this  danger  does  not 
present  itself. 

For  the  information  of  practitioners  who  may  wish  to  give 
this  treatment  a trial  I append  a list  of  references  to  papers 
of  workers  who  have  written  on  the  subject  of  the  antimony 
tartrate  cure  for  bilharziasis. 

References. 

1.  Macdonagh,  J.  E.  K. : The  Biology  and  Treatment  of  Venereal 
Disease,  1915. 

2.  Wiley.  C.  J. : Brit.  Med.  Jour.,  1918,  ii.,  716. 

3.  Low,  G.  C.:  Jour,  of  Trop.  Med.  and  Hygiene,  May  18th,  1919. 

4.  Archibald  and  Innes  : Jour,  of  Trop.  Med.  and  Hygiene,  April  1st, 
1919. 

5.  Taylor,  P.  E. : The  Lancet,  August  9th,  1919,462. 

6.  Christopherson,  J.  B.  : The  Lancet,  Sept.  7th,  1918,  325;  Brit. 
Med.  Jour.,  1918,  ii  , 652,  and  April  19th,  1919,  489  ; The  Lancet, 
June  14tb,  1919,  1021;  J >ur.  of  Trop.  Med.  and  Hygiene,  June  16th, 
1919,  ii.,  and  July  15th,  1919. 

I am,  Sir,  yours  faithfully, 

August  loth,  1919.  J.  B.  Christopherson. 


THE  ORIGIN  OF  LIFE:  THE  WORK  OF  THE 
LATE  CHARLTON  BASTIAN. 

To  the  Editor  of  The  Lancet. 

Sir, — In  my  letter  concerning  the  origin  of  life  published 
in  your  issue  of  August  2nd  I said,  referring  to  Hon.  H. 
Onslow’s  experiments,  “ I suggest  that  Mr.  Onslow  kept 
some  of  his  ‘ white  solution  ’ tubes  far  too  loDg — three  years 
in  some  cases — before  opening  them  and  examining  their 
contents.”  Mr.  Onslow  refers  to  this  as  a misrepresentation. 
I should  be  sorry  to  have  misrepresented  Mr.  Onslow  in  any 
way  in  discussing  his  experiments  or  the  results  thereof,  but 
my  information  was  obtained  solely  from  bis  own  published 
report,  contained  in  the  Proceedings  of  the  Royal  Society, 
B 628,  p.  268,  wherein  he  seeks  to  prove — and  does  prove  to 
the  entire  satisfaction  of  several  persons — that  my  father  was 
totally  in  error  not  only  in  regard  to  his  facts,  as  recorded  in 
his  book,  “ The  Origin  of  Life,”  but  in  regard  to  the  necessary 
interpretation  arising  therefrom.  Mr.  Onslow  states  that 
8 out  of  10  tubes  of  his  “white  solution,”  cited  as  being 
typical  examples  of  the  whole  series,  were  kept  for  33£ 
months  before  they  were  opened.  This  is  certainly  too  long, 
and  in  such  circumstances  the  tubes  could  only  contain,  as 
they  did,  dead  organisms. 

Without  quoting  in  extenso  what  is  said  in  Mr.  Onslow’s 
report,  I think  any  reader  of  it  will  acquit  me  of  mis- 
representation. I plead  guilty  only  to  a legitimate  mis- 
understanding of  this  account  of  scientific  experiments, 
which,  by  Mr.  Onslow’s  own  showing,  is  a very  incomplete 
one,  in  parts  somewhat  vague.  Furthermore,  the  experiments 
strike  me  as  being  open  to  criticism  in  some  other  respects, 
notably  as  regards  the  kind  of  glass  used,  which,  to  the  best 
of  my  recollection,  was  not  “ hard  German  glass  ” but  soft 
soda  glass.  I consider  Mr.  Onslow’s  conclusions  should 
not  be  finally  accepted  as  refuting  the  conclusions  of  my 
father  which  were  based  on  such  a prolonged,  careful  and 
systematic  research.  It  is,  perhaps,  just  as  likely  that 
Mr.  Onslow’s  comparatively  few  negative  results  are 
open  to  as  much  criticism  as  the  many  alleged  positive 
results  obtained  by  my  father  and  others.  What  work 
of  this  nature  could  be  expected  to  be  entirely  free  from 
error?  In  any  case  we  are  not  in  a position  to  judge  as 
to  the  cogency  of  this  or  that  series  of  experimental  results 
unless  we  are  put  in  possession  of  all  the  facts  and  are 
shown,  by  way  of  some  help,  photomicrographs  of  what 
was  actually  found  in  the  experimental  tubes — dead  or 
alive. 

It  is  for  these  reasons,  and  because  I venture  to  think  that 
sufficient  evidence  has  not  yet  been  produced  to  disprove  the 
reality  of  archebiosis,  that  I would  urge  the  necessity  of  my 
father’s  experiments,  not  only  in  archebiosis  but  also  in 


300  The  Lancet,] 


TALENT  AND  MISCEGENATION. 


[August  16,  1919 


heterogenesis,  being  repeated  in  many  different  quarters  by 
independent  observers.  It  is  only  by  these  means  that  we 
may  expect  the  ultimate  truth  to  be  revealed. 

I am,  Sir,  yours  faithfully, 

W.  Bastian, 

Chesham  Boie,  August  10th,  1919.  Surgeon  Commander,  lt.N. 


To  the  Editor  of  The  Lancet. 

Sir, — A word  of  explanation  is  needed  in  reply  to 
M.  Albert  Mary’s  interesting  letter  in  your  issue  of  August  9th. 
The  effects  due  to  radioactivity  are  totally  distinct  from 
those  produced  by  barium,  strontium,  calcium,  manganese, 
or  lead.  For  the  latter  precipitate  in  the  course  of  time  to 
the  bottom  of  the  test-tubes,  whilst  the  former  remain  at  the 
top.  These  disappear  when  heated  or  exposed  to  daylight, 
and  reappear  again  when  kept  for  some  hours  in  the  dark. 
They  have  all  the  properties  of  Mr.  Emil  Hatschek’s  vortices 
referred  to  in  my  previous  letter  of  July  26th.  Mr.  Raphael 
Dubois,  as  M.  Mary  is  perhaps  unaware,  did  not  describe 
anything  of  the  sort,  and  his  observations  refer  merely  to 
the  “grosses  vacuolides,”  which  are  undoubtedly  not  due  to 
radioactivity.  It  is  clear,  therefore,  that  he  did  not,  in  the 
first  instance  at  any  rate,  observe  the  bodies  I have  called 
radiobes,  which  1 am  convinced  are  due  to  radium  and  are 
totally  distinct  from  his  vacuolides,  for  they  are  much 
smaller  and  possess  different  properties.  Furthermore,  they 
are  not  vesicles,  and  are,  on  the  other  hand,  too  large  to 
be  bubbles  of  the  emanation  (as  Sir  William  Ramsay 
suggested),  the  quantity  of  radium  salt  used  being  insufficient 
for  this.  The  best  results  are  obtained  with  the  weak 
salt  of  radium  chloride.  Strong  radium  bromide  almost 
obliterates  the  effect,  probably  owing  to  the  heat  evolved 
or  other  influence  of  the  bombardment. 

As  I have  already  suggested,  each  a-particle  should  give 
rise  to  a vortex  in  the  “gel”;  and  as  these  particles  are 
being  continually  projected  in  all  directions  a series  of  such 
bodies  in  “massed  formations,”  ever  moving  forward, 
would  endeavour  to  force  their  way  out,  and  ultimately  a 
scrimmage  would  ensue,  when  the , group  finally  segregated  ; 
each  half  going  its  own  way.  I estimate  on  Sir  Ernest 
Rutherford’s  most  recent  work  on  a-particles 1 that  the  boundary 
would  be  about  0'3/z,  the  size  I had  found  to  be  the  maximum 
for  radiobes.-  This  boundary  formed  by  the  a-particles’ 
vortices  would  be  the  nucleus  which  I have  observed,  whereas 
the  outer  boundary  would  be  due  to  the  fast-moving 
H-atoms  which  Rutherford  and  Marsden  have  found  to  be 
projected  through  the  violent  impact  of  the  a-particles 
with  oxygen,  nitrogen,  carbon,  and  hydrogen.  It  is  note- 
worthy, as  it  appears  from  their  latest  results,  that  the 
principal  constituents  of  protoplasm — namely,  H,  C,  N, 
and  O— are  the  ones  which  are  thus  broken  up  by  the 
a-particles  ; heavier  atoms  not  being  so  affected. 

According  to  the  “ principle  of  relativity  ” now  so  much 
discussed  by  physicists,  there  should  be  a directional  force  as 
the  resultant  influence  of  all  the  a-particles ; for  the 
effect  of  the  earth’s  rotation  would  impart  to  these  an 
unequal  motion  in  different  directions  ; an  effect  of  about 
0 4 per  cent.  This  should  give  the  aggregate  of  vortices  so 
produced  a tendency  to  evolve  in  one  particular  direction 
rather  than  another  ; and  thus,  perhaps,  give  us  a physical 
analogue  to  the  “elan  vital”  of  living  matter,  to  which 
hitherto  there  has  been  no  clue,  from  physico-chemical 
considerations.  My  earlier  experiments  seemed  to  indicate 
something  of  the  sort  with  radium,  that  could  not  be 
accounted  for  at  the  time  ; but  I am  investigating  the  matter 
further  in  the  light  of  more  recent  facts  on  these  lines.  The 
suggestion,  then,  in  my  previous  letter  to  you  was  that  similar 
effects  might  be  set  going  by  purely  catalytic  actions,  if 
a-particles  are  emitted  with  sufficient  violence  in  chemical 
reactions  ; and  it  is  possible,  in  the  light  of  these  con- 
siderations, that  Dr.  Bastian’s  and  M.  Mary’s  synthetic 
corpuscles  may  owe  their  origin  to  this  cause,  which,  whether 
it  produces  them  or  not,  should  thus  give  rise  to  others  like 
them.  I am,  Sir,  yours  faithfully, 

Kingston  11111,  August  9th,  1919.  J.  BUTLER  BURKE. 

%*  The  original  title  of  this  correspondence  indicated  the 
question  at  issue  to  be  the  accuracy  of  the  work  of  the  late 
Charlton  Bastian. — En.L. 


1 See  his  papers  in  the  Philosophical  Magazine,  June,  1919,  and  his 
Royal  Institution  lecture,  Nature.  July  31st  1919. 

- Natuie.  May  25th.  1905. 


TALENT  AND  MISCEGENATION. 

To  the  Editor  of  The  Lancet. 

Sir, — It  is  reported  of  one  of  the  modern  gladiators  who, 
for  good  or  evil,  command  to-day  so  much  public  attention 
and  support,  that  he  has  in  him  a good  deal  of  American 
Indian  blood.  The  same  was  said  of  Longboat,  a Marathon 
runner,  as  also  of  a musical  comedy  actress  well  known  over 
here  in  the  “ nineties.”  But  the  coincidence  of  mixed  race 
with  distinction  is  not  confined  to  those  whom  Aristotle  would 
have  called  professors  of  the  little  arts.  Ouida  was  half 
French,  Lettsom  of  creole  extraction.  The  late  Watts 
Dunton’s  origin  was  always  supposed  to  include  a gypsy 
element.  It  is  curious  that  Mr.  W.  B.  Yeats,  the  noted  poet, 
has  a parentage  exactly  similar  to  that  of  the  Brontes — 
namely,  an  Irish  father  and  a Cornish  mother.  Rossetti  was 
three-quarter  English  and  one-quarter  Italian.  Freud, 
Ehrlich,  Bergson,  and  Kerensky  have,  or  had,  plenty  of 
Jewish  blood.  And  one  could  go  on  in  like  fashion  for  a 
long  time,  overloading  this  letter  with  capitals  and  proper 
names.  It  seems  a pity  that  the  subject  is  not  investigated 
more.  There  does  exist  a German  work  upon  it,  reviewed  in 
the  medical  press  of  this  country  about  a dozen  years 
ago.  Mr.  Havelock  Ellis,  too,  has  touched  it  in  his 
study  of  British  genius.  Of  his  1030  persons  of  ability. 
143  sprang  from  some  degree  of  miscegenation,  which 
is,  perhaps,  a high  proportion  for  an  island  country, 
97  being  mixed  British — i.e.,  of  intermingled  English, 
Irish,  Scotch,  or  Welsh  origin — and  46  mixed  British  and 
foreign.  English- Irish  was  found  to  be  the  commonest  of 
the  former  crosses,  and  of  the  latter  English-French.  Among 
the  few  women  in  the  list  about  a third  were  of  mixed  race, 
the  English-Irish  combination  again  coming  first.  Mr. 
Ellis’s  qualification  for  inclusion  in  his  study  material  was 
rather  high,  as  a general  thing  a notice  of  at  least  three 
pages  in  the  “Dictionary  of  National  Biography.”  It  is 
possible,  however,  that  miscegenation  tends  to  the  production 
of  various  kinds  of  minor  talent,  too.  In  turning  over  the 
pages  of  a large  encyclopaedia,  in  reading  obituary  notices, 
in  recalling  persons  of  ability  among  ordinary  acquaint- 
ances, one  is  apt  to  come  upon  the  phenomenon  under  notice. 

Miscegenation  in  Theatrical  Celebrities. 

It  is  curious,  again,  on  going  through  Mr.  Ellis's  detailed 
list,  to  have  found  that  the  celebrities  of  mixed  blood 
include  Garrick,  Mrs.  Siddons,  Macready,  the  two  Kembles, 
Helen  Faucit,  Kitty  Clive,  Barry  Sullivan,  and  Kelly. 
Clearly  there  are  here  the  flower  of  British  acting.  Five  out 
of  these  nine  owned  continental  strains  of  blood.  Play- 
writers  are  numerous  too — Marston,  D’Urfey,  Lillo,  Killigrew, 
Vanbrugh,  Beddoes,  and  Browning.  No  other  calling  was 
so  strongly  represented  as  actors  and  dramatists.  The  rest 
were  mostly  occupied  with  art  or  literature,  there  being  only 
two  men  of  science,  and  no  inventors.  This  last  is  a little 
surprising.  It  had  seemed  possible  that’  American 
inventiveness  might  have  been  traceable  to  the  copious 
American  miscegenation,  that  country  being  now  “ the  jakes 
of  Europe,”  as  England,  with  doubtful  correctness,  was 
called  by  Defoe. 

Row  does  Mixture  of  Race  Originate  Talent  ? 

Several  speculations  are  possible  as  to  how  the  mixture 
of  race  originates  talent.  The  simplest  supposition,  perhaps, 
is  that  the  mere  cross  is  without  influence,  persons  of  ability 
being  more  likely  than  others  to  travel  and  meet  and  marry 
foreigners,  their  offspring  inheriting  their  talent.  It  may  be 
so.  The  comparative  lack  of  high  grade  talent  (except,  as 
already  stated,  inventiveness)  in  America  seems  to  corroborate 
this  view,  for  emigrants  nowadays  are  not  persons  of  eminent 
ability.  Peter  the  Great  took  his  Deptford  paramour  home 
with  him  and  begat  the  elder  Cozens,  known  widely  as  a 
painter  in  water-colours.  The  elder  begat  the  younger 
Cozens,  also  a painter,  whose  works  Constable  described  as 
being  “ all  poetry.”  But  why  painting  talent  ? We  do  not 
know  that  either  Peter  or  the  mother  had  any  ability  that 
way.  We  do  know  that  Peter  had  other  ability.  Also  that 
he  showed  atavistic  traits — for  instance,  primitive  savage 
callousness  notable  even  in  an  absolute  monarch  of  an 
uncivilised  seventeenth-century  people.  Those  of  strong 
nerves  may  read  how  he  conducted  a mistress  of  his,  a 
noblewoman,  as  far  as  the  arms  of  the  executioner,  slipped 
round  to  the  front  for  the  final  spectacle,  picked  up  the  head, 


Thh  Lanobt,] 


THE  POSITION  AND  PAYMENT  OF  THE  PENSIONS  BOARDS. 


[August  16,  1919  301 


demonstrated  rather  competently— he  was  always  interested 
in  anatomy — to  his  courtiers  the  musculature  surrounding 
the  severed  vertebra,  turned  it  round,  lightly  kissed  the  lips, 
put  it  down  again,  and  went  off  upon  his  business.  This 
may  suggest  remotely  another  explanation.  The  crossing  of 
breeds  was  shown  by  Darwin  to  lead  to  reversion  or  atavism, 
and  atavistic  traits  of  various  kinds  are  common  accompani- 
ments of  artistic  talent. 

Again,  first  crosses  in  domestic  stock  do  seem  to  result  in 
hardiness  and  good  constitution,  as  in  the  mule  or  in 
poultry  ; mongrel  dogs,  too,  are  often  more  sagacious  than 
pure-breds.  Besides  the  instance  given,  many  others  exist 
of  pugilists  of  mixed  race:  Jewish  half-breeds,  gypsy  half- 
breeds,  are  frequent  in  the  history  of  the  ring.  The  many 
professional  golfers  from  the  Channel  Islands  may  be  a 
further  example  of  physical  ability  caused  by  miscegenation, 
this  territory  having  been  alternately  French  and  English 
for  some  centuries. 

The  Lumas  Family. 

In  face  of  the  history  of  the  Dumas  family  it  is  hard 
to  rule  out  the  mere  blending  of  race  as  the  prime  cause. 
Here  miscegenation  seems  all-important,  producing  talent, 
indeed  genius,  out  of  nothing.  An  undistinguished  French 
aristocrat  meets  an  undistinguished  Hayti  negress  wench. 
Their  child  is  a prodigy  of  physical  courage,  development, 
and  prowess.  A noted  cavalry  leader,  he  can  gallop  at  a 
grenadier,  pluck  him  from  the  ground,  and  throw  him  across 
his  saddle-bow.  With  other  environment,  say  poverty  in 
present-day  America,  this  “Horatius  Codes  of  the  Tyrol” 
would  have  been  one  of  the  half-breed  boxers,  who,  although 
mostly  Roumanian  or  Mexican  or  Scandinavian,  for  some 
reason  call  themselves  by  a true  blue  Anglo-Saxon  name. 
Horatius’s  son,  by  an  undistinguished  woman,  is  Dumas  pere, 
the  best  story-teller  pure  and  simple  in  the  world.  His  son, 
again,  by  another  out-cross,  a mere  Belgian  milliner,  is 
Dumas  fils,  the  best  playwright  of  latter-day  France  (in  both 
note  again  the  association  with  the  stage). 

Generalisations. 

On  this  pedigree,  certainly  a slender  foundation,  it  is 
possible  to  construct  a theory  of  the  origin  of  miscegenate 
talent.  That,  to  begin  with,  the  lowest  form  mostly  results, 
mere  physical  aptitude,  or  histrionic  ability,  the  lowest  form 
of  art — the  production  of  histrionic  capacity  being  how 
miscegenation  helps  up  so  the  list  of  distinguished  women, 
because  acting  is  the  only  art  in  which  women  quite  equal 
men.  Then  sometimes  the  original  physical  or  histrionic 
talent  may  transmute  in  the  succeeding  generation  into 
psychical  or  higher  psychical,  a professional  cricketer 
begetting  a novelist,  an  actor  begetting  a Wagner.  But 
these  generalisations  grow  dangerously  top-heavy.  The 
subject,  not  in  the  line  of  present-day  thought,  is  likely  to 
attract  much  interest  before,  say,  the  end  of  the  century. 
Its  Darwin  may  be  some  unorthodox  scholar-biologist, 
roaming  happily,  his  life  through,  from  Bibliothek  to 
Bibliothek.  I am,  Sir,  yours  faithfully, 

August  4th,  1919  CADUCEUS. 


THE  POSITION  AND  PAYMENT  OF  THE 
PENSIONS  BOARDS. 

To  the  Editor  nf  Thb  Lancet. 

Sir, — Dr.  Lauriston  E.  Shaw  propounds  a scheme  to  relieve 
the  temporary  financial  embarrassment  of  “partial”  pen- 
sioners who  break  down.  He  does  not  know,  it  seems,  that 
these  cases  are  already  provided  for  admirably  or  that  the 
Medical  Services  Branch  of  the  Ministry  has  given  birth  to  a 
body  of  experts  in  assessment  whose  work  is  far  from  likely 
to  bring  blame  upon  our  profession,  as  he  suggests.  A little 
practical  knowledge  would  convince  him  that  it  is  these 
experts  rather  than  the  well-cared-for  pensioners  who  stand 
in  need  of  sympathetic  advocacy.  On  my  board  the  senior 
members  (engaged  and  paid  by  the  session)  hold  responsible 
posts  requiring  daily  attendance,  special  knowledge,  and 
some  administrative  ability.  Officially  part-time,  we  are 
actually  whole-time  members,  and  yet  if  we  are  all  ill  or 
there  is  a bank  or  peace  holiday  our  pay  ceases.  We  have 
protested  more  than  once,  claiming  pay  proportionate  to  the 
nature  and  value  of  our  work  and  to  the  cost  of  living,  with 
security  of  tenure  and  right  to  a holiday.  We  have  been 
told — our  claim  receives  sympathy — the  value  of  our  work 
is  recognised  ; if  we  will  kindly  carry  on  something  may  be 


done  some  day,  nobody  is  to  blame  except  the  Treasury. 
Meanwhile,  by  way  of  humour,  perhaps,  batches  of  men 
paid  more  than  ourselves  and  on  the  teims  we  ask,  are  sent 
to  be  trained  by  us  for  similar  work  in  the  provinces.  We 
remain  at  our  posts  as  much  from  interest  and  pride  in  our 
board — a model  of  organisation — as  from  loyalty  to  our 
president,  to  whom  it  owes  its  unique  value  for  the  pensioner 
and  taxpayer.  But  we  feel  that  we  are  entitled  to  relief 
from  an  unjustifiable  financial  anxiety— a relief  that  is 
essential  if  our  work  is  to  be  continued  at  its  present  level  of 
efficiency. 

YTour  admirable  leading  article  of  August  2nd  points  out 
that  the  common  policy  of  the  profession  is  to  serve  humanity 
but  carries  a right  to  remuneration  calculated  to  secure  good 
service.  The  bare  fact  is  that  we  are  denied  a living  wage, 
and  are  suffering  in  consequence.  The  outlook  is  alarming. 
Is  it  the  desire  of  the  Treasury  to  reduce  our  families  to  the 
standard  of  living  which  the  Ministry  of  Health  has  been  set 
up  to  abolish  ? Are  we  to  be  a precedent  upon  which  our 
profession  will  be  made  to  suffer  in  the  future  ? We  should 
welcome  investigation  by  any  body  standing  for  the  ideals 
of  our  profession.  1 enclose  my  card  with  the  name  and 
address  of  my  board  for  your  use  should  any  such  body 
propose  to  accept  the  invitation,  and  would  appeal  especially 
to  the  medical  Members  of  Parliament  to  assist  us  to  prevent 
circumstances  and  the  spreading  spirit  of  discontent  from 
forcing  us  unwillingly  in  a wrong  direction. 

I am,  Sir,  yours  faithfully, 

August  loth,  1919.  Medico. 


THE  INCIDENCE  OF  TUBERCULOSIS  AMONGST 
ASYLUM  PATIENTS. 

To  the  Editor  of  The  Lancet. 

Sir, — The  figures  and  conclusions  given  by  Dr.  F.  A. 
Elkins  and  Dr.  Hyslop  Thomson  in  their  valuable  paper  in 
your  issue  of  August  9th  will  not  surprise  those  acquainted 
with  an  essay  on  the  frequency,  causation,  prevention,  and 
treatment  of  phthisis  pulmonalis  in  asylums  for  the  insane, 
which  was  printed  in  the  Journal  of  Mental  Science  for 
October,  1899.  In  this  paper,  however,  any  special  liability 
of  the  insane  to  tuberculosis,  apart  from  hereditary  and 
environmental  conditions,  was  ascribed  rather  to  the  shallow- 
ness and  infrequency  of  the  respiratory  movements  than  to 
lowered  tissue  resistance.  The  conclusions  reached  in  this 
essay  were  in  1901  entirely  and  handsomely  endorsed  by  the 
report  of  a special  commission  of  the  Medico-Psychological 
Association,  though  the  findings  of  this  commission  perhaps 
received  somewhat  less  than  their  due  meed  owing  to  the 
fact  that  certain  tables  drawn  up  by  the  commissioners 
were  afterwards  shown  to  be  not  free  from  statistical  error. 

But  no  statistical  or  other  error  was  ever  shown  to  have  had 
place  in  the  original  essay  which  provoked  the  appointment 
of  the  commission,  and  Dr.  Elkins  and  Dr.  Thomson  now, 
by  implication,  have  not  only  vindicated  its  conclusions  but 
drawn  attention  to  the  consequences  of  neglect  of  its  lessons. 
War  has  been  responsible  for  much,  but  there  is  no  reason 
why  we  should  not  now  recognise  that  which  was  pointed  out 
in  1899 — namely,  that  “ in  the  majority  of  cases  in  which 
phthisis  leads  to  a fatal  issue  the  disease  is  acquired  in  the 
asylum,”  and  that  aggregation,  lack  of  ventilation,  over- 
crowding, and  a diet  poor  in  fats,  are  each  and  all  in  measure 
responsible  for  the  deplorable  results. 

I am,  Sir,  yours  faithfully, 

London,  W.,  August  10th,  1919.  F.  G.  C. 


Lieutenant-Colonel  W.  B.  Edwards,  C.B.E., 
R.A.M.C. ; Lieutenant-Colonel  J.  E.  H.  Davies,  D.S.U., 
R.A.M.C.  ; Lieutenant-Colonel  D.  Hepburn,  C.M.G., 
R.A.M.C.  (T.)  ; and  Colonel  Sir  Charles  A.  Ballance, 
K.C.M.G.,  C.B.,  M.V.O.,  A.M.S.,  have  been  appointed 
Knights  of  Grace  of  the  Order  of  the  Hospital  of  St.  John 
of  Jerusalem  in  England. 

Death  from  Status  Lymphaticus. — At  an 

inquest  held  by  Mr.  Wynne  Baxter  at  Stepney  on 
August  5th  on  the  body  of  Eric  Richardson,  aged  3 years, 
who  died  while  under  an  anesthetic  in  the  Poplar  Hospital, 
it  was  stated  that  death  was  due  to  the  existence  of  status 
lymphaticus.  The  coroner,  having  pointed  out  to  the  jury 
that  the  existence  of  this  condition  was  not  possible  to 
discover  before  the  administration  of  the  anesthetic,  a 
verdict  of  “ Death  from  misadventure  " was  returned. 


302  The  Lancet.] 


THE  SERVICES. 


[August  16,  1919 


®I;e  Services. 


THE  HONOURS  LIST. 

The  following  “statements  of  services  " are  announced  for  the  awards 
recorded  in  The  Lancet  of  Match  8th,  1919,  p.398.  All  are  members 
of  the  It.A.M.C.  except  where  otherwise  stated  :— 

Bar  to  the  Distinguished  Service  Order. 

Capt.  (aoting  Lieut.-Col.)  JAMES  HKNKY  FI, ETCHER,  D.8.O., 
M.C.,  comdg.  36th  Fid.  Amb. — For  most  conspicuous  gallantry  and 
devotion  to  duty  near  Mametz,  on  August  26th,  1918,  when  in  command 
of  bearers.  With  another  offcer  he  crawled  out  under  heavy  machine- 
gun  fire  into  “ Wo  Man’s  Land,’’  dragged  back  two  wounded  bearers  to 
a more  sheltered  spot,  and  after  dressing  them  crawled  back  for 
assistance,  organised  two  squads  of  bearers  and  brought  the  wounded 
men  in  under  heavy  tire ; also  two  more  wounded  men  found  lying 
out.  He  set  a splendid  example  to  all  serving  under  him. 

Maj.  (Temp.  Lieut.-Col.)  FRANCIS  CORNELIUS  SAMP30N, 
D.S  O.,  91st  Fid.  Amb. — For  e-emplary  devotion  to  duty  on  tue 
night  of  Oct.  3 d/4th,  1918,  at  Le  Baraque  (north  of  St  Quentin)  when 
this  area  was  heavily  bombed.  This  officer,  regardless  of  personal 
danger,  by  his  initiative  and  personal  ihfluence  organised  and  accom- 
panied relief  parties  and  was  instrumental  in  the  rapid  evacuation  of 
the  wounded.  The  bombing  was  very  severe  and  the  casualties  heavy, 
there  being  13  amongst  the  K.A.  M.C.  bearers  alone  ; the  actual  number 
of  killed  exceeded  40. 

Distinguished  Service  Order. 

Capt.  PATRICK  AUGUSTINE  eRDAGH,  M.C.,  New  Zealand  M.C., 
attd.  1st  Bu.  Auck.  R.— For  conspicuous  gallantry  and  devotion  to  duty 
during  an  attack  east  of  Masnieres.  being  forced  to  place  his  dressing 
station  in  a spot  constantly  shelled  by  the  enemy  for  36  hours, 
he  continued  to  dress  wounded  while  shells  fell  on  the  station.  He 
attended,  not  only  his  own  battalion  wounded,  but  men  of  three  other 
battalions,  and  worked  continuously  without  sleep  all  the  time.  He 
displayed  high  courage  and  resource,  and  was  the  means  of  saving 
many  lives. 

Temp.  Major  CHARLES  FRASER  KNIGHT,  133rd  Fid.  Amb.— 
For  conspicuous  gallautry  and  devotion  to  duty  in  personally  super 
vising  the  collection  of  wounded  and  visiting  forwar.t  posts  regularly 
under  heavy  shell  fire.  It  was  largely  due  to  his  energy  and  disregard 
of  danger  that  the  large  number  ot  wounded  in  his  sector  were  success- 
fully cleared.  This  was  curing  the  operation  against  the  Hindenburg 
Line,  east  of  ltonssoy,  on  Sept.  27ih,  28th,  and  29th,  1918. 

Major  LEONARD  MAY,  M.C.,  Aust.  A.M.C.,  attd.  llth  Bn  Aust 
Infy.— During  the  attack  near  Villeret  on  Sept.  18th,  1918,  he  displayed 
great  gallautry  and  devotion  to  duty  whilst  atteuding  to  the  wounded 
In  consequence  of  his  excellent  organisation  for  clearing  the  wounded 
he  was  able  to  keep  in  touch  with  the  advance,  constantly  moving  his 
aid-post  forward  with  the  barrage,  and  maintaining  liaison  with  the 
attacking  companies  throughout.  He  showed  great  disregard  of  danger 
under  heavy  artillery  and  macnine  gun  fire,  and  by  his  skill  saved 
many  lives. 

Lieut.-Col.  STANLEY  PAULIN,  llth  Fid.  Amb.,  Can.  A M C.— He 
was  in  charge  ot  the  evacuation  of  the  brigade  wounded  in  the  opera- 
tions about  Cambrai. . For  the  five  days  of  that  battle  he  worked  day 
and  night  with  very  little  rest.  He  was  always  leading  and  directing 
his  men,  and  by  his  splendid  example  was  responsible  for  the  wonderful 
work  done  by  those  under  him.  His  work  under  heavy  shell  and 
machine-gun  tire  was  admirable. 


Second  Bar  to  the  Military  Cross. 

Temp.  Capt.  GEORGE  OLIVER  FAIRl'CLOUGH  ALLEY,  M.C. 
attd.  2nd  Bn.  H.  Ir.  Regt. — For  conspicuous  courage,  energy  anc 
initiative  during  the  operations  on  Oct.  8th,  1918,  in  front  of  Niergnies 
He  followed  up  the  battalion  in  the  attack,  dressing  and  evacuating 
wounded  under  heavy  shelling,  eventually  establishing  his  aid-post 
right  lorwaid  in  a section  of  trench  in  the  rear  of  the  front  line  Herf 
he  dressed  aud  evacuated  wounded,  not  omy  of  his  own  battalion  anc 
brigade,  but  of  battalions  operating  on  the  right  and  left  flauks 
Throughout  the  day  he  behaved  splendidly,  and  by  his  fine  devotion  tc 
duty  saved  many  lives.  (M  C.  gazetted  June  4th,  19l7  ) 

(temp'  Capt.)  WILLIAM  JOHN  KNIGHT.  M.C.,  attd 
syth  Fid.  Amb. -During  the  operations  east  of  Ypres  from  Sept.  28tt 
a.  i j . 16  was  1,1  ckmr*te  foe  8 tre teber- bearers  attached  tc 

a brigade.  He  led  his  bearers  in  the  rear  of  the  attacking  infantry 
dressing  the  wounded  as  they  fell,  and  seeing  that  every  case  wai 
carried  away  from  the  battlefield.  During  the  whole  of  the  advance 
he  snowed  an  utter  contompt  lor  danger,  dressing  the  wounded  undei 
shell,  machine  gun,  and  rifle  fire.  Laier,  when  the  advance  came  to  c 
standstill  he  established  touch  with  all  tbe  regimental  medica 
officers  and  personally  conducted  the  evacuation  of  wounded  from  the 
K.A.i.s.  On  many  occasions  he  went  forward  with  stretcher  squadi 
to  bring  back  wounded  to  the  R.A.P.’s.  He  dislayed  great  gallantry 
throughout  and  did  admirable  work.  “ s J 

Uapt.  (acting  Major)  MAURICE  ALOYSIUS  POWER,  M.C. 
attd  148th  Fid.  Amb.— For  conspicuous  gallautry  and  oevoti..n  to  duty 
li^iSfoT01  bearors  during  the  operations  on  Niergnies  oc 
Oot.  oth.  1J18.  He  personally  t olio  wed  the  attacking  troops  to  the 
hnal  objective  establishing  bearer  relay  po*ts  en  route,  all  the  while 
regardleas  of  personal  danger,  though  exposed  to  heavy  enemy 
shell  lire,  ills  skillul  organisation  of  the  evacuation  of  wounded,  anc 
his  maintenance  of  touch  with  all  battalion  meoical  officers,  ensurec 
the  speedy  evacuation  of  casualties.  He  set  a splendid  example  to  al 
ranks  under  his  command. 


Bar  to  the  Military  Cross. 

1 1 SSPpi <acti,1K  Major)  JOHN  BERNARD  CAVENAGH.  M.C.,  at 
itinoo  n.  A'ul!--°n  Oct  1st.  1918,  when  the  advanced  dressl 
Cambrai,  was  shelled,  he  went  out  to  see  about  his  men  a 
ordered  them  under  cover  quite  regardless  of  his  own  saiety.  On  t 
occasion  be  was  slightly  wounded,  but  made  no  mention  of  it.  Aga 
the  penoti  from  Oct.  llth  15th,  when  his  advanced  dressl 

lanrTL  S°nVr\n  Was  displayed  «reat  coolness  a 

8®*  following  on  this,  while  advanced  dress  ng  stactous  were 
turn  established  at  Berclau,  Provin,  Cam  phi  a,  Les  Croquet.  Templeu 


Bachy,  Humes,  and  Faintignies,  he  displayed  great  initiative  and 
daring  In  keeping  in  close  touch  with  the  infantry.  It  was  chiefly  due 
to  his  sound  judgment  and  coolness  during  the  most  trying  circum- 
stances that  all  the  wounded  and  sick  were  so  successfully  evacuated. 

Temp.  Capt.  FREDERICK  ORLANDO  CLARKE.  M.C.,  attd.  149th 
Fid.  Amb.  — For  great  gallantry  and  devotion  to  duty.  During  the 
operations  against  the  village  of  Niergnies  on  Oct.  8th,  1918,  when  his 
aid-post  was  established  in  a dug-out  at  the  Slag  Heap,  he  observed  two 
men  lying  out  in  the  open  about  50  yards  off.  Though  a heavy 
bombardment  at  the  time  was  on,  be  at  once  called  for  volunteers  and, 
regardless  of  his  own  safety,  went  out  and  dressed  them,  and  helped  to 
carry  them  in.  During  this  time  one  of  the  men  was  killed.  It  was 
undoubtedly  owing  to  the  gallant  conduct  of  this  officer  that  the  man's 
life  w&s  sftvcd. 

Temp.  Capt.  CLAUDE  NORMAN  COAD,  M.O.,  74th  Fid.  Amb.— For 
great  gallantry  and  oevotion  to  duty  when  in  charge  of  bearers  during 
heavy  fighting  on  Oct.  llth  between  Avesnes  and  St.  Aubert.  It  was  due 
to  his  fine  personal  example  and  total  disregard  of  danger  that  over  400 
casualties  were  evacuated  on  that  day.  He  carried  on  his  work  often 
in  front  of  the  forward  posts  under  heavy  artillery  and  machine-gun 
fire  until  all  the  casualties  had  been  brought  back. 

Capt.  (acting  Major)  THOMAS  FREDERICK  CORKILL,  M.C., 
attd.  139th  Fid.  Amb. — While  acting  as  officer  in  charge  of  forward 
bearers  during  the  operations  from  Sept.  29th  to  Oct.  3rd,  1918,  south- 
east of  Y’pres,  he  not  only  showed  great  resource  in  dealing  with 
difficult  evacuation  to  advanced  dressing  station,  but  a total  disregard 
of  danger.  He  personally  frequently  visited  all  posts  at  all  times,  both 
night  and  day,  with  most  untiring  energy  and  c ourage. 

Temp.  Capt.  (acting  Major)  JOHN  EDGAR  DAVIES,  M.C.. 
131st  Fid.  Amb.— For  conspicuous  gallantry  and  devotion  to  duty  at 
Euglefontaine  on  Oct.  26th,  1918.  Hearing  that  there  were  over  1000 
civilians  in  the  captured  town,  he  volunteered  to  go  into  it,  interview 
the  Mayor,  and  make  the  necessary  arrangements  for  the  distribution 
of  smoke  helmets.  He  entered  the  town  under  heavy  bombardment 
and  made  his  way  to  the  cellar  occupied  by  the  Mayor  through  streets 
swept  by  enemy  machine-gun  fire.  Several  casualties  occurred  on  the 
way  up  to  a support  battalion,  and  these  he  attended  to  and  removed 
to  safety. 

Capt.  FRANKLIN  FLETCHER  DUNHAM,  M.C.,  Can.  A.M.C., 
attd.  No.  5 Fid.  Amb.— During  operations  about  Neuville  Vitasse, 
August  26th,  27th,  and  28th,  1918,  for  conspicuous  gallantry  and 
devotion  to  duty.  He  organised  stretcher  parties  under  heavy  shell 
fire,  and  located  and  dressed  many  wounded.  On  the  28th  the  stretcher- 
bearers  under  him  moved  practically  with  the  infantry,  and  he  per- 
sonally directed  the  clearing  of  wounded  from  “No  Mm's  Land ’’ in 
daylight,  under  heavy  machine-gun  fire.  His  initiative  and  coolness 
were  the  means  of  saving  many  lives. 

Capt.  (acting  Major)  FREDERICK  GAMM.  M.C..  attd.  2/3rd  (Home 
Counties)  Fid.  Amb..  T.F.— During  the  attacks  and  counter-attacks 
near  Peiziere  from  Sept.  22nd  to  24th,  1918,  when  It  was  found 
impossible  to  obtain  in  tbe  village  a suitable  spot  for  an  advanced 
dressing  station,  he  took  up  an  ambulance  car  and  used  it  as  a dressing- 
room.  working  under  constant  shell  fire  all  tbe  time.  His  boldness  and 
devotion  to  duty  undoubtedly  resulted  in  the  saving  of  many  lives  and 
the  mitigation  of  much  Buffering. 

Capt.  (acting  Major)  WILLIAM  CLAVERING  HARTGILL,  H.C., 
55th  Fid.  Amb. —For  conspicuous  gallantry  and  devotion  to  duty  when 
supervising  the  evacuation  of  brigade  casualties  during  the  attack  on 
Ronssoy,  Sept.  18th,  1918.  He  early  established  his  various  posts  and 
went  forward  and  assisted  in  clearing  wounded  of  his  own  and  other 
brigades  under  heavy  machire-gun  and  sheli  fire.  He  worked  un- 
ceasingly, and  it  was  greatly  owing  to  the  coordination  of  the  arrange- 
ments and  his  personal  supervision  that  casualties  were  cleared  in  a 
markedly  efficient  and  speedy  manner.  Throughout  he  has  done  fine 
work. 

Capt.  (temp.  Major)  ROBERT  ALEXANDER  HEPPLE,  M C.,  attd. 
28th  Fid.  Amb. — For  conspicuous  gallantry  and  devotion  to  duty  during 
the  operations  at  Roulers.  Menin  R rad,  and  Ledeghem,  Sept.  28th  to 
Oct.  5th.  1918.  As  officer  in  charge  of  bearers  he  worked  incessantly  l 
day  and  night,  personally  keeping  in  touch  with  the  battalions  in  spite 
of  shell  aud  mmhlne-gun  fire;  he  never  once  lost  touch  with  the 
regimental  medical  officers,  evacuating  the  wounded  with  the  utmost 
rapidity,  thereby  saving  numerous  lives. 

Temp.  Capt.  (acting  Major)  BENJAMIN  KNOWLES,  M C.,  attd. 
88th  Fid.  Amb.,  T.F  —For  conspicuous  gallantry  and  initiative  in 
charge  of  stretcher-bearers  during  operations  east  of  Ypres  from 
Sep>.  28th  to  Oct.  3rd.  1918.  He  led  his  stretcher  bearers  fo  lowing  a 
barrage  during  the  attack  and  organised  relays  for  bis  men  along  the 
road  of  evacuation.  Later  he  visited  regimental  aid-posts,  often  under 
heavy  fire,  and  several  times  took  up  ambulance  cars  to  casualties, 
carrying  them  axvay  under  fire.  For  six  whole  days  he  supei  intended  > 
the  evacuation  of  wounded  from  the  forward  areas,  and  it  was  due  to  I 
his  great  energy  and  disregard  of  personal  danger  that  the  wounded 
were  evacuated  wiihout  a hitch. 

Temp.  Capt.  ALEXANDER  CAMPBELL  WHITE  KNOX.  M.C.. 
attd.  2nd  Bn.  R.  Suss.  R. — For  conspicuous  gallantry  and  devotion  to 
duty  throughout  the  operations  north  and  south  of  the  river  d’Oraignon 
from  Sept.  18th  to  24th,  1918.  As  medical  officer  of  the  battalion  he 
organised  and  supervised  the  evacuation  of  the  wounded  in  the  most 
perfect  manner  despite  shell  fire  and  gas.  Besides  superintending  the  " 
work  at  the  regimental  aid-post  he  personally  supervised  the  work 
of  the  stretcher  bearers  with  the  leading  waves  of  the  assaulting 
troops.  Owing  to  his  energy  and  personal  supervision  every  wounded 
man  was  attended  to  and  evacuated  without  delav.  He  did  fine  work. 

Temp  Capt.  (acting  Major)  HAROLD  DUN  MORE  LANE.  M.C., 
attd.  1 1st  N.  Mid.  Fid.  Amb.  (T.F.).— For  conspicuous  gallantry 
and  devotion  to  duty.  On  Oct.  3rd.  1918,  du-ing  the  attack 
on  Ratnlcourt  and  Wiancourt  he.  who  had  already  done  magnificent 
work  during  the  capture  of  Bellenglise  on  Sept.  29tb,  1918,  and  since 
that  date  bad  worked  unceasingly  under  heavy  fire,  pushed  forward 
through  the  enemy's  barrage,  and,  although  wounded,  continued  to 
search  for  and  dress  wouuded  under  heavy  shell  and  machine  gun  fire. 

By  his  absolute  disregard  of  danger  he  set  a splendid  example  to  the 
men  serving  under  him. 

Capt.  JOHN  SHAW  MACKAY,  M.C..  12th  Fid.  Amb., 
Aust.  A. M.C. —For  conspicuous  gallantry  and  devotion  to  duty  on 
Sept.  18' h.  1918.  south  of  Le  Verguler.  He  moved  forward  with  his 
bearers  closely  in  rear  of  advancing  battalions  and  under  heavy  machine- 
gun  and  shell  fire,  and  by  absolute  disregard  of  his  own  personal  safety 


The  Lancet,] 


THE  SERVICES. 


[August  16,  1919  303 


was  able  to  keep  in  close  contact  with  brigade  R.M.O.'s.  By  tills 
action  the  wounded  were  evacuatod  in  the  quickest  possible  manner,  all 
congestion  at  regimental  aid-posts  was  prevented,  and  undoubtedly 
many  IIvob  were  saved. 

Temp.  Capt.  JAMES  DAVID  MACKINNON,  M.C.,  afctd.  4th 
Bn.  Liverpool  R.— During  the  operations  on  Sept.  29th  and 
Oct.  lOtb/llth,  1918,  at  Villers  Guislain  and  Le  Gateau,  he  displayed 
consistent  and  conspicuous  gallantry  in  attending  to  wounded  under 
heavy  lire,  and  saved  many  lives.  His  example  of  coolness  and 
devotion  to  duty  was  very  hue. 

Capt.  (acting  Major)  WILLIAM  ARCHIBALD  MILLER.  D.S.O., 
M.O.,  attd.  No.  6 Fid.  Amb. — For  conspicuous  gallantry  and  devotion  to 
du  y from  Sept.  27th  to  Sept.  29th,  1918,  when  in  charge  of  stretcher 
bearers  during  the  advance  from  the  Canal  du  Nord  to  the  Canal  de 
St.  Quentin.  He  worked  for  three  days  without  rest,  and  repeatedly 
led  his  stretcher  bearers  to  the  front  line,  exposing  himself  io  direct 
lire  from  enemy  machine-gun  posts.  Especially  on  Sept.  28uh,  he  led 
his  bearers  across  the  canal  in  close  touch  with  the  infantry,  and 
brought  back  wounded  through  intense  machine-gun  and  shell  barrage. 
By  his  fine  behaviour  he  saved  the  lives  of  many  men. 

Capt.  LAUREL  COLE  PALMER,  M.C.,  13th  Fid.  Amb., Can.  A.M.C.— 
In  the  operations  before  Cambrai  he  was  in  charge  of  stretcher-bearer 
squads  from  Sept.  27th  to  Sept.  30th,  1918.  During  this  period  he  had 
absolutely  no  rest  day  or  night,  and  wai  constantly  under  heavy  shell 
fire  ; and  on  the  28th  he  personally  brought  up  field  ambulance  squads, 
and  carried  out  the  wounded  from  in  front  of  the  front  line  under 
heavy  shell  and  machine-gun  fire.  His  untiring  energy  and  disregard 
of  personal  danger  were  admirable. 

Capt.  JOSEPH  GREGOR  SHAW,  M.C.,  12th  Fid.  Amb.,  Can.  A.M.G. 
—During  operations  near  Cambrai  from  Sept  26th  to  Oct.  1st,  1918,  he 
was  in  charge  of  a party  of  stretcher  bearers  clearing  the  12th  Cana  iian 
Infpntry  Brigaie.  He  went  for  four  days  practically  without,  sleep, 
during  which  time  he  was  constantly  superintending  clearing  opera- 
tions in  the  vicinity  of  the  regimental  aid-posts.  After  two  days,  his 
senior  officer  having  been  gassed,  the  total  responsibility  devolved  upon 
him.  During  this  time,  while  constantly  exposed  to  shell  and  machine- 
gun  fire,  his  conduct  was  splendid,  and  he  was  the  means  of  saving  the 
lives  of  many  wounded. 

Capt.  (accinS  Major)  JAMES  CALVBRT  SPENCE,  M.C.,  attached 
o4th  Fid.  Amb.— For  conspicuous  gallantry  and  devotion  to  duty 
while  In  command  of  a bearer  division,  duriog  the  attack  on  Oisy- 
le- Verger  and  the  subsequent  operations  from  Sept.  28th  to  Oct.  2nd, 
1918.  In  addition  to  handling  his  bearers  with  marked  skill  and  initia- 
tive,  he  reconnoitred  and  selected  sites  for  regimental  aid-posts  under 
heavy  fire.  Throughout  the  operations  he  showed  untiring  energy  and 
complete  disregard  of  danger.  His  fine  leading  of  bearers  on  several 
occasions  through  heavy  barrages  enabled  the  wounded  to  be  rapidly 
cleared,  and  undoubtedly  resulted  in  the  saving  of  many  lives 
Capt.  DONALD  GEORGE  KENNEDY  TURNBULL,  M.C.,  11th  Pld. 
Amb.,  Can.  A. M.C.— During  the  recent  operations  before  Cambrai, 
Sept.  29th,  1918,  it  was  reported  that  there  were  still  a great  many 
wounded  out  in  front  of  the  regimental  aid-posts  of  another  brigade 
He  at  once  proceeded  up  the  line  with  all  available  bearers,  and  under 
heavy  fire  Investigated  the  conditions  as  to  wounded.  He  got  them  all 
out  so  that  none  were  left  during  the  night  of  Sept.  29/30th,  thus 
assisting  materially  in  preventing  deaths  from  exposure. 


The  Military  Cross. 

Temp.  Capt.  (acting  Major)  JOHN  RICHARD  PERCY  ALLIN, 
90th  Pld.  Amb.— For  conspicuous  gallantry  and  devotion  to  duty  in 
charge  of  bearers  on  Sept.  29th,  1918,  and  following  days.  On  the 
29th,  during  the  advance,  he  made  his  way  through  Lehaucourt  to  Le 
Tronquay  despite  severe  shell  and  machine-gun  fire.  He  promptly 
organised  the  evacuation  of  the  wounded,  and  by  his  fine  example  and 
energy  secured  the  rapid  evacuation  of  over  250  casualties. 

Capt.  ALAN  FENTON  ARGUE,  Can.  A.M.C.,  attd.  87th  Can.  Bn  , 
Quebec  R.— For  conspicuous  gallantry  and  devotion  to  duty, 
Sept.  2nd/3rd,  1918,  at  the  Dury-Arras  sector.  During  the  attack  he 
accompanied  the  battalion  during  its  advance  under  very  heavy  fire 
and  established  his  first-aid  post  in  a trench  close  to  the  front  line 
reached  by  the  battalion,  and  continuously  during  the  day  and  night 
worked  without  any  rest  and  under  constant  fire.  Later,  he  went  to 
the  assistance  of  a wounded  officer  under  heavy  shell  fire,  dressed  his 
wounds,  and  remained  with  him  until  he  died  in  his  arms.  Throughout 
he  behaved  admirably. 

CaPt' (act,in"  Major)  BASIL  WILLIAM  ARMSTRONG,  attd 
100th  Fid.  Amb.— For  conspicuous  gallantry  and  devotion  to  duty. 
Honng  the  fighting  around  Forenviile  and  Seranvillers  on  Oct  8th 
1918,  he  was  in  charge  of  the  bearers  clearing  casualties  of  an  infantry 
brigade.  He  constantly  visited  all  the  regimental  aid-posts,  havinv  to 
pass  along  roads  and  tracks  subjected  to  very  heavy  machine-gun  "fire 
throughout  the  whole  day.  All  his  work  was  done  in  the  open,  and 
by  his  energy,  disregard  of  danger,  aud  skilful  organisation  he 
succeeded  in  evacuating  a'l  the  wounded  in  a very  short  time 
Capt.  FREDERICK  GRANT  BANTING.  13th  Fid.  Amb.,  Can  A M C 
-Near  Hay  necourt  on  Sept.  28th,  1918.  when  the  medical  officer  of  the 
4bth  Canadian  battalion  was  wounded,  he  immediately  proceeded 
forward  through  intense  shell  fire  to  reach  the  battalion.  Seve-al  of 
ms  men  were  wounded,  and  he,  neglecting  his  own  safety,  stopped  to 
attend  to  them.  While  doing  this  he  was  wounded  himself  and  was 
36nt  out  notwithstanding  his  plea  to  be  left  at  the  front.  His  energy 
and  pluck  were  of  a very  high  order. 

Capt.  JAMES  HAROLD  BLAIR,  C.A.M.C.,  attd.  72nd  Bn  Brit 
5°  ' , ~Zor  ,c0n3P'cl.10u3  gallantry  and  devotion  to  duty  during  the 
Bourlon  Wood  operations  before  Cambrai  from  Sept.  27th  to  Oct  1st 
1918.  During  the  aittek  on  Sept.  27th  he  rushed  ahead  under  heavy 
hre  and  rendered  immediate  medical  attention  to  all  wounded  in  the 
Vicinity.  During  the  attack  on  the  29th  he  followed  the  attacking 
troops  closely  and  dressed  the  wounded  as  he  went  forward,  and 
formed  the  enemy  prisoners  into  stretcher  parties.  Immediately  after 
the  town  of  Sancourt  was  captured  he  established  a regimental  aid- 
post  there  and  continued  to  work  under  heavy  fire.  His  work  through- 
out,  was  of  the  highest-  order.  & 

Capt  EOWUf  JOHN  BRADLEY,  attd.  l/3rd  (N.  Mid.)  Fid.  Amb., 
i.r.  He  was  in  charge  of  the  b*arers  during  the  attack  on  th6 
Q'tsnb'h  Canal  on  Sept  29th,  1918,  and  dieplayei  great  gallantry 
“?'!?'  He 'v?,nt  forward  and  sought  a position  for  an  advanced 
dressing  station  in  Bellenglise  when  it  was  being  heavily  shelled  by  the 


enomy,  and  finally  organised  collecting  and  relay  posts  on  a route 
farther  north.  His  dispositions  were  most,  skilful  and  too  rapid  evacua 
tlon  of  the  wounded  was  mainly  due  to  the  exertions  of  this  officer. 

Capt.  MILES  GILLESPIE  BROWN,  Can.  A.M.O.,  attd.  85th  Can. 
Bn.  Nova  Scotia  It.— For  conspicu  ms  gallantry  and  devotion  to  duty 
during  the  Bourlon  Wood  operations  before  Cambrai  On  Sept.  27th, 
1918,  he  advanced  with  the  attacking  wave  from  the  assembly  position, 
and  attended  woundol  in  the  open  under  constant  machine  gun  and 
shell  lire.  He  established  Ids  rogimental  aid-post  in  an  open  trench, 
no  other  place  being  available.  Later,  after  his  assistant  was  killed 
beside  him  and  his  sergeant  wounded,  he  continued  his  work  with 
absolute  coolness  and  outstanding  devotion  to  duty.  He  behaved 
splendidly  throughout  an  I save  < many  lives. 

Capt  EDWIN  THOMAS  CATO,  Aust.  A.M.O.,  attd.  1st  Bn.  Aust. 
Infy.— In  the  operations  near  Hargicourt,  from  Sept.  18th-2lst,  1918,  he 
showed  untiring  energy  and  devotion  to  duty  in  his  care  of  the 
wounded,  particularly  on  Sept.  21st,  when  in  order  to  give  early 
attention  he  established  his  aid-post  in  an  open  trench  which  was 
under  shell  fire  and  moved  about  the  area  continually,  dressing 
wounded  in  shell  holes  and  open  country.  By  his  d-sregard  for 
personal  safety  and  his  cheerful  confidence  he  set  a splendid  example 
to  all. 

Capt.  HERBERT  TROUGIITON  CH  ATFIELD,  attd.  No.  6 Fid.  Amb. 
— For  conspicuous  gallantry  and  devotion  to  duty  from  Sept.  27th  to 
Sept.  29th,  1918.  when  in  charge  of  stretcher-bearers.  He  frequently 
led  his  parties  through  machine-gun  and  shell  fire  to  bring  in  wounded. 
He  succeeded  in  keeping  in  close  touch  with  the  infantry  throughout 
the  advance  to  and  the  crossing  of  the  St.  Q lentin  Canal  near 
Noyelles.  By  his  fine  conduct  and  example  he  was  instrumental  in 
saving  many  lives. 

Temp.  Capt  THOMAS  CLAPPERTON,  141st  Fid.  Amb. — For  con- 
spicuous gallantry  and  devotion  to  duty  during  the  attack  on  the 
Hindenburg  Line  on  Sept.  29th,  1918.  Throughout  the  day  he 
repeatedly  conducted  bearers  to  the  most  exposed  parts  of  the  line  to 
search  for  casualties.  Though  his  advanced  bearer  post  at  B rthaucourt 
was  heavily  shelled  he  succeeded  by  his  prompr,itude  an  d energy  in 
getting  his  wounded  away  without  further  casualties.  His  fine  work 
was  the  means  of  saving  many  lives. 

Capt.  (acting  Major)  HUBERT  ROY  DIVE,  l/2nd  IJtd.  Bde., 
Fid.  Arab.,  attd.  230th  Fid.  Amb.— On  Sept.  21st,  1918.  at 

Templeax  le  Guerard,  when  in  charge  of  evacuation  of 
casualties  from  the  front  line,  he  w irked  incessantly  without 
rest  under  intense  shell  fire,  exposing  himself  in  the  most  fearless 
manner  when  bringing  in  casualties.  He  showed  a very  fine 
example  of  devotion  to  duty,  and  the  successful  evacuation  was  entirely 
due  to  his  personal  gallantry  and  initiative  He  has  been  super- 
intending the  evacuation  from  the  front  line  continuously  since 
Sept.  2nd,  and  during  all  this  period  has  shown  the  greatest  zeal  and 
resource. 

Temp.  Capt.  ROBERT  DONALD,  attd.  35th  Fid.  Amb — For  con- 
spicuous gallantry  and  devotion  to  duty  on  Sept.  27th,  1918,  during  the 
advance  on  Epinoy.  He  dressed  cases  in  the  open  all  day  under  fire, 
and  established  a chain  of  aid-posts  as  the  infantry  advanced.  It  was 
solely  due  to  his  unflagging  zeal,  his  initiative  and  absolute  disregard 
for  personal  safety,  that  a most  difficult  front-line  evacuation  was 
carried  out  with  the  utmost  rapidity. 

Capt.  LEWIS  HAYES  FRASER,  Can.  A.M.C.,  attd.  R.  Can.  Horse 
Arty. — On  Oct.  10th,  1918.  near  Le  Cateau,  when  a battery  commander 
was  reported  badly  wounied  at  the  observation  p >st,  this  officer  went 
forward  some  1500  yards  through  heavy  fire  to  attend  him  He  arrived 
at  the  observation  post  just  after  the  enemy  barrage  came  down  on  it. 
Having  attended  to  the  battery  commander  he  went  out  of  t"e  trench 
and  crawled  about  under  the  heavy  barrage  for  nearly  an  hour  attending 
to  wounded  infantry  He  showed  great  gallantry  and  devotion  to  duty. 

Temp.  Capt.  WILLIAM  BALFOUR  GOURLAY  (N.  Russia). - 
Throughout  the  period  Oct.  7th-15  h,  1918,  he  showed  exceptional  devo- 
tion to  duty  in  the  care  of  the  sick  and  wounded  in  the  village  of  Borok, 
under  frequent  shell  fire  and  several  infantry  attacks.  His  hospital  at 
Borok  had  twice  to  be  moved  owing  to  fires  caused  by  shelling;  and 
though  worn  out  by  want  of  sleep  and  hard  work  he  attended  to  the 
evacuation  of  the  wounded  when  the  troops  moved  back  from  the 
village,  marching  with  t hem  for  a long  distance  and  helping  to  ease  them 
over  bad  roads  under  difficult  circumstances.  He  set  a tine  example 
throughout  of  unselfish  endurance  in  the  performance  of  his  duties. 

Temp.  Capt.  NORMAN  FRANKISH  GRAHAM,  artd.  6th  Bn. 
Land.  R.— Near  Maricourt,  during  the  operations  of  August  26th, 
27th,  28th,  and  31st.  1918,  this  officer  showed  the  greatest  c mrage  and 
devotion  to  duty.  On  three  occasions,  when  the  battalion  to  which  he 
was  attached  moved  forward,  he  immediately  followed  behind  the 
battalion  and  established  his  regimental  aid-post  close  up  to  the  line, 
tending  and  superintending  the  collection  of  wounded  under  very 
heavy  shell  fire.  He  so  organised  the  stretcher-bearer  parties,  largely 
using  prisoners  for  this  task,  that  the  wounded  were  evacuated  with  a 
minimum  of  delay  and  discomfort.  He  was  twice  slightly  wounded 
but  carried  on. 

Capt.  GERALD  WALLACE  GRANT.  4th  Fid.  Amb..  Can.  A.M.C.— 
For  conspicuous  gallantry  and  devotion  to  duty  near  Vis-en  Artois  on 
August  27th/28r.h,  1918.  He  was  in  charge  of  15  squads  of  bearers,  and 
throughout  the  whole  operations  superintended  the  clearing  of 
casualties  under  almost  continuous  fire  from  the  area  allotted  to  him. 
On  the  28th  he  led  his  squads  in  advance  of  the  infantrv  position,  and 
under  machine-gun  fire  succeeded  in  removing  from  shell  holes 
several  badly  wounded  men  to  the  collecting  posts,  whence  they  could 
be  evacuated.  He  set  a splendid  example  to  those  under  him. 

Temp.  Capt.  RICHARD  PERROTT  HADDEN,  103rd  Fid.  Arab., 
attd.  152nd  Bde.,  R.F.A. — ror  consnicuous  gallantry  and  devotion  to 
duty  when  some  transport  came  under  heavy  howitzer  fire  near 
Tenbrielen  on  Oct.  8th,  1918.  He  went  straight  to  the  place  through 
heavy  shelling  to  attend  to  a wounded  man,  and  by  his  prompt  action 
and  disregard  of  danger  prebablv  saved  the  man's  life. 

Capt.  ALBERT  ROBERT  HAGERMAN,  Can.  A.M.C.,  attd.  78th 
Can.  Bn.,  Manitoba  R.— F or  conspicuous  gallantry  and  devotion  to 
duty  during  the  Bourlon  Wood  operations  before  Cambrai.  On 
Sept..  27th.  1918,  he  followed  close  behind  the  attacking  in'antry  and 
established  a regimental  aid-post  in  the  open  unier  heavy  shelling  and 
dres=ed  wounded  under  heavy  machine-gun  fire.  On  Sepf.  29th  he 
established  a dressing  station  in  a forward  trench,  and  for  two  days  he 
worked  unceasingly  under  shell  fire  in  this  position,  dressing  hundreds 
of  wounded.  He  did  admirable  work. 


304  The  Lancet,] 


THE  SERVICES. 


[August  16,  1919 


Capt.  JAMES  MANN  HENDERSON,  Aust.  A.M.C.,  attd.  12th  Bn. 
Auet.  Infy. — During  the  attack  near  Jeancourt  on  Sept.  18th,  1918,  he 
established  his  regimental  aid-post  immediately  in  rear  of  the  jumping- 
off  place  and  attended  to  the  wounded  of  his  and  of  a supporting  battalion 
under  heavy  shell  fire  in  an  exposed  position.  As  the  attack  progressed 
he  moved  forward  and  treated  large  numbers  of  casualties  in  the  open. 
By  his  energy,  disregard  of  danger,  and  clever  organisation,  he  relieved 
a great  deal  of  suffering,  and  throughout  set  a splendid  example  to 
those  under  him. 

Temp.  Capt.  ALEXANDER  HUNTER, attd.  63rd  Divl.  Eng.— During 
the  operations  on  Nlergnies  on  Oct.  8th,  1918,  whilst  attached  to  the 
advanced  dressing  station,  when  the  advanced  dressing  station  was 
being  heavily  shelled  he  went  out  to  attend  to  some  wounded.  On 
his  way  be  was  knocked  down  by  the  explosion  of  a gas  shell,  but 
although  severely  burned  he  continued  to  attend  to  the  wounded, 
displaying  a remarkable  coolness  and  utter  disregard  to  personal 
danger.  He  refused  to  be  evacuated  and  remained  on  duty  until  relief. 

Temp.  Capt.  WILLIAM  BOYD  JACK,  attd.  5th  Bn.  Leic.  Ii  , T.F  — 
For  conspicuous  gallantry  and  devotion  to  duty  during  the  attack  on 
Pontruet  on  the  morning  of  Sept.  24th,  1918.  His  regimental  aid-post 
was  situated  in  a valley  which  was  shelled  consistently  with  gas  and 
high-explosive  shell.  He  had  no  dug-out  and  his  work  was  entirely  in 
the  open.  From  5 a.m.  till  3 a.m.  the  following  morning  he  worked 
unceasingly,  entirely  regardless  of  danger,  and  his  fine  conduct  saved 
many  lives. 

Temp.  Capt.  MATTHEW  JAMES  JOHNSTON. — During  an  airraid 
at  St.  Omer  on  the  evening  of  May  30th,  1918,  four  men  had  been 
buried  at  the  Caserne  d’Albret  in  the  debris  of  part  of  the  building 
which  had  been  destroyed  by  bombs.  He  arrived  immediately  with  an 
ambulance,  and,  in  spite  of  the  fact  that  the  enemy  planes  were  still 
overhead,  set  to  w ork  at  once  to  effect  a rescue.  This  had  to  be  done 
in  the  dark,  but  the  men  were  got  out  alive,  and  only  one  of  them 
subsequently  died.  Other  bombs  were  dropped  near  by  whilst  the 
work  of  rescue  by  this  officer  was  still  proceeding.  On  this,  as  on 
many  other  similar  occasions,  the  conduct  of  this  officer  was  very 
gallant. 

Capt.  CHARLES  TERRELL  LEWIS,  Can.  A.M. C.,  attd.  10th  Bde. 
Can.  F.A.— For  gallantry  and  devotion  to  duty.  On  August  29th,  1918, 
during  file  operations  along  the  Arras-Cambrai  road,  two  gun  pits  were 
set  on  fire  by  hostile  shells.  An  ammunition  dump  was  exploded  and 
several  men  wounded.  He  hastened  to  the  spot  and  dressed  the 
wounded  and  removed  them  to  a dressing  station.  Throughout  the 
w-hole  operations  he  was  untiring  in  his  efforts  to  afford  immediate 
medical  attention  to  the  wounded,  many  times  under  severe  tire. 

Temp.  Capt.  CHARLES  WILLIAM  BERRY  LITTLEJOHN,  140th 
Fid.  Arab.— For  great  gallantry  and  initiative  in  the  operations  south- 
east of  Ypres  from  Sept.  28th  to  Oct.  4th,  1918.  During  this  period  he 
was  in  command  of  forward  stretcher  bearers,  and  it  was  solely  due  tp 
his  energy  and  dash  that  close  touch  was  kept  with  battalions  and 
their  wounded  promptly  evacuated.  He  exposed  himself  freely  to 
sniping,  machine-gun  and  shell  fire  to  get  at  the  wounded  of  not  only 
liis  own  brigade  but  of  other  divisions,  and  by  his  fine  conduct  saved 
many  lives. 

Temp.  Capt.  ALFRED  MASON,  attd. 229th  Fid.  Amb. — NearMoislains 
and  Hargicourt,  Sept.  2nd,/25th,  1918.  While  in  charge  of  the  bearer 
division  working  in  front  of  the  advanced  dressing  station  he  was 
unceasing  in  his  efforts  on  behalf  of  the  wounded.  Although  his  area 
was  on  many  occasions  subject  to  very  severe  shell  fire,  and  although 
he  w’as  for  6ome  days  himself  ill,  he  succeeded  through  sheer  gallantry 
and  devotion  to  duty  in  maintaining  touch  with  the  regimental  aid- 
posts  continuously  during  the  advance,  thereby  securing  the  rapid 
evacuation  of  the  wounded.  His  work  was  admirable. 

Capt.  HARRY  CLARKE  MOSES.  Can.  A.M.C.,  attd.  No.  5 Fid.  Amb. 
—For  conspicuous  gallantry  and  devotion  to  duty  in  charge  of  the 
advanced  post  of  the  right  sector  during  operations  round  Neuville, 
Vitasse.  Waneourt,  and  CheriBy,  August  26th/27th,  1918.  He  was 
exposed  to  frequent  §nemy  shelling,  bombing,  and  machine-gun  fire 
from  aeroplanes,  and  when  a shell  exploded  among  a number  of 
wounded  awaiting  evacuation  he  directed  the  adjustment  of  the  masks 
on  the  wounded  and  succeeded  in  protecting  them  from  all  effects  of 
the  gas. 

Lieut.  WILLIAM  PERCIVAL  NELSON,  attd.  1 28th  Bn.  Lond.  R.— 
At  Rumillies,  on  Oct.  8th,  1918,  for  gallantry  and  devotion  to  duty. 
During  a very  severe  bombardment  of  both  artillery  and  machine  guns 
he  constantly  went  out  to  the  help  of  the  wounded,  attending  them 
with  utter  disregard  for  danger,  and  was  the  means  of  saving  several 
lives  and  alleviating  a great  deal  of  suffering.  He  has  at  all  times  set 
a striking  example  by  his  fearlessness  and  devotion  to  duty. 

Capt.  JOHN  ARCHIBALD  NICHOLSON,  attd.  1st  Bn.  Sea.  Highrs. 
(Egypt).— For  most  gallant  conduct  and  devotion  to  duty  near  Tabsor 
on  Sept.  20th,  1918.  He  moved  about  in  the  open  under  a heavy 
machine-gun  tire  to  dress  the  wounded  and  bring  them  to  a place  of 
safety.  Though  casualties  were  very  heavy,  he  continued  to  perform 
his  duties  with  the  greatest  calmness  and  disregard  of  danger.  He  set 
a very  fine  example  of  devotion  to  dutv  and  showed  great  courage 

Capt.  KENNETH  CLAUD  PURNELL,  Aust.  A.M  C.,  attd.  11th  Bde. 
Aust.  Fid.  Arty.— For  conspicuous  gallantry  and  marked  devotion  to 
duty  during  the  attack  on  the  Hindenburg  line,  south  of  Vendhuile  on 
Sept.  29th.  1918.  He  dressed  the  wounded  under  very  heavy  shell  fire, 
and  organised  a stretcher  party,  and  conducted  them  to  the  battery 
positions,  and  by  his  personal  and  untiring  efforts  assisted  in  getting 
them  to  the  nearest  dressing  station,  a distance  of  about  1000 yards,  and 
still  under  heavy  fire.  Throughout  the  day  he  worked  splendidly. 

Capt.  ALLAN  MELROSE  PUliYES,  Aust.  A.M. C., attd.  2nd Tunnelg. 
Coy..  Aust.  Engrs.— On  Sept.  29th,  1918,  during  the  operations  against 
the  Hindenburg  line,  in  the  neighbourhood  of  Bellicourt,  he  formed  an 
aid-post  in  a forward  position.  At  this  point  the  enemy  put  down  a 
very  heavy  barrage  which  lasted  about  six  hours  and  caused  heavy- 
casualties  amongst  the  road  party  and  the  infantry  in  the  vicinity. 
The  whole  of  this  time  he  attended  to  the  wounded  in  the  open,  showing 
great  gallantry  and  devotion  to  duty,  and  undoubtedly  saved  many 
lives. 

Temp.  Capt.  EDWARD  ROGERSON,  attd.  2nd  Bn.  K.R.R.C.— 
For  gallantry  and  devotion  to  duty  east  of  Maissemy  on  Sept.  18th. 
1918,  and  during  the  operations  of  Sept.  24th/28th.  On  Sept.  18th  he 
attended  to  and  bandaged  wounded  men  under  heavy  machine-gun 
fire.  His  actions  undoubtedly  saved  many  lives.  During  the  heavy 
shelling  of  our  positions  on  Sept.  24th  25th  he  was  conspicuous  for  his 
utter  disregard  of  danger  while  carrying  out  his  duties,  and  throughout 
the  operations  he  set  a splendid  example  to  those  under  him. 


Temp.  Capt.  JAMES  SCOTT,  attd.  12th  Bn.  Manch.  R. — On  Oct.  12th, 
1918,  in  front  of  Neuvilly,  under  heavy  and  accurate  shell  fire  out  in 
the  open,  he  dressed  the  wounded  without  cessation.  His  cool  courage 
under  fire  and  his  speed  and  skill,  combined  with  his  energy  in  keeping 
the  stretcher-bearers  going  and  in  working  eight  enemy  squads,  saved 
many  lives.  He  worked  untiringly,  and  showed  such  spirit  as 
inspired  all  who  came  near  him. 

Temp.  Capt.  THOMAS  McCALL  SELLAR,  attd.  l/18th  Bn.  Lond.  R. 
—During  the  period  August  28th  to  Sept.  6th,  1918,  the  battalion  was 
continually  in  offensive  fiction.  Most  of  the  stretcher-bearers  became 
casualties.  Throughout  this  time  he  worked  with  such  untiring  energy 
and  marked  gallantry  that  the  regimental  aid-post  was  constantly  in 
touch  with  the  attacking  troops,  and  wounded  were  got  back  to  the  aid- 
post  by  his  continually  organising  and  leading  forward  small  parties  of 
bearers  under  heavy  fire. 

Capt.  (acting  Major)  ARTHUR  LEONARD  SHEARWOOD,  attd. 
33rd  Fid.  Amb. — For  conspicuous  gallantry  and  devotion  to  duty  on 
Sept.  27tb/28tb,  1918,  during  and  after  the  attack  on  Oisy-le-Verger  and 
Epinoy,  when  in  charge  of  the  evacuation  of  the  wounded  from  the 
divisional  front  by  motor  ambulance.  He  worked  for  36  hours 
unceasingly,  visiting  forward  positions  and  establishing  car-posts, 
under  shell  fire.  His  initiative  and  skill  in  carrying  out  these  dis- 
positions and  his  complete  disregard  for  personal  danger  and  fine 
example  to  all  those  under  his  command  saved  many  lives  and 
rendered  the  evacuation  a complete  success. 

Capt.  GEORGE  ALEXANDER  SMITH,  Can.  A.M.C.,attd.  47th  Can. 
Bn.  W.  Ont.  R. — For  conspicuous  gallantryand  devotion  to  duty  during 
the  operations  in  front  of  Cambrai  from  Sept.  27th/29th,  1918.  He 
followed  the  battalion  closely  throughout  the  operations,  showed  great 
energy,  and  dressed  many  eases  under  heavy  shell  fire,  working  out  in 
the  open  with  practically  no  shelter.  He  set  a very  fine  example  to 
those  under  him. 

Capt  CLIFFORD  HALLIDAY  KERR  SMITH,  attd.  14th  Bn. 
K.O.S.B.,  T.F.— During  the  enemy  attack  on  Mceuvres  on  Sept.  17th, 
1918,  this  officer,  when  informed  that  there  were  many  serious  cases 
lying  out  requiring  immediate  attention,  went  forward  in  face  of  a 
very  heavy  artillery,  rifle,  and  machine^un  fire  and  gave  them  his 
personal  attention.  As  those  urgent  cases  could  not  have  been  brought 
to  the  regimental  aid-post  in  time  for  the  necessary  attention,  this 
officer,  by  his  prompt  action  and  fearless  devotion  to  duty,  was 
undoubtedly  the  means  of  saving  manv  lives  of  men  in  this  battalion. 

Capt.  JOHN  STIRLING,  attd.  H.Q.  112th  Bde.  R.F.A.— On 
August  26th,  1918,  north  of  Maricourt,  bearing  that  D 112th  Brigade 
was  being  heavily  shelled  by  the  enemy,  he  immediately  went  to  the 
battery  and  attended  the  wounded.  Again,  near  Moislains,  on  Sept.  9th, 
1918,  when  battalions  were  suffering  casualties  from  enemy  long-range 
guns,  he  went  to  them  and  attended  their  wounded.  His  gallantryand 
devotion  to  dutv  on  numerous  occasions  have  been  most  marked. 

Capt.  JOSEPH  TOWNSEND  STIRLING,  11th  Fid.  Amb.,  Can.  . 
A.M. C.— For  conspicuous  gallantry  and  devotion  to  duty.  During  the 
attack  on  Bourlon  Wood  on  Sept.  27th,  1918,  he  dressed  wounded  in  the 
open  in  the  vicinity,  under  heavy  shelling  and  machine-gun  fire.  , 
Again,  on  Sept.  29th,  when  one  of  his  men  was  killed  and  several  others 
seriously  wounded,  he  went  to  their  assistance,  got  them  dressed,  and 
carried  to  safety. 

Capt.  RICHARD  CHAPMAN  WELDON,  Can.  A.M.C.,  attd.  2nd  Can. 
Motor  M.G.  Bde. — While  in  action  east  of  Arras  on  August  29th,  1918,  ' 
at  Jig-Saw  Wood  and  Artillery  Hill,  he  was  in  charge  of  the  regimental 
aid-post,  where  he  showed  great  gallantry  and  devotion  to  duty.  The 
heavy  and  continuous  shell  fire  made  the  work  at  the  aid-post  both 
heavy  and  difficult,  entailing  constant  work  for  36  hours  without  rest. 

Temp.  Capt.  GEORGE.'BURKETT  WILKINSON.  28th  Fid.  Amb.— On 
the  night  of  Oct.  3rd/4th,  1918,  at  Waterdamboek,  he  was  in  charge  of 
advanced  dressing  station.  Everyone  had  left  the  village  on  account  of 
intense  shelling.  As  wounded  continued  to  come  in  he  carried  on 
dressing  and  evacuating  wounded  regardless  of  the  risk  he  ran  till  the  < 
advanced  dressing  station  was  closed  down.  He  showed  great  courage  I 
and  devotion  to  duty. 


ROYAL  ARMY  MEDICAL  CORPS. 

Lieut.-Col.  E.  W.  P.  V.  Marriott  retires  on  retired  pay. 

Capt.  W.  C.  Hartgill  relinquishes  the  acting  rank  of  Major. 

Temp.  Capt.  J.  McP.  MacKinnon  to  be  Lieutenant  and  to  be 
temporary  Captain. 

Lieut,  (temp.  Capt.)  T.  C.  Bowie  to  be  Captain. 

Temp.  Lieut.  H.  C.  Hinwood  to  be  temporary  Captain. 

Officers  relinquishing  their  commissions: — Temp.  Lieut.-Col.  J.  F. 
Woodyatt  (on  ceasing  to  be  in  charge  of  Halifax  War  Hospital,  and 
retains  the  rank  of  Lieutenant-Colonel) ; Temp.  Hon.  Lieut.-Col.  W.  J. 
Richard  (on  ceasing  to  be  employed  at  the  Merryflats  War  Hospital,  and 
retains  the  honorary  rank  of  Lieutenant-Colonel) ; Temporary  Captains 
retaining  rank  of  Captain  : M.  A.  McKeever,  W.  P.  Over.  B.  J.  Hackett, 

J.  A.  G.  Sparrow.  J.  N.  Donnellan,  J.  A.  N.  Scott,  E.  E.  Frazer,  F.  J. 
Wheeler,  J.  A.  MacLeod ; Temp.  Lieut.  C.  O.  Miller  (retains  the  rank 
of  Lieutenant). 

Canadian  Army  Medical  Corps.  I 

Temp.  Lieut.-Col.  (acting  Col.)  T.  C.  D.  Bedell  to  be  temporary  > 
Colonel. 

Temp.  Major  W.  J.  McAlister  to  be  acting  Lieutenant-Colonel 
while  in  command  C.C.O.H.,  Matlock,  Bath. 

Temp.  Majors  (acting  Lieut. -Cols.)  R.  M.  Filson  and  E.  A.  Neff 
relinquish  the  acting  rank  of  Lieutenant-Colonel. 

The  undermentioned  temporary  Captains  (acting  Majors)  relinquish- 
ing the  acting  rank  of  Major : A.  M.  Y'eates,  J.  N.  Taylor,  H.  C.  Allison, 

M.  G.  Thomson. 

The  undermentioned  temporary  Captains  (acting  Majors)  to  be 
temporary  Majors  : P.  D.  Saylor,  H.  C.  Davis,  D.  J.  Millar. 

The  undermentioned  retire  in  the  British  Isles  -.  Temp.  Col.  W.  L 
Watt;  Temp.  Lieut. -Cols.  S.  R.  Harrison,  E.  L.  Pope;  Hon.  Major  I. 

D.  Carson  ; Temp.  Majors  A.  B.  Walker.  S.  G.  Ross.  D.  J.  Cochrane 
H.  W.  Wbytock  ; Temp.  Capts.  H.  C.  W'atson,  V.  D.  Davidson,  J.  W 
Dorsey,  J.  K.  C.  Henderson,  M.  G.  Thomson,  Wr.  E.  Jones,  O.  E 
Kennedy,  F.  A.  O'Reilly,  G.  W.  M.  Smith.  T.  G.  Macdonald,  R.  G 
Moffat,  L.  C.  Reid,  M.  Krolik,  T.  Campbell,  T.  D.  Wheeler,  F.  B.  Sharp 
R.  MacKlnlav.  J.  L Poirier.  J.  W.  Begg,  G.  B.  Ferguson,  D.  Smith 
R.  F.  Price.  H.  G.  McCarthy,  W.  C.  Jx>wry,  M.  F.  D.  Graham.  V.  K 
O'Gorman,  H.  J.  G.  Geggie  B.  Cohen  Temp.  Hon.  Capt.  A.  V 
Whipple. 


The  Lanoet,] 


MEDICAL  NEWS.— PARLIAMENTARY  INTELLIGENCE. 


[August  16,  1919  305 


Canadian  Army  Dental  Corps. 

Temp.  Major  G.  N.  Briggs  retires  In  the  British  Isles. 

South  African  Medical  Corps. 

Temp.  Capt.  E.  L.  Reid  relinquishes  his  commission  and  retains  the 
rank  ot'  Captain. 

TERRITORIAL  FORCE. 

Lieut.-Col.  (acting  Col.)  H.  Golltnson  relinquishes  the  acting  rank  of 
Colonel  on  vacating  the  appointment  of  Assistant  Director  of  Medical 
Services. 

Majors  (acting  Lleut.-Cols.)  A.  YV.  Moore,  J.  Wood,  and  D.  H.  Weir 
relinquish  the  acting  rank  of  Lieutenant-Colonel  on  ceasing  to  be 
specially  employed. 

Capts.  (acting  Lieut.-Cols.)  H.  H.  B.  Cunningham,  W.  Brown,  and 
F.  G.  Dobson  relinquish  the  acting  rank  of  Lieutenant-Colonel  on 
ceasing  to  be  specially  employed. 

Capt.  (acting  Lieut.-Col.)  L.  D.  B.  Cogan  to  be  Assistant  Director  of 
Medical  Services,  and  to  be  acting  Colonel  whilst  so  employed. 

Capts.  (acting  Majors)  F.  E.  Stokes,  J.  W.  Thomson,  A.  L.  Heiser, 
C.  S.  P.  Black,  J.  W.  McIntosh,  and  A.  E.  Ironside  relinquish  the 
acting  rank  of  Major  on  ceasing  to  be  specially  employed. 

Capt.  H.  H.  B.  Cunningham  to  be  a Deputy  Assistant  Director  of 
Medical  Services,  and  to  he  acting  Major  whilst  so  employed. 

1st  London  General  Hospital : Lieut.-Col.  Sir  Anthony  A.  Bowlby, 
K.O.M.G.,  K.C.V.O.,  C.B.,  is  retired  and  is  granted  the  honorary  rank 
of  Major-General. 

4tli  Northern  General  Hospital  : Major  (acting  Lieut.-Col.)  F.  S. 
Genney  relinquishes  the  acting  rank  of  Lieutenant-Colonel  on  ceasing 
to  be  specially  employed. 

1st  London  Sanitary  Company  : Lleuts.  J.  Buckland  and  W.  H.  S. 
Dunn  to  be  Captains. 

1st  Eastern  General  Hospital:  Capt.  P.  N.  B.  Odgers  is  restored  to 
the  establishment. 

3rd  Western  General  Hospital : Capt.  (acting  Major)  R.  C.  Elsworth 
relinquishes  the  acting  rank  of  Major  on  ceasing  to  be  specially 
employed. 

ROYAL  AIR  FORCE. 

Medical  Branch. — Lieut.-Col.  H.  E.  South  (Fleet-Surgeon,  R.N.) 
relinquishes  his  commission  on  ceasing  to  be  employed. 

Capt.  (acting  Major)  C.  J.  G.  Taylor  and  Capt.  T.  H.  James  are  trans- 
ferred to  the  unemployed  list. 

Dental  Branch.— G.  Packman  is  granted  a temporary  commission  as 
Captiin. 

P.  E.  Bernard  and  R.  H.  More  are  granted  temporary  commissions  as 
Lieutenants.  

INDIA  AND  THE  INDIAN  MEDICAL  SERVICE. 

Lieut.-Col.  J.  Jackson,  C.I.E.,  to  be  Colonel. 

The  King  has  approved  the  retirement  of  Lieut.-Col.  A.  H.  Nott  and 
Major  D.  S.  A.  O'Keeffe. 

Lieut.-Col.  J.  Stevenson,  C.I.E.,  is  retiring  from  the  appointment  of 
Principal  of  the  Government  College,  Lahore.  Capt.  C.  E.  R.  Norman 
resigns  the  service.  Lieut.-Col.  W.  Vonney,  Civil  Surgeon,  Cawnpore, 
has  been  granted  leave,  and  Dr.  C.  A.  Fuller  officiates  as  Civil  Surgeon, 
Cawnpore,  during  his  absence.  The  Secretary  of  State  for  India  has 
appointed  Mr.  Nihiatan  Dhar  to  the  Indian  Educational  Service  as 
Professor  of  Physical  and  Inorganic  Chemistry,  Muir  Central  College, 
Allahabad.  Capt.  R.  B.  Lloyd,  Imperial  Serologist,  has  been  appointed 
Chemical  Examiner  to  the  Government  of  Burma. 


Stoital  $tdD$. 


The  death  is  announced  of  Dr.  William  Smith 
■Greenfield,  F.R.S.  Edin.,  at  the  age  of  73,  who  was  Emeritus 
Professor  of  Pathology  and  Clinical  Medicine,  Edinburgh 
University,  from  1881  to  1912. 

University  of  London. — At  the  Second  Examina- 
tion for  medical  degrees  (Part  I.)  held  recently  the  following 
candidates  were  successful : — 

Francis  Glen  Allan,  St.  Thomas's  Hosp.;  Katharine  Margaret 
Andrew,  Newnham  College;  Joseph  Atkin  and  Philip  Bernard 
Atkinson,  King’s  College;  Grace  Lily  Austin,  University  College  ; 
Maud  Kirkdale  Baden-Powell,  London  School  of  Medicine  for 
Women;  Judah  Samuel  Benzecry,  University  College;  William 
Claude  Morpott  Berridge,  St.  Thomas's  Hosp. ; Mark  Bersinski, 
Middlesex  Hosp. ; Hilda  Alice  Bond  and  Gwenddnlen  Jane  Brooke, 
University  College ; Grace  Emily  Budge,  London  School  of  Medicine 
for  Women ; Helen  Bumstead,  King's  College ; Lily  Clarkson 
Butler  and  Hilda  Louisa  Byett,  London  School  of  Medicine  for 
Women;  Dorothy  Maude  Campbell-Meiklejohn  and  Fanny  Louise 
Cattle,  University  College  ; Gladys  Maud  Clarke  and'  Marian 
Bertha  Coleman,  London  School  of  Medicine  for  Women  ; Arthur 
Basil  Cooper,  St.  Paul’s  School ; William  Leigh  Spencer  Cox  and 
Eleanor  Mildred  Creak,  University  College  ; Hilda  Mary  Cunnington, 
London  School  of  Medicine  for  Women  ; Donald  Vaughan 
Davies,  St.  Paul’s  School ; Morris  Denman,  Middlesex  Hosp. ; 
Barbara  Joan  Edwards,  University  of  Birmingham  ; David  Glyn 
Mason  Edwards  and  Alfred  Claude  Mitchell  Elman,  University 
College;  Brenda  Harks  English,  London  School  of  Medicine  for 
Women ; Charles  Walter  Evans,  University  College ; George 
Morgan  Evans,  University  College,  Cardiff;  Shafik  Abd-el-Malek 
Fam,  King’s  College;  Mary  Dorothy  Fletcher,  University  College; 
Louis  Fogelman,  Guy’s  Hospital ; Annie  Foner,  University  College ; 
Mary  Elizabeth  Fox,  London  School  of  Medicine  for  Women; 
Emily  Lorna  Franklin  and  Labib  Ghabrial,  King's  College;  Laura 
Phmbe  Gibbon,  Lady  Margaret  Hall.  Oxford ; Cecil  Percy 
Roderick  Gibson,  St.  Thomas’s  Hosp. ; Winefride  Mary  Gibson, 
A ictoria  Tutorial  College  ; Horace  Philip  Goldsmith,  University 


College;  Dorothy  Eva  Gray,  London  School  of  Medicine  for 
Women;  John  Griffiths,  University  College,  Cardiff;  Aaron 
Gullortein,  London  Hosp.  ; Margaret  Constance  Noe!  Iladley  and 
Samuel  Halporin,  University  College;  James  Rowland  Hamer- 
ton,  St.  Bartholomew’s  Hosp.  ; Marjorie  Florence  Hayward 
and  Barbara  Joan  Ilick,  London  School  of  Medicine  for 
Women;  Norman  Gray  Ilill,  London  Hosp.;  Gwynedd 
Hugh-Jones,  London  School  of  Medicine  for  Women  ; 
Robert  Hunt  Cooke,  St.  Bartholomew's  Hosp.  ; Morris  Jablonsky, 
King's  College ; Douglas  James  Tendron  Jeans,  Guy’s  Hosp. ; 
Harry  Victor  Malnwaring  Jones,  St.  Thomas’s  Hosp.  ; Robert  Owen 
Jones,  Middlesex  Hosp.;  Norman  Adams  Jury,  St.  Bartholomew's 
Hosp. ; Jean  Pierre  Kies,  St.  Thomas's  Hosp. ; Alfred  Charles  King. 
London  Hosp. ; Charlotte  Anne  Kingdon,  London  School  of 
Medicine  for  Women  ; Isaac  Ivinsler,  St.  Bartholomew's  Hosp.; 
Charles  Henry  Landau,  London  Hosp. ; Miriam  Annabella  Lawson, 
London  School  of  Medicine  for  Women  ; Charles  Emile  Marie 
Joseph  Libert,  King’s  College  ; *Edith  Treliving  Marshall,  London 
School  of  Medicine  for  Women ; Doris  Ivy  Mart,  University 
College  ; Annie  Pearce  Martin,  London  School  of  Medicine 
for  Women ; Y'sobel  Maisie  Howard  Martin,  Newnham  College ; 
Lucy  Margaret  Theodora  Masternran  and  Margarethe  Mautner, 
London  School  of  Medicine  for  Women ; Alan  Aird  Moncrieff, 
Middlesex  Hosp.  ; Thomas  Walter  Morgan,  University  College, 
Cardiff ; Richard  Murchison  Morris,  London  Hosp. ; Herman 
Mould,  University  College ; Ethel  Murgatroyd,  Newnham  College ; 
Frances  Louisa  Nichol,  London  School  of  Medicine  for  Women  ; 
Albert  Boswell  Nutt,  University  of  Sheffield  ; Herbert  Leslie  Older- 
shaw,  St.  Bartholomew's  Hosp.  ; Guan  Yong  Oon ; University 
College ; Beryl  Palmer-Jones,  University  College,  Cardiff ; Emily 
Constance  Noel  Paterson,  Newnham  College ; Dorothy  Edith 
Peake,  London  School  of  Medicine  for  Women  ; Cyril  Morgan  Pearce, 
St.  Bartholomew’s  Hosp. ; Herbert  John  Plowright,  Guy’s  Hosp.  ; 
Kathleen  Mary  Potter,  University  of  Leeds  ; Violet  Alice  Quilley 
and  Alysoun  Hurndall  Rowntree,  London  School  of  Medicine  for 
Women  ; Dorothy  Stuart  Russell,  Girton  College ; George  Drury 
Shaw  and  Thomas  Archibald  Shaw,  Guy’s  Hosp.  ; Elizabeth 
Shlounde,  King’s  College;  Walter  Roworth  Spurrell,  Guy’s  Hosp. ; 
Betty  Stainer,  King's  College ; Edith  Emily  Stephens, 
Hilda  North  Stoessiger,  and  Margaret  Swete,  London  School  of 
Medicine  for  Women  ; Selwyn  Edward  Tanner,  University  College, 
Cardiff ; Robert  Wise  Holden  Tincker,  St.  Bartholomew’s  Hosp.  ; 
Maurice  Auvache  Townshend,  University  College;  John 
Rutherford  Tree,  Middlesex  Hosp.  ; Olga  Frances  Tregelles, 
London  School  of  Medicine  for  Women ; Thomas  Fenemore 
Waring,  London  Hosp. ; Reginald  Lawson  Waterfield,  Guy’s  Hosp.; 
Lewis  John  Watkins  University  College,  Cardiff,  and  private 
study;  Constance  Clara  Maude  Watson,  King’s  College  and 
Charing  Cross  Hosp. ; Hilda  Marion  Weber,  University  College  ; 
Henry  John  William  Jennings  Westlake,  Guy's  Hospital;  Edward 
Lincoln  Williams,  London  Hosp. ; and  Esther  Wingate  and 
Isabelle  Joan  Woodhouse,  London  School  of  Medicine  for  Women. 

* Awarded  a mark  of  distinction. 


parliamentary  Intelligence. 

NOTES  ON  CURRENT  TOPICS. 

War  Pensions  (Administrative  Provisions)  Bill. 

The  House  went  into  Committee  on  Thursday,  August  7th, 
on  the  War  Pensions  (Administrative  Provisions)  Bill. 

The  Right  of  Appeal. 

On  the  motion  “that  this  be  the  Schedule  of  the  Bill,” 

Mr.  Hogge  complained  that  many  of  the  men  who  were 
wounded  in  1914-15  had  not  even  an  appeal  against  the 
asse^ment  of  the  Medical  Board.  There  was  no  medical 
referee  in  those  days  attached  to  the  Local  War  Pensions 
Committee  to  which  any  of  these  men  could  appeal.  He 
wanted  to  know  if  the  appeal  set  up  in  Clause  8 of  this  Bill 
enabled  any  man  who  was  eligible  for  a pension  from  the 
first  date  on  which  men  were  being  wounded  to  go  to  this 
tribunal  ? This  was  an  extraordinarily  important  point. 

Sir  James  Craig  said  it  was  the  desire  and  duty  of  the 
Pensions  Minister  to  see  that  the  responsibility  of  passing 
men  on  to  the  Ministry  of  Labour  rested  with  the  medical 
advisers.  Consequently,  the  desire  of  Mr.  Hogge  was 
adequately  met.  No  pensioner  left  the  auspices  of  the 
Pensions  Ministry  until  he  was  certified  by  their  own 
medical  staff  to  be  absolutely  fit  to  undertake  the  training 
which  the  Ministry  of  Labour  proposed  to  give  him.  As 
to  an  appeal  to  a superior  class  of  medical  board,  the  door 
was  by  no  means  closed,  but  he  could  not  pledge  the 
Minister  without  having  first  consulted  him. 

The  Committee  Stage  was  concluded,  and  the  Bill  was 
reported  to  the  House  and  read  a third  time. 


HOUSE  OF  COMMONS. 

Wednesday,  August  6th. 

Hospital  Arrangements  in  India. 

Colonel  Yate  asked  the  Secretary  for  India  whether  he 
could  make  any  statement  as  to  the  amelioration  of  the 
hospital  arrangements  for  the  sick  and  wounded  in  the 
operations  on  the  North-WTest  Frontier  of  India : whether 
he  was  aware  that  one  officers’  hospital  was  so  badly 
equipped  that  the  patients  had  to  use  their  shaving  mugs 


306  Thb  Lanobt,] 


PARLIAMENTARY  INTELLIGENCE. 


[August  16,  1919 


as  drinkiDg  cups  and  tumblers;  that  do  casualty  lists  were 
issued  for  more  than  a month  subsequent  to  May  17th  ; and 
even  wives  were  Dot  officially  informed  of  their  husbands’ 
deaths  and  were  left  to  hear  of  it  from  other  sources. — Mr. 
Montagu  replied  : As  regards  the  first  part  of  the  question, 
I would  refer  my  honourable  and  gallant  friend  to  the  very 
full  statement  which  I have  made  in  answer  to  another 
question  of  his  (summarised  in  The  Lancet  of  lastweekj. 
The  second  part  is  covered  by  the  request  which  I have 
already  addressed  to  the  Government  of  India  for  a report 
on  the  hospital  referred  to.  It  is  not  the  case,  so  far  as  I 
am  aware,  that  no  casualty  lists  were  published  for  more 
than  a moDth  subsequent  to  May  17th.  Reports  of  casualties 
are  communicated  to  the  War  Office  as  they  are  received  by 
the  India  Office  and  are  published  by  the  former.  Apart 
from  publication,  reports  of  casualties  are  immediately 
communicated  by  the  India  Office  to  the  next-of-kin  in  all 
cases  in  which  the  names  of  the  next-of-kin  have  been 
registered.  If  the  honourable  and  gallant  Member  will 
inform  me  what  are  the  cases  to  which  he  refers  in  the 
last  part  of  his  question  I will  have  inquiry  made. 

Colonel  Yate  : 1 refer  to  the  publication  by  the  Govern- 
ment of  India.  I would  ask  with  regard  to  the  statement  in 
yesterday’s  full  statement  which  is  referred  to  that  the 
scale  of  equipment  of  Indian  general  hospitals  has  been 
reviewed  and  that  arrangements  for  providing  additional 
equipment  are  in  progress  does  not  that  show  that  the  short- 
age brought  to  light  by  the  Mesopotamia  Commission  has  not 
yet  been  remedied  in  India,  and  that  the  pernicious  report 
of  Lord  Nicholson  and  Sir  William  Meyer,  which  caused 
Lord  Crewe  to  limit  the  expenditure  on  the  Indian  Army  to 
£19,500,000  is  still  operating,  and 

The  Speaker:  The  honourable  and  gallant  Member  is 
making  an  argumentative  speech. 

Hospital  Carriers  for  Russia. 

Lieutenant-Commander  Kenworthy  asked  the  First  Lord 
of  the  Admiralty  whether  he  was  aware  of  the  fact  that  six 
hospital  carriers  had  been  sent  to  North  Russia  for  service 
on  the  River  Dwina  which  could  not  ascend  that  river 
owing  to  their  excessive  draught ; whether,  in  consequence, 
the  arrangements  for  transporting  wounded  might  be 
insufficient  should  heavy  casualties  be  inflicted  on  our 
forces;  and  whether  all  possible  steps  were  being  taken  to 
send  out  smaller  carriers  for  wounded  with  all  dispatch. — 
Dr.  Macnamara  (Secretary  to  the  Admiralty)  replied:  The 
six  hospital  carriers  referred  to  are  six  paddle  steamers 
which  were  fitted  out  temporarily  owing  to  the  unavoidable 
delay  on  passage  from  Mesopotamia  of  vessels  of  smaller 
draught.  They  were  the  shallowest  draught  craft  available 
at  the  time,  and  but  for  the  abnormally  low  river  would  have 
been  entirely  suitable  for  the  service.  I am  advised  that 
adequate  craft  are  now  available  at  Archangel,  and  should 
more  be  required  others  are  on  their  way. 

Public  Health  Research. 

Mr.  Waterson  asked  the  Prime  Minister  whether  the 
Minister  of  Health  would  throw  wide  open  the  door  of 
research  to  all  new  ideas  and  methods,  so  far  as  the 
promotion  of  health  was  concerned.— Dr.  Addison  replied : 
I have  been  asked  to  answer  this  question.  It  is  certainly 
the  intention  of  the  Ministry  of  Health  to  utilise  every 
possible  means  for  promoting  the  health  of  the  people  in 
cooperation  with  the  Medical  Research  Committee  and 
otherwise,  and  including  in  particular  the  investigation  of 
the  causes  of  disease  and  the  encouragement  of  research, 
with  an  open  mind  for  the  reception  of  new  ideas  and 
methods. 

Medical  Arrangements  in  Russia. 

Mr.  Rawlinson  asked  the  Secretary  for  War  if  he  would 
state  how  many  hospital  ships  were  now  being  used  for  the 
troops  in  North  Russia  ; and  whether  an  adequate  supply  of 
doctors,  nurses,  and  hospital  requirements  had  now  reached 
our  troops.— Mr.  Churchill  replied : Two  hospital  ships  are 
being  used  to  evacuate  patients  from  the  military  hospitals 
in  North  Russia.  An  adequate  supply  of  doctors  and  hospital 
requirements  are  present  at  both  Archangel  and  Murmansk. 
Six  British  nurses  are  doiDg  duty  in  the  hospital  at 
Murmansk.  There  are  no  British  nurses  stationed  at 
Archangel. 

Venereal  Disease. 

Major  Waring  asked  the  Secretary  for  War  whether  he 
was  aware  that  patients  undergoing  treatment  for  venereal 
disease  in  certain  military  hospitals  in  this  country  were 
permitted  to  move  freely  in  populous  districts  every" after- 
noon ; and  would  he  issue  instructions  that  these  infected 
persons  should  be  confined  to  the  precincts  of  the  hospital 
throughout  their  period  of  treatment. — Mr.  Churchill 
replied  : Patients  undergoing  treatment  for  venereal  disease 
in  military  hospitals  are  not  permitted  to  move  freely,  as 
suggested  in  the  first  part  of  my  honourable  and  gallant 
friend’s  question.  Except  under  very  exceptional  circum- 
stances patients  who  are  in  a condition  to  spread  infection 
are  not  granted  leave  from  the  hospital. 


Food  for  Patients  in  Sanatoriums. 

Mr.  Grattan  Doyle  asked  the  Minister  of  Health  whether 
his  attention  had  been  called  to  the  complaints  that  many 
tuberculosis  patients  in  sanatoriums  and  similar  institution's 
under  the  control  of  local  authorities  still  suffered  from  the 
severe  regime  imposed  by  the  war  and  food  control  as  to 
food  and  nourishment;  and  whether  he  would  cause  such 
inquiries  and  alterations  to  be  made  as  would  ensure  to  such 
patients  every  consideration  and  help. — Major  Astor  (Parlia- 
mentary Secretary  to  the  Ministry  of  Health)  replied  : I am 
aware  that  complaints  have  been  made  from  time  to  time  in 
respect  of  food  and  other  matters  in  sanatoriums  and  similar 
institutions,  and  I am  now  inquiring  into  a particular  case 
which  has  just  been  brought  to  my  notice.  I am  advised 
that  where  the  official  dietary  scales  are  properly  carried  out 
they  are  found  suitable,  but  if  the  honourable  Member  will 
give  me  the  details  of  any  particular  place  where  he  has 
information  that  the  food  is  inadequate,  I will  gladly  have  it 
investigated  and  reported  upon. 

Thursday,  August  7th. 

Filthy  Streets  and  the  Public  Health. 

Major  C.  W.  Lowther  asked  the  Minister  of  Health 
whether  he  was  aware  of  the  dirty  condition  of  the  streets  in 
the  neighbourhood  of  Paddington,  and  whether  he  would 
take  steps  to  cause  the  streets  in  question  to  be  thoroughly 
disinfected  with  a view  to  preventing  the  propagation  of 
disease. — Major  Astor  replied : My  right  honourable  friend 
has  no  official  representations  on  the  subject,  but  in  view  of 
what  has  otherwise  come  to  his  knowledge  he  is  in  communi-  i 
cation  with  the  local  authority  with  a view  to  considering 
what  steps  it  may  be  desirable  to  take  to  safeguard  the  health 
of  the  people. 

Colonel  Yate  : Is  the  right  honourable  gentleman  in  com- 
munication with  the  Kensington  authorities,  where  the 
situation  is  very  serious? — Major  Astor:  Yes,  my  right 
honourable  friend  has  been  in  touch  with  Kensington  for 
some  time,  and  I understand  that  seven  vans  are  collecting 
refuse  in  Kensington  and  that  there  will  be  20  on  the  streets 
to-morrow. 

Breaches  of  Discipline  at  Warlingham  Hospital. 

Sir  Stuart  Coats  asked  the  Secretary  for  War  whether 
on  Peace  Day  it  was  necessary,  in  answer  to  an  urgent 
summons,  to  send  a detachment  of  troops  in  motor  lorries, 
with  a machine-gun,  from  the  Guards’  barracks  atCaternam 
to  suppress  a serious  riot  at  the  military  hospital  for  venereal 
diseases  at  Warlingham;  and  whether  he  was  now  in  a 
position  to  state  what  steps  he  was  taking  to  prevent  in 
future  the  recurrence  of  such  breaches  of  discipline. — Mr. 
Churchill  replied : I am  informed  that  there  has  never 
been  a riot  at  the  military  hospital  at  Warlingham.  A number 
of  patients  were,  or  had  been,  absent  without  leave  on  the 
night  July  I8th-19th,  and  to  prevent  additional  men  leaving 
the  hospital  a detachment  from  the  Guards’  Depot  was  sent 
on  the  morning  of  the  19th.  No  machine-gun  accompanied 
the  troops.  The  detachment  of  Guards  was  relieved  the 
next  day  bv  other  troops,  who  are  still  there.  The  breaches 
of  discipline  have  been,  and  are  being,  dealt  with  in  the 
ordinary  course,  and  20  men  are  now  awaiting  trial  by 
district  court-martial  in  connexion  with  the  occurrence. 

Nurses  at  Archangel. 

Mr.  Jodrell  asked  the  Secretary  for  W7ar  if  there  were 
any  British  nurses  in  the  port  and  town  of  Arcnangel ; and, 
if  so,  how  many,  and  when  did  they  arrive. — Mr.  Churchill 
replied  : There  are  at  present  no  British  women  nurses  in 
the  port  and  town  of  Archangel.  A matron  and  13  sisters 
were,  however,  on  duty  on  a hospital  ship  which  was  • 
stationed  at  Archangel  from  Nov.  2nd  till  June  2nd  last, 
when  the  ship  returned  with  them  to  this  country.  The 
hospital  ship  returned  to  Archangel  on  July  7th  with  one 
matron  and  tan  sisters  and  left  again  on  the  28th  with  the 
nursing  staff  on  board. 

Small-pox  and  the  Italian  Expeditionary  Force. 

Mr.  Waterson  asked  the  Secretary  for  War  if  he  could 
state  how  many  men  who  went  to  Italy  in  the  spring  of  1918 
well  vaccinated  contracted  small-pox. — Mr.  Churchill 
replied:  T.vo  cases  of  small-pox  were  reported  as  occurring 
among  the  troops  of  the  Italian  Expeditionary  Force  during 
the  year  1918.  One  was  reported  in  January  and  the  other  in 
April.  I cannot  say  whether  the  latter  went  to  Italy  in  the 
spring  of  1918  nor  whether  the  soldier  was  vaccinated. 

Treatment  Jor  Neurasthenic  Patients. 

Major  Prescott  asked  the  Pensions  Minister  whether  he 
could  make  any  statement  as  to  the  amelioration  of  the 
hospital  arrangements  for  discharged  sailors  and  soldiers 
suffering  from  neurosis  and  neurasthenia;  whether  he  was 
aware  that  many  of  these  Tottenham  cases,  together  with 
those  of  epilepsy,  were  still  awaiting  admission  into  homes 
of  recovery;  whether  he  was  aware  that  Mr.  H.  G.  Cooke,  a 
discharged  soldier,  of  39,  Franklin-street,  Tottenham,  had 
been  waiting  for  over  five  weeks  to  be  admitted  into 


The  Lanoht,] 


M1SDICAL  DIAKY.— APPOINTMENTS.— VACANCIES. 


[August  16,  1919  307 


hospital ; whether  he  was  aware  that  a similar  case 
which  had  been  waiting  for  a similar  period  ended 
fatally  a few  days  ago;  and  would  he  take  immediate 
action  to  see  that  all  outstanding  cases  were  admitted 
to  hospital  without  further  delay.— Sir  J.  Craig  (Parlia- 
mentary Secretary  to  the  Ministry  of  Pensions)  replied  : This 
matter  has  engaged  the  serious  attention  of  the  medical 
officers.  It  is  hoped  that  soon  a central  neurological 
institution  will  be  established  in  each  region,  available  for 
both  in-patient  and  out-patient  treatment.  It  is  recognised 
that  in  a great  number  of  neurasthenic  cases  in-patient 
treatment  is  not  required,  and  in  order  to  provide  for  this 
a number  of  clinics  are  being  established  in  various  parts  of 
the  country  where  expert  out-patient  treatment  will  be 
given.  It  is  therefore  confidently  expected  that  very  soon 
ample  accommodation  will  be  available  for  the  efficient 
treatment  of  these  cases.  As  regards  the  case  of  Mr.  Cooke 
his  admission  to  an  institution  has  now  been  arranged. 
There  was,  unfortunately,  a little  delay  in  obtaining  a 
vacancy  in  a suitable  hospital.  The  other  case  quoted  was 
-complicated  by  the  fact  that  the  patient  was  also  suffering 
from  epilepsy,  and  it  was  from  this  disease  that  he  died. 

Monday,  August  11th. 

Insurance  Medical  Benefit. 

Mr.  G.  Locker-Lampson  asked  the  Minister  of  Health  if 
he  could  make  any  announcement  about  the  proposed 
extension  of  medical  benefit  under  the  National  Insurance 
(Health)  Acts. — Major  Astor  (Parliamentary  Secretary  to 
the  Ministry  of  Health)  replied ; The  question  of  what 
changes,  if  any,  in  the  existing  medical  benefit  under  the 
Insurance  Acts  will  be  proposed  for  1920  is  not  yet  decided. 
Various  improvements  in  the  conditions  of  service  and  the 
possible  establishment  of  some  of  the  additional  matters 
that  were  suggested  in  the  Estimates  of  1914  have  been  under 
-consideration  at  the  Ministry  and  in  conference  with  the 
practitioners,  and  will  be  further  discussed  with  the  new 
consultative  councils,  with  the  insurance  committees,  and 
with  approved  societies.  But  these  matters  are  not  yet  in  a 
sufficiently  advanced  state  to  admit  of  any  precise  statement 
from  me  to-day. 

Seale-Hayne  Hospital  Victualling . 

Mr.  George  Lambert  asked  the  Secretary  for  War  whether 
-tenders  had  been  invited  for  the  Victualling  of  the  Seale- 
Hayne  Hospital,  Devon;  and  when  the  promise  made  to 
•evacuate  this  institucion  would  be  fulfilled. — Mr.  Churchill 
replied  : Inquiry  is  being  made  as  to  the  first  part  of  my 
right  honourable  friend’s  question.  As  regard  the  latter 
part,  I can  add  nothing  at  present  to  the  letter  that  was  sent- 
&o  him  on  Friday  last. 

Tuesday,  August  12th. 

Medical  Treatment  at  Ilford  and  Barking. 

Sir  Peter  Griggs  asked  the  Pensions  Minister  whether 
he  was  aware  that  notice  had  been  given  to  stop  the  medical 
and  surgical  treatment  of  pensioners  and  discharged  soldiers 
-at  the  Ilford  Emergency  Hospital  for  the  towns  of  Ilford, 
Barking,  and  district,  some  of  these  men  badly  requiring 
treatment,  having  had  to  leave  their  military  hospitals  too 
soon  ; and  whether  he  would  make  arrangements  for  the 
doctors  to  be  paid  for  continuing  the  work  which  they  had 
•done  gratuitously  in  the  past. — Sir  J.  Craig  (Parliamentary 
Secretary  to  the  Ministry  of  Pensions)  replied  : My  right 
honourable  friend  is  aware  that  the  authorities  of  the  Ilford 
Emergency  Hospital  have  given  notice  to  terminate  the 
treatment  at  their  hospital  of  pensioners  and  discharged 
soldiers  at  the  end  of  next  month  owing  to  lack  of  accom- 
modation. Arrangements  will  be  made  at  the  earliest 
possible  date  for  providing  the  necessary  and  suitable 
treatment  for  discharged  men  in  the  areas  mentioned. 


Utefrbl  $iar|r  for  % ensuing  ffifteet 


LECTURES,  ADDRESSES,  DEMONSTRATIONS,  &c. 

LONDON  HOSPITAL  MEDICAL  COLLEGE,  in  the  Clinical  Theatre 
of  the  Hospital. 

A Special  Course  of  Instruction  in  the  Surgical  Dyspepsias  will  be 
given  by  Mr.  A.  J.  Walton 

Monday,  August  18th.— 4.30  p.m..  Lecture  V.: — Gastric  Ulcer. 
.•Etiology  and  Pathology. 

Friday. — 4.30  p.m..  Lecture  VI.: — Gastric  Ulcer.  Symptoms, 
General  and  Special. 

A Course  of  Clinical  Lectures  for  Advanced  Students  on  Intermittent 
Blood  Infections  and  their  Relation  to  Certain  Common  Diseases 
of  the  Kidney,  Prostate,  Testicle,  and  other  Organs  will  be 
delivered  by  Mr.  F.  Kidd : — 

Wednesday. — 4.15  p.m..  Lecture  III. : — Haematogenous  Infections 
of  the  Testicles  and  Bladder.  Clinical  Course ; Diagnosis ; 
Treatment. 


Appointments. 


Successful  applicants  for  vacancies,  Secretaries  qJ  Public  Institutions, 
and  others  possessing  information  suitable  for  this  column,  acre 
invited  to  forward  to  The  Lancet  Office,  directed  to  the  Sub- 
Editor,  not  later  than  9 o'clock  on  the  Thursday  morning  o)  each 
week,  such  information  for  gratuitous  publication. 

Barling,  Seymour,  C.M.G.,  M.S.Lond.,  F.H.C.S.,  has  been  appointed 
Honorary  Surgeon  to  tbe  General  Hospital,  Birmingham. 

Berry,  W.  A.,  M.D.  (Slate  Med.),  B.S.Lond.,  D.P.H.,  Medical  Officer 
of  Health  and  School  Medical  Officer  for  the  Heston  and  Isleworth 
Urhsn  District  Connell. 

Cook,  W.  W.,  M.R.C.S..  L.R.C.P.  Lond.,  one  tbe  Medical  Referees 
under  the  Workmen’s  Compensation  Act,  19C6,  for  County  Court 
Circuit  No.  2. 

Davies,  Trevor  B.,  M.D.,  B.S.Lond.,  M.R.C.P.  Lond.,  F.R.C.S.  Eng., 
Obstetric  Surgeon  to  Out-Patients,  Queen  Charlotte's  Hospital. 

Hardy,  T.  Lionel,  M.B.  Cantab.,  M.R.C.P.  Lond.,  Assistant  Physician 
to  the  General  Hospital,  Birmingham. 

Hood,  J.  H.,  M.B.,  Ch.B.  Edin.,  Honorary  Surgeon  to  the  Royal 
Cornwall  Infirmary,  Truro. 

Quine,  A.  E , M B..  Ch.B.  Viet.  Manch., F.R.C.S.  Eng.,  joint  Venereal 
Diseases  Medical  Officer  for  the  Cumberland  and  Carlisle  City 
County  Councils. 

Certifying  Surgeons  under  the  Factory  and  Workshop  Acts:  Lavin, 
M.  F.  (Ballymore  Eustace  District),  Ferguson,  J.  (Manchester, 
South-East  District),  Rees-Tiiomas,  W.  H.,  M.R.C.S., 

L.R  C.P.  Lond.  (Basingstoke). 


For  further  information  refer  to  the  advertisement  columns. 
Adelaide  University. — Prof,  of  Path,  and  Bact.  £800. 

Ashford,  Kent,  Grosvenor  Sanatorium. — Sec.  Asst.  M.O.  £250. 
Barnsley,  Beckett  Hospital—  Res.  H.S. 

Bath  City  Council. — M.O.H.  £700. 

Battersea  General  Hospital,  S.  IF.— Res.  M.O.  for  Cancer  Wing. 
Birmingham  Education  Committee. — Asst.  Sch.  M.O.  £300. 

Bradford  Royal  Infirmary  .—Res.  Surg.  O.  £250. 

Brighton  Education  Committee.—  Sen.  Sch.  Doctor.  £600. 

Brighton  and  Hove  Hospital  for  Women.— Hon.  S. 

Cairo,  Egyptian  Government  School  of  Medicine. — Professors  and 
Lecturers.  £E.1000  and  £E.600.  Also  Radiologist  and  Lect.  in 
Radiology,  £E.500,  Anaesthetist  and  Lect.  in  Anaesthetics,  £E.500, 
and  Registrar  and  Tutor,  £E.600. 

Canterbury,  Kent  and  Canterbury  Hospital.— Jnn.  Res.  M.O.  £150. 
Carlisle,  Cumberland  Infirmary.— Res.  M.O.  £200. 

Chester  County  Asylum.—  Locum  Tenens.  7 gs.  per  week. 

Charley  Education  Committee. — Asst.  Sch.  M.O.  £400. 

Derby , County  Borough  Education  Committee.  — Asst.  Sch.  M.O.  £500. 
Derbyshire  Royal  Infirmary. — Oph.  H.S.  £200. 

Devonport.  Royal  Albert  Hospital.— Res.  H.S.  £200. 

Dumfriesshire' Education  Authority. — Med.  Asst.  £350. 

Durham  County  Council  — Asst.  Welfare  M.O.  £500.  Also  District 
Tuberc.  M.O.’s.  £600. 

East  London  Hospital  for  Children,  Shadwell.  E. — Cas.  O.  £120. 

George  Town  Municipality,  Penang , Straits  Settlements.— Asst.  M.O.H. 
$4200. 

Glamorgan  County  Asylum,  Bridgend. — Fourth  Asst.  M.O.  £400. 
Great  Yarmou'h  Hospital.— H.S.  £200. 

Greenwich  Metropolitan  Borough.— M.O.  for  Maternity  and  Child 
Welfare  Work.  £540. 

Quisborough  Union. — M.O.  £700. 

Hong-Kong  Government.— Bad.  and  Path.  £600. 

Hong- Kong  University. — Lecturer  in  Biologv.  £400. 

Huddersfield,  Pontefract,  and  Wakefield,  West  Riding  County  Council. 
— Dist.  Tuberc.  O.’s  £500. 

Ilford  Urban  District  Council. — M.O.H.  and  Female  Asst.  M.O.H.  £650 
and  £400. 

Kent  County  Mental  Hospital  — Jun.  Asst.  M.O.  £300. 

Khartoum,  Wellcome  Tropical  Research  Laboratories.— Asst.  Bacterio- 
logist. £R.600. 

King's  Lynn.  West,  Norfolk  Hospital.— H.S.  £150. 

Leeds  General  Infirmary. — Ophth.  and  Aur.  H.S.  £50.  Res.  M.O.  £60. 
Two  H.S.’s  and  Two  H.P.’s. 

Leeds  Public  Dispensary,  North-street.— Res.  M.O.  £200. 

Leyton  U.D.C.  Education  Committee. — Asst.  M.O.  £350. 

Liverpool,  David  Lewis  Northern  Hospital.—  Three  S.’s  and  Two  P.’s. 
£150. 

Liverpool  Hospital  for  Consumption,  &c.— Vacancies  on  Hon.  Med  Staff. 
Liverpool  School  of  Tropical  Medicine. — Tropical  Research,  Brazil. 
£300. 

Manchester,  Ancoals  Hospital.— Res.  S.O.  £200. 

Manchester,  Baguley  Sanatorium  for  Tuberculosis. — Three  M.O.’s. 
£400,  £350,  and  £300  respectively. 

Manchester,  Monsall  Fever  Hospital. — First  Med.  Asst.  £350.  Second 
Med.  Asst.  £300. 

Manchester  Royal  Infirmary.— Med.  and  Surg.  Registrars.  £75. 

Surg.  Tutor.  £30.  Also  H.S.’s.  £25. 

Manchester,  St.  Mary’s  Hospitals  for  Women  and  Children. — Res. 

Obst.  S.  and  Res.  Surg.  O.  £250  each. 

Melbourne  University. — Lecturer  in  Pathology.  £600. 

National  Hospital  for  Diseases  of  the  Heart,  Westmoreland-street,  W. — 
Res.  and  Non-Res.  M.O.’s.  £100  and  £50. 

Nelson.  Lancs.— M.O.H.  and  Sch.  M.O.  £700. 

Newark  Hospital  and  Dispensary.— Res.  H.S. 

Newcastle-upon-Tyne,  Hospitalfor  Sick  Children.— Sea.  Res.  M.O.  £200. 
Newcastle-upon-Tyne  Poor-law  Infirmary—  Second  Res.  M.O.  (Female). 
£250. 

Newport  Borough  Asylum,  Caerleon,  Mon.— Asst.  M.O  £300. 


308  The  Lancet,]  NOTES,  SHORT  COMMENTS,  AND  ANSWERS  TO  CORRESPONDENTS.  [August  16,  1919 


Northampton  General  Hospital  —Two  U.S.'s  £?no  pach. 

Northamptonshire  C.C.  Education  Committee  — Sch.  Denti-t,  £350. 

Nottingham.  Knits  Education  ommitlee  — A“»t.  School  MO.  £425. 

Prince  oj  Wales  s General  Hospital,  Tottenham. — Hon.  Asst.  P.  and 
Hon.  Asst.  Of  hth.  S.  Also  (Hill.  A*-st.’s. 

Putney  Hospital,  N.W.— Kes.  M.O.  £'50. 

Queen’s  Hospital  for  ChHaren.  Hackney  road,  Bethnal  Green,  E.— 
H.S  an  i Cas.  H.S.  £'00  each. 

Rochester.  Kent.  St.  harthol/  mew's  Hospital.  —.Inn.  Kes.  M.O  £150. 

Rochdale  Infirmary  and  Dispensary. —Sen  H.S.  £200.  Also  Jun.  H.S. 

£100. 

Royal  National  Orthopaedic  Hospital.  London.  IT.  - Hon.  P. 

Royal  Society.  Burlington  House,  London. — Two  Roller  ton  Student- 
ships. £400  each. 

St.  George’s  IIos,  Hal,  S.  W. — Two  Css.  Officers.  £200. 

St.  Helen*  Education  Committee.— Wt  ole-time  Dentist.  £460. 

St.  Mary’s  Hospital  Medic  it  School,  Paddington,  II'.  —Lecturer  on 
Chemistry.  £300. 

Sheffield  Royal  Infirmary. — H.S.  £150. 

Shetland— Tingwall  Whiteness,  and  Weisdale.—Kl.O.  and  Pub.  Vac.  £45. 

Southampton,  Free  Eye  Hospital.—  H.S . £150. 

Swansea  General  and.  Eye  Hospital  —Kes.  M.O.  £200. 

Taunton  and  Somerset  Hospital.— lies.  Asst.  H.S.  £80. 

Notice  is  given  of  a vacancy  for  a Specialist  Medical  Keferee  for  Cases 
of  Industri  i)  Disease,  in  County  Court  Circuits  Nos.  24,  28,  30.  31 , 
and  54.  Applications  should  be  addressed  to  the  Private  Secretary, 
Home  Office,  not  later  t han  Sept.  4t.h. 

Notice  is  given  of  a vacancy  for  a Metical  Referee  under  the  Work- 
men’s Comoensition  Act  for  the  Shetiffdom  of  Toe  Lothians  and 
Peebles,  and  also  for  Circuit  No.  11  (Bradford,  Keighley,  Otley.  and 
Skipton  County  Courts).  Aoplications  should  he  addressed, 
respectively,  to  the  Private  Secretary.  Scottish  Office  aud  Home 
Office,  Whitehall.  London.  S.W.  1 . not  later  than  Sept.  4th. 

The  post  of  Medical  Adviser  at  Liverpool,  under  the  Colonial  Office,  is 
vacant.  Application  for  particulars  should  be  made  to  the  Colonial 
Office,  London,  S.W. 

The  Chief  Inspector  of  Factories.  Home  Office.  S.W.,  gives  notice  of 
vacancies  for  Certifying  Surgeons  under  the  Factory  and  Workshop 
Acts  at  Absrtilicry.  Bishop’s  Castle,  Borrisaleigh,  Darlington, 
Staveley,  and  Tallow. 


Carriages,  ani>  §ea^s. 


BIRTHS. 

Hill. — On  August  7th,  at  " Dalestead.”  Caterham  Valiev,  Surrey,  the 
wife  of  Fred.  T.  Hill.  M.R.C.S.,  L K.C.P..  of  a son  (Anthony). 

J effreys. — On  August,  5tb,  at  Brookvale-road,  Southampton,  the  wife 
of  Walter  M.  Jeffreys,  M.B..  of  a daughter. 

Joly. — On  August  10th.  at  Watford,  the  wife  of  James  Moncrieff  Joly, 
M.B..  B.S.Lond.,  of  Doom  Dooma,  Assam,  of  a son. 

Whitnky.— On  August  7th,  at  High  View,  Maidon,  Essex,  the  wife  of 

C.  Underwood  Whitney,  L.K  C.P.,  M.K.C.S.  (late  Captain, 
R.A.M.C.),  of  a son. 

DEATHS. 

Knight  — On  August  7i,h,  at  his  residence,  Swansea,  Frederick  Knight 
M.D.Lond.,  M.K.C.S.,  aged  59. 

N.B.—A  fee  of  6s.  is  charged  tor  the  insertion  of  Notices  of  Births, 
Marriages,  and  Deaths. 


Communication-,  *c..  to  thelEditor  kav<- 

been  received  from— 


A.  — Mr.  P.  A.  Agutter.  Welling- 
borough Mr.  K.  J.  Albery. 
Lond.;  Sir  R.  Armstrong-Jones, 
Carnarvon;  Mr.  J.  K Aiams. 
Lond.;  Mrs.  V.  B.  Alvarez,  New 
York. 

B.  Lieut.  Col.  Sir  J.  Barrett, 
Melbourne;  Mr.  J.  R.  Burke, 
Kingston  Hill  British  Dental 
Association,  Lond.,  Sec.  of;  Dr. 
G.  J.  Branson,  Birmingham  ; Mr. 
J.  P.  Buckley,  Manchester;  Mrs. 

C.  Brereton,  Lond  ; Dr.  W.  A. 
Berry,  Lond.;  British  Thomsou- 
Houston  Co..  Lond.;  Dr.  E.  A. 
Barton,  Lond.  Surg.  Commdr. 
W.  Bastian,  R N. 

C.  — Dr.  J.  B.  Crozier,  Lond.;  Dr. 
J.  B.  Christopherson,  Lond.;  Dr. 
F.  G.  Crookshank,  Lond.;  Dr. 
J.  C.  Clayton,  Lond.;  Colonial 
Office,  Lond.,  Asst.  Private  Sec.; 
Dr.  C.  R.  Corfield,  Manchester. 

D.  — Dr.  L.  S.  Dudgeon,  Lond.;  Sir 

D.  Duckworth,  Bt.,  Lond. 

E. — Evelina  Hospital,  Lond.,  Sec. 
of. 

F. — Food E ^ucatlon  Society,  Lond.; 
Dr.  A.  R.  Fraser,  Aberdeen;  Fac- 
tories. Chief  Inspector  of.  Lond. 

G. — Major  W.  R.  Galwey  .•  Dr. 
A.  L.  Grant,  Burghead  ; Prof.  G. 
Galll,  Rome;  Dr  H.  L.  Gordon, 
Lond.;  Dr.  R.  G.  Gordon,  Bath  ; 
Mr  W.  E.  Gurden,  Lond. 

H. --Fleet-Surg.  W.  E.  Home.  R.N.; 
Dr.  J.  U.  Hood,  Truro;  Dr.  H. 


Head,  Chateau  de  la  Mimerolle; 
Capt.  H.  A.  Haig,  R.  A. M.O. 

K.  — Dr.  H.  C.  Kidd,  Bromsgrov** ; 
Dr.  R.  Knox,  Lond.;  Mrs.  Y.  M. 
Kirkwood,  Lond. 

L.  — Dr.  C.  E.  Lakin,  Lond  ; Dr. 
W.  J.  Le  Grand,  Blackwell ; Dr. 
rT.  C.  Low,  Lond.;  Mr.  E.  M. 
Little,  Lond. 

M -Manchester,  School  Medical 
Officer  of;  Dr.  J.  B.  Mennell, 
Lond.;  Mr.  E.  Miles,  Lond.; 
Major  P.  Manson-Bahr,  D.S.O  , 
R.A.M.C.;  Ministry  of  Health, 
Lond. 

N. — National  Association  for  the 
Prevention  of  Tuberculosis, 
Lond.;  Dr.  A.  Napier,  Glasgow. 

P.  — Mr.  V.  G.  Plarr,  Lond.;  Mr. 
T.  D.  Pryce.  Nottingham. 

Q. — Queen  Charlottes  Hospital, 
Lond.,  Sec  of. 

S.  — Dr.  A.  G.  Bhera,  Eastbourne ; 
Stoke  Newington,  Medical  Officer 
of  Health  of  ; Dr.  K.  I.  Spriggs, 
Banff;  Mr.  D.  M.  Shaw,  Cheddar  ; 
Dr.  E.  B.  Sherlock,  Darenth ; 
Student;  Mr.  S.  Stephenson, 
Lond. 

T. — Dr.  A.  H.  Thompson,  Lond.; 
Dr.  J.  Tatham,  Oxted. 

U.  — University  of  Liverpool,  Dean 
of  Faculty  of  Medicine  of. 

W.— Dr.  L.  A.  Weatherly,  Bourne- 
mouth ; Dr.  F.  J.  Wethered,  Fal- 
mouth; Mr.  H.  Wiltshire,  Lond. 
Y.— Mr.  P.  Yates,  Mauchester. 


Commnnicafcions  relating  to  editorial  business  should  be 
addressed  exclusively  to  the  Editor  of  The  Lancet, 
423,  Strand,  London,  YV.C.  2. 


lilies,  Sjjort  (tomrats,  attb  pastes 
ta  Corresponkitts. 

AN  EMERGENCY  CASES  HOSPITAL  IN  THE 
MEUSE. 

By  J.  A.  Cairns  Forsyth,  M.Sc.,  M.B.,  F.R.C.S., 

SUKGKHN  TO  THE  FRENCH  HOSPITAL. 

( Concluded  /romp.  272.) 


The  Defence  of  Verdun. 

On  Feb.  23rd,  1916,  wounded  began  to  arrive  from  Verdan. 
They  were  in  a bad  way,  and  very  “ jumpy,”  having 
suffered  much  during  the  terrible  bombardment,  which 
they  described  as  something  quite  extraordinary  in  the 
way  of  shell  fire.  Certainly  some  of  the  shells  which  fell 
around  Verdun  were  of  uncommon  size. 

The  first  fortnight  of  that  historic  battle  will  always  live 
in  our  memories.  Work  was  at  the  highest  pressure  on 
account  of  the  constant  stream  of  wounded  that  flowed 
through  Bar-ie-Duc.  How  the  staff  of  the  Evacuating 
Hospital  stood  the  strain  I do  not  know,  but  they  went  about 
their  work  uncomplaining,  their  bodies  limp  with  fatigue 
and  their  eyes  heavy  from  want  of  sleep. 

The  battle  was  practically  directed  from  Bar-le-Duc,  which 
soon  became  a very  busy  place.  You  will  all  have  read  of 
the  wonderful  motor  transport  service  that  was  so  quickly 
organised  to  assist  the  railway  transport,  for  the  only 
railway  to  Verdun  that  was  of  any  service  was  a narrow 
gauge  line,  and  much  time  was  lost  in  transferring  material 
from  broad  gauge  wagons  to  narrow  gauge.  24,000  motor 
lorries  made  the  tour  to  Verdun  and  back,  each  day  and 
night.  Bar-le-Duc  was  so  policed  that  no  civilian  vehicles 
of  any  kind  were  allowed  in,  and  even  military  vehicles  had 
to  enter  by  one  way  and  leave  by  another.  Stopping  or 
turning  in  the  main  streets  was  prohibited.  On  the  roads  to 
Verdun  traffio  was  as  well  managed,  and  each  class  of  troop 
and  transport  had  its  different  route,  according  to  the  speed 
of  its  travelling. 

With  the  opening  of  the  battle  there  hurried  to  the  Verdun 
front  numerous  British  ambulance  sections  belonging  to  the 
British  Ambulance  Committee,  the  British  Red  Cross,  and 
’the  British  Committee  of  the  French  Red  Cross.  All  of 
them  got  arduous  and  dangerous  work  transporting  wounded 
from  the  “ postes  de  secours.” 

Shell  I Pounds  and  Gas  Gangrene. 

The  wouuds  received  around  Verdun  were  in  quite  another 
class  from  those  of  the  Argonne  fighting  in  1915.  They 
were  practically  all  shell  wounds,  horrible  tearing  smashes, 
and  tbe  oroportion  of  fractures  was  very  high.  Of  the  3000 
wounded  that  came  to  us  in  1916  over  1000  had  compound  ‘ 
fractures,  many  of  them  multiple.  Gas  gangrene  was  also 
very  rife,  and  we  had  266  cases  of  gross  gas  infection,  gas 
that  could  be  detected  by  the  senses.  Of  these  266  cases  179  ; 
were  of  the  local  type,  and  the  majority  remained  so.  Only 
eight  of  these  patients  died.  The  remaining  87  were  cases  of 
the  fulminating  tyne,  where  a whole  limb  or  a large  area 
such  as  the  shoulder,  back,  or  buttock  was  involved.  59  of 
tbe  87  died.  Included  in  this  series  are  eight  cases  of  that 
carious  condition,  “white  gangrene”  of  the  lower  limb. 
The  limb  then  had  the  appearance  of  a gigantic  phlegmasia 
alba  dolens,  and  the  toxasmia  was  especially  profound.  In 
seven  of  the  eight  cases  the  whole  limb  was  affected  and  all 
died.  The  remaining  case  was  atypical,  for  the  condition 
extended  up  only  to  the  knee.  That  case  got  well. 

French  Colonials. 

As  the  battle  continued  we  were  brought  more  and  more 
into  touch  with  the  Colonial  troops-  of  France— Arabs  from 
North  Africa,  blacks  from  Senegal,  Somaliland,  and  the 
French  Soudan,  Auuamites  from  French  Indo-China.  In 
the  French  hospitals  there  was  no  separation  of  the  coloured 
men  from  the  white— they  were  treated  just  like  the  others, 
except  that  iu  the  case  of  the  Arabs  and  certain  blacks  their 
food  had  to  be  in  accordance  with  their  religious  laws.  Many 
of  the  blacks  partook  of  auything  that  was  going,  but  the 
Arabs  were  most  particular  in  their  diet. 

Of  all  these  men  of  oolour  we  were  specially  attached  to 
the  primitive  black.  They  were  a most  well-behaved,  poiite 
lot  of  men,  who  showed  an  almost  dog-like  devotion  to  those 
who  ministered  to  their  wants.  Some  of  them  were  men  of 
huge  stature,  vet  they  were  among  the  gentlest  patients  that 
ever  entered  the  hospital.  One  gathered  from  their  officers 
that  they  were  terrible  fellows  in  the  fight,  giving  no  quarter 
and  asking  for  none.  At  times  they  were  difficult  to  hold, 
especially  under  heavv  shell  fire,  but  once  launched  at  the 
attack  they  proved  their  mettle.  Then  they  were  prone  to 


sll01ir  COMMIT  l-S.  AND  ANSWERS  To  CORRESPONDENTS.  [ApopM  16,  1919 


throw  awtiy ‘heir  rifles,  ami  they  entered  battle  armed  onlv 

,ii’o'Lfe,l?i0rile  !<nlfe’  “,couP  OOUP  ” as  they  called  it, 
that  deals  a blow  akm  to  that  ol  the  Gurkha  kukri  One 
can  imagine  the  effect  on  the  Bosche  wlieu  ho  saw  a 
regiment  of  these  ebouy  giants  coming  on,  brandishing  such 
weapoDs. 

, The  Nightly  Alerte : 

In  the  autumn  of  1917  there  commenced  a long  period  of 
bombing  of  the  Meuse  district,  no  doubt  in  response  to  the 
PiPv?g  °f  ^ermau  territory  by  the  British  Independent 
V Wf8  an  ,auxloU8  time,  especially  during  the 
September,  when  we  got  the  “ alerte  ” every  night. 
Bar-le-Duc  suffered  baaly,  one  corner  of  it  being  blowu 
away.  The  Credit  Lyonnais  was  burned  to  the  ground 
and  the  civil  hospital  had  to  be  evacuated.  Revignv  sniftered 
in  like  manner,  especially  round  the  railway  station  and 
the  artillery  park.  We  soon  realised,  however,  after  the 
first  few  nights  that  the  Bosche  did  not  intend  to  harm  our 
hospital  When  they  had  finished  bombmg  Revigny  they 
crossed  the  ridge  and  made  for  our  lake  as  a rallyingpoinT 
Keeping  well  down  so  as  to  be  safe  from  the  guns!  which 
could  not  fire  low  on  account  of  the  ridge,  they  passed  ove*- 

vi!fblea  n '?h  ' of  a^o>ft  100  yards.  With  our  wa?ds  plainly 
visible  in  the  moonlight,  our  unit  must  have  been  aii 
excellent  target,  but  they  left  us  alone.  U “ 

;•  , British  Wounded  from  Champagne 

bbe  aPri°g  of  1918  the  great  German  offensive  com- 
menced, and  among  the  wounded  who  came  to  us  from  the 
Champagne  were  many  British.  They  had  been  tadS 
knooked  about,  and  we  were  glad  to  see  them.  A few  weeks 
later  and  the  wounded  Highlanders  of  the  51st  Division 
hpb?Led’  b P had  Sot  the  turn  and  the  Bosche  was 

being  pushed  back.  These  were  the  days  of  open  warfare 
hnh  wounds,  and  it  was  quite  a pleasure  to  treat 

them  SuppuraStead.ter  SheI1  W°UDds  °f  Verdun-  for  few  of 
Summer  saw  the  advent  of  the  American  Army  to  Verdun 

!ren^hehvBtghn-De;  and  IhTi  gradual  replacement  of  the 
French  by  their  troops.  We  now  had  to  rely  entirely  on 

J8*™?  of,,the  Champagne  for  patients,  and  many  came 
to  us  from  that  .army  of  Colonial  regiments.  Our  hosoital 

wta  thU1f6  a u !f'fe  laib  ” appearance,  and  our  only  regret 
was  that  we  did  not  speak  Arabic.  “ g cc 

I A Long  Farewell. 

signing  of  the  Armistice,  we  got  leave  to  return 
“ Snd,f  80  we  Packed  UP  our  tents  and  stole  awav  Our 
last  patients  went  into  the  interior  or  “ en  permission  ” 
vowing  undying  friendship,  and  the  hosmta  !™s  fh0’,, 
rapidly  dismantled  . The  bulk  of  our  equipment  wls  sent  to 
a chateau  near  Paris,  recently  purchased  by  the  British 
Committee  of  the  Croix  Rouge,  and  presented  to  the  French 
Mismtonnm  for  consumptives.  cil 

tnnl6  SaiA  good'^ye  to  our  many  friends  in  the  district  and 
took  a sad  and  long  farewell  of  Faux  Miroir.  It  had  been 

hnf  b°me  f0r  0Ver  tbree  years  and  we  were  loth  to  leave  it 
hein  !fCame  aWay  •wilth  the  Pardonable  feeling  that  we  had 
been  of  some  assistance  to  a nation  in  the  hour  of  her 
sorest  need.  Verdun  now  is  but  “ a tale  that  is  told  ” fn 
comparison  with  the  more  recent  glories  of  the  Wo  t n 

rout  buttons  there  will  everremamthe  memory  of  & 
great  defence  and  the  sacrifice  it  entailed  The  part  tint 
our  unit  played  may  have  been  small  and  unimportant  but 
perhaps  it  may  be  that  the  equal  treatment  of  all*  tho 
specimens  of  humanity  of  the  French  world  the  fair  division 
aa<l  C0mf0rts  from  borne, °the  littlesprees  ^nd 

zgs3ni^htpnfn  Ksaar- that  reai  kins"p 


309 


said  that  the  old  man,  formerly  charming  and  benevo- 
on  6 hi  <)V  |Ug  h‘8t  grandchildren  much  and  taking  them 
ou  his  knee,  became  indifferent  He  often  became 
I depressed,  bad-tempered,  and  exacting.  If  not  told  it 

20  to  VialvgaUd  (Julck|y  ‘bvmed  that  he  bad  a mistress  of 
20  to  35  years.  1<  rom  the  earliest  period  of  his  career  bis 
observations  tended  to  convince  him  that  genital  excesses 
were  often  the  cause  of  apoplexy,  cerebral  congestion  and 
so  t.ening,  heart  affections,  and  rapid  decline  of  intelligence 

the  men  0f  60  1°  70  >ears  He  resolved  to  study 

the  question  as  soon  as  he  had  the  cases  which  would 
enable  him  to  do  so.  When  such  a case  arrived  his  view 
was  confirmed.  He  told  the  anxious  wife  to  send  her  husband 
I hl™  as  80pn  be  complained  of  the  slightest  malaise 
| Questioning  led  the  patient  to  admit  that  he  had  a mistress' 
y<?ang-  Armaingaud  pointed  out  the  ill-results’ 
reminding  him  of  the  death  of  a contemporary,  wtiich  was 
m evr°Rut0  age  but  t0  e?ceS8’  absolute  or  relati've,  and  after 

excess  in'hllgence  ™ight  consttaute 

excess.  He  added  that  it  was  to  old  men  especially 

S ” In  38ylnUsgseHa?9liedf-  '\Po>t  e,oitum  omne  animh 
• . ' lu  38  cases  12  patients  would  not  give  up  the 

mistress,  7 did  so  for  a few  years  and  thin  relapsed 
19  did  so  permanently.  The  12  who  did  not  were  from  62  to 

Y3  yt,rs  °f  Tf  (a,Vel;age  63b  They  died  at  an  average  age  of 
f3  years.  They  lost  on  the  average  four  years  of  life^  for 
the  expectancy  of  life,  according  to  the  tables  of  Fre’noh 
insurance  companies,  for  63  years  is  14  years  The  7 who 
pai tially  followed  the  advice  were  aued  no  to  no 
(average  65).  According  to  tofUfe^  “eta  IZ 
expectancy  was  13  years,  bringing  the  average  age  at  death 
to  16.  Rut  6 died  at  an  average  age  of  75  • 1 was  an  evoon 

ag0edataoml3  M'  Tbe  19  Wb°  did  take  the  advice  werPe 
aged  from  63  to  69  years  (average  66).  Three  who  were 
exceptions,  lived  until  68,  70,  and  72  years - but  the  51 
others,  wno  had  an  average  expectancy  of  life  of  12  years— 
that  is,  to  78  years— lived  until  an  average  age  of  86  \ ears  13 
more  tban  the  first  class  and  11  than  the  second  The 
“ pl0V!!.u  quotfd  by  Professor  Lacassagne  in  his  book 
1 he  worst  things  for  an  old  man  are  a good  cook  and  vorme 
woman,”  expresses  a great  truth.  ^oou  cook  and  young 

“DIADEM”  TALCUM  POWDER. 

It  is  well  known  that  talc  provides  an  pYrniinni  a 
lubricant  for  toilet  purposes.  Ita  Xus greasy ^r  Ln£ 
feel  is  a remarkable  characteristic.  In  “ Diadem  ” nowder 
a particularly  fine  impalpable  talc  is  selected^ 

?hf!6ab  y Perfunied  with  unirritating  agents.  In  addition 
fin6!6  a8  Pre8ent  a well-known  antiseptic  powder  also  in  a 
finely  divided  state.  Altogether  this  toilet  powder  reaches  a 
very  good  standard,  having  regard  to  the  purposes  for  which 


MOTHERCRAFT.i 


THE  ILL-EFFECTS  OF  THE  AMOURS  OF  OLD  MEN 

Las«,  ssris, 

krmaingaud  has  ha|  snehciai  f an  'mportant  clientele,  M. 

‘ge.  But  there  were  others  whn  fin  V a?,  advanced 
differed  from  ennui  ThotrSmWh°  ,fe*l  1Dto  idleness  and 

» to  65  years  or  more,  Jh0  haTretired  bn®!neS8!nen  aged 
ortunes  Thnnoh  in  a u after  making  their 


™ZnL%.  ‘he  t,reg““oy 

ire*  Hssffigr 
ssr«&  <5.  “ a 

clean  milk  lias  met  with  little  or  no  response  mlPwe 
only  hope  with  Dr.  Kenwood  tPat  tUsiXTilwaW  b,Z 
He  condemns  m no  uncertain  language  the  milk  which  i=Tf 

present  sold,  and  which  is  so  frequently  used  as  a fond 

for  infants  He  says  that  “much  of  the  milk  w if 
is  sold  is  dangerously  dirty,  and  this  dirt  in 
responsible  for  much  infant  sickness d and 
especially  in  toe  summer  months.  From  5 to  in  nJ’ 
cent,  of  all  toe  samples  of  cow’s 

contained  the  cow  germ  of  consumption  *nPed  have 
London:  John  IWe.  Sons,  and  Danlelsson,  Ltd,  KatoS 


310 


The  Lancet,]  NOTES,  SHORT  COMMENTS,  AND  ANSWERS  TO  CORRESPONDENTS.  [August  16,  1919 


by  human  agencies  causes  epidemics  of  diphtheria,  enteric 
fiver  scarlet  fever,  &c. : 10  per  cent,  of  all  the  samples  of 
milk  taken  under  the  Sale  of  Food  and  Drugs  Acts  in 
England  and  Wales  and  submitted  to  the  public  analyst 
are^ found  to  be  adulterated.”  Simple  tests  which  can  be 
applied  by  any  intelligent  person  are  given  for  the  content 
of*  cream,  and  the  presence  of  dirt  or  sourness.  It  is 
impossible  to  mention  in  detail  the  subjects  which  are 
dealt  with  so  helpfully,  but  those  which  will  be  found  of 
great  use  include  Causes,  Recognition  and  Prevention  of 
Dental  Defects,  by  Mr.  C.  Peyton  Baly;  Diseases  of  Jhe  Skin 
in  Infancy,  by  Dr.  H.  G.  Adamson ; and  the  Law  Relating  to 
Maternity  art  Child  Welfare,  by  Dr.  T.  Shad.ck  Higgins. 

In  the  appendix  is  given  a selection  of  the  best  answers 
to  questions  on  infant  care  which  have  been  set  by .the 
National  Association  for  the  Prevention  of  Infant  Mortality 
at  the  examination  held  at  the  conclusion  of  each  course 
of  lectures.  The  answers  are  reproduced  as  a guide  to  other 
students,  and  will,  with  the  examiner’s  note,  be  of  great 
assistance  to  health  visitors  and  others  who  intend  to 
present  themselves  as  candidates  at  future  examinations. 

A MEDICAL  REFORMER. 

In  its  “News,  Notes,  and  Queries,”  the  Liverpool  Post 
appositely  remarks  that  Parliament  would  be  muchJ^ 
better  these  days  if  it  could  boast  a Joseph  Hume,  who 
set  himself  to  check  Ministerial  extravagance  and  abuses 
wherever  he  could  detect  them,  and  maintained  a small 
staff  at  his  own  expense,  for  ferreting  out  and  exposing 
everything  prejudicial  to  the  public  purse.  So  formidable 
did  he  prove  that  Ministers  framed  their  estimates  in  fear 
of  him.  Joseph  Hume  was  born  on  Jan.  22nd,  1777,  and 
was  the  son  of  a Montrose  shipmaster.  On  the  death  of 
his  father,  his  mother  was  forced  to  sell  crockery  in  the 
market-place,  but  managed  to  send  her  son  to  school,  a11®,  ”1 
1790  he  was  apprenticed  to  a local  surgeon.  Subsequently, 
he  studied  medicine  at  Aberdeen,  Edinburgh,  and  London, 
and  entered  as  a surgeon  in  the  sea  service  of  the  East  India 
Company.  He  was  afterwards  transferred  to  the  land  service 
of  the  Company,  and  having  mastered  Hindustani and 
Persian  was  employed  in  political  duties.  In  1801  he  joined 
the  army  at  Bundelcund  as  a surgeon,  and  during  the 
Mahratta  war  rendered  the  Government  important  services, 
including  a means  of  drying  the  stock  gunpowder  which  had 
become  wet.  Leaving  the  army,  having  somehow  amassed 
£40  000,  he  spent  some  time  in  travel  and  study,  publishing 
in  1812  a translation  in  blank  verse  of  the  Inferno  of  Dante. 
His  political  career  at  home  began  in  the  fame  year  and 
he  represented  at  different  times  Weymouth,  the  Border 
burghs,  Aberdeen,  Middlesex,  Kilkenny,  and  Montrose. 
Like  his  personal  and  political  friend,  the  Founder  of 
The  Lancet,  the  late  Thomas  Wakley,  he  urged  the  aboli- 
tion of  flogging  in  the  army.  He  was  a Privy  Councillor,  a 
Fellow  of  the  Royal  Society,  and  twice  Lord  Rector  of 
Aberdeen  University.  He  died  in  1855. 

PREGNANCY  AND  CHILD  BIRTH  AMONG  SIBERIAN 
ABORIGINES. 

Miss  M.  A.  Czaplicka,  a Russian  lady  who  lived  for  some 
years  in  Siberia  among  the  primitive  people,  has  shed  a good 
deal  iaf  light  on  the  mode  of  life,  habits,  customs,  and 
superstitious  practices  in  a book  entitled  “ Aboriginal 
Siberia,  a Study  in  Social  Anthropology  ” (Clarendon  Press. 
14s.  net).  Among  other  things  she  has  collected  data 
relating  to  pregnancy  and  childbirth,  some  of  the  more 
interesting  of  which  are  here  given  with  the  names  of  the 
tribes  concerned 


The  Kamchadal.— Acaording  to  Krasbeninmkoff,  an  eighteenth- 
century  traveller,  a woman  gave  birth  to  a child  kneeling  and 1 in  the 
presence  of  all  the  villagers  without  regard  to  sex  or  age  The  ne  wly 
born  child  was  wiped  with  and  wrapped  in  a species  of  grass  called 
(ouchitch  : a stone  knife  was  used  to  cut  the  umbilical  cord,  and  the 
placenta  was  thrown  to  the  dogs.  A woman  who  wished  to  become 
pregnant  had  to  eat  spiders  ; some  women  for  this  purpose  would  eat 
the  umbilical  cord  together  with  a grass  called  kt pen.  On  the  other 
hand  if  a child  was  not  desired  there  was  a widespread  custom  of 
causing  abortion  by  shock,  or  by  killing  in  utero.  The  old  women 
••  specialists  ” who  carried  out  the  operation  frequently  caused  the 
death  of  the  mother.  In  order  to  induce  sterility  concoctions  made 
from  certain  grasses  were  taken. 

The  Yukaghir.—AM  cases  of  childbirth  among  the  Aukaghir  were 
very  difficult  , and  the  barbarous  practices  attendant 
nervous  diseases  and  premature  age  in  the  mothers.  The  foundation 
of  these  practices  is  the  belief  that  difficult  labour  and  unfortunate  birth 
ate  caused  by  the  entry  of  an  evil  spirit  into  the  woman.  Difficult 
labour  is  also  attributed  either  tithe  failure  of  the  mother  to  observe 
certain  taboos  or  to  the  ill-will  of  the  child  itself.  Therefore  two 
pregnant  women  are  not  allowed  to  live  in  the  same  house  in  case 
the  two  unborn  obtldren  should  communicate  and  decide  which 
mother  should  die.  Sometimes  the  husband  helps  his  wife  who  is  in 
difficult  labour  by  placing  his  arm  around  her  abdomen.  The  taboos 
connected  with  childbirth  affect  not  only  the  mother,  but  also  the 
rest  of  the  household.  Some  of  these  taboos  are:  the  pregnant 
woman  must  not  eat  the  fat  of  the  cow  or  reindeer,  or  larch-gum,  as 
these  things  are  believed  to  ••freeze"  or  thicken  in  the  stomach  and 
to  fasten  the  child  to  the  inside  of  the  uterus ; but  butter  of  the  cow 
or  horse’s  fat  may  be  eaten.  She  ought  not  only  to  be  active  and 


energetic  during  the  puerperium,  but  ought,  in  walking,  to  raise 
her  feet  high  and  also  to  kick  away  stones  or  lumps  of  earth  in 
her  path  thus  symbolising  the  rem  ival  of  obstructions  at  childbirth. 

At  the  first  attack  of  lab  .ur-palns  not  only  the  wife,  but  the  husband 
and  midwife,  must  loosen  all  their  girments,  so  that  the  child  may 
not  be  hamperel  in  any  way. 

The  Chukhee.—Th\e  tribe  is  one  of  the  moit  prolific  in  North-Bast 
Asia  and  the  women  are  delivered  with  little  trouble.  Custom  forbids 
the  mother  receiving  any  help  at  childbirth -help  may  only  be  given 
in  cases  of  absolute  necessity.  She  must  not  groin,  an i has  to  attend 
to  her  own  needs  as  well  as  to  those  of  the  new-born  infant.  She  cuts 
the  cord  (with  a stone  skin-scraper)  and  pulls  away  the  placenta. 
Accordingly,  a Urge  pelvis -beciuse  it  eases  delivery— is  considered 
one  of  the  chief  features  of  womanly  beauty. 

The  Qiluak  —The  Gilyak  woman  never  dares  to  give  birth  to  a child 
at  home  ; she  must,  in  spite  of  the  severity  of  the  weather,  go  out  of 
the  hut  for  this  purpose.  In  late  fall  or  winter  a special  hut  is  built 
for  the  woman,  but  it  is  a very  uncomfortable  affair,  so  that  mother 
and  child  suffer  from  exposure  to  cold  and  wind.  To  help  the  woman 
in  labour  a wooden  figure  is  carved,  representing  a woman  in  the  act  of 
delivery,  and  to  it  are  sacrificed  different  kinds  of  foods,  with  a view  to 
placate  the  evil  influences  which  are  at  work.  Special  knives  are  used 
to  cut  the  cord.  The  woman  returns  home  on  the  eighth  or  ninth  day. 

A woman  who  wishes  to  have  a child  wears  various  amulets,  such  as  a 
dog’s  tooth,  & c. 

The  Buryat, -Among  the  Buryat  of  Alarsk  during  delivery  the 
women  of  the  family  are  gathered  near  the  mother  and  take  the  child 
and  drop  it  in  a horizontal  position  on  the  floor,  which  has  been  made 
soft  for  the  purpose,  after  which  it  <s  washed  and  wrapped  up.  Two  or 
three  days  later  a feast  is  held  at  which  the  ceremony  of  wrapping  up 
the  child  bsgins.  Ab)y  or  girl  present  is  chosen  to  reply  to  questions 
Dut  by  a temporary  “mother,”  who  holds  in  her  hands  an  arrow  and  a 
right  haunch  of  bone  of  an  animal.  After  the  questions  have  been 
asked  and  answered  three  times  a name  is  given  to  the  child.  The 
feast  ends  with  the  making  of  a fire  in  the  place  where  the  birtn 
occurred  ; the  guests,  including  the  father,  surround  the  fire  and  squirt 
into  it  from  their  mouths  a mixture  madefrom  meal  and  oil,  all  in  one 
voice  exclaiming  " Give  more  happiness!  Give  a son  —repeated  three 
times.  General  excitement  prevails  and  they  vie  with  each  other  in 
smearing  their  friends’  faces  and  clothes  with  oil,  ashes,  and  fresh 
animal  excrement. 

The  Yakut  —Yakut  marriages  are  generally  fruitful,  averaging  ten 
children  to  one  woman,  but  becoming  less  so  towards  the  northern 
districts,  although  the  Yakut  are  everywhere  more  prolific  than  the 
Tungus.  The  lack  of  children  is  ascribel  solely  to  the  woman. 
According  to  the  explorer  Jochelson,  women  from  the  JJave  Y,eiJ 

difficult  delivery.  The  Yakut  regard  the  pangs  of  childbirth  as  sick- 
ness caused  by  evil  spirits,  and  therefore  if  the  assistance  of  a midwife 
or  the  goddess  of  fertility.  Ayisit,  is  of  no  avail,  a shaman  is  called  in 
to  fight  the  spirit.  A Yakut  woman  is  always  delivered  on  the  bare 
earth,  for  the  Yakut  believe  that  the  “ earth-soul  is  communicated  to 
the  infant  from  the  earth  at  the  moment  of  birth.  No  consideration  is 
shown  to  mother  or  child,  for  women  possessed  evil  Bpirite  are 
regarded  as  no  less  perilous  to  society  than  those  infected  with  epidemic 
disease  This  accounts  for  the  cruelty  manifested  by  the  Yakut 
towards  women  suffering  the  pains  of  labour.  Cases  have  been  known 
where  the  woman  has  died  as  a result  of  such  cruelty.  To  hasten 
delivery  two  posts  are  driven  into  the  ground  and  a third  one  is 
fastened  across  the  top  of  thpm.  The  woman  kneels  and  places  her 
arms  over  the  cross-piece  far  enough  to  bring  the  latter  under  the 
arm-pits.  One  man  from  behind  holds  her  shoulders  and  another  in 
front  holds  her  hands  to  prevent  any  possibility  of  her  resisting  the 
operations  of  the  midwife.  The  latter  kneels  in  front  of  the  patient 
and  presses  upon  her  abdomen,  at  the  same  time  imploring  the  aid  of 
the  benevolent  goddess,  Ayisit.  who  is  believed  to  be  present  at  chiM- 
birth  and  to  assist  the  patient.  Certain  food  taboos  are  chived 
before  childbirth  : the  expectant  mother  must  eat  neither  swan  s flesh 
nor  wild  birds’  eggs,  because  the  child  might  otherwise  be  deaf  and 
imbecile. 

The  customs  collected  by  Miss  Czaplicka  are  foun“  among 
aborigines  more  or  less  all  over  the  world.  The  custom 
mentioned  as  existing  among  the  Yukaghir  of  the  .specta- 
tors loosening  their  garments  is  in  one  form  or  other 
very  old.  It  was  a belief  of  ancient  Roman  and  Greek  fo.k- 
iore  that  the  goddess  of  delivery,  Lucina  or  Ilithyia,  could 
hinder  delivery  according  to  the  attitude  which  she  took  up, 
a belief  referred  to' by  Herrick,  who  says,  ‘At  thy  birth 
Lucina  cross-legged  sat.” 


REDUCING  A DISLOCATION. 

Retired  Major,  R.A.M.C.,  asks  : — “ What  are  the 
chances  of  successfully  reducing  a backward  dislocation  oi 
both  bones  of  the  forearm  in  a boy  of  12  years,  hve  week 
after  its  occurrence?  What  is  the  latest  time  after  wine 
such  an  injury  has  been  reduced  ? ” 


BOOKS,  ETC.,  RECEIVED. 

LrppixcOTT  (J.  B.)  Company.  London  and  Philadelphia.  , h_ 
Text-book  of  Ophthalmology.  Bv  H.  E.  Fuchs.  Translated  by 
A.  Duane.  M.D.  6th  ed.  Pp.  10S8.  30$. 

Longmans.  Green,  and  Co.,  London.  D ~ c Ath 

Dental  Surgery  and  Pathology.  By  J.  F.  Colyer,  F.R.C.S.  «tb  “■ 

Essentials  oVpbysiologv.  By  F.  A.  Bainbridge.  F.R.S.,  M.D.,and 
J.  A.  Menzies.  M.D.  3rd  ed.  Pp.  434.  12*.  6d. 

Macmillan  and  Co..  London.  , .aI8 

Lectures  on  Sex  and  Heredity,  delivered  in  Glasgow  1917-1918,  by 
F.  O.  Bower.  J.  Graham  Kerr,  and  W.  B.  Agar.  Pp.  120.  b*. 
Maloine.  A.  et  Fils.  Paris. 

Le ,Lait  Condense.  By  Dr.  P.  Lassabli^re.  Pp.  110. 

University  of  London  Press.  London.  _ ... 

Mental  Diseases.  By  R.  H.  Cole.  M.D.  2nd  ed.  Pp.  351.  15*. 


THE  LANCET, 


lltetjjofts  of  Sfeatmcnt 

OF 

FRACTURES  OF  THE  FEMUR. 

By  JAMES  DIIIBERG,  M.C.,  F.R.C.S., 

LATE  OArTAIN,  R.A  M.C.  ; SURGICAL  REGISTRAR,  LONDON  HOSPITAL. 


In  no  branch  of  surgery  has  the  present  war  done  more  to 
modify  treatment  than  in  that  of  fractures  of  the  femur, 
and  not  only  to  modify  but  also  to  simplify  the  treatment. 
Whereas  in  pre-war  days  a different  splint  was  regarded  as 
more  or  less  specific  for  each  variety  of  fracture,  the  piesent 
method  is  to  treat  all  forms  of  fracture  of  the  femur,  and 
even  of  the  whole  leg,  in  a Thomas  knee-splint. 

By  this  means  every  sort  of  deformity  can  be  entirely 
overcome  and  an  ideal  result  obtained,  whereas  it  is  to  be 
remembered  that  in  the  pre-war  days  shortening  of  from 
one  to  two  inches  was  common  with  a simple  fracture,  and 
the  results  of  compound  fractures  often  hopeless. 

It  is  true  that  in  many  cases  of  war  wounds  with  gross 
destruction  of  bone  and  tissue  the  ideal  has  been  impossible 
to  attain  ; but  these  war  wounds  are,  we  hope,  things  of  the 
past,  and  the  object  of  this  paper  is  to  apply  the  methods 
learnt  and  studied  in  the  war  to  civil  practice,  in  which, 
happily,  compound  fractured  femurs  are  rare,  and  seldom  do 
we  see  the  ghastly  shattering  of  a limb  as  may  be  caused  by 
a high-explosive  shell. 

It  is  not  difficult  to  see  why  the  treatment  of  fractured 
femurs  should  have  improved  to  so  great  an  extent.  In  civil 
hospitals  before  the  war  there  would  seldom  be  more  than 
15  to  20  fractures  in  the  same  hospital  at  the  same  time,  and 
these  under  the  care  of  various  surgeons  and  house  surgeons, 
all  working  independently.  Whereas  during  the  last  two 
or  three  years  it  has  been  possible  to  go  to  any  military 
fractured  femur  centre  and  see  anywhere  up  to  500  cases,  all 
under  the  care  of  the  same  surgeon  (with,  of  course,  adequate 
assistants).  The  treatment  of  these  large  numbers  of 
fractured  femurs  has  been  systematised — team  work  has 
been  introduced,  and  it  has  been  possible  to  compare 
results  on  a scale  which  has  never  before  been  practicable. 
The  natural  outcome  of  this  is  that  the  treatment  of  fractured 
femurs  has  been  vastly  improved. 

The  treatment  of  fractured  femurs  falls  automatically  into 
two  main  groups  : (1)  the  surgical  ; and  (2)  the  mechanical. 
They  are  both  important,  but  it  must  not  be  forgotten  that 
the  surgical  is  the  life-saving  treatment,  and  therefore  must 
always  take  precedence,  when  necessary,  of  the  mechanical. 

I.  Surgical  Treatment. 

This  naturally  confines  itself  to  compound  fractures— and 
whereas  in  war-time  the  greater  percentage  of  fractured 
femurs  were  compound,  in  civil  practice  the  reverse  holds 
good.  In  war  wounds  energetic  surgical  treatment  had  to 
be  adopted — the  wounds  widely  excised,  damaged  tissue 
excised,  muscle  cut  away  till  healthy,  bleeding,  contractile 
fibres  are  reached,  all  fragments  of  metal  and  clothing 
extracted— because  of  the  great  dangers  of  infection  partly 
by  ordinary  pyogenic  organisms  and  partly  by  specific  gas- 
forming bacilli,  which  were  so  disastrous  to  life  and  limb 
before  adequate  surgical  treatment  was  adopted.  The 
wound  should  not  be  stitched,  but  should  be  packed  with 
gauze  soaked  in  flavine,  brilliant  green,  or  some  form  of 
antiseptic  ; this  dressing  should  not  be  changed,  and  the 
wound  should  be  closed  by  delayed  primary  suture  on  the 
third  day,  with  a rubber  drain  inserted  at  the  lower  end  for 
24-48  hours. 

In  civil  practice  if  there  is  any  suspicion  of  gross  infec- 
tion, such  as  in  badly  lacerated  railway  or  other  accidents, 
these  same  surgical  measures  should  undoubtedly  be  carried 
out,  and  so  eliminate  the  sepsis  that  used  to  be  so  common 
and  disastrous.  If  there  is  extreme  shock  this  has  to  be 
treated  by  the  usual  methods— the  application  of  heat  and 
the  injection  of  morphia,  or  strychnine,  or  of  some  other 
stimulant.  There  is  also  no  doubt  that  in  cases  of  shock, 
especially  if  associated  with  haemorrhage,  blood  transfusion 
is  of  great  value.  When  the  patient  is  fit  for  operation  the 
depressing  effects  of  chloroform  and  ether  may  be  obviated  by 
administering  gas  and  oxygen  anaesthetic. 

In  most  cases  it  will  be  found  that  these  compound  wounds 
heal  well,  and  with  little  trouble.  But  if  sepsis  supervenes 

No  5008. 


August  23,  1919. 


dependent  drainage  is  essential.  If  drainage  is  not  satis- 
factory the  pus  tracks  up  the  thigh  towards  the  hip-joint, 
especially  along  the  adductor  and  ham-string  muscles,  and 
along  the  sheath  of  the  sciatic  nerve.  The  temperature 
chart  taken  on  a “septic  ” character,  the  pulse-rate  rises,  the 
tongue  is  dry  and  dirty,  an  intractable  diarrhoea  may  set  in, 
there  is  risk  of  secondary  hemorrhage,  and  if  adequate 
drainage  is  not  supplied  both  limb  and  life  are  in  danger. 

Secondary  haemorrhage. — Secondary  hemorrhage,  which 
used  to  be  the  bugbear  of  military  surgeons,  is  now, 
fortunately,  becoming  more  uncommon.  It  is  treated  by 
tying  the  bleeding  point  ; if  this  is  not  possible  the  main 
artery  may  have  to  be  ligated,  but  this  only  too  often  ends 
in  gangrene  and  subsequent  loss  of  the  limb.  If  a severe 
haemorrhage  has  taken  place  intravenous  transfusion  of 
normal  saline  gum  solution  or  blood  may  be  necessary. 

Tetanus. — Another  condition  in  compound  fractured  femur 
which  may  require  surgical  treatment  is  tetanus.  In  every 
case  where  dirt  has  entered  the  wound  it  is  advisable  to  give 
a prophylactic  dose  of  antitetanic  serum  of  1500  units, 
followed  eight  days  later  by  a smaller  dose.  If  tetanus 
supervenes  any  drastic  treatment,  such  as  amputation,  is 
contra-indicated.  Various  sedatives  have  been  used,  but 
experience  has  shown  that  the  best  is  morphia — in  i gr. 
doses,  given  four-hourly,  or  as  often  as  is  necessary  to  control 
the  spasms.  Large  doses  of  antitetanic  serum  (10.000-12,000 
units  a day)  should  be  given  intramuscularly.  Intrathecal 
injections  have  not  been  found  to  give  better  results,  and 
have  been  more  or  less  universally  discarded.  The  severe 
spasms  of  the  thigh  muscles  in  the  “ local  ” form  of  tetanus 
may  interfere  with  the  extension  and  position  of  the  bone 
fragments,  but  they  are  usually  amenable  to  treatment.  In 
one  case,  under  Major  E.  C.  Lindsay,  R.A.M.C.,  and 
operated  on  by  Colonel  Percy  Sargent,  DSO.,  the  spasm 
of  the  adductors  was  so  severe  and  uncontrollable  that 
eventually  the  obturator  nerve  had  to  be  exposed  and  crushed, 
with  a satisfactory  result. 

II.  Mechanical  Treatment. 

This  consists  of  (a)  fixation  of  the  limb  ; ( b ) extension  of 
the  limb  ; (c)  suspension  of  the  limb. 

Before  proceeding  to  the  consideration  of  these  three  it  is 
necessary  to  say  a few  words  about  the  bed.  Any  hospital 
or  other  bed  with  an  iron  framework  will  suffice,  and  it  is  not 
necessary  to  have  a special  mattress  with  a movable  segment 
for  dressings  ; for,  by  the  method  presently  to  be  described, 
it  is  easy  for  the  patient  to  raise  his  body  well  clear  of  the 
bed  for  dressings,  bed-pan,  and  other  nursing  necessities. 

Attached  to  the  bed  is  a wooden  framework  for  the  purpose 
of  extension  and  suspension  of  the  limb,  and  this  should  be 
as  simple  as  possible  ; there  should  be  two  upright  bars  at 
the  foot  of  the  bed,  one  at  each  corner,  reaching  about  5 feet 
above  the  level  of  the  bedclothes.  These  are  joined  by  a 
cross-bar  at  the  top  and  a cross-bar  about  2 feet  lower 
down ; this  lower  cross-bar  can  be  extended  outwards  on 
either  side  if  the  fracture  is  in  the  upper  one-third  and 
abduction  is  required.  At  the  head  end  of  the  bed  are  two 
similar  upright  bars,  but  these  are  clamped  on  in  the  centre 
of  the  bed  about  4 inches  apart.  Prom  the  top  of  each  of 
these  is  a longitudinal  bar  running  to  the  upper  cross-bar 
at  the  foot  of  the  bed,  placed  in  position  for  either  leg 
with  the  requisite  amount  of  abduction.  Each  of  these 
longitudinal  bars  has  four  pulleys  on  it,  one  at  the  foot 
end,  one  in  the  middle  about  the  level  of  the  patient’s 
pelvis,  and  two  at  the  head  end. 

Having  dealt  with  the  bed  and  the  framework,  and  having 
got  the  patient  into  bed,  it  is  now  possible  to  consider  the 
fractured  limb. 

(A)  Fixation. 

By  fixation  is  meant  the  application  of  a splint  to  the 
fractured  leg  and  the  retention  of  the  leg  to,  or  in,  that 
splint.  Many  splints  have  been  used,  the  best  known  being 
Liston’s,  Macintyre’s,  Hodgen’s,  and  the  Thomas  knee-splint. 
Gradually  every  form  of  splint  has  been  discarded  by  the 
majority  of  surgeons  in  favour  of  the  Thomas  knee-splint  or 
one  of  its  modifications,  and  this  is  the  only  splint  whose 
method  of  application  need  be  described.  There  may  be  a few 
forms  of  fracture,  especially  of  the  upper  one-third,  which 
are  more  easily  treated  in  a Hodgen’s  splint ; but  there  is 
no  type  of  fractured  femur  which  cannot  be  treated 
adequately  in  a Thomas  knee-splint. 

Before  the  splint  is  actually  applied  the  leg  has  to  be 
prepared  in  some  way  so  that  it  may  be  fixed  in  the  splint. 
To  do  this  a general  anaesthetic  should  be  given,  unless 

H 


312  The  Lancet,]  MR.  J.  DRIBERG  : TREATMENT  OF  FRACTURES  OF  THE  FEMUR.  [August  23, 1919 


contra-indicated  by  the  general  condition  of  the  patient  or 
some  concomitant  disease,  such  as  Bright’s,  diabetes,  &c. 
All  manipulation  of  the  leg  is  painful,  and  an  anaesthetic 
helps  both  the  patient  and  the  surgeon.  The  various  methods 
of  fixing  the  leg  are  : — 

1.  Methods  mhioh  Obtain  Traction  from  the  Skin  Surface. 

(a)  Adhesive  strapping.  -This  is  probably  the  best  in  all 
cases  where  traction  is  applied  directly  to  the  skin  surface. 
The  method  of  application  is  so  well  known  that  it  is 
unnecessary  to  describe  it,  except  to  say  that  it  need  not  be 
applied  above  the  knee.  The  skin  of  the  leg  need  not  be 
shaved  beforehand.  The  purpose  of  shaving  was  to  make 
removal  of  the  strapping  more  comfortable,  but  by  the  time 
the  strapping  is  ready  to  come  off  the  hairs  will  all  have 
grown  again.  And,  in  any  case,  strapping  can  be  painlessly 
removed  with  ether  or  turpentine. 

( b ) Qlue. — This  was  first  introduced  by  Major  M.  Sinclair, 
C.M.G.,  of  the  R.A.M.C.  It  consists  of  commercial  glue 
made  up  according  to  the  following  formula  : glue,  50  parts  ; 
water,  50  parts ; glycerine,  2 parts ; calcium  chloride, 
1 part  ; thymol,  1 part. 

Two  strips  of  gauze,  8-fold  thick  and  5 inches  wide,  are  cut 
long  enough  to  reach  from  the  knee  to  6 inches  below  the 
bottom  of  the  Thomas  splint.  The  leg  is  then  washed  with 
a solution  of  sodium  bicarbonate  (3i.  ad  Oi.)  in  order  to 
remove  all  grease'  from  the  skin.  The  glue,  heated  to 
melting  point,  is  then  applied  to  the  skin  of  the  leg  between 
the  ankle  and  the  knee  as  evenly  as  possible.  It  is  preferable 
to  apply  this  with  the  hand  and  not  with  a brush,  for  with 
the  hand  it  can  be  applied  more  evenly;  and  also  this 
method  ensures  that  the  glue  is  not  too  hot  for  the  patient’s 
skin.  The  two  strips  of  gauze  are  then  placed  evenly  on  the 
glue,  one  on  either  side  of  the  leg,  and  about  as  high  up  as 
the  tuberosity  of  the  tibia.  The  whole  leg  from  just  above 
the  ankle  to  just  below  the  knee  is  bandaged  firmly,  but 
evenly,  with  a 3-inch  cotton  bandage.  It  is  essential  that 
the  bandage  and  gauze  should  be  evenly  applied,  for  any 
unevenness  is  bound  to  cause  blistering  of  the  skin.  If, 
after  the  glue  has  dried,  the  bandage  is  too  tight,  it  can  be 
snipped  with  a pair  of  scissors.  A common  place  for 
blistering  is  over  the  tendo  Achillis,  and  here,  if  necessary, 
the  bandage  can  be  cut  for  an  inch  or  two  without  harm. 

The  glue  takes  about  ten  minutes  to  dry,  and  the  chief 
advantage  is  the  ease  and  speed  with  which  it  is  applied. 
Its  disadvantages  are  that  it  has  to  be  renewed  more 
frequently  than  strapping  and  is  rather  apt  to  blister  the 
skin,  causing  pain  and  discomfort  to  the  patient. 

( c ) Mastisol. — This  is  a rubber  solution  which  is  applied  in 
exactly  the  same  manner  as  glue.  It  dries  more  rapidly,  but 
is  rather  more  apt  to  blister  the  skin. 

2.  Methods  which  Obtain  Traction  Directly  from  the  Bone. 

( a ) Fixation  by  calipers. — This  is  the  ideal  method,  as  it 
gives  direct  control  of  the  lower  fragment  of  bone,  and  in 
careful  hands  no  sepsis  or  ill-results  ensue.  The  calipers 
are  shaped  like  ordinary  ice-tongs,  the  ends  being  pointed, 
and,  when  opened  at  the  angle  at  which  they  will  be  applied, 
in  the  same  straight  line  with  each  other.  The  first  calipers 
to  be  used  were  ordinary  commercial  carpenter’s  calipers, 
the  ends  being  curved  and  bent  in.  Since  then  various  types 
have  been  devised,  the  latest  and  best  being  that  of  Major 
M.  G.  Pearson,  S.A.M.C.,  which  has  in  the  handles  a screw 
adjustment  which  prevents  any  further  penetration  of  the 
bone  once  the  calipers  are  fixed  in  position. 

There  are  two  methods  of  applying  the  calipers.  In  the 
first  slight  penetration  of  the  bone  is  aimed  at,  and  this 
method  is  adopted  if  fixed  extension  is  afterwards  going  to 
be  applied,  for  otherwise  any  movement  on  the  part  of  the 
patient  which  eases  the  extention  momentarily  might  cause 
the  calipers  to  slip.  In  the  second  method  the  calipers  are 
introduced  down  to,  but  not  penetrating,  the  bone.  With 
weight  and  pulley  extensions  there  is  a constant  pull  at  all 
times,  so  there  is  no  tendency  for  the  calipers  to  slip.  The 
points  of  the  calipers  get  a perfect  grip  on  the  bone,  which 
in  maintained  by  the  pull  of  the  weight ; the  screw  adjust- 
ment in  the  handles  of  the  calipers  prevent  penetration  of 
the  bone,  and  the  extension  cord  attached  to  the  handles 
prevents  the  points  of  the  calipers  coming  apart. 

The  technique  of  applying  the  calipers  is  simple,  but  all 
due  antiseptic  and  aseptic  precautions  must  be  taken. 

The  skin  round  the  knee  having  been  shaved  and  prepared 
for  operation,  and  the  patient  having  been  given  a general 
amesthetic  (gas  and  oxygen  is  usually  quite  sufficient),  an 
incision  is  made  with  a scalpel  down"  to  the  bone  on  each 


side  immediately  above  the  thickest  and  most  prominent 
portion  of  the  condyles  of  the  femur.  Each  incision  should 
be  half  an  inch  long.  If  the  incision  is  too  short  pressure 
sepsis  may  result  in  the  skin  and  cause  considerable  pain. 
The  sterilised  calipers  are  then  taken  and  the  points 
inserted  down  to  the  bone,  one  in  each  incision.  If 
penetration  of  the  bone  is  desired  the  points  are  hammered 
in  with  a mallet  to  a distance  of  from  J to  i in.,  and  the 
screw  in  the  handle  of  the  calipers  adjusted  till  the  handles 
just  touch  each  other.  In  no  case  is  it  necessary  to  drill  a 
hole  in  the  bone  beforehand.  If  penetration  of  the  bone  is 
not  desired  the  same  steps  are  carried  out,  except  that  the 
points  of  the  calipers  are  not  hammered  in.  The  handles 
of  the  calipers  are  then  tied  together  to  prevent  separation 
of  the  points.  A piece  of  cord  about  3 ft.  long  is  then 
tied  to  each  handle.  To  keep  the  incisions  over  the 
condyles  clean  it  is  merelv  necessary  to  apply  to  each  a 
piece  of  gauze  soaked  in  iodine  or  flavine  or  some  other 
antiseptic ; this  piece  of  gauze  need  never  be  removed,  but 
every  two  or  three  days  a few  drops  of  the  antiseptic  should 
be  poured  on  to  it. 

Calipers  are  contra-indicated  in  fractures  of  the  lower 
one-third  actually  involving  the  knee-joint  if  there  is  dis- 
tension of  the  synovial  membrane,  because  of  the  danger  of 
damage  to  the  membrane  ; also  in  lower  one-third  compound 
fractures  with  T-shaped  fracture  into  the  knee-joint,  for  then 
the  pressure  of  the  calipers  may  cause  pocketing  and 
accumulation  of  pus  between  the  fragments. 

General  diseases,  such  as  diabetes,  &c.,  are  no  contra- 
indication, for  the  calipers  may  be  applied  under  gas  and 
oxygen  or  local  anaesthetic.  The  same  is  true  of  a septic 
wound  over  the  condyles,  for  the  introduction  of  calipers 
actually  into  a septic  wound  neither  increases  the  sepsis 
nor  inhibits  healing,  provided  the  calipers  are  only  applied 
down  to  the  bone  and  there  is  no  penetration. 

Occasionally,  in  spite  of  careful  technique,  a slight,  though 
painful,  skin  sepsis  may  arise,  or  the  calipers  may  slip  owing 
to  an  orderly  or  nurse  relieving  the  extension  by  lifting  the 
attached  weight  (a  thing  which  they  should  strictly  be 
warned  not  to  do)  ; in  these  cases  the  calipers  should  be 
removed  and  reinserted  at  a somewhat  higher  level. 

The  patient  usually  suffers  a little  pain  and  discomfort  for 
24  hours,  sufficient  to  warrant  the  injection  of  morphia  gr.  i 
before  the  anaesthetic. 

The  two  risks  of  calipers  are  bone  sepsis  and  penetration 
of  the  knee-joint  ; with  careful  technique  neither  of  these 
ought  ever  to  occur. 

( b ) Ankle  calipers. — They  are  similar  to,  though  smaller 
than,  the  femur  calipers.  They  are  applied  in  exactly  the 
same  way,  and  with  the  same  precautions,  into  the  thickest 
part  of  the  malleoli.  They  are  useful  in  those  cases  where, 
owing  to  the  involvement  of  the  knee-joint,  &c.,  femur 
calipers  are  contra-indicated  ; and  especially  so  if  there 
should  also  be  a fracture  of  the  tibia  or  fibula. 

(c)  Hey  Groves’s  transfixation  pin  is  a steel  rod  which  is 
driven  through  the  lower  end  of  the  femur  just  above  the 
thickest  part  of  the  condyles — traction  being  maintained 
from  either  end  of  the  rod.  This  has  to  pass  through  the 
cancellous  and  easily  infected  portion  of  the  bone,  and  in 
removing  the  pin  one  end — which  has  been  exposed,  has 
possibly  become  septic  and  is  difficult  to  re-sterilise — has  to 
be  pulled  through  the  bone,  and  infection  may  result. 

(d)  Tibial  screws. — These  are  two  silver  screws,  2 in.  long, 
which  are  screwed  li  in.  into  the  tibia  about  6 in.  below  the 
knee-joint.  A cord  or  tape  is  attached  to  each  screw  so  as 
to  maintain  traction.  They  have  no  particular  advantage, 
but  may  be  useful  if  the  skin  of  the  leg  blisters  badly  with 
strapping  or  glue. 

(e)  Schutro's  stirrup. — This  consists  of  a short,  narrow 
steel  rod,  which  is  inserted  between  the  tendo -Achillis  and 
the  bone,  and  rests  against  the  os  calcis.  Traction  is 
maintained  from  each  end  of  the  rod.  This  method,  too, 
has  no  marked  advantage  over  others ; and  in  unskilled 
hands  the  steel  rod  has  been  known  to  cut  through  the 
tendo- Achillis — a most  unfortunate  accident. 

Strapping  and  Calipers. 

The  next  consideration  is  which  of  these  eight  methods 
to  apply.  Except  in  special  cases  it  is  probable  that  only 
one  of  two  methods  will  be  adopted  ; these  two  are 
strapping  and  calipers.  There  is  no  doubt  that  the  best 
results  are  obtained  with  calipers.  Having  a direct  control 
on  the  lower  fragment  ensures  more  accurate  correction  of 
any  displacement.  With  this  method  the  period  of  con- 
valescence is  decreased  ; for,  as  massage  and  passive  move- 


ThhLanoht,]  MR.  J.  DKIBERG:  TREATMENT  OF  FRACTURES  OF  THE  FEMUR.  [August  23,  1919  313 


merits  of  the  joints  can  be  applied  from  the  very  beginning, 
the  patient,  when  union  has  taken  place,  is  able  to  walk  with 
a good,  strong,  muscular,  well-nourished  leg.  Moreover 
the  increased  nutrition,  due  to  massage,  See.,  very  probably 
has  a beneficial  effect  on,  and  hastens,  union  ; for  it  is  a 
fact  that  patients  who  have  calipers  applied  do  get  union 
somewhat  sooner  than  those  who  have  some  other  form  of 
fixation. 

There  are  certain  cases,  which  have  already  been  dis- 
cussed, where  calipers  are  contra-indicated.  In  these  cases 
strapping  should  be  used.  Also,  where  aseptic  and  anti- 
septic conditions  cannot  be  guaranteed  the  caliper  method, 
perhaps,  should  be  discarded  ; for  any  sepsis  round  the 
caliper  points,  though  not  necessarily  of  surgical  import, 
causes  great  pain  and  necessitates  the  removal  of  the 
calipers.  And,  finally,  the  personal  equation  of  the  medical 
attendant  and  the  facilities  at  hand  for  operative  treatment 
have  to  be  taken  into  consideration. 

Application  of  the  Splint. 

The  leg  having  been  prepared  in  one  of  these  methods  for 
fixation,  the  next  step  is  the  application  of  the  splint.  Some 
surgeons  prefer  a Thomas  splint  with  a large  ring,  but 
most  use  one  with  a small  ring,  on  tne  grounds  that  it  is 
more  comfortable  for  the  patient  and  allows  less  lateral 
movement  at  the  seat  of  fracture. 

Having  chosen  a well-fitting  Thomas  knee-splint,  it  is 
passed  on  to  the  leg.  An  assistant  should  throughout 
apply  traction  on  the  leg  from  the  ankle,  in  order  to  limit 
as  far  as  possible  movement  of  the  bone  fragments  and 
consequent  damage  to  the  tissue  of  the  thigh.  The  leg  is 
then  supported  in  the  splint  by  slings.  These  are  short 
lengths  of  3-inch  flannel  bandage.  Each  one  is  looped  over 
the  inner  bar  of  the  Thomas  splint,  the  doubled  bandage 
is  then  passed  under  the  thigh  and  fixed  in  position  over  the 
outer  bar  by  safety-pins  or  by  3-inch  paper  clips,  which  are 
much  more  convenient  and  easy  to  use.  The  sling  under 
the  upper  end  of  the  lower  fragment  should  be  pulled  tight 
and  should  always  be  kept  tight,  for  this  sling  corrects  the 
backward  displacement  of  the  lower  fragment.  By  having 
this  sling  tight  the  lower  fragment  is  pulled  forward  into 
position  with  the  upper,  and  the  anterior  arch  of  the  femur 
is  restored.  Malunion  of  the  femur  with  ba6kward  displace- 
ment of  the  lower  fragment  is  the  most  disabling  form  of 
malunion  known.  The  other  slings  merely  form  a trough 
for  the  leg,  and  are  slackened  or  tightened  according  to  the 
comfort  of  the  patient. 

The  ring  of  the  splint  should  fit  snugly  against  the  tuber 
iscbii,  the  cord  from  the  strapping  or  the  calipers  or  the 
gauze  from  the  “glue  method  ” is  tied  firmly  to  the  end  of 
the  splint,  and  the  leg  is  now  “ fixed  ” in  the  splint. 

If  strapping  has  been  used  it  is  advisable  to  bend  the 
Thomas  splint  to  an  angle  of  about  15°  at  the  level  of  the 
knee-joint.  This,  of  course,  is  done  before  the  Thomas 
splint  is  put  on  to  the  leg.  By  doing  this  the  knee  is 
slightly  bent  and  the  gastrocnemii  muscles  are  relaxed,  so 
helping  to  correct  the  backward  displacement  of  the  lower 
fragment. 

If  calipers  have  been  applied  a straight  splint  should  be 
used  and  a “ knee-flexion  splint  ” applied. 

The  “knee-flexion  splint,”  introduced  by  Major  M.  G. 
Pearson,  consists  of  the  lower  part  of  an  ordinary  Thomas 
knee-splint  cut  off  to  a length  of  2J  ft.  At  each  upper  free 
end  is  a joint  and  a thumb-screw.  The  knee-flexion  splint  is 
fixed  to  the  under  surface  of  the  Thomas  knee-splint  by  the 
thumb-screws,  which  should  be  opposite  the  knee-joint.  The 
flannel  slings  below  the  knee  are  now  transferred  from  the 
Thomas  to  the  knee-flexion  splint,  and  the  leg  below  the 
knee  is  allowed  to  hang  in  the  knee-flexion  splint.  This  it 
will  do  by  its  own  weight,  for  it  must  be  remembered  that 
when  calipers  are  applied  the  whole  of  the  leg  below  the  knee 
is  free.  By  means  of  the  joint  between  the  upper  end  of  the 
knee-flexion  splint  and  the  thumb-screw  the  splint  can  be 
moved  up  and  down,  and  so  passive  movement  given  to  the 
knee-joint  daily  throughout  the  whole  time  that  the  patient 
is  under  treatment.  This  is  the  greatest  advantage  of  the 
caliper  method,  for  it  obviates  any  stiffness  of  the  knee-joint, 
which  is  so  common  with  other  forms  of  fixation  and  which 
is  nearly  as  crippling  as  malposition  of  the  femur.  The 
lower  end  of  the  knee-flexion  splint  is  tied  to  the  lower  end 
of  the  Thomas  splint  by  a hook  and  chain,  and  can  be 
adjusted  to  any  angle. 

To  prevent  “foot-drop”  a small,  rectangular  wire  foot-piece 
is  strapped  on  either  to  the  Thomas  or  the  knee-flexion 
splint,  and  the  foot  fastened  to  this  in  correct  position.  The 
most  convenient  way  is  to  take  a strip  of  gauze,  fix  one  end 
to  the  sole  of  the  foot  with  glue,  and  tie  the  other  end  to  the 


top  of  the  foot-piece.  This  leaves  the  dorsum  of  the  foot 
free  for  massage,  and  also  allows  of  a certain  amount  of 
passive  movement  of  the  ankle-joint. 

(B)  Extension. 

There  are  two  main  methods  of  extension — fixed  extension 
and  “ weight-and-pulley  ” extension.  It  must  be  remembered 
that  fixing  the  leg  in  the  splint  does  not  provide  extension. 
It  may  appear  to  do  so  temporarily,  but  if  no  further 
measures  are  adopted  the  leg  very  soon  lies  quite  loose  in 
the  splint,  partly  due  to  stretching  of  the  gauze  or  the  cord, 
and  partly  due  to  relaxation  of  the  muscles  of  the  thigh. 

If  fixed  extension  is  to  be  used  the  bottom  end  of  the 
Thomas  splint  is  tied  firmly  to  the  lower  of  the  two  wooden 
cross-bars  at  the  foot  of  the  bed,  and  the  foot  of  the  bed  is- 
raised  12  inches  on  blocks.  The  patient  is  only  allowed  one 
pillow  under  his  head.  This  method  of  extension  is  very 
simple. 

The  leg  is  fixed  in  the  splint,  the  splint  is  fixed  to  the  foot 
of  the  bed,  which  is  raised  on  blocks,  and  the  body  weight 
continually  slippingaway  forms  a counter-extension  and  pulls 
the  leg  out.  If  several  pillows  are  allowed  the  patient  puts 
them  under  his  shoulder,  and  this  immediately  releases  the 
extension.  In  most  cases  of  recently  fractured  femurs,  the 
leg  can  be  pulled  out  to  its  correct  length  in  24  hours  or  evem 
less.  When  this  result  has  been  obtained,  and  that  can  only 
be  determined  by  careful  measurements  and  by  the  X ray, 
the  patient  can  be  allowed  an  extra  pillow,  but  this  may  have 
to  be  taken  away  again  if  the  leg  shortens  at  all  ; it  is  most 
important  to  keep  up  full  extension  for  the  first  three  to  four 
weeks.  The  patient  may  complain  of  discomfort  for  the  first 
day  or  two — it  is  usually  due  to  the  unaccustomed  position — 
but  he  very  soon  gets  used  to  it  and  becomes  happy  and  com- 
fortable. It  is  unusual  for  there  to  be  any  pain  in  the  seat  of 
fracture  once  extension  has  been  applied.  There  may  be 
pain  in  the  thigh  due  to  trauma  received  at  the  time  of 
injury,  but  this  is  usually  relieved  by  small  doses  of  aspirin. 

If  “ weight  and  pulley  ” extension  is  employed,  the  lower 
end  of  the  splint  is  again  tied  to  the  cross-bar  at  the  foot  of 
the  bed  ; but  the  cord  from  the  strapping  or  calipers,  instead 
of  being  tied  to  the  bottom  of  the  splint,  is  attached  to  a 
weight  and  passes  over  a pulley  which  is  screwed  into  the 
cross-bar  opposite  the  lower  end  of  the  splint.  The  foot  of 
the  bed  is  not  raised  on  blocks.  A weight  of  7-10  lb.  is 
usually  quite  sufficient,  and  it  is  seldom  necessary  to  use 
more  than  15  lb.  In  fractures  several  weeks’  old  with  some 
union  in  malposition  it  may  be  necessary  to  have  a heavier 
weight.  It  must  be  remembered  that  when  the  calipers  do- 
not  penetrate  the  bone  they  are  kept  in  position  chiefly  by 
the  pull  of  the  extension  weight.  Consequently,  anyone  in 
charge  of  the  patient,  such  as  nurses,  orderlies,  &c.,  must 
be  carefully  warned  never  to  lift  the  weight  ; for  this 
immediately  relaxes  the  extension  and  the  calipers  are  then- 
liable  to  slip.  In  order  to  ensure  against  this  accident 
occurring  it  may  be  as  well  to  have  a small  wire  cage  fitted 
to  the  foot  end  of  the  bed,  inside  which  the  weight  may 
hang.  The  cage  will  not  only  remind  the  staff  that  the 
weight  is  not  to  be  disturbed,  but  it  will  also  prevent  the 
weight  from  being  knocked  by  passers  by. 

The  advantage  of  the  “ weight  and  pulley  ” method  is  that 
the  foot  of  the  bed  need  not  be  raised  and  the  patient  can  be 
propped  up  as  much  as  is  desired  by  pillows,  bed-rest,  &c. , 
which  in  elderly  or  bronchitic  patients  greatly  reduces  the 
danger  of  hypostatic  pneumonia.  With  the  “weight  and 
pulley  ” extension  the  patient  sometimes  complains  of 
pressure  pain  over  the  tuber  ischii,  and  occasionally  a definite 
sore  appears.  With  fixed  extension  this  never  happens,  for 
the  body  weight  pulls  the  upper  end  of  the  thigh  out  of  the 
ring  of  the  Thomas  splint. 

But  apart  from  these  there  is  nothing  to  choose  between 
the  two  methods.  Equally  good  results  are  obtained  with 
both,  and  after  the  first  day  or  two  the  patients  are  equally 
comfortable  in  either  position. 

The  other  methods  of  extension  are  not  so  satisfactory,  and 
need  only  be  shortly  described. 

Spring  extension. — The  cord  of  the  strapping  or  calipers  is 
tied  either  to  a powerful  elastic  or  a strong  steel  spring, 
which  in  turn  is  fixed  to  the  lower  end  of  the  splint.  With- 
this  the  amount  of  extension  is  difficult  to  gauge  and  regulate. 

Screw  extension. — As  in  the  Wallace- May  bury  splint. 

The  patient’s  leg  is  fastened  to  a wooden  foot-piece,  which 
is  pulled  away  by  an  adjustable  screw.  This  is  not  a very 
comfortable  method  for  the  patient,  nor  is  it  very  accurate, 
though  it  is  sometimes  useful  for  purposes  of  transport. 


314  ThhLanobt,]  MR.  J.  DRIBERG  : TREATMENT  OF  FRAOTURES  OF  THE  FEMUR.  [August  23,  1919 


(0)  Suspension. 

The  object  of  suspending  the  limb  is  three-fold  : (1)  it 
enables  the  patient  to  move  about  comfortably  in  bed  ; 
(2)  the  necessary  rotation  of  the  lower  fragment  may  be 
obtained  so  as  to  correspond  with  any  outward  rotation  of 
the  upper  fragment;  (3)  in  the  “ weight-and-pulley  ” 
method  of  extension  the  ring  of  the  splint  can  be  kept 
close  up  against  the  tuber  ischii  and  prevented  from  slipping 
over  that  bone,  thus  ensuring  satisfactory  counter-extension 
from  the  tuber  ischii. 

In  order  to  suspend  the  leg  four  lengths  of  cord  and  four 
weights  of  about  5 lb.  each  are  necessary. 

The  cords  are  attached  to  the  splint,  two  at  the  foot  and 
two  at  the  upper  end  just  below  the  ring — one  on  the  inner 
and  one  on  the  outer  side.  They  are  then  passed  through 
the  pulleys  which  have  been  fixed  to  the  two  longitudinal 
bars  of  the  wooden  framework,  and  finally  the  weights  are 
attached  to  the  free  ends  of  the  cord  and  hang  down  behind 
the  patient’s  head.  The  two  cords  from  the  foot  end  pass 
through  the  two  pulleys  at  the  foot  end  of  the  bed  and  then 
through  two  of  the  four  pulleys  at  the  head  end.  The  two 
cords  from  the  upper  end  of  the  splint  pass  first  through  the 
two  pulleys  midway  along  the  longitudinal  wooden  bars  and 
then  through  the  remaining  two  pulleys  at  the  head  end. 

In  order  to  get  outward  rotation  of  the  leg  and  lower 
fragment  it  is  merely  necessary  for  the  weights  attached  to 
the  two  inner  suspension  cords  to  be  slightly  heavier  than 
those  attached  to  the  two  outer  suspension  cords. 

With  this  suspension  method  the  patient  can  lift  himself 
off  the  bed  with  the  greatest  ease.  He  should,  of  course, 
have  a rope  with  a wooden  handle  above  his  head  by  which 
he  pulls  himself  up,  at  the  same  time  assisting  by  bending 
up  his  sound  leg  and  levering  himself  off  the  bed  with  his 
heel.  The  whole  weight  of  the  fractured  leg  is  taken  by  the 
four  suspension  weights  and  the  patient  has  practically  only 
the  weight  of  his  trunk  to  support.  Most  patients  can 
easily  raise  themselves  12-18  inches  off  the  bed,  and  remain 
in  that  position  long  enough  for  purpose  of  dressing, 
nursing,  &c. 

If  the  patient  is  very  weak  and  debilitated  another  method 
can  be  used  for  keeping  him  raised  up 

A strong  piece  of  flannel,  2 ft.  long  by  10  in.  wide,  is 
passed  under  the  patient’s  back.  Each  end  of  the  flannel  is 
looped  and  through  each  loop  is  passed  a narrow  bar  of  iron 
(the  bar  of  a Thomas  splint,  cut  down,  answers  the  purpose 
very  well) ; each  bar  is  fixed  from  its  centre  to  the  longitudinal 
wooden  bars  of  the  framework  by  a hook  and  chain.  The 
flannel  binder  can  be  adjusted  to  any  height  and  the  patient 
remains  raised  comfortably  for  as  long  as  is  necessary. 

Five  pounds  is  the  average  weight  necessary  for  each 
suspension  cord,  but  this  varies,  and  can  be  adjusted  to 
the  size  and  weight  of  the  patient ; and,  as  already 
mentioned,  outward  rotation  of  the  leg  may  be  obtained  by 
increasing  the  weight  attached  to  the  inner  two  cords. 

To  recapitulate,  the  steps  in  "putting  up”  a fractured 
femur  are  : 1.  The  wooden  framework  is  clamped  on  to  the 
bed.  2.  Some  method  of  traction  is  applied  to  the  leg.  And 
of  all  the  methods  it  is  probable  that  only  one  of  two  will  be 
adopted— either  strapping  or  calipers.  3.  The  splint  is  put 
on  ; the  slings  applied  and  the  leg  firmly  fixed  in  the  splint  ; 
knee-flexion  splint  adjusted  if  it  is  used.  4.  Extension 
(fixed  or  “ weight  and  pulley  ”)  is  applied.  5.  The  leg  is 
suspended.  This  is  the  procedure  in  every  case  of  fractured 
femur.  Variations  in  the  treatment  of  individual  cases  will 
be  considered  later  on. 

So  far  nothing  has  been  said  about  fixing  the  bone  frag- 
ments by  direct  control  at  the  seat  of  fracture — i.e.,  by 
plating,  wiring,  or  screwing.  The  plating  of  fractures  is  a 
large  subject  and  quite  beyond  the  scope  of  this  article. 
Moreover,  one  of  the  objects  of  this  article  is  to  show  that 
perfect  results  may  be  obtained  by  other  methods.  Plating, 
in  the  hands  of  experts,  may  give  excellent  results,  but  in 
inexpert  hands  may  have  most  disastrous  consequences. 
Furthermore,  plating  does  not  diminish  the  length  of  time 
the  patient  has  to  remain  in  bed,  nor  does  it  shorten  the 
period  of  convalescence.  It  is  merely  a method  of  internal, 
as  opposed  to  external,  splinting.  And  as  equally  good 
results  may  be  ob'ained  by  other  methods,  it  seems  unneces- 
sary to  expose  the  patient  to  the  risk  of  a lengthy  anaesthetic 
and  a severe  operation.  There  is  a small  percentage  of  cases 
in  which  plating  may  be  necessary ; these  will  be  considered 
later  on  amongst  the  complications  of  fractured  femur.  In  no 
case  of  compound  fracture  should  plating  be  even  suggested. 


Varieties  of  Fracture. 

The  next  step  to  consider  is  the  varieties  of  fractured 
femur,  the  po-ition  of  the  fracture,  and  the  bony  displace- 
ments. The  varieties  of  fracture — transverse,  oblique,  spiral, 
comminuted,  &c.—  have  been  so  often  and  ably  described  in 
text- books  that  they  heed  not;  be  discussed  here,  especially 
as  they  each  require  identically  the  same  treatment.  Their 
only  importance  is  with  regard  to  the  length  of  time  exten- 
sion should  be  maintained,  and  they  will  be  considered  later 
on  under  that  heading. 

Of  much  greater  importance  is  the  situation  of  the  fracture. 
Of  late  it  seems  to  be  the  fashion  to  divide  the  femur  into 
fourths,  but  this  has  absolutely  no  advantage  over  the 
previous  system  of  division  into  thirds. 

1.  Ft  nature  of  the  Upper  Third. 

(a)  Intra-capmlar  fractures  of  the  necli  of  the  femur  show 
little  displacement,  and  merely  require  fixation,  slight 
extension,  and  extreme  abduction  until  union  is  complete. 

(Jo')  In  extra-capsular  fractwres  of  the  nech  shortening  is  the 
main  displacement  to  be  overcome  ; this  requires  consider- 
able extension  and  usually  slight  abduction.  The  result  has 
to  be  accurately  checked  by  X ray  and  the  tape  measure. 

(o)  fracture  of  the  upper  one-third  of  the  shaft. — The  usual 
situation  is  just  below  the  small  trochanter,  and  the  dis- 
placement is  typical  and  very  general.  The  displacement  of 
the  upper  fragment  is  three-fold — flexion,  abduction,  and 
external  rotation.  Flexion  is  caused  by  the  upward  pull  of 
the  iliopsoas  muscle  ; abduction  is  caused  by  the  glutei ; and 
outward  rotation  by  the  external  rotators  of  the  hip — 
obturators,  pyriformis,  quadratus,  and  gemelli.  Conse- 
quently the  lower  fragment  has  to  be  similarly  displaced  in 
order  to  bring  it  in  line  with  the  upper.  External  rotation 
is  obtained  by  increasing  the  weights  attached  to  the  two 
inner  suspension  cords  ; abduction,  by  prolonging  outwards 
as  far  as  necessary  the  lower  cross-bar  to  which  the  lower 
end  of  the  Thomas  splint  is  fixed,  and  flexion  is  already 
provided  for  by  raising  the  lower  end  of  the  splint  up  to  the 
level  of  the  lower  cross-bar. 

It  has  been  stated  that  in  order  to  get  true  abduction 
both  legs  should  be  abducted,  otherwise  the  patient  twists 
himself  round  in  bed,  tilts  his  pelvis,  and  false  abduction 
occurs.  This  is  not  correct.  For  the  abduction  that  is 
applied  in  order  to  bring  the  fragments  into  line  takes 
place  at  the  seat  of  fracture  and  not  at  the  hip-joint,  and 
there  is  no  inducement  for  the  patient  to  tilt  his  pelvis ; 
for  this  position,  which  restores  the  natural  alignment  of  the 
leg,  is  the  position  of  greatest  comfort  and  rest.  That  this 
is  so  can  be  proved  by  examining  the  anterior  superior  iliac 
spines  of  a patient  with  one  leg  abducted  ; it  will  be  found 
that  the  spines  are  at  the  same  level.  In  this  the  treatment 
of  upper-third  fractures  varies  from  that  of  tubercular  disease 
of  the  hip-joint,  in  which  double  abduction  is  necessary.  An 
exception  to  this  is  also  found  in  intra-capsular  fractures  of 
the  neck  of  the  femur,  where  extreme  abduction  is  desired, 
and  it  is  advisable  widely  to  abduct  both  legs.  In  upper- 
third  fractures  the  lower  fragment  is  pulled  up  by  the  ham- 
strings and  inwards  by  ths  adductors  ; this  is  corrected  by 
extension.  In  fractures  above  the  small  trochanter  the  only 
difference  in  displacement  is  that  the  upper  fragment  is  not 
pulled  forward  by  the  ilio-psoas. 

2.  Fraotures  of  the  Middle  Third. 

The  upper  fragment  is  very  slightly  abducted  and 
externally  rotated  ; the  lower  fragment  is  displaced  upwards 
and  inwards.  This  displacement  is  usually  easy  to  correct ; 
the  shortening  is  reduced  by  extension,  and  any  “ sagging  ” 
or  backward  displacement  by  tightening  the  supporting 
slings.  It  is  essential  to  keep  these  slings  firm  in  order  to 
restore  the  anterior  curve  of  the  femur. 

3.  fraotures  of  the  Lorce’r  Third. 

In  these  the  lower  fragment  is  always  pulled  back  by  the 
gastrocnemii,  and  usually  adducted  and  slightly  rotated 
outwards  by  the  adductor  magnus.  The  lower  fragment  is 
also  pulled  up  by  action  of  all  the  thigh  muscles. 

Shortening  is  corrected  by  extension  ; and  the  backward 
displacement  by  tightening  the  sling  under  the  lower 
fragment,  and  by  flexing  the  knee,  which  relaxes  the 
gastrocnemii  muscles.  Flexion  of  the  knee  is  easily  obtained 
bv  using  the  knee-flexion  splint,  already  described.  The  use 
of  calipers  is  more  essential  in  this  than  in  any  other  type  of 
fracture,  for  often  it  is  the  only  possible  method  of  controlling 


The  Lancet,]  MR.  J.  DIIIBERG  : TREATMENT  OF  FRACTURES  OF  THE  FEMUR.  [August  23, 1919  3]  5 


the  short  and  easily  displaced  lower  fragment,  and  of 
allowing  the  full  amount  of  knee  flexion  that  is  so  essential. 

In  all  fractures  backward  displacement  is  more  or  less 
easy  to  correct  by  tightening  the  supporting  slings.  Lateral 
displacement  can  be  similarly  corrected.  If,  for  example, 
the  lower  fragment  is  displaced  inwards. and  is  not  corrected 
by  extension,  a flannel  sling  is  passed  round  the  thigh  at  the 
level  of  the  upper  end  of  the  lower  fragment  and  pinned 
securely  to  the  outer  side  bar  of  the  splint.  This  will  pull 
the  lower  fragment  out,  and  the  sling  can  be  further 
tightened  daily  until  good  position  is  obtained  and 
maintained. 

Of  the  various  fractures  those  of  the  upper  third  usually 
require  more  extension  than  those  of  the  middle  or  lower. 
That  shortening  and  displacement  have  been  correctly  re- 
duced is  decided  by  inspection,  palpation,  measurement,  and 
radiography.  Inspection  and  palpation  will  show  whether 
the  limb  looks  normal  as  regards  size  and  shape,  and  whether 
the  anterior  and  outward  curve  of  the  femur  has  been 
correctly  restored,  but  the  only  true  and  satisfactory  tests 
are  measurement  and  radiography. 

Transverse  fractures  of  the  femur  are  rather  more  difficult 
to  get  into  perfect  position  than  the  other  varieties,  but 
once  in  position  their  natural  tendency  is  to  keep  in  that 
position.  Oblique,  spiral,  and  comminuted  fractures  are 
very  liable  to  “ telescope  ” if  good  extension  is  not  kept  up. 

In  all  varieties  of  fracture,  except  the  transverse,  it  is 
desirable  to  apply  sufficient  extension  to  obtain  1 cm. 
lengthening  ; the  reason  for  this  is  that  as  soon  as  the 
patient  starts  to  walk  there  is  a tendency  for  the  callus  to 
contract  and  the  limb  to  shorten  up  just  a trifle.  This  is 
more  particularly  marked  in  cases  where  there  has  been  a 
prolonged  sepsis  and  the  callus  is  “ sticky.” 

Both  legs  should  be  measured  daily  for  the  first  week  or 
ten  days  in  order  to  be  certain  that  sufficient  extension  is 
being  applied  ; after  that  it  is  only  necessary  to  measure 
the  legs  every  few  days.  Sometimes,  especially  in  compound 
comminuted  fractures  with  much  laceration  of  the  thigh 
muscles,  there  is  over-correction  with  lengthening  of  the 
limb.  In  this  case  the  amount  of  extension  is  reduced,  in 
one  method  by  decreasing  the  amount  of  the  weight 
attached,  and  in  the  other  by  allowing  the  patient  more 
pillows  or  by  putting  the  foot  end  of  the  bed  on  lower 
blocks.  The  legs  should  be  measured  in  centimetres,  which 
decreases  the  margin  of  error,  and  can  be  carried  out  either 
with  a tape  measure  from  the  tip  of  the  anterior  superior 
iliac  spine  to  the  internal  malleolus  or  with  a wooden 
measure  from  the  under-surface  of  the  anterior  superior 
spine  to  the  upper  border  of  the  patella. 

It  is  convenient  to  chart  the  length  of  the  leg  each  time. 

It  is  measured  on  a special  chart  drawn  out  in  centimetres 
The  normal  line  is  the  length  of  the  sound  leg,  and  the 
amount  of  shortening  or  lengthening  is  charted  above  and 
below  this  line  respectively. 


Radiography  Essential. 

Radiography  is  absolutely  essential  if  good  results  are  to 
be  obtained. 

The  patient  is  photographed  in  bed  with  a portable  X rav 
apparatus.  Either  two  views,  antero-posterior  and  lateral 
or  the  leg  is  photographed  stereoscopically  from 
srlor  view  If  the  position  of  the  bone  is  not  satis- 
factory an  attempt  is  made  to  correct  the  deformity  bv  the 
methods  described  and  a further  radiograph  taken.  Once 
the  position  and  length  are  satisfactory  it  is  only  necessary  to 
radiograph  the  leg  every  two  or  three  weeks  in  order  be 
certain  that  the  correct  position  is  being  maintained.  It  is 
convenient  and  useful,  though  not  always  possible  to  have 
small  reduced  prints  of  these  radiographs  pasted  on  a board 
and  hung  by  the  patient’s  bedside.  P oard 

During  the  entire  time  that  the  patient  is  in  the  splint 
massage  of  the  whole  limb  and  (if  calipers  have  been  used') 
passive  movements  of  the  joints  should  be  carried  out  • it  is 
also  advisable  to  have  massage  of  the  sound  leg,  so  that 
when  the  patient  starts  to  walk  all  his  muscles  are  strong 
and  he  is  able  to  stand  up  and  retain  his  balance.  Passive 
movement  of  the  knee-joint  of  the  broken  leg  is  obtained  by 
ally  alteration  in  the  level,  and  movement  of  the  knee- 
fo^hp  thls  fbouM  at  first  be  done  very  carefully  and 

for  the  first  two  or  three  weeks,  at  any  rate,  by  the  medical 
attendant  himself,  for  in  the  early  stages  any  Careless 

tTeTrao?  “lghi  CT6  S°me  alteration  ia  the  position  of 
the  fracture,  and  will  certainly  cause  pain. 


Length  of  Time  during  which  the  Leg  should  be  Lett  in  the 
Splint. 

This  varies  to  a certain  extent,  but,  on  an  average,  the 
splint  can  usually  be  dispensed  with  at  the  end  of  the  tenth 
or  eleventh  week.  Fractures  of  the  lower  third,  probably 
because  of  the  excellent  blood-supply,  seem  to  unite  rather 
quicker  than  those  of  the  upper  and  middle  thirds.  Oblique, 
spiral,  and  comminuted  fractures  should  be  kept  in  the  splint’ 
with  extension,  for  a week  or  ten  days  longer  than  transverse’ 
fractures.  For  in  transverse  fractures,  provided  the  position 
of  the  fragments  is  good,  the  interlocking  of  the  two  ends 
prevents  any  shortening,  bowing,  or  sagging. 

The  only  real  method  of  judging  whether  the  leg  is  fit  to 
come  out  of  the  splint  is  by  palpation  and  the  X ray.  By 
firm  palpation  it  is  possible  to  estimate  whether  the  union  is 
firm,  and  whether  there  is  any  mobility  at  the  seat  of  frac- 
ture. Any  tenderness,  on  pressure,  in  the  fracture,  means 
that  the  callus  is  not  yet  firm  enough.  X rays  at  this  stage 
are  very  important.  They  demonstrate  the  amount  and 
density  of  the  callus.  The  presence  of  callus  first  appears 
in  a radiograph  about  the  end  of  the  fourth  week  as  a very 
faint  haze  ; this  gradually  increases  in  extent  and  intensity, 
till  about  the  tenth  or  eleventh  week  it  appears  as  a dense  homo- 
geneous mass,  firmly  knitting  all  the  bone  fragments  together. 
In  compound  fractures,  if  there  has  been  marked  sepsis,  the 
callus  may  present  a honeycombed  appearance.  Such  callus 
is  weak  and  points  to  the  need  of  further  treatment  in  the 
splint. 

Having  decided,  about  the  tenth  week,  that  the  leg  may 
soon  come  out  of  the  splint,  the  extension  can  be  removed 
and  the  leg  left  merely  fixed  in  the  splint  and  suspended.  In 
the  “ weight-and-pulley  ” method,  the  weight  is  removed 
and  the  cord  tied  to  the  end  of  the  splint,  which  is  loosed 
from  the  cross-bar.  In  the  fixed  extension  method  the  bed 
is  taken  off  the  blocks,  the  patient  is  allowed  as  many 
pillows  as  he  desires,  and  the  splint  loosed  from  the  cross- 
bar ; it  will  be  found  that  the  patient  has  slipped  out  of  the 
splint  for  an  inch  or  two,  and  it  is  necessary  to  readjust  the 
splint  so  that  the  ring  fits  snugly  against  the  tuber  ischii ; 
the  cord  is  then  fastened  firmly  to  the  lower  end  of  the  splint! 

This  may  be  called  the  second  position  and  it  is  continued 
for  a week  or  ten  days.  During  this  period  the  patient  is 
encouraged  to  move  about  as  much  as  possible  in  bed,  in 
order  to  exercise  thoroughly  all  his  muscles  preparatory  to 
walking.  It  is  possible  and  desirable  for  the  patient  to  get 
out  of  bed  and  sit  in  a chair  by  the  bedside,  his  broken  leg 
being  suspended  the  whole  time. 

During  this  period,  too,  massage  is  actively  continued. 
And,  by  suspending  the  leg  higher  in  the  bed,  the  knee-flexion 
splint  can  be  further  dropped  till  the  kDee  bends  to  an  angle 
of  90°.  If  strapping  has  been  used  instead  of  calipers  the 
leg  can  be  taken  out  of  the  splint  daily  under  supervision  of 
the  medical  attendant  and  knee  movements  started. 

About  the  eleventh  week  the  leg  is  taken  out  of  the  splint 
permanently.  The  patient  should  be  able  to  lift  the  leg 
clear  of  the  j?ed,  if  his  muscles  have  been  kept  in  good  tone 
by  massage,  &c.,  and  there  should  also  be  appreciable  active 
movement  of  the  knee-joint.  He  is  kept  like  this  for  a 
further  three  or  four  days,  the  leg  being  supported  on  a 
pillow.  The  leg  must  be  carefully  watched  lest  any  bowing 
or  sagging  takes  place,  in  which  case  the  splint  must  be 
reapplied  at  once,  for  it  means  that  union  is  not  sufficiently 
firm. 

Union  being  firm  enough  and  the  patient  being  used  to 
freedom  from  the  splint,  he  is  now  allowed  to  walk  ; but 
for  at  least  another  three  months  he  is  not  allowed  to  put 
any  weight  on  the  heel,  for  the  callus  is  not  firm  enough  to 
take  the  body  weight..  This  difficulty  is  overcome  by  the 
use  of  what  are  called  “walking  calipers”  or  “caliper 
boots.”  These  consist  of  a Thomas  knee-splint  with  the 
lower  end  cut  off  and  the  loose  points  turned  in  and  fitted 
into  a hole  drjlled  through  the  heel  of  the  boot.  • 

Measurements. 

The  measurements  required  by  the  splint-maker  are 
(!)  The  circumference  of  the  thigh  at  the  level  of  the 
tuber  ischii ; (2)  the  length  from  the  tuber  ischii  to  I in. 
below  the  sole  of  the  foot. 

The  splint-maker  chooses  a splint  with  a neatlv  paddefl 
well-fitting  ring,  cuts  the  lower  end  of  the  splint  off  and  fits 
the  ®wo  loose  ends  with  a sliding  screw  adjustment  6 in. 
Jong.  With  this  the  length  of  the  splint  can  be  varied,  so  as 
to  be  accurately,  adjusted  to  the  leg.  Each  .of  the  screw 


316  Th«  Lanoht,] 


[August  23, 1919 


MR.  D.  M.  SHAW  , JAW  DEFORMITIES. 


pieces  has  a transverse  steel  rod  attached  to  the  lower  end 

in.  long,  which  fits  into  a hole  in  the  heel  of  the  boot. 
Tne  outer  bar  of  the  splint  should  fix  into  the  heel  of  the 
boot  1 inch  in  front  of  the  inner  bar,  so  that  when  the 
bars  are  level  the  boot  is  turned  out  and  corresponds  to  the 
natural  eversion  of  the  foot  in  walking.  If  this  is  not  done 
considerable  discomfort  will  be  caused. 

When  the  splint  is  on  the  leg  and  fixed  into  the  patient’s 
boot  the  heel  should  not  touch  the  bottom  of  the  boot.  If 
it  does  touch  the  splint  should  be  lengthened  by  a few  turns 
of  the  screw  adjustment.  If  the  heel  touches  the  boot  the 
weight  of  the  body  is  transmitted  through  the  fracture  and 
may  cause  bendihg.  If  the  heel  does  not  touch  all  the 
weight  is  taken  by  the  tuber  ischii.  In  a correctly  fitting 
splint  very  little  weight  should  be  taken  by  the  great 
trochanter  or  the  pubic  bone. 

Provided  both  legs  are  of  the  same  length,  the  good  leg 
should  be  raised  by  a 1-inch  patten  on  the  boot;  this  is  to 
enable  the  bad  leg  to  swing  clear  of  the  ground  in  walking, 
for,  of  course,  while  in  the  walking  splint  it  is  impossible 
for  the  knee  to  bend. 

At  first  the  patient  will  have  to  be  assisted  and  supported 
in  walking,  but  usually  he  very  soon  can  walk  alone.  It  is 
purely  a matter  of  self-confidence  and  balance ; even  if  he 
were  to  fall  down  he  would  not  fracture  his  leg  while  it  was 
in  the  walking  splint.  Crutches  are  not  necessary  and  are 
to  be  discouraged  ; one,  or  sometimes  two,  walking  sticks 
may  be  used,  but  the  patient  quickly  learns  to  walk  without 
any  form  of  support  at  all. 

Every  morning  before  putting  on  the  walking  splint 
massage  and  passive  movement  should  be  given  ; and  two 
or  three  times  during  the  day  the  splint  should  be  freed 
from  the  boot  and  knee  movements  actively  exercised. 

The  caliper  boots  should  be  worn  until  at  least  six  months 
have  elapsed  since  the  date  of  fracture ; by  that  time  the 
splint  can  be  discarded  and  the  patient  walk  naturally  and 
with  a perfectly  movable  knee-joint.  Here,  again,  an 
X ray  is  of  great  value.  If  the  callus  is  very  dense  and  bone 
canaliculi  can  be  discovered,  then  the  callus  has  been  con- 
verted into  true  bone  and  can  only  be  broken  by  trauma, 
such  as  would  be  needed  to  fracture  any  sound,  healthy 
femur. 

On  first  getting  up  the  patient  may  find  that  his  leg  swells 
considerably.  This  will  gradually  disappear  as  his  muscular 
and  vaso-motor  systems  regain  their  normal  tone.  As  the 
muscles  of  the  thigh  grow  bigger  it  may  be  necessary  to 
have  a fresh  splint  with  a larger  ring. 

Some  Complications  of  Fractured  Femurs  which 
mat  Occur. 

(1)  Mal-union. — In  early  cases — that  is,  in  simple  fracture 
up  to  about  six  or  seven  weeks  and  in  compound  fractures 
up  to  the  end  of  the  twelfth  week — it  is  usually  possible  to 
break  down  the  union  by  hand  and  apply  satisfactory 
extension.  In  later  cases  osteotomy  will  be  required  if  the 
deformity  and  disability  are  sufficient  to  warrant  it. 

(2)  Delayed  union  and  non-union  may  be  caused  by  ( a ) 
sepsis  with  formation  of  a large  sequestrum  ; after  sequestro- 
tomy  with  satisfactory  drainage  the  bone  ugually  unites 
rapidly  ; ( b ) gross  destruction  o£  bone,  so  that  when  exten- 
sion is  applied  the  ends  of  the  bone  are  too  far  apart  for 
union  to  take  place.  This  may  be  treated  either  by  bone- 
grafting or  by  deciding  to  allow  some  shortening aDd  relaxing 
the  extension,  so  as  to  permit  of  the  ends  of  the  bone  coming 
together.  When  union  is  taking  place,  but  while  the  callus 
is  still  “ sticky,”  increased  extension  will  probably  cause  a 
little  more  lengthening  without  interfering  with  union. 

Delayed  union  may  be  caused  by  general  disease,  such  as 
debility,  malnutrition,  anaemia,  cachexia  from  malignant 
disease,  tabes  dorsalis,  rickets  in  childhood,  &c.  The  treat- 
ment of  the  disease  is  the  treatment  of  the  delayed  union  ; 
but  assistance  may  be  given  by  some  form  of  passive 
congestion  of  the  limb,  such  as  Bier’s  treatment. 

In  spite  of  treatment  a few  cases  of  fractured  femur  will 
not  unite  ; occasionally  this  may  be  due  to  pieces  of  muscle 
fascia  or  other  tissue  which  have  been  caught  between  the  bone 
ends  ; but  usually  the  reason  is  obscure.  No  fractured  femur 
should  be  diagnosed  as  a case  of  non-union  till  af  least  12 
months  from  the  date  of  injury  ; and  then  if  there  is  still  no 
union,  surgical  treatment  may  be  considered.  It  is  doubtful 
if  plating  will  ever  help  if  the  ends  of  the  bone  are  already 
in  good  position  ; in  these  cases  it  is  probably  better  to  adopt 
some  form  of  bone-grafting.  Even  when  the  bone  has  been 
plated  the  freshening  of  the  bone  ends  during  operation,  and 
the  increased  supply  of  blood  brought  to  .the  parts  during 


the  healing  of  the  operation  wounds  probably  play  as  big  a 
part  as  the  plate  itself  in  stimulating  the  bone  to  callus 
formation. 

(3)  Tetanus  has  already  been  discussed. 

(4)  Nerve  lesions  form  a subject  for  treatment  beyond  the 
scope  of  this  article.  It  is  sufficient  here  to  say  that  if 
“ foot-drop  ” is  present  an  uplifting  toe-spring  can  be  easily 
attached  to  the  walking  caliper  splint. 

(5)  Neuralgia  grain  along  the  dorsum  of  the  foot  is  not  very 
uncommon.  Its  cause  is  obscure.  It  cannot  be  entirely  due 
to  a neuritis  of  the  sciatic  nerve  as  it  is  met  with  both  in 
simple  and  compound  fractures.  It  may  be  treated  (often 
without  marked  success)  by  drugs  such  as  aspirin,  bromide, 
phenacetin,  &c. , or  by  local  applications — heat ; cold  ; 
ointments,  such  as  ung.  methyl  salicylate,  2 per  cent.  ; 
formalin  solution  ; blisters  ; antiphlogistine,  &c.  Sometimes 
a rubber  bandage  firmly  applied  gives  relief.  Unfortunately 
the  pain  is  always  worse  at  night  and  is  often  sufficiently 
severe  to  keep  the  patient  awake.  The  pain,  though  not 
very  amenable  to  treatment,  usually  decreases  and  disappears 
after  a few  weeks. 

(6)  Stiffness  of  the  hnee  due  to  adhesions  in  the  thigh 
between  muscle,  fascia,  and  bone.  This  is,  of  course,  much 
more  common  in  compound  fracture,  especially  where  there 
has  been  marked  sepsis.  The  worst  cases,  and  most  difficult 
to  treat,  are  when  the  extensors  of  the  thigh  are  bound  down 
to  the  bone  by  scar  tissue.  The  scar  may  be  loosened 
by  massagfe  and  forcible  flexion  under  an  anaesthetic. 
Sometimes  the  scar  can  be  separated  from  the  bone  by  the 
introduction  of  a tenotome.  If  these  methods  fail  excision 
of  the  scar  will  be  necessary. 

Conclusion. 

In  conclusion  it  may  be  said  that  by  the  methods  that 
have  been  described  a perfect  result  can  be  obtained  in  the 
vast  majority  of  fractured  femurs.  But,  like  everything  else, 
a fractured  femur  requires  constant  care  and  attention  to 
detail.  The  adjustment  of  the  slings,  the  maintenance  of 
extension,  the  movements  of  the  knee-joint,  the  correct 
suspension  with  slight  eversion  of  the  limb,  the  prevention 
of  foot-drop,  massage,  and  the  upkeep  of  general  health  and 
nutrition  of  the  patient— each  of  these  plays  its  allotted 
part  in  the  attainment  of  perfection ; and  if  anyone  is 
neglected  the  seeker  after  perfection  is  apt  to  be 
disappointed.  


PERVERTED  “FUNCTIONAL'’  ACTIVITY 
IN  THE  PRODUCTION  OF  JAW 
DEFORMITIES. 

By  D.  M.  S H AW, 

curator  of  the  prosthetic  laboratories,  rotal  dental  hospital 

OF  LONDON. 


The  “ perverted  ” or  non-normal  activities  which  it  is 
desired  here  to  draw  attention  to  are  “ functional  ” only  in 
so  far  as  they  are  excited  and  exhibited  in  the  oral  prepara- 
tion of  alimentary  substances.  The  “jaw  deformities  ” that 
it  is  hoped  to  throw  some  additional  light  upon  are  those 
occurring  among  children,  and  chiefly  recognised  and 
estimated  (in  occlusion)  as  irregularities  or  abnormalities  in 
the  position  of  teeth,  the  teeth  themselves  emerging  struc- 
turally sound  and  normal  in  shape.  The  various  dental 
units  are  constructed  faultlessly  and  are  ready  (we  may 
assume)  to  time.  They  are  then  potentially  available  for 
building  into  a machine  which  is  highly  efficient  as  a food- 
preparing mechanism  when  the  units  are  normally  arranged, 
and  which  then  also,  when  normally  exercised,  is  adapted  to 
maintain  the  health  and  integrity  of  its  various  parts  and 
investing  tissues.  But  in  the  abnormalities  frequently  seen 
the  functional  efficiency  is  greatly  depreciated  ; the  specific 
shapes  that  in  man  have  for  ages  remained  morpho- 
logically constant  are  there  present,  but  the  teeth  are 
thrown  together  in  such  disorder  as  to  more  or  less  abort 
their  utility,  and  the  normal  rhythmical  activity  in  mastica- 
tion becomes  impossible.  It  will  be  agreed,  and  without 
touching  at  all  upon  the  many  other  consequences  involved, 
that  this  is  a somewhat  poor  beginning  for  that  part  of 
the  alimentary  processes  over  which  we  could  safely  exercise 
the  most  direct  and  most  knowledgable  controlr 


Thk  Lanoht,] 


MR.  D.  M.  SHAW:  JAW  DEFORMITIES. 


[August  23,  1919  317 


The  “ Soft  Food”  Theory. 

Any  references  to  current  theories  of  causation  will  here 
be  closely  restricted  to  what  may  seem  helpful  in  bringing 
my  proposition  into  reasonably  clear  view.  Absence  or 
insufficiency  of  the  harder  foodstuffs  has  long  been  held  to 
be  a dominant  cause  of  malocclusion.  The  “soft  food” 
theory  and  the  indicated  remedy  have  been  insistently  kept 
in  the  forefront  by  several  accepted  authorities,  and  in  the 
general  lay  and  professional  mind  there  is,  at  any  rate,  a 
pious  if  not  a very  active  belief  in  the  soundness  of  that 
view.  While  no  one  seeks  to  deny  that  by  lack  of  functional 
exercise  the  jaws  may  fail  to  attain  their  full  development, 
there  are  yet  large  groups  of  malocclusion  cases  (involving 
protrusions,  retrusious,  contracted  arches,  spread  arches, 
and  excessive  anterior  overlap)  wherein  this  explanation  has 
been  rejected  by  the  majority  of  those  interested  in  the 
subject.  The  limb  muscles  of  different  children  undergo 
widely  differing  amounts  of  exercise  ; in  many  individuals 
the  exercise  may  be  deficient  in  amount,  but  no  concomitant 
bone  deformity  ensues. 

Professor  A.  Keith,  whose  suggestion  that  the  “sensitising” 
action  of  the  pituitary  secretion  may  be  at  fault  was  so  finely 
lit  up  by  the  searching  beam  he  cast  into  the  less-explored 
field  of  comparative  odontology,  is  at  the  same  time  in 
entire  agreement  that  one  should  also  give  exhaustive  atten- 
tion to  those  “ grosser”  agencies  which  are  known  to  alter 
and  regulate  growth — “the  mechanical  impulses  which 
arise  from  the  natural  use  of  parts.” 

Quite  a number  of  alternative  explanations  have  been 
offered  with  varying  degrees  of  confidence  and  support 
the  difficulty  and  low  solubility  of  the  problem  being  illus- 
trated by  the  emergence,  for  example,  of  theories  of  causa- 
tion, some  of  which  are  diametrically  opposed — viz.,  the 
theory  held  by  Dr.  Sim  Wallace  and  Sir  Arbuthnot  Lane  that 
contracted  or  narrow  jaws  are  caused  by  a feeble  musculature 
of  the  tongue  resulting  mostly  from  the  use  of  soft  food,  and 
the  explanation  advanced  by  Professor  H.  P.  Pickerill  that 
narrow  jaws  are  due  to  the  use  of  food  that  is  too  hard  or 
tough.  Again,. in  regard  to  defects  or  wrong  use  of  the 
respiratory  ports  as  a factor  in  jaw  deformities,  although 
the  vitiating  physical  or  mechanical  conditions  that  exist 
during  free  mouth  breathing  are  distinctly  different  to  the 
conditions  during  obstructed  nasal  breathing,  and  therefore 
the  effects  directly  due  to  the  former  must  differ  markedly 
from  those  due  to  the  latter  cause,  yet  in  articles  and 
discussions  those  important  differences  are  usually  either 
glossed  over  or  ignored. 

The  Existence  of  Positive  Factors. 

Whether  or  no  in  modern  times  a harmful  change  has 
taken  place  in  the  kind  of  food  given  to  children,  the 
number  of  meals  per  day  has  probably  not  lessened  and 
the  total  time  given  to  eating  may  be  taken  as  not  less 
now  than  was  customary  among  children  in  the  near  or 
more  distant  past.  Therefore,  as  the  mouth  is  in  some 
kind  of  activity  during  that  time,  inquiry  into  the  effects 
or  defects  arising  should  not  be  confined  to  consideration 
of  the  merely  passive  or  negative  factors.  The  absence  of 
positive  factors  cannot  be  assumed,  and  they  should  be 
searched  for  and  their  value  as  far  as  possible  ascertained 
by  close  and  persistent  observation  of  the  machine  at  work  in 
large  numbers  of  children.  For  some  years  past  I have  missed 
no  opportunity  (and  have  artfully  created  a good  many)  of 
observing  the  different  ways  in  which  the  mouth's  of 
children  deal  with  food. 

A direct  view  of  what  is  going  on  in  the  mouth  is,  of 
course,  very  much  cut  off  and  masked  by  the  cheeks  and 
lips,  but  this  drawback  is  in  some  degree  compensated  for 
by  the  fact  that  watchful  observation  of  those  same  moving 
curtains  will  often  betray  what  is  happening  behind  the 
scenes.  Correct  interpretation  of  the  mouth  and  jaw  move- 
ments which  take  place  and  of  the  probable  results  of  the 
various  efforts  in  manipulating  food  will,  it  is  reasonable  to 
believe,  be  favoured  a good  deal  by  previous  close  study  of 
the  chewing  mechanism  in  children  and  adults,  and  not 
only  in  normal  but  also  in  abnormal,  crippled,  and  mutilated 
dentitions.  The  small  amount  of  interest  up  to  the  present 
taken  in  the  physiological  morphology  does  not  warrant 
however,  the  entering  into  details,  “tedious”  details  that 
are  in  reality  essential  in  this  as  in  any  other  mechanism. 
The  following  is  a rough  summary  of  the  results  of  observa- 
tion of  many  groups  of  children. 


1.  There  is  in  many  cases  an  excessive  amount  of 
manipulation  of  food  by  the  tongue.  The  tongue  move- 
ments vary  from  very  languid  to  very  energetic,  sweetened 
foods  usually  exciting  the  tongue  to  the  greater  activity, 
especially  in  upward  pressure. 

2.  The  normal  work  of  fine  reduction  by  the  oheelt  teeth’ia 
only  partially  carried  out,  and  is  often  not  performed  at  all. 
Morsels  are  merely  rolled  about  in  the  mouth,  with  an 
occasional  squeeze  from  tongue  or  teeth,  and  what  are  in 
reality  remarkable  feats  of  food-bolting  pass  quite  unnoticed. 
The  performances  of  some  of  these  juvenile,  yet  often  well- 
mannered,  “ bolters  ” are  so  mysterious  and  finished  that  it 
is  almost  impossible  to  understand  how  it  is  done. 

3.  Certain  foodstuffs  which  constitute  a large  proportion 
of  the  daily  intake  (including  cereals  and  breadstuffs 
permeable  and  softened  by  saliva,  sweetened  puddings,  &c., 
porridge,  sweets,  jam,  and  confectionary)  are  manipulated 
and  “ mashed  ” by  the  tongue  against  the  anterior  surface  of 
the  palate,  partly  to  break  up  their  consistency  and  partly  to 
develop  and  extend  the  gustatory  enjoyment.  Sucking 
actions  are  often  involved,  and  among  the  several  reflex 
actions  excited  by  very  sweet  substances  is  a frequent  strong 
pressure  of  the  anterior  dorsal  surface  of  the  tongue  against 
the  front  of  the  palate.  In  these  various  movements  the 
muscular  pressure  exerted  by  the  tongue  is  many  times 
greater  than  that  required  either  for  the  successive  liftings 
of  portions  of  food  into  position  between  the  cheek  teeth 
or  for  moving  food  from  one  part  of  the  mouth  to  the  other. 
Here  we  have  a kind  of  “tongue  mastication”  (vide  Mr. 
J.  G.  Turner)  which,  while  admittedly  falling  within  the 
limits  of  normal  function  when  performed  occasionally, 
becomes  abnormal  or  perverted  when  exercised  frequently 
and  to  the  extent  of  in  large  part  supplanting  normal 
mastication  by  ihe  cheek  teeth. 

4.  In  some  children — more  usually  of  the  “vigorous  mouth 
and  hearty  eater  ” type — the  reduction  of  tough  morsels  is  to 
an  abnormal  extent  effected  by  the  anterior  teeth  instead  of 
by  the  cheek  teeth,  which  latter  teeth  may  either  be  absent 
or  crippled  by  caries,  or,  if  present,  they  are  thrown  out  of 
effective  shearing  align- 
ment by  a malocclusion 
already  established.  In 
this  type  the  cutting 
edges  of  the  anterior 
teeth  are  found  to  be 
more  worn — and  to  an 
undue  or  abnormal  extent 
— than  those  of  the  pos- 
terior teeth.  Later  on  one 
may  often  observe  pre- 
molars and  molars  that 
have  been  fully  erupted 
for  several  years  and 
yet  show  not  a trace  of 
intermaxillary  attrition 
or  of  food  abrasion.  Now, 
when  for  any  reason  fine 
(or  moderately  fine)  re- 
duction of  tough  food  is 
attempted  by  the  incisors 
alone,  the  tongue  has  to 
exert  considerable  up- 
ward and  forward  pres- 
sure in  order  to  hold  the 
small  morsels  in  proper 
position  for  each  succes- 
sive shearing  stroke  (Fig.  1.)  This  work  of  reduction  (which 
by  the  arithmetical  increase  of  the  divided  fragments  must 
constitute  by  far  the  greater  part  of  the  total  masticating 
effort)  is  effected  normally  by  the  multi-bladed  cheek  teeth, 
in  which  the  rows  of  lingual  cusps  automatically,  as  it  were, 
hold  and  support  the  fragments  in  position,  and  without 
calling  for  more  than  the  very  lightest  use  or  pressure  of  the 
tongue.1 

Some  Predominant  Features  in  Malooolusion. 

The  bearing  of  the  above-mentioned  perverted  activities  of 
the  tongue  upon  jaw  deformities  may  here  be  best  brought 
out  by  a short  consideration  of  certain  features  that  are 
often  found  associated  in  various  classes  of  malocclusion. 


Fig.  1.— Strong  forward  pressure  of  the 
tongue  is  always  exerted  when  small 
tough  morsels  are  reduced  by  the 
incisors,  and  is  required  in  order  to 
hold  the  morsels  in  proper  position  for 
shearing.  Externally  the  small  morsel 
is  held  bv  the  lips,  as  indicated  at  L. 
This  action  may  become  abnormal  in 
frequency  when  the  cheek  teeth  are 
lost,  or  crippled  by  caries,  &e.  It 
always  involves  an  upward  and  back- 
ward pull  upon  the  inner  surface  of 
the  mandible,  as  at  P. 


1 “Mechanism  of  Mastication  in  Man."  Trans.  Sixth  Internat.  Dental 
Congress,  p.  63  et  seq.  “Form  and  Function  of  Teeth,"  Journ.  Anat. 
vol.  lii. , October,  1917. 

H 2 


318  The  Lancet,] 


MR.  D.  M.  SHAW  : JAW  DEFORMITIES. 


[August  23,  1919 


Twenty  years  ago  (1899)  the  adjourned  discussion  of  a 
paper  on  “ The  Treatment  of  Superior  Protrusion,”  read  by 
Mr.  J.  F.  Colyer  at  the  Odontological  Society  of  Great 
Britain,  included  a full  and  interesting  contribution  from 
Mr.  E.  Lloyd-Williams  on  the  aetiology  of  that  deformity. 
In  the  discussion  following — deservedly  a “classic”  upon 
the  particular  subject— all  the  known  explanations  were  in 
turn  advanced,  excepting  perhaps  only  the  ductless  gland 
theory  and  the  antenatal  and  parturition  theories.  Yet,  as 
one  of  the  speakers  very  moderately  expressed  it,  “there 
was  still  something  missing  in  all  the  hints  which  had  been 
thrown  out  with  regard  to  causation.” 

There  was  general  agreement  upon  the  points  men- 
tioned by  Mr.  W.  Hern  and  Mr.  Lloyd-Williams  as  to  the 


Fig.  2.— High  level  of  incisors,  without  ‘‘crowding”  of  crowns. 

following  three  or  four  abnormalities  found  associated  in  the 
majority  of  superior  protrusion  cases:  (1)  The  high  level 
attained  by  the  alveolar  anterior  border  of  the  mandible  ; 
(2)  shortening  of  the  body  of  the  mandible  ; (3)  the  increased 
depth  or  low  level  of  the  premolar  and  molar  region  in  both 
maxilla  and  mandible  ; (4)  some  narrowing  of  the  arches  ; 
(5)  a backward  “ bite”  of  all,  or  nearly  all,  the  mandibular 
teeth.  (Figs.  2,  3,  and  4.) 

Significance  of  the  Abnormal  Vertical  Overlag). 

The  high  level  or  uprising  of  the  incisive  border  of  the 
mandible  involves,  ipso  facto  (excepting  only  in  cases  of 
“ open  bite  ”)  an  abnormal  degree  of  vertical  overlap  in  the 
occlusal  relationship  of  the  incisors,  the  opposed  incisors 
quite  often  overlapping  one  another  to  the  full  length  of 
their  crowns — that  is,  from  two  to  three  times  more  than 
the  normal  amount.  Now  it  is  a remarkable  and  perhaps 
hardly  recognised  fact  that  if  and  when — from  whatever 
cause — this  excessive  overlap  is  in  any  particular  case  once 
established,  the  several  other  abnormalities  set  out  above 
must  then  of  mechanical  necessity  be  concomitant,  if  not 


actually  consequent,  features.  This  statement  requires 
qualifying  in  regard  to  the  fourth  abnormal  feature, 
inasmuch  as  the  arch  in  some  cases  does  not  undergo  a 
general  narrowing.  But  excessive  overlap  must  in  most 
cases  involve  a narrowing  of,  at  any  rate,  the 
anterior  portion  of  the  mandibular  arch,  because  the 
lower  anterior  teeth  are  shifted  to  a smaller  "circle” 
(shorter  tract)  within  or  behind  the  lingual  walls  of 
the  upper  ones ; the  only  two  alternatives  possible 
being  a broadening  (anteriorly)  of  the  upper  arch,  or  an 
excessive  retrusion  of  the  lower  one.  Excessive  overlap  is  a 
feature  of  many  cases  other  than  those  of  superior  protrusion, 
and  the  search  for  its  origin — as  probably  the  master-key  to 
the  causal  explanation  of  many  jaw  deformities — has  always 
made  a fascinating  appeal  to  the  writer. 


Perverted  Aotivity  of  the  Tongue  Produces  Deforming  Strains 
in  the  Tooth-bea/ring  Tissues. 

The  diagram  in  Fig.  5 shows  the  position  of  the  tongue  and 
the  muscles  chiefly  concerned  in  its  upward  and  forward 
thrust,  a kind  of  activity  that  in  many  young  children  has 
been  observed,  as  above  stated,  to  constitute  an  abnormally 
large  share  of  the  total  effort  expended  in  the  oral  prepara- 
tion of  food.  The  tongue  is  drawn  forward  and  pressed 
against  the  lingual  walls  of  the  upper  anterior  teeth  and 
anterior  surface  of  the  palate  chiefly  or  almost  entirely  by 


Fig.  3. — “Superior  protrusion,"  with  the  several  other  abnormalities 
that  are  nearly  always  found  associated  with  that  deformity. 

the  contraction  of  the  geniohyoglossal  muscle.  Although 
theoretical  consideration  of  the  normal  anatomy  and 
physiology  of  the  parts  might  bar  out  any  dispute  upon  that 
point,  it  may  be  well  to  mention  in  addition  the  following 
demonstrable  evidence  : 1.  Subjective  experiments  by  the 

writer  and  some  others  in  whom  the  lower  premolars  were 
missing.  By  inserting  a hooked  finger  at  the  angle  of  the 
mouth  the  strong  contraction  of  the  genioglossal  muscle 
could  be  distinctly  felt  whenever  the  tongue  was  thrust 
upward  and  forward  as  described.  2.  Experiments  upon  two 
subjects  in  whom  the  symphyseal  portion  of  the  mandible 
had  been  removed,  and  as  a consequence  the  tongue  (sound 
and  about  normal  in  size)  could  not  be  protruded  beyond  the 
lips,  and  even  when  the  tongue  was  kept  inside  the  mouth 
no  forward  pressure  could  be  exerted  with  it. 


Fig.  5.— Diagrammatic  vertical  section,  showing  the  chief  muscles  con- 
tracted or  called  into  play  during  the  tongue  s perverted  activity  in 
food  “mashing.”  sucking,  Ac.,  aud  by  the  reflex  pressure  incited  by 
sweet  (also  “sharp,”  sour,  &c.)  substances.  A backward  traction  on 
the  mandible  takes  place  and  falls  upon  the  frail  bony  tissues  during 
the  “reconstruction”  period. 

It  is  clear,  then,  that  by  the  contraction  of  the  genio- 
glossal muscle  the  lower  jaw  is  subjected  to  a backward 
pull  at  and  about  the  region  of  the  genial  tubercles,  which 
backward  traction  is  abnormal  just  in  proportion  as 
the  forward  thrust  of  the  tongue  is  abnormal  in  force  and 
frequency  of  action.  This  backward  pull  is  in  daily  opera- 
tion during  the  four  or  five  years’  reign  of  the  deciduous  denti- 
tion, and,  in  addition,  throughout  the  period  of  change  to 
the  permanent  dentition.  During  most  of  that  time  the 
horizontal  U-shaped  cortical  tube  of  a child’s  mandible  is  a 


The  Lanoet,] 


MR.  D.  M.  SHAW:  JAW  DEFORMITIES. 


[August  23,  1919  3 1 9 


frail  box  almost  “cram  full”  of  teeth.  Moreover,  the 
strut-and-stay  system  of  trabeculae,  the  tooth  crypts,  and  to 
some  extent  even  the  cortical  bone  of  the  main  beam,  are 
undergoing  a constant  process  of  breaking  down  and  recon- 
struction ; the  alveoli,  too,  are  in  turn  “swept  away” — as 
Sir  C.  S.  Tomes  describes  it — and  rebuilt.  Even  in  the 
completed  jaw  bone  of  the  adult  the  long-continued  action 
of  abnormal  stresses  brings  about  bending  and  shearing 
strains  that  in  time  appear  as  obvious  deformities ; the 
striking  deformity  observed  (in  the  horizontal  branch 
of  the  mandible)  in  some  cases  of  ankylosis  has 
been  attributed  by  Dr.  M.  H.  Cryer  to  the  abnormal 
action  of  the  depressor  muscles,  the  power  of  which 
is,  nevertheless,  thought  to  be  fractionally  small  com- 
pared with  that  of  the  elevator  muscles.  The  more  readily, 
then,  will  one  admit  that  during  the  growing  and  recon- 
struction period  the  reaction  of  the  mandible  to  abnormal 
stresses  may  take  effect  both  in  inhibiting  and  disorganising 
growth  and  producing  durable  strains  (deforming  changes  of 
shape)  whenever  the  stresses  exceed  certain  limits  of  force 
and  time  (or  frequency)  of  action.  These  limits  are  known 
to  be  low  for  young  children  ; in  the  routine  practice  of 
orthodontics  they  are  purposely  overpassed  by  the  artificial 
application  of  very  small  forces. 

I have  estimated  quantitatively  the  force  of  the  tongue’s 
upward  and  forward  thrust,  and  although  my  measuring 
apparatus  is  too  crude  and  imperfect  to  warrant  presenting 
figures,  I am  quite  satisfied  that  this  force  is  many  times 
greater  in  amount  than  that  effectively  used  by  dentists  to 
move  teeth  and  alveoli — often,  too.  in  the  permanent 
dentition. 

Those  who  regard  with  some  doubt  the  various  explana- 
tions that  the  mandibular  retrusion  is  due  to  “ want  of 
development,”  “heredity,”  “small  tongue,”  and  other 

suggested  factors  that  are 
ill-defined  and  mostly 
negative,  will  be  glad  to 
turn  to  the  consideration 
of  a positive  factor  that 
can  be  seen  in  action , that 
acts  in  the  precise  direc- 
tion required  to  produce 
the  observed  phenomena, 
and  the  more  hidden  re- 
sults of  which  in  changing 
the  normal  disposition  of 
the  bony  tissues  can  be 
further  investigated  by 
X ray  examination  and 
also  in  the  dissecting  room. 
In  some  cases  it  may  be 
that  the  backward  or  cen- 
tripetal pull  of  the  genioglossal  and  “sublingual”  muscles 
produces  retrusion  of  the  mandible  solely  or  mainly  by 
inhibiting  or  restraining  its  development.  But  to  deny 
or  exclude  the  possibility  of  actual  deforming  strains 
(that  is,  slow  yielding  of  the  bony  tissues)  occurring, 
would  be  to  make  a unique  exception  of  a particular 
part  of  the  jaw  and  to  endow  it  with  an  unknown 
super-resistant  quality.  And  if  growth-inhibition  or  yield- 
ing from  backward  traction  did  in  point  of  fact  occur, 
the  resulting  deformities  would  be  exactly  like  those 
that  confront  us  daily  and  with  increasing  frequency,  and 
that,  in  this  country  alone,  must  affect  many  thousands  of 
children  in  whom  the  handicapping  disorder  will  not  be 
treated  or  ever  right  itself. 


Fig.  6. — To  illustrate,  in  simpler 
diagram,  the  conditions  detailed 
in  Fig.  5. 


I turn  now  to  the  excessive  overlap  or  (what  is  practically 
the  same  thing)  abnormally  high  level  of  the  incisive  border 
of  the  mandible.  The  majority  of  observers  are  agreed  that 
the  causes  of  this  very  common  deformity,  by  no  means 
confined  to  superior  protrusion  cases,  “ remain  shrouded  in 
sphynx-like  mystery.”  Explanations  such  as  “ pressure  of 
the  lower  lip,”  “eruptive  pressure  of  the  canines”  have 
been  somewhat  waveringly  offered,  and  in  application  to  but 
a few  cases  only  ; the  explanation  I here  advance  applies  to 
a wide  range  of  cases,  possibly  to  nearly  all  cases  of 
excessive  overlap. 

The  diagrams,  Figs.  1,  5,  and  6,  help  to  show  that 
the  part  of  the  tongue  whereat  (during  eating,  sucking, 
&c.)  pressure  is  applied  against  the  palate  and  anterior 
upper  teeth  lies  at  a higher  level  than  the  bony  area 
of  attachment  of  the  genioglossal  muscle.  There- 


fore in  the  resistant  pull  of  this  muscle  upon  the 
tongue  there  must  be  a downward  as  well  as  a back- 
ward component,  the  general  substance  of  the  tongue 
being  at  the  same  time  stiffened  to  a quasi-rigidity  by  a 
number  of  other  muscles,  the  coordinated  actions  of  which 
it  is  needless  at  present  to  attempt  to  analyse.  When 
holding  the  raised  tongue  against  the  resistance  offered  on 
or  at  the  anterior  maxillary  surfaces,  the  genioglossal 
fibres  are  perforce  inclined  markedly  upward,  so  that  (re- 
action being  equal  and  opposite)  their  contraction  must 
exert  an  obliquely  upward  and  backward  pull  upon  their 
place  of  origin  on  the  mandible.  The  existence  and  the 
strength  of  this  upward  pull  can  be  felt  and  realised  when 
(under  the  conditions  described),  with  an  inserted  finger,  an 


Fig.  7. — Diagram  showing  that  the  resistive  reaction  to  the  upward 
thrust  of  the  muscle-stiffened  tongue  must  involve  a downward 
pressure  upon  the  mylohyoid,  thus  causing  a downward  and 
(narrowing)  centripetal  pull  upon  the  inner  surfaces  of  the  mandible. 

attempt  is  made  to  press  or  keep  the  converging  anterior 
part  of  the  muscle  down.  Under  this  upward  tensional 
stress  the  young  “ unready  ” bone  is  strained  and  very  slowly 
and  gradually  yields  in  an  upward  direction.  The  force  of 
the  pull  is  distributed  on  and  about  just  that  very  region 
where  the  apices  of  the  milk  anterior  teeth  and  the  crypts  of 
the  permanent  ones  lie,  so  that  it  would  undoubtedly  tend 
to  produce  the  unexplained  variety  of  phenomena  found 
associated  with  uprising  of  the  alveolar  border — -“apical 
crowding  ” and  anterior  “ crowding  ” with  or  without  spacing 
of  the  crowns,  the  “fan”  arrangement,  and  the  (hitherto) 
completely  puzzling  type  mentioned  by  Sir  Harry  Baldwin, 
wherein  the  lower  incisors  “were  jumbled  together  into 
two  lines.” 

And  the  “ low  level  ” of  the  mandibular  post-canine  teeth 
is  a further  and  almost  inevitable  consequence  ensuing  from 
the  downward  component  of  the  toDgue’s  pressure  upon  the 
diaphragmatic  floor  of  the  mouth,  whereon  the  base  of  the 
muscle-stiffened  tongue  finds  the  necessary  resistance  to  its 
own  upward  thrust.  The  digastric  and  geniohyoid  muscles 
play  a considerable  part  in  supporting  the  upward  thrusting 
tongue,  but  certainly  the  mylohyoid  “ slings  ” upon  which 
the  tongue  is  seated  must  exert  a downward  pull  upon  those 
inner  surfaces  of  the  mandible  from  which  they  are  hung. 
(Fig.  7.)  Experimental  trial  (subjective  and  objective) 
readily  shows  that  in  reaction  to  the  tongue’s  upward 
thrust  the  downward  bulge  of  the  oral  floor  is  both  seen 
and  felt  to  be  lowest  or  most  prominent  in  the  region  of  the 
lower  premolars  and  first  molars,  where,  as  it  happens,  the 
“low  level”  of  the  alveolar  border  or  teeth  is  found  to  be 
the  most  marked.  It  is  worth  noting,  too,  in  view  of  the 
downward  traction  internally,  that  the  mandibular  cheek 
teeth  often  have  an  abnormally  inward  tilt. 

The  pull  of  the  mylohyoid  (under  the  tongue’s  perverted 
activity)  will  of  course  vary  in  strength  and  direction  with 
the  individual,  and  with  the  varying  proportional  develop- 
ment of  the  different  tissues,  including  the  tongue  itself. 
So  that  when  the  tongue  is  (constitutionally  ?)  small  and 
narrow,  the  supporting  mylohyoid  sheet  may  attain  a more 
nearly  horizontal  plane  and  its  pull  will  then  be  the  more 
directly  inward , tending  to  draw  the  two  sides  of  the 
mandible  together.  Thus  if  a tongue  small  or  subnormal 
in  volume  is  found  associated  with  a narrow  arch,  the  usual 
explanation  that  the  small  tongue  (negatively  or  by  its 
passivity)  causes  the  narrow  arch  may  be  wrong,  and  is 
based  too  much  upon  assumption.  The  significance,  if  any, 
of  the  association  can  be  more  instructively  interpreted  by 
taking  into  account  the  more  horizontal  direction  of  the 


320  The  Lancet,]  DR.  HARRIETTS  CHICK  & OTHERS  : RESEARCHES  ON  SCURVY.  [August  23, 1919 


contractile  pull  of  the  mylohyoid  upon  the  mandible.  A 
large  tongue  will,  on  the  other  hand,  the  more  deeply  bulge 
into  and  fill  the  oral  floor-space,  partly  overcoming  the 
resistance  of  the  mylohyoid  sheet  and  causing  its  pull  upon 
the  mandible  to  be  more  downward  and  less  inward.  In 
regard  to  the  inward  traction  the  following  observation  may 
be  significant. 

During  the  routine  examination  of  many  thousands  of 
occluded  plaster  casts,  I observed  that  in  a proportion  of 
those  in  which  the  occlusion  of  molars  might  be  reckoned 
as  good  mesio-distally  the  occlusion  bucco-lingually  would 
have  been  better  or  more  normal  if  the  mandibular  molars 
were  moved  buecally  or  wider  apart — that  is  to  say,  the 
mandibular  arch  was  a little  too  narrow  at  the  first  molars 
for  the  normal  occlusion  of  these  teeth  with  their  maxillary 
opponents.  This  in  itself  suggests  the  possibility  that  in 
some  cases  the  lower  jaw  leads  the  way  in  the  contraction  of 
both  arches. 

In  conclusion,  it  is  urged  that  what  I have  called  (in  short 
phrase)  “perverted  activity  of  the  tongue”  is  harmfully 
frequent  among  children,  and  is  incited  chiefly  in  the  oral 
manipulation  of  foods  a preponderant  amount  of  which  is  of 
a sweet,  soft,  or  glutinous  nature  ; and  also  less  frequently 
by  the  crippling  or  (from  whatever  reason)  insufficient  use  of 
the  cheek  teeth. 

At  the  same  time  it  is  possible  to  go  to  the  other  extreme 
by  encouraging  young  children  to  masticate  well  an  unduly 
large  proportion  of  tough  food,  so  that  the  anterior  teeth  are 
to  an  undue  extent  called  upon  to  relieve  the  overworked 
cheek  teeth  in  the  extra  labour  of  fine  reduction  ; the 
forward-thrusting  and  holding  action  of  the  tongue  is  thus 
brought  into  too  frequent  use,  and  the  mandible  is  subjected 
to  an  upward  and  backward  traction.  In  several  reported 
cases  (including  children  of  dentists)  where  the  precepts  of 
vigorous  mastication  were  faithfully  and  conscientiously 
put  into  practice,  the  deciduous  arches  were  seen  to  be  broad 
and  fine,  and  the  teeth  individually  were  in  every  way 
satisfactory  ; nevertheless,  the  puzzling  excessive  overlap 
was  there,  as  well  as  some  degree  of  post-normal  occlusion. 

That  the  forward  thrust  of  the  tongue  during  its  perverted 
activity  must,  in  some  cases,  induce  protrusion  of  the  upper 
teeth  is  so  evident  a proposition  that  I omitted  any  explicit 
statement  on  the  point,  and  detailed  discussion  is  here  barred 
out  from  want  of  space.  But  what  I regard  as  remarkable 
and  important  in  my  discovery  (about  five  years  ago)  of  the 
tongue’s  abnormal  activity,  is  its  unsuspected  yet  inevitable 
reaction  on  the  mandible.  The  tongue  exerts  a oentrifugal 
pressure  on  the  maxilla  anteriorly,  and  the  main  resistance 
and  reaction  to  the  tongue’s  thrust  takes  effect  as  a centri- 
petal traction  on  the  mandible , the  one  being  in  effect  the 
reciprocal  of  the  other. 

The  great  majority  of  superior  protrusion  cases  are  asso- 
ciated with  inferior  retrusion,  as  stated  by  Mr  Norman  G. 
Bennett  when  reporting  (March.  1912)  to  the  British  Society 
for  the  Study  of  Orthodontics,  for  the  Committee  on  Ortho- 
dontic Classification.  The  degree  of  superior  protrusion 
actually  produced  during  functional  activity  must  depend 
upon  the  greater  or  less  amount  of  counteracting  restraint 
and  inward  pressure  from  the  upper  lip,  which  effective  centri- 
petal pressure  varies,  I think,  not  so  much  or  so  entirely  with 
the  length,  thickness,  or  “poise”  of  the  lip  as  with  the 
“ temperamental  ” and  muscular  motility  in  the  particular 
individual.  This  line  of  investigation  may  seem  too  obscure 
to  bring  out  anything  helpful,  but  in  point  of  fact  striking 
differences  in  the  functional  labial  movements  of  different 
individuals  are  made  evident  merely  by  visual  observation. 
More  important,  however,  and  more  directly  bearing  upon 
my  present  thesis  concerning  the  identification  of  primary 
causes  and  the  actions  they  evoke,  is  the  marked  influence  of 
reflex  movement  and  pressure,  here  just  touched  upon  as 
follows : — 

Gustatory  Reflexes. 

Among  the  oral  reflexes  incited  by  sweetened  food  and 
sweet  substances,  as  well  as  substances  with  an  acid  or  a 
“ sharp  ” taste,  there  are  certain  labial  and  buccal  muscular 
actions  which  very  probably  play  a part  in  the  contraction  of 
the  upper  arch.  Discussion  of  this  would  be  quite  relevant, 
but  must  be  deferred. 

I propose  in  a future  communication  to  show  that  perveited 
activity  of  the  tongue  may  also  bear  a causal  relationship 
to  two  other  deformities  of  the  jaw — namely,  (I)  inferior 
protrusion  or  “ underhung  ” bite  ; and  (2)  open  bite. 


I.— THE  ANTISCORBUTIC  AND  GROWTH- 
PROMOTING  VALUE  OF  CANNED 
VEGETABLES. 

By  MABEL  E.  D.  CAMPBELL  and  HARRIETTE  CHICK. 

( Prom  the  Lister  Institute , Department  of  Experimental 
Pathology .) 


The  experimental  work  described  below  was  undertaken 
in  August,  1918,  at  the  request  of  the  Controller  of  Horti- 
culture, Food  Production  Department,  and  Miss  Campbell, 
of  that  department,  was  detailed  to  work  upon  this  problem 
at  the  Lister  Institute.  It  forms  one  of  a series  of  researches 
on  experimental  scurvy  carried  out  at  this  Institute.  The 
aim  was  to  ascertain  what  changes  take  place  in  the  nutritive 
value  of  vegetables  during  the  process  of  canning,  with 
special  reference  to  vitamine-content. 

It  was  to  be  presumed,  from  the  information  already 
available  as  to  the  destructive  effect  of  heat  upon  the  anti- 
scorbutic factor  in  cabbage  leaves  (Delf,  1918).  that  canned 
vegetables  would  suffer  considerable  deterioration  in  anti- 
scorbutic value  owing  to  the  high  temperature  to  which  they 
are  exposed  in  the  process  of  preparation.  The  present  work 
was  directed  to^obtaining  an  accurate  estimate  of  what  that 
loss  might  be.  /Cabbage  and  green  (runner)  bean  pods  were 
selected  as  suitable  vegetables  for  the  experiment?)  Cabbage 
was  chosen  because  many  data  as  to  its  antiscorbutic  value, 
both  in  the  raw  and  cooked  condition,  were  already  avail- 
able from  the  researches  of  Dr.  Marion  Delf  (1918)  at  the 
Lister  Institute  ; green  runner  beans  because  they  are  a 
good  example  of  a vegetable  frequently  chosen  by  the  public 
for  preservation  by  canningj 

The  experiments  consisted  essentially  in  estimating  and 
comparing  the  minimal  amounts  of  these  vegetables — 
(<z)  when  raw,  and  ( b ) after  canning — which  must  be  added 
daily  to  a basal  scurvy-producing  diet  in  order  to  protect 
young  guinea-pigs  from  scurvy  dver  a period  of  three 
months.  These  results  are  set  out  in  the  accompanying 
table,  in  which  data  obtained  with  other  foodstuffs  are 
included  for  purposes  of  comparison. 

Method  of  Experiment. 

The  method  of  experiment  was  the  same  as  that  adopted 
generally  in  the  series  of  researches  on  experimental  scurvy 
published  from  this  Institute.3-10  It  is  based  on  that 
employed  by  Holst  and  Frohlich,12  who  chose  the  guinea-pig 
as  experimental  animal  and  grain  of  various  kinds  with 
water  as  the  basal  “scurvy  diet.”  On  such  a diet  young 
guinea-pigs  are  found  to  sicken  and  die  of  scurvy  in  from 
three  to  four  weeks  with  great  loss  of  weight. 

In  a study  of  the  antiscurvy  value  of  foodstuffs  the  aim  is 
to  devise  a diet  which  shall  afford  abundance  of  all  necessary 
factors  except  the  antiscorbutic  factor.  This  basal  diet 
must  contain  suitable  proportions  of  (a)  carbohydrate  and 
(J)  fat,  the  right  kind  and  amount  of  (c)  mineral  salts  and 
(d)  protein,  and  in  addition  an  adequate  quantity  of  the  two 
so-called  growth  accessory  factors  described  by  McCollum 
and  his  co-workers  as  (e)  “ fat-soluble  ” growth  factor  and 
(r)  “ water-soluble  ” or  an tineuritic  (antiberi-beri)  factor.  In 
the  diet  of  oats,  bran  and  water  which  we  have  employed  in 
many  cases  ( a ).  (i)  and  (/)  are  provided  in  sufficient  quantity 
and  probably  in  the  mixture  of  the  two  grains,  oats  and 
wheat  (<j)  and  (d),  are  also  adequate  for  the  nutrition  of  the 
guinea-pig.  The  diet  is,  however,  deficient  in  both  the  anti- 
scurvy factor  and  the  “ fat-soluble  ” growth  factor,  pt  has 
therefore  been  our  practice  in  many  experiments  to  supply 
the  latter  by  means  of  a daily  ration  (60  c.cm.)  of  milk  heated 
for  one  hour  to  120°  C.  to  destroy  its  original  antiscorbutic 
properties.  This  addition  also  affords  an  extra  supply  of 
protein  of  a highly  nutritious  character,  and  upon  this 
“scurvy  diet”  the  animals  grow  well  until  loss  of  weight 
sets  in  with  the  occurrence  of  scurvy  symptoms.  Death 
from  scurvy  occurs  in  from  four  to  six  weeks. 

By  addition  to  the  basal  diet  of  various  weighed  daily 
rations  of  (<i)  raw  b^ans  and  canned  beans,  (i)  raw  cabbage 
and  canned  cabbage,  the  minimal  amounts  required  to 
protect  from  scurvy  were  estimated.  On  comparison  of  these 
values  the  degree  of  destruction  experienced  by  the  anti- 
scorbutic factor  during  the  process  of  canning  and  storage 
could  be  approximately  determined. 


The  Lancet,] 


DR.  HARRIETTS  CHICK  & OTHERS:  RESEARCHES  ON  SCURVY.  [August  23,  1919  321 


” Weighed  amounts  of  the  vegetables  (cut  into  small  pieces) 
were  offered  to  the  animals  daily.  Usually  the  ration  was 
consumed  greedily,  but  any  residue  noted  on  the  next  day 
was  weighed  (after  soaking  in  water)  and  the  amount 
deducted  from  the  original  weight  given.  If  a residue 
was  found  on  several  succeeding  days  the  animal  was 
rejected,  as  band-feeding  of  soft  vegetables  is  too  laborious 
and  inaccurate  a procedure.  While  animals  were  developing 
scurvy,  hand-feeding  cf  milk  with  a glass  syringe  was 
frequently  resorted  to  in  order  to  maintain  an  average 
consumption  of  60  c.cm.  daily. 


namely,  2-3  months.  All  canned  samples  were  drained  and 
turned  out  into  a dish  immediately  on  opening  the  can. 
The  residue  not  used  for  the  day’s  ration  was  kept  in  cold 
store.  It  was  rarely  used  later  than  two  days  after  opening. 

Cabbage — (1)  Antiscorbutio  value. — In  this  case  the  experi- 
ments were  arranged  to  test  the  canned  material  as  fresh  as 
possible  ; it  was  never  more  than  three  weeks  old,  and  the 
average  age  was  two  weeks.  Previous  results  obtained  by 
Dr.  Marion  Delf  (1918)  showed  that  15  g.  of  raw  cabbage 
added  to  a diet  of  oats,  bran  and  autoclaved  milk 
sufficed  to  prevent  scurvy  in  young  guinea-pigs,  but  that 


Diet. 

No  of 

Result  as  regards— 

** 

Observer. 

Special  ration. 

Amount 

(grams). 

Basal. 

animals. 

experi- 

ment. 

Growth. 

Occurrence  of 
Scurvy. 

Cabbage  leaves  — 

Days. 

(1)  Kaw  

5-0 

3 

90 

Good. 

Protection . 

Delf,  1918. 

2 5 

5 

90 

Fair. 

1-5 

Oats, 

6 

70-90 

Very  little. 

,, 

0'5 

bran. 

4 

67-90 

Scurvy,  but  some 

(2)  Cooked  in  steam  — 

50 

auto- 

claved 

degree  of  protection . 
Severe  scurvy. 

(a)  60  min.  90°  C. 

4 

21-50 

Fair. 

(6)  20  min.  100°  C.  ... 

50 

milk. 

4 

90 

Protection  almost 

7-5 

complete. 

(3)  Canned— 60  min.90-100°C. 

3 

90-95 

Very  good. 

Protection. 

Campbell  and  Chick. 

50 

> 

3 

33-90 

Good  io  2 

Scurvy,  but  some 

cases. 

degree  of  protection 

in  2 cases. 

(4)  Raw  

15  0 

Oats, 
* bran, 

4 

90 

Very  good. 

Protection. 

Delf,  1918. 

(5)  Cooked  in  steam  — 

60  min.  100°  C 

15-0 

3 

90 

Campbell  and  Chick. 

(6)  Canned— 60  min. 90-100°C. 

15-0 

. 

3 

66-93 

Very  poor. 

»»  1* 

15-0 

4-  20 c.cm. 

3 

90 

Fair. 

M 

liquor  from 

cans. 

Runner  beans — 

(1)  Raw  

5-0 

] Oats, 

3 

84-91 

Good. 

Scurvy. 

2-5 

I brao, 

3 

59-64 

Very  little. 

,, 

1-5 

V auto- 

4 

48-61 

(2)  Canned— 140  min.  100°C. 

20-0 

I claved 

3 

28-40 

• » t 

10-0 

) milk. 

1 

28 

None. 

,, 

,,  ,, 

Carrot  juice.  Raw 

200 

) 

3 

75-95 

Fair. 

Protection. 

Chick  and  Rhodes,  1918. 

Swede  ,,  ,,  

2-5 

f •• 

4 

90-100 

Good. 

Lemon  ,,  ,,  

1-5 

4 

90 

,, 

,, 

Chick.  Hume,  Skelton  and  Smith, 

Fresh  milk  

1C0-150 

1918.  and  unpublished  experiments. 

Oats,  bran, 

2 

90-113 

,, 

Chick,  Hume  and  Skelton,  1918,  I., 

Germinating  peas  

5'0 

water. 

and  unpublished  experiments. 

Oats,  bran. 

5 

87-97 

„ 

Chick  and  Delf,  1919. 

autoclaved 

milk. 

Dried  cabbage*  

5'0 

Oats,  bran, 

6 

66-134 

None. 

Protection  in  some 

Delf  and  Skelton,  1918. 

• 

water. 

cases. 

*'  Equivalent  to  50  g.  fresh  cabbage. 


Methods  Employed  in  Canninq. 

Cabbage. — The  methods  used  were  those  advocated  by 
the  Food  Production  Department  in  their  pamphlet  No.  34. 
Fresh  green  outer  leaves  were  chosen.  These  were  washed 
in  cold  water,  blanched,  and  cold-dipped  (i.e. , exposed  to 
boiling  water  containing  a little  sodium  bicarbonate  for 

3 minutes,  then  plunged  into  cold  water),  and  packed  into 
lacquered  cans.  These  were  filled  with  boiling  water  to 
within  J inch  of  the  top,  and  at  once  hermetically  sealed 
by  soldering  the  lids.  Sterilisation  was  effected  by  exposure 
of  the  cans  to  steam  at  100°  C.  for  1^  hours  in  a closed  boiler. 
After  cooling  by  plunging  into  cold  water  the  cans  were 
stored  at  laboratory  temperature  (60-65°  F.).  Experiments 
with  control  tins  in  which  the  lids  were  replaced  by  corks 
carrying  thermometers  showed  that  this  process  of  canning 
involved  the  exposure  of  the  cabbage  in  the  cans  to  a 
temperature  of  90-100°  0.  for  1 hour.  The  average  proportion 
of  cabbage  to  water  in  the  cans  wa9  found  to  be  16  to  1-0 
by  weight  and  the  water  content  of  the  drained  cabbage  as 
fed  to  the  animals,  90-92  per  cent.,  was  approximately  the 
same  as  that  of  fresh  cabbage.  The  approximate  mean  age 
when  tested  was  two  weeks  after  canning. 

Beans. — Young  crisp  runner  bean  pods  were  selected  where 
possible.  The  method  in  outline  resembled  that  used  with 
cabbage,  with  the  difference  that  the  blanching  lasted 

4 minutes,  and  the  sterilising  was  done  intermittently — i.e., 
for  lj  hours  on  one  day  and  1 hour  on  the  succeeding  day. 
Control  experiments  showed  that  the  contents  of  the  cans 
were  exposed  to  a temperature  of  100°  C.  for  a total  period  of 
approximately  2 hours  20  minutes.  The  proportion  of  beans 
to  water  was  approximately  17  to  10,  and  the  water  content 
of  the  canned  samples  94-96  per  cent.  The  time  of  storage 
at  laboratory  temperature  before  testing  of  the  canned  beans 
was  longer  than  was  the  case  with  the  canned  cabbage, 


0 5 g.  daily  was  insufficient  for  that  purpose.  With 
7 5 g.  daily  of  canned  cabbage  growth  was  well  main- 
tained in  three  animals,  and  there  were  no  symptoms  of 
scurvy  during  life  or  post  mortem.  With  a 5 g.  ration 
daily,  good  health  was  enjoyed  by  two  animals  out  of  three, 
but  in  these  cases  distinct  signs  of  scurvy  were  shown 
by  soreness  of  the  limbs  and  characteristic  hemorrhages  post 
mortem.  The  third  animal  developed  severe  scurvy  during 
life  and  showed  the  usual  signs  at  post-mortem  examination. 
Although  these  animals  showed  good  health  in  two  cases 
out  of  three  the  degree  of  protection  from  scurvy  was  less 
than  that  enjoyed  upon  a 15  g.  ration  of  raw  cabbage  ; 
it  was,  however,  distinctly  greater  than  upon  a 0 5 g.  ration. 
7 he  loss  of  antis onrvq  value  during  canning  would,  therefore . 
appear  to  be  about  TO  per  cent. — i.e..  an  antiscurvy  value  of 
5 g.  raw  cabbage  was  reduoed  to  that  of  about  15  g.  raw 
cabbage.  » 

(2)  Growth-promoting  value.— In  a further  set  of  experi- 
ments an  attenfpt  was  made  to  trace  the  fate  during  canning  of 
the  growtfa-prcfm<Jting  “ fat-solub'e”  accessory  factor  known 
to  be  present* in  green  leaves  (McCollum,  Simmonds,  and 
Pitz.^fllff).  The  ration  was  much  increased — viz.,  to  15  g. 
daily — and  autoclaved  milk,  which  provided  the  “fat  soluble” 
grotvth  factor  in  the  preceding  experiments,  was  omitted 
from  the  dietary,  which  consisted  therefore  of  oats  and  bran 
alone.  Delf  (loc.  cit.)  has  shown  that  a diet  of  oats  and 
bran  and  15  g.  of  raw  cabbage  is  sufficient  to  promote  good 
growth  and  provide  ample  protection  from  scurvy.  This 
ration  of  fresh  green  leaves  provides  a large  excess  of  the 
antiscorbutic  factor,  and  is  evidently  also  large  enough  to 
afford  the  necessary  fat-soluble  growth  factor  and  to  supple- 
ment any  defect  in  the  nature  of  the  proteins  in  oats  and 
bran,  if  such  exists.  After  heating  in  steam  for  1-2  hours  at 
100°  C.,  Delf  found  the  same  .ration,  15  g.,  adequate  for 


[August  23,  1919 


322  The  Lancet,]  DR.  HARRIETTE  CHICK  & OTHERS:  RESEARCHES  ON  SCURVY. 


the  purpose  ; the  animals  were  maintained  in  good  health, 
and  in  one  case  healthy  young  were  born. 

In  the  case  of  canned  cabbage,  also  employing  a 15  g. 
ration,  the  result  was  otherwise.  Scurvy  was  certainly 
prevented,  but  the  animals  showed  little  or  no  growth  during 
the  three  months  of  the  experiment.  In  the  case  of  one 
animal  autoclaved  milk  was  provided  from  the  sixty-fourth 
day,  and  growth  immediately  began.  This  result  suggests 
that  during  heating  and  storing  in  water  the  growth- 
promoting  vitaraine  originally  present  in  the  green  leaves 
was  either  (1)  destroyed  to  a large  extent,  or  (2)  had  escaped 
into  the  water  in  which  they  had  been  immersed  (the  pro- 
portion of  cabbage  to  water  by  weight  in  the  cans  was 
approximately  3:2).  A series  of  further  experiments  was 
made  in  which  the  water  in  the  tins  was  fed  to  the  animals, 
together  with  the  canned  cabbage  ; much  better  growth  was 
obtained,  a result  which  seems  to  support  the  second  view. 

In  the  experiments  described  in  the  preceding  section  with 
smaller  rations  of  canned  cabbage,  5 to  7 5 g.,  the  “fat- 
soluble  ” growth-promoting  factor  was  provided  in  the  ration 
of  autoclaved  milk. 

Beans. — Antiscorbutic  value. — There  are  no  quantitative 
data  available  as  to  the  antiscorbutic  value  of  the  raw  runner 
bean  pods  in  comparison  with  other  vegetables.  Special 
experiments  had  therefore  to  be  made  in  order  to  determine 
the  minimum  amount  which  must  be  fed  daily  to  guinea-pigs 
on  a scurvy  diet  in  order  to  prevent  onset  of  the  disease.  - 
They  showed  that  a 5 g.  ration  may  be  taken  as  the  minimum 
amount  giving  protection  from  scurvy.  With  2 5 g.  and  less 
all  animals  developed  the  disease,  and  with  5 g.  and  over  all 
escaped.  After  canning,  however,  a daily  ration  of  20  g. 
was  found  inadequate,  and  severe  scurvy  was  developed  in 
every  case.  By  the  prooess  of  canning , therefore , the  anti- 
scurvy  value  of  20  g.  rare  bean  pods  was  reduced  to  less  than 
that  of  5 g. , and  was  not  superior  to  1-5  or  2-5 g.  raw  beam, 
pods — in  other  words , 75  per  cent,  to  90  per  cent,  had  been 
destroyed. 

Conclusion. 

1.  In  the  process  of  canning  vegetables  the  greater  part 
of  the  original  antiscurvy  value  of  the  raw  vegetable  is 
destroyed.  In  the  case  of  runner  bean  pods  the  loss  is  esti- 
mated at  about  90  per  cent,  of  the  original  value  ; in  the 
case  of  cabbage  at  about  70  per  cent,  of  the  original  value. 
The  process  of  canning  cabbage  included  heating  in  water 
for  about  one  hour  at  90°  to  100°  C.,  and  for  beans  the 
process  was  repeated  on  the  day  following. 

2.  This  loss  is  primarily  due  to  the  destruction  of  anti- 
scurvy material  occurring  during  the  heating  involved  in 
the  process  of  canning.  A further  loss  may  be  expected  to 
take  place  during  the  period  of  storage.  The  canned 
cabbage  was  examined  two  weeks  after  preparation  and  the 
canned  beans  three  months  after. 

3.  In  the  case  of  green-leaf  vegetables  which  possess,  in 
addition  to  the  antiscurvy  vitamine,  the  “ fat-soluble  ” 
growth-promoting  accessory  factor,  the  latter  substance  is 
also  lacking  in  the  canned  material  unless  ttfe  liquor  be 
also  taken. 

4.  The  value  of  canned  vegetables  as  regard  antiscurvy  and 
growth-promoting  properties  must  be  regarded  as  negligible. 

References.— 1-  Holst  and  Frohlich  (1907):  Journal  of  Hygigne, 
vol  vii  . p.  619.  2.  Holst  and  Frohlich  (1912)  : Zeitschrift  f.  Hygiene, 
vol.  lxxii.,  p.  1.  3.  Chick  and  Hume  (1917):  Trans.  Soc.  Trop  Med. 
and  Hygiene,  vol.  x..  p.  141.  4.  Chick,  Hume,  and  Skelton  (1918): 
Biochemical  Journal,  vol.  xii.,  p.  131;  and  (5)  The  Lancet,  Jan.  5th. 

6.  Chick,  Hume,  Skelton,  and  Smith  (1918):  The  Lancet,  Nov.  30th. 

7.  Chick  and  Delf  (1919):  Biochem.  Journal,  vol.  xiii.,  p.  199.  8.  Chick 
and  Rhodes  (1918) ; The  Lancet,  Dec.  7th.  9.  Delf  (1918) : Biochemical 
Journal,  vol.  xii.,  p.  416.  10.  Delf  and  Skelton  (19181:  Biochemical 
Journal,  vol.  xii.,  p.  448.  11.  McCollum,  Simmonds,  and  Pitz  (1916): 
Amer.  Jour.  Phys.,  xii.,  p.  361. 

II  —THE  ANTISCORBUTIC  VALUE  OF  SOME  INDIAN 
DRIED  FRUITS  : 

(a)  TAMARIND,  (>)  COCUM,  AND  (c)  MANGO  (“  AMCHUR  "). 

By  Harriette  Chick,  E.  Margaret  Hume,  and 
Ruth  F.  Skelton. 

(From  the  Lister  Institute,  Department  of  Experimental  Pathology.) 

The  experimental  investigation  of  these  dried  fruits  was 
undertaken  early  in  1917,  at  a period  in  the  war  when 
scurvy  was  still  proving  a serious  menace  to  our  native  troops 
in  Asia.  These  and  similar  materials  have  long  been 
esteemed  as  antiscorbutics  by  the  native  population  of  India, 


and  instances  are  to  be  found  in  the  literature  and  elsewhere 
in  which  the  prevention  and  cure  of  human  scurvy  has  been 
attributed  to  their  agency.  For  example,  MacNab1  (1837) 
relates  how  an  outbreak  of  Scurvy  at  Nassirabad,  Rajputana, 
in  1833-34  was  treated  with  good  results  by  an  infusion 
made  from  “anola,  ” the  dried  fruits  of  Phyllanthus 
emblica.  This  product  was  commonly  bought  and  sold  in 
the  native  bazaars  and  considered  to  possess  great  anti- 
scorbutic virtue.  The  dose  taken  amounted  to  J oz.  (14  g.) 
daily,  calculated  on  the  original  dry  material. 

Major-General  Sir  Havelock  Charles,2  who  was  attached 
as  medical  officer  to  the  Afghan  Boundary  Commission  in 
1884-86,  ascribes  the  freedom  from  scurvy  of  the  native 
troops  accompanying  this  expedition  to  the  regular  con- 
sumption of  “amchur,”  or  dried  mango,  whenever  fresh 
fruits  or  vegetables  were  unavailable.  It  was  at  his 
suggestion  that  we  undertook  the  following  experimental 
study,  and  the  samples  of  tamarind,  cocum,  and  amchur 
investigated  were  obtained  from  India  with  his  assistance. 
Of  these,  the  two  first-named  are  commonly  included  in  the 
native  soldiers’  ration. 

The  method  adopted  for  studying  the  antiscorbutic  value 
of  these  fruits  was  as  follows.  Guinea-pigs  were  used  as 
experimental  animals,  following  in  principle  the  methods 
employed  by  Holst  and  Frohlich  3 as  modified  by  Chick  and 
Hume.4  If  greenstuff  is  removed  from  their  normal  diet  of 
grain  and  green  leaves  these  animals  sicken  and  die  of 
scurvy  in  3-6  weeks.  In  the  present  experiments  the  basal 
“scurvy”  diet  consisted  of  oats  and  bran  ad  libitum, 
together  with  a daily  ration  of  60  c.cm.  of  milk,  heated  to 
120°  C.,  for  one  hour  to  destroy  its  original  antiscorbutic 
value.  This  diet  is  satisfactory  for  the  nourishment  of  these 
animals  in  every  respect  save  only  that  it  lacks  the  anti- 
scorbutic vitamine.  Good  growth  is  made  until  the  onset 
of  scurvy.  The  antiscorbutic  value  of  any  foodstuff  is 
determined  by  observing  the  effect  of  adding  measured  daily 
rations  to  the  basal  diet  and  estimating  the  average  minimum 
daily  addition  necessary  to  prevent  scurvy. 

Antiscorbutic  Value  of  Dried  Tamarind,  Cocum  and  Amchur, 
compared  with  other  Fruits  and  Vegetables  in  the  Fresh 
Condition,  based  on  Experimental  Work  with  Guinea-pigs. 

Basal  diet:  Oats  and  bran  ad  libitum  ; autoclaved  milk,  60 c.cm.  daily. 


— CO 

«g  J.^1 

Antiscorbutic 

Dose. 

^ - 

o © c | 

Result. 

material. 

£ 

§ x s i 
s 1 

None. 

4 

days.  ; 
34-40 

death  from  scurvy  in  4-6  weeks. 

Tamarind 

3-5  g. 

4 

60-92 

Scurvy,  but  some  protection. 

life  prolonged. 

Cocum. 

4 g- 

4 

38-91 j 

Scurvy,  but  some  protection, 
life  prolonged  In  some  cases. 

“ Amchur.” 

4 5 g. 

4 

50-71 

Scurvy,  but  some  protection. 

Fresh  meat  juice, 
raw. 

2C  c.cm 

4 

29-66 

Scurvy,  slight  protection  in 
some  cases,  life  prolonged  to 

9 weeks  in  1 case. 

Beetroot  juice,  raw. 

20  c.cm. 

2 

67-88 

Scurvy,  slight  protection  only. 

* Carrot  juice,  raw. 

20  c.cm 

4 

58-95 

* Swede  ,, 

2‘5c.cm. 

4 

90-100 

* Cabbage  leaves. 

15  g. 

6 

70-90 

* (terminated  peas. 
“ Green  bean-pods 

5g- 

5g. 

5 

3 

87-97 

84-91 

► Protection  from  scurvy. 

(scarlet  runner). 

* Fresh  lemon  juice. 

l'5c.cm. 

4 

90 

*T  Fresh  lime  juice. 

10  c.cm. 

2 

61-90 

* Potato,  cooked. 

20  c.cm. 

3 

73-92 

, 

Minimum  doses  required  for  prevention  of  scurvy, 
t Sour  lime,  West  Indian. 


The  investigation  of  these  dried  fruits  presented  great 
technical  difficulty,  as  the  animals  could  not  be  induced  to 
eat  them  in  the  dry  condition.  It  was  necessary  to  make 
decoctions  by  soaking  in  water  and  squeezing  the  pulp 
through  muslin  and  hand-feeding  the  thick  liquor  obtained 
to  the  animals  by  means  of  a syringe.  Even  so  it  was 
distasteful,  and  £bere  was  a limit  to  the  amount  that  conld 
be  tolerated.  The  daily  doses  shown  in  the  accompanying 
table  3 to  5 g.,  are  calculated  in  terms  of  the  original  dry 
material,  and  represent  the  largest  amounts  it  was  found 
possible  to  administer. 


Thh  Lancet,]  DR.  HARRIETTS  CHIOK  & OTHERS  : RESEARCHES  ON  SCURVY.  [August  23,  1919 


323 


With  these  doses  there  was  evidence  of  a small  but  distinct 
protective  action.  This  action  was  not  complete,  and 
scurvy  occurred  invariably,  but  a fair  measure  of  health  and 
growth  was  apparent,  and  in  some  cases  life  was  prolonged 
for  as  long  as  three  months.  Animals  surviving  this  period 
were  killed  by  chloroform  and  post-mortem  examinations 
were  made. 

In  absence  of  any  addition  to  the  “scurvy”  diet,  death 
from  severe  scurvy  took  place  in  30-40  days,  and  there  is 
little  doubt  that  had  it  been  possible  to  administer  larger 
amounts  a more  complete  protection  from  scurvy  would 
have  been  obtained. 

In  the  accompanying  table  are  given  also  the  minimum 
amounts  of  other  foodstuifs  required  to  prevent  scurvy  under 
similar  conditions  for  purposes  of  comparison.  It  will  be 
seen  that  the  value  of  these  dried  fruits  is  much  inferior  to 
that  of  many  vegetables  and  fruits  (cabbages,  swedes,  ger- 
minated pulses,  oranges,  lemons) ; is  equal  or  superior  to 
others  (carrots,  beetroot),  and  to  meat  juice. 

Conclusion. 

Dry  tamarind,  cocum,  and  mango  possess  a definite  but 
small  antiscorbutic  value.  This  value  is  greatly  inferior  to 
that  of  raw  cabbages,  swedes,  germinated  pulses,  orange 
juice,  lemon  juice,  but  equal  or  superior  to  that  of  carrots, 
beetroots,  cooked  potatoes,  raw  meat  juice,  reckoned  weight 
for  weight  in  the  natural  condition. 

Bibliography.— 1 MacNab : Quart.  Journ.  Calcutta  Medical  and 
HRK SoejetiI;  1837>  vol.  i 2.  Afghan  Boundary  Commission  Heport, 
1884-1886.  3 Holst  and  Frohlieh : Zeitschrift  fur  Hygiene  1912 

tov7  XXJ1"  P-  h 4.  Chick  and  Hume:  Trans.  Soc.  Trop.  Med.  and  Hyg  ! 
1917,  vol.  x. 

>-■ 

III.— A COMPARISON  BETWEEN  THE  ANTISCORBUTIC 
PROPERTIES  OF  FRESH,  HEATED,  AND  DRIED 
COW’S  MILK. 

By  Rosamund  E.  Barnes  and  E.  Margaret  Hume. 
(From  the  Lister  Institute,  Department  of  Experimental  Pathology.) 

In  previous  communications,  one  of  us(E.  M.  H.),  in  con- 
junction with  Chick  and  Skelton  (1918,  I.  and  II.),  has  shown 
that  raw  cow’s  milk  must  be  classed  among  the  less  valuable 
foodstuffs  as  regards  its  antiscorbutic  properties.  Whereas 
in  the  case  of  many  raw  fruits  and  vegetables,  amounts  vary- 
ing from  15  to  10  g.  daily  will  prevent  scurvy  in  guinea-pigs 
upon  a diet  otherwise  devoid  of  antiscorbutic  material 
100  to  150  c. cm.  of  raw  cow’s  milk  is  required.  The  present 
work,  which  will  shortly  be  published  in  greater  detail  in  the- 
Biochemioal  Journal,  consists  of  an  attempt  to  make  a direct 
comparison  between  the  antiscorbutic  value  of  dried  and  raw' 
milk,  in  order  to  ascertain  to  what  extent,  if  any,  the  former 
is  inferior. 

Inferiority  of  Dried,  Milk. 

Two  series  of  experiments  were  made,  one  series  with 
guinea-pigs  and  the  second  with  monkeys,  young  growing 
animals  being  selected  in  both  instances.  Ij^  each  series  the 
same  result  was  obtained,  showing  the  marked  inferiority  of 


the  dried  milk  for  the  prevention  of  scurvy.  The  dried  milk 
used  was  a well-known  commercial  brand  manufactured  by 
the  Just  Hatmaker  process.  Two  sets  of  samples  were 
tested  : .Sample  A was  delivered  regularly  immediately  after 
manufacture  and  was  less  than  three  weeks  old  when  used 
for  experiment ; Sample  B was  6 to  12  months  old  when 
tested  Jhe  Iresh  milk  used  for  comparison  was  very  pure 
specially  delivered,  country  milk,  obtained  from  a model 
dairy.  The  methods  adopted  in  the  experiments  were  the 
same  as  those  previously  described  by  Chick,  Hume,  and 
Skelton  (1918,  II.). 

The  results  obtained  with  raw  milk  confirm  those  of  the 
earlier  work,  100  to  150  c.cm.  daily  being  found  necessary 
to  prevent  scurvy  in  animals  of  300  to  500  g.  weight.  In 
case  of  the  dried  milk  these  amounts  proved  inadequate,  and 
every  animal  developed  the  disease  after  periods  of  time 
varying  from  20  to  30  days.  These  experiments  with  guinea- 
pigs  are  extremely  difficult  to  carry  out,  as  comparatively 
few  animals  of  this  size  are  able  to  tolerate  these  large 
amounts  of  fluid  without  digestive  disturbance.  For  this 
reason  the  animals  receiving  dried  milk  were  at  an 
advantage,  because  it  could  be  given  in  a concentration 
greater  than  that  of  ordinary  milk  and  the  quantity  of  fluid 
taken  could  thus  be  lessened.  The  results  of  these  experi- 
merits  are  summarised  in  the  table  (A). 

The  monkeys  used  in  the  second  series  of  experiments 
were  a varied  collection.  In  all  8 animals  were  used, 
including  the  following  genera  : macacus,  2 species  • 

cercopithecus,  2 species  ; cercocebus,  1 species,  of  weight 
varying  from  2 to  3 kilogrammes.  The  results  are  sum- 
marised m the  table  (B)  and  completely  confirm  those 
obtained  with  guinea-pigs.  In  case  of  raw  milk  a ration  of 
1 ^ to  1/5  c.cm.  daily  was  found  adequate  to  maintain  health 
and  to  prevent  scurvy  ; but  with  dried  milk  severe  scurvy 
was  developed  on  daily  amounts  equivalent  to  200  c.cm.  and 
a ration  of  about  250  to  300  c.cm.  was  found  necessary  for 
sa  ety  The  dried  milk  used  in  these  experiments  was  all 
taken  from  Sample  A,  and  fed  less  than  three  weeks  after 
manufacture. 

With  animals  so  few  and  so  various  there  was  danger  of 
drawing  erroneous  conclusions  due  to  idiosyncrasy  of 
individuals,  but  this  was  avoided  by  observing  the  effect  of 
fresh  and  dried  milk  upon  the  same  animal.  Thus  monkey 
No.  6 in  the  table  (B),  which  acquired  severe  scurvy  on  a 
daily  ration  of  dried  milk  equivalent  to  175  c.cm.,  was  cured 
completely  when  a daily  average  of  175  c.cm.  fresh  milk  was 
substituted  for  the  dried  milk  ration.  In  fact,  this  animal 
remained  in  good  health  during  a long  subsequent  period 
when  this  amount  was  cut  down  to  125  c.cm.  daily. 

Value  of 


Scalded  ” Iresh  Milk. 

Monkey  No.  7 had  developed  severe  scurvy  when  receiving 
a daily  ration  of  dried  milk  equivalent  to  200  c.cm  and  had 
shown  no  improvement,  but  grew  progressively  worse  when 
this  was  increased  to  300  c.cm.  daily.  The  milk  ration  was 
then  changed  to  200  c.cm.  daily  of  “ scalded  ” milk— i.e. . 
milk  brought  rapidly  to  the  boil  in  a saucepan  over  a gas- 

Table  showing  Antiscorbutic  Value  of  Cow’s  Milk,  Fresh  and  Dried  and  Heated. 

(A)  Experiments  with  Guinea-pigs. 

(The  Diet  Consisted  Otherwise  of  10-23  g.  Oats  and  Bran.) 


^ (B)  Experiments  with  Monkeys. 

(The  Diet  Consisted  Otherwise  of  Boiled,  Polished  Rice , Wheat  Germ, 

d 1>  No-  of  animals  used  (2)  Average  amount  consumed  daily  (c.cm.)  (4)  No  of  monkev  m a fUtS'^ed  Peas-'> 

(3)  Time  of  experiment  (days).  ’ . \ 


Description  of 
milk. 

(1) 

(2) 

(3) 

Result. 

_ * 

(4) 

Wt. 

<£■)■ 

(5)  (6) 

Fresh  milk,  full 
cream  or  separ- 
ated. 

6 

113 

36-111 

Death  from  scurvy  in  1 case.  Death 
from  other  diseases  in  2 cases 
one  showing  slight  traces.  Scurvy 
post-morten.  Good  health  in  3 
cases. 

Fresh  raw' 
milk. 

|i 

2080 

2770 

1940 

50(maxi-i  150 
mum) 

75  143 

125  182 

Dried  milk,  full 
cream,  1-2  weeks 
after  manufac- 
ture. 

Dried  milk,  full 
cream  6-12 
months  after 
manufacture. 

5 

108* 

25-48 

Scurvy  in  all  cases,  very  severe  in 
4 cases. 

1: 

2770 

2230 

150  ; 184 

200  i 225 

5 

97 

1 

33-72 

Scurvy  in  all  cases,  severe  in  4 cases. 

Dried  milk, 
less  than 
3 weeks 
after  date 
of  manu- 
facture. 

'8 

2090 

2470 

2740 

175  142 

200-300  104 
250  1 161 

m 


Result. 


Scurvy. 

Scurvy,  cured  with  10  g. 
raw  germinated  peas. 
Good  health. 
Inconclusive  result. 
Good  health. 


r uuuuuea 

with  175  c.cm.  fresh  milk 
daily, consolidated  on  125  c.cm. 
bevere  scurvy, cured  by  200  c.cm . 
daily  of  “ scalded  ” raw  milk. 
Inconclusive  result. 


* „p  * .< «- g ^ Mnaa„t- 


324  The  Lanoet,] 


DR.  A.  L.  YATES  : IMMUNISED  SKIN-GRAFTS. 


[August  23,  1919 


burner,  and  then  immediately  set  to  cool.  This  procedure 
was  arranged  to  imitate,  as  far  as  possible,  a common  house- 
hold method  of  boiling  milk  before  feeding  to  infants,  and 
one  that  may  be  relied  upon  to  destroy  the  tubercle  bacillus 
and  other  infective  disease  germs.  Measurements  of  tem- 
perature were  made,  and  it  was  ascertained  that  during  this 
process  the  milk  was  exposed  to  a temperature  between  70° 
and  100°  C.  for  1|  minutes  during  the  heating,  and  4 minutes 
during  the  cooling. 

Milk  so  treated  was  found  to  possess  an  antiscorbutic 
value  much  in  excess  of  that  possessed  by  dried  milk.  A 
rapid  cure  was  the  result  of  substituting  200  c.cm.  of  this 
“scalded”  milk  for  the  dried  milk  ration  in  case  of 
monkey  No.  7.  The  day  after  the  change  was  made  the 
animal  showed  a very  slight  improvement,  and  in  a week 
was  markedly  better  ; in  16  days  he  had  regained  the  use  of 
his  hind  limbs  and  loss  of  weight  had  ceased,  and  satisfactory 
growth  became  established.  Two  experiments  in  the  table 
(B)  are  described  as  yielding  an  inconclusive  result.  In  both 
cases  symptoms  of  scurvy  developing  on  a certain  ration  of 
milk,  raw  in  one  case  and  dried  in  the  other,  disappeared 
later  without  any  intentional  change  in  diet.  The  expel i- 
ments  were  started  in  Che  winter  and  scurvy  was  detected 
about  four  months  later,' in  April-May,  but  soon  afterwards 
the  symptoms  began  to  clear  up.  This  we  attribute  to  the 
change  in  the  cow’s  diet  about  this  time  of  year — i.e. , from 
the  hay,  roots,  oil-cake,  and  cereals  of  the  winter  feed  to 
the  fresh  grass  of  the  open  pasture.  In  consequence  of  the 
great  increase  of  antiscorbutic  material  in  the  cow’s  diet, 
one  would  expect  a corresponding  increase  in  the  anti- 
scorbutic value  of  the  milk  given-. 

Summary  and  Conclusions. 

1.  The  antiscorbutic  value  of  cow’s  milk,  fresh,  heated, 
and  dried,  was  determined  by  means  of  quantitative  nutri- 
tional experiments  with  guinea-pigs  and  nfonkeys.  Cow’s 
milk,  even  when  fresh,  was  found  to  be  a foodstuff  com- 
paratively poor  in  antiscorbutic  properties,  and  large  daily 
rations,  100  to  150  c.cm.  daily  for  guinea-pigs  and  125  to 
175  c.cm.  daily  for  monkeys,  were  needed  to  protect  these 
animals  from  scurvy,  when  upon  a diet  otherwise  devoid  of 
antiscorbutic  material.  Dried  milk  was  found  inferior  to  raw 
milk  in  this  respect.  Even  with  material  of  quite  recent 
manufacture  we  were  unable  to  protect  guinea-pigs  from 
scurvy  with  any  amounts  that  it  was  found  possible  to 
administer.  In  case  of  monkeys  the  minimum  protective 
dose  was  found  to  be  approximately  from  250  to  300  c.cm. 
daily  ; in  other  words,  about  half  the  original  antiscorbutic 
value  of  the  fresh  milk’  had  been  destroyed  in  the  process  of 
drying.  “Scalded  ” milk  was  found  distinctly  superior  to 
dried  milk. 

2.  These  facts  form  a strong  argument  for  the  desirability 
of  adding  an  extra  antiscorbutic  to  the  diet  of  infants 
nourished  on  dried  milk.  The  most  suitable  substances  for 
this  purpose  are  raw  orange  juice,  raw  swede  juicefChickand 
Rhodes,  1918),  or  juice  of  tomatoes,  raw  or  canned  (Hess  and 
Unger,  1919).  Grape  juice  and  carrot  juice  are  also  useful 
but  less  valuable,  as,  being  inferior  in  potency,  correspond- 
ingly larger  doses  are  required.  Potatoes  cooked  and  mashed 
can  be  employed  in  cases  where  starchy  foods  are  not  con- 
sidered unsuitable  (Hess  and  Fish,  1914). 

3.  Some  evidence  was  obtained  showing  that  winter  milk 
is  inferior  to  summer  milk  in  antiscorbutic  properties,  corre- 
sponding to  the  differences  in  the  cow’s  diet  at  these  different 
seasons.  In  this  connexion  the  suggestion  is  made  that  the 
value  of  winter  milk  in  this  respect  might  be  raised  if  swedes 
were  employed  for  winter  feedingin  place  of  mangolds,  where 
possible.  In  the  investigation  of  Chick  and  Rhodes  alluded 
to  above,  the  raw  juice  of  beetroot,  to  which  plant  the  man- 
gold is  nearly  related  botanically,  was  found  to  be  much 
inferior  to  that  of  swede  as  an  antiscorbutic. 

4.  No  significant  difference  was  detected  in  the  growth- 
promoting  properties  of  raw  and  dried  milk  respectively,  and 
this  was  true  with  both  guinea-pigs  and  monkeys.  In  both 
cases  growth  declined  with  onset  of  scurvy  symptoms,  but 
until  this  occurred  the  growth  made  upon  Siets  containing 
dried  milk  was  equal  to  that  obtaining  when  equal  rations  of 
fresh  milk  were  substituted. 

References.— Chick,  Hume,  and  SkeUon  (1918) : 1..  The  Lancet, 
Jan  5t,h  ; it..  Biochemical  Journal,  xti. . p.  13?.  Chick  and  Rhodes 
(1918)  The  Lancet,  Dec.  7th.  Hess  and  Fish  (1914) : Amenean  Journal 
of  Diseases  of  Children,  vlll.,  p.  386.  Hess  and  Unger  (1918):  Proceed- 
ings of  the  Societyof  Experimental  Biology  and  Medicine,  xvi.,  p.  1. 


A NOTE  ON 

IMMUNISED  SKIN-GRAFTS. 

By  ARTHUR  L.  YATES,  M.C.,  M.D.  Lond.,  F.R.C.S.  Edin. 

Certain  German  writers  during  the  war  described  a 
process  of  rendering  the  skin  immune  to  the  toxins  present 
in  the  wound  for  which  the  skin-graft  was  intended,  and 
claimed  that  if  skin  immunised  in  this  way  was  employed 
for  skin-grafts  the  growth  of  epithelium  was  quicker  and 
more  certain  than  if  the  usual  methods  were  followed. 

Description  of  the  Process. 

The  method  consists  of  placing  the  dressing  which  has 
been  in  contact  with  the  surface  of  the  wound  it  is  intended 
to  treat,  and  which  is  therefore  soaked  in  the  discharges  of 
the  wound,  upon  an  area  of  skin  suitable  for  obtaining 
grafts  by  the  Thiersch  method  and  allowing  this  dressing 
to  remain  in  position  for  24  hours,  after  which  it  is 
replaced  by  another  dressing  removed  from  contact  with 
the  wound. 

It  was  found  necessary  to  moisten  dressings  on  which  the 
discharges  had  dried  and  to  mark  out  the  skin  selected  for 
yielding  the  graft  by  means  of  nitrate  of  silver. 

Applied  with  these  precautions,  the  skin  to  which  the 
wound  discharges  were  brought  into  contact  was  found  to 
redden  and  to  show  on  the  third  day  of  the  application  a 
slight  prominence  of  the  papillae.  It  was  necessary  to  watch 
the  skin  carefully  at  this  point  in  the  treatment,  as  it  is  of 
considerable  importance  to  guard  against  the  occurrence  of 
a violent  reaction.  When  the  skin  showed  a marked 
elevation  of  the  papillae  and  slight  reddening  the  treatment 
of  the  area  was  stopped  for  a day,  but  in  most  cases  it  was 
possible  to  treat  the  skin  in  this  way  for  a period  of  seven 
days,  after  which  the  graft  was  ready  for  removal. 

It  was  found  that  the  severity  of  the  reaction  varied  within 
rather  wide  limits,  and  that  it  was  necessary  to  guard  against 
a violent  reaction.  In  two  or  three  cases  no  reaction  occurred. 
This  was  thought  to  indicate  that  the  skin  already  possessed 
immunity  to  the  organisms  of  the  wound,  and  to  a certain 
extent  this  view  was  borne  out  by  the  fact  that  the  graft 
“ took  ” readily  in  these  cases. 

Technique. 

I found  that  the  following  technique  gave  the  most 
satisfactory  results. 

The  granulations  of  the  wound  were  rubbed  with  dry 
unmedicated  gauze  and  the  graft  removed  by  the  method  of 
Thiersch,  applied  to  these  granulations,  and  well  pressed 
down.  The  graft  was  then  covered  with  a piece  of  water- 
proof tissue,  in  which  a number  of  holes  of  about  one-eighth 
of  an  inch  diameter  had  been  cut,  and  the  opposite  edges  of 
this  waterproof  tissue  were  fixed  to  the  skin  with  adhesive 
plaster.  This  was  then  covered  with  unmedicated  gauze  i 
and  wool,  and  bandaged  in  position.  The  wound  was 
examined  every  second  or  third  day  and  any  discharge 

moved  by  gently  syringing  through  the  holes  in  the  water- 
proof tissue,  which  was  not  otherwise  disturbed. 

Jlesvlts. 

Applied  in  this  way,  I have  not  seen  a case  of  failure  by 
this  method,  although  up  till  now  I have  only  treated 
27  cases,  and  of  these  only  three  were  cases  that  had  failed 
to  give  a successful  result  by  the  ordinary  methods.  Of  | 
these  27  cases,  10  were  cases  of  ecthyma,  where  deep  ulcers 
had  developed  and  which  had  resisted  treatment  for  several 
weeks  previously  to  the  grafting,  13  were  cases  of  infected 
lacerations,  where  healing  was  delayed  for  several  weeks,  and 
4 were  cases  of  chronic  ulcer,  which  had  resisted  treat- 
ment for  a long  time.  In  several  cases  a certain  amount  of 
movement  of  the  limb  was  allowed,  and  all  the  cases  in 
which  walking  with  a fresh  graft  applied  to  some  part  of  the 
lower  limb  was  permitted,  the  graft  took  without  any 
difficulty. 

Local  anaesthesia  was  employed  in  all  the  cases,  and  in 
the  case  of  ulcers  with  thickened  bases  the  ulcer  also  was 
anaesthetised  and  the  thickened  base  punctured  a 

needle  in  numerous  places  after  the  method  originally 
described  by  Tubby  for  freeing  contracted  scar  tissue. 


The  Lancet,] 


DR.  S.  G.  BILLINGTON  : MUCUS  DEPOSIT  OF  URINE. 


[August  23,  1919  325 


Although  the  character  and  small  numbers  of  the  cases 
in  which  I have  made  use  of  this  method  does  not  permit 
of  any  definite  conclusion  as  to  the  superiority  of  this 
method  over  any  previously  employed,  the  method  appeared 
to  me  to  be  based  on  such  logical  principles  and,  in  the 
limited  number  of  cases  in  which  it  has  been  tried,  to 
have  been  so  successful  that  I have  ventured  to  bring  it  to 
the  notice  of  those  practitioners  who  did  not  have  an 
opportunity  of  seeing  the  resume  of  the  original  article, 
which  appeared  in  the  “Summary  of  the  Foreign  Press” 
issued  to  certain  medical  units  of  the  Array.  I regret  that 
I have  been  unable  to  obtain  the  names  of  the  German 
authors,  but  the  impossibility  of  obtaining  the  literature 
must  be  my  excuse. 

Lincoln. 


MUCUS  DEPOSIT  OF  URINE. 

By  S.  G.  BILLINGTON,  M.B.,  B S.  Lond., 

LATE  CAPTAIN,  R.A.M.C;  BACTERIOLOGIST,  WOLVERHAMPTON  GENERAL 
HOSPITAL. 


If  a sample  of  this  deposit  in  a febrile  or  convalescent 
urine  be  pipetted  up  from  about  the  junction  of  the  upper 
and  second  fourths  it  will  show  on  direct  examination  an 
interlacing  mass  of  strands,  many  resembling  gigantic 
flagella.  These  structures  are  very  dim  and  indefinite, 
and  no  satisfactory  impression  of  their  form  can  be  obtained 
except  under  the  low  power  and  with  the  light,  preferably 
daylight,  almost  entirely  shut  off. 

If  the  deposit  is  washed  with  filtered  water  to  remove 
the  soluble  constituents  of  the  urine  the  same  structures 
will  still  be  dimly  seen  ; but  they  at  once  stand  out  clearly 
on  adding  one  drop  of  10  per  cent,  tannic  acid  to  the  fluid 
film,  and  they  will  be  seen  lying  in  the  midst  of  a coagu- 
lated homogeneous  material.  The  structures  also  take  up 
added  watery  stains  at  this  stage,  although  they  would  not 
do  so  before  the  addition  of  the  tannic  acid.  If  the  fluid- 
stained  film  obtained  in  this  way  is  dried  while  under 
observation  all  the  structures  will  be  seen  to  disintegrate 
as  the  evaporating  line  crosses  the  field  of  vision. 

When  fixed  and  stained  the  structures  show  a most  extra- 
ordinary variation  in  size  and  form,  and  resemble  somewhat 
an  interlacing  mass  of  worms.  They  may  be  straight, 
curved,  or  wavy  ; some  resemble  gigantic  spirochsetes,  others 
resemble  more  or  less  closely  enormous  trypanosomes  or 


Fig.  1. — Mucus  deposit  of  urine.  Flagellate-like  structures 
lyiDg  in  masses  of  coagulated  matrix.  Stained  with  methy- 
lene-blue. 

Leishman-Donovan  bodies.  Bodies  resembling  miniature 
tadpoles  with  an  apparent  vacuole  at  the  blunt  end  are  also 
frequently  seen.  With  the  Romanowski  stains  the  blue 
only  is  taken  up.  With  Indian  ink  the  general  morphology 
is  brought  out  more  distinctly  than  in  stained  films,  espe- 
cially as  regards  the  perfect  fine  flagellate-like  extremities 
and  processes. 

Under  the  higher  powers  these  structures  appear  to  be 
made  up  of  enormous  numbers  of  filamentous  strands 


Some  show  darker  centres,  probably  due  to  contained 
minute  granules,  and  the  forms  resembling  trypanosomes 
frequently  contain  one  or  more  deeply  staining  bodies 
about  the  size  of  a red  blood  cell. 

The  Origin  of  the  Deposit. 

As  far  as  I am  aware,  the  mode  and  site  of  origin,  the 
significance  and  the  reasons  for  variation  in  amount  of  this 
substance,  are  shrouded  in  obscurity.  There  are,  however, 
two  points  of  interest.  1.  When  there  is  an  actual  excre- 
tion of  organisms,  as  in  bacilluria,  and  a catarihal  condition 
of  the  urinary  tract  may  be  presumed,  the  mucus  deposit  is 
slight  or  absent.  2.  From  chemical  examination  we  are  told 
that  this  substance  in  many  cases  is  not  true  mucin,  probably 
a nucleo-protein.  3.  The  structures  described  as  being 
present  in  mucus  deposits  vary  in  size  and  texture  much  as 
in  the  case  of  casts.  They  are  much  larger  and  coarser  in 
the  urine  from  a case  of  febrile  or  post-febrile  trench  fever 
than  in  the  case  of  influenza. 

A year  ago  the  urines  of  300  men  were  examined  with 
regard  to  the  mucus  deposit.  200  were  patients  in  hospital 


Fig.  2. — Masses  of  structures  in  the  mucus  deposit  of  urine  resembling 
spirochetes.  Stained  with  Indian  ink. 

and  100  were  the  staS  of  a medical  unit.  The  urines  of  the 
200  patients  all  showed  a pronounced  deposit,  and  the  struc- 
tures described  could  be  readily  seen  with  the  lower  power 
on  direct  examination.  Over  70  per  cent,  of  the  controls 
showed  a varying  amount  of  deposit  with  similar  structures. 
The  difference  in  the  bulk  of  deposit,  however,  in  the  two 
series  was  extraordinary,  and  would  never  have  been  sealised 
unless  series  of  20  urines,  10  from  patients  and  10  from 
controls,  had  been  placed  in  line.  It  may  also  be  added 
that  quite  50  per  cent,  of  the  controls  had  been  marked  for 
base  duty  on  account  of  previous  or  existing  disease  of  various 
kinds. 

These  examinations  demonstrated  that  active  disease 
produces  a pronounced  increase  in  the  mucus  deposit  in 
the  urine.  In  the  absence  of  any  definite  knowledge  as  to 
the  origin  or  significance  of  the  mucus,  knowing  that  the 
kidneys  are  the  natural  filters  of  the  body  and  the  urine  the 
filtrate  containing  undesirable  excreted  products,  it  would 
not  appear  to  be  illogical  to  suspect  that  the  addition  to  the 
deposit  represents  some  form  of  the  infecting  agent  after 
excretion. 

The  presence  of  spirochsetes  in  the  urine  in  trench  fever 
and  also  in  normal  urine  has  been  recorded  on  several 
occasions.  One  source  of  these  spirochsetes  has  been  found 
by  Japanese  workers  to  be  the  urethral  mucous  membrane, 
and  as  to  that  source  no  comments  can  be  made.  The  origin 
of  morphologically  perfect  spirochsetes  from  the  deposit  of 
urine,  however,  can  be  directly  watched  under  the  micro- 
scope. The  mucus  deposit  is  washed  once,  and  to  a sample 
on  a slide  a drop  of  tannic  acid  and  watery  stain  are  added, 
as  previously  described.  The  film  is  then  gently  dried,  and 
as  the  evaporating  zone  crosses  the  field  under  observation 
all  the  large  structures  mentioned  will  disintegrate.  It  will 
be  seen,  however,  that  here  and  there  one  of  the  fine 
spirochsetal-like  processes  apparently  project  beyond  the 
hygroscopic  surrounding  matrix,  and  these  will  be  left  in 
the  debris  as  morphological  spirochsetes. 


326  The  Lancet,]  MR.  0.  NOON:  SPONTANEOUS  FRACTURE  IN  SERVING  SOLDIERS.  [August  23,  1919 


FIVE  CASES  OF 

SPONTANEOUS  FRACTURE  OCCURRING 
IN  SERVING  SOLDIERS. 

By  C.  NOON,  F.R.C.S., 

TEMPORARY  MAJOR,  R.A.M.C.  ; OFFICER  IN  CHARGE  OF  THE  SURGICAL 
DIVISION  OF  THE  NORFOLK  WAR  HOSPITAL. 


The  following  cases  of  spontaneous  fractures  were  admitted 
to  the  Norfolk  War  Hospital  between  November,  1916,  and 
February,  1919.  They  illustrate  some  of  the  most  important 
causes  of  pathological  fractures  of  bones.  They  all  occurred 
in  serving  soldiers.  The  information  with  regard  to  the 
diagnosis  and  treatment  of  spontaneous  fractures  to  be 
obtained  from  the  ordinary  text-books  on  surgery  is  extremely 
brief  and  scanty.  A study  of  these  cases  shows  how 
important  it  is  to  make  a most  complete  and  careful  examina- 
tion of  a patient  suffering  with  a fractured  bone. 

Osteomyelitis  Fibrosa  ( Medullary  Fibromatosis ) of  the  Right 
Humerus;  Spontaneous  fracture;  Union  of  the  Fracture. 

Case  1. — W.  ti.  J.,  a private,  aged  19,  was  transferred  to  the 
Norfolk  War  Hospital  on  Jan.  28th,  1916,  complaining  of  an 
injury  to  the  right  arm.  The  history  of  the  patient’s  present 
condition  was  as  follows.  He  stated  that  he  had  always  been 
a healthy  youth,  and  had  suffered  with  no  previous  illness, 
except  that  he  had  twice  previously  met  with  slight  injuries 
to  the  right  arm,  which  had  resulted  in  fractures.  The  arm 
was  “ set”  by  a doctor,  and  on  both  occasions  after  rest  in 
splints  it  united.  The  first  fracture  occurred  at  the  age  of 
14,  and  resulted  from  throwing  a cricket-ball.  A year  later 
he  again  broke  the  same  arm  by  falling  off  a bicycle.  In 
December,  1915,  at  the  age  of  19,  his  arm  was  again  broken 
while  driving  a horse  and  cart,  a sudden  jerk  of  the  reins 
causing  the  fracture.  As  far  as  he  was  able  to  judge  all 
the  other  bones  of  his  body  were  natural  and  quite  strong. 
No  other  members  of  his  family,  as  far  as  he  could  tell, 
had  ever  suffered  with  repeated  fractures.  His  father  and 
mother  were  both  quite  healthy. 

Condition  on  admission. — The  patient  was  a well-developed 
healthy  youth ; temperature  normal ; pulse-rate  80  per 
minute.  Pupils  equal  and  reacted  normally  to  light  and 
accommodation  ; teeth  good  and  quite  clean ; no  discharge 
from  ears.  Chest,  heart,  and  lungs  natural ; abdomen 
natural. 

The  muscles  of  the  upper  arm  and  forearm  were  wasted, 
but  the  hand  muscles  were  natural.  There  was  a slight 
angular  deformity  and  swelling  in  middle  third  of  upper 
arm.  The  elbow  could  not  be  completely  flexed  or  extended. 
On  palpation  there  was  a well-marked  thickening  in  the 
middle  third  of  the  humerus ; the  swelling  was  tender  to 
touch,  hard,  and  felt  bony,  and  could  not  be  distinguished 
by  palpation  from  callus  formed  around  a uniting  fracture. 
Crepitus  could  not  be  obtained,  but  there  was  abnormal 
mobility  to  be  felt  in  middle  third  of  humerus.  There  was 
half  an  inch  of  shortening  of  the  right  upper  arm.  The 
axillary  glands  were  not  enlarged.  The  sensation  of  the 
arm  and  hand  was  not  impaired. 

X ray  examination  showed  a fracture  through  middle  third 
of  right  humerus.  In  this  situation  there  was  a spindle- 
shaped  enlargement  of  the  bone.  In  the  interior  of  the 
bone  the  osseous  tissue  had  been  replaced  by  clear  areas 
which,  from  their  even  contour,  sharp  definition,  and 
translucency,  suggested  the  presence  of  cysts.  X ray 
examination  of  the  other  bones  of  the  body  did  not  reveal 
anything  abnormal.  Wassermann  reaction  was  negative. 

Treatment. — The  fracture  was  treated  by  the  usual  method 
of  splinting  protection  and  massage.  It  united  rather 
slowly,  but  except  for  rather  an  excessive  amount  of  pain, 
felt  especially  at  night,  at  the  seat  of  injury  the  broken  bone 
did  not  behave  in  any  abnormal  way,  in  spite  of  the  disease 
at  the  site  of  fracture. 

Remarks. — The  two  main  factors  for  consideration  in  this 
case  were,  firstly,  the  diagnosis  and,  secondly,  the  correct 
treatment.  In  considering  the  diagnosis,  the  points  of 
importance  are  the  age  of  the  patient  and  the  long  duration 
of  the  disease — five  years  almost  excludes  the  possibility  of 
malignant  disease. 

“ The  diagnosis  from  other  chronic  affections  of  bone  was 
readily  made  with  the  assistance  of  skiagrams.  These 
showed  that  the  contour  and  architecture  of  the  bones  were 
greatly  altered  ; there  was  a localised  increase  in  the  girth  ; 
the  surface  of  the  bone  was  uneven,  and  in  the  interior  the 
osseous  tissue  had  almost  disappeared,  and  there  were  clear 


areas  which,  from  their  even  contour,  sharp  definition,  and 
translucency,  suggested  the  presence  of  cysts.”  (Thomson 
and  Miles.) 

With  regard  to  treatment  the  affected  bones  should  be 
protected  from  injury.  If  fractures  should  occur  every 
attempt  must  be  made  to  prevent  deformity,  and  to  fix  the 
parts  by  the  aid  of  splints  for  a considerable  time.  Union 
will  generally  take  place,  but  will  be  slow,  and  repeated 
fractures  are  likely  to  occur.  It  is  improbable  that  any 
operative  procedure  on  the  fracture  will  meet  with  good 
result,  but  scraping  away  the  disease  from  the  interior  of  the 
bone  where  there  has  been  no  fracture  may  sometimes  be 
followed  with  good  results. 

Multiple  Gummaia  of  the  Bones  of  the  Left  Foot ; Spontaneous 
Fractures  ; Improvement. 

Case  2.— J.  C.,  aged  41,  was  admitted  to  the  Norfolk  War 
Hospital  on  Nov.  29th,  1917,  complaining  of  swelling  of  the 
left  foot.  The  history  of  the  present  condition  was  as 
follows.  The  patient  had  been  in  his  usual  health  until 
about  two  months  ago,  when  he  noticed  swelling  of  the  left 
foot.  This  was  increased  by  exercise,  and  he  was  unable  to 
march.  He  had  been  serving  in  the  Army  for  three  months 
before  he  noticed  the  disability.  The  condition  of  the  foot 
had  caused  him  little  pain,  but  he  had  noticed  sharp  pains 
shooting  down  both  legs  for  the  last  three  or  four  months. 

He  had  contracted  syphilis  19  years  ago,  for  which  he  was 
treated. 

Condition  on  admission. — The  patient  was  a fairly  healthy 
looking  man.  Temp.  98'4G.  Special  senses,  such  as  hearing, 
smelling,  tasting,  and  seeing,  normal.  Pupils  unequal,  the 
right  did  not  react  to  light  and  left  pupil  sluggish,  but  a 
faint  reaction  to  light  could  be  obtained.  No  nystagmus. 
Disc  normal  ; no  squint  on  narrowing  of  palpebral  fissure. 
Nothing  abnormal  discovered  on  examination  of  remaining 
cranial  nerves.  No  paralysis  on  spasm  of  any  of  the  muscles 
of  arms  or  legs  and  no  incoordination.  Dullness  of  sensation  | 
over  both  legs  and  feet,  but  no  absolute  loss  of  sensation. 
Sensation  to  heat  and  cold  natural.  Knee-jerks  present,  I 
but  no  ankle  clonus  and  no  Babinski  sign.  No  wasting  of 
muscles  of  arms  or  legs.  No  loss  of  control  over  sphincters.  , 
Memory  and  mental  power  apparently  normal.  Chest, 
heart,  and  lungs  natural ; abdomen  natural. 

Local  condition. — The  skin  over  the  left  foot  looked  1 
natural,  but  the  foot  was  swollen  and  pitted  on  pressure. 
Well-marked  flat  foot.  The  dorsum  of  the  foot  looked  , I 
unduly  prominent.  There  was  little  or  no  pain  on  j 
manipulation  of  the  foot.  The  bony  point  could  not  be 
easily  palpated,  owing  to  swelling  and  thickening  of  tissues. 

No  crepitus  could  be  obtained. 

X ray  examination  showed  the  bones  of  the  foot  rarefied. 

All  metatarsal  bones  were  fractured  at  their  base.  There  was  j 
some  evidence  of  new  bone  formation  around  seat  of  fracture. 
Wassermann  reaction  was  negative. 

Treatment. — The  patient  was  put  on  a course  of  potassium 
iodide,  and  mercury,  given  by  the  mouth.  The  fractures 
were  treated  by  the  application  of  splints,  rest,  massage,  and  1 
electrical  treatment.  Great  benefit  followed  these  lines  of  I 
treatment.  There  was  great  improvement  in  the  general 
condition  of  the  patient.  Locally  the  condition  of  the  foot  I 
improved  and  the  fractures  united. 

Case  3. — J.  M.,  a private,  aged  38,  was  admitted  to  the  -I 
Norfolk  War  Hospital  complaining  of  swelling  of  the  left  j 
foot.  The  history  of  the  present  condition  was  as  follows.  The 
patient  stated  that  he  was  quite  well  until  early  in  September, 
1918;  he  then  twisted  his  foot  on  parade  and  noticed  that 
when  he  removed  his  boot  the  same  evening  the  foot  was  j 
swollen.  He  was  unable  to  get  his  boot  on  next  morning 
and  the  foot  remained  painful  for  four  or  five  days.  He  also 
experienced  shooting  pains  in  the  left  leg  as  far  as  the  knee.  | 
Walking  increased  the  pain  in  the  leg  and  discomfort  in  the 
foot.  The  swelling  gradually  subsided,  but  some  deformity  | 
and  swelling  still  persisted. 

Previous  history. — The  patient  said  that  he  suffered  with 
gonorrhoea  in  1901,  whilst  he  was  stationed  in  Ireland.  He 
was  treated  successfully  for  several  weeks.  In  1915  he  trod  i 
on  a nail.  It  entered  the  sole  of  the  foot  in  the  situation  of 
the  head  of  the  fifth  metatarsal  bone.  The  wound  sup-  j 
purated,  and  an  operation  was  performed  to  drain  an 
abscess.  After  the  operation  the  wound  healed  well,  and 
he  recovered  with  complete  use  of  the  foot.  He  stated  that 
he  had  never  suffered  from  syphilis. 

Condition  on  admission. — The  patient  was  a healthy-looking,  ; 
well-nourished,  and  muscular  man.  Temp.  98°  ; pulse  80. 

He  answered  questions  with  intelligence.  The  special 
senses  appeared  normal.  Eyes : pupils  unequal,  right  , 
dilated,  left  contracted,  both  reacted  sluggishly  to  light  and 
accommodation.  No  squint  and  no  nystagmus,  fundus  was 
natural,  tongue  protruded  straight,  tremulous,  and  furred;  i I 
fauces  natural.  The  remaining  cranial  nerves  were  normal. 


The  Lanoht,]  MR,  0.  NOON  : SPONTANEOUS  FRACTURE  IN  SERVING  SOLDIERS.  [August  23,  1919  327 


No  paralysis  or  spasm  of  any  of  the  muscles  of  arms  or 
legs  anil  no  incoordination.  Dullness  of  sensation  over  both 
legs  and  feet,  but  no  loss  of  sensation  to  heat  and  cold. 
Knee-jerks  exaggerated,  especially  on  left  side.  Babinski’s 
sign  well  marked  in  left  foot  and  present,  but  less  well 
marked,  in  right;  no  ankle  clonus. 

Examination  of  left  foot.— The  skin  over  the  left  foot  looked 
natural,  but  the  foot  was  swollen  and  cedematous,  the 
dorsum  being  unduly  prominent.  The  normal  arch  of 
the  foot  had  disappeared,  and  there  was  well-marked 
flat  foot.  There  was  little  or  no  pain  on  palpation.  The 
bony  points  of  the  foot  could  not  be  easily  felt  owing  to 
swelling  and  thickening  of  tissues.  On  deep  palpation  in 
the  region  of  the  base  of  the  first  metatarsal  bone  crepitus 
could  be  obtained,  but  manipulation  produced  very  little,  if 
any,  pain. 

On  X ray  examination  of  the  left  foot  the  tarsal  bones 
were  found  to  be  rarified.  There  was  a fracture  in  the  situa- 
tion of  the  base  of  the  first  metatarsal  bone.  In  the  situation 
of  the  fracture  there  was  marked  destruction  and  absorption 
of  bone,  and  around  the  fracture  some  evidence  of  new  bone 
formation.  There  was  also  a fracture  of  the  second  and 
fifth  metatarsal  bone,  with  marked  absorption  of  bone. 
Wasaermann  reaction  (blood)  was  positive. 

Treatment. — The  patient  was  given  a course  of  potassium 
iodide — 20  gr.  three  times  daily  for  six  weeks — and  mercury 
by  the  mouth.  The  fractures  were  treated  by  splints,  rest, 
massage,  and  electrical  treatment.  Great  benefit  was 
derived  from  the  treatment,  both  generally  and  locally.  The 
fractured  bones  united. 

Remarks  on  Case  2 and  3. — Case  2 : There  was  a definite 
history  of  syphilis,  but  the  Wassermann  reaction  was 
negative.  Case  3 : Syphilis  was  denied,  but  the  Wassermann 
reaction  was  positive,  and  the  signs  and  symptoms  of  the 
case  were  such  as  to  justify  a diagnosis  of  syphilis.  A 
diagnosis  of  gummata  osteitis  was  considered  to  be  the 
•condition  from  which  both  patients  were  suffering.  Both 
showed  symptoms  and  signs  of  tertiary  syphilis,  and  both 
showed  marked  signs  of  improvement  on  the  administration 
of  active  syphilitic  treatment. 

Chronic  Suppurative  Otitis  Media ; Abscess  of  the  Thigh  ; 

Bony  Swelling  of  the  Right  Temur ; Spontaneous  Fracture 
of  the  Second  Metatarsal  Bone  of  the  Left  Foot. 

Case  4.— A.  R.,  a private,  aged  19,  was  admitted  to  the 
Norfolk  War  (Hospital  on  Nov.  22nd,  1918,  complaining  of 
a painful  swelling  in  the  right  thigh  and  swelling  of  the  left 
foot.  The  history  of  the  present  condition  was  as  follows. 
The  patient  said  that  he  was  quite  well  ten  days  previously. 
For  the  last  week  he  had  had  pain  and  swelling  of  the  right 
thigh.  This  had  gradually  got  worse— he  could  not  account 
for  the  swelling,  as  there  had  been  no  injury.  The  left  foot 
became  swollen  three  days  previously,  when  he  reported 
sick,  and  since  then  had  been  painful.  "Had  had  discharging 
ears  as  long  as  he  could  remember. 

Condition  on  admission. — The  patient  was  an  ill-developed 
and  badly  nourished  youth,  who  looked  ill  and  pale. 
Temp.  99° ; pulse  80.  Very  deaf,  profuse  discharge  from 
both  ears,  no  mastoid  tenderness.  Eyes  natural,  teeth  very 
bad,  many  carious.  Chest,  heart,  and  lungs  natural. 
Abdomen  natural.  On  the  outer  side  of  the  middle  third 
of  the  right  thigh  there  was  a well-marked  swelling  which 
extended  from  2 inches  below  the  great  trochanter  to  within 
1 inch  of  the  knee  joint.  The  skin  over  the  swelling  was  not 
red  or  discoloured,  but  on  palpation  it  felt  hotter  than  the 
skin  of  the  opposite  side.  The  swelling  had  fairly  well-defined 
margins,  was  painful  to  touch,  and  fluctuated  at  its  centre. 
The  femur  felt  thickened  and  irregular  in  its  middle  third. 

X ray  examination  of  left  femur  showed  on  anterior 
aspect  of  middle  third  a localised  bony  swelling  attached 
to  the  bone  and  tapering  at  both  ends  into  its  substance. 
Outline  of  shaft  of  femur  natural.  The  appearance  shown 
in  the  X ray  photograph  is  indistinguishable  from  the  con- 
dition described  as  traumatic  myositis  ossificans.  Over 
the  dorsum  of  the  right  foot  the  skin  was  reddened 
and  inflamed,  hot  to  touch,  and  rather  painful,  but  there 
was  not  so  much  pain  on  manipulation  as  might  be 
expected  from  the  appearance  of  the  part.  There  was  no 
fluctuation.  X ray  examination  of  the  foot  showed  a frac- 
ture of  the  shaft  of  the  second  metatarsal  bone.  The  other 
bones  of  the  foot  appeared  natural. 

Treatment. — An  operation  was  performed  on  Nov.  24th 
under  chloroform.  An  incision  was  made  into  the  swelling 
on  outer  side  of  left  thigh  and  a considerable  quantity  of 
purulent  matter  evacuated.  The  swelling  appeared  to  be  a 
breaking  down  hrematoma.  The  abscess  was  drained. 
Bacteriological  examination  of  the  pus  showed  presence  of 
staphylococci 

Progress  and  remarks. — There  are  three  conditions  for 
diagnosis  in  this  case  : (1)  Abscess  of  the  thigh  ; (2)  bony 
swelling  of  femur ; and  (3)  spontaneous  fracture  of  the 


second  metatarsal  bone.  With  regard  to  the  thigh  con- 
dition the  X ray  appearance  strongly  suggests  the  condition 
known  as  traumatic  myositis  ossificans,  but  in  the  presence 
of  an  abscess  it  is  difficult  to  exclude  the  possibility  of 
chronic  inflammation  as  the  cause  of  the  bony  swelling  ; in 
other  words,  the  condition  may  be  a chronic  pyaimic  abscess 
with  inflammatory  thickening  of  the  underlying  bone. 

The  reason  for  the  spontaneous  fracture  of  the  metatarsal 
bone  does  not  appear  clear  unless  the  cause  could  be  one  of 
general  debility  and  toxremia  associated  with  excessive 
absorption  of  septic  material  from  the  ears  and  teeth. 
The  abscess  of  the  thigh  healed  well.  The  fracture  of  the 
second  metatarsal  bone  of  the  foot  gave  little  trouble.  It 
was  treated  by  splints,  rest,  and  massage.  At  the  end  of  a 
month  the  patient  could  walk  without  pain. 

Periosteal  Sarcoma  of  the  Lower  Third  of  the  Right  Thigh  ; 

Spontaneous  Fracture  ; Amputation  of  the  Thigh. 

Case  5. — A.  Mcl.,  a private,  aged  19,  was  transferred  to 
the  Norfolk  War  Hospital  on  Jan.  20th,  1919,  complaining  of 
swelling  of  the  right  knee.  The  history  of  the  present 
condition  was  as  follows.  The  patient  stated  that  he  was 
quite  well  until  May,  1918.  He  then  noticed  slight  pain  in 
his  right  knee,  perhaps  caused  by  a twist.  It  was  not  severe, 
but  gradually  got  worse,  although  it  did  not  cause  him 
enough  trouble  to  report  sick  before  Oct.  2nd,  1918.  He  was 
passed  through  a field  ambulance,  a casualty  clearing  station, 
and  a general  hospital,  the  condition  being  then  diagnosed 
on  his  field  medical  card  as  synovitis  of  the  right  knee.  On 
Oct.  8th  he  was  evacuated  to  England.  Since  October,  in 
spite  of  treatment,  the  knee  had  gradually  got  worse.  It  had 
become  more  swollen  and  he  had  been  unable  to  move  it 
without  pain,  which  had  been  especially  severe  at  night, 
often  keeping  him  awake  for  many  hours.  He  had  noticed 
that  in  spite  of  increasing  swelling  of  the  knee  the  muscles 
of  the  leg  had  become  very  wasted.  He  had  lost  weight 
rapidly  ; he  had  no  cough. 

Condition  on  admission  (20-1-19).— The  patient  was  a pale, 
ill-nourished  youth  ; obviously  in  pain.  Temp.  98-4°  ; had 
occasionally  been  99°  at  night  during  the  last  month. 
Pulse  80;  respiration  20.  Eyes  : pupils  equal,  react  to  light 
and  accommodation.  Tongue  clean  ; teeth  fair,  some  caries. 
No  scars  at  angle  of  mouth.  Ears;  no  discharge.  No 
enlarged  lymphatic  glands  felt  in  neck  or  axilla.  Chest  wall 
poorly  covered.  Skin  dry;  little  subcutaneous  fat.  Heart 
and  lungs  natural.  Abdominal  wall  very  thin,  nothing 
abnormal  discovered  in  abdomen.  No  enlarged  or  palpable 
iliac  glands.  Inguinal  glands  palpable,  both  not  markedly 
enlarged. 

Local  condition. — The  patient  lay  with  the  right  knee 
flexed,  unable  to  extend  or  move  the  joint  without  severe 
pain.  There  was  marked  swelling  of  right  knee-joint,  the 
swelling  having  the  characteristic  form  of  distension  of  the 
synovial  cavity,  except  that  the  swelling  was  especially 
prominent  on  the  inner  side  of  the  joint  just  above  the 
internal  condyle.  The  skin  over  the  joint  looked  natural ; 
no  enlarged  veins  over  the  swelling.  Marked  wasting  of 
muscles  of  thigh  and  calf.  On  palpation  the  skin  over  the 
joint  felt  hot,  the  joint  being  very  tender  to  touch,  so  that 
any  attempt  at  movement  caused  great  pain.  An  irregular, 
ill-defined  swelling  could  be  felt  over  and  above  the  internal 
condyle.  The  upper  margin  of  the  swelling  could  be 
palpated  1 inch  above  the  condyle,  but  no  lower  margin 
could  be  palpated.  The  swelling  did  not  fluctuate.  The 
lower  end  of  the  femur  felt  enlarged  and  there  was  abnormal 
mobility  to  be  made  out.  The  situation  of  the  bony  points 
was  natural ; no  riding  of  the  patella.  There  was  1§  inches 
of  wasting  in  the  thigh  and  calf  of  right  leg.  The 
circumference  of  right  knee-joint  was  11  inches  greater 
than  that  of  left.  There  was  no  loss  of  sensation  and 
reflexes  were  natural.  Wassermann  reaction  was  negative. 

X ray  examination  showed  very  extensive  destruction  of 
bone  at  the  lower  end  of  the  femur.  At  one  situation  the 
destruction  had  been  so  great  that  the  bone  appeared  to  have 
been  “ eaten  ” through.  There  was  no  evidence  of  any  new 
bone  formation.  Microscopic  examination  of  a sector 
removed  from  the  growth  showed  that  the  growth  was  a 
spindle-celled  sarcoma. 

Treatment. — Amputation  of  the  thigh. 

Remarks. — This  case  illustrates  a not  unusual  mistake  in 
diagnosis,  the  case  being  first  diagnosed  as  synovitis  of  the 
knee.  The  importance  of  an  X ray  examination  in  all 
cases  where  there  is  any  suspicion  of  disease  of  a joint 
cannot  be  over-estimated.  It  is  probable  that  this  case 
would  have  shown  changes  in  the  bone  had  an  X ray 
been  taken  when  the  case  was  first  seen.  The  second  point 
of  interest  is  the  X ray  appearance,  the  destruction  of  bone 
being  very  considerable  and  the  appearance  being  not  unlike 
that  exhibited  by  a case  of  advanced  necrosis. 


328  The  Lancet,] 


CLINICAL  NOTES. 


[August  23, 1919 


MEDICAL,  SURGICAL,  OBSTETRICAL,  AND 
THERAPEUTICAL. 


THE  EFFECTS  OF  EXPOSURE  UPON  THE 
TERMINALS  OF  HANDS  AND  FEET. 

By  F.  Jeeves,  L.R.C.P.  & S.  Edin.,  L.R.F.P.S.  Glasg., 

CAPTAIN,  R.A.M.C.  (T.)j  MEDICAL  OFFICER,  H.M.  HOSPITAL  SHIP ; 

AND 

E.  R.  Hunt,  M.D.  Cantab.,  M.R.C.P.  Lond., 

LIEUTENANT-  COLON  EL,  R.  A.M.C.  (T.C.) ; CONSULTING  PHYSICIAN  TO  THE 
NORTH  RUSSIAN  EXPEDITIONARY’  FORCE. 


The  following  case  illustrates  the  different  effects  of 
exposure  to  (1)  alternating  extremes  of  temperature,  (2)  pro- 
longed low  temperature  : — 

Corporal  W.  B.,  aged  39,  a monumental  mason  in  civilian 
life,  came  out  to  North  Russia  on  Oct.  1st,  1918.  He  had 
since  been  employed  at  the  base.  He  gives  a history  of 
having  been  rejected  for  the  Army  in  1914 — be  believes  on 
account  of  his  teeth.  He  was  in  France  from  January,  1917, 
to  October,  1917,  where  he  was  gassed,  but  did  not  suffer 
from  trench-feet  or  frost-bite. 

From  Oct.  20th  to  Dec.  16th,  1918,  he  was  employed  in 
building  stoves.  As  is  customary  among  Russian  masons,  a 
mortar  was  used  composed  of  clay  and  sand.  The  workmen 
use  this  with  their  hands  instead  of  with  a trowel,  as  in 
England,  and  they  dip  their  hands  at  frequent  intervals  in 
extremely  hot  water  to  prevent  the  mortar  sticking  to  them. 
He  did  the  same.  The  weather  was  very  cold,  and  his 
hands  were  consequently  being  exposed  to  extremes  of  heat 
and  cold  alternately.  His  feet,  on  the  contrary,  were  con- 
stantly wet  and  cold,  for  he  was  unable  to  wear  hi's  Sbackleton 
boots,  and  his  ordinary  boots  were  wet  through,  as  he  was 
frequently  standing  in  water.  He  was  wearing  these  wet 
boots  for  many  hours  daily.  The  first  parts  affected  were 


Fig.  1. — Shows  increased  bone  formation  in  the  lingers. 

his  hands  and  left  great  toe;  then  the  other  foot.  They 
swelled  up  and  “ the  nails  seemed  to  spread.”  He  had  pains 
of  a stinging  character,  worse  when  the  hands  and  feet  were 
getting  warm  again  and  after  he  had  stopped  moving  about. 
The  pain  in  his  toes  at  night  kept  him  awake. 

He  continued  to  work  in  spite  of  the  pain  until  Dec.  16th, 
1918,  when  he  went  sick  on  account  of  the  severity  of  the 
pain  in  his  left  great  toe.  He  states  that  he  had  little 
blisters  at  the  bases  of  his  finger-nails,  but  that  his  feet  were 
not  blistered,  although  distinctly  blue.  He  was  admitted  to 
the  hospital  ship  on  Dec.  19th. 

I (E.  R.  H.)  saw  him  for  the  first  time  some  three  weeks 
later.  He  was  then  recovering  and  was  able  to  be  up  and 
about  the  ward.  The  terminal  phalanges  of  all  his  fingers, 
his  thumbs,  and  the  toes  of  both  feet  were  much  enlarged, 
presenting  the  appearance  of  clubbed  fingers  and  toes  seen 
in  cases  of  congenital  heart  disease,  though  without  the 
discolouration  usual  in  this  condition.  Sensation  to  pin- 
prick was  very  much  diminished  over  the  terminal  phalanges 
of  his  right  thumb  and  forefinger  and  middle  finger.  The 


level  of  diminished  sensation  extended  down  to  the  middle 
of  the  second  phalanx  of  the  right  ring  finger  and  to  the 
joint  between  the  first  and  second  phalanges  of  the  right  little 
finger  behind,  and  to  the  metacarpo  phalangeal  joint  of  the 
same  finger  in  front.  The  left  hand  was  less  affected, 
but  sensation  was  diminished  over  all  the  terminal 
phalanges.  A very  similar  distribution  of  impaired  sensi- 
bility was  present  over  the  toes  of  both  feet.  The  knee- 
jerks  were  normal,  but  plantar  reflexes  only  just  obtainable. 
His  pupils  reacted  to  light.  The  luDgs  were  normal.  The 
first  sound  at  the  apex  of  the  heart  was  reduplicated. 


Fig.  Shows  erosion  of  the  terminal  phalanges  of  the  tees. 

The  excellent  skiagrams,  for  which  I am  indebted  to 
Captain  H.  J.  Cotter,  M.C.,  R.A.M.C.,  show  an  interesting 
condition  of  the  bones  of  the  terminal  phalanges  of  both 
hands  and  feet.  In  the  fingers  these  bones  show  increased 
bone  formation,  whereas  the  terminal  phalanges  of  the  toes 
are  eroded. 

These  different  conditions  illustrate  remarkably  the 
effects  of  alternating  extremes  of  temperature  as  compared 
with  that  of  prolonged  exposure  to  cold  only.  The  distri- 
bution of  the  sensory  changes  point  to  injury  of  the  nerve 
endings  and  not  to  any  peripheral  neuritis.  There  was 
nothing  to  suggest  a functional  origin.  The  similarity  of 
the  sensory  changes  in  both  hands  and  feet  suggests  that 
the  bone  changes  were  caused  by  direct  action  of  the 
temperature  on  the  blood-vessels,  and  not  primarily  by 
interference  with  vaso-motor  action  through  the  damage  to 
nerve-endings. 

North  Russia. 


A CASE  OF 

KERATODERMIA  BLENNORRHAGICA. 

By  S.  C.  Dyke,  M.B.,  B.Ch.  Oxon.,  D.P.H.  Oxon., 

ASSISTANT  BACTERIOLOGIST,  COLLEGE  OF  MEDICINE,  NEWCA8TLE- 
UPON-TY'NE. 

As  details  have  been  published  of  comparatively  few  cases 
of  keratodermia  occurring  in  association  with  gonorrhoea, 
the  following  may  be  of  interest : — 

The  Case  Described. 

Patient,  a private  in  a Labour  Company  in  France,  who, 
throughout  his  illness  denied  having  ever  had  any  venereal 
disease,  was  taken  ill  with  “pains  in  the  joints  ’’  about  the 
last  week  of  April,  1918.  On  May  5th  he  was  admitted  to  a 
C.C.S. ; temperature  was  then  100-6°  F.  and  the  left  knee  was 
greatly  swollen.  A diagnosis  of  acute  rheumatism  was  made. 
Salicylates  were  administered  and  50c. cm.  of  turbid  fluid 
showing  polymorphonuclear  lecuocytes  was  aspirated  from 
the  left  knee.  On  May  23rd  the  notes  record  swelling  of  the 
joints  of  the  right  shoulder,  wrist,  and  hand. 

He  was  admitted  to  hospital  in  England  at  the  beginning 
of  June.  The  affected  joints  were  all  still  swollen  and  tender, 
though  not  containing  appreciable  fluid.  A soft  systolic 
bruit  was  present  at  the  apex  which  was  in  the  fifth  inter- 
costal space,  half  inch  internal  to  the  vertical  nipple  line. 
Patient  was  weak  and  emaciated.  There  was  still  irregular 
pyrexia,  up  to  about  100-5°  F.  at  night.  Salicylates  gave  no 
relief  and  were  discontinued. 

Condition  of  the  Patient's  Feet. 

About  the  beginning  of  July  the  condition  of  the  patient’s 
feet  began  to  attract  attention.  On  admission  the  skin  of 
the  plantar  surface  was  thick  and  calloused  and  showed  a 


The  Lanobt,] 


CLINICAL  NOTES. 


[August  23,  1919  329 


tendency  to  oome  off  in  crusts.  This  is  a state  of  affairs 
occasionally  seen  in  men  after  they  have  been  in  bed  some 
weeks,  and  no  particular  attention  was  paid  to  it  until  it 
was  noticed  that  as  the  flakes  separated  they  did  not  leave 
clean  pink  skin  underneath;  on  the  contrary,  as  the  Hakes 
of  thickened  epidermis  came  away  new  ones  formed  under- 
neath them.  This  condition  became  rapidly  aggravated 
until  the  whole  plantar  surface,  the  sides  of  the  feet,  and 
the  dorsal  surfaces  of  the  ungual  and,  to  a less  degree,  of 
the  second  phalanges  were  covered  with  a thick  horny 
layer  of  desquamating  epidermis.  Cracks  appeared  in  this 


Fig.  1. — Feet  before  commencement  of  vaccine  treatment. 


desquamating  layer,  which  was  shed  in  fragments  from  the 
size  of  half-a-crown  to  a fine  dust.  As  fast  as  the  epidermis 
was  thrown  off  further  keratisation  occurred  in  the  under- 
lying epithelium,  which  was  later  in  its  turn  desquamated. 
The  process  went  on  underneath  the  nails,  most  of  which 
in  time  separated  and  came  away.  Some  traces  of  the  same 
condition,  in  the  shape  of  a branny  desquamation  around 


Fig.  2. — Feet  one  month  after  commencement  of  vaccine  treatment. 

the  finger-nails,  occurred  on  the  hands.  The  palms  were 
not  affected.  No  inflammatory  reaction  accompanied  the 
process,  which  was  almost  painless. 

On  June  6th  a little  sugar  was  present  in  the  urine  ; this 
was  absent  at  the  next  examination  a few  days  later  and 
thereafter. 

Treatment  with  Gonorrhoeal  Vaeeine. 

At  the  end  of  June  the  case  came  under  my  care.  The 
association  of  an  arthritis,  not  responding  to  salicylates,  with 
hyperkeratosis  aroused  suspicions  of  gonorrhoea.  On  looking 
for  it  a scanty  purulent  urethral  discharge  was  found,  which 
on  examination  by  the  pathologist  to  the  hospital,  Major 
A.  G.  Gibson,  R.A.M.C.,  was  found  to  contain  Gram-negative 
diplococci.  Further  investigation  revealed  similar  cocci  and 
prostatic  threads  in  large  quantities  in  the  urine.  The 
Wassermann  reaction  was  negative. 

On  the  strength  of  the  pathological  report  a course  of 
gonococcal  vaccine  was  given  from  July  10th  to  August  10th. 
A start  was  made  with  a dose  of  5 millions,  the  dose  being 
worked  up  to  300  millions,  and  850  millions  being  given  in 
the  course  of  the  month.  The  improvement  in  the  condition 


of  the  feet  was  immediate  and  marked.  After  the  first  few 
doses  the  further  keratisation  beneath  the  already  separating 
epidermis  ceased,  and  at  the  end  of  the  month  most  of  the 
thickened  skin  had  separated,  leaving  normal  epidermis 
beneath.  At  the.  same  time  the  pyrexia  ceased.  The  joint 
condition,  which,  under  radiant  heat  and  massage,  was 
improving  before  the  commencement  of  the  vaccine  showed 
no  marked  change. 

About  the  middle  of  August  the  patient  was  evacuated  to 
an  auxiliary  hospital.  His  general  health  was  then  excellent. 
The  condition  of  the  skin  was  normal,  but  there  were  still 
considerable  thickening  and  stiffness  of  the  affected  joints, 
particularly  of  those  of  the  right  hand.  The  urethral 
discharge  had  disappeared. 

Remarks. 

The  points  of  interest  in  this  case  would  seem  to  be : — 

1.  The  association  of  the  skin  condition  with  what  .'was 
evidently  a very  severe  attack  of  gonorrhceal  arthritis. 

2.  Its  late  appearance  in  the  disease.  3.  Its  prompt 
disappearance  under  vaccine  treatment. 

Oxford. 

CRYPTOPODIA:  AN  UNDESCRIBED  DISEASE. 

By  E.  C.  Bousfield,  L.R.C.P.  Lond.,  M.R.C.S., 
D.P.H.  Camb.  & Lond., 

DIRECTOR,  CAMBERWELL  RESEARCH  LABORATORIES;  BACTERIOLOGIST 
CAMBERWELL  AND  HACKNEY. 


The  remarkable  case  described  below,  unique,  so  far  as  I 
have  been  able  to  discover,  came  under  my  notice  whilst 
taking  a “busman’s  holiday”  in  charge  of  the  practice  of 
my  friend,  Dr.  T.  T.  Brunyate,  of  Woodstock,  by  whose 
kind  help  I was  able  to  get  the  patient  to  London  for 
exhibition  at  a scientific  meeting. 

History  of  the  Case. 

The  patient,  a fresh-complexioned  woman  of  44,  had  never 
been  out  of  the  country.  Enlargement  of  the  feet  was  first 
noticed  at  the  age  of  15,  coming  on  during  the  day  and  dis- 
appearing during  sleep.  In  the  following  year  it  increased 
so  much  whilst  she  was  in  service  that  she  sought  advice  as 
an  out-patient  at  St.  Bartholomew’s  Hospital,  but  attended 
once  only,  as  she  had  to  leave  her  situation.  She  appears 


Fig.  1. -Dorsal  aspect,  showing  the  widely-separated  hair  follicles. 

to  have  continued  in  service,  though  with  increasing  diffi- 
culty, until  her  twenty-fifth  year,  when  she  was  attacked  by 
rheumatoid  arthritis,  which  left  her  hands  crippled,  and 
since  then  the  feet  have  got  steadily  worse,  so  that  for  ten 
years  she  has  not  been  able  to  walk. 

The  photographs  which  I took  of  her  in  the  Woodstock 
Infirmary  show  the  condition  better  than  any  description. 
At  the  first  glance  the  suggestion  is  that  of  elephantiasis, 
but  the  fact  that  the  toes  are  not  involved  in  the  tumour,  and 


3.50  The  Lancet,] 


REVIEWS  AND  NOTICES  OF  BOOKS. 


[August  23,  1919 


the  great  separation  of  the  hair-follicles,  indicating  dis- 
tension, not  hypertrophy,  together  with  the  translucency  of 
the  tumours,  negative  the  idea  of  that  disease. 

The  swelling  extends  from  about  three  inches  below  the 
knees,  and  involves  the  whole  of  both  legs  and  the  dorsa  of 
the  feet,  but  stops  absolutely  short  at  the  margins  of  the 
soles,  or  rather  folds  over  about  half  an  inch  higher  all 


Fig.  2.— Plantar  aspect,  showing  growth  protruding  between  the  toes. 

round.  Round  each  ankle  there  is  a well-marked  collar, 
with  protuberances  not  coinciding  with  any  anatomical 
structures.  The  skin  pits  deeply  on  pressure,  but  there  is 
neither  pain  nor  tenderness. 

Heart,  lungs,  and  kidneys  are  sound.  A somewhat  hasty 
blood  count  showed  32  per  cent,  polymorphonuclear  leuco- 
cytes, 17  per  cent,  transitionals,  51  per  cent,  small  lympho- 
cytes, but  neither  large  mononuclears  nor  eosinophiles. 
The  red  cells  were  very  irregular  in  size,  varying  from 
0 5 to  T5  of  the  normal,  but  poikilocytes  were  few. 

• Remarks. 

The  condition  of  the  blood  seems  to  indicate  profound 
myeloid  or  lymphatic  changes,  especially  as  there  was 
marked  leucopenia.  No  mechanical  obstacle  to  the  return 
flow  of  blood  or  lymph  appears  adequate  to  explain  the 
peculiar  features,  the  immunity  of  the  feet  for  example. 
Numerous  specimens  of  blood  taken  at  night  failed  to  show 
evidence  of  filaria.  The  only  suggestion  as  to  the  nature  of 
the  case  was  that  it  might  be  a variant  of  Milroy’s  disease, 
but  there  is  an  entire  absence  of  hereditary  element. 

Note. — Since  the  above  was  written  my  attention  has  been 
drawn  by  Colonel  McAdam  Eccles  to  a case  which  he 
published  in  the  St.  Bartholomew' s Hospital  Journal  in  April, 
1906.  He  described  it  as  a case  of  elephantiasis,  and,  as  the 
toes  appear  to  partake  in  the  enlargement,  this  is  probably 
correct,  though  I cannot  pretend  to  decide  in  the  absence  of 
more  exact  details.  My  own  case  is  now  in  the  same 
hospital,  under  Dr?  Morley  Fletcher,  and  is  improving 
greatly  under  thyroid  treatment,  though  why  it  should  is 
hard  to  say.  The  skin,  as  it  contracts,  is  piling  up  into  thick 
ridges,  so  that  there  has  evidently  been  some  hypertrophy. 

De  Crespignv  Park,  S.E. 


Literary  Intelligence. — Messrs.  W.  Heller  and 
Sons,  Ltd.,  Cambridge,  announce  tbe  early  appearance  of 
“Groundwork  of  Surgery  for  First  Year  Students,’’ by  Mr. 
Arthur  Cooke.  The  book  is  intended  for  students  just 
beginning  clinical  work  in  the  wards  or  out-patient 
department. 

Mr.  William  Lauzun  Brown. — The  death  is 
announced  of  Mr.  W.  L.  Brown,  L.R.C.S.  Edin.,  L.R.C.P. 
Glasg.,who  before  qualifying  as  a medical  man  was  attached  to 
the  editorial  office  of  The  Lancet,  first  as  a medical  reporter 
and  latterly  as  one  of  the  sub-editors.  He  was  a good  short- 
hand writer  and,  having  won  a competition  in  stenography 
while  a Scottish  medical  student,  he  attracted  the  attention 
of  Sir  William  Gowers,  at  that  time  closely  connected  with 
the  editorial  staff  of  The  Lancet,  and  to  Gowers  Mr.  Brown 
owed  his  start  at  this  office.  He  did  much  useful  work  for 
The  Lancet  for  nearly  five  years,  especially  in  taking 
charge  of  the  reporting  of  various  congresses  and  medical 
meetings.  In  1894  he  returned  to  Glasgow  to  complete  his 
medical  education,  and  on  obtaining  the  Scottish  diplomas 
went  into  general  practice  in  London.  He  remained  attached 
to  journalism,  and  in  papers  and  from  platforms  was  the 
advocate  of  medical  movements  of  various  sorts.  He  was  a 
member  of  the  Finsbury  Borough  Council  and  Holborn 
Board  of  Guardians. 


anb  Notices  of  ’Boob. 


Mortality  Statistics  of  Insured  Wage-earners  and  their 
Families  in  the  United  States  and  Canada.  By  Louis 
I.  Dublin,  Ph.D.,  Statistician.  With  the  collaboration 
of  Edwin  W.  Kopf,  Assistant  Statistician,  and  George 
H.  Van  Buren,  Supervisor,  Statistical  Bureau.  New 
York  : Metropolitan  Life  Insurance  Company.  1919. 
Pp.  397. 

This  publication  presents  the  mortality  statistics  of  the 
Industrial  policy-holders  of  the  Metropolitan  Life  Insurance 
Company  for  the  six-year  period  1911  to  1916,  with  a 
supplement  for  the  year  1917.  The  statistics  are  essentially 
those  of  the  wage-earning  group  of  the  population.  In  view 
of  the  circumstances  and  time  covered,  and  the  care 
exercised  in  gathering,  editing,  and  tabulating  the  data,  it  is 
safe  to  say  that  these  statistics  constitute  one  of  the  best 
indices  available  of  mortality  and  its  causes  among  wage- 
earners  and  their  families.  Those  working  in  mortality 
statistics,  especially  in  connexion  with  life  insurance,  will 
find  much  to  interest  them.  In  order  fully  to  appreciate 
the  facts  careful  study  is  necessary,  and  many  important 
matters  are  presented  which  are  not  to  be  found  in  works 
published  in  this  country,  such  as  the  comparative  mortality 
of  the  white  and  coloured  races  at  the  various  age-periods. 
The  comparative  mortality  from  different  diseases  in  the 
industrial  population  on  the  one  hand,  and  in  the  general 
population  on  the  other,  forms  an  interesting  study,  and 
here  the  area  covered  by  the  data — it  includes  nearly  all 
the  states  of  the  United  States  and  the  provinces  of 
Canada — makes  the  investigation  particularly  valuable.  The 
statistics,  indeed,  reflect  the  sanitary  and  social  conditions 
prevailing  throughout  the  industrial  population  of  two  great 
national  units.  The  members  of  wage-earners’  families  are 
also  accounted  for  in  good  measure,  for  a very  large  propor- 
tion of  the  total  number  of  persons  observed  are  the  wives 
and  children  of  wage  workers. 

The  number  of  diseases  dealt  with  is,  of  course,  large,  but 
attention  may  be  usefully  directed  to  certain  maladies,  such 
as  tuberculosis,  cancer,  and  syphilis,  whose  rates  of  incidence 
are  especially  interesting  to  official  medicine.  Taking  first 
pulmonary  tuberculosis,  a total  of  99,906  deaths  is  reported 
under  this  head,  corresponding  to  a death-rate  of  185 -7 
per  100,000  in  the  six  years  1911  to  1916.  A table  is 
given  showing  the  mortality  from  this  disease,  classified 
by  colour,  sex,  and  by  age-period.  The  group  of  coloured 
persons  in  this  experience  displays  a pulmonary  tuber- 
culosis death-rate  at  all  ages  between  two  and  two  and 
one-half  times  that  of  white  persons.  One  interesting 
feature  is  the  comparatively  early  age  at  which  the  maximum 
death-rate  is  found  among  the  negroes — namely,  between  20 
and  24  years  of  age.  Among  white  males  the  maximum  is 
reached  between  35  and  44  years,  and  among  white  females 
between  25  and  34  years.  Further,  the  mortality  from  tuber- 
culosis of  the  lungs  among  coloured  males  at  the  age-period 
5 to  9 years  is  over  ten  times  as  great  as  among  white 
males  at  that  age.  In  discussing  the  comparative  mortality 
from  pulmonary  tuberculosis  among  the  industrial  and 
general  population  respectively,  it  is  shown  that  among 
insured  white  males,  at  all  ages,  the  mortality  is  31 
per  cent,  higher  than  among  all  males  of  the  general 
population.  Females  in  the  families  of  wage-earners  showed 
an  excess  of  only  13  per  cent.  Another  point  of  interest 
brought  out  is  that  the  children  of  wage-earners  who  reside 
in  cities  and  are  presumably  more  exposed  to  infection  and 
to  the  hardshipsincident  to  their  economic  stratum,  show  no 
higher  rates  from  pulmonary  tuberculosis  than  children  in 
the  general  population,  of  whom  one-half  reside  in  rural 
areas.  Judging  by  the  way  in  which  children  are  housed  in 
this  country  in  country  districts  this  experience  is  not  so 
surprising  as  it  appears  at  first  sight. 

Turning  now  to  oancer,  the  statistics  show  that  white  males 
show  emphatically  higher  cancer  death-rates  at  every  age 
period  than  were  recorded  for  coloured  males.  Comparisons 
between  the  cancer  death-rates  of  white  and  coloured  females 
are  practicable  beginning  with  the  age-period  25  to  34  years. 
Between  25  and  44  years  the  cancer  death-rates  of  white 
females  were  decidedly  lower  than  the  rates  for  coloured 
females.  Between  45  and  54  years  the  rates  were  practi- 
cally the  same.  Beginning  with  the  age-period  55  to  64 


The  Lancet,] 


REVIEWS  AND  NOTICES  OF  BOOKS. 


[August  23,  1919  331 


years  and  continuing  to  the  highest  age-period  in  the  table, 
the  cancer  death-rates  of  white  females  were  higher  than 
the  rates  for  coloured  females. 

In  discussing  the  mortality  from  syphilis  the  authors 
remark  that  statistics  are  likely  to  be  fallacious  because  of 
the  tendency  of  medical  men  to  conceal  this  disease  in  their 
reports  of  causes  of  death.  But  even  the  figures,  defective 
as  they  are,  serve  to  indicate  some  important  relations  (of 
syphilis  mortality)  in  the  several  colour  and  sex  classes. 
The  death-rate  among  coloured  lives  is  consistently  higher 
than  among  whites.  The  rates  are  about  3 to  1.  The  rates 
are  much  higher  for  males  than  for  females  in  each  one  of 
the  colour  groups. 

The  figures  concerned  with  the  mortality  from  other 
diseases  are  similarly  considered,  the  whole  work  forming  a 
valuable  addition  to  our  statistical  knowledge  of  the  causes 
of  death  in  the  varying  conditions  of  race,  age,  and  sex. 
The  authors  may  be  congratulated  on  the  success  of  their 
endeavours  in  collecting  and  criticising  an  enormous  mass 
of  material,  and  the  results  will  doubtless  be  received  with 
the  greatest  interest  by  all  concerned  in  the  insurance  world. 


Airfs  to  Ophthalmology.  By  N.  Bishop  Harman,  M.A., 
M.B.  Cantab.,  F.R.C.S.  Eng.  Sixth  edition.  With 
163  illustrations.  1919.  London  : Bailliere,  Tindall,  and 
Cox.  Pp.  226.  3s.  6 d. 

We  can  thoroughly  recommend  this  little  book  to  every 
student  of  ophthalmology.  It  is  written  in  an  easy,  interest- 
ing style,  and  contains  as  much  useful  information  in  pro- 
portion to  its  size  as  any  book  we  know.  Moreover,  it  can 
be  carried  about  in  the  pocket.  The  chapters  on  the  external 
diseases  of  the  eye  include  some  elementary  bacteriology  of 
the  conjunctiva.  The  different  forms  of  cataract  are  clearly 
explained.  The  main  facts  about  glaucoma  are  stated,  while 
the  controversies  to  which  it  has  given  rise  are  left  on  one 
side.  The  chapters  on  refraction  and  the  fitting  of  glasses 
are  practical  and  sufficient.  When  he  comes  to  the 
ophthalmoscopic  diagnosis  of  fundus  disease  the  student 
will  need  to  supplement  what  he  finds  here.  There  is,  for 
instance,  no  mention  of  such  a common  disease  as  albumin- 
uric retinitis.  References  are  given,  however,  to  ophthalmo- 
scopic atlases,  one  of  which  would  be  found  a most  useful 
adjunct  by  the  beginner. 

The  chapter  on  Ocular  Therapeutics,  while  excellent  so 
far  as  it  goes,  does  not  go  very  far.  The  advice,  however, 
to  use  nitrate  of  silver  in  a solution  of  glycerine  and  to  com- 
pare its  action  with  that  of  the  newer  proprietary  silver 
salts  on  patients  who  have  both  eyes  affected  with  con- 
junctivitis is  worth  following.  Of  the  additions  in  the 
sixth  edition,  compared  with  the  fifth,  we  note  a new 
chapter  on  Diseases  of  the  Vitreous,  and  the  inclusion  in 
the  final  chapter  on  operations  of  a description  of  the 
author’s  reefing  operation  for  the  advancement  of  a 
muscle  in  cases  of  squint.  This  operation,  in  its  originator’s 
hands,  has  given  good  results  and  it  does  not  entail  the 
bandaging  of  both  eyes  and  consequent  confinement  to  the 
house  or  hospital  ; but  it  is  a difficult  one  to  perform.  A 
chapter  on  Eye  Conditions  in  School  Children  is  of  special 
value,  embodying  the  author’s  experience  of  many  years’ 
work  in  connexion  with  the  public  elementary  schools  of 
London. 


Constipation  and  Allied  Intestinal  Disorders.  By  Arthur  F. 
Hurst,  M.A.,  M.D.  Oxon.,  F.R.C.P.,  Physician  and 
Neurologist  to  Guy’s  Hospital  ; formerly  Consulting 
Physician,  Salonica  Army.  Second  edition.  London  : 
Henry  Frowde,  Hodder  and  Stoughton.  1919.  Pp.  440. 
16s. 

The  present  volume,  though  described  as  a second  edition 
of  the  book  first  published  in  1909,  is  very  largely  a new 
publication.  Much  has  been  rewritten,  and  new  chapters 
have  been  added  on  such  subjects  as  methods  of  examina- 
tion, intestinal  adhesions,  visceroptosis,  stasis  in  the 
caecum  and  ascending  colon,  and  spa  treatment.  While  the 
book  presents  the  results  of  the  author’s  own  observations, 
it  also  embodies  the  more  important  facts  relating  to  the 
subject  to  be  found  in  the  English,  the  American,  the  French, 
and  the  German  literature.  The  subject-matter  is  divided 
into  convenient  sections.  The  first  of  these  deals  with  the 
physiology  of  the  intestinal  movements  and  of  deisecation, 
and  includes  an  interesting  account  of  ‘ mass  peristalsis,” 


the  term  which  is  now  usually  employed  to  describe  the 
movements  of  the  colon.  The  next  section  deals  with 
methods  of  examination.  These  include  the  usual  physical 
examination  ; the  giving  of  charcoal  lozenges,  by  which 
device  it  is  possible  to  estimate  the  total  time  taken  in  the 
passage  of  any  particular  meal  through  the  alimentary  canal  ; 
examination  by  X rays  ; the  examination  of  fames  by 
physical,  chemical,  and  bacteriological  methods  ; and,  finally, 
examination  of  the  lower  bowel  by  the  sigmoidoscope. 
Section  3 treats  of  the  causes  of  constipation  : factors 
influencing  the  passage  of  intestinal  contents  along  the  colon 
are  first  considered  and  then  the  causes  of  “dyschezia”  or 
defective  defamation  are  passed  in  review.  The  next 
section  considers  the  symptoms  of  constipation  in  all 
their  protean  manifestations.  Section  5 is  concerned 
with  treatment,  and  the  importance  of  prophylaxis  is  duly 
emphasised.  The  majority  of  cases  of  constipation,  as  the 
author  insistently  teaches,  can  be  cured  without  drugs  if 
proper  treatment  is  instituted  at  a sufficiently  early  stage. 
Indeed,  in  dyschezia  purgatives  are  either  absolutely  useless 
or  they  only  have  an  effect  when  fluid  stools  are  produced,  a 
considerable  quantity  of  fluid  and  nutritive  material  being 
thereby  wasted.  Two  further  sections  deal  with  the  rather 
more  special  subjects  of  constipation  in  infants  and  in 
soldiers. 

The  book  is  illustrated  by  56  figures,  most  of  which  are 
reproductions  in  black  and  white  outline  of  bismuth  meal 
investigations.  It  is  seldom  that  the  reader  of  medical 
monographs  meets  with  an  account  of  a subject  so  rationally 
set  forth  and  in  which  the  conclusions  are  so  intimately 
based  upon  direct  experiment  and  observation.  The  author 
is  to  be  congratulated  upon  the  scientific  acumen  which  has 
shaped  his  labours. 


Heredity.  By  J.  Arthur  Thomson,  M.A.,  LL.D.,  Pro- 
fessor of  Natural  History  in  the  University  of  Aberdeen. 
Third  edition.  London : John  Murray.  1919.  Pp.  627.  15s. 

A third  edition  has  just  appeared  of  this  valuable  manual, 
published  originally  12  years  ago.  During  that  time  it  has 
served,  as  it  was  intended  to  do,  as  an  introduction  to  the 
study  of  heredity,  and  the  fascinating  interest  of  the  subject 
and  its  great  practical  importance  have  been  proved  by  the 
success  of  the  manual.  Professor  Thomson  has  furnished  a 
book  which  illustrates  for  the  benefit  of  those  who  are  not 
experts  in  biology  the  main  views  which  are  held  in  this 
sphere.  He  defines  the  terms  in  common  employment,  and 
discusses  the  accepted  theories  as  to  the  physical  basis  of 
inheritance,  showing  how  the  tendency  to  breed  true  is 
subject  to  variations,  fluctuations,  and  mutations.  Disputed 
questions  like  telegony  and  the  transmission  of  acquired 
characteristics  are  dealt  with  in  comprehensible  language  ; 
a long  chapter  on  heredity  in  disease  may  be  commended 
to  all  our  readers,  and  the  same  may  be  said  for  the 
exposition  of  Mendelian  law.  The  whole  book  is,  as  we 
have  said  before  in  much  the  same  terms,  fascinating  and 
instructive,  while  apt  illustrations  and  a full  index  add  to 
its  value. 


Manual  of  Anatomy , Systematic  and  Practical , including 
Embryology.  Originally  written  by  the  late  A.  M. 
Buchanan,  M.A.,  M.D.,  C.M.,  F.R.F.P.S.  Glasg. 

Fourth  edition.  With  677  illustrations.  London  : Bailliere, 
Tindall,  and  Cox.  1919.  Pp.  xii.  + 1743.  30s. 

The  general  arrangement  of  this  edition  remains  as  in 
the  last,  and  the  old  terminology  is  still  adhered  to.  The 
book  is  now  in  the  hands  of  a committee  of  London 
anatomists,  who  have  made  only  a few  alterations  in  the 
text,  and  are  clearly  waiting  for  an  increase  in  their  number 
before  dealing  at  all  drastically  with  the  revision  of  the 
whole  work. 


Studies  on  Aoari.  A/o.  1 , the  Genus  Demodex,  Omen.  By 
Stanley  Hirst.  London  : Longmans,  Green,  and  Co. 
1919.  Pp.  44  4-  xiii.  10.s. 

Mr.  Hirst  has  carried  out  a very  painstaking  research  into 
the  distribution  and  morphology  of  the  genus  Demodex , and 
has  discovered  the  parasite  in  certain  mammals  in  which  until 
now  it  has  not  been  known’  to  occur.  His  descriptions  are 
careful  and  clear,  and  are  admirably  illustrated  in  13  plates 
and  four  text-figures. 


332  The  Lancet,] 


FRENCH  SUPPLEMENT  TO  THE  LANCET. 


[August  23,  1919 


FRENCH  SUPPLEMENT  TO  THE  LANCET 

Under  the  Editorial  Direction  of 

Professor  CHARLES  ACHARD,  AND  Dr.  CHARLES  FLANDIN,  D.S.O., 

PROFESSOR  OF  PATHOLOGY  AND  THERAPEUTICS  IN  THE  CHEF  DE  CLINIQUE  A LA  FACULTY  DE  PARIS. 

UNIVERSITY  OF  PARIS.  


RADIOLOGICAL  EXAMINATION  OF  PSEUD- 
ARTHROSES  BEFORE  AND  AFTER 
OPERATIONS  OF  BONY  GRAFTS. 

By  PAUL  AUBOURG, 

PROFESSOR  AGR£g4,  CUNEO'S  LABORATORY  FOR  RADIOLOGY. 

(i Centre  for  Surgery  of  Bones,  Hospital  75,  Cannes.) 


Judging  from  the  reports  of  the  last  French  Surgical 
Congress  (Paris,  Oct.  4th,  1918),  the  treatment  of 
pseudarthroses  is  at  present  very  much  to  the  front. 
In  this  highly  complex  question  of  the  reparation  of 
pseudarthroses  radiology  can  give  the  surgeon  valuable 
indications — before  intervention,  in  order  to  get  an  idea  of 
the  structure  of  the  bony  extremities,  of  their  morphology, 
and  of  their  mutual  relationship  ; alter  intervention,  in 
order  to  get  an  idea  of  the  evolution  of  the  gratt,  of  the 
bony  reparation  of  the  extremities,  and,  above  all,  of 
secondary  deviations  which  could  invalidate  the  primary 
and  immediate  results  of  the  operation. 

Surgeons  know  how  great  the  number  of  pseudarthroses  is 
at  present,  and  how  much  greater  it  will  be  by  the  huge 
number  of  wounded  who  now  decline,  but  will  demand  inter- 
vention later.  Our  colleagues  at  the  demobilisation  centres 
estimate  the  number  of  wounded  now  declining  any  interven- 
tion in  the  case  of  pseudarthrosis  as  8 out  of  10.  But  if  it  is 
difficult  to  ascertain  even  approximately  the  number  of 
wounded  who  will  have  to  be  sen  t to  hospital  and  operated  upon 
later  on,  one  can  at  least  compute  the  percentage  of  lesions  in 
the  case  of  wounded  sent  to  the  Centre  for  Surgery  of  Bones 
at  Cannes.  In  a first  series  of  161  wounded,  six  humeri, 
five  forearms,  and  four  tibias  are  found  to  one  femur.  I 
would  remind  my  readers  that  this  centre  was  formed  a 
year  ago  at  the  request  of  my  teacher  and  friend  B.  Cuneo, 
prufesseur  agrcgc  in  the  Medical  Faculty  of  Paris,  in  o'der  to 
study,  experimentally  on  animals  and  clinically  on  men,  the 
development  of  grafts  in  pseudarthroses,  the  losses  cf  bony 
substances,  and  serious  lesions  in  articulation. 

The  Surgeon  and  the  Radiologist. 

Radiology  plays  such  an  important  part  in  the  study  of 
pseudarthroses  that  one  can  say  without  exaggeration  that 
there  are  few  branches  of  surgery,  recent  fractures  included, 
in  which  the  close,  constant,  coordinated  abd  methodical 
cooperation  of  the  surgeon  and  the  radiologist  is  more 
strictly  demanded.  To  discuss  the  radiological  side  of 
pseudarthroses  would  therefore  be  equivalent  to  going  to 
the  bottom  of  the  study  of  these  lesions.  Now,  at  the 
present  time  this  is  not  possible,  for  “ not  a single  chapter 
of  this  study  can  be  looked  upon  as  definitely  closed  ” 
(B.  Cuneo).  Consequently  the  present  article  has  no  other 
aim  than  to  show  which  are  the  problems  set  the  radiologist 
by  the  surgeon  and  the  way  in  which  the  former  must  strive 
to  solve  them. 

It  seems  fairly  difficult,  from  the  radiological  as  well  as 
from  the  clinical  point  of  view,  to  give  a precise  definition 
of  pseudarthroses.  According  to  PI.  Mauclaire  there  is  a 
pseudarthrosis  when  the  deviation  between  the  fragments 
does  not  exceed  3 cm.;  there  is  loss  of  substanoe  properly 
so  called  when  there  is  more  than  3 cm.  deviation  between 
the  bony  extremities.  The  first  conception  that  must 
be  gained  in  the  case  of  pseudarthrosis  is  the  conception 
of  non-consolidation.  Radiological  diagnosis  between  simple 
retardation  of  consolidation  and  definite  absence  of  con- 
solidation is  often  impossible  ; it  is  therefore  advisable  to 
perform  successive  examinations,  say  one  each  month.  If 
at  the  end  of  several  months  the  extremities  of  the  bones 
not  only  do  not  present  any  apparent  growth,  but  even  seem 
to  be  decalcifying  and  becoming  atonic,  it  is  possible,  in 
view  of  this  retrograde  process,  to  discuss  the  possibility  of 
definite  non-consolidation.  Moreover,  it  is  well  to  dis- 


tinguish pseudo-losses  of  substance  by  lengthening  of  the  limb 
amongst  true  pseudarthroses  when  the  bones  are  in  contact 
from  true  losses  of  substanoe;  they  are  easily  reducible  and 
have  only  been  ascertained  in  the  case  of  the  humerus. 

The  Types  of  Pseudarthrosis. 

From  the  radiological  point  of  view  two  principal  types  of 
pseudarthroses  may  be  distinguished.  According  to  the 
aspect  of  the  bony  extremities,  they  may  be  classified  into  : 
(1)  pseudarthroses  where  the  more  or  less  fine  bony  ex- 
tremities, sometimes  lanceolate,  sometimes  regularly  trans- 
versal, do  not  present  any  growth,  whether  they  are  in 
contact  or  at  a distance  from  each  other;  (2)  pseudarthroses 
where  the  bony  extremities  on  the  contrary  present  bony 
proliferations  recalling  articular  extremities  and  presenting 
at  first  sight  a more  or  less  perfect  (Obs.  232)  and  more  or 
less  close  pseudo-articulation. 

Sometimes,  when  there  is  a deviation  between  the  two 
fragments,  one  may  find,  when  very  soft  rays  are  used, 
traces  on  the  plate  of  an  opaque  trail  which  might  be 
remains  of  subperiosteal  resection  for  removal  of  splinters 
(Obs.  320),  for  in  the  huge  majority  of  wounded  where  the 
fractured  bones  have  not  united  splinters  have  been  freely 
removed,  mostly  within  48  hours  of  being  wounded.  Some- 
times the  intervention  occurs  of  a fibrous  or  osteofibrous  callus 
between  the  two  fragments,  not  sufficiently  thick  to  appear 
as  a shadow  projected  on  the  radiograph.  This  fibrous, 
invisible  callus  of  slight  density  may  in  time  and  under 
certain  circumstances  become  progressively  ossified  ; it  may 
be  considered  as  intermediary  between  a very  soft  fibrous 
callus  which  allows  of  a certain  mobility  of  the  diaphysis, 
and  a bony  callus  which  in  time  becomes  a vicious  callus  in 
consequence  of  secondary  deformations  at  the  point  of 
fracture  or  resection.  In  fine,  all  intermediary  states 
between  pseudarthrosis  in  which  the  fine  extremities  are 
not  joined  by  any  visible  tissue  and  badly  set  fractures  are 
found  with  a more  or  less  soft  fibrous  tissue  or,  on  the  other 
hand,  more  or  less  ossified.  In  these  circumstances  it 
seems  impossible  to  attribute  any  radiological  pathogno- 
monic character  to  pseudarthroses. 

As  a result  of  radiological  examinations  the  arrest  of 
ossification  has  been  noted  several  times  and  seems  more  estab- 
lished. Such  a bony  extremity  which  seemed  to  be  putting 
forth  growth  halts  in  its  expansion  in  the  articular  type  ; 
another  ends  in  a transversal  shaft  or  in  an  oblique  spire  with- 
out proliferation.  One  would  think  that  the  two  bones  were 
struck  into  sterility,  with  impossibility  of  forming  any  conjunc- 
tion. This  phase  betrays  itself  very  often  on  the  plates  by  the 
closing  of  the  medullary  canal,  as  in  amputations.  From 
the  radiological  point  of  view  it  is  important  to  study  the 
medullary  canal  throughout  all  its  length.  One  sometimes 
finds  several  centimetres  from  the  pseudarthrosis  spots  where 
the  medullary  canal  seems  closed  a second  time,  as  in  certain 
cases  of  infantile  osteomyelitis.  (Obs.  46.)  In  general  the 
bony  tissue  is  less  thick  and  more  transparent  than  usual ; 
it  is  decalcified.  But  it  is  to  be  borne  in  mind  that  even 
with  a normal  radiological  appearance  the  bone  may  be  found 
very  pliant,  “like  cardboard,”  at  the  moment  of  interven- 
tion, or  actual  operative  interference.  (Obs.  283.) 

On  the  other  hand,  under  a linear  aspect,  a bone  may 
appear  not  joined,  and  another  bone  may  appear  to  be  grow- 
ing and  joined  on  the  plates,  whilst  intervention  shows  the 
contrary.  (Obs.  333.)  In  a case  of  double  pseudarthrosis  of 
the  forearm,  the  radius,  which  on  the  radiograph  appeared 
consolidated,  proved  on  intervention  to  be  mobile  in  a pseud- 
arthrosis of  the  close  type  ; whilst  the  ulna,  which  appeared 
in  linear  aspect  on  the  radiograph  to  be  without  growth,  was 
found  to  be  quite  solid. 

Many  wounded  men  have  come  to  the  prosthesis  centre 
with  osseous  fistulas  ; the  radiograph  has  made  it  possible 
to  recognise  the  splinters — but  without  giving  assurance 
whether  they  were  adherent  or  not — and  above  all  the 
sequestra  with  their  characteristic  bell-like  shape,  bony  islets 


The  Lancet,] 


FRENCH  SUPPLEMENT  TO  THE  LANCET. 


[August  23,  1919  333 


surrounded  by  a clear  zone.  (Obs.  13.)  The  X rays  have 
permitted  the  observation  of  the  results  of  preliminary 
operations  for  osteitis,  performed  before  the  actual  operation 
of  bone-graftiDg. 

Radiological  Study  of  the  Reformations  and  their  Reduction. 

Some  writers  have  thought  that  the  decalcification  or 
osteoporosis  of  the  extremities  in  cases  of  pseudarthrosis 
might  be  due  to  a lesion  of  the  artery  nourishing  the  bone. 
Examination  of  the  plates  enables  us  to  invalidate  this 
opinion,  which  PI.  Mauclaire  had  already  placed  in  doubt. 
Contrary  to  the  opinion  of  M.  Chutro,  the  best  argument 
lies  in  the  verification  of  osteoporosis  and  decalcification  at 
a distance,  outside  the  bone  attacked  by  pseudarthrosis. 
Observation  71  is  typical  : there  exists  a decalcification  of 
the  radius,  but  also  of  the  carpus  and  metacarpus  as 
marked  as  of  the  radius,  recalling  the  appearance  of 
certain  tuberculous  “rheumatisms.”  It  is  certain  that  lesion 
of  the  artery  nourishing  the  radius  cannot  be  made 
responsible  for  these  lesions.  Perhaps  the  ligatures  of  the 
great  trunk  arteries  of  the  limbs  are  more  important. 

The  X rays  give  us  information  about  some  certainly 
rare  results  of  the  forms  of  treatment  given  to  the  wounded 


determine  the  frontal  and  lateral  correspondences  on  which 
the  graft  is  to  be  made. 

It  may  be  laid  down  as  a rule  that  in  all  cases  where  a 
bone  has  suffered  loss  of  substance  there  is  produced 
automatically  a frontal  deformation  and  often  a deviation 
from  the  axis  on' the  part  of  one  or  both  fragments.  It  is 
most  important  to  investigate  these  deformations  in  order  to 
correct  them  as  far  as  possible  before  intervention.  We 
have  here  an  indication  not  to  put  off  intervention  too 
long  in  the  case  of  wounded  men  ; the  deformations  are 
the  more  marked  and  difficult  to  reduce  the  older  the 
cases  are.  Experience  shows  that  this  reduction  of 
deformity  cannot  always  be  made  at  the  moment  of  inter- 
vention, even  with  the  powerful  forceps  of  the  Heitz- 
Boyer  or  B.  Cuneo  types.  As  a matter  of  fact,  the 
deformities  would  inevitably  have  a tendency  to  reproduce 
themselves,  after  reduction,  accompanied  by  much  loss  of 
blood,  under  anaesthetics.  On  the  contrary,  the  facts  show 
that  the  reduction  of  bony  deformations  before  operation  in 
pseudarthroses  must  be  slow,  gentle,  with  continuous  progres- 
sive traction.  The  devices  invented  by  P.  Rolland,  head  of 
the  laboratory  of  the  Centre  for  Osseous  Prosthesis  at  Cannes, 
are  based  on  this  idea.  But  if  the  general  principles  are 


i) 


Fig.  1. — Deviation  of  the  inferior 
segment  of  the  radius  in  con- 
sequence of  a loss  of  substance  of 
10  cm. 


Fig.  2. — Progressive  reduction  of  the  displacement 
of  the  inferior  fragment  of  the  radius  in  Pig.  1 
with  the  aid  of  a corrective  appliance  with  screws 
applied  to  the  ulnar  side  and  over  the  metacarpal 
bones. 


Fig.  3.— Pseudarthrosis  of  the 
ulna.  The  plate  shows  the 
deviation  of  the  superior  frag 
ment  of  the  ulna  towards  the 
radial  diaphysis.  There  is  a 
separation  between  the  rad'al 
cupule  and  the  humeral  condyle, 
and  there  is  also  a subluxation 
outwards  of  the  ladial  cupule. 


before  their  admission  to  the  centre  for  bony  grafts  : Very 
prolonged  immobilisation  or  simple  removal  of  morbid  parts, 
with  the  same  hopeless  state  of  sterility  of  the  bony 
extremities,  verified  by  radiography  for  several  months  in 
succession  ; bone  sutures  after  such  removals  with  wires  which 
end  either  by  breaking  or  by  sawing  through  the  bony 
extremities  which  they  are  intended  to  keep  in  contact 
(Obs.  18) ; application  of  metallic  plates , which  sometimes 
produce,  on  the  side  opposed  to  the  plate,  proliferous  osteitis, 
often  of  great  size  (Obs.  500),  presenting  the  appearance 
of  an  inflammatory  type  of  osteitis  ; application  of  clasps , 
which  in  spite  of  their  perfect  application  have  not  been 
able  to  bring  about  (Obs.  285)  any  bony  proliferation  of  the 
extremities  ; pegging  with  ivory  or  segments  of  the  fibula,  in 
spite  of  which  the  mobility  has  persisted.  (Obs.  320.) 

Far  more  important  than  the  information  given  as  to  the 
structural  state  is  the  radiological  study  of  the  deformations 
of  the  bone  before  operation.  Examination  by  X rays  is  here 
of  capital  importance.  Clinical  examination  alone  cannot 


uniform,  the  application  is  and  must  be  particular  to  each 
case,  after  examination  of  the  plates.  And  so  X rays  are 
wanted  first  of  all  to  ascertain  the  deformations  in  such  a 
way  as  to  give  instructions  for  constructing  the  apparatus, 
then  in  order  to  judge  of  the  successive  advances  of  the 
reduction,  and  lastly  in  order  to  decide  on  intervention 
when  the  maximum  reduction  has  been  attained. 

Prevalent  Deformities  of  Particular  Limbs. 

It  is  interesting  to  note  for  each  limb  the  deformations 
most  usually  ascertained  on  the  plates. 

Forearm. — Pseudarthroses  of  the  radius,  especially  in  its 
middle  part,  without  and  still  more  with  loss  of  substance 
amounting  even  to  several  centimetres,  produce  a deforma- 
tion which  may  be  called  characteristic.  (Obs.  71.)  Viewed 
from  the  front  the  inferior  radial  fragment  has  a marked 
inward  deviation,  and  its  superior  extremity  places  itself 
before  or  behind  the  ulna.  This  deformation  is  sometimes  so 
great  that  it  can  be  felt  on  the  ulnar  edge  of  the  forearm. 


334  The  Lancet,] 


FRENCH  SUPPLEMENT  TO  THE  LANCET. 


[August  23,  1919 


(Fig.  1.)  There  follows  an  ascension  of  the  radial  styloid 
which,  instead  of  being  below  the  ulnar  styloid,  reaches  the 
same  or  even  a higher  level ; there  is  a projection  outwards 
from  the  carpal  group.  Viewed  laterally,  it  sometimes 
shows  on  the  plate  exactly  like  the  back  of  a fork  on  the 
posterior  or  anterior  face  of  the  forearm.  However  marked 
these  deviations  may  appear  on  the  radiograph,  they  are 
generally  reducible  by  means  of  the  apparatus  of  P.  Rolland. 
(Fig.  2.)  As  for  the  superior  fragment  of  the  radius,  it  is 
in  general  less  inclined  towards  the  ulna  ; it  is  often  found 
in  light  flexion,  and  most  often  in  rotation  ; on  the  whole, 
a radius  is  found  in  pronation  as  regards  its  inferior 
fragment  and  in  supination  as  regards  the  superior 
fragment.  From  the  radiological  point  of  view  it  is 
difficult  to  estimate  the  amount  of  supination  of  the 
superior  fragment ; it  is  therefore  advisable  in  such  cases 
to  take  plates  of  the  limb  on  the  healthy  side  in  absolutely 
pronate  and  supine  positions  as  well  as  in  intermediate 
positions,  in  order  to  judge  by  comparison,  relying  above  all 
on  the  bicipital  tuberosity.  (Obs.  407.) 

Losses  of  substance  of  the  ulna  may  bring  about  a falling 
back  of  the  superior  humeral  fragment,  together  with  a 
raising  of  the  inferior  fragment  on  the  anterior  face  of  the 
forearm.  (Obs.  246.)  Laterally  there  may  exist  a deviation 
of  the  two  fragments  of  the  ulna  towards  the  radius,  forming 
the  shape  of  a capital  K.  (Obs.  401.) 

But  whether  the  radius  or  the  ulna  be  involved,  it  is 
important  to  recognise  one  fact  which  is  marked  at  the 
outset  and  only  accentuated  in  the  sequel — viz.,  the  incurva- 
tion of  the  healthy  bone  in  isolated  pseudarthroses  of  the  fore- 
arm. Radius  curvus  is  extremely  frequent  in  pseudarthroses 
of  the  ulna,  and  ulna  curva  in  pseudarthroses  of  the  radius. 
They  may  be  observed  even  with  a minimum  loss  of 
substance.  (Obs.  317.)  The  incurvation  may  be  axial, 
causing  the  interosseous  space  to  disappear  (Obs.  16),  or 
peripheral.  In  the  course  of  intervention  any  attempt  at 
reduction  is  most  difficult,  if  not  impossible.  Obs.  36  is 
characteristic  on  this  point : 

“Wounded  man  presenting  pseudarthrosis  with  inward 
deviation  of  the  radius,  in  contact  with  the  ulna.  After 
resection  of  the  fragments  it  is  impossible,  in  spite  of  all 
efforts,  in  the  course  of  the  intervention  to  put  the  two 
fragments  indirect  prolongation  of  each  other.” 

It  must  be  added  that  an  incurved  radius  or  ulna  has  a 
quite  natural  tendency  to  become  exaggerated  in  the  sequel. 
Consequently  B.  Cuneodoes  not  fail  to  draw  attention  in  the 
discharge  papers  of  wounded  men  who  have  declined  inter- 
vention to  the  possible  aggravation  of  the  ulterior  functional 
prognosis. 

Both  in  simple  pseudarthroses  and  in  double  pseudarthroses 
(Obs.  15,  30)  one  can  observe  radio-ulnar  synostoses.  Always 
more  marked,  more  extensive,  and  more  dense  at  the  time  of 
intervention  than  appears  on  examination  of  the  radiological 
plates,  these  synostoses  are  in  themselves  causes  of  super- 
added  deviations. 

With  all  these  deformations,  exaggerations  of  pronation 
and  supination,  incurvations  and  synostoses,  reactions  on  the 
adjoining  articulations  are  naturally  expected.  With  regard 
to  the  articulation  of  the  wrist  all  degrees  of  subluxation 
may  be  found  ; external  subluxation  pushing  the  cuneiform 
and  the  pisiform  within  the  axis  of  the  ulna  and  causing  the 
ulnar  styloid  to  rise  beneath  the  skin  (Obs.  264) — internal 
subluxation  with  the  scaphoid  and  semilunar  separated  from 
their  facets  at  the  inferior  extremity  of  the  radius.  (Obs.  100.) 
With  regard  to  the  articulation  of  the  elbow,  an  external 
radio-humeral  subluxation  can  be  verified.  (Obs.  15,  84.) 
(Fig.  3.)  The  older  the  pseudarthroses  involved  the  more 
frequent  and  marked  are  the  subluxations. 

Upper  arm. — Solutions  of  continuity  of  the  humerus  have 
as  corollary  a forward  flexion  of  the  inferior  fragment  on  the 
fold  of  the  elbow;  the  flexion  may  exceed  45°.  (Obs.  66.) 
This  swing  of  the  inferior  fragment  is  also  accompanied  by 
an  inward  or  outward  twist.  It  is  useful  to  know  this  fact 
in  order  to  interpret  the  plates,  which  on  a first  examination 
would  give  the  impression  of  a lesion  of  the  elbow,  whilst 
it  is  really  a matter  of  a faulty  position.  On  the  other 
hand,  it  is  hard  or  even  impossible  to  correct  this  faulty 
position  at  the  time  of  taking  the  radiograph,  for  this  torsion 
is  sometimes  accompanied  by  an  ankylosis  (at  least  func- 
tional) of  the  elbow  ; the  olecranon  then  appears  hidden  by 
the  epicondyle  or  the  epitrochlea,  whilst  it  ought  to 
appear  clearly  disengaged  below  the  condyle  or  the  cochlea. 


(Obs.  31.)  This  deformation  is  common  in  pseudarthroses  of 
the  middle  third,  but  especially  so  in  those  of  the  inferior 
third  ; it  is  then  often  combined  with  a twist  or  deviation 
from  the  axis  of  the  superior  fragment.  As  to  abduction  of 
the  superior  fragment,  it  has  been  verified  particularly  in 
pseudarthroses  of  the  superior  third. 

Thigh. — Two  deviations  are  particularly  met  with  in 
pseudarthroses  of  the  femur  : ahduotion  of  the  superior  frag- 
ment and  backward  lapse  of  the  inferior  fragment.  (Fig.  4.) 
The  abduction  takes  place  in  pseudarthroses  situated  high 
up  (Obs.  135)  or  pseudarthroses  of  the  lower  third.  (Obs.  59.) 
It  is  progressive  and  very  difficult  of  reduction,  either  under 
chloroform  or  by  means  of  corrective  apparatus  before  opera- 
tion. The  same  is  true  of  the  lower  fragment ; its  reduction 
is  very  difficult  in  pre-operative  stage. 

Leg. — The  deformations  of  the  leg  recall  the  usual 
deformations  in  fractures  : flexion  and  backward  swing  of 
the  fragments.  Sometimes  there  is  conjoined  with  it  either 
an  attraction  of  the  tibia  towards  the  fibula  forming  the 
picture  of  a capital  K,  or,  on  the  contrary,  a lozenge-shaped 

0 separation.  But  it  is  above  all  important  to  examine  the 


articular  modifications  at  the  level  of  the  knee  and  the 
instep.  At  the  knee  there  may  exist  either  an  internal 
subluxation  (Obs.  88),  or  a marked  separation  between  the 
external  condyle  and  the  external  tibial  plateau  (Obs.  126). 
At  the  instep  there  may  be  an  outward  lapse  of  the  astra- 
galus ; with  regard  to  the  fibula,  the  tibio-fibular  diastasis 
must  be  investigated. 


The  Responsibility  of  the  Radiologist  Before  and  After 
Intervention. 


Such  are  the  bone  deformations  which  may  be  met  with 
in  pseudarthroses  before  intervention.  From  the  point  of 
view  of  radiological  technique  there  follows  for  the  radio- 
logist the  indication  to  take  a plate  of  the  whole  bone 
segment  (diaphysis  and  epiphyses)  and  of  the  nearest 
articulations.  It  is  very  frequently  useful  to  take  a plate 
of  all  the  opposite  healthy  bone  segment  in  order  to  judge 
of  the  often  very  small  differences  in  the  articular  relations. 
Moreover,  the  radiologist  must  strive  to  place  the  limb  to  be 
radiographed  in  the  most  favourable  anatomical  position. 
Where  this  is  impossible  stereoscopic  radiography  is  useful  to 
allow  of  estimating  the  relationships  of  the  two  fragments  to 
each  other  and  the  mutual  obliquity  of  their  separation. 
Finally,  in  the  case  of  lengthening  or  shortening  of  the  limb 
radioscopic  examination  can  be  useful  before  intervention,  in 
order  to  mark  on  the  skin  the  point  corresponding  to  the 
pseudarthrosis,  so  as  to  permit  the  surgeon  to  centralise  his 
incision.  In  general  all  plates  (from  30/40  to  13/18)  are 
reduced  to  glass  positives  9,12.  They  are  more  easy  to  read 
as  a series,  especially  with  a strong  magnifying  glass. 
Stereoscopic  plates  are  reduced  to  glass  positives  45/107,  so 
as  to  be  examined  as  a series  in  a Richard’s  taxiphote. 

According  to  the  practice  of  B.  Cuneo  intervention  con- 
sists in  taking  an  inlay  from  the  tibia,  of  such  length  and 
breadth  that  it  can  be  fixed  in  the  two  grooves  cut  in  the 
superior  and  inferior  fragments  of  the  bone  to  be  grafted. 
P.  Rolland’s  apparatus  made  by  the  firm  of  Barriquand  and 
Marre,  a first  model  of  which  has  been  presented  to  the 
Surgical  Society  by  B.  Cuneo,1  allows  with  the  greatest 
precision  of  cutting  mortises  and  inlays  from  an  inlay  of 
21  cm.  in  length  by  15  mm.  in  breadth  placed  on  a tibia 
(Obs.  293),  to  an  inlay  3 cm.  long  and  3 mm.  broad  placed 
on  a phalanx.  (Obs.  319.)  The  fixation  of  the  inlay  in  the 
mortises  is  performed  by  means  of  metallic  cables  of  soft 
galvanised  steel  either  round  the  bone  or  through  the  bone 
by  means  of  drilling.  In  order  to  be  immobilised  as 
rigorously  as  possible  the  limb  is  finally  placed  either  in 
P.  Rolland's  appliances  of  moulded  leather  or  in  plaster 
appliances.  ] 

B.  Cuneo  teaches  that  in  order  to  obtain  a good  result 
there  must  be  intimate  contact  between  the  faces  of  the 
inlay  and  the  mortises,  so  as  to  establish  reciprocal  penetra- 
tion of  the  vessels  of  the  recipient  bone  into  the  inlay.  But 
above  all  things  this  contact  must  be  very  prolonged  (nearly 
a year)  and  remain  as  perfectly  intimate  as  possible.  Now, 
after  intervention,  as  the  result  of  haematoma  or  of  suppura- 
tion in  the  first  days,  after  cicatrisation  following  on 
muscular  atrophy  in  the  following  months,  the  volume  of  the 
member  placed  in  the  containing  appliance  may  vary  as 


i B.  Cuneo : Soc.  de  Chir.,  June  25th,  1918. 


The  Lancet,] 


FRENCH  SUPPLEMENT  TO  THE  LANCET. 


[August  23,  1919  335 


Fig.  4. — Pseudarthrosis  of  the  femur.  The 
superior  fragment  is  in  abduction,  the 
inferior  in  adduction. 


Pig.  5. — Osteoperiosteal  graft  of  the 
radius  performed  without  previous 
correction.  The  plate  shows  the 
disappearance  of  the  inter-radio- 
ulnar interosseous  space.  There 
is  also  an  ascension  of  the  radial 
styloid  apophysis. 


Fig.  6.— Pseudarthrosis  of 
the  tibia.  Bony  graft  per- 
formed without  reduction 
before  intervention.  After 
intervention,  in  which  the 
reduction  was  only  tem- 
porary, progressive  post- 
operative deformation. 


2 to  1.  Radiological  examination  is  indispensable  to  know 
whether  the  graft  has  remained  in  its  proper  place  and  in 
proper  contact  with  the  bony  extremities.  It  is  advisable 
to  watch  it  by  repeated  examinations  ; the  radiograph  only 
allows  us  to  know  whether  the  inlay  has  really  remained  in 
contact.  If  there  is  any  slight  displacement  the  plates 
show  us  in  which  direction  it  must  be  reduced  when  bringing 
a fresh  appliance  into  use.  Radiological  examination 
is  all  the  more  important  in  the  consequences  of 
operations  for  pseudarthrosis,  as  two  factors  may  dis- 
place the  inlay  during  the  phase  of  cicatrisation — 
firstly,  the  prolonged  presence  of  the  wires  sustaining 
the  inlay ; secondly,  the  tendency  of  the  fragments  of  the 
bone  to  reproduce  progressively  the  same  deformations  which 
we  have  noticed  above  in  the  examination  of  the  bone  before 
operation.  With  regard  to  the  metal  mires  which  sustain  the 
inlay,  radiography  shows  us  two  evolutions  of  the  holes 
drilled  at  the  time  of  intervention  in  order  to  pass  the  wires. 
The  hole  may  either  remain  the  same  in  size  as  when  first 
drilled,  or  it  may  become  enlarged  in  the  proportion  of 
1 to  3.  (Obs.  66.)  It  is  clear  that  in  these  conditions  of 
enlargements  of  the  holes,  due  either  to  a very  slow  sawing 
action  of  the  bone,  or  perhaps  to  electrolytic  phenomena, 
the  imperfect  immobilisation  of  the  inlay  as  revealed  by  the 
plates  must  be  removed  by  corrective  appliances.  As  to 
secondary  deformations , it  cannot  be  repeated  too  often  that 
limbs  affected  with  pseudarthrosis,  even  when  reduced  before 
intervention,  have  a tendency  to  reproduce  the  ante-opera- 
tion deformations  after  intervention.  (Figs.  5 and  6.)  The 
same  muscular,  tendinous,  and  even  cutaneous  causes  pro- 
duce the  identical  results  after  intervention.  It  is  desirable 
to  watch  the  deviations  in  the  containing  appliances,  and 
even  sometimes  to  apply  corrective  appliances  with  con- 
tinuous, very  slow  and  gentle  extension,  just  as  in  the 
attempts  at  straightening  and  correction  before  the  operation. 

The  Technique  of  Intervention. 

The  inlay  must  be  maintained  in  its  proper  place, 
directly  by  metallic  wires  operating  at  the  point  of  contact, 
indirectly  by  retaining  and  reducing  appliances  which  operate 
chiefly  to  hinder  secondary  deviations  of  the  bone  fragments 
and  to  avoid  partial  or  total  luxations  of  the  inlay  outside 
of  the  mortises.  Numerous  facts  have  shown  the  value  of 
this  intimate  and  necessary  contact — e.g.,  the  following 
observation  (Obs.  29)— which  has  all  the  value  of  a real 
experience  : — 

“Wounded  man  presenting  a fracture  of  the  second 
metacarpal  necessitating  excision  of  four-fifths  of  the  second 
metacarpal.  In  spite  of  subperiosteal  ablation  no  bony 
regeneration.  A third  metatarsal  was  grafted  in  place  of 


the  wanting  metacarpal.  Intervention  took  place  on  account 
of  the  non-regeneration  and  especially  of  the  functional 
trouble  of  the  index  which  placed  itself  faultily  under  the 
medius  in  flexion.  Eight  months  afterwards  a radiograph 
taken  from  the  front  shows  that  the  head  of  the  grafted 
metatarsal,  which  had  at  first  retained  its  normal  original 
configuration  and  structural  aspect,  has  now  become  com- 
pletely atrophied,  has  disappeared  as  to  its  external  radial 
half  and  become  rarefied  and  decalcified  as  to  its  internal 
ulnar  half.  But  above  all  the  radiograph  of  the  profile 


Fig.  7.— Inlay  placed  cn  a long  loss 
of  substance  of  the  radius  after 
reduction  of  the  inferior  fragment 
before  intervention.  (Comp.  Fig.  2.) 
As  a precaution  the  reducing  appa- 
ratus has  been  left  in  place  after 
intervention  to  prevent  secondary 
deplacements. 


Fig.  8. — Evolution  of  a graft  of 
16  cm.  placed  on  a loss  of  sub- 
stance of  the  radius.  The 
inlay  is  being  sheathed  pro- 
gressively by  the  bony 
tissue  which  seems  to  start 
from  the  extremities  of  the 
bones  on  which  the  inlay  has 
been  grafted. 


336  The  Lancet,] 


FRENCH  SUPPLEMENT  TO  THE  LANCET. 


[August  23,  1919 


shows  that  the  segment  of  the  metatarsal,  resting  in  a small 
groove  at  the  base  of  the  metacarpal,  is  now  shifted;  the 
grafted  metatarsal  is  now  displaced  forwards  and  outwards 
in  the  palm,  losing  all  contact  with  the  stump  of  the 
metacarpal. 

A second  intervention  consisted  in  placing  the  two  bones 
in  contact  by  means  of  a metal  wire.  Successive  radiographs 
have  shown  that  the  head  of  the  metatarsal  has  not  only 
ceased  its  regressive  process,  but  has  also  become  markedly 
recalcified.” 

In  this  case  radiography  has  shown  that  a grafted  bone 
atrophies  when  it  has  lost  its  vasculo-nervous  contacts  with 
the  receiving  bone  of  the  graft.  But  provided  that  the 
contacts  are  re-established,  there  is  not  only  an  arrest  of 
atrophy,  but  there  is  also  a marked  tendency  to  reparation 
and  recalcification. 

As  to  the  inlay,  it  follows  that  if  the  inlay  dislocates  itself 
entirely  and  slips  out  of  the  mortises  its  work  on  the  bony 
extremities  completely  ceases.  The  fact  is  proved  still 
better  in  the  case  when  the  inlay  is  dislocated  at  one  of  its 
ends  and  remains  in  osseous  contact  at  the  other.  The  first 
remains  sterile  and  makes  a new  pseudarthrosis  ; the  second 
continues  in  osseous  proliferation  on  the  good  path  of  bony 
reparation  of  the  extremity  with  which  it  has  remained  in 
contact.  (Obs.  18,  arm  ; Obs,  10,  leg.)  These  dislocations 
are  the  more  important,  as  they  may  be  accompanied  by 
fracture  of  the  inlay  (Obs.  19)  at  the  time  when  the  inlay  is 
passing  through  a period  of  atrophy,  regression,  or  softening. 
Further,  to  study  the  typical  method  of  reparation  of  the 
extremities  of  the  bone  and  the  evolution  of  the  inlay  it  is 
advisable  to  examine  the  plates  of  a case  where  the  inlay  has 
retained  intimate  contact  with  the  mortises,  without  secondary 
deviations  of  the  bony  segments,  throughout  several  months. 
(Fig.  7.)  The  diagram,  issued  by  B.  Cuneo  to  the  Society 
for  Surgery,  of  the  evolution  of  a graft  for  loss  of  substance 
of  the  ulna  is  characteristic.  In  the  first  month  one  may 
not  see  any  perceptible  structural  modification  on  the  plates, 
but  in  the  second  or  third  month  one  sees  two  kinds  of 
modification  of  the  inlay.  Its  two  bony  extremities  in 
contact  with  the  mortises  seem  to  be  lightly  atrophied,  or, 
more  precisely,  appear  to  be  becoming  a little  decalcified, 
whilst  the  middle  part  of  the  inlay  seems  to  undergo  hyper- 
trophy. It  must  be  noted  that  the  atrophy  of  the  extremities 
and  the  hypertrophy  of  the  middle  part  occupy  the  medullary 
zone  of  the  inlay  ; on  the  other  hand,  the  cortical  sub- 
periosteal zone  of  the  inlay  does  not  undergo  any  modifications 
at  this  time. 

At  the  level  of  the  bony  extremities  the  bones  which  have 
been  cut  transversely  appear  in  the  second  and  third  month 
to  be  budding  out  in  conical  shape  towards  the  inlay,  espe- 
cially on  its  medullary  face,  as  if  to  sheathe  the  inlay. 
(Fig.  8. ) It  follows  that  the  intersegmentary  zone  diminishes  ; 
it  is  easy  to  measure  on  the  plates  (taken  at  the  same  dis- 
tance) the  distance  between  the  segments  of  the  bone  during 
the  subsequent  days  and  months.  This  distance  diminishes 
progressively,  especially  in  the  fourth  month.  Later  on  the 
two  bony  cones  come  into  contact,  and  the  inlay  appears 
like  a prop  which  the  two  extremities  of  the  bone  sheathe 
completely.  Even  after  a year  (Obs.  18)  it  is  easy  to  trace 
the  inlay  on  the  plates,  perhaps  somewhat  modified  as 
regards  density  and  volume,  in  the  midst  of  the  new  bony 
growth  of  the  extremities. 

As  regards  the  subperiosteal  cortical  face  of  the  inlay,  one 
sees  a kind  of  atrophy  from  the  fourth  to  the  sixth  month, 
revealing  itself  on  the  plate  by  a wavy  line  which  contrasts 
with  the  linear  straightness  of  this  vertical  face  immediately 
after  intervention.  This  atrophy  usually  appears  in  the 
centre  part  of  the  inlay.  If  this  atrophy  is  exaggerated, 
either  as  the  result  of  too  prolonged  suppuration  (Obs.  246) 
or  of  a loss  of  contact  which  suppresses  vascularisation  by 
tearing  the  newly  formed  vessels  (Obs.  84),  necrosis  in  the 
first  case  and  reabsorption  in  the  second  may  produce  a 
sequestrum,  usually  lamellar,  which  is  isolated  and  is  very 
easy  to  remove  secondarily.  If  these  lesions  reach  a greater 
degree  one  can  see  on  the  plates  such  a loss  of  substance  and 
such  a degree  of  atrophy  that  the  inlay  may  present  a veritable 
spontaneous  fracture.  Finally,  the  entire  loss  of  contact  or 
exaggerated  suppuration  may  end  in  either  complete  atrophy 
of  the  inlay  and  its  disappearance,  or  in  a state  of  free 
foreign  body,  necessitating  excision.  (Obs.  167.)  It  is 
possible  that  even  with  the  inlay  removed  the  bony  extremities 
may  continue  to  grow,  as  if  by  some  osteotropic  power 
(Imbert) ; the  inlay  has,  by  its  temporary  presence,  given 
some  proliferative  power  to  replace  sterility. 


There  remains  the  reparation  of  the  tibia  from  which  the 
inlay  has  been  taken.  Radiographic  series  show  that  the 
closing  up  of  the  bone  is  radiologically  finished  between  the 
third  and  sixth  month  ; by  means  of  palpation  it  can  often 
be  established  clinically  in  advance  of  radiology. 

In  Conclusion. 

Such  is  in  brief  the  information  which  radiology  can  give 
in  pseudarthroses  and  their  treatment  by  bony  grafts.  But 
in  spite  of  the  precision  of  the  structural  details  and  the 
knowledge  about  the  deviations  before  intervention,  in  spite 
of  the  information  furnished  about  the  evolution  of  the  graft 
and  the  reparation  of  the  extremities  of  the  bone,  it  is 
necessary  to  be  quite  clear  that  it  does  not  do  to  ask  more 
from  the  X rays  than  they  can  supply.  Radiology  may 
reveal  many  details,  but  it  cannot  reveal  them  all  ; once 
more  it  is  only  the  complement  of  clinical  observation.  With 
these  reservations  it  must  also  be  borne  in  mind  that  in 
order  to  obtain  the  maximum  of  precision  the  plates  must  be 
examined  long  and  often  ; they  must  be  compared  with  each 
other  and  with  cases  already  operated  upon  ; in  a word,  a 
reasoned  diagnosis  of  a radiograph  must  be  made,  bearing 
in  mind  the  causes  of  error,  deformations  of  the  plates  and 
superadded  invisible  elements.  Understood  in  this  way 
radiology  seems  to  be  a valuable  auxiliary  in  the  surgical 
treatment  of  pseudarthroses.  As  such  B.  Cuneo  has  studied 
it  with  all  the  authority  which  attaches  to  his  work. 


The  French  Supplement  to  The  Lancet — under  the 
Editorial  Direction  of  Professor  Charles  Achard,  Professor 
of  Pathology  and  Therapeutics  in  the  University  of  Paris; 
and  Dr.  Charles  Flandin,  D.S.O-,  Medecin-Major  de  2me 
Classe,  Chef  de  Clinique  a la  Faculte  de  Paris— has  appeared 
on  the  dates  given  in  the  following  list,  which  sets  out 
the  titles  and  authors  of  the  contributions 
Sept.  21st,  1918  : (1)  The  Microbic  Diversity  of  the  Enteric 
Fevers,  by  Professor  Achard.  (2)  Post-Typhoid  Atony  of  the 
Caecum,  by  Maurice  Loeper,  Professor  of  the  Faculty  of 
Medicine  and  Physician  to  the  Paris  Hospitals. 

Oct.  19th,  1918:  (1)  What  the  War  has  Taught  Us  about 
Tetanus,  by  Louis  Bazy.  (2)  Tetanus  Consecutive  to  Super- 
ficial Wounds  and  to  Trench  Foot : Treatment  and  Prevention, 
by  Professor  Raymond,  Medecin  Principal  de  2me  Classe. 

Nov.  30th,  1918 : (1)  General  Review  of  French  Cardio- 
Pathology  during  the  War,  by  Ch.  Laubry,  Physician  to  the 
Paris  Hospitals,  Medecin  Major  de  2me  Classe.  (2)  Methods 
of  Estimating  Augmentation  in  Depth  of  Volume  of  Left 
Ventricle,  by  Dr.  Bordet,  Director  of  the  Radiological  Labo- 
ratory of  the  Centre  of  Cardiology  of  Professor  Vaquez, 
Hopital  St.  Antoine. 

Jan.  11th,  1919 : (1)  Gunshot  Concussion  of  the  Spinal 
Cord,  by  Henri  Claude,  Professor  in  the  Paris  Faculty  of 
Medicine,  Physician  to  the  Paris  Hospitals;  and  Jean 
Lhermitte,  formerly  Chef  de  Clinique  in  the  Paris  Faculty  ' 
of  Medicine.  (2)  Contribution  to  the  Study  of  the  Manifes- 
tations of  Emotional  Shock  on  the  Battlefield,  by  Cl.  Vincent, 
Physician  to  the  Paris  Hospitals,  formerly  Medical  Officer 
to  the  46th  and  98th  R.I.  and  to  the  44th  B.C.P. 

March  1st,  1919 : The  Surgical  Complications  following 
Exanthematic  Typhus,  by  Dr.  Paul  Moure  and  Dr.  Etienne 
Sorrel,  Prosectors  to  the  Faculty  of  Medicine.  Paris,  M^decins 
Aide-Majors  de  ler  Classe,  Surgeons  to  the  French  Hospital 
at  Jassy.  , _ 

April  5th,  1919  : (1)  Nervous  Complications  of  Exanthe- 
matic Typhus,  by  A.  Devaux,  formerly  Interne  of  the  Paris 
Hospitals,  Medecin-Major  de  2me  Classe.  (2)  Note  on  the 
Epidemic  Diseases  Observed  in  Rumania  during  the 
Campaign  of  1916-17,  by  Dr.  Henri  Vuillet,  late  Interne  of 
the  Paris  Hospitals. 

May  3rd,  1919  : (1)  Malaria  During  the  War,  by  G.  Paisseau, 
Medecin-Major  de  2me  Classe.  (2)  Distribution  of  Soldiers, 
Temporarily  Unfit  through  Malaria,  in  Agricultural  Colonies, 
by  Professor  E.  Jeanselme.  (3)  Studies  on  Renal  Function 
in  Chronic  Nephritis,  thesis  by  Pasteur  Vallery-Radot,  I 
reviewed  by  Professor  Charles  Achard. 

June  21st,  1919  : (1)  Recent  Work  on  Cerebro-spinal  Fever, 
by  C.  Dopt9r,  Professor,  Val-de-Grfice,  Medecin-Chef  to  an 
Infantry  Division.  (2)  Meningococcal  Rheumatism  and 
Arthritis,  by  Dr.  Paul  Sainton,  Physician  to  the  Paris 

Hospitals.  ___ 

THE  LANCET  can  be  ordered  through  any  Library  in  Franoe,  or 
through  the  following  special  agents 
PARIS.— Masson  et  Cie.  120,  Boulevard  St,  Germain. 

Emile  Bougault,  48,  Rue  des  Ecoles. 

Ca.  BoULANQfi,  14,  Rue  de  l’Ancienne  Comedie. 

Felix  Alcan,  108,  Boulevard  St.  Germain. 

M.  Choisnet,  30,  Rue  des  St.  P£res. 

H.  Le  Soudier,  174,  Boulevard  St.  Germain. 

Maloine  et  Fils,  27,  Rue  de  l'Ecole  de  Medecine. 

Vigot  Freres,  23,  Rue  de  l'Ecole  de  Medecine. 

MARSEILLES. — Tacussel  and  Lombard,  54,  Rue  Paradis. 
TOULOUSE. — Edouard  Privat,  14,  Rue  des  Arts. 


Thb  Lancet,] 


SMALL-rOX  ON  THE  CONTINENT. 


[August  23,  1919  337 


THE  LANCET. 


LONDON:  SATURDAY,  AUGUST 23,  1919. 


Small-Pox  on  the  Continent. 

The  recent  increased  incidence  of  small-pox  on 
the  continent  of  Europe  is  likely  to  give  rise  to 
some  uneasiness  among  those  who  are  acquainted 
with  the  comparatively  unprotected  state  of  a large 
section  of  our  population  against  the  onset  of  this 
dangerous  and  infectious  disease.  The  present 
circumstances,  as  we  have  on  previous  occasions 
pointed  out,  are  entirely  favourable  to  the  spread 
of  small-pox  to  our  shores.  Hundreds  of  thousands 
of  soldiers  are  returning  from  the  various  war 
zones,  in  some  of  which  small-pox  has  lately  been 
occurring,  and  the  pent-up  trade  and  shipping,  so 
long  restrained  by  the  war,  are  now  being  let  loose 
and  bringing  many  passenger  ships  and  cargo  boats 
to  British  ports  from  the  Mediterranean  littoral, 
the  Baltic,  and  the  Black  Sea,  in  all  of  which  regions 
small-pox  was  recently,  or  still  is,  occurring  in 
epidemic  form.  A brief  outline  of  the  incidence  of 
small-pox  on  the  continent  during  the  first  half  of 
the  present  year,  so  far,  at  least,  as  information  is 
available,  may  help  the  reader  to  gauge  the  extent 
of  the  danger  already  threatening  this  country — a 
danger  which  in  the  late  autumn  may,  in  our 
opinion,  become  still  more  acute  and  menacing. 

Up  to  the  middle  of  June  2586  small  pox  cases 
had  been  notified  in  Germany,  of  which  734  were 
referred  to  the  city  of  Dresden,  which  lies  not  very 
far  from  the  borders  of  Austria.  The  disease  has 
also  been  occurring  at  several  ports  along  the 
German  shores  of  the  Baltic,  including  Danzig, 
Stettin,  Sweinemiinde,  and  Konigsberg.  In  the 
interior  outbreaks  were  reported  in  several  cities, 
among  which  were  Berlin,  Baden-Baden,  Aachen, 
Leipzig,  Frankfort,  and  Hanover.  At  the  last- 
named  town  the  outbreak  began  in  a camp  in  which 
Russian  prisoners  of  war  were  interned.  Previous 
to  the  war  Germany  occupied  a high  position  as 
regards  its  vaccination  and  revaccination,  and  its 
resulting  comparative  immunity  from  the  ravages 
of  small-pox,  notwithstanding  frequent  importa- 
tions of  the  infection  from  Russia  and  Austria. 
The  withdrawal  for  war  service  of  many  medical 
practitioners  in  Germany  from  practice  and 
from  public  appointments,  including  that  of 
public  vaccinator,  no  doubt  served  to  upset  the 
routine  arrangements  for  vaccination  and  revaccina- 
tion. Another  factor  favouring  recent  small-pox  in 
Germany  has  been  the  presence  of  large  numbers  of 
unvaccinated  Russian  prisoners  of  war,  whom,  even 
after  the  cessation  of  hostilities,  it  was  impossible 
to  repatriate.  Very  little  information  has  come 
to  hand  from  Austria,  but  small-pox  is  known  to 
have  been  recently  prevalent  in  Vienna,  Prague, 
and  other  places.  At  Budapest,  the  Hungarian 
capital,  there  has  been  a sharp  outbreak  of  the 
disease.  Italy  of  late  has  been,  and  still  is, 
suffering  from  a widespread  epidemic  of  small  pox. 
In  the  seven  weeks’  period  ended  July  6th  4645 
cases  of  the  disease  were  reported.  During  the 
month  of  June  small-pox  occurred  at  some  Italian 
ports,  including  Bisceglia  with  232  cases  and 
Taranto  335  cases,  both  ports  being  situated  on  the 
Adriatic  coast  of  the  province  of  Bari.  At  the 


Sicilian  port  of  Trapani  230  cases  were  notified 
during  the  month.  Outbreaks  also  occurred  at  a 
number  of  towns,  including  Naples  and  Pagani. 
In  Greece  small  pox  has  been  prevalent  at  Salonica, 
where  42  deaths  have  been  certified  from  it ; cases 
have  also  been  occurring  at  the  port  of  Cavalla  and 
on  the  island  of  Corfu.  There  has  been  a 
recent  epidemic  of  small  pox  in  Roumania,  and 
in  the  four  weeks  ended  July  15th  1595  cases 
were  reported  with  553  deaths,  giving  the  high 
fatality  rate  of  34'6  per  cent.  The  disease  was  also 
present  at  Bucharest  and  Jassy,  as  well  as  at  the 
ports  of  Galatz,  Braila,  and  Constanza. 

Owing  to  the  Bolshevist  regime  in  Russia  little 
information  is  allowed  to  pass  over  the  frontier  as 
to  the  incidence  of  infectious  diseases.  It  is,  how- 
ever, a well-known  fact  that  for  many  years  small- 
pox has  been  more  prevalent  in  Russia  than  in  any 
other  European  country.  With  the  suppression  of 
sanitary  administration  and  the  disregard  of 
scientific  advice  by  those  now  exercising  power  in 
various  parts  of  Russia,  small-pox  has  become  more 
prevalent  at  the  present  than  in  the  past. 
Indirectly  we  have  heard  that  the  hasmorrhagic 
form  of  small  pox,  notoriously  attended  with  great 
mortality,  is  epidemic  in  the  town  of  Simbirsk, 
which  lies  about  400  miles  east  of  Moscow.  In 
Southern  Russia  outbreaks  have  occurred  at 
Ekaterinodar,  in  the  province  of  Kuban,  and  at 
the  Black  Sea  port  of  Novorossick,  some  90  kilo- 
metres from  Ekaterinodar.  Small-pox  is  at 
present  epidemic  in  Finland,  and  during 
the  first  three  months  of  this  year  778 
cases  were  recorded,  372  of  which  occurred 
in  the  province  of  Viborg,  which  adjoins  the 
Russian  Government  District  of  Petrograd.  In 
Sweden  small-pox  has  appeared  at  Stockholm 
and  also  in  Denmark  at  Copenhagen.  The  disease, 
though  not  in  large  amount,  has  been  reported  to 
be  present  in  Belgium  during  each  of  the  first  five 
months  of  1919.  There  have  been  recent  outbreaks 
of  small-pox  in  France,  and  among  the  places 
invaded  were  Paris,  Toulon,  Brest,  and  Havre. 
Spain  frequently  suffers  from  epidemic  small-pox, 
and  in  the  present  year  some  of  the  large  towns 
were  affected  ; in  Madrid,  for  example,  81  deaths 
from  this  cause  were  reported  during  the  first 
quarter,  and  outbreaks  also  occurred  in  the  Spanish 
ports  of  Cadiz,  Barcelona,  and  Valencia;  at  the 
last-named  port  568  cases  were  recorded  in  the 
first  three  months  of  1919.  The  disease  had  been 
epidemic  in  Portugal  towards  the  end  of  1918,  and 
this  continued  during  the  first  half  of  the  present 
year,  160  cases  being  reported  at  Oporto  and  116  at 
Lisbon.  Little  information  has  come  to  hand 
from  Turkey,  but  indirectly  we  hear  of  small- 
pox having  occurred  recently  in  Constantinople, 
as  well  as  in  some  places  in  Western  Anatolia.  In 
addition,  as  the  voyage  to  England  from  Egypt  can  be 
done  in  less  time  than  is  represented  by  the  incuba- 
tion period  of  small-pox,  there  is  a possibility  of  the 
infection  being  introduced  into  our  own  country 
from  this  source  before  the  disease  can  be  recog- 
nised. Up  to  the  beginning  of  June  close  upon 
3000  small  pox  cases  had  been  recorded  in  Egypt, 
and  of  these  500  occurred  in  the  fortnight  ended 
June  10th. 

It  is  probable  that  if  the  pre-war  sources  of 
information  had  been  available  now  the  above 
details  of  the  small-pox  incidence  would  have  been 
greatly  extended.  But  the  figures  we  have  given 
will  suffice  to  show  that  many  countries  in  Europe 
are  now  suffering  from  small-pox,  and  that  a 


338  The  Lanoet,]  FOOD  PRESERVATION  IN  RELATION  TO  ACCESSORY  FACTORS.  [August  23,  1919 


number  of  ports  in  the  Mediterranean  and  along 
the  Atlantic  shores  of  Europe,  as  well  as  in  the 
Baltic  and  Black  Seas,  are  infected  by  small-pox, 
and  therefore  possible  sources  of  infection  for  this 
country.  Meanwhile,  the  disregard  in  England  of 
vaccination  and  revaccination  continues  as  before, 
and  the  unprotected  proportion  of  the  people 
increases  day  by  day.  In  The  Lancet  of  Aug.  16th 
Dr.  W.  McConnel  Wanklyn,  a recognised  authority, 
gave  some  useful  notes  on  small  pox  for  the 
assistance  of  general  practitioners.  He  directed 
attention  to  the  numerous  outbreaks  of  the 
disease  which  have  occurred  this  year  in  England 
and  Wales,  due  in  some  instances  to  imported 
infection.  He  emphasised  the  importance  of 
a correct  * diagnosis,  missed  diagnosis  being  a 
frequent  source  of  the  spread  of  the  disease. 
In  the  same  issue  we  reproduced  a memorandum 
recently  sent  out  by  the  Ministry  of  Health 
on  “The  Public  Supply  of  Vaccine  Lymph,” 
explaining  how  lymph  may  be  obtained  without 
delay,  by  those  medical  officers  who  are  called  upon 
to  deal  with  local  small  pox  cases,  for  the  vaccina- 
tion or  re-vaccination  of  contacts  and  other  persons 
in  the  invaded  locality.  This  memorandum  is 
timely,  and  will  prove  of  service  to  those  concerned. 
As  we  have  already  stated,  the  small-pox  danger  is 
more  likely  to  become  acute  in  this  country  in  the 
latter  months  of  the  year. 

♦ ■■  - 

Food  Preservation  in  Relation  to 
Accessory  Factors. 

The  busy  and  fruitful  researches  which  are  being 
carried  on  at  the  present  time  in  regard  to  the 
kind  and  degree  of  accessory  factors  in  the  common 
dietary  are  rapidly  suggesting  that  our  methods  of 
food  preservation  in  some  directions  need  revision. 
For  example,  it  is  shown  that  the  value  of  canned 
vegetables  in  regard  to  antiscurvy  and  growth- 
promoting  properties  is  negligible.  That,  at  all 
events,  is  the  purport  of  an  investigation  which  we 
publish  this  week  by  Dr.  Mabel  E.  D.  Campbell 
and  Dr.  Harriette  Chick.  It  is  here  shown  that 
in  the  case  of  runner  beans  the  antiscorbutic 
value  of  20  >g.  was  reduced  by  canning  to  less  than 
that  of  5 g.,  and  was  not  superior  to  1'5  or  2'5  raw 
beans.  In  other  words,  this  preserving  process 
means  that  75  to  90  per  cent,  of  the  antiscorbutic 
value  had  been  destroyed.  In  the  case  of  cabbage 
the  loss  is  estimated  at  about  70  per  cent,  of  the 
original  value.  This  loss  is  attributed  to  the  destruc- 
tion of  antiscurvy  factors  occurring  during  the 
heating  involved  in  the  process  of  canning,  and  a 
further  loss  occurs  during  the  period  of  storage.  In 
the  case  of  green  leaf  vegetables  possessing  in  addi- 
tion to  the  antiscurvy  vitamins  the  growth- 
promoting  accessory  factor,  this  was  also  lacking 
in  the  canned  material,  but  was  present  in  the 
liquor.  It  would  seem  undesirable,  however,  to 
take  the  liquor  on  the  ground  conceivably  that  it 
might  be  contaminated  with  metal,  though  this 
difficulty  may  be  got  over  by  lacquering  the  tins, 
as  is  done  in  some  cases,  or  coating  them  lightly 
with  an  innocuous  varnish.  The  results  in  regard 
to  the  deterioration  in  canned  vegetables  in  growth- 
promoting  and  antiscurvy  factors  are  strikingly 
brought  out  in  a table.  In  the  majority  of  instances 
the  process  of  canning  reduced  the  protective  power 
against  scurvy  to  a negligible  quantity  and  the 
growth-promoting  properties  were  likewise  much 
diminished.  The  well-known  method  of  preserving 
vegetables  by  brine  and  vinegar  is  not  referred  to ; 


nowhere  in  these  important  researches  do  we  find 
pickles  mentioned.  It  would  be  interesting  to  have 
determined  whether  the  activities  of  the  food 
accessory  factors  in  vegetables  preserved  in  salt 
and  vinegar  are  disturbed.  The  investigation  should 
of  course  include  walnut,  cabbage,  onion,  beetroot, 
all  of  which,  in  their  fresh  state,  are  protective 
against  scurvy.  In  the  records  previously  published 1 
pickles  appear  to  have  been  disregarded.  Admirable 
additions  to  certain  foods,  it  would  be  interesting 
to  discover  whether  they  fill  a gap  also  by  supplying 
accessory  food  factors.  If  so,  there  is  greater  reason 
for  consuming  them  than  on  the  mere  ground  of 
condimental  value.  Pickled  vegetables,  of  course, 
may  well  be  distasteful  to  the  animals  selected  for 
the  experiments,  but  this  technical  difficulty 
occurred  in  the  investigation  of  dried  fruitB,  when 
it  was  overcome  by  making  decoctions,  the  liquor 
obtained  being  administered  to  the  animals  by 
means  of  a syringe.  The  same  procedure,  perhaps, 
could  be  adopted  with  pickles,  and  an  evaluation 
of  antiscorbutic  and  growth-promoting  principles 
obtained. 

In  a second  contribution  by  Dr.  Harriette  Chick, 
Miss  E.  Margaret  Hume,  and  Miss  Ruth  F. 
Skelton  on  the  Antiscorbutic  Value  of  some  Indian 
Dried  Fruits  it  is  shown  that  the  dry  tamarind, 
cocum,  and  mango  possess  a definite  but  small 
antiscorbutic  value.  This  value  is  greatly  inferior 
to  that  possessed  by  raw  cabbages,  swedes, 
germinated  pulses,  orange  juice,  lemon  juice,  but 
equal  or  superior  to  that  of  carrots,  beetroots, 
cooked  potatoes,  raw  meat  juice,  reckoned  weight 
for  weight  in  the  natural  conditions.  This  investi- 
gation was  undertaken  early  in  1917,  at  a period  in 
the  war  when  scurvy  was  proving  a serious  menace 
to  our  native  troops  in  Asia.  In  the  Afghan 
Boundary  Commission  in  1884-1886  it  was  observed 
by  Major-General  Sir  Havelock  Charles  that  a 
freedom  from  scurvy  was  enjoyed  by  the  native 
soldiers  who  consumed  dried  mango  when  fresh 
fruits  or  vegetables  were  not  procurable,  and  these 
investigations  show  that  the  dried  mango  is  to 
some  extent  protective,  but  with  nothing  like  the 
power  of  fresh  fruit  or  their  juices. 

Some  valuable  observations,  again,  occur  in  a third 
contribution  on  the  subject  by  Miss  Rosamund  E. 
Barnes  and  Miss  E.  Margaret  Hume,  who  have 
in  their  investigation  set  out  an  interesting  com- 
parison between  the  antiscorbutic  properties  of 
fresh,  heated,  and  dried  cow’s  milk,  the  subjects 
of  these  nutritional  experiments  being  guinea-pigs 
and  monkeys.  The  dried  milk  used  was  prepared 
by  a process  involving  the  use  of  a high  tempera- 
ture, which,  amongst  other  things,  destroys  enzymes, 
coagulates  albumin,  and  separates  fat.  It  would  be 
well  before  deciding  upon  the  position  of  dried 
milk  to  examine  the  milk  powder  obtained  by  the 
spray  process,  which,  being  conducted  at  a rela- 
tively low  temperature,  may  possibly  secure  the 
retention  of  antiscorbutic  principles.  If  so,  an 
important  differentiation  between  these  methods 
of  drying  may  be  established.  At  the  outset  cow's 
milk,  even  when  fresh,  proved  to  be  a foodstuff 
comparatively  poor  in  antiscorbutic  properties. 
Dried  milk  was  still  less  protective,  and  “ scalded  " 
milk  was  superior  to  it.  This  observation  bears,  of 
course,  upon  the  practice  of  just  boiling  milk  and 
setting  it  to  cool  rapidly  before  giving  it  to  infants. 
Apparently,  however,  raw  milk  varies  in  its  acces- 
sory food  factor  value  according  to  whether  the 
cow  has  received  a winter  dietary  (hay,  roots,  oil- 


i Thr  Lancet,  July  5th,  1919,  p.  28. 


Thb  Lancet,] 


UNQUALIFIED  TREATMENT  OF  VENEREAL  DISEASE. 


[August  23,  1919  339 


cake,  and  cereals),  or  the  early  summer  dietary  of 
fresh  grass  from  the  open  pasture.  In  other  words, 
the  great  increase  of  antiscorbutic  material  in  the 
latter  diet  resulted  in  a corresponding  increase  in 
the  antiscorbutic  value  of  the  milk  given.  It 
is  true  that  these  observations  are  not  based 
on  experiments  on  the  human  subject,  and 
as  Mr.  E.  A.  Barton  points  out  in  a letter 
published  in  another  column,  there  seems  to  be 
no  doubt  that  animals  suffer  from  the  deprivation 
of  the  antiscorbutic  vitamine  in  their  food  much 
more  rapidly  and  severely  that  does  the  human 
infant.  It  is  to  be  remembered  that  the  animal 
diet  in  the  main  is  raw  and  growing  food.  Whether 
the  human  mother  is  able  to  transmit  a tolerance 
in  her  infant  to  a diet  poor  in  vitamines,  or  whether 
the  human  young  require  much  less  than  other 
animals  to  keep  them  in  health  is,  as  Mr.  Barton 
points  out,  pure  speculation ; but  there  is 
a probability  that  when  infantile  scurvy  has 
advanced  to  the  stage  of  physical  signs  we  have 
arrived  at  the  last  chapter  of  the  disease  and  not 
the  first.  A valuable  region  of  study  in  dietetics 
is  being  opened  up  by  these  investigations. 


Unqualified  Treatment  of  Venereal 
Disease. 

At  the  London  Sessions  recently  two  men, 
J.  Shadforth  and  J.  Wilson,  were  convicted  and 
sentenced  to  imprisonment  in  the  second  division 
for  four  and  three  months  respectively,  for  offences 
against  the  Venereal  Diseases  Act,  1917.  The  Act, 
it  will  be  remembered,  forbids  the  treatment  of 
venereal  disease  by  persons  who  are  not  qualified 
medical  practitioners,  in  areas  in  which  the  Act  is 
adopted  and  in  which  gratuitous  treatment  for 
such  disease  is  provided.  The  Act  also  forbids  the 
advertisement  of  treatment  and  alleged  remedies 
for  venereal  disease.  The  defendants  were  described 
as  “chemists,” engaged  inabusiness  conducted  under 
the  name  of  Shadforth’s  Prescription  Service,  Ltd. 
Shadforth  called  himself  the  “ governing  director,” 
and  stated  that  he  employed  a staff  of  50  persons. 
The  nature  of  the  business  transacted  by  “ a pre- 
scription service  ” is  probably  indicated  by  its 
name  and  by  the  fact  that  Shadforth  advertised 
in  a daily  newspaper  a variety  of  alleged 
medicines  for  the  treatment  of  disease,  including 
one  described  as  prescription  606,  with  a recom- 
mendation of  it  as  a “ bad  blood  tonic.”  In 
a pamphlet,  the  purchase  of  which  was  recom- 
mended by  the  same  advertisement,  occurred  the 
passage  “ even  syphilis  in  most  instances  can  be 
cured  by  the  patient  himself,  with  practically  no 
supervision,  provided  he  is  told  at  the  outset  in 
plain  English  what  to  do  and  what  remedy  to  take.” 
At  Shadforth’s  shop  detectives  were  able  to 
purchase  tablets  purporting  to  be  those  advertised 
as  606,  and  one  of  them  was  told  by  Wilson  that  it 
was  the  best  he  could  have  for  syphilis.  As  to  the 
tablets  being  advertised  for  bad  blood  without 
mentioning  syphilis,  Wilson  explained:  “ Well,  we 
could  not  put  that  in,  could  we?”  As  a point  of  law 
it  was  submitted  that  the  section  of  the  Act 
involved  referred  to  actual  dealing  with  a person 
affected  by  venereal  disease,  and  that  there  was  no 
evidence  of  treatment,  prescription,  or  the  giving 
of  advice.  Mr.  Laurie,  the  deputy  chairman, 
however,  declined  to  withdraw  the  case  from  the 
jury,  with  the  result  recorded  above.  The  verdict 
followed  after  Shadforth  had  himself  gone  into 
the  witness-box  and  had  stated  with  considerable 


candour  that  he  had  done  his  utmost  to  oppose  the 
passing  of  the  Venereal  Diseases  Act,  1917,  by 
writing  letters  to  Members  of  Parliament,  and  even 
by  standing  himself  as  an  independent  candidate 
for  election  to  the  House  of  Commons.  Since  the 
Act  became  law  he  had  written  to  every  Member  of 
Parliament  to  inform  him  that  he  intended  to  defy 
the  Act,  but  he  alleged  that  he  had  since  changed 
his  attitude  and  had  decided  to  comply  with  the 
law,  although  continuing  to  protest.  He  denied 
that  he  had  advertised  “ 606  ” with  any  intention 
that  it  should  be  taken  to  have  any  relation  to 
salvarsan,  and  said  he  had  forbidden  his  assistants 
to  sell  remedies  for  venereal  disease.  He  admitted, 
however,  that  in  a letter  to  Sir  Edwin  Cornwall 
he  had  written,  “ For  many  years  I have  openly, 
honourably,  lawfully,  and  successfully  supplied  the 
remedies  and  treatment  for  venereal  diseases.” 

The  result  of  this  prosecution  is  one  upon  which 
the  public  and  those  concerned  in  the  passing  of 
the  Venereal  Diseases  Act,  1917,  are  to  be  con- 
gratulated ; the  case  shows  “ Shadforth’s  Pre- 
scription Service,  Ltd.,”  to  be  one  of  those  institu- 
tions conducted  for  profit,  and  no  doubt  with 
considerable  profit,  the  activities  of  which  are 
dangerous  to  sufferers  from  venereal  disease, 
and  so  to  the  public.  Shadforth  said  in  the 
witness-box  that  he  had  made  a special  study 
of  venereal  diseases.  No  doubt  he  had,  from 
his  point  of  view.  If  he  had  studied  them  from 
the  point  of  view  of  the  medical  profession, 
however,  he  would  have  recognised  willingly  that 
syphilis  and  gonorrhoea  and  their  complications 
cannot,  consistently  with  the  welfare  of  the 
patient,  be  dealt  with  by  a shop  assistant  selling 
tablets  over  a counter,  or  posting  them,  to  one  who 
applies  for  them  in  response  to  an  ingenious 
advertisement.  We  are  writing  of  particular 
diseases  for  sufferers  from  which  a limited  form  of 
protection  has  tardily  been  provided  by  Parliament. 
Our  view  and  that  of  the  medical  profession 
is,  however,  without  any  qualification,  that 
whatever  may  or  may  not  be  the  matter 
with  the  patient,  he  cannot  be  treated  properly, 
and  he  ought  not  to  be  treated  at  all,  by  an  un- 
qualified person,  who  sells  him  a nostrum  for 
profit  in  response  to  his  statement  that  he  is 
suffering  from  - — — . He  may  name  any  disease 
from  which  he  fancies  that  his  symptoms  proceed, 
and,  indeed,  he  may  name  it  correctly,  but  a phy- 
sician before  prescribing  for  him  would  require  to 
know  more  about  his  condition  than  that. 
Diagnosis  is  not  as  simple  a matter  as  the  labelling 
of  the  bottles  and  pill-boxes  that  the  quack  sells. 
Of  course,  in  trifling  cases,  or  where  the  patient 
has  nothing  the  matter  with  him,  the  credulous 
purchaser  may  suffer  only  in  his  pocket.  He  may 
be  sold  something  which,  if  costly,  is  quite  harm- 
less ; but  even  then  he  is  likely  to  acquire  a habit 
of  self-treatment  that  may  one  day  prove  his 
undoing.  All  this  is  quite  well  known  to  the 
medical  profession,  but  we  comment  on  the  case 
because  these  are  the  sort  of  incidents  that  our 
readers  ought  to  bear  in  mind  when  advocating 
firmer  legislation  in  the  repression  of  quackery. 

» 

INDEX  TO  THE  LANCET. 

(Vol.  I.,  1919.) 

Will  those  subscribers  who  have  written  to  the 
Manager  asking  for  copies  of  this  Index  kindly 
note  that  it  was  given  in  the  issue  of  The  Lancet 
of  July  5th  and  is  not  printed  separately,  thus 
reverting  to  pre-war  custom  ? 


340  ThbLanoht,] 


“THE  OSLER  MEDICAL  LIBRARY.” 


[August  23,  1919 


^nnfltdbns. 

"He  quid  nimle.” 

“THE  OSLER  MEDICAL  LIBRARY.” 

A distinguished  foreign  physician  attended  the 
recent  Osier  presentation  ceremony  at  the  Royal 
Society  of  Medicine,  fully  believing  that  the  under- 
graduates from  the  University  of  Oxford  would  be 
present  in  swarms  and  that  the  occasion  would  be 
marked  by  noisy  demonstrations  in  honour  of  a 
great  teacher.  He  was  not  so  much  disappointed 
as  puzzled  by  what  actually  happened.  No  noisy 
students  were  present  and  the  proceedings  were 
simple,  dignified,  and  not  unmarked  by  a touch 
of  pathos  in  Sir  William  Osier’s  charming  and 
characteristic  reply  to  Sir  Clifford  Allbutt,  after 
the  latter  had  handed  him  the  Birthday  Book. 
Sir  John  MacAlister  struck  a right  note  in  the 
chorus  that  greets  the  Regius  Professor  of  Medi- 
cine at  Oxford  on  the  occasion  of  his  seventieth 
birthday.  This  contribution  to  the  Osier  Birthday 
Book  is  a brilliant  essay  in  Utopianism.  Sir 
John  MacAlister  dreams  a dream  and  imagines 
himself  the  guest  of  the  librarian  of  an  ideal  Osier 
Medical  Library,  situated  in  Regent’s  Park.  It  is 
a palace  with  a Greek  portico,  and  in  the  centre 
of  the  great  inner  quadrangle  stands  a noble  marble 
statue,  which  at  first  the  dreamer  mistakes  for 
the  “ Hope  Asklepios,”  but  soon  recognises  as  a 
living,  smiling  William  Osier.  “ I could  have 
sworn,”  he  says  in  ecstasy,  “ that  one  of 
those  wonderful  eyes  solemnly  winked  at  me.” 
The  wink  gives  the  cue  to  the  further  experi- 
ences inside  the  remarkable  building  which  con- 
tains a magnificent  collection  of  books,  besides 
printing  presses,  a bindery  or  binding-room,  tele- 
phones galore,  and  a system  of  pneumatic  tubes  so 
designed  as  to  drop  volumes  at  the  proper  instant  of 
time  in  front  of  the  pampered  researchers  at  their 
desks  in  the  large  main  library.  These  tubes 
manifestly  do  the  work  of  the  grey  matter  in  the 
brain : they  are  the  thinking  machine  of  the  ideal 
library.  Librarians  are  there,  it  is  true,  but  we 
feel  from  the  first  that  these  persons  are  only  a 
kind  of  mechanics  or  tradesmen  of  books,  however 
much  they  may  be  renowned  as  specialists  in 
particular  branches  of  medical  and  surgical  learning. 
The  poor  fellows,  harassed  at  all  hours  of  the 
working  day  by  telephone  calls,  will  take  their 
meals  together  in  a refectory  and  talk  shop  there  to 
the  ruin  of  their  digestions  and  of  general  conversa- 
tion. The  noble  library  is  very  nearly  dust-free,  and 
apart  from  its  wealth  and  variety,  this  is  the  best 
thing  a library  can  be.  The  grand  aim  of  a librarian 
in  his  house-keeping  capacity  should  be  the  com- 
plete deportation  of  dust  from  his  precincts,  but  in 
too  many  cases  dusting  of  books  only  creates  a local 
dun-coloured  cloud  which  re-settles  in  the  old 
situations.  In  the  “Osier  Medical  Library”  dust 
is  removed  from  the  volumes  by  damp  clean  saw- 
dust which  is  sprinkled  on  their  top  edges  : this 
gathers  up  the  book-dust  to  be  swept  off  the  floor 
clinging  to  the  particles  of  sawdust.  In  a dream 
the  process  is  fine,  but  is  it  not  a little  perilous  ? 
Damp  sawdust  is  difficult  to  regulate.  If  a little 
too  wet  it  cakes  and  exudes  small  drops  of  water, 
which  would  be  fatal  to  fine  bindings.  “Pulvo,” 
fitted  with  the  proper  shape  of  nozzle,  is  the 
advice  of  our  own  dreamer  of  the  model  library. 
But  Sir  John  MacAlister  need  not  be  taught  any 
lessons  about  “ pulvo,”  though  we  should  like  to 


learn  if  he  has  any  criticisms  to  offer,  for  his  article 
is  full  of  practical  suggestions.  All  he  tells  us 
about  the  manner  in  which  an  ideal  library 
should  be  catalogued  is  admirable,  and  we  are 
glad  to  know  that  this  dream-system  is  already 
virtually  in  use  in  some  of  the  great  scientific 
libraries.  Admirable,  too,  is  his  suggestion  that 
the  records  of  research  in  the  shape  of  literatures 
and  bibliographies  made  by  medical  authors  should 
be  preserved  by  librarians.  At  his  own  library  this, 
we  believe,  has  been  done  for  some  years,  while  at 
the  library  of  the  Royal  College  of  Surgeons  of 
England  Mr.  Victor  Plarr  has  catalogued  all  biblio- 
graphies and  literatures  in  the  printed  books  under 
his  charge.  This  catalogue  of  bibliographies  is  a 
large  one  and  has  proved  most  useful  to  researchers, 
among  others  to  Sir  William  Osier. 


ALCOHOL  IN  A NEW  ROLE. 

There  are  some  points  of  medical  interest  in  the 
proposal  to  bring  alcohol  into  prominence  as  a 
source  of  power.  Incidentally  the  moment  that 
facilities  are  given  for  its  production  on  a large  and 
economic  scale  its  application  would  not  be  limited 
to  traction  and  like  purposes,  for  cheap  alcohol 
would  give  an  immense  stimulus  to  many  industries 
dependent  upon  it  as  a solvent.  Alcohol  for  general 
industrial  purposes,  however,  must  be  made 
undrinkable.  The  de-naturing  of  alcohol  so  that  I 
it  shall  be  made  unfit  for  consumption  offers  no 
difficulty,  though,  of  course,  precaution  must  be 
taken  that  the  altered  alcohol  cannot  be  again 
purified  and  used  as  potable.  At  present  the 
process  of  rendering  industrial  alcohol  undrinkable 
adds  materially  to  its  cost,  but  recent  inquiries 
have  shown  that  the  price  of  the  deterrents 
can  be  considerably  reduced,  and  our  legislators 
could  further  help  in  this  matter  by  imposing  much 
heavier  penalties  than  those  now  sanctioned  by  law 
for  evasion  of  the  spirits  duty  in  any  case  of 
illicit  purification  of  “power”  alcohol  to  render  it 
potable.  The  question  is  of  undoubted  importance, 
when  it  can  be  shown  that  although  the 
United  Kingdom  may  be  unable  to  supply 
enough  raw  material  to  make  the  manufacture 
of  “ power  ” alcohol  a commercial  success,  the 
resources  of  its  dominions  in  this  regard  are 
potentially  very  great.  The  vegetable  sources  in 
the  British  Islands  afford  but  a poor  stock  of 
material  for  the  manufacture  of  alcohol.  But  in 
this  matter  the  Empire  could  come  to  our  aid 
most  effectively  with  its  vast  carbohydrate  pro- 
ductive capacity.  Apart,  however,  from  that  great 
asset,  chemists  have  recently  turned  their  attention 
to  the  possibility  of  producing  alcohol  synthetically, 
and  the  results  are  so  far  promising.  The  starting 
point  is  coal  gas  or  coke-oven  gas,  which  contains  a 
small  though  not  negligible  amount  of  ethylene. 
This  can  be  removed  by  charcoal  without  disturbing 
materially  the  quality  of  the  gas.  The  charcoal  then 
is  immersed  in  molten  lead,  which  drives  out  the 
gas,  which,  as  most  students  of  chemistry  know, 
was  the  basis  of  the  synthesis  of  alcohol  many  years 
ago.  That  this  process  should  be  advanced  beyond 
its  stage  of  flask  and  still  in  the  laboratory,  and 
become  a commercial  proposition  to-day.  -is  a 
matter  of  some  wonder  even  to  the  chemist  himself. 

In  many  text-books  will  be  found  the  statement 
that  these  reactions  are  of  considerable  theoretical 
importance,  but  now  we  are  told  it  has  been 
demonstrated  that  our  gas-works  are  capable  of 
yielding  annually  150  million  gallons  of  90  per  cent. 


The  Lancet,] 


DENTAL  TREATMENT  AND  NATIONAL  HEALTH. 


[August  23,  1919  34 1 


alcohol  by  this  synthetic  process,  which  has  been 
proved  to  be  commercially  workable.  Ethylene 
(C2H.1)  is  absorbed  by  sulphuric  acid  to  form  ethyl 
hydrogen  sulphate.  This,  boiled  with  water,  yields 
alcohol  and  sulphuric  acid  again.  Distillation  com- 
pletes the  process.  The  catalyst,  that  mysterious 
third  party  in  chemical  reactions,  has  been  made  to 
intervene,  and  the  yield  of  alcohol  then  becomes 
greater  than  of  “ theoretical  importance.”  Alcohol 
will  play  an  entirely  new  role  in  our  industrial  and 
domestic  affairs  if  these  things  be  true. 


A REMINISCENCE  OF  WILLIAM  HUNTER, 

Dr.  Alexander  Napier,  the  honorary  librarian  of 
the  Royal  Faculty  of  Physicians  and  Surgeons  of 
Glasgow,  has  published  in  the  Glasgoiv  Medical 
Journal  for  July  an  interesting  note  concerning 
William  Hunter.  Dr.  Napier  numbers  among  his 
friends  a certain  Mrs.  Kean,  whose  family  is  con- 
nected with  the  Hunters  through  Archibald 
Hunter,  an  uncle  of  William  and  John,  and  from 
a grandson  of  this  Archibald  Hunter,  another 
William  Hunter,  she  received  the  relics  which 
form  the  subject  of  the  memorial.  They  are  a 
letter  and  a portrait.  The  letter,  dated  Windmill- 
street,  March  20fh,  1782,  is  written  to  one  Robert 
Barclay,  evidently  in  response  to  one  from  him 
asking  Hunter  to  intercede  with  the  Queen  on 
behalf  of  a seaman  who  had  been  condemned  to 
death.  Hunter  refused  on  very  sound  reasoning. 
The  other  relic,  the  portrait,  is  a copy  of  a stipple' 
engraving  by  Thornthwaite,  and  is  well  reproduced 
in  Dr.  Napier's  paper.  It  shows,  as  Dr.  Napier 
remarks,  a different  type  of  face  from  the  better 
known  portraits,  which  are  characterised  by 
elegance  and  grace.  The  Thornthwaite  portrait 
is  that  of  a masterful  and  determined  man. 


DENTAL  TREATMENT  AND  NATIONAL  HEALTH. 

In  the  report  issued  by  the  Departmental  Com- 
mittee on  the  Dentists  Act  attention  has  been  drawn 
to  the  necessity  of  enlightening  the  public  by  every 
possible  means  as  to  the  need  for  conservative 
treatment  of  diseased  teeth.  A committee  of  the 
British  Dental  Association  has  recently  considered 
how  this  could  best  be  carried  out,  and  has  embodied 
its  views  in  a pamphlet  which,  we  believe,  has  been 
circulated  amongst  education  and  public  authorities. 
The  committee,  after  due  deliberation,  are  of  the 
opinion  that  it  is  impossible,  owing  to  the  present 
condition  of  the  dental  profession,  to  formulate  an 
extensive  system  of  State  dental  service,  and  con- 
sider that,  in  the  first  place,  every  endeavour  should 
be  made  to  obtain  a complete  school  dental  service. 
For  the  latter  purpose  they  recommend,  as  a rule, 
whole-time  officers,  and  are  of  the  opinion  that 
on  the  staffs  of  the  Educational  Departments 
of  England  and  Scotland  there  should  be  dental 
officers  responsible  for  the  work  done  in  local 
educational  areas.  For  the  treatment  of  expectant 
mothers  and  of  children  under  school  age  they 
suggest,  if  possible,  the  appointment  of  whole-time 
dental  officers,  and  the  institution,  where  possible, 
of  central  laboratories  for  the  provision  of  dentures. 
The  requirements  of  the  adult  population,  they 
think,  might  for  the  present  be  met  by  an  extension 
of  the  system  of  factory  clinics,  by  affording  support 
to  the  public  dental  services  established  by  members 
of  the  profession,  and  by  the  creation  in  certain 
large  industrial  areas  of  experimental  clinics.  The 
report  shows  very  clearly  the  difficulties  of  pro- 


viding an  adequate  service  for  the  whole  com- 
munity. It  quite  rightly  emphasises  the  desir- 
ability of  treating  children  of  school  age,  but  we 
consider  that,  important  as  this  is,  there  is  a greater 
need  to  deal  with  those  under  school  age,  for  in  the 
children  of  the  masses  irretrievable  damage  has 
often  been  done  to  the  teeth  before  school  age. 
A feasible  plan  would,  we  think,  be  to  co- 
ordinate the  work  of  the  children’s  welfare 
committees  with  that  of  the  school  authorities,  and 
make  it  possible  for  those  under  school  age  to  be 
treated  by  the  school  dental  officers.  In  reading 
the  report  we  feel  that  by  no  means  sufficient  con- 
sideration has  been  given  to  the  question  of  pre- 
vention. If  we  are  to  obtain  an  improvement  in 
the  condition  of  the  teeth  of  the  nation,  it  will  be 
by  teaching  the  individual  to  prevent  the  condition 
and  not  to  rely  upon  a cure.  One  trouble  is  the 
indifference  of  the  majority  to  the  question  of 
dental  disease,  and  this  can  only  be  overcome  by 
widespread  propaganda  on  the  harm  which  arises 
therefrom.  The  establishment  of  free  public 
lectures  and  the  issue  of  a small  pamphlet  written 
in  popular  language  would  prove  of  inestimable 
value.  By  this  means  the  amount  of  disease  would 
be  considerably  lessened  and  there  would  be  a 
corresponding  diminution  in  the  amount  of  con- 
servative dentistry  required. 


THE  METROPOLITAN  HOSPITAL  SUNDAY  FUND. 

At  a recent  meeting  of  the  Council  of  the  Metro- 
politan Hospital  Sunday  Fund  the  Distribution 
Committee  reported  that  the  total  amount  of  the 
Fund  on  August  11th  would  amount  to  £83,000, 
of  which  it  recommended  the  distribution  of 
£82,462  13s  8 d.  The  amount  will  strike  many  as 
large,  having  regard  to  the  financial  situation  pro- 
duced by  the  war.  Others  will  compare  it  with  far 
smaller  sums  which  were  regarded  as  satisfactory 
totals  not  many  years  ago.  If,  however,  we  contrast 
its  purchasing  power  with  that  of  a sum  of 
£50,000  or  £40,000  before  the  war  we  realise  that, 
generous  though  the  public  may  have  been  in  sub- 
scribing, the  hospitals  will  receive  allotments 
small  in  value  by  comparison  with  those  of  the 
past.  Hospitals  have  been  hardened  to  rigorous 
economy,  but  their  need  for  it  has  become  even 
greater  in  an  epoch  when  science  has  increased 
their  powers  of  usefulness  and  when  the  ravages 
of  war  have  augmented  the  number  of  patients 
likely  to  crave  their  aid.  It  is  a recognised  func- 
tion of  the  Metropolitan  Hospital  Sunday  Fund  to 
promote  economy  of  management,  and  a timely 
recommendation  of  the  Distribution  Committee 
suggests  that  in  some  cases  where  two  or  three 
cottage  hospitals  are  within  a reasonable  distance 
of  one  another  they  should  be  recommended  to 
amalgamate  with  a view  to  more  economical 
working.  The  Committee  points  out  that  the 
relatively  small  proportion  of  occupied  beds  appears 
to  account  for  the  high  cost  of  treatment  shown  at 
some  cottage  hospitals.  The  recommendation  is 
in  all  the  circumstances  a sound  .one.  The 
sums  allotted  to  individual  cottage  hospitals 
amount  in  some  instances  to  between  £100 
and  £200,  the  smallest  being  under  £20.  These 
are  not  large  amounts  for  the  supporters  of 
a cottage  hospital  to  make  up  if  they  should  prefer 
to  retain  as  exclusively  local  an  institution  of 
which  they  are  naturally  and  justly  proud.  They 
might  then  reject  with  a clearer  conscience  the 
advice  of  the  Distribution  Committee,  and  refuse 
amalgamation,  although  the  resulting  economy 


342  The  Lancet,] 


“THE  DANGERS  OF  THE  NEW  PUBLIC  HEALTH  ACT.” 


[August  23,  1919 


would  mean  obtaining  the  best  possible  result  for 
their  money.  Apart  from  such  voluntary  renuncia- 
tion, the  Distribution  Committee  has,  of  course,  the 
right  to  refuse  to  allocate  money  where  it  is  not 
satisfied  that  economy  is  practised. 


“THE  DANGERS  OF  THE  NEW  PUBLIC  HEALTH 
ACT.” 

Under  the  above  heading  appears  an  article  in 
the  July  number  of  a well-known  Roman  Catholic 
organ,  The  Month , which  shows  the  apprehension 
with  which  legislation,  apparently  good  in  itself, 
excites  among  a large  section  of  our  fellow- 
citizens.  The  writer  takes  exception  to  the  new 
Act  (its  proper  title  is  the  “ Ministry  of  Health  Act, 
1919,”)  on  two  main  grounds,  namely: — “A.  The 
respects  in  which  this  Act  is  liable  to  abuse  through 
administrative  action  (1)  on  account  of,  perhaps, 
accidental  vagueness  in  the  text,  or  (2)  on  account 
of  phrasing  apparently  designed  to  admit  of  large 
modifications  in  administration.  B.  The  actual  viola- 
tions contained  therein  of  (1)  general  first  principles, 
and  (2)  definite  and  precise  Catholic  doctrine.”  We 
are  in  sympathy  with  the  writer  in  The  Month  as 
to  the  provision  made  for  legislation  by  Orders  in 
Council,  a procedure  of  which  we  have  seen  far  too 
much  during  the  war,  but  he  is  in  error  when  he 
says  that  provision  for  legislation  of  this  character 
is  made  in  “ no  less  than  seven  of  the  11  clauses  of 
the  Act.”  As  a matter  of  fact  Orders  in  Council  are 
only  mentioned  in  three  of  the  11  clauses — namely, 
Clauses  3,  4,  and  8— though  in  fairness  we  must 
allow  that  provisions  for  Orders  in  Council  in 
Clause  3 are  very  wide-spreading.  As  regards 
objection  B,we  think  he  is  somewhat  in  the  mental 
condition  of  those  who  worry  about  crossing  the 
river  before  they  come  to  the  bridge,  and  we 
doubt  whether  the  views  of  extreme  “Eugenists” 
will  affect  the  working  of  the  Act  as  much  as  he 
fears.  Anyway,  we  recommend  him  to  reconsider 
his  judgment  until  the  appearance  of  the  Medical 
Services  Bill.  With  regard  to  the  question  of 
“ birth  control,”  upon  which  he  lays  special  stress, 
we  recommend  to  his  attention  a work  by  his 
co-religionist,  Dr.  C.  Capellman,  seventh  edition, 
1890,  entitled,  “ Medicina  Pastoralis.” 


COMMON  LANDS  AND  MEDICAL  USAGE. 

Doubts  are  being  expressed  by  the  press  and 
members  of  the  public  as  to  the  effect  upon 
common  lands  which  may  be  produced  by  the 
provisions  of  the  Land  Settlement  (Facilities)  Bill 
now  before  Parliament.  Lord  Eversley,  in  a letter 
recently  published  in  The  Times,  pointed  out  that 
although  various  safeguarding  amendments  pro- 
posed by  the  Commons  Preservation  Society  have 
been  accepted  by  the  Board  of  Agriculture,  whereby 
no  part  of  a common  or  open  space  vested  in  a 
local  authority  can  be  alienated  without  Parlia- 
mentary sanction,  and  no  rural  or  suburban 
common  without  the  consent  of  the  Board  of 
Agriculture,  yet  the  reclamation  schemes  included 
in  the  Bill  constitute  a real  and  serious  menace. 
For  the  schemes  will  be  initiated  by  a department 
of  the  Board  itself,  and  there  will  he  no  appeal  from 
any  decision  of  the  Board  to  acquire  and  enclose 
a common.  We  are  glad  to  know  that  local 
authorities  must  obtain  the  consent  of  Parliament 
to  alienate  a common,  for  in  past  times  local 
authorities  have  not  hesitated  to  get  hold  of 
oommon  land  for  use  as  the  site  of  a cemetery,  a 


sewage  farm,  or  an  isolation  hospital.  It  is  true 
that  all  three  institutions  are  necessities  of  modern 
civilisation,  and  are  all  abominations  in  a thickly 
populated  district ; but  there  is  plenty  of  prac- 
tically barren  land  in  private  ownership  which 
should  be  taken  up  before  common  lands  are 
alienated,  either  with  a view  to  their  being  turned 
into  cultivated  land  or  used  as  building  sites.  There 
is  no  clause  in  the  Bill  providing  that  the  land 
shall  be  restored  as  common  if  cultivation  proves 
unsuccessful,  and  this,  surely,  is  an  error.  Much 
common  land  was  put  under  cultivation  with  very 
good  results  during  the  war,  but  then  the  circum- 
stances were  such  as  to  make  the  experiment 
likely  to  succeed.  For  instance,  some  30  or  40 
acres  of  Ashdown  Forest  were  put  under  cultiva- 
tion by  the  military  of  a large  camp.  Two  essentials 
of  successful  cultivation  were  present — namely, 
labour  and  manure — and  magnificent  crops  were 
grown.  The  land  is  too  far  away  from  the 
neighbouring  village  to  serve  as  allotments  and 
the  conservators  of  the  forest  have  insisted 
on  the  land  going  back  to  its  original  con- 
dition now  that  the  camp  is  practically  broken 
up.  They  have  arguments  on  their  side,  though 
they  may  not  be  irrefutable.  Commons  and  forest 
lands  are  of  the  greatest  importance  to  the 
welfare  of  the  community  not  only  as  “ open 
spaces  ” but  as  pasturage,  and  sources  of  litter — 
e.g.,  heather  and  bracken.  They  are  sanctuaries 
for  insect-eating  birds,  which  are  of  enormous  value 
to  agriculture,  for  every  crop  is  not  as  assailable  as 
a cherry,  nor  every  bird  as  mischievous  as  a 
bullfinch.  So  long  as  other  land  can  be  obtained 
of  equal  suitability,  commons  should  be  exempt 
from  alienation,  and  economy  in  purchase  is  a 
secondary  consideration.  But  where  it  is  a 
question  between  public  health  and  pleasant 
amenities  public  health  must  be  allowed  to  win. 


THE  RAISING  OF  THE  INCOME  FOR  COMPULSORY 
INSURANCE. 

The  attention  of  employers  is  being  called  by  the 
Ministry  of  Health  to  the  fact  that  by  the  National 
Health  Insurance  Act,  1919,  which  has  just  received 
the  Royal  Assent,  the  limit  of  remuneration  up  to 
which  persons  employed  otherwise  than  by  way  of 
manual  labour  are  liable  to  compulsory  health 
insurance  has  been  raised  from  £160  to  £250  a 
year.  Employers  are  required  for  the  future  to 
pay  health  insurance  contributions  in  respect  of 
persons  employed  by  them  under  a contract  of 
service  as  follows : for  non-manual  workers,  where 
the  rate  of  remuneration  (including  any  regular 
bonus,  &c.)  does  not  exceed  £250  a year ; for 
manual  workers,  irrespective  of  the  rate  of  re- 
muneration. Anon-manual  worker  whose  remunera- 
tion is  over  £160  a year  but  not  over  £250  a year 
may,  within  a limited  period  and  under  certain 
conditions,  claim  a certificate  of  exemption,  and  on 
the  grant  of  such  a certificate  the  employer's  con- 
tributions (3 d.  a week)  are  alone  payable.  Forms 
of  application  for  exemption  will  be  obtainable 
shortly  at  any  post  office. 


St.  Thomas’s  Hospital,  London. — The  following 
scholarships  have  been  awarded : Entrance  Science  Scholar- 
ships, 1919-20:  1st,  £150,  T.  V.  Pearce;  2nd,  £60,  E.  G.  L. 
Walker;  Arts  Scholarship,  £15  15s.,  M.  W.  P.  Hudson; 
Musgrove  Scholarship,  £35,  F.  J.  Hackwood ; William  Tite 
Scholarship,  £25,  E.  G.  Housden. 


The  Lancet,] 


REGISTRAR-GENERAL'S  DECENNIAL  SUPPLEMENT  (1901-1910).  [August  23,  1919  ;34;j 


REGISTRAR-GENERAL’S  DECENNIAL 
SUPPLEMENT  (1901-1910). 


II. 

Up  to  the  close  of  last  century  the  diseases  returned  as 
causes  of  death  were  classified  ac  the  Central  Office  according 
to  the  system  adopted  by  Dr.  William  Ogle.  But  in  1901  this 
system  was  modified  by  his  successor,  Dr.  John  Tatham,  in 
order  to  coordinate  the  national  records  with  the  revised 
Nomenclature  of  Diseases  promulgated  at  that  time  by  the 
Royal  College  of  Physicians  of  London.  Only  a few  of  the 
headings  in  the  tables  are  affected  by  this  modification,  the  list 
of  diseases  having  been  rearranged  with  a view  to  the  preser  va- 
tion of  continuity.  Under  the  present  scheme  of  tabulation 
the  number  of  deaths  assignable  to  a particular  heading  is 
determined  by  the  rule  that  out  of  several  causes  of  death 
mentioned  in  a certificate  only  one  disease  is  to  be  selected 
for  registration.  Greater  precision  of  certification  has 
recently  led  to  increased  transference  of  deaths  from 
indefinite  to  definite  headings.  Transfer  on  these  lines  has 
been  materially  aided  in  recent  years  by  the  judicious 
practice  of  appealing  from  the  Central  Office  to  medical 
certifiers  for  additional  information  in  cases  of  deaths 
imperfectly  attested.  As  a result  of  this  expedient  it  is 
stated  that  in  the  course  of  last  decennium  more  than  5000 
additions  were  made  to  the  entries  both  of  tuberculosis  and 
of  cancer,  and  more  than  1000  each  to  those  of  puerperal 
sepsis  and  appendicitis. 

The  Registrar-General  highly  appreciates  the  cooperation 
thus  rendered  gratuitously  by  the  medical  profession, 
without  which  correction  of  this  kind  would  obviously  be 
unattainable. 

Mortality  at  Different  Stages  of  Life  and  in  the  Two  Sexes. 

From  an  instructive  series  of  tables  we  learn  how  the  chief 
fatal  diseases  stand  in  relation  both  to  one  another  and  to  the 
age  constitution  of  the  victims.  The  proportions,  having 
been  calculated  on  the  facts  of  ten  years,  may  be  regarded 
as  resting  on  a fairly  reliable  basis. 

According  to  the  experience  of  1901-10  not  less  than 
10  8 per  cent,  of  the  total  mortality  is  due  to  tuberculosis, 
a larger  proportion  than  that  attributed  to  any  other  single 
cause.  From  age  15-20  onwards  the  bulk  of  this  mortality 
is  due  to  the  pulmonary  form  of  the  malady.  Next  to  tuber- 
culosis stands  heart  disease,  accounting  for  nearly  another 
10  per  cent.  Following  these  in  order  of  importance  the 
remaining  chief  causes  of  death  are  pneumonia,  bronchitis, 
cancer,  disease  of  blood-vessels,  and  diarrhoea.  At  ages  10 
to  20  and  35  to  55  heart  disease  ranks  second  in  order  as  a 
cause  of  death,  while  in  the  intervening  period,  20  to  35, 
it  ranks  third.  Thus  for  the  greater  part  of  life  these 
disorders  of  the  circulation,  when  they  do  not  actually 
occupy  first  place,  come  second  only  to  tuberculosis  as 
causes  of  death.  The  second  place  is  occupied  by  pneu- 
monia at  ages  0 to  5 and  20  to  35,  by  diphtheria  and  croup 
at  5 to  10,  by  cancer  at  55  to  65,  by  diseases  of  blood- 
vessels at  65  to  75,  and  by  bronchitis  at  ages  above  75.  At 
ages  25  to  65  pneumonia  and  appendicitis  are  most  fatal  to 
males,  and  whooping-cough,  heart  disease,  and  cancer  to 
females. 

The  familiar  epidemic  diseases  are  generally  more  destruc- 
tive to  life  in  the  first  five  years  than  in  the  whole  remainder 
of  life.  This  is  particularly  noticeable  in  the  case  of 
whooping-cough,  measles,  scarlet  fever,  diphtheria,  and 
diarrhoea.  With  reference  to  the  behaviour  of  these  epidemic 
diseases  in  later  life,  and  to  the  fact  that  adult  mortality 
thus  caused  is  generally  greater  amongst  females,  Dr.  T.  H.  C. 
Stevenson  suggests  that  this  may  be  due  to  their  more 
frequent  exposure  to  infection  through  sick  nursing  and 
other  family  duties.  He  finds  that  adult  mortality  from 
scarlet  fever  and  from  diphtheria  is  higher  among  women, 
whereas  from  small-pox,  enteric  fever,  and  cerebro- 
spinal fever  it  is  considerably  higher  in  men,  among 
whom  the  risk  of  infection  from  domestic  sources  would 
often  not  be  so  serious.  The  incidence  on  the  sexes  of 
mortality  from  small-pox  and  enteric  fever  does  not  greatly 
differ  throughout  childhood,  but  on  the  attainment  of  adult 
age  the  mortality  of  males  far  exceeds  that  of  females.  This 
is  also  true  of  pneumonia. 

Streptococcus  diseases. — This  group,  including  erysipelas, 
septicaemia,  pyaemia,  and  phlegmon,  with  carbuncle  and 


cellulitis,  may  be  said  to  possess  in  some  sense  a common 
type  of  age  distribution,  about  25  per  cent,  occurring  in  the 
first  five  years,  and  the  remainder  being  widely  scattered 
over  the  rest  of  life.  But  whilst  the  looal  infections  are 
seldom  dangerous  to  older  children  and  young  adults,  the 
general  infections,  pyaemia  and  septicaemia,  are  very  fatal 
during  youth  and  correspondingly  less  fatal  in  old  age. 

Syphilis. — General  paralysis  of  the  insane  and  locomotor 
ataxy  being  now  regarded  as  particular  manifestations  of 
syphilitic  infection,  much  attention  has  recently  been  devoted 
to  these  diseases.  The  total  mortality  from  the  first  of  these 
conditions  is  more  than  three  times  as  heavy  for  males  as  for 
females.  There  appears  to  exist  little  difference  between 
the  sexes  in  regard  to  the  loss  of  life  thus  caused  among 
young  persons,  the  higher  proportion  of  juvenile  to  total 
mortality  in  the  female  sex  being  due  to  the  lower 
aggregate  mortality  of  females.  We  learn  that  at  ages 
below  20  years,  when  the  disease  originates  in  congenital 
syphilis,  which  affects  both  sexes  alike,  males  and  females 
are  equally  liable  ; but  that  at  ages  above  25  years,  when 
most  of  the  cases  are  due  to  acquired  syphilis,  the  remarkable 
excess  of  male  mortality  becomes  evident.  The  same  feature 
obtains  in  a less  degree  in  the  case  of  syphilis  itself,  and  it 
may  be  that  the  suppression  of  facts  which  notoriously 
prevails  in  regard  to  that  disease  affects  men  more  than 
women.  That  sex  has  a real  influence  on  mortality  arising 
from  syphilitic  taint  appears  from  comparison  with  locomotor 
ataxy.  Although  both  this  disease  and  general  paralysis 
have  a common  origin  in  syphilitic  contamination,  the  excess 
of  male  mortality  is  considerably  greater  in  the  case  of 
locomotor  ataxy.  Moreover,  the  tendency  of  approximation 
of  female  to  male  mortality  in  old  age,  which  is  apparent  in 
the  case  of  syphilis  as  well  as  of  general  paralysis,  is  believed 
to  be  absent  in  the  case  of  locomotor  ataxy. 

Tuberculosis. — The  most  striking  feature  of  these  tables  is 
the  prominent  position  occupied  by  tuberculosis,  which  at 
ages  from  5 to  55  accounts  for  more  deaths  than  any  other 
single  cause.  Between  the  ages  of  20  and  25  it  causes  more 
than  40  per  cent,  of  the  aggregrate  mortality  in  both  sexes 
The  deaths  assigned  to  tuberculosis  in  1901-10  amounted  to 
565,161,  and  were  fewer  by  50,845  than  in  the  previous 
decennium.  Corrected  for  estimated  increase  of  the  popula- 
tion the  difference  becomes  121,941.  The  life  saving  claimed 
may  be  still  further  increased  if  allowance  is  made  for  the 
fact  that  the  constitution  of  the  population  in  the  recent 
decennium  was  more  favourable  to  tubercle  mortality  than 
had  been  that  of  1891-1900. 

The  standardised  death-rate  in  1901-10  was  equal  to 
1646  per  million  living,  or  18  6 per  cent,  less  than  in  the 
decennium  immediately  preceding.  During  the  50  years 
elapsed  since  1861-70,  tuberculous  mortality  has  been  nearly 
halved  among  males  and  more  than  halved  among  females. 
The  greatest  reduction  among  males  occurred  at  ages  10-25, 
and  among  females  at  ages  15-45.  At  ages  45-65  the 
mortality  of  women  has  fallen  more  than  twice  as  much  as 
that  of  men. 

From  the  degree  in  which  tuberculosis  has  contributed  to 
the  total  deaths  at  various  ages  during  the  last  60  years  it 
appears  that  the  disease  is  now  of  less  relative  importance  as 
a cause  of  death  than  in  earlier  years.  This  change  is  much 
more  conspicuous  amongst  females.  It  applies  in  each  sex 
to  all  ages,  except  5-10  and  10-15,  when  mortality  from 
all  causes  is  relatively  low.  The  ages  at  which  tubercle 
contributed  most  to  the  total  death-rate  ever  since  1860  have 
been  20-35  for  males  and  15-25  for  females.  At  the  latter 
age  it  accounted  for  rather  more  than  half  the  total  deaths 
of  females  during  1851-70,  but  this  proportion  has  recently 
fallen  to  a little  over  40  per  cent.  At  all  adult  ages  the 
disease  now  plays  a more  important  part  in  the  mortality  of 
males  than  of  females,  although  during  1851-70  this  was  the 
case  only  at  ages  above  45.  The  concentration  of  tuber- 
culous fatality  upon  the  most  valuable  working  period  of 
life  is  a startling  fact  which  should  receive  the  earnest 
attention  of  the  new  Minister  of  Health,  to  whom  it  may 
be  suggested  in  the  words  of  the  text,  that  “the  period  of 
early  maturity  which  is  specially  attacked  in  bath  sexes  is 
that  at  which  the  proportion  of  future  productivity  to 
dependence  is  at  its  maximum,  and  at  which,  therefore, 
deaths  are  the  greatest  loss  to  the  community.” 

Changes  of  Mortality  in  Three  Deeennia. 

Hitherto  the  study  of  disease  incidence  and  mortality  has 
been  limited  in  these  pages  to  the  experience  of  a single 


344  The  Lancet,] 


TUBERCULOSIS  IN  ITALY. 


[August  23,  1919 


decennium.  But  Dr.  Stevenson  now  furnishes  us  with  the 
means  of  tracing  the  changes  of  this  incidence  in  the 
course  of  the  three  successive  decennia  from  1881-90 
onwards.  The  standardised  death-rates  in  each  of  the  last 
three  decennial  periods  are  compared  with  the  aid  of  a table 
from  which  it  appears  that  for  all  causes  jointly  a decrease 
of  16  per  cent,  in  1891-1910  has  succeeded  to  a decrease  of 
3 per  cent,  only  in  the  decennium  immediately  preceding. 

The  following  are  the  principal  declines  in  mortality 
recorded  during  the  last  30  years — a period  nearly  corre- 
sponding to  that  which  has  elapsed  since  the  passing  of  the 
great  Public  Health  Act.  From  enteric  fever  the  fall  has 
been  equal  to  48  per  cent.,  from  influenza  to  43  per  cent., 
from  diphtheria  and  croup  to  36  per  cent. , from  bronchitis 
to  36  per  cent. , from  puerperal  septic  diseases  to  34  per  cent., 
from  gout  to  32  per  cent. , and  from  pleurisy  to  31  per  cent. 

As  against  these  large  declines,  as  well  as  many  others  of 
a substantial  nature,  the  only  important  increases  recorded 
are  those  from  cancer,  diabetes  mellitus,  and  Bright’s  disease. 
Of  these  by  far  the  most  important  is  the  increase  of  cancer, 
the  standardised  rate  for  which  is  higher  by  13  per  cent, 
than  in  the  previous  decennium,  this  increase  being  only  at 
half  the  rate  shown  in  the  preceding  period. 

It  is  significant  that  the  two  chief  diseases  for  the  recogni- 
tion of  which  examination  of  the  urine  is  important,  diabetes 
and  Bright’s  disease,  are  both  included  in  the  short  list  of 
recorded  increases.  Such  aids  to  medical  diagnosis  are  no 
doubt  more  generally  practised  by  physicians  as  time  goes 
on.  and  Dr.  Stevenson  regards  it  as  quite  conceivable  that 
this  fact  may  largely  or  wholly  account  for  the  increase 
shown  in  the  tables.  The  slight  increases  recorded  from 
valvular  heart  diseases  and  from  angina  pectoris  may  be 
dismissed  as  due  merely  to  improvements  in  certification, 
seeing  that  diseases  of  the  heart  and  blood-vessels  in  the 
aggregate  show  a considerable  reduction.  For  a similar 
reason  the  slight  increase  from  pneumonia  may  be  also 
dismissed. 


TUBERCULOSIS  IN  ITALY.1 


The  American  Red  Cross  Commission  on  Tuberculosis  in 
Italy  entered  on  its  inquiry  with  three  guiding  principles 
of  action:  “First,  that  no  wise  plan  of  cooperation 
could  be  drafted  in  a foreign  country  without  first  gathering 
intimate  knowledge  of  its  people  and  of  existing  health 
conditions  ; second,  that  no  matter  how  well  trained 
men  and  women  might  be  for  work  in  America,  this 
was  not  necessarily  an  indication  of  their  preparation 
for  work  in  a foreign  country  ; third,  that  sympathetic 
relations  between  workers  and  people  must  be  developed 
through  the  avenue  of  mutual  knowledge.”  A long  course  of 
preliminary  study  was  accordingly  undertaken  before  the 
actual  work  was  entered  on ; and,  indeed,  the  entire 
investigation  appears  to  have  been  conceived  and  carried  out 
in  the  most  thorough  and  exhaustive  manner  possible. 
Mortality  from  Tuberculosis  in  Italy  Compared  with  other 
Countries. 

The  mortality  from  pulmonary  tuberculosis  in  Italy  was 
115  per  100,000  in  the  quinquennium  1909-1913,  the  same 
as  in  Scotland  and  the  Netherlands ; in  Ireland  and  in 
Norway  it  was  173  ; in  England  and  Wales  it  was  105  ; in 
Belgium  (1908-1912),  99;  in  France  (1907-1911),  183. 
Though  there  are  20,540  beds  available  for  tuberculous 
soldiers  and  discharged  prisoners,  it  is  stated  that  more 
than  half  are  unoccupied,  and  that  in  Sicily  a hospital  with 
800  beds  has  only  five  patients.  Hospital  life  and  its 
restrictions  are  said  to  be  disliked  by  the  Italians.  Although 
the  tuberculosis  question  is  therefore  not  so  serious  as  in 
some  other  countries,  the  decline  in  mortality  from  this 
cause  has  not  been  satisfactory  during  the  last  50  years, 
and  during  the  war  there  has  been  a larger  proportional 
increase  in  spite  of  favourable  conditions  of  climate. 

Scope  of  the  Inquiry. 

In  view  of  existing  organisations  of  the  Italian  Red  Cross 
and  the  Government,  the  American  Commission  decided,  after 
careful  inquiry,  to  limit  their  work  to  the  provinces  of 
Liguria,  Umbria,  Palermo,  and  the  island  of  Sardinia.  The 
ideal  organisation  that  was  aimed  at  comprised  these  four 

1 Report  of  the  American  Red  Cross  Commission. 


sections  : — Public  health,  Antituberculosis  methods,  Child  1 
welfare,  and  School  hygiene  ; and  committees  were  appointed  t 
to  deal  with  (1)  hospitals  and  6anatoriums,  (2)  dispensaries, 

(3)  teaching  of  general  hygiene,  (4)  fiaance,  (5)  medical 
instruction,  (6)  research  into  social  conditions,  with  various 
subcommittees.  Local  authorities  and  influential  persons 
were  approached  and  assistance  offered  on  the  lines  sug- 
gested. Says  the  report : — 

“ The  Italian  minds  were  open  and  alert  to  the  necessity 
for  it  (the  inquiry),  keen  to  put  it  into  operation;  the 
American  minds,  constantly  having  in  view  what  was  best 
for  Italy  adapted  as  the  Italian  saw  it,  were  willing  to 
cooperate  in  order  to  enable  the  Italians  to  secure  it.  The 
combination  made  a successful  issue  in  each  of  the  pro- 
vinces chosen.” 

Thus,  in  Sardinia  Mr.  and  Mrs.  Charles  W.  Wright  estab- 
lished a provincial  organisation  ; at  Palermo  an  anti-tuber- 
culosis league  was  formed,  with  correlation  of  the  work  of 
existing  organisations  and  extending  it  throughout  the  whole 
of  Sicily.  In  the  organisation  the  keystone  was  the  full-time 
paid  executive  secretary,  as  would  always  be  the  case  in 
similar  movements  in  this  country  or  in  America,  though  in 
Italy  the  plan  was  practically  unknown  and  untried.  The 
public  health  nurse  or  visitor,  who  would  carry  the  instruction 
given  by  the  physicians  in  the  dispensaries  directly  into  the 
homes  of  the  applicants  for  relief,  was  also  practically 
unknown  in  Italy. 

Schools  Opened  for  Italian  Students. 

Three  schools  were  opened  in  Rome,  Genoa,  and  Palermo, 
committees  of  Italian  women  being  formed  to  act  as  boards  of 
trustees,  to  assure  the  continuance  of  the  work  ; only  Italian 
students  were  accepted,  and  American  nurses  acted  as 
teachers  and  consultants,  their  value  being  fully  appre- 
ciated 'by  the  Italian  physicians,  and  their  services  being 
completely  and  immediately  acceptable  in  the  homes  of 
the  people.  A Section  of  School  Hygiene  was  established 
to  deal  with  the  needs  of  the  3^  million  children  on 
the  school  registers,  as  well  as  those  of  an  additional 
million  not  so  accounted  for.  The  birth-rate  in  1914  was  h 
311  per  1000 ; in  1916  it  had  dropped  to  24  4 ; in  1918  it 
is  considered  that  this  ratio  had  fallen  to  somewhere  I 
between  19  and  16  for  the  whole  country ; the  infantile  . j 
death-rate  (1910-1914)  was  138  per  1000  living  births;  I 
this  had  risen  to  171  per  1000  in  the  large  cities  in  1917 

Housing  Difficulties:  An  Anti  malarial  Campaign  Wanted. 

The  question  of  housing  is  considered  in  the  report,  among 
the  special  points  being  the  size  of  the  tenement  dwellings 
generally  occupied  by  the  working  classes  in  the  large 
towns,  and  the  difficulties  presented  by  the  numerous  villages 
situated  on  hill-tops,  of  historic  interest  and  picturesque 
charm,  but  hygienically  presenting  “so  serious  a problem 
that  one  wonders  what  the  next  step  for  Italy  can  be  to 
secure  an  amelioration  of  their  darkness,  and  dampness, 
and  sanitary  inefficiency.”  A long  antimalarial  campaign 
is  first  required.  Malaria,  which  in  1914  had  been  reduced 
to  129,000  cases,  increased  during  the  war  to  302,499  cases 
in  1917  ; and  these  were  only  the  “ reported  cases,”  probably 
not  nearly  all  that  occurred.  Pellagra  has  apparently  not 
increased,  but  returns  are  not  available  for  this  disease. 

Italian  Claims  for  Cooperation  : Practical  Suggestions. 

In  conclusion,  the  report  states  that  Italy,  “the  youngest 
of  the  nations,”  has  the  following  claims  for  full  cooperation 
with  the  other  nations  of  the  world : (1)  a low  death-rate 
and  high  birth-rate ; (2)  a people  who  love  her,  no  matter 
where  they  go ; (3)  an  accomplishment  as  United  Italy 
which  justifies  her  ancient  tradition  ; (4)  as  one  of  the 
greatest  contributors  to  the  labour  of  construction  throughout  j 
the  world.  America  owes  her  an  especial  debt,  not  to  be  j 
paid  in  material  things,  but  by  fraternal  cooperation.  Four  j 
practical  suggestions  are  given  for  carrying  this  out  : the  ] 
preparation  annually  in  foreign  languages  by  national  ; 
and  State  governments  of  “descriptive  material  and 
charts,  showing  their  progress  in  the  great  social  move- 
ments, to  be  sent  with  the  general  reports  for  fuller  refer- 
ence to  foreign  Ministers  and  libraries.  This  method  has  long 
been  used  by  industrial  concerns  in  Germany,  which  prepare 
their  catalogues  in  the  language  of  the  country  in  which  they 
propose  to  sell,  with  the  price  quotations  in  the  money 
of  that  country,  based  upon  delivery  at  the  door  of  the 
consumer.  At  ‘ the  same  time  information  as  to  inter- 
national standards  of  public  health  and  welfare  should  be 


The  Lancet,] 


URBAN  VITAL  STATISTICS. 


interchanged  by  means  of  a sanitary  commission.  Secondly 

raa  LC,rSUitatl,V/  commissitons'  working  through  diplomatic 
channels  should  secure  the  adoption  of  similar  public 
health  and  welfare  standards,  as  already  has  been  done  in 
regard  to  military  and  industrial  affairs.  A third  suggestion 
is  the  establishment  of  international  scholarships  for  the 
teaching  and  practice  of  public  health  and  welfare  work  a 
beginning  in  this  direction  has  already  been  made  in  the 
scholarships  offered  to  France  by  Miss  E.  Chalfant  and  Mrs. 
V . 8.  Mitchell  of  Pittsburgh,  and  the  Boston  French  Tuber- 
culosis Committee,  also  by  Mr.  R.  B.  Mellon,  of  Pittsburgh 
rhw-hnS  Pr°vided  three  scholarships  for  an  exchanged 
public  health  nurses  between  America  and  Italy  The  value 

P LcttrpXf ,0n  " Und°Ubted’  aQd  ^P-s/nt  instance  js 

Supplementary  Reports. 

, Y?  \1,.en?ene^1  report  above  summarised,  which  is  signed 
ly  Di.  William  Charles  White,  the  Director  of  the  Commission 

by  Mary  S report  of  the  Nursing  Section 

y Mary  S.  Gaidner,  which  describes  the  various  forms 
of  nursing  that  are  actually  in  operation,  and  the  chief 
points  that  need  attention  to  make  the  service  a satisfactory 
one  according  to  modern  requirements.  To  this  succeeds  a 

excePe°nVhe  ^ h statistics  by  Mr.  Knud  Stouman.  An 
excellent  map  of  Italy  shows  by  graduated  shading  the 

Kingdom0.818  m0rtaUty  ^ the  Vali°US  Pl0vinces  of  the 


[August  23,  1919  345 


URBAN  VITAL  STATISTICS. 

VITAL  STATISTICS  OF  LONDON  DURING  JULY  1919 

lre“,;,uTrei  *"5““ 

e.oh  of  the  metropoliun 

minster,  Hampstead,  and  the  Citv  of  r 1 U?e.  of  West 


2naMinsettfi°I}0lttan  f M8  HoBP'ta,R  at  the  end  of  the  month  numbered 

sgspssl 

valent  in  Stoke Newington  StenneriorS^T0  ni0nally,  m0StT  I,re 

recorded  ^ Hackney  ShSrtb  Pr?w?nC,e  ?!  thia  disease  was 
Bermondsey,  anffSham  ^The  number  Of  dmhti  JS?utW1 
beenrn34ati036nt  ^P^'*  wh?c“ 

rose  to  1108  at  the  end  of  July  ?he  weekYTsA Pr.ec?ding  months, 

somewhat^  * more6  ^ 

frTe|nn#edmtTtVoolwichhe5  ^to^ Wandsworth , Tt7  Cam 

timee^reced.ng  months  • the  weekly’admissions  averaged  5?  against 

belo^mg'to't^e^everaf  boTOuehs^^h'e  deatif  *°  the  deathsof  Lilians 
p revlou  sly  resided  ^ U D u ri  ng°uf  Y" * boro!^h8  inwhichtoe' “die"  had' 

and  97  per  ““  rates  had  b^n  l5-0,  11  1? 

Lewisham  7 9 in'  w' ^th-rates  ranged  from  6'5  in  Fulham,  7'8  in 

Eewisham  / 9 m Stoke  Newington,  8'4  in  Battersea,  8’4  in  Woolwich 
n Hampstead,  and  8’7  in  Shoreditch,  to  11 '1  in  Southwark  11-3  in' 

^he  3801'  deaths'  U’5  in  DePtford-  and  T2‘4  m HoYborn 

fn  deaths  from  all  causes  included  154  which  were  referred 

detthh?  and  en.ter!tls  among  children  under  2 years  of  age  No 
a"Y  of  these  diseases  was  recorded  in  Fulham  gand  the 

death  rlte^Trom' th«?°d“g  the  metroPoIitan  boroughs  the  lowest 
u . LY  rates  rrom  these  diseases  were  recorded  in  thn  (^txr  r»f 

wortYera  dV  Mar,yleb°ne'  HampsteaS, ^Ihoredltch,^ Lambeth WYnds 
stennkv  pY  iW19hai^;  £nd  the  highest  in  Chelsea,  Stoke  Newington 
Stepney,  Poplar,  and  Camberwell.  The  2 fatal  rasps  of 
belonged  to  Woolwich.  The  24  deaths  from  measles  were  one-fiftlfof 
the  average  number  in  the  corresponding  peri^  of  the  five 
preceding  years ; ot  these  deaths  4 belonged  t0P  Bermondsey?  4 to 


. , _ , _ - “ - - » — ~~~  -T  uciuupeu 

SIS  OF  SICKNESS  AND  MORTALITY  STATISTICS  IN  LONDON  DURING  JULY,  1919. 
{specially  compiled  for  The  Lancet.) 


Notified  Cases  of  Infectious  Disease. 


Cities  awd 
Boroughs. 


LONDON 

West  Districts  : 
Paddington 
Kensington  ... 
Hammersmith 

Fulham  

Chelsea  

City  of  Westminster 
North  Districts : 
St.  Marylebone 
Hampstead  ... 

St.  Pancras 

Islington 

Stoke  Newington... 

Hackney 

Central  Districts  : 

Holborn  

Finsbury [ 

City  of  London 
East  Districts  : 

Shoreditch  

Bethnal  Green 

Stepney  

Poplar  

South  Districts : 

Southwark  

Bermondsey  ...  ", 

Lambeth 

Battersea 

Wandsworth  ...  *' 
Camberwell 

Deptford 

Greenwich 
Lewisham 
Woolwich...  .[[ 

Port  of  London 


• 

a a?  | s 

r£j 

g-S  % 

? ta 

£■2  a 

i-  0) 

® ft 

<D 

X3  a § 

DO) 

H 

£8  o 
O Ps 

2 189 

14  14 

2 5 

- 2 

1 6 

1 1 

1 5 

— 1 

1 7 

- 5 

8 

III 

N 1 1 1 

13 



16 

— 1 

4 

1 — 

13 

1 1 

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1 1 

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15 

- 1 1 

8 

1 — 

9 

2 — 

14 

2 - 

14 

— i 1 

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8 

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3 

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5 

1 , — 

2 

1 ; - 

3 

j 

doJ 

i8.1 

cfS  *—* 

3 u ‘ 
O o £ 
! 3 Q = 
<1  i 


Deaths  from  Principal  Infectious  Diseases. 


2286 

63 

64 
44 
52 
26 
27 

40 

19 

85 

166 

32 

124 


59 

5-4 

4-4 

4-0 

3'7 

4-7 

2’3 

4- 5 
2-6 
48 

5- 8 
7-0 

6- 6 


16  4-7 

39  6-0 

3 1 1-9 


24 


14 


45 

99 

218 

72 

150 

123 

135 

64 

143 

116 

69 

82 

104 

66 


5'2 

9'6 

9'8 

5-2 

9-3 

11-9 

5'2 

4- 4 

5- 0 

5- 1 
7-0 
9-5 

6- 7 
5-2 


12 


ro  ® i 
O'O 
cs  a . 

2~£l 

8 ® a3  | 

-as  ® 

I St:  H 

<U  cs] 


Q d 
M a> 


6 55  154 


- 1 

— 3 

1 3 

— 2 

1 — 


- 1 


— 3 


SgS 

— . o ~ 

CD 

a u a 
a ® ° 
a a£ 


°‘ai 

a>  a 
xi  Z 


- , — 2 

- ; 1 2 


1 - 


— II  1 


0-4 

0-3 
0-3 
0 6 | 

0-7 

0-2 


3801 


108 

165 

105 

91 

59 

118 


0-2 
0-1 
0-3 
0 6 
0-7 
0-3 


93 

63 

191 

303 

36 

178 


0 6 42 

0-3  74 

- I 15 

0- 2  I 75 
0 4 ! 101 

1- 0  . 217 
0-7  | 141 


0-3 
0-5 
02 
0-3 
0-2 
0-7 
0-5 
0-3 
01 
0-4  j 


178 

102 

282 

121 

275 

241 

114 

86 

121 

106 


Including  membranous  croup 


98 

9-2 
11-4 
9-5 
6 5 
10-7 
10-1 

105 

8- 7 

10- 7 
10-6 

7-9 

9- 4 

12-4 

11- 3 

9-7 

8 7 

9 8 
9-8 

10- 3 

11- 1 

99 
10-8 
8 4 
95 

10- 5 

11- 5 
9-9 
7'8 
8-4 


346  The  Lancet,] 


THE  SERVICES. 


[August  23,  1919 


Camberwell,  3 to  St.  Pancras,  3 to  Lambeth,  and  2 to  Wandsworth. 
The  14  fatal  cases  of  scarlet  fever  were  3 less  than  the  average ; 3 of 
these  b jlonged  to  Stepney.  The  41  deaths  from  diphtheria  were  10 
below  the  average;  of  these  deaths  7 belonged  to  Islington,  5 to 
Poplar,  4 to  Camberwell,  and  3 to  Stepney.  The  12  fatal  cases  of 
whoopi ng-couyh  were  one-sixth  of  the  average  number;  of  these, 
2 belonged  respectively  to  Hammersmith,  Stepney,  and  Poplar.  The 
6 deaths  from  enteric  fever  were  4 less  than  the  average.  The  55  deaths 
from  diarrhoea  and  enteritis  among  children  under  2 years  of  age 
were  64  below  the  average  number;  the  greatest  pioportional  mortality 
fromthis  disease  was  recorded  in  Hammersmith,  Chelsea,  Islington, 
Stepney,  and  Camberwell.  In  conclusion,  it  may  be  stated  that  the 
aggregate  mortality  from  these  principal  infectious  diseases  in  London 
during  July  was  60  per  cent,  below  the  average. 


(Week  ended  August  16th,  1919.) 

English  and  Welsh  Towns. — In  the  96  English  and  Welsh  towns, 
with  an  aggregate  civil  population  estimated  at  16,500,000  persons, 
the  annual  rate  of  mortality,  which  had  been  10‘3,  9 7,  and  9 7 in 
the  three  preceding  weeks,  rose  to  10  0 per  1000.  In  London,  with 
a population  slightly  exceeding  4,000,000  persons,  the  annual  rate 
was  10‘4,  or  0*9  per  1000  above  that  recorded  in  the  previous 
week,  while  among  the  remaining  towns  the  rates  ranged 
from  3'2  in  Hornsey,  37  in  Wallasey,  and  4*1  in  Walsall, 
to  15‘5  in  Southport,  16*1  in  Hastings,  and  17'5  in  Gates- 
head. The  principal  epidemic  diseases  caused  174  deaths, 
which  corresponded  to  an  annual  rate  of  05  per  1000,  and 
included  92  from  infantile  diarrhoea,  35  from  diphtheria,  28  from 
measles,  10  from  whooping-cough,  5 from  scarlet  fever,  and  4 
from  enteric  fever.  Measles  caused  a death-rate  of  1*3  in  Gateshead, 
1*5  in  Salford,  and  17  in  Edmonton.  There  were  1517  cases  of  scarlet 
fever  and  1112  of  diphtheria  under  treatment  in  the  Metropolitan 
Asvlums  Hospitals  and  the  London  Fever  Hospital,  against  1547  and 
1092  respectively  at  the  end  of  the  previous  week.  The  causes  of 
21  deaths  in  the  96  towns  were  uncertified,  of  which  6 were  registered 
in  Birmingham  and  2 each  in  Gloucester  and  Gateshead. 

Scotch  Towns. — In  the  16  largest  Scotch  towns,  with  an  aggregate 
population  estimated  at  nearly  2.500,000  persons,  the  annual  rate  of 
mortalitv,  which  had  been  11 T,  10*6,  and  10  0 in  the  three  preceding 
weeks,  further  fell  to  9 9 per  1000.  The  232  deaths  in  Glasgow 
corresponded  to  an  annual  rate  of  10’8  per  1000,  and  included  14  from 
infantile  diarrhoea,  6 from  diphtheria,  4 whooping-cough,  and  1 each 
from  enteric  fever  and  measles.  The  70  deaths  in  Edinburgh  were 
also  equal  to  a rate  of  10  8 per  1000,  but  did  not  include  any  from  the 
principal  epidemic  diseases. 

Irish  Towns.— The  111  deaths  in  Dublin  corresponded  to  an  annual 
rate  of  14‘3,  or  1*6  per  1000  above  that  recorded  in  the  previous 
week,  and  included  28  from  infantile  diarrhoea  and  1 from  measles. 
The  82  deaths  in  Belfast  were  equal  to  a rate  of  10  7 per  1000,  and 
Included  6 from  infantile  diarrhoea  and  1 from  scarlet  fever. 


®[je  Strikes. 


ROYAL  NAVAL  MEDICAL  SERVICE. 

Surg.-Cdr.  J.  Chambers  to  be  Surgeon-Captain. 

Surg  -Cdr.  T.  H.  Vickers  is  placed  on  the  Retired  List  at  own  request. 
Surg. -Capt.  E.  C.  Lomas  is  placed  on  the  Retired  List. 

ARMY  MEDICAL  SERVICE. 

Col.  C.  H.  Melville,  C.M.G.,  retires  on  retired  pay. 


ROYAL  ARMY  MEDICAL  CORPS. 

Majors  relinquish  the  acting  rank  of  Lieutenant-Colonel  on  re-posting : 
A.  C.  H.  Gray,  C.  R.  Millar. 

Major  S.  M.  W.  Meadows,  D.S.O.,  and  Major  and  Bt.  Lieut. -Col.  A. 
McMunn  relinquish  the  temporary  rank  of  Lieutenant-Colonel  on 
re-posting. 

The  undermentioned  relinquish  the  acting  rank  of  Major:  Capt.  and 
Bt.  Major  K.  E.  Barnsley ; Capts.  L.  J.  Sheil,  O.  H.  Brennan.  K A. 
Austin  ; Temp.  Capts.  W.  Haward,  J.  V.  Grant,  M.  R.  Mackay,  W.  T. 
Bessel.  Joseph  S.  Stewart,  A.  C.  B.  McMurtrie,  R.  J.  Vernon.  H.  M. 
Vickers,  I.  Jones,  L.  M.  Smith,  G.  Jackson,  G.  E.  Neligan,  J.  F.  McG. 
Sloen.  T.  E.  Amyot,  J.  McDonnell,  M.  A.  Power,  L.  G.  McCune,  C.  G. 
McAdam,  F.  W.  Wesley,  T.  Muir  Crawford. 

To  be  acting  Majors : Capts.  F.  W.  Matheson,  W.  E.  Adam  ; Temp. 
Capts.  S.  Stockman,  K.  S.  S.  Statham,  R.  E.  H.  Leach,  P.  P.  J.  Stewart, 
C.  E.  Walker. 

Capt.  G.  D.  Robertson  resigns  his  commission. 

Capt.  N.  T.  Whitehead  relinquishes  the  acting  rank  of  Lieutenant- 
Colonel  on  ceasing  to  command  a Medical  Unit. 

Capt.  D.  II.  C.  MacArthur  relinquishes  the  acting  rank  of  Major. 
Capt.  R.  11.  Graham,  from  Spec.  Res.,  to  be  Captain. 

Temporary  Captains  to  be  Captains  : R.  N.  Porritt,  A.  R.  Oram. 
Captains  from  the  T.F.  to  be  Captains : G F.  Carr,  C.  M.  Gozney. 
Temporary  Lieutenants  to  be  temporary  Captains  : J.  Paxton,  V.  D. 
Pennefalher,  Q.  S.  Livingston,  N.  B.  Benjatield,  J.  McClellan,  A.  P. 
Mitchell,  G.  H.  Dart,  J.  C.  Warwick,  E.  H.  Milson,  A.  E.  Hodgkins. 

Capt.  A.  G.  Harsant,  from  Spec.  Res.,  to  be  Lieutenant,  and  to  be 
temporary  Captain. 

Temp.  Lieut.  J.  E Rea  to  be  Lieutenant. 

Officers  relinquishing  their  commissions: — Temp.  Lieut. Cols, 
(retaining  the  rank  of  Lieutenant-Colonel)  E.  W.  Goodall,  W.  D. 
Buncombe,  F.  S.  Toogood,  A.  D.  Reid,  H.  L.  Eason;  Temp.  Hon.  Major 
G.  Hodge  (retains  the  honorary  rank  of  Major)  ; Temp.  Major  and 
Brevet  Lieut.-Col.  A.  W.  Robinson  (retaius  the  rank  of  Brevet 
Lieutenant-Colonel) ; Temp.  Majors  (retaining  the  rank  of  Major) 
G.  H.  Ross,  T.  Macsenzie  ; Temp.  Capts.  and  Brevet  Majors  Retaining 
the  rank  of  Brevet.  Major)  W.  S.  Stalker,  E.  C.  Williams,  it.  McC.  Hill ; 
Temporary  Captains  granted  the  rank  of  Major:  D.  D.  Craig,  W.  B. 
Davy,  J.  R.  M.  Whigham,  A.  W.  Uloth,  A.  K.  H.  Pollock,  A.  E. 


Marsack,  J.  W.  Littlejohn,  F.  W. Wesley ; Temporary  Captains  retaining 
the  rank  of  Captain  : J.  Scott.  R.  W.  Valentine,  H.  L.  Morrow,  R.  T. 
Stoney,  T.  F.  S.  Fulton,  J.  H.  Wilke,  T.  Brodie,  C.  Brash.  D.  McCormack, 
J.  S.  Annandale,  B.  L.  Livingstone-Learmouth,  J.  M.  Wnyte,  J.  E.  M. 
Wiglev,  P.  A.  Creux,  S.  H.  L.  Archer,  S.  E.  Murray.  R.  H.  S.  Marshall, 
P.  J.  Kelly,  J.  C.  D.  Allan.  L.  H.  Leeson.  B.  F.  Macnaughton,  F.  R. 
Haesard,  D.  Whyte,  S.  Y.  Walsh.  W.  A.  Proud,  G.  R Bickerstaff,  A.  W. 
Adams,  E.  G.  Fenton,  J.  M.  Wlshart,  W.  B.  A.  Moore,  H.  W.  Crowe, 
J.  M.  Gibson,  D.  MacGregor,  J.  C.  Hindley,  J.  Patrick,  L.  Zealand,  F.F. 
Carr-Harris,  C.  G.  G.  Winter,  J.  S.  Stewart,  D.  H.  Paul,  R.  F.  Wilkinson, 
A.  G.  Gilchrist.,  C.  W.  Smith,  G.  Matthews,  D.  F.  A.  Neilson,  R.  W. 
Smith,  A.  B.  Raffle,  J H.  Wrightson,  E Duke,  A . M.  Clare.  R.  A.  Flvnn, 
E.  Billing,  A.  Brown.  C.  W.  Fowler,  F.  H.  Diggle,  P.  N.  Vellacott,  B.  G. 
Gutteridge,  J.  R.  Marrack,  H W.  Parnis,  J.  F.  Carroll,  C.  H.  Aylen, 

G.  O.  Grain,  C.  E.  Bashall,  A.  G.  Naismith,  O.  H.  Bowen,  B.  T.  Parsons- 
Smith,  G.  M.  C.  Powell,  L.  P.  Booth  ; Temp.  Hon.  Capt.  J.  B.  Feam 
(retains  the  honorary  rank  of  Captain);  Temporary  Lieutenants 
retaining  the  rank  of  Captain  : W.  A.  Mein,  L.  H.  McConnell, 
D.  R.  Wheeler,  W.  Gilmore. 

Canadian  Army  Medical  Corps. 

Temp.  Major  (acting  Lieut.-Col.)  E.  L.  Pope  to  be  temporary 
Lieutenant  Colonel . 

Temporary  Captains  (acting  Majors)  relinquishing  the  acting  rank  of 
Major  : N.  W.  Strong,  W.  E.  Gallie. 

The  undermentioned  temporary  Captains  retire  in  the  British 
Isles:— W.  B.  Honey,  C.  V.  Bailey,  T.  V.  Hunter,  H.  J Theriault, 
J.  A.  MacKenzie,  J.  A.  Jardine,  J.  R.  Le  Touzel,  W.  A Marshall,  P.  A. 
Leacy,  W.  H.  Hills,  C.  V.  Mills,  M.  R.  Boe,  H.  H.  Perry. 

Canadian  Army  Dental  Corps. 

Temp.  Capt.  B.  E.  Brownlee  retires  in  the  British  Isles. 

SPECIAL  RESERVE  OF  OFFICERS. 

Capt.  J.  P.  Chamock  relinquishes  the  acting  rank  of  Major. 

Capt.  O.  Williams  to  be  acting  Major. 

Capt.  A.  C.  Irvine  relinquishes  his  commission. 

Lieutenants  to  be  Captains:  M.  Jackson,  G.  P.  W.  Staunton,  T.  H. 
Almond,  J.  N.  Gale,  J.  W.  Mann,  F.  K.  Bscritt,  A.  C.  Paterson, 
A.  E.  B.  Paul. 

TERRITORIAL  FORCE. 

Lieut.-Col.  (acting  Col.)  F.  W.  Higgs  relinquishes  the  acting  rank  of 
Colonel  on  vacating  the  appointment  of  Assistant  Director  of  Medical 
Services. 

Lieut.-Col.  G.  C.  Taylor  vacates  the  appointment  of  Deputy  Assistant 
Director  of  Medical  Services. 

Lieut.-Col.  R.  Emmett  relinquishes  his  commission  on  account  of 
ill-health,  and  retains  the  rank  of  Lieutenant-Colonel. 

Capts.  (acting  Majors)  relinquishing  the  acting  rank  of  Major  on 
ceasing  to  be  specially  employed : C.  S.  Wink,  C.  M.  Nicol,  J. 
Anderson,  W.  E.  Lee,  J.  Ramsay,  J.  Turtle,  A.  Wilson,  D.  G.  Kennard. 

H.  S.  Wallace,  A.  J.  A.  McC.  Dallas.  P.  J.  Smyth. 

Capt.  (acting  Major)  M.  B.  G.  Sinnnette  relinquishes  the  acting  rank 
of  Major  on  vacating  the  appointment  of  Deputy  Assistant  Director  oi 
Medical  Services. 

To  be  acting  Majors  while  specia'ly  employed  -.  Capts.  C.  E.  White- 
head,  A.  M.  Jones,  C.  M.  Nicol. 

Capt.  W.  J.  Hoyten  relinquishes  his  commission  on  account  of  ill- 
health,  and  is  granted  the  rank  of  Major. 

Capt.  S.  A.  McPhee  relinquishes  his  commission  on  account  of  ill- 
health  contracted  on  active  service,  and  retains  the  rank  of  Captain. 

4th  London  General  Hospital : Lieut.-Col.  A.  H.  Tubby  is  restored  to 
the  establishment. 

1st  Scottish  General  Hospital  : Major  H.  Me  I.  W.  Gray  is  restored  to 
the  establishment  on  ceasing  to  hold  a temporary  commission  in  the 
Army  Medical  Service. 

2nd  Scottish  General  Hospital : Capt.  J.  W.  Simpson  is  restored  to 
the  establishment. 

2nd  Western  General  Hospital  ; Capt.  (acting  Major)  G.  M.  Benton 
relinquishes  the  acting  rank  of  Major  on  ceasing  to  be  specially 
employed. 

2nd  London  Sanitary  Company : Capt.  B.  R.  Hebblethwaite  Is 
seconded  for  set  vice  under  the  Egyptian  Government. 


ROYAL  AIR  FORCE. 

Medical  Branch.— Major  (acting  Lieut.-Col.)  B.  R.  Bickford,  D.S  O. 
(Staff  Surgeon,  R.N.),  relinquishes  his  commission  on  ceasing  to  be 
employed. 

The  undermentioned  are  transferred  to  unemployed  list : Major 
C.  F.  Bainbridge.  Capts.  K.  B.  Aickman,  R.  Hall,  Lieut.  N.  Homewood. 

Capt.  T.  E.  Mulvany  relinquishes  his  commission  on  account  of  ill- 
health  contracted  on  active  service,  and  is  permitted  to  retain  his  rank. 

Lieutenants  to  be  Captains  : C.  T.  Costello,  G.  M.  Mellor,  H.  C.  Cox, 
G.  Meadows,  L.  C.  Broughton-Head,  H.  B.  Troup,  H.  T.  Prya-Jones, 
J.  Coulter-Smith,  R.  Mugliston,  P.  E.  Williams,  C.  Lsmbrinudl,  A. 
Kirkhope,  P.  M.  Carroll,  J.  P.  Horsford,  A.^T.  Soutar,  G.  Dunderdale. 
J.  P.  Hennessy,  G.  W.  Harbottle,  M.  J.  Whelton,  J.  Valerie,  J.  P. 
Wells,  A.  St.  J.  Hennessey,  G.  W.  J.  Bonsfield. 

Denial  Branch. — Lieutenants  to  be  Captains  : G.  Warner,  R.  Fvscn. 
C M.  Shirreff,  H.  L.  Thorn,  N.  H.  Medhuret,  N.  L.  Smallbone,  C.  M- 
John,  G.  Hughes,  G.  F.  H.  Bloom. 

INDIAN  MEDICAL  SERVICE. 

Captains  to  be  Majors  : V.  B.  Green-Armytage.  A.  N.  Dickson,  A.  G. 
Coullie,  A.  J.  H.  Russell,  Dewan  Hakumat  Rai,  W.  H.  Riddell. 

Lieutenants  to  be  Captains  : J.  P.  Huban,  Erach  Ruttanji  Daboo, 
M.  M.  Ctuicbshank,  Anant  Yashwant  Dabholkar,  Kekhaaru  Sorabji 
Master,  S.  A.  McSwiney. 

Temporary  Lieutenants  to  be  temporary  Captains  : Har  Sukh  Rai, 
Nawab-ud-Din,  M.  J.  Saldanha,  Yeshwant  Vaman  Modak,  Ragavan 
Cheruvari  Toyle,  Abdul  Kadir  Muhammad  Mahiuddin,  A.  Noble,  Joy 
Devananda  Sinha,  Dinesh  Chandra  Chakrabatti,  Ravu  Venkata  Rao, 
Annaswamy  Muthnukrishnan,  Sadashiva  Chintamon  Lele.  Jagdish 
Chandra  Gupta,  Coimbatore  Srinivasa  Rao  Venkata  Krishna  Rao. 

The  following  officers  are  permitted  to  retain  the  temporary  rank  of 
Captain  on  permanent  appointment  as  Lieutenants  : Durgadas  Sanya), 
Fazal-ud-Din,  Girlsh  Chandra  Maitra.  Bijitendra  Basu,  Sankaranai- 
narkoil  Chidambaranatha  Alagappan. 


The  Lancet,] 


MEDICAL  NEWS. 


[August  23, 1919  347 


The  King  has  approved  the  appointment  of  the  undermentioned 
Lieutenants  permanently  to  the  Indian  Medical  Service:  John  Patrick 
Huban,  Eraoh  Ruttanji  Dafioo,  Martin  Melvin  Cruickshank,  R.A.M.C. 
<T.0.)»  Anant  Yashwant  Dabholkar,  I.M.S.  (T.C.),  Kekhasru  Sorabji 
Master,  I.M.S.  (T.C.).  Stephen  Alplionsus  McSwiney,  R.  A M.C.  (T.C.), 
Durgadas  Sanyal,  I.M.S  (T.C.),  Fazat-ud-Din,  I.M.S.  (T.C.),  Girish 
Chondrn  Mait-ra,  I . M.S.  (T.C.).  Bi.jitendra  Basil.  I M.S.  (T.C.), 
Sankaranainarkoil  Chidambaranatha  Alagappan,  I.M.S.  (T.C.). 

Indian  Defence  Force.— Lieutenant  to  be  Captain:  J.  S.  Nicolson, 
w The  King  has  approved  the  relinquishment  of  temporary  rank  in  the 
Indian  Medical  Service  and  Indian  Defence  For'ce  by  Captain  A.  Macl. 
Ramsay.  

HEALTH  OF  TROOPS  ON  AFGHAN  FRONTIER. 

The  Secretary  uf  State  for  India,  in  a written  answer  to  a question 
by  Colonel  Yate  concerning  the  arrangements  made  for  the  health  and 
comfort  of  the  troops  on  the  North-West  Frontier  of  India,  denies  the 
reports  of  deficiencies  in  the  Afghan  campaign.  Quoting  from  a 
telegraphic  report,  he  says  that  with  regard  to  food,  &c.,  two  essentials 
at  this  time  of  the  year  are  ice  and  mineral  waters.  Ice-machines  are 
working  at  the  following  places : Rawal  Pindi,  Nowshera,  Peshawar, 
Kohat,  Bannu,  Darden!,  Tank,  Dera  Ismail  Khan,  and  Quetta,  and 
further  machines  are  under  erection.  As  regards  soda-water  machines, 
22  are  already  working  on  the  frontier  and  six  more  are  on  their  way  to 
the  frontier.  The  total  daily  output  of  thes9  machines  will  be 
approximately  90,000  bottles.  This  output  is  in  addition  to  that  of 
local  factories.  Each  machine  is  being  sent  up  complete  with  cylinders 
and  bottles  for  one  month's  consumption,  and  a reserve  of  three  months 
has  been  arranged  for.  Mineral  waters  are  issued  to  all  officers  and 
men  in  hospital.  The  scale  of  rations  for  British  and  Indian  troops  is 
much  superior  to  any  previously  granted  for  campaigns  in  India. 
Under  the  new  scale  for  Indian  troops  the  meat  ration  has  been 
doubled  and  a duly  issue  of  fresh  vegetables,  condensed  milk, 
as  well  as  weekly  issues  of  cigarettes,  provided.  Orders  have 
been  issued  to  all  generals  in  command  that  medical  officers 
are  to  ask  for  whatever  they  deem  necessary  for  the  comfort  of 
the  sick  and  wounded  in  their  charge  and  that  their  demands  are  to  be 
met  at  once.  Additional  hospitals  for  4000  British  and  8000  Indian 
troops  have  been  established  in  specially  fitted  barracks  in 
proximity  to  the  frontier,  and  electric  lighting  and  fans,  where  none 
already  exist,  are  being  supplied  to  the  former.  Convalescent  depots 
for  officers  and  soldiers  h&ve,  in  addition,  been  formed,  mainly  in  the 
Murree  hills.  Special  arrangements  have  been  made  for  the  supply  of 
fresh  milk  to  the  sick.  Arrangements  for  providing  additional  equip- 
ment are  in  progress,  and  have  been  made  already  for  the  estab- 
lishment of  field  force  canteens  for  British  and  Indian  troops.  Special 
messes  have  been  formed  at  various  places  for  the  use  of  individual 
officers  passing  through.  Rest  camps  for  British  and  Indian  troops 
en  route  to  the  front  have  also  been  organised.  To  ensure  that  the 
arrangements  for  the  health  and  comfort  of  the  troops  are  working 
satisfactorily  and  up  to  the  standard  designed  by  the  Commander-in- 
Chief  in  India,  staff  officers  from  general  headquarters  carry  out  under 
his  Excellency’s  orders  frequent  tours  of  inspection  on  the  frontier. 
Specific  inquiry  is  being  made  into  each  definite  allegation  of  deficiency 
that  is  brought  to  notice. 


Pebital  Stetos. 


Royal  College  of  Physicians  of  Edinburgh. — 

An  extraordinary  meeting  of  the  College  was  held  on 
August  8th,  Sir  Robert  Philip,  the  President,  in  the  chair. 
H.R.H.  the  Prince  of  Wales  having  signified  his  willingness 
to  accept  the  Honorary  Fellowship  of  the  College,  was  elected 
by  acclamation. 

Royal  College  of  Physicians  of  Ireland 
and  Royal  College  of  Surgeons  in  Ireland.— At  the 
Conjoint  Examinations  held  recently  the  following  candidates 
were  successful  : — 

Third  Professional  Examination. 

H.  C.  Bell,  Miss  L.  H.  Byrne,  J.  F.  J.  Cleary,  R.  H.  Dolan,  M.  A 
Eng'isb.  J.  Fitzsimons,  J.  J.  Fitzsimons  (honours),  Mrs.  M.  W. 
Frazer,  T.  P.  Hefferman,  T E.  Kavanagh,  Miss  A.  Ledlie,  J.  I. 
Levi.  J.  J.  McHenry,  Miss  M.  G.  Ne’ll  Miss  I.  P.  Nelis,  Miss  M.  C, 
O'Brien,  R.  C.  Ogden.  J O’Leary.  J J.  O'Sullivan,  P.  J.  Quigley, 
T.  J.  Ryan,  W.  H.  Sexton,  R.  B.  Shaw,  J.  Tehan  (honours),  J.  W. 
Tighe,  A.  D.  Watchman,  and  T.  G.  Whitcroft. 

Final  Professional  Examination. 

Michael  Barden,  Baron  Asher  Cowan,  Joseph  Cockburn.  Thomas 
Coffey,  Robert  Stafford  Conyngham.  John  Francis  Gallagher, 
Daniel  Hegarty.  Alexander  Francis  Mallon,  John  Patrick  Morgan, 
Bernadine  Thomas  McMahon,  James  McAleer,  Michael  Joseph 
O'Connor.  Frank  Gaeds  Phillips.  Joseph  Power.  Joshua  Pousner, 
Andrew  Thomas  Rhatigan,  Thomas  Kerry  Reddin,  and  William 
Edward  Shipsey. 

Diploma  of  Public  Health. 

Patrick  Ashe,  Geoffrey  Collins,  Ignatius  B.  Culhane,  Edmund  W. 
Lynch,  John  D MacCormack,  S.  D.  G.  McEntire,  C.  C.  Macredy, 
Lionel  M.  Rowlette,  and  J.  R.  Bibby. 

Royal  College  of  Surgeons  in  Ireland.— At 
examinations  held  recently  the  following  candidates  were 
successful  :— 

Primary  Fellowship  Examination. 

Robert  H.  L.  M.  Corbet,  W.  J.  Corkey,  Mary  G.  Hogan  (honours), 
and  Eric  S.  Horgan. 

Final  Fellowship  Examination. 

W.  H.  W.  0.  Carden,  J.  V.  Cope,  and  J.  A.  Fretton, 


As  we  announced  last  week,  the  League  of  Red 
Cross  Societies  have  appointed  an  International  Commission 
to  investigate  the  public  health  conditions  in  Poland,  with  a 
special  view. to  providing  against  the  spread  of  typhus  and 
other  epidemics  across  Western  Europe.  Dr.  Addison,  the 
Minister  of  Health,  has  lent  to  the  International  Commission 
the  services  of  Dr.  G.  S.  Buchanan,  the  other  members  of 
the  Commission  being:  for  Italy,  Professor  Castellani ; for 
the  United  States,  Colonel  H.  Gumming;  and  for  France, 
Lieutenant-Colonel  Visbecq,  of  the  Service  de  Sant6  of  the 
French  Army,  the  last  in  place  of  Monsieur  E.  Dopter,  who 
has  been  prevented  from  starting  for  Poland. 

Eastbourne  and  Child  Welfare. — The  members 
of  the  corporation  of  Eastbourne  are  far-seeing,  and  without 
opposition  have  voted  no  less'a  sum  than  £4500  for  maternity 
and  child  welfare  purposes.  A home  where  the  work  has 
been  carried  on  some  time  voluntarily  has  closed  through 
lack  of  funds,  and  the  corporation  has  stepped  into  the  void. 
The  scheme  is  being  pushed  on  as  the  need  is  urgent  owing 
tp  the  house  famine.  Eastbourne  is  thus  doing  its  part  in 
the  great  work  of  conserving  child  life,  the  necessity  for 
which  has  never  been  brought  home  so  much  as  it  is  to-day. 

Medical  Sickness,  Annuity,  and  Life  Assur- 
ance Friendly  Society.— A committee  meeting  of  this 
society  was  held  at  300,  High  Holborn  on  August  15th,  when 
the  accounts  presented  showed  that  influenza  had  practi- 
cally disappeared  in  the  claims  for  insurance.  The  volume 
of  new  business  continues  to  be  exceptionally  good,  but  an 
increasing  number  of  medical  men  appear  to  be  retiring 
from  practice  at  a comparatively  early  age,  necessitating 
increased  new  business  in  maintaining  the  total  member- 
ship. The  claims  are  under  the  expectation  for  the  month, 
but  signs  are  not  wanting  that  the  strain  on  older  members 
of  the  society  during  the  last  years  is  beginning  to  show, 
long  rest  from  all  work  being  then  compulsory.  This  is 
essentially  the  kind  of  claim  that  proves  the  value  of  the 
society’s  sickness  contract,  for  in  many  policies  the  benefit 
only  lasts  a certain  time,  while  the  society  goes  on  paying 
for  years  if  required. 

All  particulars  may  be  had  Irom  the  Secretary,  Medical 
Sickness  and  Accident  Society,  300,  High  Holborn,  W.C.  1. 

Royal  Medical  Benevolent  Fund. — At  the 
last  meeting  of  the  committee,  held  on  August  12th,  30  cases 
were  considered  And  £308  10s.  voted  to  27  of  the  applicants. 
The  following  is  a summary  of  some  of  the  cases  relieved  : — 
Daughter,  aged  47,  of  VI. D.  Lond.  who  practised  in  London  and  died 
in  1873.  Lives  with  two  elder  sisters,  one  of  whom  receives  help  from 
the  Fund.  Has  £15  per  annum  from  dividends.  Used  to  take  in  pupils, 
but  now  wishes  to  commence  a school,  and  she  asks  for  help  towards 
books,  stationery,  &c.  Voted  £12  10s.— M. R.C. S.  Eng.,  aged  44,  who 
practised  at  Tbeale.  Was  in  a serious  motor  accident  in  June,  1918, 
and  is  still  suffering  from  head  in  jury  and  loss  of  memory  and  is  quite 
unable  to  work,  and  has  had  to  sell  his  practice.  Receives  £24  pension 
from  workhouse  and  £6  6s.  a month  from  the  Medical  Sickness  Society. 
Rent  and  rates  £37  13s.  6d.  Has  three  children;  the  eldest  girl  is  at 
home  and  the  other  two  children  are  at  school.  Voted  £50. — Widow, 
aged  47,  of  F.R.C.S.  E iin.  who  practised  in  London  and  died  in 
February.  1919.  Was  left  totally  unprovided  for,  and  is  now  acting  as 
a temporary  clerk  at  37 s.  6 d.  a week.  Lives  in  one  room  and  pays  8s.  a 
week  rent.  Applicant's  husband  was  helped  by  the  Fund.  Voted  £5. — 
Widow,  aged  53.  of  M.B..  C.M.  Aberd.  who  practised  in  London  and 
died  in  1917.  Was  left  without  means.  Has  three  children  ; the  two 
eldest  are  in  the  Army  and  both  have  been  wounded,  and  the  youngest 
is  still  in  the  hospiral  waiting  to  undergo  an  operation.  She  receives 
£62  a year  from  children  and  £26  from  the  Pensions  Committee. 
Pays  £26  a year  rent.  Vo-ed  £12  in  12  instalments. — Widow, 
aged  60,  of  L.R.C.P.  Edin.  who  practised  at  Blackburn  and  died 
in  1902.  Is  at  present  doing  domestic  work  at  9s.  a week, 
but  she  suffers  from  ill-health  and  cannot  stay  long  at  any 
post.  Was  in  the  infirmary  for  a greater  part  of  last  summer. 
Has  one  daughter  who  acts  as  a children’s  nurse  and  receives  £26 
a year.  Relieved  six  times.  £30.  Voted  £12,  in  12  inst»lments.— 
Daughter,  age!  61,  of  L.F.P.S.  Glasg.  who  practised  at  Lauchline, 
Ayrshire,  and  died  in  1883.  Is  unable  to  work  owing  to  ill  health. 
OdyinconTe  £15  from  the  Scottish  Indigent  Womens  Fund.  Pays 
£10  a year  rent.  Relieved  11  times,  £116.  Voted  £18  in  12  instal- 
ments.—Daughter,  aged  38,  of  M.D.  Dub.  who  practised  at  Moorcrnft, 
British  Guiana,  and  died  in  1884.  Lives  with  her  mother,  who  receives 
a pension  of  £50  per  annum,  Suffers  from  ill-health  and  is  unable  to 
aarn  her  own  living.  Relieved  13  times.  £120.  Voted  £10  in  two 
instalments. — Widow,  aged  63.  of  L.R.C.P.  & S.  Glasg.  who  practised 
at  Walsall  and  died  in  1902.  Was"  left  unprovided  for  with  two 
children,  who  are  now  working  and  pay  their  mother  £1  a week  each, 
and  apolicant  receives  about  £12  a year  bv  needlework.  Relieved 
13  times,  £142.  Voted  £5  —Daughter,  aged  68,  of  M.R  C S.  Eng.  who 
practised  at  Liverpool  and  died  in  1851.  Receives  £6  a year  from 
dividends  and  £52  a vear  from  friends.  Lost  all  her  money  through 
the  failure  of  an  Australian  bank.  Suffers  from  ill-health.  Re  ieved 
six  times,  £72.  Voted  £12  in  12  ins'alments. —Widow,  aged  51,  of 
L.S  A.  Lond.  who  practised  at  Plaistow  and  died  in  1911.  Was  left 
with  two  children,  now  aged  16  and  14.  The  elder  one  wishes  to  train 
for  a nurse  ; the  younger  is  still  at  school.  Applicant  receives  £100  a 
year  from  the  sale  of  the  practice  and  from  late  husband’s  life 
insurance,  and  has  to  pay  £27  a year  rent.  A«ks  for  help  owing  to 
increased  c >st  of  living.'  Relieved  twice,  £17.  Voted  £5. 
Subscriptions  may  be  sent  to  the  acting  honorary  treasurer, 
Dr.  Samuel  West,  at  11,  Chandos-street,  Cavendish-square, 
London,  W,  1. 


1 


348  The  lancet,]  THE  NEED  FOR  ACCESSORY  FOOD  FACTORS  IN  INFANT  FEEDING.  [August  23,  1919 


&0m8p0ttktue. 

“ Audi  alteram  partem." 


THE  NEED  FOR  ACCESSORY  FOOD  FACTORS 
IN  INFANT  FEEDING. 

To  the  Editor  of  The  Lancet. 

Sib, — The  appalling  loss  of  life  which  occurred  during  the 
war  brought  into  prominence  for  the  first  time  the  need  for 
economy  in  life  generally,  and  more  especially  that  of  infants. 
The  survival  of  the  less  fit  may  be  eugenically  wrong,  but  so 
often  infant  life  depends  not  on  fitness  to  survive  so  much  as 
in  the  knowledge  and  fitness  of  the  mother.  And  so  there 
came  into  being  the  vast  organisation  of  infant  welfare  centres 
throughout  the  country  and  the  initiation  of  schemes  for 
ensuring  adequate  nourishment  and  care  to  growing  infants. 
In  London  the  raids  put  many  nursing  mothers  off  their 
milk,  especially  in  the  areas  severely  visited,  and  this  at  a 
time  when  the  scarcity  of  cow's  milk  was  keenly  felt,  and 
when  whole  districts  were  without  adequate  supply.  Then 
it  was  that  the  Government  wisely  encouraged  the  use  of 
dried  milk,  and  an  exhaustive  report  on  dried  milk  was  made 
to  the  Local  Government  Board.  It  was  shown  that  the  absence 
or  destruction  of  antiscorbutic  factor  in  the  dried  milk  had  no 
apparent  influence  on  the  children’s  growth,  nor  did  Barlow’s 
disease  appear  save  in  very  exceptional  cases.  There  is 
no  doubt  that  animals  suffer  from  the  deprivation  of  the 
antiscorbutic  vitamine  in  their  food  much  more  rapidly  and 
severely  than  does  the  human  infant.  The  reason  for  this  is 
not  known.  Whether  the  mother  is  able  to  transmit  a 
tolerance  in  her  infant  to  a vitamineless  diet,  or  whether 
the  human  young  require  much  less  than  do  animals  to  keep 
them  in  health  is  pure  speculation,  but  the  probability  is 
that  when  infantile  scurvy  has  advanced  to  the  stage  of 
physical  signs  we  have  arrived  at  the  last  chapter  of  the 
disease,  not  the  first.  Zilva  has  shown  that  the  growing 
teeth  of  the  guinea-pig  are  very  early  affected  by  the  absence 
of  vitamine  in  the  diet,  and  there  is  reason  to  suppose  that 
the  cause  of  some  of  the  ailing,  without  actual  disease,  of 
infants  is  caused  by  the  absence  of  vitamine.  So  far  we 
have  no  knowledge  of  the  influence  of  such  absence  on  the 
early  growth  of  the  permanent  teeth.  At  University  College 
Hospital  it  has  long  been  felt  that  it  was  not  right  wilfully  to 
withdraw  this  vitamine  from  the  diet  of  these  artificially  fed 
infants,  even  although  no  very  obvious  symptoms  of  scurvy 
had  been  encountered,  and  Dr.  Harriette  Chick  suggested 
two  years  ago  the  use  of  an  apple  jelly  the  vitamine  in 
which  was  not  destroyed  in  the  process  of  manufacture.  This 
jelly  was  made  for  the  Army,  and,  alas,  is  now  unobtainable. 
It  did  not  disagree,  and  was  quite  palatable.  As  the  manu- 
facture was  discontinued,  orange-juice  has  been  used,  and 
successfully,  and  is  well  tolerated  by  even  the  youngest 
infants.  The  rind  is  mixed  with  the  pulp,  as  the  essential  oil, 
present  only  in  the  rind,  preserves  the  juice  for  quite  a long 
period.  The  minced  orange  is  then  squeezed  through  a 
tincture  press  and  the  juice  collected.  The  doses  given  are 
a teaspoonful  in  a little  sugared  water  twice  daily  under 
three  months,  and  double  that  amount  over  that  age. 

As  to  the  fat-soluble  A factor,  this  is  present  in  the  dried 
milk  in  sufficient  quantity  to  prevent  rickets,  but  where  in 
some  cases  the  infant  does  not  tolerate  dried  milk  and 
diluted  cow’s  milk  has  to  be  substituted  the  dilution  of  the 
cow’s  milk  becomes  an  anxiety  unless  cream  is  added  to 
the  feed.  Cream  is  unobtainable  or  prohibitive,  and  as  the 
Marylebone  cream  is  useless  so  far  as  fat-soluble  is  concerned 
a cream  has  been  in  use  for  many  months  at  the  Infant 
Department  at  University  College  Hospital  made  of  beef 
suet,  which  is  rich  in  fat-soluble.  This  cream  has  a richness 
in  fat  equal  to  ordinary  skimmed  cream,  cannot  go  bad,  and 
is  dispensed  at  a very  low  cost.  The  conversion  of  suet  into 
an  emulsion  miscible  with  all  dilutions  of  milk  was  found  to 
be  difficult  by  reason  of  the  high  melting  point  of  suet.  This 
was  overcome  at  last,  and  the  method  of  manufacture  and 
the  formula  (I  quote  from  a paper  by  Mr.  Hampshire 
and  Mr.  Hawkerin  Transactions  of  the  British  Pharmaceutical 
Conference,  1919)  are  as  follows : — 

Beef  suet,  40oz. ; olive  oil,  5 oz. ; syrup,  25  fl.  oz. ; benzoic 
acid.  35gr. ; decoction  of  Irish  moss,  70 fl.  oz.;  water  to 
1 gallon.  “The  oil  is  added  to  the  melted  suet  and  the 
benzoio  acid  dissolved  in  the  mixture.  The  decoction  is 


heated  to  about  60°  C.  and  placed  in  the  emulsifier,  and  the 
fats  are  then  added  at  about  the  same  temperature.  The 
emulsion  is  then  worked  up  and  the  syrup  and  water  added 
last.’’  I am,  Sir,  yours  faithfully, 

E.  A.  Barton, 

Medicsl  Officer  to  Infant  Department, 
August  14th,  1919.  University  College  Hospital. 


THE  INCIDENCE  OF  TUBERCULOSIS  AMONGST 
ASYLUM  PATIENTS. 

To  the  Editor  of  The  Lancet. 

Sir, — The  paper  by  Dr.  F.  A.  Elkins  and  Dr.  Hyslop 
Thomson  in  your  issue  of  August  9th  brings  forward  many 
interesting  points,  to  me  none  more  so  than  the  paragraph 
on  clinical  features,  in  which  they  insist  on  the  extra- 
ordinary absence  of  the  classical  symptoms  and  signs  of 
pulmonary  tubercle  which  obtains  in  the  asylum  phthisical 
patient.  This  is,  of  course,  a fact  that  is  perfectly  well 
known  to  those  of  us  who  have  spent  some  time  resident 
in  institutions  for  the  care  of  the  insane,  but  it  is,  I find, 
not  appreciated  by  those  who  have  not,  and  it  is  important 
that  it  should  be  more  widely  known  because,  for  one  thing, 
large  numbers  of  the  more  chronic  insane  are  still  under 
treatment  in  the  union  wards,  where  the  resident  or  other 
medical  officers  are  often  of  a temporary  character,  or,  even 
if  this  is  not  the  case,  are  not  so  an  fait  with  these  matters 
as  the  expert  alienist. 

My  experience  as  medical  officer  in  charge  of  the  Western 
Command  Epileptic  Centre  at  the  Nell  Lane  Military 
Hospital,  where  for  the  last  two  years  of  the  war  we  have 
had  68  beds  occupied  by  epileptic  soldiers  under  careful 
observation,  does  not  lead  me  to  include  epileptics  under  the 
heading  of  those  predisposed  to  tubercle  ; these  were,  with 
few  exceptions,  sane  epileptics,  but  we  were  struck  with  the 
small  incidence  of  tubercle  amongst  them,  smaller  indeed,  by 
a good  deal,  than  the  average  incidence  of  tubercle  amongst 
medical  military  patients  as  a whole. 

I do  not  altogether  agree  with  Dr.  Elkins  and  Dr.  Thomson 
in  ascribing  so  much  importance  to  contact  infection  when 
seeking  for  explanations  of  the  war-time  increase  in  asylum 
tubercle.  To  my  mind,  most  of  these  patients  had  a latent 
focus  of  tubercle  on  admission,  and  owing  to  the  poor  food, 
the  war-time  rationed  deficiency  of  fats,  sugar,  &c.,  the 
resistance  was  diminished  so  that  the  dormant  focus  became 
active  again.  Those  who  have  made  post-mortems  at  all 
frequently  on  the  asylum  type  of  patient  know  well  that 
scars  of  healed  apical  tubercle  are  met  with  in  the  vast 
majority  of  these  bodies,  and  it  is  casting  no  stigma  on  the 
asylum  medical  officer  to  suggest  that  on  admission  a far 
greater  number  were  suffering  from  tubercle  than  are  so 
recorded  in  the  table  given.  His  duties  on  the  admission  of 
a patient  are  to  examine  that  patient  and  to  fill  up  forms 
concerning  him  ; he  is  especially  interested  in  the  mental 
condition,  and  it  is  not  to  be  expected  that  he  is  likely  to 
spot  doubtful  or  latent  foci  in  the  lungs  in  the  way  that  a 
tuberculosis  specialist  would. 

“It  is  true  that  insane  tuberculous  patients  have  rarely  any 
expectoration,  and  therefore  the  medium  of  infection  is 
obviously  not  sputum.”  This  seems  to  be  going  rather  too 
far,  both  as  regards  reinfection  in  the  bowel  of  the  patient 
himself  and  infection  of  others  in  the  same  ward.  In  the 
insane  phthisical  patient  the  cough  is  absent,  and  sputum,  in 
the  strict  sense  of  the  word,  is  also  absent,  but  the  morbid 
material  and  secretion  from  the  air  passages  it  pro- 
duced, and  reaches  the  oro-pharyngeal  cavity  in  some, 
though  it  may  be  in  small,  quantity,  and  is  doubtless 
swallowed,  constituting  a medium  of  contact  infection.  In 
addition  to  this,  the  contents  of  the  mouth  and  pharynx  may 
be,  as  is  well  known,  disseminated  through  the  air  for  many 
feet— in  the  absence  of  coughing— by  speaking,  sneezing,  or 
even  bv  tbe  snoring  and  stertorous  breathing  of  so  many  of 
these  cases,  and  such  morbid  material,  being  presant  in  the 
mouth,  may  contaminate  spoons,  forks,  and  drinking  vessels, 
hence  infecting  others  if  the  washing  arrangements  are  at  all 
perfunctory.  The  same  absence  of  cough  and  sputum,  the 
same  laryngeal  anaesthesia,  occur  also  in  the  deglutition 
pneumonia  and  pulmonary  gangrene  of  asylum  patients, 
another  common  cause  of  an  insane  patient’s  rapid  decline, 
which  has  in  these  subjects  the  same  insidious  onset  as 
pulmonary  tubercle  has. 

The  authors  of  the  paper  ascribe  the  transference  of 
disease  to  infected  hands  and  bedclothes.  I believe  this 


Thb  Lancet,] 


THE  RESULTS  OK  COMPLETE  COLECTOMY. 


[Auguht  23,  1919  349 


holds  good,  to  some  extent,  as  far  as  the  patient  himself  is 
concerned,  but  I do  not  think,  in  a well-ordered  asylum,  that 
the  infection  extends  to  those  in  neighbouring  beds,  where 
I think  the  natural  predisposition  of  the  mental  case  to 
tubercle  or  the  lighting  up  of  an  old  focus  plus  the 
diminished  resistance  from  war-time  poverty  of  rations  will 
explain  everything  not  explained  by  aerial  transmission  of 
mouth  contents  and  possibly  by  contaminated  eating  and 
drinking  utensils. 

I agree  entirely  as  to  the  importance  of  cubic  space  and 
ventilation.  In  asylum  hospital  wards  it  is  often  the  case 
that  too  little  air  space  is  allowed  fpr  the  case  of  acute 
infection.  It  is  often  also  a fact  that  asylum  ward  ventila- 
tion is  poor,  given  sufficient  air  space,  owing  to  the  bottoms 
of  the  windows  being  for  other  reasons  at  a higher  level  than 
usual  from  the  floor.  Tubercle  in  the  insane  is  hopeless  ; in 
them  “ early  or  suspected  cases  ” are  in  reality  too  advanced 
for  any  treatment  to  arrest  the  disease. 

I am,  Sir,  yours  faithfully, 

Frank  E.  Tylecote,  M.D.,  D.P.H.,  M.R.C.P., 
Assistant  Phjsician.  Manchester  Royal  Infirmary;  Visiting 
Physician  to  the  South  Manchester  Union  Hospitals  and 
Lunacy  Wards ; sometime  A. M.O.  and  Pathologist, 
Winwick  Asylum. 

Manchester,  August  12th,  1919. 


To  the  Editor  of  The  Lancet. 

Sir, — I do  not  think  that  Dr.  F.  A.  Elkins  and  Dr.  Hyslop 
Thomson,  in  their  paper  published  in  The  Lancet  of 
August  9th,  lay  enough  stress  on  the  importance  of  ventila- 
tion in  asylums  when  writing  on  the  incidence  of  tuberculosis. 
In  my  opinion  the  bed-space  requirements  of  the  Board  of 
■Control  (50  square  feet  in  ordinary  wards  and  67  in  hospital 
wards)  is  quite  inadequate  for  an  asylum  population.  It 
•must  be  borne  in  mind  that  even  for  a large  asylum  they 
■only  recommend  an  isolation  hospital  with  three  beds  for 
each  sex,  which  quite  precludes  the  treatment  of  colitis, 
for  instance,  in  such  hospital.  Some  years  ago  I saw  at 
Shrewsbury  Asylum  what  I thought  was  an  admirable  arrange- 
ment for  ventilation,  especially  in  hot  weather.  The  lower 
sash  of  each  window  was  of  double  length,  the  lower  half 
being  unglazed  and  being  housed  below  the  window-sill  when 
the  window  was  closed ; when  raised  it  had  the  effect  of  a 
widely  open  window,  the  empty  frames  fulfilling  the 
purpose  of  bars  without  their  appearance.  I suggested  the 
adoption  of  this  arrangement  in  a new  asylum  some  years 
ago,  but  the  Commissioner  to  whom  my  suggestion  was 
referred  poohpoohed  it. 

As  regards  the  dietetic  requirements,  I do  not  think  that 
any  asylum  superintendent  would  deny  that  the  excessive 
mortality  from  tuberculosis  since  1914  was  due  to  insufficient 
food,  and  that  it  would  have  been  much  greater  if  the 
requirements  of  the  Board  of  Control  (no  doubt  under  the 
direction  of  the  Food  Controller)  had  been  carried  out 
literally. — I am.  Sir,  yours  faithfully, 

H.  K.  Abbott, 

Medical  Superintendent,  Hants  County  Asylum, 

August  18th,  1919.  Knowle,  Fareham. 


THE  RESULTS  OF  COMPLETE  COLECTOMY. 

To  the  Editor  of  The  Lancet. 

Sir, — Under  the  above  heading  Mr.  J.  F.  Dobson  criticises, 
I think  with  justice,  the  imperfect  manner  in  which  Major 
(James  Taylor  has  recorded  his  series  of  six  total  colectomies 
in  The  Lancet  of  August  2nd,  Apparently  Major  Taylor 
is  a whole-hearted  disciple  of  Sir  Arbuthnot  Lane,  and  he 
•carries  his  intimation  so  far  as  to  imagine  that  his  readers 
will  be  satisfied  with  the  statement  that  the  patients  made 
an  excellent  recovery  frotn  the  operation  ; that  he  has  seen 
four  of  his  cases  recently,  of  whom  three  were  not  troubled 
•with  looseness  of  the  bowels. 

My  own  experience  of  total  colectomy  is  limited  to  one 
case,  and  I freely  admit  that  only  a few  days  ago  the 
patient  consulted  me  on  account  of  disturbed  nights  owing 
to  looseness  of  the  bowels.  The  colon  in  this  case  was 
excised  for  dilatation  and  recurrent  attacks  of  obstruction. 
Her  symptoms  are  markedly  improved,  and  her  looks  are 
satisfactory,  but  she  is  not  yet  free  from  intestinal  troubles. 

It  appears  to  me  high  time  for  a clinical  demonstration  of 
these  cases  of  complete  colectomy,  and  I hope  that  steps  may 
be  taken  in  this  direction  at  the  Surgical  Section  of  the  Royal 
'Society  of  Medicine.  We  must  be  supplied  with  scientific 
■data  on  this  subject,  and  the  matter  should  no  longer  be 
obscured  by  such  literature  as  is  provided  in  Sir  Arbuthnot 


Lane’s  book,  entitled  “ The  Operative  Treatment  of  Chronic 
Intestinal  Stasis  ” ; a rather  quarrelsome  symposium  by 
several  authors,  abounding  both  in  contradictions  and  repeti- 
tions. This  has  been  adequately  reviewed  in  the  April 
number  of  the  British  Journal  of  Surgery,  and  apparently  the 
art  of  “slating”  is  not  quite  a lost  one. 

The  pity  of  it  is  that  such  a straightforward  surgical 
question  Should  not  receive  a clear  answer.  If  the  whole 
colon  should  be  removed  by  all  means  let  us  resect  it,  not 
because  we  can,  but  because  we  ought. 

I am,  Sir,  yours  faithfully, 

Devoushire-place,  W.,  August  14th,  1919.  JOSEPH  E.  ADAMS. 


A CRITICISM  OF 

THE  MEMORANDUM  ON  MALARIA. 

To  the  Editor  of  The  Lancet. 

Sir, — May  I offer  one  more  criticism  of  the  Memorandum 
on  Malaria  recently  issued  by  the  Ministry  of  Pensions  ? 
The  object  of  such  a publication  is,  I imagine,  to  give  help 
to  the  civil  practitioner  when  called  upon  to  diagnose  and 
treat  cases  of  malaria  that  have  been  discharged  from  the 
Army,  but  the  vague  instructions  and  information  that  it 
gives  must,  I feel  sure,  mislead  rather  than  guide  him. 

Description  of  the  Forms  of  Malaria. 

The  diagnosis  as  described  is  correct,  but  it  deals 
almost  exclusively  with  the  features  of  what  I call  a true 
tropical  attack.  When  demobilised  and  sent  home  to 
England,  cases  often  show  symptoms  of  a far  different 
nature,  their  condition  being  post  malarial,  and  post 
malarial  conditions  are  essentially  influenced  by  climatic 
and  hygienic  conditions.  The  practitioner  will,  in  all 
probability,  be  called  to  treat  cases  confined  largely  to 
the  following  classes  : 1.  Those  who  have  already  been 
through  a thorough  course  of  hospital  treatment  following 
the  acute  attack — and  the  vitality  of  the  infecting 
plasmodium  therefore  reduced.  2.  Those  who  have  already 
become  reacclimatised  to  home  conditions. 

Cases  such  as  these  will  not  give  symptoms  of  true 
tropical  attacks.  It  is  the  subsequent  general  constitutional 
disturbances  that  will  make  for  difficulty  of  diagnosis. 
There  will  be  every  kind  of  obscure  symptoms,  and  men 
without  knowledge  of  these,  whilst  looking  for  the  standard 
symptoms,  will  probably  fail  even  to  recognise  them. 
Therefore  the  Memorandum  should  have  laid  special 
emphasis  on  the  symptoms  and  appearances  of  post  tertian 
and  quartan  cases,  as  it  is  highly  improbable  that  men 
suffering  from  the  more  severe  forms  would  be  discharged 
and  sent  home. 

The  Memorandum  makes  a strong  point  of  “periodic 
attacks,”  but  this,  I think,  is  misleading;  it  should  only 
arouse  suspicion  ; it  should  surely  never  make  diagnosis 
certain.  Many  chronic  cases  never  show  a typical  rigor. 
Enlargement  of  the  spleen  is  mentioned  as  being  important ; 
this  is  correct,  but  no  word  is  spoken  as  to  the  character  of 
enlargement — i.e.,  the  recent  case  giving  “soft”  and  the 
long  and  chronic  case  giving  the  “ hard  ” (ague  cake) — two 
conditions  requiring  entirely  different  treatment.  Pigmenta- 
tion of  various  degree,  especially  around  the  eye,  jaundice, 
the  cold  clammy  skin  with  sweating  head  and  tachycardia — 
these  I have  seen  as  giving  the  only  symptoms  of  undoubted 
malarial  cases.  Fine  muscular  tremors,  with  anaemia  and 
emaciation,  likewise. are  the  only  symptoms  of  another 
group  of  cases. 

Nervous  disorders  should  have  been  given  a very  import- 
ant place.  Peripheral  neuritis,  muscular  and  auditory 
hyper-  and  an-algesia,  vertigOgand  impotence  should  all  have 
been  laid  stress  upon.  “Severe  symptoms  are  usually 
absent,”  so  says  the  Memorandum,  but  surely  many  of  the 
conditions  I have  mentioned  may  be  most  serious,  and 
nephritis,  which  is  often  present,  especially  so. 

Under  the  vague  term  “malarial  cachexia”  a countless 
number  of  important  symptoms  are  summarily  dismissed. 
Diagnosis  by  aid  of  the  blood  film  is  good  in  the  hands  of  an 
expert,  but  almost  impossible  to  the  practitioner.  A great 
amount  of  patience  and  quite  a fair  amount  of  experience  is 
necessary,  and  no  mention  is  made  of  the  very  important 
fact  that  a blood  film  taken  within  24  hours  of  a patient 
being  given  large  doses  of  quinine  is  almost  valueless. 
Films  taken  between  attacks  often  give  negative  results.  The 
best  time  to  take  the  blood  is  about  ten  hours  after  the  rigor. 
In  brief,  instead  of  diagnosis  being  a simple  thing,  as  the 


350  The  Lancet,] 


THE  CONDUCT  OF  LABOUR  AND  PUERPERAL  SEPSIS. 


[August  23,  1919 


Memorandum  assumes,  except  in  acute  cases,  it  may  be 
extremely  difficult. 

Treatment. 

I agree  with  Dr.  Gordon  Ward  that  the  general  and 
indiscriminate  administration  of  quinine  is  not  sound 
advice.  Quinine  is  the  standby  in  acute  cases — given  a few 
hours  before  or  during  sporulation  (i.e.,  the  attack)  and  for 
some  time  afterwards — but  to  give  this  drug  for  several 
months  on  end  to  chronic  antemic  and  emaciated  non-febrile 
cases  is  folly.  A man  must  “ know  ” quinine  and  under- 
stand malaria.  Dr.  T.  H.  Jamieson,  in  his  letter  of 
August  9th,  makes  the  same  mistake  as  the  Memorandum. 
He  speaks  as  if  there  were  but  one  type  of  case  to  consider. 
The  cessation  of  rigors  by  the  action  of  quinine  does  not 
mean  that  there  has  been  any  cure  of  malaria.  To  the 
civil  practitioner  this  above  all  things  should  be  pointed  out 
to  him — viz.,  that  for  any  length  of  time  after  the  attack  is 
cured  later  symptoms  may,  and  probably  will,  develop,  and 
that  when  these  later  symptoms  follow  quinine  is  to  be 
avoided.  The  administration  of  a powerful  protoplasmic, 
and  therefore  metabolic,  poison  to  a person  whose  natural 
bodily  resistance  has  already  been  lowered  by  the  infection, 
is  obviously  a practice  to  be  condemned.  The  danger  we 
have  to  fight  against  is  not  the  one  Dr.  Jamieson  suggests — 
i.e.,  the  failure  to  give  adequate  doses  of  quinine  for  a 
sufficiently  long  period — but  the  very  opposite  ; the  failure 
to  discontinue  quinine  in  cases  of  malaria  showing  a 
post-malarial  condition.  Dr.  Jamieson’s  statement  that 
such  a condition — i.e.,  “chronic  tachycardia  and  effort 
syndrome” — “is  in  most  cases  the  result  of  inadequate 
doses  of  quinine  for  a short  period  ” shows  merely  an  attempt 
to  substitute  fancy  for  fact.  I have  suffered  myself  from 
the  effects  of  malarial  infection  for  the  last  ten  years — 
I have  undergone  thorough  hospital  treatment  with  quinine 
in  full  doses  for  some  time.  I have  been  cured  of  the 
attacks,  but  no  amount  of  quinine  could  have  prevented 
my  present  post-malarial  symptoms  from  developing, 
and  it  is  because  my  experience  has  taught  me  to  avoid 
quinine  now  that  I am  able  to  enjoy  comparatively  good 
health.  It  is  the  post-malarial  conditions  that  will  be  met 
with  mostly  in  this  country,  and  for  these  the  iron  salts  with 
arsenic, colloid  preparations  of  iodides,  organotherapy,  high 
frequency,  &c. , all  find  their  legitimate  use. 

I have  had  a varied  and  extensive  practical  experience, 
extending  over  ten  years  in  the  native  and  European  hospitals 
in  Africa  (and  more  recently  in  the  last  campaign),  and  I 
know  that  the  civil  practitioner  at  home  here  will,  if  he 
adheres  to  the  principles  laid  down  in  the  Memorandum  and 
Dr.  Jamieson’s  letter,  find  much  to  perplex  and  deceive  him. 

I am.  Sir,  yours  faithfully, 

C.  R.  Corfield,  B.Sc.,  L M.S  S.A., 

Late  Superintendent,  Govt.  Area  and  Glencairn  Hospitals, 
August  16th,  1919.  Transvaal,  South  Africa. 


To  the  Editor  of  Thb  Lanobt. 

Sir, — In  your  issue  of  August  9th  Dr.  T.  H.  Jamieson  takes 
me  to  task  for  what  he  describes  as  ‘ ‘ pernicious  and  dangerous 
advice.”  May  I be  permitted  a few  words  in  reply?  Dr. 
Jamieson  seems  to  assume  that  I habitually  give  smaller 
doses  of  quinine  than  he  considers  correct.  As  a matter  of 
fact,  I give  the  same  doses  as  he  does  himself  ; nor  is  there 
anything  in  my  previous  letter  to  suggest  that  I ever  aid 
otherwise  I plead  guilty,  however,  to  calling  attention  to 
the  fact  that  there  is  something  more  than  quinine  adminis- 
tration to  be  thought  of — i.e.,  “improvement  of  the  natural 
resistance  of  the  body.”  Anyone  who  was  able  to  judge  of 
the  results  obtained  by  hospital  and  convalescent  camp 
treatment  respectively,  the  quinine  dosage  being  the  same, 
must  bear  me  out  in  this.  leather  that  Dr.  Jamieson  has 
not  had  the  opportunity  of  studying  this  experiment — for  as 
snch  it  may  be  regarded — which  was  so  successful  with  the 
10th  Division  on  their  return  from  the  East  to  France.  This 
same  experiment  also  goes  far  to  disprove  Dr.  Jamieson's 
assertion  that  effort  syndrome  is  commonly  due  to  in- 
sufficient or  irregular  quinine  treatment,  inasmuch  as  the 
effort  syndrome,  &c.,  persisted  in  hospital  but  disappeared  in 
convalescent  camps. 

I stated  that  the  instructions  about  intramuscular  injec- 
tion in  the  Memorandum  were  unwise.  I still  think  so. 
Dr.  Jamieson  says  that  “ a very  elementary  knowledge  of 
anatomy  will  enable  one  not  to  inject  in  the  close  proximity 
of  an  important  nerve  trunk.”  So  it  will,  but  this  elementary 
knowledge  is  not  always  available,  as  witness  the  fact  that 


the  official  instructions  on  this  matter  issued  to  M.O.’s  of  the 
Salonika  army  were  grossly  inaccurate  as  to  the  position  of 
structures  in  the  buttock. 

Dr.  Jamieson  speaks  as  if  he  believed  that  quinine  killed 
the  malaria  parasite  and  that  no  other  treatment  was 
necessary.  This  view  has  been  widely  held,  but  I recently 
had  the  pleasure  of  hearing  Sir  Ronald  Ross  admit  publicly 
that  he  had  grave  doubts  whether  quinine  had  any  direct 
effect  at  all  on  the  parasite — a conclusion  to  which  many 
others  have  come.  In  the  circumstances  blind  reliance  on 
quinine  ought  not  to  constitute  the  whole  therapy  of  the 
disease,  as  was  usually  the  case  in  military  hospitals. 

In  conclusion,  may  I say  that  the  Medical  Society  of 
London  is  holding  a discussion  on  the  treatment  of  malaria 
on  Nov.  24th.  I should  feel  honoured  if  Dr.  Jamieson  would 
be  my  guest  on  that  occasion,  if  he  has  not  had  an  invitation 
from  other  sources.  He  may  rest  assured  that  I may  be 
“pernicious,”  but  I am  not  “dangerous,”  so  that  he  can  * 
accept  with  safety.  I am,  Sir,  yours  faithfully, 

Sevenoaks,  Kent,  August  18th,  1919.  GORDON  WARD. 


THE  CONDUCT  OF  LABOUR  AND  PUERPERAL 
SEPSIS. 

To  the  Editor  of  The  Lancet. 

Sir, — Dr.  J.  H.  E.  Brock,  discussing  in  your  columns  last 
week  an  aspect  of  puerperal  sepsis  which  has  been  neglected 
for  some  years,  would  have  us  believe  that  “ the  reason  why 
there  is  such  a large  amount  of  sepsis  still  rampant  in 
parturition  is  that  the  woman  begins  her  labour  with  the 
vaginal  canal,  and  sometimes  the  uterine  canal,  surgically 
unclean,”  and  that  the  sepsis  is  due  to  the  inoculation,  by  the 
examining  finger,  of  the  cervix  and  uterine  wall  with  organisms 
introduced  into  the  vagina  during  sexual  intercourse.  I 
think  it  can  be  shown  that  Dr.  Brock  has  over-estimated  the 
danger  of  intercourse  during  pregnancy,  and  I should  like 
to  suggest  one  or  two  points  for  consideration. 

Examining  the  evidence  brought  forward  : 

1.  I submit  that  it  is  not  reasonable  to  assume  that 
because  conjunctivitis  is  prevalent  within  the  first  week  of 
birth,  therefore  the  maternal  passages  are  “ practically  never 
sterile.”  We  have  still  to  learn  what  numbers  of  the  cases 
of  conjunctival  inflammation  are  due  to  simple,  non-infected 
irritation  by  the  vaginal  secretions  (?  lactic  acid),  what 
numbers  become  infected  immediately  after  birth  (there  is 
ample  opportunity),  and  what  numbers  are  infected  in  the 
vagina. 

2.  It  is  beyond  aispute,  of  course,  that  every  time  sexual 
intercourse  takes  place  the  vagina  is  contaminated  by  a 
variety  of  organisms,  but  evidence  of  sepsis  of  the  vagina 
at  term  which  consists  of  proof  (if  proof  were  needed)  that 
the  organisms  were  introduced  into  the  vagina  by  intercourse 
sometime  during  the  pregnancy  is  not,  I think,  worth  very 
much.  Even  if  intercourse  far  on  into  pregnancy  is  the  rule, 
there  must  be  a period  of  one  or  two  months  during  which 
there  is  no  fresh  infection,  and  there  are  at  least  two  factors 
to  be  considered — in  a question  of  evidence — during  this 
period  : the  destruction  or  neutralisation  of  the  organisms  by 
the  mother,  and  the  possibility  that  the  organisms  may  die 
or  destroy  each  other  from  other  causes. 

3.  I cannot  understand  Dr.  Brock’s  11  very  conclusive  proof 
(my  italics)  of  the  capability  of  the  uncleansed,  but  other- 
wise healthy,  penis  of  causing  puerperal  sepsis.”  I should 
expect  a rise  of  temperature  after  intercourse  on  the  seventh 
night  of  the  puerperium  if  the  penis  had  been  boiled. 

But  let  it  be  granted  that  the  passages  at  term  are  practi- 
cally never  sterile ; what  is  the  true  significance  of  the 
organisms  present  ? If  a man  presents  his  wife  during  her 
pregnancy  with  virulent  germs  from  a diseased  urethra  it  is 
one  thing,  but  puerperal  fever  occurs  in  women  whose 
genitals,  and  whose  husbands’  genitals,  are  healthy.  Is 
there  any  evidence  to  show  that  in  such  a case  the  infection 
is  due  to  organisms  present  in  the  vagina  before  labour  ? 

On  general  grounds  one  would  not  expect  intercourse 
during  pregnancy  by  healthy  Deople  to  be  dangerous.  It  is 
not  probable  that  a man  and  woman  can  both  harbour  in 
the  genital  region  a germ  of  great  virulence  for  months 
without  symptoms.  It  must  happen  frequently  that  bacteria 
are  placed  during  intercourse  very  near  the  cervical  canal 
immediately  before  the  onset  of  the  menstrual  flow  and  very 
soon  after  the  period,  almost  certainly  whilst  there  are  raw 
areas  in  the  uterus.  It  is  reasonable  to  suppose  that 
organisms  (as  well  as  spermatozoa)  enter  the  uterus,  and  yet 


The  Lanoht,] 


OBITUARY. 


[August  23,  1919  351 


no  harm  follows.  I suggest  that  there  is  some  factor  (other 
than  fatigue,  size  of  wound,  access  to  open  vessels,  ice. , which, 
to  my  mind,  do  not  meet  the  case)  which  operates  to  make  a 
woman  particularly  susceptible  during  a particular  labour. 

Dr.  Brock  asks  what  a surgeon  would  say  if  he  were  asked 
to  operate  in  a region  so  soiled  as  the  vagina  Probably — 
“ It  might  have  been  piles.” — I am,  Sir,  yours  faithfully, 
Lansdowne-road,  S.E.,  August  19th.  R-  L.  KlTCHING,  M.B. , B S. 


WILLIAM  SMITH  GREENFIELD,  M.D.  Lond., 
F.R.C.P.  Lond.  & Edin., 

EMERITUS  PROFESSOR  OF  PATHOLOGY  AND  OF  CLINICAL  MEDICINE  IN 
THE  UNIVERSITY  OF  EDINBURGH. 

William  Smith  Greenfield  was  born  at  Salisbury  and 
received  his  medical  education  at  University  College  Hospital, 
London,  graduating  M.D.  in  1874.  In  the  same  year  he 
became  demonstrator  in  morbid  anatomy  and  pathology  at 
St.  Thomas’s  Hospital,  where  for  two  years  previously  he  bad 
been  registrar.  Later  he  became  assistant  physician  and 
physician  for  diseases  of  the  throat  at  the  hospital.  In 
1878  he  succeeded  Dr.  Burdon  Sanderson  as  professor  of 
pathology  at  the  Brown  Institute. 

It  was  at  St.  Thomas’s  Hospital  that  William  Greenfield 
laid  the  foundation  of  a great  career  in  pathology,  influenced 
by  such  leaders  of  thought  as  Wilson  Fox  and  Murchison. 
When  in  1881,  he  came  to  Edinburgh,  he  had  already  made 
his  name  as  a teacher,  a clinician,  and  a pathologist.  Both 
at  St.  Thomas's  and  at  the  Brown  Institute  he  made  full  use 
of  all  the  material  at  his  disposal  and  devoted  himself  with 
great  enthusiasm  to  the  study  of  contagious  and  infectious 
disease.  His  work  on  anthrax  stands  out  as  the  record  of  a 
great  scientific  observer,  and  his  original  publication  on 
“ wool-sorter’s  disease  ” is  still  the  classic  on  the  subject. 
Encouraged  and  abundantly  supplied  with  means  by  the  French 
Government,  Pasteur  carried  out  a great  piece  of  experimental 
work,  which  in  1881  resulted  in  a communication  to  the  Inter- 
national Medical  Congress  in  London  dealing  with  a suc- 
cessful means  of  protecting  animals  against  infection  with 
B.  anthracis.  This  work  is  justly  recognised  as  one  of  the 
greatest  contributions  on  the  subject  of  vaccination,  but  it  is 
not  generally  recognised  that  priority  for  the  discovery  must 
be  given  to  Greenfield.  Working  with  a small  and  inade- 
quate sum  of  money  furnished  by  the  generosity  of  a private 
society,  and  hampered  by  the  difficulties  interposed  by  the 
law  dealing  with  experiments  on  animals,  he  obtained  the 
same  results  working  with  similar  methods.  His  work  was 
published  in  the  Proceedings  of  the  Royal  Society  in  1880. 

Greenfield’s  work  on  the  “ Pathology  of  the  Kidney,” 
published  by  the  New  Sydenham  Society,  is,  one  of 
the  most  accurate  pieces  of  pathological  work  on  the 
kidney  in  the  English  language.  All  his  other  work 
shows  the  same  accuracy  and  attention  to  detail.  All 
pathologists  regret  that  during  his  later  years  he  did  not 
give  to  the  world  of  science  the  results  of  his  wide 
experience,  which  would  have  been  invaluable  to  all 
working  in  the  same  field  as  himself.  Those  of  us  who 
admire  him  most  are  fully  conscious  of  this  defect,  which 
was  largely  due  to  self-consciousness.  He  was  a critic  of 
all  scientific  work,  but  his  most  severe  criticism  was 
reserved  for  his  own  and,  though  much  work  was  got 
ready  for  publication,  it  never  satisfied  the  demands  of 
its  author.  This  hypercriticism  may  be  regarded  as  a 
great  fault  in  a teacher,  but  though  he  did  not  publish 
widely,  he  gave  his  rich  experience  to  those  who  worked 
under  him,  and  the  pathological  world  has  benefited 
indirectly  through  the  work  of  Woodhead,  Muir,  and  the 
other  professors  of  pathology  and  bacteriology  who  com- 
menced their  careers  as  Greenfield’s  assistants.  Trained 
as  a clinician  and  having  the  only  sound  basis  for  clinical 
medicine,  a thorough  knowledge  of  morbid  anatomy  and 
histology  and  experimental  pathology,  it  is  not  surprising 
that  in  his  introductory  lecture  at  Edinburgh  Greenfield 
said  : “ It  is  living  matter  with  which  we  have  to  deal,  and 
it  is  by  the  exact  study  of  the  phenomena  of  life  that  we 
must  bridge  over  the  chasm  between  dead  morbid  anatomy 
and  living  pathology.”  Or  again:  “The  study  of  clinical 
medicine  and  pathological  experiment  are,  in  my  opinion, 
the  inseparable  adjuncts  of  pathological  study.  That  would 
be  a strange  physiology  which  should  conduct  its  study  on 


dead  animals  alone,  and  no  less  strange  a pathology  studied 
only  on  dead  subjects.”  Believing  this,  and  striving  with 
all  his  energy  to  give  the  living  pathology  to  his  students, 
one  cannot  wonder  at  his  success — a success  which  is  not 
measured,  but  which  is  partly  shown  by  the  number  of 
his  pupils  who  have  held  or  are  holding  important  posts  in 
pathology  and  bacteriology  in  this  country  and  in  our 
Dominions.  It  may  be  said  that  the  Pathological  School  of 
Edinburgh  has  in  the  past  directed  the  pathological  teaching 
of  this  country,  and  that  largely  because  Greenfield  inspired 
those  who  worked  under  him  to  search  for  truth.  Never 
bound  by  old  shibboleths  but  always  sceptical  of  the  new, 
he  taught  others  to  do  that  which  he  himself  always  did — 
viz.,  examine  all  new  facts  and  theories  brought  forward, 
try  them,  and,  if  the  evidence  justified  them,  then  have  no 
hesitation  in  accepting  them  and  making  them  bases  for 
further  work. 

One  of  his  best-known  lieutenants  thus  writes  about  him  : 
“To  his  assistants  he  was  always  ready  to  give  help  and 
advice,  and  I often  marvelled  at  his  knowledge  of  the  litera- 
ture of  his  subject.  To  be  an  assistant  with  him  was  both 
an  honour  and  a privilege,  for  it  was  only  those  who  were 
intimately  associated  with  him  who  knew  the  real  man.  Sir 
German  Sims  Woodhead,  in  a letter  to  me  the  other  day, 
said,  ■ I always  look  back  to  the  period  of  association  with 
Greenfield  as  a very  pleasant  and  profitable  time.  I was 
fond  of  the  man.’  That,  I am  sure,  will  be  the  feeling  of 
everyone  who  has  been  an  assistant  with  him.  We  were 
drawn  to  him,  not  by  the  mere  admiration  of  a student  for  a 
great  and  brilliant  chief,  nor  by  the  pride  of  being  asso- 
ciated with  a really  great  pathologist,  but  by  a real  bond  of 
friendship  and  love  for  the  man.  A severe  but  just  critic,  a 
man  who  could  not  tolerate  slackness,  and  one  who  loathed 
toadyism  in  all  its  forms,  it  is  not  to  be  wordered  at  that  he 
made  enemies.  But  his  enemies  were  never  those  who  really 
knew  him.  To  see  him  in  his  own  home,  to  know  his  real 
interest  in  his  students,  and  to  have  evidence,  as  I abundantly 
had,  of  the  true  greatness  of  his  character,  is  to  make  .me 
look  back  with  pleasure  to  the  years  I spent  with  him.  He 
himself  has  passed,  but  his  memory  must  always  remain  to 
those,  who,  like  myself,  have  been  closely  associated  with 
him  and  who  owe  so  much  to  him.”  J.  M.  B. 


LOVELL  DRAGE,  M.D.  Oxon. 

The  profession  has  lost  a valuable  and  well-known  practi- 
tioner by  the  death,  from  septic  poisoning,  of  Dr.  Lovell  Drage, 
of  Hatfield.  Born  in  1859,  he  was  educated  at  Winchester, 
Christ  Church,  Oxford,  Owens  College,  Manchester,  and  at  St. 
Bartholomew’s  Hospital,  where  he  was  house  surgeon  to  the 
late  Sir  Thomas  Smith,  and  resident  midwifery  assistant 
under  Dr.  J.  Matthews  Duncan.  He  took  a science  degree 
at  Oxford  in  1881,  and  proceeded  to  M.B. , B.Ch.  in  1887,  and 
M.D.  in  1893.  After  a distinguished  career  as  a student  and 
member  of  the  junior  staff  at  St.  Bartholomew’s,  he  joined 
his  father  in  practice  at  Hatfield,  Herts,  and  was  for  many 
years  well  known  in  the  country  and  in  medical  circles  in 
London.  His  tall  figure  and  cheery  greetings  of  numerous 
old  friends  were  a feature  of  many  meetings.. whether  social 
or  scientific,  in  the  medical  world.  In  spite  of  the  claims 
of  large  and  important  practice  and  much  public  work  of 
an  urgent  character,  Drage  found  time  to  pursue  original 
clinical  observation.  His  inquiry  into  the  use  of  the 
derivatives  of  cinnamic  acid  in  malignant  disease  is  a case 
in  point.  Various  papers  on  this  subject  from  his  pen 
appeared  in  the  columns  of  The  Lancet,  and  though  his 
views  got  no  strong  outside  support,  they  obtained  the 
respect  earned  by  his  obvious  sincerity.  A man  of  clear  and 
decided  opinions,  he  was  a generous  and  straightforward 
opponent  of  those  with  whom  he  disagreed  ; but  he  will  be 
remembered  far  more  widely  as  a warm-hearted  and  genial 
friend. 

Drage  was  a typical  country  sportsman,  and  in  his  earlier 
years  a fine  horseman  and  good  shot.  He  had  a faculty 
for  preserving  old  friendships,  many  of  them  begun  at  school 
or  at  St.  Bartholomew’s  Hospital,  and  a large  group  of  men 
will  regret  the  genuine  and  warm  hospitality  of  the  old  house 
at  Hatfield.  He  will  be  widely  and  acutely  missed  in  his 
county  of  Hertfordshire,  where  among  other  important  public 
posts  he  held  the  office  of  coroner,  and  in  that  capacity 
conducted  the  inquest  upon  the  bodies  of  the  crew  of  the 
Schutte-Lanz  airship  which  was  brought  down  in  flames  at 
Cuffiey  on  Sept.  3rd,  1916.  The  sympathy  of  many  will  go  out 
to  his  widow,  his  son,  Major  R.  L.  Drage,  and  his  daughter. 


352  The  Lancet,] 


PARLIAMENTARY  INTELLIGENCE. 


[August  23,  1919 


IJarliatwittarg  Intelligence. 

HOUSE  OF  LORDS. 

Wednesday,  August  13th. 

Closing  of  Dublin  Hospitals. 

Lord  Shandon  asked  whether  the  attention  of  H.M. 
Government  had  been  directed  to  the  impending  closing 
of  the  Houses  of  Industry  Hospitafs  in  Dublin  ; if  it  was 
intended  to  take  any  action  relatiug  thereto  ; and  moved  for 
papers.  He  said  that  he  desired,  if  possible,  to  draw  from 
the  Government  some  sympathetic  view  and  practical 
assistance  in  connexion  with  the  serious  difficulty  that 
had  arisen  with  regard  to  the  management  of  four 
hospitals,  which  were  essentially  State  hospitals,  and  at 
the  present  time  were  supposed  to  be  supported  by  a 
grant  from  Imperial  resources.  This  was  really  a serious 
matter  which  ought  to  be  dealt  with,  and  he  hoped  to  suggest 
one  practical  way  of  dealing  with  it.  In  the  eighteenth  century 
there  were  established  by  the  Irish  Government  of  the  time  a 
series  of  hospitals  to  provide  surgical  and  medical  aid  for  the 
poorer  classes  in  Dublin  and  Ireland  generally,  and  these 
hospitals  for  a time  fulfilled  the  functions  now  fulfilled  by 
Poor-law  relief  hospitals.  Under  the  Act  of  Union  this 
was  one  of  the  liabilities  taken  over  by  the  Imperial 
Government,  and  a short  time  after  the  operation  of  the 
Act  of  Union  it  was  found  that  difficulties,  both  from  a 
monetary  and  a practical  point  of  view,  arose  with  regard 
to  these  hospitals.  Two  inquiries  were  held.  One  was  an 
inquiry  by  the  House  of  Commons  in  1854  and  the  second 
was  an  inquiry  held  by  a commission,  generally  referred  to 
as  the  South  Commission,  in  1856.  The  South  Commission 
reported  that  these  hospitals  were  doing  such  good  work 
that  they  should  be  maintained  in  their  then  state  of  efficiency. 
The  report  of  the  South  Commission  was  followed  by  an  Act 
of  Parliament  called  the  Hospitals  Regulation  Act,  1856, 
which  constituted  the  hospitals  in  their  present  form.  They 
consisted  of  a group  and  were  called  the  Richmond,  a 
surgical  hospital;  the  Whitworth,  a medical  hospital; 
the  Hardwicke,  a purely  fever  hospital;  and  the  Auxiliary 
block  for  surgical  and  certain  emergency  services.  These 
four  hospitals  were  constituted  under  the  statute  with  a 
government  of  a very  peculiar  character.  The  Lord- 
Lieutenant  of  Ireland,  through  the  Irish  Office,  exercised 
complete  control  over  the  management  of  these  hospitals. 
The  buildings  themselves  were  not  private  property,  but  were 
vested  in  the  Commissioners  of  Public  Works  in  Ireland,  and 
nothing  could  be  done  in  that  way  to  mortgage  or  charge 
these  buildings  except  with  the  Commissioners’  approval. 
This  showed  how  completely  they  were  State  institutions. 
But  more  than  that,  resulting  from  the  recommendations  of 
the  South  Commission,  a sum  of  £7600  originally,  and  now 
£7500,  per  annum  was  provided  as  being  sufficient  to  keep 
up  these  hospitals.  From  1856,  down  to  the  beginning  of 
the  war,  this  grant  was  found  sufficient— a rather  tight  fit, 
perhaps,  but  still  sufficient— to  keep  them  going.  It  was 
quite  impossible  to  keep  any  institution  going  on  the  same 
rate  of  contribution  that  was  possible  before  the  war.  He 
was  informed  that  while  prior  to  the  war  £64  12s.  lid.  per 
patient  was  sufficient  to  keep  the  hospitals  going,  in  1919  the 
sum  required  per  patient  was  £119  Is.  lOd.  In  Dublin  there 
were  a number  of  hospitals  supported  by  voluntary  con- 
tributions, most  of  them  being  at  present  in  debt.'  The 
difficulty  of  getting  the  public  under  present  conditions  to 
clear  off  debt  or  to  keep  the  hospitals  going  in  their  old 
condition  of  efficiency  was  practically  insuperable.  These 
particular  hospitals  had  no  private  subscriptions,  and  though 
the  statute  under  which  they  were  constituted  did  con- 
template private  subscriptions,  the  power  had  never  been 
used,  and  the  hope  of  getting  money  in  present  circum- 
stances from  private  sources  was,  he  was  afraid,  an 
impossibility.  The  four  hospitals  together  were  practically 
the  largest  institution  of  the  kind  in  Ireland.  The 
closing  of  them  would  not  only  affect  the  indigent  poor,  but 
seriously  affect  medical  science  and  practice  in  Irelaud.  It 
would  also  seriously  affect  the  training  of  nurses.  The  hos- 
pitals were  practically  closed  and  there  was  no  chance  of 
their  being  opened  unless  some  practical  solution  was 
found.  Perhaps  a business  inquiry  representing  the  Treasury, 
the  medical  profession,  the  governors,  and  perhaps  some  of 
the  business  men  of  Dublin,  might  come  to  some  conclusion. 
The  doctors  said,  he  was  informed,  that  suddenly  to  shut 
down  one  of  these  hospitals  was  practically  impossible.  If 
they  shut  down  the  fever  hospital  there  would  be  no 
sufficient  accommodation  for  fever  patients  in  Dublin.  If 
the  emergency  block  were  shut  down  they  would  have  to 
take  serious  cases  across  the  city  .in  cars  or  ambulances,  with 
great  suffering  to  the  patients.  The  doctors  said  it  was 
practically  impossible.  Surely  some  solution  might  be 
found  before  the  winter. 

The  Earl  of  Mayo  supported  Lord  Shandon’s  motion, 
and  expressed  the  view  that  he  had  made  out  a strong  case 
for  these  hospitals,  which  were  much  needed  in  Dublin. 


The  Earl  of  Crawford  (Chancellor  of  the  Duchy  of 
Lancaster),  replying  for  the  Government,  said  these  hospitals 
were  not  State  hospitals  in  the  sense  that  they  rendered 
any  special  service  to  the  State.  They  differed  in  no  degree 
from  any  other  hospital  in  Ireland  or  in  Great  Britain, 
except  that  they  had  the  good  fortune  for  many  years  to 
have  received  a special  grant.  From  accounts  he  had 
before  him  it  would  certainly  appear  that  the  State  subsidy 
of  £7600  was  not  the  only  source  of  income  available  to  this  ! 
charitable  institution. 

Lord  Shandon  : It  is  the  only  one  except  the  private 
patients. 

The  Earl  of  Crawford,  continuing,  said  that  during  the 
last  two  or  three  years  the  hospital  had  had  a very  consider-  | 
able  income  from  the  War  Office  apart  from  the  money  i 
voted  by  Parliament.  Last  year  it  was  £7000 ; the  year  | 
before  £6300;  this  was  in  addition  to  the  income  from  ! 
patients  who  could  afford  to  pay. 

Lord  Shandon  : They  are  not  very  large,  but  there  are  some.  I 

The  Earl  of  Crawford:  They  are  upwards  of  £3000  a 
year.  He  was  afraid  he  could  not  hold  out  hopes  to  the 
noble  and  learned  Lord  that  the  Treasury  would  see  its  way 
to  recommend  Parliament  to  pay  a larger  sum  than  the 
present  annual  grant.  He  did  not  think  it  would  be  wise  to 
do  so. — The  motion  was  by  leave  withdrawn. 

War  Pensions  Bill. 

Their  Lordships  went  into  Committee  on  the  War  Pensions 
(Administrative  Provisions)  Bill,  the  Earl  of  Rintore  in  the 
chair.  On  Clause  8 (dealing  with  appeals  to  Pensions 
Appeal  Tribunals), 

The  Earl  of  Crawford  moved  an  amendment  to  provide 
that  no  appeal  should  lie  in  the  case  of  any  claim  already 
heard  and  rejected  by  a Ministry  Appeal  Tribunal.  This  I 
prevented  a man  having  his  case  dealt  with  by  a new  i 
tribunal  after  it  had  already  been  settled  by  a competent  \ 
tribunal  in  existence. 

The  amendment  was  agreed  to. 

The  Committee  stage  of  the  Bill  was  concluded,  the  Bill 
was  reported  and  read  a third  time  and  passed. 


HOUSE  OF  COMMONS. 

Wednesday,  August  13th. 

Medical  Breakdown  in  Afghan  Campaign. 

Major  Earl  Winterton  asked  the  Secretary  of  State  for 
India  if  he  would  state  what  steps  he  was  taking  to  inquire 
into  the  allegations  regarding  transport  and  medical  break- 
down in  the  Indian  Army  operations  against  Afghanistan. — 
Mr.  Montagu  replied  : I have  caused  inquiry  to  be  made  on 
every  definite  allegation  that  is  brought  to  my  notice  and  I 
hope  to  lay  papers  on  the  table  very  shortly  dealing  with 
the  medical  arrangements  in  the  North-West  Frontier 
campaign. 

Lieutenant-Colonel  Sir  S.  Hoare  : Will  the  papers  be  laid 
before  the  rising  of  the  House  for  the  holidays?— Mr. 
Montagu  replied : I do  not  yet  know  when  the  House  is 
going  to  rise,  but  I want  to  get  out  the  telegrams  that  I have 
received  from  the  Government  of  India  as  soon  as  possible 
and  I hope  to  have  the  papers  ready  at  the  end  of  this  week. 


Small-pox  in  the  Country. 

Mr.  Clough  asked  the  Minister  of  Health  if  he  would  state 
how  manv  cases  of  small-pox  there  were  in  this  country,  and 
whether  any  of  them  had  been  introduced  from  outside.— 
Major  Astor  (Parliamentary  Secretary  to  the  Ministry  of 
Health)  replied  : During  the  month  of  July  and  the  first  week 
in  August  60  cases  of  small-pox  have  come  to  the  knowledge 
of  the  Ministry  of  Health.  Of  these  one  group  of  cases 
numbering  25  up  to  August  7th  is  associated  with  the  return 
home  of  a sailor  and  three  groups  numbering  eight  cases  in 
all  up  to  August  7th  to  soldiers  returning  home  from  abroad. 
There  have  been  three  ship-borne  cases  intercepted  by  port 
sanitary  authorities  from  which  there  has  been  no  spread  of 
infection.  q Pensions  Disablement  Appeal. 


Sir  Montague  Barlow  asked  the  Pensions  Minister 
whether  he  would  have  inquiries  made  into  the  case  of 
Ir.  A.  Wakefield,  late  able-bodied  seaman  No.  16,273,  of 
I.M.S.  Ruby , of  15,  Enbridge-street,  Trafford-road,  Salford; 
fbether  this  man  was  invalided  from  the  Navy  with  flat 
eet  caused  through  wounds  in  the  leg  and  ankle  after 
7 years’  service,  naving  joined  at  the  age  of  155  years; 
rhether,  on  discharge,  he  was  awarded  a temporary  pension  ; 
rhether  be  applied  to  the  local  War  Pensions  Committee 
or  reassessment  and  was  examined  by  the  medical  referees 
,n  April  29th ; and  whether,  in  spite  of  the  fact  that  his 
ecommendations  were  forwarded  to  the  Ministry  of 
’ensions  and  a further  medical  board  ordered,  the  man  was 
till  unable  to  ascertain  what  pension,  if  any,  has  been 
.warded  to  him.— Sir  J.  Craig  replied  : Mr.  Wakefield  was 
uvalided  for  injury  to  his  right  leg  and  was  in  receipt  oi 
lisablement  pension  until  May  15th,  1919.  The  disability 
>f  flat  feet  has  been  found  to  be  neither  attributable  to  nor 
.egravated  bv  service.  He  was  medically  examined  on 
flarch  6th.  1919,  when  the  disablement  arising  from  the 


Thb  Lancet,] 


PARLIAMENTARY  INTELLIGENCE. 


[August  23,  1919  353 


injury  was  assessed  at  nil.  He  therefore  reverted  to  a 
pension  of  4s.  8 d.  a week  for  life  awarded  in  respect  of  his 
service.  On  an  appeal  being  received  from  the  local  War 
Pensions  Committee  on  his  behalf  he  was  further  exa- 
mined on  June  3rd,  1919,  when  the  extent  of  disablement 
was  again  assessed  at  nil.  He  is  therefore  ineligible  for 
resumption  of  his  disablement  pension,  and  the  fact  has  now 
been  oommunicated  to  him. 

Thursday,  August  14th. 

The  Isolation  of  Tuberculous  Patients. 

Mr.  Grattan  Doyle  asked  the  Minister  of  Health  if  he 
was  aware  that  at  the  Northern  Hospital,  Winchmore  Hill, 
London,  certain  wards  were  used  for  consumptive  patients 
in  all  stages  of  the  disease,  the  patients  including  men, 
women,  and  children,  while  other  wards  were  being  used 
for  children  convalescent  from  scarlet  fever  and  diphtheria 
removed  from  other  infectious  hospitals;  if  his  attention 
had  been  drawn  to  the  fact  that  the  whole  of  the  wards 
referred  to  were  enclosed  in  one  building,  that  the  nursing 
staff  was  presided  over  by  one  matron,  and  that  the  nurses 
were  employed  indiscriminately  in  either  infectious  or 
tuberculosis  wards  ; whether,  if  he  decided  that  the  hospital 
should  still  house  both  classes  of  patients,  steps  would  be 
taken  to  appoint  a recognised  expert  to  take  responsible 
charge  of  che  tuberculosis  wards;  and  if  he  would  ascertain 
if  there  was  sufficient  and  suitable  space  for  recreation  for 
sanatorium  patients. — Major  Astor  replied  : Some  blocks  at 
the  Metropolitan  Asylums  Board  Hospital,  Winchmore  Hill, 
are  used  for  the  treatment  of  tuberculous  patients  and  other 
blocks  for  convalescent  cases  of  acute  infectious  disease,  but 
no  ward  and  no  block  is  used  for  more  than  one  disease. 
The  tuberculous  patients  are  classified  in  their  respective 
wards  according  to  the  stages  of  the  disease.  A nurse 
engaged  in  nursing  tuberculosis  is  not  allowed  to  come  into 
contact  with  cases  of  acute  infectious  disease.  An  entirely 
separate  medical  staff,  with  special  experience  in  tuber- 
culosis, under  the  general  supervision  of  the  medical  super- 
intendent of  the  hospital,  is  in  charge  of  the  blocks  for  the 
treatment  of  tuberculosis.  Having  regard  to  the  class  of 
cases  admitted  to  these  blocks  the  space  available  for 
recreation  is  sufficient  and  suitable. 

Grants  to  Panel  Practitioners. 

Mr.  Godfrey  Locker-Lampson  asked  the  Minister  of 
Health  if  he  would  state  what  was  the  cost  each  year  of  the 
grants  made  and  promised  to  panel  doctors  and  chemists 
in  respect  of  war  bonuses  or  allowances. — Major  Astor 
replied : Grants  by  way  of  war  bonuses  or  allowances  as 
distinct  from  the  regular  payments  for  remuneration  for 
insurance  practice  have  been  made  to  insurance  practi- 
tioners in  respect  of  the  year  1918,  amounting  to  approxi- 
mately £300,000.  Approval  has  been  given  by  the  Treasury 
for  the  grant  of  a war  bonus  to  insurance  practitioners  in 
respect  of  the  year  1919  on  a basis  corresponding  broadly 
to  that  laid  down  by  the  Conciliation  and  Arbitration  Board 
for  Civil  Servants.  The  cost  of  the  grants  for  the  year  1919 
is  estimated  to  be  approximately  £950,000.  These  figures  are 
for  Great  Britain.  As  regards  chemists,  the  increase  in 
remuneration  afforded  them  in  respect  of  war  conditions 
forms  part  of  a general  charge  upon  funds  provided  for 
defraying  the  cost  of  medical  benefit,  and  cannot  be  readily 
separated. 

Medical  Officers  obtained  by  the  War  Office. 

Major  Farquharson  asked  the  Secretary  for  War  if  he 
would  sta,te  the  number  of  new  medical  officers  which  had 
been  obtained  by  the  War  Office  upon  the  consolidated  rates 
of  pay  offered  at  the  commencement  of  July  of  this  year. — 
Mr.  Forster  (Financial  Secretary  to  the  War  Office)  replied : 
The  number  of  new  medical  officers  obtained  is  27. 

Release  of  Medical  Officers  in  the  Army. 

Major  Farquharson  asked  the  Secretary  for  War  (1)  if  he 
was  aware  that  the  contract  under  which  a number  of 
medical  practitioners  held  temporary  commissions  in  the 
Royal  Army  Medical  Corps  would  expire  on  the  date  on 
which  the  termination  of  the  war  was  officially  declared  ; 
and  what  arrangements  had  been  made  to  enable  those 
practitioners  now  serving  in  India  and  Mesopotamia  to 
return  to  this  country  immediately  on  the  termination  of 
their  contracts ; (2)  if  he  would  state  under  what  authority 
medical  and  other  officers  were  being  temporarily  retained 
in  India ; and  what  steps  were  being  taken  to  ensure  the 
immediate  release  of  those  medical  officers  who  were  marked 
for  early  demobilisation  by  the  Ministry  of  National  Service 
prior  to  April  of  this  year. 

Mr.  Bennett  asked  the  Secretary  for  War  whether,  in 
view  of  the  fact  that  Royal  Army  Medical  Corps  officers  in 
India  serving  under  yearly  contracts  were  to  be  demobilised 
previously  to  those  who  volunteered  for  the  duration  of  the 
war,  he  would  consider  the  claim  to  compensation  of 
officers  of  the  latter  category  whose  practices,  which  they 
had  built  up  by  their  exertions  and  for  which  they  paid 
substantial  sums,  had  been  virtually  ruined  and  absorbed 
by  the  large  number  of  medical  officers  demobilised  from 
Trance  and  other  theatres  of  war;  and  whether  he  would 


state  how  many  temporary  medical  officers,  exclusive  of 
sick,  had  been  sent  home  from  India  since  the  armistice 
and  how  many  remained  in  India. — Mr.  Forster  replied  : 
Temporary  medical. officers  are  being  retained  in  India  under 
the  terms  of  their  contracts,  which  render  them  liable  for 
service  for  the  duration  of  the  present  emergency.  The  only 
officers  who  are  serving  on  yearly  contracts  are  those  who 
are  not  liable  to  the  Military  Service  Act,  and  cannot  there- 
fore be  retained  beyond  the  termination  of  their  contracts. 
The  contracts  of  temporary  officers  serving  for  the  duration 
of  the  present  emergency  terminate  on  the  statutory  date 
for  the  end  of  the  war,  and  everything  possible  will  be  done 
to  enable  them  to  be  returned  to  the  United  Kingdom  by 
that  date.  In  theeventof  this  being  effected  the  question  of 
compensation  does  not  arise.  One  hundred  and  forty-five 
temporary,  Special  Reserve,  and  Territorial  Force  officers 
(exclusive  of  sick)  have  been  sent  home  since  the  armistice, 
and  335  remain,  including  100  officers  temporarily  detained 
while  en  route  from  Mesopotamia  on  account  of  the  situation 
prevailing  in  India.  I would  add  that  every  available  medical 
officer  who  is  liable  for  further  service  is  being  placed  under 
orders  for  India  or  Egypt  in  order  to  relieve  those  who  have 
been  asked  for  by  the  Ministry  of  National  Service. 

Monday,  August  18th. 

Neurasthenia  and  Shell  Shock  Treatment  in  Ireland. 

Lieutenant-Colonel  Walter  Guinness  asked  the  Pensions 
Minister  whether  he  was  now  in  a position  to  make  a state- 
ment on  the  provision  for  the  accommodation  and  general 
treatment  of  disabled  men  in  the  southern  region  of 
Ireland  who  had  been  discharged  suffering  from  neuras- 
thenia and  shell  shock ; whether  accommodation  could 
be  found  for  such  invalided  men  who  were  on  the  border- 
line of  lunacy,  and  who  in  consequence  must  be  detained, 
even  against  their  wishes,  in  institutions;  whether 
he  was  aware  that  the  authorities  of  the  two  institu- 
tions in  the  neighbourhood  of  Dublin  were  prohibited  from 
detaining  men  against  their  wishes  and,  therefore,  that  such 
institutions  were  of  little  value  in  the  case  of  neurasthenia 
or  shell  shock  that  bordered  on  lunacy ; whether  he  was  aware 
that  in  the  absence  of  such  accommodation  most  of  the  men 
in  question  who  had  no  homes  were  living  in  lodging-houses, 
that  a few  were  certified  as  being  potentially  dangerous,  that 
the  procedure  of  getting  men  into  an  asylum  was  trouble- 
some and  lengthy,  and  that  on  more  than  one  occasion  before 
the  admission  of  the  man  to  an  asylum  had  been  secured 
friends  interested  in  his  welfare  had  lost  sight  of  him  ; 
whether  he  considered  it  satisfactory  that  ex-Service  men 
should  be  committed  to  lunatic  asylums  in  Ireland  and 
treated  as  paupers  in  accordance  with  the  Lunacy  Laws  as 
they  operated  in  Ireland ; whether  provision  could  be  made 
at  once  to  set  up  a separate  institution  for  the  Southern 
region  of  Ireland,  to  which  such  cases  might  be  admitted  and 
detained  for  a time  even  against  the  wishes  of  the  patient ; 
and  whether  the  scientific  treatment  accorded  to  such  cases 
at  the  Seale  Hayne  Institution  could  be  introduced  into 
Ireland.— Sir  L.  Worthington  Evans  replied:  I have  no 
power  to  keep  any  man  in  an  institution  against  his  will 
unless  he  is  certified  under  the  Lunacy  Laws.  A man  so 
certified  and  sent  to  an  asylum  in  Ireland  has  hitherto  been 
treated  as  an  ordinary  patient,  but  under  a scheme  which 
will  come  into  force  at  an  early  date  he  will  in  future  be 
treated  as  a Service  patient.  Arrangements  are  being  made 
to  establish  a neurological  hospital  in  the  South  of  Ireland 
for  ex-Service  men  at  which  scientific  treatment  for 
neurasthenia  and  shell  shock  will  be  provided. 

Seale  Hayne  Hospital. 

Mr.  Lambert  asked  the  Secretary  for  War  if  he  could  now 
state  definitely  when  the  Seale  Hayne  Military  Ho-ipital, 
Newton  Abbot,  would  be  evacuated. — Mr.  Churchill 
replied:  The  work  of  reinstatement  is  proceeding  as 
rapidly  as  is  possible,  but  I am  afraid  that  it  is  not  yet 
possible  to  fix  a definite  date.  Three  out  of  the  four  blocks 
of  the  building  are  empty  and  are  ready  for  handiDg  over  to 
the  owners,  who,  however,  are  not  prepared  to  take  over 
portions  of  the  hospital  and  prefer  to  wait  until  the  whole 
can  be  handed  over  on  the  completion  of  reinstatement. 
At  the  present  moment  the  laboratory  is  being  reinstated, 
and  the  reinstatement  of  technical  and  scientific  apparatus 
is  a matter  which  necessarily  takes  some  time. 

Clothes  of  Asylum  Patients. 

Sir  J.  Bruton  asked  the  Home  Secretary  whether  he  was 
aware  that  Service  or  ex-Service  men  when  sent  to  lunatic 
asylums  were  put  into  pauper  clothes  until  the  asylum 
authorities  were  notified  by  the  Home  Office  ; that  they 
accepted  them  as  Service  patients ; and,  pending  accept- 
ance (which  might  not  be  given  for  six  weeks  to  three 
months),  whether  it  would  be  possible  to  allow  these  men 
to  wear  their  Service  or  civilian  clothes,  and  thus  avoid 
the  distress  caused  to  their  relatives  on  finding  them  in 
pauper  attire. — Mr.  Shortt  replied : Ex-Service  men  sent 
to  lunatic  asylums  direct  from  war  hospitals  under 
Section  91  of  the  Army  Act  or  Section  3 of  the  Naval 
Enlistment  Act,  1884,  are  immediately  transferred  to  the 


354  The  Lancet,] 


APPOINTMENTS.— VACANCIES. 


[August  23,  1919 


private  class,  and  as  private  patients  are  allowed  to  wear 
their  own  clothes.  This  class  form  the  bulk  of  the 
ex-8ervice  men  admitted  to  asylums.  Ex-Service  men 
admitted  on  summary  reception  orders  after  discharge 
from  the  Army  or  Navy  are  chargeable  to  the  rates  until 
their  eligibility  to  be  classed  as  “Service”  patients  has 
been  investigated  by  the  Ministry  of  Pensions,  and  they 
are  clothed  for  the  time  being  as  ordinary  patients. 
Where  a medical  superintendent  has  reason  to  believe  that 
a man  of  the  latter  class  will  be  accepted  as  a “ Service  ” 
patient  I think  he  might  properly  allow  such  a patient  to 
wear  his  own  clothing,  and  I will  ask  the  Board  of  Control 
to  make  this  suggestion  to  the  asylum  authorities. 

Tuberculous  Ex-Service  Men. 

Lieutenant-Colonel  Raw  asked  the  Minister  of  Health  if 
he  would  state  what  steps  he  proposed  to  take  in  connexion 
with  the  recent  report  of  the  inter-departmental  committee 
on  tuberculous  ex-Service  men  in  view  of  the  urgency  of  the 
matter. — Mr.  TOWYN  Jones  replied  : The  report  has  been  in 
my  right  honourable  friend’s  hands  for  a very  short  time ; 
and  while  he  quite  agrees  that  the  matter  is  urgent,  he  is 
not  yet  in  a position  to  state  what  action  the  Government 
propose  to  take. 

Medical  Inspection  of  Aliens. 

Mr.  C.  K.  Murchison  asked  the  Minister  of  Health  if  a 
decision  had  been  reached,  in  conjunction  with  the  Home 
Office,  concerning  the  regulations  to  be  carried  out  in  the 
medical  inspection  of  aliens  arriving  in  this  country;  and, 
if  so,  whether  these  regulations  could  now  be  published. — 
Mr.  Towyn  Jones  replied  : An  Order  in  Council  containing 
further  provisions  with  regard  to  the  medical  inspection  of 
aliens  will  be  issued  at  an  early  date.  I will  see  that  a copy 
is  sent  to  my  honourable  friend  when  available. 

Expenses  of  Port  Sanitary  Authorities. 

Mr.  Murchison  asked  the  Minister  of  Health  whether  he 
would  consider  the  desirability  of  taking  steps  to  secure  that 
the  cost  incurred  by  the  port  sanitary  authorities,  especially 
in  East  Coast  ports  like  Hull  and  Newcastle,  in  protecting 
the  people  of  this  country  from  the  inroads  of  infectious 
diseases  from  abroad  should  be  treated  as  a national  charge 
at  least  to  the  extent  of  50  per  cent,  of  the  amount  so 
incurred. — Mr.  Towyn  .Jones  replied  : Yes,  sir,  this  question 
is  already  under  consideration. 

Scottish  Board  of  Health. 

Mr.  Joseph  Johnstone  asked  the  Secretary  for  Scotland 
whether  he  was  aware  that  the  Minister  of  Health  for 
England  was  now  in  process  of  forming  the  consultative 
councils  provided  for  under  the  Ministry  of  Health  Act; 
and  whether  he  proposed  similary  to  appoint  the  consulta- 
tive- council  provided  for  under  the  Scottish  Board  of 
Health  Act. — Mr.  Pratt  (Parliamentary  Secretary  to  the 
Scottish  Board  of  Health)  replied:  The  answer  to* the  first 
part  of  the  question  is  in  the  affirmative.  The  proposals 
of  the  Scottish  Board  of  Health  for  the  establishment  of 
consultative  councils  are  being  embodied  in  a draft  Order 
in  Council.  The  actual  constitution  of  the  councils  must, 
however,  await  the  fulfilment  of  the  requirements  of  the 
Act  as  to  the  Order  in  Council  lying  before  Parliament  for 
30  days. 

Tuesday,  August  19th. 

V.A.D.  Nurses  and  Gratuity. 

Mr.  Hogge  asked  the  Financial  Secretary  to  the  War 
Office  whether  Voluntary  Aid  Detachment  nursing  members 
who  had  worked  in  military  hospitals  received  gratuity  ; 
whether  Voluntary  Aid  Detachmentgeneral  service  members 
working  in  the  same  hospitals  received  no  gratuity;  whether, 
if  a Voluntary  Aid  Detachment  nurse  had  served  any  part  of 
her  time  as  a general  service  member,  she  was  debarred 
from  gratuity  ; aud  whether  he  could  revise  these  anomalies. 
— Mr.  Forster  replied  : The  facts  are  a$  stated,  except  that 
a nurse  is  not  debarred  from  gratuity  on  her  service  in  a 
non-professional  capacity.  The  nursing  members  receive 
gratuity  because  they  are  part  of  the  nursing  service ; the 
general  service  members  receive,  instead,  furlough  and  out- 
of-work  donation  on  termination  on  the  same  lines  as 
members  of  the  Queen  Mary’s  Army  Auxiliary  Corps.  It  is 
not  proposed  to  make  any  change. 

Patients  in  Military  Hospitals. 

Major  Glyn  asked  the  Secretary  for  War  if  any  arrange- 
ment had  been  arrived  at  with  the  Ministry  of  Pensions  in 
regard  to  patients  under  treatment  in  military  hospitals  that 
were  to  be  taken  over  by  the  Ministry  of  Pensions;  and 
whether  the  arrangements  insured  the  continuance  of  treat- 
ment by  the  doctors  and  nurses  who  had  had  previous  charge 
of  all  non-convalescent  cases.— Mr.  Forster  replied : An 
arrangement  has  been  arrived  at.  The  staff  will  not  be 
transferred  en  bloc,  as  transfer  is  dependent  in  part  on  the 
wishes  of  the  individuals,  but  no  doubt  the  Ministry  of 
Pensions  will  be  glad  to  take  into  their  service  as  many  as 
possible  of  the  old  staffs  who  are  desirous  of  remaining. 


^ointments. 


Wobster-Droucht,  C , M.B.,  B.C.  Cantab.,  has  been  appointed 
Honorary  Neurologist  to  Out-patients,  Betblera  Royal  Hospital. 

St.  Thomas's  Hospital:  Wayte,  J.  W.,  M.R.C.S.,  ’L.R.C.P.  Lond., k 
Showfj.i.  Rogers,  E.  X.,  81. B.,  B.Cb.  Cantab.,  Smart.  A.  H.  J.,L 
M.8..  B.Ch.  Cantab..  Brockman.  E.  P„  M R. C.S.,  L.R.C.P.  Lond., I 
Carter,  E.  E„  M.R.C.S  , L.I1.C.P.  Lond..  Moor,  F.,  M.R.C  S., | 
L.R.C.P.  Lond.,  Procter,  R.  A.  W..  M.R.C.S.,  L.R  C.P.  Lond.,|* 
Casualty  Officers  and  Resident  Anaesthetists;  Smith.  J.  F.,1 
M R C.S..  L.R.C.P.  Lond.,  Amos,  S.  K„  Eccles,  C.  Y..  M R.C.S..B 

L. R.C.P.  Lond.,  Thomas,  A.  15.,  M.B..  B.Ch.  Oxon.,  Resident  House® 
Physicians:  Le  Gros  Clark,  W.  E„  M.R.C.S.,  L. K.C. P.  Lond.,H 
Sprott,  N.  a..  M.B.,  B Ch.  Oxon.,  Walker,  J.  P.  S.,  H.B..I 
B.Ch.  Oxon.,  Higgins,  L.  G.,  VLB..  B.Ch.  Cantab.,  Resident  House  I 
Surgeons;  Ryan,  J F.,  M.R.C  S . L.R.C  P.  Lond.,  House  Surgeon  ; I 
Potter.  A.  F.,  M.R.C.S.,  L.R.C.P. Lond.,  Bigger,  W.  G . D.S  O.,  I 

M. B.,  B.Ch.  Cantab.,  Obstetric  House  Physicians;  Dickson,  I 
D.  McM.,  M.R.C.S..  L R C.P.  Lond.,  Evans,'  H.  L.,  M.R.C.S.,  I 
L.R.C.P.  Lond.,  Ophthalmic  House  Surgeons;  Smith,  F.  P.,  I 
M . R.C.S.,  L R.C.P.  Lond.,  Clinical  Assistant  to  the  Throat  Depart- 1 
ment. ; Vihey.  a.,  M.R.C.S..  L.R.C  P.  Loud.,  Clinical  Assistant  to 
the  Children's  Medical  Department. 

Certifying  Surgeons  under  the  Factory  and  Workshop  Acts:  Wilson, 

J.  C.,  M.B..  B.Cb.  Belf.  (Ballywardt;  Stewart,  J.  K..  M.B., 
Ch.B.  Belt.  (Randalstown:  ; Aitken  Quine,  W.  J.,  M.B.,  B S.  Lond. 
(Chapel  en-le-Frith);  Selkirk,  A..  VLB.,  C.M.  Edm.  (Cowden- 
beath) ; Donohoe,  D.  B.,  L.  A L M.  R.C.P.  & R.C.S.  Irel.  (Rithvilly). 


fearas. 


For  farther  information  refer  to  the  advertisement  columns. 

Adelaide  University. — Prof,  of  P^th.  and  Bact.  £500. 

Barnsley,  Beckett  Hospital. — Res.  H.S. 

Bath  Riyal  United.  Hospital.—  H P.  £150. 

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Great  Yarmou'h  Hospital.— H.S.  £200. 

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Liverpool.  David  Lewis  Northern  Hospital. — Three  S.'s  and  Two  P.'s. 
£150. 

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Liverpool'  School  of  Tropical  Meaiciue.—  Tropical  Research,  Brazil. 
£3C0. 

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County  Mental  Hospitals.  Fourth  Assts.,  £425  to  £5C0 ; Fifth  Assts..  i 

£300  to  £490. 

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Mi  id  esbrough.  North  tfrmeshy  Hos,  Hal.— A-st.  H.S.  £175. 

Middlesex  ' minty  Council  — Female  Asst,  M.O.  £500. 

National  Hospital  for  Diseases  of  the  Hear'.  Westmireland-streel,  IF.—  ' i 
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Preston  Royal  Infirmary.— Res.  H.S. 

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Queen's  Hospital  for  Children,  Hackney-road,  Bethnal  Green,  E.— 
H.S.  aud  Cas.  H.S.  £100  each. 


The  Lancet,] 


MEDICAL  DIARY.— NOTES,  SHORT  COMMENTS,  ETC. 


[August  23,  1919  355 


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Hirtfes,  Jltarriaps,  anb  iiatfri 

BIRTHS. 

Gakdneb^-O'1  August  15th  at  Merton  street,  Oxford,  the  wife 
of  A.  Duncan  Gardner,  M.D.,  F.R.C.S.,  of  a son 

'wffeof^e^re^Kejraes^JUD^^fa^on!  Hol!ywood'road-  S-W., 
TAT?aXm0R.lTcVo“^daughterng’  ***  WUe  °f  Captain  G’  T’  P’ 

GUWens,1DhS.0at,  HaDtS’  «“  ">'•  of 

MARRIAGES. 

H^Tf7elAr°V0n£IA^gl'St.12t'h’  at  St-  Andrew's  Church,  Holborn 
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of  the  Rev.  D.  and  Mrs.  Tattoo,  of  Moorlands,  Edgware  “ 

deaths. 

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Marriages , and  Deaths.  * 


Iteitifal  fljkg  for  % asuiitg  Wdt. 

LECTURES,  ADDRESSES,  DEMONSTRATIONS  &e 

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pital Medical  School,  Lond.,  See. 

P?‘  *!•  A.  Shaw-Mackenzie, 
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G-.  Ward,  Sevenoaks  ; Dr.  L.  A 
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A.  C.  Wilson. 


. ’ ■ a.  wiison. 

ddreSsedCaex0cl|fv|‘ln^  Editor  ^IThe ^Lancet" 
423,  Strand,  London,  W.C.  2. 


ijfltes,  j%rt  Comments,  anb  %m\am 
to  Corresjjonbents. 

STAMMERING  AND  VOICE  DEFECTS. 

By  Mabel  V.  o.  Oswald, 

SPEECH  SPECIALIST;  LATE  1ST  SOUTHER*  GENERAL  HOSPITAL 
NEUROLOGICAL  SECTION,  BIRMINGHAM. 

With  a Preliminary  Note  by  Dr.  J.  N.  Robins. 


Dr.  J.  N.  Robins,  lately  in  charge  of  the  Neurological 
Section  at  the  1st  Southern  General  Hospital,  writes  as 
follows  : — 

“ Th®  PaP®r  on  Stammering  and  Voice  Defects,  written  bv 
Miss  Oswald  will  be  appreciated  by  the  members  of  the 
medical  profession  as  it  illustrates  in  a simple  and  comore 
heninve  manner  a line  of  treatment  which  was  found  to 
yield  highly  satisfactory  results.  Miss  Oswald’s  assistance 
in  the  treatment  of  functional  voice  defects  was  of  much 
Xaue’al^®  *0  her  patients  and  to  me  as  officer  in  charge  of 
the  Mony hull  Neurological  Section  of  the  1st  Southern 
General  Hospital.  There  appear  to  be  two  schools  of 
thought  on  the  treatment  of  stammering : (1)  deals  with 
the  psychic  cause  and  leaves  the  symptoms  (stammering 
aphonia,  &c.)  alone;  and  (2)  deals  with  the  symptoms 
(stammering,  &c.),  and  leaves  the  psychic  cause  alone.  Both 
of  these  appear  to  me  to  be  wrong,  for  in  the  first  case  Scylla 
is  avoided  but  the  danger  of  Charybdis  remains,  and  in  the 
second  case  the  reverse  happens.  Therefore,  let  us  take  a 
middle  path  and  deal  by  mental  exploration  with  the  under- 
lying  uniecognised  cause,  and  also  the  symptom  bv  re- 
education ; m this  way  really  good  results  may  be  achieved.” 


Experimental  Treatment. 

Stammering  and  functional  voice  defects  have  until 
““‘  I been  looked  upon  as  unfortunate  disabilities,  and 
no  real  scientific  attempt  was  made  thoroughly  to  deal  with 
such  cases,  and  hence  there  was  no  recognised  cure.  Various 
treatments  have  been  in  vogue,  each  one  more  or  lesl 
experimental.  ess 

The  more  successful  regarded  stammering  as  the  result 
of  some  purely  physical  cause-i.e.,  incorrect  respiration 
spasmodic  contractions  of  the  laryngeal  muscles  Unco- 
ordinated movements  of  the  organs  of  articulation  &c 
Hence  the  treatment  was  directed  to  the  correction  of  these 
physical  disabilities  exclusively.  In  many  cases  the  actual 
speech  defect  was  overcome,  but  as  a rule  the  treatment  was 
a prolonged  one  and  the  cure  by  no  means  permanent  thp- 
speech  defect  (in  varying  degree)  tending  to  reappear.  ’ th 

Tricks  Designed,  to  Overcome  Speech  Defects 

In  some  cases  the  patient  was  taught  to  resort  to  tricks  in 
order  to  overcome  his  difficulty-e.g.,  when  comment  £ 
speak  : (1)  to  pitch  his  voice  on  a note  higher  or  lower  than 
his  natural-speaking  voice;  (2)  to  resort  to  certain  rhythmical 
gestures  to  induce  smooth  speech  ; (3)  to  “sing  ” his  w^rds 
4)  to  press  his  knee  firmly  with  the  right  hand;  (5)  ol  even 
to  hold  a pebble  in  his  mouth  ! ’ ' J even 

Such  methods  of  treatment  obviously  could  not  cure  and 
have  done  much  harm  in  making  the  general  nubhV  dhf. 
trustful  as  to  the  possibility  of  a genuine  cure.  That  such 

™a"s  7®r.e  Att®nled  by  fleetlD§  success  is  probably  due 
to  the  fact  that  the  patient’s  attention  for  the  time  being 
was  diverted  from  his  speech  anxiety  to  the  very  unusual 
method  of  cure,  the  later  being  far  more  inconvenient  as  a 
rule,  than  the  orginal  disability.  . enc’  as  a 

Stammering  Dependent  on  a Psychic  Cause. 

The  frequent  occurrence  of  stammering,  mutism  and 
aphonia  during  the  war,  in  patients  with  no  such  p“e-tar 
history,  has  opened  a field  of  inquiry  which  has  had  con- 
siderable attention  paid  to  it  by  those  medical  officers  who 

ha,veube“  ln  Psycho-therapy.  It  has  now  teen 

established  that  stammering  is  dependent  on  a psychic 
cause,  with  which  it  is  necessary  to  deal  adequately  PHence 
the  original  cause  of  the  speech  defect  is  psychical  the 
stammer  being  the  expression  of  a memory  of  slme  painful 
nature  which  is  either  wholly  or  partially  repressed 
ihe  presence  of  a stammer,  however,  gives  rise  to  thA 
°f,.“  fear  of  speech,’’  and  the  patient  loses  confidence 
in  his  ability  to  speak  before  others.  He  then  trips  tn  in,™ 
himself  to  speak  naturally,  but  this,  as  a rul^  onfy  resulto 
n incorrect  respiration,  spasmodic  contraction  of  toe 
laryngeal  and  other  muscles,  and  incodrdinated  movements 
of  the  organs  of  speech.  By  degrees  these  uncontooltor! 
movements  incorrect  breathing,  Ic„  become  established 

feed  TtoftoenT6  the  Tech  defect  *0  become  mor6’ 
of  the  speech  defect?  SeCOndary  and  not  *he  original  cause 


356  The  Lancet,]  NOTES,  SHORT  COMMENTS,  AND  ANSWERS  TO  CORRESPONDENTS.  [August  23,  1919 


From  regarding  stammering  as  a purely  physical  defect, 
to  be  remedied  solely  by  treating  the  physical  symptom,  at 
the  present  time  there  may  be  a danger  of  going  to  the 
opposite  extreme  and  looking  upon  it  as  a symptom  which 
will  automatically  disappear  when  the  underlying  psychical 
cause  has  been  discovered  and  fully  explained  to  the  patient. 

In  cases  of  mutism  and  aphonia,  however,  the  symptom 
does  tend  to  disappear  automatically.  The  underlying 
psychic  cause  is  discovered  and  brought  into  consciousness, 
and  by  means  of  strong  suggestion  the  patient  is  induced  to 
use  his  voice,  which  invariably  he  is  able  to  do.  At  this 
juncture,  in  order  to  avoid  any  resultant  stammer,  care 
must  be  taken  that  the  patient  produces  his  voice  correctly 
and  has  been  convinced  of  his  ability  to  continue  speech. 
This  is  important,  as  so  many  cases  of  mutism  and  aphonia 
became  stammerers — i.e.,  their  voice  returns,  but  “ anxiety  ” 
as  to  their  ability  to  continue  producing  it  results  in  a 
stammer.  Convince  the  patient,  and  the  anxiety  disappears 
and  there  is  no  resultant  stammer. 

Cases  SuccessJ ully  Treated. 

One  case  of  aphonia— the  result  of  gassing  and  being  buried  by  shell 
— had  persisted  for  nine  months  in  spite  of  various  treatments  (massage, 
electrical  treatment,  &c.)  tried  previously  in  other  hospitals.  I treated 
the  patient  on  the  lines  indicated  above,  and  he  was  cured  in  two  treat- 
ments (of  about  half  an  hour  each)  with  no  resultant  stammer. 

In  another  case  the  patient  lost  his  voice  gradually  and  the  aphonic 
condition  had  persisted  for  nine  months.  I treated  him  similarly  and 
he  was  cured  in  two  treatments  with  no  resultant  stammer. 

Another  case  I treated  had  already  lost  his  voice  twice  as  a result  of 
gassing ; the  first  time  (4/8/16),  he  recovered  his  voice  after  three 
weeks  in  hospital;  the  second  time  (18/9/18)  he  was  gassed  again  and 
aphonia  had  persisted  for  two  months,  when  he  was  sent  to  me.  He 
also  was  cured  with  no  resultant  stammer  ; and  similarly  other  cases. 

But  in  my  experience  with  cases  of  stammering — especially 
those  of  long  standing — tbe  removal  of  the  psychic  cause 
does  not  necessarily  mean  that  the  symptom  (stammering) 
disappears  automatically.  Logically,  this  should  be  so, 
since  stammering  (like  tremors,  monoplegias,  Ac.)  is  the 
outward  expression  of  the  patient’s  subconscious  mental 
state.  In  practice,  however,  the  stammer  tends  to  remain 
even  though  the  repressed  memories  have  been  brought  to 
the  surface  and  rendered  ineffective.  This  is  probably 
explained  by  the  fact  that  an  incorrect  habit  of  breathing 
and  speech  production  has  been  acquired,  which  the  patient 
must  voluntarily  overcome. 

“ Mental  Exploration  ” and  “ Speech  Relief." 

In  the  stammering  cases  I have  treated  the  quickest 
results  have  been  obtained  where  the  patient  has  been 
treated  both  physically  and  psychically — i.e.,  by  giving  him 
certain  respiratory  and  voice  exercises  together  with  strong 
suggestion,  at  the  same  time  the  psychic  cause  being 
removed  by  means  of  “ mental  exploration,” — and  this  latter 
can  only  be  successfully  accomplished  by  those  with  know- 
ledge of  psychological  medicine.  In  order  to  effect  a cure, 
therefore,  it  is  obviously  necessary  to  discover  the  original 
psychic  cause  of  the  stammer. 

Hence  the  method  of  procedure  would  be,  first,  to 
explain  fully  to  the  patient  why  he  stammers;  next,  and 
especially  in  cases  of  severe  stammer,  to  give  the  patient 
“speech  relief”  by  showing  him  howto  breathe  correctly, 
relax  his  muscles,  Ac.,  at  the  same  time  using  strong 
suggestion  that  he  will  be  able  to  read  or  sav  a certain 
thing  correctly  and  not  permitting  him  to  fail.  The  patient 
having  obtained  an  initial  success  must  be  convinced  that 
he  is  able  to  repeat  it,  and  so  led  to  perceive  that  the  cure 
in  reality  depends  upon  himself.  By  these  means  of 
re-education  the  patient  will  have  gained  confidence  and 
lost  to  some  extent  “ the  fear  of  his  own  speech,”  but  a per- 
manent cure  will  not  be  effected  till  the  psychic  cause  has 
been  explored. 

Examples  of  Treatment. 

The  following  are  a few  practical  examples  of  the  above 
method  of  treatment.  In  each  case  the  psychic  cause  was 
being  specially  dealt  with  by  neurological  medical  officers: — 

I had  a patient  with  a very  severe  stammer  dating  from  September, 
1918,  when  he  had  been  blown  up  by  a shell  and  left  dazed.  He  was 
being  treated  by  one  of  the  neurological  medical  officers  who  sent  him 
to  me  for  his  stammer.  I gave  him  certain  breathing  and  voice 
exercises,  which  enabled  him  at  once  to  speak  with  less  difficulty. 
By  means  of  strong  suggestion  he  was  able  to  read  al  ud  without 
stammering.  I explained  things  to  him  and  convinced  him  that, 
having  done  so  once,  lie  could  repeat  it,  and  that  the  cure  now 
depended  on  himself.  He  determined  hecould  and  would  be  successful. 
1 saw  him  once  again  (making  two  treatments  in  all),  when  he  was  able 
to  read  aloud  and  speak  with  no  difficulty  and  continued  to  do  so. 

Another  patient  had  a nervous  hesitating  stammer  when  I saw  him. 
He  had  been  blown  up  and  four  months  later  had  lost  his  voice. 
Aphonia  had  persisted  for  seven  months,  when  his  voice  returned 
under  treatment,  leaving,  however,  this  stammer.  He  was  sent  to  me 
for  treatment.  In  this  case  I chiefly  used  strong  suggestion  to  convince 
him  of  his  ability  to  speak  with  uo  stammer.  He  was  cured  in  two 
treatments. 

Another  patient  with  a stammer  of  three  months'  duration— after 
aphonia  of  eight  months— was  convinced  that  he  could  not  be  cured. 


He  stammered  badly  while  reading  and  speaking.  I explained  things 
to  him  and  gave  him  certain  breathing  and  voice  exercises,  showing 
him  how  to  control  his  breath  while  reading.  I then  made  him  read 
aloud  which,  after  a few  attempts,  he  did  with  no  stammer.  When  I 
saw  him  the  second  time,  he  said  the  stammer  now  only  affected  him  if 
nervous.  I again  explained  the  nature  of  his  stammer  and  by  strong 
suggestion  convinced  him  he  could  overcome  it.  After  four  treatments 
he  could  read  and  speak  fluently  on  all  occasions. 

Pre-War  Stammerers. 

Similar  treatment  will  be  found  to  apply  to  pre-war 
stammerers.  In  these  cases  tbe  habit  of  incorrect  speech 
production  is  more  strongly  fixed  and,  therefore,  will  take 
rather  longer  to  remove,  but  the  permanency  of  the  cure 
will  depend  (as  in  cases  of  war  neuroses)  on  the  removal  of 
the  psychic  cause  which  originated  the  stammer. 

One  patient  I treated,  who  had  stammered  very  severely  since 
experiencing  a bad  fright  in  early  manhood  (in  civil  life).  He  joined 
up  and  out  of  two  years’  foreign  service  had  spent  111  months  off 
and  on  in  hospital.  While  recounting  the  bad  fright  experienced  years 
ago.  tbe  stammer  became  extremely  severe,  at  times  totally  inhibiting 
speech,  accompanied  by  tremors,  &c.  His  respiration  was  incorrect, 
with  spasms  of  the  diaphragm.  I explained  to  him  why  he  stammered, 
and  gave  him  special  breathing  and  voice  exercises,  showing  him  how 
to  relax  his  muscles.  I then  made  him  read  aloud,  which  he  did  fairly. 
At  subsequent  interviews  the  stammer  and  tremors  were  much  less 
marked,  till  the  patient  was  able  to  talk  over  his  experience  with 
absolute  calm  and  no  attendant  stammer.  He  had  eight  treatments 
altogether,  after  which  he  could  speak  and  read  aloud  fluently  on  all 
occasions. 

Another  patient  had  stammered  slightly  since  six  years  of  age,  the 
stammer  increasing  alter  experiencing  air-raids.  When  I saw  him  tbe 
stammer  was  very  severe,  his  breathing  incorrect  and  uncontrolled, 
accompanied  by  strong  muscular  contraction  of  the  laryngeal  and  other 
muscles  during  speech.  I explained  his  stammer  lo  him.  showed  him 
how  to  breathe  diaphragmatically  and  to  relax  his  muscles,  and  in  ten 
treatments  he  wasspeakingand  reading  aloud  with  no  stammer. 

Stammering  in  Young  Children. 

In  cases  of  purely  imitative  stammer  in  young  children 
who  are  treated  immediately,  breathing  and  voice  exercises 
with  strong  suggestion  are  sufficient  to  effect  a rapid  and 
permanent  cure,  probing  into  their  subconsciousness  beiDg 
unnecessary. 

A boy  of  7,  whom  I treated,  had  a severe  stammer.  He  was  highly 
excitable,  with  little  self-control.  Though'well-built,  be  had  very  poor 
respiratory  expansion.  By  teaching  him  correct  diaphragmatic  breath- 
ing. giving  him  easy  voice  exercises,  explaining  his  “ fear  of  speech," 
using  strong  suggestion  to  give  him  confidence,  and  training  him  in 
self-control,  he  was  soon  absolutely  cured.  I had  him  under  my  direct 
observe  ion  all  the  time,  this  being  advisable  in  young  children,  but 
not  necessary,  if  older,  where  the  patient  will  carry  out  instructions. 

I would  lay  stress  on  the  importance  of  at  once  treating  a 
stammer  jn  young  children,  since,  if  taken  at  an  early  stage, 
the  cure  is  certain.  Most  of  the  adult  stammerers  in  civil 
life  might  have  been  cured  when  young.  Thus  it  seems 
apparent,  in  the  case  of  adults,  that  to  treat  the  symptom 
alone,  ignoring  the  repressed  memory  or,  conversely,  to 
revive  the  repressed  memory  ignoring  the  symptom  is,  in 
either  case,  insufficient.  The  quickest  and  most  permanent 
results  being  obtained  by  a combination  of  the  two — i.e., 
“ mental  exploration  ” and  re-education. 


WELFARE  OF  THE  BLIND. 

The  Ministry  of  Health  announce  that  they  have,  after 
consultation  with  the  Advisory  Committee  on'  the  Welfare 
of  the  Blind,  issued  Regulations  under  which,  subject  to  the 
consent  of  Parliament,  grants  will  be  paid  in  aid  of  certain 
services  carried  on  on  behalf  of  the  blind.  These  services 
include  workshops,  assistance  to  home-workers,  home 
teaching,  homes  and  hostels,  book  production,  Ac.  In  a 
covering  letter  to  the  regulations  the  needs  of  the  un- 
employable blind  living  in  their  own  homes  are  recognised 
as  requiring  legislative  treatment,  and  it  is  indicated  that 
proposals  will  be  laid  before  Parliament  as  early  as  possible. 
The  regulations  have  been  put  on  sale  (price  3d.)  and  can  be 
obtained  directly  from  the  Stationery  Office  or  through  any 
bookseller. 

VIVISECTION  EXPERIMENTS. 

A return  issued  by  the  Home  Office  shows  the  nnmber 
of  experiments  on  living  animals  during  1918  in  the  United 
Kingdom.  In  England  and  Scotland  licences  were  held  by 
701  persons,  of  whom  401  performed  no  experiments.  In 
Ireland  there  were  22  licensees,  of  whom  6 performed  no 
experiments.  In  England  and  Scotland  the  total  number 
of  experiments  was  77,610;  under  Group  A 1557,  and  under 
Group  B 76.053.  In  Group  A anaesthesia  was  required— 951 
all  the  time  and  606  part  of  the  time.  In  Group  S no  anses- 
thetic  was  required.  They  were  simple  inoculations,  hypo- 
dermic injections,  feeding,  and  similar  proceedings.  Cancer 
investigation  accounted  for  137  in  Group  A and  5890  in 
Group  B;  29,000  were  on  behalf  of  Government  Departments 
and  public  health  authorities,  and  over  37,000  for  tbe  pre- 
paration, standardising,  and  testing  of  sera,  vaccines,  and 
drugs.  In  Ireland  313  experiments  were  performed  by  16 
licensees,  of  which  232  were  simple  inoculations. 


THE  LANCET,  August  30,  1919 


GENERAL  COUNCIL  OF  MEDICAL  EDUCA- 
TION AND  REGISTRATION  OF  THE 
UNITED  KINGDOM. 


Powers,  Duties,  and  Constitution  of  the  General 
Medical  Council. 

The  powers  and  duties  of  the  General  Medical  Council,  or 
“General  Council  of  Medical  Education  and  Registration  of 
the  United  Kingdom  ” to  give  the  Council  its  full  title,  have 
been  set  out  in  detail  in  many  previous  Students’  Numbers  of 
The  Lancet.  It  is  first  a registering  body  : no  person,  even 
though  his  qualifications  have  been  obtained,  is  a legally 
qualified  medical  practitioner  unless  his  name  appears  on  the 
Medical  Register.  Secondly,  it  is  a standardising  body, 
ensuring  that  the  education  of  medical  men  is  kept  up  to  an 
efficient  standard  by  scientific  examination.  Thirdly,  it  is  a 
penal  and  disciplinary  body,  having  power  to  remove  from 
the  Register  any  practitioner  adjudged  guilty  of  conduct 
“ infamous  in  a professional  respect.”  Fourthly,  to  the 
Council  is  committed  the  codification  of  pharmaceutical 
remedies. 

The  duties  of  the  Council  are  thus  primarily  of  a public 
nature,  and  its  construction  shows  its  fitness  for  its  fourfold 
responsibilities. 

The  Council  at  present  consists  of  38  members,  of  whom, 
as  will  be  seen  by  the  annexed  list,  all  but  11  are  official 
representatives  of  some  corporate  body.  Five  members 
are  chosen  by  the  Crown  on  the  advice  of  the  Privy  Council, 
and  six  others  are  elected  by  the  members  of  the  medical 
profession  as  Direct  Representatives. 

President  of  the  General  Council  : Sir  Donald  MacAlister. 
Members  of  the  General  Council:  Sir  Norman  Moore,  chosen 
by  the  Royal  College  of  Physicians  of  London  ; Mr.  Holburt 
Jacob  Waring,  Royal  College  of  Surgeons  of  England  ; 
Dr.  Benjamin  Bloomfield  Connolly,  Apothecaries’  Society  of 
London ; Dr.  Arthur  Thomson,  University  of  Oxford ; 
Professor  Frederick  Gowland  Hopkins,  University  of  Cam- 
bridge ; Dr.  Robert  Howden,  University  of  Durham ; Dr. 
Sydney  Russell  Wells,  University  of  London  ; Dr.  Grafton 
Elliot  Smith,  Victoria  University  of  Manchester  ; Sir  Harry 
Gilbert  Barling,  University  of  Birmingham  ; Dr.  Richard 
Caton,  University  of  Liverpool  ; Dr.  Thomas  Wardrop 
Griffith,  University  of  Leeds;  Mr.  Rutherfoord  John  Pye- 
Smith,  University  of  Sheffield  ; Sir  Isambard  Owen,  Uni- 
versity of  Bristol ; and  Dr.  David  Hepburn,  University  of 
Wales.  Dr.  William  Russell,  chosen  by  the  Royal  College  of 
Physicians  of  Edinburgh ; Mr.  James  William  Beeman 
Hodsdon,  Royal  College  of  Surgeons  of  Edinburgh  ; Dr.  David 
Neilson  Knox,  Royal  Faculty  of  Physicians  and  Surgeons  of 
Glasgow  ; Dr.  H.  Harvey  Littlejohn,  University  of  Edin- 
burgh ; Sir  Donald  MacAlister,  University  of  Glasgow  ; Dr. 
Matthew  Hay,  University  of  Aberdeen  ; and  Dr.  John  Yule 
Mackay,  University  of  St.  Andrews.  Sir  John  William 
Moore,  chosen  by  the  Royal  College  of  Physicians  of  Ireland  ; 
Sir  Arthur  Gerald  Chance,  Royal  College  of  Surgeons  in 
Ireland ; Dr.  Edward  Magennis,  Apothecaries’  Hall  of 
Ireland;  Dr.  Arthur  Francis  Dixon,  University  of  Dublin; 
Sir  Bertram  Coghill  Alan  Windle,  National  University 
of  Ireland  ; and  Dr.  Thomas  Sinclair,  Queen’s  University 
of  Belfast.  Nominated  by  His  Majesty,  with  the  advice  of 
his  Privy  Council : Sir  Charles  Sissmore  Tomes,  Sir  Arthur 
Newsholme,  Sir  Francis  Henry  Champneys,  Dr.  John  Christie 
McVail,  and  Dr.  Edward  Coey  Bigger.  Elected  as  Direct 
Representatives  : Dr.  Langley  Browne,  Dr.  H.  A.  Latimer,  Dr. 
J.  A.  MacDonald,  Mr.  Thomas  Jenner  Verrall,  Dr.  Norman 
Walker,  and  Dr.  Leonard  Kidd.  Treasurers  of  the  General 
Council  : Sir  Charles  Sissmore  Tomes  and  Sir  Norman 
Moore. 

The  Educational  Curriculum. 

Professional  Education. — The  course  of  professional  study 
after  registration  occupies  at  least  five  years.  The  Final 
Examination  in  Medicine,  Surgery,  and  Midwifery  must  not 
be  passed  before  the  close  of  the  fifth  academic  year  of 
medical  study. 

Registration  and  Preliminary  Examination  of  Medical 
Students. — The  following  are  the  General  Medical  Council’s 
Regulations  in  reference  to  the  registration  of  students  in 
medicine. 

Every  medical  student  should  be  registered  in  the  manner 
prescribed  by  the  General  Medical  Council.  The  registration 

No.  5009.' 


of  medical  students  is  placed  under  the  charge  of  the 
Branch  Registrars.  Every  person  desirous  of  being  registered 
as  a medical  student  should  apply  to  the  Branch  Registrar  of 
the  division  of  the  United  Kingdom  in  which  he  is  residing  ; 
and  should  produce  or  forward  to  the  Branch  Registrar  a 
certificate  of  his  having  passed  a preliminary  examination  as 
required  by  the  General  Medical  Council,  and  evidence  that 
he  has  attained  the  age  of  16  years,  and  has  commenced 
medical  study  at  an  institution  approved  by  the  Council. 
The  Branch  Registrar  shall  enter  the  applicant’s  name 
and  other  particulars  in  the  Students’  Register  and  shall 
give  him  a certificate  of  such  registration.  Each  of 
the  Branch  Registrars  shall  supply  to  the  several  licensing 
bodies,  medical  schools,  and  hospitals,  in  that  part  of  the 
United  Kingdom  of  which  he  is  registrar,  a sufficient  number 
of  blank  forms  of  application  for  the  registration  of  medical 
students.  The  commencement  of  the  course  of  professional 
study  recognised  by  any  of  the  qualifying  bodies  should  not 
be  reckoned  as  dating  earlier  than  15  days  before  the 
date  of  registration.  In  addition  to  the  universities  and 
schools  of  medicine  there  are  many  institutions  where 
medical  study  may  be  commenced.  Applications  for 
special  exceptions  are  dealt  with  by  the  Students’ 
Registration  Committee,  which  reports  all  such  cases  to 
the  Council. 

Regulations  for  the  Maintenance  of  the  Register  of  Medical 
Students. 

The  following  examinations  have  been  approved  by  the 
Council  : — (a)  The  final  examinations  for  the  degrees  in 
Arts  and  Science  of  any  University  of  the  United  Kingdom 
or  of  the  British  Dominions,  (b)  All  examinations  which 
are  accepted  for  Matriculation  in  the  Faculties  of  Arts  and 
Science  in  any  one  University  of  Great  Britain,  provided  the 
pass-certificate  includes  English,  Mathematics,  and  at  least 
two  other  subjects  named  in  the  following  list : —Latin,  Greek, 
Hebrew,  Arabic,  Persian  ; French,  German,  Spanish,  Italian, 
Russian,  or  any  approved  modern  language  ; History,  Geo- 
graphy, Natural  Philosophy  or  Physics,  Chemistry,  Biology, 
Phjsical  Geography,  and  Geology,  (c)  All  examinations  not 
included  under  the  foregoing  section  (S),  which  are  accepted 
for  Matriculation  in  the  Faculty  of  Medicine  in  any  one  Uni- 
versity of  the  United  Kingdom  of  Great  Britain  and  Ireland 
provided  the  examination  is  completed  at  not  more  than 
two  periods  of  examination,  and  that  the  pass-certificate 
includes  English,  Mathematics,  Latin  (or  Greek  or  Hebrew), 
and  at  least  one  other  subject  named  in  the  follow- 
ing list  : — Latin,  Greek,  Hebrew,  Arabic,  Persian,  French, 
German,  Spanish,  Italian,  Russian,  or  any  approved  modern 
language.  (rf)  The  Council  may  grant  special  recognition 
to  the  following  examinations  not  included  under  the 
foregoing  sections  ( a ),  (b),  and  (o)  : — (1)  The  final  examina- 
tions for  the  degrees  in  Arts  and  Science  of  any  specially 
recognised  Foreign  University.  (2)  Examinations  conducted 
by  approved  Examining  Bodies  within  the  United  Kingdom 
under  the  provisions  set  forth  in  the  foregoing  section  (c). 
(3)  Examinations  conducted  by  approved  Examining  Bodies 
out  of  the  United  Kingdom  under  the  provisions  set  forth  in 
the  foregoing  section  (<?),  and  under  such  other  conditions  as 
the  Council  may  impose  in  each  case. 

List  of  Bodies  whose  Examinations  are  accepted  under  the 
Foregoing  Regulations. 

I.  Examinations  in  Great  Britain. 

(1)  The  Matriculation  Examinations  in  the  Faculties  of 
Arts  and  Science  of,  and  all  examinations  accepted  in  lieu 
thereof  by,  the  following  Universities  : Oxford  (including 
Responsions  and  Moderations),  Cambridge  (including  the 
Previous  Examination  and  the  General  Examination), 
Durham,  London,  Manchester,  Birmingham,  Liverpool, 
Leeds,  Sheffield,  Bristol,  Wales,  Edinburgh,  Glasgow, 
Aberdeen,  St.  Andrews.  These  examinations  are  accepted 
subject  to  the  conditions  set  foith  under  Section  2 ( [b ) above. 
(2)  • he  Preliminary  Examinations  in  the  Faculty  of  Medicine 
of,  and  all  examinations  accepted  in  lieu  thereof  by,  the 
Universities  of  Durham,  Edinburgh,  Glasgow,  Aberdeen, 
St.  Andrews.  These  examinations  are  accepted  subject  to 
the  conditions  of  Section  2 (c)  above.  (3)  Specially  recognised 
Examinations  conducted  by  approved  bodies. 

The  following  Schools  Examinations  have  been  recog- 
nised by  the  English  Board  of  Education  and  are  accepted 
by  the  General  Medical  Council  under  the  conditions  noted 
below. 


35 s The  Lancet,] 


UNIVERSITY  OF  OXFORD. 


[August  30,  1919 


As  First  Examinations. 

1.  The  School  Certificate  Examination  of  the  Oxford  and  Cambridge 
Schools  Examination  Board. 

2.  The  Senior  Local  Examination"  of  the  Oxford  Delegacy  for  Local 
Examinations. 

3.  The  Senior  Local  Examination  of  the  Cambridge  Local  Examina- 
tions and  Lectures  Syndicate. 

4.  The  School  Certificate  Examination  of  the  University  of  Bristol. 

5.  The  First  School  Certificate  Examination  of  the  University  of 
Durham . 

6.  The  General  School  Examination  of  the  University  of  London. 

7.  The  School  Certificate  Examination  of  the  Northern  Universities 
Joint  Matriculation  Board. 

As  Second  Examinations. 

8.  The  Higher  Certificate  Examination  of  the  Oxford  and  Cambridge 
Schools  Examination  Board. 

9.  The  Higher  School  Certificate  Examination  of  the  Oxford  Delegacy 
for  Local  Examinations. 

10.  Tne  Higher  School  Certificate  Examination  of  the  Cambridge 
Local  Examinations  and  Lectures  Syndicate. 

(a)  11.  The  Higher  School  Certificate  Examination  of  the  University 
of  Bristol. 

12.  The  Higher  Certificate  Examination  of  the  University  of  Durham. 

(a)  13.  The  Higher  School  Certificate  Examination  of  the  University 
of  London. 

14.  The  Higher  Certificate  Examination  of  the  Northern  Universities 
Joint  Matriculation  Bo^rd. 

(a)  These  Examinations  will  be  held  for  the  first  time  in  1919. 

In  the  First  Examinations:  School  Certificates (“  passes  with  credit") 
and  in  the  Second  Examinations:  Higher  Certificates,  provide  t in  both 
instances  that  they  fulfil  the  conditions  required  for  Matricu'ation  in 
the  Faculties  of  Arts  or  Pure  Science  in  any  University  of  Great 
Britain,  are  accepted  by  the  General  Medical  Council  under  Clause  2 (6) ; 
otherwise  they  are  accepted  under  Clause  2 (c),  provided  that 
evidence  is  afforded  that  all  the  subjects  required  by  the  Council  have 
been  actually  passed  on  an  approved  standard.  ( Applicants  are  advised 
to  apply  to  the  Examining  Bodies  for  the  necessary  evidence.) 

Other  Certificates  accepted  under  Clause  2 (b).  Scottish  Education 
Department : Leaving  Certificates. 

Other  certificates  accepted  under  Clause  2 (c).  Intermediate  Certifi- 
cate. Central  Welsh  Board  : Senior  Certificate.  University  of 
St.  Andrews:  Final  Examination  for  Diploma  of  L.L.A.  College  of 
Preceptors:  Senior  Certifina'e;  Preliminary  Examination  for  Medical 
Students  Certificate.  Educational  Institute  of  Scotland  : Preliminary 
Medical  Examination  Certificate. 

II.  Irish  Examinations. 

University  of  Dublin:  Matriculation  Examination  : (a)  Junior  Fresh- 
man Term  Examination  (exclusive  of  Trigonometry);  (6)  Special  Pre- 
liminary Examination  to  be  held  in  March,  the  standard  and  subjects  of 
which  shall  be  those  of  a Junior  Freshman  Examination  (exclusive  of 
Trigonometry) ; (c)  Junior  Exhibition  Examination  on  obtaining  marks 
of  sufficient  merit  in  the  subjects  of  (a)  or  (!>);  (d)  Examinations  for 
the  First,  Second,  Third,  or  Fourth  Year  in  Arts.  (Certificate  to  be 
signed  in  the  approved  form  by  the  Medical  Registrar  of  the  Univer- 
sity.) Queen’s  University  of  Belfast:  Matriculation  Examination. 
National  University  of  Ireland:  Matriculation  Examination.  Inter- 
mediate Education  Board  of  Ireland  : Middle  Grade  Examination,  with 
Honours  in  three  subjects  ; Senior  Grade  Examination.  Royal  Colleges 
of  Physicians  and  Surgeons  in  Ireland : Preliminary  Examination. 
These  Examinations  are  accepted  subject  to  the  conditions  set  forth  in 
Section  2 (c)  above. 

The  remainder  of  the  curriculum,  though  all  under 
the  supervision  of  the  Council,  is  in  detail  in  the 
hands  of  the  various  degree-  and  diploma-granting  bodies 
whose  representatives  are  members  of  the  General 
Medical  Council.  In  the  next  pages  we  give  the 
regulations  of  the  various  examining  bodies,  but  it  must 
always  be  remembered  that  the  examinations  are  under 
the  supervision  of  the  General  Medical  Council,  who 
visit  the  various  centres  in  turn  and  closely  inspect  the 
procedure. 

III.  Examinations  Held  Out  of  the  United  Kingdom 

Every  Certificate  from  Indian,  Colonial,  and  Foreign 
Universities  and  Colleges  must  contain  evidence  that  the 
Examination  has  been  conducted  by  or  under  the  authority 
of  the  Body  granting  it,  must  include  all  the  subjects  required 
by  the  General  Medical  Council,  and  must  state  that  all  the 
subjects  of  Examination  have  been  passed  in  at  not  more 
than  two  examinations  ; copies  of  the  form  of  the  required 
Certificate  are  supplied  by  the  Registrar  of  the  Council  for 
the  purpose.  In  the  case  of  Natives  of  India  or  other 
Oriental  countries  whose  vernacular  is  other  than  English 
an  Examination  in  a Classical  Oriental  Language  (e.g., 
Sanskrit,  Arabic,  Chinese)  may  be  accepted  instead  of 
an  Examination  in  Latin.  The  German  Abiturienten- 

Examen  of  the  Gymnasia  and  Real-Schulen  and  the 
examinations  entitling  to  the  French  diplomas  of 
Bachelier  es  Lettres  and  Bachelier  6s  Sciences  and 
other  corresponding  Entrance  Examinations  to  the  Uni- 
versities in  Europe  are  recognised  by  the  General  Medical 
Council. 

These  examinations  are  accepted  subject  to  the  conditions 
set  forth  in  Section  2 (c)  above. 

Further  particulars  are  given  in  the  Students’  Regulations, 
which  can  be  obtained  at  the  offices  of  the  Council,  price  9 d. 


The  Registration  of  Medical  Practitioners. 

Under  the  provisions  of  the  Medical  Act,  1858,  any  person 
possessing  one  or  other  of  the  medical  qualifications 
enumerated  in  the  schedule  to  the  Act  is  entitled  to  regis- 
tration by  the  General  Medical  Council  on  producing  to  the 
registrar  of  a Branch  Council  proper  evidence  of  qualification. 
Registration  entitles  him,  in  the  words  of  the  Act  of  1886: — 

"• To  practice  medicine,  surgery,  and  midwifery  in  the  United 

Kingdom,  and  (subject,  to  any  local  law)  in  any  other  part  of  [Her] 
Majesty  's  dominions,  and  to  recover  in  due  course  of  law  in  respect  of 
such  practice  any  expenses,  charges  in  respect  of  medicaments  or  other 

aopllances,  or  any  fees  to  which  he  may  be  entitled ” 

These  qualifications  are  enumerated  in  the  Medical  Register, 
printed  each  year  under  the  direction  of  the  Council,  and  the 
course  of  study  necessary  to  obtain  each  of  them  is  duly  set 
out  in  the  succeeding  pages. 

A number  of  diplomas  granted  in  British  possessions  and 
in  certain  foreign  countries  entitle  the  holder  to  registration 
in  the  colonial  or  foreign  list  respectively  of  the  Medical 
Register,  and  therefore  to  practise  medicine  within  the 
borders  of  the  United  Kingdom.  Some  account  of  these 
diplomas  is  given  on  p.  373  and  following  pages. 

The  Officers  of  the  Coxmcil. 

Norman  C.  King,  Registrar  of  the  General  Council 
and  of  the  Branch  Council  for  England,  44,  Hallam-street, 
Portland-place,  W.  1. — James  Robertson,  Registrar  of  the 
Branch  Council  for  Scotland.  54,  George-square,  Edinburgh. 
— Richard  J.  E.  Roe,  Registrar  of  the  Branch  Council  for 
Ireland,  35,  Dawson-street,  Dublin.  All  communications 
should  be  addressed  to  “The  Registrar”  and  not  by  name. 

Postponement  of  the  Election  of  Direct 
Representatives. 

By  an  Order  in  Council  dated  August  14th  the  provisions 
of  the  Parliament  and  Local  Elections  Act,  1918,  have  been 
extended  to  the  election  of  members  of  this  Council  by 
registered  practitioners  resident  in  the  United  Kingdom,  the 
effect  of  which  is  to  extend  the  term  of  office  of  the  existing 
Direct  Representatives  until  Dec.  31st,  1919. 


THE 

MEDICAL  EXAMINING  BODIES 

AND 

SCHOOLS  OF  THE  UNITED  KINGDOM. 

A Guide  to  the  Facilities  for  Obtaining  the  Various 
Medical  Degrees  and  Other  Qualifications 
for  the  British  Medical  Register. 

I.— ENGLAND  AND  WALES. 

THE  UNIVERSITIES. 

UNIVERSITY  OF  OXFORD. 

There  are  two  degrees  in  Medicine,  B.M.  and  D.M., 
two  degrees  in  Surgery,  B.  Ch.  and  M.  Ch.,  and  two  diplomas, 
Public  Health  and  Ophthalmology . 

Graduates  in  Arts  (B.A.  or  M.A.)  are  alone  eligible  for 
the  degrees.  The  most  convenient  course  for  the  B.A. 
degree  for  intending  graduates  in  Medicine  is  to  take 
Responsions,  the  Preliminary  Science  Examinations  men- 
tioned below,  and  the  Final  Honour  School  of  Physiology.  I 
In  order  to  obtain  the  degrees  of  B.M.  and  B.Ch.  the  | 
following  examinations  must  be  passed  : — 1.  Preliminary 
subjects:  Mechanics  and  Physics,  Chemistry,  Zoology,  and 
Botany.  2.  Professional,  (a)  First  Examination : Subjects — I 
Organic  Chemistry,  unless  the  candidate  has  obtained  a first 
or  second  class  in  Chemistry  in  the  Natural  Science  School ; 
Human  Physiology,  unless  he  has  obtained  a first  or  second 
class  in  Animal  Physiology  in  the  Natural  Science  School ; 
Human  Anatomy.  ( b ) Second  Examination  : Subjects — 
Medicine,  Surgery,  Midwifery,  Pathology,  Forensic  Medicine 
with  Hygiene,  Materia  Medica  and  Pharmacology.  The 
approximate  dates  of  the  examinations  are  as  follows  : — Pre- 
liminaries— Zoology,  Botany,  and  Chemistry,  December  and 
June ; Mechanics  and  Physics,  March  and  June ; Profes- 
sional (First  and  Second  B.M.),  June  and  December. 

The  Hr st  Examination  for  the  degrees  of  B.M.  and  B.Ch. 
may  be  passed  as  soon  as  the  Preliminary  Scientific  Exami- 
nations have  been  completed.  Anatomy  and  Physiology  are 
to  be  passed  together,  and  Organic  Chemistry  may  be  taken 
before  or  after  these  have  been  passed. 


The  Lancet,] 


UNIVERSITY  OF  CAMBRIDGE. 


[August  30,  1919  359 


The  Second  Examination  may  be  passed  after  the  com- 
pletion of  the  first,  but  Pathology,  Hygiene,  and  Materia 
Medica  and  Pharmacology  may  be  taken  before  or  with 
the  remaining  subjects.  Before  admission  to  the  Second 
Examination  candidates  must  present  certificates  of  attend- 
ance on  a course  of  laboratory  instruction  in  Practical 
Pathology  and  Bacteriology  and  of  having  acted  as  post- 
mortem clerk  for  three  months,  surgical  dresser  for  six 
months,  and  clinical  clerk  for  six  months.  Also  they  must 
produce  certificates  of  instruction  in  Infectious  and  Mental 
Diseases,  and  of  attendance  on  Labours,  of  proficiency  in 
the  practice  of  Vaccination  and  Anaesthetics,  and  of  having 
attended  a course  of  Practical  Pharmacology.  Also  in 
respect  of  the  First  Examination  candidates  must  present 
certificates  showing  that  they  have  dissected  the  whole 
body  once  and  have  attended  courses  of  laboratory  instruc- 
tion in  Practical  Histology  and  Practical  Physiology. 

The  degree  of  D.  M.  is  granted  to  Bachelors  of  Medicine  of 
the  University  provided  they  have  entered  their  thirtieth 
term  and  have  composed  on  some  medical  subject  a disserta- 
tion which  is  approved  by  the  professors  in  the  Faculty  of 
Medicine  and  examiners  for  the  degree  of  B.M.  whose 
subject  is  dealt  with.  The  degree  of  M.Ch.  is  granted  to 
Bachelors  of  Surgery  of  the  University  who  have  entered  their 
twenty-first  term,  who  are  members  of  the  surgical  staff  of  a 
recognised  hospital,  or  have  acted  as  Dresser  or  House  Surgeon 
in  such  a hospital  for  six  months,  and  who  have  passed  the 
M.Ch.  examination  in  Surgery,  Surgical  Anatomy,  and 
Surgical  Operations.  This  examination  is  held  annually,  in 
June,  at  the  end  of  the  Second  B.M.  Examination. 

Diploma  in  Ophthalmology. — The  examination  is  held  in 
July. 

Diploma  in  Public-  Health. — Examinations  in  June  and 
November. 

Travelling  Fellowship,  Scholarships,  and  Prizes.  — A 
Radcliffe  Travelling  Fellowship  is  awarded  annually  after 
an  examination  held  in  February.  It  is  tenable  for 
three  years  and  is  of  the  annual  value  of  £200.  The 
examination  is  in  Physiology,  Pathology,  and  Hygiene, 
and  is  partly  “practical.”  Candidates  must  be  graduates 
in  Medicine  of  the  University.  The  holder  must  travel 
abroad  for  the  purpose  of  medical  study.  Application 
should  be  made  to  the  Radcliffe  Examiners,  Radcliffe 
Library,  University  Museum.  A Rolleston  Memorial  Prize  is 
awarded  once  in  two  years  to  members  of  the  Universities 
of  Oxford  and  Cambridge  of  not  more  than  ten  years’  stand- 
ing for  an  original  research  in  some  Biological  subject, 
including  Physiology  or  Pathology.  The  Radcliffe  Prize, 
founded  by  University  College  (1907),  is  of  the  value  of 
£50  and  is  awarded  biennially  for  research  in  some  branch 
of  medical  science.  The  Theodore  Williams  Scholarships 
of  the  value  of  £50  each  are  awarded  annually  in  the 
subjects  of  Anatomy,  Physiology,  and  Pathology.  A King’s 
College  Hospital  Burney  Yeo  Scholarship  of  £80  is  awarded 
each  year.  The  Scholarships  in  Science  which  are  offered 
by  several  Colleges  are  open  to  those  who  intend  to  pursue 
Medicine.  The  value  of  these  scholarships  is  usually  £80  a 
year  for  four  years. 

In  addition  to  the  University  lectures  and  classes  the 
several  Colleges  provide  their  undergraduates  with  tuition 
for  all  examinations  up  to  the  B.A.  degree. 

In  the  Radcliffe  Infirmary  and  County  Hospital  clinical 
instruction  is  given  by  the  Regius  Professor  of  Medicine,  the 
Litchfield  Lecturers  in  Medicine  and  Surgery,  and  the  other 
physicians  and  surgeons.  Instruction  is  also  given  in  post- 
mortem work  and  Clinical  Pathology  in  connexion  with  the 
courses  in  Pathology. 

More  detailed  information  may  be  obtained  from  the 
University  Calendar  ; from  the  Examination  Statutes,  1918 
(both  of  which  are  published  by  the  Clarendon  Press)  ; 
from  the  Regius  Professor  of  Medicine  ; and  from  the 
Professors  in  the  several  departments  of  medical  science. 
Certain  special  conditions  as  regards  students  wbo  have  been 
engaged  on  war  service  may  be  obtained  on  application  to 
the  Assistant  Registrar  of  the  University,  Clarendon  Build- 
ing, Oxford.  


University  of  Oxford  : Radcliffe  Infirmary  and 
County  Hospital. — Courses  of  instruction  are  given  in 
connexion  with  the  Oxford  University  Medical  School.  These 
include  (1)  a course  in  Practical  Medicine  by  the  Regius  Pro- 
fessor of  Medicine  ; (2)  Clinical  lectures  by  the  Litchfield  Lec- 


turers in  Medicine  and  Surgery  ; and  (3)  tutorial  instruction 
and  demonstrations  in  special  Regional  Anatomy  (medical 
and  surgical),  methods  of  Medical  and  Surgical  Diagnosis, 
and  Surgical  Manipulation.  (4)  Pathological  demonstrations 
and  instruction  in  post-mortem  work  are  given  by  the 
Assistant  Pathologist.  Practical  Pharmacy  is  taught  in 
the  Radcliffe  Dispensary.  Opportunities  are  offered  to 
students  who  wish  to  act  as  surgical  dressers  and  clerks. 
The  Hospital  contains  170  beds. 


UNIVERSITY  OF  CAMBRIDGE. 

The  student  must  enter  at  one  of  the  Colleges,  or  as 
a non-collegiate  student,  and  keep  nine  terms  (three 
years)  by  residence  in  the  University.  He  must  pass 
the  Previous  Examination  in  Classics,  Mathematics, 
& c.,  if  possible,  before  he  comes  into  residence  in 
October,  or  he  may  obtain  exemption  through  the  Oxford 
and  Cambridge  Schools  Examination  Board,  the  Oxford 
or  Cambridge  Senior  Local  Examinations,  the  London 
Matriculation  Examination,  the  Scotch  Education  Depart- 
ment, Responsions  at  Oxford,  and  the  Joint  Matriculation 
Board  of  the  Universities  of  Manchester,  Liverpool,  Leeds, 
and  Sheffield,  the  Matriculation  Examination  of  the  Uni- 
versity of  Birmingham,  or  by  being  graduatesof  certain  ether 
Universities  in  the  United  Kingdom.  He  may  then  devote  him- 
self to  medical  study  in  the  University,  &c.  Or  he  may,  as 
nearly  all  students  now  do,  proceed  to  take  a degree  in 
Arts  by  passing  either  (a)  the  General  Examination  and  one 
Special  Examination,  or  (b)  two  Special  Examinations  for 
the  ordinary  B.A.  degree,  or  an  Honours  degree  in  one 
of  the  Triposes.  The  Natural  Sciences  Tripos  is  taken 
most  frequently,  as  some  of  the  subjects  are  practically  the 
same  as  those  for  the  first  and  second  M.B. 

For  the  degree  of  Bachelor  of  Medicine  (M.B.')  five  years 
of  medical  study  are  required  either  in  Cambridge  or 
at  one  of  the  recognised  Schools  of  Medicine.  The  first 
three  or  four  years  are  usually  spent  in  Cambridge  till 
he  has  passed,  say,  the  examination  for  Part  I.  of  the 
Natural  Sciences  Tripos  and  the  first  and  second  examina- 
tions for  M.B.  Hospital  practice  and  many  of  the  requisite 
lectures  may  be  attended  in  Cambridge,  and  some  students 
remain  to  attend  lectures  and  hospital  practice  until  they 
have  passed  the  second  part  of  the  second  examination  for 
M.B.  The  laboratories  for  Botany,  Chemistry,  Physics, 
Biology,  Zoology,  Human  Anatomy,  Physiology,  Bio- 
chemistry, Pathology,  Bacteriology,  Pharmacology,  Psych- 
ology, and  Public  Health  are  well  equipped.  Adden- 
brooke’s  Hospital,  the  Infectious  Diseases  Hospital,  the 
Cambridge  Research  Hospital,  and  the  Field  Laboratories 
are  utilised  for  study  and  research. 

There  are  three  examinations  for  M.B.  The  first  includes 
(1)  Chemistry  and  other  branches  of  Physics,  and  (2)  Ele- 
mentary Biology.  These  parts  may  be  taken  together 
or  separately.  The  second  is  divided  into  two  parts — 
viz.,  (1)  Human  Anatomy  and  Physiology;  and  (2)  Phar- 
macology and  General  Pathology.  The  third  is  also 
divided  into  two  parts : (1)  Principles  and  Practice  of 
Surgery  (including  Special  Pathology  and  Midwifery  and 
Diseases  Peculiar  to  Women)  ; and  (2)  Principles  and 
Practice  of  Physic  (including  Diseases  of  Children,  Mental 
Diseases,  Medical  Jurisprudence),  Pathology  (including 
Hygiene  and  Preventive  Medicine),  and  Pharmacology 
(including  Therapeutics  and  Toxicology).  The  examina- 
tions are  partly  in  writing,  partly  oral,  and  partly  practical, 
in  the  hospital,  in  the  dissecting  room,  and  in  the  labora- 
tories. An  Act  has  then  to  be  kept  in  the  Public  Schools, 
by  the  candidate  reading  an  original  dissertation  composed 
by  himself  and  being  examined  orally  on  some  subject 
approved  by  the  Regius  Professor  of  Physic. 

Candidates  who  have  passed  both  parts  of  the  third  M.B. 
examination  are  admitted  to  the  registrable  degree  of 
Bachelor  of  Surgery  (B.  Ch.)  without  separate  examination 
and  without  keeping  an  Act. 

The  degree  of  Doctor  of  Medicine  (M.D.)  may  be  taken 
three  years  after  that  of  M.B.  or  four  years  after  that  of 
M.A.  The  candidate  is  required  to  produce  certificates 
of  having  been  engaged  in  Medical  Study  for  five  years, 
and  if  an  M.A.,  to  pass  the  same  examinations  as  are 
required  for  the  degree  of  M.B.  An  Act  has  to  be 
kept,  consisting  of  an  original  Thesis  sustained  in  the 
Public  Schools  with  viva  voce  examination ; and  a short 


360  The  Lancet, 


UNIVERSITY  OF  LONDON. 


[August  30,  1919 


extempore  essay  has  to  be  written  on  a topic  taken  from 
the  general  subject  of  his  thesis,  whether  it  be  Physiology, 
Pathology,  Pharmacology,  the  Practice  of  Medicine,  State 
Medicine,  or  the  History  of  Medicine. 

For  the  degree  of  Master  of  Surgery  (.V.  Ch.)  the  candidate 
must  have  passed  all  the  examinations  for  B.Ch.,  or,  if  he 
is  an  M.A. , have  obtained  some  other  registrable  qualifica- 
tion in  surgery.  He  is  required  either  (1)  to  pass  an 
examination  in  Principles  and  Practice  of  Surgery, 
Surgical  Anatomy  and  Surgical  Operations,  and  Pathology, 
and  to  write  an  extempore  essay  on  a Surgical  Subject ; or  (2) 
to  submit  to  the  Medical  Board  original  contributions  to  the 
advancement  of  the  Science  or  Art  of  Surgery.  Before  he 
can  be  admitted  to  the  examination  two  years  at  least 
must  have  elapsed  from  the  time  when  he  completed  all 
required  for  the  degree  of  B.Ch.  Before  submitting  original 
contributions  he  must  have  been  qualified  at  least  three  years. 

Women  Students. — Increased  facilities  have  been  offered 
to  students  of  Girton  and  Newnham  Colleges,  and  they  are 
admitted  to  the  First  and  Second  M.B.  Examinations  under 
certain  conditions. 

University  Prize  in  Medicine. — The  one  University  Prize 
in  Medicine,  the  Raymond  Horton  Smith  Prize  (value  £19), 
is  awarded  to  that  candidate  for  the  degree  of  M.D.  who 
presents  the  best  thesis  for  the  degree  during  the  academical 
year,  provided  that  he  has  taken  honours  in  a tripos 
examination.  Medical  Studies  are  endowed  by  the  numerous 
Natural  Science  scholarships  at  the  various  colleges, 
information  about  which  can  be  obtained  from  the  respective 
Tutors. 

An  abstract  of  the  Regulations  and  Schedules  of  the  range 
of  the  examinations  in  Chemistry,  Physics,  Biology,  Pharma- 
cology, and  General  Pathology  may  be  obtained  upon 
sending  a stamped  directed  envelope  to  the  Registrary, 
the  Registry,  Cambridge.  

Addenbrooke’s  Hospital. — Clinical  Lectures  in  Medicine 
and  Surgery,  in  connexion  with  Cambridge  University 
Medical  School,  are  given  at  this  hospital  twice  a week 
during  the  academical  year ; and  practical  instruction  in 
Medicine  and  Surgery  is  given  in  the  wards  and  out-patients’ 
rooms  by  the  physicians  and  surgeons  daily  during  the 
term  time  and  vacations.  The  fee  for  pupilship  is  3 guineas 
a term.  All  communications  by  students  should  be  made  to 
Dr.  Aldren  Wright. 


UNIVERSITY  OF  LONDON. 

The  University  of  London  was  established  by  Royal 
Charter  in  1836  as  an  examining  and  degree  conferring 
body  with  affiliated  colleges  but  no  direct  teaching  func- 
tions. In  1900  it  was  reconstituted  under  the  Act  of  Parliament 
1898  and  became  a teaching  as  well  as  an  examining  body. 
Many  schools  already  existing  became  constituent  colleges, 
including  all  the  metropolitan  medical  schools.  Teachers 
were  also  appointed  in  special  subjects  to  give  lectures  at  the 
University. 

Teachiny  Staff. — The  teaching  staff  of  the  University  is 
organised  under  two  heads:  1.  Appointed  teachers— i.e., 
such  as  are  appointed  by,  and  are  paid  out  of  the  funds  of,  the 
University.  2.  Recognised  teachers — i.e.,  those  who  have 
been  appointed  and  are  paid  by  the  several  schools  of  the 
University  and  other  institutions  at  which  instruction 
is  given  under  the  auspices  of  the  University,  and  who  have 
been  recognised  by  the  Senate  as  conducting  work  of 
University  standard.  Courses  by  non-recognised  teachers 
may  also  be  approved  in  schools  of  the  University.  The 
lecturers  in  the  Medical  Sciences  and  the  professors  in  the 
Faculties  of  Medicine  in  University  College,  London,  and 
King’s  College,  London,  will  be  found  enumerated  under 
their  respective  medical  schools. 

Internal  and  External  Students. — All  the  examinations  of 
this  University  are  open  to  men  and  women  alike.  Matricu- 
lated students  of  the  University  may  be  either  internal 
or  external.  Internal  students  of  the  University  are 
students  who  have  matriculated  at  the  University  and 
who  are  pursuing  a course  of  study  approved  by 
the  University,  either  (a)  under  the  direct  control 
of  the  University  or  a committee  appointed  thereby ; 
or  (J>)  under  one  or  more  of  the  appointed  or  recognised 
teachers  of  the  University.  Centres  for  preliminary  and 
intermediate  medical  studies  have  been  established  by 


the  University  at  .University  and  King’s  Colleges.  Internal 
students  must  pursue  their  studies  at  one  of  the  above 
centres,  or  at  one  of  the  medical  schools  connected  with 
the  University.  These  are  St.  Bartholomew’s  Hospital, 
Charing  Cross  Hospital,  St.  George’s  Hospital,  Guy’s 
Hospital,  King’s  College  Hospital,  the  London  Hospital, 

St.  Mary’s  Hospital,  the  Middlesex  Hospital,  St.  Thomas’s 
Hospital,  University  College  Hospital,  Westminster  Hospital, 
and  the  London  (Royal  Free  Hospital)  School  of  Medicine 
for  Women.  The  London  School  of  Tropical  Medicine  and 
the  Lister  Institute  of  Preventive  Medicine  are  also  recognised 
as  schools  of  the  University  in  special  departments.  External 
students  are  all  other  matriculated  students,  and  may  pursue 
their  studies  at  other  universities  and  medical  schools,  pre- 
senting themselves  for  examination  at  the  University  of 
London. 

Faculty  of  Medicine. — The  Faculty  of  Medicine  grants  the 
joint  degrees  of  M.B.,  B.S.  ( Bachelor  of  Medicine  and  Sur- 
gery), and  the  higher  separate  degrees  of  M.D.  ( Doctor  of 
Medicine)  and  M.S.  ( Master  of  Surgery). 

The  curriculum  for  the  Bachelor’s  degrees  is  now  five  and  a 
half  years  from  the  time  of  matriculation,  with  certain 
exceptions  which  must  be  looked  for  in  the  official  regula- 
tions of  the  University,  to  be  obtained  from  the  Principal 
Officer,  University  of  London,  South  Kensington,  S.W.  7, 
and  the  examinations  formerly  known  as  the  Preliminary 
Scientific,  the  Intermediate,  and  the  Final  Examination  in 
Medicine  are  now  respectively  entitled  the  First,  Second, 
and  Third  Examinations  for  Medical  Degrees.  Part  II.  of 
the  former  Preliminary  Scientific  Examination  has  now  been 
made  Part  I.  of  the  Second  Examination. 

A.  Internal  Students. — In  order  to  be  admitted  to  the 

Bachelor’s  degrees  a student  must  normally,  after  regis- 
tration as  an  internal  student,  have : (1)  Attended  pre- 
scribed courses  of  study  for  five  and  a half  years  in  one  or 
more  schools  of  the  University.  (2)  Passed  the  follow- 
ing examinations,  under  the  conditions  mentioned  below  : j 

(a)  The  First  Examination  for  Medical  Degrees  in  Inorganic  > 
Chemistry,  Physics,  and  General  Biology ; (b)  the  Second  Exa- 
mination for  Medical  Degrees  : Part  I.,  Organic  and  Applied 
Chemistry  ; Part  II.,  Anatomy,  Physiology,  and  Pharma-  • 
cology,  including  Pharmacy  and  Materia  Medica ; (c)  the  . | 
Third  Examination  for  Medical  Degrees,  or  M.B.,  B.S. 
Examination  : Medicine  and  Surgery,  Midwifery  and  Diseases 

of  Women,  Pathology,  Forensic  Medicine  and  Hygiene. 

B.  External  Students. — To  be  admitted  to  the  Bachelor’s 
degrees  an  external  student  must  (1)  have  passed  the  Matri- 
culation examination  or  have  been  exempted  therefrom  - 
under  Statute  116  not  less  than  five  and  a half  years  pre- 
viously ; (2)  have  passed  subsequent  examinations  similar  to.  ; 
those  required  of  an  internal  student ; and  (3)  have  been 
engaged  in  professional  studies  during  the  five  and  a half  : 
years  subsequently  to  Matriculation  and  four  and  a half 
years  subsequently  to  passing  the  First  Examination  for 
Medical  Degrees  at  one  or  more  of  the  medical  institutions 
or  schools  recognised  by  this  University  for  the  purpose,  one  i 
year  at  least  of  the  four  and  a half  years  to  have  been  spent 
in  one  or  more  of  the  recognised  institutions  or  schools  in 
the  United  Kingdom. 

Ike  First  Examination  for  Medical  Degrees  ( Inorganic  | 
Chemistry,  Physics,  and  General  Biology)  will  take  place  ( 
twice  in  each  year,  commencing  on  the  Monday  following  I 
Dec.  7th  and  on  the  second  Monday  in  July.  It  must  t 
as  a rule  be  passed  not  less  than  nine  months  after 
matriculation. 

The  Second  Examination  for  Medical  Degrees  (Part  I. ): 
Organic  and  Applied  Chemistry. — This  examination  will  take 
place  twice  in  each  year,  commencing  on  the  Wednesday 
following  the  third  Monday  in  March  and  on  the  afternoon  : 
of  the  Thursday  following  the  second  Monday  in  July.  No 
candidate  will  be  admitted  to  this  examination  within  six 
months  of  having  passed  the  First  Examination. 

Jhc  Second  Examination  for  Medical  Degrees  ( Part  II.) 
takes  place  twice  in  every  year,  commencing  on  the 
Tuesday  following  the  third  Monday  in  March  and  on  the 
Tuesday  following  the  first  Monday  in  July.  The  subjects 
of  the  examination  are  Anatomy,  Physiology,  and  Pharma- 
cology, including  Pharmacy  and  Materia  Medica.  No  candi- 
date shall  be  admitted  to  the  examination  unless  he  has 
passed  the  First  Examination  for  Medical  Degrees  at  least 
18  months  previously,  and  has  passed  Part  I.  of  the  Second 
Examination  for  Medical  Degrees. 


The  Lancet,] 


MEDICAL  SCHOOLS  OF  THE  UNIVERSITY  OF  LONDON.  [August  30,  1919  361 


The  Third  or  M.  B. , B.S.  Examination. — The  M.  Ii. , B.S.  exa- 
mination takes  place  twice  in  each  year,  commencing  on  the 
fourth  Monday  in  October  and  on  the  first  Monday  in  May. 
No  candidate  will  be  admitted  to  this  examination  unless 
lie  has  completed  the  Second  Examination,  for  Medical 
Degrees,  together  with  a course  of  study  summarised 
below,  nor  within  three  years  from  the  date  of  passing 
the  Second  Examination,  Part.  II.  (1)  Principles  and 
Practice  of  Medicine  ; (2)  Clinical  Methods  and  Physical 
Diagnosis  ; (3)  Insanity  (with  clinical  demonstrations  at  a 
recognised  Asylum);  (4)  Therapeutics  ; (5)  Vaccination  ; (6; 
Principles  and  Practice  of  Surgery  ; (7)  Operative  Surgery, 
Surgical  Anatomy,  Practical  Surgery,  and  the  Administration 
of  Anaesthetics  ; (8)  Diseases  of  the  Eye,  Ear,  Throat,  and 
Skin  ; (9)  Lectures  and  Demonstrations  on  Midwifery  and 
Diseases  of  Women ; (10)  Practical  Midwifery,  the  con- 
duct of  at  least  20  Labours,  and  practice  as  a 
Clinical  clerk  in  Gynaecological  work  ; (11)  Pathology  and 
Bacteriology  ; (12)  work  of  the  Post-mortem  room ; (13) 
Forensic  Medicine ; and  (14)  Hygiene.  He  must  also  have 
attended  the  Medical  and  Surgical  practice  of  a recognised 
hospital  for  two  years  and  a course  of  instruction  at  a 
recognised  Fever  Hospital  for  two  months.  He  must  have 
had  clinical  instruction  and  must  have  held  the  posts  of 
medical  clinical  clerk  and  surgical  dresser  for  periods  of  six 
months  each.  Candidates  will  be  examined  in  Medicine 
(including  Therapeutics  and  Mental  Diseases),  Patho- 
logy, Forensic  Medicine  and  Hygiene,  Surgery,  Mid- 
wifery, and  Diseases  of  Women.  The  subjects  may  be 
divided  into  two  groups — namely  : (1)  Medicine,  Pathology, 
Forensic  Medicine,  and  Hygiene  ; and  (2)  Surgery,  Midwifery, 
and  Diseases  of  Women.  These  groups  may  be  taken  either 
separately  or  together.  The  list  of  candidates  who  have  passed 
will  be  published  in  two  parts — namely,  an  Honours  list  and 
a Pass  list.  Bachelors  of  Medicine  of  this  University  who 
graduated  in  or  before  May,  1904,  may  obtain  the  B.S.  degree 
by  passing  the  Surgical  part  of  the  M.B.,  B.S.  examination. 

Doctor  of  Medicine. — The  examination  for  this  degree 
takes  place  twice  in  each  year,  commencing  on  the  first 
Monday  in  December  and  on  the  first  Monday  in  July. 
Candidates  may  present  themselves  for  examination  in  one 
of  the  following,  branches,  namely  : (1)  Medicine  ; (2)  Patho- 
logy ; (3)  Mental  Diseases  ; (4)  Midwifery  and  Diseases  of 
Women  ; (5)  State  Medicine ; and  (6)  Tropical  Medicine. 
Any  candidate  for  the  degree  of  M.  D.  may  transmit  to  the 
Registrar  a thesis  or  published  work  having  definite  relation 
to  the  branch  of  Medicine  in  which  he  is  a candidate,  and 
if  the  thesis  be  approved  by  the  examiners  the  candidate 
may  be  exempted  from  a part  or  from  the  whole  of  the 
written  examination  in  that  subject. 

Master  in  Surgery. — The  examination  for  the  degree  of 
Master  in  Surgery  takes  place  twice  in  each  year  and  com- 
mences on  the  first  Monday  in  December  and  on  the  first 
Monday  in  July. 

Fees.—  Matriculation  £2  2s.  for  each  entry.  At  provincial 
examinations  an  additional  local  fee  is  charged.  First 
examination  for  Medical  Degrees  : £5  5s.  for  each  entry  to 
the  entire  examination.  For  re-examination  in  one  subject 
the  fee  is  £2  2s.  In  the  second  examination,  Part  I.  £2  2s., 
repeats  d on  each  subsequent  entry  ; Part  II.  £8  8s.  for  the 
whole  examination.  Third  examination  : £10  10s.  for  each 
entry  to  the  whole  examination.  M.D.  Examination  : £21  ; 
for  re-examination  £10  10s.  M.S.  Examination  : As  for  M.D. 

Full  details  of  the  prescribed  curricula  of  study  and  the 
names  of  the  recognised  Internal  and  External  Schools  of  the 
University,  can  be  obtained  free  on  application  to  the  Principal 
Officer,  University  of  London,  South  Kensington,  S.W. 


MEDICAL  SCHOOLS  OF  THE  UNIVERSITY 
OF  LONDON.1 

St.  Bartholomew’s  Hospital  and  College. — The 
hospital  contains  757  beds,  of  which  687  are  for  patients 
in  the  hospital  at  Smithfield  and  70  for  convalescent  patients 
at  Swanley.  It  receives  over  8000  in-patients  annually  and 
its  out-patients  and  casualties  amount  to  more  than  75,000 
annually.  Special  departments  have  been  organised  for 
Diseases  of  Women  and  Children,  the  Eye,  Ear,  Larynx, 
and  Skin,  as  well  as  for  Orthopaedic  and  Dental  Surgery, 
and  for  Electro-therapeutics  and  X Ray  work.  Surgical 

1 For  Ancillary  Metropolitan  Medical  Schools  see  p.  376. 


operations  take  place  every  day  at  1.30  p.m.  and  Surgical 
Consultations  are  held  on  Thursdays  at  the  same  hour. 
Medical  Consultations  are  held  on  Thursdays  at  3.15  P.M. 
The  physicians  and  surgeons  deliver  clinical  lectures  weekly 
during  both  the  winter  and  the  summer  sessions.  Clinical 
Lectures  on  all  special  subjects  are  also  given.  The  visits 
of  the  physicians  and  surgeons  are  made  at  1.30. 

Ten  house  physicians  and  ten  house  surgeons  are 
appointed  annually,  and  are  provided  with  rooms  by  the 
hospital  authorities  and  receive  £80  a year  as  salary. 
A resident  midwifery  assistant,  an  ophthalmic  house 
surgeon,  and  a house  surgeon  for  diseases  of  the  throat, 
nose,  and  ear  are  appointed  eve.'y  six  months,  and  are 
provided  with  rooms  and  receive  a salary  of  £80  a year. 
Three  resident  anaesthetists  are  appointed  annually,  and 
receive  salaries  ,of  £120,  £100,  and  £100  respectively,  with 
rooms.  An  extern  midwifery  assistant  is  appointed  every 
three  months,  and  receives  a salary  of  £80  a year.  The 
clinical  clerks,  the  obstetric  clerks,  the  clerks  to  the  medical 
out-patients,  the  dressers  to  the  surgical  in-patients  and 
to  the  out-patients,  and  the  dressers  in  the  special  depart- 
ments are  chosen  from  the  students.  A residential  college 
is  attached  to  the  hospital. 

New  Buildings. — The  new  buildings  comprise  residential 
quarters  for  the  resident  staff,  casualty,  medical,  surgical, 
and  special  out-patient  departments,  casualty  wards, 
dispensary,  and  clinical  lecture  theatre.  A new  chemical 
laboratory  has  been  added  to  the  Medical  School,  and 
a laboratory  devoted  to  instruction  in  Public  Health.  A 
second  new  block  is  devoted  to  Pathology,  and  contains 
the  post-mortem  room  as  well  as  extensive  laboratories 
for  bacteriology,  clinical  pathology,  pathological  histology, 
and  pathological  chemistry.  The  Medical  School  Buildings 
include  three  large  lecture  theatres,  a large  dissecting  room, 
a spacious  library  (containing  13,000  volumes),  a well- 
appointed  museum  of  anatomy,  physiology,  comparative 
anatomy,  materia  medica,  botany,  and  pathological  anatomy. 
The  pathological  museum  is  the  most  complete  in  the 
kingdom.  There  are  laboratories  for  chemistry,  physiology, 
pharmacology,  physics,  public  health,  and  biology,  giving 
ample  accommodation  in  every  department. 

Special  Classes  for  the  Primary  and  Final  F.R.C.S.  are  held 
twice  yearly.  Instruction  in  Preliminary  Science  is  given 
to  University  of  London  students  in  chemistry,  biology, 
and  physics  throughout  the  year.  Laboratory  Instruction  for 
the  D.P.H.  is  provided  during  the  winter  and  summer 
sessions. 

The  recreation  ground  of  10  acres  is  at  Winchmore 
Hill  for  the  use  of  the  members  of  the  Students’ 
Union,  which  all  students  are  expected  to  join.  The 
Students’  Union  contains  a large  reading  and  smoking 
room,  a committee  and  writing  room,  luncheon  and 
dining  hall,  and  a miniature  rifle  range. 

Scholarships  given  in  aid  of  Medical  Study. — At  this  school 
various  Scholarships,  prizes,  &c.,  are  given.  For  five  of 
the  Scholarships  and  the  Exhibition — namely,  ( a ),  (b), 
two  Entrance  Scholarships  of  the  respective  values 
of  £75  and  £100  ; ( c ) Entrance  Scholarship  in  Arts, 
£100  ; (d)  Jeaffreson  Exhibition,  £50 ; and  (e)  Shuter 

Scholarship,  £50 — a full  or  University  course  at  St. 
Bartholomew’s  Hospital  is  required.  The  awards  of  (a), 
and  (b)  are  made  after  examination  in  selections  from  the 
subjects  of  Chemistry,  Physics,  Zoology,  Botany,  Physio- 
logy, and  Anatomy  ; ( [c ) and  (d)  are  awarded  after  exa- 
mination in  Latin,  Mathematics,  and  Greek  or  French 
or  German  ; ( e ) is  awarded  after  competitive  examination 
among  Cambridge  Graduates  in  Anatomy  and  Physio- 
logy. The  remaining  Scholarships  and  prizes  are  as 
follows  : — Four  Junior  Scholarships  : (/)  No.  1,  £30, 

Anatomy  and  Physiology  ; (y)  No.  2,  £20,  Anatomy  and 
Physiology  ; ( [h ) No.  3,  £25,  Chemistry,  Physics,  and 

Biology  ; ( 'i ) No.  4,  £15,  Chemistry,  Physics,  and  Biology  ; 
(J)  Senior  Scholarship,  £50,  Anatomy,  Physiology,  and 
Chemistry  ; (A)  Kirkes  Scholarship,  £30  and  medal,  Clinical 
Medicine  ; ( l ) and  (m)  two  Brackenbury  Scholarships,  £39 
each,  one  in  Medicine  and  one  in  Surgery ; (n)  Sir  G. 
Burrows  Prize,  £10,  Pathology  ; ( o ) Skynner  Prize,  13 

guineas,  Regional  and  Morbid  Anatomy  ; ( p ) Matthews 
Duncan  Medal  and  Prize,  £20,  Midwifery  and  Gynaecology  ; 
(y)  Luther  Holden  Research  Scholarship  in  Surgery,  awarded 
by  election,  £105  ; and  (r)  Lawrence  Research  Scholarship 
and  gold  medal  in  Pathology,  awarded  by  election,  £115. 


362  Thu  Lancet,] 


MEDICAL  SCHOOLS  OF  THE  UNIVERSITY  OF  LONDON. 


[August  30,  1919 


Information  may  be  obtained  on  application  to  the  Dean 
of  the  Medical  School : Dr.  T.  W.  Shore.  The  Warden  of 
the  College  is  Mr.  W.  Girling  Ball. 


Charing  Cross  Hospital. — The  Hospital,  to  which  the 
School  is  attached,  contains  300  beds.  Over  3000  cases  pass 
through  its  wards  each  year,  and  some  24,000  out-patients 
and  casualties  are  treated.  There  are  special  departments 
for  Mental  Diseases,  Midwifery,  Diseases  of  Women,  of 
Children,  of  the  Skin,  Eye,  Ear,  Throat,  Nose,  and  Teeth, 
for  Ortbopiedic  Cases,  X Ray  work,  and  for  Electrical 
Examination  and  Treatment. 

Appointments. — In  the  Medical  School  Demonstratorships 
and  Assistant  Demonstratorships  are  open  to  students  of  the 
School.  Medical,  Surgical,  and  Obstetric  Registrars  to  the 
Hospital  are  appointed  annually.  Six  House  Physicians,  six 
House  Surgeons,  and  two  Resident  Obstetric  Officers  are 
appointed  each  year  after  competitive  examination. 

Primary  and  Intermediate  Studies. — By  an  agreement  with 
the  University  of  London  the  School  sends  its  Primary  and 
Intermediate  Students  to  receive  their  lectures  and  practical 
work  at  King's  College,  which  is  situated  within  four 
minutes’  walk.  This  arrangement  has  proved  most 
successful. 

Final  Studies. — These  are  taken  in  the  school  and  hospital, 
where  systematic  lectures,  demonstrations,  and  tutorial 
classes  are  arranged  to  cover  all  the  subjects  necessary  for 
qualifying  examinations.  Departments  are  also  available 
for  other  final  subjects  of  Materia  Medica,  Toxicology,  and 
Operative  Surgery. 

An  Institute  of  Pathology  with  a whole-time  staff  of 
scientific  workers  and  fully  equipped  Laboratories  has  been 
established  in  the  School.  Students  receive  their  training 
in  "Preventive  Medicine,  Pathology,  and  Bacteriology  here, 
and  are  encouraged  to  undertake  Research.  Special  facilities 
for  Post-graduate  Research  and  Study. 

The  course  in  Ophthalmology  is  given  in  the  Royal  West- 
minster Ophthalmic  Hospital.  Special  lectures  and  demon- 
strations are  arranged  for  Post-graduates. 

The  Museum  contains  over  4000  specimens,  including  a 
notable  collection  of  over  800  gynecological  specimens, 
“The  Cuthbert  Lockyer  Collection.” 

Students'  Club. — The  social  comfort  and  convenience  of 
students  are  met  by  library,  reading,  and  smoking-rooms, 
refreshment-room,  &c.  The  Club,  which  is  under  the  control 
of  a Committee  of  Students,  provides  needful  athletic 
recreation,  and  includes  the  Medical  Society. 

Women  Students. — Women  students  are  accepted  by  the 
School  and  Hospital  upon  the  same  terms  and  conditions  as 
men,  and  after  qualification  are  eligible  for  resident  Hospital 
appointments.  A separate  common-room  and  a female 
attendant  are  provided,  but  beyond  this  no  further  distinc- 
tion is  made.  This  system  of  co-education,  under  which 
men  and  women  are  placed  on  terms  of  complete  equality 
throughout  the  whole  of  the  curriculum,  has  been  found  to 
work  successfully  and  to  their  mutual  advantage. 

Fees. — An  entrance  fee  of  10  guineas  and  8 guineas  is 
payable  by  full-course  and  final-course  students  respectively, 
and  an  annual  fee  of  26  guineas  covers  all  other  expenditure, 
with  the  exception  of  7 guineas  for  vaccination,  dispensing, 
and  fever  hospital  attendance,  which  must  be  taken  outside 
the  hospital.  Membership  of  the  Students’  Club  is  included 
in  these  fees. 

Further  information  may  be  obtained  on  application  to 
the  Dean,  Dr.  W.  J.  Fenton,  Medical  School,  Charing  Cross 
Hospital,  London,  W.C.  

St.  George’s  Hospital. — This  hospital  has  a service  of 
436  beds,  of  which  180  are  allotted  to  surgical,  150  to 
medical  cases,  and  100  are  at  the  Convalescent  Hospital  at 
Wimbledon.  One  ward  is  set  apart  for  Diseases  Peculiar 
to  Women.  Children’s  beds  are  placed  in  all  the  women’s 
wards.  Two  wards  are  allotted  to  ophthalmic  cases. 

Entrance  Scholarships  and  Endowed  Prizes  of  a total 
value  of  £576  are  awarded  annually ; a detailed  list  is 
placed  below.  The  entire  teaching  and  laboratories  are 
now  devoted  to  purely  clinical  subjects,  and  arrangements 
have  been  made  with  the  University  of  London  for  students 
who  enter  during  the  first,  second,  or  third  year  of  the 
curriculum  as  students  of  St.  George's  to  carry  out  the 
necessary  courses  of  instruction  at  either  University  College 
or  King’s  College.  Students  then  complete  their  course, 


without  payment  of  any  entrance  fee,  in  a school  entirely 
devoted  to  Clinical  work. 

Eight  house  physicians  and  eight  house  surgeons  are 
appointed  annually.  Special  attention  is  directed  to  the 
following  paid  appointments,  among  others,  which  are  open 
to  students  after  they  have  held  house  office : — Resident 
Assistant  Physician  and  Resident  Assistant  Smgeon, 
at  £350  per  annum  each  ; Medical  Registrarship  at 
£200  per  annum ; Surgical  Registrarship  at  £200  ; 
Assistant  Curatorship  of  the  Museum  at  £100  ; Obstetric 
Assistantship  (Resident)  at  £50  ; the  post  of  Resi- 
dent Anaesthetist  at  £100 ; the  post  of  Senior  Anaes- 
thetist at  £50  ; the  posts  (3)  of  Junior  Anaesthetists, 
each  at  £30.  The  St.  George’s  Hospital  Club,  with 
smoking-  and  luncheon-rooms  on  the  hospital  premises, 
and  an  athletic  ground  at  Wimbledon,  is  an  amalgamation 
of  the  Hunterian  Society,  the  Gazette , and  the  chess,  lawn 
tennis,  boxing,  hockey,  rifle,  and  golf  clubs.  Students  have 
the  advantage  of  a library  of  medical  and  scientific  books 
which  is  kept  up  to  date. 

Scholarships  and  Prizes. — At  this  school  two  entrance 
scholarships  are  given,  the  money  value  and  the  subjects 
of  examination  being  as  follows  : (a)  and  ( b ) two  Uni- 
versity Entrance  Scholarships,  70  guineas  and  £50 
respectively.  Anatomy  and  Physiology.  The  others  are 
as  follows : ( o ) William  Brown  Exhibition,  tenable  for 
two  years  and  open  to  perpetual  pupils  having  registrable 
qualifications,  £135  per  annum,  Practice  of  Medicine, 
Midwifery,  and  Surgery  ; (d)  William  Brown  Exhibition, 
tenable  for  three  years  and  open  to  perpetual  pupils 
qualified  not  more  than  three  years  previously,  £45 
per  annum,  Essay  and  Original  Work ; (e)  Allingham 
Scholarship  in  Surgery  for  Students  qualified  not  more 
than  three  years,  £60,  Competitive  Essay  ; ( f ) and  (g)  two 
Brackenbury  Prizes,  one  in  Medicine  and  one  in  Surgery, 
£30  each,  open  to  students  of  not  more  than  five  years’ 
standing  ; ( h ) H.  C.  Johnson  Memorial  Prize,  £15,  Practical 
Anatomy  ; (i)  Pollock  Prize,  £17,  Physiology,  Physiological 
Chemistry,  and  Histology  ; (J)  Clarke  Prize,  £5  ; (k)  ‘ 
Thompson  Medal,  £5,  Clinical  Reports ; (I)  Brodie  Prize, 
£7,  Clinical  Reports  ; («)  Webb  Prize,  open  to  perpetual 
pupils,  £30,  Bacteriology  ; (»)  Sir  Francis  Labing  Memorial 
Prize,  £65,  open  to  students  having  registrable  qualifications. 

further  information  may  be  obtained  from  the  Acting 
Dean  of  the  Medical  School,  Mr.  R.  R.  James. 


Gut’s  Hospital. — This  hospital,  founded  by  Thomas  Guy  I 
in  1721  for  the  reception  of  400  patients,  and  enlarged  , I 
through  the  aid  of  a large  bequest  from  the  late  William 
Hunt,  contains  at  the  present  time  644  beds.  The 
school  buildings  have  been  rebuilt  and  now  offer  very 
complete  accommodation.  Within  the  grounds  of  the  j 
hospital  are  situated  the  residential  college,  with  accommo- 
dation for  60  students,  the  students’  club,  with  reading, 
smoking,  luncheon,  and  dining-rooms,  a fives  court,  and 
swimming  bath.  The  athletic  ground  and  club  house  is  I 
situated  at  Honor  Oak  Park,  and  can  be  reached  in  20  | 
minutes  from  the  hospital. 

House  physicians,  house  surgeons,  out-patient  officers  ! 
and  assistant  house  surgeons,  obstetric  residents,  oph- 
thalmic house  surgeons,  clinical  assistants,  clerks  to  anaes- 
thetists, surgeons’  dressers,  medical  clinical  clerks,  post-  | 
mortem  clerks,  extern  obstetric  attendants,  and  dressers  and 
clerks  in  the  special  departments  are  appointed  from  among 
the  students  upon  the  recommendation  of  the  Medical 
Council  according  to  merit. 

There  is  a Medical  Section  of  the  Officers’  Training  Corps 
of  the  University  of  London  in  connexion  with  the  Hospital. 
Drill  is  held  in  the  grounds  of  the  Hospital,  so  that  the 
senior  students  can  carry  out  the  necessary  military  training 
without  any  serious  interruption  of  their  work  in  the  wards. 

The  establishment  of  a Venereal  Clinic,  in  accordance  with 
the  Scheme  of  the  Local  Government  Board  and  London 
County  Council.  Lectures  and  clinical  instruction  are  given, 
to  which  Medical  Students  and  Practitioners  are  admitted 
without  fee.  Residential  College  : the  rent  of  rooms  remains 
the  same,  but  the  cost  of  board  has  increased. 

Scholarships. — Five  entrance  scholarships  are  awarded 
annually  as  follows : — (a)  one  scholarship  of  £100  for 
students  under  21  years  of  age,  Latin,  English,  Greek 
or  French  or  German,  Arithmetic,  Euclid,  and  Algebra ; 

(b)  one  scholarship  for  students  under  21  years,  £120, 


Thh  Lanoht,] 


MEDICAL  SCHOOLS  OF  THE  UNIVERSITY  OF  LONDON. 


[August  30,  1919  3 0 3 


Inorganic  Chemistry,  Physics,  and  Biology  ; ( c ) a Scholarship 
of  £50,  open  to  candidates  under  21  years  of  age,  to  be 
awarded  either  in  Arts  or  in  Science,  according  to  the 
discretion  of  the  Examiners,  and  to  the  percentage  of  the 
marks  obtained  ; (d)  two  scholarships,  one  of  £75  and  one 
of  £35,  for  students  under  25  years  of  age  who  have  com- 
pleted the  curriculum  for,  or  passed  the  examination  in, 
Anatomy  and  Physiology  for  a medical  degree  in  any  Uni- 
versity of  the  British  Empire.  Subjects  : Any  two  of  the 
following  : Anatomy,  Physiology,  Pharmacology,  General 
Pathology,  Organic  Chemistry. 

In  agreement,  with  the  practice  of  the  Universities,  an 
allowance  will  be  made  (1)  for  Military  Service  performed 
by  candidates,  the  term  “military  service”  meaning  service 
in  the  Naval  or  Military  Forces  of  His  Majesty  or  of  His 
Majesty’s  Allies  during  the  war  ; or  (2)  in  respect  of 
other  approved  duties  in  connexion  with  national  defence. 

The  Dean  of  the  Medical  School  is  L.  Bromley,  M.Ch., 
from  whom  further  information  may  be  obtained. 


University  of  London  : King’s  College. — The  medical 
department  (Faculty  of  Science,  Medical  Division)  at  this 
College  only  deals  with  Preliminary  and  Intermediate  sub- 
jects, and  instruction  in  these  subjects  is  given  in  the  College 
laboratories  by  university  professors  and  their  assistants. 
The  following  four  hospital  schools  prepare  their  students 
only  for  the  final  examinations — viz.,  King’s  College  Hos- 
pital, Westminster  Hospital,  St.  George’s  Hospital,  and 
Charing  Cross  Hospital — sending  them  to  King’s  College  for 
the  earlier  part  of  the  curriculum.  The  department  is  open 
to  both  men  and  women. 

Fees. — For  London  University  course  : For  First  examina- 
tion for  medical  degrees,  25  guineas ; for  the  Second 
examination,  58  guineas,  or  two  instalments  of  30  guineas 
each.  For  Conjoint  Board  course  : For  First  examination, 
20  guineas  ; for  Second  examination,  58  guineas,  or  two 
instalments  of  30  guineas  each.  For  prospectus  and  further 
information  application  should  be  made  to  the  Dean  of  the 
department  (Professor  W.  D Halliburton). 


King’s  College  Hospital  Medical  School.— The 
advanced  subjects  in  the  curriculum  are  dealt  with  at  the 
Medical  School  attached  to  King’s  College  Hospital,  which 
is  situated  at  Denmark  Hill,  S.E.  The  hospital  stands 
in  the  midst  of  a South  London  population,  from  which 
an  immense  amount  of  clinical  material  is  forthcoming,  an 
average  of  3500  out-patients  being  dealt  with  weekly.  There 
are  400  beds  available  for  in-patients,  and  provision  will 
ultimately  be  made  for  600  beds.  Special  departments  are 
provided  for  the  following  : diseases  of  women  and  children, 
the  eye,  ear,  throat  and  nose,  skin,  teeth  ; radiography,  radio- 
therapy and  radium-therapy  ; pathology,  massage,  medical 
gymnastics,  and  electro-therapeutics.  The  appointments 
open  to  students  are  those  of  senior  clinical  assistant  to  the 
special  departments  ; medical,  surgical,  and  obstetric  tutor- 
ships ; resident  casualty  officer  ; resident  anaesthetist ; resi- 
dent assistant  pathologist  ; and  medical,  surgical,  and 
obstetric  registrarships.  There  are  16  resident  medical 
and  surgical  officers  appointed  yearly. 

Scholarships  and  Prizes. — For  the  first  two  scholar- 
ships in  the  list  here  shown  a complete  course  at  King’s 
College  is  required.  The  money  value  and  subjects  of 
examination  are  as  follows  : — ( a ) Two  Warneford  Scholar- 
ships, tenable  for  four  years,  £25  each  per  annum  ; ( b ) Sam- 
brooke  Scholarship,  £50  ; (c)  Rabbeth  Scholarship,  £20 ; 
(d)  Medical  Entrance  Scholarships,  £50,  Anatomy  and 
Physiology,  and,  £50,  Pathology  and  Pharmacology,  open 
to  students  who  (1)  propose  to  take  a degree  at  any  British 
University,  and  have  passed  their  University  examination  in 
Biology,  Chemistry,  and  Physics,  and  who  (2)  will  become 
students  at  King’s  College  Hospital  from  date  of  entering 
upon  Scholarship  ; (e)  Two  Medical  Entrance  Scholarships 
one  in  Arts  and  one  in  Science,  £50  each,  tenable  for  five 
years,  successful  candidates  to  study  at  King’s  College  and 
King’s  College  Hospital  ; (f)  Three  Medical  Scholarships, 
£40  for  fifth-year  students,  £20  for  third-year  students, 
and  £20  for  second-year  students  ; (g)  Two  Sambrooke 
Registrarships,  open  to  matriculated  students  who  have  filled 
certain  appointments  in  hospital,  £50  each  ; ( h ) Carter 
Prize,  £15,  Botany  ; (i)  Tanner  Prize,  £10,  Obstetrics  and 
Diseases  of  Women  ; (j)  Todd  Prize,  £4  4s.  and  medal, 
Clinical  Medicine  ; (h)  Two  Burney  Yeo  Entrance  Scholar- 
ships, £80  each,  open  to  students  of  Oxford  and  Cambridge. 


Athletics. — The  King’s  College  Hospital  Clubs  and 
Societies  Union  was  formed  in  1908,  and  consists  of  the 
Listerian  and  Musical  Societies,  the  Students’  Common  Rooms, 
and  the  various  athletic  and  sports  clubs.  Admirable 
playing  fields,  over  six  acres  in  extent,  have  been  provided 
for  the  use  of  the  students  on  Dog  Kennel  Hill,  Lordship- 
lane,  S.E  , about  ten  minutes’  walk  from  the  hospital.  There 
are  also  Tennis  Courts  in  the  grounds  of  the  Hospital  and  of 
“The  Platanes,”  the  hall  of  residence  for  students  belonging 
to  the  hospital. 

Fees. — The  composition  fee  for  Hospital  work  and  Final 
subjects  of  the  curriculum  is  70  guineas  if  paid  in  one  sum, 
or  72  guineas  if  paid  in  two  instalments,  in  addition  to  the 
Entrance  Fee  of  10  guineas.  For  information  and 
prospectus  application  should  be  made  to  either  of  the 
following:  H.  Willoughby  Lyle,  M.D.  Lond  , F.R.C  S., 
Dean  ; S.  C.  Ranner,  M A.  Cantab  , Secretary  of  the  Medical 
School,  King's  College  Hospital,  Denmark  Hill,  S.E.  5 


London  Hospital. — The  hospital,  with  its  Medical  College 
and  Dental  School,  is"  situated  in  the  Mile  End-road,  E. 
The  hospital  contains  933  beds,  which  are  in  constant  use, 
and  is  the  only  general  hospital  for  East  London.  Duiing 
last  year  17,247  in-patients  and  94,554  out-patients  received 
treatment,  while  9056  major  operations  were  performed. 
26,319  out-patients  attended  the  special  departments  of  the 
Ear,  Nose,  Throat,  Skin,  Teeth,  &c.,  and  the  Obstetric, 
Orthorepdic,  and  Venereal  Departments.  The  hospital 
presents,  therefore,  a large  field  for  clinical  instruction,  and 
in  its  Wards  and  Out-patient  Departments  exceptional 
opportunities  are  offered  for  acquiring  an  extensive  and 
practical  experience  of  all  phases  of  disease.  Owing  to  the 
, large  number  of  patients  more  appointments  are  open  to 
students  before  and  after  qualification  than  at  any  other 
hospital.  Holders  of  resident  appointments  have  free  board. 
Special  classes  are  held  for  the  degrees  of  the  University 
of  London,  the  Fellowship  of  the  Royal  College  of  Surgeons, 
and  other  higher  examinations.  Special  entries  for  medical 
and  surgical  practice  can  be  made.  A residential  Hostel 
on  hospital  grounds  is  provided  for  the  convenience  of 
students.  The  Clubs  Union  Athletic  Ground  is  within  easy 
reach  of  the  hospital. 

Scholarships  and  Prizes. — At  this  school  the  successful 
candidates  for  the  first  items  in  the  list  here  shown 
must  enter  as  full  students.  The  value  and  the  sub- 
jects of  examination  are  as  follows : — Price  Scholarship 
£100  ; and  one  Entrance  Scholarship  of  £50,  subjects  of 
First  Medical  Examination  at  the  University  of  London  ; 
Epsom  College  Scholarship,  free  education,  subjects  of 
First  Medical  Examination  as  above ; Price  Scholarship, 
open  to  students  of  Oxford  and  Cambridge  Universities, 
£52  10,s‘. , Human  Anatomy  and  Physiology;  Buxton 

Scholarship,  £31  10s.,  subjects  of  Anatomy  and  Physiology  ; 
three  Scholarships  for  Clinical  Work,  £20  each,  Medicine, 
Surgery,  and  Obstetrics  ; Sutton  Prize.  £20,  Pathology ; 
Duckworth  Nelson  Prize,  biennial,  £10,  Pathology,  Practical 
Medicine,  and  Surgery  ; Letheby  Prizes  (2),  £25,  Chemistry  ; 
eight  Dressers’  Prizes,  amounting  to  £40,  zeal,  efficiency,  and 
knowledge  of  Elementary  Clinical  and  Minor  Surgery  ; 
Hutchinson  Prize,  triennial,  £40.  Clinical  Surgery  ; two 
Practical  Anatomy  Prizes,  £6  and  £4  respectively  ; Andrew 
Clark  Prize,  biennial,  £26.  Clinical  Medicine  and  Pathology  ; 
James  Anderson  Prizes,  £9,  Elementary  Clinical  Medicine  ; 
Forensic  Medicine  ; Arnold  Thompson  Prize,  £15  ; Wynne 
Baxter  Prize,  £5  5s.  : and  Liddle  Prize,  triennial,  £120. 

Medical  Research  Funds  — Research  Funds  of  over  £25,000, 
including  the  Eliza  Ann  Alston  Endowment  Fund  for  Medical 
Research,  provide  valuable  scholarships  for  men  wishing  to 
undertake  research  or  desirous  of  preparing  Theses  for 
University  degrees. 

The  Schorstein  Memoiial  hetures  in  Clinical  Medicine, 
which  have  been  postponed  during  the  war.  will  he  given 
during  1919-20  by  Sir  Archibald  E.  Gairod,  K.C.M.G  , 
F.R.S.,  physician  to  St.  Bartholomew’s  Hospital. 


St.  Mary’s  Hospital. — 305  beds.  The  number  of  in- 
patients treated  during  1918  was  3034.  The  number  of 
out-patients  was  11,346  with  19,145  casualty  cases,  a total 
of  30,491.  The  situation  of  the  hospital  and  Medical  School 
in  the  centre  of  the  residential  districts  of  Paddington, 
Bayswater,  and  North  Kensington  renders  it  exceptionally 
convenient  for  students’  rooms,  a register  of  which  is  kept 
by  the  authorities  for  the  use  of  students. 


364  The  Lancet,] 


MEDICAL  SCHOOLS  OF  THE  UNIVERSITY  OF  LONDON. 


[August  30, 1919 


Laboratories,  4'°-— The  Medical  School  provides  for  the 
entire  curriculum.  Special  laboratories  are  in  use  for 
Biology,  Chemistry,  and  l’hysics,  a series  of  lecture  theatres 
and  laboratories  for  Anatomy  and  Physiology,  and  a spacious 
and  well-lighted  dissecting-room.  The  Pathological  Depart- 
ment is  under  the  direction  of  Dr.  B.  H.  Spilsbury,  and  a 
block  of  consulting-rooms  and  laboratories  in  the  New  Wing 
of  the  Hospital  has  been  equipped  for  the  department  of 
Therapeutic  Inoculation. 

Appointments. — All  clinical  appointments  in  the  hospital 
are  free  to  students  of  the  Medical  School  and  the  resident 
medical  officers  are  chosen  by  competitive  examination. 
Six  house  physicians,  six  house  surgeons,  four  obstetric 
officers  are  appointed  in  each  year  and  receive  board  and 
lodging  in  the  hospital.  Two  resident  anaesthetists  are 
appointed  in  each  year  and  receive  a salary  at  the  rate  of 
£100  per  annum,  with  board  and  lodging.  Four  casualty 
house  surgeons  are  appointed  in  each  year  upon  the  same 
conditions.  Several  assistants  in  the  department  of  Thera- 
peutic Inoculation  are  appointed  annually  at  salaries  of 
£100  per  annum  and  upwards.  In  addition  to  the  above, 
the  senior  appointments,  medical,  surgical,  and  obstetric 
registrar,  casualty  physician,  demonstrator  of  anatomy, 
physiology,  and  biology,  are  made  annually. 

Clubs,  4'o. — The  amalgamated  clubs  include  all  the  various 
athletic  clubs,  as  well  as  the  medical  society,  &c. 
There  is  a students’  club  on  the  Hospital  premises,  the 
membership  of  which  is  included  in  the  amalgamated  clubs. 
The  athletic  clubs’  ground  at  Park  Royal,  Acton,  has  been 
commandeered  by  the  War  Office  and  sold.  Steps  are  now 
beiDg  taken  to  procure  a new  site. 

Special  Tuition. — Special  tuition  is  provided  for  the 
Intermediate  and  Final  Examinations  of  the  Universities 
of  Oxford,  Cambridge,  and  London,  and  for  the  Primary  and 
Final  F.R.C.S. 

The  composition  fee  for  full  students  is  £140  if  paid  in 
one  sum,  or  £145  if  paid  in  four  instalments.  University 
students  who  have  completed  their  examinations  in  Anatomy 
and  Physiology  are  admitted  on  payment  of  a composition 
fee  of  65  guineas  (£68  5s.)  paid  in  one  sum  or  by  payment 
of  two  annual  instalments  of  40  guineas  (£42)  and  30 
guineas  (£31  10s.)  respectively.  A system  of  annual  fees 
is  also  in  force  as  an  alternative  to  composition  fees. 
Separate  courses  of  lectures,  laboratory  work,  or  hospital 
practice  may  be  taken. 

Scholarships  and  Prizes. — The  money  value  and  subjects  of 
examination  of  these  are  as  follows : (a)  and  ( b ) Entrance 
Scholarships  in  Natural  Science,  £100  and  £50  respectively, 
awarded  by  competition  in  September  ; (c)  the  Frederic 
John  Palmer  Scholarship  in  Natural  Science,  £25  ; ( d ) 
University  Scholarship  in  Natural  Science,  open  to  members 
of  Oxford  or  Cambridge  University,  £52  10s.  ; (e)  University 
Scholarship  in  Natural  Science,  open  to  members  of  any 
British  University,  £52  10s.;  (/)  Epsom  Scholarship,  awarded 
by  nomination,  £52  10s.  ; ( g ) Gold  Medal,  £20.  an  Essay  on 
Some  Special  Point  in  Clinical  Medicine ; ( h ) Meadows’ 
Prize,  awarded  in  alternate  years,  £8,  Obstetrics  ; (i)  Wallace 
Memorial  Prize  and  Medal,  for  work  in  Vaccine  Therapy, 
£5  5s.;  (j)  David  Lees  Prize  in  Clinical  Medicine,  £8. 

Sir  John  Broadbent  is  Dean  of  the  Medical  School.  The 
School  Calendar  and  full  information  can  be  obtained  from 
the  Secretary,  Mr.  B.  E.  Matthews,  St.  Mary’s  Hospital 
Medical  School,  Paddington,  W. 


Middlesex  Hospital. — The  Hospital  and  Medical  School 
are  situated  in  Mortimer-street,  at  the  top  of  Berners-street, 
and  only  a few  minutes’  walk  from  Goodge-street  Station 
(Hampstead  and  Charing  Cross  Tube),  Oxford  Circus 
Stations  (Bakerloo  and  Central  London  Tubes),  and  Great 
Portland-street  Station  (Metropolitan  Railway). 

The  hospital  contains  455  beds,  including  special  wards 
for  Cancer  Cases,  Maternity  and  Gynecological  Cases,  and 
for  Diseases  of  Children  and  the  Skin  and  Eye. 

The  Cancer  Charity,  containing  92  beds  and  Special  Investi- 
gation Laboratories,  offers  unrivalled  opportunities  for  the 
study  of  Cancer,  both  in  its  clinical  and  pathological  aspects. 

In  the  Electro-Therapeutic  Department  students  obtain 
instruction  in  the  Treatment  of  Lupus  and  Cancer  by  the 
X Ray  method  of  treatment.  An  Electrocardiograph  Depart- 
ment has  recently  been  established. 

The  Hospital  and  Medical  School  are  fully  equipped  for 
the  theoretical  and  practical  teaching  of  all  the  subjects  of 


the  medical  curriculum,  and  for  the  Diplomas  in  Public 
Health,  for  which  two  courses  are  held  yearly,  commencing 
in  April  and  October.  Ample  laboratory  and  class-room 
accommodation  is  provided. 

The  Bland-Sutton  Institute  of  Pathology  contains  a new 
lecture  theatre  and  large  pathological,  bacteriological,  and 
clinical  laboratories  where  every  facility  is  given  for  original 
research.  The  Anatomical  and  Pathological  Museum  is  now 
part  of  the  Institute. 

Special  classes  are  held  to  prepare  students  for  the 
Intermediate  examinations  of  the  Universities,  and  for  the 
Primary  and  Final  examinations  for  the  F.R.C.S.  (England) 
Diploma.  There  is  a Residential  College  in  the  hospital  for 
students. 

Hospital  Appointments. — All  appointments  are  made  with- 
out fee  of  any  kind,  and  the  following  are  appointed 
at  intervals  annually  : six  house  physicians,  eight  house 
surgeons,  two  obstetric  and  gynaecological  house  surgeons, 
two  casualty  medical  officers,  two  casualty  surgical  officers, 
one  resident  anaesthetist,  and  two  resident  officers  to  the 
special  departments.  The  medical  and  surgical  casualty 
officers  are  appointed  twice  a year.  The  medical,  surgical, 
and  obstetric  and  gynaecological  registrars  are  appointed  as 
vacancies  arise. 

Non-resident  qualified  clinical  assistants  are  appointed  to 
assist  in  the  various  out-patient  departments.  Clinical  clerks 
and  surgical  dressers  are  also  appointed  in  every  department. 

Scholarships,  Prizes,  4'0. — (a),  (b),  and  (c)  Three  Entrance 
Scholarships,  value  £100,  £50,  and  £25,  and  (d)  a Uni- 
versity Scholarship,  value  £50,  are  awarded  annually  in 
September.  The  successful  candidates  are  required  to  become 
general  students  of  the  school,  (e)  A Freer  Lucas  Scholarship 
for  Students  of  Epsom  College  is  awarded  annually  on  the 
nomination  of  the  Headmaster.  There  are  also,  (f)  and  (g), 
two  Broderip  Scholarships,  value  £60  and  £40  respectively  ; 
(A)  the  Lyell  Gold  Medal  and  Scholarship,  value  £55  5s.  ; 
(i)  the  John  Murray  Medal  and  Scholarship,  value  £25 
(awarded  every  third  year)  ; (h)  the  Freeman  Scholarship, 
value  £30  ; (l)  the  Hetley  Clinical  Prize,  value  £25  ; (m)  the 
Leopold  Hudson  Prize,  value  11  guineas  ; and  (n)  the  Second 
Year’s  Exhibition,  value  10  guineas.  There  are  also  numerous 
class  prize  examinations. 

In  connexion  with  the  Cancer  Investigation  Department 
the  following  Scholarships  are  awarded  : — Richard  Hollins 
Research'  Scholarship,  value  £100  ; Walter  Emden  Scholar- 
ship, value  £100 ; and  a Cancer  Research  Scholarship, 
value  £60. 

Fees. — The  fees  are  arranged  on  a basis  of  an  annual  pay- 
ment of  £30  for  the  five  years  of  the  curriculum.  After  five 
years,  if  the  student  is  not  qualified,  the  annual  fee  is  £20. 

The  Amalgamated  Students’  Club  includes  the  following  : 
the  Medical  Society,  the  Common  Room  Society,  the 
cricket  club,  the  football  clubs,  the  athletic  club,  the 
rowing  club,  the  musical  society,  the  chess  club,  the  lawn 
tennis  club,  and  the  hockey  club.  A subscription  to  the 
Amalgamated  Students’  Club  is  payable  by  all  General  and 
Dental  students.  


St.  Thomas’s  Hospital. — This  hospital  received  its 
present  charter  from  King  Edward  VI.,  but  as  a monastic 
institution  was  in  existence  prior  to  the  year  1207.  The 
building  occupies  a unique  position  by  the  river,  opposite 
the  Houses  of  Parliament,  and  contains  1014  beds,  including 
530  for  military  patients.  The  in-patients  last  year 
numbered  9780,  whilst  the  number  of  attendances  as 
out-patients,  including  the  casualty  and  light  depart- 
ments, was  242,686.  There  are  special  departments  for  the 
treatment  of  women,  children,  the  eye,  ear,  nose  and  throat, 
skin,  and  teeth.  The  Tuberculosis  Department  forms  a part 
of  the  Lambeth  scheme  for  treatment  of  patients  and  for 
instruction.  The  Venereal  Department  has  been  established 
as  part  of  the  London  County  Council  scheme.  Depart- 
ments for  light  treatment.  X rajs,  and  the  Physico- 
therapeutic  Department  are  also  special  features.  A speech 
clinic  has  recently  been  inaugurated  in  connexion  with 
the  Children's  Department.  Exceptional  facilities  are  offered 
in  the  hospital  laboratories  for  the  study  of  general  patho- 
logy, clinical  pathology,  chemical  pathology,  cardiology,  and 
of"  treatment  by  serums  and  vaccines.  Surgical  operations 
take  place  in  the  main  theatres  every  day  except  Saturdays 
at  2 p.m.  Clinical  teaching  in  the  wards,  out-patients' and 
special  departments,  is  available  every  day  of  the  week. 


The  Lancet,] 


MEDICAL  SCHOOLS  OF  THE  UNIVERSITY  OF  LONDON.  [August  30,  1919  335 


Clinical  lectures  are  delivered  every  Wednesday  during 
the  sessions.  All  appointments  in  the  hospital  are 
open  to  students  without  extra  fee.  Clinical  assistants 
to  all  the  special  departments  are  appointed  every  three 
months.  A resident  assistant  physician  and  a resi- 
dent assistant  surgeon,  at  a salary  of  £150  each, 
are  appointed  biennially ; also  four  hospital  registrars 
(medical,  surgical,  obstetric,  and  ophthalmic),  the  two 
former  receive  a salary  of  £150  and  the  two  latter  £50. 
An  assistant  in  the  clinical  laboratory  and  an  assistant 
pathologist  are  paid  at  the  rate  of  £200  per  annum. 
Appointments  open  to  students  before  qualification : 
Clinical  clerks  and  dressers  for  in-  and  out-patients 
are  selected  from  students  who  have  completed  their 
third  year’s  work.  Every  student  acts  as  clerk  in  the  post- 
mortem room  and  in  one  of  the  pathological  laboratories, 
takes  his  turn  on  maternity  duty  under  proper  supervision 
in  the  maternity  ward,  thus  obviating  any  necessity  for 
seeking  instruction  elsewhere.  Students  are  instructed  in 
the  administration  of  anesthetics  by  one  of  the  hospital 
anesthetists.  The  Students’  Club  comprises  a spacious 
restaurant  and  smoking  and  reading  room.  There  is  no 
occasion  for  students  to  leave  the  hospital  buildings 
during  working  hours.  The  curriculum  is  arranged  to 
meet  the  requirements  of  all  the  Examining  Bodies. 
Special  classes  are  held  for  the  examinations  at  the  Uni- 
versity of  London  and  for  the  First  and  Final  Fellowship 
Examinations  of  the  Royal  College  of  Surgeons  of  England. 
Tutorial  classes  in  all  subjects  precede  the  various  exa- 
minations. The  hospital  is  easily  accessible  from  all  parts. 

Fees. — The  annual  composition  fee  is  30  guineas, 
covering  all  tutorial  classes — in  addition  to  a fee  on  en- 
trance. Qualified  practitioners  are  permitted  to  attend  the 
hospital  practice  on  terms  which  may  be  ascertained  from 
the  secretary. 

Scholarships  and  Prizes. — At  this  school  there  are  five 
Entrance  Scholarships — namely,  two  in  Arts,  equivalent  to 
the  tuition  fees  for  the  first  medical  examination  ; two  in 
Natural  Science,  of  the  value  of  £150  and  £60  respectively, 
to  be  taken  out  in  tuition  fees  ; and  the  University  Scholar- 
ship of  £50  in  Anatomy,  Physiology,  and  Chemistry.  The 
money  value  and  subjects  of  examination  of  the 
remainder  are  as  follows : (a)  and  ( b ) two  College 

Prizes,  one  for  second-year  students  and  one  for  third-year 
students,  £10  and  £5  respectively  ; (0)  William  Tite 

Scholarship  for  second-year  students,  £25  ; ( d ) and  ( e ) 
Musgrove  Scholarship  or  (alternately)  Peacock  Scholar- 
ship, each  for  third-year  students  and  tenable  for  two 
years,  £35  each ; (/)  three  College  Prizes  for  fifth-year 
students  of  £10  each  and  three  of  £5  each  ; (y)  Cheselden 
Medal,  Surgery  and  Anatomy;  (A)  Mead  Medal,  Medicine, 
Pathology,  and  Hygiene ; (i)  Toller  Prize,  Medicine, 
Pathology,  and  Hygiene  ; (j)  Bristowe  Medal,  Pathology 
and  Morbid  Anatomy  : ( k ) Solly  Medal  and  Prize,  biennially, 
Surgical  Reports  ; (l)  Treasurer’s  Gold  Medal  for  the  most  dis- 
tinguished fifth-yearstudent  ; (to)  Wain  wright  Prize,  Medicine, 
Pathology,  and  Hygiene  ; ( n ) Hadden  Prize,  Pathology ; (0) 
Beaney  Scholarship,  £50  biennially,  Surgery  and  Surgical 
Pathology;  (p)  Sutton  Sams  Prize,  biennially,  reports  of 
cases  in  Obstetric  Medicine  ; (y)  Grainger  Testimonial  Prize, 
£31  10s.  Anatomy  and  Physiology  ; ( r ) Salters’  Company 
Research  Fellowship,  tenable  for  three  years,  £100  annually, 
Pharmacology  ; (s)  Louis  Jenner  Research  Scholarship, 

tenable  for  two  years,  £60  annually,  Pathology ; and 
(f)  Research  Scholarship,  tenable  for  two  years,  £200  per 
annum. 

The  Dean  of  the  Medical  School  is  S'r  Cuthbert  S. 
Wallace,  the  Sub-Dean  Dr.  C.  R.  Box,  and  the  Secretary 
Dr.  A.  Elliot,  from  whom  any  further  information  may  be  I 
obtained. 


University  of  London,  University  College. — Uni- 
versity College  has  been  constituted  a University  centre 
for  the  teaching  of  medical  sciences.  The  College  Faculty 
of  Medical  Sciences  comprises  the  Departments  of  Physics, 
Chemistry,  Botany,  and  Zoology  (the  Preliminary  Medical 
Sciences)  ; also  the  Departments  of  Anatomy,  Physiology, 
and  Pharmacology  (the  Intermediate  Medical  Sciences),  and 
the  Department  of  Hygiene  and  Public  Health  (Post-graduate 
Study). 

faculty  of  Medical  Sciences. — Composition  fees. — For 
the  courses  required  by  the  University  of  London.  1.  For 


the  First  Medical  Course,  26  guineas,  entitling  to  one 
attendance  and  to  the  privileges  of  the  Union  Society 
for  one  session.  2.  For  the  Second  Medical  (Intermediate) 
Course,  58  guineas  if  paid  in  one  sum ; 60  guineas  if  paid 
in  two  instalments  of  30  guineas  each.  This  fee  entitles 
to  attendance  at  Anatomy  and  Physiology  during  three 
years  and  to  one  attendance  at  Organic  and  Applied 
Chemistry,  Pharmacology,  and  Materia  Medica,  and  to  the 
privileges  of  the  Union  Society  for  two  sessions. 

For  the  medical  education  required  by  the  Examining 
Board  in  England  and  the  Society  of  Apothecaries.  First 
examination,  Parts  I.,  II.,  III.,  21  guineas,  entitling  to 
attendance  for  the  First  and  Second  Terms  and  to  the 
privileges  of  the  Union  Society  for  one  session  ; 26  guineas, 
entitling  to  attendance  throughout  the  session  and  to  the 
privileges  of  the  Union  Society  for  one  session.  First  Exa- 
mination, Part  IV.,  and  second  examination,  58  guineas  if 
paid  in  one  sum,  and  60  guineas  if  paid  in  two  instalments 
of  30  guineas  each.  This  fee  entitles  to  attendance  during 
three  years  in  all  subjects  but  Practical  Pharmacy  and  to 
the  privileges  of  the  Union  Society  for  two  sessions. 

Scholarships  and  Prizes. — The  first  three  items  on  the 
present  list  require  a complete  intermediate  course  ate 
University  College.  The  money  value  and  subjects  at  exami  - 
nations are  as  follows  : ( a ) The  Bucknill  Scholarship,  135- 
guineas  ; ( b ) and  (c)  two  Entrance  Exhibitions,  55  guineas 
each,  Chemistry,  Physics,  Botany,  and  Zoology  ; ( d ) Cluff 
Memorial  Prize,  £15  biennially,  Anatomy,  Physiology,  and 
Chemistry  ; ( e ) Schafer  Prize  in  Physiology,  £18  triennially  ; 
(_/ ) Sharpey  Physiological  Scholarship,  £105,  Biological 
Sciences  ; (y)  Morris  Bursary  for  sons  of  deceased  profes- 
sional men,  by  nomination,  tenable  for  two  years,  £16  a 
year  ; and  (A)  five  Gold  and  five  Silver  Medals  awarded 
annually  in  various  departments. 

Women  students  are  admitted. 

University  College  Hospital  Medical  School. — 
Dean  : Dr.  G.  F.  Blacker.  Acting  Secretary  : G.  E. 

Adams.  Open  to  men  and  women  students.  Fees  for 

Preliminary  and  Intermediate  Course  : See  under  University 
College.  For  the  Final  M.B. , B.S.  (London)  Course, 

80  guineas  if  paid  in  one  sum,  82  guineas  if  paid 

in  two  instalments,  as  follows — first  year,  50  guineas  ; 
second  year,  32  guineas.  This  fee  entitles  to  attendance 
on  Lectures  and  Hospital  Practice  during  three  years  and 
to  one  attendance  on  Practical  Pathology  and  Practical 
Surgery.  Vaccination  and  attendance  at  a Fever  Hospital 
are  not  included.  This  course  of  instruction  is  also  suitable 
for  the  corresponding  examinations  at  the  Universities  of 
Oxford,  Cambridge,  and  Durham,  and  for  the  medical 
education  required  by  the  Examining  Board  in  England 
and  the  Society  of  Apothecaries. 

There  are  over  300  beds  in  the  hospital. 

Special  Departments , Clinical  and  Laboratory  Facilities. — 
Those  who  are  desirous  of  carrying  out  original  research  in 
Pathology,  including  Morbid  Anatomy,  Bacteriology,  Experi- 
mental Pathology,  and  Chemical  Pathology,  are  admitted  to 
work  in  the  laboratories  of  the  school  by  the  Professor  of 
Pathology,  and  under  certain  conditions  can  receive  grants 
from  the  Charles  Graham  Medical  Research  Fund.  A special 
course  of  instruction  is  given  in  conjunction  with  Uni- 
versity College  for  preparation  for  the  examinations  for 
Diplomas  in  Public  Health  of  the  various  universities  and 
examining  bodies.  Special  courses  of  Lectures  and 
Demonstrations  in  Anesthetics,  Diseases  of  the  Eye,  of 
the  Ear,  Nose,  and  Throat,  and  of  the  Skin,  in  Elec- 
trical and  Radioscopic  Diagnosis  and  Treatment,  and 
in  Clinical  and  Cardiac  Pathology  are  also  given. 
These  courses  are  designed  for  senior  students  and 
graduates.  Special  arrangements  have  been  made  which 
enable  students  of  University  College  Hospital  to 
carry  out  a portion  of  their  clinical  studies  at  the 
National  Hospital  for  Nervous  Diseases,  Queen-square, 
the  Children’s  Hospital,  Great  Ormond-street,  and  the 
Central  London  Ophthalmic  Hospital,  Judd-street.  The 
Royal  Ear  Hospital,  Dean-street,  Soho,  has  been  amalga- 
mated with  University  College  Hospital  as  the  Ear,  Nose 
and  Throat  Department.  In  the  Dental  Department  in  Great 
Portland- street,  formerly  known  as  the  National  Dental 
Hospital,  there  is  afforded  the  opportunity  for  attending 
lectures  and  practical  instruction  in  diseases  of  the  mouth 
and  teeth. 


366  Thb  Lancet,] 


MEDICAL  SCHOOLS  OF  THE  UNIVERSITY  OF  LONDON. 


[August  30,  1919 


Appointments  tenable  by  Students. — Clerkships  and  dresser- 
ships  to  the  physicians,  surgeons,  anaesthetist,  and  patho- 
logist are  allotted  amongst  the  students  of  the  hospital. 
Maternity  students  are  appointed  each  month  and  reside  in 
the  Studentb’  House  connected  with  the  Medical  School  and 
Hospital.  Eight  house  physicians  and  house  surgeons,  four 
senior  and  four  junior  obstetric  assistants,  are  selected 
annually  by  examination  from  among  the  senior  students 
who  have  a medical  qualification.  The  house  physicians 
and  house  surgeons  reside  free  in  the  hospital  for  six  months, 
and  the  senior  obstetric  assistants  for  three  months.  In 
addition  to  these  posts  there  are  certain  special  appoint- 
ments which  are  vacant  from  time  to  time  and  are  filled  by 
senior  students  of  the  hospital  : 1.  The  Resident  Medical 
Officer.  This  officer  is  appointed  for  a period  of  two  years 
and  is  chosen  from  amongst  the  more  senior  recent  residents 
of  the  hospital.  2.  The  two  Surgical  Registrars  are  also  chosen 
from  among  the  more  senior  recent  residents  of  the  hospital. 
3.  The  Obstetric  Registrar.  4.  Two  Casualty  Medical  Officers 
and  a Casualty  Surgical  Officer  are  appointed,  each  for  a 
period  of  six  months.  5.  Assistant  in  Ear  and  Throat 
Department,  appointed  for  one  year.  6.  Assistant  in  Oph- 
thalmic Department,  appointed  for  one  year.  7.  Registrar  in 
Anaesthetic  Department,  appointed  for  one  year.  8.  Deputy 
Anaesthetists.  During  the  absence  of  one  or  another  of  the 
Anaesthetists  in  the  summer  months  a senior  qualified  student 
is  appointed  as  a substitute  and  is  granted  a special 
certificate. 

Museum  of  Pathological  Anatomy.  -The  Museum  is  open 
for  study  from  9 a.m.  to  5 p.m.  Microscopic  sections  of 
most  of  the  specimens  in  the  Museum  have  been  prepared 
and  are  available  for  the  use  of  students  on  application  to 
the  Curator.  The  Museum  contains  1100  admirable  paint- 
ings by  Sir  Robert  Carswell  and  Sir  Charles  Bell  and  a 
collection  of  old  surgical  instruments  formerly  belonging 
to  Robert  Liston. 

The  Anatomical  Museum  of  the  University  of  London, 
University  College,  is  open  to  all  students  of  University 
College  Hospital  and  Medical  School  on  the  recommendation 
of  the  School  Committee. 

The  Medical  Library  is  open  daily  for  the  purposes  of  study 
to  every  student  of  the  Medical  School  from  9 a.m.  to  5 P.M., 
Saturdays  9 a.m.  to  1 p.m.  It  contains  about  13,500  works 
on  medical  subjects,  including  all  the  current  text-books 
and  works  of  reference  required  for  study  or  research. 

The  Medical  Society  of  University  College  Hospital 
Medical  School  exists  for  the  dual  purpose  (1)  of  pro- 
moting the  study  of  Medical  and  Surgical  Science, 
and  (2)  of  promoting  social  intercourse  among  its 
members.  All  Students  of  the  Medical  School  are  eligible 
for  membership.  Meetings  are  held  once  a fortnight 
for  the  purpose  of  discussing  subjects  connected  with 
the  study  of  medicine.  In  its  social  aspect  the  society 
includes  various  athletic  clubs  and  superintends  the 
gymnasium  and  squash  racquet  court  in  the  Medical 
School.  The  Athletic  Ground,  which  is  used  in 
conjunction  with  the  Union  Society  of  the  University  of 
Loudon  University  College,  is  situated  near  the  Great 
Western  Railway  station  at  Perivale. 

Scholarships  and  Prizes. — At  this  School  the  first  two 
Scholarships  ( a ) and  (A)  entitle  the  holder  to  a complete  course 
at  University  College  and  University  College  Hospital  Medical 
School  ; the  second  two  (e)  and  ( d ) entitle  to  a final  course 
at  the  Medical  School.  The  money  value  and  subjects 
of  examination  are  as  follows : — (a)  Entrance  Scholar- 
ship, Bucknill,  135  guineas,  Chemistry.  Physics,  Botany, 
and  Zoology  ; (A)  Epsom  Free  Medical  Scholarship,  subjects 
of  Preliminary  Scientific  Examination  and  Nomination  by 
Epsom  College  ; ( o ) and  ( d ) two  Goldsmid  Entrance  Exhibi- 
tions. 80  guineas  each.  Anatomy  and  Physiology  ; ( e ) Graham 
Scholarship  in  Pathology,  £200  per  annum  for  two  years, 
awarded  by  the  Senate  of  the  University  of  London  ; 
(/■)  Atkinson  Morley  Scholarship,  tenable  for  three  years, 
£45  per  annum,  Surgery  ; (g)  Atchison  Scholarship,  tenable 
for  two  years,  £55  per  annum  ; General  Proficiency  in 
Medical  Studies : (A)  Magrath  Clinical  Scholarship,  about 
£100,  Clinical  Cases  ; (i)  Percival  Alleyn  Scholarship,  about 
£60,  Surgery;  (j)  Filliter  Exhibition,  £30,  Pathology; 
(A)  Erichsen  Prize,  £10  10s.,  Practical  Surgery;  ( l ) two 
Senior  and  two  Junior  Fellowgs  Clinical  Medals  for  Clinical 
Medicine  ; (»i)  two  Liston  Gold  Medals  for  Clinical  Surgery  ; 
(»)  Alexander  Bruce  Gold  Medal  for  Pathology  and 


Surgery  ; and  (o)  Tuke  Silver  and  Bronze  Medals  for 
Pathology,  (p)  Radcliffe  Crocker  Travelling  Scholarship 
for  Dermatology.  ( q ) Leslie  Pearce  Gould  Travelling 

Scholarship  tor  Surgery. 

Residence  of  Students. — University  College  Hall,  Ealing, 
is  recognised  by  the  Medical  School  authorities  as  a 
residential  hostel.  The  Students’  House  in  University- 
street  contains  large  and  comfortable  rooms.  The  Maternity 
Students  occupy  them  on  payment  of  a moderate  charge. 
Gentlemen  who  desire  assistance  in  their  studies  should 
consult  the  Dean  or  Lecturers. 

Westminster  Hospital.— The  hospital  contains  215 
beds  and  affords  relief  to  upwards  of  2000  in-patients  and 
30,000  out-patients  annually.  There  are  separate  depart- 
ments for  Diseases  of  the  Eye,  Ear,  Skiif,  Teeth,  and  Throat, 
for  Orthopedic,  practice,  for  Diseases  of  Women,  for  Diseases 
of  Children,  for  Radiography,  and  for  the  Light  Treatment. 
The  Anatomical,  Pathological,  and  Materia  Medica  Museums 
are  open  to  all  students  of  the  school. 

The  usual  registrarships  and  house  appointments  will  be 
made  as  soon  after  the  conclusion  of  the  war  as  possible. 

By  a scheme  for  the  concentration  of  the  teaching  of  the 
preliminary  and  intermediate  subjects  of  the  curriculum, 
which  has  the  support  of  the  London  University,  an 
arrangement  has  been  made  by  the  Westminster  School 
for  the  teaching  of  these  subjects  at  King’s  College. 
Students,  however,  may  join  the  Westminster  Medical  School 
as  formerly  and  may  compete  for  Entrance  Scholarships  as 
heretofore. 

Scholarships  and  Prizes. — The  following  Entrance  Scholar- 
ships are  offered  for  competition  : Winter  Session  : (a)  Arts 
Scholarship,  the  “Guthrie,”  £60.  (A)  Science  Scholarships  : 

Natural  Science  Scholarship,  £60  ; Chemistry  and  Physics 
Scholarship,  £30  ; and  Two  Scholarships  in  Anatomy  and 
Physiology,  £50  each.  Summer  Session : Two  Scholar- 

ships in  Anatomy  and  Physiology,  £50  each.  During 
the  period  of  study  the  following  prizes  may  be 
competed  for : Sturges  Prize  in  Clinical  Medicine, 

about  £6,  Notes  of  Cases ; Clinical  Surgery  Prize, 
£5,  Notes  of  Cases  ; Chadwick  Prize  £21  in  books 
or  instruments — Medicine  and  Surgery,  including  Patho- 
logy and  Applied  Anatomy  and  Physiology ; Frederic 
Bird  Medal  and  Prize,  open  to  Fourth-year  Students, 
£14  in  medal  and  books  or  instruments — Midwifery, 
Diseases  of  Women,  Medicine,  Pathology,  Forensic 
Medicine  and  Bacteriology,  and  Public  Health  and  Toxico- 
logy ; Abrahams  Prize  in  Clinical  Pathology,  5 guineas,  a 
Paper  and  Tests  in  Practical  Work  ; Alfred  Hughes  Memorial 
Prize,  open  to  Second-year  Students,  about  £5  in  books 
or  insiruments — Anatomy  ; Huxley  Memorial  Prize,  3 
guineas  in  books  or  cash,  open  to  Second-year  Students — 
Physiology ; Carter  Gold  Medal  and  Prize  for  Botany, 
open  to  Students  of  not  more  than  three  years’  attendance, 
gold  medal  and  books  of  the  joint  value  of  £15 ; 
Jelf  Medal  awarded  to  Third-year  Students ; Second- 
year  Scholarship,  £20,  Elementary  Anatomy,  Physiology, 
Histology,  and  Organic  Chemistry ; Daniell  Scholarship, 
tenable  for  two  years,  £20,  Chemistry  ; Rabbeth  Scholar- 
ship, open  to  First-year  Students,  £20,  Class  Examinations 
in  the  Preliminary  Scientific  Course  ; and  the  Sambrooke 
King’s  College  Scholarship  in  Science,  value  £25. 

The  Dean  is  Dr.  David  de  Souza,  to  whom  inquiries  may 
be  addressed.  

London  (Royal  Free  Hospital)  School  of  Medicine 
for  Women,  8,  Hunter-street,  Brunswick-square,  W.C. — 
The  fee  for  the  medical  course  for  the  degrees  of  the 
University  of  London  and  for  the  diplomas  of  the  Royal 
Colleges  of  England  and  for  other  qualifications  is  £169 
in  one  sum,  or  £179  in  five  instalments.  These  sums 
include  library  and  laboratory  fees. 

The  Royal  Free  Hospital  contains  230  beds.  Students 
also  attend  the  in-patient  and  out-patient  practice  of  the 
Elizabeth  Garrett  Anderson  Hospital,  Cancer  Hospital, 
Hospital  for  Sick  Children.  Great  Ormond-street,  National 
Hospital  for  Paralysed  and  Epileptic,  and  Brompton  Chest 
Hospital. 

An  agreement  has  been  made  under  which  students  of 
the  school  attend  full  clinical  courses  at  St.  Mary’s  Hospital, 
Paddington  (305  beds). 

Special  courses  are  arranged  for  the  Primary  Fellowship 
Examination  of  the  College  of  Surgeons  ; also  for  dental 


The  Lancet,] 


UNIVERSITY  OF  DURHAM. 


[August  30, 1919  367 


students  in  conjunction  with  the  London  Dental  Hospital, 
Leicester-square,  and  the  National  Dental  Hospital. 

Students  after  qualification  can  hold  the  posts  of  house 
physician,  house  surgeon,  obstetric  assistants,  clinical  assist- 
ants, assistant  anaesthetist,  medical,  gynaecological,  and 
surgical  registrars,  assistant  pathologist,  and  museum  curator ; 
and  at  the  Medical  School  the  posts  of  demonstrators  in  the 
departments  of  Anatomy,  Physiology,  Pharmacology,  Biology, 
Chemistry,  and  Physics.  Many  other  resident  posts  in 
London  and  elsewhere  are  also  open  to  them. 

The  School  buildings  have  been  entirely  rebuilt  in  recent 
years,  and  there  are  spacious,  well-equipped  laboratories, 
which  afford  every  facility  for  efficiency  of  teaching  and 
practical  work  in  all  departments. 

There  are  residential  chambers  at  8,  Hunter-street, 
25,  Gordon-square,  16,  Brunswick-square,  and  36,  Tavistock- 
square,  and  the  Warden  can  be  consulted  on  the  subject  of 
other  residences  for  students.  The  Students’ Union  arranges 
the  social,  athletic,  and  other  clubs  and  societies  at  the 
School. 

Scholarships  and  Prizes. — ( a ) Isabel  Thorne  Scholarship, 
£30,  ( b ) St  Dunstan’s  Medical  Exhibition,  £60  a year, 

tenable  for  three  or  five  years,  (c)  Mrs.  George  M.  Smith 
Scholarship,  £50  a year,  tenable  for  three  or  five  years 
and  next  to  be  awarded  in  1921.  (d)  Bostock  Scholarship, 

tenable  for  two  or  four  years,  and  next  to  be  awarded  in 
June,  1923,  £60.  (e)  Mabel  Sharman-Crawford  Scholarship, 

tenable  for  four  years,  £20  a year.  ( f ) Sir  Owen  Roberts 
Scholarship,  £75  a year  for  four  years.  (g)  Mabel  Webb 
Research  Scholarship,  tenable  for  one  year  and  renewable, 
£30,  Physiology,  Chemistry,  or  Pathology.  (A)  Fanny 
Butler  Scholarship,  tenable  for  four  years  ; next  award  in 
July,  1922,  £14  10s.  (i)  John  Byron  Bursary,  tenable 

from  two  to  four  years,  for  students  already  in  the  School 
requiring  assistance  for  the  prosecution  of  their  medical 
studies,  application  to  the  Secretary  by  March  31st  ; next 
award  in  March,  1921,  £20.  (h)  Ellen  Walker  Bursary  tenable 
for  two  years,  awarded  to  a student  beginning  fourth  year  of 
medical  study,  £25  a year.  (1)  Helen  Prideaux  Scholarship, 
awarded  every  second  year  to  a student  who  has  become 
qualified  during  the  two  years  immediately  preceding  the 
award,  and  to  be  spent  in  assisting  the  holder  to  further 
study,  £40.  ( m ) Agnes  Guthrie  Bursary,  value  £50,  is  offered 
annually  to  students  who  desire  to  pursue  a full  course  of 
study  for  the  Licentiateship  in  Dental  Surgery,  (n)  Dr.  Edith 
Pechey  Phipson  Post-graduate  Scholarship  of  the  value  of 
£40,  awarded  annually  in  June.  It  is  open  to  all  medical 
women,  preferably  coming  from  India,  or  going  to  work  in 
India,  for  assistance  in  Post-graduate  study.  ( o ) Sarah 

Holborn  Scholarship,  value  £20  a year  for  three  or  five 
years,  awarded  every  alternate  year  ; next  award  in 
1921.  (p)  Dr.  Margaret  Todd  Scholarship,  tenable  for  four 

years,  £37  10s.  a year,  awarded  in  alternate  years  ; next 
award  in  July,  1921.  (q)  Lieutenant  Edmund  Lewis  and 

Lieutenant  Alan  Lewis  Memorial  Scholarship,  tenable  for 
four  years,  awarded  every  four  years  ; next  award  in  July, 
1920.  Two  Richardson- Kuhlmann  Prizes  are  given  each 
year,  value  £12,  for  proficiency  in  Clinical  Obstetrics, 
value  £8,  for  proficiency  in  senior  subjects  respectively. 
Two  Evans  Prizes  of  £2  2s.  and  £1  Is.  are  given  each  year 
on  the  results  of  the  class  examination  in  Midwifery.  The 
Evans  Prize  for  Operative  Midwifery,  value  £5  5s.,  is 
awarded  yearly.  The  Edith  Pechey  Phipson  Prize  in  Pharma- 
cology, value  £3  3s.,  is  awarded  annually.  There  is  also  a 
small  loan  fund  from  which  assistance  can  occasionally  be 
given  to  students  and  to  graduates  who  specially  require 
pecuniary  help.  Prizes  and  Certificates  of  Honour  are 
awarded  in  each  class  at  the  end  of  the  session. 

The  Dean  of  the  Medical  School  is  Miss  Aldrich-Blake, 
M.D.,  M.S.  ; the  Honorary  Secretary,  Dr.  May  Thorne  ; and 
the  Warden  and  Secretary,  Miss  L.  M.  Brooks,  to  whom 
inquiries  may  be  addressed. 


UNIVERSITY  OF  DURHAM. 

Two  Diplomas,  one  Licence,  and  six  degrees  are  conferred 
— viz.,  the  Diploma  in  Public  Health,  Diploma  in  Psychiatry, 
the  Licence  in  Dental  Surgery,  and  the  degrees  of  Bachelor 
of  Medicine,  Bachelor  of  Surgery,  Master  of  Surgery, 
Doctor  of  Medicine,  Bachelor  of  Hygiene,  and  Doctor  of 
Hygiene. 

For  the  degree  of  Bachelor  of  Medicine  there  are 
four  professional  examinations.  The  subjects  of  the 


First  Examination  are — Elementary  Anatomy,  Elementary 
Biology,  Chemistry,  and  Physics.  The  subjects  of  the 
Seoond  Examination  are— Anatomy  and  Physiology.  The 
subjects  for  the  Third  Examination  are — Materia  Medica 
and  Pharmacy,  Pathology,  Medical  Jurisprudence,  Public 
Health,  and  Pathology  and  Elementary  Bacteriology.  The 
subjects  of  the  Fourth  Examination  are — Medicine,  Clinical 
Medicine  and  Psychological  Medicine,  Surgery  and  Clinical 
Surgery,  Midwifery  and  Gynaecology,  Therapeutics,  and 
Diseases  of  the  Skin,  of  the  Throat,  Nose,  and  Ear,  and  of 
Children. 

It  is  required  that  at  least  one  of  the  five  years  of 
professional  education  shall  be  spent  in  attendance  at 
the  University  College  of  Medicine,  Newcastle-upon-Tyne. 
Candidates  who  have  passed  the  First  and  Second  Examina- 
tions of  the  University  will  be  exempt  from  First  and  Second 
Examinations  of  the  Conjoint  Board. 

For  the  degree  of  Bachelor  of  Surgery  every  candidate 
must  have  passed  the  examination  for  the  degree  of 
Bachelor  of  Medicine  of  the  University  of  Durham  and  must 
have  attended  one  course  of  lectures  on  Operative  Surgery 
and  one  course  on  Applied  Anatomy.  Candidates  will  be 
required  to  perform  operations  on  the  dead  body  and  to 
give  proof  of  practical  knowledge  of  the  use  of  surgical 
instruments  and  appliances. 

For  the  degrees  of  Doctor  oj  Medicine  and  Master  of 
Surgery  a candidate  must  not  be  less  than  24  years 
of  age  and  must  satisfy  the  University  as  to  knowledge 
of  Greek  or  German.  If  he  has  not  already  satisfied 
the  Matriculation  Examiners  in  either  Greek  or  German 
he  must  pass  in  one  of  these  subjects  at  one  of  the 
ordinary  matriculation  examinations  of  the  Newcastle 
division  of  the  University.  He  must  also  have  obtained 
the  degree  of  Bachelor  of  Surgery  of  the  University  of  Durham 
and  must  have  been  engaged  for  at  least  two  years  sub- 
sequently to  the  date  of  acquirement  of  the  degree  of  Bachelor 
of  Surgery,  in  attendance  on  the  practice  of  a recognised 
hospital,  or  in  the  naval  or  military  services,  or  in  medical 
or  surgical  practice.  The  candidate  for  the  M.D.  degree 
must  present  an  essay.  The  subjects  of  examination  for 
the  M S.  are: — Principles  and  Practice  of  Surgery,  Surgical 
Pathology,  Surgical  Anatomy,  Surgical  Operations,  Clinical 
Surgery. 

Doctor  of  Medicine  (without  residence). — The  Uni- 
versity of  Durham  has  instituted  a special  examina- 
tion whereby  the  degree  of  Doctor  of  Medicine  may  be 
obtained  without  residence.  Candidates  shall  not  be  under 
40  years  of  age  and  shall  have  been  in  active  practice  for 
15  years  as  registered  medical  practitioners.  They  shall 
produce  certificates  of  moral  character  from  three  registered 
members  of  the  medical  profession.  The  fee  will  be 
50  guineas,  of  which  20  guineas  will  be  retained  if  the 
candidate  fails  to  satisfy  the  examiners. 

Candidates  for  any  of  the  above  degrees,  diplomas  or 
licence,  must  give  at  least  28  days’  notice  to  Professor 
Howden,  Secretary,  College  of  Medicine,  Newcastle-upon- 
Tyne.  In  the  case  of  the  M.D.  (essay)  examination  candi- 
dates must  send  in  their  essays  six  weeks  before  the  date  of 
the  examination. 

Scholarships  and  Prizes. — In  connexion  with  this  Uni- 
versity the  following  Scholarships  and  prizes  are 
awarded  : — (a),  (h),  ( c ),  and  (d).  Four  Scholarships 
of  £25  a year  each,  tenable  for  four  years  ; the  exa- 
mination will  be  the  September  Matriculation  Examina- 
tion. Candidates  must  take  English,  Latin,  Arithmetic, 
Euclid,'  Algebra,  Geography,  English  History,  and  one, 
or  two,  of  the  three  languages — French,  Greek, 
German.  (See  College  Calendar  for  special  books.) 
Open  to  candidates  desirous  of  being  admitted  as  Medical 
Students.  The  successful  candidates  must  take  out  their 
entire  curriculum  at  the  University  of  Durham  College  of 
Medicine,  Newcastle-upon-Tyne.  ( e ) Pears  Scholarship  of  £50 
a year  (when  vacant),  tenable  for  three  years  ; Ma'riculation 
Examination. — At  the  College  of  Medicine  are  : (/)  Dickinson 
Scholarship,  interest  on  £400  and  gold  medal  ; examination 
in  Medicine,  Surgery,  Midwifery,  and  Pathology.  Open  to 
full  students  of  the  College  of  Medicine  who  have  passed  the 
third  M.B.  Examination,  (g)  Tulloch  Scholarship,  interest- 
on  £400  ; examination  in  Elementary  Anatomy,  Biology, 
Chemistry,  and  Physics.  (A)  Charlton  Memorial  Scholar- 
ship, interest  on  £700  ; examination  in  Medicine.  Open 
to  full  students  of  the  College  entered  for  the  class  on  the 


H68  Thb  Lancet,] 


UNIVERSITY  OF  BIRMINGHAM. 


[August  30, 1919 


Principles  and  Practice  of  Medicine,  (i)  Gibb  Scholarship, 
interest  on  £500  ; awarded  annually  as  a Scholarship  in 
Pathology  to  full  student  who  passes  the  best  examination 
in  that  subject.  No  student  is  eligible  after  completion  of 
his  curriculum,  (j)  Luke  Armstrong  Memorial  Scholarship, 
interest  on  £680  : Original  Essay  on  some  subject  in  Com- 
parative Pathology.  (If  no  essay  of  sufficient  merit  be 
presented  the  scholarship  may  be  awarded  to  the  candidate 
who,  in  passing  the  first  part  of  the  Examination  for  the 
B.Hy.  Degree,  obtains  the  highest  number  of  marks  in 
Comparative  Pathology  during  the  year.)  Open  to  all 
Graduates  in  Medicine  or  Hygiene  and  candidates  for  these 
degrees  who  have  spent  six  months  at  the  University  and 
whose  age  does  not  exceed  30  years.  (It)  Stephen  Scott 
Scholarship,  interest  on  £1000 ; Original  Essay  on  any 
Surgical  subject.  Open  to  any  graduate  in  Medicine  or 
Surgery  of  the  University  or  any  student  of  the  College 
of  Medicine.  Student's  age  must  not  exceed  30  years. 
( l ) Heath  Scholarship  in  Surgery,  of  the  value  of  £200, 
awarded  every  second  year.  All  Graduates  in  Medicine  or 
Surgery  of  the  University  are  eligible.  (m)  Philipson 
Scholarships  (2).  The  interest  on  £1800  to  the 
candidates  who  obtain  the  highest  marks  in  the 
Final  M.B.  Examinations  held  in  March  and  June 
respectively,  (n)  Gibson  Prize,  interest  on  £250  stock ; 
examination  in  subject  of  Midwifery  and  Diseases  of  Women 
and  Children.  Open  to  students  who  have  attended  one 
course  of  lectures  on  Midwifery  and  Gynaecology, 
(o)  Outterson-Wood  Prize,  interest  on  £250,  in  Psycho- 
logical Medicine.  (p)  Turnbull  Prize  and  Medal  ; exa- 
mination in  Surface  Anatomy.  Open  to  students  at 
end  of  their  second  winter  session. — At  the  Royal  Infirmary 
is  (q)  Goyder  Memorial  Scholarship,  interest  on  £325 ; 
awarded  annually  to  student  who  most  distinguishes 
himself  in  Clinical  Medicine  and  Clinical  Surgery  at  the 
Royal  Infirmary.  For  further  information  apply  to  Pro- 
fessor R.  Howden,  Secretary  of  the  College. 

Hygiene. — The  regulations  with  regard  to  the  degrees  in 
Sanitary  Science  will  be  found  under  the  section  on  Public 
Health. 


The  College  of  Medicine,  Newcastle-upon-Tyne.— 
Clinical  instruction  is  given  at  the  Royal  Victoria  Infirmary, 
containing  600  beds.  In  it  adequate  accommodation  is 
provided  for  the  study  of  the  various  special  subjects,  in 
addition  to  the  ordinary  clinical  work. 

Newcastle-upon-Tyne  Royal  Victoria  Infirmary. — 
The  Infirmary  was  founded  in  1751,  but  has  been  entirely 
rebuilt,  the  new  hospital  being  opened  by  His  late  Majesty 
King  Edward  VII.  in  1906.  The  number  of  beds  is  585.  The 
number  of  in-patients  annually  is  9200  and  of  out-patients 
69,000.  The  medical  students  of  the  University  of  Durham 
attend  the  practice  of  this  hospital.  Clinical  Lectures  are 
delivered  by  the  Physicians  and  Surgeons  weekly  and  ward 
demonstrations  are  given  daily.  Tutorial  classes  are  held 
by  the  Assistant  Physicians,  Assistant  Surgeons,  and 
Surgical  Registrars  weekly,  and  demonstrations  are  given  in 
the  several  out-patient  departments  daily.  Pathological 
demonstrations  are  given  by  the  Pathologist  daily  or  as 
opportunity  occurs,  and  in  the  new  buildings  nothing  has 
been  spared  in  perfecting  scientific  equipment.  In  addition 
to  medical  and  surgical  in-patient  and  out-patient  depart- 
ments the  following  special  departments  are  fully  equipped 
for  teaching  students  : Ophthalmic,  Throat,  Nose,  and 

Ear,  Skin,  Gynaecological,  and  Electrical.  The  hospital 
building  contains  the  following  laboratories : 1.  Special 
Pathological  Laboratory,  attached  to  the  post-mortem 
rooms.  2.  Bacteriological  Laboratory,  in  which  all 
clinical  bacteriological  investigations  are  carried  out — 
opsonic  indices  estimated  with  a view  to  treatment  by 
vaccines  and  serums,  Ac.  3.  There  is  in  addition  a 
Clinical  Laboratory  attached  to  each  ward  and  to  the  out- 
patient department.  There  are  five  operating  theatres  in 
use  in  the  hospital.  The  surgical  practice  is  especially 
good.  The  session  opens  on  April  17th  and  Oct.  2nd  of 
each  year.  Applications  for  detailed  information  should  be 
made  to  the  Dean,  Dr.  Horsley  Drummond,  at  the  hospital. 

There  are  other  institutions  in  addition  to  the  Royal 
Victoria  Infirmary  at  which  the  student  of  medicine  of  the 
University  of  Durham  can  receive  clinical  instruction. 
Practical  Midwifery  can  be  studied  at  the  Newcastle 
Lying-in  Hospital.  Instruction  is  given  in  Psychological 


Medicine  at  the  Sunderland  Mental  Hospital,  Rvhope. 
A special  course  of  instruction  is  given  in  the  City 
Hospital  for  Infectious  Diseases  by  the  City  Officer  of  Health. 
Ophthalmology  is  further  taught  at  the  Northumberland, 
Durham,  and  Newcastle  Infirmary  for  Diseases  of  the  Eye. 
Secretary  : Mr.  Richard  Smith,  61,  Westgate-road, 

Newcastle-on-Tyne. 


UNIVERSITY  OF  BIRMINGHAM. 

The  University  of  Birmingham  grants  the  degrees 
of  M.B.,  Ch.B.,  M.D. , Ch.M.,  and  Ph.D.  (for 
Research  Study),  and  also  a degree  and  a diploma  in 
Public  Health.  The  course  for  the  Bachelors’  degrees  ex- 
tends over  five  years  from  the  date  of  commencement  of 
professional  study.  As  a rule  the  first  four  of  these 
years  must  be  spent  in  the  University,  but  the  Senate  has 
power  of  recognising  attendance  at  another  University  as 
part  of  the  attendance  qualifying  for  these  degrees  and  of 
recognising  examinations  passed  at  such  other  Universities  as 
exempting  from  the  examinations  in  Chemistry,  Physics,  and 
Elementary  Biology.  In  the  case  of  such  students  at 
least  three  years  must  be  spent  in  attendance  upon  classes 
at  the  University.  The  fifth  year  may  be  spent  at  any 
other  school  or  schools  of  medicine  recognised  by  the 
University.  The  students  of  the  Medical  Faculty  can  be 
members  of  the  University  Club,  the  University  Athletic 
Club,  and  the  University  Officers’  Training  Corps,  while  they 
possess  a guild — the  Guild  of  Undergraduates — which  is 
designed  to  be  a recognised  medium  of  communication 
between  the  teachers  and  the  taught.  The  University 
Medical  Society  and  the  Dental  Students’  Society  also  offer 
opportunities  of  cooperation  for  mutual  benefit. 

Degrees  of  Bachelor  of  Medicine  and  Bachelor  of  Surgery. — 
The  student  must  have  passed  the  Matriculation  Examina- 
tion of  the  Joint  Board  or  an  examination  accepted  in  lieu 
thereof.  All  communications  respecting  the  Matriculation 
Examination,  and  examinations  accepted  in  lieu  thereof,  must 
be  sent  to  the  Secretary  to  the  Board,  Joint  Matriculation 
Board,  315.  Oxford-road,  Manchester.  First  Examination. — 
Chemistry  and  Physics  and  Elementary  Biology.  Second 
Examination. — Anatomy  and  Physiology.  Third  Examina- 
tion.— General  Pathology  and  Bacteriology,  Materia  Medica, 
and  Practical  Pharmacy.  Fourth  Examination  (at  the  end  of 
the  fourth  year). — Forensic  Medicine,  Toxicology,  Public 
Health,  Therapeutics,  and  Special  Pathology.  Two  years’ 
hospital  work  must  have  been  accomplished.  Final 
Examination.  — Medicine,  Surgery,  Midwifery,  Diseases 
of  Women,  Mental  Diseases,  and  Ophthalmology.  Attend- 
ance at  a general  hospital  for  a year  after  the  passing 
of  the  fourth  examination  will  be  required,  also  attend- 
ance at  a fever  hospital  three  months,  maternity  hospital 
one  month,  and  lunatic  asylum  three  months.  Vaccination 
instruction  must  be  taken  out  and  courses  of  Ophthalmology, 
Medical  and  Surgical  Anatomy,  and  Operative  Surgery. 

Degrees  of  Doctor  of  Medicine  and  Master  of  Surgery. — 
At  the  end  of  one  year  from  the  date  of  having  passed 
the  final  M.B.,  Ch.B.  examination  the  candidate  will  be 
eligible  to  present  himself  for  the  higher  degrees  of  either 
Doctor  of  Medicine  or  Master  of  Surgery  or  both. 

Candidates  for  either  of  these  degrees  have  to  present  a 
thesis  embodying  observations  in  some  subject  embraced  in 
one  of  the  departments  of  the  medical  curriculum,  and  in 
addition  pass  a general  examination  in  Principles  and 
Practice  of  Medicine  for  the  M.D.,  and  general  examination 
in  Principles  and  Practice  of  Surgery,  including  operations 
on  the  cadaver  for  the  M.Ch.  It  will  be  in  the  power  of  the 
Board  of  Examiners  to  exempt  from  the  practical  parts  of 
the  examination  a candidate  whose  thesis  is  of  exceptional 
merit  from  any  part  of  these  examinations. 

Degree  of  Ph.  D. — The  Degree  of  Doctor  of  Philosophy  in 
the  Faculty  of  Medicine  is  conferred  under  the  following 
regulations  : — (1)  Candidates  must  possess  a medical  degree 
of  a British,  Colonial,  or  other  university  approved  of  by  the 
Senate  of  the  University.  (2)  Candidates  must  have  been 
engaged,  to  the  satisfaction  of  the  Medical  Faculty,  in 
advanced  study  and  research  for  a period  of  not  less  than 
two  years,  either  in  a laboratory  of  the  University  or  in 
one  or  more  of  the  hospitals  associated  with  the  University, 
provided  that  after  the  first  year  of  the  course  candidates 
may  be  permitted  to  devote  such  periods  as  may  be  deemed 
desirable  by  the  University  to  research  elsewhere,  under 
approved  conditions.  (3)  On  completing  the  course  of 


The  Lancet,] 


UNIVERSITY  OF  LIVERPOOL. 


[August  30,  1919  369 


advanced  study  and  research  candidates  are  required  (a)  to 
present  a thesis  on  the  subject  of  their  advanced  study  and 
research,  and  to  satisfy  the  examiners  that  it  contains 
original  work  worthy  of  publication ; ( b ) to  submit  them- 
selves for  an  oral  examination  on  the  subject  of  the  thesis 
and  on  the  general  field  to  which  their  subject  belongs,  and, 
if  required,  for  a written  examination  and  to  satisfy  the 
examiners  in  the  examination  as  well  as  in  the  thesis 
presented.  (4)  The  minimum  fee  payable  by  candidates  to 
be  10  guineas  for  each  academic  year,  exclusive  of  laboratory 
fees.  As  in  the  case  of  other  doctorates,  a fee  of  £10  to  be 
payable  for  the  examination. 

lees. — Matriculation,  £2;  First  Examination,  £2;  Second 
Examination,  £2  ; Third  Examination,  £2  ; Fourth  Examina- 
tion, £2  ; Final  Examination,  £8  ; M.D.  or  Ch.M.,  £10. 

At  the  University  of  Birmingham  the  following  Scholarships 
are  awarded  : — (a)  Myers  Travelling  Studentship  of  £150, 
tenable  for  one  year,  awarded  by  vote  of  committee  to  M.B., 
Ch.B.  Birm.,  B.Sc.  candidates,  tenable  at  some  University  or 
Hospital  not  in  Great  Britain  or  Ireland  ; (i)  Ingleby  Scholar- 
ship of  £10,  awarded  to  the  candidate  at  Final  Examina- 
tion obtaining  highest  “ first-class  ” marks  in  the  subjects 
of  Midwifery  and  Diseases  of  Women ; (o')  Sydenham 
Scholarship  of  £42,  tenable  for  three  years,  award  of  Council 
to  orphan  sons  of  medical  practitioners ; (d)  Sands  Cox 
Scholarship  of  £42,  tenable  for  three  years,  awarded  to  the 
candidate,  not  being  more  than  19  years  of  age,  taking  the 
highest  marks  at  the  July  Matriculation  ; (e)  Dental  Scholar- 
ship of  £37  10.?.,  Open  Competitive  Examination  in  subjects 
learned  during  apprenticeship  ; (/),  (g),  (h),  and  (i)  Four 
Queen’s  Scholarships  of  £10  10s.  each.  In  the  Second  and 
Fourth  Examinations  the  Scholarship  is  awarded  respec- 
tively to  the  student  taking  the  first  place  and  obtaining 
“first-class  ” marks.  In  the  Third  Examination  the  Scholar- 
ship is  awarded  to  the  student  obtaining  the  highest  1 ‘ first- 
class  ” marks  in  Pathology  and  Bacteriology,  provided  that 
such  student  passes  at  the  same  examination  in  the  subjects 
of  Materia  Medica  and  Practical  Pharmacy.  In  the  Final 
Examination  the  Scholarship  is  awarded  to  the  candidate 
taking  the  first  place  in  the  examination — that  is,  obtaining 
the  greatest  aggregate  number  of  marks — provided  that  in 
each  of  the  subjects  of  Medicine,  Surgery,  and  Midwifery 
he  gains  not  less  than  60  per  cent,  of  the  total 
available  marks  ; (j)  George  Henry  Marshall  Scholar- 

ship of  £10,  awarded  annually,  for  the  encouragement 
of  Research  Work  in  Ophthalmology ; and  (h)  Russell 
Memorial  Prize,  a prize  of  books,  value  about  £2,  awarded 
annually  to  the  student  who,  not  being  of  more  than  six 
years’  standing  as  a student  of  the  School  of  Medicine  of 
the  University,  shall  pass  the  best  examination  in  the  subject 
of  Nervous  Diseases. 

Clinical  Instruction. — The  medical  students  of  the  Uni- 
versity receive  their  clinical  instruction  by  attending  the 
amalgamated  practice  of  the  General  Hospital  and  the 
Queen’s  Hospital,  details  of  which  follow. 

The  clinical  instruction  of  the  Birmingham  medical 
students  is  carried  on  under  the  direction  of  the  University 
Clinical  Board.  The  hospitals  present  an  excellent  field 
for  clinical  work,  possessing  more  than  500  beds,  treating 
annually  over  8000  in-patients  and  100,000  out-patients. 
The  students  spend  part  of  their  curriculum  in  each 
hospital,  and  thus  have  every  opportunity  of  acquiring  a 
varied,  full,  and  practical  knowledge  of  their  professional 
work.  The  curriculum  is  adapted  in  the  first  place  to 
meet  the  needs  of  the  students  of  the  University  of  Bir- 
mingham, but  it  is  also  well  adapted  to  the  requirements 
of  students  preparing  for  the  examinations  of  all  other 
universities  and  licensing  bodies.  At  the  General  Hos- 
pital there  are  open  to  the  students  the  following 
appointments : A surgical  registrar,  £200  per  annum  ; 
a resident  medical  officer,  elected  annually  (£155) ; a 
resident  surgical  officer,  elected  annually  and  eligible  for 
re-election  for  three  years  (£180) ; a resident  pathologist, 
elected  for  six  months  (£100)  ; three  surgical  casualty 
officers,  elected  annually  and  eligible  for  re-election 
(£50) ; three  house  physicians  and  four  house  surgeons 
hold  office  for  six  months,  receiving  board,  residence, 
and  salaries  at  the  rate  of  £100  a year ; two  house 
surgeons  to  the  gynaecological,  ophthalmic,  and  aural 
departments  are  elected  every  six  months,  receiving  board, 
residence,  and  a salary  of  £100  a year  ; two  assistant  house 
surgeons  are  elected  every  three  months,  receiving  board, 


residence,  and  salaries  at  the  rate  of  £40  a year  ; a resident 
medical  officer  at  the  Jaffray  Hospital,  who  is  elected 
annually  but  is  eligible  for  re-election,  and  who  receives 
£150  a year  ; and  a resident  medical  assistant  at  this  hos- 
pital, who  is  not  necessarily  qualified,  is  provided  with  board 
and  residence,  and  holds  office  for  three  months.  At  the 
Queen’s  Hospital  there  are  open  to  the  student  the  following 
appointments  : Three  house  physicians,  three  house  surgeons, 
and  one  obstetric  and  ophthalmic  house  surgeon,  who  hold 
office  for  six  months  and  have  salaries  at  the  rate  of  £90 
a year.  Thirty-eight  other  appointments  of  varying  value 
are  at  the  City  Workhouse  and  Workhouse  Infirmary,  at 
the  Birmingham  General  and  Branch  Dispensaries,  at  the 
Birmingham  Lunatic  Asylums,  at  the  City  Fever  Hospitals, 
at  the  Children’s  Hospital,  at  the  Birmingham  and  Midland 
Eye  Hospital,  at  the  Orthopaedic  and  Spinal  Hospital,  at  the 
Maternity  Hospital,  and  at  the  Ear  and  Throat  Hospital. 

Post-graduate  Courses. — A “ Lectureship  in  Psycho- 
therapy” has  recently  been  established  in  the  University, 
the  first  annual  lecturer  beiDg  Dr.  Bernard  Hart,  of 
University  College  Hospital,  who  gave  a course  of  ten 
lectures  during  the  Summer  Session  for  practitioners  and 
students  of  the  University  Medical  School.  The  Lecturer 
for  1920  has  not  yet  been  appointed. 

A course  of  six  lectures  (with  clinical  demonstrations)  on 
“Venereal  Diseases”  was  also  held  during  the  Summer 
Session  for  practitioners  and  students,  the  lecturer  being 
Dr.  A.  Douglas  Heath,  Physician  to  Skin  Department  of 
the  Birmingham  General  Hospital.  It  is  proposed  to 

provide  a further  course  of  instruction  in  this  subject  during 
the  ensuing  session.  


The  Birmingham  General  Hospital.— 360  beds  are  in 
daily  use,  5620  in-patients  per  annum.  Special  wards  for 
children,  gynaecological,  septic  and  infectious  cases  ; special 
beds  for  eye,  ear,  and  skin  cases.  About  50,000  out-patients  per 
annum.  Laboratories  for  bacteriology  and  morbid  histology. 
Separate  rooms  adjoin  the  medical  and  surgical  wards  for 
clinical  pathology.  Five  operating  theatres  (one  for  out- 
patients), all  designed  and  fitted  on  the  most  modern  lines. 
In  addition  to  clinical  teaching  given  in  the  wards  and  out- 
patient department  by  the  honorary  staff,  medical  and 
surgical  tutorial  classes  are  held  for  senior  and  junior 
students.  Clinical  instruction  in  all  the  special  departments. 
The  Jaffray  Branch  Hospital  contains  54  beds. 

The  Queen’s  Hospital.  — Similar  arrangements  for  clinical 
teaching  are  made  here,  and  the  material  also  is  excellent. 
Ward  and  tutorial  classes  are  regularly  conducted  by  the 
staff,  there  are  daily  clinics  in  the  out-patient  department, 
while  teaching  duties  are  definitely  assigned  to  the  house 
physicians  and  house  surgeons.  There  are  also  special 
departments  for  gynsecology  and  ophthalmology. 

Birmingham  and  Midland  Eye  Hospital,  Church- 
street,  Birmingham. — This  hospital  possesses  120  beds,  and 
there  is  an  average  daily  attendance  of  out-patients  of  over 
250.  This  institution  is  recognised  by  Universities  and  the 
Royal  College  of  Surgeons,  England,  and  Royal  College  of 
Physicians,  London,  as  an  ophthalmic  hospital  at  which 
clinical  instruction  in  ophthalmology  may  be  received. 
Students  attending  for  a period  of  three  months  will  be 
granted  certificates  which  will  qualify  for  the  University 
and  Conjoint  Board  examinations. 


UNIVERSITY  OF  LIVERPOOL. 

The  degrees  in  the  Faculty  of  Medicine  are  Bachelor  of 
Medicine  and  Bachelor  of  Surgery  (M.B.  and  Ch.B.),  Doctor 
of  Medicine  (M.D.),  Master  of  Surgery  (Ch.M.),  and  Master 
of  Hygiene  (M.H.). 

Degrees  of  Bachelor  of  Medicine  and  Bachelor  of 
Surgery. — Candidates  for  the  degrees  of  Bachelor  of 
Medicine  and  of  Surgery  must  have  attained  the  age  of 
21  years  on  the  day  of  graduation.  At  least  two  of  the 
five  years  of  medical  study  must  have  been  passed  in  the 
University,  and  one  year  at  least  must  have  been  passed  in 
the  University  subsequently  to  the  date  of  passing  the  First 
Examination.  The  other  three  years  may  be  passed  at  any 
college  or  medical  school  recognised  for  this  purpose  by  the 
University.  Candidates  must  pass  three  examinations  entitled 
respectively : the  First  Examination,  the  Second  Examina- 
tion, and  the  Final  Examination.  The  fee  is  £5  for  each 
examination.  The  subjects  of  the  First  Examination  are : 
I 2 


370  The  Lancet,] 


THE  VICTORIA  UNIVERSITY  OF  MANCHESTER. 


[August  30,  1919 


(1)  Chemistry,  Inorganic,  Organic,  and  Physical ; (2)  Biology 
(Zoology  and  Botany)  ; and  (3)  Physics.  The  examination  is 
divided  into  two  parts— namely,  (1)  Chemistry  and  Physics, 
and  (2)  Biology  ; and  candidates  may  present  themselves 
in  these  parts  separately.  The  subjects  of  the  Second 
Examination  are  (a)  Anatomy  and  Physiology  (including 
Physiological  Chemistry  and  Histology),  and  (b)  Materia 
Medica,  Pharmacy,  and  Pharmacology.  Candidates  may 
present  themselves  in  (a)  or  (b)  separately.  The  subjects 
for  the  Final  Examination  are  : (1)  General  Pathology,  Morbid 
Anatomy,  and  Bacteriology  ; (2)  Forensic  Medicine,  Toxic- 
ology, and  Public  Health  ; (3)  Obstetrics  and  Diseases  of 
Women  ; (4)  Surgery,  Systematic,  Clinical,  Operative,  and 
Practical, including  Ophthalmology  ; (5)  Medicine,  Systematic 
and  Clinical,  including  Mental  Diseases  and  Diseases 
of  Children,  and  Therapeutics.  The  Final  Examination  is 
divided  into  three  parts,  the  first  consisting  of  subject  (1), 
the  second  of  subject  (2),  the  third  of  subjects  (3),  (4), 
and  (5).  Candidates  may  present  themselves  in  these  parts 
separately.  Candidates  for  the  third  part  must  have  com- 
pleted the  fifth  year  of  medical  study. 

Degrees  of  Doctor  of  Medicine  and  Master  of  Surgery. — 
No  candidate  will  be  admitted  to  the  degree  of  Doctor 
of  Medicine  or  Master  of  Surgery  unless  he  has  previously 
received  the  Degrees  of  Bachelor  of  Medicine  and  Bachelor 
of  Surgery,  and  at  least  one  year  has  elapsed  since  he  passed 
the  examinations  for  those  degrees.  Candidates  for  the 
degree  of  Doctor  of  Medicine  are  required  to  present  a 
dissertation  embodying  the  results  of  personal  observations 
or  original  research,  either  in  some  department  of  medicine 
or  of  some  science  directly  relative  to  medicine  : provided 
always  that  original  work  published  in  scientific  journals 
or  separately  shall  be  admissible  in  lieu  of,  or  in  addition  to, 
a dissertation  specially  written  for  the  degree. 

At  this  University  the  following  Scholarships  and  Fellow- 
ships and  Prizes  are  awarded : — (a)  and  (J)  Robert  Gee 
Entrance  Scholarships,  two  annually,  of  £25  each,  tenable 
for  two  years,  Joint  Matriculation  Board  Examination  held 
in  July,  open  to  First  M.B.  Course  Students  ; (c)  Lyon  Jones 
Scholarship,  No.  1,  of  £21  per  annum,  tenable  for  two  years, 
Competitive  Examination  among  Junior  Students  in  First 
M.B.  Subjects,  Perpetual  Course  at  the  University;  ( d ) Lyon 
Jones  Scholarship,  No.  2,  of  £21,  Competitive  Exa- 
mination among  Senior  Students  in  Anatomy,  Physio- 
logy, Pharmacology,  and  Materia  Medica ; ( e ) Derby 

Exhibition  of  £15,  Competitive  Examination  among  Fourth- 
or  Fifth-year  Students  in  Clinical  Subjects,  and  Clinical 
School  Exhibition  of  £15  annually  for  Fourth-  or  Fifth-year 
students  ; (f)  University  Scholarship  of  £25  for  one  year, 
awarded  on  results  of  Second  Examination  for  the  degrees ; (g) 
Holt  Fellowships,  Physiology  and  Pathology,  of  £100  each,  for 
one  year ; (&)  Gee  Fellowship,  Anatomy,  of  £100,  for  one 
year  ; (i)  Alexander  Fellowship,  Bacteriology  and  Pathology, 
of  £100,  for  one  year;  (j)  Johnston  Colonial  Fellowship, 
Bio-Chemistry,  of  £100,  for  one  year  ; (A)  John  W.  Garrett 
International  Fellowship,  Bacteriology,  of  £100,  for  one 
year ; ( l ) Thelwall  Thomas  Fellowship,  Surgical  Pathology, 
of  £100,  for  one  year  ; ( m ) Ethel  Boyce  Fellowship  in 
Gynaecological  Pathology,  of  £100,  for  one  year  ; numerous 
prizes  and  medals ; (»)  Mary  Birrell  Davies  Memorial  Fund 
Scholarship,  of  the  value  of  £60,  tenable  for  four  years, 
offered  for  competition  in  alternate  years  ; open  only  to 
women  students  who  will  have  attained  the  age  of  19  on  the 
first  day  of  October  next  following  the  award  ; students  who 
are  or  have  been  registered  day  students  of  the  University 
are  eligible  for  election  ; holder  to  proceed  to  a University 
degree  in  Medicine  ; candidates  must  apply  in  writing  to 
the  Registrar,  forwarding  evidence  of  their  qualifications, 
on  or  before  July  1st. 

Medical  School  Buildings. — Medical  research  has  also 
been  endowed  with  several  new  laboratories  in  which 
students  can  pursue  research  work  after  graduation.  All  the 
laboratories  and  class-rooms  are  situated  close  together, 
communicating  with  one  another,  and  are  made  up  of  four 
large  blocks  of  buildings  which  form  one  side  of  the  College 
quadrangle.  There  are  the  Johnston  Laboratories  for 
Experimental  Medicine,  Bio-Chemistry,  and  Tropical 
Medicine ; the  Medical  School  for  Anatomy,  Surgery,  Toxi- 
cology, and  Ophthalmology  ; and  the  Thompson- Yates 
Laboratories  for  Physiology  and  Pathology. 

Clinical  Instruction. — The  Clinical  School  of  the  University 
now  consists  of  four  general  hospitals — the  Royal  Infirmary, 


the  David  Lewis  Northern  Hospital,  the  Royal  Southern  Hos- 
pital, and  the  Stanley  Hospital ; and  of  five  special  hospitals 
— the  Eye  and  Ear  Infirmary,  the  Hospital  for  Women, 
the  Infirmary  for  Children,  St.  Paul’s  Eye  Hospital,  and 
St.  George’s  Hospital  for  Skin  Diseases.  These  hospitals 
contain  in  all  a total  of  about  1134  beds.  The  organisation  of 
these  hospitals  to  form  one  teaching  institution  provides  the 
medical  student  and  the  medical  practitioner  with  a field  for 
clinical  education  and  study  which  is  unrivalled  in  extent  in 
the  United  Kingdom.  All  the  hospitals  are  within  easy 
access  of  the  University.  There  are  a large  number  of 
appointments  to  house  physicianships  and  surgeonships  both 
at  the  general  and  special  hospitals  which  are  open  to 
qualified  students  of  the  school. 

School  of  Veterinary  Science.— There  is  a school  of 
Veterinary  Science  in  connexion  with  the  University  which 
provides  full  courses  of  instruction  for  the  M.R.C.V.S. 
Degrees  of  B.V.Sc. , M.V.Sc.,  and  D.V.Sc.,  together  with  a 
diploma  in  Veterinary  Hygiene,  are  also  granted  by  the 
University. 

Public  Health  Depa/rtment. — This  is  located  in  a separate 
building  known  as  Ashton  Hall,  in  which  full  courses  of 
instruction  are  given  to  students  for  the  Diplomas  and 
Degrees  of  the  University  and  of  other  Examining  Boards. 

Prospectuses  and  further  information  may  be  had  on  appli- 
cation to  the  Dean  of  the  Faculty  of  Medicine,  University  of 
Liverpool. 

THE  VICTORIA  UNIVERSITY  OF  MANCHESTER. 

Four  degrees  in  Medicine  and  Surgery  are  conferred  by  the  | 
University — viz.,  Bachelor  of  Medicine  and  Bachelor  of 
Surgery  (M.B.  and  Ch.B.),  Doctor  of  Medicine  (M.D.),  and 
Master  of  Surgery  (Ch.M.).  A Diploma  in  Psychological 
Medicine  is  awarded  by  examination  to  registered  medical 
practitioners. 

Degrees  of  Bachelor  of  Medicine  and  Bachelor  of  Surgery. — 
Before  admission  to  the  degree  of  M.B.  or  Ch.B.  candi- 
dates are  required  to  present  certificates  that  they  will 
have  attained  the  age  of  21  years  on  the  day  of  I 
graduation  and  that  they  have  pursued  the  courses  of 
study  required  by  the  University  Regulations  during  a 
period  of  not  less  than  five  years  subsequently  to  the  I i 
date  of  their  registration  by  the  General  Medical  Council, 
two  of  such  years  having  been  passed  in  the  University  i 
and  one  year  at  least  having  been  passed  in  the  University 
subsequently  to  the  date  of  passing  the  first  M.B.  Examina-  i 
tion.  All  candidates  for  the  degrees  of  Bachelor  of  Medi- 
cine and  Bachelor  of  Surgery  are  required  to  satisfy  the 
examiners  in  the  several  subjects  of  the  following  examina- 
tions. (These  are  now  under  revision.) 

The  First  Examination. — (1)  Inorganic  Chemistry  and 
Physics;  (2)  Biology;  and  (3)  Elementary  Organic  Chemistry 
and  Bio-Chemistry.  Candidates  must  have  attended  during  1 i 
at  least  one  year  courses  both  of  lectures  and  of  laboratory 
work  in  each  of  the  above-named  subjects.  The  Examina- 
tion is  divided  into  three  parts  : Part  1,  Inorganic  Chemistry 
and  Physics ; Part  2,  Biology ; Part  3,  Elementary 
Organic  Chemistry  and  Bio-Chemistry  ; and  the  candidates  J 
may  pass  in  these  parts  separately  under  certain  con- 
ditions. 

The  Second  Examination. — (1)  Anatomy  ; (2)  Physiology, 
including  Physiological  Chemistry  and  Histology.  Candi- 
dates may  pass  in  (1)  and  (2)  separately  under  certain 
conditions. 

The  Third  Examination. — (1)  Pathology  ; (2)  Pharma- 
cology and  Therapeutics  ; (3)  Hygiene.  These  subjects  may 
be  taken  separately  under  certain  conditions. 

The  Final  Examination. — (1)  Medicine,  Systematic  and 
Clinical  (including  Mental  Diseases  and  Diseases  of 
Children)  ; (2)  Surgery,  Systematic,  Clinical,  and  Practical ; 

(3)  Obstetrics  and  Gynascology  (including  Clinical  and  Prac- 
tical) ; (4)  Forensic  Medicine  (including  an  Oral  Examina- 
tion). These  subjects  may  be  taken  separately  under  certain 
conditions. 

Candidates  for  the  Final  Examination  must  have  com- 
pleted the  fifth  year  of  medical  study. 

Degree  of  Doctor  of  Medicine. — Candidates  are  not  eligible 
for  the  degree  of  Doctor  of  Medicine  unless  they  have 
previously  received  the  degrees  of  Bachelor  of  Medicine 
and  Bachelor  of  Surgery  and  at  least  one  year  has  elapsed 
since  they  passed  the  examination  for  those  degrees. 
Candidates  may  elect  either  (1)  to  present  an  original  dis- 


The  Lancet,] 


UNIVERSITY  OF  LEEDS. 


[August  30,  1919  371 


sertation  ; or  (2)  to  undergo  an  examination.  The  disserta- 
tion must  embody  the  results  of  personal  observation  or 
original  research,  either  in  some  department  of  medicine  or 
of  some  science  directly  relative  to  medicine.  The  examina- 
tion, which  will  be  partly  written,  partly  practical,  is 
in  the  Principles  and  Practice  of  Medicine,  in  Patho- 
logy, and  in  some  other  subject  to  be  selected  by  the 
candidate. 

Degree  of  Master  of  Surgery. — Candidates  are  not  eligible 
for  the  degree  of  Master  of  Surgery  unless  they  have  pre- 
viously received  the  degrees  of  Bachelor  of  Medicine  and 
Bachelor  of  Surgery  and  at  least  one  year  has  elapsed 
since  they  passed  the  examination  for  those  degrees.  The 
subjects  of  examination  are  as  follows : (1)  Surgical 

Anatomy  ; (2)  Surgery  ; (3)  Operative  Surgery  ; (4)  Clinical 
Surgery  ; (5)  Ophthalmology  ; and  (6)  Pathology  and 
Bacteriology. 

Communications  should  be  addressed  to  the  Registrar, 
The  University,  Manchester. 

Scholarships,  Fellowships,  and  Prizes. — At  this  Uni- 
versity there  are  22  Foundation  Scholarships,  12  Exhibi- 
tions, five  being  for  subjects  connected  with  medical 
study,  a Surgical  Prize,  a University  Fellowship  (Leech 
Fellowship,  £100),  Research  Fellowships  in  Public  Health, 
and  Honorary  Research  Fellowships.  13  Entrance  Scholar- 
ships are  tenable  for  Medical  courses  ; one  Scholarship  is 
offered  in  Surgery,  Biology,  Physiology,  and  Diseases  of 
Children  respectively,  and  one  General  Medical  and  Surgical. 
Exhibitions  are  offered  in  Physiology  and  Anatomy,  and  one 
for  French  and  German.  “ The  Dumville  ” Surgical  Prize  is 
awarded  on  the  results  of  the  Final  Examination  in  Surgery 
in  the  Summer  Term,  £15.  The  Leech  Fellowship  (£100) 
is  for  the  encouragement  of  study  and  research,  and  is 
open  to  persons  who  have  graduated  M.B.,  Ch.B.,  in  the 
University  not  more  than  18  months  previously.  The 
Honorary  Research  Fellowships,  tenable  for  two  years, 
conferring  the  right  of  free  use  of  the  laboratories,  are 
awarded  generally  in  October  on  application,  with  evidence 
of  capacity  for  independent  investigation. 

There  are  many  entrance  scholarships,  the  examinations 
for  which  are  held  in  the  month  of  May.  Full  particulars 
can  be  obtained  from  the  Dean. 

The  Medical  School. — This  medical  school,  largely  extended 
in  1895,  is  provided  with  dissecting-rooms,  physiological 
laboratories,  private  laboratories,  and  work-rooms,  besides 
lecture-rooms,  a museum,  and  a library.  A special 
laboratory  is  equipped  for  experimental  work  on  the 
central  nervous  system.  In  the  pathological  laboratories 
ample  provision  is  made  for  the  teaching  of  pathology  and 
bacteriology  and  for  the  prosecution  of  original  research. 
The  Helen  Swindells  Laboratory  is  specially  equipped  for 
cancer  research  and  investigation  in  general  pathology. 
Ample  facilities  for  investigation  are  provided  in  Anatomy, 
Physiology,  and  Materia  Medica.  In  the  public  health 
department,  which  is  lodged  in  a separate  institute  in  York 
Place,  near  the  Royal  Infirmary,  suitable  laboratory  accom- 
modation is  provided  for  the  study  of  sanitary  chemistry, 
physics,  and  practical  bacteriology  in  the  departments  of 
chemistry  and  physics  and  in  that  of  pathology. 

Clinical  Studies. — The  clinical  and  practical  depart- 
ments of  medical  study  are  taught  partly  in  the  Medical 
School  and  partly  in  the  Royal  Infirmary  and  St.  Mary’s 
Hospitals  for  Women  and  Children,  a fever  hospital,  a lunatic 
asylum,  and  a convalescent  home,  and  other  special  hospitals. 
Medical  and  Surgical  Clinical  Classes  are  conducted  in  the 
Infirmary,  which  together  with  the  associated  hospitals  at 
Cheadle  contains  1109  beds,  exclusive  of  those  reserved  for 
military  cases,  and  separate  instruction  is  afforded  in  the 
elements  of  Medical  and  Surgical  Physical  Diagnosis,  in 
Obstetric  Medicine,  Ophthalmic  Surgery,  and  Pathological 
Anatomy  by  the  different  members  of  the  staff  of  the  Medical 
School  and  Infirmary. 

Clinical  Instruction. — The  Manchester  Royal  In- 
firmary.— The  Royal  Infirmary  is  built  on  the  pavilion 
system,  near  the  University,  and  has  accommodation  for  884 
(including  472  temporary  military  beds).  The  remaining  beds 
are  allocated  to  civilians.  The  medical  side  consists  of  five 
units,  each  unit  having  a testing  room  for  the  scientific  inves- 
tigation of  morbid  products  and  a class-room.  The  surgical 
beds  are  also  arranged  in  five  units,  each  unit  having  its  own 
operation  theatre,  with  anaesthetising,  recovery,  sterilising, 
testing,  and  apparatus  rooms,  and  its  own  class-room  attached. 


Of  these  units  all  are  occupied.  The  fine  educational 
block  provides  very  handsomely  for  the  wants  and  comforts 
of  the  students,  there  being  separate  suites  of  rooms  for 
the  men  and  the  women,  and  also  a large  common  reading 
room,  a lecture  theatre,  and  a museum.  The  present 
annual  average  number  of  in-patients  is  12,500,  of  out- 
and  home-patients  25,000,  and  the  list  of  casualties  in 
the  accident  room  has  averaged  17,000  per  annum.  About 
8200  operations  are  performed  annually  in  the  operation 
theatres.  Associated  with  the  infirmary  are:  (1)  the  Con- 
valescent Hospital  at  Cheadle,  containing  136  beds  ; (2)  the 
Royal  Lunatic  Hospital  at  Cheadle,  accommodating  with  its 
branches  430  patients  ; and  (3)  the  Central  Branch  in 
the  city  for  casualty  and  out-patient  work,  and  62  temporary 
military  beds.  The  Associated  Hospitals  thus  contain  1450 
beds  and  are  under  the  same  management.  Women  students 
are  admitted  to  the  practice  of  the  Infirmary  on  the  same 
terms  as  men. 

Fees. — Medical  Practice  : Three  months,  5 guineas  ; six 
months,  8 guineas;  12  months,  12  guineas;  full  period 
required  by  the  Examining  Boards,  42  guineas. 

Two  Entrance  Scholarships  in  Medicine  of  the  value  of 
£100  each  are  offered  annually  by  the  Council  of  the 
Manchester  University  and  the  Medical  Board  of  the  Man- 
chester Royal  Infirmary  for  proficiency  in  Arts  and  Science 
subjects  respectively.  Other  scholarships  and  prizes  are  in 
the  College  Syllabus.  Numerous  annual  appointments  and 
junior  appointments  may  be  held  by  those  who  have  attended 
the  practice  of  the  Infirmary. 

The  secretary  to  the  Infirmary  is  Mr.  F.  G.  Hazel!. 


Manchester  Children’s  Hospital,  Pendlebury,  Gart- 
side-street,  Manchester,  and  St.  Anne’s-on-the-Sea. — The 
hospital  contains  188  beds  and  24  in  the  Convalescent  Home, 
St.  Anne’s-on-the-Sea.  The  medical  staff  visit  the  hospital 
daily  at  10  A.M.  Clinical  instruction  is  given  by  the  medical 
staff  at  the  Hospital  and  Dispensary.  Out-patients  are 
seen  daily  at  9 A.M.  at  the  new  Out-patient  Department, 
Gartside- street,  Manchester.  Secretary  : Mr.  W.  M.  Humphry. 

The  Manchester  Northern  Hospital  for  Women 
and  Children,  Park-place,  Cheetbam  Hill-road,  Man- 
chester.— The  hospital  contains  70  beds.  Out-patients  are 
seen  daily  from  8.30  to  10  a.m. 


UNIVERSITY  OF  LEEDS. 

Four  degrees  in  Medicine  and  Surgery  are  conferred — viz.  : 
Bachelor  of  Medicine  and  Bachelor  of  Surgery  (M.B.  and 
Ch.B.),  Doctor  of  Medicine  (M.D.),  Master  of  Surgery 
(Ch.M.),  also  Degrees  and  Diplomas  in  Dental  Surgery  and 
Diplomas  in  Public  Health  and  in  Psychological  Medicine. 

Degrees  of  Bachelor  of  Medicine  and  Bachelor  of  Surgery. — 
Candidates  for  these  degrees  are  required  to  present  certifi- 
cates showing  that  they  will  have  attained  the  age  of  21 
years  on  the  day  of  graduation,  and  have  attended  courses 
approved  by  the  University  extending  over  not  less  than 
five  years,  two  of  such  years  at  least  having  been  passed  in 
the  University  subsequently  to  the  date  of  passing  the  First 
Examination.  Candidates  must  also  satisfy  the  examiners 
in  the  several  subjects  of  the  following  examinations 
entitled  respectively  : the  Matriculation  Examination,  or 
such  other  examination  as  may  have  been  recognised 
by  the  Joint  Matriculation  Board  in  its  stead  ; the  First 
Examination  ; the  Second  Examination ; and  the  Final 
Examination. 

The  First  Examination. — The  First  Examination  consists 
of:  Part  I.,  Physics  and  Chemistry;  Part  II.,  Biology. 
Candidates  will  be  allowed  to  pass  the  two  parts  separately. 

The  Second  Examination. — The  Second  Examination  con- 
sists of : Part  I.,  Anatomy  and  Physiology  ; Part  II.,  Materia 
Medica  and  Pharmacy.  Candidates  will  be  allowed  to  pass 
the  two  parts  separately. 

The  Final  Examination. — The  Final  Examination  consists 
of  : Part  I.,  Pathology  and  Bacteriology.  Part  II.,  Forensic 
Medicine  and  Public  Health.  Part  III.,  Medicine:  Sys- 
tematic and  Clinical,  including  Mental  Diseases  and  Diseases 
of  Children;  Surgery— Systematic,  Clinical,  and  Practical; 
Obstetrics,  and  Gynsecology — Systematic,  Clinical,  and 
Practical  ; Pharmacology  and  Therapeutics.  Candidates 
will  be  allowed  to  pass  Parts  II.  and  III.  separately  or 
together,  and  they  may  present  themselves  for  examination 
in  Part  I.  at  the  end  of  the  tenth  term. 


[August  30,  1919 


372  The  Lancet,]  UNIVERSITY  OF  SHEFFIELD. 


Degree  of  Doctor  of  Medicine.  — Candidates  are  not  eligible 
for  the  degree  of  Doctor  of  Medicine  or  Master  of  Surgery 
unless  they  have  previously  received  the  degrees  of  Bachelor 
of  Medicine  and  Bachelor  of  Surgery  and  at  least  one  year 
has  elapsed  since  they  passed  the  examination  for  those 
degrees.  Candidates  for  the  degree  of  Doctor  of  Medicine  are 
required  to  present  a dissertation  and,  if  the  dissertation  be 
accepted,  to  pass  an  examination. 

The  first  term  commences  on  Oct.  1st.  Prospectus,  &c. , 
can  be  obtained  from  the  Dean  of  the  Medical  School. 

Clinical  Instruction. — The  Leeds  General  Infirmary, 
in  connexion  with  this  medical  faculty,  has  accommoda- 
tion for  620  in-patients,  including  88  beds  at  branch 
hospitals  in  the  country.  During  the  last  year  9910  in- 
patients and  34,143  new  out-patients  were  treated.  Clinical 
teaching  takes  place  daily  in  the  wards,  and  Clinical 
lectures  are  given  in  Medicine  and  Surgery  by  the  Physicians 
and  Surgeons.  There  are  Medical,  Surgical,  Ophthalmic, 
Aural,  Electro-therapeutic,  and  Radiographic  Depart- 
ments, in  each  of  which  special  instruction  is  im- 
parted to  students.  A Gynaecological  and  Extern  Obstetric 
Department,  together  with  Laryngeal  and  Skin  Clinics,  are 
in  operation.  Several  valuable  prizes  are  given  at  the  end 
of  each  session.  Numerous  appointments  at  the  Infirmary 
are  annually  open  to  students  after  qualification. 


UNIVERSITY  OF  SHEFFIELD. 

The  Degrees  in  the  Faculty  of  Medicine  are  Bachelor 
of  Medicine  and  Bachelor  of  Surgery  (M.B.,  Ch.B.),  Doctor 
of  Medicine  (M.  D.),  and  Master  of  Surgery  (Ch.M.).  The 
courses  and  degrees  in  the  Faculty  of  Medicine  are  open  to 
men  and  women  alike. 

Candidates  for  a medical  degree  shall  have  matriculated  in 
the  University  or  have  passed  such  other  examination  as 
may  be  recognised  for  this  purpose  by  the  University  and 
sanctioned  by  the  Joint  Matriculation  Board. 

A candidate  for  the  degrees  of  M.B.,  Ch.B.  shall  produce 
certificates  that  he  will  have  attained  the  age  of  21  years  on 
the  day  of  graduation  ; that  he  has  pursued  the  courses  of 
study  required  by  the  University  regulations  during  a period 
of  not  less  than  five  years  subsequently  to  the  date  of  his 
matriculation,  three  of  such  years  at  least  having  been 
passed  in  the  University,  one  at  least  being  subsequent  to 
the  passing  of  the  First  Examination. 

Degrees  of  Bachelor  of  Medicine  and  Bachelor  of  Surgery. 

The  First  Examination. — The  subjects  of  the  examination 
are  Chemistry,  Physics,  and  Biology.  The  Intermediate 
B.Sc.  Examination  in  these  subjects  will,  on  payment 
of  the  required  additional  fee,  be  accepted  instead  of 
this  examination.  Candidates  must,  after  matriculation 
and  registration  as  medical  students,  have  attended  courses 
of  instruction  (lectures  and  laboratory  work)  in  chemistry, 
physics,  and  biology  for  one  year  each. 

The  Second  Examination. — The  subjects  of  the  examination 
are  Anatomy  and  Physiology. 

The  Third  Examination. — The  subjects  of  the  examina- 
tion are  Pathology  and  Pharmacology.  A candidate  entering 
for  the  first,  second,  or  third  examination,  who  shall  pass 
creditably  in  one  subject  of  either  examination  and  obtain  a 
certain  minimum  of  marks  in  the  other,  may  enter  for  such 
other  subject  separately  in  a subsequent  examination.  Candi- 
dates must  have  completed  the  fourth  year  of  professional 
study. 

The  Final  Examination.—  The  subjects  of  the  examination 
are  Medicine  (including  Forensic  Medicine,  Public  Health, 
Mental  Diseases,  and  Diseases  of  Children)  ; Surgery  ; and 
Obstetrics  (including  Gynaecology).  Candidates  must 
satisfy  the  examiners  in  all  subjects  at  the  same  examina- 
tion. Candidates  must  have  completed  the  fifth  year  of 
professional  study. 

Degree  of  Doctor  of  Medicine. — Candidates  for  the  degree 
of  Doctor  of  Medicine  must  have  passed  the  examination  for 
the  degrees  of  M.B.,  Ch.B.  at  least  one  year  previously,  must 
present  a thesis  embodying  observations  in  some  subject 
approved  by  the  professor  of  medicine,  and  must  pass  an 
examination  in  the  Principles  and  Practice  of  Medicine. 

Degree  of  Master  of  Surgery. — Candidates  for  the  degree  of 
Ch.M.  must  have  passed  the  examination  for  the  degrees  of 
M.B.,  Ch.B.  at  least  one  year  previously,  and  must,  since 
taking  the  degrees  of  M.B.,  Ch.B.,  have  held  for  not  less 
than  six  months  a surgical  appointment  in  a public  hospital 


UNIVERSITY  OF  BRISTOL. 


or  other  public  institution,  affording  full  opportunity  for  the 
study  of  Practical  Surgery. 

The  subjects  of  examination  are  Systematic, [Clinical,  and 
Operative  Surgery,  Surgical  Anatomy,  Surgical  Pathology, 
and  Bacteriology. 

Scholarships,  $c. — At  this  University,  in  addition  to  four 
Edgar  Allen  scholarships  of  £100  a year  for  three  years, 
holders  of  which  can  take  the  courses  in  the  Faculty  of 
Medicine,  there  are  8 scholarships  and  a Town  Trust  Fellow- 
ship. Full  particulars  as  to  curriculum,  scholarships,  &c., 
may  be  had  on  application  to  the  Registrar  or  to  the  Dean 
of  the  Medical  Faculty. 

The  Medical  School. — The  new  buildings  of  the  University 
opened  in  1905  are  situated  at  the  west  end  of  the  city, 
adjoining  Weston  Park,  and  the  Medical  Department  occupies 
the  entire  north  wing  of  the  University  quadrangle.  The 
various  athletic  and  other  students’  societies  are  under  the 
management  of  a Students’  Representative  Council,  elected 
annually.  There  are  large  and  comfortable  common  rooms 
both  for  men  and  women  students.  A refectory  is  open  daily 
at  the  University  where  students  may  obtain  refreshments, 
lunch,  dinner,  See.,  at  extremely  moderate  prices.  The 
University  journal,  Floreamxis,  edited  by  a committee  of 
stafF and  students,  is  published  each  term.  The  University 
Hostel,  “Oakholme,”  Clarkehouse-road,  is  recognised  by  the 
Senate  as  a residence  for  women  students,  full  particulars  of 
which  may  be  obtained  of  the  tutor  for  women  students. 

Clinical  Instruction. — The  University  is  within  easy  reach 
of  the  various  hospitals  with  which  it  is  connected  for 
clinical  purposes.  These  are  as  follows  : The  Royal  Infir- 
mary (Secretary,  Mr.  J.  W.  Barnes),  containing  320  beds, 
with  an  annual  average  number  of  over  3800  in-patients, 
over  11,500  out-patients,  and  over  23,000  casualties;  the 
Royal  Hospital  (Hon.  Sec.,  pro  tem.,  to  the  medical  and 
surgical  staff,  Mr.  Vincent  Townrow),  with  191  beds,  and  an 
annual  number  of  3000  in-patients,  over  20,000  out-patients, 
and  nearly  20,000  casualties  ; and  the  Jessop  Hospital  for 
Diseases  of  Women,  with  80  beds,  about  750  in-patients,  and 
over  3000  out-patients  ; also  a Maternity  department,  with 
about  450  in-patients  per  annum  and  about  700  out-patient 
cases  attended.  Special  courses  on  Fevers  are  held  at  the 
City  Fever  Hospitals  (570  beds)  and  on  Mental  Diseases  at 
the  South  Yorkshire  Asylum  (1610  beds).  For  purposes  of 
clinical  practice  the  practices  of  the  Royal  Infirmary  and 
Royal  Hospital  are  amalgamated,  giving  a total  of  511  beds 
for  the  treatment  of  medical,  surgical,  and  special  cases. 
There  are  special  departments  for  the  treatment  of  Diseases 
of  the  Eye  at  each  institution,  with  wards  assigned  to  them. 

In  addition  to  these  the  Royal  Infirmary  has  special  depart- 
ments for  the  treatment  of  Diseases  of  the  Skin  and  Ear, 
with  beds  assigned  to  them,  whilst  at  the  Royal  Hospital 
there  are  special  out-patient  departments  for  Diseases  of 
the  Throat,  Ear,  Skin,  Orthopaedics,  and  Mental  Diseases. 
During  the  last  year  over  6000  patients  passed  through  the 
wards  of  the  two  institutions,  while  those  attending  as  out- 
patients numbered  over  45,000.  The  department  of  Path- 
ology and  Bacteriology  in  the  University  is  fitted  with  I 
every  requirement  for  the  most  advanced  work  in  these 
subjects. 

Fees. — The  Composition  Fee  is  £30  a year  for  each  of 
the  five  years  and  entitles  the  student  to  attendance  on  all 
the  Lectures,  Laboratory  Classes,  and  Hospital  practice 
required  for  a Medical  and  Surgical  Degree  in  the  University 
or  for  the  ordinary  qualifying  examinations  of  the  various 
Examining  Boards.  The  composition  fees  do  not  cover  the 
cost  of  apparatus,  instruments,  parts  for  dissection  in 
anatomy,  &c. , all  of  which  must  be  provided  by  the  student 
when  and  as  required.  The  fees  are  payable  in  instalments 
extending  over  the  five  years  of  the  curriculum. 


UNIVERSITY  OF  BRISTOL. 

In  the  Faculty  of  Medicine  there  are  the  following 
degrees : — Bachelor  of  Medicine  and  Bachelor  of  Surgery 
(M.B.  and  Ch.B.),  Doctor  of  Medicine  (M.D.),  Master  of 
Surgery  (Ch.M.),  Bachelor  of  Dental  Surgery  (B.D.S.),  and 
Master  of  Dental  Surgery  (M.D.S.).  There  are  also  the 
following  diplomas:  Diploma  in  Public  Health  (D.P.H.), 
Diploma  in  Dental  Surgery  (L.D.S.),  and  Diploma  in 
Veterinary  State  Medicine. 

All  candidates  for  degrees  in  Medicine,  Surgery,  and 
Dentistry  are  required  to  pass  an  examination  called  the 
Matriculation  Examination,  or  to  pass  such  examination  as 


THE  LANCET,] 


UNIVERSITY  OF  WALES. 


[August  30, 1919  373 


may  be  regarded  as  equivalent  by  the  Senate.  All  courses, 
degrees,  and  diplomas  are  open  to  men  and  women  alike. 
The  winter  session  commences  on  Oct.  1st,  1919. 

Conjoined  Degrees  of  Bachelor  of  Medicine  and  Bachelor  < f 
Surgery. — Candidates  shall  be  not  less  than  21  years  of  age 
and  shall  have  pursued  the  courses  prescribed  by  University 
Regulations  during  not  less  than  five  and  a half  years,  of 
which  three  shall  have  been  passed  in  the  University,  and 
two  of  these  three  subsequent  to  pass  in  the  second 
examination.  All  candidates  for  the  degrees  of  M.B.,  Ch.B., 
are  required  to  satisfy  the  examiners  in  the  several  subjects 
of  three  examinations. 

The  First  Examination. — The  subjects  of  examination  are: 
Chemistry  (Inorganic),  Physics,  and  Biology,  the  courses 
pursued  being  those  for  the  time  being  approved  for  the 
intermediate  part  of  the  B.Sc.  curriculum.  This  part  of  the 
curriculum  shall  extend  over  one  year.  (Candidates  who 
have  passed  the  Higher  School  Ceitificate  approved  by  the 
Board  of  Education  in  these  subjects  will  not  be  required  to 
sit  for  the  first  examination  and  will  be  regarded  as  having 
completed  one  year  of  study.) 

The  Second  Examination. — The  subjects  of  examination  are  : 
Organic  Chemistry  and  Elementary  Anatomy  (Part  I.)  and 
Advanced  Anatomy  and  Physiology  (Part  II.).  Parts  I.  and 
II.  may  be  passed  separately  or  together. 

The  Final  Examination. — The  subjects  of  examination  are  : 
Materia  Medica  and  Pharmacy,  Pharmacology  and  Thera- 
peutics, General  Pathology,  Morbid  Anatomy,  and  Bacterio- 
logy (Part  I.)  ; Special  Pathology,  Forensic  Medicine, 
Toxicology,  and  Public  Health,  Obstetrics  (including 
Diseases  of  Women),'  Surgery  (Systematic,  Clinical,  Prac- 
tical, and  Operative),  Medicine  (Systematic,  Clinical,  and 
Practical,  including  Mental  Diseases) (Part  II.).  Candidates 
may  pass  I.  and  II.  together,  or  separately,  and  Forensic 
Medicine  and  Toxicology  may,  at  the  option  of  the  candi- 
date, be  taken  either  with  Part  I.  or  Part  II. 

Degree  of  Doctor  of  Medicine. — Candidates  shall  be 
Bachelors  of  the  University  of  not  less  than  two  years’ 
standing  as  such  and  may  elect  either  (1)  to  pass  an  exami- 
nation in  General  Medicine,  or  (2)  to  pass  an  examination  in 
State  Medicine,  or  (3)  to  present  a Dissertation.  The  candi- 
date who  elects  to  pass  the  examination  in  State  Medicine 
must  hold  a diploma  in  Public  Health  of  some  University  or 
College,  and  the  candidate  who  elects  to  present  a 
Dissertation  may  be  examiued  in  the  subject  thereof. 

Degree  of  Master  of  Surgery.  — Candidates  shall  be  Bachelors 
of  not  less  than  two  years  as  such,  during  which  period  they 
shall  have  attended  the  Surgical  Practice  of  an  institution 
approved  for  the  purpose.  They  shall  pass  an  examination 
in  Surgical  Anatomy,  Pathology,  and  Bacteriology,  and 
Operative,  Clinical,  and  General  Surgery,  and  present  to  the 
University  a Dissertation  on  some  subject  of  Surgery. 

Clinical  Instruction. — The  allied  hospitals  (Bristol  Royal 
Infirmary  and  Bristol  General  Hospital)  have  between  them 
about  600  beds  and  extensive  out-patient  departments,  special 
clinics  for  Diseases  of  Women  and  Children  and  those  of 
the  Eye,  Throat,  and  Ear,  in  addition  to  large  and  well- 
equipped  departments  for  Dental  work  and  large  outdoor 
Maternity  Departments. 

At  each  of  these  institutions  there  are  well-arranged 
pathological  museums,  post-mortem  rooms,  and  laboratories 
for  Morbid  Anatomy.  There  are  also  laboratories  for  work 
in  Clinical  Pathology,  Bacteriology,  and  Cytology,  in  which 
special  instruction  is  given  in  these  subjects.  Departments 
are  provided  and  well-equipped  for  X ray  work,  both  for 
diagnosis  and  treatment.,  the  various  forms  of  Electrical 
treatment,  including  High  Frequency  Currents,  Electric 
Baths,  F’insen  Light  treatment.,  and  Massage. 

The  students  of  the  school  also  attend  the  practice  of 
the  Royal  Hospital  for  Sick  Children  and  Women,  con- 
taining 140  beds,  and  that  of  (he  Bristol  Eve  Hospital, 
with  40  beds.  The  total  number  of  beds  available  for  clinical 
instruction  is  therefore  about  750. 

Further  information  as  to  scholarships,  curricula,  and  fees 
can  be  obtained  from  the  Dean  of  the  Faculty  of  Medicine 
or  the  Registrar  of  the  University. 


UNIVERSITY  OF  WALES. 

This  University  has  the  privilege  of  granting  degrees 
in  Medicine  and  Diplomas  in  Public  Health.  At  the  three 
constituent  Colleges  of  Aberystwyth,  Bangor,  and  Cardiff 
there  are  Professors  of  Chemistry,  Botany,  Zoology,  and 


Physics,  so  that  the  students  of  the  University  can  obtain 
proper  instruction  in  the  ancillary  subjects.  The  founda- 
tion of  a Medical  Faculty  has  been  laid  at  University 
College,  Cardiff,  where  there  is  a recognised  school  of 
medicine. 

University  College , Cardiff:  School  of  Medicine.--  All 

classes  are  open  to  both  men  and  women  students  who  may 
spend  three  or  four  out  of  their  five  years  of  medical  study 
at  Cardiff.  The  courses  of  instruction  given  at  Cardiff  are 
recognised  as  qualifying  for  the  examinations  of  the 
Universities,  Royal  Colleges,  and  other  licensing  bodies  of 
Great  Britain  and  Ireland,  and  they  arc  specially  adapted  to 
meet  the  needs  of  those  University  students  studying 
for  Cambridge  and  London  degrees.  Students  who  are 
preparing  for  these  examinations  may  compound  for 
their  courses  by  paying  a fee  of  £63,  while  a com- 
position fee  of  £41  10s.  includes  all  the  necessary 
courses  for  the  first  and  second  examinations  for  the 
Diploma  of  the  Conjoint  Board.  In  all  cases  the  com- 
position fees  may  be  paid  by  instalments.  Hospital 
instruction  is  given  at  the  King  Edward  VII. ’s  Hospital, 
Cardiff.  The  attention  of  students  about  to  matriculate  is 
drawn  to  the  numerous  entrance  scholarships  offered  for 
competition  at  University  College,  Cardiff,  in  April  next, 
most  of  which  may  be  held  by  medical  students.  Full 
particulars  of  the  examination  for  these  may  be  obtained  by 
application  to  the  Registrar.  In  the  department  of  Public 
Health  established  in  1899  instruction  is  given  qualifying 
for  the  D.P.H.  examinations.  Further  information  maybe 
obtained  from  the  Dean  of  the  Faculty  of  Medicine. 

Clinical  Instruction. — King  Edward  VII. ’s  Hospital, 
Cardiff. — Students  can  attend  the  practice  of  this 
Hospital,  which  contains  320  beds,  104  beds  for  military 
patients.  Founded  1837.  In-patients,  2830  ; out-patients, 

16,303. Swansea  General  and  Eye  Hospital. — 

Hospital,  288  beds,  188  civilian,  100  (sailor  and  soldier 
pensioners) , Convalescent  Home,  27  beds.  In-patients, 
2516  ; out-patients,  7953. 


ENGLISH  MEDICAL  CORPORATIONS 
GRANTING  DIPLOMAS. 


EXAMINING  BOARD  IN  ENGLAND  BY  THE  ROYAL 

COLLEGE  OF  PHYSICIANS  OF  LONDON  AND  THE 
ROYAL  COLLEGE  OF  SURGEONS  OF  ENGLAND. 

Under  this  heading  we  give  the  regulations  for  the  exa- 
minations enjoined  by  the  Conjoint  Examining  Board  of  the 
Royal  Colleges  of  Physicians  of  London  and  Surgeons  of 
England  and  of  the  Society  of  Apothecaries  upon  students 
desiring  their  respective  diplomas  of  qualification.  We  do 
not  give  any  list  of  schools  recognised  by  these  bodies  as 
eligible  to  prepare  students  for  their  examinations  beyond 
mentioning  that  all  the  schools  which  we  have  already 
described  (under  the  heading  of  the  Universities  to  which 
they  are  attached)  are  recognised  as  suitable  places  of 
instruction  by  the  corporations  granting  medical  diplomas. 
The  courses  of  study  at  the  principal  colonial  medical 
schools  are  also  recognised  as  qualifying  for  the  examina- 
tions of  these  corporations. 

Any  candidate  who  desires  to  obtain  both  the  Licence  of 
the  Royal  College  of  Physicians  of  London  and  the  diploma 
of  Member  of  the  Royal  College  of  Surgeons  of  England  is 
required  to  complete  five  years  of  professional  study  at 
recognised  Medical  Schools  and  Hospitals  and  to  comply 
with  the  following  regulations  and  to  pass  the  examinations 
hereinafter  set  forth.  Six  months  of  the  curriculum  may 
be  spent  in  an  Institution  recognised  by  the  Board  for  in- 
struction in  Chemistry,  Physics,  Practical  Chemistry,  and 
Biology. 

Professional  Examinations. — There  are  three  Examina- 
tions, called  herein  the  First  Examination,  the  Second 
Examination,  and  the  Third  or  Final  Examination, 
each  being  partly  written,  partly  oral,  and  partly 
practical.  These  examinations  will  be  held  in  the 
months  of  January,  April,  July,  and  September  or  October 
unless  otherwise  appointed.  Every  candidate  intending 
to  present  himself  for  examination  is  required  to  give  notice 
in  writing  to  Mr.  F.  G.  Hallett,  O.B  E.,  secretary  of  the  Exa- 
mining Board,  Examination  Hall,  Queen-square,  Bloomsbury, 
W.C.,  14  clear  days  before  the  day  on  which  the  examination 


374  The  Lancet,] 


ENGLISH  MEDICAL  CORPORATIONS  GRANTING  DIPLOMAS. 


[August  30,  1919 


commences,  transmitting  at  the  same  time  the  required 
certificates. 

The  subjects  of  the  First  Examination  are — Chemistry, 
Physics,  Elementary  Biology,  and  Practical  Pharmacy.  A 
candidate  may  take  this  examination  in  three  parts  at 
different  times  (Chemistry  and  Physics  must  be  taken 
together  until  the  required  standard  is  reached  in  both  or  in 
one  of  these  subjects,  but  a candidate  will  not  be  allowed  to 
jrass  in  one  without  obtaining  at  the  same  time  at  least 
naif  the  number  of  marks  required  to  pass  in  the 
other).  A candidate  will  be  admitted  to  examina- 
tion in  Chemistry  and  Physics,  in  Practical  Pharmacy, 
and  Elementary  Biology  on  producing  evidence  of  having 
passed  the  required  Preliminary  Examination  and  of 
having  received  instruction  in  these  subjects  at  a recognised 
institution,  but  he  may  take  Pharmacy  at  any  time  during 
the  curriculum.  A candidate  rejected  in  one  part  or 
more  of  the  First  Examination  will  not  be  admitted 
to  re-examination  until  after  the  lapse  of  a period  of 
not  less  than  three  months  from  the  date  of  rejection, 
and  he  will  be  re-examined  in  the  subject  or  subjects 
in  which  he  has  been  rejected.  If  referred  in  Chemistry, 
Physics,-  or  Biology  he  must  produce  evidence  of  further 
instruction  at  a recognised  institution.  Any  candi- 
date who  shall  produce  satisfactory  evidence  of  having 
passed  an  examination  for  a degree  in  Medicine  on  any 
of  the  subjects  of  this  examination  conducted  at  a university 
in  the  United  Kingdom,  in  India,  or  in  a British  colony  will 
be  exempt  from  examination  in  those  subjects  in  which  he 
has  passed. 

Note.  — Candidates  who  have  not  passed  Parts  I.,  II..  and 
III.  by  May  1st,  1920,  will  be  examined  in  Materia  Medica 
and  Pharmacology  as  part  of  the  Second  Examination  instead 
of  Practical  Pharmacy.  The  new  regulations  and  the 
synopsis  of  the  examination  will  be  issued  shortly 

The  fees  for  admission  to  the  First  Examination  are  as 
follows  : For  the  whole  examination,  £10  10s.  ; for  re- 
examination after  rejection  in  Parts  I.  and  II.,  £3  3j>\  ; and 
for  re-examination  in  each  of  the  other  parts,  £2  2 s. 

The  subjects  of  the  Second  Examination  are  Anatomy 
and  Physiology.  Candidates  will  be  required  to  pass  in 
both  subjects  at  one  and  the  same  time.  Candidates  will 
be  admissible  to  the  Second  Examination  on  production  of 
the  required  certificates  of  professional  study.  The  study  of 
Anatomy  and  Physiology  before  passing  in  two  of  t-  e first 
three  parts  of  the  First  Professional  Examination  is  not 
recognised. 

A candidate  referred  on  the  Second  Examination  will  be 
required,  before  being  admitted  to  re-examination,  to  pro- 
duce a certificate  that  he  has  pursued,  to  the  satisfaction  of 
his  teachers,  in  a recognised  place  of  study,  his  Anatomical 
and  Physiological  studies  during  a period  of  not  less  than 
three  months  subsequently  to  the  date  of  his  reference. 

The  fees  for  admission  to  the  Second  Examination  are  : 
£10  10s.  for  the  whole  examination  and  £6  6s.  for  re- 
examination after  rejection. 

The  subjects  of  the  Third  or  Final  Examination  are : 
Part  I.  Medicine,  including  Medical  Anatomy,  Pathology, 
Practical  Pharmacy,  Therapeutics,  Forensic  Medicine, 
and  Public  Health.  Candidates  who  have  passed  in 
Practical  Pharmacy  at  the  First  Examination  will  not  be 
re-examined  in  that  subject  at  the  Third  Examination. 
Part  II.  Surgery,  including  Pathology,  Surgical  Anatomy, 
and  the  use  of  Surgical  Appliances.  Part  III.  Midwifery 
and  Diseases  Peculiar  to  Women.  Candidates  may  pre-ent 
themselves  for  Parts  I.,  II.,  and  III.  of  the  examination 
separately  or  together  at  the  expiration  of  not  less  than 
two  years  (24  months)  from  the  date  of  passing  the 
Second  Examination  on  production  of  the  certificates  of 
study  required  for  the  respective  parts,  provided  that  the 
examination  is  not  completed  before  the  expiration  of  five 
years  from  the  date  of  passing  the  Preliminary  Examination. 

The  fees  for  admission  to  the  Third  or  Final  Examination 
arc  as  follows  : For  the  w-hole  examination,  £21.  Part  I. 
For  re-examination  in  Medicine,  including  Medical  Anatomy, 
Pathology,  Therapeutics,  Forensic  Medicine,  and  Public 
Health,  £5  5s.  ; for  re-examination  in  Practical  Pharmacy 
(if  taken  at  this  examination).  £2  2s.  Part  II.  For  re-exami- 
nation  in  Surgery,  including  Pathology,  Surgical  Anatom' , and 
the  use  of  Surgical  Appliances,  £5  5s.  Part  III.  Forre-exami- 
nation  in  Midwifery  and  Diseases  Peculiar  to  Women.  £3  3s. 

A candidate  referred  on  the  Third  or  Final  Examina- 
tion will  not  be  admitted  to  re-examination  until  after 


the  lapse  of  a period  of  not  less  than  three  months 
from  the  date  of  rejection  and  will  be  required, 
before  being  admitted  to  re-examination,  to  produce  a 
certificate,  in  regard  to  Medicine  and  Surgery,  of  having 
attended  the  Medical  and  Surgical  Practice,  or  the  Medical 
or  Surgical  Practice,  as  the  case  may  be.  during  the 
period  of  his  reference  ; and  in  regard  to  Midwifery  and 
Diseases  Peculiar  to  Women  a certificate  of  having  received, 
subsequently  to  the  date  ofTiis  reference,  not  less  than  three 
months’  instruction  in  that  subject  by  a recognised  teacher. 

Students  of  recognised  universities  in  England,  Scotland, 
and  Ireland,  who  have  passed  examinations  for  a degree  in 
Medicine  at  their  universities  in  the  subjects  of  the  First  and 
Second  Examinations  of  the  Examining  Board,  may  enter 
for  the  Final  Examination  at  the  expiration  of  two  years 
from  the  date  of  passing  in  Anatomy  and  Physiology  on 
production  of  the  required  certificates. 

Members  of  certain  recognised  Indian,  Colonial,  and 
Foreign  universities  who  have  passed  examinations  for  the 
Degree  of  Doctor  or  Bachelor  of  Medicine  or  Surgery  in  the 
subjects  of  the  First  and  Second  Examinations  of  the 
Examining  Beard  may  present  themselves  for  the  Final 
Examination  under  special  conditions  which  can  be  ascer- 
tained on  application  to  the  Secretary. 


ROYAL  COLLEGE  OF  PHYSICIANS  OF  LONDON: 
THE  MEMBERSHIP  AND  FELLOWSHIP. 

In  addition  to  the  diplomas  granted  by  the  English  Con- 
joint Board,  the  Royal  College  of  Physicians  of  London  and 
the  Royal  College  of  Surgeons  of  England  grant  honour 
diplomas,  which  no  longer  give  the  right  to  practise  pro- 
fessionally if  held  separately.  The  Royal  College  of  Phy- 
sicians of  London  has  two  such  diplomas,  the  Fellowship 
which  is  a puiely  honorary  distinction  and  the  Membership 
which  is  obtained  by  examination. 

Membership. — Every  candidate  for  the  Membership  of 
the  College  must  furnish  proof  of  having  attained  the 
age  of  25  years.  Candidates  must  not  be  engaged  in  trade, 
dispense  medicine,  make  any  arrangement  with  a chemist 
or  any  other  person  for  the  supply  of  medicine,  or 
practise  medicine  or  surgery  in  partnership,  by  deed  or 
otherwise.  Any  candidate  being  already  registered  or  having 
passed  a qualifying  examination  in  accordance  with  the 
Medical  Act  of  1886.  who  has  obtained  the  degree  of  Doctor 
or  Bachelor  of  Medicine  at  a University  in  the  United 
Kingdom,  in  India,  or  a British  colony,  or  who  has  obtained  a 
foreign  qualification  entitling  him  or  her  to  practice  medicine 
or  surgery  in  the  country  where  such  qualification  has  been 
conferred,  wherein  the  courses  of  studyand  the  examinations 
to  be  undergone  previously  to  graduation  have  been  adjudged 
by  the  Censors’  Board  to  be  satisfactory,  will  (if  the  Censors 
think  fit)  be  admitted  to  the  Pass  Examination.  The  nature 
and  extent,  of  this  examination  will,  in  the  case  of  each 
candidate,  be  determined  by  the  Censors’  Board.  Ml  other 
candidates  must  produce  proof  of  having  passed  the  examina- 
tions required  for  the  Licence  of  the  College.  The  examina- 
tion is  directed  partly  to  pathology  and  partly  to  the  prmtice 
of  medicine  and  may  be  modified  in  circumstance'  to  be 
ascertained  by  application  to  the  Registrar.  For  example, 
candidates  under  40  yea  s of  age  are  examined  in  an  amm-nt 
and  a modern  language,  a test  from  which  their  senior'  are 
exempt.  The  fee  for  admission  as  a Member  of  the  College 
is  40  guineas,  except,  when  the  candidare  for  Membership  is 
a Licentiate  of  the  College,  in  which  case  the  fee  already 
paid  for  the  Licence  sh -i II  be  deducted  from  the  4h  guineas. 
The  fee  for  the  examination  is  £6  6s. 

Fellowship. — The  Fellows  are  selected  annually  from  the 
ranks  of  the  Members  by  the  Comitia  of  the  College. 


ROYAL  COLLEGE  OF  SURGEONS  OF  ENGLAND: 
THE  FELLOWSHIP. 

The  Roval  College  of  Surgeons  of  England  confets  its 
diploma  of  Fellow  up  >n  a few  distinguished  person'  i>  an 
honorary  capacity.  Two  Members  of  long  standing  ni-v 
also  be  elected  to  the  Fellowship  annually.  R-t  'he 
bulk  of  the  Fellows  obtain  the  diploma  as  the  result  of 
examination. 

Fellowship. — The  examination  for  the  Fellowship  is 
divided  into  two  parts — viz.,  the  First  Examination  and 


The  Lancet,] 


ENGLISH  MEDICAL  CORPORATIONS  GRANTING  DIPLOMAS. 


[August  30,  1919  375 


the  Second  Examination.  The  subjects  of  the  First 
Examination  are  Anatomy  and  Physiology,  and  the  ques- 
tions on  these  subjects  may  require  an  elementary 
acquaintance  with  Comparative  Anatomy  and  Physiology. 
The  examination  is  partly  written  and  partly  viva  voce.  The 
subjects  of  the  Second  Examination  are  Surgery,  including 
Surgical  Anatomy  and  Pathology.  The  examination  is  partly 
written  and  partly  viva  voce  and  includes  the  examination 
of  patients  and  the  performance  of  operations  on  the  dead 
body.  The  examinations  are  held  during  the  months  of 
May  and  November  of  each  year. 

The  fees  for  examination  are  : — First  Examination,  each 
admission,  5 guineas.  Second  Examination,  each  admission, 
12  guineas.  Of  such  examination  fees  17  guineas  will  be 
reckoned  as  part  of  the  fee  payable  upon  admission  to  the 
Fellowship.  The  fee  to  be  paid  upon  admission  to  the 
Fellowship  is  30  guineas,  except  when  the  candidate  is  a 
Member  of  the  College,  in  which  case  the  fee  is  20  guineas. 

A Member  of  the  College  is  admissible  to  the  First  Exa- 
mination at  any  time  after  receiving  bis  Diploma  of  Member- 
ship. A candidate  who  is  not  a member  of  the  College  is 
admissible  to  the  first  Professional  Examination  for  the 
Fellowship  on  the  production  of  evidence  of  having  passed 
the  First  and  Second  Examinations  ot  the  Examining  Board 
in  England  by  the  Royal  College  of  Physicians  of  London 
and  the  Royal  College  of  Surgeons  of  England  (or,  if  a 
member  of  a University  recognised  by  the  College  for  the 
purpose,  of  having  passed  the  Examinations  in  his  Uni- 
versity equivalent  to  the  First  and  Second  Examinations  of 
the  Board)  and  on  the  production  of  certificates  of  attend- 
ance upon  certain  courses  of  study  described  in  the 
Regulations. 

A Member  of  the  College  is  admissible  to  the  Second 
Examination  at  any  time  after  having  passed  the  First 
Examination,  on  producing  satisfactory  evidence  of  having 
been  engaged  not  less  than  six  years  in  the  study  (or  study 
and  prac'ice)  of  the  profession. 

A candidate  who  is  not  a Member  of  the  College  must 
possess  the  registrable  surgical  and  medical  degrees  of 
universities  recognised  by  the  Council  and  must  have  been 
engaged  in  the  study  (or  study  and  practice)  of  the  profes- 
sion for  not  less  than  four  years  subsequent  to  the  date  of 
obtaining  the  recognised  qualification,  one  year  of  which 
shall  have  been  spent  in  attendance  on  the  Surgical  Practice 
of  a recognised  hospital.  The  diploma  of  Fellow  is  not  con- 
ferred upon  successful  candidates  until  they  have  attained 
the  age  of  25  years. 

The  Regulations  may  be  obtained  on  application  to  the 
Director  of  Examinations,  Examination  Hall,  Queen-square, 
Bloomsbury,  London,  W.C.  1. 

SOCIETY  OF  APOTHECARIES  OF  LONDON. 

There  are  two  examinationr—  Primary  and  Final.  The 
Final  examination  is  divided  into  Section  I.  and  Section  II. 
The  Primary  examination  is  held  quaiterly.  Final  examina- 
tions are  held  monthly.  No  examinations  are  held  in  the 
month  of  September. 

The  Primary  examination  consists  of  two  parts.  Part  I. 
Elementary  Biology  ; Chemistry,  Chemical  Physics,  including 
the  Elementary  Mechanics  of  Solids  and  Fluids,  Heat,  Light, 
and  Electricity  ; Practical  Chemistry  ; and  Materia  Medica 
and  Pharmacy.  Part  II.  includes  Anatomy,  Physiology,  and 
Histology.  This  examination  cannot  be  passed  before  the 
completion  of  twelve  months’  Practical  Anatomy  with 
Demonstrations,  and  thesesnbjeets  cannot  be  taken  separately 
except  in  the  event  of  the  candidate  having  previously 
passed  in  one  A schedule  for  the  Primary  examination, 
to  be  obtained  of  the  Secretary,  must  be  signed  by 
the  Dean  of  the  Medical  School  or  other  authority. 
Section  I.  of  the  Final  examination  consists  of  three  parts. 
Part  I.  includes  the  Principles  and  Practice  of  Surgery, 
Surgical  Pathology,  and  Surgical  Anatomy,  Operative 
Manipulation,  Instruments,  and  Appliances.  Part  II. 
includes  the  Principles  and  Practice  of  Medicine,  Phar- 
macology, Pathology,  and  Morbid  Histology  ; Forensic 
Medicine,  Hygiene,  Theory  and  Practice  of  Vaccination  ; 
and  Mental  Diseases.  Part  Iff  includes  Midwifery, 
Gynecology,  and  Diseases  of  New-born  Children  and  the 
Use  of  Obstetric  Instruments  and  Appliances.  Section  I 
of  the  Final  examination  cannot  be  passed  before  the 
expiration  of  45  months  from  the  date  of  commencement  of 


medical  study,  during  which  time  not  less  than  three  winter 
sessions  and  two  summer  sessions  must  have  been  passed 
at  one  or  mo're  of  the  medical  schools  connected  with  a 
general  hospital  recognised  by  the  Society.  Section  II. 
of  the  Final  examination  consists  of  two  Parts.  Part  1. 
Clinical  Surgery;  Part  II.  Clinical  Medicine  and  Medical 
Anatomy.  Section  11.  cannot  be  passed  before  the  end  of 
the  fifth  year. 

The  course  of  study  for  the  Primary  examination  is 
as  follows  : — Elementary  Biology,  not  less  than  three 
months ; Chemistry  and  Chemical  Physics,  six  months  ; 
Practical  Chemistry,  three  months  ; Pharmacy  and  Dis- 
pensing, three  months  ; Anatomy,  six  months  ; Practical 
Anatomy  with  Demonstrations,  12  months  ; Physiology, 
six  months  ; Histology  with  Demonstrations,  three  months. 
The  study  of  these  subjects  must  be  pursued  at  a Medical 
School  recognised  by  the  Society.  Instruction  in  Pharmacy 
and  Dispensing  must  be  given  by  a registered  medical  prac- 
titioner or  by  a member  of  the  Pharmaceutical  Society 
by  examination,  or  in  a public  hospital,  infirmary,  or 
dispensary. 

The  course  of  study  for  the  Final  examination , Section  I., 
includes  attendance  on  the  Surgical  and  Medical  Practice 
(with  Post-mortem  Examinations)  at  a hospital  connected  with 
a medical  school  for  a period  of  two  winter  and  two  summer 
sessions  ; lectures  on  the  Principles  and  Practice  of  Surgery, 
six  months  ; Practical  Surgery,  three  months  ; Clinical 
Surgical  Lectures,  nine  months;  Dressership,  six  months; 
Performance  of  Surgical  Operations  on  the  Dead  Body  ; 
lectures  on  Principles  and  Practice  of  Medicine,  six  months  ; 
Pathology,  three  months  ; Clinical  Medical  Lectures,  nine 
months;  Clinical  Clerkship,  six  months;  Forensic  Medi- 
cine, Hygiene,  and  Insanity,  three  months  ; Midwifery  and 
Gynaecology,  three  months ; Clinical  Instruction  in  the 
same,  three  months ; a course  of  Practical  Midwifery ; 
attendance  on  20  Midwifery  cases.  The  course  of  medical 
study  must  extend  over  the  above-mentioned  period  of 
45  months,  and  the  offices  of  dresser  or  clinical  clerk 
must  be  held  at  a hospital  or  other  institution  recognised 
by  the  Society.  Two  rears  must  elapse  after  a candidate 
has  passed  the  examination  in  Anatomy  and  Physiology 
before  he  is  eligible  to  sit  for  any  part  of  the  Final 
examination. 

The  course  of  study  for  the  Final  examination , Section  II., 
includes  either  attendance  on  the  Practice  of  Medicine 
and  Surgery  at  a hospital  or  other  institution  recognised 
by  the  Society  for  a further  period  of  12  months, 

or  six  months  as  above  and  six  months  as  a pupil 

of  a retjisterfd  practitioner  holding  a public  medical 

or  surgical  appointment,  or  attendance  at  two  special 

hospitals  for  six  months  (three  months  at  each  hos- 
pital), and  for  six  months  at  a general  hospital,  all  such 
hospitals  to  be  recognised  by  the  Society.  Evidence  shall 
also  be  given  of  practical  instruction  in  Infectious  Diseases 
and  in  Mental  Diseases  (at  a lunatic  asylum  or  in  the  wards 
of  an  institution  containing  a special  ward  set  apart  for 
the  treatment  of  mental  diseases),  and  in  any  two  of 
the  following  subjects  : Ophthalmic  Surgery,  Laryngology 
with  Rhinology  and  Otology,  Dermatology,  and  Diseases 
of  Children.  No  candidate  is  eligible  for  the  Final 
examination  who  has  not  completed  the  curriculum  pre- 
scribed by  the  Society,  in  evidence  of  which  a schedule, 
to  be  obtained  of  the  Secretary,  must  be  produced,  signed  by 
the  Dean  of  the  Medical  School  or  other  authority.  Prior  to 
Section  II.  of  the  Final  examination  the  candidate  must 
produce  certificates  : (1)  of  being  21  years  of  age  ; (2) 
of  moral  character  ; (3)  of  the  course  of  medical  study ; 
(4)  of  proficiency  in  vaccination  signed  by  a teacher 
authorised  by  the  Local  Government  Board ; and  (5)  of 
instruction  in  the  administration  of  anaesthetics.  Candidates 
intending  to  present  themselves  for  examination  are  required 
to  give  14  days’  notice.  A form  for  this  purpose  will  be  sent 
on  application. 

Licentiates  are  eligible  for  the  Membership  of  the  Society 
of  Apothecaries.  Particulars  may  be  obtained  on  application 
to  ihe  clerk. 

The  fee  for  the  Licence  is  20  guineas.  Female  candidates 
are  admitted  to  examinations.  The  examination  offices  are 
open  from  10  A.M.  to  4 P.M.  : on  Saturdays  from  10  a.m.  to 
1 p.m.  All  letters  should  be  addressed  to  the  Secretary. 
Court  of  Examiners,  Society  of  Apothecaries  of  London, 
Blaekfriars,  E.C.  4. 


376  The  Lancet,] 


METROPOLITAN  ANCILLARY  SCHOOLS  AND  HOSPITALS. 


[August  30,  1919 


METROPOLITAN  ANCILLARY  SCHOOLS  AND 
HOSPITALS  AFFORDING  FACILITIES  FOR 
CLINICAL  OBSERVATION. 

The  institutions  which  follow  provide  to  the  medical 
student  and  medical  graduate  facilities  for  different  forms 
of  instruction  and  clinical  observation.  In  each  case  further 
information  can  be  obtained  from  the  secretary  of  the 
hospital. 

The  Seamen's  Hospital  Society  possesses  two  hospitals 
— the  Dreadnought  Hospital  at  Greenwich,  250  beds, 
and  the  Branch  Hospital  in  the  Royal  Victoria  and 
Albert  Docks,  E.,  50  beds  ; and  the  Angas  Home  30  beds. 
It  has  also  two  Dispensaries — one  in  the  East  India  Dock- 
road  and  the  other  at  Gravesend  from  which  the  patients 
are  transferred  to  the  hospitals.  Secretary  : Mr.  P.  J. 
Michelli,  C.M.G. 

West  London  Hospital,  Hammersmith,  W.  — This 
hospital  has  160  beds,  all  of  which  are  constantly  in 
use.  2440  in-patients  and  30,322  out-patients,  whose 
attendances  numbered  155,870,  were  treated  last  year. 
Attached  to  the  hospital  is  the  West  London  Post- 
Graduate  College.  The  practice  of  the  hospital  is  re- 
served exclusively  for  qualified  men,  no  junior  students 
being  admitted.  Instruction  is  given  in  the  medical  and 
surgical  out-patient  rooms  and  demonstrations  are  given  in 
the  wards  every  morning  and  afternoon.  Lectures  and 
demonstrations  are  in  abeyance  during  the  war.  Special 
Classes  are  held  in  Diseases  of  the  Throat  and  Nose, 
Skin,  and  Eye,  and  in  Gynaecology,  Medical  Electricity, 
Operative  Surgery,  Bacteriology,  Anaesthetics,  Intestinal 
Surgery,  Medical  and  Surgical  Diseases  of  Children, 
Blood  and  Urine,  Clinical  Microscopy,  Tropical  Medicine, 
Cystoscopy,  Venereal  Diseases,  and  Operative  Ophthalmo- 
logy. The  accommodation  for  post-graduates  consists  of  a 
large  lecture  room,  together  with  reading,  writing,  and  class 
rooms,  &c.  The  hospital  has  a fully  equipped  pathological 
laboratory  at  which  instruction  is  given  in  elementary 
bacteriology,  a class  being  held  every  month.  The  fees  for 
hospital  practice,  including  lectures,  are  £6  6i\  for  three 
months,  or  £15  15s.  for  one  year.  The  certificate  of  the  hos- 
pital is  accepted  by  the  Admiralty,  War  Office,  Colonial  Office, 
and  India  Office  in  cases  of  study  leave.  Further  information 
can  be  obtained  on  application  to  the  Dean,  Dr.  Arthur 
Saunders,  or  Vice-Dean,  Mr.  Bishop  Harman,  at  the  hospital. 
Secretary  of  the  Hospital  : Mr.  A.  Betteridge. 

Great  Northern  Central  Hospital,  Hollo  way- road,  N. 
— This  hospital  is  recognised  by  the  Examining  Board 
in  England  of  the  Royal  Colleges  of  Physicians  and 
Surgeons  as  a place  of  study  during  the  fifth  year 
of  the  medical  curriculum.  Besides  the  Honorary  Staff 
there  are  six  Anaesthetists,  Pathologist,  Resident  Medical 
Officer,  one  resident  House  Physician,  three  resident  House 
Surgeons,  and  resident  casualty  ■ fficer.  The  hospital  contains 
430  beds  (including  emergency  b-ds),  which  are  fully 
occupied.  There  is  also  a ward  for  children  under  five 
years  of  age.  The  large  rectangular  and  circular  wards,  each 
of  which  contains  35  beds,  the  observation  wards,  the 
two  operation  theatres,  general  and  special  out-patient  and 
pathological  departments,  are  specially  designed  with  a 
view  of  offering  the  greatest  facilities  for  clinical  work. 
There  is  also  a well-appointed  electro- therapeutic  department. 
The  Pathological  Department  has  been  extended  and  is  under 
the  control  of  a Director  of  Clinical  Pathology.  TheReckitt 
Convalescent  Home  at  Clacton-on-Sea  belongs  to  the 
hospital.  It  contains  60  beds.  Special  departments  have 
also  been  established  for  the  treatment  of  tuberculosis  and 
venereal  diseases.  A Hospital  of  Recovery  has  now  been 
established  at  “ Summerlee,”  Ea-t,  Finchley,  which  is  placed 
at  the  disposal  of  discharged  soldiers  and  sailors  as  well  as 
civilians  Medical  practitioners  are  cordially  invited  to  see 
the  general  and  special  practice  of  the  hospital.  Demon- 
strations are  given  daily  in  the  wards  and  out-patient 
departments.  Clinical  assistants  (qualified),  clinical  clerks 
and  pathological  clerks  are  appointed  in  the  general  and 
special  departments  and  may  receive  certificates  at  the 
end  of  their  terms  of  office.  Further  particulars  from  the 
Secretary  of  the  Medical  Committee  at  the  Hospital. 

Prince  of  Wales's  General  Hospital,  Tottenham.  N. — 
This  general  hospital  is  iu  the  midst  of  a densely  populated 
neighbourhood  of  more  than  half  a million  inhabitants.  It 
contains  medical,  surgical,  gynaecological,  and  children's 


wards,  having  125  beds.  There  are  special  departments  for 
gynaecological  cases,  diseases  of  the  eye,  ear,  throat,  and 
nose,  skin  diseases,  medical  electricity,  radiography,  and 
dentistry.  Operations  are  performed  every  afternoon  of  the 
week  (except  Saturday)  at  2.30  p.m.  Clinical  instruction, 
ordinarily  including  laboratory  classes,  and  lectures  are 
given  in  the  wards  and  out-patient  departments,  labora- 
tories, and  lecture  hall  in  connexion  with  the  North-East 
London  Post-Graduate  College  attached.  There  are  four 
Resident  Medical  Officers,  and  Clinical  Assistants  are 
appointed  under  certain  conditions.  Further  particulars 
in  regard  to  the  hospital  may  be  obtained  from  Mr.  H.  W. 
Carson,  Secretary  to  the  Medical  Committee,  111,  Harley- 
street,  W.  ; or  from  Dr.  A.  J.  Whiting,  Dean  of  the  North- 
East  London  Post  Graduate  College,  19a,  Cavendish- 
cquare,  W.  Secretary  : Mr.  F.  W.  Drewett. 

London  Temperance  Hospital.  Hampstead- road,  N.W. 
(Established  1873  ; Incorporated  1917). — The  hospital  con- 
tains 120  beds.  The  in-patients  in  1918  were  1154, 
and  the  out-patients  and  casualties  numbered  15  803 
new  cases.  The  medical  and  surgical  practice  of  the 
hospital  is  open  to  students  and  practitioners.  Opera- 
tions: Mondays  at  2 p.m.,  Tuesdays,  Wednesdays,  and 
Fridays  at  9 A.M. 

Hampstead  General  and  North-West  London  Hos- 
pital.— The  Hampstead  General  Hospital  (Haverstock  Hill) 
and  the  North-West  London  Hospital  (formerly  at  Kentish 
Town)  have  been  amalgamated  since  1907.  The  Hampstead 
General  Hospital  (128  beds— viz.,  102  free,  6 isolation,  &c., 
and  20  paying  or  contributory)  accommodates  the  in- 
patients from  the  districts  hitherto  served  by  both  hospitals. 
The  out-patients,  with  the  exception  of  Hampstead 
casualty  and  emergency  cases,  attend  exclusively  at  the 
Out-patients  Department,  Bayliam-street,  Camden  Town. 
Further  particulars  from  the  secretary  at  the  hospital 
(Haverstock  Hill,  N.W.  3). 

Elizabeth  Garrett  Anderson  Hospital,.  144.  Euston- 
road,  N.W. — A considerable  number  of  the  students  work 
in  the  E.G.A.  Hospital  under  the  visiting  staff,  and  in  return 
for  much  valued  clinical  teaching  they  perform  the  duties 
assigned  to  students  in  the  wards  of  a general  hospital. 
Secretary  : Miss  Imogen  H.  Murphy. 

The  South  London  Hospital  for  Women,  South 
Side,  Clapham  Common,  S.W.  ; Out-patient  Department: 
86-90,  Newington  Causeway,  S.E. — This  hospital,  officered 
entirely  by  medical  women,  is  a general  hospital  for  women, 
girls,  and  small  children  of  both  sexes,  and  provides  accom- 
modation for  80  patients.  All  diseases  are  treated  with  the 
exception  of  acute  infectious  fevers  and  mental  disease. 
There  are  Ophthalmic,  X Ray,  and  Pathological  Depart- 
ments. The  provision  of  additional  facilities  for  post- 
graduate training  for  medical  women  is  one  of  the  special 
objects  of  the  hospital.  The  number  of  in-patients  treated 
during  the  year  1918  was  1173.  At  the  Out-patient  Depart- 
ment in  Newington  Causeway  7386  new  cases  were  treated 
during  the  past  year,  the  total  number  of  ont-patient  attend- 
ances amounting  to  31  416.  Clinical  assistants  (qualified 
women  only)  are  from  time  to  time  appointed  in  the  Out- 
patient Department.  Secretary:  Miss  M.  E.  Ridler. 

French  Hospital  and  Dispensary.  Shaftesbury -avenue, 
W.C. — This  hospital,  which  was  founded  in  1867  to  afford 
medical  treatment  for  poor  foreigners  who  speak  the  French 
language,  has  74  beds.  The  Convalescent  Home  and  Retreat 
for  Aged  French  People  at  Brighton  contains  61  beds. 
Secretary  : Mr.  G.  Tondepeyre. 

Italian  Hospital,  Queen-square,  W.C. — This  insti- 
tution was  established  in  1884  for  the  maintenance 
and  medical  treatment,  of  Italian  and  Italian-speaking 
people,  irrespective  of  their  religious  and  political 
opinions,  who  may  be  suffering  frora  sickness  or  bodily 
infirmity,  but  the  sick  poor  of  any  nationality  are  also 
admitted  for  treatment.  The  institution  also  provides 

surgical  and  medical  relief  to  Italians  and  others  not  being 
inmates  of  the  hospital.  It  has  50  beds. 

German  Hospital,  Dalston,  E.  8. —This  hospital  was 
founded  in  1845  with  the  object  of  supplying  medical  aid 
to  poor  people  speaking  the  German  language  and  for 
cases  of  emergency  and  of  accident.  It  has  142  beds, 
including  a sanatorium  with  10  beds.  Also  a convalescent 
home  at  Hitchin  with  40  beds,  occupied,  since  1915,  by 
convalescent  Biitisli  so’diers. 


The  Lancet,] 


METROPOLITAN  ANCILLARY  SCHOOLS  AND  HOSPITALS. 


National  Hospital  for  the  Paralysed  and  Epileptic 
(Albany  Memorial),  Queen-square,  Bloomsbury,  W.O. — The 
hospital,  with  the  Finchley  branch,  and  branches  in 
Bloomsbury,  Maidenhead,  and  Clapham  Park,  contains  324 
beds  and  cots.  The  physicians  attend  every  Monday,  Tuesday, 
Thursday,  and  Friday  at  2 p.  M.  In-  and  out-patient  practice 
at  that  hour.  Clinical  Clerks  are  appointed  under  the  in-patient 
and  out-patient  physicians.  Lectures  are  given  on  Tuesiays 
and  Fridays  at  3.30.  The  hospital  has  been  recognised  by 
the  Conjoint  Board  for  England  as  a place  where  part  of 
the  fifth  year  may  be  devoted  to  clinical  work.  All 
communications  concerning  clinical  appointments,  lectures, 
hospital  practice,  and  fees  should  be  addressed  to  the 
Secretary  at  the  hospital. 

Hospital  for  Epilepsy  and  Paralysis,  &c.,  Maida  Yale, 
W.  (85  beds). — Both  in-patient  and  out-patient  departments 
of  this  hospital  are  open  free  to  students  as  well  as  to  medical 
graduates.  Secretary  and  General  Superintendent : Mr. 
H.  W.  Burleigh. 

West-End  Hospital  for  Diseases  of  the  Nervous 
System,  Paralysis,  and  Epilepsy,  73,  Wei  beck- street, 
W. — Graduates  in  medicine  and  senior  students  may  attend 
•demonstrations  in  the  Out-patient  Department.  No  fees 
are  charged.  The  Savill  Prize  and  Medal  are  at  present  in 
abeyance,  as  well  as  routine  demonstrations  by  the  staff. 

Bethlem  Royal  Hospital,  St.  George’s-road,  S.E. 
— This  hospital  is  open  for  the  admission  of  two 
Resident  House  Physicians  who  have  recently  obtained 
their  diplomas  to  practise  Medicine  and  Surgery.  They 
are  permitted  to  reside  in  the  hospital  for  a term 
generally  not  exceeding  six  months,  commencing  May  1st 
and  Nov.  1st,  and  are  provided  with  apartments,  complete 
board,  attendance,  laundry,  and  a salary  at  the  rate  of 
£100  per  annum.  They  are  under  the  direction  of  the 
'Physician  Superintendent  and  are  elected  by  the  Committee 
from  candidates  whose  testimonials  appear  to  be  most 
satisfactory.  The  students  of  certain  specified  London 
Medical  Schools  receive  Clinical  Instruction  in  the  wards  of 
•the  hospital  and  qualified  practitioners  and  other  students 
may  attend  for  a period  of  three  months  on  payment 
<of  a fee. 

Hospital  for  Consumption  and  Diseases  of  the  Chest, 
Brompton. — The  hospital  contains  333  beds.  The  Sanatorium 
at  Frimley  contains  100  beds  and  50  beds  for  paying  patients. 
Six  House  Physicians  reside  in  the  hospital  for  a term  of  six 
months  ; their  duties  include  attendance  in  the  out-patient 
department.  Pupils  are  admitted  to  the  practice  of  the 
hospital  : terms,  £1  Is.  for  one  month ; three  months,  £2  2s.  ; 
perpetual,  £5  5s.  Clinical  Demonstrations  are  given  tlyoughout 
the  year  by  members  of  the  medical  staff.  Clinical  Assistants 
are  appointed  to  the  Assistant  Physicians  in  the  out-patient 
department  and  Clinical  Clerks  to  the  Physicians  in  the 
wards.  The  hospital  has  been  recognised  by  the  Conjoint 
Board  for  England  as  a place  where  six  months  of  the  fifth  year 
may  be  spent  in  clinical  work.  The  medical  practice  of  the 
hospital  is  also  recognised  by  the  University  of  London, 
the  Apothecaries’  Society,  and  the  Army  and  Navy  and 
Indian  Medical  Boards.  Dean  of  the  Medical  School  : Dr. 
L.  S.  Burrell.  Lectures  are  given  on  Wednesday  afternoons 
•during  the  terms.  Free  to  students  and  post-graduates. 

City  of  London  Hospital  for  Diseases  of  the  Chest, 
Victoria  Park,  E. — During  the  past  year  1083  in-patients 
have  been  treated  in  the  wards.  The  out-patients  treated 
during  1918  numbered  10,596.  Address  “Secretary  of  the 
Medical  Committee.” 

Royal  Chest  Hospital  (for  all  affections  of  the  heart 
and  lungs).  C’ty-road,  E.C.  (80  beds.) — This  hospital  provides 
accommodation  for  80  in-patients.  Expenditure  for  1918 
£14  409  income  £16,375.  The  attendance  of  out-patients 
averages  25,000  annually.  Secretary  : Mr.  A.  T.  Mays. 

The  Mount  Vernon  Hospital  for  Consumption  and 
Diseases  of  the  Chest,  Northwood.  Central  Out- 
patient Department,  Fitzroy-square,  W.— The  hospital 
■contains  110  beds.  Number  of  in-patients,  437  ; out- 
patients, 3546.  Resident  Medical  Staff.  Clinical  Demon- 
strations are  given  by  the  Visiting  Medicat  Staff  at  the 
hospital  at  Northwood.  Clinical  assistants  are  appointed 
to  physicians  in  the  wards  and  in  the  out- patient  department. 
Secretary  : Mr.  W.  J.  Morton.  Offices : 7,  Fitzroy-square,  W. 


[August  30,  1919  ,377 


Queen  Charlotte’s  Lying-in  Hospital  and  Mid- 
wifery Training  School,  Marylebone-road,  N.W. — This 
hospital  receives  about  1800  patients  annually,  besides 
having  a large  out-patient  department.  Medical  pupils  are 
received  at  all  times  of  the  year.  Pupils  have  unusual 
opportunities  of  seeing  obstetric  complications  and  operative 
midwifery,  on  account  of  the  very  large  number  of  primi- 
parous  cases — nearly  one-half  of  the  total  admissions. 
Clinical  instruction  is  given  on  the  more  important  cases 
which  present  themselves.  Special  Lectuie-demonstrations 
are  given  by  members  of  the  staff.  Certificates  of  attendance 
at  this  hospital  are  recognised  by  all  the  Universities,  Colleges, 
and  licensing  bodies.  Pupil  midwives  and  monthly  nurses 
are  received  and  specially  trained.  A Residential  College 
provides  accommodation  for  five  men  at  a time,  students  and 
qualified  practitioners  and  is  opposite  the  hospital,  with 
which  it  is  in  telephonic  communication.  Arrangements 
have  been  made  for  Medical  Students  to  receive  the  pre- 
liminary instruction  in  Practical  Midwifery  recommended  by 
the  General  Medical  Council.  Women  students  are  received. 
For  further  particulars  application  should  be  made  to  Mr. 
Arthur  Watts,  Secretary,  at  the  hospital. 

The  Hospital  for  Women,  Soho-square,  W. — In  con- 
nexion with  the  out-patient  department  there  has  been 
for  some  years  a well-organised  Clinical  Department*  The 
appointments  are  open  to  qualified  medical  men  and  women. 
Every  facility  is  afforded  them  by  the  gynaecologists  in  the 
out-patient  department  of  obtaining  experience  in  diagnosis 
and  treatment  and  the  practical  use  of  instruments.  Fee 
for  one  month  £2  2,?.  ; for  each  subsequent  month  the  same. 
The  hospital  contains  67  beds.  In  the  out-patient  depart- 
ment there  were  over  4000  new  cases  during  the  past 
year,  the  total  number  of  out-patient  attendances  being 
14.500.  This  large  number  affords  exceptional  opportunities 
for  examining  and  studying  most  of  the  varieties  of  the 
diseases  of  women.  Applications  should  be  made  to  the 
Secretary,  Mr.  Alfred  Hayward. 

Samaritan  Free  Hospital  for  Women,  Marylebone- 
road,  N.W. — Qualified  practitioners  are  admitted  as  clinical 
assistants  to  both  the  in-  and  out-patient  departments. 
Demonstrations  are  given  daily  in  both  departments.  The 
fees,  payable  in  advance,  are  £3  3s.  for  three  months.  Full 
particulars  may  be  obtained  on  application  to  the  Secretary 
at  the  hospital.  There  are  70  beds.  Secretary  : Mr.  G,  H. 
Hawkins. 

East  London  Hospital  for  Children  and  Dis- 
pensary for  Women,  Glamis-road,  Shadwell,  E. — The 
hospital  maintains  130  cots,  and  on  an  average  245 
out-patients  are  seen  daily.  Clinical  instruction  is  given 
by  the  physicians  and  surgeons  to  the  hospital,  which 
is  recognised  by  the  Conjoint  Board  for  England  as 
a school  of  medical  teaching  for  students  in  the  fifth 
year  of  the  curriculum.  All  particulars  may  be  obtained 
on  application  to  the  Secretary.  Two  clinical  clerkships 
for  qualified  or  unqualified  students  are  open  every  three 
months  subject  to  reappointment  if  desired.  Clinical 
assistants  (qualified  men  only)  are  from  time  to  time 
appointed  in  the  out-patient  department.  Any  additional 
information  may  be  obtained  on  applying  to  Mr.  W.  M. 
Wilcox,  the  Secretary,  at  the  hospital. 

The  Hospital  for  Sick  Children,  Great  Ormond- 
street,  W.C.  1,  contains  210  beds,  besides  30  beds  at  the 
Branch  Hospital,  Highgate.  The  hospital  having  been 
recognised  by  the  Conjoint  Board  for  England  as  a place 
where,  under  the  new  curriculum,  six  months  of  the  fifth 
year  may  be  spent  in  clinical  work,  the  practice  is  arranged 
to  meet  this  need  and  is  open  to  students  of  both  sexes  who 
have  completed  four  years  of  medical  study  and  also  to 
qualified  medical  men  and  women.  The  medical  staff  are 
recognised  by  the  University  of  London  as  teachers  in 
Diseases  of  Children.  Arrangements  have  also  been  made 
with  University  College  Hospital  and  the  London  School 
of  Medicine  for  Women  for  the  routine  admission  of 
their  students  of  both  sexes  to  clerkships  and  dresser- 
ships  in  the  wards.  Appointments  are  made  every  three 
months  to  six  medical  clerkships,  which  are  open  to  students 
of  the  hospital.  Clinical  instruction  is  given  daily  by 
members  of  the  visiting  staff.  Fees  for  hospital  practice, 
one  month,  £2  2s.  ; three  months,  5 guineas  ; perpetual 
ticket,  10  guineas.  Clinical  Clerks,  1 guinea  for  one 
month.  Ophthalmological  Clerkships. — Clinical  Clerks  are 


378  The  Lancet,] 


METROPOLITAN  ANCILLARY  SCHOOLS  AND  HOSPITALS. 


[August  30.  1919 


appointed  once  a month.  Fees  £1  1*.  for  one  month's 
attendance.  Pathological  Clerkships. — Facilities  are  afforded 
for  obtaining  theoretical  and  practical  instruction  in  Clinical 
Pathology  and  Bacteriology  in  the  Pathological  Laboratories. 
Clerks  attend  for  about  four  hours  daily.  Fees  : For  one 
month,  £3  3s.  ; for  two  months,  £5  5s.;  for  three  months, 
£6  6s.  A reduction  is  made  in  the  case  of  those  already 
holding  tickets  for  general  attendance  at  the  hospital. 
Time  so  spent  in  clerking  and  dressing  is  recognised  by  the 
Universities  of  London,  Oxford,  and  Cambridge,  and  by  the 
Conjoint  Board  for  England  as  part  of  the  approved  cur- 
riculum for  students  entering  for  a final  examination.  These 
appointments  are  open  to  students  of  all  recognised  medical 
schools.  In  addition,  special  courses  in  post  graduate  work 
are  held  throughout  each  term  of  the  year,  as  well  as  routine 
post-graduate  instruction  daily.  Details  may  be  obtained  by 
application  to  the  dean  or  secretary  at  the  hospital.  The 
medical  school  is  a constituent  part  of  the  new  London  Post- 
Graduate  Association.  Secretary  : Mr.  Stewart  Darmady. 

Evelina  Hospital  for  Sick  Children,  Southwark 
Bridge-road,  S.E. — This  hospital  contains  76  cots  and  a 
very  extensive  Out-patient  Department.  About  ten  clinical 
assistants  (either  sex),  to  work  with  the  Honorary  Medical 
Staff  for  Out-patients,  are  appointed  quarterly  for  a period 
of  three  months ; there  is  no  salary  attached  to  these 
posts ; but,  on  the  other  hand,  no  fees  are  charged. 
Secretary  : H.  C.  Staniland  Smith. 

Victoria  Hospital  for  Children,  Tite-street,  Chelsea, 
S.W. — The  hospital  contains  104  beds  and  has  a large  out- 
patient department  (over  1200  weekly)  ; the  home  at  Broad- 
stairs  has  50  beds.  Out-patients  are  seen  as  under  : — Diseases 
of  the  Eye:  Tuesday,  2 p.m.  Diseases  of  the  Skin  : Wednes-. 
day,  1.30  p.m.  Whooping-cough  Cases  : Friday,  2.30  p.m. 
Dental  Cases:  Thursday,  1.30  p.m.  Medical  and  Surgical 
Cases:  Mornings  at  9.30.  Accidents  and  urgent  cases  are 
admitted  at  any  time.  Post-graduate  courses  of  lectures  are 
being  arranged  for  the  winter.  Secretary,  Mr.  H.  G. 
Evered. 

The  Queen’s  Hospital  for  Children  (late  North-Eastern 
Hospital  for  Children ),  Hackney-road,  Bethnal  Green,  E.  2 
(Telephone  305  Dalston.)  For  the  sick  children  of  the  poor 
under  14  years  of  age.  Established  1867.  134  beds  in  London 
and  36  at  the  seaside  branch.  “ Little  Folks  ” Home,  Bexhill. 
— During  the  past  year  1481  in-patients  and  53,119  out- 
patients (attendance  107  075)  were  received.  The  surgeons 
attend  on  Tuesdays  and  Wednesdays  at  1.45  p.m.  and  Fridays 
and  Saturdays  at  9.30  a.m.  ; the  physicians  daily  at 
1.45  p.m.,  except  Saturday,  9.30  A.M.,  and  Wednesday 
and  Friday,  9.30  A.M.,  as  well  as  1.45  p.m.  The  practice 
of  the  hospital  is  open  to  students  by  arrangement  with  the 
medical  staff.  Applications  should  be  made  to  the  Secretary, 
Mr.  T.  Glenton-Kerr. 

The  Belgrave  Hospital  for  Children,  Clapham-road, 
S.W. —Clinical  Assistants  (men  or  women)  are  from  time  to 
time  appointed  to  the  members  of  the  Visiting  Staff  attend- 
ing in  the  Out-patient  Department  at  this  hospital,  and 
facilities  are  given  for  attendance  in  the  wards. 

Alexandra  Hospital  for  Children  with  Hip  Disease, 
Queen-square,  W.C.  — At  this  hospital  students  who  have 
obtained  a recommendation  from  their  teachers  can  attend 
to  see  the  practice.  The  out-  and  in-patients’  clinic  is  held 
on  Mondays  and  Thursdays  at  3 p.m.. 

Royal  London  Ophthalmic  Hospital  (Moorfields, 
1804-1899),  City-road,  E.C.  138  beds. — This  hospital, 
known  as  Moorfields  Eye  Hospital,  was  moved  in  1899  to 
larger  buildings  in  City-road.  In  1918  there  were 
2339  in-patients,  the  out-patients  were  41,725,  of  whom 
36,101  were  new  out-patients,  and  the  attendances 
were  98,186.  Operations  are  performed  daily  from 
10  A.m.  to  1 P. M.,  and  four  surgeons  attend  on  each 
day.  Students  are  admitted  to  the  practice  of  the 
hospital.  Fee  for  six  months,  £3  3s.  ; perpetual,  £5  5s. 
Special  courses  of  instruction,  which  extend  over  a peiiod  of 
five  months  are  given  by  members  of  the  Surgical  Staff  ; 
beginning  in  October  and  March.  A composition  fee  of 
24  guineas  (£25  4 s.)  will  entitle  students  to  a perpetual 
ticket,  and  will  admit  them  once  to  all  the  lectures  and 
classes  and  to  the  examination  for  the  hospital’s  f 11 
certificate.  Students  of  the  hospital  are  eligible  for 
the  offices  of  house  surgeon  or  clinical  and  junior  assistants. 


Junior  assistants  are  appointed  every  three  months.  Any 
further  information  will  be  furnished  by  Mr.  Robert  J. 
Bland,  Secretary  Superintendent. 

Royal  Westminster  Ophthalmic  Hospital,  King 
William-street,  West  Strand. — The  hospital  contains  40  beds. 
Out-patients,  who  number  over  15,000  annually,  are  seen  at- 
1 p.m.,  and  operations  are  performed  daily  at  about  3 p.m. 

The  practice  of  the  hospital  is  open  to  practitioners  and 
students,  jnen  and  women.  Fees  for  six  months,  £3  3*.  ; 
perpetual,  £5  5s. ; shorter  periods  by  arrangement.  Students, 
of  the  hospital  are  eligible  for  the  posts  of  house  surgeon, 
assistant  house  surgeon,  pathologist,  and  clinical  assistants. 
Secretary  : Mr.  John  Hy.  Johnson. 

Royal  Eye  Hospital,  St.  George’s-circus,  Southwark,. 

S.E. — There  are  40  beds  and  2 cots.  There  were 
56,513  attendances  in  the  Out-patient  Department  last 
year,  and  the  new  patients  numbered  21.848.  Out- 
patients are  seen  daily  1.30  to  2.30  p.m.  Dean  : Mr.  A.  D. 
Griffith. 

Central  London  Ophthalmic  Hospital,  Judd-streefr, 

St.  Pancras,  W.C. — This  Hospital  has  40  beds  and  possesses- 
facilities  for  clinical  teaching-daily.  Classes  of  instruction 
in  the  use  of  the  ophthalmoscope,  with  demonstrations  on 
cases,  and  also  classes  on  refraction  and  other  subjects  are 
given  during  the  winter  months,  commencing  in  October. 

The  out-patient  work  begins  at  1 o’clock,  and  operations  are 
performed  daily  between  1 and  4 o’clock.  Secretary  : Mr, 

H.  R.  S.  Druce. 

Western  Ophthalmic  Hospital,  Marvlebone-road, 
N.W. — 16  beds.  Out-patient  attendances  20  000.  Botb 
In-patient  and  Out-patient  Departments  cf  this  Hospital  are 
open  to  medical  graduates.  Fees  £1.  Is.  per  three  months. 

Hospital  for  Diseases  of  the  Throat.  Golden-square, 

W.  (with  which  is  amalgamated  The  London  Throat. 
Hospital,  Great  Portland-street). — Clinical  instruction  ir»  I 
the  diagnosis  and  treatment  of  disease  is  given  daily  in  the- 
out-patient  department  from  2 to  5 P.M,  and  on  Tuesdays 
and  Fridays  from  6 30  to  9 p.m.  The  hospital  contains 
60  beds  for  in-patients.  There  is  an  annual  out-patient 
attendance  of  over  60  000.  Minor  operations  are  performed 
daily  (except  Monday)  at  9 30  a.m.  Major  operations  are  ' 
performed  on  Tuesdays,  Wednesdays,  Thursdays,  Fridays, 
and  Saturdays  at  10  a.m.  Also  Fridays  at  2 p.m.  Practi- 
tioners and  medical  students  a'e  admitted  to  the  practice  of 
the  hospital  at  a fee  of  £5  5s.  for  three  months.  £7  Is.  for  I 
six  months,  or  £10  10s.  for  perpetual  studentship.  From  I 
amongst  the  students  junior  clinical  assistants  are  appointed 
periodically.  For  terms  and  further  information  apply  to  the  i 
Dean,  Mr.  Geo.  W.  Dawson. 

Central  London  Throat  and  Ear  Hospital,  Gray’s  \ j 
Inn-road. — Clinical  lectures:  The  hospital  is  open  daily  to-  1 
all  qualified  medical  practitioners  on  presentation  of  their 
visiting  cards.  Demonstrations  of  the  cases  and  clinical  i I 
instruction  are  given  daily  by  the  chief  surgeon  of  each 
Clinique.  Medical  practitioners  are  invited  to  visit  the 
wards,  and  are  welcomed  both  in  the  operating  theatre, 
when  they  are  desin  us  of  viewing  the  major  operations,  and 
in  the  out-patient  operating  room  when  minor  operations  are 
being  performed.  Clinical  lectures  are  delivered  from  time 
to  time,  particulars  of  which  are  given  in  the  medical 
journals,  and  at  the  hospital.  Systematic  classes  and  course* 
of  instruction  and  demonstrations.  Three  courses  of  instruc- 
tion are  open  to  practitioners  attending  the  hospital : First, 
the  course  in  methods  of  examination  and  diagnosis  ; second, 
the  couri-e  of  systematic  instruction  in  the  diseases  of  the 
nose,  throat,  and  ear  ; and  third,  the  operative  snrgery  class. 

The  course  in  methods  of  examination  and  diagnosis  is 
introductory  in  character.  It  comprises  lessons  of  practical 
teaching  in  the  actual  examination  of  patients  and  in  the  1 
manipffiation  of  instruments.  Systematic  instruction  in  | 
Diseases  is  more  advanced.  It  consists  of  over  30  lessons  in 
all  on  pathology,  diagnosis,  and  treatment.  Minute  details 
in  operative  surgery  are  not  gone  into,  as  this  is  left  to  the 
operative  surgery  class.  Full  syllabus  will  be  sent  on  applica- 
tion to  the  Secretary. 

The  Metropolitan  Ear.  Nose,  and  Throat  Hospital,  j 
— The  hospital  is  in  Fitzroy-square,  W.  The  Out-patient 
Department  is  opened  daily  at  2.30  p.m.  to  all  medical  | 
practitioners  and  senior  students  for  acquiring  clinical 
instruction  and  technical  knowledge.  Operations  upon 
in-patients  are  performed  on  Tuesdays,  Wednesdays, 


T".  L.mc«T.]  IMGLI8I1  PHOVIMUIAL  ANCII.LAUY  SCHOOLS  AND  UJSI'ITAI.S  rA™„«,Rh  ,0,0  .... 

Iinmlouo  17... • .1 i ~ ~ ‘ ■ — O I & 


Thursdays,  and  Fridays  at,  10  a.m.  Fee  for  one  month’s 
attendant  at  the  hospital  £1  Is.,  and  for  three  months 

occur*'  and^ha  vf>°a  Assl®t1ant;s  are  appointed  as  vacancies 
occui,  and  nave  responsible  duties. 

. Il0VAL  Eau  Hospital,  Dean-street,  Soho  -Stens  are 

ZSSTT  f°I  i,nCOrP°ra,ing  this  h^pital  with  Uidverstty 
College  Hospital  as  an  Err  N,.s*  a>,,t  , 

department  of  the  latter.  At  present  the  Hospital  is  closed. 
St.  Mark  s Hospital  for  Cancer,  Fistula  and  other 
iseases  of  THE  Rectum,  City-road,  E.C.  (Founded  1835  )— 
The  hospital  contains  for  men  and  women  56  beds  Opera 

SysS  aT2  30  pTe^  MTdayS^fednesdays’  and  Thurs- 
<tays  at  A 30  p.m.  Medical  practitioners  and  students  are 

invited  to  the  operations  and  to  the  clinical  instruction  in 
le  wards  and  in  the  out-patient  department.  The  number 

sssssiassr 

dILST*  “h,  ™"  Stosb  ak"  other  Urirart 

JflfiO  v’  Renn®tfca-street,  Covent  Garden.  Established 

3fbeds?oerWm?nSanda2  $7?  1882— The  hospital  contains 
“v;?  men  and  2 beds  for  women  and  children.  Medical 
practitioners  and  students  are  invited  to  the  clinical  instruc 

mentdS\anedforin  thVwarda  “d  out-patient  deplrt- 
ment  da  ly,  and  to  the  operations  in  the  theatre  on  Mondays 

Wednesdays  and  Fridays  at  2 p.  m.  Average  beds  occuffied 
daily,  24  , average  out-patients  seen  daily,  100.  1 

St.  John’s  Hospital  for  Diseases  of  the  Skin  49 
•sTSrriT’i  G '“The  in-patient  department,  40  beds’ 

?!  at  262f’  Hxbndge-road,  W.  12.  The  out-patient  practice 
is  open  to  the  medical  profession  every  day  at  2 and  everv 
evening  (except  Saturday)  at  6.  At  the  afternoon  clinics 
demonstrations  on  the  different  diseases  presentee-  them 
se  ves  are  given.  Venereal  Diseases,  underlie  Government 
scheme,  are  admitted  at  all  clinics.  The  X ray  department 
Is  open  every  afternoon  except  Saturday.  The  Chesterfield 
Lectures  are  given  on  Thursdays  at  6 p.m  , October  to  Sch 
commencing  Oct  10th.  At  the  end  of  the  iourSeS- 

SeSiiT 

Pathology  and  Bacteriology  of  the  Skin  may  be  arrangedfon 
London  Lock  Hospital  and  Rescue  Home  —In  the 
Feraaie  Hospita1  at  Harrow-road,  W.,  there  are  162  beds  and 
^)33  patients  were  admitted  in  1918  In  the  Ar^ip  tt™’  1 

“d  1«  Deatleet  fofo  PW 

St  ents6  40  441  oS\WhiCl\dnrin"  1918  accommodated  351 
patients.  40,441  out-patients  were  treated.  10  000  inieetions 

the  substitutes  for  salvarsan  were  made  in  19  7 Male 
patients  are  seen  at  91,  Dean-street,  on  Mondays  and 
Tuesdays  from  1 to  2 p.m.  and  from  6 to  - 

a'nd  5 30  Tp  mT;  6 V*  8 f-M-;  °n  Thursdays  at  H.30  a.m 

7a  (female  patients);  on  Fridays  from  5 30pm 
Patle«fs):  and  on  Saturdays  from  2 to  4 p.m  (males) 
pathological  Department,  Tuesdays  at  6.30  p m Days  for 
intravenous  injections  91,  Dean-street,  W.  1 Tuesdays  and 

SdHU'i;duoS  at  9t'M  (meD)’'  women,  Thursdays  1130  a m 
and  5.30  p.m.,  Fridays  at  5.30  pm  Secretary  - Hr  t 
Eason.  Head  office  : 283,  Harrow-road,  W.  9.  7 ' y J' 


ENGLISH  PROVINCIAL  ANCILLARY  SCHOOLS  AND 

hospitals. 

required  attendance  on  medical  and  surgical  practice  for 
medical  clerkships,  and  surgical  dresserships  The  ’ list 

Sff  alPhabetica"y  as  to  the  town  where  the  hospS  S 

Bath  Royal  United  Hospital  Bath  This  v,„  -a  ^ 
«ns!30  beds,  and  possesses  a fine ¥bra7y ^ StcreR 
‘ ' &^ePPard.  1 D Clinics  are  held  on  Tuesdays  rfor 

women),  a,  d o„  Fridays  (for  men)  from  5 to  7 p m " J f 


contltns^^lA  lN™RMARY’  Bradford. — This  hospital 

‘ j ° beds.  I he  material  passing  throuLrh  the 

S and* TSiSt81°f  rnai°r  operations!  chiefly  abdo? 
for-11  either  gJT°  °g‘  work,  an, 1 affords  excellent  facilities 

hosffi  S of  S?  °L  p0StgradlJates.  Plans  for  a new 
operations^  wdf  . Ve  bee”  adopted,  and  the  building 
handSll||  L°mmenced  as  soon  as  the  funds  in 

. JH®  p°YAu  Sussex  County  Hospital,  Brighton  1220 
e s)’  . f 118  hospital  affords  ample  facilities  for  students 
possessing  a arge  out-patient  department,  a library  and  a 
well-appointed  clinical  research  and  bacteriologicaf depart- 
men  . ie  hospital  does  not  take  resident  pupils  but 
out-pupils  may  attend  the  practice  of  the  hospital  for  an! 

S’ *t,eTJdi°e  ‘7  - w»»»*  SSSS 

MSgaemSt"w“ng  of 

Kent  and  Canterbury  General  Hospital,  Canterbury 

adm  tt?d TS  T8  110  beds’  Pupils  °f  the  staff  aJe 

admitted  to  the  practice  of  the  hospital  and  have  the  use 

Society  fOTa£7  7.  a EySt  Kent  aud  Canterbury  Medical 
V .I,  1 7i'-  An  X'ray  apparatus  has  recently  been 

given  to  the  hospital.  Operation  day,  Thursday  11  a m 
Secretary:  Mr.  Arthur  J.  Lancaster.  y’ 

Derbyshire  Royal  Infirmary,  Derby.— This  hosDital 
contains  320  beds.  It  was  founded  in  1810,  and  was  entirely 
rebuilt  and  enlarged  1892-1915  on  the  most  modern  lines  at  a 

33Sbe°ds°Vaer  £144',°00;  Pher®  is  a separate  ophthalmic  block  of 
33  beds,  a separate  children  s block  of  34  beds,  and  a special 
department  for  gynecological  cases.  There  are  three  resi- 
dent house  surgeons  and  a resident  house  physician.  There 
are  also  well-equipped  orthopedic,  X ray,  electrical  and 

admitted^!  departmea(s-  Registered  medical  students  are 
admitted  to  witness  the  medical  and  surgical  practice  on 
payment  of  10  guineas  annually. 

Koyal  Devon  and  Exeteu  Hospital,  Exeter —The 

™rdfld°ht",S  20°,  Mds  <il,d"di"'  ohiidJn'l 

fa  Let1  f g0°d  hbrary’  museum,  dissecting  room 
and  post-mortem  room.  Attendance  on  the  practice  of 
ns  hospital  qualifies  for  all  the  examining  boards  There 
is  also  a Private  Nursing  Staff  attached  to  the  hospital 
For  particulars  as  to  fees.  &c„  apply  to  the  Matron  A 
new  wing  was  added  in  1897.  Arrangements  may  be  made 
by  which  gentlemen  in  practice  desiring  to  increase  their 
qualifications  may  have  the  use  of  the  museum  and  library 
and  other  facilities  and  by  which  students  may  attend  mid! 
W1f,ery‘  A new  Operating  Theatre  was  opened  in  1906  (the 
g’ffc.°rf  Mra-  Nosworthy  of  Newlands,  Dawlish,  Devon).  The 
Electncal  lreatment  Department  (the  gift  of  Mrs  M A 
Sanders)  was  opened  in  1907  by  Lady  Duckworth-King 
inJ„pal rfcmenfc, was  opened  >n  1917  for  the  treatment  of 
gemto-unnary  diseases  ; there  are  three  sessions  per  week 
two  for  men  at  4 p.m.  and  7 P m..  and  one  for  women^t  4 p.m.’ 

M,WWTWF  dNGLAtI,>  EY«  1 nf l RM A ry,  Exeter. -Secretary  : 

;,u  • • Beeyr-  phe  infirmary  contains  64  beds.  Students 

of  the  Exeter  Hospital  can  attend  the  practice  of  the  Eye 
Infirmary.  Patients  for  the  year  ending  Michaelmas,  1918? 

The  Gloucestershire  Royal  Infirmary  and  Eyf 
teTiTOT’ON,  Gloucester. — This  hospital,  which 
the  titie  of  Royal  on  the  occasion  of  King  Edward  VII  ’s 

M?  H £ pT  I1"  the  Jear  1909‘  has  140  beds-  Secretary: 

"J  ..  f’  Plk®'  In-patients,  1683;  out-patients,  6739.  An 
e ectncal  and  massage  de,  ar-  meet  has  been  established  and 
venereal  and  neurological  clinics  opened. 

Tr?n°tRTHTLTAMF0R?S«mE  1nfirma«y>  Hartshill,  Stoke-on- 
irent.  — ihe  New  Infirmary,  opened  in  1869,  is  built  on 
the  pavilion  plan,  has  accommodation  for  about  250 
patients,  including  Children’s  wards,  and  a special  depart 
men.  for  the  treatment  of  Disease, ’of  the  a ,S 

L -"Tt1  D»l»"ment,  a special  department  for 

the  treatment  of  Diseases  of  the  Ear,  Nose,  and  Throat  a 

so  that  t°WPfed,C  dertmrt-  and  Veneleal  d ’ s e as e s dfn !cs? 
knowlfdi  ?LeXC  rent-faCilitieS  f0r  acquiri«g  a practical 

the  sumgof  £3?nnrL  eSK°n-  DuriDg  the  last  ^ years 
e .urn  of  £35,000  has  been  spent  on  new  buildings  and 

alterations.  A new  Out-patient  Department,  costing  £12  000 

ei  f:!S  Ward  1 30  beds’  a a®-  Pagtholog"c"i 
amL^  tG  fd  f SiC°nd  ,argd  °Perati°n  Theatre  are 
amongst  the  structural  improvements  already  completed. 


380  Thh  Lancet,]  ENGLISH  PROVINCIAL  ANCILLARY  SCHOOLS  AND  HOSPITALS.  [August  30,  1919 


The  whole  institution  is  now  equipped  in  a thoroughly  up-to- 
date  manner.  Secretary  and  House  Governor : Mr.  W. 
Stevenson. 

Hull  Royal  Infirmary,  Hull. — This  hospital  contains 
256  beds,  and  since  its  establishment  in  1782  until  the 
erection  of  the  circular  wards  in  1907  has  undergone  steady 
additions  and  improvements.  A branch  convalescent  home 
and  sanatorium  for  consumption  at  Withernsea  are  special 
features  of  the  charity. 

Leicester  Royal  Infirmary,  Leicester. — Instruction  in 
the  infirmary  for  first-year  students  is  duly  recognised  by 
the  various  examining  bodies.  At  the  General  Infirmary 
there  are  230  beds,  and  at  the  Children’s  Hospital  in 
connexion  70  ; total  300.  A new  wing  containing 
100  beds  was  recently  opened  by  H.R.H.  the  Duchess  of 
Argvll,  and  a new  Nurses’  Home  containing  separate 
accommodation  for  100  nurses  has  also  been  opened.  A recon- 
struction scheme  has  been  carried  out,  and  £120,000  spent 
on  bringing  the  accommodation  of  the  institution  to  a 
modern  standard  of  efficiency.  This  scheme  has  included 
the  provision  of  two  modern  operating  theatres,  and  a 
self-contained  out-patients’  department.  The  Children’s 
Hospital  has  been  reconstructed  and  enlarged  by  the 
addition  of  a third  ward  at  a cost  of  £14,500.  Open- 
air  balconies  on  all  three  floors  are  a feature.  A central 
sterilising  department  has  been  provided.  A new  Patho- 
logical Laboratory  and  post-mortem  rooms  at  an  estimated 
cost  of  £8000  are  now  in  course  of  construction,  also  an 
or'hopaedic  out-patients  department  at  a cost  of  £8000, 
£5000  of  which  is  being  provided  by  the  Freemasons  of  the 
province  as  their  war  memorial.  Further  additions  are  in 
contemplation.  A city  university  will  not  unlikely  be  the 
town's  memorial  of  the  war.  and  a splendid  site  has  just 
been  presented  by  Mr.  J.  Fielding  Johnson,  J P.,  an  ex- 
chairman of  the  Royal  Infirmary.  There  are  eight  resident 
medical  officers — viz.,  four  house  surgeons,  one  house 
physician,  one  assistant  house  physician,  and  two  dressers. 
All  receive  salaries.  The  dressers  are  given  an  honorarium. 
House  Governor  and  Secretary  : Mr.  Harry  Johnson. 

Northampton  General  Hospital,  Northampton. — Two 
new  wings  were  opened  in  1904  and  the  old  buildings 
entirely  renovated  aud  rearranged.  The  number  of  beds  is 
298,  120  of  which  are  occupied  by  wounded  soldiers. 
Non-resident  pupils  are  received  and  have  every  oppor- 
tunity of  acquiring  a practical  knowledge  of  their  profession. 
The  fee  is  £10  10s.  Pupils  can  be  received  at  any  time.  An 
up  to-date  Pathological  Laboratory  is  now  being  erected. 

Norfolk  and  Norwich  Hospital,  Norwich. — This 
hospital  has  at  present  350  beds.  There  is  a convalescent 
home  at  Cromer,  and  a large  staff  of  visiting  nurses  is 
maintained.  Secretary:  Mr.  F.  Inch. 

Nottingham  General  Hospital. — At  the  present  time 
there  are  233  beds  available  for  civilian  patients.  The 
accommodation  of  sick  and  wounded  soldiers  from  overseas 
was  a great  feature  at  this  hospital,  which  is  fully  equipped 
in  every  branch  of  medicine  and  surgery. 

South  Devon  and  East  Cornwall  Hospital,  Plymouth. 
— This  hospital  contains  183  beds  (12  of  whicli  are  for 
Venereal  Diseases  in  a separate  building).  There  is  also  an 
Out-patient  Venereal  Diseases  Clinic. 

The  Royal  Hospital,  Portsmouth  (founded  1847).— 
The  number  of  beds  is  160.  The  hospital  has  X Ray  and 
Massage  Departments.  The  hospital  is  a preparatory  School 
of  Medicine  and  Surgery  ; the  attendance  of  pupils  at  this 
hospital  is  recognised  by  the  Examining  Boards.  Particulars 
of  the  Secretary  at  the  hospital. 

Royal  Berkshire  Hospital,  Reading. — This  hospital, 
which  contains  220  beds,  has  been  recently  enlarged,  the 
additions  including  a new  Out-patient  Department,  a 
Casualty  Department,  an  X Ray  Department,  a Laboratory, 
an  Eye  Theatre,  and  Eye  Wards. 

Salisbury  General  Infirmary,  Salisbury. — This  hos- 
pital contains  145  beds.  In-patients,  160  daily  average; 
out-patients,  550,  including  ophthalmic  cases  185  and  X ray 
cases  1073  ; attendances  on  4683  casuals.  Secretary,  Mr.  S.  B. 
Smith 

Royal  Salop  Infirmary,  Shrewsbury.— This  hospital 
has  160  beds.  In-patients,  1472;  out-patients,  1030  ; out- 
patients’attendances  for  the  year,  16.542.  Secretary:  Mr. 
Alfred  Sugden. 


Royal  South  Hants  and  Southampton  Hospital, 
Southampton. — This  hospital  contains  130  beds.  In-patients, 
1969  ; out-patients,  7843.  Secretary  : Mr.  T.  A.  Fisher  Hall. 

Staffordshire  General  Infirmary,  Stafford. — This 
hospital  has  80  beds.  In-patients,  854 ; out-patients,  2205. 
Secretary  : Mr.  R.  Battle. 

Royal  Hants  County  Hospital,  Winchester.— This 
hospital  has  160  civilian  beds.  Secretary:  Mr.  Herbert 
Maslen. 

Wolverhampton  and  Staffordshire  General  Hos- 
pital, Wolverhampton. — There  are  262  beds.  Special 
departments  for  Children,  Gynaecology,  Ear.  Throat, 
and  Nose  Diseases,  Electro-therapeutic  and  X ray  and 
Pathological  departments.  There  is  an  excellent  library. 
The  resident  officers  are  a resident  medical  officer 
and  three  house  surgeons.  Pupils  are  allowed  to  witness  the 
whole  of  the  practice  of  the  hospital  and  to  be  present  at 
operations  and  have  every  opportunity  of  acquiring  a 
practical  knowledge  of  their  profession.  A course  of 
Practical  Pharmacy  is  given  by  the  dispenser.  Fees  on 
application.  Applications  should  be  made  to  the  Secretary 
of  the  Medical  Committee. 

Worcester  General  Infirmary,  Worcester. — This 
hospital  has  132  beds  (temporarily  reduced  to  70).  Pupils 
are  taken  by  members  of  the  Honorary  Medical  and 
Surgical  Staff.  Number  of  operations  last  year  891. 
New  X Ray  and  Electrical  Departments  have  been 
recently  erected  and  are  now  in  use.  Additional 
accommodation  for  the  Honorary  Staff  and  Out-patients 
and  also  an  Outdoor  Shelter  in  connexion  with  the 
Children’s  Ward  have  been  built  as  a memorial  to  King 
Edward  VII.  In-patients,  966  ; out-patients,  2990.  Secre- 
tary : Mr.  E.  J.  Holland. 

York  County  Hospital,  York. — This  hospital  contains 
170  beds.  There  are  balconies  for  outdoor  treatment  and 
two  installations  of  X Ray  apparatus.  A Venereal  Diseases 
Clinic  is  held. 


School  of  the  Pharmaceutical  Society  of  Great  1 
Britain. — The  subjects  of  the  Qualifying  examination  of  the 
Pharmaceutical  Society  (for  registration  as  “chemist  and 
druggist  ”)  are  botany,  chemistry  and  physics,  materia 
medica,  pharmacy,  and  pharmacy  law.  Fee,  12  guineas ; 
for  each  subsequent  examination  after  failure,  3 guineas. 
The  advanced  or  Major  examination  (for  registration  as- 
“pharmaceutical  chemist  ”)  includes  botany,  chemistry  and 
physics,  practical  chemistry,  and  materia  medica.  Fee,  j 
3 guineas.  The  inaugural  address  will  be  delivered  on  Wednes-  < 
day,  Oct.  1st.  Medical  students  are  admitted  to  the  lectures 
and  laboratory  work  in  any  or  all  the  courses.  Certificates- 
of  instruction  in  this  school  are  received  by  the  Conjoint 
Board  of  the  Royal  Colleges  and  by  the  University  of 
London.  Application  for  admission  to  the  school,  or  for 
further  information,  may  be  made  to  the  Dean.  Professor 
Greenish,  17.  Bloom«bury-square.  London,  W.C.  1.  There 
are  no  vacancies  for  October,  1919. 


The  Training  of  Masseuses. — In  order  to  meet 
the  need  for  a more  thorough  training  of  masseuses,  and 
to  secure  in  the  future  a uniform  course  of  instruction 
in  massage  and  medical  gymnastics,  it  has  been  decided  by 
the  Council  of  the  Incorporated  Society  of  Trained  Masseuses 
that  from  Sept.  1st  no  new  schools  will  be  recognised  as 
teaching  centres  by  the  Council  unless  the  school  authorities 
undertake  to  give  not  less  than  one  year  of  training 
(48  weeks).  No  new  teacher  of  massage  will  be  accepted 
by  the  Council  unless  he  or  she  hold  the  Society’s  certificates, 
or  other  specially  approved  certificates.  From  Jan.  1st, 
1921,  no  candidate  will  he  admitted  to  the  Society’s  I 
examinations  unless  they  have  fulfilled  one  year  of  training. 

Death  of  Dr.  W.  H.  Peile. — William  Hall  Peile, 
M.A.  Cantab.,  M.A.,  M.D.  Dub.,  L.R.C.P.,  M.R  C.S., 
D.P.H..  died  recently  at  his  residence,  Sidmouth,  Devon, 
in  his  fifty-first  year,  after  a long  illness  Dr.  Peile  was 
formerly  medical  officer  of  health  for  Sidmouth,  and  did 
much  useful  work  in  connexion  with  the  housing  question, 
and  was  largely  instrumental  in  bringing  about  the  erection 
of  4S  cottages  iD  Sid  Park-road.  He  was  greatly  respected 
aud  esteemed,  especially  among  the  poor,  to  whom  he  was 
always  kind  and  generous.  The  funeral  was  largely 
attended,  the  deceased's  brother,  Bishop  Peile,  being  one 
of  the  officiating  clergy. 


Thu  Lancet,]  UNIVERSITY  OF  EDINBURGH. [August  30,  1919  3b  1 


II.— SCOTLAND. 
THE  UNIVERSITIES. 


UNIVERSITY  OF  EDINBURGH. 

Four  Degrees  in  Medicine  and  Surgery  are  conferred  by 
the  University  of  Edinburgh — viz.,  Bachelor  of  Medicine 
(M.B.),  Bachelor  of  Surgery  (Ch.B.),  Doctor  of  Medicine 
(M.D.),  and  Master  of  Surgery  (Ch.M.).  The  degree  of 
Bachelor  of  Surgery  cannot  be  conferred  on  any  person 
who  does  not  at  the  same  time  obtain  the  degree  of  Bachelor 
of  Medicine,  and  similarly  the  degree  of  Bachelor  of  Medicine 
is  not  conferred  on  any  person  who  does  not  at  the  same 
time  obtain  the  degree  of  Bachelor  of  Surgery. 

No  one  is  admitted  to  the  degrees  of  Bachelor  of  Medicine 
and  Bachelor  of  Surgery  who  has  not  been  engaged 
in  Medical  and  Surgical  study  for  five  years.  No  course 
of  lectures  will  be  allowed  to  qualify  unless  the  lecturer 
certifies  that  it  has  embraced  at  least  100  lectures, 
or  50  lectures,  as  may  be  required  by  the  regulations, 
and  that  the  student  has  also  duly  performed  the  work  of 
the  class. 

Candidates  for  the  degrees  of  M.B.  and  Ch.B.  must  have 
attended  for  at  least  three  academic  years  the  medical  and 
surgical  practice  either  of  the  Royal  Infirmary,  Edinburgh,  or 
of  a general  hospital  elsewhere  which  accommodates  not 
fewer  than  80  patients  and  possesses  a distinct  staff  of 
physicians  and  surgeons.  They  must  have  attended  Clinical 
Surgery  during  a course  or  courses  extending  over  not  less 
than  nine  months,  and  courses  of  instruction  in  all  the  sub- 
sidiary subjects.  They  must  have  personally  conducted,  under 
the  superintendence  of  a registered  medical  practitioner,  20 
cases  of  labour  at  least. 

With  respect  to  the  places  and  institutions  at  which  the 
studies  of  the  candidate  may  be  prosecuted  the  following 
regulations  have  effect : — Two  of  the  five  years  of  medical 
study  must  be  spent  in  the  University  of  Edinburgh.  The 
remaining  three  years  may  be  spent  in  any  University  of 
the  United  Kingdom,  or  in  any  Indian,  Colonial,  or  Foreign 
university  recognised  for  the  purpose  by  the  University 
Court,  or  in  such  medical  schools  or  under  such  teachers 
as  may  be  recognised  for  the  purpose  by  the  University 
Court.  Of  the  subjects  of  study — viz..  Anatomy,  Practical 
Anatomy,  Chemistry,  Practical  Chemistry,  Materia  Medica, 
Physiology,  Practical  Physiology,  Practice  of  Medicine, 
Surgery,  Midwifery  and  Diseases  of  Women,  Pathology, 
Practical  Pathology,  Physics,  Botany,  Zoology,  Medical 
Jurisprudence,  and  Public  Health — not  less  than  one-half 
must  be  taken  in  the  University  of  Edinburgh,  which 
corresponds  to  the  two  years  above  referred  to. 

Women  are  admitted  to  graduation  in  medicine  under  i 
practically  the  same  conditions  as  men. 

The  fee  to  be  paid  for  the  degrees  of  Bachelor  of  Medicine 
and  Bachelor  of  Surgery  is  £23  2s. , and  the  proportion  of 
this  sum  to  be  paid  by  a candidate  at  each  division  of 
the  examination  shall  be  as  follows — viz.  : For  the  First 
Division  of  the  Examination  (Botany,  Zoology,  Physics, 
and  Chemistry),  £6  6s.  ; for  the  Second  Division  (Anatomy 
and  Physiology),  £5  5s.  ; for  the  Third  Division  (Pathology 
and  Materia  Medica  and  Therapeutics),  £4  4s.  ; and  for  the 
Final  Division  ' Surgery  and  Clinical  Surgery,  Medicine  and 
Clinical  Medicine,  Midwifery,  Clinical  Gynaecology,  and 
Forensic  Medicine  and  Public  Health),  £7  7s. 

Bachelors  of  Medicine  and  Bachelors  of  Surgery  may 
proceed  to  the  degrees  of  Doctor  of  Medicine  and  Master 
of  Surgery  after  they  have  spent  one  year  in  the  medical 
or  surgical  wards  respectively  of  a hospital,  or  the  Military 
or  Naval  Medical  Services,  or  in  scientific  work  bearing 
directly  on  their  profession,  or  two  years  in  practice.  In 
each  case  an  examination  must  be  passed  and  a thesis 
submitted  for  approval  of  the  Faculty.  The  fee  to  be  paid 
for  the  degree  of  M.D.  is  £15  15s.,  and  the  fee  to  be  paid  for 
the  degree  of  Ch.M.  is  £15  15s. 

A diploma  in  Tropical  Medicine  and  Hygiene  (D.T.M.  and 
H.)  is  granted  to  graduates  in  Medicine  and  Surgery  of  the  I 
University  of  not  less  than  six  months’  standing,  and  to 
Registered  Medical  Practitioners  who,  having  resided  in  a 
tropical  country,  may  be  approved  by  the  Senatus,  on  the 
recommendation  of  the  Faculty  of  Medicine. 

Diploma  in  Psychiatry. — Courses  of  instruction  have  also 
been  instituted  for  a Diploma  in  Psychiatry,  open  to  all 


I legally  qualified  Medical  Practitioners  who  conform  with  the 
Regulations.  There  shall  be  two  examinations  for  the 
Diploma,  the  first  comprising  the  subjects  of  Anatomy  of  the 
Nervous  System  ; Physiology,  Histology,  and  Chemistry  of 
the  Nervous  System  ; Pathology  of  the  Brain  and  Nervous 
System  ; and  Practical  Bacteriology  in  its  relation  to  Mental 
Diseases ; and  the  second  examination  comprising  the 
subjects  of  Psychology  with  Experimental  Psychology, 
Clinical  Neurology,  and  Psychiatry  (systematic  and  clinical). 
The  fee  for  each  examination  shall  be  £5  5s. 

Diploma  in  Public  Health  (D.  P.  IT.  Univ.  Edin .)  — Courses 
of  instruction  are  also  being  instituted  as  from  October  next 
for  a Diploma  in  Public  Health. 

The  University  of  Edinburgh  is  especially  rich  in  scholar- 
ships and  prizes  in  medical  subjects.  Full  particulars  can  be 
obtained  from  the  Dean  of  the  Medical  Faculty. 

School  of  Medicine  of  the  Royal  Colleges, 
Edinburgh. — The  number  of  students  varies  much  in  the 
classes  and  subjects.  It  is  within  the  limit  to  say  that  before 
the  war  about  1000  students  availed  themselves  each  session 
of  the  opportunity  of  attending  the  school.  The  lectures 
qualify  for  the  University  of  Edinburgh  and  other  Univer- 
sities, the  Royal  Colleges  of  Physicians  and  Surgeons  of 
London,  Edinburgh,  and  Dublin,  the  Faculty  of  Physicians 
and  Surgeons  of  Glasgow,  and  other  Medical  and  Surgical 
and  Public  Boards. 

The  practical  classes  and  laboratories  will  open  and  the 
lectures  commence  on  Oct.  7th. 

In  accordance  with  the  statutes  of  the  University  of 
Edinburgh  one-half  of  the  qualifying  classes  required  for 
graduation  may  be  attended  in  this  school.  The  regulations 
require  that  the  fee  for  any  class  taken  for  graduation  in 
Edinburgh  shall  be  the  same  as  that  for  the  corresponding 
class  in  the  University.  The  whole  education  required  for 
graduation  at  the  University  of  London  may  be  taken  in  this 
school. 

Special  courses  of  instruction  for  dental  students  are  also 
included  in  the  curriculum  of  this  school. 

The  minimum  cost  of  the  education  in  this  School 
of  Medicine  for  the  Triple  Qualification  of  Physician  and 
Surgeon  from  the  Royal  Colleges  of  Physicians  and  Surgeons 
of  Edinburgh  and  the  Faculty  of  Physicians  and  Surgeons 
of  Glasgow,  including  the  fees  for  the  Joint  Examinations, 
is  about  £130,  payment  of  which  is  distributed  over  the 
period  of  study.  There  is  no  composition  fee. 

Further  particulars  regarding  the  school,  also  its  calendar, 
may  be  had  on  application  to  the  Dean  of  the  School,  11, 
Bristo-place,  Edinburgh. 

Clinical  Instruction. — Royal  Infirmary,  Edinburgh. — 
This  hospital  has  921  beds  and  42  cots  for  children.  Courses 
of  Clinical  Medicine  and  Surgery  are  given  by  the  physicians 
and  surgeons  to  male  and  female  students.  Special  instruc- 
tion is  given  on  Diseases  of  Women,  Physical  Diagnosis, 
Diseases  of  the  Skin,  Diseases  of  the  Eye,  the  Ear,  the 
Larynx,  and  the  Teeth.  Separate  wards  are  devoted  to 
Venereal  Diseases,  Diseases  of  Women,  Diseases  of  the  Eye, 
the  Ear,  Throat  and  Nose,  and  the  Skin,  and  also  to  cases  of 
Incidental  Delirium  or  Insanity.  There  are  also  large  and 
complete  Medico-Electrical  aod  X Ray  and  Bathing 
Departments.  Post-mortem  examinations  are  conducted 
in  the  anatomical  theatre  by  the  pathologist  and  his 
assistants,  who  also  give  practical  instruction  in  Patho- 
logical Anatomy  and  Histology.  The  fees  for  hospital 
attendance  are  as  follows — viz.  : Perpetual  ticket,  in  one 
payment,  £12  ; annual  ticket,  £6  6s.  ; six  months,  £4  4*.  ; 
three  months,  £2  2,9.  ; monthly,  £1  Is.  Separate  pay- 
ments amounting  to  £12  12,9.  entitle  the  student  to  a life 
ticket.  No  fees  are  paid  for  any  medical  or  surgical  appoint- 
ment. The  appointments  are  as  follows  : 1.  Resident  phy- 
sicians and  surgeons  are  appointed  and  live  in  the  house  free 
of  charge.  The  appointment  is  for  six  months,  but  may  be 
renewed  at  the  end  of  that  period  by  special  recommenda- 
tion. 2.  Non-resident  house  physicians  and  surgeons  and 
clinical  assistants  are  appointed  for  six  months.  The 
appointment  may  be  renewed  for  a like  period  by  special 
recommendation.  3.  Clerks  and  dressers  are  appointed  by 
the  physicians  and  surgeons.  These  appointments  are  open 
to  all  students  and  junior  practitioners  holding  hospital 
tickets.  4.  Assistants  in  the  Pathological  Department  are 
appointed  by  the  pathologist. 


UNIVERSITY  OF  GLASGOW. 


382  The  Lancet,] 


Royal  Hospital  for  Sick  Children,  Sciennes-road, 
Edinburgh. — This  hospital  contains  120  beds,  and  is  fitted 
with  every  modern  improvement.  A fully  equipped  out- 
patient department  (medical  and  surgical)  is  conducted 
daily  in  a building  adjoining  the  hospital.  Systematic 
courses  of  instruction,  which  qualify  for  graduation  in  the 
Edinburgh  University  and  elsewhere,  are  given  from  time 
to  time  throughout  the  year  by  the  staff.  Students  may 
enter  at  any  time.  Full  particulars  can  be  obtained  from 
the  Registrar  at  the  hospital. 

Eye,  Ear,  and  Throat  Infirmary  of  Edinburgh, 
6,  Cambridge-street,  Lothian-road. — Clinical  Lectures  and 
Instruction  are  given  in  this  institution,  which  is  open  at 
1 o’clock  daily  for  outdoor  patients  for  Eye  Diseases  ; 
Mondays,  Thursdays,  and  Saturdays  at  12  noon,  and 
Tuesdays  and  Fridays  at  4 P.M.  for  outdoor  Ear,  Nose,  and 
Throat  Patients.  Special  Practical  Ophthalmoscopic  Classes 
by  arrangement.  Patients  whose  diseases  require  opera- 
tions or  more  than  ordinary  care  are  accommodated  in  the 
house.  Secretary:  Sir.  J.  P.  Watson,  W.S.,  32,  Charlotte- 
square. 

Post-Graduate  Instruction — In  connexion  with  the  Uni- 
versity and  Royal  Colleges  post-graduate  courses  of  lectures 
in  medicine  have  been  arranged  for  the  special  needs  of 
graduates  returned  from  active  service  on  demobilisation. 
These  courses  are  open  to  women.  Three  courses  have  been 
arranged.  Courses  in  Clinical  Medicine  and  Clinical  Surgery 
are  conducted  during  each  of  the  academic  terms,  the  next 
commencing  on  Oct.  14th,  and  the  Winter  Term  (January  to 
March)  commencing  Jan.  6th,  1920.  A course  in  Obstetrics, 
Gynaecology,  and  Child  Welfare  is  conducted  during  the 
summer  vacation  (August  and  September)  only.  As  the  work 
of  each  course  occupies  the  greater  part  of  each  day  only 
one  course  can  be  taken  at  a time.  The  instruction  is  given 
conjointly  by  the  Professors  in  the  Faculty  of  Medicine,  the 
University  lecturers  and  assistants,  the  lecturers  in  the 
Extra-Mural  School,  and  the  members  of  the  honorary  staffs 
of  the  hospitals.  The  course  in  Clinical  Medicine  includes  a 
series  of  daily  lecture-demonstrations  on  General  Medicine, 
Medical  Diseases  of  Children,  Tuberculosis,  Medical 
Ophthalmology,  Neurology,  Dermatology,  Infectious  Dis- 
eases, Mental  Diseases,  &c.  Arrangements  are  made  by 
which  members  of  the  course  may  follow  the  general  medical 
practice  of  the  Royal  Infirmary  and  Royal  Hospital  for  Sick 
Children  in  the  wards  and  out-patient  departments.  Tho-se 
members  of  the  course  who  desire  to  concentrate  their  atten- 
tion on  a special  subject  may,  by  arrangement,  be  attached 
as  extra  clinical  assistants  in  the  medical  wards  of  the  Royal 
Infirmary,  the  Royal  Hospital  for  Sick  Children,  the  Royal 
Victoria  Dispensary  for  Tuberculosis,  the  Eye  Department  or 
the  Skin  Department  of  the  Royal  Infirmary.  Provision  is 
also  made  for  practical  instruction  in  Applied  Anatomy, 
Physiology,  Pathology,  Bacteriology,  and  a limited  number 
of  members  of  the  course  may,  by  arrangement,  act  as 
assistant-demonstrators  in  the  practical  classes  on  these 
subjects  under  the  professors  and  lecturers.  Members  who 
desire  to  act  as  Demonstrators  in  practical  classes  and 
Clinical  Assistants  in  special  departments  are  allocated  to 
these  in  order  of  application  up  to  the  number  of  vacancies. 
Similar  provisions  are  made  for  the  courses  in  Clinical 
Surgery  and  in  Obstetrics,  Gynaecology,  and  Child  Welfare. 

The  fee  for  each  of  the  two  first  courses  is  25  guineas, 
including  hospital  tickets,  and  for  the  third  course  20  guineas. 
All  particulars  may  be  had  on  application  to  the  Secretary, 
Post-Graduate  Courses  in  Medicine,  University  NewBuildings, 
Edinburgh. 


UNIVERSITY  OF  GLASGOW. 

The  University  of  Glasgow  is  both  a teaching  and  a 
degree-granting  body,  but  admits  to  graduation  only 
candidates  whose  preliminary  examination  and  course 
of  study  conform  to  its  own  regulations.  Within 
certain  limits  instruction  given  by  recognised  medical 
schools  and  teachers  may  be  accepted,  but  not  less  than 
one-half  of  the  subjects  other  than  clinical  must  be 
taken  in  this  or  some  other  recognised  university,  and  at 
least  two  years  of  the  course  must  be  taken  in  Glasgow 
University.  Six  degrees,  open  both  to  men  and  women, 
are  conferred : MB.  and  Ch.B.  (always  conjointly),  M.D. 
and  Ch.M.  ; B.Sc.  in  Public  Health  ; D.Sc.  in  Public  Health  ; 
and  B.Sc.  in  Pharmacy.  A Preliminary  Examination  must 


[August  33,  1919 


be  passed  in  (1)  English,  (2)  Latin,  (3)  Elementary  Mathe- 
matics, and  (4)  Greek,  or  French,  or  German,  or  Italian, 
with  possible  options  to  students  whose  native  language  is 
not  English.  Candidates  taking  the  University  preliminary 
examination  are  not  obliged  to  pass  in  all  the  four  subjects 
at  one  examination,  but  must  do  so  at  not  more  than  two 
occasions. 

For  the  degrees  of  M.  13.  and  Ch.B.  a curriculum  of  five  years 
is  required.  The  candidate  must,  during  his  curriculum, 
have  attended  a course  or  courses  of  instruction  in  each 
of  the  following  subjects  of  study,  extending  over  not  less 
than  the  number  of  terms  specified  in  each  case,  and 
including  such  class  examinations  as  may  be  prescribed  in 
connexion  with  the  several  courses: — Chemistry  (including 
Organic  Chemistry),  two  terms  ; with  Practical  Chemistry, 
one  term  ; Physics  (with  practical  work),  one  term  ; Botany 
(with  practical  work),  one  term  ; Zoology  (with  practical 
work),  one  term  ; Anatomy  and  Practical  Anatomy,  five 
terms ; Physiology  and  Practical  Physiology,  three  terms  ; 
Materia  Medica  and  Therapeutics  (together  or  separately), 
each  subject,  one  term  ; Pathology  and  Practical  Pathology, 
three  terms ; Medical  Jurisprudence  and  Public  Health 
(together  or  separately),  each  subject,  one  term  ; Midwifery 
and  Diseases  peculiar  to  Women  and  to  Infants,  two  terms  'r 
Surgery,  two  terms  ; Medicine,  two  terms.  Candidates 
must  attend  at  least  three  years  the  Medical  and  Surgical 
Practice  of  a recognised  hospital  accommodating  at 
least  80  patients  and  having  a distinct  staff  of  physicians 
and  surgeons.  At  least  nine  months’  hospital  attendance 
is  required  on  both  Clinical  Surgery  and  Clinical 
Medicine,  and  the  student  must  have  acted  for  six  months 
as  clerk  in  medical  and  dresser  in  surgical  wards,  and 
must  have  had  six  months’  outdoor  practice ; he  must 
also  have  attended  a course  of  Mental  Diseases  and  of 
Practical  Pharmacy  (25  meetings),  must  have  been 
properly  instructed  in  Vaccination  at  a public  vaccination 
station,  and  must  have  attended  at  least  20  cases  of 
labour  and  the  Practice  of  a Lying-in  Hospital.  The 
University  also  requires  further  study  in  various  special 
subjects. 

There  are  four  Professional  Examinations,  the  first- 
comprising  Botany,  Zoology,  Physics,  and  Chemistry ; the 
second  comprising  Anatomy  and  Physiology ; the  third 
comprising  Materia  Medica  and  Therapeutics  and  Patho- 
logy; and  the  fourth  or  final,  comprising  Medical  Juris- 
prudence and  Public  Health,  Surgery  and  Clinical  Surgery, 
Practice  of  Medicine  and  Clinical  Medicine,  and  Midwifery 
and  the  Diseases  peculiar  to  Women  and  to  Infants. 

The  degrees  of  M.D.  (Doctor  of  Medicine)  and  Ch.M. 
( Master  of  Surgery ) are  higher  degrees  in  Medicine  and 
Surgery  respectively,  and  candidates  (not  under  24  years 
of  age)  who  have  previously  obtained  the  double  bachelor- 
ship may  be  admitted  to  either  M.D.  or  Ch.M.  on  com- 
pleting the  after  course  prescribed,  including  an  examina- 
tion in  Clinical  Medicine  for  M.D.  and  an  examination  in 
.Surgical  Anatomy,  operations  on  the  dead  body,  and  Clinical 
Surgery  for  Ch.M. 

Fees. — The  Fees  for  M.B.  and  Ch.B.  are  £23  2s.  The 
class  fee  in  each  subject  of  the  curriculum  for  M.  B.  and 
Ch.B.  is  £2  2s.,  £3  3*'.,  or  £4  4s.,  and  the  present,  fee  for 
hospital  attendance  is  £7.  The  fee  for  M.D.  is  £15  15s., 
and  for  Ch.M.  £15  15s. 

The  great  majority  of  the  students  take  their  hospital 
course  at  the  Western  Infirmary,  or  the  Royal  Infirmary, 
where  clinical  instruction  is  given  by  professors  of  the 
University  and  others.  Clinical  instruction  on  Fevers  is 
given  at  Ruchill  and  Belvidere  Hospitals,  while  special 
courses,  largely  of  a practical  nature  and  embracing  work 
in  Hospital  or  Asylum  wards,  are  conducted  by  University 
Lecturers  on  the  Ear,  the  Throat  and  Nose,  Dermatology, 
Ophthalmology,  Venereal  Diseases,  and  Insanity.  Queen 
Margaret  College,  sometime  conducted  as  a separate  institu- 
tion for  the  higher  education  of  women,  was  made  over  to 
the  University  in  1892,  and  in  it  medical  classes  for  women 
are  conducted  under  University  professors  and  other  lec- 
turers appointed  by  the  University  Court,  whilst  for  clinical 
instruction  female  students  are  admitted  to  the  Royal 
Infirmary. 

In  this  University  Bursaries  and  Prizes  to  the  annual 
amount  of  over  £1000  are  appropriated  to  students  in  the 
Medical  Faculty,  and  there  are  also  several  Scholar- 
ships and  Fellowships  which  may  be  held  by  medical 


The  Lancet,] 


UNIVERSITY  OK  GLiSGOW. 


[August  30,  1919  383 


students  who  have  gone  through  the  Arts  course.  A full 
list  will  be  found  in  the  University  Calendar. 

The  Anderson  College  oe  Medicine,  Duinbarton- 
road,  Glasgow,  VV. — Courses  are  given  which  qualify  for  all 
the  licensing  boards  and  for  the  Universities  of  London, 
Durham,  Edinburgh,  and  Glasgow  (the  latter  two  under  certain 
conditions).  Candidates  for  the  Licence  in  Dental  Surgery 
can  obtain  the  full  medical  curriculum  in  Anatomy,  Chemistry, 
Physiology,  Surgery,  Practice  of  Medicine,  and  Materia 
Medica.  The  courses  special  to  Dentistry  are  also  con- 
ducted in  the  Anderson  College  of  Medicine. 

The  buildings  are  situated  in  Dumbarton-road,  im- 
mediately to  the  west  of  the  entrance  to  the  Western 
Infirmary,  and  adjoining  the  University.  Extensive  accom- 
modation is  provided  for  Practical  Anatomy,  Practical 
Chemistry,  Practical  Botany,  Practical  Zoology,  Practical 
Physiology,  Practical  Fharmacy,  Operative  Surgery,  and 
Public  Health.  Ample  provision  has  also  been  made  for 
the  comfort  of  students. 

Women  students  are  admitted  on  the  same  terms  as  men. 

The  Carnegie  Trust  extends  its  benefactions  to  students 
of  the  Anderson  College  of  Medicine.  Full  particulars  may 
be  obtained  from  Sir  W.  S.  McCormick,  the  Carnegie  Trust 
Offices,  Merchants’  Hall,  Edinburgh. 

Communications  relating  to  the  College  to  be  addressed 
to  the  Secretary  of  the  Medical  Faculty,  The  Anderson 
College  of  Medicine,  Glasgow,  W.  Communications 
relating  to  the  Preliminary  Examination  in  General 
Education  to  be  addressed  to  Mr.  Hugh  Cameron,  M.A., 
F.E.I.S  , Educational  Institute  Office,  34,  North  Bridge- 
street,  Edinburgh.  Communications  relating  to  the  Triple 
Qualification  to  be  addressed  to  Mr.  Walter  Hurst,  Royal 
Faculty  Hall,  242,  St.  Yincent-street,  Glasgow. 

The  Winter  Session  will  open  on  Monday,  Oct.  13th, 

1919,  and  will  close  on  Thursday,  March  18th,  1920. 

The  Summer  Session  will  open  on  Wednesday,  April  21st, 

1920,  and  will  close  on  Wednesday,  June  30th,  1920. 


St.  Mungo's  College  and  Glasgow  Royal  Infirmary. 
— The  classes  in  St.  Mungo’s  College  qualify  for  the 
English,  Scotch,  and  Irish  Conjoint  Boards  and,  under 
certain  conditions,  for  the  various  universities,  including 
the  University  of  London.  Students  who  have  fulfilled 
the  conditions  of  the  Carnegie  Trust  as  regards  Scottish 
birth  or  extraction,  age  (16  years),  and  Preliminary  Exa- 
mination, are  eligible  for  the  benefits  of  this  Trust  during 
the  whole  course  of  their  studies  at  St.  Mungo’s  College. 
The  classes  are  open  to  male  and  female  students  equally 
The  minimum  fees  for  all  the  lectures,  including  hospital 
attendance,  necessary  for  candidates  for  the  Diplomas  of 
the  English  or  Scotch  Colleges  of  Physicians  and  Surgeons, 
amount  to  £100.  Further  particulars  can  be  obtained  from  a 
syllabus  which  may  be  procured  free  on  application  to  the 
Secretary  of  the  Medical  Faculty,  86,  Castle-street,  Glasgow 
Queen  Margaret  College  (Women’s  Department  of 
the  University). — This  is  an  integral  part  of  the  University  of 
Glasgow.  The  classes  are  taught  by  professors  of  the  Uni- 
versity and  other  lecturers  appointed  by  the  University  Court, 
and  it  is  governed  by  the  University  Court  and  Senate.  The 
curriculum,  regulations,  and  fees  are  the  same  as  those  of 
the  male  students,  and  the  University  degrees  are  open  to 
women  on  the  same  conditions  as  to  men.  They  have 
access  to  the  University  Museum  and  can  borrow  books 
from  the  University  Library,  besides  having  a library 
of  reference  in  Queen  Margaret  College.  The  School 
of  Medicine  is  a special  feature  of  the  College,  and 
gives  full  preparation  for  the  medical  degrees  of  the  Uni- 
versity. In  July,  1894,  for  the  first  time  in  the  history  of  any 
Scottish  University,  women  students  graduated  in  medicine 
in  Glasgow  University.  Over  300  women  have  now  taken  the 
degree  of  M.B.,  C.M.,  or  M.B.,  Ch.  B.  of  the  University  of 
Glasgow  and  24  the  degree  of  M.D.  The  women  students 
attend  classes  in  the  various  University  Buildings  at 
Gilmore-hill,  Queen  Margaret  College,  and  the  Royal 
Infirmary.  Excellent  facilities  for  clinical  work  are 
given  in  the  Royal  Infirmary,  in  the  Maternity,  and  other 
hospitals.  The  Arthur  Scholarship  is  open  every  third  year 
to  students  of  first  year  ; other  Bursaries  are  open  in  Arts 
and  Medicine;  and  by  an  ordinance  of  the  Universities 
Commissioners  women  are  admitted  to  certain  University 
bursaries,  scholarships,  and  fellowships.  The  Winter  Session 


will  open  on  Oct.  14th,  but  owing  to  the  pressure  upon 
accommodation  in  classes  no  new  students  of  Medicine  are  to 
be  admitted  until  April,  1920.  Applications  for  entrance  at 
that  date  should  be  made  before  F’eb.  1st,  1920. 

Royal  Infirmary,  Glasgow. — The  ancient  connexion 
between  the  University  of  Glasgow  and  the  Royal  Infirmary 
was  revived  in  1911,  when  four  University  Chairs  and  several 
University  Lectureships  were  established  at  the  infirmary. 
St.  Mungo’s  College  is  situated  in  the  infirmary  grounds. 
The  infirmary  has,  including  the  Ophthalmic  Department, 
700  beds.  There  are  special  beds  and  wards  for  diseases  of 
women,  of  the  throat,  nose,  and  ear,  skin,  venereal  diseases, 
burns  and  septic  cases.  The  wards  are  open  to  Women 
Students.  At  the  Out-door  Department  the  attendances  in 
1918  numbered  about  114,000.  In  addition  to  the  large 
medical  and  surgical  departments  there  are  departments  for 
special  diseases — viz.,  diseases  of  women,  of  the  throat  and 
nose,  of  the  ear,  of  the  eye,  of  the  skin,  and  of  the  teeth. 
Five  house  physicians  and  12  house  surgeons,  having  a 
legal  qualification  in  medicine  and  surgery,  who  board  in 
the  hospital  free  of  charge,  are  appointed  every  six  months. 
Clerks  and  dressers  are  appointed  by  the  physicians  and 
surgeons.  As  a large  number  of  cases  of  acute  diseases  and 
accidents  of  a varied  character  are  received  these  appoint- 
ments are  very  valuable  and  desirable.  There  is  a modern 
and  fully  equipped  Electrical  Pavilion,  and  year  by  year 
the  latest  and  most  approved  apparatus  for  diagnosis 
and  treatment  has  been  added.  The  fees  are  as  follows  : 

(a)  For  hospital  practice,  including  attendance  at  the  out- 
door department,  at  the  pathological  department,  post- 
mortem examinations,  and  the  use  of  the  museum  : Perpetual 
ticket,  £7  ; six  months,  £2  2s.  ; three  months,  £1  Is.  ; 
separate  payments  amounting  to  £7  7s.  entitle  the  student 
to  a perpetual  ticket,  on  return  of  previous  season  tickets  ; 

( b ) for  Clinical  Lectures,  six  months,  £3  10s.  ; three  months, 
£1  15s.  ; (c)  Vaccination,  £1  Is.  ; Pathology,  £4  4s.  ; 
Bacteriology,  £2  2s. 

Glasgow  Western  Infirmary. — This  hospital  adjoins 
the  University  of  Glasgow.  Number  of  beds  upwards  of 
600.  Special  wards  are  set  apart  for  Diseases  of  Women, 
Throat,  Nose,  and  Ear,  and  for  Affections  of  the  Skin. 
In  the  out-patient  department  there  are  special  cliniques 
for  Diseases  of  Women  and  for  Diseases  of  the  Throat, 
Ear,  Teeth,  Skin,  and  Venereal  Disease.  The  Clinical 
Courses  are  given  by  the  physicians  and  surgeons,  each  of 
whom  conducts  a separate  class,  and  students  require  to 
enter  their  names  at  the  beginning  of  the  session  for  the 
class  which  they  propose  to  attend.  Special  instruc- 
tion is  given  to  junior  students  by  tutors  or  assistants, 
and  clinical  clerks  and  dressers  are  selected  from  the 
members  of  the  class.  All  the  courses  of  clinical  instruc- 
tion are  recognised  by  the  University  of  Glasgow  and  the 
other  boards  in  the  kingdom.  In  the  Pathological  Department 
the  course  is  both  systematic  and  practical,  also  post-graduate 
courses,  and  extends  through  the  winter  and  following 
summer  ; these  are  likewise  recognised  by  the  Liniversity 
for  graduation.  Eighteen  resident  assistants  are  appointed 
annually,  without  salary,  from  those  who  have  completed 
their  course.  The  fee  for  hospital  attendance  is  £7,  and 
the  fees  for  clinical  instruction  are  £3  3s.  for  the  Winter 
Session  and  £2  2s.  for  the  Summer  Session.  A Clinical 
Laboratory  has  been  opened,  and  students  receive  laboratory 
instruction  from  the  lecturer  on  clinical  methods.  Secretary  : 
J.  Matheson  Johnston,  C.A.,  87,  Union-street 

A School  of  Massage,  Medical  Electricity,  and  Swedish 
Remedial  Exercises  has  been  established  to  qualify  for  the 
Certificate  of  the  Incorporated  Society  of  Trained  Masseuses. 

Royal  Hospital  for  Sick  Children,  Yorkhill,  Glasgow. 
— This  institution,  which  was  founded  in  1882,  consists  of  : 
(1)  a hospital  at  Yorkhill  containing  204  cots  built  on  an 
elevated  and  central  site  close  to  the  University  and  opened 
in  July,  1914  ; (2)  a Dispensary,  or  Out-patient  Department, 
in  West  Graham-street,  opened  in  October,  1888  ; and  (3) 
a country  branch  at  Drumchapel,  Dumbartonshire,  contain- 
ing 24  cots,  opened  in  1903.  Children  treated  must  be  under 
12  years  of  age  and  suffering  from  non-infectious  diseases. 
In  the  hospital  about  5000  children  are  treated  annually. 
In  the  Out-patient  Department  over  12,000  are  treated 
annually,  involving  nearly  50,000  attendances.  In  the 
present  year  two  lectureships  in  the  University  of  Glasgow 
nave  been  founded  in  connexion  with  the  hospital,  one  on 


384  The  Lanobt,] 


UNIVERSITY  OF  ST.  ANDREWS. 


[August  3D,  1919 


the  Medical  Diseases  of  Infancy  and  Childhood,  and  the 
other  on  Surgery  and  Orthopaedics  in  Relation  to  Infancy 
and  Childhood.  These  lectureships  are  held  by  the  Visiting 
Physician,  Dr.  Leonard  Findlay,  and  the  Visiting  Surgeon, 
Mr.  Alexander  MacLennan.  The  lectures  are  both  systematic 
and  clinical,  but  particularly  and  chiefly  the  latter.  Informa- 
tion with  regard  to  clinical  instruction,  lectures,  demonstra- 
tions, &c. , may  be  obtained  from  the  Medical  Superintendent 

Glasgow  Royal  Maternity  and  Women’s  Hospital, 
Rottenrow. — The  new  hospital,  which  was  opened  in  1908, 
is  in  point  of  size  the  largest  of  its  kind  in  Britain  and  has 
accommodation  for  108  patients.  A Maternity  and  Child 
Welfare  Centre  has  been  established  in  connexion  with 
the  hospital,  consisting  of  a complete  In-door  and  Out-door 
Ante-natal  Department  and  an  Infant  Consultation  Clinic. 
In  1918  2158  normal  cases  and  1369  abnormal  cases  were 
treated  by  the  hospital  in  the  In  door  and  Out-door  Depart- 
ments. Secretary:  Mr.  William  Guy,  146,  Buchanan-street. 
Full  particulars  as  to  fees  and  accommodation  may  be 
obtained  from  the  House  Superintendent  at  the  Hospital. 

The  Royal  Samaritan  Hospital  for  Women,  Glas- 
gow.— This  hospital,  founded  in  1886,  is  one  of  the  largest 
purely  gynaecological  hospitals  in  Great  Britain,  possessing, 
as  it  does,  over  90  beds.  It  offers  excellent  facilities  for 
clinical  instruction  in  the  diseases  peculiar  to  women, 
treating  in  the  wards  and  in  the  out-pat  ient  department  some 
4000  cases  per  annum.  The  surgeons,  four  in  number,  visit 
the  wards  in  the  mornings.  For  further  information  applica- 
tion may  be  made  at  the  Hospital,  or  to  Thos.  Macquaker, 
honorary  secretary,  89,  West  Regent-street,  Glasgow. 

Glasgow  Lock  Hospital,  Rottenrow. — The  Hospital 
contains  83  beds.  During  1918  426  patients  were  admitted 
to  the  wards  ; 9109  visits  were  made  by  out-door  patients  at 
the  Dispensary.  Classes  are  held  for  the  clinical  instruction 
of  medical  students  and  practitioners. 

Glasgow  Ophthalmic  Institution,  126,  West  Regent- 
street  (29  beds  and  six  cots). — Clinical  and  systematic 
course  of  lectures  for  students  during  the  winter  and  summer 
sessions.  In-patients,  812  ; out-  or  dispensaiy  patients, 
13,927 ; total  attendances,  31,553.  Operations  on  Wednesdays 
and  Saturdays.  This  institution  is  the  Ophthalmic  Depart- 
ment of  the  Royal  Infirmary.  Clinical  instruction  is  given 
during  both  summer  and  winter  sessions  to  men  and  women 
students  attending  the  University.  Secretary  and  Cashier: 
R.  Morrison  Smith,  C.A.,  135,  Buchanan-street,  Glasgow. 

Glasgow  Eye  Infirmary,  Berkeley-street  and  Charlotte- 
street. — This  institution,  the  largest  of  its  kind  in  Scotland, 
was  founded  in  1824.  The  average  number  of  new  patients 
for  the  last  ten  years  has  been  26,837  and  the  total  number  of 
cases  in  1918  was  27,303.  The  wards  and  dispensary  are 
recognised  by  the  University  of  Glasgow  for  the  purpose  of 
instruction  in  ophthalmology  for  graduation  in  medicine. 
Secretary  and  Acting  Treasurer:  Harold  John  Black, 

88,  West  Regent- street,  Glasgow.  The  medical  session  opens 
in  October.  A Post-graduate  Class  will  be  held. 

Glasgow  Hospital  for  Diseases  of  the  Ear,  Nose, 
and  Throat,  27  and  28,  Elmbank-crescent. — 12  beds  and 
two  cots.  New  patients,  4096.  Attendances  at  out-patient 
department  16,188.  Admitted  to  in-door  department  331. 
Clinical  instruction  is  given  in  connexion  with  Dr.  Connal’s 
course  on  Diseases  of  the  Ear  at  Anderson’s  College  and 
Dr.  Syme’s  course  on  Diseases  of  the  Throat  and  Nose  at  the 
Western  Medical  School.  A course  of  post-graduate  study 
has  been  conducted  by  the  staff  of  the  hospital.  Secretary  : 
Mr.  P.  T.  Young. 


UNIVERSITY  OF  ST.  ANDREWS  (UNITED  COLLEGE, 
ST.  ANDREWS  AND  UNIVERSITY  COLLEGE, 
DUNDEE). 

Four  degrees  in  Medicine  and  Surgery  are  conferred  by 
the  University  of  St.  Andrews — viz.,  Bachelor  of  Medi- 
cine (M.B.),  Bachelor  of  Surgery  (Ch.B.),  Doctor  of 
Medicine  (M.D.),  Master  of  Surgery  (Ch.M.),  a Diploma 
in  Public  Health,  and  Diploma  in  Dental  Surgery  (L  D S.). 
The  whole  curriculum  may  be  taken  at  University 
College,  Dundee,  or  the  first  two  years  of  the  course 
may  be  taken  at  St.  Andrews  and  the  remaining  three 
years  in  Dundee.  The  degrees  of  M.B.  and  Ch.B.  shall 
always  be  conjoined.  Before  commencing  his  medical 
studies  each  student  shall  pass  a Preliminary  Examination 


in  ( a ) Englibh,  (b)  Latin,  (c)  Elementary  Mathematics,  and 
(d)  one  of  the  following  optional  subjects : (a)  Greek, 

(P)  French,  (7)  German,  (5)  Italian,  (e)  any  other  approved 
Modern  Language.  A degree  in  Arts  or  in  Science  in  any 
of  the  Universities  of  the  United  Kingdom  and  in  some 
colonial  and  foreign  universities  shall  exempt  from  the 
Preliminary  Examination.  The  Preliminary  Examination  for 
graduation  in  Medicine  and  Surgery,  Arts  or  Science,  of  the 
University  of  St.  Andrews  is  accepted  as  equivalent  to  the 
Registration  Examination  required  by  the  General  Medical 
Council  (the  certificate  to  include  the  required  subjects). 
Also  the  Final  Examination  for  a degree  in  Arts  or  Science 
and  the  Final  Examination  for  the  Diploma  of  LL.A. 

Degree  of  Bachelor  of  Medicine  and  Bachelor  of  Surgery.— 
Candidates  must  have  been  engaged  in  medical  study  for 
at  least  five  years.  In  each  of  the  first  four  years  the 
candidate  must  have  attended  at  least  two  courses  of  in- 
struction in  one  or  more  of  the  subjects  of  study  specified 
below,  each  course  extending  over  a session  of  not  less 
than  five  months,  either  continuous  or  divided  into  two 
terms,  or,  alternatively,  one  such  course  along  with  two 
courses,  each  extending  over  a session  of  not  less  than 
two  and  a half  months.  During  the  fifth  or  final  year  the 
candidate  shall  be  engaged  in  clinical  study  for  at  least  nine 
months  at  the  Infirmary  of  Dundee  or  at  one  or  more  of  such 
public  hospitals  or  dispensaries,  British  or  foreign,  as  may 
be  recognised  for  the  purpose  by  the  University  Court.  The 
candidate  must  have  received  instruction  in  each  of  the 
following  subjects  of  study,  including  such  examinations  as 
may  be  prescribed  in  the  various  classes— viz.  : Anatomy, 
Practical  Anatomy,  Chemistry,  Materia  Medica,  Physiology, 
or  Institutes  of  Medicine,  Practice  of  Medicine,  Surgery, 
Midwifery  and  the  Diseases  peculiar  to  Women  and  Infants. 
Pathology,  Practical  Chemistiy,  Physics  (including  the 
Dynamics  of  Solids,  Liquids,  and  Gases,  and  the  Rudi- 
ments of  Sound,  Heat,  Light,  and  Electricity),  Elementary 
Botany,  Elementary  Zoology,  Practical  Physiology,  Practical  ' 
Pathology,  Forensic  Medicine,  and  Public  Health.  The 
candidate  must  have  attended  for  at  least  three  years  the  1 
Medical  and  Surgical  Practice  either  of  the  Infirmary  of  ' 
Dundee  or  of  a General  Hospital  elsewhere  which  accommo-  « 
dates  not  fewer  than  80  patients  and  possesses  a distinct 
staff  of  physicians  and  surgeons  and  is  recognised  for 
the  purpose  by  the  University  Court.  Additional  subjects 
of  study  are  Practical  Pharmacy,  Mental  Diseases,  Practical 
Midwifery,  Operative  Surgery,  Vaccination,  Children’s 
Diseases,  Fevers,  Ophthalmology,  Diseases  of  the  Ear,  Throat,  i 
and  Nose,  Anaesthetics,  and  Post-mortem  Examinations. 

With  respect  to  the  places  and  institutions  at  which  the  <• 
studies  of  the  candidate  may  be  prosecuted  the  following  ' 
regulations  shall  have  effect : — 1.  Two  of  the  five  years  of 
medical  study  must  be  spent  in  the  University  of  St.  Andrews.  . 
2.  The  remaining  three  years  may  be  spent  in  any  University 
of  the  United  Kingdom  or  in  any  Indian,  Colonial,  or 
Foreign  University  recognised  for  the  purpose  by  the 
University  Court,  or  in  such  medical  schools  or  under  such 
teachers  as  may  be  recognised  for  the  purpose  by  the 
University  Court.  Women  are  admitted  to  graduation  in 
Medicine,  subject  to  certain  provisions. 

Professional  Examinations  for  the  Degrees  of  Bachelor  of 
Medicine  and  Bachelor  of  Surgery.  —Each  candidate  will  be 
examined  both  in  w-riting  and  orally,  and  also  clinically 
where  the  nature  of  the  subject  admits,  in  the  following 
divisions — viz.,  first,  in  Botany,  Zoology.  Physics,  and 
Chemistry  ; second,  in  Anatomy  and  Physiology  ; third,  in 
Materia  Medica  and  Pathology  and  Forensic  Medicine  and 
Public  Health ; and  fourth,  in  Surgery,  Clinical  and 
Operative  Surgery,  Practice  of  Medicine  and  Clinical 
Medicine,  and  Midwifery  and  Gynaecology  (Systematic  and  j 
Clinical). 

The  fee  to  be  paid  for  the  degrees  of  Bachelor  of  Medicine  ■ 
and  Bachelor  of  Surgery  shall  be  22  guineas,  and  the  pro- 
portion of  this  sum  to  be  paid  by  a candidate  at  each  division  i 
of  the  examination  shall  be  regulated  from  time  to  time  by 
the  University  Court.  The  fee  to  be  paid  for  the  degree  of 
Doctor  of  Medicine  shall  be  15  guineas,  and  for  the  degree 
of  Master  of  Surgery  15  guineas.  The  whole  medical  : 
curriculum  can  be  taken  in  University  College,  Dundee,  or 
the  first  two  years  in  United  College,  S‘.  Andrews. 

For  further  particulars  and  details  as  to  scholarships  and 
bursaries  application  should  be  made  to  Professor  Kynoch, 
Dean  of  the  Medical  Faculty,  University  College,  Dundee. 


The  Lancet,) 


UNIVERSITY  OF  ABERDEEN, 


[August  30,  1919  ‘J85 


University  College,  Dundee. — This  College  is  one  of 
the  constituent  colleges  of  the  University  of  St.  Andrews. 
In  the  medical  buildings  there  are  spacious  and  well- 
equipped  laboratories.  The  complete  medical  curriculum 
can  be  taken  in  Dundee.  For  classes,  fees,  &.C.,  see  under 
University  of  St.  Andrews. 

Royal  Infirmary,  Dundee. — The  Infirmary  contains 
408  beds,  including  special  wards  for  the  Diseases 
of  Women,  Children,  Eye,  Ear,  and  Throat,  Skin,  and 
for  Obstetric  cases.  There  is  in  addition  an  Extern 
Obstetric  Department.  There  were  during  last  year 
13,895  out-patients  and  471  home  (maternity)  patients. 
The  Royal  Infirmary  offers  facilities  for  practical  work 
to  students.  Appointments  : Six  qualified  Resident  Medical 
Officers  (Male  or  Female)  are  appointed  every  six  months 
and  one  Obstetric  Assistant.  Clinical  Clerks  and  Dressers 
are  attached  to  the  Physicians  and  Surgeons,  and  students 
are  appointed  as  assistants  in  the  Pathological  Depart- 
ment. There  are  in  connexion  with  the  clinical  courses 
Tutorial  Classes  in  Medicine  and  Surgery.  Instruction  is 
also  given  in  Practical  Pharmacy  and  Materia  Medica. 
Further  information  can  be  obtained  from  the  Medical 
Superintendent. 


UNIVERSITY  OF  ABERDEEN. 

The  University  of  Aberdeen  grants  four  degrees  in  Medi- 
cine and  Surgery — viz.,  Doctor  of  Medicine  (M.D.),  Master 
of  Surgery  (Ch.M.),  Bachelor  of  Medicine  (M.B.),  and 
Bachelor  of  Surgery  (Ch.  B.). 

Degrees  of  M.B.  and  Ch.B. — Before  commencing  his 
medical  studies  each  student  must  pass  a Preliminary  Exa- 
mination in  (1)  English.  (2)  Latin,  (3)  Mathematics,  and 
(4)  Greek,  or  French,  or  German.  The  curriculum  for  the 
degrees  extends  over  a period  of  five  years,  during  which 
attendance  is  required  in  the  following  subjects  : Botany, 
Zoology,  Physics,  Chemistry  (Systematic  and  Practical), 
Anatomy  (Systematic  and  Practical),  Physiology  (Systematic 
and  Practical),  Materia  Medica  and  Therapeutics,  Practical 
Pharmacy,  Pathology  vSyst.ematic  and  Practical),  Medical 
Jurisprudence,  Public  Health,  Surgery,  Medicine,  and  Mid- 
wifery. 

Candidates  must  attend  for  at  least  three  years  the 
medical  and  surgical  practice  of  a recognised  hospital ; they 
must  have  attended  courses  of  at  least  nine  months  in 
clinical  medicine  and  clinical  surgery,  and  have  acted  as 
clerk  in  the  medical  and  dresser  in  the  surgical  wards  of  a 
hospital.  Attendance  is  required  on  the  practice  of  a dis- 
pensary or  the  out-practice  of  a hospital  and  also  on  courses 
in  Mental  Diseases,  Fevers,  Ophthalmology,  Post-mortem 
examinations,  Venereal  Diseases,  and  other  special  subjects. 
The  candidate  is  also  required  to  have  been  properly  in- 
structed in  Vaccination  and  to  have  attended  at  least  20 
Midwifery  cases. 

The  fee  for  the  degrees  of  M.B.  and  Ch.B.  amounts  to 
£23  2s. 

Besides  the  Royal  Infirmary  (270  beds),  students  have  the 
opportunity  of  attending  the  following  institutions  : City 
Fever  Hospital,  Sick  Children’s  Hospital,  General  Dispen- 
sary, and  Lying-in  and  Vaccine  Institutions,  Royal  Lunatic 
Asylum,  Ophthalmic  Institution,  &c. 

Degrees  of  M.D.  and  Ch.M. — Candidates  for  either  of 
these  degrees  must  already  hold  the  degrees  of  M.B.  and 
Ch.B.  of  Aberdeen.  A thesis  has  to  be  presented  and  an 
examination  has  to  be  passed  in  Clinical  Medicine  (or  in  some 
special  Depaitment  of  Medical  Science)  or  Clinical  Surgery, 
as  the  case  may  be. 

A diploma  in  Public  Health  is  granted  by  the  University 
to  graduates  in  Medicine  of  a University  in  the  United 
Kingdom,  after  a special  examination. 

Application  for  further  information  should  be  addressed 
to  the  Secretary  of  the  Medical  Faculty. 

Scholarships  and  Prizes. — In  the  Faculty  of  Medicine  of 
the  University  of  Aberdeen  there  are  the  following  Bursaries, 
Scholarships,  and  Prizes : — Bursaries  : about  15  Bursaries 
(competition  and  presentation)  are  open  each  year,  of  £15 
to  £30  per  annum  in  value,  most  of  them  being  tenable  for 
three  years.  Scholarships  : five  Post-Graduate  Scholarships, 
value  £36  to  £160  per  annum.  Prizes  and  Medals  : 13  Gold 
Medals  and  Prizes  for  proficiency  in  special  departments.  &c. 

Clinical  Instruction  is  given  in  the  Aberdeen  Royal 
Infirmary  (270  beds)  by  the  physicians  and  surgeons  on  the 
staff. 


Aberdeen  Royal  Asylum.— Contains,  with  hospital 
attached  to  main  institution  and  agricultural  branch,  about 
986  beds.  Clinical  instruction  is  given  to  students  during 
three  months  in  summer.  Clerk  and  Treasurer,  Mr.  A.  , Scott 
Finnie,  343,  Union-street,  Aberdeen. 


SCOTTISH  MEDICAL  CORPORATIONS 
GRANTING  DIPLOMAS. 


ROYAL  COLLEGE  OF  PHYSICIANS  OF  EDIN- 
BURGH. ROYAL  COLLEGE  OF  SURGEONS 
OF  EDINBURGH,  ROYAL  FACULTY  OF 
PHYSICIANS  AND  SURGEONS 
OF  GLASGOW. 

These  Colleges  have  made  arrangements  by  which,  after 
one  series  of  examinations,  held  in  Edinburgh  or  Glasgow, 
or  both,  the  student  may  obtain  the  diplomas  of  the  three 
Bodies. 

The  three  Bodies  grant  their  Single  Licences  only  to 
candidates  who  already  possess  legal  qualifications  in  Medi- 
cine or  Surgery.  Copies  of  the  Regulations  for  the  Single 
Licence  of  any  of  the  Bodies  may  be  had  on  application  to 
the  respective  secretaries. 

Professional  Education. — The  candidate  must  produce 
certificates  or  other  satisfactory  evidence  of  having 
attended  the  following  separate  and  distinct  courses  of 
instruction  : Physics,  three  months  ; Elementary  Biology, 
three  months;  Chemistry,  six  months  ; Practical  or  Analytical 
Chemistry,  three  months ; Anatomy,  during  at  least  six  months  ; 
Practical  Anatomy,  twelve  months  ; Physiology,  six  months  ; 
Practical  Physiology,  three  months  ; Materia  Medica,  three 
months  ; Pathology  (including  Practical  Pathology),  nine 
months  ; Practice  of  Medicine,  six  months  ; Clinical  Medicine, 
nine  months  ; Principles  and  Practice  of  Surgery,  six  months  ; 
Clinical  Surgery,  nine  months  ; Midwifery,  three  months  ; 
Gynaecology,  one  course  of  not  less  than  13  meetings  ; 
Diseases  of  Children,  one  course  of  Dot  less  than  13  meet- 
ings. Medical  Jurisprudence  and  Public  Health,  three 
months.  The  certified  attendance  on  lectures,  demonstra- 
tions, and  practical  work  must  not  be  less  than  three-fourths 
of  the  total  number  of  roll-calls.  Every  student  undergoes 
a course  of  Practical  Midwifery,  but  before  attending  at 
labours  he  is  required  to  attend  a course  of  lectures  on 
Surgery  and  Midwifery  and  to  hold  the  offices  of  Clinical 
Medical  Clerk  and  Surgical  Dresser.  He  must  also  attend  for 
two  and  a half  months  instruction  in  Practical  Pharmacy  ; the 
certificate  to  be  signed  by  the  teacher,  who  must  be  a member 
of  the  Pharmaceutical  Society  of  Great  Britain,  or  the 
superintendent  of  the  laboratory  of  a public  hospital  or  dis- 
pensary, or  a registered  practitioner  who  dispenses  medicines 
to  his  patients,  or  a teacher  of  a class  of  Practical  Pharmacy. 

The  student  must  attend  for  27  months  the  Medical 
and  Surgical  practice  of  a public  general  hospital  contain- 
ing on  an  average  at  least  80  patients  available  for 
clinical  instruction  and  possessing  distinct  staffs  of  phy- 
sicians and  of  surgeons.  He  must  act  as  Surgical  Dresser  and 
Medical  Clinical  Clerk  for  not  less  than  six  months  in  the 
wards  in  each  case,  and  receive  practical  instruction  in 
administration  of  ansesthetics.  He  must  attend  for  six 
months  the  practice  of  a public  dispensary  especially  re- 
cognised by  any  of  the  above  authorities,  or  the  out- 
patient practice  of  a recognised  general  hospital  or  act  for 
six  months  as  pupil  to  a registered  practitioner  who  either 
holds  such  a public  appointment,  or  has  such  opportunities 
of  imparting  practical  knowledge  as  shall  be  satisfactory  to 
the  cooperating  authorities ; this  attendance  should  be 
made  after  the  student  has  passed  the  First  and  Second 
examinations. 

Candidates,  are  also  required  to  attend  the  following 
courses  : Diseases  and  Injuries  of  the  Eye,  three  months  ; 
Insanity,  three  months;  Infectious  Diseases,  three  months; 
Gynaecology,  three  months  ; Diseases  of  Children,  three 
months. 

The  curriculum  lasts  for  five  years,  the  fifth  year  being 
devoted  to  clinical  work. 

There  are  four  professional  examinations  : — 

First  Examination  includes  Physics,  Chemistry,  and 
Elementary  Biology. 

Second  Examination  includes  Anatomy  and  Physiology 
and  Histology  ; and  candidates  may  be  admitted  to  this 
examination  at  the  end  of  the  second  year  of  medical  study. 


386  Thk  Lancet,] 


UMVERSITY  OF  DUBLIN. 


[August  30,  1919 


Third  Examination  includes  Pathology  and  Materia  Medica 
with  Pharmacology. 

Final  Examination.  -The  Final  examination  shall  not  be 
taken  earlier  than  the  end  of  the  fifth  year  of  study  and  shall 
embrace  the  following  subjects  : — Medicine,  including  Thera- 
peutics, Medical  Anatomy,  and  Clinical  Medicine  ; Surgery, 
including  Surgical  Anatomy,  Clinical  Surgery,  and  Diseases 
and  Injuries  of  the  Eye  ; Midwifery  and  Diseases  of 
Women  ; and,  if  not  passed  previously,  Medical  Juris- 
prudence and  Public  Health,  but  it  is  optional  to  candi- 
dates who  have  passed  the  Third  Examination  to  be 
admitted  to  the  subject  of  Medical  Jurisprudence  and 
Public  Health  on  lodging  certificates  of  having  attended 
the  necessary  course  in  that  subject  at  any  time  ; but 
the  subjects  of  Medicine,  Surgery,  and  Midwifery  shall 
be  taken  together  at  any  time  after  the  end  of  the  fifth 
Winter  Session,  provided  that  a period  of  24  months  has 
elapsed  since  passing  the  Second  Examination.  All  candi- 
dates shall  be  subjected,  in  addition  to  the  written  and 
oral  examinations,  to  clinical  examinations  in  Medicine  and 
Surgery,  which  shall  include  the  Examination  of  Patients, 
Physical  Diagnosis,  the  Clinical  use  of  the  Microscope, 
Examination  of  the  Urine  and  Urinary  Deposits,  Surgical 
Appliances,  Bandages,  Surface  Markings,  &c.  The  fees 
payable  for  the  Final  Examination  shall  be— for  the  whole 
examination,  £15,  for  re-entry  after  rejection,  £5,  and  for 
the  subjects  of  Medical  Jurisprudence  and  Public  Health  when 
taken  separately,  £5  with  £3  for  re-entry  in  that  subject. 

There  are  four  periods  of  examination  annually  during  the 
present  reconstruction  period,  two  in  Edinburgh  and  two  in 
Glasgow,  in  1919-20.  The  Registrar  in  Edinburgh  is  Mr. 
D.  L.  Eadie,  49,  Lauriston-place,  and  the  Registrar  in 
Glasgow,  Mr.  Waller  Hurst,  242,  St.  Vincent-street,  to 
whom  fees  and  certificates  must  be  sent  for  the  respective 
examinations,  and  from  whom  further  particulars  concerning 
fees  can  be  obtained. 


ROYAL  COLLEGE  OF  PHYSICIANS  OF  EDINBURGH: 
THE  MEMBERSHIP  AND  FELLOWSHIP. 

In  addition  to  the  diplomas  granted  by  the  Scottish  Con- 
joint Bo  xrd  the  Royal  College  of  Physicians  grants  its 
Single  Licence  to  candidates  already  possessing  legal  quali- 
fications for  professional  practice. 

The  Royal  College  of  Physicians  of  Edinburgh  grants  a 
Membership  and  a Fellowship. 

Membership. — A candidate,  who  must  be  a Licentiate 
of  a British  or  Irish  College  of  Physicians,  or  a graduate 
in  medicine  of  a University  within  the  British  E npire. 
approved  by  the  Council  and  24  years  of  age,  is  examined 
in  medicine,  therapeutics,  and  in  any  branch  of  the  depart- 
ments of  medicine  specially  professed,  such  as  general 
pathology,  psychology,  public  health,  obstetrics,  gynaecology, 
diseases  of  childreu,  tropical  medicine,  or  medical  juris- 
prudence. The  fee  for  the  Membership  is  £36  15.''.. 
15  guineas  of  which  will  be  returned  to  any  successful 
candidate  who  was  already  a Licentiate  of  the  College  at 
the  time  of  qualifying  for  the  Membership. 

Fellowship. — The  Fellows  are  selected  from  the  ranks  of 
the  Members.  The  fee  is  £64  18s. 


ROYAL  COLLEGE  OF  SURGEONS  OF  EDINBURGH: 
THE  FELLOWSHIP. 

The  Royal  College  of  Surgeons  of  Edinburgh  also  admits 
to  the  examination  for  its  Single  Licence  any  candidates 
who  hold  a Diploma  in  Medicine  of  any  British,  Indian, 
or  Colonial  university  or  of  any  British  or  Colonial  College 
of  Physicians,  or  of  the  Society  of  Apothecaries  of  London 
or  Apothecaries’  Hall,  Dublin,  granted  under  the  provisions 
of  the  Medical  Act,  1886,  whose  preliminary  examination 
and  course  of  professional  study  is  proved  to  be  sufficient  to 
fulfil  the  requirements  of  the  College,  or  to  those  who  have 
passed  a full  examination  for  any  of  the  above.  Female 
practitioners  are  now  admitted  to  the  Licence  of  the  College 
but  not  to  the  Fellowship,  and  the  regulations  for  the 
Licence  apply  to  practitioners  of  either  sex. 

The  Royal  College  of  Surgeons  of  Edinburgh  grants  a 
diploma  of  Fellowship  after  examination  to  the  holders  of 
the  surgical  degrees  of  diplomas  of  such  British  examining 
bodies,  as  w’ell  as  of  the  holders  of  such  surgical  degrees 
of  the  Universities  of  Canada,  Australia,  New  Zealand,  and 
the  Indian  Empire  as  are  recognised  by  the  College. 


The  Fellowship.  — Candidates  for  the  examination  must 
be  25  years  of  age  and  must  have  been  engaged  in 
practice  for  at  least  two  years.  The  examination  is  of 
a practical  nature,  parily  written  and  partly  viva  voce, 
and  must  include  surgery  and  surgical  anatomy,  opera- 
tive surgery,  and  clinical  practice.  One  optional  subject 
must  also  be  taken,  the  range  of  these  specialisms 
covering  nearly  every  branch  of  medicine.  The  fee 
to  be  paid  on  entering  for  examination  for  Fellowship 
is  £45,  £10  of  which  is  remitted  to  those  who  already 
hold  the  Licentiatesbip  of  the  College.  Candidates  re- 
jected at  the  examination  obtain  repayment  of  fee  less  £10 
retained  for  examination  expenses.  One  month’s  notice  of 
intention  to  present  himself  for  examination  must  be  given 
by  the  candidate  to  Mr.  D.  L.  Eadie,  49,  Lauriston-place, 
Edinburgh,  clerk  to  the  College,  together  wdth  credentials 
signed  by  two  Fellows  of  the  College,  one  of  whom  must  be 
a resident  in  Edinburgh,  unless  a special  application,  with 
testimonials,  be  made  to  the  President  and  the  Council  of 
the  College.  


THE  ROYAL  FACULTY  OF  PHYSICIANS  AND 
SURGEONS  OF  GLASGOW. 

Like  the  preceding  corporations,  the  Royal  Faculty  of 
Physicians  and  Surgeons  of  Glasgow  grants  a Fellowship  and 
a Licence  to  be  held  as  separate  qualifications. 

Fellowship. — The  Fellowship  of  the  Faculty  is  granted 
after  examination  in  medicine  or  surgery,  together  witluan 
optional  subject,  which  may  be  anatomy  or  physiology  or  be 
selected  from  any  special  branch  of  medicine  or  surgery. 
14  days’  notice  must  be  given  by  the  candidate  of  his 
intention  to  present  himself  to  Mr.  Walter  Hurst,  the  Faculty 
Hall,  242,  St.  Vincent-street,  Glasgow.  The  fee  for  the  Fellow- 
ship is  £30,  £10  of  which  sum  are  returned  to  any  successful 
candidate  who  already  holds  the  Licence  of  the  Faculty.  An 
additional  sum  of  £20  is  required  in  the  case  of  candidates 
resident  within  seven  miles  of  Glasgow.  In  certain  circum- 
stances Fellows  may  be  elected  as  a mark  of  distinction. 

Licence. — The  Licence  of  the  Royal  Faculty  is  granted  as 
a separate  qualification  to  qualified  practitioners  in  Medicine 
after  examination  in  surgery,  including  surgical  anatomy 
and  clinical  surgery.  The  fee  is  15  guineas. 


SCOTTISH  PROVINCIAL  ANCILLARY  SCHOOLS  AND 
HOSPITALS. 

The  hospitals  which  are  recognised  by  the  Scottish  Con- 
joint Board,  as  places  where  professional  study  Tor  their 
diplomas  can  be  pursued  are  all  those  institutions  which 
feed  the  medical  faculties  of  the  universities.  In  addition 
the  Scottish  Boards  recognise  • all  the  places  which  are 
recognised  by  the  English  Conjoint  Board  (see  p.  379) 
and  the  Irish  Conjoint  Board  (see  p.  391). 


III.— IRELAND. 
THE  UNIVERSITIES. 


UNIVERSITY  OF  DUBLIN,  TRINITY  COLLEGE 
(SCHOOL  OF  PHYSIC). 

Matriculation. — In  order  to  join  the  School  of  Physic 
students  pass  a matriculation  examination.  University 
students  take  the  Entrance  of  Trinity  College  and  a 
Junior  Freshman  Term  or  a special  Medical  Preliminary ; 
Extern  Students,  any  examination  recognised  by  the  General 
Medical  Council.  The  winter  courses  begin  on  Oct.  1st. 

Degrees  in  Medicine  (MB.),  Surgery  (B.Ch.),  and 
Midwifery  (B.A.O.). — Candidates  for  these  degrees  must  be 
of  B.A.  standing  and  must  be  for  at  least  five  academic 
years  on  the  books  of  the  Medical  School,  reckoned  from 
the  date  of  matriculation.  The  Arts  course  may  be  taken 
concurrently  with  the  Medical  course,  and  the  B.  A.  degree 
need  not  be  taken  before  the  final  medical  examinations, 
but  the  Medical  degrees  are  not  conferred  without  the 
Arts  degree.  The  following  courses  must  be  attended : — 
(1)  Lectures — Systematic.  Descriptive  and  Applied  Anatomy, 
Chemistry  and  Practical  Chemistry,  Surgery  and  Opera- 
tive Surgery,  Histology,  Botany,  Zoology,  Physics  and 
Practical  Physics,  Physiology  and  Practical  Physiology, 
Practice  of  Medicine,  Midwifery,  Pathology,  Materia 


The  Lancet,] 


THE  NATIONAL  UNIVERSITY  OF  IRELAND. 


[August  30,  1919  3^7 


Mediea  and  Therapeutics,  Medical  Jurisprudence  and 
Hygiene  ; (2)  three  courses  of  nine  months’  attendance 
on  the  Clinical  Lectures  of  Sir  Patrick  Dun’s  or  other 
recognised  Hospital  ; (3)  Practical  Vaccination,  one 

month’s  instruction  ; (4)  Mental  Disease,  three  months  ; 
(5)  Practical  Midwifery  with  Clinical  Lectures,  including 
not  less  than  30  cases,  six  months  ; (6)  Ophthalmic 

Surgery,  three  months.  Three  groups  of  examinations 
have  to  be  passed.  Preliminary  Scientific  Examina- 
tion, including  Physics  and  Chemistry,  Botany,  and 
Zoology.  The  Intermediate  Medical.  Part  I.,  including 
Anatomy  and  Physiology.  The  Intermediate  Medical,  Part  II., 
including  Applied  Anatomy  and  Applied  Physiology  ; and 
the  Final  Examination,  which  is  divided  into  Part  I.,  Materia 
Mediea,  Hygiene  and  Jurisprudence,  and  Pathology  ; and 
Part  II.,  Medicine,  including  Clinical,  Surgery,  Midwifery, 
Gynaecology,  Mental  Diseases,  Operations,  and  Clinical 
Ophthalmology.  Part  I.  may  be  passed  in  the  fourth  year 
and  Part  II.  completed  at  the  end  of  the  fifth  year. 

Doctor  in  Medicine. — A Doctor  in  Medicine  must  have 
passed  all  the  qualifying  examinations  and  must  be  a B.A. 
of  three  years’  standing.  He  must  also  read  a thesis  before 
the  Regius  Professor  of  Physic. 

Master  in  Surgery. — A Master  in  Surgery  must  be  a 
Bachelor  in  Surgery  of  the  University  of  Dublin  of  not 
less  than  three  years’  standing,  and  must  produce  satis- 
factory evidence  of  having  been  engaged  for  not  less  than 
two  years  from  the  date  of  his  registration  in  the  study,  or 
study  and  practice,  of  his  profession.  He  must  then  pass 
a special  examination. 

Master  in  Obstetric  Science. — A Master  in  Obstetric 
Science  must  be  a Bachelor  of  two  years’  standing  and 
produce  evidence  of  having  been  engaged  in  the  study  of 
Obstetric  Medicine  and  Surgery  during  two  years.  He  is 
then  required  to  pass  a special  examination. 

Diploma  in  Gynceculogy  and  Obstetrics. — A post-graduate 
is  conferred  upon  registered  medical  practitioners  who  take 
a six  months’  course  at  the  Rotunda  Hospital  and  a six 
months’  course  in  Trinity  College  when  they  have  passed  a 
special  examination. 

Baobelor  in  Dental  Science  and  Master  in  Dental  Science.— 
The  regulations  under  which  these  degrees  are  awarded  can 
be  obtained  by  application  to  the  Registrar  of  the  School 
of  Physic. 

All  Degrees  and  Courses  of  Instruction  are  open  to  women 
students. 

Clinical  instruction. — The  hospital  facilities  for  clinical 
instruction  available  in  Dublin  will  be  described  below. 


THE  NATIONAL  UNIVERSITY  OF  IRELAND. 

Matriculation. — All  students  intending  to  proceed  to  the 
medical  degree  of  the  University  of  Ireland  must  pass  a 
matriculation  examination,  the  examination  taking  place 
in  June  and  September  in  Dublin  and  at  certain  local  centres. 
All  students  must  pass  in  five  subjects  (three  of  which 
must  be  Irish,  English,  and  mathematics).  All  students 
must  pass  in  Irish 1 except  students  not  born  in 
Ireland,  and  other  students  whose  home  residence  shall 
have  been  outside  Ireland  during  the  three  years  imme- 
diately preceding  their  matriculation  ; but  all  such 
students  will  be  expected  to  attend  a course  of  instruc- 
tion in  Irish  Literature  and  History  prior  to  obtaining 
any  degree  in  the  University.  The  following  are 

the  subjects  for  examination  : — 1.  Irish.  2.  Latin  or 
Greek.  3.  French,  German,  Italian,  Spanish,  Portuguese, 
Welsh,  or  any  ofher  language  approved  by  the  Senate. 
4.  English.  5.  Mathematics.  6.  Latin,  Greek,  French, 


1 The  Senate  has  directed  that  candidates  who  presented  themselves 
for  the  Matriculation  Examination  and  who  passed  in  certain  subjects 
In  1912  or  any  previous  year,  may,  when  presenting  themselves  in  1920, 
in  the  remaining  subjects  necessary  to  complete  the  examination,  select 
such  completing  subjects  in  accordance  with  the  regulations  as  to 
groups  of  subjects  which  were  in  force  in  1912.  Such  candidates  will 
not  be  obliged  to  present  themselves  for  examination  in  Irish.  Such 
candidates,  however,  while  they  may  select  the  completing  subjects  as 
abwe,  must  present  themselves  for  examination  in  these  subjects  on 
the  courses  prescribed  in  each  by  the  Regulations  in  1920.  Candidates 
who  presented  themselves  for  the  Matriculation  Examination,  and  who 
passed  in  certain  subjects  in  1913,  when  presenting  themselves  in  1920 
in  the  remaining  subjects  necessary  to  complete  the  examination, 
must  select  such  completing  subjects  in  accordance  with  the  regula- 
tions as  to  groups  of  subjects  which  were  in  force  in  1913.  The  courses 
in  such  completing  subjects  will  be  the  courses  prescribed  in  those 
subjects  respectively  for  1920. 


German,  Welsh,  Spanish,  Italian,  Portuguese,  or  any 
other  modern  language  approved  by  the  Senate, 
History  and  Geography  (as  a ; composite  subject),  Natural 
Philosophy,  or  Physics  as  an  alternative,  Chemistry, 
Botany,  and  for  women  candidates  only,  Physiology,  and 
Hygiene.  Candidates  who  under  the  regulations  are 
exempted  from  the  necessity  of  presenting  Irish  as  one 
of  their  subjects  may  present  as  their  fifth  subject  either 
a second  language  or  a second  science  subject.  Students 
entering  for  degrees  in  Medicine  or  Dentistry,  if  already 
registered  by  the  General  Medical  Council,  may  be  accepted 
as  matriculated  students  of  the  Faculty  of  Medicine  on 
passing  the  matriculation  examination  in  any  faculty  of  the 
University. 

The  medical  degrees  granted  are  r — 

M.  B„  B.  Oh. , and  B.A.  O ; and  M.  D. , M.  Oh. , and  M.A.  O.— 
Printed  forms  ot  application  for  admission  to  any  medical 
examination  may  be  had  from  “The  Registrar,  The  National 
University  of  Ireland,  Dublin.” 

The  Constituent  Colleges  of  the  National  University  of 
Ireland  at  which  the  full  curriculum  for  medical  degrees  can 
be  obtained  are  University  College,  Dublin  ; University 
College,  Cork  ; and  University  College,  Galway. 


University  College,  Dublin. — The  University  and 
the  College  were  created  by  the  Irish  University  Act, 
1908,  and  by  Charters  issued  in  December,  1908.  Former 
students  of  the  Cecilia-street  School  of  Medicine  who 
graduated  in  the  Royal  University  may  become  graduate 
members  of  the  new  College.  The  constitution  of  the 
College,  like  that  of  the  Constituent  Colleges  of  Cork  and 
Galway,  provides  for  a governing  body,  an  academic  council 
consisting  of  professors  and  coopted  lecturers,  a bodv  of 
graduate  members,  and  a body  of  student  members  matri- 
culated in  the  University.  The  first  professors  and  lecturers 
were  appointed  by  the  Dublin  Commissioners  Irish  Universities 
Act,  1908. 

Matriculation. — Almost  all  the  students  of  the  College 
are  matriculated  students  of  the  National  University  of 
Ireland. 

University  Examinations  in  Medicine. — The  First  Examina- 
tion includes  Physics,  Chemistry.  Botany,  and  Zoology. 
The  examination  may  be  taken  in  two  parts:  Part  I., 
Physics  and  Chemistry  ; Part  II.,  Botany  and  Zoology. 
Honours  may  be  obtained  only  when  both  parts  are  taken  as 
one  examination.  The  Second  Examination  includes 
Anatomy  and  Physiology.  Both  must  be  passed  at  the  same 
time.  The  Third  Examination  includes  Pathology,  Medical 
Jurisprudence  and  Hygiene,  and  Materia  Mediea. 

Degrees  of  M.B.,  B.  Ch.,  and  B.A.  O. — The  Examination  in 
Medicine,  Midwifery,  Surgery,  and  Ophthalmology  includes 
both  the  theoretical  and  the  clinical  branches.  No  student 
can  enter  for  the  M.B.,  B.Ch. , or  B.A.O.  until  the  end  of  the 
fifth  year  when  the  curriculum  has  been  completed.  The 
course  of  study  is  as  follows  : — First  year.— Winter : 
Anatomy  and  Practical  Anatomy  (required  for  the  Second 
Examination),  Chemistry,  Practical  Chemistry,  and  Experi- 
mental Physics  (with  Laboratory  Course).  Summer  : 
Zoology,  Practical  Zoology,  Botany,  and  Practical  Botany. 
Second  year. — Winter  : Anatomy,  Practical  Anatomy, 

Physiology,  and  Practical  Physiology  (physical  and 
chemical).  Summer  : Anatomy,  Practical  Anatomy, 

Physiology,  and  Practical  Histology.  Third  year. — 

Winter  : Pathology,  Surgery  or  Medicine,  Hygiene, 

Medical  Jurisprudence,  and  Practical  Pharmacy.  Summer: 
Materia  Mediea  and  Therapeutics,  and  Practical  Patho- 
logy. Candidates  are  also  required  to  attend  a General 
Hospital  for  nine  months  (winter  and  summer).  Fourth 
year,  or  fourth  and  fifth  years. — Winter  : Medicine  or 
Surgery  (the  subject  to  be  that  not  taken  in  the  third  year), 
and  Midwifery  and  Gynaecology.  Summer : Operative 

Surgery,  Applied  Anatomy,  and  Ophthalmology  and  Otology. 
Candidates  are  also  required  to  attend  a General  Hospital 
for  nine  months  (winter  and  summer),  and  to  take  instruc- 
tion in  Vaccination,  and  three  months  Fever  Hospital.  Fifth 
year. — If  the  Academic  (C  dlegiate)  Courses  are  taken  as 
above,  the  Courses  of  the  fifth  year  will  be  the  following  : 
Hospital  Attendance,  General  Hospital,  nine  months  ; 
Clinical  Ophthalmology  and  Otology,  three  months;  Practical 
Midwifery  and  Gynaecology,  six  months;  Mental  Diseases, 
to  be  attended  at  a Lunatic  Asylum,  three  months.  (Note. — 

I Practical  Midwifery  and  Gynaecology  may  be  taken  in 


388  Thb  Lanoet,] 


THE  NATIONAL  UNIVERSITY  OF  IRELAND. 


[August  30, 1919 


the  fourth  year  after  the  Systematic  Course  of  Midwifery 
but  it  must  not  be  taken  concurrently  with  the  period  of 
attendance  at  Fever  Hospital.)  The  degree  of  M.D.  may  be 
obtained  either  by  examination  or  on  published  work. 

lees. — The  fees  for  Courses  are  similar  to  those  of  the  other 
Dublin  Medical  Schools. 

Information  concerning  these,  and  the  numerous  scholar- 
ships and  exhibitions  of  the  College  can  be  obtained  from 
the  Dean  of  the  Faculty,  Professor  E.  P.  McLoughlin. 

University  College,  Cork  : the  School  of  Medicine. 
— The  building  is  provided  with  a very  large,  well-ventilated 
dissecting  room  supplied  with  electric  light,  with  physio- 
logical, toxicological,  pathological,  and  pharmaceutical 
laboratories,  materia  medica,  anatomical  and  pathological 
museums,  as  well  as  a collection  of  surgical  and  obstetrical 
instruments  and  appliances.  There  are  well-appointed 
physical,  chemical,  and  biological  laboratories,  and  a large 
natural  history  museum  in  the  adjoining  building,  and  part 
of  the  College  ground  is  laid  out  as  a botanical  garden. 
The  plant  houses  are  well  filled  with  plants  and  are  open  to 
the  students  in  the  class  of  Botany.  The  Library  contains 
over  50,000  volumes  and  is  open  daily  during  term  time  to 
students.  The  Medical  Museum  occupies  a large  room 
erected  at  the  northern  end  of  the  medical  buildings.  There 
are  Students’  Clubs  for  men  and  women  students  of  the 
College  and  various  athletic  clubs,  the  last  of  these  holding  a 
public  meeting  once  in  each  year  in  the  Mardyke  grounds. 

All  students  who  have  been  admitted  as  matriculated 
students  are  required  to  attend  before  the  President  and 
sign  the  Roll  of  Matriculated  Students.  Students  who  may  be 
candidates  for  degrees  in  the  National  University  of  Ireland 
must  have  passed  the  Matriculation  Examination  of  that 
University  or  other  recognised  examination,  and  medical 
students  must  have  passed  a preliminary  examination 
recognised  by  the  General  Medical  Council.  Candidates 
will  be  examined  in  Irish,  Greek,  or  French  or  German, 
Latin,  History,  Geography,  English,  and  Mathematics. 

Admission  of  Medical  Students. — Students  in  the  Faculty 
of  Medicine  who  have  passed  the  First  Professional 
Examination  of  the  Conjoint  Examinations  of  the  Royal 
College  of  Physicians  and  the  Royal  College  of  Surgeons  in 
Ireland,  or  of  the  Royal  College  of  Physicians  and  Royal 
College  of  Surgeons  of  Edinburgh  and  the  Faculty  of 
Physicians  and  Surgeons  of  Glasgow,  or  of  the  Royal  College 
of  Physicians,  London,  and  Royal  College  of  Surgeons, 
England,  may  be  admitted  to  the  rank  of  second-year 
students  on  making  application  to  the  Council  and  sub- 
mitting a certificate  of  having  passed  the  examination. 
Similarly,  students  who  have  passed  the  Second  Professional 
Examination  of  the  same  Colleges  may  be  admitted  to  the 
rank  of  third-year  students  ; and  those  who  have  passed  the 
Third  Professional  Examination  of  the  Dublin  Colleges,  or  of 
the  Edinburgh  Colleges  and  Glasgow  Faculties,  may  be 
admitted  to  the  rank  of  fourth-year  students. 

Besidence  of  St u dents.  — T here  is  no  accommodation  for  the 
residence  of  students  within  the  College,  but  students 
not  living  at  home,  or  with  relatives  or  friends,  sanctioned 
by  their  parents  or  guardians,  are  required  to  live  in  a hostel 
or  in  recognised  lodgings,  a list  of  which  can  be  obtained 
from  the  Secretary.  All  students  are  required  to  register 
their  addresses  each  session  in  the  book  kept  for 
that  purpose  in  the  hall  porter’s  office,  and  to  notify 
immediately  to  the  Registrar  any  change  of  address 
during  the  session.  The  Honan  Hostel,  adjoining  the  College, 
is  equipped  by  private  endowment.  A number  of  sets  of 
rooms,  together  with  recreation  and  common  rooms,  are 
provided  for  lay  students  who  may  desire  to  live  there.  For 
full  particulars  apply  to  the  Warden.  The  Ursuline  Convent, 
Blackrock,  has  a house  of  residence,  quite  separate  from 
their  Secondary  School,  for  Catholic  women  students. 

Clinical  Instruction. — Students  may  attend  the  South 
Infirmary,  Cork  North  Charitable  Infirmary,  the  Mercy 
Hospital,  the  Cork  District  Lunatic  Asylum,  the  Victoria 
Hospital  for  Diseases  of  Women  and  Children,  the  County 
Lying-in  Hospital,  the  Cork  Maternity,  the  Cork  Fever  Hos- 
pital, the  Cork  District  Hospital,  and  the  Cork  Ear,  Eye,  and 
Throat  Hospital. 

Complete  information  with  regard  to  class  fees,  scholar- 
ships, and  prizes  can  be  obtained  from  the  Dean  of  the 
College,  Professor  A.  E.  Moore. 


South  Infirmary  and  County  of  Cork  General  Hospital  (100 
beds).  — Clinical  instruction  is  given  daily  in  the  wards. 
Special  instruction  on  Diseases  of  Women  and  Children 
will  be  given  in  the  special  wards  for  such  cases.  Fee  for 
perpetual  ticket,  £22  1*.  ; for  nine  months,  £9  9s.  ; for  six 
months,  £6  6*.  ; for  three  months,  £3  3s.  Two  resident  pupils 
will  be  appointed  by  competitive  examination.  Honorary 
Secretary : Dr.  N.  I.  Townsend. 

Cork  North  Charitable  Infirmary  and  County  and  City  of 
Cork  General  Hospital  (112  beds). — Clinical  instruction  is 
given  daily  in  the  wards  by  the  physicians  and  surgeons. 
Special  instruction  is  given  to  Junior  Students  on  two  days 
weekly.  Fee  for  perpetual  ticket,  £22  Is.  ; for  12  or  nine 
months,  £9  9s.  ; for  six  months,  £5  5s.  ; and  for  three 
months,  £3  3s.  Two  resident  pupils  are  appointed  quarterly  by 
the  medical  staif.  All  resident  pupils  are  required  to  be  regis- 
tered pupils  of  the  hospital.  There  is  a special  department 
for  treatment  of  the  eye,  ear,  throat,  and  nose,  under  the 
charge  of  Mr.  J.  Bowring  Horgan,  and  a special  dental 
department.  Honorary  Secretary  : Mr.  R.  B.  Dalton.  A 
fully  equipped  Pathological  Department  has  recently  been 
added  to  the  hospital. 

Mercy  Hospital.  — This  hospital  contains  130  beds  for 
medical  and  surgical  cases.  There  is  also  a daily  extern 
for  medical  and  surgical  cases,  as  well  as  for  diseases  of 
the  eye,  ear,  and  throat.  Extern  medical  attendances  for  1917 
and  1918,  10,935  ; surgical  attendances,  2361 ; eye,  ear,  nose, 
and  throat  attendances,  7200  ; intern  patients  1918,  1558. 
Major  operations,  698  ; minor  operations,  643.  Minor 
accidents,  3310.  Total  extern  fiee  attendances,  36,105. 
Two  resident  students.  Honorary  Secretary  to  the  Staff  : 
Dr.  D.  J.  O’Connor. 

Cork  District  Lunatic  Asylum.  — Psychological  Medicine  : 
A course  of  Clinical  Lectures  on  Mental  Disease  and  Allied 
Neuroses  will  be  delivered  in  the  Cork  District  Lunatic 
Asylum  on  Mondays  and  Thursdays,  commencing  the  first 
Thursday  in  May,  by  the  Resident  Medical  Super- 
intendent. All  students  wishing  to  enter  for  the  course  are 
expected  to  attend  at  the  Asylum  at  4 p.m.  on  that 
day.  All  information  may  be  had  at  the  Asylum  from  the 
resident  medical  superintendent. 

Victoria  Hospital  ( Incorporated ) (Cork).— There  are  75 
beds.  Clinical  instruction  on  Diseases  Peculiar  to  Children 
is  given.  The  extern  department  is  open  daily  at  9.30. 

County  and  City  of  Cork  Lying-in  Hospital  (Erinville, 
Western-road  ; founded  1798). — This  hospital  contains  22 
beds,  an  Extern  Midwifery  Department,  Gynaecological 
Department,  Extern  Department  for  Women,  and  Child 
Welfare  Centre.  Fee  for  six  months’  attendance,  including 
clinical  lectures,  £3  3s.  For  further  particulars  apply  to 
Lucy  E.  Smith,  M.D.,  secretary  to  staff. 

Cork  Maternity  (Batchelor’s  Quay). — Three  resident  pupils 
are  taken  into  the  Maternity.  Poor  women  are  attended 
at  their  own  homes.  Clinical  lectures  are  delivered  during 
the  session.  There  is  an  extern  department  for  the  treat- 
ment of  women’s  and  children’s  diseases.  Fee  for  attend- 
ance at  clinical  lectures  and  certificate,  £3  3s.  Honorary 
secretary  to  staff,  Dr.  Henry  Corby. 

Cork  lever  Hospital. — Upwards  of  500  cases  of  various 
forms  of  fever  and  zymotic  disease  are  treated  yearly  in 
this  hospital.  The  Resident  Medical  Officer  gives  instruc- 
tion in  Practical  Pharmacy,  a certificate  of  which  is  neces- 
sary for  the  National  University  and  Colleges  of  Physicians 
and  Surgeons  of  Edinburgh. 

Cork  District  Hospital  (Douglas-road  ; 1200  beds). — 
This  hospital  includes  special  buildings  for  fever  and 
other  infectious  diseases  (100  beds)  ; for  children's  diseases 
(100  beds) ; and  a Lock  hospital,  the  only  one  in  the 
South  of  Ireland  (80  beds).  It  affords  an  extensive  field 
for  the  study  of  all  classes  of  diseases,  acute  and  chronic, 
including  special  departments  for  gynaecology  and  diseases 
of  the  skin  andnervous  system.  The  physicians  and  surgeons 
visit  the  hospitals  every  morning  at  10  o’clock.  Lectures 
and  clinical  instruction  are  given  daily  in  the  wards  by  the 
physiciaus  and  surgeons.  Further  particulars  may  be 
obtained  from  Dr.  W.  E.  Ashley  Cummins.  17,  St.  Patrick’s- 
place,  honorary  secretary,  medical  staff. 

Cork  Eye , Ear , and  Throat  Hospital  (Western-road). — 
This  hospital  is  open  to  student^  attending  the  University 
College  and  others.  Certificates  of  attendance  for  three  or 


Thk  Lancet,] 


QUEEN’S  UNIVERSITY  OF  BELFAST. 


[August  30,  1919  389 


six  months  can  be  obtained.  The  hospital  contains  35  beds. 
Over  4000  cases  are  treated  during  the  year.  A course  of 
Lectures  on  Ophthalmic  Surgery  is  delivered  during  the 
session.  For  further  information  apply  to  Dr.  Arthur 
Sandford,  13,  St.  Patrick’s-place,  Cork. 


University  College,  Galway  : School  of  Medicine. 
— The  College  contains  a well-lighted  and  ventilated  dis- 
secting-room and  an  anatomical  lecture  theatre ; physiological , 
pathological,  pharmaceutical,  chemical,  and  physical  labora- 
tories ; anatomical,  pathological,  gynaecological,  and  materia 
medica  museums ; as  well  as  large  natural  history  and 
geological  museums  and  an  extensive  library  in  which  students 
can  read  and  from  which  they  can  borrow  books.  There 
are  12  Entrance  Scholarsnips,  value  £25  each,  for  which 
Medical  Students  compete  with  other  Students  on  the 
Entrance  Course.  In  the  Second,  Third,  and  Fourth  Years 
three  Scholarships  in  each  year,  value  £25  each,  are  reserved 
for  Medical  Students.  Exhibitions  of  £10  and  £5  are  awarded 
on  results  of  1st,  2nd,  3rd,  and  Degree  Examinations  in 
Medicine.  H.  H.  Stewart  Scholarships  (£10  a year  for 
three  years)  are  awarded  by  the  University  in  Anatomy  and 
Physiology  at  Second  Medical  Examination  amongst  Students 
of  the  three  constituent  Colleges.  Travelling  Studentships 
(£200  a year  for  two  years)  are  offered  by  the  University 
for  competition  amongst  Medical  Graduates  of  the 
three  Colleges  of  not  more  than  two  years’  standing. 
Women  students  are  eligible  for  all  College  and  University 
Degrees,  Distinctions,  and  Prizes.  There  are  extensive 
grounds,  a portion  of  which  is  occupied  by  a Botanic 
Garden  and  a portion  is  at  the  disposal  of  the  College 
Athletic  Union.  There  are  several  student  societies 
in  the  College,  including  a Biological  Society.  There  are 
abundant  facilities  for  research  and  Post-graduate  work 
in  the  Chemistry,  Physiology,  and  Pathology  departments. 
There  are  ample  facilities  for  Women  Students.  Further 
information  can  be  obtained  from  the  Registrar  of  the  College. 

Clinical  Instruction  is  given  in  the  Galway  Hospital  and 
in  the  Galway  Union  and  Fever  Hospitals,  containing  on  an 
average  200  patients. 

Galway  County  Hospital  (62  beds). — Founded  by  Act  of 
Parliament. 

Galway  Union  and  Fever  Hospitals  (150  beds).— Clinical 
instruction  is  given  in  these  hospitals  to  the  Medical  Students 
of  University  College,  Galway.  The  regulations  for  Scholar- 
ships tenable  in  the  C liege,  and  the  regulations  for  degrees 
and  for  courses  can  be  obtained  from  Messrs.  O'Gorman  and 
Co.,  Galway. 


QUEEN’S  UNIVERSITY  OF  BELFAST. 

There  are  six  degrees  in  the  Faculty  of  Medicine  of  the 
University — viz.,  Bachelor  of  Medicine  (M.B.),  Bachelor  of 
Surgery  (B.Ch.),  Bachelor  of  Obstetrics  (B.A.O.),  Doctor  of 
Medicine  (M.D.),  Master  of  Surgery  (M.Ch.),  and  Master  of 
Obstetrics  (M.A.O.).  The  University  also  grants  a Diploma 
in  Public  Health,  particulars  of  which  will  be  found  in  the 
University  Calendar.  The  degrees  of  M.B.,  B.Ch.,  and 
B.A.O.  are  the  primary  degrees  in  the  Faculty  of  Medicine, 
and  are  conferred  at  the  same  time  and  after  the  same  course 
of  study.  No  student  is  admitted  to  the  final  examination  for 
these  degrees  until  he  has  shown  : (1)  that  he  is  a matricu- 
lated student  of  the  University  ; (2)  that  he  has  completed 
the  prescribed  course  of  study  in  the  Faculty  of  Medicine 
extending  over  a period  of  not  less  than  five  academic  years 
from  the  date  of  his  registration  as  a student  of  Medicine 
by  the  General  Council  of  Medical  Education  and  Regis- 
tration of  the  United  Kingdom ; (3)  that  he  has  passed 
the  several  examinations  prescribed  ; (4)  that  he  has 

attended  in  the  University  during  three  academic  years  at 
least  the  courses  of  study  prescribed  for  such  degrees  (the 
Senate  may  accept,  for  not  more  than  two  academic 
years  of  the  required  five,  courses  of  study  pursued  in 
any  other  University  or  School  of  Medicine  approved  by  the 
Senate) ; and  (5)  that  he  has  attained  the  age  of  21  years. 
Every  candidate  for  admission  as  a matriculated  student 
of  the  University  shall  pass  such  Matriculation  Examination 
or  fulfil  such  other  test  of  fitness  as  may  be  prescribed  by 
the  Senate,  which  may  prescribe  the  conditions  under  which 
students  who  have  passed  the  Matriculation  or  Entrance 
Examination  of  any  other  University  or  College  approved  for 


that  purpose  (or  who  have  fulfilled  such  other  test  of  fitness 
as  may  be  prescribed)  may  be  exempted  from  passing  the 
Matriculation  .Examination  of  the  University.  For  informa- 
tion as  to  Scholarships  and  Prizes  inquiry  should  be  made  of 
the  Secretary  of  the  University. 

Primary  Degrees  of  M.D.,  D.Ch.,  B.A.O. — All  can- 
didates for  these  degrees  must  satisfy  the  examiners  in  the 
subjects  of  four  examinations  known  as  the  First,  Second, 
Third,  and  Fourth  Medical  Examinations  respectively. 

Hie  First  Medical  Examination. — The  subjects  of  this 
examination  are  Chemistry  (Inorganic  and  Organic),  Experi- 
mental Physics,  Botany  and  Zoology.  The  examination  will 
be  divided  into  two  parts  which  may  be  taken  separately  : 
I.,  Chemistry  and  Physics  ; II.,  Botany  and  Zoology. 

The  Seoond  Medical  Examination. — The  subjects  are 
Anatomy  and  Practical  Anatomy,  Physiology  and  Practical 
Physiology.  Candidates  who  have  previously  passed  the 
First  Medical  Examination  may  present  themselves  for  this 
examination  at  the  close  of  their  second  year. 

The  Third  Medical  Examination. — The  subjects  are : 
(1)  Pathology  and  Practical  Pathology  ; (2)  Materia 

Medica,  Pharmacology  and  Therapeutics  ; (3)  Medical 
Jurisprudence  ; (4)  Hygiene.  Candidates  who  have  pre- 
viously passed  the  Second  Medical  Examination  may  present 
themselves  for  this  examination  at  the  close  of  the  third 
year.  Attendance  on  a course  in  any  subject  of  the  Third 
Medical  Examination  shall  not  entitle  a student  to  a certifi- 
cate of  attendance  unless  he  has  previously  passed  in  all  the 
subjects  of  the  First  Medical  Examination. 

The  Fourth  Medical  Examination. — The  subjects  are : 
(1)  Medicine  ; (2)  Surgery  ; (3)  Midwifery  ; (4)  Ophthalmo- 
logy and  Otology.  This  examination  may  be  taken  in  two 
parts:  I.,  Systematic;  II.,  Clinical,  Practical  and  Oral. 
Candidates  wh6  have  previously  passed  the  Third  Examina- 
tion may  present  themselves  for  Part  I.  of  the  Fourth 
Examination  at  the  close  of  the  fourth  year,  provided  that 
they  have  fulfilled  the  necessary  requirements  as  to  attend- 
ance, &c.,  on  the  courses  of  instruction  in  the  subjects  of 
examination.  Candidates  who  have  passed  Part  I.  of 
this  examination  may  present  themselves  for  Part  II. 
at  the  close  of  the  fifth  year,  provided  that  they  have 
fulfilled  the  necessary  requirements  as  to  hospital  attend- 
ance on  the  various  clinical  courses  in  the  subjects  of 
examination.  Parts  I.  and  II.  may  be  taken  together  at  the 
close  of  the  fifth  year.  Attendance  on  a course  in  any 
subject  of  the  Fourth  Medical  Examination  shall  not  entitle 
a student  to  a certificate  of  attendance  unless  he  has 
previously  passed  in  all  the  subjects  of  the  Second  Medical 
Examination. 

Degrees  of  M.D.,  M.Ch.,  and  M.  A.  O. — These  degrees 
are  not  conferred  until  the  expiration  of  at  least  three 
academic  years,  or  in  the  case  of  graduates  of  the 
University  in  Arts  or  Science  of  at  least  two  academic 
years,  after  admission  to  the  primary  degrees  in  the 
Faculty  of  Medicine.  Every  candidate  must  show  that  in 
the  interval  he  has  pursued  such  courses  of  study,  or  been 
engaged  in  such  practical  work  as  may  be  prescribed.  These 
degrees  may  be  conferred  by  the  Senate  either  (a)  after 
an  examination,  which  includes  written,  oral,  clinical, 
and  practical  examinations  ; or  (J)  on  the  submission  of  a 
thesis  or  other  evidence  of  original  study  or  research,  to  be 
approved  by  the  Faculty  of  Medicine  after  an  oral  or  other 
examination  of  the  candidate  on  the  subject  thereof. 

The  Medical  School. — The  Donald  Currie  Chemical  Buildings 
contain  a lecture  theatre,  a preparation  room,  a chemical 
museum,  a large  class-room  for  elementary  practical 
chemistry,  laboratories  for  qualitative  and  quantitative 
analysis,  rooms  for  water  and  gas  analysis,  dark  room  for 
photographic  purposes  and  balance  room,  provided  with  all 
modern  appliances.  The  Anatomical  Department  contains 
a large  and  well-lighted  dissecting-room,  a lecture-room, 
a professor’s  and  demonstrator’s  room,  a bone-room,  and  a 
laboratory  for  microscopic  and  photographic  work.  The 
Medical  Museum  is  in  the  same  building.  The  Jaffe 
Laboratories  for  Physiology  comprise  a lecture  theatre, 
laboratories  for  practical  work  in  chemical  physiology,  his- 
tology, and  experimental  physiology,  and  in  addition  small 
private  research  rooms,  including  balance,  galvanometer, 
and  centrifuge  rooms.  The  Musgrave  Pathological  Labo- 
ratory.— In  this  department  opportunity  is  afforded  for 
research  in  pathology  and  bacteriology.  The  department  is 


390  Tub  Lavobt,] 


IRISH  MEDICAL  C JRPORATIONS  GRANTING  DIPLOMAS. 


[August  30,  1919 


in  touch  with  most  of  the  hospitals  in  Belfast,  and  there  is 
an  ample  supply  of  material  for  investigation  by  graduates 
in  morbid  histology,  clinical  pathology,  and  the  bacteriology 
of  infectious  diseases.  A course  in  pathology  or  bacterio- 
logy is  given  to  graduates,  and  members  of  this  class  have 
an  opportunity  of  seeing  the  methods  employed  in  the 
various  investigations  carried  out  in  the  department  for  the 
Public  Health  Committee  of  the  corporation  in  connexion 
with  water-supply,  sewage  disposal,  meat-  and  milk-supply, 
the  diagnosis  of  cases  of  infectious  diseases,  &c.  The 
certificate  issued  to  members  of  the  class  in  bacteriology 
qualifies  for  the  D.P.H.  degree.  The  Pharmaceutical  Labora- 
tory is  fitted  and  equipped  for  the  work  of  practically 
instructing  students  in  the  compounding  and  dispensing  of 
medicines. 

Clinical  instruction. — The  following  institutions  are  recog- 
nised by  the  University  as  affording  proper  opportunities 
for  clinical  instruction  : the  Royal  Victoria  Hospital,  the 
Mater  Infirmorum  Hospital,  the  Union  Hospitals,  the  Belfast 
Hospital  for  Sick  Children,  the  Belfast  Maternity,  the 
Ulster  Hospital  for  Women  and  Children,  the  Ulster  Eye, 
Ear,  and  Throat  Hospital,  the  Belfast  Ophthalmic  Hospital, 
the  Purdysburn  Fever  Hospital,  and  the  Belfast  District 
Lunatic  Asylum. 

The  Roijal  Victoria  Hospital  (300  beds). — Women  students 
are  now  admitted  as  resident  medical  pupils  the  same  as 
men. 

Mater  Infirmorum.  Hospital  (200  beds). — Hoao-a-y  Secre- 
tary Medical  Staff  : Mr.  J.  B.  Moore. 

Belfast  Union.  Infir  man/  and  Hospital  (1700  beds). — 
Clinical  courses  are  given  biannually,  and  Course ior  D.P.H. 
in  Hospital.  Intern  Venereal  Clinic  in  Infirmary  under 
Corporation  Scheme.  Particulars  may  be  obtained  on 
application,  as  to  classes,  to  Dr.  McLiesb. 

Hospital  for  Sick  Children , Queen -street  (52  beds). — 
Hbnorary  Secretary,  Medical  Staff  : John  McCaw,  M.D. 

The  Incorporated  Belfast  Maternity  Hospital,  Townsend- 
street  (32  beds). 

Ulster  Hospital  for  Children  and  Women  (44  beds). 

Bonn  Ulster  Eye,  Ear,  and  Throat  Hospital  (30  beds). 

Belfast  Ophthalmic  Hospital,  Great  Victoria-street  (30 
beds). — Practical  demonstrations  by  the  staff  and  occasional 
clinical  lectures  in  the  subjects  of  Ophthalmology,  Otology, 
and  Laryngology.  Clinical  instruction  is  given  daily.  Fee 
for  three  months  £2  2s. 

Belfast  Fever  Hospitals. — City  Fever  Hospital,  Purdysburn 
(330  beds);  Union  Fever  Hospital  (200  beds).  Clinical 
Classes  are  held  during  the  winter  and  summer  sessions. 
Post-Graduate  (D.P.H.)  Classes  are  also  held. 

Belfast  District  Lunatic  Asylum  (1250  beds). 


IRISH  MEDICAL  CORPORATIONS 
GRANTING  DIPLOMAS. 


ROYAL  COLLEGE  OF  PHYSICIANS  OF  IRELAND. 

The  College  issues  its  Licences  in  Medicine  and  in 
Midwifery  to  practitioners  whose  names  appear  on  the 
Medical  Register  of  the  United  Kingdom. 

The  Licence  in  Medicine.—  The  subjects  of  examination  are : 
Practice  of  Medicine,  Clinical  Medicine,  Pathology,  Medical 
Jurisprudence,  Midwifery,  Hygiene,  and  Therapeutics. 

The  Licence  in  Midwifery . — Candidates  must  produce 
certificates  of  registration.  A registered  medical  prac- 
titioner of  five  years’  standing  may  be  exempted  from  the 
examination  by  printed  questions. 

Ihe  Membership. — Examinations  for  Membership  are  held 
in  February,  June,  and  November.  The  fee  for  the  exa- 
mination is  £21  to  Licentiates  of  the  College,  or  £36  15s. 
to  non-Licentiates.  Further  particulars  can  be  obtained 
from  the  Registrar  of  the  Royal  College  of  Physicians  of 
Ireland,  Kildare-street,  Dublin. 

The  Fellowship. — Fellows  are  elected  by  ballot.  Applicants 
must  have  been  a Member  of  the  College  for  at  least  one 
year  and  must  have  attained  the  age  of  27  years.  There  is  a 
fee  of  £35  in  addition  to  a stamp  duty  of  £25. 


ROYAL  COLLEGE  OF  SURGEONS  IN  IRELAND. 

The  Licence  in  Entry  cry. — A candidate  whose  Dame  is 
entered  either  on  the  Medical  Register  for  the  United 
Kingdom,  the  Colonial  Medical  Register,  or  the  Foreign 
Medical  R ’gister  of  the  year  in  which  he  presents  himself 
for  examination,  and  who  satisfies  the  Council  that  he  has 
passfed  through  a course  of  btudy  and  Examinations 
equivalent  to  those  required  by  the  Regulations  of  the 
Conjoint  Board  of  the  Royal  College  of  Physicians  of  Ireland 
and  the  Royal  College  of  Surgeons  in  Ireland,  preceded  by 
the  passing  cf  ar.  Examination  in  Arts  recognised  by  the 
General  Medical  C mncil,  may,  at  the  discretion  of  the 
Council,  be  admitted  to  the  Examination. 

Candidates  are  examined  in  Surgery,  Clinical  Surgery, 
Operative  Surgery  on  the  subject,  Surgical  Appliances, 
and  Ophthalmic  Surgery. 

Diploma  in  Midwifery. — A diploma  in  Midwifery  is 
granted  after  examination  to  persons  possessing  a registrable 
qualification. 

Fellowship  Examinations. — Candidates  for  the  Fellowship 
shall  make  application  to  the  President  and  Council  to  be 
admitted  to  examination.  They  are  required  to  pass  two 
examinations— Primary  and  Final.  Candidates  may  present 
themselves  for  the  Final  Examination  immediately  after 
passing  the  Primary  part,  provided  they  have  complied  with 
the  necessary  regulations.  The  subjects  for  the  Primary 
Examination  are  (a)  Anatomy,  including  Dissections  ; and 
( h ) Physiology  and  Histology.  The  subjects  for  the  Final 
Examination  are  Surgery,  including  Surgical  Anatomy  and 
Pathology.  For  admission  to  the  Final  Examination  the 
candidate  must  have  passed  the  Primary  Examination,  and 
must  be  a Licentiate  or  Graduate  in  Surgery  of  a university 
or  licensing  body  recognised  by  the  General  Medical  Council ; 
all  such  candidates  must  not  be  less  than  25  years  of  age. 

Further  particulars  a3  to  fees  and  conditions  of  examina- 
tion can  be  obtained  from  the  Registrar  of  the  College, 
Stephen’s-green,  West  Dublin. 


ROYAL  COLLEGE  OF  PHYSICIANS  OF  IRELAND 
AND  ROYAL  COLLEGE  OF  SURGEONS  IN 
IRELAND. 

Every  candidate  for  the  Conjoint  Examinations  of  the 
Colleges  shall  produce  evidence  of  having  before  entering 
on  medical  studies  passed  a Preliminary  Examination  in 
general  education  recognised  by  the  Royal  Colleges.  Each 
candidate  before  receiving  his  diplomas  must  produce  a 
registrar’s  certificate  or  other  satisfactory  evidence  that  he 
has  attained  the  age  of  21  years. 

Preliminary  Examination. — The  subjects  for  examination 
are  identical  with  those  prescribed  for  the  Preliminary 
Examination  by  the  General  Council  of  Medical  Education 
and  Registration. 

Professional  Examinations. — Every  candid  ite  must  pass 
four  Professional  Examinations — at  the  end  of  the  first, 
second,  third,  and  fifth  years  respectively  of  his  professional 
studies.  No  candidate  shall  be  admitted  to  the  Final  or 
Qualifying  Examination  within  three  months  of  his 
rejection  at  the  Final  or  Qualifying  Examination  by  any 
other  licensing  body. 

First  Professional  Examination. — Every  candidate  is 
required,  before  admission  to  the  First  Professional  Exa- 
mination, to  produce  evidence— (1)  of  having  passed  in  the 
subjects  of  the  Preliminary  Examination  ; and  (2)  of  having 
attended  a course  of — («)  lectures  on  Theoretical  Chemistry, 
six  months  ; ( h ) Practical  Chemistry,  three  months  ; (e) 
Biology,  three  months  ; and  ( d ) Physics. 

The  subjects  of  the  First  Professional  Examination  are  the 
following : — 1.  (a)  Chemistry  ; (6)  Physics.  2.  Biology. 
The  fee  for  this  examination  is  £15  15s. 

Second  Professional  Examination. — Candidates  are  not 
admissible  to  this  examination  till  they  have  passed  in  the 
subjects  of  the  First  Professional  Examination,  and  they  mnst 
produce  evidence  of  having  attended  (a)  anatomical  dissec- 
tions, six  months  ; and  Lectures  on  (b)  Anatomy,  si* 
months  ; (c)  Physiology,  six  months  ; (d)  Practical  Physio- 
logy and  Histology,  three  months. 

The  subjects  of  the  Second  Professional  Examination  are 
the  following : — (1)  Anatomy ; and  (2)  Physiology  and 
Histology.  The  fee  for  this  examination  is  £10  10*. 

Third  Professional  Examination. — Every  candidate  is 
required,  before  admission  to  the  Third  Professional  Examina- 


The  Lancet.]  HOSPITALS  RECOGNISED  DY  IRISH  UNIVERSITIES  k CORPORATIONS.  [AUGUST  3D.  1913  :jg  l 


lion,  to  produce  evidence  of  having  passed  the  Second 
Professional  Examination,  and  certificates  of  having  attended 
courses  of  instruction  in  (a)  the  practice  of  a medico- 
chirurgical  hospital  for  nine  months  ; (4)  Pathology — 

(1)  Systematic,  (2)  Practical,  three  months  each ; 
(o)  Materia  Medica,  Pharmacy,  and  Therapeutics,  three 
months;  ( d ) Forensic  Medicine  and  Public  Health,  three 
months.  The  subjects  for  the  Third  Professional  Examina- 
tion are  the  following  : — (1)  Pathology  ; (2)  Materia 
Medica,  Pharmacy,  and  Therapeutics;  (3;  Public  Health  and 
Forensic  Medicine.  The  fee  for  this  examination  is  £9  9$. 

Final  Professional  Examination.  — Before  admission  to  'he 
Final  Examination  candidates  must  have  passed  the  Third 
Professional  Examination  and  produced  evidence  of  having 
attended  in  Division  I.  the  practice  of  a medico-chirurgical 
hospital  for  two  periods  of  nine  months  each  (unless 
such  evidence  has  been  previously  produced  for  admis- 
sion in  Division  II  );  the  practice  of  a recognised  fever 
hospital  or  the  fever  wards  of  a recognised  clinical 
hospital,  three  months  ; clinical  instruction  in  Mental 
Diseases,  one  month  (12  attendances)  ; lectures  on  Medi- 
cine, six  months  at  a recognised  medical  school ; of 
having  performed  the  duties  of  medical  clinical  clerk  in  a 
recognised  hospital  for  three  months  ; of  having  attend,  d a 
course  of  instruction  in  post-mortem  examinations  and 
demonstrations  during  one  session.  In  Division  II.  of  having 
attended  the  practice  of  a medico-chirurgical  hospital  for 
two  periods  of  nine  months  each  (unless  such  evidence 
has  been  previously  produced  for  admission  to  Division  I.); 
clinical  instruction  in  Ophthalmic  and  Aural  Surgery,  three 
months ; lectures  on  Surgery,  six  months  at  a recognised 
medical  school  ; instruction  in  Operative  Surgery,  three 
months  at  a recognised  medical  school ; of  having  performed 
the  duties  of  surgical  dresser  in  a recognised  hospital  for 
three  months  ; of  having  attended  a course  of  instruction 
in  the  practical  administration  of  general  anaesthetics. 
In  Division  III.  of  having  attended  a midwifery  hospital 
or  maternity  and  having  been  present  at  20  labours,  six 
months;  instruction  on  vaccination,  six  attendances  to  be 
certified  by  a public  vaccinator;  lectures  on  midwifery  (in- 
cluding diseases  peculiar  to  women  and  to  new-born  children), 
six  months  at  a recognised  medical  school.  Candidates  are 
recommended  to  present  themselves  in  all  the  subjects  of 
the  Final  Examination  at  one  time,  but  a candidate  at 
or  after  the  end  of  the  fourth  year  may  present  himself 
in  any  one  of  the  Divisions  I.,  II.,  or  III.,  provided  he  has 
completed  his  curriculum  as  far  as  concerns  the  division  in 
which  he  presents  himself.  The  examination  in  at  least  one 
of  the  divisions  must  be  deferred  till  the  end  of  the  fifth  year. 

The  subjects  of  the  Final  Examination  are  : (1)  Medicine, 
including  Fevers,  Mental  Diseases,  and  Diseases  of  Children  ; 

(2)  Surgery,  Operative  and  Ophthalmic  ; and  (3)  Midwifery  and 
Gynaecology,  Vaccination,  and  Diseases  of  New-born  Children. 
The  fee  is  £6  6.«.  Further  particulars  can  be  obtained  from 
Alfred  Miller,  the  Secretary  of  the  Committee  of  Management, 
Royal  College  of  Surgeons,  Stephen’s-greec,  Dublin. 


Royal  College  of  Surgeons  in  Ireland  (Schools 
of  Surgery). — The  schools  of  surgery  are  attached  by 
Charter  to  the  Royal  College  of  Surgeons  and  have 
existed  as  a department  of  the  College  for  over  a century. 
They  are  carried  on  within  the  College  buildings  and  are 
specially  subject  to  the  supervision  and  control  of  the 
Council,  who  are  empowered  to  appoint  and  remove  the 
professors  and  to  regulate  the  methods  of  teaching  pursued. 
The  buildings  have  been  reconstructed,  the  capacity  of  the 
dissecting-room  nearly  trebled,  and  special  pathological, 
bacteriological,  public  health,  and  pharmaceutical  labora- 
tories fitted  with  the  most  approved  appliances  in  order  that 
students  may  have  the  advantage  of  the  most  modern 
methods  of  instruction.  There  are  special  rooms  set 
apart  for  lady  students.  The  entire  building  is  heated  by 
hot-water  pipes  and  lighted  throughout  by  the  electric  light. 
Winter  Session  commences  in  October  ; Summer  Session 
in  April.  Scholarships  and  Prizes  : Carmichael  Scholarship, 
£15  ; Mayne  Scholarship,  £8  ; Stoney  Memorial  gold  medal ; 
Operative  Surgery,  gold  and  silver  medals  ; Barker  Prize, 
£26  5*.  ; H.  Macnaughton- Jones  gold  medal  in  Obstetrics  and 
Gynecology  ; and  class  prizes  and  medals.  Prospectuses  and 
guide  for  medical  students  can  be  obtained  post  free  on  written 
application  to  the  Registrar,  Royal  College  of  Surgeons, 
Stephen’s-green,  W. , Dublin. 


APOTHECARIES’  HALL  OF  IRELAND. 

The  Licence  of  this  Hall  is  granted  to  students  who 
present  certificates  of  having  fully  o<  mpleted  the  course  of 
study  as  laid  down  in  the  curriculum  and  who  pass  the 
necessary  examinations.  The  diploma  of  the  Apothecaries’ 
Hall  of  Ireland  entitles  the  holder  to  be  registered  as  a prac- 
titioner in  medicine,  surgery,  and  midwifery,  with  also  the 
privileges  of  the  Apothecary's  Licence.  There  are  three 
professional  examinai ions,  the  total  fees  for  which  amount  to 
30  guineas.  Women  are  eligible  for  the  diploma. 

There  are  four  examinations — primary,  inti  rmediate, 
Parts  I.  and  II.,  and  final.  They  are  held  three  times  a year, 
in  March,  June,  and  December.  The  ( rimaty  examination 
comprises  biology,  physics,  theoreticaland  practical  chemistry 
(witii  an  examination  at  the  bench).  Candidates  holding 
a Pharmaceutical  licence  are  exempt  from  this  subject. 
Intermediate,  Part  I.,  Anatomy  ar.d  Physiology.  Inter- 
mediate. Part  II..  Pathology,  Medical  Juiisprudence,  and 
Ma' ei ia  Medica  and  Pharmacy.  The  inte  midiste  examina- 
tion compiises  anatomy  ot  the  wholebody  (including  practical 
dissections),  physiology,  practical  histology,  and  materia 
medica.  The  final  examination  comprises  medicine,  surgery, 
and  midwifery. 

Each  candidate  before  receiving  his  diploma  must  produce 
evidence  that  he  has  attained  the  age  of  21  years.  The 
details  of  the  course  of  education  required  and  syllabus  of 
the  examinations  will  be  supplied  on  application  to  the 
Registrar  at  40,  Mary-street,  Dublin. 


HOSPITALS  AFFORDING  PRACTICE  RECOGNISED 
BY  THE  IRISH  UNIVERSITIES  AND 
CORPORATIONS.1 

Adelaide  Hospital,  Peter-street,  Dublin. — Fee  for  nine 
months’  hospital  attendance,  £12  12s.  ; six  months,  £8  8.?. 
Summer,  three  months,  £5  5*\  Two  resident  surgeons  are 
elected  yearly  and  four  resident  pupils  half-yearly.  At  the 
termination  of  the  session  prizes  in  Clinical  Medicine  and 
Surgery  and  in  Dermatology  will  be  awarded. 

Hudson  Scholarship. — In  addition  to  the  junior  prizes  the 
Hudson  Scholarship,  £30  and  a gold  medal,  as  well  as  a 
prize  of  £10,  together  with  a silver  medal,  will  be  awarded 
at  the  end  of  the  session  for  proficiency  in  medicine,  surgery, 
gyntecology,  and  pathology. 

The  certificates  of  attendance  are  recognised  by  all  the 
Universities  and  licensing  bodies  in  the  United  Kingdom. 
Further  particulars  may  be  obtained  from  Dr.  H.  Bewley. 

Coombe  Lying-in  Hospital  and  Guinness  Dispensary 
for.  the  Treatment  of  Diseases  Peculiar  to  Women, 
Dublin.* — This  hospital  contains  nearly  70  beds  and 
consists  of  two  divisions,  one  of  which  is  devoted  to  lying-in 
cases  and  the  other  to  the  treatment  of  diseases  peculiar 
to  women.  The  practice  of  this  hospital  is  one  of  the 
largest  in  Ireland.  Lectures  are  delivered,  practical  in- 
struction given,  and  gynecological  operations  are  per- 
formed in  the  theatres  daily.  There  is  a general  dispensary 
held  daily,  at  which  instruction  is  given  on  the  Diseases  of 
Women  and  Children.  There  is  a special  afternoon  dis- 
pensary held  by  the  Master  and  his  assistants,  at  which 
practical  instruction  in  gynaecology  is  given.  There  is  no  extra 
charge  for  attendance  at  this  dispensary.  There  is  accom- 
modation for  intern  pupils  who  enjoy  exceptional  advantages 
of  acquiring  a thorough  knowledge  of  this  branch  of  their 
profession.  Lady  medical  students  can  reside  in  the 
hospital.  The  residents’ quarters  are  comfortable.  Clinical 
assistants  are  appointed  from  amongst  the  pupils  as  vacancies 
occur.  Certificates  of  attendance  at  this  hospital  are  accepted 
by  all  licensing  bodies.  Fees  : Extern  pupils  for  full  course 
of  six  months,  £8  8.?.  ; three  months,  £4  4*.  Intern  pupils, 
one  month,  £4  4s.  ; each  consecutive  month,  £3  3s.  ; six 
months,  £18  18s.  ; board  and  lodging  in  the  hospital,  25s. 
per  week.  Lady  students,  intern,  one  month,  £4  4s.  ; each 
consecutive  month,  £3  3s.  Registration  fee,  in  advance, 
10s.  6 d.  Students  can  enter  for  attendance  at  any  time, 
but  preference  is  given  to  those  entering  from  the  first  day 
of  the  month.  Further  particulars  may  be  had  on  applica- 
tion to  the  Master  or  the  Registrar  at  the  hospital. 

i This  list  of  the  institutions  recognised  by  the  Conjoint  Board  of  < 
Ireland  is  supplemented  in  the  regulations  of  the  Colleges  by  those 
hospitals  mentioned  as  recognised  institutions  in  Scotland  and  England. 
The  recognised  facilities  for  clinical  instruction  in  Belfast,  Cork,  and 
Galway  have  been  described  in  connexion  with  the  Belfast  and  Natioral 
Universities.  * No  returns. 


392  The  Lanoet,]  HOSPITALS  RECOGNISED  BY  IRISH  UNIVERSITIES  & CORPORATIONS.  [August 30. 1919 


Sir  Patrick  Dun’s  Hospital,  Grand  Canal-street, 
Dublin. — Classes  both  in  Medicine  and  Surgery  are  held  each 
morning  from  9 o’clock  from  Oct.  1st  till  the  end  of  June. 
Special  classes  for  junior  students  will  be  held  in  the  wards 
during  the  months  of  October,  November,  and  December. 
A Resident  Surgeon,  with  salary,  is  appointed  annually.  Six 
Resident  Pupils  are  appointed  each  half-year.  Six  Surgical 
Dressers  and  six  Clinical  Clerks  are  appointed  each  month. 
There  are  facilities  for  women  students. 

Prizes  and  Medals. — Clinical  medals  and  prizes  amounting 
to  about  £15  each  will  be  awarded  in  Medicine  and  in  Surgery 
respectively  in  -accordance  with  the  will  of  the  late  Rev. 
Samuel  Haughton,  M.D.,  S.F.T.C.D.  Candidates  who-fail 
to  obtain  these  medals  and  prizes  will  be  awarded  special 
certificates  in  Medicine  and  in  Surgery  provided  they  show 
sufficient  merit. 

Fees. — Winter  and  summer  session,  £12  12s.  ; winter 
session  (six  months),  £8  8s.  ; and  summer  session  (three 
months),  £5  5 s.  Special  certificate  in  anaesthetics, 

£1  Is.  The  practice  of  this  hospital  is  open  to  all  students, 
and  the  certificates  are  recognised  by  Dublin  University,  the 
National  University  and  Royal  Colleges  of  Surgeons  of 
England,  Ireland,  and  Scotland. 

Further  information  will  be  supplied  by  the  Hon. 
Secretary  to  the  Medical  Board. 

Jervis-street  Hospital,  Dublin. — Founded  1718  ; re- 
built 1886.  130  beds.  A new  out-patient  department  has  been 
completed  and  contains  all  modern  requirements.  Secretary  : 
Mr.  Kieran  O'Dea. 

Mater  Misericordi^e  Hospital,  Dublin.*— This  hospital, 
the  largest  in  Ireland,  containing  345  beds,  is  open  at  all 
hours  for  the  reception  of  accidents  and  urgent  cases.  Clinical 
instruction  will  be  given  by  the  Physicians  and  Surgeons 
at  9 a.m.  daily.  Ophthalmic  Surgery  will  be  taught  in  the 
Special  Wards  and  in  the  Dispensary.  Surgical  Opera- 
tions will  be  performed  daily.  Connected  with  the  hos- 
pital are  extensive  Dispensaries,  which  afford  valuable 
opportunities  for  the  study  of  general  Medical  and  Sur- 
gical Diseases,  and  Accidents.  Instruction  will  be  given 
on  Pathology  and  Bacteriology.  Three  House  Physicians, 
six  House  Surgeons,  and  16  resident  pupils  will  be  elected 
annually.  Dressers  and  Clinical  Clerks  will  also  be  appointed, 
and  certificates  will  be  given  to  those  who  perform  their 
duties  to  the  satisfaction  of  the  staff.  Leonard  Prizes 
will  be  offered  for  competition  annually.  For  further 
particulars  see  prospectus.  Certificates  of  attendance 
upon  this  hospital  are  recognised  by  all  the  Universities 
and  licensing  bodies  in  the  United  Kingdom.  A Private 
Hospital  has  been  opened  for  the  reception  of  Medical  and 
Surgical  cases.  A Training  School  and  a Home  for  Trained 
Nurses  have  been  opened  in  connexion  with  the  Hospital. 

Terms  of  attendance. — Nine  months,  £12  12s.  ; six  winter 
months,  £8  8s.  ; three  summer  months,  £5  5s.  Entries  can 
be  made  with  any  of  the  physicians  or  surgeons,  or  with  the 
Registrar,  Dr.  Martin  Dempsey,  35,  Merrion-square.  A 
prospectus  containing  in  detail  the  arrangements  for  Clinical 
Instruction,  Prizes,  &c.,  may  be  obtained  from  the  Secretary, 
Medical  Board,  Mr.  A.  Blayney,  15,  Merrion-square. 

Meath  Hospital  and  County  Dublin  Infirmary. — 
This  hospital  was  founded  in  1753  and  now  contains  166  beds 
available  for  clinical  teaching.  A building  containing  40  beds 
for  the  isolated  treatment  of  fevers  is  attached  to  the  hospital. 
The  certificates  of  this  hospital  are  recognised  by  all  the  uni- 
versities and  licensing  bodies  of  the  United  Kingdom.  Six 
Medical  Clinical  Clerks  and  12  Surgical  Resident  Pupils  and 
Dressers  are  appointed  every  six  months,  and  House  Surgeons 
and  Clinical  Assistants  are  elected  annually.  A prospectus 
giving  the  complete  arrangements  for  the  coming  session  may* 
be  obtained  from  the  Honorary  Treasurer  of  the  Medical 
Board,  Sir  L.  H.  Ormsby,  92,  Merrion-square,  Dublin. 

Mercer's  Hospital.* — This  hospital,  founded  in  1734,  is 
situated  in  the  centre  of  Dublin,  in  the  immediate  vicinity 
of  the  Schools  of  Surgery  of  the  Royal  College  of  Surgeons, 
the  Catholic  University  School  of  Medicine,  and  within  five 
minutes’  walk  of  Trinity  College.  It  contains  120  beds  for 
medical  and  surgical  cases,  and  arrangements  have  been 
made  with  the  medical  officers  of  Cork-street  Fever  Hospital 
whereby  all  students  of  this  hospital  are  entitled  to  attend 
the  clinical  instruction  of  that  institution  and  become 


* No  returns. 


eligible  for  the  posts  of  Resident  Pupil,  &c.  There  is  a large 
dispensary  for  out-patients.  Students  of  the  hospital  are 
permitted  to  attend  ihe  gynajcological  department,  where 
they  receive  practical  instruction.  There  are  special  wards 
for  the  treatment  and  study  of  children’s  diseases.  During 
the  past  few  years  the  hospital  has  undergone  extensive 
alterations  in  order  to  bring  it  up  to  modern  requirements. 

Appointments. — A House  Surgeon  is  appointed  annually. 
There  are  Five  Resident  Pupils,  and  Clinical  Clerks  and 
Dressers  are  appointed  monthly  from  amongst  the  most 
deserving  membersof  the  class.  Women  stude  n>  s are  admit  ted. 

bees. — Winter,  six  months,  £8  8s.  ; Summer,  three  montns, 

£5  5s.  ; nine  months,  £12  12*. 

For  further  particulars  apply  to  Dr.  Bethel  Solomons, 
Hon.  Sec.,  Medical  Board,  42,  Fitzwilliam-square,  Dublin. 

National  Maternity  Hospital,  Holles-street,  Dublin. — 
Established  1894.  The  Hospital  consists  of  an  Intern 
and  Extern  Maternity,  and  a Dispensary  for  the  treatment 
of  Diseases  of  Women  and  Children.  About  1000  cases  are 
admitted  and  over  300  operations  are  performed  annually. 
Every  facility  is  given  for  the  carrying  out  of  practical  woik. 
Post-graduate  and  special  courses  are  arranged  for  at  any 
time.  Certificates  of  attendance  at  this  hospital  are  recog- 
nised bv  all  the  licensing  bodies.  Terms  (three  months’ 
course)  6 guineas.  Board  25*.  per  week.  Further  particulars 
can  be  obtained  from  the  Masters  : Sir  Andrew  Horne, 

94,  Merrion-square.  Dublin  ; Dr.  Reginald  J.  White, 

23,  Merrion-square,  Dublin  ; or  from  the  Secretary,  Holles- 
street,  Dublin. 

Richmond,  Whitworth,  and  Hardwicke  Hospitals 
(House  of  Industry  Hospitals).  Dublin. — These  hospitals 
contain  330  beds — 130  for  Surgical  cases,  80  for  Medical  cases, 

78  for  Fever  and  other  Epidemic  Diseases,  and  an  Auxiliary 
Wing  of  42  beds  for  sick  soldiers.  A Resident  Phy- 
sician and  a Resident  Surgeon  are  appointed  each  half 
year  and  are  paid  for  their  services.  12  Resident  Clinical  i 
Clerks  are  appointed  each  quarter  and  provided  with  : 
furnished  apartments,  fuel,  &c.  These  appointments  are 
open  not  only  to  advanced  Students  but  also  to  those  who  <| 
are  qualified  in  Medicine  and  Surgery.  The  Dressers  are  i . 
selected  from  among  the  best  qualified  of  the  pupils  without  ■ 
the  payment  of  any  additional  fee.  Women  students  are 
eligible  for  election  as  residents  and  special  apartments 
are  reserved  for  their  use.  For  prospectuses  apply 
to  Mr.  Adams  McConnell.  F.R.C.S.I.,  Hon.  Secretary, 

69,  Fitzwilliam-square,  Dublin.  The  sad  pecuniary  posi- 
tion of  the  House  of  Industry  Hospitals  is  giving  much  ; I 
anxiety  to  the  city  of  Dublin.  It  seems  that  they  will  have 
to  be  closed  unless  the  authorities  can  find  means  to  support  ■ I 
them. 

Rotunda  Hospital,  Dublin. — This  institution  is  the 
largest  combined  gynaecological  and  maternity  hospital  in 
the  British  Empire.  Nearly  4000  confinements  attended 
annually.  Students  can  take  out  their  necessary  gynaeco- 
logical and  midwifery  practical  courses.  Appointments  open 
to  qualified  practitioners  as  Assistant  to  the  Master  and 
Extern  Assistants.  Women  students  can  reside  in  the  j 
hospital  on  terms  similar  to  those  for  men.  For  further  J 
particulars  apply  to  the  Master. 

Royal  City  of  Dublin  Hospital. — Founded  1832  ; 
enlarged  1851 ; rebuilt  1893.  150  beds.  There  is  a special 

wing  for  the  treatment  of  fevers  and  contagious  diseases  j 
founded  by  the  late  Mr.  Drummond.  Secretary  : Mr.  Edw.  B. 
Armstrong. 

Royal  Victoria  Eye  and  Ear  Hospital,  Dublin.—  j 
Established  1844.  Incorporated  1897.  102  beds.  In-patients,  i 
1311  ; out-patients,  9481.  Two  house  surgeons  appointed 
annuallv. 

Dr.  Steevens’  Hospital,  Dublin. — Established  1720.  ; 
250  beds.  Patients,  12,834.  Secretary:  Mr.  R.  J.  Ogden. 

St.  Vincent’s  Hospital  and  Dispensary,  Dublin.  — Estab- 
lished 1834.  200  beds. 


We  have  received  from  the  Deans  and  Secretaries 
of  the  various  centres  the  corrected  lists  of  tbe  teachers  at  the 
schools  and  of  the  medical  staffs  of  the  hospitals  at  which 
clinical  education  is  being  carried  on.  We  take  the  oppor- 
tunity of  thanking  these  officers  for  their  valuable  coopera- 
tion, as  it  enables  us  to  keep  the  lists  revised  for  reference. 
We  hope  to  publish  the  lists  in  an  early  issue  ; they  are  not 
yet  complete. 


Thh  Lancet,] 


THE  FUTURE  OF  THE  MEDICAL  PROFESSION. 


[August  30,  1919  393 


THE  LANCET. 


LONDON:  SATURDAY,  AUGUST  30,  1919. 


The  Future  of  the  Medical 
Profession. 

The  educational  medical  year  opens  in  circum- 
stances so  uncertain,  so  involved,  and  in  many 
directions  so  difficult  for  the  medical  profession, 
that  those  for  whom  the  Students’  Number  is 
primarily  issued  may  be  excused  if  they  can  know 
little  of  their  worldly  prospects.  Indeed,  we  think 
it  is  well  that  this  should  be  so ; for  the  greatest 
driving  force  which  the  medical  student  can  possibly 
possess  is  his  desire  to  get  into  the  service  of 
healing,  whatever  the  conditions  may  be.  The 
best  student  is  he  whose  first  object  is  to  gain 
admission  to  this  service,  influenced  by  the 
certainty  that  he  may  become  a power  for  good, 
and  undeterred  by  the  warnings  of  self-interest. 
We  are  not,  however,  suggesting  that  the  con- 
ditions of  medical  service  are  at  the  moment 
particularly  unpromising,  or  even  ominous,  because 
they  happen  to  be  sharing  in  an  all-pervading 
social  muddle.  The  whole  of  our  advanced  civilisa- 
tion is  in  flux,  and  all  the  world  rings  with  the 
cries  of  reorganisation  and  reconstruction.  In 
every  country  leaders  of  men,  made  to  admit  by 
the  revelations  of  the  war  the  many  weak  joints 
in  their  social  armour,  have  resolved  that  those 
joints  shall  be  mended  or  that  armour  of  a new 
pattern  shall  be  employed.  But  for  the  moment 
there  is  necessarily  more  confusion  than  recon- 
struction, and,  alas  ! more  words  than  deeds.  This 
cannot  be  helped.  The  necessary  qualities  in  these 
days  of  transition  are  hope  and  belief — hope  that 
the  endurance  which  has  carried  us  through  days 
of  trial  will  be  with  us  in  those  of  reac- 
tion, and  belief  that  knowledge  will  triumph 
over  ignorance,  when  inequalities  will  be  righted 
by  a general  sense  of  justice.  For  there  is  only 
a certain  amount  of  happiness  to  go  round.  That 
truism,  brought  home  to  us  by  the  necessity  of 
maintaining  to-day  the  food  control  at  first  insti- 
tuted as  a war  measure,  is  not  sufficiently  remem- 
bered. It  is  an  unfortunate,  though  pardonable, 
fact  that  the  protagonists  of  different  reforms,  in 
single-hearted  intent  to  secure  along  their  own 
lines  the  best  of  everything  for  everybody, 
postulate  the  depriving  many  other  people 
of  things  essential  to  prosperity.  Such  champions 
of  individual  views  forget  that  there  may 
not  be  enough  happiness  to  go  round.  There 
has  to  be  throughout  the  world  an  immense 
amount  of  give-and-take,  or  what  happiness 
that  exists  will  undergo  no  fair  division.  This  is 
universally  true  ; but  medicine  is,  perhaps,  more 
sorely  tried  than  any  vocation  in  the  position  thus 
set  out,  for  medicine  enters  into  all  the  activities 
of  the  world,  epitomises  by  its  exploits  the  most 


poignant  and  permanent  virtues  which  citizens 
can  display  for  the  good  of  others,  and  probes  in 
its  daily  life  the  wants  and  miseries  of  all  sorts 
and  conditions  of  men,  codifying,  evaluating,  and. 
where  possible,  remedying  them.  No  class  like  the 
medical  class  is  so  much  part  and  parcel  of  the 
intimate  lives  of  everybody  else,  and,  as  a conse- 
quence, the  muddles  of  all  the  other  sections  of 
the  population  are  reflected  in  the  life  of  the 
general  practitioner.  The  medical  student  must 
not  at  the  outset  of  his  career  allow  his  equanimity 
to  be  disturbed  by  prophecies  of  ill  in  the  future 
or  by  fables  of  the  resplendent  past.  He  has  chosen 
a high  calling  for  its  own  sake,  and  a high 
calling  it  must  always  be.  It  is  our  belief,  also, 
that  he  has  chosen  a calling  whose  value  to  the 
State  is  in  a better  way  to  receive  public  and 
material  acknowledgment  than  heretofore. 

He  who  joins  our  ranks  to-day  begins  his  medical 
life  under  the  aegis  of  the  Ministry  of  Health— a 
new  Government  Department  designed  at  one  and 
the  same  time  to  provide  for  the  people  an  efficient 
and  orderly  medical  service  and  to  secure  for  the 
members  of  that  service  the  best  means  of  dis- 
charging their  important  functions.  Such  a Govern- 
ment Department  has  long  been  desired,  and  it  is 
impossible  that  its  activities  should  fail  to  operate 
in  the  near  future  to  the  advantage  of  medicine. 
There  is  at  the  present  moment  in  the  country  a 
large  number  of  young  medical  men  at  a loose 
end.  Many  of  them  are  full  of  new  experiences, 
and  they  are  not  finding  opportunities  for  bringing 
those  experiences  to  market  in  such  a way  that- 
they  can  obtain  good  terms.  The  undoubted  hard- 
ship felt  by  many  of  the  medical  men  returning 
from  war  to  practice  must  not  dash  the  spirits  of 
the  recruits  ; and  those  who  in  this  generation  are 
suffering  from  the  helplessness  of  medicine  as  an 
unorganised  calling  should  be  ready  for  united 
action,  which  will  be  of  present  worth,  but  whose- 
benefit  to  future  practitioners  must  be  very  great. 
Some  genuine  form  of  union  is  needed  : some  way 
by  which  we  can  find  out  what  is  the  right  medical 
view  and  what  is  the  proper  public  claim,  and  can 
adjust  these  two  things  to  the  common  satisfac- 
tion. A number  of  administrative  or  subadminis- 
trative  posts,  carrying  regular  salaries,  and  graded 
not  only  in  accordance  with  the  importance  of  the 
responsibilities  incurred,  but  in  accordance  with 
the  time  to  be  taken  up,  will  probably  come  into 
being  soon ; and  it  may  be  presumed  that  many  of 
these  posts  will  be  part-time  offices.  Reorganisation 
of  panel  practice,  which  in  some  directions  is 
imminent,  will  certainly  place  at  the  disposal  of 
young  medical  men  many  chances  of  obtaining  an 
assured  livelihood  and  good  scope  for  general  or 
special  clinical  knowledge.  When  the  panel  practice, 
over  and  above  the  flat-rate  payments  of  subscribers, 
brings  with  it  a part-time  appointment  the  aggregate 
emolument  will  make  the  young  medical  man  far 
better  paid  at  the  opening  of  his  career  than  his 
father  or  his  grandfather  could  ever  have  expected 
to  be,  had  he  joined  our  profession.  Hitherto  the  one 


394  The  Lancet,] 


THE  FUTURE  OF  THE  MEDICAL  PROFESSION. 


[August  30,  1919 


great  and  condero  natory  criticism  of  the  position  has 
been  that  while  the  start  is  so  fair  the  sequel 
holds  no  greater  promise.  In  panel  practice  a 
man  may  make  almost  at  the  outset  what  turns 
out  to  be  his  maximum  income.  It  is  clear 
to  everyone  that  in  the  public  employment 
of  the  future  some  flexible  system  of  pro- 
motion will  have  to  be  laid  down,  so  that  the 
inexperienced  man  does  not  receive  as  much  money 
as  his  senior.  The  income  from  panel  subscribers 
can  only  go  up  if  the  practitioner  increases  the  size 
of  his  panel,  and  while  for  physical  reasons  this 
may  be  an  impossibility  for  public  as  well  as 
scientific  reasons,  it  is  an  undesirable  form  of 
success.  Justifiable  comment  on  the  position  of 
panel  practice  has  always  been  that  the  good  start 
does  not  necessarily  ensure  the  good  future,  and 
if  we  had  come  as  a profession  to  any  common 
conclusion  we  should  realise  that  this  is  the  main 
direction  in  which  panel  practice  requires  reform, 
once  the  question  of  proper  emolument  has  been 
settled.  But  the  meaning  of  all  this  is  that  general 
practice  in  Great  Britain,  as  we  have  hitherto 
understood  it,  is  largely  in  the  melting-pot.  In  a 
few  years’  time  there  may  no  longer  be  a group 
of  family  practitioners  having  sole  charge  of  the 
health  of  certain  districts,  each  of  them  supposed 
to  represent  all  the  medical  and  surgical  wisdom 
required  in  that  district,  save  where  the  Ministry 
of  Health,  as  medical  heir  to  the  Local  Government 
Board  or  the  Board  of  Education,  annexes  a portion 
of  the  burden  and  therefore  of  the  remuneration. 
But  the  destruction  of  the  old-time  practices 
will  go  hand-in-hand  with  added  opportunity, 
both  for  specialisation  and  for  the  passage 
from  the  ranks  of  general  practice  to  those 
of  hospital  surgeon  and  physician  and  scientific 
expert.  For  as  there  will  be  no  segregated  class 
of  general  practitioner,  so  there  will  be  no  segre- 
gated class  of  hospital  officer  and  scientific  expert. 
The  provincial  hospitals,  becoming  centres  of 
scientific  medicine  in  their  localities,  will  be 
officered  by  men  who,  by  fusion  of  duty  with 
the  general  practitioners  of  the  neighbourhood, 
will  make  of  the  whole  of  the  medical  officers  one 
general  scheme  for  the  good  of  the  populace.  The 
medical  men  of  the  district  will  have  beds  in  their 
own  hospitals,  and  will  receive  for  their  patients 
the  consultative  advice  of  their  fellows  and  the 
assistance  supplied  by  a laboratory  of  chemical 
research. 

This  is  rather  a picture  of  the  future,  but  it  is 
not  so  much  an  imaginary  one  as  the  common 
derivative  from  many  schemes  for  reconstruction 
and  reorganisation.  The  new  recruits  of  medicine 
will  be  placed  in  regard  to  these  large  changes  in 
a more  favourable  position  than  the  young  practi- 
tioners immediately  preceding  them,  whose  pro- 
fessional prospects  have  been  so  involved  with  the 
struggles  of  war.  Our  new  students,  having  at 
least  five  years  to  wait  before  material  conditions 
of  life  affect  them,  will  find  many  modifications 
of  practice,  amounting  to  large  revolutions,  quietly 


arranged,  and,  we  hope,  for  the  common  good. 
The  difficulty  in  which  the  young  practitioners 
who  desire  to  settle  down  in  general  practice  are 
now  placed  is  that  they  have  little  evidence  which 
developments  are  inevitable  and  which  will  be  for 
their  material  good.  These  young  men  have  seen 
many  things  and  done  many  things,  and  while  some 
find  the  prospect  of  private  practice  humdrum, 
others  find  it  attractive,  but  the  future  depressingly 
doubtful.  To  these,  as  to  the  students  of  to-day, 
we  suggest  that  it  requires  no  great  spirit 
of  prophecy  to  say  that  all  things  in  the 
social  world  are  working  in  favour  of  a 
properly  treated  and  properly  remunerated 
medical  profession.  The  position  of  medicine 
has  risen  steadily  in  public  esteem,  the  association 
of  medicine  with  every  form  of  domestic,  national, 
and  international  politics  alike  has  become  very 
close,  and  the  demand  for  medical  counsel  in  every 
direction  will  grow  keener.  The  profession  must 
gain  in  strength  under  such  public  support,  and  it 
is  impossible  that  the  question  of  emolument  can 
always  be  decided  in  the  future  against  medical 
interests.  These  things  being  so,  let  us  remember 
that  while  the  medical  life  has  many  charms,  the 
work  to  be  done  is  anxious  and  exacting  beyond  the 
reach  of  adjectives,  while  the  portals  of  entrance 
are  strictly  kept.  For  this  reason,  as  well  as  for 
reasons  connected  with  the  suspension  during  the 
war  of  medical  education,  it  will  be  a long  time  before 
there  is  an  over-supply  of  medical  men.  At  the 
present  moment  young  men  are  sorely  needed  in 
civil  and  in  official  or  service  circles.  The  con- 
ditions of  service  in  the  Army  and  Navy,  Indian 
Medical  Services,  and  the  Colonial  Medical  Service 
have  been  steadily  improved  into  attractive  terms. 
And  just  as  these  services  cannot  very  well 
challenge  each  other  in  rates  of  pay,  so  their  rates 
of  pay  must  influence  civilian  rates  and  maintain  a 
good  standard  all  round.  Thus  young  men  who  are 
choosing  the  medical  profession  as  a career  will  find 
that  they  have  chosen  wisely,  apart  from  the 
delight  and  utility  of  the  life.  They  are 
entering  a profession  which  tends  to  be  well  paid, 
and  the  advent  of  the  Ministry  of  Health  on  the 
scene  must  turn  all  the  circumstances  to  the 
favour  of  medicine  in  the  end,  even  though  we 
have  a trying  time  of  transition.  It  is,  however, 
to  be  regretted  deeply  that  during  this  time  no 
form  of  political  union  among  medical  men  is  really 
effective  to  help  the  profession  in  arriving  at 
proper  terms.  The  British  Medical  Association,  a 
powerful  body,  speaks  for  half  the  medical  pro- 
fession. but  not,  and  very  properly  not,  in  unanimous 
sense  on  many  questions.  The  British  Federation 
of  Medical  and  Allied  Societies  has  a brave  pro- 
gramme, and  if  properly  supported  should  gain  for 
the  medical  profession  a sympathetic  hearing  from 
the  public,  but  the  size  and  good  sense  of  its 
design  must  make  a larger  appeal  to  practitioners 
before  its  influence  can  be  felt.  Some  channel 
through  which  the  current  of  medical  opinion  can 
reach  the  stream  of  public  action  is  needed. 


ROYAL  NAVAL  MEDICAL  SERVICE. 


[August  30.  1919  395 


Thb  Lancet,] 


THE  NAVAL,  MILITARY,  INDIAN,  AND 
AIR  FORCE  MEDICAL  SERVICES. 


The  conditions  of  service  in  the  medical  departments  of 
the  Royal  Navy,  the  Army,  and  Indian  Army  have  consider- 
ably changed  for  the  better  since  (and  previous  to  the  war) 
we  had  occasion  to  give  a resume  of  those  conditions  to  our 
readers.  It  will  be  seen  that  in  some  particulars  our 
account  is  imperfect,  but  formal  approval  has  not  yet  been 
received  for  the  revised  rate  of  pay  in  all  three  services, 
and  in  certain  places  the  conditions  are  open  to  change. 
Common  sense,  however,  tells  us  that  an  attempt  will  be 
made  to  equalise  the  rates  of  pay. 

The  medical  service  of  the  Royal  Air  Force  had,  of  course, 
no  existence  before  the  war.  The  conditions  here  can  only 
be  described  in  general  terms. 

ROYAL  NAVAL  MEDICAL  SERVICE. 

Regulations. 

Following  are  the  Regulations  for  the  entry  of  candidates 
for  commissions  in  the  Medical  Department  of  the  Royal 
Navy.  A copy  of  the  regulations  can  be  obtained,  together 
with  the  form  to  be  filled  up,  on  application  to  the  Medical 
Director-General . 


Every  candidate  for  admission  into  the  Medical  Department  of  the 
Royal  Navy  must  be  not  under  21  nor  over  28  years  of  ago  on  the  day 
of  the  commencement  of  the  competitive  examination.  He  must  pro- 
duce an  extract  from  the  register  of  the  date  of  his  birth ; or,  in 
default,  a declaration  made  before  a magistrate,  from  one  of  his  parents 
or  other  near  relative,  stating  the  date  of  birth. 

He  must  declare  (1)  his  age  and  date  aad  place  of  birth  ; (2)  that  he  is 
of  pure  European  descent  i and  the  son  either  of  natural-born  British 
subjects  ; (3)  that  he  labours  under  no  mental  or  constitutional  disease  or 
weakness,  nor  any  other  imperfection  or  disability  which  may  interfere 
with  the  most  efficient  discharge  of  the  duties  of  a medical  officer  in 
any  climate  ; (4)  that  he  is  ready  to  engage  for  general  service  at  home 
or  abroad,  as  required  ; (5)  whether  he  holds,  or  has  held,  any 
commission  or  appointment  in  the  public  services;  (6)  that  he  is 
registered  under  the  Medical  Act,  giving  the  date  of  his  registration  as  a 
medical  student,  or  of  his  beginning  professional  study  ; and  (7)  whether 
he  has  previously  been  examined  for  entry  in  the  Naval  Service,  and, 
if  so,  when. 

The  certificates  of  registration  and  birth  must  accompany  the  declara- 
tion, which  is  to  be  filled  up  and  returned  as  soon  a9  possible,  addressed 
to  the  Director  General,  Medical  Department,  Admiralty,  London, 
S.W.,  to  permit  of  reference  to  the  candidate’s  medical  school.  The 
Dean  or  other  responsible  authority  of  such  school  will  be  requested  by 
the  Medical  Director-General  to  render  a confidential  report  as  to  the 
candidate’s  character,  conduct,  professional  ability,  and  fitness  to  hold  a 
commission  in  the  Royal  Navy.  The  candidate  will  then  be  interviewed 
by  the  Medical  Director-General,  and  his  physical  fitness  will  be  deter- 
mined by  a board  of  Naval  Medical  Officers.  The  Medical  Director- 
General  will  then  decide  whether  he  maybe  allowed  to  compete.  If 
accepted,  the  candidate  will  be  eligible  to  present  himself  at  the 
entrance  examination,  which  will  be  held  twice  a year.  Notification  of 
the  exact  date  of  this,  as  well  as  the  number  of  commissions  to  be 
competed  for,  will  be  advertised  in  The  Lancet.  Candidates  will  be 
examined  in  the  following  subjects:  (a)  Medicine,  including  Medical 
Pathology  and  Therapeutics  ; and  (6)  Surgery,  ineluding  Surgical  Patho- 
logy and  Clinical  Surgery.  The  examination  will  be  partly  written  and 
partly  practical,  marks  being  allotted  under  the  following  scheme : — 


Medicine. 


Paper  

400 

Clinical 

400 

Oral  

400 

Surgery. 

Paper  ...  400 

Clinical 400 

Oral  400 


Total  1200 


Total  1200 


No  candidate  will  be  considered  eligible  who  obtains  less  than  50  per 
cent,  of  marks  in  each  subject.  The  examination  will  be  held  in  Loudon 
and  will  occupy  four  days. 

The  appointments  announced  for  competition,  will  be  filled  from  the 
list  of  qualified  candidates,  arranged  in  order  of  merit;  but  should  it 
at  any  time  be  considered  expedient  to  grant  Commissions  beyond  those 
periodically  competed  for,  the  Admiralty  have  power  to  admit 
annually  not  more  than  six  candidates,  according  to  requirements, 
specially  recommended  by  the  governing  bodies  of  such  Colonial  Univer- 
sities as  may  be  selected  and  whose  qualifications  are  recognised  by  the 
General  Medical  Council.  Candidates  so  proposed  are  to  be  approved 
by  the  Director-General  of  the  Medical  Department  of  the  Navy. 
Colonial  candidates  will  have  to  pass  a physical  examination  before 
a board  of  Naval  Medical  Officers  in  their  colony,  and  will  be  required  to 
register  their  qualifications  on  arrival  in  England.  They  will  be 
allowed,  if  they  wish  it.  to  compete  at  the  next  examination  for 
entrance  and  take  their  position  according  to  the  order  of  merit ; should 
they  decide  not  to  compete  they  will  be  placed  at  the  bottom  of  the 
list.  It  will,  however,  be  necessary  in  any  case  for  them  to  pass  a 
qualifying  test  at  the  time  of  the  usual  half-yearly  examinations,  when 
they  will  be  required  to  obtain  a minimum  of  50  per  cent,  of  the  total 
marks  in  each  subject.  In  oas«  of  failure  in  this  test  examination  the 
Admiralty  will  not  undertake  to  defray  the  cost  of  the  return  lournev 
to  the  candidate’s  colon v or  «<ther  expanses  thereby  incurred.  A fee  of 
£1  will  have  to  be  paid  by  each  candidate  to  entitle  him  to  take  part  in 
the  competition. 

Candidates  who  have  served  in  the  Officers  Training  Corps,  and  who 
are  in  possession  of  the  certificates  laid  down  in  the  regulations  for 


1 If  any  doubt  should  arise  on  this  question  the  burden  of  clear 
proof  that  he  is  qualified  will  rest  upon  the  candidate  himself. 


that  Corps,  will  he  credited  at  the  entrance  examination  with 
additional  marks  as  follows  : Candidates  in  possession  of  Cert  ificate  A 
will  receive  1 per  cent.,  and  those  who  possess  Certificates  A and  B 
2 per  cent,  of  the  maximum  number  of  marks  allotted. 

A candidate  will  not  be  allowed  to  compete  at  more  than  two 
examinations. 

A candidate  successful  at  the  entrance  examination  will  be  appointed 
as  Acting  Surgeon-Lieutenant  in  the  Royal  Navy  and  will  he  required  to 
pass  through  such  courses  of  instruction  as  t he  Admiralty  may  decide. 
At  the  end  of  the  courses  the  acting  surgeon-lieutenant  will  be  exa- 
mined and  after  he  has  passed  will  bo  given  a commission  as  Surgeon- 
Lieutenant  in  the  Royal  Navy.  The  commission  will  date  from  the  day 
of  passing  the  entrance  examination.  An  acting  surgeon-lieutenant  who 
fails  to  qualify  in  the  above  examination  (i.e. , who  tails  toget50  percent, 
of  marks  in  each  subject  of  the  Greenwich  and  Unslar  courses)  will  be 
allowed  a second  trial  at  the  next  examination,  tl^e  period  between  the 
two  examinations  not  being  counted  as  service  for  either  promotion, 
withdrawal  with  gratuity,  or  retirement  after  20  years’  service,  and 
should  he  qualify  he  will  be  placed  at  the  bottom  of  his  list;  should 
he  again  fail  his  appointment  will  not  be  confirmed  and  he  will  be 
required  to  withdraw. 

A gold  medal,  a silver  medal,  and  three  navy  regulation  pocket  cases 
wil  1 be  awarded  as  prizes  in  connexion  with  these  examinations,  and  the 
gold  medallist  will  have  a distinguishing  mark  afler  his  name  in  the 
Navy  List,  provided  he  obtains  75  percent,  of  the  aggregate  maximum. 

Surgeon  Lieutenants  on  entry  are  only  required  to  provide  them- 
selves with  a regulation  pocket  case  of  instruments.  Acting  Surgeon- 
Lieutenants  need  only  provide  themselves  with  undress  and  mess 
uniforms. 

A candidate,  who  at  the  time  of  passing  the  examination  for  entry 
holds  or  is  about  to  hold  an  appointment  as  Resident  Medical  or 
Surgical  Officer  in  a recognised  civil  hospital,  may  be  allowed  to  serve 
in  such  civil  appointment,  provided  that  tbe  period  of  such  service 
after  the  date  of  entry  into  the  Royal  Navy  does  not  exceed  one  year. 
Pay  from  Naval  funds  will  be  withheld  from  officers  while  thus  serving, 
but  the  time  concerned  will  reckon  for  increase  of  full  and  half  pay 
while  on  the  active  list,  and  retired  pay  or  gratuity  on  retirement  of 
withdrawal ; except  that  no  officer  will  be  allowed  to  retire  on  a gratuity 
until  be  has  completed  four  years’  service,  exclusive  of  the  time  spent 
as  Resident  Medical  or  Surgical  Officer.  The  eligibility  of  this  appoint- 
ment to  count  for  time  will  be  decided  by  the  Medical  Director- 
General. 

The  seniority  of  Surgeon- Lieutenants  on  entry  will  be  determined  by 
the  sum  total  of  the  marks  they  obtain  at  the  London  examination  and 
those  at  the  conclusion  of  their  probationary  peiiod  as  Acting  Surgeon- 
Lieutenant.  Their  names  will  then  be  placed  in  the  official  navy  list. 
Candidates  who  hold,  or  are  about  to  hold,  a post  as  resident  medical  or 
surgical  officer  to  a recognised  civil  hospital  will  retain  the  position  in 
the  list  which  they  obtained  on  entry,  and  when  their  period  of  service 
as  resident  officer  is  over  they  will  join  the  next  Acting  Surgeon-Lieu- 
tenant’s course  and  will  be  required  to  obtain  qualifying  marks. 
Surgeon  Lieutenants  entered  without  competition  will  take  seniority 
next  after  the  last  Surgeon-Lieutenant  entered  at  the  same  time  by 
competition. 

A Naval  Medical  School  has  been  established  at  the  Royal  Naval 
College,  Greenwich.  As  tbe  nucleus  of  an  Instructional  Staff  two 
Surgeon-Commanders  fill  the  posts  of  Professor  of  Bacteriol  gy  and 
Clinical  Pathology  and  Professor  of  Hygiene  The  coime  of  instruc- 
tion for  Acting  Surgeon-Lieutenants  is  six  months  in  duration, 
two  of  which  are  passed  at  Greenwich  in  the  stud v of  Tropical  Medicine, 
Bacteriology,  Pathology,  and  Hygiene;  and  the  remaining  four  at 
Haslar  in  the  study  of  Naval  Hygiene,  Recruiting.  Physical  Training, 
Diving,  Submarine  Work,  Radiography,  An<e  thetics.  Dentistry,  &c. 
A Surgeon  Commander  superintends  these  studies  at  Haslar  and  fills 
the  post  of  Lecturer  on  Naval  Hygiene.  At  the  conclusion  of  the  six 
months’ course  an  examination  is  carried  out  as  above  mentioned. 

Post-Qradua'e  Instruction  and  Examination  for  the  Bank  oj 
Surgeon  Lie  utniant- Commander . 

The  post-graduate  instruction  of  Naval  Medical  Officers  consists  of 
two  courses:  (1)  A five  months’  course  before  promotion  to  Surgeon 
Lieutenant-Commander;  (2)  a second  course  of  three  months  for 
officers  of  not  lees  than  14  years’  seniority.  The  first  course  is  com- 
pulsory for  all  Surgeon-Lieutenants,  and  is  followed  by  examination 
before  the  Medical  Examining  Board  in  London,  in  order  to  qualify 
for  promotion  to  Surgeon  Lieutenant-Commander.  The  course  is 
to  be  taken  when  tbe  6urgeon  has  between  three  and  five  years' 
seniority,  as  near  tbe  latter  date  as  practicable.  These  courses 
take  place  twice  a year.  There  are  six  compulsory  subjects : 
Clinical  Medicine  and  Surgery,  Operative  Surgery,  Practical  Anaes- 
thetics, Ophthalmology,  Clinical  Pathology,  and  Hygiene;  and  two 
optional  subjects:  Diseases  of  the  Throat,  Nose,  and  Ear,  and 

Skiagraphy.  A Surgeon-Lieutenant  who  fails  to  obtain  a pass  will  be 
allowed  a second  trial;  if  again  unsuccessful,  he  will  be  compulsorily 
retired  with  such  gratuity  as  the  AdmiraPy  may  see  fit  to  grant. 

Instruction  in  clinical  pithology  and  hygiene,  and  skiagraphy  is 
given  at  the  Naval  Medical  School;  the  other  subjects  are  studied  at 
civil  hospitals  in  London,  as  may  be  arranged  by  the  Medical  Director- 
General.  The  Surgeon- 1 ieutenants  going  through  the  course  are 
accommodated  at  the  Royal  Naval  College,  Greenwich,  under  the 
general  control  of  the  President ; their  instruction  being  supervised  by 
the  Professor  of  Hygiene. 

The  second  course  is  not  compulsory,  but  is  designed  to  afford 
senior  officers  an  opportunity  for  refreshing  their  knowledge  of  surgery 
and  medicine. and  making  themselves  familiar  with  modern  advances. 
There  will  not  be  any  fixed  syllabus,  but  arrangements  will  be  made 
to  meet,  individual  requirements.  The  officers  attending  the  course 
will  also  be  accommodated  at  Greenwich 

Voluntary  classes  for  instruction  of  about  six  weeks’  duration  are 
held  a*  the  Naval  Hospitals  at  the  three  h'*me  ports  (Chatham,  Haslar, 
Plymouth'  for  the  benefit  of  medical  officers  of  ships  and  establish- 
ments at  these  ports.  to  whom  every  facility  will  be  afforded  for  the 
study  and  practiceof  bacteriology,  clinical  pathology,  skiagraphy,  &c.» 
in  the  hospital  laboratories,  a report  being  forwarded  to  the  Admiralty 
at  the  close  of  each  course. 

Promotion  to  Surgeon  lieutenant- Commander. 

(a)  Rank  as  Surgeon  L’eutenant-CommaMder  will  he  granted,  subject 
to  their  Lordships’ approval,  to  Surgeon-Lieutenants  at  the  expiration  of 


396  The  Lancet,] 


ROYAL  NAVAL  MEDICAL  SERVICE. 


[August  30,  1919 


••six  years  yoin  the  date  ot  entry,  provided  they  are  recoin  mended  by  the 
Medical  Director  General,  have  served  at  sea  for  three  years,  and  have 
parsed  the  qualifying  examination  for  this  rank.  ( b ) Special  promotions 
will  be  made  at  their  Lordships’ discretion  to  the  rank  ol  Surgeon  Lieu- 
'tenant-Comm  inder  in  cases  of  distinguished  service  or  conspicuous  pro- 
fessional merit.  Such  promotions  will  be  exceptional  and  not  exceed 
the  rate  of  one  a year.  The  total  number  at  any  one  time  of  Surgeon 
Lieutenant  Ci  m nandere  holding  that  rank  by  such  special  promotions 
will  not  exceed  eight.  These  limitations  do  not  apply  to  promotions 
ior  gallantry  in  action. 

(c)  Accelerated  Promotion. — Certificates  will  be  granted  at  the 
qualifying  examination  for  Surgeon  Lieutenant-Commander  as 
follows  : — 50  per  cent,  of  marks  for  a pass  ; 75  per  cent,  for  a first  class, 
a,nd  85  per  cent,  for  a special  certificate.  An  officer  obtaining  a first 
•class  is  eligible  for  an  advance  of  12  months’ seniority,  and  one  obtaining 
•a  special  certificate  for  18  months'  seniority;  this  acceleration  will  not 
be  granted  on  examination  results  alone,  and  an  officer  must  also  be 
recommended  as  deserving  of  advancement.  The  amouut  of  seniority 
allowed  may  be  reduced,  if  considered  advisable  by  the  Director-General ; 
and  if  a Surgeon-Lieutenant  fails  to  pass  at  the  first  attempt.,  the 
results  of  a second  successful  trial  will  not  count  towards  accelerated 
promotion. 

Promotion  to  Surgeon-Commander . 

(a)  Subject  to  the  approval  of  the  Lords  Commissioners  of  the 
Admiralty  rank  as  Surgeon-Commander  will  be  granted  to  Surgeon 
Lieutenant-Commander  at  the  expiration  of  six  years  from  the 
date  of  promotion  to  Surgeon  Lieutenant-Commander,  provided  they 
^tre  recommended  by  the  Medical  Director  General,  have  served  in 
that  rank  at  sea  for  three  y-^ars,  and  have  not  declined  service  except 
■for  reasons  which  in  the  opinion  of  the  Lords  Commissioners  of  the 
Admiralty  are  satisfactory.  (6)  Special  promotions  from  the  rank  of 
Surgeon  Lieutenant-Com<n  in  ier  to  that  of  Surgeon  Commander  will 
t*e  made  at  their  Lirdships’  discretion  in  cases  of  distinguished  service 
or  conspicuous  professional  merit.  Such  promotions  will  be  exceptional 
and  will  not  exceed  the  rate  of  one  in  two  years  ; the  total  number 
at  anyone  time  of  Surgeon-Commanders  holding  that  rank  by  such 
special  promotions  will  not  exceed  six  : these  limitations  do  not  apply 
to  promotion  f >r  gallantry  in  action. 

Promotions  to  Surgeon  Rear-Admiral  and  Surgeon-Captain  will  be 
made  strictly  by  selection,  and  will  be  confined  to  officers  who  have 
proved  themselves  to  be  fitt.ed,  both  professionally  and  as  administrators, 
for  these  ranks  For  advancement  to  Surgeon-Captain  two  years’  fcea 
service  in  the  rank  of  Surgeon-Commander  will  be  required,  or  five 
years’  combined  service  at  sea  in  the  ranks  of  Surgeon-Commander  and 
Surgeon  Lieutenant-Commander. 

Miscellaneous. 

The  special  attention  of  candidates  is  directed  to  the  following  rules 
under  which  officers  are  allowed  to  withdraw  from  the  service  after 
four  vears’ full  pay  service  in  the  Royal  Navy,  with  the  advantage  of 
Joining  the  Reserve  of  Naval  Medical  Officers  : — 

After  four  years’ service  in  the  Royal  Navy,  an  officer,  if  he  wishes, 
may  pass  from  active  service  to  the  Reserve  of  Naval  Medical  Officers, 
when  he  will  reap  the  following  advantages  : — 

(1)  He  will  be  granted  a gratuity  of  £500  on  passing  into  the  Reserve. 

(2)  Ilis  name  will  be  retained  in  the  Navy  List;  he  will  retain  hie 
naval  rank  and  be  entitled  to  wear  his  naval  uniform  under  the  regula 
£ions  applying  to  officers  on  the  retired  and  reserved  lists  of  His  Majesty’s 
Navy. 

(3)  If  he  agree  to  remain  in  the  Reserve  for  four  years  he  will 
receive  a retaining  fee  of  £25  per  annum.  If  at  the  expiration  of 
this  period  he  agree  to  remain  in  the  Reserve  for  a further  period  of 
four  years  he  will  continue  to  receive  the  same  retaining  fee. 

Should  an  officer  prefer  it,  however,  he  may  simply  enter  the  Reserve 
for  a period  not  exceeding  eight  years,  with  power  to  give  six  months’ 
notice  of  his  intention  to  resign  his  position  at  any  time  (in  which  case 
iie  will  receive  no  retaining  fee).  He  may  also  adopt  this  method  of 
Reserve  service  after  the  expiration  of  four  years  served  under  tne 
conditions  referred  to  in  (3),  by  renouncing  his  retaining  fee  for  his  last 
four  years’ service  in  the  Reserve. 

No  officer  will  be  allowed  to  remain  in  the  Reserve  for  a longer  period 
than  eight  years.  Whilst  belonging  to  the  Reserve,  officers  must  report 
•any  change  of  a idress  to  t »e  Secre^arv  of  the  Admiralty. 

Any  officers  who  from  residence  abroad,  physical  disability,  or  for 
other  reason  maybe  considered  by  the  Admiralty  to  be  not  imme  HatHy 
available  f »r  service  if  required,  will  be  liable  to  removal  from  the 
Reserve  and  forfeiture  of  retainer. 

Officers  of  the  Reserve  will  be  liable  to  serve  in  the  Royal  Navy  in 
time  of  war  or  emergency.  When  called  up  for  such  service  they  will 
’receive  the  rate  of  pay— viz.,  29$.  a day  and  allowances — to  which  they 
would  have  been  entitled  after  four  years' service  on  the  Active  List, 
and  an  outfit,  allowance  of  £20. 

A limited  number  of  active  or  retire!  medical  officers  are  appointed 
Honorary  Physician  or  ILmorarv  Surgeon  to  the  King.  There  are 
•three  good  service  pensions  of  £100  a year;  two  Greenwich  Hospital 
pensions  of  £100  a year;  and  13  of  £50  a year  awarded  to  Naval 
Medical  Officers.  The  Gilbert  Blane  gold  medal  is  awarded  every  year 
to  the  medical  **fficer  who  obtains  the  highest  aggregate  marks  at  the 
(promotion  examination  to  Surgeon  Lieutenant-Commander,  held  at  the 
Royal  Naval  Medical  School,  Greenwich.  Once  in  every  five  years  a gold 
•medal  and  £100.  the  Chadwick  Naval  or  Military  Prize,  is  presented  to  a 
•naval  or  military  medical  ofiicer  who  has  specially  assisted  in  promoting 
the  health  of  the  men  in  the  Navy  or  Army. 

A special  cabin  will  be  appropriated  to  the  Surgeon-Commander  or 
•Surgeon  Lie  denant-Comman  *er,  or  the  Surgeon-LieutenarP  in  charge 
of  the  medical  duties  in  each  ship.  Medical  officers  not  in  charge 
will  select  their  cabins,  according  to  their  rank  and  relative  seniority, 
with  other  ward  room  officers. 

Relative  rank  is  accorded  to  medical  officers  as  laid  down  in  the 
King’s  Regulations  and  Admiralty  Instructions. 

Temporary  Surgeon  Lieuten  ants  transferring  to  the  permanent 
Service  will  be  allowed  to  count  seniority  from  date  of  original  entry 
i(  their  application  to  transfer  is  approved  by  the  Board  of  Admiralty/ 

Retired  Pag. 

Surgeon  Rear-Admiral,  £^00:  service,  27  years  Addition  for  each 
Additional  year  or  oed notion  for  each  year  short  , £22. 

Surgeon  Captains  retire  at.  the  age  of  55,  maximum  retired  pay,  £900. 


Surgeon-Commanders  retire  at  50,  maximum  retired  pay  £600. 
Lieutenant-Commanders  and  Lieutenants  retire  at  age  of  45,  maximum 
retired  pay  £459. 

Widow' 8 Pension. 

Widows’  pensions  and  compassionate  allowances  for  children  are 
given  under  the  conditions  as  specified  in  the  King’s  Regulations  and 
Admiralty  Instructions. 

When  an  otfi  cr  retires  on  a gratuity  or  withdraws  on  a gratuity  his 
widow  and  children  will  have  no  claim  to  pension  or  compassionate 
allowance. 

The  fact  of  an  officer  retiring  on  pension  does  not  deprive  the  widow 
or  children  of  any  claim  to  pension  if  they  arc  so  entitled  at  the  time 
of  his  retiring. 

Officers  serving  in  the  Reserve,  who  during  re-employment  are 
injured  on  duty  or  lose  their  lives  from  causes  attributable  to  the 
Service,  come  under  the  same  regulations  as  regards  compensation  for 
themselves  or  pensions  and  compassion  ite  allowances  for  their  widows 
and  children  as  officers  of  the  same  rank  on  the  permanent  Active 
List. 

The  Pay  of  Naval  Medical  Officers. 

The  following  improvements  in  the  rates  of  full,  half,  and 
retired  pay  of  naval  officers  have  been  approved  by  the 
Government  after  consideration  of  the  report  of  the  Board 
of  Admiralty  upon  the  recommendations  of  the  subcommittee 
of  Admiral  Jerram’s  Committee,  presided  over  by  Rear- 
Admiral  Halsey  : — 

Full  Fay. 

The  new  rates  of  pav  will  apply  tc  officers  of  the  Eoyal  Navy  and 
Royal  Naval  Volunteer  Reserve.  • 1 


Rank. 

Before 
Feb.  1st. 

Total  Pay 
plus  Bonus 
Feb.  1st. 

New  Rate. 

£ s.  d. 

£ s d. 

£ s.  d. 

Surg.-Lt.— On  entry 

0 14  0 

0 18  6 

1 4 0 

After  2 years 

0 15  0 

0 19  6 

— 

After  3 years 

— 

— 

19  0 

After  4 years 

0 17  0 

1 1 6 

— 

After  6 years 

0 18  0 

12  6 

Becomes 

Surg.  Lt.-Cdr. — 

Surg.  Lt.-Cdr. 

On  promotion  

10  0 

1 5 0 

1 15  0 

After  2 years 

1 1 0 

1 6 0 

— 

After  3 years 

— 

— 

1 17  0 

At’1  er  4 years 

1 4 0 

19  0 

— 

After  6 years 

1 5 0 

1 10  0 

Becomes 

Surg. -Udr. — 

Surg  -Cdr. 

On  promotion 

1 7 0 

1 12  6 

2 5 0 

After  2 years 

1 8 0 

1 13  6 

— 

After  3 tears 

— 

— 

2 9 0 

After  4 years 

1 10  0 

1 15  6 



After  6 years 

1 11  0 

1 16  6 

2 13  0 

After  8 years 

1 13  0 

1 18  6 

— 

After  9 years 

— 

— 

2 17  0 

Aft*r  10  years 

Surg  -Capt. — 

1 15  0 

2 0 6 

— 

On  promotion 

2 5 0 

2 11  0 

3 5 0 

Af  er  3 years 

— 

. 

3 10  0 

After  6 vears 

— 

— 

3 15  0 

After  9 vears 

— 

— 

4 0 0 

Surg.  R.-Adml 

£1300  a 

£1409  1 0s.  a 

5 5 0 

year. 

year. 

£2500  a 

Medical  Director-General 

— 

— 

year. 

Dental  Surgeons  — 

Surg.-Lt  (D). — 

On  entry 

1 

i 

116 

Af  er  3 vears 

Permanent  rank  not  in  1 

1 6 6 

Surg.  Lt.-Cdr  (D).  — 

existence.  -{ 

On  promotion 

1 12  6 

After  3 years 

1 14  6 

After  6 years 

\ 

1 16  6 

A Dental  Surgeon  who  is  also  qualifiat  medically  to  receive  pay  on 
the  Medical  Officers’  scale. 


Specialist  Allowances. 

Specialist  allowances  to  tficers  sp-cialised  in  professional  subjects  as 
indicated  below.  If  a Surge, m-C  uninander  >s  appointed  solely  for 
soecialist  duties  he  will  ree-ive  pay  as  a Surgeon  Commander  only. 
These  allowances  will  not  e paid  after  promotion  to  Surgeon-Captain, 
2s.  6cl.  Anirsthetists  not  exceeding  six  al  owances.  Ophthalmic  not 
exc  eding  13  allowances  Ear  an  t Th-o  t not  exceeding  13  allowances. 
Genito  urinary  and  Venereal  not  exceeding  six  allowances.  Physical 
Training  not  exceeding  six  allowances. 

Promotion : Few  Scheme. 

The  following  alterations  are  made  in  the  rules  regarding  promotion : — 
Medical  Officers  : (a  Surgeon-Lieutenants  will  be  eligible  for  promotion 
after  six  years,  instead  of  eight  as  at  present,  the  promotion  of  those  on 
the  list  on  July  1st,  1919,  bei  g antedated  as  necessary.  (6)  Surgeon 
Lieutenant-Commanders  will  he  eligible  for  p omotlon  to  Surgeon- 
Commander  after  six  years,  instead  of  eig  >t  as  at  present,  those  on  the 
list,  on  July  1st.  1919.  being  given  two  years'  seniority  Instructions 
will  be  issued  to  t he  Fleet  as  regards  the  senio  ity  of  those  Surgeon 
Lieutenant-Commanders  now  due  for  promotion  owing  to  the  double 
acceleration.  (C ■ Surgeon-Commanders  on  the  list  on  July  1st,  1919. 
will  be  given  two  years’  seniority. 

Retirement. 

The  following  alterations  in  the  regulations  for  retirement  will  be 
introduced Medical  Officers:  (a)  Compulsory.  Surgeon  Rear- 

Admirals  in  future  to  be  invariably  retired  at  60,  the  p wer  of  retention 
to  the  age  of  62  in  special  cases  being  abolished.  Surgeon-Captains  to 
retireat55.  Surgeon-Commanders  to  retiieat50.  Surgeon  Lieutenant- 


The  Lancet,] 


ARMY  MEDICAL  SERVICE.  — INDIAN  MEDICAL  SERVICE. 


[August  30,  1919  397 


Commanders  to  retire  at  45.  tb)  Optional  retirement  at  4U  to  De 
allowed  tor  all  ranks  at  Admiralty  discretion.  The  new  ages  for  com- 
pulsory retirement  will  bo  worked  down  to  in  live  years,  beginning 
with  January  1st,  1920. 

Miscellaneous. 

Medical  and  Dental  Attendance.— Officers  on  consolidated  salary  will 
in  future  be  allowed  the  benefits  of  medical  and  dental  attendance  under 
the  rules  applicable  to  the  Service  generally. 

Increase  in  Higher  Rank < of  Certain  Branches.— Proposals  are  under 
consideration  to  increase  the  number  in  the  higher  ranks  of  the  Medical 
Branch. 

Dental  Surgeons.— A.  branch  of  Dental  S irgeons  will  be  permanently 
instituted,  with  pay  as  shown  in  Appendix  I Surgeon-Lieutenants  (D) 
will  rank  with  Surgeon-Lieutenants,  and  wdl  be  eligible  for  promotion 
to  Surgeon  Lieutenant-Commander  (D)  on  attaining  six  years'  seniority. 
No  higher  rank  than  that  of  Lieutenant  Commander  will  obtain  in  this 
branch.  These  officers  will  otherwise  conform  to  the  regulations 
applicable  to  officers  of  the  Medical  Branch.  Further  instructions  will 
be  issued  as  to  the  transfer  of  existing  officers  to  the  New  Branch. 


ARMY  MEDICAL  SERVICE. 

There  has  come  into  existence  an  alteration  in  the 
conditions  of  service  in  the  Royal  Army  Medical  Corps 
which  constitutes  the  greatest  reform  that  has  taken  place 
in  that  service  for  a generation.  Moreover,  it  is  a reform  of 
promise  as  well  as  of  performance.  Directorates  in  Patho- 
logy and  in  Hygiene  have  now  been  creited  within  the  Army 
Medical  Department,  the  scheme  permitting  for  specially 
selected  men  to- rise  through  all  ranks  of  the  Army  to  Major- 
General  on  the  strength  of  their  scientific  work.  Hitherto,  a 
few  notable  men  being  excepted,  the  custom  intheR.A.M.C. 
has  been  that  whatever  a man’s  qualifications,  tastes,  or 
abilities,  he  must,  at  any  rate  on  attaining  the  rank  of 
colonel,  be  prepared  to  go  off  into  administrative  work  and 
leave  his  scientific  duties  to  his  juniors.  If  he  preferred  to 
remain  working  in  bacteriology,  in  preventive  medicine  and 
hygiene,  or  in  tropical  diseases,  for  example,  he  could  do  so, 
but  at  the  risk  of  losing  appointments  carrying  temporarily 
higher  rank  and  increased  pay.  Always  young  men  were 
being  taught,  and  well  taught,  how  to  become  the  scientific 
branch  of  their  Corps,  and  exactly  as  they  had  found 
their  metier , precisely  as  they  had  become  valuable 
advisers  of  officers,  men,  the  Army,  and  indeed  the 
nation,  they  were  asked  to  choose  between  sacrifice 
of  their  scientific  work  or  a career  of  superintending 
other  people,  of  giving  orders,  of  supervising  hospitals  and 
military  establishments  generally — in  short,  a career  of  what 
is  called  administration.  How  could  the  younger  men  be 
expected  to  preserve  their  interest  in  their  scientific  studies 
if  such  was  the  outcome  ? And  how  could  their  seniors  be 
expected  to  remain  in  touch  with  the  scientific  developments 
in  whose  working  out  they  no  longer  had  any  personal  share  ? 
This  now  has  all  been  changed,  largely  owing  to  the  per- 
tinaceous,  skilful,  and  sympathetic  work  of  Sir  John  Goodwin, 
Director-General  of  theR.A.M.C.,  who  has  for  over  a year 
been  preparing  his  scheme  of  reform  with  the  assistance 
of  the  two  principal  exponents  of  scientific  work  with  the 
Corps,  Sir  William  Leishman  and  Sir  William  Horrocks.  It 
is  certain  that  the  possibility,  and  for  good  workers  the 
probability,  of  attaining  to  positions  of  proper  trust  and 
emolument  by  scientific  work  will  much  improve  recruiting 
among  the  officers  of  the  R.A.M  C. — that  will  be  the 
immediate  outcome  of  the  new  scheme  ; but  there  will 
almost  certainly  follow  similar  arrangements  by  which 
special  medical  service  generally  will  receive  higher  con- 
sideration in  the  Corps.  Not  only  is  there  in  the  work  of 
the  Army  Medical  Department  scope  for  original  labour  and 
research  in  tropical  disease,  in  preventive  medicine,  and  in 
bacteriology,  but  a vast  clinical  field  is  also  open  to  the 
specialist  in  medicine,  surgery,  venereal  disease,  and  oph- 
thalmology. Further  developments  will  shortly  follow,  as 
well  as  properly  increased  rates  of  pay.  These  we  hoped 
to  have  been  able  to  publish  this  week,  but  they  are  not  yet 
made  formally  available. 

Regulations. 

Following  are  the  Regulations  for  admission  to  the  Royal 
Armv  Medical  Corps  (issued  with  Army  Orders  dated 
Jan.  1st,  1912). 

A candidate  for  a commission  in  the  Royal  Army  Medical  Corps 
must  be  21  years  and  not  over  28  years  of  age  at  the  date  of  the  com- 
mencement of  the  entrance  examination,  and  must  be  unmarried. 
He  must,  at  the  time  of  his  appointment,  be  registered  under  the 
Medical  Acts  in  force  in  the  United  Kingdom.  A candidate  must  com- 
plete the  subjoined  form  of  application  and  declaration  and  submit 
it,  together  with  an  extract  from  the  register  of  bis  birth,  and  his 
medical  registration  certificate,  to  the  Secretary,  War  Office,  as  early 
as  possible  before  the  date  on  which  the  entries  are  closed. 


Application  of  a Candidate  fob  a Commission  in  thf.  Royal 
Army  Medical  Corps. 

( A Candidate  will  not  be  permitted  to  compete  oflener  than  t wice.) 

1.  Name  in  full. 

2.  Address. 

3.  Date  of  birth. 

4.  Nature  and  date  of  examination  qualifying  for  registration. 

5.  Date  of  registration  as  a medical  student.. 

6.  Dates  of  passing  medical  examinations— First,  Second,  Final. 

7.  Qualifications.  (Medical  Registration  Certificate,  or,  if  noV 
registered,  Diplomas  to  be  furnished.) 

8.  Academic  and  other  distinctions. 

9.  Medical  school  or  schools  in  which  the  candidate  pursued  hie 
course  as  a medical  student,  and  name  or  names  of  the  deans  or  other- 
responsible  authorities. 

10.  Particulars  of  any  commission  or  appointment  held  in  the  public- 
services,  including  service  in  the  Officers  training  Corps. 

11.  Date  of  examination  at  which  the  candidate  proposes  to  present 
himself. 

Declaration. 

(N.B. — A mis-statement  by  the  candidate  will  invalidate  any  sub- 
sequent appointment  and  cause  forfeiture  of  all  privileges  for  services 
rendered.) 

1 hereby  declare  upon  my  honour  that  the  above  statements  are  true- 
to  the  best  of  my  knowledge  and  belief  and  further  : — 

1.  That  I am  a British  subject  of  unmixed  European  blood. 

2.  That  I am  not,  as  far  as  I know,  at  present  suffering  from  any 
mental  or  bodily  infirmity,  or  physical  imperfection  or  disability  that 
is  likely  to  preclude  me  from  efficiently  discharging  the  duties  of  an 
officer  in  any  climate. 

3.  That  I will  fully  reveal  to  the  Medical  Board,  when  physically 
examined,  all  circumstances  within  my  knowledge  that  concern  my 
health. 

A candidate  will  not  be  permitted  to  compete  oft.ener  than  twice. 

The  Army  Council  reserves  the  right  of  rejecting  any  candidate 
who  may  show  a deficiency  in  his  general  education. 

An  entrance  fee  of  £1  is  required  from  each  candidate  admitted  to 
the  examination. 

Candidates  who  have  served  in  the  Officers  Training  Corps  will  b& 
credited  at  the  entrance  examination  with  additional  marks  as  follows  ; 
those  having  Certificate  A will  receive  1 per  cent.,  and  those  having 
B 2 per  cent,  of  the  total.  Service  marks  are  also  credited  to  a candi- 
date who  has  been  employed  as  an  officer  in  consequence  of  a national' 
emergency,  the  number  of  marks  depending  on  the  period  of  employ- 
ment and  the  circumstances  of  the  case 

A candidate  successful  at  the  entrance  examination  will  be  appointed 
a Lieutenant  on  probation  and  will  be  required  to  pass  through  courses- 
of  instruction  at  the  Royal  Army  Medical  College,  London,  and  at  t b e 
Royal  Army  Medical  Corps  School  of  Instruction,  Aldershot,  and,  after- 
passing the  examinations  in  the  subjects  taught  and  satisfying  the 
Director-General  that  Repossesses  the  necessary  skill,  knowledge,  and 
character  for  permanent  appointment  to  the  Royal  Army  Medical 
Corps,  his  commission  as  Lieutenant  will  be  confirmed  The  commis- 
sion will  bear  the  date  of  passing  the  entrance  examination.  A Lieu- 
tenant who.  at  the  time  of  passing  the  examination  for  admission  to- 
the  Royal  Army  Medical  Corps,  holds,  or  is  about  to  hold,  a resident 
appointment  in  a recognised  civil  hospital,  may  be  seconded  for  the 
period,  not  exceeding  one  year,  of  his  appomtment;  he  will  not 
receive  army  pay,  but  his  service  will  reckon  towards  pay,  promotion, 
and  retirement;  he  will  retain  the  seniority  obtained  at  the  entrance 
examination. 

The  precedence  of  Lieutenants  among  each  other  will  be  in  order 
of  merit  as  determined  by  the  combined  results  of  the  entrance 
examination  and  the  examinations  undergone  while  on  probation, 
except  that  the  position  on  the  list  of  a lieutenant  on  probation, 
seconded  to  hold  a resident  appointment  in  a recognised  civil  hospital 
will  be  determined  by  the  place  he  has  gained  at  the  entrance 
examination.  lie  will  be  required,  at  the  conclusion  of  his  hospital 
appointment,  to  attend  the  courses  of  instruction  at  the  Royal  Army 
Medical  College  and  at  Aldershot;  but  the  subsequent  examinations 
will  he  of  a qualifying  character  and  will  not.  influence  his  position  on 
the  seniority  list  of  the  Corps. 

Lieutenants  when  appointed  on  probation  will  receive  instructions  as 
to  the  provision  of  uniform. 

On  completion  of  his  probationary  training  an  officer  is  posted  for 
duty  to  one  of  the  military  hospital)  at  home,  his  wishes  being  met  as- 
far  as  possible  in  regard  to  the  command  to  which  he  is  posted. 


INDIAN  MEDICAL  SERVICE. 

Regulations. 

Following  are  the  Regulations  for  the  examination  of 
candidates  for  admission  to  the  Indian  Medical  Service.  The 
grades  of  officers  in  the  Indian  Medical  Service  are  the  same- 
as  those  of  the  Army  Medical  Service  and  Royal  Army 
Medical  Corps.  The  Director-General  will  rank  either  as 
Major-General  or  Lieutenant-General  as  may  be  decided  in 
each  case  by  the  Secretary  of  State  for  India  in  Council. 

Candidates  must  be  natural-born  subjects  of  His  Majesty,  of 
European  or  East  Indian  descent,  of  sound  bodily  health,  and  in  the 
opinion  of  the  Secretary  of  State  for  India  in  Council  in  all  respects 
suitable  to  hold  commissions  in  the  Indian  Medical  Service.  They 
may  he  married  or  unmarried.  They  must  possess  under  the  Medical 
Acts  a qualification  registrable  in  Great  Britain  and  Ireland.  No  candi- 
date will  be  permitted  to  compete  more  than  three  times.  Examina- 
tions for  admission  to  the  service  are  he'd  twice  in  the  year,  usually 
in  January  and  Julv.  Candidates  for  the  January  examination  must 
be  between  21  and  28  years  of  age  on  Feb.  1st,  anil  those  for  the  July 
examination  must  be  between  21  and  28  on  August  1st.  The  exact,  date- 
of  each  examination  and  the  number  of  appointments,  together  with, 
the  latest  date  at  which  applications  will  be  received,  wiil  be  notified  in. 
The  Lancet. 

They  must  subscribe  and  send  in  to  the  Military  Secretary,  India. 
Office  London,  S.W.,so  as  to  reach  that  address  by  the  dale  fixed  in  the 
advertisement  of  the  examination,  a declaration  according  to  ths 
annexed  form,  which  is  procurable  from  the  Military  Secretary. 


398  The  Lancet,] 


INDIAN  MEDICAL  SERVICE. 


[August  30,  1919 


Declaration  and  Schedule  of  Qualifications  to  be  Filled  up  by 
Candidates. 

I,  a candidate  for 

employment  in  Ilis  Majesty’s  Indian  Melicil  Service,  do  hereby  attest 
ray  readiness  to  engage  for  that  service,  and  to  proceed  on  duty  imme- 
diately on  being  gazetted. 

I declare  that  I labour  under  no  mental  or  constitutional  disease, 
nor  any  imperfection  or  disability  that  can  interfere  with  the  most 
efficient  discharge  of  the  duties  of  a medical  officer. 

I hereby  declare  upon  my  honour  that  the  above  statements  are  true 
to  the  best  of  my  knowledge  and  belief. 

I enclose,  in  accordance  with  Paragraph  4 of  the  Regulations. 
(a)  proof  of  age;  (b)  two  certificates  of  character;  (c)  certificate  of 
having  attended  a course  of  ophthalmic  instruction,  showing  that  the 
course  included  instruction  in  errors  of  refraction;  (d)  evidence  of  a 
registrable  qualification;  (e)  in  case  of  natives  of  India  or  others 
educated  in  that  country  only , a certificate  from  the  Director-General, 
Indian  Medical  Service. 

Signature 

Date . 19  . 

1.  Name  in  full. 

2.  Address.  (Any  alteration  to  be  notified  to  the  Military  Secretary , 
India  Office.  London , S.  W.) 

3.  Date  of  birth.  (This  must  be  supported  by  a certificate  or  statu- 
tory declaration.  See  Paragraph  4 of  the  Regulations.) 

4.  Profession  or  occupation  of  father,  and  whether,  at  the  time  of 
candidate’s  birth,  his  father  was  a British  subject  of  European  or  East 
Indian  descent. 

5.  Statement  as  to  whether  the  candidate  is  married  or  single. 

6.  Colleges  and  Medical  Schools  at  which  the  candidate  has  received 
his  medical  education. 

7.  Medical  School  in  which  the  candidate  completed  his  course  as  a, 
medical  student,  and  name  of  the  Dean  or  other  responsible  authority. 

8.  Degrees  of  B.A.  or  M.A. ; details  as  to  any  prizes,  university 
honours,  &c. 

9.  Registrable  qualifications. 

10.  Date  of  examination  at  which  the  candidate  proposes  to  present 
himself. 

11.  Date  of  any  previous  occasions  on  which  the  candidate  may 
have  presented  himself  for  examination  for  admission  to  the  Indian 
Medical  Service,  or  other  examination  for  the  Public  Services. 

12.  Particulars  of  any  commission  or  appointment  held  in  the  Public 
Services. 

The  declaration  must  be  accompanied  by  the  following  documents: — 
a.  Proof  of  age  either  by  Registrar-General’s  certificate,  or,  where 
such  certificate  is  unattainable,  by  the  candidate’s  own  statutory 
declaration,  form  for  which  can  be  obtained  at  the  India  Office, 
supported,  if  required  by  the  Secretary  of  State,  by  such  evidence  as 
he  may  consider  satisfactory.  A certificate  of  baptism  which  does  not 
afford  proof  of  age  will  be  useless.  In  the  case  of  natives  of  India  and 
Tamils  of  Ceylon  it  will  be  necessary  for  a candidate  to  obtain  a 
certificate  of  age  and  nationality  in  the  form  laid  down  by  the 
Government  of  India  which  is  obtainable  from  the  Director-General  of 
the  Indian  Medical  Service,  Simla.  A c indidate  of  East  Indian  descent, 
not  born  in  British  India,  must  produce  a certificate  of  age  and  nation- 
ality from  the  Government  of  the  country  where  he  was  born,  showing 
that  he  is  the  son  or  grandson  of  a person  born  in  British  India,  b.  A 
recommendation  and  certificate  of  moral  character  from  two  responsible 
persons — not  members  of  his  own  family — to  the  effect  that  he  is  of 
regular  and  steady  habits  and  likely  in  every  respect  to  prove  creditable 
to  the  service  if  admitted,  c.  A certificate  of  having  attended  a course 
of  instruction  for  not  less  than  three  months  at  an  ophthalmic  hospital 
or  the  ophthalmic  department  of  a general  hospital,  which  course  shall 
include  instruction  in  the  errors  of  refraction,  d.  Some  evidence  of 
having  obtained  a registrable  qualification,  e.  Any  European  educated 
in  India  and  every  native  of  that  country,  whether  born  or  medically 
educated  in  India  or  not,  will  be  required  to  produce  a certificate  signed 
by  the  Director-General.  Indian  Medical  Service,  that  he  is  a suitable 
person  to  hold  a commission  in  the  Indian  Medical  Service.  A candi- 
date should  apply  to  the  Director-General,  Indian  Medical  Se  vice,  for 
the  necessary  certificate  at  least  three  months  before  the  date  on  which 
the  declaration  is  to  be  submitted  according  to  the  advertisement  of 
the  examination.  This  rule  also  applies  to  Tamils  of  Ceylon 

The  Secretary  of  State  for  India  reserves  the  right  of  deciding 
whether  the  candidate  may  be  allowed  to  compete  for  a commission  in 
His  Majesty’s  Indian  Medical  Service. 

The  physical  fitness  of  each  candidate  w ill  be  determined  by  a Board 
of  Medical  Officers  who  are  required  to  certify  that  his  vision  is 
sufficiently  good  to  enable  him  to  pass  the  regulation  tests  (see  under 
Army  Medical  Service).  Every  candidate  must  also  be  free  from  all 
organic  disease  and  from  constitutional  weakness  or  other  disability 
likely  to  unfit  him  for  military  service  in  India.  Candidates  will  be 
required  to  pay  a fee  of  £1  before  being  examined  by  the  Medical  Board. 
No  candidate  will  be  permitted  to  compete  more  than  three  times. 
More  detailed  regulations  as  to  the  physical  requirements  can  be 
obtained  on  application  to  the  India  Office. 

Candidates  for  the  Indian  Medical  Service  may,  if  they  like,  undergo 
a preliminary  examination  by  the  Medical  Board  which  meets  at  the 
India  Office  every  Tuesday  by  applying  to  the  Under  Secretary  of  State, 
India  Office,  enclosing  a fee  of  two  guineas,  and  stating  the  particular 
appointment  which  the  candidate  desires  to  obtain.  They  must  pay 
their  own  travelling  expenses.  The  decision  must  be  understood,  how- 
ever, not  to  be  final.  It  may  be  reversed  in  either  direction  bv  the 
Examining  Medical  Board  immediately  prior  to  the  Professional 
Examination. 

On  proving  possession  of  the  foregoing  qualifications  the  candidate 
will  be  examined  by  the  Examining  Board  in  the  following  subjects 
and  the  highest  number  of  marks  attainable  will  be  distributed  as 
follows : — Marks. 

1.  Medicine,  including  therapeutics 1200 

2.  Surgery,  including  diseases  of  the  eye  1200 

3.  Applied  anatomy  and  physiology 600 

4.  Pathology  and  bacteriology  900 

5.  Midwifery  and  diseases  of  women  and  children  600 

6.  Materia  medica,  pharmacology,  and  toxicology  600 

The  examination  in  medicine  and  surgery  will  be  in  part 

practical  and  will  include  operations  on  the  dead  body,  the  application 


of  surgical  apparatus,  and  the  examination  of  medical  and  surgical 
patients  at  the  bedside.  No  syllabus  is  issued  in  the  subjects  of  the 
examination,  but  it  will  be  conducted  bo  as  to  test  the  general 
knowledge  of  the  candidate  in  all  subjects.  No  candidate  shall  be 
considered  eligible  who  shall  not  have  obtained  at  least  one-third  of 
the  marks  obtainable  in  each  of  the  above  subjects  and  one-half  of  the 
aggregate  marks  for  all  the  subjects. 

After  passing  this  examination  the  successful  candidates  will  be 
commissioned  as  lieutenantu-on-probation,  and  will  be  granted  about  a 
mouth’s  leave.  They  will  then  be  required  to  atteud  two  successive 
courses  of  two  months  each  at  the  Royal  Array  Medical  College, 
Millbank,  and  at  Aldershot.  Thecandidate’scoramission  as  a lieutenant- 
on-probatioa  will  bear  the  date  on  which  the  result  of  the  entrance 
examination  is  announced,  but  his  rank  as  lieutenant  will  not  be  con- 
firmed until  he  has  passed  the  final  examination,  held  at  the  conclusion 
of  his  period  of  instruction. 

The  course  at  the  Royal  Army  Medical  College  will  be  in  (1)  hygiene, 
(2)  military  and  tropical  medicine,  (3)  military  surgery,  (4)  pathology 
of  diseases  and  injuries  incidental  to  military  and  tropical  service;  and 
(5)  military  medical  administration. 

The  course  at  Aldershot  will  include  instruction  in  (1)  interna 
economy,  (2)  Army  Service  Corps  subjects,  (3)  hospital  administration, 
(4)  stretcher  aud  ambulance  drill,  and  (5)  equitation. 

Lieutenants- on  - probation  will  receive  an  allowance  of  14s.  per 
diem,  and  during  the  period  of  instruction  they  will  be  provided 
with  quarters  (where  quarters  are  not  provided  they  will  obtain 
the  usual  allowances  of  a subaltern  in  lieu  thereof),  to  cover  all  costs 
of  maintenance,  and  they  will  be  required  to  provide  themselves 
with  uniform  ; a detailed  list  of  the  uniform  and  articles  required  will 
be  sent  to  each  successful  candidate. 

A lieutenant-on-probation  who  is  granted  sick  leave  before  the  com- 
pletion of  his  course  of  instruction  and  final  admission  to  the  service  will 
receive  pay  at  the  rate  of  10s.  6d.  a day  for  the  period  of  his  sick  leave. 

Candidates  will  be  required  to  conform  to  such  rules  of  discipline  as 
may  from  time  to  time  be  laid  down. 

At  the  conclusion  of  each  course  the  candidate  will  be  required  to 
pass  an  examination  on  the  subjects  taught,  and  in  order  to  qualify 
must  obtain  50  per  cent,  of  the  total  marks.  If  he  fails  to  qualify  in 
either  of  these  examinations  he  will  be  liable  to  removal  from  the 
service,  but  if  specially  recommended  he  may  be  allowed  to  undergo  the 
course  or  courses  again  under  certain  restrictions  as  to  pay  and  position. 

Officers  appointed  to  the  Indian  Medical  Service  will  be  placed  on  one 
list,  their  position  on  it  being  determined  by  the  combined  results  of  the 
preliminary  and  final  examinations.  They  will  be  liable  for  military 
employment  in  any  part  of  India,  but  in  view  to  future  transfers  to 
civil  employment,  they  will  stand  posted  to  one  of  the  following  civil 
areas :—(l)  Madras  and  Burma;  (2)  Bombay  with  Aden;  (3)  Upper 
Provinces— i.e..  United  Provinces.  Punjab,  and  Central  Provinces;  and 
(4)  Lower  Provinces— i.e.,  Bengal,  Bihar,  Orissa,  and  Assam.  The  alloca- 
tion of  officers  to  these  areas  of  employment  will  be  determined  upon 
a consideration  of  all  the  circumstances,  including,  as  far  as  possible, 
the  candidate's  own  wishes  Officers  transferred  to  civil  employment, 
though  ordinarily  employed  within  the  area  to  which  they  may  have 
been  assigned,  will  remain  liable  to  employment  elsewhere  according 
to  the  exigencies  of  the  service. 

A lieutenant  who,  within  a reasonable  period  before  the  date  at 
which  he  would  otherwise  sail  for  India,  furnishes  proof  of  his  election 
to  a resident  appointment  (or  to  a preliminary  appointment  leading  in 
due  course  to  a resident  one)  at  a recognised  civil  hospital,  may  be 
seconded  for  a period  not  exceeding  one  year  from  the  date  on  which  he 
takes  up  such  appointment . provided  that  he  joins  it  within  three  months 
of  passing  his  final  examination,  and  t hat  he  holds  himself  in  readiness 
to  sail  for  India  within  14  days  of  the  termination  of  the  appointment. 
While  seconded  he  will  receive  no  pay  from  Indian  funds,  but  his 
service  towards  promotion,  increase  of  pay,  and  pension  will  reckon 
from  the  date  borne  on  his  commission.  In  special  cases  permission 
may  be  granted  to  lieutenants  to  delav  their  departure  for  India,  in 
order  to  sit  for  some  further  medical  examination.  Lieutenants  remain- 
ing in  England  under  such  circumstances  will  receive  no  pav  for  any 
period  beyond  two  months  from  the  date  of  termination  of  the  course 
of  instruction,  unless  the  period  elapsing  before  the  day  on  which  the 
majority  of  the  lieutenants  of  the  same  seniority  sail  to  India  exceeds 
two  months,  in  which  case  lieutenants  allowed  to  remain  in  England  will 
receive  pay  up  to  that  day.  In  such  cases  pay  will  recommence  on  the 
day  of  embarkation  for  India.  All  the  provisions  of  this  clause  are 
subject  to  the  general  exigencies  of  the  service.  Before  the  commission 
of  a lieutenant-on-probation  is  confirmed  he  must  be  registered  under 
the  Medical  Acts  in  force  at  the  time  of  his  appointment.  Candidates 
who  have  been  specially  employed  in  consequence  of  a national 
emergency,  either  as  an  officer,  or  in  a position  usually  filled  by  an 
officer,  will  be  allowed,  under  certain  circumstances,  to  reckon  such 
service  towards  pension. 

New  Rates  of  Pay. 


The  new  rates  of  pay  in  the  Indian  Medical  Service,  of 
which  particulars  follow,  have  been  arrived  at  by  adding 
approximately  33£  per  cent,  to  that  portion  of  the  old  rates 
of  pay  which  represented  military  grade  pay.  The  old  rates 
are  shown  in  the  second  column  for  comparison.  The  new 
rates  are  effective  from  Dec.  1st,  1918,  and  the  necessary 
adjustments  will  be  carried  out  as  soon  as  possible. 

A. — Military  Side. 

(1)  New  rate.  (2)  Old  rate.* 


Lieutenants  

Captains  

Captains  (after  5 years'  total  service)  

Captains  (after  7 years'  total  service)  

Captains  (after  10  years'  total  service) 

Majors  

Majors  (after  3 years'  service  as  such) 

Lieut. -Colonels  

Lieut.-Coloneis  (of  over  25  years’  service)  ... 
Lieut. -ColoneU  (selected  f t ii  creased  I ay) 


chargeonly  has  been  shown,  as  this  is  the  most  probable  position  of  a 


Rs.  p.m. 

Rs.  o.m. 

550 

(450)t 

700 

(550) 

750 

i600' 

800 

<P50) 

000 

(700) 

...  1000 

(800) 

...  1150 

.900) 

...  1550 

(1250) 

...  1600 

(1300) 

...  1750 

(1400) 

;im“nt. 

an  officer 

in  officiating 

Lieutenant. 


The  Lancet.]  ROYAL  AIK  FORCE  MEDICAL  SERVICE.— COLONIAL  MEDICAL  SERVICE.  [August  30,  1919  399 


These  rat.es  were  previously  announced  in  May.  hut  at  that  time  the 
rates  for  the  civil  sido  were  not  available.  They  are  now  republished 
with  the  civil  rates  in  order  that  full  information  for  the  whole  service 
nm.v  be  available. 

The  now  rates  are  consolidated  and  include  charge  pay  for  the 
command  of  station  hospitals. 

The  following  rates  are  those  for  certain  of  the  higher  military 
appointments  : — 

(1)  New  rate.  (2)  Old  rate. 


Its.  p.m. 
2650 
2150 


Its.  p.m. 
(2200) 
(1800) 


D.D.M.S.  (if  held  bv  a Major-General) 

D.D.M.S.  and  A.D.M.S. (it  held  by  a Colonel) 

A.D.M.S.  of  Aden:  Inspector  ot  Medical] 

Services.  Army  Headquarters  I 

A.D.M.S.  in  the  Field  (when  held  by  an  officer  1 jggg 

below  Colonel’s  rank)  j 

Officer  Commanding  general  hospital  in  .the  I 

field  of  500  beds J 

A.D.M.S.,  Army  Headquarters  1700 

It.  — Civilian  Side. 

(1)  The  rates  for  certain  of  the  superior  appointments  are  as  follows : — 

(1)  New  rate.  (2)  Old  rate. 
Rs.  p.m. 

3500 


(1600) 


(1100) 


2150 

1700 


3000 

2600 


l(s.  p.m. 
3000 
1500* 
1100* 


2500 

2250 


Director-General  

Deputy  Director-General  

Assistant  Director-General 

Surgeon-General,  Bengal,  Madras,  and 

Bom  l ay 

Inspeetors-General  of  Civil  Hospitals  in  non- 

Presidency  Provinces  t 

Sanitary  Commissioner  to  Government  of 

India  

Sanitary  Commissioner  (for  all  provinces 
except  Central  Provinces  and  Assam)  ...  1800 — 2100  I 
Sanitary  Commissioner,  Central  Provinces  | 

and  Assam  1550—2050 ) 

Inspectors-Generalof  Prisons.  Madras.  Bengal, 

Burma,  Bombay,  and  United  Provinces  ...  2100—2300  | 

InspectorB-General  of  Prisons,  Pun  jab,  and 

Bihar  and  Orissa 2100 

Inspeetors-General  of  Prisons,  Central 

Provinces  1800 

* Rates  drawn  bv  present  incumbents, 
f Corresponding  to  the  appointments  of  Surgeon-General  in  the 
three  Presidency  Provinces. 


2300-2800  2000-2500 


1250-1800 


1500-2000 


(2)  The  distinction  between  1st  and  2nd  class  civil  surgeoncies  is 
abolished,  and  holders  of  there  appointments  will,  in  future,  be  paid  at 
the  new  consolidated  r»tes,  given  under  A above,  according  to  their 
military  rank.  This  change  results  in  increases  varying  according  to 
rank  from  Rs.  2f0  J-400  per  mensem. 

I Assuming  that  a civil  surgeoncy  is  not  held  by  an  officer  of  lower 
rank  than  a Captain. 

(3)  Holders  of  professorial  and  bacteriological  appointments  will,  like 
civilsurgeons.be  paid  at  the  new  consolidated  rates,  given  under  A 
above,  plus  a special  allowance  of  Rs.250  per  mensem.  The  resultant 
increase  over  the  old  rates  varies  from  Rs.150  per  mensem  in  the 
cas6  of  junior  Captains  to  Rs.400  per  mensem  in  the  case  of  senior 
Lieutenant-Colonels. 

(4)  Holders  of  other  srecial  classes  of  appointments  will  receive  the 
consolidated  pay  of  rank,  as  under  A above,  plus  special  allowances  of 
differing  am  unis  e.g.,  alienists  and  plague  officers  Rs.  200  per  mensem, 
superintenden' s of  first-class  jailsRs  150 permensem,  personal  assistants 
to  Surgeons-Gcneral  Rs.100  per  mensem,  superintendents  to  stcond- 
class  jailB  Rs.  50  per  mensem. 

The  examples  above  are  not  exhaustive,  but  are  given  as 
illustrations  of  the  manner  in  which  the  principle  previously 
announced  has  been  carried  into  effect. 


ROYAL  AIR  FORCE  MEDICAL  SERVICE. 

The  Medical  Service  of  the  Royal  Air  Force  has  not  yet 
been  placed  upon  a permanent  basis  ; the  definite  conditions 
of  service  are  not  therefore  available  for  publication.  It  is 
understood,  however,  that  the  general  organisation  of  the 
Service  will  be  on  the  lines  followed  by  the  other  branches  of 
the  Force,  and  that  the  establishment  will  consist  partly  of 
permanent  and  partly  of  temporary  officers. 

Temporary  officers  will  be  required  to  engage  for  a period 
of  four  years,  and  may  be  called  upon  to  spend  part  of  their 
service  at  overseas  stations — chiefly  in  Egypt  or  India — and 
must  be  physically  fit  for  service  in  all  climates. 

Unless  taken  in  for  some  specific  duty  on  account  of  special 
professional  qualifications,  medical  officers  will  be  required 
to  pass  the  usual  medical  tests  required  of  other  officers 
of  the  flying  service,  and  at  the  time  of  entry  must  sign 
a declaration  that  they  are  willing  to  fly  when  called  upon 
to  do  so. 

Vacancies  in  the  establishment  of  permanent  commis- 
sioned officers  will  be  filled  from  the  temporary  list  by 
selection.  Those  selected  for  permanent  commissions  wiil 
count  the  period  of  their  temporary  service  towards  eventual 
pension,  the  remainder  will  receive  a gratuity  on  leaving 
the  Service  at  the  expiration  of  their  contract. 

There  will  be  no  competitive  examination  on  entry; 
candidates  must  be  under  28  years  of  age,  be  nominated  by 
the  Dean  of  a recognised  medical  school  or  teaching 
hospital,  and  will  be  interviewed  personally  by  tbe  Director 
of  Medical  Services,  Royal  Air  Force,  before  acceptance. 

Arrangements  are  being  made  to  allow  post-graduate 
courses  after  selection  to  permanent  commission. 


Officers  engaged  in  research  or  pathological  work  will  be 
promoted  separately  from  tbe  general  roster. 

Officers  selected  for  the  permanent  service  will  normally 
be  promoted  to  the  rank  of  major  after  a fixed  period  of 
service,  but  officers  specially  selected  on  account  of  pro- 
fessional or  administrative  ability  will  become  available  for 
promotion  to  the  rank  of  major  at  an  earlier  date. 

Promotion  to  the  higher  ranks  will  be  by  selection  only. 

Tbe  rates  of  pay  and  pension  are  not  yet  finally  fixed,  but 
it  is  understood  that  in  the  junior  ranks  the  rates  will  be 
rather  higher  than  the  corresponding  rates  in  the  R.A.M.G. 
to  cover  the  flying  risk. 


THE  COLONIAL  MEDICAL  SERVICE. 

IN  the  self-governing  dominions,  Canada,  Australia,  New 
Zealand,  the  Union  of  South  Africa,  and  Newfoundland, 
medical  appointments  are  made  concerning  which  informa- 
tion can  be  obtained  from  the  High  Commissioners  or 
Agents-General  in  London  ; appointments  in  Egypt  aDd 
the  Soudan  are  regulated  from  the  Foreign  Office  ; in  Aden 
and  adjacent  territories  the  appointments  are  under  the 
control  of  the  Government  of  Bombay  ; in  Rhodesia  the 
appointments  are  made  by  the  British  South  Africa 
Company,  London  Wall  Buildings,  E.C.  ; in  North  Borneo 
application  should  be  made  to  the  British  North  Borneo 
Company,  37,  Threadneedle-street,  E.C.,  for  appointments; 
and  those  in  Sarawak  are  in  the  hands  of  H.H.  the  Rajah. 

But  in  addition  to  all  these  there  are  a large  number 
of  important  posts  under  the  patronage  of  the  Secretary 
of  State  for  the  Colonies.  These  concern  East  Africa 
(the  East  Africa,  Uganda,  Nyasaland,  Somaliland,  and 
Zanzibar  Protectorates);  Eastern  (Ceylon,  the  Straits 
Settlements,  and  Federated  Malay  States,  Hong-KoDg, 
Weihaiwei,  Mauritius,  and  Seychelles)  ; West  India 
(British  Guiana,  Jamaica,  Trinidad,  the  Windward  Islands, 
the  Leeward  I-lands,  Barbados,  British  Honduras,  and  the 
Bahamas)-;  Fiji  and  the  Western  Pacific,  Cyprus,  Malta, 
Gibraltar,  St.  Helena,  Bermuda,  and  the  Falkland  Islands  ; 
and  West  Africa  (Nigeria,  the  Gold  Coast,  Sierra  Leone, 
and  the  Gambia).  As  a general  rule,  each  Colony  or  Pro- 
tectorate has  its  own  public  service  distinct  from  that  of 
every  other,  and  it  is  usually  only  the  higher  officers  who  are 
transferred  by  the  Secretary  of  State  from  one  Colony  to 
another  ; but  there  are  two  exceptions  to  this  rule.  The 
West  African  Medical  Staff,  which  serves  Nigeria,  the  Gold 
Coast,  Sierra  Leone,  and  the  Gambia,  form  one  service,  and 
in  practice  the  medical  services  of  the  Straits  Settlements 
and  the  Federated  Malay  States  may  be  regarded  as  one,  as 
the  officers  maybe  and  frequently  are  transferred  from  the 
Colony  to  the  States,  or  vice  versa.  In  Ceylon,  Mauritius, 
Jamaica,  Barbados,  the  Bahamas,  and  Bermuda  vacancies 
are  almost  always  filled  locally  by  the  appointment  of 
qualified  native  candidates,  or — in  the  case  of  some  of  the 
higher  posts — by  transfer  from  other  Colonies.  Appoint- 
ments in  Malta  are  all  filled  locally.  Vacancies  in  the  Hong- 
Kong  Medical  Department  are  generally  filled  by  transfer 
from  other  Colonies.  Medical  appointments  in  the  Bechu- 
analand  Protectorate,  Bisutoland,  and  Swaziland  are  made 
only  on  the  recommendation  of  the  High  Commissioner 
for  South  Africa,  who  usually  appoints  local  candidates. 
In  most  cases  the  duties  of  a colonial  medical  officer  are 
of  a very  general  character,  including  medical,  surgical 
and  often  public  health  work.  It  is  only  occasionally 
that  a specialist  is  required.  All  applicants  must  be 
between  the  ages  of  33  and  35.  but  in  the  case  of  East 
Africa,  Uganda,  Nyasaland,  Somaliland,  and  Zanzibar  pre- 
ference will  be  given  to  candidates  who  are  over  25  years 
of  age,  while  in  the  case  of  Fiji  and  the  Western  Pacific 
preference  will  be  given  to  candidates  who  are  under  30. 
Candidates  must  be  doubly  qualified,  and  the  choice  will 
usually  fall,  otherthings  being  equal,  on  those  who  have  held 
hospital  appointments.  Before  being  definitely  appointed 
candidates  will  be  medically  examined  by  one  of  the  con- 
sulting physicians  of  the  Colonial  Office : Sir  J.  Rose 
Bradford,  K C.M.G.,  8,  Manchester-square,  London,  W.  ; 
Sir  J.  Hawtrey  Benson,  57,  Fitzwilliam-square,  Dublin  ; 
Lieutenant  Colonel  J.  Arnott,  I.M.S.,  8,  Rothesay-place, 
Edinburgh;  and  W.  T.  Prout,  Esq.,  C.M.G. , 14,  Rodney- 
street,  Liverpool. 

East  AJrican  Protectorates. — Medical  Officers  in  the  East  Africa, 
Uganda,  Nyasaland,  Somaliland,  and  Zanzibar  Protectorates  are 
appointed  on  probation  in  the  first  instance  for  three  years,  at  the  end 


400  The  Lancet,] 


THE  COLONIAL  MEDICAL  SERVICE. 


[August  30,  1919 


of  which  period  their  appointments  are  made  permanent  if  their 
service  has  been  satisfactory,  but  special  arrangements  are  now  in  force 
in  Uganda.  The  salary  of  a Medical  Officer  during  probation  is  £4b0 
per  annum  fixed,  but  ass  ion  as  he  has  been  confirmed  in  the  permanent 
appointment  his  salary  rises  by  annual  increments  of  £20  to  £500  per 
annum,  with  duty  allowance  of  £50  a year;  and  aft<r  six  year*’ 
service,  £525,  rising  by  annual  increments  of  £25  to  £6C0  a year  with 
duty  allowance  of  £50  a year.  There  are  23  appointments  of  this 
nature  in  the  East  Africa  Protectorate,  14  in  Uganda.  11  in  Nyasaland, 

4 in  Zanzibar,  and  3 in  Somaliland.  In  the  East  Africa  Protectorate 
there  are  certain  special  appointments  — viz.,  Deputy  Principal  Medical 
Officer  (£750-25-850  and  £75  duty  allowance).  Bacteriologist 
(£600-25-750,  duty  allowance  £60i.  Assistant  Bacteriologist  (£500-25-600 
dutv  allowance  £50),  two  Senior  Medical  Officers  (£6°0-25-750,  duty 
allowance  £60),  Principal  Sanitation  Officer  (£750-25-850  duty 
allowance  £75),  13  Medical  Officers  of  Health,  graded  as  Medical 
Officers.  In  Uganda  the  p >st  of  a Deputy  Principal  Medical  Officer 
is  under  consideration;  here  are  two  Senior  Medical  Officers,  a 
Bacteriologist,  and  a Medical  Sanitarv  Officer  at  £600-25-750,  with  duty 
adowance  of  £60.  and  a Medical  Officer  of  Health  on  the  same  scale  as 
a Medical  Officer.  In  Zar  zibar  there  is  a Medical  Officer  of  Health 
graded  as  a Senior  Medical  Officer,  and  an  Assistant  Medical  Officer  of 
Health  graded  as  a Medical  Officer,  with  allowances  of  £100  and  £50 
respectively,  subject  to  their  possessing  the  Diploma  in  Public  Health. 
The  sa’ary  attached  to  the  appointment  of  Principal  Medical  Officer 
in  the  East  Africa  Protectorate  and  Uganda  is  £850  per  annum,  rising 
to  £1000  per  annum  bv  annual  increments  of  £50,  and  duty  allowance 
£85;  in  Nvasaland  £750-25-850  and  duty  allowance,  £75;  and  in 
Zanzibar  £600-25-750  and  duty  allowance,  £60.  The  Head  of  the 
Medical  Department  in  Somaliland  is  graded  as  a Senior  Medical 
Officer.  Medical  Officers  are  permitted  to  take  private  practice  on 
the  understanding  that,  they  give  precedence  to  their  official  duties. 

Stiaits  Settlements.1  Medical  Officers  are  appointed  as  House 
Surgeons  or  Assistant  Health  Officers  at  a salary  of  £350.  After  one 
year’s  satisfactory  service  House  Surgeons  are  appointed  Medical 
Officers  with  salary  rising  from  £400  to  £600.  Above  this  clas9  there 
are  nine  senior  appointments  carrying  salaries  ranging  from  £600 
(rising  to  £720)  to  £750  (rising  to  £900).  The  Principal  Civil  Medical 
Officer  receives  £1050,  rising  to  £12C0.  Duty  allowances  are  attached 
to  all  appointments  and  free  quarters,  or  an  additional  allowance  in 
lieu  thereof,  are  given  to  House  Surgeons.  The  authorised  establish- 
ment is  at,  present  32  officers. 

Federated  Malgy  States.1— Appointments  are  graded  a9  follows 
Principal  Medical  Officer,  £1050  to  £1200;  Senior  Medical  Officer, 
Perak,  £750,  rising  to  £900;  Senior  Medical  Officer,  Selangor,  £800, 
rising  to  £1000 ; seven  Medical  Officer?  Grade  I.,  £600,  by  £20  annually 
to  £720;  18  Medical  Officers,  Grade  II  , fr'350,  and  after  one  year’s  satis- 
factory service  £400,  rising  to  £600,  with  free  furnished  quarters, 
without  private  practice.  The  Senior  Medical  Officers,  in  Perak 
and  Selangor  and  the  two  Grade  I.  Medical  Officers  in  charge 
of  Negri  Sembilan  and  Pahang  are  allowed  consulting  practice 
only.  Other  Medical  Officers  are  prohibited  from  private  practice 
except  in  very  special  cases  where  the  Chief  Secretary  is  satistied 
that,  owing  to  the  absence  of  private  practitioners,  it  is  absolutely 
necessary  to  allow  the  Government  Medical  Officer  to  attend 
to  private  patients.  The  posts  of  Medical  Officer,  Grade  II.,  in  the 
Federated  Malay  States  and  the  corresponding  appointments  in  the 
Sftraits  Settlements  are  filled  by  the  promotion  of  officers  who  have 
entered  the  service  as  House  Surgeons.  A non-pensionable  allowance, 
varying  w-ith  the  appointment,  is  attached  to  a 1 medical  posts  in  the 
Straits  Settlements  and  Federated  Malay  States.  In  the  case  of  House 
Surgeons  the  allowance  is  at  the  rate  of  £40  a year. 

Seychelles.— There  are  four  medical  appointments.  The  Assistant 
Government  Medical  Officers  receive  Rs.5000.  The  holders  of  these 
appointments  have  free  quarters.  Private  practice  is  allowed. 

Weihaiwei.— There  are  two  non-pensionable  Medical  Officers  on 
salaries  £400-25-500,  with  free  quarters. 

British  Guiana.— There  are  35  appointments.  Candidates  must  have 
held  for  at  least,  6ix  months  a resident  medical  appointment  in  some 
public  institution.  Officers  are  appointed  on  two  y ears’  probation  as 
assistant  medical  officers,  and  are  paid  a salary  at  the  rate  of  £300  per 
annum,  with  quarters,  without  the  right  to  private  pracice.  The  per- 
manent staff,  to  which  officers  may  be  appointed  at  the  expiration 
of  the  probationary  periol,  in- ludes  the  following  appointments: 
Surgeon-General,  £9  0,  with  travelling  expensesand  consulting  practice  ; 
Bac  eriologist  and  Pa  hologist,  £300  to  £600;  14  Medical  Officers  at 
£500  to  £600  ; 17  Medical  Officers  at  £300  to  £500;  and  two  at  £300 
Officers  on  the  completion  of  two  years’  service  in  the  fixed  £300  cla>s, 
automatically  rise  to  the  £30G-£400  class.  Medical  officers  appointe  i 
to  districts  receive  travelling  a lowanccs  varying  with  the  nature  of  the 
district.  They  are  also  allowed  private  practice.  Medical  Officers 
attached  to  public  institutions  arc.  in  general,  allowed  free  quarters, 
and  receive  a duty  allowance.  A deduction  of  4 per  cent,  is  made 
from  their  salaries  for  the  payment  of  the  premiums  on  an  insurance 
of  the  officer’s  life  for  the  benefit,  of  the  widow  or  orphans.  The 
Governor  has  the  power  to  appoint  private  practitioners  on  temporary 
agreements  to  perfo  m the  duties  of  me  deal  officers  of  districts. 

Trinidad  and  Tobago. — In  TrinMad  and  Tobago  there  are  over  40 
appointments.  Officers  are  appointed  in  the  first  instance  on  two 
years'  probation  as  supc  numeraries  and  are  eligible  for  appointment, 
as  Government  Medical  Officers  at,  the  end  of  this  period.  Applicants 
must,  be  unmarried  and  must  remain  unmarried  whilst  supernumerary 
Medical  Officers.  Supernumeraries  receive  a salary  of  £250  per  annum 
with  furnished  quarters,  and  are  usually  attached  to  the  Government 
hospital.  Government,  Medical  Officers  receive  sa'arv  at  the  rate  of 
£250  per  annum  with  quinquennial  increments  of  £50  accruing  from 
the  date  of  first,  app  in’ mem  as  •'iipernumerary  Medtcal  Officers.  Most 
a»e  employed  as  District  M«dieai  Offi  e»s,  with  privnte  p act  ice,  a 
residence  or  a rent  allowance  of  £50,  a horse  allowance,  except  in  one 
district,  and  in  some  cases  other  allowances  for  institution  work.  All 
officers  are  required  to  contribute  4 per  cent,  of  their  salaries  towards 
the  pensions  of  the  widows  and  orphans  of  public  officers. 

Windward  Islands  (Grenada,  St.  Lucia,  St  Vincent). — The  25 
appointments  are,  with  few  exceptions,  distiict  app  intments  with 
the  right  to  private  practice  attached  ; the  salaries  pai  . by  Government 


1 In  the  Straits  Settlements  and  Federated  Malay  States  all  perma- 
nent Government  servants  are  required  to  contribute  4 per  cent,  of 
their  salaries  towards  the  provision  of  pensions  for  the  widows  and 
orphans  of  public  officers. 


vary  from  £250  to  £350,  with  allowances  in  certain  cases.  The 
Governor  has  the  power  to  transfer  a medical  officer  from  one  island  to 
another  at  hi*  discretion.  The  appointments  are  pensionable. 

Leeward  Islands  (Antigua,  St.  Christopher  and  Nevis,  Dominica, 
Montserrat,  Virgin  Islands). — The  24  appointments  are  of  the  same 
nature  as  in  the  Windward  Islands,  but  are  not  pensionable.  An 
officer  w hen  fust  sent  out  is  not  appointed  to  a particular  island  bnt  to 
the  service  of  the  Leeward  Islands,  with  a salary  of  £ib 0 or  £300 
according  to  h tat  ion,  and  the  Governor  decides  as  to  the  district  which 
is  to  be  allotted  to  him.  He  is  liable  to  be  transferred  to  any  medical 
district  in  the  Islands,  and  in  certain  districts  he  may  be  required  to 
perform  magisterial  duties  The  medical  officers  receive  fees  for 
successful  vaccinations,  post-mortem  examinations  attendance  and 
giving  evidence  at  courts  of  justice,  certificates  of  lunacy,  and,  in  the 
larger  islands,  for  burial  certificates.  They  ate  also,  as  a rule,  allowed 
private  prac’  ice. 

British  Honduras.— There  are  seven  medical  appointments  (besidee 
the  principal  post  of  Colonial  Surgeon)  each  carrying  a salary  of  §1701) 
per  annum.  Unless  they  already  poises*  a Diploma  of  Public  Health, 
medical  officers  are  liable  to  be  required  before  they  join  the  colony  to 
undergo  a course  ot  instruction  at  a laboratory  of  public  health  or 
analogous  institution.  The  dollar  = about.  4g.  2 d 

Fiji  and  the  Western  Pacific. — In  Fiji  the  Government  Medical 
Officers  receive  a salary  of  £4  0,  rising  by  annual  increments  of  £25  to 
£500,witn  pvrtly  furni-thed  quarters,  ora  house  allowance  of  £50.  In 
some  districts  a medical  officer  is  also  a magistrate  wif»  a combined 
salary  of  £500,  rising  to  £600,  with  free  quarters.  They  are  allowed 
privaie  practice,  so  ftr  as  is  consistent  with  the  proper  discharge  of 
their  duty  to  the  Government,  but  in  most  districts  the  priva’e  practice 
is  very’  small.  In  districts  where  there  is  no  private  practice,  an  allow- 
ance "f  £50  a year  is  grafted.  The}’  are  required  either  to  take  charge 
of  hospitals  or  of  districts,  at  the  discretion  of  the  authorities.  The 
posts  are  pensionable.  There  are  at  present  18  Medical  Officers,  three 
of  whom  are  also  Magi -t  rates,  in  addition  to  a Chief  Medical  Officer 
(£700  a year,  rising  to  £800),  a Medical  Officer  of  Health  (£500,  rising  to* 
£600),  and  a Senior  Medical  Officer  (£450- £500)  The  medical  services  of 
Fiji  and  the  Western  Pacific  are  interchangeable.  While  serving  in 
the  Western  Pacific  Protectorates  their  duties  may  be  of  a quasl- 
magisterial  nature,  and  they  draw’  an  extra  non-pen*ionable  allowance 
of  £50  per  annum. 

Cyprus.  - There  is  a Chief  Medical  Officer  paid  at  the  rate  of  £550  per 
annum,  and  three  Di-trict  Medical  Officers  paid  at  the  rate  of  £3*0  per 
annum,  all  enjoying  private  practice  (except  the  Chief  Medical  Officer, 
who  is  allowed  consulting  practice  only)  and  receiving  2s.  per  diem 
forage  allowance;  the^e  are  the  only  medical  appointments  in  the 
island  which  are  open  to  English  candidates. 

Gibraltar.  - The«e  is  a surgeon  of  the  Colonial  Hospital  receiving 
£400  with  fuel  and  light  allowance*,  and  private  p actiee.  He  also 
receives  £50  for  medical  examination  of  school  children.  There  are 
also  two  Assistant  Surgeons  with  a salary  of  £350  per  annum,  wrho  are 
allowed  private  consulting  practice  only.  Free  quarters,  unfurnished, 
are  pr  video  for  all  three  officers. 

St.  Helena. — The  Colonial  surgeon  at  present  receives  £270  per  annum 
£20  fees  as  Health  Officer,  and  £27  horse  allowance.  Pri  ate  practice 
is  allowed.  The  Assistant  Colonial  Surgeon  receives  £350  a year  *nd  a 
horse,  with  forage  allowance;  but  no  private  practice  is  allowed  without 
special  permission. 

Falkland  Islands.— There  are  two  appointments.  The  Colonial 
Surgeon  is  paid  at  the  rate  of  £350  per  annum,  with  £25  as  Health 
Officer.  The  Assistant  Colonial  Surgeon  is  paid  at  the  r*»te  of  £400  per 
annum  without  quarters.  Part  of  the  salary  is  provided  from  private 
sources.  Private  practice  is  allowed  to  the  Colonial  Surgeon,  and  to  a. 
lesser  extent  to  the  Assistant  Colonial  Su-geon. 

Leave  and  Passages.— In  the  East  African  Protect  «ra  e*  leave  of 
absence  on  full  salary  is  granted  in  the  normal  case  after  a tour  of 
residenti  A service  (of  not,  less  than  20  nor  more  than  30  momh-)  to  an 
amoum  of  five  days  for  each  completed  month  of  resioeno*  tor  2^  days- 
when  for  any  reason  the  officer  is  nut  returning  to  East  Atrica)  exclusive 
of  the  periods  of  the  voyages  to  and  fro.  Officers  serving  in  Uganda, 
Zanzibar,  or  in  certain  stations  in  the  East.  Africa  and  Nyasaland  rro- 
tectorates  are  allowed  six  or  three  days'  leave  respectively  in  respect 
of  each  month  of  service.  In  Somaliland  special  leave  regulations 
exist  which  provide  for  an  officer  taking  leave  approximately  every 
year.  Free  first-class  pas*a«es  are  provided  for  the  officer  only.  Ii> 
t he  Malay  Peninsula  two  months'  leave  of  absence  with  full  ~ai  iry  may 
be  granted  in  respect  of  each  year  s service,  and  th  s leave  may  be 
accumulated  up  to  a maximum  « f eight  m »nths.  Add  tional  leave 
on  half  pay  max  be  granted  on  special  grounds.  If  an  officer  « n the 
occasion  of  his  fir  t leave  Is  in  receipt  of  a pensionable  salary  of  less 
than  t5C0  a year,  he  is  granted  a free  return  passage  to  the  United 
Kingdom.  In  Hong- Kong  leave  of  absence  on  half  salary  may  be 
granted  after  4$  years’  service,  and  a p >rtion  of  such  leave  in  »y  l»e 
commuted,  if  the  Governor  agrees.  f'»r  half  the  amount  on  full  pay. 
Leave  of  absence  in  excessof  10  months  at  * time  will  not  b-*  grained,  but 
an  extension  may  be  allowed  for  ill-health  or  very  urgent  private  a£f  »irs. 

Subject  to  the  necessities  of  the  service,  leave  of  absence  on  half 
sa'ary  may  be  granted  to  officers  in  other  Colonies  on  sine  tropical 
Africa  after  a period  of  six  years’ resident  service  with-  u»  any  special 
grounds.  Officers  of  th  Fiji  and  Western  Pacific  service  prop  sing  to 
spend  their  leave  in  Eur  pc  may  receive  a grant  in  aid  ot  passage 
expenses  of  £60.  Le*ve  may  be  given  before  the  expiration  of  ti  e due 
period  in  caseof  serious  indisposition,  or  of  urgent  privaie  affdrs  Irv 
the  ab-ence  of  special  gr  unds,  the  leave  must  n t exceed  one-sixth  of 
the  officer  s resident  service;  on  special  grounds  it  may  exceed  that 
period  by  six  months.  In  addition  to  the  above,  vacation  leave  oft 
full  pay’  may  be  granted,  if  no  inconvenience  or  expens**  is  caused 
thereby,  not  exceeding  three  months  in  am  two  years.  In  »he  caseof 
Fiji  Hint  the  Western  Pacific  and  the  Falkland  Inlands  4g  months 
leave  may  he  granted  in  any  three  years. 

On  first  appointment  an  officer  whose  salary  and  fees  together  do  not 
exceed  £500  a year  will,  except  in  the  case  of  a few  » olonie»  uossesstng. 
Repre-entativeAsseublies.be  provided  by  the  Grown  A ente  tor  the 
Colonies  with  free  passages  to  the  C lony  for  himself  ami  bis  wde 
and  children,  if  any,  n t exceeding  four  persons  besides  himself.  The 
officer  so  appointed  will  be  required  to  execute  an  agreement  finding 
him  to  repay’  the  cost  of  the  passage  or  parages  so  ob'ained  in  the 
event  ot  his  leaving  tbe  Government  service  within  three  y ars.  Tnia 
rule  applies  also  to  officers  appointed  to  the  Malay  Peninsula  and 
Hong-Kong.  An  officer  taking  leave  out  of  the  Colony  has  to  provute 
his  own  passages. 


Thh  Lanckt.J 


the  colonial  medical  service. 


AM^U  7nlt.ecuZaes  are  rt*  C?vfct|e‘tabUBf“?nt  ***'■ 

f°years'  ,Ear,ier  retirement  in  the^vent  oninieah  h"1''^  the  "Ke  of 
*or-  pensions  me  computed  on  the  . a|th  Illso  provided 

annual  .salary  of  the  retiring  office rVnxld  .r  °“r6ixtie!h  ,,f  «>e  average 
P>  mr  to  re.  iremen. . but  for  purposes  of  me'ds  -f°r  ,hree  ^ars 

service  i»  reckoned  as  servicelnr,  Penslo,'s  two  years' 

Colonies  an  officer  holdiri"  a nensionaldo  yuar?\  1,1  most  of  the  other 
in  .he  case  of  illdmalth  o re^  may  bo  allowed 

resident  service,  otherwise  be  ml, et  hi S '-n  aftor  ten  full  years' 
ten  full  , ears’  resident  service  lifteen  ». r®  "ttained  the  age  ol  55.  For 
salary  of  the  retiring  officer's  fixed  aupoiidum  V*  ^ th?  ave|  age  annual 
to  retireni  nt  may  be  awarded,  to  whidi  ?•  o thr<>e  yearfi  Pril’<' 

each  addu lonal  year's  service  . but  n '.  add  -n  u may  be  added  for 

of  any  service  beyond  35  years  IV  ,!.  wdl  1>e  made  in  respect 
vacation  leave  counts  as  full  service  f " PurP''ses  absence  on 
ser.  ice.  I„  a few  cases  the  retiring  a™  is  Rn  ,1Tk0"  half  PaF  as  half 
years  service  is  ten-sixtieths  instead  of  fifteen  d pension  after  ten 


[August  30,  1919 


West  African  Medical  Staff 

^fotectorates 

Secretary  of  State  for  the  Colonies and  frvle«are  elected  by  the 
and  promotion.  As  in  other  Oolon  g l r one  llst  for  employment 
and  o5  years  of  age  and  possess  a double  lP\C.«n,s  must  he  between 
,s  Si'en  to  those  over  25  The  L<rher  ffqr^  ,Catl0ri'  but  Preference 
promotion  from  the  lower.  "her  grades  are  usually  filled  by 

The  OmectOT1 of  t h/e  *Med ical  and^nlt^  “5?  Staff  are  as  f»"ows 
a salary  of  £1400  a year  with  a d ,tv  y Serv,ce  in  Nigeria  receives 

Principal  Medical  Officer  Th  VJ  T,at  the  rate  of  t 280 ay Zr 

salaries  as  follows  . In  thHl'old  rw  “P  ..  M^dicaI  Officers  receive 
Nigeria  £1200  a year  with  a dotv  all  a"d  the  Southern  Provinces  of 
*“  Nigeria  (Northern  Provinces)  £1100  at  tbeurate  of  £240  a year 
aUnw!^  rate  °f  £220ayear.  In  lierraLeon^  * duty  allowance 

<Offic.r'h,ethe  Gambia6  °f  £20°  a year-  There  is  noVr/ncipa’/1  Vetfcal 

th' NM'ahe’  tW°  Southe^^ftovin^e^o^lf'  f°Ur  aPPointments  of 

the  mi'e’  oM “sSffi? riling  Coast^fpeeUv^^sZy  it 

year,  is  attached  re  these  apporntm^nts  to C0re™e,,ts  of  £25  to  £1000  a 
ance  at  the  rate  of  £180  a year  * ’ together  with  a duty  allow- 

bemor  Sanitary  Officer  • Tho'ro  „„„  c 
two  in  Nigeria,  one  in  the  Gold  Coast  an^  appoh‘tmer!ts  of  this  grade, 
at  the  rat  e ot  £900  a year,  rising  bv  annual  / Slerra  Leone.  Salary 

ayear(inS.enaLeonero£950mdv) Ts„tt  ,,n<Tements  of  £25  to  £1000 
together  with  a duty  allowance  ’a  ftbe rate o/pwn th6Se  Wolntmento" 
Provincial  Medical  Officer  ■ tu™  te  ' il8°  a year, 
title  (ton,  in  Nig.  ria,  two  in  the ^ Gold  Coas"  ap/f'ltn’.rnts bearing  this 
with  sa  a-y  at.  the  rate  of  £800  a vear  lnd  one  ln  Sierra  Leone) 

£25  TO  £900  a year,  and  duty  allowance’at  the  /X  inerements  of 

Sen.or  Medical  Officer.  There  are  20  ^ 6 °f  £16°  a Pear. 

£25^toa£7^iat  the  rate  °f  £60°  a year,  rising°hJ °'f  tMs  grade’ 

±,/o0  a vp*ar,  and  a dntu  oiiv.,,  11  ^ nyanf*ual  increments  nf 

The  Senior  Medical  o£r  of  fhe  G^bia  d^  ,he  "“S9  of  £120  a year 
£120  a yean  m addb  ion  to  duty  pay  bit  is  on  „'nStaff  pay. at  ,he  rafe  of 
Sanitary  Officer  . There  are  seven  1,11  allowed  private  practice 
salary  at  the  rate  of  £700  a , ear.  ris^ng  by  annlfa'l  f °f  tbis  srade'  w»h 

“e^aT^em  a/i  ^ °f  £25  t0 

^uty  allowance'at^he'^ate0^8^©0^^6^8  ^^20  to  i'SO^^yeamwith 

pla^d’  on'^^  endV  of 

1 00^e^T,tS  1 tv"  f 

=erv.d  for  three  years  on  fhe  maximum  A.  Mpdical  Officer  who  has 
at  the°  rafe°of  ^ 

rif^^^^'^^^^’^h^Institute6^  ^a|Ib”*‘1'^'s°at^fccra.  Assist* 

‘ns;::  !?*r^  | 

staff  pav  at  the  rate  of  £100  a year  is  also  atraci  “r  ? P>'v  (£10°  a year)  1 
the  h„l  e.  of  the  at, pointmeni draws  hffi  of  en  ® .‘S,*11636  »"  ***  ; and 
of  ab-euee.  the  remainder  being  drawn  hi  n-  sfaff  PaP  during  leave 

Leave  and.  Passages.— The  ordinary  tn  ^ ^is  ocnm  ^nens.  ^ 

Enela  °d  ""I'1,  by{  'ea''e  witowTOfei  ;Zide''tia'  service  is  one 
ii/ngland.  and  forfnn*.^  + • y-  ri  v^yages  to  and  from 


duties,8  but  pow1eerno/,etrh°erGan00  °f  thelr  "f'bdal 

at  the  majority  of  staUons  a°nd  i TtJ™0?™,  does  "<>t  exist 
exigencies  of  the  service,  stations  when  Rfnera.1  r**><*.  subject  to  the 

ullocated  to  senior  members  of  the  staff  U‘er°  18  pnvale  practice  are 

1 ensions  cind  Gratuities  

regulations  ,f  eacl.  Colony  hti?  gemwad  acc'f rdanee  will,  the 

Which  'f1".8  (he  ot'  50  years  or  ,tpeakm<?  ftn  ofIi"tr 

which  at  least  12  must  have  been  ^esffieuti  ,,y-arB  eervice  (<>f 
a pension  calculated  at  one-fortierh  of  ul  ,a  l ls  cillali('e.t  for 
for  each  year  of  service.  If  invalided  aft  *G  b'S^  annualti  svlary 
years’  service,  he  is  qualified  for  a nensim!  r f n?'!?imum  of  •seven 
rate.  If  invalided  before  completi^  sevL  Cu  ated  at  tho  same 
qudified  for  a gratuity  not  exceeding  th  60  yearB  service  he  is 
salary  for  each  Six  months  of  se^vSlrovh  ed^e^8  ,°f  a mo-‘th's 
firmedm  lus  appointment.  For  the  mirnoKc  ofam  i1®  bas  b,en 
of  these  pensions  and  gratuities  leav?  lP  . f calculal,nS  the  amount 
counted,  .bile  leave  with  Llf’ fa?arr  isle  rV V'tbo"t  sala,  V is  not 
month  for  every  . wo  months “f  such  iJale  An  the  rate  of  'ine 
tbe  value  of  free  quarters,  is  made  to  the  1od’  rePrp sentinff 

ls[ as  follows.  To  salaries  of  £400  a This  addition 

above  £400,  but  not  exceeding  £500  an  ..  °J  £^5 ; to  salaries 

above  £500.  bn.  nut  excetdi,  f £700  a"  Jl  t'.on  of  £50;  to  salaries 

above  £7(0.  but  not  exceed/, If  £9ro’  add'tIon  of  £60;  to  salaries 

exceeding  £900.  an  addition  f ,^£80  fi-/?  of  £7°  : to  salaries 

rpgulatioiis,  an  officer  of  the  West  Afriean  M JV.011.  ’^e  9rc^natT 

following  special  privilege  At,  the  end  nf  ni  e(1lca  Staff  enjoys  the 
less  than  six  must  have  neen  reside,  tial)  he  w,'ne,'VearS  ^of  wh'ch  not 
with  a grat  uity  of  £1000.  or  a,,  t he  end  , f 1?  vl be  P^mittef  to  retire 
than  eight  must  have  been  residential)  wdh  J ! (of  which  n' t less 
claims  to  pensions  are,  h,  wever  thrfhiteri  nlg/h  U,ty  of  £125°  A" 
gratuity  In  the  event  of  an  offiler  dv!nc  in  , h reC"pt  of  such  a 
pleting  the  period  of  residence  oualifvh  ff  f®rvlce  after  com- 

■arger  of  these  gratuities  T sl?m  ^ the  smaller  or  the 

Will  be  paid  to  the  credit  of  his  estate  8ratuity  in  question 

take  their  wives  out  with  them  Imii  tn  °fce's  are  not  allowed  to 
of  the  local  conditions,  and  have  obtained  the^f/fr01^ 'frert  Kpe’ieilce 
Passages  for  wives  end  children  are  not  provfdfd  “ tbe  Governor. 

ferred  afterwards  if  necessarv  tn  lu  instance,  or  trane- 

Protectorate  at  the  discfltion’of  the^ef™/  Wes,t  African  Colony  nr 
Who  wish  to  be  posted  to  1 j&0,St“&  Candidltes 
should  be  able  to  ride.  Candioates  shMdd  Provmces  of  Nigeria 
for,  or  accept  a West  A-rican  armointu  / n°  acc°unt  a,.,  lv 
ultimate!-  being  transferred  elsewhere  as  thl  n/"  nhe  ,exPect!’«on  of 
is  exceedingly  small.  No  applications’  tort  Z I f ^ber  of  such  ’ransfers 
until  an  ..fficer  has  served  for  fi,  e vears  in* / can.  be  entertained 
Staff,  and  officers  desiring  to  lit  trll,  the,ffescAfric!m  Mwiral 
to  find  that  medical  sanies  in  other  nf  -must  be  Prepared 
in  West,  Africa.  Only  a small  r.tlll.f  CoI°oies  are  lower  than 
in  obtaining  a transfer.  Office, s who'°m  aPP*icanfs  succeed 

pens, ona, , le  appoin-menrs  under  the  cT.  wu^?y  transferred  to 

A no,  do  not  forfeit  ,heir  cWfc  to  ^,,?*ewhere  tban  in  West 

African  service  or,  final  retirement  uPen-j°r  m reePect  of  their  West 
of  the  staff  tnr  at  least  12  mmdhs  ’ tbey  ha'e  been  memners 

Instruction  in  Tropical  Medicine  j.. 

appointment  will,  unless  the  Secretary  of  Stltfa?  .nate  8elecfed  for 
If/TJrlt  a course  of  5.^-e.  he 


Leave  granted  on  the  undersSdinl' 'Tg  *S  be  fs  returning  or  nol 

known  as  • ret.'  rn  leave  d S t'bat  an  officer  w-11  retnim  ; 

with'haif' ’ b®  rfunded  >f  he  doesliotle't.iTrn"  'j’„resPe<‘t  of  such  leave 
with  half  pay  fur  a period  not  exceedinf/f  Lpave  may  be  extended 

« ba.i  romithoutnpay  - the  sr°^f 

given  t h 11  officers  who  are  granted  leavp  ?nd  ‘ Free  Passages  are 

finit  Hppc,  nf  ment,  subject  to  the  free  passaS:e  is  also  given 

under  whud,  he  iR  M,bIe  to  refund  its  J?oSt  ^h7  r*"in.*  an  freemen? 

appointment/08’  Hd,f  P'y  ’s  dU'i„g  the  vo^e  ^t  on  firsl 

Offi^rf  "12  Staff  except  Ptincipa,  Medina, 

Samtaiy  Officers,  and  a few  mher^ffi'"'  Pr?v,ri,'ia1  Medical  Officers1 

■*  w— • *»•>«  ••  —tsafjsajg&sstg 


Scbeo  of  Tropical  Medicine  at  thc  Unh e/  i / t'r*  at  tbe-»w»i 
of  the  tuition  fees,  hoard,  and  residence ^ dT,°-f  L,verP°o1-  Th- cost 
amounting  to  a maximum  of  £48  8,s  1M  w 8uch  instruct, on, 
home  W the  Government  in  the  ease  oft he!  is  thare!  m,onfhs.  will  be 
thecost,  oftuiti  n will  r,e borne  bvlheo/,L.dl ?eh°o1  J ' t Liverpool 
makethe’r  own  arrangetnents  for  board  miH  l bu!:  candidates  must, 

a week  will  he  paid  to  them  monthly  in  auMHnmhi  an  al,owanc'e  <>f  £2 
allowance  of  5s.  (hut  no  salary)  will  be  paid  to  ol  n P«rP,,se.  A ai-y 
in  ar,  ear.  during  the  course  and  may  be  conl'm  i 0a,[dldate.  monthly 
the  date  of  embarkation.  These  DavmentJ nu®d  subsequently  up  to 
candidate  if  he  declines  to  accent  ^ / -USt  be  refunded  by  the 
Colonies  or  Protectorates  for  which  he  aPP''[ntm®ut  in  any  of  the 
obtain  a certificate -bowing/ TbaJ be  hS " bd  fails 
or  if  he  relinquishes  the  West  Afric  atlshed  the  school  authorif ies, 
than  mental  or  physical  ifirmfl  ol  i/™6  f°r  any  otbpr  reason 
vvithm  three  years  of  the  date  of  hTs  am  1S 1 ^er?iJVed  for  misconduct, 

I “nd  of  the  session  there  exist  n,,  1/LIS21  "‘  West  Africa.  If  at,  the 
didate  can  he  appointed  he  will  be  placed’ in^V^  t0  Whi^*  a can‘ 

vacancy/8"06  the  rate  uf  £2°«  a ^tSil  ^ZluTrL^Tl 

s> udy Isltlle  ZeZ  ^ntS’^^^ofthe  W^’7?6  approved  of 

College  or  the  London  IcW.I  of  Chn  cYl  m ^P-d°n  P°st-Graduate 
clinical  medicine;  clinical  surgerv°and  nathi, ^edlcl2?2.'  Greenwich,  in 
t-  substitute  for  this  course  either  the  course  oP,’  ®ffice/s  are  allowed 
for  a recognised  diploma  or  degree  ini nubile health  y a-ld  examiuation 
State  medl.ine;  the  course  of  stud,  .!/  ea,f.h- sanitary  science,  or 
medical  or  surgical  diploma  , r degree  f°r  a fur  b‘r 

recommendation  of  the  Principal  Medici  in*  the  G"vernor,  on  the 
of  study  in  some  special  branch  of  medic*  l CGr’  aPProves~a  course 
ophthalmology , dermatoiogylglnitomHnSl^  SUr«leal  Practice  (e.g.. 
23"fse  at  the  London  or  yLiverpo,,rSch7offrS “5?^*  °-r  an  advanced 
Whichever  «.f  these  courses  „f  study  s selected  fthTr°plCaI  Mediei„e. 
and  examination  fees  will  he  paid  by  thllol Sr?"  n<,oessary  tu-tion 

**  ^ ^ «,». 

always  insisted  upon  and  that  in  \ dppo,Ptments  are  not 

temporary  war  bon^sau^tt^theLrarynUmber  °f  C88es  a 


within  three  years’  of PhisS’reti /ement °i?caleulhfD^a  be6n  Pr'  moted 
hie  salary  for  the  last  three  years/  * calculated  on  the  average  of 


402  The  Lancet,] 


DIPLOMAS  IN  STATE  AND  TROPIC  VL  MEDICINE. 


[August  30,  1919 


DIPLOMAS  IN  STATE  AND  TROPICAL 
MEDICINE. 


As  usual  we  include  in  the  Students’  Number  of 
The  Lancet  an  epitome  of  the  instruction  given  at 
various  universities  and  centres  of  medical  education  to 
medical  men  desiring  to  obtain  diplomas  in  sanitary  science, 
pubWc  health,  State  medicine,  and  tropical  medicine.  During 
the  war  some  of  this  work  has  been  suspended,  for  both 
teachers  and  taught  being  already  registered  medical  men 
have  been  required  in  other  spheres.  But  the  public  health 
of  the  country  and  of  our  colonial  dependencies  must  be 
maintained,  for  this  is  one  of  our  greatest  guarantees  of 
ultimate  success  in  the  struggle  of  endurance ; and  the 
machinery  for  the  special  education  of  public  medical 
servants  exists,  as  appears  from  what  follows,  and  is  ready  to 
resume  full  activity  at  the  earliest  opportunity. 

Resolutions,  designed  with  a view  of  ensuring  “ the 
possession  of  a distinctively  high  proficiency,  scientific  and 
practical,  in  all  the  branches  of  study  which  concern  the 
public  health,”  have  been  adopted  at  various  times  by 
the  General  Medical  Council  from  1902  to  1911.  Certain 
universities  and  corporations  grant  qualifications  in  Tropical 
Medicine  which  have  not  as  yet  been  made  registrable  by 
statute. 

University  of  Oxford.  — An  examination,  conducted  partly  in 
writing,  partly  viva  voce,  and  in  each  subject  partly  practical, 
is  held  in  Michaelmas  and  Trinity  Term  in  the  following 
subjects : — General  Hygiene,  General  Pathology  (with 
special  relation  to  Infectious  Diseases),  the  Laws  relating  to 
Public  Health,  Sanitary  Engineering,  Vital  Statistics.  The 
examination  is  in  two  parts,  which  may  be  taken  together  or 
separately  ; but  Part  I.  must  be  passed  either  before  or  at 
the  same  examination  as  Part  II.  The  fee  for  admission  to 
the  examination  is  £5  for  each  part.  Successful  candidates 
are  entitled  to  receive  the  Diploma  in  Public  Health. 

The  First  Part  of  the  examination  will  comprise  ( a ) a 
written  paper  of  three  hours  in  Chemistry  and  Physics  ; 
(4)  a three  hours’  practical  and  viva  voce  examination  in 
Chemistry  and  Physics. 

The  Second  Part  of  the  examination  will  consist  of  the 
following  parts: — («)  Two  written  papers,  each  of  three 
hours,  dealing  with  General  Hygiene  (including  Sanitary 
Engineering,  Vital  Statistics,  and  the  Laws  relating  to 
Public  Health)  ; (4)  a practical  and  viva  voce  examination  in 
General  Hygiene  ; (c)  a written  paper  of  three  hours  in 
Pathology  and  Bacteriology  ; and  (d)  a three  honrs'  practical 
and  viva  voce  examination  in  Pathology  and  Bacteriology. 

Candidates  in  Part  I.  of  the  examination  will  be  required 
to  produce  a certificate  (1)  of  Laboratory  Work  in  Chemistry 
as  applied  to  Hygiene. 

Candidates  in  Part  II.  will  produce  the  following  further 
certificates  : (2)  of  a Practical  Knowledge  of  the  Duties, 
Routine  and  Special,  of  Public  Health  Administration  ; 
(3)  of  having  had  Practical  Instruction  in  Bacteriology,  and 
the  Pathology  of  the  Diseases  of  Animals  transmissible  to 
Man  ; and  (4)  of  having  attended  the  practice  of  a Hospital 
for  Infectious  Diseases  at  which  opportunities  are  afforded 
for  the  study  of  the  Methods  of  Administration.  The 
names  of  candidates  must  be  sent  to  the  Assistant  Regis- 
trar of  the  University,  Clarendon  Building,  Oxford,  to 
whom  applications  for  any  further  information  should  be 
addressed. 

University  of  Cambridge. — Two  examinations  in  so  much 
of  State  medicine  as  comprised  in  the  functions  of 
medical  officers  of  health  are  held  during  the  year. 
Thj  examination  is  divided  into  two  parts  and  demands 
proficiency  in  all  the  branches  of  study  which  bear 
upon  the  duties  of  medical  officers  of  health  The 
examinations  in  both  parts  will  be  oral  and  practical,  as 
well  as  in  writing.  Crndidates  may  present  themselves 
for  either  part  separately  or  for  both  together  at  their 
option ; but  the  result  of  the  examination  in  the  case 
of  any  candidate  will  not  be  published  until  he  has 
satisfied  the  examiners  in  both  parts.  Marks  of  distinc- 
tion will  be  placed  against  the  names  of  candidates  who 
have  specially  distinguished  themselves  in  either  (1)  general 
principles  of  hygiene  ; (2)  bacteriology  ; (3)  chemistry  in 
Part  I.  of  the  examination  ; or  (4)  the  second  part  of  the 
examination,  which  has  reference  to  State  Medicine  and  to 
the  applications  of  Pathology  and  Sanitary  Science.  Every 


candidate  will  be  required  to  pay  a fee  of  £6  6s.  before 
admission  or  readmission  to  either  g>ait  of  the  examination, 
but  candidates  who  have  presented  themselves  before  the 
year  1896  will  be  readmitted  to  either  part  on  payment  of 
a fee  of  £5  5«.  Candidates  must  before  admission  to  either 
part  of  the  examination  produce  evidence  of  having  satisfied 
provisions  (1),  (2),  and  (3).  and  before  admission  to  Part  II. 
having  satisfied  provision  (4),  above  mentioned. 

For  Part  I.  of  the  examination  courses  of  lectures  and 
laboratory  instruction  are  given  in  the  University  by  Mr. 
J.  E.  Purvis  on  Hygiene,  Chemistry,  &c. . and  by  Dr.  Graham- 
Smith  on  Bacteriology.  Professor  G.  H.  F.  Nuttall  gives  a 
course  of  lectures  on  Protozoal  Diseases,  and  Dr.  A E.  Shipley 
on  Animal  Parasites.  For  Part  II  Dr.  A.  J.  Laird,  the  Medical 
Officer  of  Health  for  Cambridge,  gives  courses  on  Practical 
Sanitary  Administration  and  in  the  Administrative  Methods 
of  the  Infectious  Diseases  Hospital  and  Dr.  F.  Robinson, 
the  Medical  Officer  of  Health  to  the  Cambridgeshire  County 
Council,  on  Sanitary  Laws,  School  Hygiene,  Epidemiology, 
Vital  Statistics,  Ac.  These  courses  are  open  to  non-members 
of  the  University. 

All  applications  for  further  information  respecting  exa- 
minations and  the  courses  of  study  should  be  addressed 
to  Mr.  Purvis,  Chemical  Laboratory,  Pembroke-street, 
Cambridge. 

Two  Examinations  in  Tropical  Medicine  and  Hygiene  are 
conducted  yearly  by  the  State  Medicine  Syndicate  of  the 
University  of  Cambridge.  The  examinations  are  held  in 
Cambridge  early  in  January  and  in  the  middle  of  August. 
Each  examination  will  extend  over  four  days. 

Any  person  whose  name  is  on  the  Medical  Register  is 
admissible  as  a candidate  to  the  examination  provided 
(I.)  that  a period  of  not  less  than  12  months  have  elapsed 
between  his  attainment  of  a registrable  qualification  and  his 
admission  to  the  examination;  (II.)  that  he  produce  evidence, 
satisfactory  to  the  Syndicate,  that  he  has  diligently  studied 
Pathology  (including  parasitology  and  bacteriology)  in  rela- 
tion to  Tropical  Diseases.  Clinical  Medicine,  and  Surgery  at 
a Hospital  for  Tropical  Diseases,  and  Hygiene  and  Methods 
of  Sanitation  applicable  to  Tropical  Climates.  As  evidence 
of  study  and  attainments  a candidate  may  present  to  the 
Syndicate  (1)  any  dissertation,  memoir,  or  other  record  of 
work  carried  out  by  himself  on  a subject  connected  with 
Tropical  Medicine  or  Hygiene  ; (2)  any  Certificate  or 
Diploma  in  Public  Health  or  Sanitary  Science  he  may 
have  obtained  from  a recognised  Examining  Bodv.  Such 
evidence  will  be  considered  by  the  Syndicate  in  determining 
whether  he  is  qualified  for  admission  to  the  examination  and 
by  the  examiners  in  determining  whether,  if  admitted,  he 
shall  be  included  in  the  list  of  successful  candidates. 

The  examination  will  be  partly  in  writing,  partly  oral,  and 
partly  practical  and  clinical  (the  clinical  part  will  be  con- 
ducted at  a hospital  for  tropical  diseases,  at  which  cases 
will  be  submitted  for  diagnosis  and  comment),  and  will 
have  reference  to  the  nature,  incidence,  prevention,  and 
treatment  of  the  epidemic  and  other  diseases  prevalent 
in  tropical  countries.  Every  candidate  who  passes  the 
examination  to  the  satisfaction  of  the  examiners  will 
receive  from  the  University  a diploma  testifying  to  his 
knowledge  and  skill  in  tropical  medicine  and  hygiene.  The 
fee  for  the  examination  is  £9  9s..  and  applications  should  be 
addressed  to  Dr.  Graham-Smith.  Medical  Schools.  Cambridge. 

University  of  London. — Candidates  for  the  M D.  degree 
may  offer  State  medicine  as  a subject  in  which  to  graduate. 
They  must  send  to  the  Academic  Registrar  with  their  forms 
of  entry  certificates  (i.)  of  having,  subsequently  to  having 
obtained  a registrable  qualification  to  practise  Medicine, 
attended  a course  of  practical  instruction  in  a laboratory  or 
laboratories.  British  or  foreign,  approved  by  the  University, 
in  which  chemistry,  bacteriology,  and  the  pathology  of  the 
diseases  of  animals  transmissible  to  man  are  taught;  such 
course  to  extend  over  a period  of  not  less  than  six  months 
and  to  consist  of  at  least  240  honrs,  of  which  not  more  than 
one-half  shall  be  devoted  to  practical  chemistry,  (ii.)  Either 
of  having,  subsequently  to  having  obtained  a registrable 
qualification  to  practise  Medicine,  during  six  months  (of 
which  at  least  three  months  shall  be  distinct  and  separate 
from  the  above-mentioned  period  of  laboratory  instruction) 
been  diligently  engaged  on  not  less  than  60  working  days  in 
acquiring  a practical  knowledge  of  the  duties,  routine  and 
special,  of  Public  Health  Administration  under  the  super- 
vision of  a person  recognised  by  the  University  as  entitled  to 


The  Lancet,] 


DIPLOMAS  IN  STATE  AND  TROPICAL  MEDICINE. 


[August  30,  1919  403 


grant  certificates.  Or  of  having  held  for  a period  of  not  less 
than  three  years  an  appointment  as  Medical  Officer  of 
Health  of  a Sanitary  District  within  the  British  Dominions, 
and  having  a population  of  not  less  than  15,000.  (iii.)  Of 
having,  subsequently  to  having  obtained  a registrable 
qualification  to  practise  Medicine,  attended  at  least  twice 
weekly  during  a period  of  not  less  than  three  months  a 
practice  of  a hospital  for  infectious  diseases  at  which 
opportunities  are  afforded  for  the  study  of  methods  of 
administration.  In  connexion  with  this  degree  the  various 
metropolitan  medical  schools  hold  regular  classes  under 
teachers  of  Public  Health  and  Sanitary  Science,  such 
instruction  being  also  used  to  obtain  the  various  diplomas 
of  other  Universities  and  of  those  Royal  Corporations  which 
grant  them. 

University  of  Durham. — Candidates  for  the  degree  of 
Bachelor  of  Hygiene  (B.Hy.)  must  be  at  least  22  years  of 
age,  registered,  and  a graduate  in  Medicine  of  a recognised 
university.  They  must  spend  six  months  at  Newcastle-upon- 
Tyne  studying  Comparative  Pathology,  Practical  Bacterio- 
logy, Sanitary  Chemistry,  and  Physics,  and  have  to  pass  an 
examination  in  Sanitary  Chemistry,  Physics,  Comparative 
Pathology,  Sanitary  Legislation,  Vital  Statistics,  Nosology, 
Ulimatology,  Meteorology,  Distribution  of  Health  and 
Disease,  Sanitary  Medicine  and  Practical  Hygiene.  The  fee 
for  the  examination  for  the  degree  of  B.Hy.  is  £10  10s. 
and  for  the  degree  £6  6s.  Candidates  for  the  degree 
of  Doctor  of  Hygiene  (D.Hy.)  must  have  acquired 
the  degree  of  Bachelor  of  Hygiene,  must  for  two  years 
subsequently  have  been  engaged  in  Public  Health  adminis- 
tration, or  in  research  work  relating  to  Public  Health. 
The  fee  for  the  examination  for  the  degree  of  D.Hy. 
is  £5  and  for  the  degree  £10.  The  regulations  for 

examination  for  the  Diploma  in  Public  Health  (D.P.H.) 
are  the  same  as  those  for  the  degree  of  Bachelor  of 
Hygiene,  except  that  the  candidate  is  not  required  to  be  a 
graduate  in  Medicine  of  a recognised  University  and  the 
course  of  study  need  not  be  passed  at  Newcastle-upon- 
Tyne.  The  fee  for  the  examination  is  £10  10s.  and  for 
the  diploma  £3. 

Victoria  University  of  Manchester. — An  examination  in 
Public  Health  is  held  twice  yearly.  The  examination  is 
in  two  parts  and  is  written,  oral,  and  practical.  Candidates 
may  present  themselves  for  Parts  I.  and  II.  separately  or 
at  the  same  time  provided  that  no  candidate  be  admitted 
to  Part  II.  unless  he  has  already  passed  in  Part  I.  No 
candidate’s  name  will  be  published  until  he  has  satisfied 
the  examiners  in  both  parts  of  the  examination.  The  fee 
for  each  part  is  £5  5s.,  and  must  be  paid  on  or  before 
July  1st  in  each  year.  For  any  subsequent  examination  in 
the  same  part  the  fee  will  be  £3  3s.  Every  candidate  who 
has  passed  both  parts  of  the  examination  to  the  satisfaction 
of  the  examiners,  and  who  is  legally  registered,  will  receive 
a Diploma  in  Public  Health.  The  examinations  will  begin 
about  the  end  of  March  and  the  middle  of  July  in  each 
year.  Holders  of  the  Diploma  in  Public  Health  are  eligible 
for  examination  for  the  Certificates  in  School  Hygiene  and 
Factory  Hygiene  after  attending  the  prescribed  periods  of 
study  and  hospital  practice. 

University  of  Birmingham. — The  University  grants  a 
degree  of  B.Sc.  in  Public  Health  and  also  a Diploma  in  the 
same  subject  on  the  following  conditions  : Graduates  in 
Medicine  of  this  University  may  become  candidates  for  the 
degree  of  Bachelor  of  Science  in  Public  Health  by  con- 
forming to  all  the  requirements  laid  down  for  candidates 
for  the  Diploma  in  Public  Health,  except  that  after 
graduating  in  Medicine  all  courses  of  study  must  be  taken 
out  in  the  University,  and  they  must,  in  addition,  have 
attended  a three  months’  course  of  Geology  in  the  University. 
The  examinations  will  be  held  in  the  months  of  March  and 
June  and  will  consist  of  two  parts,  each  part  being  written, 
oral,  and  practical.  No  candidate  will  be  allowed  to  pass 
Part  II.  until  he  has  passed  Part  I.  Candidates  may 
enter  for  Parts  I.  and  II.  separately  or  at  the  same 
time.  The  fee  for  each  part  of  the  examination  is  £5. 
Medical  Officers  of  the  Royal  Navy  who  have  attended 
courses  in  Hygienic  Chemistry,  Bacteriology,  and  Public 
Health  at  the  Naval  Medical  School,  Greenwich,  will  be 
admitted  to  the  examinations  for  the  Diploma  in  Public 
Health,  whether  they  have  previously  been  students  at  the 
Birmingham  School  or  not ; and  the  same  applies  to  officers 
of  the  Royal  Army  Medical  Corps  who  have  studied 


Chemistry  and  Bacteriology  at  the  Staff  College  and 
pursued  the  further  course  of  study  approved  by  the 
General  Medical  Council. 

University  of  Liverpool. — The  University  grants  a Degree 
in  Hygiene  (M.H.)  and  a Diploma  (D.P.H. ),  and  every 
facility  is  afforded  for  training  in  Sanitary  Science  and 
State  Medicine.  The  curriculum  for  the  Degree  extends 
over  a period  of  two  years,  the  first  of  which  is  devoted  to 
laboratory  instruction  and  practical  classes  (including  those 
for  the  Diploma) ; the  second  being  devoted  to  advanced 
study  and  research.  The  D.P.H.  curriculum  fees  are: 
Chemistry,  £5  5s.  ; Bacteriology,  £5  5s.  ; Practical  Sanita- 
tion, £15  ; Infectious  Diseases,  £3  3s.  The  courses  may  be 
taken  out  at  any  time,  and  students  are  allowed  to  work 
daily  in  the  laboratories. 

The  University  grants  a Diploma  in  Tropical  Medicine. 
Three  courses  of  instruction  are  given  every  year.  Two 
of  these  last  for  three  full  months — the  Lent  Course 
from  Jan.  6th  to  April  5th  and  the  Autumn  Course  from 
Sept.  15th  to  Dec.  13th.  The  Third  Course,  an  Advanced 
Course,  lasts  one  month,  from  June  1st  to  the  30th. 
At  the  end  of  each  full  course  an  examination  is  held 
by  the  University  for  its  Diploma  of  Tropical  Medicine 
(D.T.M.),  which  is  open  only  to  those  who  have  been  through 
the  course  of  instruction  of  the  school.  The  examination 
lasts  three  days  and  consists  (1)  of  papers  on  Tropical 
Medicine,  Tropical  Pathology,  and  Tropical  Sanitation  and 
Entomology  respectively  ; (2)  of  a clinical  examination  ; and 
(3)  of  an  oral  examination.  The  advanced  course  consists 
entirely  of  Practical  and  Clinical  Laboratory  Work,  given  at 
the  laboratory  at  the  University.  The  fee  for  the  full 
course  of  instruction  is  13  guineas,  with  an  extra  charge 
of  10s.  6 d.  for  the  use  of  a microscope  if  required. 
The  fee  for  the  examination  is  5 guineas.  Applications 

should  be  made  to  the  Dean  of  the  Medical  Faculty, 
University  of  Liverpool.  Two  University  Fellowships  of 
£100  a year  each  are  open  to  students  of  the  school,  amongst 
others.  Accommodation  for  research  work  is  to  be  had 
at  the  University  Laboratory.  The  Mary  Kingsley  Medal 
is  awarded  by  the  school  for  distinguished  work  in 
connexion  with  Tropical  Medicine.  The  new  laboratories  are 
completed  and  ready  for  occupation  on  the  termination  of 
the  war. 

University  of  Leeds. — The  University  grants  a Diploma  in 
Public  Health,  and  every  facility  is  afforded  for  training  in 
Sanitary  Science  and  State  Medicine.  The  examination, 
which  is  held  twice  in  each  year — namely,  in  June  and 
December— is  in  two  parts,  and  is  written,  oral,  and  prac- 
tical. Candidates  may  present  themselves  for  Part  I.  (a), 
Part  I.  ( h ),  and  II.  separately  or  at  the  same  time,  provided 
that  no  candidate  be  allowed  to  pass  in  Part  II.  unless  he 
has  already  passed  in  Part  I.  Fees — The  fee  for  each  part  is 
£5  5s.,  and  for  any  subsequent  examination  in  the  same 
part  £3  3s.  Instruction  in  Sanitary  Chemistry  is  given  in 
the  second  and  third  terms  and  in  Bacteriology  during  the 
first  and  second  terms.  Practical  work  under  arrangement 
with  the  Leeds  City  Council.  Prospectus  can  be  obtained 
from  the  Dean  of  the  Medical  School. 

University  of  Bristol. — Diploma  in  Public  Health.  Candi- 
dates must  be  at  least  23  years  of  age,  shall  be  fully  regis- 
tered medical  practitioners  of  not  less  than  12  months’ 
standing  as  such,  and  shall  have  passed  the  examination 
prescribed  by  regulation.  The  examination  is  divided  into 
two  parts.  The  subjects  of  the  First  Part  are  Chemistry  as 
applied  to  Public  Health  and  Pathology  and  Bacteriology. 
Candidates  for  the  First  Part  shall,  during  six  months  after 
having  obtained  a registrable  qualification,  have  received 
practical  laboratory  instruction  in  Hygienic  Chemistry,  in 
Bacteriology,  and  in  the  Pathology  of  the  Diseases  of 
Animals  Transmissible  to  Man.  The  subjects  of  the  Second 
Part  are  : Public  Health  and  Epidemiology,  Sanitary  Law, 
Vital  Statistics,  and  Sanitary  Reporting. 

For  information  as  to  Post  graduate  instruction  apply  to 
the  Director  of  Post-graduate  Studies,  Professor  Walker  Hall. 

University  of  Edinburgh. — Two  degrees  in  Science  in  the 
Department  of  Public  Health  are  conferred  by  the  University 
of  Edinburgh — viz.,  Bachelor  of  Science  in  Public  Health 
and  Doctor  of  Science  in  Public  Health.  A Diploma  in 
Tropical  Medicine  and  Hygiene  is  also  granted.  Candidates 
for  the  degree  of  B.Sc.  in  Public  Health  must  be  graduates 
in  Medicine  of  a recognised  University,  and  must  pass 
two  examinations,  for  the  first  of  which  they  must,  after 


404  The  Lancet,] 


DIPLOMAS  IN  STATE  AND  TROPICAL  MEDICINE. 


[August  30,  1910 


graduation  in  Medicine,  have  worked  for  at  least  20  hours 
per  week  during  a period  of  not  less  than  eight  months, 
of  which  at  least  five  consecutive  months  must  be  in  the 
Public  Health  Laboratory  of  the  University  of  Edinburgh 
and  the  remainder  either  there  or  in  a laboratory  recog- 
nised by  that  University  ; they  must  also  have  attended 
courses  of  instruction  in  Physics  and  Geology  in  some 
Scottish  University.  Candidates  are  not  admitted  to  the 
Second  Examination  sooner  than  six  months  after  having 
passed  the  First  Examination,  nor  sooner  than  18  months 
after  having  taken  their  degree  in  Medicine,  and 
they  must  have  attended  two  separate  courses  in  Public 
Health  in  some  University  of  the  United  Kingdom  or  in 
such  medical  school  or  Indian,  Colonial,  or  Foreign  Univer- 
sity as  may  be  approved  for  the  purpose  by  Edinburgh 
University,  each  course  consisting  of  40  lectures  at 
least ; one  of  which  courses  shall  deal  with  medicine  and 
the  other  with  engineering,  each  in  its  relation  to  public 
health.  The  subjects  of  examination  include  Laboratory 
work,  Physics,  Geology,  Medicine  in  its  application  to  Public 
Health,  Sanitation,  Sanitary  Law,  and  Vital  Statistics. 
Graduates  who  have  held  the  degree  of  B.Sc.  in  Public 
Health  from  the  University  of  Edinburgh  for  a term  of 
five  years  may  offer  themselves  for  the  degree  of  D.Sc.  in 
Public  Health  in  that  University.  They  must  then  present 
a Thesis  and  pass  an  examination  in  Public  Health.  The 
fees  are  £3  3*.  for  the  First  and  £3  3*.  for  the  Second 
B.Sc.  Examinations,  and  £10  10s.  for  the  degree  of  D.Sc. 

University  of  Aberdeen. — The  Diploma  in  Public  Health 
(D.P.H.)  is  conferred  only  on  graduates  in  Medicine 
of  a University  in  the  United  Kingdom  not  less 
than  12  months  after  medical  graduation.  Every  candi- 
date must  produce  evidence  of  having  attended,  after 
graduation  in  Medicine,  during  a period  of  six  months, 
practical  instruction  in  Hygiene  and  Bacteriology  in 
laboratories  approved  of  by  the  University,  together  with 
having  during  six  months  (whereof  three  months  must  be 
distinct  from  the  period  of  laboratory  instruction)  been 
diligently  engaged  in  acquiring  a practical  knowledge  of  the 
duties,  routine  and  special,  of  Public  Heath  administration 
under  the  medical  officer  of  health  of  a county  or  large 
urban  district.  He  must  have  regularly  attended  for  three 
months  the  practice  of  a hospital  for  infectious  diseases  at 
which  opportunities  are  afforded  for  the  study  of  methods  of 
administration.  He  must  also  have  obtained  practical 
instruction  in  the  drawing  and  interpretation  of  plans.  The 
diploma  is  conferred  after  an  examination  in  Public  Health 
held  in  March  and  July  of  each  year.  The  fee  is  £5  5s. 

University  of  Dublin  ( Trinity  College). — The  Diploma 
in  Public  Health  is  conferred,  after  examination,  on  the 
following  conditions.  The  candidate  must  be  a registered 
medical  practitioner  and  have  obtained  a registrable  qualifi- 
cation at  least  nine  months  before  the  examination.  The 
candidate  must  have  completed,  subsequently  to  obtain- 
ing a registrable  qualification,  four  months’  practical  in- 
struction in  a chemical  and  bacteriological  laboratory,  or 
laboratories,  approved  by  the  University,  must  have  studied 
practically  outdoor  sanitary  work  for  six  months  under 
an  approved  officer  of  health,  and  must  have  spent  three 
months’  attendance  at  a fever  hospital  where  opportunities 
are  afforded  for  the  study  of  methods  of  administration.  A 
special  prospectus  and  a list  of  recognised  laboratories  may 
be  obtained  by  application  to  the  Registrar  of  the  School  of 
Physic,  Trinity  College,  Dublin. 

National  University  of  Ireland. — At  this  University  there 
is  a Diploma  in  Public  Health  and  a B.Sc.  in  Public  Health. 
The  Diploma  may  be  granted  to  matriculated  or  non- 
matriculated  students  of  the  University  who  shall  have 
completed  approved  courses  of  study  and  shall  have  passed 
the  prescribed  examinations,  provided  that  it  shall  not  be 
granted  except  to  a registered  medical  practitioner.  Candi- 
dates may  present  themselves  for  the  examination  after 
an  interval  of  not  less  than  12  months  from  the  time 
of  obtaining  a registrable  qualification.  The  curriculum 
extends  over  a period  of  not  less  than  nine  calendar 
months.  Every  candidate  must  produce  a certificate 
that  he  has  attended  practical  instruction  in  a laboratory, 
approved  by  the  University,  in  Chemistry,  Bacteriology, 
and  the  Pathology  of  the  diseases  of  animals  transmissible 
to  man.  The  examination  consists  of  two  parts,  which  may 
be  passed  separately  or  together.  Part  I.  comprises  the 
following  subjects  : Chemistry,  Meteorology  and  Climato- 


logy, and  Sanitary  Engineering  and  Architecture.  Part  II. 
comprises  the  following  subjects : Bacteriology,  Hygiene, 
Sanitary  Law,  and  Vital  Statistics.  The  examination  in 
each  part  will  be  oral  and  practical  as  well  as  written. 

For  the  B.Sc.  in  Public  Health  a candidate  shall  not 
be  admitted  unless  he  (a)  shall  have  received  the  degrees  of 
M. B.,  B.Ch. , and  B.A.O.  at  least  one  year  previously; 
( b ) shall  have  pursued  an  approved  course  of  study  in  the 
Faculty  of  Medicine ; and  (c)  shall  have  passed  the  pre- 
scribed examination.  In  addition  to  D.P.H.  course  the 
candidate  will  be  required  to  take  up  (1)  a Special  Course  of 
Pathology ; (2)  Bacteriology ; and  (3)  Advanced  Course  in 
Hygiene.  Each  of  these  courses  lasts  three  months. 

University  of  Belfast. — A Diploma  in  Public  Health 
is  given  by  examination.  Every  candidate  must  produce 
evidence  that,  after  obtaining  a registrable  qualification, 
he  has  during  six  months  received  practical  instruction  in 
an  approved  laboratory  in  which  Chemistry,  Bacteriology, 
and  the  Pathology  of  the  diseases  of  animals  transmissible 
to  man  are  taught.  After  obtaining  a registrable  qualifica- 
tion every  candidate  must  produce  evidence  that  he  has 
attended  during  three  months  the  practice  of  a hospital  for 
infectious  diseases  at  which  opportunities  are  afforded  for 
the  study  of  methods  of  administration.  The  examination 
must  have  extended  over  not  less  than  four  days,  one  of 
which  shall  have  been  devoted  to  practical  work  in  a 
laboratory,  and  one  to  practical  examination  in,  and  reporting 
on,  subjects  which  fall  within  the  special  outdoor  duties 
of  a medical  officer  of  health.  The  examination  will  be  held 
once  yearly,  Part  I.  in  March  and  Part  II.  in  June.  The 
first  part  of  the  examination  will  have  reference  to  the 
general  principles  of  sanitary  science,  and  the  second  part 
to  State  Medicine  and  to  the  applications  of  Pathology  and 
Sanitary  Science.  The  fee  for  each  part  is  1 guinea 

Royal  College  of  Physioians  of  London  and  the  Royal 
College  of  Sturgeons  of  England. — The  following  are  the 
regulations  for  obtaining  the  Diploma  in  Public  Health  : 
The  examination  consists  of  two  parts.  The  first  part 
of  the  examination  takes  place  in  January  and  July, 
and  the  second  part  in  January  and  July.  The  fee  for 
each  part  is  £10  10s.,  except  for  those  who  are  diplomates 
of  the  lloyal  Colleges,  who  pay  £6  6s.  for  each  part. 
A candidate  intending  to  present  himself  must  give 
14  days’  written  notice  to  the  Secretary,  at  the  Examination 
Hall,  Queen-square,  London,  W.C.  1.  He  will  be  admis- 
sible to  examination  in  Part  I.  on  producing  evidence  (1)  of 
having  been  in  possession  of  a registrable  qualification  for  at 
least  12  months  ; (2)  of  having  attended  thereafter  practical 
instruction  in  a laboratory  recognised  by  the  Examining 
Board  in  England  for  at  least  240  hours  during  a period 
of  six  months ; and  (3)  of  being  at  least  23  years  of  age. 
A candidate  will  be  admitted  to  Part  II.  of  the  examination 
on  producing  evidence  (1)  of  having  been  diligently  engaged 
in  acquiring  a practical  knowledge  of  Public  Health 

administration  during  six  months  under  certain  specified 
conditions  ; (2)  of  having  attended  during  three  months  the 
clinical  practice  of  a hospital  for  infectious  diseases  ; and  (3) 
of  being  at  least  24  years  of  age. 

The  Royal  College  of  Physioians  of  Edinburgh,  the 

Royal  College  of  Surgeons  of  Edinburgh,  the  Royal  Faculty 
of  Physioians  and  Surgeons  of  Glasgow. — All  candidates 
for  the  Diploma  in  Public  Health  must  have  a qualification 
which  has  been  registered  under  the  Medical  Acts.  Candi- 
dates must  have  attended  not  less  than  four  calendar  months’ 
practical  instruction  in  Chemistry  and  Bacteriology  in  a 
recognised  laboratory  or  laboratories,  must  have  studied 
outdoor  sanitary  work  for  six  months  under  a medical  officer 
of  health  or  other  sanitary  officer  ; and  must  give  evidence 
of  attendance  for  three  months  at  the  practice  of  a 

Hospital  for  Infectious  Diseases,  at  which  he  has 

received  instruction  in  the  methods  of  administration. 
The  examination  consists  of  two  parts,  and  candidates  may 
enter  for  both  at  one  period  or  for  either  separately. 
The  First  Part  includes  (a)  Laboratory  Work  (Chemistry 
and  Bacteriology),  ( b ) Physics  and  Meteorology ; and  the 
Second  Examination  embraces  (a)  Report  on  Premises 
visited,  (b)  Examination  at  Fever  Hospital,  (c)  Examina- 
tion at  Public  Abattoir,  (d)  Written  and  Oral  Examinations 
on  Epidemiology  and  Endemiology,  (e)  A ital  Statistics  and 
Sanitary  Law,  and  ( f ) Practical  Sanitation.  The  fee  is 
12  guineas  for  both  examinations,  or  6 guineas  for  either 
of  them.  A fee  of  3 guineas  is  payable  by  rejected 


Thk  Lancet,] 


DENTAL  SURGERY. 


[August  30,  1919  405 


candidates  for  either  examination.  The  examination  is 
held  twice  yearly,  in  May  and  October.  The  published 
regulations  provide  detailed  synopses  of  the  subjects  of 
examination.  The  Registrar  for  Edinburgh  is  Mr.  D.  L. 
Eadie,  49,  Lauriston-place,  and  for  Glasgow  Mr.  Walter 
Hurst,  242,  St.  Vincent-street. 

Royal  College  of  Physicians:  of  Ireland  and  Royal  College  of 
Surgeons  in  Ireland. — Every  candidate  for  the  Diploma  in 
Public  Health  must  be  a registered  medical  practitioner. 
He  must  subsequently  to  qualification  (1)  receive  six  months’ 
laboratory  instruction  in  Chemistry,  Bacteriology,  and  the 
Diseases  of  Animals  transmissible  to  man  ; and  (2)  during 
six  months  practically  study  outdoor  sanitary  work  under 
a medical  officer  of  health,  and  shall  as  an  additional 
requirement  attend  a hospital  for  infectious  diseases. 
Candidates  are  examined  on  four  days,  commencing  on 
the  first  Monday  of  February,  May,  and  November.  The 
examination  comprises  the  following  subjects  : — Hygiene, 
Chemistry,  Meteorology  and  Climatology,  Engineering, 
Vital  Statistics,  Sanitary  Law,  and  Bacteriology.  The  fee 
for  the  examination  is  £10  10s.  For  further  particulars 
apply  to  Alfred  Miller,  Secretary,  Committee  of  Manage- 
ment ; Office,  Royal  College  of  Surgeons,  Dublin. 


DENTAL  SURGERY. 


Anyone  who  is  on  the  Medical  Register  is  entitled  to 
practise  as  a dentist,  although  he  cannot  register  as  such 
without  the  special  licence  ; but  it  is  of  eminent  advantage 
to  take  the  L.D.S.,  otherwise  few  dental  appointments  at 
general  or  special  hospitals  or  dispensaries  are  available. 
The  subjects  beyond  those  included  in  the  general 
qualification  are — Dental  Anatomy  and  Physiology  (Human 
and  Comparative),  one  course ; a separate  course  of 
Dental  Histology,  including  the  preparation  of  micro- 
scopical sections ; Dental  Surgery,  one  course  ; a separate 
course  of  Practical  Dental  Surgery ; a course  of  not 
less  than  five  lectures  on  the  Surgery  of  the  Mouth ; 
Dental  Mechanics,  one  course ; a course  of  Practical 
Dental  Mechanics,  including  the  manufacture  and  adjust- 
ment of  six  dentures  and  six  crowns  ; Dental  Metallurgy, 
one  course  ; a course  of  Practical  Dental  Metallurgy  ; Prac- 
tice of  Dental  Surgery  at  a recognised  school,  two  years,  and 
a certificate  of  having  been  engaged  during  a period  of  not 
less  than  two  years  in  acquiring  a knowledge  of  Dental 
Mechanics  (this  may  be  obtained  by  apprenticeship 
to  a duly  qualified  dental  practitioner  or  in  the 
mechanical  department  of  a recognised  dental  hospital). 
The  Dental  Schools  in  London  are  the  Royal  Dental 
Hospital  of  Loudon,  the  National  Dental  Hospital,  Guy’s 
Hospital  Dental  School,  and  the  London  Hospital  Dental 
School.  Most  of  the  large  provincial  towns,  where  there 
are  medical  schools,  have  now  dental  hospitals. 

The  Registration  of  Dental  Students  is  carried  on  at  the 
Medical  Council  Office  in  London  in  the  same  manner  as 
the  existing  registration  of  medical  students,  and  subject  to 
the  same  regulations  as  regards  Preliminary  Examinations. 
Candidates  for  a diploma  in  Dental  Surgery  must  produce 
certificates  of  having  been  engaged  during  four  years  in 
professional  studies,  including  two  years’  instruction  in 
mechanical  dentistry.  The  two  years  of  instruction  in 
mechanical  dentistry,  or  any  part  of  them,  may  be  taken 
by  the  dental  student  either  before  or  after  his  registration 
as  a student,  but  no  portion  of  such  mechanical  instruction 
will  be  counted  as  one  of  the  four  years  of  professional 
study  unless  taken  after  registration.  The  recommendations 
as  to  the  course  of  study  and  examinations  adopted  by  the 
General  Medical  Council  in  November,  1909,  are  under 
revision  by  the  Council,  but  consideration  of  them  is  post- 
poned until  the  Departmental  Committee  on  the  Dentists 
Act  has  reported. 

It  is  necessary  for  anyone  practising  Dental  Surgery 
in  this  country  to  be  on  the  Register,  and  no  foreign  qualifi- 
cations are  recognised,  except  the  Dental  Diploma  granted  in 
Belgium  after  examination  by  the  Provincial  Medical  Com- 
mission, provided  the  holder  has  obtained  the  grade  of 
“Candidate  in  Medicine”  at  one  of  the  four  Belgian 
Universities.  Persons  with  Colonial  and  Foreign  qualifica- 
tions which  have  been  obtained  after  a four  years’ curriculum 
can  apply  for  special  registration.  Certain  dental  qualifica- 
tions granted  in  Australia  and  New  Zealand  are  also 


registrable.  The  Royal  Colleges  of  the  United  Kingdom 
and  ten  of  the  Universities  grant  degrees  or  licences  in 
Dental  Surgery. 

The  Registering  Bodies  in  Dentistry. 

The  Royal  College  of  Surgeons  of  England  grants  a 
diploma  in  Dental  Surgery  under  the  following  regulations, 
which  apply  to  all  candidates  who  have  registered  as  dental 
students  after  Jan.  1st,  1897.  Candidates  are  required  to 
pass  three  examinations  : the  Preliminary  Science  Exami- 
nation, the  First  Professional  Examination,  and  the  Second 
Professional  Examination.  I.  Preliminary  Science  Exami- 
nation.— This  is  identical  with  Part  I.  of  the  First 
Examination  of  the  Examining  Board  in  England. 
Candidates  who  commenced  professional  study  on  or  after 
Oct.  1st,  1913,  must  pass  the  Preliminary  Science  Exa- 
mination before  commencing  the  courses  required  for 
the  Second  Professional  Examination.  II.  The  First 
Professional  Examination. — The  candidate  must  produce 
evidence  of  instruction  in  Dental  Metallurgy  and  Practical 
Dental  Mechanics.  The  Examination  consists  of  Part  I. 
(Mechanical  Dentistry)  and  Part  II.  (Dental  Metallurgy), 
the  examination  in  Dental  Metallurgy  being  by  written 
paper.  The  parts  may  be  taken  together  or  separately. 
III.  The  Second  Professional  Examination. — This  is  divided 
into  two  parts  : (a)  the  General,  ( b ) the  Dental.  The  General 
part  must  be  passed  before  the  Dental  portion.  The  instruc- 
tion is  obtained  partly  at  a General  Hospital  and  partly 
at  a Dental  Hospital. — The  Second  Professional  Examination 
consists  of:  Part  I.,  General  Anatomy  and  Physiology, 
General  Surgery  and  Pathology  ; Part  II.,  Dental 
Anatomy  and  Physiology,  Dental  Pathology  and  Surgery, 
and  Practical  Dental  Surgery.  There  is  a written  and 
viva  voce  examination  in  each  part  and  a practical 
examination  as  well  in  Part  II.  Exemption  from 

the  Preliminary  Science  Examination  is  granted  to 
candidates  who  have  passed  an  Examination  in  Chemistry 
and  Physics  for  a degree  in  Medicine  at  a University 
in  the  United  Kingdom,  in  India,  or  in  a British 
colony.  Exemption  from  Examination  in  Anatomy  and 
Physiology  is  granted  to  candidates  who  have  passed  the 
Second  Examination  of  the  Examining  Board  in  England  or 
the  corresponding  Examination  for  any  degree  or  qualifica- 
tion in  Medicine  or  Surgery  registrable  under  the  Medical 
Act  of  1886.  Exemption  from  Examination  in  General  Sur- 
gery and  Pathology  is  granted  to  candidates  who  have  passed 
the  Examination  in  Surgery  of  the  Examining  Board  in 
England  or  the  corresponding  Examinations  of  the  Col- 
leges and  University  above  mentioned.  The  fee  for 
the  diploma  is  20  guineas,  and  is  payable  as  follows  : — 
Preliminary  Science  Examination,  3 guineas ; First  Pro- 
fessional Examination,  7 guineas  ; Second  Professional 
Examination,  10  guineas.  Synopses  of  examinations  and 
all  further  information  can  be  obtained  from  the  Secretary, 
Examination  Hall,  Queen-square,  London,  W.C.  1. 

Royal  College  of  Surgeons , Edinburgh. — Regulations 
giving  a list  of  Preliminary  Examinations  recognised 
for  obtaining  the  Licence  in  Dental  Surgery,  as  well 
as  of  the  subjects  of  the  Professional  Examinations, 
may  be  obtained  from  Mr.  D.  L.  Eadie,  Clerk  to  the 
Royal  College  of  Surgeons,  at  49,  Lauriston-place,  Edin- 
burgh. Candidates  must  produce  certificates  of  having, 
subsequently  to  the  date  of  registration,  been  engaged 
for  four  years  in  professional  studies  and  of  three 
years’  instruction  in  Mechanical  Dentistry  from  a regis- 
tered dental  practitioner,  except  in  the  case  of  previously 
registered  medical  practitioners,  when  two  years  will  be 
considered  sufficient.  Candidates  must  also  have  attended 
a course  of  instruction  at  a University  or  in  an  established 
school  of  medicine  or  in  a provincial  school  specially 
recognised  by  the  College  as  qualifying  for  the  Diploma  in 
Surgery.  In  addition  they  will  be  required  to  have  attended 
in  a recognised  dental  hospital, or  with  teachers  recognised 
by  the  College,  special  courses  of  lectures  and  instruction 
in  Anatomy  and  Physiology  (Human  and  Comparative), 
Surgery,  Pathology,  Materia  Medica,  Dental  Histology,  and 
Practical  Dental  Mechanics  and  Metallurgy ; two  years’ 
attendance  at  a dental  hospital  or  the  dental  depart- 
ment of  a general  hospital  recognised  by  the  College. 
Practical  instruction  in  Mechanical  Dentistry  from  a 
registered  Dentist,  or  in  the  Mechanical  Depart- 
ment of  a recognised  Dental  Hospital  and  School,  for 


406  The  Lancet,] 


THE  REGISTERING  BODIES  IN  DENTISTRY. 


[August  30,  1919 


three  years.  Candidates  who  have  passed  the  First  and 
Second  Examinations  for  the  Triple  Qualification  will  be 
exempt  from  the  First  Dental  Examination,  and  will  have 
the  advantage  of  being  admissible  either  to  the  Final  Dental 
Examination  or  to  the  subsequent  Examination  for  the  Triple 
Qualification,  or  to  both.  But  the  First  Dental  Examination 
will  not  be  held  as  equivalent  to  the  First  and  Second  Triple 
Examinations,  and  will  admit  to  the  Final  Dental  Examina- 
tion only.  Candidates  who  are  Licentiates  of  this  College  or 
who  may  be  registered  medical  practitioners  will  be  required 
to  produce  certificates  of  attendance  on  the  special  subjects 
only  and  will  be  examined  in  these  only  for  the  dental 
diploma.  First  Professional  Examination  : The  candidate 
must  have  attended  the  required  courses.  The  examination 
embraces  (1)  Chemistry  and  Physics  ; and  (2)  Anatomy  and 
Physiology.  The  fee  is  £5  5s.  for  the  complete  examina- 
tion, and  £3  3s.  is  payable  for  each  division.  In  all  cases  of 
rejected  candidates  the  fee  for  re-entry  is  £3  3s.  Second 
Examination  : The  candidate  must  have  attended  the  remain- 
ing courses  of  the  curriculum,  must  produce  certificates 
showing  that  he  is  21  years  of  age,  and  must  pay  a fee 
of  £10  10s.,  for  re-entry  £5  5s.  The  examination  embraces 
(1)  Surgery  and  Medicine  ; and  (2)  the  special  subjects  of 
Dental  Anatomy  and  Physiology,  Dental  Surgery  and 
Pathology,  Dental  Materia  Medica,  Dental  Mechanics  and 
Dental  Metallurgy,  with  a practical  as  well  as  the  written 
and  oral  examinations  in  the  subjects  of  Dental  and  Oral 
Surgeiy,  Pathology,  and  Mechanics.  The  candidate  will 
be  tested  in  the  Treatment  of  Dental  Diseases,  in  Operative 
Dentistry,  the  Administration  of  Anesthetics,  Ortho- 
dontics, and  in  Prosthetic  and  Mechanical  Dentistry. 
Candidates  who  claim  exemption  from  the  First  Dental 
Examination  on  the  ground  of  having  passed  the  First  and 
Second  Triple  Qualification  Examinations  or  other  recognised 
examinations  will,  before  being  admitted  to  the  Second 
Dental  Examination,  be  required  to  pay  the  total  fee  of 
£15  15s.  payable  for  the  dental  diploma.  Fees  and  schedules 
must  be  lodged  with  the  Clerk  not  later  than  one  week 
before  the  examination. 

Royal  Faculty  of  Physicians  and  Surgeons  of  Glasgow. — 
The  regulations  as  to  certificates,  curriculum,  number,  and 
subjects  of  examinations,  fees,  &c.,  are  in  effect  similar 
to  those  of  the  Royal  College  of  Surgeons  of  Edinburgh, 
but  embrace  Dental  Bacteriology.  Candidates  can  enter  for 
the  First  Examination  in  three  divisions,  the  first  embracing 
Physics  and  Chemistry,  the  second  Dental  Metallurgy  and 
Dental  Mechanics,  and  the  third  Anatomy  and  Physiology. 
The  examination  in  Dental  Mechanics  is  practical  ; and 
there  is  at  the  Final  Examination  an  examination  in 
Practical  Dentistry  conducted  in  a dental  hospital.  Copies 
of  regulations,  &.C.,  to  be  obtained  from  Mr.  Walter  Hurst, 
Registrar,  Faculty  Hall,  242,  St.  Vincent-street,  Glasgow. 

Royal  College  of  Surgeons  in  Ireland. — Candidates  for  the 
Licence  in  Dental  Surgery  are  required  to  pass  two  pro- 
fessional examinations.  Before  the  First  Examination  the 
candidate  must  produce  evidence  of  having  attended  courses 
in  Theoretical  and  Practical  Chemistry,  including  Metallurgy 
and  Physics,  at  a recognised  institution  ; of  having  been 
registered  as  a medical  or  dental  student  by  the  General 
Medical  Council  ; and  of  having  attended  courses  of  instruc- 
tion in  the  following  subjects  at  a recognised  school  of 
medicine : {a)  Anatomy  Lectures  ; (A)  Dissections  with 
Demonstrations  ; {o')  Physiology,  including  Dental  Physio- 
logy ; {d)  Practical  Physiology  and  Histology,  including 
Dental  Physiology  and  Histology,  Human  and  Comparative. 
Before  the  Final  Dental  Examination  the  candidate  must 
have  been  engaged  during  a period  of  two  years  in  acquiring  a 
practical  familiarity  with  the  details  of  Mechanical  Dentistry 
under  the  instruction  of  a registered  dentist,  or  under  the 
direction  of  the  superintendent  of  the  Mechanical  Depart- 
ment of  a recognised  Dental  Hospital,  and  have  attended,  at 
institutions  recognised  by  the  College  for  the  purpose,  the 
following  courses  of  instruction : {a)  Dental  Surgery  and 
Pathology,  Orthodontia,  and  the  Materia  Medica  and  Thera- 
peutics applicable  to  Dental  Surgery.  Lectures.  Two  courses. 
( h ) Dental  Mechanics.  Lectures.  Two  courses,  (c)  Dental 
Anatomy.  Lectures.  One  course,  (d)  The  practice  of  a 
Dental  Hospital,  or  of  the  Dental  Department  of  a General 
Hospital.  Two  years.  He  must  also  have  attended  Clinical 
instructions  at  a recognised  General  Hospital  during  the 
ordinary  teaching  sessions  (nine  months),  and  have  been 
engaged  during  four  years  in  the  acquirement  of  pro- 


fessional knowledge  subsequently  to  the  date  of  registration 
as  a medical  or  dental  student.  One  year’s  bona-fide  appren- 
ticeship with  a registered  dental  practitioner,  after  being 
registered  as  a medical  or  dental  student,  may  be  counted 
as  one  of  the  four  years  of  professional  study.  He  must  be 
21  years  of  age. 

In  the  First  Dental  Examination  candidates  will  be 
examined  in  (A)  Physics  and  Chemistry,  including  Practical 
Chemistry  and  Metallurgy.  (B)  Anatomy,  Physiology,  and 
Histology — General  and  Dental.  All  the  subjects  may  be 
passed  at  the  same  time,  or  they  may  be  passed  in  two  groups, 
(A)  and  (B).  The  examination  is  partly  written,  partly 
viva  voce,  and  partly  practical. 

In  the  Final  Dental  Examination  candidates  will  be 
examined  in  General  Pathology,  Medicine,  and  Surgery ; 
Dental  Surgery,  and  Dental  Pathology,  with  the  Materia 
Medica  and  Therapeutics  applicable  to  Dental  Surgery  ; 
Dental  Mechanics  and  Metallurgy ; Orthodontia.  Candi- 
dates must  pass  in  all  the  subjects  at  one  examination.  The 
examination  is  partly  written,  partly  viva  voce,  and  partly 
practical,  and  includes  the  examination  of  patients  and  the 
performance  of  dental  operations.  Candidates  are  required 
to  provide  their  own  instruments  and  gold  for  filling.  The 
First  Dental  Examination  will  commence  on  the  first 
Mondays  in  the  months  of  February,  May,  and  November. 
The  Final  Dental  Examination  will  commence  on  the 
second  Mondays  in  the  months  of  February,  May,  and 
November.  The  total  fee  for  the  Diploma  in  Dental  Surgery 
is  20  guineas.  Candidates  must  pay  the  fees  for  examina- 
tions from  which  they  are  exempted,  unless  when  such 
exemptions  have  been  granted  in  virtue  of  examinations 
passed  before  the  Conjoint  Board  in  Ireland. 

University  of  Birmingham.. — The  teaching  of  Dentistry  is 
undertaken  by  the  University  acting  in  association  with  the 
Birmingham  Dental  Hospital  and  the  Birmingham  Clinical 
Board.  The  instruction  at  the  Dental  Hospital  is  carried 
out  under  the  direction  of  the  University  Dental  Clinical 
Board,  so  that  students  may  fully  qualify  themselves  for 
the  Dental  Diploma  (L.D.S.)  of  this  and  other  universities 
and  licensing  bodies.  There  is  a special  and  well-equipped 
Dental  Museum  and  Laboratory.  An  Entrance  Exhibition, 
value  £37  10*.  is  awarded  annually  at  the  commencement  of 
the  winter  session.  The  following  are  the  regulations  for 
Degrees  in  Dentistry  : — 1.  The  degrees  conferred  by  the  Uni- 
versity are  those  of  Bachelor  and  Master  of  Dental  Surgery 
(B.D.S.  and  M.D.S.).  2.  All  candidates  for  these  degrees 

must  pass  the  same  Matriculation  Examination  as  that 
required  from  candidates  for  Medical  Degrees.  3.  The 
degree  of  Bachelor  of  Dental  Surgery  is  not  conferred 
upon  any  candidate  who  has  not  obtained  a Licence  in  ; 
Dental  Surgery.  The  candidate  is  not  eligible  for  the  J 
degree  until  a period  of  12  months  has  elapsed  from  the  1 
passing  of  his  examination  for  the  Licence  in  Dental  Surgery. 

Of  this  period  at  least  six  months  must  be  spent  in  the  dental 
department  of  a general  hospital  approved  by  the  University.  | 
4.  A.  In  addition  to  the  Licence  in  Dental  Surgery  the 
candidate  must  produce  evidence  that  he  has  attended  the 
courses  required  by  medical  students  of  the  University  in 
the  following  subjects  and  passed  the  Examinations  held  in 
the  same  for  Medical  and  Surgical  Degrees  : (a)  Chemistry 
and  Practical  Chemistry,  {b)  Physics  and  Practical  Physics,  (<?) 
Elementary  Biology,  (d)  Anatomy  and  Practical  Anatomy, 
and  (e)  Physiology  and  Practical  Physiology.  B.  That  he  has 
passed  the  class  examinations  in  : (/")  One  Special  Course  of 
Lectures  on  Medicine,  (g)  One  Special  Course  of  Lectures 
on  Surgery,  and  (A)  Pathology  and  Bacteriology.  C.  That 
he  has  attended  courses  and  passed  the  class  examina- 
tions in  : (A)  Dental  Histology  and  Patho- Histology,  (0 
Comparative  Dental  Anatomy,  and  (»i)  Dental  Surgery  and 
Prosthetic  Dentistry.  B.  That  he  has  received  instruction 
in  the  Clinical  Examination  of  living  cases  at  the  dental 
department  of  a general  hospital  for  a period  of  not  less  than 
six  months.  5.  The  Final  Examination  will  deal  with  the 
subjects  in  Classes  C and  D.  6.  On  the  expiration  of 
12  months  from  the  date  of  passing  the  Examination  for 
the  Degree  of  Bachelor  of  Dental  Surgery,  the  candi- 
date will  be  eligible  for  that  of  Master  of  Dental  Surgery. 

7.  For  this  degree  candidates  will  be  required  to  submit  a 
thesis  containing  original  work  and  investigations  in  some 
subject  connected  with  Dentistry,  which  thesis  shall  be 
submitted  to  examiners  to  be  nominated  by  the  Dental 
Advisory  Board. 


The  lancet,] 


THE  REGISTERING  BODIES  IN  DENTISTRY. 


[August  30,  1919  407 


University  of  Bristol. — Candidates  for  the  degree  of 
Bachelor  of  Dental  Surgery  must  be  not  less  than  21 
years  of  age  and  shall  have  pursued  the  courses  prescribed 
"by  University  regulations  during  not  less  than  five  years,  of 
which  three  shall  have  been  passed  in  the  University,  and 
shall  have  been  registered  as  dental  students  by  the  General 
Medical  Council.  All  candidates  for  the  degree  of  B.D.S. 
are  required  to  satisfy  the  examiners  in  the  several  subjects 
of  four  examinations.  The  First  Examination  : The  subjects 
are  Chemistry,  Physics,  and  Zoology,  and  the  curriculum 
extends  over  one  year.  The  Second  Examination : The 
subjects  are  Dental  Mechanics,  Dental  Metallurgy,  and 
Dental  Materia  Medica,  and  the  candidate  shall  produce 
evidence  of  having  served  for  two  years  an  approved  pupilage 
in  Dental  Mechanics.  The  Third  Examination  : The  sub- 
jects are  Anatomy,  Physiology,  and  Histology,  Dental 
Anatomy,  and  Dental  Histology.  The  Final  Examination  : 
The  subjects  are  Medicine  and  Surgery,  Dental  Surgery 
(including  Prosthetics),  Operative  Dental  Surgery,  and 
Dental  Bacteriology.  Degree  of  Master  of  Dental  Surgery  : 
Candidates  shall  be  Bachelors  of  the  University,  shall 
present  a Dissertation  on  some  subject  of  Dental  Surgery  to 
be  approved  by  the  Examiners,  and  pass  an  examination  in 
Dental  Surgery.  Diploma  in  Dental  Surgery  : Candidates 
need  not  be  undergraduates,  but  shall  be  registered  dental 
students  before  being  admitted  to  any  professional  examina- 
tion ; the  curriculum  extends  over  four  years.  A two  years’ 
pupilage  in  Mechanical  Dentistry  is  required,  and  four 
examinations  must  be  passed,  the  subjects  of  which  differ 
only  from  those  of  the  B.D.S.  in  that  Zoology  is  not 
required  for  the  First  Examination,  and  Medicine  is  not 
required  for  the  Final  Examination.  Candidates  who  are 
already  registered  medical  practitioners  shall  be  further 
exempted  from  study  and  examination  in  Physics  and 
Chemistry,  Anatomy,  Physiology  and  Histology,  Medicine, 
and  General  Surgery. 

University  of  Durham. — Every  candidate  for  the  Licence 
in  Dental  Surgery  must  be  registered  as  a dental  student. 
There  are  four  Examinations.  The  subjects  are: — First: 
(a)  Chemistry ; and  ( h ) Physics.  Second : («)  Dental 

Mechanics,  Theoretical  and  Practical  ; ( b ) Dental  Metallurgy. 
Third : (a)  Anatomy ; (b)  Physiology  and  Histology ; 

(0)  Dental  Anatomy  and  Dental  Histology  ; and  ( d ) Dental 
Materia  Medica.  Final : (a)  Surgery  ; (b)  Dental  Surgery, 
including  Prosthetics  and  Orthodontia  ; ( c ) Operative  Dental 
Surgery,  Practical  Examination  ; and  (d)  Dental  Pathology 
and  Bacteriology.  A candidate  before  presenting  himself 
for  examination  is  required  to  furnish  certificates  of 
instruction  in  the  following  subjects,  attended  after 
registration  as  a dental  student  at  recognised  Colleges 
or  Schools  : — First  Examination  : Chemistry  and  Physics. 
Second  Examination  : Dental  Mechanics  and  Dental  Metal- 
lurgy. Third  Examination : Anatomy,  with  Dissections ; 
Physiology ; Histology  ; Dental  Anatomy  and  Physiology  ; 
Dental  Histology  ; and  Dental  Materia  Medica.  Final 
Examination : Dental  Hospital  Practice  (two  years) ; 

General  Hospital  Practice  (nine  months)  ; Medicine  Lectures 
(two  terms)  ; Surgery  Lectures  (two  terms)  ; Dental  Surgery 
and  Pathology  (a  course  of  not  less  than  20  lectures) ; 
Dental  Bacteriology  (three  terms)  ; Operative  Dental  Surgery 
(not  less  than  12  lectures)  ; and  Anaesthetics  (a  course  of 
not  less  than  one  month). 

Before  admission  to  the  Final  Examination  each  candidate 
must  furnish  evidence  (1)  of  having  attained  the  age  of  21 
years  ; (2)  of  having  undergone  a three  years’  pupilage  in 
Mechanical  Dentistry  with  a registered  dentist ; and  (3)  of 
having  been  engaged  in  professional  study  for  at  least  four 
years  subsequent  to  registration  as  a dental  student.  The 
examinations  will  be  held  concurrently  with  the  medical 
examinations,  and  the  fees  payable  by  candidates  are  as 
follows  : First  Examination,  £2  10*’.  ; Second  Examination, 
£2  10s.  ; Third  Examination,  £3  10s.  ; Final  Examination, 
£3  10s.  ; fee  for  Licence,  £3  ; total,  £15.  For  re-examina- 
tion : First  Examination,  £1  10s.  ; Second  Examination, 
£2;  Third  Examination,  £2  (in  one  part  only,  £1);  Fourth 
Examination,  £2.  The  practical  examinations  in  dentistry 
will  be  conducted  at  the  Newcastle  Dental  Hospital. 


Candidates  who  have  passed  the  Higher  School  Certificate  approved 
uy  the  Board  of  Education  in  these  subjects  will  not  be  required  to  sit 
for  the  first  examination  for  either  the  B.D.S.  or  the  L.D.S.,  and  will 
oe  regarded  as  having  completed  one  year  of  study. 


University  of  Leeds. — The  degrees  in  Dental  Surgery 
are  Bachelor  of  Dental  Surgery  (B.Ch.D.)  and  Master  of 
Dental  Surgery  (M.Ch.  D.).  All  candidates  for  the  degree  of 
Bachelor  of  Dental  Surgery  shall  be  required  to  have  passed 
the  Matriculation  Examination,  to  have  pursued  thereafter 
approved  courses  of  study  for  not  less  than  five  academic 
years,  two  of  such  years  at  least  having  been  passed  in  the 
University  subsequently  to  the  date  of  passing  Parts  I.  and 
II.  of  the  First  Examination,  and  to  have  completed  such 
period  of  pupilage  or  hospital  attendance,  or  both,  as  may 
be  prescribed  by  the  regulations  of  the  University.  No 
candidate  will  be  admitted  to  the  degree  who  has  not 
attained  the  age  of  21  years  on  the  day  of  graduation. 
The  classes  in  the  Department  of  Dentistry  begin  on 
Oct.  1st.  The  instruction  in  the  Preliminary  subjects  of 
Chemistry,  Physics,  and  Biology  are  given  at  the  Uni- 
versity in  College-road.  The  classes  in  the  other 
subjects  and  the  systematic  courses  in  Dental  subjects 
are  held  in  the  School  of  Medicine  of  the  University  in 
Thoresby  Place.  The  clinical  instruction  is  given  in  the 
Dental  Department  of  the  Leeds  Public  Dispensary,  which 
is  affiliated  with  the  University  and  recognised  by  the  Royal 
College  of  Surgeons.  Applications  for  the  prospectus  should 
be  made  to  the  Dean  of  the  Faculty  of  Medicine. 

University  of  Liverpool  ( Liverpool  Dental  Hospital  Clinical 
School  and  School  of  Dental  Surgery'). — The  University  grants 
a Licence  in  Dental  Surgery  (L.D.S.)  and  degrees  in  Dental 
Surgery  (B.D.S.  and  M.D.S.).  The  courses  of  systematic 
instruction  are  given  in  the  University  buildings,  five  minutes’ 
walk  from  the  Dental  Hospital.  The  two  institutions  are 
now  closely  associated,  and  the  management  of  the  curri- 
culum is  in  the  hands  of  the  Board  of  Dental  Studies.  The 
Dental  Hospital,  covering  a site  of  672  square  yards,  is 
equipped  in  each  department  with  every  modern  accessory 
and  receives  constant  additions.  The  laboratory  is  in  charge 
of  a skilled  dental  mechanic  under  the  supervision  of 
the  Director  of  Dental  Education  and  Dental  Staff,  and 
students  are  able  to  undertake  at  the  hospital  the 
whole  of  their  training  in  Mechanical  Dentistry.  The  times 
of  the  lectures  at  the  University  are  arranged  to 
meet  the  convenience  of  students,  thus  allowing  the 
maximum  time  for  attendance  upon  Dental  Hospital 
practice.  Fees:  The  composition  fees  are  as  follows: 

Licence  course  (L.D.S.)  : Composition  fee  £58  10s.,  for  the 
course  of  other  licensing  bodies  £61  10*’.,  payable  in  two 
equal  instalments,  the  first  on  entry,  the  second  12  months 
later.  Two  years’  instruction  in  Mechanical  Dentistry 
(pupilage)  and  two  years’  Dental  Hospital  Practice  (com- 
bined), £100,  or  in  two  instalments  of  £52  10s.  each.  Degree 
course(B.D.S-):  £67  10s.  for  all  lectures  (including  Chemistry, 
Physics,  and  Zoology)  in  three  instalments.  Two  years’ 
dental  hospital,  £21 ; general  hospital  practice,  £10  10s.  ; 
three  years’  mechanical  instruction  (pupilage),  £105.  Further 
information  may  be  had  from  the  Director  of  Dental 
Education,  Mr.  W.  H.  Gilmour. 

University  of  Manchester. — In  the  University  of  Man- 
chester the  Dental  Department  forms  an  integral  part  of  the 
Faculty  of  Medicine.  This  contains  a series  of  laboratories, 
lecture  rooms,  and  museums  which  will  bear  comparison 
with  those  of  any  other  school  in  the  kingdom,  and  the  fullest 
opportunities  for  study  are  offered  to  students  preparing  for 
any  of  the  professional  examinations.  Instruction  adapted 
to  the  requirements  of  students  preparing  for  the  B.D.S. 
Degree  and  the  Dental  Diplomas  of  the  University,  the  Royal 
College  of  Surgeons  of  England,  and  of  other  licensing  bodies 
is  given  during  the  Winter  and  Summer  Sessions  both  at  the 
University  and  at  the  Dental  Hospital  of  Manchester  adjoin- 
ing the  University.  The  required  general  hospital  practice  is 
taken  at  the  Manchester  Royal  Infirmary.  Women  students 
are  admitted  to  the  classes  in  the  Dental  Department,  and 
for  them  common  rooms  are  provided.  The  composition 
fee  for  candidates  for  the  University  degree  of  Bachelor  of 
Dental  Surgery  is  60  guineas,  payable  in  two  equal 
instalments  at  the  beginning  of  the  first  and  third 
years  of  studentship.  The  composition  fee  for  candidates 
for  the  University  Diploma  in  Dentistry  is  55  guineas, 
payable  in  two  equal  instalments  at  the  beginning  of 
the  first  and  third  years  of  studentship.  The  composi- 
tion fee  for  candidates  for  the  L.D.S.  of  England  is  60 
guineas,  payable  in  two  equal  instalments  at  the  beginning 
of  the  first  and  third  years  of  studentship.  Students  who 
have  already  served  their  apprenticeship  with  a private 


408  The  Lancet,] 


TEACHING  INSTITUTIONS  IN  DENTISTRY. 


[August  30,  1919 


practitioner,  and  who  propose  to  complete  the  final  portion 
of  their  attendance  at  the  University  and  at  an  approved 
dental  hospital,  will  be  required  to  pay  the  composition  fee 
in  two  equal  instalments  at  the  commencement  of  the  first 
and  second  years  of  studentship.  The  composition  fee  does 
not  include  the  hospital  fees,  the  examination  fees,  the  fee  for 
the  conferment  of  the  degree  or  the  diploma,  the  registration 
fee,  nor  the  fees  for  chemicals  and  chemical  apparatus. 

National  University  of  Ireland. — This  University  grants 
the  degrees  of  Bachelor  of  Dental  Surgery  and  a degree 
of  Master  of  Dental  Surgery.  A student  may  not  be 
admitted  to  the  Degree  of  Bachelor  of  Dental  Surgery 
unless  a period  of  not  less  than  four  years  shall  have  elapsed 
from  the  date  of  his  matriculation,  during  which  period  he 
must  have  pursued  an  approved  course  of  study  of  not  less 
than  nine  terms.  For  the  degree  of  Bachelor  of  Dental 
Surgery  candidates  must  pass  four  examinations,  the  first 
two  being  the  same  as  those  for  the  first  and  second 
examination  in  Medicine.  The  subjects  of  the  third  examina- 
tion are  Dental  and  Practical  Pathology,  Dental  Surgery 
and  Dental  Medicine,  the  subjects  of  the  fourth  being 
Dental  Surgery  and  Pathology,  Dental  Mechanics,  Operative 
Dentistry,  Orthodontia,  and  Dental  Materia  Medica.  A 
candidate  for  the  degree  of  B.D.S.  must  produce  evidence 
of  having  been  engaged  during  a period  of  two  years  in 
acquiring  a practical  familiarity  with  the  details  of 
Mechanical  Dentistry  under  the  instruction  of  a registered 
dentist,  or  under  professional  direction  in  the  mechanical 
department  of  a dental  hospital  approved  by  the  Univer- 
sity. A portion  of  or  the  entire  period  may  be  served 
before  commencing  study  for  the  degree  of  B.D.S.,  but  no 
portion  so  taken  prior  to  commencement  of  study  shall 
count  as  part  of  the  four  years  of  Dental  Study.  The  degree 
of  Master  of  Dental  Surgery  will  not  be  granted  until  three 
years  after  the  B.D.S.  has  been  obtained. 

University  of  Melbourne. — Degrees  of  Bachelor  (B.D.Sc.) 
and  Doctor  of  Dental  Science  (D.D.Sc.)  are  granted.  Candi- 
dates for  the  former  are  required.  Subsequently  to  matricula- 
tion (which  must  include  physics)  to  take  a four  years’ 
course  of  study  and  to  pass  four  examinations.  They  shall 
be  apprenticed  for  not  less  than  three  years  with  a registered 
dentist  in  some  part  of  the  British  Empire.  Fee  for  the  four 
years  £100,  payable  in  four  equal  annual  instalments.  Annual 
examination  fee  £5  5^.  Candidates  for  the  degree  of  Doctor 
must  be  Bachelors  of  Dental  Science  of  at  least  two  years’ 
standing.  The  examination  is  partly  written  and  partly  oral. 
A thesis  may  be  submitted. 

University  of  Sydney. — A degree  in  Dental  Surgery  (B.D.S.) 
is  granted  after  a four  years’  course  following  matricula- 
tion. A graduate  in  medicine  is  required  to  devote  four 
terms  to  dental  study  before  sitting  for  the  degree  of  B.D.S. 
and  a licentiate  in  dental  surgery  one  additional  year. 

University  of  Adelaide. — The  four  years’  course  for  the 
B.D.S.  is  regulated  by  similar  conditions  to  that  for  the 
M.B.,  B.S.  Four  examinations  are  held  in  November  of 
successive  years.  The  fee  for  each  ordinary  examination  is 
£3  3s.,  and  for  the  degree  £5  5s.  Fees  for  the  whole  course 
amount  to  £95  11s. 

Mo  Gill  University,  Montreal. — The  degree  of  D.D.S.  is 
granted  on  a four  years’  curriculum,  the  first  year  being  that 
demanded  of  students  in  the  Medical  Faculty. 

University  of  Toronto. — The  degree  of  D.D.S.  is  granted  on 
a four  years’  curriculum.  Annual  examinations  are  con- 
ducted under  the  joint  auspices  of  the  University  and  the 
Royal  College  of  Dental  Surgeons  of  Ontario.  Concurrent 
courses  may  be  run  in  medicine  and  dentistry  extending  over 
seven  years. 

University  of  Malta. — The  University  grants  its  diploma  in 
dental  surgery  after  examination  to  candidates  producing 
evidence  of  four  years’  professional  study  and  three  years’ 
instruction  in  mechanical  dentistry. 


TEACHING  INSTITUTIONS  IN  DENTISTRY. 

See  also  under  Universities  of  Birmingham,  Leeds,  Liver- 
pool, and  Manchester  above. 

London. 

Royal  Rental  Hospital  of  London , School  of  Dental 
Surgery,  Leicester- square. — A school  of  the  University  of 
London,  and  women  are  now  admitted  as  students  and 
are  eligible  for  all  hospital  appointments  and  school 
prizes. — The  school  provides  th ■>  special  dental  educa- 
tion required  by  the  Royal  College  of  Surgeons  for 
the  Licence  in  Dental  Surgery.  The  general  part  of  the 


curriculum  may  be  taken  at  any  general  hospital.  The 
hospital  is  open  from  9 a.m.  to  5 P.M.,  there  being 
one  _ staff  for  the  morning  and  another  for  the  after- 
noon of  each  day.  Pupils  are  received  for  the  training 
in  dental  mechanics  recognised  by  the  curriculum.  The 
demonstrators  at  the  commencement  of  each  session  give 
a course  of  lectures  on  Operative  Dental  Surgery.  The  six 
house  surgeoncies  are  held  for  six  months  each  and  are 
open  to  all  qualified  students.  The  lecturers,  in  addition  to 
their  lectures,  give  special  demonstrations  on  the  Microscopy 
of  Dental  Anatomy  and  Dental  Surgery.  The  lecturer  on 
Dental  Mechanics  also  gives  practical  demonstrations  in 
the  laboratory.  There  is  an  Entrance  Scholarship  in 
Chemistry  and  Physics  of  the  value  of  £§0.  One  Entrance 
Scholarship  in  Dental  Mechanics  and  Metallurgy  value 
£25,  open  to  pupils  of  the  Hospital  only.  One  Entrance 
Scholarship  of  £25  in  Dental  Mechanics,  open  to  pupils 
of  private  practitioners.  The  Saunders  Scholarship  of 
£20  awarded  to  second  year  students.  The  Storer  Bennett 
Research  Scholarship  for  Scientific  Research  in  any  branch 
of  Dental  Surgery,  value  £50,  is  awarded  triennially.  The 
Alfred  Woodhouse  Scholarship  of  £35  and  the  Robert 
Woodhouse  Prize  of  £10  for  Practical  Dental  Surgery. 
Prizes  and  certificates  are  awarded  by  the  lecturers  for 
the  best  examinations  in  the  subjects  of  their  respective 
courses  at  the  end  of  the  summer  and  winter  sessions. 
Fee  for  two  years’  hospital  practice  required  by  the 
curriculum,  including  lectures,  £53  3*.  in  one  payment,  or 
£55  13s.  in  two  yearly  instalments.  The  curriculum 
requires  two  years  to  be  passed  at  a General  Hospital ; the 
fee  for  this  is  about  £60.  Both  hospitals  can  be  attended 
simultaneously.  For  the  lectures  in  Chemistry  and  Physics 
for  the  Preliminary  Science  Examination  £10  10s.  The  fee 
for  the  instruction  in  Dental  Mechanics  and  the  two  years’ 
hospital  practice  required  by  the  curriculum  is  £150  if  paid 
in  one  instalment,  or  150  guineas  if  paid  in  three  equal 
instalments.  The  fee  for  tuition  in  Dental  Mechanics  is 
50  guineas  per  annum ; for  one  year's  hospital  practice  ■ 
£21.  The  Winter  Session  opens  on  Oct.  1st. 

University  College  Hospital  Dental  School. — Comer  of  Great 
Portland  and  Devonshire-streets,  W. — This  Hospital  and 
School  has  recently  been  thoroughly  reorganised,  and  is  now 
fully  equipped  with  all  the  most  modern  appliances.  Students 
are  entered  as  students  of  University  College  Hospital,  and, 
as  such,  attend  the  classes  of  Chemistry,  Physics,  Anatomy, 
and  Physiology  in  University  College,  which  is  a few 
minutes’  walk  from  the  Dental  Department  in  Great 
Portland-street,  hitherto  known  as  the  National  Dental  Hos-  ■ 
pital.  The  First  Dental  School  to  admit  Women  Students. 
Practical  courses  to  comply  with  the  R.C.S.  curriculum  are  . 
held.  Clinical  Lectures  and  Demonstrations  are  given,  and 
each  student  on  entering  passes  through  a preliminary  course 
under  a demonstrator.  Two  Entrance  Exhibitions,  of  the 
value  of  £40  and  £20,  are  open  for  competition.  Prizes 
are  open  for  competition  at  the  end  of  each  course 
of  lectures.  Fee  for  the  full  curriculum  of  four  years, 
in  all  subjects  required  by  the  Royal  College  of 
Surgeons,  also  for  other  licensing  bodies,  180  guineas, 
or  in  four  instalments  of  62,  41,  41,  41  guineas.  A com- 
position fee  foi  medical  men  has  been  arranged  covering 
the  Two  Years’  Mechanical  Work,  Hospital  Practice,  and 
Lectures  required  by  the  curriculum  of  the  Royal  College  of 
Surgeons  amounting  to  120  guineas.  Hospital  Practice  to 
registered  practitioners  by  special  permission  of  Committee, 

12  months,  £15  15s.  The  Calendar,  containing  full  informa- 
tion as  to  Lectures,  Fees,  Prizes,  and  Subjects  for  the 
Entrance  Exhibitions  may  be  had  on  application  to  the 
Dean,  who  attends  the  Hospital  on  Tuesday  mornings 
at  10.30. 

Guy's  Hospital. — The  work  of  the  Dental  Department 
begins  daily  at  9 a.m.  both  in  the  extraction  rooms  and  in  [ 
the  conservation  room.  The  Extraction  Rooms : A new 

Dental  Out-patient  Department  has  been  provided.  There 
is  ample  accommodation  for  ordinary  extractions  and  anaes- 
thetic extractions,  together  with  waiting-  and  retiring-rooms.  , 
Patients  are  admitted  between  8.45  and  9.30  a.m.,  and  j 
are  seen  by  the  dental  surgeon  for  the  day,  the 
staff  demonstrator,  the  dental  house  surgeon,  and  the 
dressers.  The  Conservation  Room  is  open  from  9 a.m 
till  5 P.M.  It  has  recently  been  entirely  remodelled 
and  greatly  enlarged,  giving  a floor  space  of  over 
6000  square  feet.  It  affords  accommodation  for  about 
100  dental  chairs,  with  the  necessary  equipment  of  the 


The  Lancet,] 


TEACHING  INSTITUTIONS  IN  DENTISTRY. 


[August  30,  1919  409 


most  modern  type,  for  the  use  of  the  Dressers,  who, 
under  the  supervision  of  the  Staff,  perform  the  various 
operations  of  Dental  Surgery.  The  members  of  the  staff 
attend  every  morning  and  afternoon  to  give  demonstra- 
tions and  otherwise  assist  students  in  their  work  in  the  Con- 
servation Room  and  Prosthetic  Laboratory.  The  Proba- 
tioners’ Laboratory  is  supervised  by  two  of  the  staff  demon- 
strators, and  instruction  is  given  in  operative  dentistry  on  a 
“mannikin”  to  students  during  their  first  three  months  of 
study.  Students  in  Dental  Prosthetics  are  received,  and  a 
graded,  systematic,  and  full  course  of  instruction,  extending 
over  two  years,  is  carried  out.  Dental  students  have  the 
opportunity  of  attending  at  this  hospital  the  whole  course 
of  instruction  required  by  the  examining  board  for  the 
L.D.S.  Eng. — viz.,  two  years’  studentship  in  dental  pros- 
thetics, the  special  lectures  and  practice  of  the  Dental  Depart- 
ment, and  the  general  lectures  and  practice  of  the 
Medical  School.  The  fees  for  these  two  courses  may 
be  paid  separately  or  together,  or  they  may  be  combined 
with  the  fees  required  to  be  paid  for  the  course  for  a 
medical  diploma.  Students  who  enter  for  a medical  as  well 
as  a dental  diploma  are  allowed  to  pursue  their  study 
of  Dentistry  during  any  period  of  their  medical  course  most 
convenient  to  themselves  without  further  charge.  Four 
Entrance  Scholarships  in  Dental  Prosthetics  of  the  value  of 
£20  each  are  offered  for  competition  annually,  two  in 
September  and  two  in  April,  and  prizes  of  the  aggregate 
value  of  £47  are  awarded  for  general  proficiency  and  for 
skill  in  Operative  Dentistry.  A Dental  Travelling  Scholar- 
ship of  the  value  of  £100  is  awarded  every  second  year. 
Dental  students  are  eligible  for  admission  to  the  Resi- 
dential College  and  enjoy  the  privileges  of  students  in  the 
Medical  School.  Application  should  be  made  to  the  Dean 
of  the  Medical  School. 

London  Hospital. — This  school  is  apart  of  the  London  Hos- 
pital and  Medical  College,  and  is  fully  equipped  on  the  most 
modern  lines  and  with  the  latest  appliances.  It  provides  a 
complete  curriculum  in  all  subjects  for  the  L.D.S.  Diploma, 
and  is  admirably  adapted  for  the  purpose  of  teaching.  The 
Conservation  Room  is  well  lighted  and  ventilated  and  fitted 
with  pump  chairs  of  the  latest  pattern  ; the  fountain  spittoon 
at  every  chair  has  been  specially  designed  and  has  attached 
to  it  a saliva  ejector,  hot  and  cold  water,  compressed  air, 
gas  and  electric  current,  also  a swing  bracket  to  carry  the 
students’  cabinet.  Electric  sterilisers  are  supplied  in  each 
department  and  motor  engines  where  required.  The  School 
possesses  in  addition  to  the  Theatres,  Laboratories  and 
Museums  in  the  College,  a special  Museum  of  Dental 
Anatomy  and  Surgery,  Operative  Dentistry,  Prosthetic  and 
Extraction  Rooms,  and  Laboratories  for  Practical  Dental 
Metallurgy  and  Dental  Prosthesis.  A systematic  course  of 
instruction  in  Dental  Prosthesis  is  arranged  for  pupils.  The 
up-to-date  Laboratory  contains  every  modern  apparatus  and 
is  in  charge  of  a skilled  curator  and  his  assistants.  Con- 
nected with  the  Medical  College  and  Dental  School  are  a 
Library,  Athenaeum,  Clubs’  Union,  Dining  Hall  with 
moderate  tariff,  Students’  Hostel,  and  an  Athletic  Ground. 
For  full  particulars  as  to  fees  and  course  of  study  advised 
apply  to  the  Dean,  Professor  William  Wright,  who  will  be 
glad  to  make  arrangements  for  anyone  wishing  to  see  the 
Dental  School  and  Medical  College. 

London  ( Royal  Free  Hospital)  School  of  Medicine  for  Women. 
— Full  courses  are  arranged  for  women  students  for  the  study 
of  dentistry,  and  in  preparation  for  the  Licence  in  Dental 
Surgery  of  the  Royal  College  of  Surgeons  of  England,  at 
the  London  (Royal  Free  Hospital)  School  of  Medicine  for 
Women,  in  conjunction  with  the  London  Dental  Hospital, 
Leicester- square,  and  the  National  Dental  Hospital,  Great 
Portland-street,  W.  The  course  is  arranged  as  follows  : First 
and  second  years : Chemistry,  Physics,  and  Dental  Mechanics. 
Third,  fourth,  and  fifth  years:  Anatomy,  Physiology,  and 
Special  Dental  Courses,  Courses  in  Medicine  and  Surgery, 
General  Hospital  Course,  Dental  Hospital  Course.  The 
combined  fees  at  the  London  School  of  Medicine  for  Women 
and  the  National  Dental  Hospital  are  £180  if  paid  in  one 
sum  on  beginning  the  course,  or  £191  if  paid  in  three  annual 
instalments.  Bursary  : The  Council  of  the  School  will  award 
annually  (until  further  notice)  an  “ Agnes  Guthrie  ” Bursary 
of  the  value  of  £50  to  a student  fulfilling  the  required  con- 
ditions, who  enters  for  the  full  dental  course.  Candidates 
are  required  to  send  in  applications  on  or  before  July  1st, 
o the  Warden  and  Secretary,  from  whom  a prospectus  of  the 
School  and  all  particulars  can  be  obtained. 


Provincial. 

Birmingham  Dental  Hospital,  Great  Charles-street. — 
Dean  : Mr.  W.  T.  Madin.  The  Dental  Hospital  was  founded 
in  1858.  and  was  recognised  by  the  Royal  College  of 
Surgeons  in  1880  for  the  teaching  of  Dental  Students. 
Having  an  annual  attendance  of  about  16,000  patients,  it 
affords  every  advantage  for  students  about  to  enter  the 
profession  to  acquire  a thorough  practical  knowledge,  as 
required  by  the  Medical  Council.  The  present  Hospital  was 
opened  on  July  6th,  1905.  It  has  accommodation  for  50 
students.  The  equipment  is  in  accordance  with  the  most 
modern  requirements  for  the  efficient  teaching  and  practice 
of  Dental  Surgery.  The  operations  performed  annually 
average  35,000,  including  5000  gold  and  other  fillings, 
and  many  cases  of  crowns,  bridges,  porcelain  inlays,  and 
regulations.  By  arrangements  with  the  Birmingham  Uni- 
versity and  with  the  General  and  Queen’s  Hospitals  the 
entire  course  of  Lectures,  Hospital  Practice,  See.,  may 
be  completed  for  an  inclusive  fee  of  £96  15s.,  or 

including  Mechanical  Pupilage,  £186.  Examination  fees 
for  L.D.S.  Birm.,  total  £18.  The  instruments  and 
materials  necessary  for  Hospital  Practice  cost  about 
£35.  The  Composition  Fee  for  the  courses  required  for 
the  L D.S.  of  the  University,  or  any  of  the  Corpora- 
tions alone,  is  £60,  payable  in  two  annual  instalments 
at  the  commencement  of  the  first  and  second  years  ; that 
for  the  courses  required  for  the  L.D.S.  and  the  Degree  in 
Dentistry  of  the  University  is  £75  ; that  for  the  L.D.S.  in 
combination  with  the  M.R.C.S.  and  L.R.C.P.  is  £85;  and 
that  for  the  M.B.,  Ch.B.,  and  B.D.S.  is  £95.  All  of  these 
composition  fees  are  payable  in  two  annual  instalments  at 
the  commencement  of  the  first  and  second  years.  Each  of 
these  fees  covers  the  cost  of  the  courses  given  at  the  Uni- 
versity for  the  qualifications  indicated,  but  does  not  include 
fees  for  Hospital  teaching.  For  two  years’  dental  hospital 
practice  the  fee  is  20  guineas,  payable  in  two  instalments  of 
10  guineas  each  at  the  commencement  of  the  first  and  second 
(hospital)  years  respectively.  For  two  years’  mechanical 
pupilage,  85  guineas,  which  may  be  paid  in  two  annual  instal- 
ments of  50  and  35  guineas  respectively  ; mechanical  pupils 
may  join  for  a probationary  period  of  one  month,  fee  5 guineas, 
which  is  deducted  upon  payment  of  the  full  amount.  For 
general  surgical  hospital  practice,  lectures,  and  demonstra- 
tions : Surgery,  two  -winters,  £10  10s.  One  Entrance  Scholar- 
ship is  offered  annually  of  the  value  of  £37  10s.  It  is 
awarded  to  the  student  who,  entering  for  the  Dental  Degree 
of  the  University  in  October,  or  having  entered  not  earlier 
than  the  previous  April,  shall  pass  the  best  examination  in 
the  subjects  studied  during  his  apprenticeship.  Candidates 
must  be  under  the  age  of  21  years.  Application  for 
admission,  together  with  a certificate  of  birth,  must  be  sent 
to  the  Dean  of  the  Medical  Faculty,  Mr.  William  F.  Haslam, 
on  or  before  Oct.  15th. 

Leeds  Public  Dispensary . — The  Dental  Department  of  the 
Leeds  Public  Dispensary  is  fully  equipped  to  provide 
training  for  Dental  Students,  and  affords  every  oppor- 
tunity for  the  student  to  prepare  for  any  of  the  Dental 
Degrees  or  Diplomas.  The  Demonstrator  of  Operative 
Dental  Surgery  instructs  students  during  their  probationary 
course.  At  the  completion  of  this  training  students  have 
patients  allotted  to  them  by  the  Demonstrator,  and  have 
every  opportunity  of  acquiring  knowledge  from  the  members 
of  the  Staff,  two  of  whom  are  in  attendance  each  day.  The 
following  prizes  are  awarded  : — First  year  Students,  value 
2 guineas.  Operative  Dental  Surgery  Prize,  value  5 guineas. 
Two  prizes  in  Prosthetic  Dentistry : (a)  a prize,  value 
2 guineas,  for  first- year  pupils  ; ( b ) a prize,  value  5 guineas, 
open  for  competition  to  all  Students.  Extraction  prize, 
value  2 guineas,  open  for  competition  to  all  Students.  A 
prize  in  Orthodontics,  value  5 guineas,  is  open  to  all 
students.  Warden  : Mr.  W.  Sinton  Thorburn,  to  whom  all 
communications  should  be  addressed. 

Dental  Hospital  of  Manchester. — This  Hospital  is  in 
association  for  teaching  purposes  with  the  University  of 
Manchester  and  the  Royal  Infirmary,  and  is  in  the  centre  of 
a very  large  population.  Courses  of  study  are  provided  to 
meet  the  requirements  of  the  various  examining  bodies, 
including  those  of  the  University  of  Manchester  for  the 
qualifications  L.D.S.  and  B.D.S.,  and  the  L.D.S.  of  the 
Royal  College  of  Surgeons  of  England.  Clinical  instruction 
is  given  by  the  members  of  the  staff  and  by  the  house 
surgeons  and  demonstrators,  and  also  by  the  honorary 


410  The  Lancet,] 


TEACHING  INSTITUTIONS  IN  DENTISTRY. 


[August  30,  1919 


anesthetists  in  the  administration  of  nitrous  oxide  gas ; a 
special  class  in  anesthetics  is  conducted  by  the  clinical 
tutor  in  that  subject,  and  a class  for  instruction  in  porcelain 
and  gold  inlay  work  by  the  demonstrator  specially  appointed 
for  that  work. 

A Travelling  Scholarship,  value  £100,  will  be  awarded 
from  time  to  time.  Ten  prizes,  varying  in  value  from  £2  to 
£8,  are  awarded  annually. 

For  the  whole  course  of  hospital  instruction  for  the  L.D.S. 
(including  two  years’  mechanical  training)  the  fee  is  £100,  or 
if  paid  in  instalments  £105.  For  the  two  years'  Operative 
Course  only,  £21,  or  if  paid  in  two  instalments  21  guineas. 
For  the  whole  course  of  hospital  instruction  fortheB.D.S. 
degree  (including  mechanical  training),  £130,  or  if  paid  in 
instalments  130  guineas.  Additional  practice  in  Dental 
Mechanics  may  be  taken  by  pupils  who  have  already  received 
their  mechanical  training  elsewhere,  at  a fee  of  £20  for  six 
months. 

All  the  courses  of  instruction  are  open  to  women  students. 

Copies  of  the  Prospectus  will  be  forwarded  on  application 
to  Mr.  J.  Hilditch  Mathews,  Dean. 

Newcastle- upon-  Tyne  Dental  Hospital  and  School. — This 
Hospital  is  centrally  situated  (within  five  minutes  of  the 
various  colleges,  infirmary,  and  railway  station) ; the  rooms 
are  well  lighted  and  thoroughly  equipped  for  carrying  on  the 
work.  Dental  surgeons  and  an  anaesthetist  attend  each 
morning.  A tutorial  dental  surgeon  is  also  in  attend- 
ance. The  Composition  Fee  for  the  special  Dental 
Lectures  and  Dental  Hospital  Practice  is  £45  3s.  if  paid  in 
one  sum,  or  £46  4s.  if  paid  in  two  instalments  of  £23  2s. 
The  Composition  Fee  for  the  Lectures  at  the  Colleges  of 
Medicine  and  Science  is  40  guineas  ; in  addition  to  this  there 
is  a library  and  an  athletic  fee.  Particulars  of  the  fee  for 
General  Hospital  Practice  may  be  obtained  from  the  Senior 
House  Physician,  Royal  Victoria  Infirmary,  Newcastle-upon- 
Tyne.  Medals  and  Certificates  of  Merit  are  granted  to 
students  showing  certain  standards  of  proficiency  in  the 
various  classes  at  the  Dental  School.  The  prospectus  of  the 
Dental  Hospital  and  School,  containing  full  information, 
may  be  obtained  from  either  Mr.  J.  T.  Jameson,  12, 
Windsor-crescent,  Newcastle-upon-Tyne,  Dean,  or  Mr. 
James  Coltman,  13,  Ellison-place,  Newcastle-upon-Tyne, 
Vice-  Dean. 

Devon  and  Exeter  Dental  Hospital , 2J/.,  Southernhay , West, 
Exeter. — Established  1880.  — The  hospital  is  open  on  Mondays, 
Tuesdays,  Wednesdays,  and  Thursdays,  and  patients  are 
admitted  between  the  hours  of  9 and  11  A.M.  Students 
attend  the  practice  of  the  hospital  under  the  control  of  the 
medical  officers.  Honorary  treasurer,  Mr.  J.  M.  Ackland  ; 
secretary  Mr.  Albert  G.  Littlejohn 


Scotland. 

The  Incorporated  Edinburgh  Dental  Hospital  and  School. — 
The  Edinburgh  Dental  Hospital  and  School  is  located  in 
a spacious  and  well-equipped  building  at  31,  Chambers- 
street  and  offers  special  advantages  to  dental  students. 
The  General  Courses  required  for  the  Dental  Diploma 
may  be  taken  in  the  Medical  School  of  the  Royal 
Colleges  of  Physicians  and  Surgeons  or  in  the  University 
schools.  The  hospital  attendance  and  clinical  instruction 
are  taken  at  the  Royal  Infirmary.  The  Universit  , Medical 
Schools,  and  Royal  Infirmary  are  within  three  minutes’ 
walk  of  the  Dental  Hospital.  The  special  courses  are  taken 
in  the  hospital.  The  Dental  Hospital  practice,  extending 
over  two  years,  affords  a student  ample  .opportunity  for 
a full  acquaintance  with  every  branch  of  dentistry.  The 
hospital  admits  a limited  number  of  indentured  pupils. 
They  receive  their  instruction  in  Mechanical  Dentistry 
concurrently  with  the  general  and  special  courses.  A 
premium  of  60  guineas  is  payable  with  each  such 
pupil.  The  practice  and  lectures  of  the  hospital  are 
recognised  by,  and  qualify  for,  all  the  Licensing  Boards. 
The  cost  of  the  hospital  outfit  of  instruments  is 
included  in  the  Dental  Hospital  fee  of  £42.  The 
minimum  cost  of  classes  and  Diploma  for  the  whole  course 
of  dental  instruction  amounts  to  £98  17s.  Those  students 
who  desire  to  take  a Medical  and  Surgical  Diploma 
in  addition  to  the  L.D.S.  have  in  this  school  admirable 
facilities  for  so  doing.  The  triple  qualification  of  the 
Royal  College  of  Physicians  and  Surgeons  of  Edinburgh  and 
the  Royal  Faculty  of  Physicians  and  Surgeons  of  Glasgow 


is  recommended.  The  minimum  cost  of  Professional  Educa- 
tion, the  Triple  Qualification,  and  the  Licence  in  Dental 
Surgery  amounts  to  £172  19s.  Further  particulars  can  be 
obtained  from  the  Dean,  Mr.  W.  Guy. 

Incorporated  Glasgow  Dental  Hospital,  15,  Dalhousie- 
street , Glasgow. — The  School  is  open  to  Men  and  Women 
Students,  and  Lectures  are  given  on  Dental  Surgery, 
Operative  Dental  Surgery,  Orthodontia,  Dental  Anatomy 
and  Physiology,  Pathology,  Dental  Histology,  Dental 
Mechanics,  Crown  and  Bridge  work,  Dental  Metallurgy, 
Dental  Bacteriology,  and  Anaesthetics.  Lectures  on  general 
subjects  required  for  Dentistry  may  be  taken  at  the  Univer- 
sity or  at  one  of  the  extra-mural  schools  where  special 
provision  is  made  for  Dental  Students.  Composition  fee  for 
two  years’  Hospital  Practice  and  Lectures  special  to  Dentistry, 
£40  on  entry  or  in  two  instalments  of  £21  each.  Fees  for 
Hospital  Practice  and  Dental  Lectures  may  be  paid  for 
separately,  at  a total  cost  of  £43  Is.  Full  information  may 
be  had  on  application  to  the  DeaD . 

Glasgow  Royal  Infirmary  (Dental  Department).* — Mr.  W. 
Taylor  attends  at  the  Royal  Infirmary  at  9 A.M.  on  Wednesdays 
and  other  days  as  arranged,  and  gives  a course  of  instruction  in 
Dental  Surgery.  The  following  course  in  the  curriculum  can  be 
taken  at  St.  Mungo’s  College  : Anatomy,  six  months  ; Practical 
Anatomy,  nine  months  ; Physiology,  six  months  ; Chemistry, 
six  months  ; Practical  Chemistry  with  Metallurgy,  three 
months  ; Surgery,  six  months  ; Medicine,  six  months  ; Materia 
Medica,  three  months  ; Clinical  Surgery,  six  months ; Dental 
Surgery,  six  months,  and  attendance  for  two  years  on  the 
dental  department  of  the  hospital.  The  attendance  on  the 
Dental  Clinic  is  free  to  students  of  the  hospital. 


Ireland. 

Incorporated  Dental  Hospital  of  Ireland,  Lincoln-place, 
Dublin .* — All  Dental  Students  who  have  passed  their  First 
Dental  Examination  in  the  Royal  College  of  Surgeons  in  , 
Ireland  (or  an  equivalent  examination  or  examinations)  are 
admissible  to  the  Clinical  Instruction  of  the  Hospital. 

In  addition  to  Clinical  Instruction  and  Special  Demon-  .] 
strations,  courses  of  lectures  are  given  at  the  hospital  , 
on  Dental  Surgery  and  Pathology,  Mechanical  Dentistry,  the 
Administration  of  Anesthetics,  Orthodontia,  Dental  Anatomy, 
and  Dental  Materia  Medica.  Practical  instruction  is  also  given 
in  Anesthetics.  In  addition  to  the  longer  courses  of  hospital 
attendance,  courses  of  three  months’  duration  will  be  given 
to  surgeons  intending  to  practise  in  the  Colonies  or  remote 
country  districts,  or  in  the  Army  and  Navy. 

Fees. — Dental  Hospital  Practioe  (each  year),  £12  12*.  ; 
Lectures,  £6  6*.  ; Composition  Fee,  £15  15*.  per  annum.  In 
addition  to  the  above  courses  registered  dentists  who  are 
members  of  the  British  Dental  Association  will  usually  be  per- 
mitted to  take  out  a three  months’  course  for  a fee  of  6 guineas. 
The  course  in  practical  Dental  Mechanics  can  be  taken  j 
in  the  Hospital  Laboratory.  Further  particulars  can  be 
obtained  from  the  Dean. 


Dominions. 

The  Australian  College  of  Dentistry,  in  connexion  with  the  , 
Melbourne  Dental  Hospital,  trains  candidates  for  the 
degrees  of  B.  D.Sc.  and  D.D.Sc.  Melb.  Students  indentured 
to  the  College  pay  £170  in  two  instalments  of  £85  each,  or 
four  instalments  of  £42  10*.  The  superintendent  of  the 
College  is  Mr.  E.  S.  Fisher,  L.D.S.,  D.D.Sc. 

United  Dental  Hospital  of  Sydney  was  established  in  1901 
to  provide  facilities  for  the  students  attending  the  University 
Dental  School.  The  fee  payable  by  University  students  for 
the  dental  practice  of  the  hospital  is  £6  6*.  per  annum. 
The  secretary  is  Mr.  H.  A.  Clarke,  F.I.A.A. 

The  Dental  Department  of  McGill  University.  Montrea  . was 
opened  in  1903  at  the  request  of  the  Dental  Association  of 
the  Province  of  Quebec  as  a section  of  the  medical  faculty. 
An  out-patient  clinic  in  dentistry  at  the  Montreal  General 
Hospital  provides  the  clinical  material.  Particulars  from  the 
Registrar  of  the  Medical  Faculty. 

The  Royal  College  of  Dental  Surgeons  of  Ontario  has  a 
school  of  dentistry  in  connexion  with  the  University  of 
Toronto.  Practical  work  is  carried  out  in  the  infirmary  and 
laboratories  of  the  College. 


* No  returns. 


The  Lancet,]  REGISTRABLE  COLONIAL  AND  FOREIGN  MEDICAL  DEGREES. 


[August  30,  1919  4 1 1 


REGISTRABLE  COLONIAL  AND  FOREIGN 
MEDICAL  DEGREES. 

Under  the  Medical  Act,  1886,  a number  of  medical 
diplomas  granted  in  British  possessions  entitle  their 
possessors  to  be  registered  without  further  examination  in 
the  Colonial  List  of  the  (British)  Medical  Register.  The 
condition  attached  to  such  registration  is  that  the  holder 
of  the  colonial  diploma  obtained  it  when  he  was  not  domi- 
ciled in  the  United  Kingdom  or  in  the  course  of  a period  of 
not  less  than  live  years  during  the  whole  of  which  he  resided 
out  of  the  United  Kingdom.  Some  account 1 of  these 
diplomas  is  here  given. 

Australasia. 

Summary  of  Registrable  Degrees. — New  South  Wales : 
University  of  Sydney,  (1)  M.B.,  (2)  M.D.,  (3)Ch.M.  New 
Zealand:  University  of  New  Zealand,  (1)  M.B.,  Ch.B., 
(2)  M.D.  South  Australia  : University  of  Adelaide, 

(1)  M.B.,  B.S.,  (2)  M.D.,  (3)  M.S.  Victoria:  University  of 
Melbourne,  (1)  M.B.,  (2)  M.D.,  B.S. 

University  of  Adelaide. 

The  University  of  Adelaide2  was  established  by  Act  of 
the  South  Australian  Legislature  in  1874.  In  1883  Sir 
Thomas  Elder  gave  £10,000  for  the  foundation  of  a school 
of  medicine.  The  Medical  Acts  of  1844  and  1880  set  up  a 
South  Australian  Medical  Board  to  issue  certificates  of 
legally  qualified  medical  practice. 

Preliminary  Examination. — Before  entering  upon  the 
medical  course  candidates  must  have  passed  the  Senior 
Public  Examination  in  at  least  five  subjects  at  one  and  the 
same  time,  and  the  higher  standard  in  physics,  chemistry, 
and  biology. 

M.B.,  B.S. — The  five  years’  course  includes  five  examina- 
tions held  in  November  of  each  year.  At  the  first  the 
subjects  are  anatomy  and  dissections,  physiology,  organic 
chemistry,  and  physical  chemistry  ; at  the  second,  anatomy, 
physiology,  and  materia  medica  ; at  the  third,  medicine, 
surgery  (including  clinical),  regional  and  surgical  anatomy, 
bacteriology  ; at  the  fourth,  medicine  (including  clinical), 
surgery,  pathology,  obstetrics,  and  forensic  medicine  (in- 
cluding insanity)  ; at  the  fifth,  medicine  (all  branches), 
surgery  (including  surgical  anatomy  and  operative  surgery), 
gynaecology,  ophthalmology,  otology,  therapeutics,  and 
elements  of  hygiene.  The  fee  for  each  examination  is  £3  3s. 
and  for  the  degree  £5  5s.  Fees  for  the  five  years’  course  of 
study  amount  to  £124  19s.  There  were  189  undergraduate 
students  in  1918. 

M.D. — Candidates  must  have  been  Bachelors  for  at  least 
nine  academic  terms,  which  may  be  shortened  on  the 
recommendation  of  the  Faculty  of  Medicine.  The  subject 
of  examination  may  be  selected  from  the  following  : General 
medicine,  diseases  of  the  nervous  system,  pathology, 
obstetrics,  State  medicine.  A thesis  may  be  submitted. 
Fee  for  the  examination  £15  15s.,  for  the  degree  £10  10s. 

M.S. — The  conditions  are  similar  to  those  for  the  M.D. 
Choice  of  subject  may  be  made  from  : Gynaecology,  the 
surgery  of  the  abdomen,  the  surgery  of  the  special  senses 
and  throat  ; in  addition  to  examination  in  the  principles  of 
surgery. 

University  of  Melbourne. 

The  University  of  Melbourne  3 was  incorporated  by  Act 
of  the  Victorian  Legislature  in  1853.  The  Medical  Act  of 
1890  set  up  the  Medical  Board  of  Victoria  to  register  legally 
qualified  medical  practitioners. 

Preliminary  Examination. — All  candidates  must  possess 
the  School  Leaving  Certificate,  which  is  based  on  education 
in  a secondary  school  during  four  years.  The  Intermediate 
Certificate  must  have  been  taken  at  least  a year  before  the 
School  Leaving.  English  is  compulsory  at  the  higher 
standard  ; Latin  and  geometry  with  trigonometry  at  the 
lower. 


1 The  information  which  was  kindly  sent  to  us  has  been  summarised. 
Where  none  appears  none  was  received.  It  is  hoped  to  make  the 
section  more  complete  another  year. 

2 The  University  Registrar  is'Mr.  C.  R.  Hodge.  The  Calendar  of  the 
University  of  Adelaide  (1919)  is  a volume  of  490  pp.,  printed  by  \V.  K. 
Thomas  and  Co.,  Grenfell  stteet,  Adelaide.  Price  2s.  Sd. 

3 The  University  Registrar  is  Mr.  J.  P.  Bainbridge,  J.P.  The 
Melbourne  University  Calendar  (1919)  is  a volume  of  934  pp.,  printed 
for  the  University  by  Ford  and  Sod,  Drummond-streer,  Carlton, 
Melbourne.  Price  3s. 


M.B.,  B.S. — The  course  extends  over  five  calendar  years, 
and  is  divided  into  two  equal  parts,  hospital  practice  being 
confined  to  the  second  half.  The  first  year  (Division  I.)  is 
devoted  to  natural  philosophy,  chemistry,  biology,  and 
botany  ; the  remainder  of  the  first  half  (Division  II.)  to 
anatomy  and  physiology.  Two  complete  courses  of  dissec- 
tions are  compulsory.  Hospital  practice  extends  through 
Divisions  III.  and  IV.  The  general  hospitals  ranking  as 
clinical  schools  are  the  Melbourne  Hospital,  the  Alfred 
Hospital,  and  the  St.  Vincent’s  Hospital.  The  recognised 
special  hospitals  include  the  Women’s  Hospital,  the  Children’s 
Hospital,  the  Eye  and  Ear  Hospital,  the  Infectious  Diseases 
Hospital,  the  Receiving  House,  and  Acute  Mental  Hospital.  A 
full  clinical  curriculum  is  arranged,  both  general  and  special, 
with  clinical  lectures.  In  Division  III.  (lasting  one  year) 
courses  of  lectures  are  given  in  pathology  (with  practical 
work  in  histology  and  in  bacteriology),  in  therapeutics, 
public  health,  materia  medica,  and  pharmacy,  and  regional 
and  applied  anatomy,  and  examination  in  all  these  subjects 
follows  immediately.  In  Division  IV.,  lasting  a year  and  a 
half,  systematic  lectures  are  confined  to  the  first  year  and 
include  medicine,  surgery,  and  forensic  medicine.  Lectures 
on  obstetrics  and  gynaecology  are  given  in  Division  III.,  but 
the  examination  in  these  subjects  is  postponed  till  the  final 
at  the  end  of  the  course,  which  also  includes  the  subjects 
of  Division  IV.  Clinical  medicine  and  clinical  surgery  rank 
as  separate  subjects  in  the  finals. 

Honour  examinations  with  exhibitions  are  held  in  all 
subjects  of  Divisions  I.,  II.,  and  III.,  and  there  is  a final 
honour  examination  with  scholarships  in  medicine,  in 
surgery,  and  in  obstetrics  and  gynaecology. 

The  yearly  fee  payable  to  the  University  is  £23,  with  a 
sports  fee  of  1 guinea  and  a club-house  fee  of  1 guinea. 
The  hospital  and  pharmacy  fees  in  Divisions  III.  and  IV. 
amount  to  £69  6s.  The  total  fees  are  £194  16s.  The 
degree  fee  for  M.B.,  B.S.,  is  7 guineas. 

The  number  of  students  now  in  attendance  is  628. 

M.D. — Candidates  must  be  Bachelors  of  Medicine  of  two 
years’  standing.  They  may  proceed  either  by  thesis  or  by 
examination.  The  thesis  must  be  a substantial  contribu- 
tion to  medical  knowledge.  The  examination  includes 
medicine,  with  either  obstetrics  and  medical  gynaecology, 
or  diseases  of  children,  or  diseases  of  the  nervous  system, 
including  insanity.  Subject  to  a dispensing  power  in  the 
case  of  theses  of  great  merit,  all  candidates  must  pass  an 
examination  in  clinical  medicine.  The  fee  for  examination 
and  degree  is  10  guineas. 

M.S. — Candidates  must  be  Bachelors  of  Surgery  of  two 
years’  standing.  Part  I.  of  the  examination  includes 

surgical  anatomy  and  surgical  pathology.  Part  II.  includes 
surgery  in  all  branches.  The  two  parts  may  be  taken 
together  or  separately.  No  candidate  can  pass  in  Part  II. 
who  has  not  passed  in  Part  I.  The  fee  for  examination 
and  degree  is  10  guineas. 

Diploma  of  Public  Health. — Granted  under  conditions 
agreeing  with  those  in  the  United  Kingdom.  Fees  for 
instruction  are  32  guineas,  apart  from  fever  hospital  prac- 
tice. The  fee  for  examination  is  10  guineas,  for  diploma 
3 guineas. 

Diploma  of  Tropical  Medicine. — Candidates  must  be 
qualified  medical  practitioners,  and  must  have  passed 
Part  I.  for  D P.H.  or  have  undergone  a special  training  in 
lieu  thereof.  They  are  trained  in  tropical  medicine  at  the 
Australian  Institute  of  Tropical  Medicine,  Townsville, 
Queensland,  having  a three  months’  course  of  theoretical 
and  practical  instruction,  followed  by  a three  months’ 
clinical  course  in  the  Townsville  Hospital.  The  examina- 
tion is  conducted  at  the  institute.  Fee  for  preliminary 
course  is  £2  2s.  ; for  course  at  institute,  10  guineas  ; for 
examination  and  diploma.  5 guineas. 

Affiliated  Colleges.  — Trinity  College  (1872),  Ormond 
College  (1879),  and  Queen’s  College  (1888)  are  affiliated  to 
the  University  and  have  medical  tutors. 

University  of  New  Zealand. 

The  University  of  New  Zealand  was  established  by  Act  of 
the  New  Zealand  Legislature  in  1870.  The  Medical  Act  of 
1908  provided  for  the  registration  of  medical  practitioners. 
The  University  has  no  fixed  home  or  buildings  ; it  is  an 
examining  body  with  four  affiliated  colleges — namely, 
University  of  Otago,  Dunedin  ; Canterbury  College, 
Christchurch  ; Auckland  University  College ; and  Victoria 


412  Thb  Lancet,]  REGISTRABLE  COLONIAL  AND  FOREIGN  MEDICAL  DEGREES. 


[August  30, 1919 


University,  Wellington.  The  degrees  of  M.B.,  Ch.B., 
M.D  , and  B.D.S.  are  conferred. 

University  of  Sydney. 

The  University  of  Sydney  1 was  incorporated  by  Act  of  the 
New  South  Wales  Legislature  in  1850.  The  Medical  Practi- 
tioners Act  of  1898  provides  for  the  registration  of  legally 
qualified  medical  practitioners. 

Matriculation  Examination. — Latin  and  another  language 
other  than  English  are  required,  one  at  the  Higher  standard. 

M.B.,  Ch.  M. — -The  course  of  study  extends  over  a period 
of  five  years.  Five  degree  and  a final  examination  are  held  : 
(1st  year)  in  physics,  chemistry,  botany  and  zoology  ; (2nd 
year)  in  anatomy  and  physiology  ; (3rd  year)  in  the  entire 
subjects  of  anatomy  and  physiology,  every  part  of  the  body 
having  been  dissected  at  least  once  ; (4th  year)  in  pathology, 
surgical  anatomy  and  operative  surgery,  materia  medica,  and 
therapeutics  : (5th  year)  in  medical  jurisprudence  and  public 
health  ; (final)  in  medicine,  surgery,  obstetrics,  and  gynre- 
cology.  Certificates  of  proficiency  in  vaccination  and 
anaesthetics  are  required.  The  fee  for  each  degree  is  £10. 
The  number  of  students  attending  degree  courses  during 
1917  was  545 — 480  men  and  65  women. 

M.D. — Candidates  must,  after  obtaining  the  degree  of 
Bachelor,  have  spent  at  least  two  years  in  medical  or 
surgical  practice  or  in  approved  study.  Examination  is 
written  or  oral  in  one  of  the  following  subjects : medicine, 
medical  jurisprudence  and  public  health,  surgery,  obstetrics 
and  gynaecology  ; or  in  any  of  the  scientific  subjects  included 
in  the  medical  curriculum.  A thesis  must  be  presented  two 
months  before  the  examination.  The  fee  for  the  degree 
is  £10. 

Diploma  in  Public  Health. — Candidates  must  be  registered 
practitioners  of  not  less  than  12  months’  standing.  The 
examination  is  in  two  parts  : (1)  relating  to  the  general 
principles  of  sanitary  medicine  ; (2)  relating  to  State  medi- 
cine and  to  the  applications  of  pathology  and  sanitary  science 
to  public  health.  The  fee  is  £10. 

A ffiliated  Colleges. — Matriculated  students  are  admitted  to 
the  following  resident  colleges — namely,  St.  Paul’s  College 
(Church  of  England),  St.  John’s  College  (Roman  Catholic), 
St.  Andrew’s  College  (Presbyterian),  Wesley  College 
(Methodist),  the  Women’s  College  (undenominational),  at 
which  scholarships  and  bursaries  are  available. 

Recognised  Hospitals  are  the  Royal  Prince  Alfred  Hospital 
with  medical  school,  the  Sydney  Hospital  with  clinical 
school,  St.  Vincent’s  Hospital,  the  Royal  Hospital  for  Women, 
the  Royal  Alexandra  Hospital  for  Children,  the  Glandesville 
and  Callan  Park  Hospitals  for  the  Insane,  the  Women’s 
Hospital,  the  Renwick  Hospital  for  Infants,  and  the  South 
Sydney  Hospital  for  Women. 

British  North  America. 

Summary  of  Registrable  Degrees  and  Diplomas. — Manitoba  : 
College  of  Physicians  and  Surgeons,  Member  ; University  of 
Manitoba,  M.D.  New  Brunswick:  Provincial  Council  of 
Physicians  and  Surgeons,  L.M.S.  Newfoundland:  Medical 
Board,  L.M.S.  Nova  Scotia:  Provincial  Medical  Board, 
L.M.S.  ; Dalhousie  University,  M.D.,  C.M.  (Halifax  Medical 
College,  M.D.,  C.M.,  if  obtained  prior  to  August  31st,  1911). 
Ontario : College  of  Physicians  and  Surgeons,  Member. 
(To  this  can  be  added  as  additional  qualifications  the  degrees 
in  medicine  of  the  Queen’s  University,  Kingston ; the 
Western  University,  London  ; and  the  University  of  Toronto.) 
Prince  Edward  Island:  Medical  Council,  L.M.S.  Quebec: 
McGill  University,  M.D.,  C.M.  ; Laval  University,  M D. 
Saskatchewan : College  of  Physicians  and  Surgeons, 

Member. 

Dalhousie  University , Halifax,  Nova  Scotia.3 * * 

The  work  of  Halifax  Medical  College  was  discontinued  in 
1911,  when  instruction  in  all  subjects  of  the  medical 
curriculum  was  undertaken  by  Dalhousie  University.  The 
professional  examinations  are  conducted  conjointly  by  the 
university  and  the  Provincial  Medical  Board  of  Nova  Scotia 
(see  below). 


* The  University  Registrar  is  Mr.  H.  E.  Barff.  M.A.  The  Calendar  of 
the  University  of  Sydney  (1918)  is  a volume  of  712  pp..  printed  for  the 
University  by  Angus  and  Robertson,  Ltd..  Sydney.  Price  2s.  6 d. 

5 The  Secretary  of  t he  Medical  Faculty  is  Professor  D.  Fraser  Harris. 
The  calendar  of  the  Faculty*.  1919-20.  is  an  excerpt  of  40  pD.  from  the 
University  Calendar,  printed  for  the  Universi'y  by  Wm.  Macnab  and 
Son,  Halifax. 


M.D.,  C.M. — In  addition  to  the  matiiculation  or  pre- 
limin  .ry  examination  candidates  are  required  to  pass  five 
professional  examinations.  For  admission  to  the  classes  of 
the  third  or  any  higher  year  the  undergraduate  must  have 
passed  in  all  the  subjects  of  the  preceding  year.  The 
curriculum  for  the  third  year  still  includes  practical  anatomy 
and  advanced  physiology,  while  the  fifth  (final)  year  subjects 
are  given  as  : Surgical  anatomy,  operative  surgery,  clinical 
surgery,  clinical  medicine,  clinical  pediatrics,  clinical 
obstetrics,  practical  obstetrics,  clinical  gynaecology,  mental 
diseases,  skin  diseases,  eye,  ear,  nose  and  throat  diseases, 
dressing,  clerking,  vaccination,  post  mortems,  hospital, 
medical  ethics.  To  win  distinction  in  any  subject  a 
mark  of  75  per  cent,  or  over  is  required.  The  total  tuition 
fees  in  any  year  amount  to  §125,  with  §10  additional  for  the 
third,  fourth,  and  fifth  years.  Tne  fee  for  each  examination 
is  §10.  There  were  114  medical  students  of  all  years  in 
1918-19. 

Queen's  University,  Kingston,  Canada. 

Queen's  College,  Kingston,6  was  established  by  Royal 
charter  in  1841,  assisted  by  grants  from  the  Presbyterian 
Church  in  Scotland.  Classes  in  medicine  were  first  held  in 
the  University  in  1854.  The  Medical  School,  conducted  for 
a time  under  the  charter  of  the  Royal  College  of  Physicians 
and  Surgeons  at  Kingston,  became  an  integral  part  of  the 
University  in  1892.  Kingston  General  Hospital  (230  beds)  is 
adjacent  to  the  University  buildings. 

M.  D..  C.M. — Candidates  for  a degree  must  pass  the  Junior 
Matriculation  of  the  University  or  its  equivalent.  The 
course  comprises  five  sessions  of  eight  months  each.  A 
combined  B.A.  and  M.D.  course  may  be  taken  in  seven 
years.  Foreign  students  must  spend  at  least  one  full  session 
in  the  University.  Examinations  are  held  at  the  end  of 
each  session.  The  average  cost  per  session  of  eight  months, 
including  board  and  lodging,  is  $376-8435.  All  students  are 
expected  to  attend  a church  of  the  denomination  to  which 
they  profess  to  belong.  228  students  were  in  attendance 
during  the  session  1918-19. 

D.Sc. — Granted  on  a thesis  embodying  original  research  of 
importance  to  medical  science  not  earlier  than  two  years 
after  graduation.  A reading  knowledge  of  scientific  French 
and  German  is  required. 

D.P.H. — The  diploma  is  granted  to  those  holding  the 
M.  D.,  or  M.D.,  B.Sc.,  after  examination  following  prescribed 
study,  which  includes  six  months  with  a recognised  medical 
officer  of  health  in  the  study  of  practical  sanitation. 

Laval  University,  Quebec. 

Laval  Catholic  LTniversity  7 was  incorporated  by  Royal 
Charter  in  1852,  absorbing  the  Quebec  School  of  Medicine  , 
organised  four  years  earlier.  The  first  class  graduated  in 
1855. 

M.B.,  M.D. — The  entrance  examination  includes  Latin, 
philosophy,  and  Canadian  history,  and  its  standard  is  pre- 
scribed by  the  College  of  Physicians  and  Surgeons  of  Quebec. 
Tht  Faculty  of  Medicine  confers  a baccalanr§at  and  a 
doctorat,  the  former  after  2 years,  comprising  6 terms  of 
study,  the  latter  after  3 further  years.  Examinations  are 
held  in  Jane  at  the  end  of  each  year  of  study.  The  total 
fee  for  examinations  is  §15,  for  the  diploma  of  bachelor  §5, 
and  for  that  of  doctor  §20.  Fees  paid  by  enrolled  students 
for  the  medical  course  amount  to  §45  a term. 

Me  Rill  University,  Montreal. 

•The  Faculty  of  Medicine  of  McGill  University'  arose  out 
of  the  Montreal  Medical  Institution,  organised  as  a medical 
school  in  1823-24,  and  incorporated  in  the  University 
in  1829. 

Preliminary  Examination. — Before  registration  an  under- 
graduate in  medicine  must  have  passed  the  Matricula- 
tion Examination  of  the  University  or  its  equivalent.  The 
examination  is  held  twice  yearly  at  McGill,  and  once  at 
Calgary,  Regina,  Winnipeg,  Toronto,  St.  John,  and  Truro. 

<>  Tbe  Secretary  of  the  Medical  Faculty  is  Dr.  A.  R.  B.  Williamson. 

Queen's  University.  Kingston,  Ont.  The  Calendar  of  tbe  Faculty  of 

Medicine.  1919-20,  is  a volume  of  104  pp.,  printed  by  the  Jackson  Press. 

Kin  gston. 

7 The  Secretary  of  the  Medical  Faculty  is  M.  Arthur  Vallce.  The 
Annuaire  de  la  Faculty  de  la  Medectne  de  l'Univereite  Laval  (1918-19 
is  a volume  of  61  pp.,  printed  by  1’ Action  Sociale.  Limitee.  Quebec. 

» The  University  registrar  is  Mr  J.  M.  Nicholson.  M.A.  The  registrar 
of  the  Faculty  of  Medicine  is  Dr.  J.  W.  Scane  The  Annual  Calendar 
of  the  Faculty  of  Medicine  and  Department  of  Dentistry  is  a volume  of 
9U  pp.,  printed  by  the  Gazette  Printing  Co.,  Ltd.,  Montreal. 


The  Lancet,]  REGISTRABLE  COLOMIAL  AND  FOREIGN  MEDICAL  DEGREES.  [August  30,  1919  4 1 3 


Also  in  June  in  London  (apply  to  Secretary,  Headmasters’ 
Conference,  12,  King’s  Bench  Walk,  E.C.).  Latin,  and 
either  Greek,  Frenoh,  or  German  must  be  taken.  Every 
student  entering  the  University  is  required  to  pass  a physical 
examination  to  detect  defects  and  weaknesses  amenable  to 
treatment.  Board  and  lodging  can  be  obtained  in  private 
houses  in  the  vicinity  of  the  University  at  $40  a month 
upwards. 

M.D.,  C.M. — The  undergraduate  course  in  medicine  has 
this  year  been  increased  to  six  years  by  a pre-medical  year 
devoted  to  chemistry,  physics,  and  biology,  with  English  and 
one  modern  language.  This  readjustment  gives  a final  year 
confined  to  hospital  work,  including  medicine,  surgery, 
obstetrics,  ophthalmology,  oto-iaryngology,  pathology,  and 
dermatology.  The  third  year  now  embraces  anatomy 
(neurology),  physiology,  general  pathology,  bacteriology, 
chemistry  (physiological  and  clinical),  parasitology,  pharma- 
cology, and  clinical  microscopy.  During  this  year  students 
begin  to  visit  the  hospitals  and  receive  instruction  in  small 
groups  in  the  elements  of  clinical  medicine  and  clinical 
surgery.  Examinations  are  held  in  the  subjects  of  each 
successive  year.  Seven  years’  (double)  courses  are  held  for 
the  B.A.,  M.D.,  or  B.Sc.,  M.D.  The  total  faculty  fees  for 
the  medical  cour.-e  of  five  years  are  $735,  payable  in  five 
annual  instalments  of  $147  each.  The  degree  fee  is  30. 
365  medical  students  were  enrolled  in  the  session  1917-18. 

D.P.H. — The  Course  for  this  diploma  is  temporarily 
withdrawn. 

New  Brunswick , Council  of  Physicians  and  Surgeons. 

The  Council  of  Physicians  and  Surgeons  of  New  Brunswick 
is  empowered  by  the  Medical  Act  to  issue  a licence  (L.M.S.) 
conferring  the  legal  right  to  practise.  The  usual  matricula- 
tion examination  is  required  and  the  graded  collegiate  course 
comprises  five  sessions  of  not  less  than  eight  months  each. 
The  examinations  are  held  twice  a year  at  St.  John,  N.B., 
the  fee  being  $30.  Candidates  may  appear  for  the  primary 
examination  at  the  end  of  the  second  year  of  study.  The 
fee  for  the  licence  is  $3  and  the  registration  fee  $40.  The 
registrar  of  the  council  is  Dr.  S.  Skinner,  64,  Charlotte- 
street,  St.  John,  N.B. 

Nova  Scotia,  Provincial  Medical  Board. 

A licence  (L.M.S.),  legally  entitling  to  practise,  is  issued 
by  the  Provincial  Medical  Board  of  Nova  Scotia  after  a pre- 
liminary (fee  $25  including  student  registration)  and  three 
professional  examinations  (fees  $75  including  registration). 
The  registrar  of  the  Board  is  Dr.  W.  H.  Hattie,  Halifax,  N.S. 

University  of  Toronto. 

The  University  of  Toronto/'  Ontario,  took  its  title  in  1849, 
a Royal  Charter  having  been  granted  in  1827.  The  Faculty 
of  Medicine  was  re-established  in  1887  under  the  Federation 
Act.  Victoria  College  (1892),  Trinity  College  (1904),  and 
St.  Michael’s  College  (1907)  are  integral  parts  of  the 
University. 

Preliminary  Examination. — The  matriculation  certificate 
of  the  University  is  required  from  entrants  unless  they  are 
graduates  in  Arts  of  a Dominion  or  British  University  or 
possess  a certificate  of  entrance  into  the  Faculty  of 
Education. 

M.B. — The  undergraduate  course  has  just  been  lengthened 
to  six  years,  with  an  exception  for  those  who  have  been  on 
military  service.  Six  examinations  are  taken  in  succession 
at  the  end  of  the  session.  The  early  years  aim  at  giving 
such  a training  in  sciences  as  is  now  exacted  of  those  who 
desire  to  obtain  a British  as  well  as  a Canadian  qualification. 
During  the  third  year  an  attempt  is  made  to  bridge  the  gap 
between  the  primary  scientific  and  the  final  clinical  subjects 
by  taking  up  anatomy  and  physiology  at  the  same  time  as 
surgery  and  medicine  throughout  the  year.  Preliminary 
courses  in  pathology  and  pathological  chemistry  are  taken  ; 
instruction  is  given  in  pharmacology  ; and  a series  of  ten 
lectures  delivered  on  psychology.  The  final  year  includes 
courses  on  anaesthesia,  dentistry,  medical  ethics,  history  of 
medicine,  and  life  insurance.  The  annual  fee  for  regular 
students  with  one  annual  examination  is  $150.  Combined 
courses  of  B.A. , M.B.  and  B.Sc.,  M.B.,  lasting  seven  years, 
are  also  arranged.  Honour  standing  can  be  obtained  in  each 
year’s  subjects.  There  is  residence  for  about  150  men  and 

- The  Secretary  of  the  Faculty  of  Medicine  is  Dr.  E.  S.  Ryerson.  The 
Calendar  of  the  University  of  Toronto,  Faculty  of  Medicine  (1919-20)  is 
a volume  of  146  pp.,  printed  by  the  University  of  Toronto  Press. 

j 


three  houses  near  to  the  University.  Each  male  student 
proceeding  to  a degree  must  take  physical  training,  the 
character  to  be  determined  by  medical  examination  in  the 
first  two  years  of  his  attendance. 

M.l). — One  year  must  elapse  after  obtaining  the  [M.B. 
degree  and  an  approved  thesis  submitted. 

D.P.H. — Candidates  must  be  graduates  in  medicine  of 
this  or  some  other  University.  The  curriculum  extends  over 
a winter  session  of  eight  months  and  a summer  session  of 
three  months.  The  fee  for  the  course  is  $150  and  for  the 
diploma  $20. 

Near  East. 

Registrable  Degree. — University  of  Malta,  M.D. 

University  of  Malta. 

The  University  of  Malta  was  added  in  1898  to  the  list  of 
institutions  recognised  by  the  English  Royal  Colleges.  Study 
in  the  Faculty  of  Medicine  and  Surgery  10  is  open  to  matricu- 
lated students  who  have  attended  a three  years’  preparatory 
course  in  the  Faculty  of  Science.  Matriculation  includes 
English,  Italian,  and  Latin,  while  history  is  also  necessary 
to  comply  with  the  G.  M.  C.  regulations.  The  preparatory 
course  in  science  in  its  third  year  comprises  English  or 
Italian  literature,  physics,  organic  chemistry,  and  human 
anatomy  and  general  histology,  with  dissection.  Medical 
botany  is  taught  at  the  Botanic  Garden.  The  academical 
course  of  medicine  and  surgery  ( M.B. , Ch.B.)  extends  over 
four  years,  the  first  year  being  devoted  solely  to  anatomy 
and  physiology,  and  the  final  year  including  clinical 
medicine,  surgery,  and  midwifery,  along  with  operative 
surgery  and  forensic  medicine,  and  continued  attendance  at 
the  clinical  laboratory  and  the  hospital.  The  degree  of 
M.D.  or  of  Ch.M.  is  conferred  on  any  M.B.,  Ch.B.  on 
passing  an  examination  at  not  less  than  one  year  after 
graduation,  in  each  case  with  an  approved  thesis.  The  fee 
for  any  of  the  three  degrees  is  £6. 

Far  East. 

Summary  of  Registrable  Degrees. — Ceylon  : Medical 

College,  L.M.S.  Hong- Kong:  University  of  Hong-Kong, 
M.B.,  [B.S.  India:  University  of  Allahabad,  M.B.,  B.S.  ; 
University  of  Bombay,11  (1)  L.M.S.,  (2)  M.B.,  B.S.‘ 
(3)  M.D.,  (4)  M.S.  ; University  of  Calcutta,  (1)  L.M  S., 
(2)  M.B.,  (3)  M.D.,  (4)  M.S.,  (5)  M.O.  ; University  of 
Madras,12  (1)  M.B.,  M.S  , (2)  M.B.,  B.S.,  (3)  M.D.  ; 
Punjab  University,  (1)  L.M.S.,  (2)  M.B.,  (3)  M.D.,  (4)  M.S. 
Straits  Settlements : King  Edward  VII.  Medical  School, 
Singapore,  L.M.S. 

University  of  Allahabad. 

The  examination  for  the  degree  of  M.  B. , B.  S.  consists  of 
three  parts  : preliminary  scientific,  first  degree,  and  final 
degree.  The  two  latter  are  held  at  Lucknow.  The  pre- 
liminary scientific  examination  in  chemistry,  physics,  and 
biology  is  open  to  candidates  who  have  passed  in  these 
subjects  at  the  intermediate  examination  of  the  University. 
The  first  degree  examination  comprises  anatomy,  physiology, 
and  materia  medica  and  pharmacy  ; it  may  be  taken  after 
two  years.  The  final  degree  examination  comprises  two 
groups : (A)  midwifery,  hygiene,  and  medical  jurisprudence, 
taken  after  two  years  ; (B)  medicine,  surgery,  and  patho- 
logy, taken  a year  later.  Honours  may  be  obtained  in  any 
subject.  The  M.D.  degree  is  obtained  within  not  less  than 
one  year  on  passing  an  examination  in  medicine  and  patho- 
logy. The  fees  for  the  M.B.,  B.S.  examination  are  Rs.140, 
for  the  M.D.  Rs  200. 

King  George's  Medical  College , Lucknow , prepares 
students  for  the  medical  degrees  of  the  University  of 
Allahabad.  The  curriculum  extends  to  five  college  years, 
each  of  three  terms.  Scholarships  and  bursaries  are 
granted. 

University  of  Bombay. 13 

Candidates  for  the  M.B.,  B.S.  must  have  passed  the 
previous  examination  or  its  equivalent,  and  be  engaged  during 
five  University  years  in  professional  study  at  a medical  college 

-1  Statute  of  the  University  of  Malta,  1915,  Government  Printing 
Office,  Malta,  price  Is. 

11  If  obtained  after  June  25th,  1912,  the  degree  must  have  been 
registered  in  the  Presidency. 

12  If  obtained  after  June  1st,  1916,  the  degree  must  have  been 
registered  in  the  Presidency. 

13  The  Registrar  of  the  University  is  Mr.  K.  B.  F.  M.  Dastur,  M.A. 
The  Bombay  University  Caleaidar  (1918)  is  a volume  of  610  pp.,  printed 
at  the  Government  Central  Press,  Bombay. 


414  The  Lancet,]  REGISTRABLE  COLONIAL  AND  FOREIGN  MEDICAL  DEGREES. 


[August  30, 1919 


recognised  by  the  University.  Three  examinations  are  held  : 
the  first,  or  preliminary  scientific  ; the  second,  or  inter- 
mediate ; and  the  third,  or  final  ; each  of  them  twice  in  the 
year.  The  two  former  are  of  the  usual  character.  The  final  is 
divided  into  two  parts,  which  may  be  taken  together  two  years 
after  the  intermediate.  Part  I.  includes  medicine,  medical 
jurisprudence,  pathology,  and  hygiene ; Part  II.  surgery, 
midwifery,  aud  ophthalmology.  203  medical  undergraduates 
passed  examinations  in  1916.  Candidature  for  the  degrees  of 
B.Hy.,  M.D. , D.Hy .,  or  M.S.  implies  that  the  M B.,  B.S. 
degree  has  been  taken  not  less  than  a year  (D.Hy.,  3 years) 
previously. 

Grant  Medical  College , Bombay , was  established  in  1345, 
to  “ impart  through  a scientific  system  the  benefit  of  medical 
instruction  to  the  Natives  of  Western  India,”  and  recognised 
by  the  University  in  1860.  Attached  is  a laboratory  for 
scientific  medical  research.  The  students  are  arranged  in  three 
classes  : (1)  graduates  and  undergraduates  of  the  University 
of  Bombay  and  other  recognised  Universities  who  are 
educated  through  the  English  language  for  medical  degrees  ; 
(2)  members  of  the  European  and  domiciled  European  com- 
munities who  are  educated  through  the  English  language  for 
the  grade  of  military  assistant  surgeon  ; (3)  undergraduates 
and  others  for  the  diplomas  of  the  College  of  Physicians  and 
Surgeons,  Bombay.  The  College  has  ceased  to  grant 
diplomas,  and  is  affiliated  to  the  University  for  medical 
education. 

University  of  Calcutta. u 

For  the  degree  of  M B.  the  preliminary  scientific,  first, 
and  final  M.B.  examinations  must  be  passed.  The  final  is 
divided  into  two  parts,  major  and  minor,  which  may  be 
taken  together.  The  former  includes  medicine,  surgery,  and 
midwifery;  the  latter  general  pathology,  medical  juris- 
prudence, and  hygiene.  An  examination  for  honours  is 
held  a week  after  the  pass  list  is  declared.  The  fees  for  the 
three  examinations  are  Rs.  25,  Rs.  30,  and  Rs.  50  respectively. 
The  M.D.  degree  is  granted  after  examination  in  medicine, 
pathology,  and  mental  diseases  not  less  than  one  year  sub- 
sequent to  the  M.B.  The  fee  is  Rs.  100.  Degrees  of  Master 
of  Surgery  (M.S.)  and  Obstetrics  ( M.  O. ) are  also  granted. 
A diploma  in  public  health  is  granted  to  possessors  of  the 
M.B.  degree  or  L.M.S.  diploma  by  examination  after  a 
prescribed  course  of  a year  has  been  carried  out.  The  fee 
is  Rs.  100. 

Ceylon  Medical  College. 

The  Ceylon  Medical  College 15  began  in  1870,  and  the 
curriculum  and  examinations  were  revised  in  1901  to  accord 
with  modern  requirements.  In  1888  the  licence  in  medicine 
and  surgery  (L.M.S.)  granted  by  the  College  was  recognised 
by  the  G.M.C.  Women  were  admitted  to  the  College  in 
1892  There  is  a medical  and  an  apothecaries’  department 
in  the  College.  A preliminary  examination  of  the  standard 
of  the  Cambridge  Senior  Local  or  School  Certificate  Exam- 
ination is  required  for  admission  to  the  five  years’  medical 
course.  The  first  professional  examination  is  passed  at  the 
end  of  the  first  year,  the  second  at  the  end  of  the  third,  and 
the  final  in  two  parts  at  the  end  of  the  fourth  and  fifth.  The 
fifth  year’s  course  includes,  besides  the  usual  final  subjects, 
instruction  in  tropical  medicine,  skiagraphic  demonstrations, 
and  attendance  at  a leper  asylum.  The  total  fees  for  the 
medical  curriculum,  including  examinations,  amount  to 
Rs.  1223.50.  Various  Government  scholarships  and  medals 
are  granted. 

University  of  Hong- Kong. 

The  Faculty  of  Medicine  of  the  University  of  Hong- Kong  16 
(1912)  had  its  origin  in  the  work  of  the  Hong- Kong  College 
of  Medicine  founded  in  1887.  The  School  of  Anatomy  was 
opened  in  1913  and  special  schools  for  physiology,  pathology, 
and  tropical  medicine  are  in  course  of  erection.  The 
University  confers  the  degrees  of  M B.,  B S.,  M.D. , and 
M.S.  The  subjects  of  the  first  medical  examination  are 
physics,  chemistry,  and  biology  ; of  the  second,  anatomy, 
physiology,  general  pathology  (including  bacteriology), 
and  elementary  pharmacology ; of  the  third,  Part  I.,  surgery 

14  The  University  of  Calcutta  Kegulations  (19141  make  a volume  of 
410  pn  , published  by  the  University. 

15  The  Registrar  of  the  college  is  Dr.  I’.  J.  Kelly.  The  Ceylon  Medical 
College  Calendar  (1917-18)  is  a volume  of  91  pp.,  published  by  authority 
and  printed  by  H.  M.  Richards,  acting  Government  printer,  Colombo. 

ld  The  acting  registrar  of  the  University  is  Mr.  K.  Brayshay,  B.A. 
The  University  Calendar  (1918-19)  is  a volume  of  116  pp..  printed  for 
the  University  by  Noronhaand  Co.,  Government  printers,  Hong- Kong. 


and  midwifery,  Part  II.,  medicine  and  pathology,  including 
hygiene  and  tropical  medicine.  The  fee  for  each  part  of 
each  examination  is  $5,  and  for  conferring  theM.B.,  B.S. 
$25.  The  candidate  for  M.  D.  may  present  himself  in  two 
years  and  must  take  general  medicine  as  well  as  one  of  the 
following : State  medicine,  pathology,  midwifery,  tropical 
medicine,  physiology.  The  rules  for  M.S.  are  similar.  The 
fee  for  each  examination  is  $100  and  for  conferring  the 
degree  $100. 

University  of  Madras. 

A medical  school  was  established  in  Madias  in  1835, 
which  became  the  Madras  Medical  College  in  1851  and  was 
affiliated  to  the  University  in  1877.  The  College  was  origin- 
ally for  supplying  assistant  surgeons  and  hospital  assistants 
to  the  army,  but  now  undertakes  also  the  training  of  students 
for  the  medical  degrees  and  diplomas  of  Madras  University. 
Candidates  for  the  degrees  of  M.B.,  B.S.  must  have  passed 
the  Intermediate  Examination  in  Arts  of  the  University  or 
its  equivalent,  and  have  studied  medicine  for  not  less  than 
five  years  in  a college  affiliated  to  the  University.  Four 
examinations  are  held,  the  third  (at  the  end  of  the  third 
year)  comprising  general  pathology  and  hygiene,  and  the 
fourth  the  other  professional  subjects.  The  examination  fees 
are  Rs.25,  Rs.25,  Rs.40,  and  Rs.50  respectively.  The  M.D. 
degree  may  be  taken  not  less  than  one  year  after  a first-class 
pass  in  either  medicine,  midwifery,  pathology,  or  tropical 
medicine.  The  conditions  for  the  M.S.  degree  are  similar. 
The  examination  fee  in  each  case  is  Rs.  100.  A degree  in 
sanitary  science  (B.S. Sc.)  can  be  taken  in  two  parts  one 
year  after  the  M.B.,  B.S.,  the  total  fee  being  Rs.100. 

The  Madras  Medical  College  17  includes  a college  depart- 
ment, an  apothecary  department,  a chemists’  and  druggists’ 
department,  and  a sanitary  inspectors’  department.  The 
course  of  training  for  the  M B.,  B.S.  is  charged  Rs.  120  a 
year,  or  a lump  sum  of  Rs.540  if  paid  in  advance.  Valuable 
scholarships  are  awarded  by  the  Government  and  by  the 
Dufferin  Fund,  and  special  Government  stipends  to  women 
medical  students. 

Punjab  University. 

An  examination  for  the  degree  of  M.B.,  B.S.  is  held 
annually  in  Lahore  in  May,  and  consists  of  three  parts — 
first,  second,  and  final.  The  first  professional  examination 
is  open  to  candidates  who  not  less  than  two  years  previously  I 
have  passed  the  intermediate  examination  of  the  Science 
Faculty  taking  the  medical  student’s  group  ; it  comprises 
anatomy,  physiology,  and  materia  medica,  and  the  lee  is  | 
Rs.  30.  The  second  examination  is  in  pathology,  forensic 
medicine,  and  hygiene,  and  is  taken  at  the  end  of  the  third 
year  ; the  fee  is  Rs.  30.  The  final  examination,  for  which 
the  fee  is  Rs.  40,  is  taken  at  the  end  of  the  fifth  year  and  1 
comprises  the  rest  of  the  professional  subjects. 

King  Edward  Medical  College,  Lahore,  trains  students 
for  the  medical  degrees  and  diplomas  of  Punjab  University. 
The  college  year  consists  of  one  long  session  of  three  terms. 
The  course  for  the  M.B.,  B.S.  occupies  five  years,  the  fees 
being  Rs.125.  Rs.115,  Rs.135,  Rs.105,  and  Rs.105  in 
successive  years.  College  scholarships  are  granted. 


Registrable  Foreign  Medical  Degrees. 

Certain  medical  diplomas  granted  in  foreign  countries 
also  entitle  to  registration  in  the  foreign  list  of  the  Medical 
Register,  provided  that  the  holder  is  not  a British  subject  or 
that,  being  a British  subject,  the  diploma  was  obtained 
under  domiciliary  conditions  similar  to  those  attached  to 
colonial  diplomas. 

Summary  of  Registrable  Degrees  (the  date  in  parentheses 
being  the  year  in  which  Part  II.  of  the  Medical  Act,  1886, 
was  applied  to  the  country  in  question). — Italy  (1901) : 
Degrees  of  Doctor  of  Medicine  and  Surgery  of  all  the  Royal 
Italian  Universities.  Japan  (1905)  : Degrees  of  Bachelor  of 
Medicine  (Igakushi)  and  Doctor  of  Medicine  (Igakn  Hakushi) 
of  the  Imperial  Universities  of  Japan  ; and  the  Degree  of 
Bachelor  of  Medicine  (Igakushi)  of  any  Government  or  Pre- 
fectural  special  medical  college,  or  of  a private  special  medical 
college  designated  by  a Minister  of  Education  of  the  Empire 
of  Japan.  Belgium  (1915)  : Degrees  of  Doctor  of  Medicine 
of  the  Belgian  Universities  of  Brussels,  Ghent,  Li£ge,  and 

17  The  Calendar  of  the  Medical  College,  Madras  (1918),  is  a volume  of 
191  pp.,  printed  by  the  Superintendent,  Government  Press,  Madras, 

price  Is. 


The  Lancet,]  REGISTRABLE  COLONIAL  AND  FOREIGN  MEDICAL  DEGREES. 


[August  30,  1919  415 


Louvain,  which  give  legal  authority  to  practise  medicine, 
.surgery,  and  midwifery  in  Belgium. 

Italy. 

The  regulation  for  the  medical  diploma  is  fixed  by  Royal 
Decree  dated  August  9th,  1910,  and  is  the  same  for  each  of 
the  20  universities  and  institutes  where  courses  of  study 
are  arranged.  These  are  in  alphabetical  order  : Bologna, 
Cagliari  (Sardinia),  Camerino,  Catania,  Ferrara,  Florence, 
Genoa,  Messina,  Modena,  Naples,  Padua,  Palermo,  Parma, 
Pavia,  Perugia,  Pisa,  Rome,  Sassari,  Siena,  and  Turin. 

The  course  covers  six  years,  and  embraces  the  following 
20  constituent  subjects  : (1)  experimental  physics,  (2)  in- 
organic and  organic  chemistry,  (3)  botany,  (4)  zoology  and 
comparative  anatomy,  (5)  normal  human  anatomy  (descriptive 
or  systematic,  macroscopic  and  microscopic),  (6)  physiology, 
(7)  general  pathology,  (8)  pharmacology  and  toxicology,  (9) 
pathological  anatomy  and  histology,  (10)  special  medical 
(practical)  pathology,  (11)  special  surgical  (practical)  patho- 
logy,  (12)  medical  clinics,  general  and  special,  (13)  pediatric 
clinic,  (14)  surgical  clinic,  general,  special  and  operative, 
(15)  obstetric  and  gynaecological  clinic,  (16)ophthalmological 
clinic,  (17)  clinics  of  nervous  and  mental  diseases, 
(18)  hygiene  and  public  health,  (19)  legal  medicine, 
(20)  dermatological  and  venereal  clinic. 

The  distribution  of  these  subjects  over  the  six  years  varies 
somewhat  at  the  different  centres,  but  the  official  course  at 
Siena  may  be  taken  as  an  example  : — 1st  year  : botany, 
zoology,  normal  human  anatomy.  2nd  year  : normal  human 
anatomy,  general  chemistry,  experimental  physics,  embryo- 
logy, experimental  physiology.  3rd  year : normal  and 
topographical  human  anatomy,  experimental  physiology, 
bacteriology,  general  pathology.  4th  year  : materia  medica, 
special  medical  and  surgical  pathology,  pathological 
anatomy,  medical  and  surgical  clinic.  5th  year : patho- 
logical anatomy,  medical,  surgical,  ophthalmological,  and 
dermatological  clinic,  hygiene  and  public  health.  6th 
year  : medical,  surgical,  nervous  and  mental,  pediatrics, 
and  obstetric  clinic,  legal  medicine,  operations,  history  of 
medical  science.  Twenty-six  optional  courses  in  special 
subjects  can  be  attended  by  students  of  various  years.  The 
examinations  are  held  in  the  latter  half  of  October  and 
June. 

Japan. 

The  medical  course  is  taken  at  the  Imperial  Universities 
of  Kyoto  and  Tokyo,  and  at  the  medical  schools  of  Formosa, 
Aichi,  Chiba,  Kanazawa,  Kumamoto,  Nagasaki,  Okayama, 
and  Sendai. 

The  Kyoto  College  of  Medicine 18  was  established  in  1899. 
It  includes  institutes  of  anatomy,  physiology,  medical 
chemistry,  pharmacology,  pathology,  hygiene,  forensic 
medicine,  medicine,  surgery,  ophthalmology,  gynaecology, 
pediatrics,  dermatology,  oto-rhino-laryngology,  orthopaedic 
surgery,  and  psychiatry,  each  in  charge  of  one  or  more  of 
the  22  professors  and  16  assistant  professors,  the  director 
being  Dr.  Hayazo  Ito.  There  is  a four  years’  course  of 
instruction,  the  first  year  being  devoted  to  anatomy,  histology, 
physiology,  medical  chemistry,  and  embryology.  In  the 
second  year  pharmacology,  general  pathology,  pathological 
anatomy  and  histology,  diagnosis,  special  medicine,  general 
surgery,  and  bandaging  are  added.  The  first  examination  is 
held  at  the  end  of  the  second  academic  year,  the  second  at 
the  end  of  the  fourth  year  in  surgery,  medicine,  ophthal- 
mology, gynaecology,  and  either  hygiene  or  forensic  medicine 
(the  choice  being  determined  by  lot).  At  request  students 
are  also  examined  in  pediatrics,  dermatology,  oto-rhino- 
laryngology,  psychiatry,  and  orthopaedic  surgery.  In  the 
year  1910  84  students  graduated  in  medicine  from  the 
College. 

Belgium. 

The  medical  course  for  the  degree  of  M.D.  may  be  taken 
at  any  of  the  four  Universities  : Free  University  of  Brussels, 
State  University  of  Ghent,  University  of  Liege,  Catholic 
University  of  Louvain.  After  a preliminary  year  and  an 
examination  which  may  be  taken  in  two  parts — (1)  logic, 
zoology,  botany  ; (2)  physics,  chemistry,  geology — the  student 
becomes  “ candidat  en  sciences  naturelles.”  Two  years  are 
then  devoted  to  the  ancillary  sciences,  the  examination 
again  being  in  two  parts — (1)  embryology,  systematic 

18  The  Kyoto  Imperial  University  Calendar  (1911)  is  a volume  of 
164  pp.,  published  by  the  University. 


anatomy  Part  I.,  histology,  comparative  anatomy,  physiology  ; 
(2)  systematic  anatomy  Part  II.,  regional  anatomy,  special 
histology,  psychology,  special  physiology — when  the  stage  of 
“candidat  en  medecine  ” is  reached.  Professional  studies 
occupy  three  years  at  least,  and  there  are  three  further  exa- 
minations. The  first  includes  (i.)  general  pathology  and 
therapeutics;  (ii.)  elements  of  pharmacology  and  pharmaco- 
dynamics; (iii.)  pathological  anatomy  ; (iv.)  general  surgical 
pathology.  The  second  includes:  (i.)  medical  pathology  and 
special  therapeutics,  including  mental  diseases;  (ii.)  special 
surgical  pathology;  (iii.)  public  and  private  hygiene  ; (iv.) 
tlie  theory  of  accouchement.  The  third  and  final  comprises 
(i.)  legal  medicine,  (ii  ) medical  clinic,  (iii.)  surgical  clinic, 
(iv.)  operations,  (v.)  ophthalmological  clinic,  (vi.)  obstetric 
clinic,  as  well  as  practical  tests  in  pathological  microscopy 
and  regional  anatomy. 

The  Universities  of  Ghent  and  Liege  grant  a diploma  of 
‘ 1 medecin-hygieniste  ’’after  examination  to  medical  graduates 
of  at  least  one  year's  standing. 

University  of  Liege. — The  Faculty  of  Medicine  includes 
15  professors  and  eight  lecturers.  The  dean  is  Professor 
L.  Fredericq- (Institut  physiologique).  The  fee  for  inscrip- 
tion in  the  medical  faculty  is  Fr.  200  for  the  grade  of  candi- 
date and  Fr.  200  for  each  of  the  three  parts  of  the  professional 
examination.  Details  of  the  courses  may  obtained  from 
Professor  Ch.  Julin,  secretary  to  the  medical  faculty. 

University  of  Louvain. — All  the  courses  in  the  Faculty  of 
Medicine  have  been  resumed.  For  the  third  professional 
examination  the  programme  is  as  follows  : A.  Lemaire 
(medical  clinic),  R.  Schoekaert  (theory  of  accouchement), 
A.  Vander  Straeten  (ophthalmological  clinic),  R.  Bruynoghe 
(legal  medicine),  G.  Debaisieux  (surgical  clinic),  L.  Van  den 
Wildenberg  (oto-rhino-laryngological  clinic),  A.  Van  Mosuenck 
(dental  clinic),  O.  De  Mees  (minor  surgery).  The  dean  of 
the  faculty  is  Professor  Schoekaert,  and  the  secretary 
Professor  Bruynoghe  (rue  Marie  Therese  100).  An“Annee 
Academique,  1919,”  has  been  issued  from  the  University 
press. 

University  of  Brussels. — The  former  courses  in  the  Faculty 
of  Medicine  were  resumed  (see  The  Lancet,  March  1st, 
1919,  p.  353)  on  Jan.  22nd  last,  as  well  as  the  clinics  at 
St.  Jean  and  St.  Pierre,  and  the  instruction  for  the  diploma 
of  public  health. 

Details  of  these  courses  may  be  obtained  from  the 
secretary  of  the  University  at  rue  des  Sols  14,  Brussels. 


The  M,D.  Brussels  for  Strangers. 

The  examination  is  arranged  in  three  parts.  No  conditions 
of  residence  are  needed  ; the  time  required  for  the  three 
examinations  seldom  exceeds  10  or  12  days,  and  candidates 
who  are  unable  to  be  so  long  away  from  home  may  take  each 
part  separately.  The  examinations  are  conducted  in  English 
through  the  medium  of  an  interpreter  (without  additional 
charge).  They  take  place  on  the  first  Tuesday  in  November, 
December,  March,  and  May,  and  the  second  Tuesday  in  June. 
They  are  viva  voce , but  candidates  may  have  a written 
examination  by  paying  an  additional  fee  of  £1  for  each  test. 
This  does  not  exempt  them  from  the  viva  voce  examination. 
Part  I.  includes  general  medicine  ; materia  medica  and 
pharmacology  ; general  surgery  ; and  the  theory  of  mid- 
wifery. Part  II.  includes  general  therapeutics  ; pathology 
and  morbid  anatomy,  and  the  use  of  the  microscope  ; special 
therapeutics  and  medicine  of  internal  diseases  ; special 
surgery  ; and  mental  diseases.  Part  III.  includes  public 
and  private  hygiene;  medical  jurisprudence;  clinical 
medicine  ; clinical  surgery ; examination  in  operative 
surgery,  consisting  of  some  of  the  usual  operations  on  the 
dead  subject — viz.,  amputation,  ligature  of  artery.  See.  ; 
ophthalmology ; examination  in  midwifery,  consisting  of 
obstetrical  operation  on  the  mannequin  (model  of  pelvis), 
examination  in  regional  anatomy  with  dissection  ; and 
bacteriology. 


Donations  and  Bequests. — Under  the  will  of  the 
late  Mrs.  M.  L.  Burns,  Mr.  Pierpont  Morgan’s  sister,  the 
testatrix  has  bequeathed  £5000  to  Guy’s  Hospital. — The  late 
Mr.  James  Stephenson  Binning  has  left  by  will  £1000  for 
such  London  hospitals  as  the  executors  may  select. — 
The  late  Mrs.  Paris  has  bequeathed  £1000  to  the  Totnes 
Cottage  Hospital  in  memory  of  her  late  sister,  Miss  F. 
Mitchell. 


416  The  Lancet,] 


OBITUARY.— URBAN  VITAL  STATISTICS. 


[August  30,  1919 


AUGUSTUS  G.  VERNON-HARCOURT,  F.R.S., 

LATE  PRESIDENT  OF  THE  CHEMICAL  SOCIETY. 

Professor  A.  G.  Vernon-Harcourfc,  whose  death 
was  announced  early  this  week,  was  a well-known 
figure  at  the  University  of  Oxford,  where  he  was 
Lees  Reader  in  Chemistry  and  attached  to  Christ 
Church,  fie  retired  from  this  appointment  some 
20  years  ago,  after  a long  record  of  chemical 
research  whose  outcome  was  of  a highly 
valuable  nature.  His  first  studies  referred 
to  the  rate  at  which  chemical  change  proceeds 
between  given  substances,  the  simple  one 
chosen  for  the  purpose  being  that  occurring 
between  hydrogen  iodide  and  hydrogen  peroxide, 
iodine  being  evolved.  He  eventually  demon- 
strated that  the  rate  of  chemical  change  was 
strictly  proportional  to  the  mass  of  the  inter- 
acting substances  concerned.  An  insight  into  the 
law  of  mass  action  was  thus  gained,  and  this  work 
was  followed  up  by  other  investigations,  which  led 
to  results  of  great  theoretical  importance.  They 
were  of  practical  importance  also,  as  in  certain  cases 
they  enabled  the  achievement  of  the  laboratory  to 
be  carried  to  the  factory.  This  work  was  begun 
at  Oxford  in  the  early  “sixties.”  Later  on  Vernon- 
Harcourt  turned  his  attention  to  the  purification 
and  testing  of  coal-gas,  and  he  evolved  an  ingenious 
method  of  eliminating  certain  sulphur  compounds 
from  this  illuminant.  His  process  for  estimating 
the  sulphur  in  coal-gas  is  in  use  at  the  present 
day.  During  this  work  he  invented  the  well- 
known  pentane  lamp  as  the  official  standard 
of  illumination,  replacing  the  doubtful  standard  of  a 
wax  candle.  In  medical  science  Vernon-Harcourt’s 
name  will  be  remembered  in  connexion  with  a 
chloroform  dosimetric  inhaler  which  he  devised. 
This  apparatus  enabled  the  anaesthetist  to  control 
the  composition  of  the  mixture  of  air  and  chloroform 
passing  to  the  patient.  The  Chloroform  Committee 
of  the  British  Medical  Association  accepted  this 
apparatus  as  satisfactory,  but  clinical  authorities 
were  not  long  in  pointing  out  its  disadvantages, 
maintaining  that  chloroform  accidents  cannot 
be  entirely  prevented  by  regulating  chloroform 
percentages.  The  inhaler,  however,  proved 

useful  when  provided  with  an  oxygen  attachment 
in  cases  in  which  a light  anaesthesia  was 
required.  The  risk  of  using  a dosimetric  inhaler 
was  that  while  it  suggested  security  it  might  divert 
the  attention  of  the  chloroformist  from  his  patient’s 
condition.  The  apparatus  was  most  ingeniously 
designed  and  succeeded  in  giving  exact  proportions 
of  chloroform  and  air  up  to  a maximum  of 
2 per  cent,  of  the  amesthetic.  Yernon-Harcourt’s 
researches  gained  for  him  the  Fellowship  of  the 
Royal  Society  in  1868,  and  he  was  elected  President 
of  the  Chemical  Society  in  1895.  He  died  on 
August  23rd  in  his  85th  year  at  his  residence 
near  Ryde  in  the  Isle  of  Wight. 


The  Oxford  Roll  of  Service. — A final  and 
enlarged  edition  of  the  Roll  of  Service  of  the  University  of 
Oxford  is  now  in  preparation.  Forms  asking  for  information 
have  been  sent  to  all  members  of  the  University,  past  or 
present,  who  are  known  to  have  been  on  military  or  naval 
service,  and  whose  addresses  could  be  obtained.  Those  who 
have  not  received  the  forms  should  send  full  information  of 
their  service  either  to  the  “ Compiler  of  the  Roll  of  Service  ” 
at  their  old  College,  or  to  E.  S.  Craig,  Esq.,  Assistant 
Registrar,  University  of  Oxford.  All  such  information 
should  be  sent  in  before  Sept.  15th. 


URBAN  VITAL  STATISTICS. 

(Week  ended  August  23rd,  1919.) 

English  and  Welsh  Towns.— la  the  96  English  and  Welsh  towns, 
with  an  aggregate  civil  population  estimated  at  16.500,000  persons, 
the  annual  rate  of  mortality,  which  had  been  9’7,  9 7,  and  10’0  in  the 
three  preceding  weeks,  was  again  10'0  per  1000.  In  London,  with 
a population  slightly  exceeding  4,000,000  persons,  the  annual  rate 
was  10'4,  and  was  the  sane  as  that  recorded  in  the  previous 
week,  while  among  the  remaining  towns  the  rates  ranged 
from  2'8  in  Ilford,  4'4  in  Northampton,  5'0  in  Wallasey,  and  5'2 
in  Bournemouth,  to  16  2 In  Middlesbrough,  16  4 in  Newcastle-on- 
Tyne,  17’2  in  Hastings,  and  190  in  Tynemouth.  The  principal 
epidemic  diseases  caused  268  deaths,  which  corresponded  to  an 
annual  rate  of  0'8  per  1000,  and  included  155  from  infantile 
diarrhoea,  44  from  measles,  41  from  diphtheria,  12  from  whooping- 
cough,  9 from  scarlet  fever,  5 from  enteric  fever,  and  2 from 
small  pox.  Measles  caused  a death-rate  of  1-2  in  Newcastle-on-Tyne, 
1'3  in  Gateshead,  and  18  in  Tynemouth,  and  scarlet  fever  of  1-9  in 
Wigan.  There  were  1464  cases  of  scarlet  fever  and  1063  of  diphtheria 
under  treatment  In  the  Metropolitan  Asylums  Hospitals  and  the 
London  Fever  Hospital,  against  1517  and  1112  respectively  at  the  end 
of  the  previous  week.  The  causes  of  26  deaths  In  the  96  towns  were 
uncertified,  of  which  6 were  registered  in  Birmingham  and  2 each  In 
Liverpool,  Manchester,  Salford,  and  Newcastle-on-Tyne. 

Scotch  Towns. — In  the  16  largest  Scotch  towns,  with  an  aggregate 
population  estimated  at  nearly  2.500,000  persons,  the  annual  rate  of 
mortality,  which  had  been  10’6,  10  0.  and  9 9 in  the  three  preceding 
weeks,  rose  last  week  to  10  7 per  1000.  The  243  deaths  in  Glasgow 
corresponded  to  an  annual  rate  of  11*3  per  1000,  and  included  28  from 
infantile  diarrhoea,  4 from  measles,  and  1 from  whooping-cough.  The 
72  deaths  in  Edinburgh  were  equal  to  a rate  of  11*2  per  1000,  and 
included  2 from  measles  and  2 from  diphtheria. 

Irish  Towns.—  The  124  deaths  lu  Dublin  corresponded  to  anannusl 
rate  of  16'0  per  1000,  and  Included  26  from  infantile  diarrhoea.  The 
130  deaths  iD  Belfast  were  equal  to  a rate  of  169  per  1000.  and 
included  16  from  infantile  diarrhoea,  1 from  scarlet  fever,  and  1 from 
diphtheria. 


SJritttal  $iarg  kx  % ensuing  ®eek. 

LECTURES,  ADDRESSES,  DEMONSTRATIONS,  &c. 

LONDON  HOSPITAL  MEDICAL  COLLEGE,  in  the  Clinical  Theatre 
of  the  Hospital. 

A Special  Course  of  Instruction  in  the  Surgical  Dyspepsias  will  be 
given  by  Mr.  A.  J.  Walton  : — 

Monday,  Sept.  1st.— 4.30  p.m.,  Lecture  XI.:— .Etiology— Symptoms. 

Compli'  ations  and  Treatment  of  Duodenal  Ulcer. 

Friday.— 4.30  p.m. , Lecture  X.:— Congenital  and  Acquired  Pyloric 
Stenosis. 


SSirtts,  Carriages,  anb  JJeatljs. 

MARRIAGES. 

Powell— Ricketts.— On  August  21st.  at.  St.  Barnabas  Church,  Pimlico- 
road,  S.W..  Mr.  L.  K.  M.  Powell,  19th  Bengal  Lancers,  son  of  the 
late  Henry  Watson  Powell,  of  the  Mercers'  Company  and  Australia, 
to  Beryl,  only  daughter  of  the  late  T.  F.  Ricketts,  M.B.,  F.R  C.S., 
and  Mrs  Ricketts 

Smith-Ellis.— On  August  26th.  at  Pbillaek  Parish  Church,  Cornwall. 
Matthew  Baird  Smith,  B.Sc.  M.B.,  Ch.B.,  to  Alice  May,  daughter 
of  Christopher  Ellis,  Hayle,  Cornwall. 

Tasker- Robinson.— On  August  21st,  at  Wouldham  Parish  Church, 
H.  L.  Tasker,  M.D.,  of  58,  New  Cavendish-street,  W.  1,  son  of  the 
Rev.  W.  Lindley  Tasker,  to  Adela  Mary,  eldest  daughter  of  Mr. 
and  Mrs.  J.  Robinscn,  of  Ring’s  Hill,  Borstal. 


Communications,  Letters,  &c.,  to  the  Editor  have 
been  received  from— 


A. — Mr.  J.  Abraham.  Lond.j  Sir 
R.  Armstrong-Jones,  Lond. 

B. — Dr.  G.  Blacker,  Lond.;  Dr.  W. 
Bennett,  Slaidburn ; Board  of 
Agriculture  and  Fisheries,  Lond.; 
Dr.  H.  S.  Baketel,  New  York ; 
Dr.  A.  T.  Blease,  Altrincham ; 
Mr.  F.  C.  Barlow,  Lond.;  Mr. 
G.  Y.  Baldock,  Lond.;  Dr.  C.  K. 
Bond,  Brighton ; Dr.  J.  H.  E. 
Brock,  Lond.;  Lieut.-Col.  Sir 
James  Barrett,  K.B.E.;  Miss  E. 
Behnke.  Lond. 

C.  — Chicago  School  of  Sanitary  In- 
struction; Dr.  R.  Creasy,  Lond.; 
Dr.  H.  W.  Crowe.  Harrogate; 
Mr.  E.  S.  Craig.  Oxford. 

D — Surg.-Commdr.  S.  F.  Dudley, 
R.N. 

E. — Maj.-Gen.  Sir  George  Evatt ; 
Dr.  R.  Eager,  Exminster:  Dr. 
T.  W.  Eden,  Lond.;  Surg.- 
Commdr.  E.  T.  P.  Eames,  R N. 

F. — Dr.  A.  R.  Fraser,  Aberdeen  ; 
Dr.  R.  C.  Fairbairn,  Lond.;  Major 

E.  R.  Fothergill,  R A.M.C.;  Dr. 
J.  G.  Forbes,  Redhill. 

G. — Dr.  A.  D.  Gardner,  Oxford; 
Capt.  R.  L.  Gamlen,  I.M.S. 
(retd.) 

H. — Dr.  R.  C.  Holt,  Didsbury ; Dr. 

F.  Hernaman-Johnson,  Lond. 

J. — John  Rylands  Library,  Man- 
chester, Librarian  of. 


L. — Dr.  A.  W.  Lemarchand,  Barns- 
staple ; Mr.  L.  Lorent,  Charleroi; 
Major  J.  H.  Lloyd.  R.A.M.C 

M.  — Mr.  J.  A.  C.  Mace  wen,  Glas- 
gow; Dr.  F.  H.  Moore,  Thaxted; 
Medico ; Medical  Research  Com- 
mittee, Lond.;  Metropolitan 
Asylums  Board,  lend.,  Clerk  to ; 
Ministry  of  Health,  Lond. 

O. — Hon.  H.  Onslow,  Cambridge. 

P.  -Mrs.  C.  P.  Plaxton,  Prince 
Albert,  Saskatchewan. 

R.  — Mr.  H.  M.  Rainsford,  Lond.; 
Dr.  O.  Richards,  C.M.G  , D.S.O.; 
Dr.  J.  D.  Rolleston,  Lond.;  Dr. 
W.  Raine,  Redcar ; Mr.  J.  Kams- 
bottom,  Lond. 

S. — Mr.  E.  G.  Stanley,  Paris; 
Messrs.  B.  Schwabe  and  Co., 
Basel ; Mr.  F.  B.  Shawe.  Bishops 
Stortford ; Society  for  the  Study 
of  Inebriety,  Lond.;  Prof.  B.  G. 
Slesinger,  Lond.;  Society  of 
Apothecaries  of  London. 

T. — Major  J.  Taylor,  R.A  M.C. 

W —Dr.  F.  P.  Weber,  Lond.:  Dr. 
S.  E.  White,  Lond.;  Dr.  F.  J 
Waldo,  Lond.;  Dr.  L.  A. 
Weatherly,  Bournemouth ; Dr. 
E.  M.  Wyche.  Nottingham;  Dr. 
C.  W.  Wirgman,  Lmd.;  Sir  G. 
Sims  Woodhead,  Cambridge. 
Y.— Dr.  F.  W.  B.  Young,  Liver- 
I pool. 


THE  LANCET,  September  6,  1919. 


THE 

(Cljabfaitli  Jtciura 

ON 

THE  PROBLEM  OE  HYGIENE  IN  EGYPT. 

Being  Three  Lectures  delivered  at  the  Summer  Session , 1919, 
By  ANDREW  BALFOUR,  C.B.,  C.M.G.,  M.D., 

DIRECTOR-IN-CHIEF,  WELLCOME  BUREAU  OF  SCIENTIFIC  RESEARCH  ; 
LATE  PRESIDENT,  EGYPTIAN  PUBLIC  HEALTH  COMMISSION. 


LECTURE  I.— THE  CAUSES  OF  THE  PROBLEM. 

Mr.  President  and  Gentlemen, — Egypt  is  the  hub  of 
the  wheel  of  Empire.  The  importance  of  that  ancient  land 
is  fully  recognised  from  a military,  political,  and  commercial 
standpoint.  It  has  bulked  largely  in  the  world’s  history, 
and  recent  events  have  certainly  not  tended  to  diminish 
its  status  in  those  directions.  It  is,  however,  doubtful  if,  in 
this  country  at  least,  the  significance  of  Egypt  from  a 
hygienic  point  of  view  is  equally  realised.  And  yet  in  what 
maybe  called  “imperial  medicine,”  Egypt  must  ever  play 
an  increasingly  important  role. 

Egypt  as  an  International  Filter. 

She  lies  at  the  gateway  to  the  East,  the  Suez  Canal 
traverses  her  territory,  she  acts  as  a great  filter,  a filter 
for  disease.  This  filter,  however,  differs  markedly  from 
others  with  which  we  are  acquainted,  for  the  filtration  it 
effects  is  a double  one.  It  protects  Europe  from  such 
diseases  as  plague  and  cholera,  ship-borne  from  India, 
Mesopotamia,  Arabia,  and  ports  on  the  western  Red  Sea 
littoral,  and  it  guards  these  countries  and  places  from  the 
risk  of  infection  coming  from  southern  Russia,  the  Levant, 
and  various  foci  in  the  Mediterranean.  In  days  to  come 
there  will  be  few  more  important  quarantine  stations  than 
Suez,  while  Port  Said  and  Alexandria  keep  watch  and  guard 
on  vessels  hailing  from  north  and  east  and  west. 

Although  a constant  vigilance  has  to  be  exercised,  no  great 
strain  is  imposed  upon  those  responsible,  save  at  the  time  of 
the  Mecca  pilgrimage,  when  the  migrations  of  the  faithful 
occasion  the  utmost  alertness.  More  especially  is  this  the 
case  when  the  pilgrimage  is  declared  “ brut  ” or  infected. 
The  term  “ brut  ” is  a French  word  which  has  various  mean- 
ings, such  as  rough,  raw,  crude,  and  so  forth.  It  also 
signifies  “void  of  reason,”  and  seems  almost  to  have  been 
adopted  on  account  of  this  meaning,  for  there  is  nothing 
about  it  to  denote  infection.  In  all  probability  it  was 
employed  merely  as  a convenient  term,  the  antithesis  of  the 
French  “ net,”  and  one  with  which  the  pilgrimage  could  be 
discreetly  labelled,  even  if  infection  was  merely  suspected, 
not  absolutely  proved.  When  such  a label  was  affixed  the 
problem  became  one  of  much  anxiety.  Picture  to  yourselves 
the  conditions  of  the  Hedjaz.  Vast  throngs  of  people,  often 
ill-fed  and  ill-clad,  crowded  together  at  such  a pestilential 
port  as  Jeddah,  an  assemblage  polyglot  in  the  extreme  and 
hailing  from  every  quarter  of  the  Moslem  world,  a concourse 
in  some  respects  cleanly  in  its  habits,  thanks  to  the  Moham- 
medan ritual,  but  ignorant  of  every  law  of  modern  hygiene, 
a great  gathering  which,  having  completed  its  devotions  at 
the  Prophet’s  shrine,  was  intent  on  one  thing  only — to  return 
home  as  quickly,  cheaply,  and  easily  as  possible. 

Pilgrims  by  Road,  Rail,  and  Sea.\ 

While  this  was  true  of  the  majority,  it  is  interesting  to 
note  that,  owing  to  the  difficulties  of  travel  in  the  Hedjaz  in 
pre-war  days,  many  pilgrims  after  travelling  by  the  railway 
to  Medina,  actually  made  for  Egypt  and  then  started  off  for 
Mecca,  a curious  roundabout  way  of  attaining  their  goal,  and 
one  which  introduced  fresh  sanitary  complications.  In  any 
case,  the  crowded  port  was  followed  by  crowded  steamers 
whereon  the  pilgrims  were  packed  almost  like  tinned  sardines, 
for  the  voyage  is  short  and  the  restrictions  are  none  too 
stringent.  Amongst  this  mass  of  humanity  sweltering  in 
the  heat  of  the  Red  Sea  plague  or  cholera  might  make  its 
appearance  and  begin  to  claim  its  victims.  The  ship  is  then 
infected  and  is  a danger  to  Egypt — a problem  to  be  solved. 
Yet,  again,  she  may  merely  hail  from  an  infected  port 
and  require  watching  for  a certain  period — a different 
proposition. 

But  all  pilgrims  did  not  reach  Egypt  by  the  southern  sea 
route.  You  are  familiar  with  the  Hedjaz  railway,  which  has 

No.  5010. 


played  so  notable  a part  in  the  war.  Formerly  it  playedjan 
equally  important  role  as  regards  the  Mecca  pilgrimage  [and 
the  trains  were,  at  the  time  of  the  Haj,  thronged  with  a 
multitude  travelling,  as  Clemow  has  described,  in  open 
trucks  or  luggage  vans.  Amongst  them  were  Egyptians,  who 
often  chose  this  route  for  their  return  journey  and  eventually 
reach  the  sea  at  Jaffa,  Haifa  or  Beyrout,  whence  they  took 
ship  to  Egypt,  avoiding  to  some  extent  the  restrictions  placed 
upon  those  travelling  via  the  Red  Sea.  (See  map.) 

So  much  for  the  role  of  Egypt  as  an  international’filter. 
The  measures  taken  to  deal  with  the  problem  of  sea 
quarantine  will  be  considered  in  due  course,  but  it  must 
be  remembered  that  the  war  has  introduced  a new  factor 
into  the  sanitary  problem  arising  out  of  the  relation  of  Egypt 
to  her  neighbours.  This  new  factor  is  the  railway  linking 
the  Nilotic  territories  with  Palestine.  Prior  to  the  war  the 
question  of  land  quarantine  was  one  of  little  importance. 
To  the  west  lay  Tripoli,  separated  from  the  populous  lands 
of  the  Delta  by  a great  desert,  which  was  seamed  only  by 
caravan  routes  and  uninhabited  save  by  wandering  Bedouins 
and  where  scattered  oases  afforded  water  and  means  of  life. 
In  the  south  Egypt  merged  with  the  Sudan,  and  there  was 
more  danger  of  the  latter  being  infected  from  Egypt  by  way 
of  the  Nile  than  there  was  of  Egypt  being  infected  from  the 
Sudan.  Eastwards  lay  the  desert  of  the  Sinai  Peninsula,  an 
effective  barrier  between  the  Suez  Canal  and  Syria. 

Now,  as  by  the  stroke  of  an  enchanter’s  wand,  all  is 
changed  so  far  as  this  eastern  frontier  is  concerned.  An 
iron  link  has  been  forged,  a link  potent  for  good  and  evil, 
and  in  a few  hours  the  traveller  passes  from  the  sands  of 
Egypt  to  the  mountains  of  Judea.  It  is  conceivable  that  in 
the  near  future  yet  a third  form  of  quarantine  may  have  to 
be  instituted,  as  there  is  every  likelihood  of  Egypt  becoming 
a halting-place  for  great  airships  en  route  from  India  to 
Europe. 

Interesting  as  are  these  questions  of  aerial,  land,  and 
maritime  quarantine,  it  must  be  understood  that  the  main 
problem  of  hygiene  in  Egypt  centres  in  the  internal  condition 
of  the  country. 

Medieval  Sanitary  Conditions. 

In  the  first  place,  it  is  necessary  to  remember  that,  so  far 
as  the  great  mass  of  the  native  population  goes,  sanitary 
conditions  may  be  described  as  mediaeval.  In  the  second 
place,  one  must  not  forget  that  all  that  really  counts  in  the 
Egypt  of  to-day  is  artificial.  The  country  as  we  know  it  is 
the  product  of  man’s  activity.  Egypt  is  so  very  old  that  it  is 
difficult  to  get  beyond  a period  when  man  was  not  busy 
modifying  it  to  suit  his  needs,  but  doubtless  at  the  beginning 
the  land  was  one  huge  desert  with  fertile  strips  bordering  the 
Nile,  strips  dependent  on  the  annual  rise  and  fall  of  the 
great  river.  Then  came  man  and  harnessed  the  water  to  his 
uses.  While,  owing  chiefly  to  the  configuration  of  the  land, 
he  has  not  created  any  great  change  in  Upper  Egypt,  he  has 
established  the  green  Delta  with  which  we  are  now  familiar, 
a Delta  which  in  many  respects  is  a hot-bed  of  disease 
Irrigation,  while  conferring  the  greatest  benefits  on  the  land 
of  the  Pharaohs,  while  in  reality  creating  modern  Egypt,  has 
been  by  no  means  an  unmixed  blessing,  for  closely  associated 
with  it  are  the  two  great  worm  diseases,  ankylostomiasis  and 
schistosomiasis  (bilharziasis),  which  have  produced  such 
dire  effects  upon  the  fellaheen. 

Considerations  of  climate  enter  little  into  the  problem  of 
hygiene  in  Egypt,  for  such  influence  as  the  climate  exerts 
is  largely  of  a beneficial  nature,  though  it  should  be  noted 
that  the  climatic  conditions  at  certain  seasons  of  the  year 
are  singularly  favourable  to  the  propagation  of  flies,  and 
hence  to  the  dissemination  of  such  diseases  as  enteric  fever 
and  dysentery. 

The  Racial  Factor  in  the  Health  Problem. 

The  race,  and  more  especially  those  fellaheen  of  whom 
we  have  spoken,  constitutes  a very  important  factor  in  the 
health  problem.  Who  are  these  brown-faced,  blue-garbed 
sons  of  the  soil  ? They  constitute  the  immense  majority  of 
the  population  ; they  form  the  lowest  stratum  of  the  social 
organisation  of  the  country ; they  are  the  descendants  of 
those  who,  until  Great  Britain  undertook  the  work  of  refor- 
mation in  Egypt,  were  beaten  and  robbed,  the  prey  of  pashas 
and  of  usurers.  Physically  they  are  a sturdy  race,  and,  as 
Lord  Cromer  has  stated,  when  left  to  themselves,  kindly  and 
even  jovial.  These  characteristics  are  more  marked  in  the 
people  of  the  Delta,  those  of  Upper  Egypt  being  somewhat 

K 


418  ThbLanobf,] 


DK.  A.  BALFOUti:  THE  PROBLEM  OF  HYGIENE  IN  EGYPT. 


[Sept.  6,  ly!9 


truculent  and  less  easy  to  handle.  Unhappily,  from  a 
hygienic  standpoint,  the  fellaheen  are  also  steeped  in 
ignorance  and  superstition,  void  of  initiative,  with  no  out- 
look, with  little  ambition,  content  with  the  daily  round  of 
labour  in  the  fields,  and  in  many  cases  doomed  to  suffer 
much  misery  from  preventable  disease.  As  a recent  Com- 
mission has  said,  and  truly  said  : “ To-day  the  greater  part 
of  Egypt  is  filthy  and  no  self-respecting  populace  can  be 
raised  in  filthy  surroundings.  As  of  old,  Egypt  is  plagued 
by  disease,  and  it  is  hopeless  to  expect  a disea3e-ridden 
people  to  play  their  proper  part  in  furthering  the  welfare  of 
their  country.  The  infant  mortality  of  Egypt  is  appalling, 
actually  one-third  of  the  children  born  dying  in  infancy. 
The  verminous  condition  of  the  fellaheen  shows  no  improve- 
ment, though  lice  are  now  known  to  be  conveyers  of  typhus 
and  relapsing  fevers  which  account  for  so  many  deaths.  ” And, 
again,  when  speaking  of  the  necessity  for  education  and  for 
improvement  in  village  sanitation,  it  is  stated  that  “the 
healthy  fellah  is  happy  and  content  because  he  has  never 


Archaic  Methods  of  Midivifery. 

Dr.  Elgood  has  pointed  out  that  there  must  be  at  least 
4,000,000  women  in  Egypt  of  child-bearing  age.  The 
general  methods  of  midwifery  she  describes  as  archaic  and 
brutal.  No  one  knows  how  much  puerperal  fever  occurs,  but, 
taking  Cairo  alone,  it  is  significant  how  many  funeral  biers 
are  seen  in  the  streets  with  silver  bridal  tresses  adorning 
their  head-pieces,  the  sign  that  a woman  has  died  during 
her  first  year  of  married  life.  In  any  case,  there  can  be  no 
doubt  that,  apart  from  other  ailments,  the  majority  of  lower- 
class  Egyptian  women  suffer  from  uterine  and  ovarian  com- 
plaints. Gonorrhoea  is  exceedingly  common,  syphilis  far 
from  rare,  while  the  mental  effect  produced  by  the  frequent 
loss  of  children  must  tend  to  depress  vitality  and  induce 
apathy  and  despair.  The  harem  system  makes  the  problem 
of  succouring  these  women  difficult,  though  not  hopeless. 
Naturally  enough,  they  and  their  husbands  object  to  male 
assistance,  and,  even  at  out-patient  clinics,  to  the  presence 


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SHOWING  SURROUNDING  COUNTRIES  AND 
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known  anything  better,  while  the  unhealthy  fellah  is  far 
from  being  happy  and  content,  though  he  is,  perhaps,  the 
most  patient  of  sufferers.” 

It  is.  indeed,  this  quality  of  patience,  an  almost  bovine 
patience,  which  is  one  of  the  chief  features  in  the  character 
of  the  fellaheen,  but,  so  far  as  disease  goes,  there  is  a kind  of 
hopelessness  about  it  which  is  pathetic.  Especially  is  this 
true  of  the  women,  who,  in  contrast  to  the  men,  wear  black 
garments.  Now  black  is  the  colour  of  mourning,  and  well  may 
it  be  worn  by  the  women  of  the  fellaheen,  for  their  lot,  from 
a medical  and  sanitary  standpoint,  is  too  often  a sad  and 
weary  one.  I propose  to  consider  the  problem  of  the  women 
first,  for  in  eastern  countries  questions  of  health  are  very 
intimately  bound  up  with  the  state  of  the  female  population. 
Happily,  the  poorer  women  of  Egypt,  be  they  fellaheen  or 
town  dwellers,  have  not  lacked  champions  in  the  past.  Their 
most  energetic  and  scientific  supporter  of  late  years  has  been 
Mrs.  Elgood,  a woman  doctor  who  has  laboured  incessantly 
to  improve  their  lot,  and  who,  as  medical  officer  to  the 
Ministry  of  Education,  has  also  fought  the  battle  of  the 
children. 


of  male  students  or  of  “ tamurgis,”  as  the  male  hospital 
orderlies  are  called. 

According  to  Dr.  Elgood,  the  absence  in  most  Government 
hospitals  oE  a European  matron  or  a woman  doctor  prevents 
the  lower-class  men  entrusting  their  women  to  the  care  of 
such  institutions.  Another  condition  which  leads  to 
difficulties  is  the  treatment  of  prostitutes  in  Government 
hospitals.  So  long  as  this  class  is  admitted  to  the  same 
building  as  the  honourable  women,  so  long  will  the  latter 
object  to  being  treated  there,  even  though  the  prostitutes  are 
housed  in  special  wards. 

Lastly,  there  is  the  question  of  hospital  fees.  Small 
though  these  are,  they  are  prohibitive,  for  many  of  the 
working-class  Egyptians  are  miserably  poor.  There  is  a rule 
that  the  very  poor  shall  not  be  charged,  but  nearly  all  who 
attend  hospital  are  in  this  state,  for  it  is  the  last  resort  of 
the  destitute.  At  the  present  time  most  of  the  maternity 
assistance  in  Egypt  is  rendered  by  dayas  or  midwives, 
poorly  trained  women  of  a low  and  dirty  class,  who  are 
responsible  for  many  of  the  deaths  both  of  mothers  and 
infants.  In  addition  a certain  number  of  hakimas  or,  as  they 


The  Lancet,] 


DR,  A.  BALFOUR:  THE  PROBLEM  OF  HYGIENE  IN  EGYPT. 


[Sept.  6,  1919  419 


are  more  usually  termed,  mumarridas,  exist,  to  whom  further 
reference  will  be  made  when  we  consider  the  solving  of  this 
part  of  the  Egyptian  health  problem. 

Effect  of  the  Mothers'  Disabilities  on  the  Child  Population. 

Healthy  children  are  a nation’s  greatest  asset,  but  how 
can  the  poorer  Egyptian  children  be  healthy  when  their 
mothers  labour  under  the  disabilities  we  have  just  con- 
sidered, and  are  in  addition  dirty  and  ignorant?  A third 
of  them  die  as  infants.  Those  who  survive,  especially  if  in 
the  large  towns,  have  a struggle  for  existence.  A great 
number  attain  adolescence  exhibiting  some  defect.  Many 
harbour  ankylostomes  or  schistosomes,  or  both,  and  suffer 
grievously  in  consequence.  A large  percentage  are  infected 
with  other  helminths,  many  have  damaged  eyes,  some  are 
cripples,  others  have  splenomegaly,  often  combined  with 
hepatic  cirrhosis.  Yet  others  acquire  pellagra.  Not  a few 
are  disfigured  by  small-pox,  and  probably  a minority  become 
healthy  men  and  women.  Yet  there  is  no  instruction  in 
diseases  of  infants  and  children  at  the  Kasr-el-Aini  School 
of  Medicine,  the  only  institution  in  Egypt  granting  diplomas 
to  practise  the  healing  art,  and  the  facilities  for  the 
gratuitous  treatment  of  infants  and  children  are  woefully 
inadequate,  save  possibly  where  eye  diseases  are  concerned. 

How  the  Fellaheen  Live. 

We  have  digressed  a little  from  the  subject  of  the  fellaheen, 
but,  returning  to  them  again,  let  us  see  how  they  live  and 
labour  and  what  ideas  they  possess  as  regards  the  cure  and 
prevention  of  disease.  They  inhabit  villages  which,  though 
often  picturesque,  transgress  wellnigh  every  law  of  health  ; 
congeries  of  flat-roofed,  ill-ventilated,  mud  dwellings,  some 
of  them  partly  underground,  crowded  like  rabbit  warrens, 
and  where  the  houses  are  shared  alike  by  man  and  his 
domestic  animals — donkeys,  cattle,  buffaloes,  sheep,  goats, 
cats,  dogs,  rabbits,  fowls,  and  pigeons.  The  roofs  are 
usually  piled  high  with  grass  or  rubbish,  and  commonly 
serve  as  latrines  for  the  women  of  the  household.  The  lanes 
or  passages  between  the  houses  are  narrow,  often  tortuous, 
and  not  infrequently  blocked  by  stacks  of  manure.  There 
are  many  blind  alleys.  There  is  no  sweep  of  purifying  air. 
No  sanitary  conveniences  of  any  kind  exist,  but  rats  swarm, 
and  at  certain  periods  there  is  a plague  of  flies.  Hard  by 
there  is  often  a birka  or  pool  which  may  serve  as  a 
mosquito  nursery,  and  the  water  of  which,  frequently  used 
for  drinking  purposes,  is  generally  grossly  polluted.  It  may 
harbour  the  infected  snail  hosts  of  the  schistosomes  and  be 
a danger  to  those  bathing  in  it.  The  usual  source  of  water- 
supply  is  a canal  into  which  all  manner  of  filth  finds  its  way 
and  in  which  buffaloes  love  to  soak  themselves. 

The  larger  villages,  if  judged  by  the  number  of  their 
inhabitants,  might  well  be  regarded  as  considerable  towns, 
and  may  contain  better-class  houses  in  which  the  wealthier 
landowners  live.  Most  of  the  fellaheen,  however,  are  small 
proprietors  subsisting  on  the  produce  of  their  fields.  Apart 
from  the  presence  of  disease  and  deformities,  their  lot  under 
British  rule  is  by  no  means  a hard  one,  and  certainly  com- 
pares favourably  with  that  of  the  poor  of  the  congested 
towns,  into  which  the  rural  population  tends  to  flock, 
thereby  creating  one  of  the  most  serious  of  the  sanitary 
problems  that  have  to  be  faced.  There  is  no  room  for  the 
newcomers,  adequate  building  schemes  to  cope  with  the 
difficulty  are  non-existent,  and  the  result  is  overcrowding 
with  all  its  attendant  ills,  evils  accentuated  in  a land  where 
the  lower  orders  are  infested  by  vermin,  and  where  the 
plague-carrying  rat  flea  abounds. 

One  has  no  wish  to  paint  too  gloomy  a picture  of  Egyptian 
life.  There  is  much  in  it  that  is  cheerful  and  attractive,  at 
least  in  the  country  districts.  The  ravages  of  disease  are  not 
very  apparent  to  the  casual  observer.  It  is  true  he  cannot 
fail  to  be  struck  by  the  number  of  blind  persons  or  un- 
fortunates with  defective  vision ; he  may  notice  that 
deformities  are  common,  and  occasionally  be  shocked  by 
the  sight  of  a wretched  leper,  but  otherwise  he  would 
probably  regard  the  populace  as  strong  and  well-liking.  It 
is  not  until  one  studies  statistics,  visits  the  dispensaries  and 
hospitals,  becomes  familiar  with  the  asylums  and  homes  for 
incurables,  inspects  the  slums  of  the  great  cities,  and  is 
brought  into  contact  with  epidemics  that  one  appreciates 
how  great  a burden  of  suffering  and  inefficiency  is  borne  by 
the  populace  of  Egypt,  and  how  much  of  this  burden  is  pre- 
ventable. Take  the  work  of  the  fellaheen,  work  with  the 
primitive  plough  and  the  fass  (hoe  or  spade)  in  the  irrigated 


fields,  work  which  entails  walking  or  standing  ankle-  and 
knee-deep  in  the  alluvial  mud.  Owing  solely  to  the  pollution 
of  the  soil  with  human  excrement,  there  is  an  ever-present 
risk  of  infection  with  the  larvae  of  ankylostomes,  resulting  in 
that  hookworm  disease  of  which,  thanks  to  the  Rockefeller 
Institute  and  its  campaign,  we  have  heard  so  much  of  late 
years. 

Abysmal  Iynoranoe  and  its  Results. 

Again,  either  in  the  course  of  his  work  or  when  bathing  or 
washing  or  drinking,  the  fellah  is  often  brought  into  contact 
with  water  which,  owing  to  pollution  with  urine  or  fasces, 
is  charged  with  the  cercariae  of  one  or  other  of  the 
human  schistosomes,  and  in  many  cases  he  falls  a victim 
to  schistosomiasis.  Both  schistosomiasis  and  ankylostomiasis 
are  serious  diseases  which  can  be  prevented  by  suitable 
hygienic  measures,  and  the  same  is  true  of  many  others. 
It  is  easy  to  proclaim  this  fact,  but  to  tackle  preventable 
diseases  properly  it  is  highly  desirable  to  enlist  the  sympathy 
and  support  of  the  populace  who  suffer  from  its  effects. 
Such  is  no  easy  task  even  amongst  an  educated  com- 
munity. The  native  Egyptian,  however,  is  still  plunged 
in  abysmal  ignorance  as  regards  the  nature  and  cure 
of  disease.  Lord  Cromer  in  his  book,  “Modern  Egypt,” 
quoting  from  an  interesting  paper  written  by  the  late  Dr, 
Sandwith  in  1884,  cites  several  instances  of  strange  super- 
stitions which  showed  that  the  medical  knowledge  amongst 
the  poorer  classes  was  not  materially  in  advance  of  that 
current  in  the  days  of  the  Pharaohs.  Here  is  one  not  quoted, 
but  culled  from  the  same  authority.  Numerous  alleged 
cures  exist  for  ophthalmia,  “such  as  wearing  a red  bead  or 
gold  ornament  on  the  forehead  or  rowing  across  the  Nile  at 
Cairo  to  deposit  a lump  of  mud  on  the  further  shore.  During 
the  process  of  some  of  these  cures  it  is  considered  most 
important  that  the  eyes  should  not  be  washed  for  40  days, 
and  it  is  not  uncommon  to  see  children  with  both  eyes  com- 
pletely covered  with  a dry  scab  which  the  parents  refuse 
to  have  removed,  although  pus  may  be  streaming  down  the 
child’s  cheeks.” 

It  is  to  be  feared  that  in  the  thirty  odd  years  which  have 
elapsed  since  Dr.  Sandwith  collected  these  curious  beliefs 
there  has  been  no  very  great  change,  though,  doubtless, 
there  has  been  some  lessening  in  this  ignorance  and 
credulity,  for  the  leaven  of  education  has  been  at  work,  new 
idea?  are  abroad,  and  the  doctor  is  more  trusted  than  he 
used  to  be. 

The  Conditions  in  Urban  Areas. 

Hitherto  we  have  been  considering  chiefly  the  rural 
districts  and  the  fallaheen.  Let  us  take  a look  at  the  urban 
populations  and  at  the  conditions  which  exist  in  such  great 
cities  as  Cairo  and  Alexandria.  I cannot  do  better  than 
quote  Lord  Cromer’s  vivid  description  of  the  first  ten  people 
a visitor  to  Cairo  may  happen  to  meet  in  the  streets  of 
“that  maze  of  old  ruin  and  modern  cafe,  that  dying  Mecca 
and  still-born  Rue  de  Rivoli,”  as  it  was  christened  by  Sir 
William  Butler. 

“ The  first  passer-by  is  manifestly  an  Egyptian  fellah  who  has  come 
into  the  city  to  sell  his  garden  produce.  The  headgear,  dress,  and 
aauiline  nose  of  the  second  render  it  easy  to  recognise  a Bedouin  who 
is,  perhaps,  come  to  Cairo  to  buy  ammunition  for  his  fliut-lock  gun. 
but  who  is  ill  at  ease  amidst  urban  surroundings,  and  will  hasten  to 
return  to  the  more  congenial  air  of  the  desert.  The  small,  thick-lipped 
man  with  dreamy  eyes,  who  has  a far-away  look  of  one  of  the  bas-reliefs 
on  an  ancient  Egyptian  tomb,  but  who  Champollion  and  other  savants 
tell  us  is  not  the  lineal  descendant  of  the  ancient  Egyptians,  is  presum- 
ably a Coptic  clerk  in  some  Government  office.  The  face,  which  peers 
somewhat  loweringly  over  a heavy  moustache  from  the  window  of  a 
passing  brougham,  is  probably  that  of  some  Tnrco-Egyptian  Pasha.  The 
man  with  a bold,  handsome,  cruel  face,  who  swaggers  by  in  long  boots 
and  baggy  trousers,  must  surely  be  a Circassian.  The  Syrian  money- 
lender, who  comeB  next,  w ill  get  out  of  his  way,  albeit  he  may  be  about 
to  sell  up  the  Circassian's  property  the  next  day  to  recover  a loan  of 
which  the  capital  and  interest  at  any  ordinary  rate  have  been  already 
paid  twenty  times  over.  The  green  turban,  dignified  mien,  and  slow 
gait  of  the  seventh  passer-by  denote  some  pious  Sheik  perhaps  on  his 
way  to  the  famous  University  of  El-Azhar.  The  eighth  must  be  a Jew, 
who  has  just  returned  from  a tour  in  Asia  Minor  with  a stock  of 
embroideries,  which  he  is  about  to  sell  to  the  winter  tourists.  The 
ninth  would  seem  to  be  some  Levantine  nondescript,  whose  ethno- 
logical status  defies  diagnosis;  and  the  tenth,  though  not  easily  dis- 
tinguishable from  the  latter  class,  is  in  reality  one  of  the  petty  traders 
of  whom  Greece  is  so  prolific,  and  who  are  to  be  found  dotted  all  over 
the  Ottoman  dominions.  Nor  is  the  list  yet  exhausted.  Armenians, 
Tunisians,  Algerians,  Soudanese,  Maltese,  half-breeds  of  every  descrip- 
tion, and  pure-blooded  Europeans  pass  by  in  procession,  and  all  go  to 
swell  the  mass,  if  not  of  Egyptians,  at  all  events  of  dwellers  in  Egypt." 

Naturally  this  mixture  of  races  adds  to  the  difficulties  of 
the  sanitarian,  which  have  been  further  enhanced  by  the 
existence  of  the  capitulations.  These  were  at  first  really 


420  Thh  Lancet,  J 


DR.  A.  BALFOUR : THE  PROBLEM  OF  HYGIENE  IN  EGYPT. 


[Sept.  6,  1919 


concessions  or  privileges  granted  by  Turkey  to  foreigners 
resident  in  Egypt,  but  under  the  lax  rule  of  the  Khedives  the 
privileges  grew  into  abuses,  multiplied  in  various  directions, 
and  became  a curse  to  the  country  and  a great  bar  to  sanitary 
reform,  because  many  of  those  who  offended  against  the 
public  health  could  not  be  brought  to  book.  Happily,  the 
capitulations  are  now  on  their  last  legs,  but  they  have 
wrought  untold  harm  for  many  years.  This  is  why  in  Cairo 
so  many  of  the  so-called  ctablissements  insalubres,  really 
offensive  trades,  thoroughly  deserve  their  title  ; this  is  one 
reason  why  it  has  been  so  difficult  to  deal  with  the  mosquito 
pest  ; this  has  been  one  of  the  causes  which  have  wellnigh 
broken  the  heart  of  the  energetic  medical  officer  of  health  in 
his  struggle  to  abate  nuisances  and  secure  convictions. 

But  the  capitulations  are  by  no  means  the  sole  reason  why 
Cairo  has  a high  death-rate  and  in  many  parts  is  insanitary 
in  the  extreme.  In  1911  in  a well-known  medical  work 
there  appeared  the  following  criticism  which  gave  rise  to 
much  heart-burning  in  certain  quarters.  After  commenting 
on  the  cesspools,  the  mosquitoes,  the  sewage-sodden  soil,  and 
the  vermin  of  the  Egyptian  capital,  the  writer  goes  on  to 
say  : — 

“ The  human  mortality  is  enormous,  especially  the  infantile  mortality. 
The  figures  supplied  by  the  Public  Health  Department  are  unreliable 
(as  I know,  for  I have  assisted  to  compile  some  of  them).  The  actual 
population  is  unknown,  many  deaths  are  probably  never  reported,  and 
sickness  is  not  usually  notified.  All  deaths  are  supposed  to  be 
registered,  the  diagnosis  usually  being  made  by  a brief  inspection  of  the 
dead  body.  Doctors  will  not  notify  disease  because  they  say  that  it 
ruins  their  practice  Landlords  prefer  to  knock  holes  in  the  sides  of 
their  cesspools  and  allow  the  sewage  to  flood  their  cellars  and  basements 
rather  than  go  to  the  expense  of  having  them  pumped  out.  The  water- 
supply  is  not  the  best  obtainable,  the  streets  are  not  properly  cleaned, 
and  enormous  heaps  of  dung  and  rubbish  have  been  allowed  to 
accumulate  for  years  past  on  the  outskirts  of  the  city.  Many  of  the 
streets  are  not  metalled ; which  perhaps  is  a good  thing,  for  the  rough 
surface  acts  as  a sponge  for  the  stale  urine  which  would  otherwise 
collect  in  puddles.  Dung  and  street  refuse  are  used  as  fuel  generally  ; 
and  large  collections  of  this  rubbish  are  kept  for  this  purpose  on  the 
roofs  of  the  ‘ Turkish  baths.'  Nearly  all  the  dogs  have  been  destroyed 
owing  to  outbreaks  of  rabies,  and  many  cats  have  taken  their  place  as 
natural  scavengers.  Hordes  of  flies,  which  breed  in  the  dung  and 
rubbish,  abound  everywhere,  and  are  nearly  as  great  a nuisance  as  the 
mosquitoes.  Without  exaggeration,  Cairo  may  be  described  as  a city 
which  is  hardly  fit  for  habitation,  and  at  present  it  must  rank  with 
Moscow,  Pekin  and  Hankow  as  being  one  of  the  most  Insanitary  spots 
in  the  world. 

Happi-ly  there  has  been  in  some  directions  a considerable 
change ' or  the  better  since  the  above  appeared. 

Insanitary  Old  Cairo. 

I myself  recall  an  incident  which  opened  my  eyes  as  to 
the  insanitary  state  of  affairs  permitted  to  exist  in  a city  the 
European  part  of  which  almost  merits  the  old  title  of  Cairo 
the  Magnificent,  so  far  as  spacious  streets  and  fine  buildings 
are  concerned.  A certain  Sewage  Transport  Company 
approached  me  with  a view  to  obtaining  a concession  for 
dealing  with  the  conservancy  of  Khartoum.  I met  the 
company’s  representatives  in  a very  ramshackle  and 
decayed  building  in  Old  Cairo.  As  is  usual  in  Egypt, 
coffee  was  served,  and  on  finishing  my  cup  I discovered 
amongst  the  syrup  at  the  bottom  of  it  a dead  fly.  I fear 
this  prejudiced  the  company’s  application  from  the  outset ; 
but  in  any  case  it  could  never  have  been  entertained,  for  the 
ideas  advanced  were,  to  say  the  least,  unprogressive,  and  the 
methods  of  working  in  Cairo  were  disgraceful.  Pail  contents 
were  collected  in  those  insanitary  juggernauts  called  Crowley 
carts,  which  jolted  and  splashed  along  the  unpaved,  badly 
kept  roads,  to  the  joy  of  thousands  of  flies  which  bore  them 
company.  The  cart  contents  were  dumped  into  shallow 
open  depressions  in  the  soil  no  great  distance  from  the  city 
confines,  and  were  there  mixed  with  material  dug  from 
the  neighbouring  gebels,  which  is  said  to  have  fertilising 
properties.  The  nauseous  mixture,  after  drying  in  some 
measure,  was  spread  out  on  the  top  of  these  same  gebels  for 
further  desiccation.  Naturally  it  pulverised  and  naturally 
the  south  wind  wafted  it  down  upon  the  city.  Is  it  possible 
to  imagine  a more  filthy  and  insanitary  procedure  1 Is  it 
strange  that  sore  throats  are  frequent  in  this  city  of  dust 
and  smells  ? These  methods  are  still  in  vogue,  for  the  great 
drainage  scheme  has  not  yet  touched  Old  Cairo,  and  though 
there  is  better  supervision  the  conditions  remain  very 
unsatisfactory.  One  has  only  to  read  the  report  of  the 
Sanitary  Commissioner  sent  out  by  The  Lancet  in  1908  to 
realise  how  necessary  it  was,  and  still  is,  to  cleanse  the 
Augean  stable.  He  paints  a lurid  picture  of  the  rubbish 
heaps  to  the  north  of  the  city,  and  though  things  have 
improved  in  some  measure,  a good  deal  yet  remains  to  be 


done.  Elsewhere,  amongst  the  tangle  of  narrow  streets  in 
the  Bulaq,  Saida  Zeinab,  and  Bab-el-Sharia  quarters  all 
manner  of  insanitary  conditions  continue  to  flourish.  The 
meat  market  is  very  far  from  ideal,  the  tripe  market  an 
abomination.  Many  of  the  cowsheds  and  dairies  are  filthy 
in  the  extreme.  The  roofs  of  the  houses  are  used  as  latrines, 
the  condition  of  the  wells  in  their  basements  is  enough  to 
suggest  cholera.  Filth  and  flies,  overcrowding,  vermin, 
infected  food  and  drink,  stagnant  air,  disease  and  destitu- 
tion, all  are  there.  Is  it  any  wonder  the  Sphinx  sits  yonder 
in  the  desert  and  gazes  with  stony  and  sardonic  smile  over  a 
city  with  a death-rate  of  nearly  40  per  1000  per  annum  ? 

The  Same  Evils  in  Modern  Alexandria. 

But  you  will  say,  after  all  Cairo  is  a great  and  ancient 
native  city,  an  eastern  city,  and  we  know  what  happens 
to  the  man  who  tries  to  hustle  the  East.  Let  us  then  take 
train  to  Alexandria,  which  is  largely  a European  city,  a 
proud  and  prosperous  city  with  a municipality  and,  mirabile 
dictu , wellnigh  as  fine  a slaughter-house  as  is  to  be  found 
anywhere  in  Europe.  Here,  however,  are  the  same  evils— 
slum  quarters  or  echeches  of  the  worst  description,  centres 
of  typhus  and  relapsing  fever,  often  cheek  by  jowl  with 
better-class  dwellings,  often  close  to  areas  inhabited  by 
well-to-do  Europeans.  The  conditions  at  the  hammams,  or 
Turkish  baths,  are  scandalous,  for  at  these  places  the  town 
refuse,  often  ill-smelling  and  foul,  is  used  as  fuel,  and, 
being  stored  anyhow  and  everywhere,  is  most  offensive  and 
dangerous.  It  breeds  flies  galore,  it  affords  a happy 
hunting-ground  for  lean  donkeys,  greedy  goats,  and  mangy 
cats.  The  creatures  who  handle  it  look  like  soot-besmirched 
myrmidons  of  Satan,  and,  strange  to  say,  in  the  furnaces 
which  it  feeds  beans  are  baked  in  earthenware  jars  from 
which  they  are  sold  in  the  neighbouring  streets. 

Until  the  sanitary  authorities  of  the  Expeditionary  Force 
took  stringent  action  most  of  the  aerated  water  factories, 
the  bakeries,  patisseries,  ice-cream  shops,  and  the 
kitchens  of  the  restaurants  were  sources  of  danger  to  the 
community,  and  in  certain  instances  disgusting  as  well  as 
dangerous.  The  markets  leave  much  to  be  desired,  the 
municipal  arrangements  for  refuse  destruction  are  totally 
inadequate,  the  methods  of  disposal  of  latrine-bucket 
contents  and  sewage  sludge  at  Mex  and  Gabriel  offensive 
and  noxious,  the  Infectious  Diseases  Hospital  a disgrace  to 
a city  like  Alexandria,  and  the  municipal  bacteriological 
laboratory  a place  in  which  it  is  a crying  shame  to  ask  any 
scientist  to  work — at  least  during  the  hot,  moist  summer. 

It  is  the  same  more  or  less  in  all  the  towns  of  Egypt. 
Here  and  there,  as  at  Suez  and  Port  Said,  good  work  by 
energetic  officials  has  remedied  matters  in  some  degree,  but 
not  so  very  long  ago  I encountered  amongst  the  mounds  of 
rubbish  awaiting  incineration  at  Port  Said  the  most  remark- 
able and  nauseating  odour  it  has  ever  been  my  ill  fortune  to 
experience,  and  I may  say  I am  somewhat  blas§  as  regards 
insanitary  effluvia.  It  had  a peculiar  sweet  flavour  which 
defies  description  and  demanded  instant  flight,  so  that  I am 
still  wondering  what  could  possibly  have  produced  it. 

The  Principal  Infective  Diseases. 

Now,  what  are  the  principal  diseases  which  form  the 
natural  corollary  to  this  state  of  affairs  in  the  Egypt  of  to-day 
— the  Egypt,  remember,  over  which  this  country  has  cast  her 
mantle  of  protection,  which  has.  a rightful  claim  upon  us  for 
assistance  and  advice  in  safeguarding  the  health  of  her 
people,  which,  if  her  sanitary  salvation  is  to  be  secured, 
must  be  guided  wisely  and  well  along  the  paths  of  hygiene  ? 

I have  already  spoken  of  the  two  great  worm  diseases, 
reference  has  been  made  to  the  frequency  of  other  helminthic 
disorders,  typhus  and  relapsing  fever  have  been  mentioned, 
allusion  has  been  made  to  enteric  fever,  dysentery,  plague, 
cholera,  small-pox,  pellagra,  leprosy,  splenomegaly,  idiopathic 
hepatic  cirrhosis,  and  ophthalmia.  There  has  been  some 
reference  to  venereal  complaints,  to  deformities,  and  to  gynae- 
cological disorders,  but  we  are  by  no  means  at  the  end  of  the 
list.  Before  proceeding,  however,  a few  words  may  be  said 
about  one  or  two  of  those  just  cited.  Dysentery  amongst  the 
native  Egyptians,  when  not  a symptom  of  rectal  bilharziasis, 
is  chiefly  of  the  amoebic  type.  Whether  bacillary  or 
amoebic,  it  is  a filth  disease  the  cause  of  which,  like  those 
of  enteric,  may  be  summarised  as  careless  contact  cases, 
carriers — chiefly  cooks — drains,  dairies,  dirty  drinking- 
water,  the  dust  of  dried  dejecta,  and  the  repulsive  regurgi- 
tation, dangerous  droppings  and  filthy  feet  of  ftecal-feediDg 


The  Lancet,] 


MR,  I.  BACK:  OPERATION  FOR  CARCINOMA  OF  THE  RECTUM. 


[Sept.  6,  1919  421 


flies  fouling  food.  Plague,  at  least  in  its  bubonic  form,  is 
due  to  vermin,  cholera  in  the  main  to  polluted  drinking 
water,  and  the  way  in  which  cholera  is  held  in  check  is  a 
fine  tribute  to  the  work  of  the  Department  of  Epidemic 
Services.  Small-pox  has  few  terrors  for  the  vaccinated,  and 
yet  it  is  sad  to  see  its  ravages  in  Egypt.  Pellagra  is  still 
a puzzle,  but  is  possibly  a combination  of  a food  deficiency 
disease  and  an  auto-intoxication  from  the  bowel.  Anyhow, 
it  helps  to  fill  the  asylums  and  causes  considerable  misery 
and  distress.  Leprosy,  another  enigma,  so  far  as  its  method 
of  spread  is  concerned,  is  certainly  associated  with  dirt  and 
destitution,  and  is  by  no  means  a stranger  to  some  parts  of 
Egypt.  Yet  nothing  is  done  for  it,  and  the  leper  is  free  to 
infect  the  healthy. 

Splenomegaly,  often  accompanied  by  cirrhosis  of  the  liver, 
may  be  due  to  various  causes,  all  of  which  are  not  yet  fully 
understood,  but  some  of  which  are  assuredly  of  an  insanitary 
nature  ; while  ophthalmia,  in  all  its  various  and  disfiguring 
forms,  is  too  often  directly  traceable  to  lack  of  the  elements  of 
hygiene  and  to  the  ubiquitous  fly.  Is  it  not  a terrible  thought 
that  at  the  time  of  the  last  Census  it  was  found  that  more 
than  half  a million  persons  in  Egypt  were  blind  in  one  or  both 
eyes  1 All  this  is  a sorry  tale,  whether  or  not  we  believe 
man  is  made  in  God’s  image,  but  there  is  more  to  tell. 
Dengue  fever,  now  definitely  known  to  be  mosquito-borne, 
occurs  every  now  and  then  in  Cairo  and  elsewhere,  malaria 
still  lingers  near  Ismailia,  and  is  by  no  means  infrequent 
along  the  Suez  Canal.  It  is  prevalent  and  severe  in  the 
Kharga  oasis  and  lurks  in  the  Delta  to  an  extent  which  is 
only  now  becoming  appreciated.  Filariasis,  another 
mosquito  carried  disease,  possesses  foci  in  the  land.  An 
unknown  fever  resembling  both  typhus  and  typhoid  but  of 
a relapsing  type  made  its  appearance  in  Cairo  in  1914  and 
accounted  for  many  deaths,  undulant  fever  (a  preventable 
malady)  occurs,  sand-fly  fever  claims  its  victims  here  and 
there,  diphtheria  is  not  uncommon,  rabies  is  present  to  a 
disquietb  g extent,  while  skin  infections,  and  more  especially 
boils,  show  that  the  plagues  of  Egypt,  if  they  once  ended  with 
the  death  of  the  first-born,  have  assuredly  assumed  a new 
lease  of  life. 


CARCINOMA  OF  THE  RECTUM: 

THE  CHOICE  OF  OPERATION. 

By  IVOR  BACK,  M.A.,  M.B.  Cantab.,  F.R.C.S.  Eng., 

SURGEON  TO  ST.  GEORGE'S  HOSPITAL  AND  TO  THE  GROSVENOR 
HOSPITAL  FOR  WOMEN. 


It  is  my  purpose  in  this  article  to  discuss  the  relative 
merits  of,  and  the  indications  for,  the  various  operations 
which  have  been  devised  for  carcinoma  of  the  rectum. 

It  must  be  regarded  as  a lamentable  fact  that  only  a 
small  percentage  of  cases  of  rectal  carcinoma  are  capable  of 
radical  extirpation  when  first  seen  by  the  surgeon.  I have 
asked  a number  of  surgeons  to  give  me  their  estimate  of  the 
percentage  of  operable  cases  ; the  lowest  figure  was  20  per 
cent,  and  the  highest  40  per  cent.  My  own  experience  is 
that  it  is  about  half-way  between  these  figures,  rather  under 
30  per  cent.  The  figures  vary  in  the  two  sexes.  Taking  a 
rough  estimate,  out  of  every  100  cases  in  the  female  40  are 
operable,  out  of  every  100  in  the  male  only  20,  giving  a 
figure  of  30  per  cent,  for  the  two  sexes. 

Early  Stages  oj  the  Disease. 

Carcinoma  of  the  rectum  probably  starts  either  as  a small 
ulcer  or  as  a small  polypoid  growth.  But  how  rarely  does 
one  come  across  a case  in  such  an  early  stage.  One  would 
think  that  either  of  these  would  cause  sufficient  discomfort 
to  arrest  the  patient’s  attention  and  cause  him  to  seek  advice. 
But  experience  shows  that  this  is  not  the  case,  and  the 
majority  of  patients,  even  intelligent  and  educated  ones, 
present  at  the  first  examination  a large  ulcerating  process 
extending  more  or  less  completely  round  the  bowel. 

The  really  early  cases  are  so  rare  that  it  is  easy  to 
remember  them. 

A lady,  aged  37,  consulted  me  in  1912  on  account  of  a single 
attack  'of  haemorrhage  from  the  rectum— bright  red,  not 
profuse.  She  had  no  other  signs  or  symptoms.  She  did  not 
look  ill,  and  rectal  examination  was  negative.  The  sigmoido- 
scope revealed  a stalked  polypus  about  the  size  of  a 
Barcelona  nut  in  the  sigmoid  colon.  I opened  the  abdomen 
and  excised  the  polypus  with  its  base  and  a wide  area  of  the 
bowel  wall  surrounding  it,  and  closed  the  opening  with 
Lembert  sutures.  She  made  an  uneventful  recovery. 


Microscopical  examination  revealed,  to  my  surprise,  a typical 
columnar-celled  carcinoma.  She  has  exhibited  no  signs  of 
recurrence.  The  case  demonstrates  the  value  of  sigmoido- 
scopic  exanTination,  if  such  demonstration  is  still  needed. 


But  this  type  of  case  is  the  exception.  The  one  we  have 
to  deal  with  most  often  is  that  in  which  a large  mass  is 
palpable  within  reach  of  the  examining  finger.  The  question 
to  be  decided  is,  Is  it  capable  of  radical  extirpation  ? I hold 
very  strongly  the  view  that  the  question  cannot  be  adequately 
decided  unless  and  until  the  patient  is  examined  under  an 
anaesthetic.  It  is  sufficient  at  the  first  examination  to  know 
that  there  is  a carcinoma.  Digital  manipulation  of  the 
growth  nearly  always  causes  great  pain. 

Examination  under  an  anaesthetic  will  reveal  a number  of 
helpful  points  : (1)  the  extent  of  the  growth  in  both 
directions — i.e.,  whether  it  completely  encircles  the  bowel 
and  (if  the  examining  finger  can  be  introduced  through  the 
lumen  of  the  growth)  how  far  it  extends  upwards  ; (2)  the 
nature  of  the  growth — i.e.,  whether  it  is  a soft  friable 
fungating  mass  (as  it  most  often  is)  or  whether  it  is  a hard 
fibrous  ring  ; (3)  the  mobility  of  the  growth— i.e.,  whether 
it  is  fixed  behind  to  the  sacrum  or  it  front  to  the  bladder  in 
the  male  or  to  the  posterior  vaginal  wall  in  the  female  ; 
(4)  deep  palpation  of  the  relaxed  abdominal  wall  may  enable 
the  surgeon  to  feel  enlargement  of  the  lumbar  glands  or  of 
the  liver. 

Colostomy . 

If  such  examination  reveals  the  case  to  be  a hopelessly 
inoperable  one  a colostomy  should  be  done,  and  done  at 
once.  I remember  being  taught  as  a student  that  the  patient 
should  be  put  on  a suitable  diet  calculated  to  leave  as  small 
a faecal  residue  as  possible  and  kept  under  observation  ; and 
that  a colostomy  should  only  be  performed  as  soon  as 
symptoms  of  obstruction  supervened.  This  teaching,  I 
believe,  to  be  wholly  and  utterly  wrong,  for  the  following 
reasons  : (1)  the  patient  will  get  progressively  weaker  as 
time  goes  on  and  less  able  to  withstand  the  shock  of  an 
abdominal  operation  ; (2)  if  the  surgeon  is  to  wait  until 
symptoms  of  obstruction  supervene  there  will  necessarily 
be  some  hypertrophy  and  dilatation  of  the  descending 
colon  and  the  operation  may  be  rendered  technically  diffi- 
cult ; (3)  it  is  probable  that  deflection  of  the  intestinal 
contents  from  passing  over  the  surface  of  the  growth  may 
retard  its  progress  ; and  (4)  last,  but  not  least,  the  patient 
is  already  suffering  from  some  degree  of  chronic  intes- 
tinal stasis,  and  an  immediate  colostomy  will  relieve  him 
from  the  multitude  of  disorders  associated  with  that  condi- 
tion. In  fact,  the  improvement  which  often  follows  colostomy 
is  quite  remarkable. 

The  colostomy  should  be  a hypogastric  one,  the  incision 
being  a vertical  one  through  the  centre  of  the  left  rectus 
abdominis  muscle  just  below  the  umbilicus  and  a.loop  of 
the  descending  colon  brought  out  and  fixed  in  position  by 
passing  a stout  glass  rod  through  its  mesentery.  Hypo- 
gastric colostomy  has  several  advantages  over  inguinal 
colostomy  done  through  a muscle-splittiDg  incision  in  the 
left  iliac  fossa.  The  opening  is  in  the  centre  of  the  abdomen 
in  a position  where  the  patient  can  attend  to  it  with  the 
greatest  ease  and  comfort,  and  the  cup  remains  in  position 
whatever  attitude  the  patient  may  adopt,  whereas  in  the 
inguinal  colostomy  the  cup  is  apt  to  ride  up  on  the  anterior 
superior  iliac  spine  when  the  patient  sits  down  and  allow 
an  escape  of  faecal  matter.  Further,  the  rectus  abdominis 
develops  in  the  course  of  time  a certain  degree  of  sphincteric 
power,  which  the  muscles  in  the  left  iliac  fossa  rarely,  if 
eVer,  do. 

Some  surgeons  perform  a transverse  colostomy.  I do  not 
advise  it  because  the  great  omentum  may  make  the  operation 
difficult,  and  my  experience  is  that  the  spur  is  rarely  as  good 
and  there  is  a tendency  to  spontaneous  closure. 

There  is  a popular  idea  that  to  have  a colostomy  is  the 
worst  fate  in  the  world,  rendering  the  owner  intolerable  to 
himself  and  to  others,  and  that  it  is  better  to  die  of  the 
cancer.  This  is  a fallacy  which  should  be  combated.  Life 
with  a colostomy  is  not,  of  course,  ideal,  but  it  is  far  from 
intolerable  ; and  I know  of  one  medical  man  who  has  had 
a colostomy  done  for  diverticulitis,  and  now  that  the  diver- 
ticulitis is  cured  refuses  to  have  the  colostomy  closed  and 
conducts  a large  practice  in  comfort. 

When  is  a Radical  Operation  Justifiable  ? 


The  contraindications  may  be  considered  under  two 
headings. 


K 2 


[Sept.  6,  1919 


422  The  Lancet,]  MR.  I.  BACK  : OPERATION  FOR  CARCINOMA  OF  THE  RECTUM. 


(1)  General. — Advanced  age  is  a contraindication.  It  is 
difficult  to  lay  down  an  absolute  rule  ; to  say,  for  instance, 
that  radical  operation  must  not  be  undertaken  jn  an  indi- 
vidual of  60  years  or  over.  Some  people  of  60  are,  patho- 
logically speaking,  only  50  ; others  are  70.  Experience  alone 
can  help  one  to  decide  on  this  point.  Recognisable  metastasis 
— e.g.,  enlargement  of  the  liver  with  umbilicated  nodules, 
or  enlarged  lumbar  glands  palpable  through  the  abdominal 
wall  under  an  anaesthetic — is  an  absolute  contraindication, 
as  is  the  condition  known  as  cachexia. 

(2)  Local. — Direct  extension  may  have  extended  so  far 
as  to  form  a recto-vesical  fistula.  This  is  an  absolute  bar 
to  radical  operation.  Fixation  of  the  growth  in  any  direction, 
anteriorly  to  the  prostate  or  bladder  in  the  male  or  to  the 
posterior  wall  of  the  vagina  in  the  female,  laterally  along 
either  levator  ani  muscle  or  posteriorly  to  the  coccyx  or 
sacrum  diminishes  the  prospect  of  success  in  proportion  to 
the  density  of  the  fixation.  Personally  I regard  dense  fixation 
anteriorly  in  the  male  as  a definite  contraindication.  In  the 
female  the  posterior  wall  of  the  vagina  can  be  removed  with 
the  bowel.  Fixation  in  other  directions  is  less  serious  and 
operability  depends  upon  the  degree  of  it  present.  In  some 
cases  fixation  has  spread  in  the  direction  of  all  points  of  the 
compass  and  these  are  inoperable. 

Unsound  Operations. 

When  a decision  has  been  arrived  at  that  the  case  is 
operable,  what  operation  should  be  done  ? I am  convinced 
that  any  operation  which  aims  at  leaving  a normal  anus — 
i.  e. , any  operation  which  is  not  associated  with  a colostomy — 
is  a bad  operation.  It  is  pathologically  unsound  because  it 
leaves  behind  those  very  areas  which  are  liable  to  become 
the  seat  of  recurrence.  Three  such  operations  have  been 
described. 

1.  Rectorrhaphy  or  trans-sacral  excision  of  the  growth  with 
end-to-end  anastomosis.  This  consists  in  a few  words  of 
removing  the  coccyx  and  part  of  the  sacrum  if  necessary, 
freeing  the  portion  of  bowel  where  the  growth  is  situated, 
dividing  the  bowel  above  and  below  the  growth  and  per- 
forming an  anastomosis  of  the  two  ends.  It  is  difficult, 
almost  impossible,  to  be  certain  of  so  removing  all  the 
affected  tissues  as  to  make  reasonably  sure  against  recur- 
rence ; the  anastomosis  rarely,  if  ever,  holds  per  primam 
and  usually  leaves  a posterior  fistula,  which  takes  weeks  or 
months  to  heal ; and,  finally,  there  is  often  left  an  ugly  and 
intractable  stricture  at  the  level  of  the  line  of  suture. 

2.  The  abdomino-anal  operation.  The  early  stages  of  this 
resemble  those  of  the  abdomino-perineal.  The  abdomen  is 
opened  in  the  middle  line,  the  lower  part  of  the  sigmoid  and 
the  rectum  freed  from  their  attachments  and  pushed  down 
below  the  peritoneal  pelvic  floor,  which  is  reconstituted  by 
suture.  The  abdomen  is  closed.  The  patient  is  turned  on 
his  side.  A posterior  incision  is  made  and  the  coccyx 
removed,  if  necessary.  The  rectum  is  cut  away  from  the 
external  sphincter,  which  is  left  but  divided  posteriorly. 
The  bowel  is  pulled  down  as  far  as  it  will  come  and  is  fixed 
inside  the  sphincter,  which  is  reunited.  All  the  bowel  distal 
to  the  sphincter,  this  being  the  portion  bearing  the  carcinoma, 
is  removed  at  a level  of  an  inch  below  the  anus.  This  opera- 
tion is  more  radical  than  the  last.  But  if  the  contents  of  the 
ischio-rectal  fossa  have  been  thoroughly  removed  with  the 
levatores  ani  and  the  internal  sphincter  the  sigmoid,  which 
has  been  brought  down  to  replace  the  rectum,  cannot  and 
does  not  behave  like  a normal  rectum,  and  infinite  trouble 
with  defsecation  is  usually  experienced,  not  to  mention  the 
fact  that  some  degree  of  stenosis  at  the  anal  orifice  is  a 
common  sequela. 

(3)  Krasko's  operation  and  its  modifications.  In  this  the 
coccyx,  and,  if  necessary,  the  lowest  part  of  the  sacrum,  is 
removed,  a perianal  incision  is  made  and  the  rectum  is 
dissected  up  until  it  is  free  well  above  the  growth.  The 
bowel  is  divided  above  the  growth  and  the  open  proximal 
end  is  fixed  on  to  the  upper  part  of  the  wound  as  an 
artificial  anus.  The  artificial  anus  so  formed  develops  no 
sort  of  control,  and  is  in  such  a position  that  the  patient 
is  totally  unable  to  look  after  himself.  This  operation  is, 
in  my  opinion,  quite  unjustifiable,  and  I hope  it  is  falling 
into  disuse. 

Satisfactory  Hadioal  Operations. 

There  are,  as  I think,  only  two  satisfactory  radical  opera- 
tions for  carcinoma  of  the  rectum : (1)  the  combined 
abdomino-perineal,  and  (2)  colostomy  with  high  perineal 
excision  later,  which  I will  call  for  short  the  two-stage 
operation,  and  I propose  to  discuss  their  respective  merits. 

(1)  The  combined  abdomino-perineal  operation.  I do 
not  propose  to  describe  the  technique  in  detail  since  it  is 
sufficiently  well  known.  The  abdomen  is  opened  by  a 
paramesial  incision  with  the  patient  in  the  Trendelenburg 
position,  the  inferior  mesenteric  artery  is  divided  between 


ligatures,  and  an  incision  made  in  the  mesentery  of  the 
colon  on  either  side.  These  incisions  are  produced  to  meet 
in  front  of  the  sigmo-rectum.  A separate  incision  about 
two  inches  long  is  made  through  the  centre  of  the  left 
rectus  abdominis  muscle.  The  bowel  is  divided  at  the  apex 
of  the  omega  loop,  and  both  ends  are  closed  with  a basting 
stitch.  The  proximal  end  is  brought  out  through  the 
separate  opening  and  fixed  in  position  so  as  to  form  a 
terminal  colostomy.  It  is  well  to  make  a small  incision  in 
the  exposed  end  and  tie  in  a catheter,  as  advocated  by  Mr. 
Sampson  Handley.  This  has  two  advantages  : (i.)  flatus  can 
escape,  and  (ii.)  saline  infusions  can  be  given  through  the 
catheter  if  desired.  The  distal  end  is  freed  from  its  con- 
nexions and  pushed  down  into  the  pelvis,  and  the  peritoneal 
pelvic  floor  is  restored  above  it  by  suture.  The  abdomen  is 
closed  and  the  patient  turned  on  the  left  side.  The  anal 
orifice  is  closed  with  a running  suture  and  an  incision  made 
round  it,  which  is  continued  upwards  in  the  middle  line 
behind.  The  coccyx  is  removed  if  necessary.  The  con- 
nexions of  the  rectum  proper  are  cut  through  at  as  wide  a 
distance  from  the  bowel  as  possible.  The  levatores  ani 
should  be  divided  near  their  origin,  and  the  whole  of  the 
bowel  below  the  point  of  section  is  removed  en  masse.  A 
large  drainage-tube  is  inserted  in  the  posterior  wound  and 
the  skin  edges  brought  together  with  sutures. 

(2)  Colostomy  with  excision  at  a later  stage.  In  this  a 
hypogastric  colostomy  is  performed  and  opened  on  the  third 
or  fourth  day.  A fortnight  later,  when  the  colostomy  is 
well  established  and  working  adequately,  the  second  stage  is 
undertaken.  The  anus  is  closed,  an  incision  made  round  it 
and  extended  upwards  in  the  middle  line  behind  and  the 
coccyx  removed  as  in  the  abdomino-perineal  operation.  The 
connexions  of  the  rectum  are  cut  through  as  far  away  from 
the  bowel  as  possible  ; and  the  freeing  of  the  rectum  is 
continued  upwards  carefully  and  gradually  until  the  pelvic 
peritoneal  floor  is  reached  anteriorly.  The  peritoneum  is 
deliberately  opened  and  the  freeing  of  the  bowel  is  con- 
tinued, clamping  the  vessels  on  its  posterior  aspect  until  a 
portion  of  bowel  completely  covered  by  peritoneum  can  be 
comfortably  reached.  A clamp  is  put  on  at  this  level  and 
the  distal  portion  of  bowel  is  removed.  The  proximal  end 
is  closed  with  a basting  stitch,  and  its  closure  made  further 
secure  by  a superimposed  circumferential  Lembert  suture.  - 
This  end  may  be  allowed  to  drop  back  into  the  peritoneal 
cavity  or  may  be  fixed  to  the  pelvic  peritoneum.  The  pelvic 
peritoneum  is  formally  closed,  as  in  a laparotomy.  A tube 
is  inserted  for  48  hours  in  case  of  oozing  and  the  skin  edges 
brought  together  by  suture.  Primary  union  of  the  posterior 
wound  should  result. 

The  important  thing  is  that  the  bowel  should  be  brought 
down  so  far  that  it  is  divided  at  a point  where  it  is  com- 
pletely covered  by  peritoneum.  If  this  is  done  it  can  be 
returned  to  the  peritoneal  cavity  without  risk.  Any  attempt 
to  divide  the  rectum  below  the  pelvic  peritoneal  floor  means 
that  a portion  of  bowel  uncovered  by  peritoneum  is  left  in 
the  pelvis.  The  stitches  give  way  and  a fistula  results  which 
may  persistently  refuse  to  close,  and  first  intention  healing 
of  the  posterior  wound  (a  point  of  prime  importance  to  the 
patient’s  comfort)  is  impossible. 

At  first  sight  the  abdomino-perineal  operation  appeals  to 
the  imagination  as  the  more  radical  and  therefore  sounder 
procedure.  But  it  has  to  be  confessed  that  the  abdomino- 
perineal operation  is  associated  even  now  with  a high  primary 
mortality — i.e.,  death  as  the  immediate  result  of  the  opera- 
tion. When  it  was  first  introduced  this  mortality  must  have 
been  at  least  40  per  cent.  It  is  difficult  to  get  exact  figures, 
but  that  is  my  impression.  With  our  improved  technique  of 
to-day,  and  the  more  judicious  selection  of  suitable  cases,  the 
figures  have  shown  an  improvement.  At  this  date  I estimate  the 
primary  mortality  as  being  roughly  15  per  cent,  in  females 
and  nearly  25  per  cent,  in  males — that  is,  20  per  cent,  in  all 
cases,  a formidable  consideration  for  any  surgeon  to  face. 

Common  Causes  of  Death. 

These  are : (1)  Shock.  This  can  be  largely  combated  by 
giving  a continuous  submammary  infusion  of  saline  during 
the  course  of  the  operation. 

(2)  Peritonitis.  This  is  a low  form  which  makes  its 
appearance  recognisable  clinically  about  the  fifth  or  sixth 
day,  and  death  ensues  two  or  three  days  later.  It  is  due  to 
soiling  of  the  peritoneal  cavity  at  the  moment  when  the 
bowel  is  divided  and  its  ends  sutured  ; in  other  words,  to 
indifferent  technique.  But  in  spite  of  every  possible  pre- 
caution, it  must  be  admitted  that  it  does  occur. 


The  Lanoht,]  DR.  GREENFIELD  : SEDIMENTATION  OF  TUBERCLE  BACILLI  IN  SPUTUM.  [Sept.  6,  1919  423 


(3)  Intestinal  obstruction.  This  is  generally  due  to  one  or 
more  coils  becoming  fixed  by  plastic  adhesions  to  the  line  of 
suture  restoring  the  pelvic  floor  and  acutely  angulated,  or  as 
happened  in  one  of  my  cases,  to  a coil  becoming  strangulated 
round  the  colon  at  the  back  of  the  colostomy  wound.  This 
occurs  a few  days  after  the  operation  and  the  patient  is 
rarely  in  a condition  successfully  to  withstand  the  shock  of 
another  laparotomy  even  if  the  diagnosis  be  made  in  time. 

In  1915  I myself  lost  four  male  patients  consecutively  in 
whom  I had  performed  the  abdomino-perineal  operation,  one 
from  shock,  one  from  peritonitis,  and  two  from  intestinal 
obstruction. 

On  the  other  hand,  the  primary  mortality  of  the  two-stage 
operation  should  be  nil  or,  at  any  rate,  so  small  as  to  be 
negligible.  Question  for  Consideration. 

This,  then,  is  the  question  we  should  put  to  ourselves. 
Is  the  possibility  of  radical  extirpation  of  the  growth  with 
freedom  from  recurrence  so  much  greater  in  the  combined 
abdomino-perineal  operation  than  in  the  two-stage  opera- 
tion that  we  are  justified  in  facing  the  extra  risk  of  its 
primary  mortality?  The  only  difference  between  the 
patients  after  the  two  operations  is  this — that  the  patient 
after  the  two-stage  operation  still  retains  a portion  of 
bowel  distal  to  the  apex  of  the  omega  loop. 

The  question,  therefore,  further  resolves  itself  into  this. 
Is  this  portion  of  bowel  a common  seat  of  recurrence  ? It 
need  hardly  be  remarked  that  recurrence  is  due  to : 
(a)  indirect  extension,  and  (b)  direct  extension.  Indirect 
extension  spreads  either  by  the  portal  venous  system  to  the 
liver  or  by  the  lymphatics  to  the  retro-peritoneal  glands.  It 
does  not  concern  us  in  this  argument,  since  in  neither 
operation  is  any  attempt  made  to  deal  with  it.  In  fact,  as  I 
said  above,  if  its  presence  is  clinically  recognisable  it  is  a 
contraindication  to  radical  operation. 

Direct  extension  may  be  (i.)  intramural  or  extramural.  My 
own  belief  is  that  intramural  extension  certainly  takes  place 
round  the  bowel  and  down  the  bowel,  but  that  if  the  growth 
extends  up  the  bowel  it  does  so  only  for  a very  short  distance. 
I have  yet  to  be  convinced  that  the  bodies  which  have  been 
described  in  the  submucous  layer  of  the  bowel  at  a distance 
of  some  inches  from  the  growth  are  carcinomatous  at  all, 
and  I have  not  seen  a case  where  a fatal  recurrence  has 
occurred  in  the  bowel  left  after  a free  perineal  intra- 
peritoneal  excision. 

But  direct  extramural  extension  is  a different  matter,  and 
I believe  that  the  most  important  channel  by  which  the 
growth  extends  is  the  fascia  covering  the  levator  ani. 
When  we  see  a recurrence  after  a radical  operation  for 
carcinoma  of  the  rectum  it  is  usually  in  the  form  of  a 
fungating  mass  which  has  spread  down  the  wall  of  the 
ischio-rectal  fossa  and  fungated  through  the  skin  in  or 
near  the  line  of  the  posterior  incision  ; it  has,  in  fact, 
spread  down  from  a portion  of  the  origin  of  the  infected 
levator  ani  which  was  left  behind. 

If  this  is  so,  the  possibility  of  eradicating  the  disease 
should  be  equally  great  in  the  two-stage  operation  as  in 
the  combined  abdomino-perineal.  I am  therefore  putting 
forward  my  view  that  considering  the  respective  mortalities 
of  the  two  operations  the  two-stage  operation  should  be 
regarded  as  preferable  in  the  great  majority  of  operable 
cases  of  carcinoma  of  the  rectum  ; it  should  be  the  operation 
of  election. 

There  is,  however,  one  class  of  case  where  the  two-stage 
operation  is  not  feasible  and  the  abdomino-perineal  is  the 
only  one  which  gives  a chance  of  removing  the  growth — i.e., 
where  the  carcinoma  is  situated  at  the  junction  of  sigmoid 
and  rectum,  too  low  down  to  admit  of  excision  and  end-to- 
end  anastomosis  from  above  and  too  high  up  to  allow  of 
excision  from  below.  Conclusions. 

(1)  Only  30  per  cent,  of  cases  of  carcinoma  of  the  rectum 
admit  of  radical  operation  when  first  seen. 

(2)  When  radical  operation  is  impossible,  a hypogastric 
colostomy  should  be  done  at  once. 

(3)  Radical  operations  which  aim  at  retaining  the  anal 
canal  are  pathologically  unsound. 

(4)  The  only  sound  radical  operations  are:  (i.)  the  two- 
stage  operation  (colostomy  and  intraperitoneal  excision  by 
the  perineal  route  later)  ; and  (ii.)  the  combined  abdomino- 
perineal operation. 

(5)  Of  these,  the  former  is  the  better  except  in  the  case  of 
a growth  situated  at  the  junction  of  the  sigmoid  and  the 
rectum. 


NOTE  ON  A METHOD  FOR  THE 

SEDIMENTATION  OF  TUBERCLE  BACILLI 
IN  SPUTUM. 

By  J.  G.  GREENFIELD,  M.B.,  M.R.C.P.,  B.Sc.  ; 

AND 

J.  ANDERSON, 

FORMERLY  PRIVATE,  R.A.M.C. 


The  following  method  has  been  in  use  for  over  a year  in 
the  laboratory  connected  with  a large  military  chest  hospital, 
which  was  constantly  receiving  fresh  cases  of  suspected 
phthisis.  Up  to  20  samples  of  sputum  per  diem  have  been 
dealt  with  by  its  use,  and  we  have  found  it  so  much  more 
practical  and  reliable  than  any  of  the  published  sedimenta- 
tion methods  that  we  think  it  is  worth  while  to  make  it  more 
generally  known. 

The  Method  Described. 

5 c.cm.  of  sputum  are  mixed  with  twice  their  volume  of— 

Sod.  carb.  (cryst.) 1 

Acid  carbolic  (cryst.)  1 

Water 100 

in  a centrifuge  tube  ; the  tube  is  then  covered  with  a rubber 
cap,  shaken  for  a few  minutes  and  put  in  the  incubator  for 
12  to  24  hours.  (If  a number  of  sputa  are  to  be  tested  they 
can  be  placed  in  numbered  tubes  in  an  ordinary  test-tube 
rack  and  kept  in  order  during  further  stages.)  At  the  end 
of  the  time  the  tubes  are  centrif  ugalised  for  about  15  minutes, 
the  supernatant  fluid  poured  off,  and  films  made  from  2 to  4 
loopsful  of  the  deposit  are  stained  in  the  usual  way. 

Advantages. 

The  chief  advantages  of  this  method  are  as  follows : — 

1.  Its  rapidity,  as  it  really  takes  less  time  than  the  direct 
smear  method,  especially  if  a large  number  of  sputa  have  to 
be  examined,  as  the  rapidity  with  which  the  frankly  positive 
sputa  can  be  picked  out  more  than  compensates  for  the 
slightly  longer  technique. 

2.  The  sputa  when  taken  out  of  the  incubator  are  sterile  in 
the  majority  of  cases.  We  have  cultured  many  sputa  on 
to  Dorset’s  egg  medium  with  uniformly  negative  results  both 
as  regards  tubercle  bacilli  and  pyogenetic  organisms.  Of 
two  guinea-pigs  inoculated  from  sputa  containing  numerous 
tubercle  in  every  field,  only  one  became  infected.  This  pig 
was  injected  with  2 c.cm.  of  a very  purulent  deposit  which 
contained  vast  numbers  of  tubercle  bacilli.  It  would 
doubtless  be  possible  so  to  arrange  the  strength  of  carbolic 
used  that  the  pyogenetic  organisms  would  be  killed  off, 
leaving  some  viable  tubercle  bacilli ; but  for  routine  labora- 
tory work  the  advantages  of  killing  off  the  bacilli  before 
making  the  smears  cannot  be  over-estimated. 

3 The  films  resemble  the  direct  smears  both  in  the 
relative  proportion  of  other  organisms  present  and  in  the 
presence  of  mononuclear  and  polymorphonuclear  cells,  but 
the  mucus  is  not  stained. 


Table,  showing  Number  of  Bacilli  Counted  in  15  Fields. 


No. 

of 

case. 

Direct 

smear. 

Eller- 

mann’s 

method. 

Simpli- 

fied 

method. 

No. 

of 

case. 

Direct 

smear. 

Eller- 

maun's 

method. 

Simpli- 

fied 

method. 

i 

49 

47 

251 

ii 

15 

18 

98 

2 

19 

109 

107 

12 

76 

+ 

+ 

3 

1 

+ 

+ 

13 

38 

96 

161 

4 

5 

149 

120 

14 

0* 

6* 

14* 

5 

2 

7 

17 

15 

2* 

104 

150 

6 

5 

72 

111 

16 

20* 

+ 

+ 

7 

16 

26 

204 

17 

12* 

104 

126 

8 

14 

453 

537 

18 

397 

+ 

+ 

9 

0 

5 

68 

19 

2 

16 

99 

10 

0 

5 

7 

20 

25* 

67* 

200* 

■f  = more  than  1000.  * = after  prolonged  search. 


The  relative  ease  with  which  tubercle  bacilli  can  be  found 
by  this  method,  as  compared  with  the  examination  of  the 
direct  smear  and  of  films  made  by  the  full  technique  of 
Ellermann  and  Erlandaen,  is  shown  in  the  above  table.  In 
almost  every  case  as  many,  or  more,  bacilli  were  found  by 
the  simplified  technique,  and  the  advantages  both  as  regards 
cleanliness  and  time  are  obvious. 


424  The  Lancet,]  DR.  A.  ABRAHAMS : LYMPHaDENOMA  WITH  PERIODIC  PtfREXIA. 


[Sept.  6,  1919 


A CASE  OF 

LYMPHADENOMA  WITH  PERIODIC 
PYREXIA 

(“  PEL-EBSTEIN  DISEASE  ”). 

By  ADOLPHE  ABRAH  V.MS,  M.D.  Cantab, 

M R C.P.  Lond.. 

OFFICER  I/C.  MEDICAL  DIVISION.  CONNAUGHT  HOSPITAL,  ALDERSHOT; 
DISTRICT  CONSULTING  PHYSICIAN  TO  THE  ALDERSHOT  COMMAND. 


I AM  encouraged  to  publish  this  case,  not  because  I atn  in 
a position  to  contribute  any  new  ideas,  but  because  I think 
its  publication  will  serve  some  purpose  in  drawing  attention 
to  a condition  which,  though  well  recognised,  is  compara- 
tively rarely  encountered  and  which  offers  some  points  of 
interest  in  diagnosis.  I venture  to  think,  also,  that  this 
case  is  an  exceptionally  striking  example  and  in  many 
respects  more  typical  than  those  which  have  been  previously 
described. 

Cases  Reported  by  Other  Observers. 

Sir  Frederick  Taylor  contributed  a very  complete  and 
exceedingly  interesting  account  of  “the  chronic  relapsing 
pyrexia  of  Hodgkin’s  disease.”1  His  article  included  a 
reference  to  the  previous  literature  on  the  subject,  a refer- 
ence which  I have  found  of  the  greatest  value  in  enabling 
me  to  trace  the  original  descriptions  by  Pel,  Eostein,  and 
others.  His  detailed  description  of  these  cases,  together 
with  a resume  of  the  types  of  pyrexia  which  are  encountered, 
1 shall  briefly  epitomise  before  referring  to  the  case  I have 
myself  had  the  opportunity  to  observe. 

Sir  Frederick  Taylor  points  out  that  the  following  types  of 
fever  may  be  encountered  in  cases  of  lyrophadenoma  : (1)  A 
continuous  pyrexia  with  slight  diurnal  variations.  (2)  Alter- 
nating periods  of  pyrexia  and  normal  temperature.  (3)  Daily 
variations  of  temperature  (in  excess  of  the  normal  physio- 
logical limits)  which  are  higher  in  the  evening  than  in  the 
morning.  (4)  Mixed  types.  Cases  exhibiting  at  different 
times  temperature  phenomena  corresponding  to  more  than 
one  of  the  above-mentioned  types. 

Ebstein  published  a paper  entitled,  “Chronic  Relapsing: 
Fever,  a New  Infectious  Disease.”  - He  first  gave  a detailed 
description  of  the  clinical  peculiarities  of  the  case  and  after- 
wards its  termination  with  the  condition  found  at  autopsy. 
His  case  was  under  observation  for  238  days,  during 
which  there  occurred  10  attacks  of  pyrexia,  each  of 
13-14  days’  duration,  with  apyrexial  intervals  of  10-11 
days.  An  eleventh  attack  was  of  longer  duration  and 


that  this  pyrexial  variety  of  lympbadenoma  is  more  frequent 
under  than  over  20.)  There  was  no  history  of  any  ante- 
cedent illness,  and  he  was  admitted  on  Oct.  3rd,  1918,  with 
“ influenza.”  At  that  time  the  hospital  was  inundated  with 
cases  of  pyrexia,  all  of  which,  very  naturally  at  that  time  of 
epidemic,  were,  in  the  absence  of  any  distinctive  features, 
labelled,  provisionally  at  any  rate,  influenza  ; and  although 
it  is  probable  that  on  his  admission  the  disease  from  which 
he  was  suffering  was  a mild  attack  of  influenza,  no  particular 
attention  was  attracted  or  directed  to  anything  which  might 
have  suggested  the  subsequent  diagnosis.  He  was  sent  to  a 
convalescent  hospital  on  Oct.  15th,  and  28  days  later  he  was 
returned  with  a history  of  attacks  of  pyrexia  and  malaise,  of 
greatly  enlarged  spleen,  and  of  doubtful  signs  of  fluid  in  the 
left  side  of  the  chest.  On  his  arrival  he  complained  of  no 
symptoms,  his  temperature  was  subnormal,  no  physical  signs 
were  present,  but  the  spleen  was  very  definitely  enlarged 
and  extended  three  fingers’  breadth  below  the  costal 
margin. 

Three  days  later  the  spleen  was  quite  impalpable,  and  in 
the  absence  of  any  other  explanation  it  was  thought  that  the 
patient  was  now  convalescent  from  what  was  a fever  of  the 
typhoid  group.  But  ou  the  22nd  there  was  a recrudescence 
of  pyrexia  and  malaise,  with  gradual  but  rapid  enlargement 
of  the  spleen.  Pathological  investigations  instituted  at  this 
time  gave  the  following  results  : — 

Total  leucocyte  count,  1560  per  c.inm.  Differential  count : 
polymorphonuclears  (per  cent.)  47,  lymphocytes  39,  large 
monocytes  12,  eosinopbiies  1,  mast  cells  1.  Erythrocytes, 
2,675,000  per  c.mm.  Haemoglobin,  52  per  cent.  Blood  film 
showed  anachromasia  of  red  cells;  otherwise  nil  abnormal. 
Urine  nil.  Blood  culture  negative.  It  will  be  observed  that 
resemblance  to  typhoid  fever  is  again  manifest  in  the 
leucopenia. 

Apart  from  the  enlarged  spleen  no  abnormalities  were 
a-certainable  ; there  was  no  trace  of  enlarged  lymphatic 
glands.  It  will  he  remembered  that  these  negative  findings 
were  characteristic  in  the  cases  described  by  Ebstein  and 
Pel. 

Remarks. 

Many  chronic  infections  are  capable  of  producing  an 
irregular  sort  of  fever.  “ Anomalous  typhoid,”  “ anomalous 
influenza,”  tuberculosis,  Malta  fever,  were  all  specifically 
excluded.  It  may  be  added  that  the  picture  of  true  relapsing 
tever  differs  from  that  of  the  condition  described,  in  that 
the  periods  of  pyrexia  terminate  suddenly  by  an  unmistakab’e 
crisis,  quite  apart,  of  course,  from  the  unequivocal  evidence 
afforded  by  the  spirilla  in  the  blood.  Cases  of  lympbadenoma 
without  any  enlarged  external  glands  are  sufficiently  rare  to 


Oct.  Nov.  Dec.  Jan.  Feb. 


was  followed  shortly  before  death  by  a brief  twelfth 
attack.  During  life  an  enlarged  spleen  was  identified, 
but  no  abnormal  appearances  in  the  blood  and  no  enlarge- 
ment of  external  lymphatic  glands  were  observed.  At  the 
autopsy  there  were  discovered  enlarged  bronchial,  mediastinal, 
and  mesenteric  glands,  as  well  as  nodules  of  lymphoid 
appearance  in  the  lungs,  liver,  kidneys,  and  spleen.  Both 
liver  and  spleen  were  substantially  enlarged  and  both 
exhibited  infarcts. 

Pel’s  case  was  described  actually  two  years  before 
Ebstein's  publication.  He  referred  to  his  case  under  the 
title  “ Pseudoleukaemia  or  Chronic  Relapsing  Fever.”’  At 
that  time  the  association  of  pyrexia  with  Hodgkin’s  disease 
was  unknown.  Again,  in  Pel’s  patient,  as  in  Ebstein’s 
no  enlarged  external  glands  were  evident,  although  hyper- 
plasia of  the  spleeu,  retroperitoneal,  mesenteric,  and  bronchial 
glands  was  found  post  mortem.  Pel’s  idea  was  that  the 
exacerbations  of  fever  were  produced  by  solid  food,  a view 
which  nobody  else  has  supported,  and  one,  indeed,  which 
observation  appears  completely  to  refute. 

The  Author's  Case. 

The  patient  whom  I have  had  the  opportunity  to  investigate 
was  a boy  17  years  of  age.  (It  appears  from  Taylor’s  account 

1 Guy's  Hnspir.il  Reports.  1906  vol.  lx. 

-'  Bei  l Kiln.  Woeli.,  1887.  vol.  xxiv..  pp  o66  an.l  837. 


excuse  ibe  failure  to  diagnose  the  patient's  illuess  emiier, 
but  once  the  condition  has  been  recognised  it  may  be  said 
that  the  occurrence  of  such  periods  of  pyrexia  with  corre- 
sponding periods  of  enlargement  of  the  spleen  afford  a most 
characteristic  picture. 

Osier,  in  referring  to  this  disease,  says : — 

“ In  a few  rare  instances  (of  lymphadenoma)  Pel  has 
described  remarkable  periods  of  fever  of  10  to  14  days’ 
duration,  alternating  with  intervals  of  complete  apyrexia. 
They  occurred  in  two  of  my  cases.  Ebstein  described  it  as 
a form  of  chronic  recurring  fever.  It  is  probably  due  to  au 
intercurrent  infection.” 

The  last  suggestion  would  appear  to  be  indisputable,  and. 
bearing  in  mind  the  character  of  the  pyrexia,  one  would 
suspect  the  parasite  to  be  of  a protozoal  character.  So  far 
as  I am  aware,  no  supposed  infective  agent  has  been 
identified.  During  one  pyrexial  period  of  the  present  case 
the  spleen  was  punctured  and  the  blood  extracted  examined 
bacteriologically,  but  with  negative  result. 

Little  further  description  of  the  case  is  necessary.  As 
will  be  seen  from  the  chart,  a remarkable  regularity  of 
periods  of  pyrexia  and  apyrexia  was  on  the  whole  sustained, 
although  the  apyrexial  intervals  were  on  two  occasions  only 
one-half  the  usual  duration.  During  each  period  of  fever 
the  spleen  increased  in  size,  although  not  to  so  great  an 
extent  in  the  last  periods  observed  as  in  the  earlier  intervals. 


The  Lancet,] 


DR.  R.  T.  WILLIAMSON:  GRAVES’S  DISEASE  AND  DIABETES,  ETC.  [Sei>t.  6,  1919  425 


Daring  the  apyrexial  phases  the  patient  always  felt  quite 
well  and  walked  about,  taking  ordinary  diet,  and  regaining 
the  four  or  five  pounds’  weight  he  had  lost  during  the 
previous  period  of  pyrexia.  So  far  as  I could  estimate,  his 
general  condition  on  Feb.  15th  was  no  worse  than  on  his 
first  admission  to  hospital.  He  was  transferred  in  order  to 
be  nearer  his  home,  and  it  is  probable  therefore  that  at  some 
future  date  a further  history  of  the  progress  of  the  case  will 
be  forthcoming. 

I must  express  my  gratitude  to  Lieutenant-Colonel  VV. 
Turner,  C.M.G.,  R.A.M.C.,  O/C.  Connaught  Hospital,  Aider- 
shot,  for  permission  to  publish  the  notes  of  this  case,  and  to 
Lieutenant- Colonel  Herbert  French,  R.A.M.C.,  consulting 
physician  to  the  Aldershot  Command,  to  whom  I am  indebted 
for  much  valuable  advice  in  the  investigation  thereof. 


THE  RELATION  OF  GRAVES’S  DISEASE 
TO  DIABETES  AND  GLYCOSURIA. 

By  R.  T.  WILLIAMSON,  M.D.,  F.R.C.P., 

CONSULTING  PHYSICIAN  TO  THE  ROYAL  INFIRMARY,  MANCHESTER. 


A NUMBER  of  interesting  facts  indicate  the  relation  of 
Graves’s  disease  to  diabetes  mellitus  and  glycosuria.  Many 
writers  have  drawn  attention  to  this  relationship.  In  this 
paper,  however,  I do  not  propose  to  refer  to  interesting 
articles  already  published  on  the  subject,  but  shall  briefly 
refer  to  cases  in  my  own  practice  which  illustrate  this 
relation  from  the  clinical  side. 

1.  Graves’s  disease  is  occasionally  followed  by,  or  asso- 
ciated with,  diabetes  mellitus,  well  marked  or  mild. 

(a)  Graves’s  disease  followed  by  severe  diabetes  mellitus. 

Case  1. — Mrs.  A.  H.,  aged  47.  Seven  years  before  she  came  under  my 
observation  she  had  suffered  from  a very  severe  mental  shock.  Her 
husband’s  hand  was  torn  off  in  an  accident  at  his  workshop.  The 
patient  was  greatly  shocked  on  hearing  of  the  accident,  and  the 
mental  distress  was  very  soon  followed  by  symptoms  of  Graves's 
disea- e.  For  some  time  these  were  severe  ; then  she  improved  slowly  ; 
but  about  six  years  after  the  shock  thirst  and  symptoms  of  diabetes 
were  noted,  the  symptoms  of  Graves’s  disease  having  persisted. 

When  admitted  into  hospital  under  my  care  definite  symptoms  of 
Graves’s  disease  could  still  be  detected,  though  they  were  not  very 
marked  (exophthalmos,  tachycardia,  pulse  120  to  180,  thyroid  slightly 
enlarged,  and  fine  tremor  of  hands).  Symptoms  of  diabetes  mellitus  of 
medium  severity  were  also  detected.  She  was  under  my  care  in 
hospital  for  three  months  and  was  treated  for  diabetes,  which  was  the 
prominent  affection.  The  sugar  in  the  urine  was  estimated  daily.  The 
daily  amount  of  urine  during  this  period  varied  from  80  to  140  ounces, 
but  sometimes  it  was  more  than  the  latter  figure  ; sp.  gr.  1030  to  1040  ; 
sugar  18  to  30  gr.  to  the  ounce  (about  4 to  6’5  per  cent.),  total  amount 
of  sugar  in  24  hours  1500  to  2000  gr.  In  course  of  time  the  urine 
gave  a deep  reaction  with  ferric  chloride  for  diacetic  acid ; then 
albumin  was  detected  in  the  urine,  and  finally  casts.  Death  occurred 
from  a sudden  attack  of  hemiplegia. 

Case  2.— Mrs.  J.,  aged  39.  Suffered  from  Graves's  disease  at  the  age 
of  21 ; goitre,  palpitation,  and  other  symptoms  well  marked.  Suffered 
for  four  years  from  these  severe  symptoms  (seen  by  the  writer  at  that 
time).  Then  recovered  practically  from  Graves’s  disease,  but  suffered 
long  from  attacks  of  asthma.  At  the  age  of  35  diabetes  detected.  At  the 
age  of  39  seen  by  writer  again.  Marked  diabetes ; diacetic  acid  also 
found  in  urine  in  large  quantity.  No  goitre,  pulse  108;  only  slight 
prominence  of  eyeballs  ; no  tremor. 

Case  3.— Mrs.  M.,  age  41.  Symptoms  of  Graves's  disease  developed 
at  the  age  of  17,  and  continued  until  the  age  of  30.  Then  practical 
recovery  occurred.  At  the  age  of  40  symptoms  of  diabetes  developed 
and  eyeballs  became  again  prominent.  When  seen  by  writer  at  the  age 
of  41  the  symptoms  and  urinary  condition  were  those  of  severe  diabetes  ; 
also  the  eyeballs  were  prominent  and  the  pulse  rapid,  104,  but  the’ 
thyroid  was  not  enlarged. 

(b)  Graves’s  disease  followed  by  mild  diabetes  mellitus  (or 
persistent  glycosuria). 

Case  4.— Male,  aged  39  At  age  of  34  Graves's  disease  developed  after 
a period  of  excessive  mental  work.  Palpitation,  exophthalmos,  tremor, 
and  thyroid  enlargement  developed.  A trace  of  sugar  was  detected  in 
the  urine  for  a time.  After  careful  treatment  the  symptoms  of  Graves's 
disease  gradually  diminished,  and  the  urine  became  quite  free  from 
sugar.  Two  years  later,  at  the  age  of  36,  he  began  to  suffer  again  from 
severe  palpitation  and  was  obliged  to  discontinue  all  work.  Three  years 
later,  at  the  age  of  39,  a trace  of  sugar  was  again  detected  in  the  urine  ; 
but  a mbnth  later  the  urine  was  free  from  sugar.  A month  afterwards 
sugar  was  again  detected,  and  the  glycosuria  continued.  The  condition 
developed  into  one  of  mild  diabetes  mellitus  or  persistent  chronic 
glycosuria,  the  urine  always  containing  sugar.  (Urine  60  oz.  daily, 
later  90  oz.,  sp.  gr.  1018,  considerable  amount  of  sugar,  no  albumin,  no 
diacetic  acid.)  The  patient  lost  weight  very  much.  He  became  nervous 
and  excitable ; pulse  120 ; no  thyroid  enlargement ; eyes  not  prominent, 
but  Stellwag’s  and  von  Graefe’s  signs,  and  slight  tremor  of  hands 
detected.  After  8 months  the  urine  became  quite  free  from  sugar ; and 
he  gained  flesh.  No  exophthalmos  could  be  detected,  the  thyroid  was 
practically  normal,  pulse  96,  no  tremor.  With  exception  of  insomnia 
he  was  practically  well. 

Case  5.— Middle  aged  man,  goitre  well  marked.  Marked  palpitation, 
and  exophthalmos ; persistent  glycosuria.  No  other  diabetic  symptoms. 


Case  6. — Young  man  ; typical  symptoms  of  Graves's  disease ; per- 
sistent glycosuria  ; no  other  diabetic  symptoms. 

2.  In  Graves’s  disease  frequently  a temporary  or  inter- 
mittent slight  glycosuria  can  be  detected.  This  fact  is  well 
known,  and  examples  need  not  be  given. 

3.  Mild  diabetes  is,  in  rare  instances,  followed  by  Graves’s 
disease  ; such  cases  are  extremely  rare.  O.  Grube  has 
recorded  the  case  of  a patient  who  was  greatly  shocked  by 
hearing  that  her  urine  contained  sugar.  The  amount  was 
only  small,  but  the  mental  shock  was  great  owing  to  the  fact 
that  a relative  had  died  of  diabetes.  In  a very  short  time 
Graves’s  disease  developed  and  steadily  advanced  and  proved 
fatal. 

4.  Graves's  disease  and  alimentary  glycosuria. — In  Graves’s 
disease  alimentary  glycosuria  is  often  produced  much  more 
readily  than  in  health  by  the  administration  of  a large 
quantity  of  sugar.  In  some  cases  of  Graves’s  disease 
glycosuria  is  produced  by  20  or  30  g.  of  grape  sugar, 
whilst  in  others  100  g.  are  required  to  produce  this  effect. 
(In  healthy  persons  180  to  250  g.  of  grape  sugar  are  required 
to  produce  alimentary  glycosuria — v.  Noorden.) 

5.  Both  Graves’s  disease  and  diabetes  mellitus  occasion- 
ally develop  directly  after  a sudden  mental  shock,  or  after 
great  mental  anxiety  of  short  or  long  duration. 

Thus  in  Case  1 recorded  in  this  article  symptoms  of  Graves’s  disease 
developed  in  a female  after  the  mental  shock  of  hearing  her  husband’s 
hand  had  been  torn  off  in  an  accident  at  his  work.  In  another  of  my 
cases  the  symptoms  of  Graves’s  disease  developed  in  a young  female 
directly  after  the  great  mental  shock  caused  by  seeing  a boy  knocked 
down  in  the  street  by  a motor  car.  In  a third  case  they  followed  the 
mental  shock  caused  by  the  capsizing  of  a small  boat  in  which  the 
patient  was  rowing  on  a river.  In  another  instance  I was  called  to  see 
a man  who  was  dying  of  acute  pneumonia.  At  that  time  his  daughter 
was  apparently  not  suffering  from  any  illness.  The  man  died  next  day. 
The  shock  to  the  daughter  was  very  great  and  she  began  to  suffer  from 
severe  palpitation.  The  symptoms  increased  rapidly  and  a month  after 
the  father’s  death  I was  called  to  see  the  daughter,  and  found  her  to  be 
then  suffering  from  marked  Graves’s  disease. 

Probably  in  these  cases  the  mental  shock  was  the  last 
factor,  or  exciting  cause,  in  the  development  of  the  disease 
in  indiyiduals  whose  nervous  system  was  already  in  some 
way  abnormal. 

In  diabetes  mellitus  we  also  sometimes  find  that  the 
disease  has  developed  directly  after  a sudden  mental  shock. 
I have  recorded  a number  of  striking  instances.1 

Amongst  discharged  soldiers  we  now  find  many  cases  of 
Graves’s  disease,  and  my  own  impression  is  that  the  number 
of  cases  of  Graves’s  disease  amongst  discharged  soldiers  is 
much  greater  than  the  number  of  cases  amongst  men  in  civil 
life  before  the  war. 

As  regards  diabetes  mellitus,  however,  I am  inclined  to 
think  that  this  disease  is  certainly  not  more  common  in 
discharged  soldiers  than  amongst  the  male  civil  population 
of  military  age  before  the  war.  These  are,  however,  only 
general  impressions  and  not  based  on  statistics. 

6.  family  history  of  diabetes  in  cases  of  Graves's  disease. — 
Occasionally  the  history  shows  that  the  two  diseases  have 
occurred  in  different  members  of  the  same  family.  If  we 
take  the  family  history  in  cases  of  diabetes  we  occasionally 
find  that  one  or  more  relatives  have  suffered  from  Graves’s 
disease,  and  if  we  take  the  family  history  in  cases  of  Graves’s 
disease  we  occasionally  find  that  one  or  more  relatives  have 
suffered  from  diabetes  mellitus.  The  following  are  a few 
examples  : — 

1.  Mrs.  S.  consulted  me  on  account  of  diabetes  mellitus.  One 
daughter  had  died  of  diabetes  mellitus  four  years  previously.  Another 
daughter  developed  Graves’s  disease  afterwards.  The  daughter  of  the 
brother  of  Mrs.  S.  suffers  from  Graves's  disease.  The  brother  of  the 
husband  of  Mrs.  S.  suffers  from  diabetes  mellitus. 

2.  Male ; severe  diabetes  mellitus.  Sister  suffers  from  Graves’s 
disease. 

3.  Female  ; Graves’s  disease.  Mother  suffered  from  diabetes. 

4.  Female ; Graves’s  disease.  Father,  one  brother,  and  a cousin  all 
suffering  from  diabetes  mellitus. 

5.  Female ; Graves’s  disease.  Mother  and  one  brother  suffer  from 
diabetes  mellitus. 

6.  Girl,  aged  .6 ; diabetes  mellitus.  Father’s  brother  and  father’s 
cousin  suffered  from  diabetes  mellitus.  Another  cousin  of  father 
suffered  from  Graves  s disease. 

7.  Female  ; Graves’s  disease.  Father  and  mother,  mother’s  sister, 
and  mother’s  father  all  suffered  from  diabetes. 

Many  other  points  of  interest  respecting  the  relation  of 
the  two  diseases,  based  on  experimental  work,  might  be 
added  ; but  in  this  note  I desire  to  refer  only  to  the  clinical 

1 Brit.  Med.  Jour.,  Feb.  2nd,  1918,  and  book  on  “ Diabetes  Mellitus 
and  its  Treatment.”  Lond.  and  Edin.  1898. 

K 3 


426  The  Lancet,] 


DR.  J.  P.  McGOWAN  : CHOLERA  OF  THE  SHEEP. 


[Sept.  6,  1919 


facts.  As  von  Noorden  states  with  reference  to  the  action 
of  the  thyroid  gland  and  the  pancreas  : — 

“ Here  wo  are  in  no  doubt  whatever.  The  thyroid  and  pancreas  have 
antagonistic  actions,  the  former  inhibits  the  excitability  of  the  latter. 
The  more  powerful  the  action  of  the  thyroid  the  more  marked  the 
inhibition.’’  a 

The  recovery  from  Graves’s  disease  or  the  marked  improve- 
ment in  the  symptoms,  followed  by  the  development  of 
diabetes,  and  the  other  facts  mentioned  in  this  article,  also 
raise  the  question  as  to  the  possibility  of  both  of  these 
diseases,  in  certain  cases,  being  due  to  fine  changes  in  the 
nervous  system  (?  medulla) — changes  which,  by  vaso-motor 
or  other  influence,  at  one  time  produce  Graves’s  disease  by 
altering  the  thyroid  activity,  and  at  another  time,  by 
extension  to  adjacent  parts  of  the  central  nervous  system, 
alter  the  activity  of  the  pancreas. 

7.  Qraves's  disease  and  acetoncemia. — In  Graves’s  disease 
occasionally  the  patient  suffers  from  nausea,  sickness,  and 
persistent  vomiting,  and  may  be  unable  to  take  food  and 
may  rapidly  become  very  wasted.  In  some  of  these  cases 
we  find  a marked  diacetic  acid  reaction  in  the  urine  (claret 
coloration  with  perchloride  of  iron),  though  the  urine  is  free 
from  sugar.  The  condition  resembles  the  acetonsemia  of 
diabetic  coma  in  many  respects.  (A  similar  acetonaemia, 
apart  from  diabetes,  is  occasionally  observed  in  cases  of 
persistent  vomiting  from  gastric  affections  and  in  a number 
of  other  affections.) 

Remarks  on  Treatment. 

The  occasional  development  of  diabetes  after  Graves’s 
disease,  and  the  frequent  occurrence  of  temporary  or  inter- 
mittent glycosuria  in  this  disease,  are  facts  which  should  be 
considered  in  the  treatment.  I think  it  is  advisable  in  the 
treatment  of  all  cases  of  Graves’s  disease  to  discontinue  the 
addition  of  sugar  to  food  and  drinks,  and  also  to  avoid  foods 
and  drinks  which  contain  much  sugar.  These  precautions 
are  especially  desirable  and  sugar  and  sweet  food  should  be 
cut  off  entirely  if  glycosuria,  temporary  or  intermittent,  has 
ever  been  detected.  Not  infrequently  in  the  treatment  of 
Graves’s  disease  nitrogenous  foods  are  restricted  or  cut  off, 
and  a diet  chiefly  of  non-nitrogenous  food  is  given  ; but  if 
such  a diet  is  advised  I think  it  desirable  that  the 
sugar  carbohydrates  should  be  much  restricted,  as  just 
stated. 

If  glycosuria  is  frequent  or  permanent  then  a diet  chiefly 
of  starchy  carbohydrate  food  is  unsuitable  in  such  cases  of 
Graves’s  disease.  In  definite  diabetes,  associated  with  or 
following  Graves’s  disease,  of  course  the  diet  suitable  for  the 
form  of  diabetes  detected  should  be  advised,  as  the  diabetes 
is  usually  more  serious  than  the  Graves’s  disease. 

To  these  statements  one  exception  may  be  mentioned.  In 
cases  of  Graves's  disease  complicated  with  persistent 
vomiting,  with  aoetonmmia,  and  with  diacetic  acid  in  the 
urine,  if  no  glycosuiia  is  detected  sugar  carbohydrates,  such 
as  sweet  fruit,  tinned  apricots,  and  syrup  of  such  tinned 
fruits,  may  be  of  much  service  for  a short  time,  along 
with  alkalies  (citrate  of  soda  or  potash,  or  bicarbonate  of 
soda  in  large  doses).  I have  found  such  treatment  followed 
by  sudden  marked  improvement  in  the  condition  just  named 
when  vomiting  has  been  most  persistent,  obstinate,  and 
serious. 

Many  cases  of  Graves’s  disease,  especially  incompletely 
developed  forms,  are  now  met  with  amongst  demobilised 
soldiers,  and  the  points  just  mentioned,  as  regards  diet,  are 
worth  bearing  in  mind  with  respect  to  the  prevention  of 
diabetes  or  glycosuria  as  a complication,  or  at  a later  date. 


2 New  Aspects  of  Diabetes.  By  Professor  von  Noorden.  Bristol, 
1912,  p.  59. 


Means  to  Avert  Mental  Collapse. — Dr.  M.  J. 
Nolan,  in  the  forty-ninth  annual  report  of  the  Down  District 
Lunatic  Asylum  (of  which  he  is  resident  medical  super- 
intendent), pays  a tribute— probably  the  first  of  its  kind  or, 
indeed,  of  any  kind — to  the  out-of-work  or  unemployment 
donation.  While  admitting  it  was  not  without  evil  results 
in  other  directions,  he  thinks  it  undoubtedly  operated  to  save 
many  deserving  individuals  from  complete  mental  collapse 
arising  from  anxiety  about  the  future,  following  a long 
period  of  stress.  The  rate  of  admission  to  the  Down 
District  Lunatic  Asylum  has  fallen,  the  total  population  of 
which  in  1918  was  714,  with  an  admission  of  105  ^53  men  and 
52  women). 


CHOLERA  OF  THE  SHEEP 

(JAUNDICE  ; YELLOWS  OR  YELLOWSES  ; HEADGRIT  OR 
PLOCACH). 

By  j.  P.  McGOWAN,  M.A.,  M.D.,  B.Sc.,  M.R.C.P.  Edin. 

( From  the  Johnston.  Laboratories,  Bacteriological  Department, 
University , Liverpool.') 


The  epizootic  and  enzootic  disease  of  sheep  dealt  with  in 
this  preliminary  article  is  recognised  throughout  Scotland, 
under  the  various  synonyms  given  above,  during  the  months 
of  August  and  September  usually.  It  affects  lambs  of  the 
year  usually,  that  is  to  say,  when  they  are  about  six  months 
old.  The  names  “ jaundice,”  “ yellows,”  and  “ yellowses  ” 
are  derived  from  jaundice  being  present  in  some  cases,  whilst 
“ headgrit  ” refers  to  a swollen  condition  of  the  head  in  the 
parotid  region,  also  occurring  in  certain  cases.  The  term 
“plocach”  is  Gaelic  and  is  synonymous  with  headgrit, 
meaning,  as  it  does,  “big  head”  or  swollen  head.  The 
designation  of  the  disease  by  the  name  of  cholera  is  a pro- 
posal of  my  own,  justifiable,  in  my  opinion,  as  will  be  seen 
later,  by  the  frequency  of  choleraic  symptoms.  That  the 
disease  has  not  before  this  been  designated  by  farmers  and 
shepherds  with  a name  indicative  of  these  important 
symptoms  may  in  part  be  explained  later. 

Account  of  the  Disease  by  a Farmer. 

I had  my  attention  first  drawn  to  this  condition  in 
September,  1915,  by  the  receipt  of  a letter  from  a farmer 
in  whose  flock  the  disease  was  markedly  present.  This 
letter  may  form  a fitting  introduction  to  a discussion  of  the 
natural  history  of  the  condition  and  is  quoted  in  full.  Under 
the  date  of  Sept.  9th,  1915,  he  writes  as  follows  : — 

“ From  August  12th  up  to  the  present  date  I have  lost 
61  lambs  with  the  disease.  In  only  one  or  two  cases  was  the 
death  sudden.  Most  of  the  lambs  after  being  noticed  ill, 
linger  for  some  days,  and  in  some  cases  longer,  on  to  a 
fortnight.  I have  one  or  two  which  have  lived  on  for  three 
weeks. 

Most  of  them  start  with  a scour  and  in  a day  or  two  shrink  -I 
to  nothing.  Theyjust  hang  about,  and  if  water  is  available 
drink  constantly.  If  they  are  unable  to  get  to  water  they  hang 
about  the  hedges  with  nose  down  and  very  dull,  lie  down  for 
a few  minutes  and  then  up  again.  Some  of  them  emit  a 
grunt  when  breathing.  Others  of  them  froth  at  the  mouth, 
but  the  froth  is  not  blood-stained.  They  also  dribble  saliva 
from  the  mouth  when  they  can  get  water. 

Most  of  them  that  I have  seen  skinned  and  opened  have  a 
lot  of  water  in  the  stomach  and  intestines,  while  their  skin 
is  glued  to  their  flesh  and  very  difficult  to  take  off.  When 
one  of  the  ailing  sheep  is  caught  hold  of,  you  can  hear  the 
water  jumbling  about  inside. 

On  opening  them  we  have  found,  as  a rule,  the  fourth 
stomach  and  the  gut  proceeding  from  it  much  congested  and 
discoloured,  and  in  most  of  them  a gritty  stuff  like  the 
husks  of  cotton  cake  and  sand  mixed  (no'  great  quantity, 
however).  The  other  stomachs  are  mostly  quite  natural. 

In  one  or  two  cases  we  found  the  first  and  second  stomachs 
compacted  with  dry,  hard  faeces.  There  seems  to  be  no  food 
in  the  bowels,  only  a greenish-yellow  water. 

Their  livers  are,  as  a rule,  all  right,  but  in  one  or  two 
cases  they  are  much  inflamed  and  brittle.  The  kidneys 
seem  all  right  and  are  quite  firm.  Diaphragm  is  often 
inflamed  and  dry.  There  is  no  water  or  fluid  in  the  chest. 
The  heart  is  natural  and  the  pericardium  contains  no 
excess  of  fluid.  Lungs  in  most  cases  (all  I have  seen)  are 
much  inflamed  and  discoloured  (one,  however,  finds  this 
often  in  cases  of  illness  which  hang  on  for  some  time). 

We  have  had  a good  few  vellowsed  sheep  (with  jaundice, 
swollen  head,  and  loss  of  ears)  this  season,  and  they  are  by 
no  means  immune.  Also  many  of  those  dying  are  affected 
with  ‘ orf  ’ (lip  and  leg  evil). 

The  cases  look  to  me  more  like  poisoning  of  some  sort. 
The  whole  of  the  sheep  have  had  a biggish  check,  not  only 
those  which  have  died  or  are  ill,  and  I cannot  conceive  how 
they  have  got  the  check,  as  the  treatment  has  been  good  all 
along. 

The  grass  this  year  is  very  rank,  but  when  most  of  the 
cases  occurred  it  was  a clean  hay  foggage.  We  have  some 
cases  from  a field  which  was  ‘ hained  ’ for  a bit,  and  tbia 
field  is  very  rank  and  a bit  ‘ tathy,’  but  nothing  to  complain 
of.  The  lambs  on  this  grass  are  getting  tares  laid  down  to 
them.  Those  on  the  fog  are  being  run  off  at  nights  on  to  an 
old  grass  field  and  are  now  getting  turnips.” 

At  the  request  of  the  owner  I visited  the  flock  on 
Sept.  17ch  and  was  able  to  confirm  the  substantial 


The  Lancet,] 


DR.  J.  P.  McGOWAN  : CHOLERA  of  the  sheep. 


[Sept. '6,  1919  427 


accuracy  of  his  observations  as  just  given.  I ascertained 
further  from  the  shepherd  that  the  affected  animals 
“squirted  out  ” the  fluid  bowel  contents.  There  were  two 
lots  of  lambs  on  the  farm.  The  worst  affected  lot  was  on 
a field  with  very  rank  foggage  ; the  lot  that  had  practi- 
cally no  cases  was  on  a better  pasture,  inasmuch  as  it 
consisted  more  largely  of  clover.  Several  of  the  surround- 
ing farms  were  affected  with  the  disease. 

Summary  Account  of  the  Disease. 

The  facts  thus  ascertained  with  regard  to  the  disease 
may  be  shortly  summarised  as  follows.  It  is  an  epizootic 
disease  affecting  lambs  during  the  months  of  August  and 
September.  Affected  animals  in  the  fatal  cases  live  for  a 
period  varying  from  a few  days  up  to  a fortnight  or  three 
weeks.  The  disease  commences  with  a colliquative  diar- 
rhoea, and  in  a few  days  the  animals  shrink  markedly  in 
size.  The  disease  is  characterised  by  great  thirst. 
Jaundice  and  headgrit  cases  and  cases  with  loss  of  ears 
are  occurring  .at  the  same  time,  and  these  cases  are 
affected  with  this  same  diarrhoea.  There  is  marked  dryness 
of  all  the  tissues  of  the  body  on  post-mortem  examination  ; 
the  intestinal  tract,  however,  is  empty  of  food  and  is  full  of 
a large  quantity  of  a greenish-yellow  watery  fluid,  which  can 
be  detected  during  the  life  of  the  animal  by  its  “jumbling.” 
There  is  marked  inflammation  of  the  fourth  stomach  and 
duodenum.  The  fact  of  the  whole  of  the  lambs,  apart  from 
those  obviously  ailing,  having  received  a bad  check  would 
seem  to  indicate  that  there  were  a large  number  of  them 
suffering  from  the  disease  in  a milder  and  not  so  noticeable 
form.  It  is  a disease  with  a high  mortality  at  times  and  can 
cause  great  financial  loss  to  the  owner. 

Post-mortem  Findings. 

On  the  occasion  of  my  visit  time  and  circumstances  did 
not  permit  of  me  doing  an  exhaustive  series  of  post  mortems 
and  on  account  of  various  factors  I had  not  an  opportunity 
of  revisiting  the  farm  during  the  continuance  of  the  disease. 

I performed,  however,  two  post  mortems,  one  on  an  acute 
case  and  the  other  on  a chronic  case,  and  the  record  of  these 
cases  are  as  follows  : — 

Lamb  1. — This  lamb  was  seen  ill  for  the  first  time  on 
the  preceding  night.  On  examination  copious  colliquative 
diarrhcea  was  present;  very  dull  and  listless;  temperature 
in  rectum  105°  F.  Killed  by  bleeding  from  throat.  It  was 
in  fairly  good  condition.  There  was  no  gangrene  of  ears,  no 
swelling  of  parotid  region,  no  jaundice.  No  discharge  from 
nose,  no  frothing  at  mouth  ; no  hemorrhages  subcutaneously 
or  in  muscles.  The  lungs  were  healthy;  no  effusion  into  peri- 
cardium. Heart  healthy,  including  valves  ; no  myocardial 
hemorrhages.  The  liver  was  apparently  healthy ; no  flukes ; 
gall-bladder  very  large  and  very  full  of  green  bile.  The 
kidneys,  spleen,  pancreas,  and  bladder  were  apparently 
healthy.  The  first  stomach  contained  a quantity  of  moist 
grass ; the  fourth  stomach  was  inflamed  and  contained  a 
little  clear  watery  fluid,  but  no  food  ; duodenum  was  markedly 
inflamed.  In  jejunum, ileum,  caecum,  colon,  &c.,no  evidence 
of  inflammation.  The  whole  intestinal  tract  from  the  duo- 
denum to  the  rectum  was  filled  with  a greenish  fluid  devoid 
of  solid  matter.  No  round  worms  or  tapeworms  were  found. 
The  mesenteric  glands  were  not  enlarged  or  congested. 
When  this  animal  was  lifted  up  prior  to  being  killed  the 
jumbling  of  the  intestinal  contents  was  distinctly  heard 
and  felt. 

Lamb  2.— This  case,  a chronic  one,  dated  from  the  onset  of 
the  disease  in  the  flock  about  August  19th.  It  appeared  to 
be  getting  better  slowly,  but  latterly  became  very  emaciated 
and  dwindled  to  a shadow.  When  seen  the  emaciated  con- 
dition was  noted,  as  also  that  the  animal  was  suffering  from 
diarrhcea.  There  was  no  evidence  of  difficulty  of  breathing  ; 
its  temperature  was  not  taken.  It  was  killed  by  bleeding 
from  the  neck.  There  was  no  gangrene  of  ears,  no  swelling 
of  parotid  region,  and  no  jaundice.  No  discharge  from  nose 
and  no  frothing  at  mouth  ; no  hsemorrhages  subcutaneously 
or  in  muscles.  The  lungs  and  heart  were  perfectly  healthy 
except  for  a few  worm  nodules  in  lung.  There  was  no 
enlargement  or  congestion  of  the  lymphatic  glands  any- 
where. The  liver  was  much  enlarged  and  very  fatty. 
Gall-bladder  was  much  distended,  and  contained  a golden- 
yellow  watery  fluid ; turbid  with  particulate  material.  The 
wall  of  the  gall-bladder  was  thickened,  and  its  lining  mem- 
brane inflamed.  No  flukes  in  the  liver  or  bile  passages. 
The  spleen,  kidneys,  pancreas,  and  urinary  bladder  appeared 
healthy.  The  first,  second,  and  third  stomachs  contained 
moist  grass ; fourth  stomach  congested  and  contained  a 
watery  fluid.  The  duodenum  showed  an  intense  haemor- 
rhagic inflammation  with  a diphtheritic  exudate  on  its 
surface.  No  apparent  congestion  of  the  ileum,  caecum, 


colon,  rectum.  The  contents  of  the  intestine  were  greenish 
and  watery,  containing  slightly  more  solids  than  was  the 
case  in  Lamb  1.  There  were  a few  whip-worms  in  the 
caecum  ; no  other  round  worms  or  tapeworms  found. 

The  points  to  be  specially  noted  are  with  regard  to  the 
acute  case,  the  watery  contents  of  the  intestine,  and  the 
inflamed  nature  of  the  duodenum.  In  the  more  chronic  case 
attention  may  be  drawn  to  the  character  of  the  intestinal 
contents,  to  the  condition  of  the  duodenum,  liver,  and  gall- 
bladder, and  to  the  emaciated  condition  of  the  animal. 

Bacteriology , 

Facilities  for  an  extensive  bacteriological  examination, 
under  the  circumstances,  were  not  good  and  I confined 
myself  to  doing  a little,  and,  if  possible,  doing  it  well.  With 
the  idea  that  the  acute  case  would  be  the  most  likely  to 
contain  the  cause  of  the  disease,  I ligatured  a portion  of  the 
duodenum  and  removed  it  to  the  laboratory  in  a sterile  bottle. 
Suspecting  that  the  conditions  found  in  the  more  chronic 
case  might  be  caused  by  secondary  invaders  I contented 
myself  with  making  a careful  naked-eye  examination  of  the 
specimens.  As  the  sequel  will  show,  portions  from  the  liver 
for  histological  and  the  contents  of  the  gall-bladder  for 
bacteriological  examination  might  have  been  of  great  service 
in  helping  to  elucidate  the  condition  further. 

Before  proceeding  to  record  the  experimental  results 
obtained  with  the  material  removed  from  Lamb  1,  it  might 
be  well  here  to  deal  with  any  literature  bearing  on  the 
subject.  There  are  many  references  scattered  through  the 
books  dealing  with  such  conditions  as  jaundice,  but  the  only 
notice  which  I can  find  bearing  indubitably  on  the  disease 
entity  described  above  occurs  in  May’s  book  on  the  sheep.1 
Under  the  names  acute  jaundice,  hepatitis,  the  bile  con- 
dition, bile  fever,  he  describes  a disease  which,  he  states, 
had  occurred  very  seldom  in  Germany,  but  had  often  been 
observed  as  an  enzootic  in  France  and  Holland.  He 
mentions  fever  as  being  a symptom  of  the  disease,  and,  of 
course,  jaundice.  He  lays  stress  on  the  swelling  of  the  head, 
but  although  he  mentions  colliquative  diarrhoea  as  being 
very  obviflus  at  one  stage  of  the  disease,  he  does  not 
emphasise  it.  Indeed,  he  rather  emphasises  a constipative 
stage  of  the  disease.  More  will  be  said  on  this  point  when 
we  come  to  deal  further  on  with  a disease  which  he  calls 
cholera  of  the  sheep. 

Results  of  Bacteriological  Investigation. 

I now  proceed  to  detail  briefly  the  results  obtained  with 
the  material  derived  from  the  duodenum  of  Lamb  1.  The 
contents  of  the  duodenum  were  diluted  in  peptone  water 
and  plated  out  on  MacConkey  lactose-agar.  After  24  hours’ 
incubation  the  plates  were  seen  to  contain  two  types,  and 
two  types  only,  of  organisms — namely,  a non-lactose 
fermenter  which  I shall  call  B,  and  a lactose  fermenter 
which  I shall  call  A.  Four  colonies  of  the  A type  were 
picked  off  and  six  of  the  B type.  Both  were  Gram-negative 
coliform  bacilli,  both  were  slightly  motile,  while  the  reaction 
of  the  two  organisms  on  various  media  may  be  given  in 
tabular  form  as  follows  : — 


— 

(A) 

(B) 

— 

(A) 

(B) 

- 

(A)  I <B) 

Lactose. 

A G 

0 

Litmus  milk. 

A C 

A 

Salicin. 

A G A G 

Dulcite. 

A g 

AG 

Glucose. 

A G 

A G 

Inulin. 

0 1 0 

Saccharose. 

A G 

0 

Mannite. 

A G 

A G 

Galactose. 

A G A G 

Raflioose. 

A G 

0 

Maltose. 

A G 

A G 

Gelatin. 

Growth* 

Sorbite. 

AG 

0 

Dextrin. 

A g 

A g 

Peptone  water.! 

Present. 

A = acid  formation  ; Li  = gas  formation  ; g = small  amount  of  gas 
formation  ; C = clot  formation  ; 0 = no  change. 

* No  liquefaction.  f Indol  formation. 


It  will  be  seen  that  type  A organism  is  a lactose  fermenter 
of  advanced  B.  coli  type,  while  type  A organism  is  a para- 
typhoid-like organism.  In  papers  about  to  be  published  I 
am  submitting  evidence  which  goes  to  show  that  type  B 
organism  can,  and  does,  mutate  into  type  A organism  ; that 
these  two  organisms,  for  all  practical  purposes,  are  one  and 
the  same  ; and  that  in  consequence  the  infection  of  the 
duodenum  in  this  case  was  a pure  infection  with  one 
organism  only.  The  further  experimental  results,  however, 
recorded  in  this  paper  are  to  be  regarded  as  pertaining  only 
to  type  B organisms,  with  which  the  experiments  were  per- 
formed, although  a fair  number  of  experiments  have  been 
performed  by  me  with  type  A organism  with  results  differ- 
ing, if  they  differ  at  all,  quantitatively  not  qualitatively. 


428  ThhLanoht,]  DR.  J.  P.  MoGOWAN : CHOLERA  OF  THE  SHEEP.  [Sept.  6,  1919 


Animal  Experiments. 

The  next  question  to  be  decided  was  whether  the  disease 
described  above  could  be  produced  in  animals. 

Sheep  were  not  available,  consequently  rabbits  were  used; 
and  as  infection  of  rabbits  with  other  pathogenic  organisms 
of  an  intestinal  type,  such  as  typhoid,  had  markedly  failed 
when  the  organisms  were  administered  by  the  mouth,  the 
cultures  here  were  given  intravenously  through  the  ear 
vein.  When  the  organism  was  administered  thus— speaking 
always  of  the  non-lactose  fermenter — it  was  seen  to  be  very 
lethal,  and  a minimal  lethal  dose  had  to  be  established  for 
working  purposes.  Working  with  a sublethal  dose,  16  experi- 
ments on  rabbits  were  performed,  and  the  clinical  symptoms 
observed,  and  the  pathological  and  bacteriological  findings 
obtained  at  various  intervals  subsequent  to  injection,  will 
now  be  briefly  described. 

With  regard  to  the  symptoms  produced,  the  animal  became 
very  ill  about  an  hour  after  injection,  and  a profuse 
colliquative  diarrhoea  commenced  which  lasted  for  about 
48  hours.  Subsequent  to  this  the  faeces  became  oat-shaped, 
small  in  size,  dark  in  colour,  hard  in  consistence,  and 
covered  in  some  cases  with  mucus  and  blood.  A few  cases 
recovered  after  this,  but  in  most  cases  the  faeces  continued 
more  or  less  of  this  nature,  the  animal  refused  its  food, 
became  more  and  more  emaciated,  and  died,  in  the  more 
prolonged  cases,  in  three  to  four  weeks. 

When  an  animal  was  killed  after  48  hours  the  contents  of 
the  intestine  were  observed  to  be  entirely  fluid,  and  there 
were  no  faecal  pellets  in  the  rectum ; the  duodenum  was 
markedly  inflamed ; there  were  haemorrhages  throughout 
the  liver,  and  the  gall-bladder  was  distended  with  pure  blood. 
Pure  cultures  of  the  organism  injected,  without  any  con- 
tamination, were  obtained  in  all  such  cases  from  the  gall- 
bladder and  duodenum. 

If  the  animal  were  killed  at  a later  period— say,  from  a 
week  to  three  to  four  weeks  after  injection— the  intestinal 
and  duodenal  changes  were  not  so  noticeable,  the  extreme 
emaciation  was  very  marked,  and  changes  in  the  liver  and 
gall-bladder  were  pre-eminent.  Thus  in  some  cases  there 
was  acute  necrosis  of  a whole  lobule  of  the  liver,  while  in 
cases  not  so  marked  as  this  there  was  evidence  of  a fibrosis 
round  the  small  bile-ducts,  a small-celled  infiltration,  a 
fibrosis,  and  proliferation  of  the  bile  capillaries  in  the  portal 
spaces.*  The  gall-bladder  showed  small-celled  infiltration 
of  the  submucosa  (and  in  one  case  ulceration)  and  fibrous 
thickening  of  the  walls.  The  common  bile-duct  and  cystic 
duct  in  one  case  were  greatly  thickened  and  greatly  dilated. 
The  contents  of  the  gall-bladder,  instead  of  being  green  and 
viscid  as  in  the  normal  condition,  were  watery-like  and 
turbid,  with  a white  sediment,  which  in  some  cases  suggested 
calculus  formation. 

A pure  uncontaminated  growth  of  the  organism  injected 
was  obtained  from  the  gall-bladder  in  these  cases;  in  one 
case  after  the  lapse  of  four  weeks.  In  all  these  cases,  too,  a 
pure  uncontaminated  culture  of  the  injected  organism  was 
also  obtained  from  the  duodenum. 

This  is  a remarkable  result,  not  because  the  organism  was 
obtained,  for  the  gall-bladder  would  act  as  a supply  reservoir, 
but  because  it  was  obtained  uncontam  inated,  considering  that 
food,  containing  organisms  of  all  sorts,  was  being  eaten  all 
the  time.  Certain  other  observations  which  I made  during 
the  course  of  the  experiment  would  support  the  view  deducible 
from  this  that  normally  the  contents  of  the  duodenum  are 
sterile,  at  least,  as  far  as  growth  on  MacConkey  lactose  agar 
is  concerned.  On  several  occasions  I made  cultures  from  the 
duodenums  of  healthy  rabbits,  killed  for  other  purposes,  and 
found  them  sterile.  The  bile  may  act  as  an  antiseptic  for 
various  organisms,  but  this  can  hardly  be  the  case  for  coliform 
organisms. 

It  is  to  be  noted  that  none  of  the  experimental  animals 
developed  jaundice,  swelling  of  the  parotid,  or  gangrene  of 
the  ears.  This  is  not  surprising,  considering  the  comparative 
rarity  of  these  conditions  in  the  natural  disease  among 
sheep. 

A few  experiments  were  performed  by  me  relative  to  the 
protective  value  of  a previous  intravenous  injection,  to  a 
similar  subsequent  inoculation  of  a much  larger  dose.  The 
experiments  are  few  in  number,  but  they  go  to  show  that  a 
protection  is  developed  in  this  way.  Thus,  rabbits  so  treated 
withstood  a subsequent  intravenous  injection  of  three  to  six 
times  the  original  dose  (which  was  just  a subminimal  lethal 
one)  and  showed  practically  no  symptoms. 

Provisional  Results  of  Inquiry. 

One  may  provisionally  here  sum  up  the  finding  so  far  in 
connexion  with  the  disease.  It  would  appear  that  the  disease 

* The  details  of  the  changes  are  at  present  the  subject  of  further 
investigation  by  Professor  Beattie  and  myself. 


in  the  sheep  is  primarily  a duodenitis  characterised  by  a 
marked  colliquative  diarrhoea  and  which  has  as  sequelae  the 
production  of  jaundice,  swelling  in  the  parotid  region,  and 
local  gangrene  of  the  ears.  Evidence  has  been  adduced  by 
me  from  the  bacteriological  examination  of  the  sheep  and 
from  experimental  work  on  rabbits,  that  a bacillus  of  the 
paratyphoid  group  has  strong  claims  to  be  considered  as 
causal.  This  work,  of  course,  will  have  to  be,  and  is  being 
as  opportunity  arises,  extended  especially  in  the  direction  of 
further  examination  of  diseased  sheep,  the  production  of  the 
disease  in  healthy  sheep  with  the  organism  in  question,  and 
the  development  of  further  prophylactic  measures,  vaccinal 
and  otherwise. 

Comparison  of  Certain  Symptoms  in  Cholera  in  Man. 

I have  already  alluded  in  passing  to  the  resemblance  of 
this  disease  to  cholera  in  human  beings.  I was  so  struck 
with  the  marked  resemblance  of  the  colliquative  diarrhoea 
of  this  disease  to  that  of  cholera,  that  I began  to  investigate 
whether  the  other  symptoms  observable  in  this  disease  had 
been  recorded  in  the  case  of  cholera. 

In  this  connexion  it  is  interesting  to  note  that  authorities 
on  the  subject,  such  as  Manson  2 and  Leonard  Rogers,3  state 
that  jaundice,  parotitis,  and  gangrene  of  extremities,  such 
as  the  nose,  the  penis,  the  scrotum,  the  fingers,  and  toes, 
kc.,  are  among  the  sequel®  of  cholera  in  the  human 
subject. 

Further,  Greig,  in  a series  of  papers,4  5 6 has  brought  to 
light  many  facts  in  relation  to  the  pathology  of  the  liver  in 
cholera.  He  quotes  Kutescha  as  having  examined  post 
mortem  109  cholera  cases  and  found  the  cholera  vibrio  in 
the  gall-bladder  of  49  cases,  while  in  10  per  cent,  of  these 
49  cases  its  presence  was  associated  with  marked  patho- 
logical changes  in  the  biliary  passages.  Again,  he  quotes 
Bruloff  as  having  found  the  cholera  vibrio  in  the  gall- 
bladder of  76  per  cent,  of  his  cases.  Greig  himself,  in 
an  examination  of  271  fatal  cases  of  cholera,  found  the 
cholera  vibrio  in  the  gall-bladder  of  80,  and  associated 
with  distinct  pathological  changes  in  12  out  of  these  80  cases. 
His  histological  findings  in  the  gall-bladder  and  liver  in 
these  cases,  as  also  in  the  gall-bladders  and  livers  of  his 
experimental  rabbits  which  he  injected  intravenously  with 
the  cholera  vibrio,  are  practically  identical  with  what  I have 
described  above  in  this  disease. 

The  further  point  from  a pathological  point  of  view  in  the 
comparison  of  the  two  diseases  is  that  cholera  is  primarily  a 
duodenitis  (Leonard  Rogers,  loc.  cit.).  This  raises  the  further 
interesting  question  of  the  cause  of  the  colliquative  diarrhoea 
in  the  two  cases. 

Causation  of  the  Colliquative  Diarrhoea. 

It  may  be  due  to  the  same  or  a similar  specific  cathartic 
toxin  in  the  two  causal  organisms,  but  it  seems  to  me  that  it 
is  more  likely  that  it  is  due  to  a toxin  (much  less  specifically 
and  drastically  cathartic  and  which  occurs  in  very  many 
intestinal  organisms  besides  the  two  mentioned),  acting  on  a 
specific  locus  of  the  intestinal  tract.  The  emphasis  of  the 
specificity  is  rather  on  this  locus — the  duodenum — than  on 
the  toxin. 

I have  had  in  progress,  though  the  progress  has  been 
interrupted  latterly,  since  1915  some  experiments  on  the 
pharmacological  action  of  emulsions  of  various  intestinal 
pathogenic  organisms,  such  as  typhoid,  paratyphoid,  the 
dysenteries,  &c.  The  organisms  were  killed  by  heat  and 
the  emulsions  so  prepared  were  injected  intravenously  into 
rabbits.  In  every  case  tested,  with  the  exception  of  Shiga’s 
dysentery  bacillus,  colliquative  diarrhoea  was  produced,  and 
post  mortem  the  duodenum  was  found  to  be  markedly  con- 
gested and  dotted  over  with  haemorrhages.  No  diarrhoea 
and  no  duodenal  change  was  produced,  however,  when  these 
emulsions  were  injected  subcutaneously  or  intraperitoneally. 
Catharsis,  again,  is  not  produced  by  the  subcutaneous 
injection  of  V.  cholera  (Manson). 

My  reading  of  these  results  is  that  the  toxic  material  was 
excreted  by  the  bile  and.  arriving  at  the  ^duodenum  first, 
exerted  its  action  there  and  produced  what  one  may  call  the 
duodenal  result — namely,  colliquative  diarrhoea.  That  this 
same  result  is  produced  in  cholera  and  in  the  disease  we  are 
dealing  with  here,  in  my  opinion,  is  due  to  the  fact  that 
their  causal  organisms  grow  in  the  duodenum  and  produce 
their  effects  from  there  ; while  the  fact  that  colliquative 
diarrhoea,  which  is  absent  in  the  natural  diseases  such  as 
typhoid,  can  yet  be  produced  on  intravenous  injection  of  the 


The  Lancet,] 


MR.  D.  GUTHRIE:  AURAL  SUPPURATION  IN  EARLY  CHILDHOOD.  [Sept.  6,  1919  429 


causal  organisms,  to  my  mind  is  explained  similarly,  in  that 
the  site  of  growth  of  these  organisms  in  the  natural  disease 
is  not  the  duodenum,  but  farther  down. 

Other  evidence  of  a specific  duodenal  action  lies  in  the 
fact  that  in  both  the  diseases  we  are  dealing  with  here, 
cholera  and  the  sheep  disease,  parotitis  is  a marked  sequel, 
while  in  medicine  generally  it  has  long  been  recognised  that 
various  grave  affections  of  the  duodenum  give  rise  to 
parotitis.  It  is  highly  speculative,  of  course,  but  it  is  per- 
missible to  wonder  if  mumps  may  not  primarily  be  a 
duodenal  affection. 

The  Overlooking  in  the  Disease  of  the  Diarrhoea. 

The  next  point  I will  deal  with  is  the  question  as  to  how 
the  diarrhoea  so  evident  in  the  disease  has  up  to  the  present 
time  been  overlooked. 

May  describes  at  another  part  of  his  book  (p.  31)  as  an 
entirely  different  disease  a condition  in  sheep  which  he  calls 
“the  cholera-like  disease  of  sheep.”  He  himself  had  not 
seen  the  disease,  and  he  is  quoting  from  an  article  in  the 
Journal  de  Medeoine  de  Bruxelles , September,  1854.  The 
disease  was  a very  fatal  one  and  was  characterised  by 
colliquative  diarrhoea  and  swelling  of  the  parotid  glands. 
The  European  epidemic  of  cholera,  1851-55,  was  raging  at 
the  time,  and  the  writer  of  the  article,  a Dr.  Liegen, 
suggested  a relation  between  the  two  conditions. 

Now  diarrhoea  in  sheep  is  almost,  one  might  say,  an  every- 
day occurrence,  even  although  it  may  not  be  of  a colliquative 
nature,  and  no  special  importance  is  attached  to  it  by 
shepherds.  Familiarity,  however,  with  the  diarrhoea  of 
cholera,  as  happened  in  this  case,  and  as  might  have 
happened  in  Scotland  had  cholera  epidemics  been  more 
frequent,  and  had  they  synchronised,  as  in  this  case,  with 
this  disease  in  sheep,  might  have  led  shepherds  and  others 
to  recognise  more  fully  its  exact  nature  and  ascribe  to  it,  by 
name  or  otherwise,  the  impo.'tance  it  undoubtedly  has  in  a 
disease  up  to  now  designated  only  by  its  sequelae. 

Epidemic  Jaundice. 

In  conclusion,  a further  point  needs  to  be  discussed. 
Attention  has  been  drawn,  owing  to  the  war,  to  the  prevalence 
of  a type  of  jaundice  among  the  Balkan  troops. 

Sarrhaile  and  Clunet,7  in  dealing  with  an  epidemic  of  this 
sort,  came  to  the  conclusion  that  the  epidemic  of  jaundice  at 
Gallipoli  was  a manifestation  of  paratyphoid  A fever  ; C.  J. 
Martin 8 opposes  this  view  on  bacteriological  grounds,  and 
suggests,  from  histological  examination  of  livers  of  affected 
cases,  that  the  infectious  jaundice  of  Gallipoli,  although 
much  milder,  presented  analogies  to  the  severer  form, 
Spirochmtosis  Ictero-hmmorrhagica,  and  believes  that  the 
symptomatology  and  morbid  histology  are  consistent  with 
the  view  that  it  is  primarily  a systemic  infection.  Hurst 9 
and  Wilcox  10  believe  that  the  condition  is  of  the  nature  of 
a catarrhal  jaundice  spreading  from  the  duodenum. 

Cantacuzene11  describes  the  disease  as  it  occurred  in 
Roumania.  It  was  of  a very  mild  type,  and  in  the  rare 
cases  which  died  there  was  fatty  infiltration  of  the  liver 
due,  in  his  opinion,  to  primary  angiocholitis  of  the  intra- 
lobular biliary  canaliculi.  The  search  for  spirochretes  by 
the  injection  of  guinea-pigs  was  negative.  Blood  culture 
was  positive  in  one- third  of  the  cases  and  yielded  atypical 
paratyphoid  bacilli  resembling  somewhat  paratyphoid  B. 
He  records  experimental  production  of  the  disease  by 
people  voluntarily  swallowing  cultures  of  the  organism. 
He  regards  this  organism  as  the  cause  of  the  disease. 

Hatiegan,12  in  an  outbreak  of  epidemic  jaundice,  obtained, 
with  the  duodenal  sound,  bile  which  showed  in  65  per  cent, 
of  the  cases  on  first  examination  a very  actively  motile 
bacillus  which  he  thinks  is  the  cause  of  the  disease. 
Meyer13  records  an  epidemic  of  jaundice  in  the  Waziristan 
Field  Force,  and  comes  to  the  conclusion,  on  rather  in- 
sufficient evidence  it  would  appear,  however,  that  an 
organism  of  the  enteric  group,  probably  closely  allied  to  the 
paratyphoid,  might  be  the  causative  agent. 

The  question  of  the  cause  of  this  disease  cannot  be  said 
to  be  settled  and,  on  the  whole,  the  evidence  so  far  adduced 
would  appear  to  be  against  the  disease  being  of  the  nature 
of  a catarrhal  jaundice. 

In  a previous  paper11 1 suggested  that  head-grit  might  be 
a haemorrhagic  septicaemia  manifestation.  This  I did  because 
from  the  head  of  a lamb,  sent  in  to  me  diagnosed  as  head- 
grit,  I obtained  a pure  culture  of  the  B.  bipolaris  septicus. 
As  swelling  of  the  head  is  also  one  of  the  marked  symptoms 


of  haemorrhagic  septicaemia  I concluded  that  this  was  the 
nature  of  the  disease  in  question  here.  Evidently  the 
diagnosis,  for  which  I was  not  responsible,  as  so  often 
happens,  though  unavoidable  under  the  circumstances,  was 
wrong,  and  I was  in  consequence  misled. 

This  paper  was  first  submitted  for  publication  six 
months  ago. 

Literature. — 1.  May:  Die  inneren  unit  ausseren  Krankbeiten  des 
Scbafes,  Breslau,  1868,  p.  35.  2.  Manson : Tropical  Diseases,  sixth 
edition,  1917.  3.  Leonard  Rogers  : On  Cholera,  Loudon,  1911.  4.  Greig : 
Ind.  Jour.  Med.  Research,  i.,  44.  5.  Greig:  Ibid.,  ii.,  28.  6.  Greig: 
Ibid.,  iii.,  397.  7.  Sarrhaile  and  Clunet:  Quoted  by  Martin  (v.  infra). 
8.  Martin,  C.  J.  : Brit.  Med.  Jour.,  April  7th,  1917.  9.  Hurst : Medical 
Diseases  of  the  War,  Arnold,  1917.  10.  Wilcox  : Brit.  Med.  Jour.,  1917,  L, 
297.  11.  Cantacuzhne  : Tropic.  Dis.  Bull.,  Jan  15th, 1919, 31.  12.  Hatiegan: 
Daily  Rev.  Foreign  Press,  December,  1918,  448.  13.  Meyer  : Ind.  Med. 
Gaz.,  1917.  iii.,  425.  14.  McGowan:  Braxy.  H.  and  Agric.  Soc. 

Transact.,  1915.  


AURAL  SUPPURATION  IN  EARLY 
CHILDHOOD : 

ITS  PREVENTION  AND  TREATMENT. 

By  DOUGLAS  GUTHRIE,  M.D.,  F.R.O.S.  Edin., 

INTERIM  SURGEON  TO  THE  EAR  AND  THROAT  DEPARTMENT,  ROYAL 
HOSPITAL  FOR  SICK  CHILDREN,  EDINBURGH,  AND  SURGEON 
TO  THE  EDINBURGH  EAR  AND  THROAT  INFIRMARY. 


In  every  clinic  devoted  to  the  ear  and  throat  diseases  of 
childhood  two  affections  command  the  attention  to  such  an 
extent  that  all  others  fade  into  insignificance — viz.,  (1)  tonsil- 
adenoid  disease,  and  (2)  middle-ear  suppuration.  90  per 
cent,  of  the  work  comes  under  one  or  other  of  those  headings. 
But  while  parents  and  practitioners  are  fully  aware  of  the  ill- 
effects  wrought  by  lymphoid  enlargements  about  the  throat 
and  of  the  improvement,  often  quite  dramatic,  which  follows 
their  removal,  suppurating  ears  are  apt  to  be  overlooked 
and  neglected. 

Middle-ear  suppuration  is  not  in  itself  a fatal  disease  ; 
indeed,  the  majority  of  cases  tend  towards  natural  cure,  but 
it  brings  many  evils  in  its  train.  The  constant  swallowing 
of  septic  material  causes  ill-health  and  sometimes  enteritis, 
meningitis  is  not  rare  as  a sequel  of  otitis,  whilst  the 
destruction  and  cicatrisation  resulting  from  the  inflamma- 
tory process  may  so  damage  the  delicate  ear  mechanism  as 
to  lead  to  deafness,  which  to  a young  child  commencing  its 
education  is  a severe  handicap.  Even  though  the  cure  of  an 
otitis  in  childhood  appears  complete,  it  is  conceivable  that 
some  of  the  deafness  of  later  life — for  example,  certain  cases 
of  otosclerosis — may  be  traceable  to  aural  suppuration  during 
early  years. 

Text-books  give  scant  information  on  suppurative  otitis 
media  as  it  affects  children.  True,  the  disease  in  a child  of 
school  age  may  closely  resemble  the  adult  type,  but  a glance 
at  the  temporal  bone  of  an  infant  suffices  to  show  the 
extent  to  which  pathology  may  be  modified  and  altered  by 
anatomy. 

Anatomical  Data. 

If  we  look  at  the  base  of  a foetal  skull,  such  as  is  used  for 
obstetrical  demonstrations,  we  see  that  the  most  prominent 
features,  next  to  the  foramen  magnum,  are  the  large  tympanic 
membranes,  lying  almost  horizonally.  There  is  no  osseous 
meatus,  and  the  drum  lies  so  obliquely  as  to  be  practically  in 
the  same  continuous  plane  as  the  upper  wall  of  the  mem- 
branous meatus.  The  mastoid  process,  as  the  specimen 
shows,  is  as  yet  undeveloped,  but  the  mastoid  antrum  is 
relatively  large,  is  well  drained  by  a roomy  aditus,  is  close 
to  the  surface  of  the  skull,  and  lies  higher  in  relation  to  the 
middle  ear  than  does  the  adult  antrum.  The  Eustachian 
tube  is  relatively  shorter,  wider,  and  more  horizontal  than  it 
is  in  the  adult,  so  that  it  acts  as  a good  drain,  though,  on  the 
other  hand,  infection  of  the  middle  ear  from  the  naso- 
pharynx is  favoured.  A final  anatomical,  or  rather  histo- 
logical, fact  of  importance  is  the  occasional  presence  in  the 
middle  ear  or  antrum  of  a network  of  embryonic  tissue. 
Usually  this  completely  disappears  before  birth,  but  at  times 
it  persists  in  the  antrum  or  attic  during  the  first  few  months 
of  extra-uterine  life,  and  in  such  cases  the  presence  of  so 
delicate  and  vulnerable  a structure  may  render  its  possessor 
peculiarly  liable  to  otitis  media. 

Otitis  Media  in  the  Difant. 

As  a matter  of  fact,  aural  suppuration  occurs  with  extreme 
frequency  during  the  first  year  of  life.  The  results  recorded 


430  Thb  Lancet,]  MR.  D.  GUTHRIE:  AURAL  SUPPURATION  IN  EARLY  CHILDHOOD. 


[Sept.  6,  1919 


in  various  papers  on  the  subject  by  eight  different  observers 
who  examined  the  ears  at  a series  of  post-mortems  on 
infants  show  that  otitis  was  present,  on  an  average,  in  82  per 
cent.  It  has  been  doubted  whether  the  presence  of  pus  in 
the  middle  ear  after  death  in  so  large  a percentage  of  cases 
was  really  pathological.  Indeed,  Aschoff  regarded  it  as  a 
“foreign  body”  suppuration,  resulting  from  the  presence  of 
vernix,  meconium,  &c. , which  had  entered  by  way  of  the 
Eustachian  tube.  While  this  explanation  may  hold  good  for 
new-born  infants,  the  pus  has  seldom  been  found  sterile,  and 
bacteriological  investigations  have  only  confirmed  the  extra- 
ordinary prevalence  of  the  disease.  Most  of  the  cases  yield 
the  pneumococcus,  while  next  in  frequency  comes  the  strepto- 
coccus, the  latter  giving  rise  to  a more  severe  infection, 
sometimes  complicated  by  mastoiditis. 

The  close  connexion  between  otitis  and  pneumonia  has 
often  been  remarked,  and  it  is  said  that  the  middle  ear  is 
infected  in  every  fatal  case  of  infantile  pneumonia.  The 
commonest  cause,  however,  of  otitis  in  infants  is  the 
ordinary  cold,  which  is  a serious  disease  in  early  life.  The 
nasal  passage  of  a baby  is  easily  blocked,  feeding  is  rendered 
difficult,  and  infected  secretions  are  readily  forced  into  the 
middle  ear. 

Symptoms. — Among  all  the  diseases  of  children  probably 
none  is  so  frequently  overlooked  as  otitis  media.  Before 
the  occurrence  of  perforation  and  consequent  appearance  of 
pus  in  the  meatus  the  diagnosis  is  no  easy  matter. 

The  ears  should  be  examined  in  all  infants  who  suffer 
from  fever  of  obscure  causation.  The  temperature  may  be 
high,  or  it  may  not  rise  above  100°  ; and  in  the  latter 
case,  as  Still  has  pointed  out,  it  is  apt  to  continue  even 
after  the  inflammation  has  subsided.  Pain,  as  evidenced 
by  continuous  crying,  restlessness  and  sleeplessness,  and 
boring  of  the  head  into  the  pillow  are  often  noted,  while 
the  appearance  of  head-retraction,  vomiting,  and  con- 
vulsions may  lead  one  to  suspect  meningitis,  until,  with 
the  occurrence  of  perforation,  the  true  .nature  of  the  case 
is  revealed.  Pain  is  not  constant,  however,  and  may 
sometimes  be  altogether  absent.  In  the  average  case  the 
drum  perforates  in  three  or  four  days,  with  prompt  relief 
of  all  symptoms.  At  first  the  pus  is  profuse,  but  later  it 
becomes  thin  and  scanty,  and  as  a rule  the  ear  is  dry 
within  two  or  three  weeks. 

Unfortunately,  otoscopic  examination  does  not  always 
assist  us  to  diagnose  otitis  prior  to  perforation.  The  tympanic 
membrane  may,  indeed,  appear  normal  if  the  stress  of  the 
disease  has  fallen  upon  other  parts  of  the  middle  ear,  and 
such  cases  are  very  deceptive.  On  the  other  hand,  a red  and 
bulging  drum  will  often  betray  the  condition,  though  we  must 
remember  that  in  a crying  infant  the  normal  drum  appears 
red.  In  examining  the  infant’s  ear  remember  the  obliquity 
of  the  drum.  The  meatus  is  a mere  slit,  whose  walls  must 
be  separated  by  pulling  the  auricle  downwards.  The  use  of 
a speculum  with  an  obliquely  cut  end  and  a collar  to  give  a 
good  grip  in  manipulation  may  assist  one  to  secure  a glimpse 
of  the  drum,  and  a fleeting  glimpse  is  often  the  best 
obtainable. 

Considering  the  frequency  of  otitis  in  infants,  mastoiditis 
is  not  a very  common  complication.  When  it  does  occur, 
the  thin  outer  wall  of  the  antrum  breaks  down,  and  a sub- 
periosteal abscess  forms  above  and  behind  the  ear,  causing 
considerable  downward  and  forward  displacement  of  the 
auricle. 

Treatment.—- In  the  early  stages  of  otitis,  dry  heat  and  the 
use  of  the  well-known  cocaine,  carbolic,  and  glycerine  drops 
will  relieve  symptoms,  but  surgical  treatment  is  more  effective, 
and  the  small  operation  of  paracentesis  tympani  might  with 
advantage  be  performed  more  frequently.  The  incision  should 
divide  the  posterior  part  of  the  drum  from  below  upwards, 
and  should  be  continued  a little  way  along  the  inflamed 
meatal  wall.  General  anaesthesia  is  advisable.  The  small  clot 
which  forms  over  the  incision  must  be  syringed  out  a few 
minutes  later,  as  it  is  apt  to  impede  drainage.  Pus  may 
not  appear  at  once,  but  the  flow  will  become  established 
within  a couple  of  days. 

Tuberculosis  of  the  Middle  Ear. 

This  disease  is  not  uncommon  in  the  infant,  though  it 
becomes  less  and  less  frequent  as  age  advances.  In  a series 
of  150  consecutive  cases  of  chronic  middle-ear  suppuration 
in  children  under  ten  years  of  age  attending  the  Royal 
Hospital  for  Sick  Children,  13  cases  were  of  definitely 


tuberculous  origin.  In  all  of  the  13  cases  save  one,  a child 
aged  3,  the  disease  commenced  during  the  first  year  of  life. 

As  regards  symptoms,  all  cases  were  characterised  by  a 
painless  and  gradual  onset,  and  all  showed  enlarged  glands 
around  the  ear.  Facial  paralysis  was  noted  in  7 cases, 
while  in  3 cases  a mastoid  abscess  had  formed  and  ruptured, 
causing  a mastoid  fistula. 

The  aetiology  of  aural  tuberculosis  is  most  important  from  a 
public  health  point  of  view,  for  there  is  little  doubt  that  the 
infection  is  milk-borne  and  reaches  the  ear  by  way  of  the 
Eustachian  tube.  Ten  of  my  patients  were  bottle-fed,  and 
only  in  one  instance  was  the  milk  boiled. 

The  treatment  of  the  condition  consists  in  a very  radical 
mastoid  operation.  This  was  carried  out  in  9 cases,  in  all  of 
which  extensive  bone  necrosis  was  found,  and  microscopic 
examination  of  the  granulations  confirmed  the  diagnosis. 
Six  did  well  and  3 died,  one  of  meningitis  a week  after 
operation,  and  the  other  two  several  months  later,  of 
pneumonia  and  convulsions  respectively. 

Otitis  Media  in  Older  Children. 

Let  us  now  consider  the  problem  of  aural  suppuration  in 
older  children.  At  the  age  of  2 the  mastoid  process  is 
already  developed,  and  the  disease  tends  more  and  more  to 
approach  the  adult  type.  Acute  inflammation  is  common, 
but  the  important  lesion,  the  disease  which  destroys  hearing 
and  yet  goes  untreated  in  so  many  cases,  is  chronic  suppura- 
tive otitis  media,  or  for  short,  aural  suppuration.  Even  in 
the  framing  of  child  welfare  schemes  the  prime  importance 
of  this  disease  is  not  recognised,  while  the  provision  of 
skilled  aural  treatment  in  fever  hospitals  remains  an  urgent 
necessity.  The  ears  of  the  school  child  are  nowadays  well 
inspected  and  treated,  but  the  child  of  more  tender  years  is 
apt  to  be  forgotten. 

Indeed,  a recent  writer  goes  so  far  as  to  say  that  “ there  is 
little  ear  disease  amongst  children  until  the  beginning  of  the 
school  period.”  Surprised  by  this  statement,  I looked  over 
my  records  of  cases  of  aural  suppuration  in  children,  and 
found  that  of  145  patients  no  less  than  95  were  under  the  age 
of  5 years.  It  would  therefore  appear  that  ear  disease  is  < 
by  no  means  uncommon  in  children  under  school  age. 

School  medical  inspection  reports  in  Scotland  show  that  of 
school  entrants  13  per  cent,  have  discharging  ears.  The 
figures  range  from  0 5 per  cent,  in  Linlithgow  county  to 
1-9  per  cent,  in  the  town  of  Stirling,  but  rural  and  urban 
populations  appear  to  suffer  with  equal  frequency.  These 
estimates  are  probably  low,  as  the  ears  may  not  be  dis- 
charging at  the  time  of  examination.  How  familiar  is  the 
statement  that  “the  ears  have  been  running  for  months  (or 
years)  off  and  on.” 

JEtioiogy. 

Now  what  is  the  cause  of  all  this  ear  disease,  and  how  may 
it  be  prevented  ? In  130  cases  of  aural  suppuration  in 
children  aged  1 to  10  years,  I have  on  66  occasions  obtained 
from  the  mother  a statement  as  to  the  supposed  cause,  with 
the  following  result : — 

Measles  40  oases  (31  %)  I Whooping-cough  5 cases  (4  '/.) 

Scarlet  fever  ...  8 „ ( 6 %)  | Injury  (?) 3 „ 1.2'/.) 

Pneumonia  ...  8 ,,  ( 6 %)  | Diphtheria  ...  2 „ (1'5  /) 

The  most  striking  fact  revealed  by  the  table  is  the  high 
percentage  of  measles  cases.  It  may  be  mentioned  that 
these  figures  were  drawn  from  two  different  years,  so  that 
they  are  not  swelled  by  any  particular  epidemic.  The  small 
number  of  scarlet  fever  cases  arises  from  the  fact  that  two- 
thirds  of  the  patients  had  not  yet  reached  the  age  at  which 
scarlet  fever  attains  its  maximum  incidence. 

Downe,  who  investigated  the  cause  of  otitis  in  500  cases, 
found  26  per  cent,  due  to  measles  and  12  per  cent,  due  to 
scarlet  fever.  Scarlet  fever  is  well  known  for  its  destructive 
effects  on  the  ear,  but  on  the  whole  it  is  well  treated,  as  it 
is  a notifiable  and  a hospital  disease.  Measles,  on  the  other 
hand,  is  not  notifiable,  is  treated  at  home,  and  is  too  often  | 
regarded  as  a trivial  complaint.  In  reality,  it  is  a more  j 
dangerous  and  disabling  disease  than  scarlet  fever,  and  the 
importance  of  measles,  as  a cause  of  chronic  middle-ear 
suppuration,  cannot  be  too  strongly  emphasised.  All 
measures  for  the  prevention  of  measles,  whether  by 
improved  housing  and  greater  cleanliness,  by  prompt 
isolation  and  more  careful  nursing,  or  by  better  treatment  \ 
during  the  convalescent  stage,  will  go  far  towards  lessening 


The  Lancet,] 


DR.  A.  H.  GOSSK:  PROPHYLAOTIO  QUININE  IN  MALARIA. 


[Sept.  0,  1919  43 1 


the  tendency  to  aural  complications  and  reducing  the 
number  of  cases  of  preventable  deafness  in  later  life. 

A second  factor  in  the  retiology  of  aural  suppuration  is 
perhaps  the  most  important  factor  of  all.  The  great 
majority  of  children  who  suffer  from  chronic  otitis  are  also 
sufferers  from  adenoids,  and  the  septic  infection  of  those 
adenoids  are  not  only  the  cause  of  the  otitis,  but  also  the 
cause  of  its  chronicity.  The  adenoid  operation,  therefore, 
has  an  important  place  in  the  prophylaxis  as  well  as  in  the 
treatment  of  ear  suppuration.  As  a portal  of  infection,  the 
pharyngeal  tonsil  is  second  to  none.  Here  enter  measles, 
meningitis,  and  many  another  ill,  and  infection  may  readily 
pass  from  septic  adenoids,  along  the  Eustachian  tube  to  the 
middle  ear. 

Measles  and  adenoids,  then,  are  the  two  principal  causes 
of  aural  suppuration  in  young  children,  and  merit  even 
greater  attention  than  has  hitherto  been  accorded  to  them. 

Treatment. 

The  following  scheme  of  treatment  may  be  a useful  guide 
in  average  cases  : (1)  cleansing  and  antisepsis  ; (2)  removal 
of  adenoids  ; (3)  conservative  operation  ; and  (4)  radical 
operation. 

(1)  and  (2)  will  cure  the  majority  of  cases.  After  having 
tried  many  methods,  I now  advise  the  mother  to  make  some 
mops  with  matches  and  cotton-wool,  and  with  these  to  mop 
out  the  ear  until  dry  ; then  to  instil  a few  drops  of  peroxide 
of  hydrogen  and  mop  out  once  more  until  dry.  This  is  to 
be  done  twice  a day.  Syringing,  in  unskilled  hands,  is  worse 
than  useless,  and,  indeed,  I have  known  ears  to  cease  dis- 
charging when  the  only  advice  was  to  stop  syringing.  The 
mopping  method  is  a much  more  effective  measure.  As  the 
discharge  lessens,  rectified  spirit  may,  with  advantage,  be 
combined  with  the  peroxide. 

The  importance  of  adenoids  has  already  been  noted. 
Large,  firm  masses  may  be  present,  but  more  frequently  a 
small  block  of  friable  and  pus-soaked  tissue  is  removed  at 
the  operation.  Should  the  removal  of  adenoids,  and  two 
or  three  months  of  systematic  “mopping  and  drops,” 
fail  to  effect  improvement,  operative  methods  must  be 
considered. 

The  radical  mastoid  operation  is  seldom  indicated  in 
childhood  and  should  only  be  performed  in  carefully 
selected  cases — e.g. , cholesteatoma,  necrosis  of  ossicles,  &c. 
One  naturally  hesitates  to  perform,  upon  a small  child,  an 
operation  whose  effects  upon  the  sense  of  hearing  cannot 
be  foretold. 

For  this  reason  the  so-called  “conservative”  mastoid 
operation  (modified  radical)  should  be  chosen  whenever 
possible.  Into  the  details  of  the  operation  I do  not  propose 
to  enter  here,  but  shall  merely  enumerate  its  various  stages 
—the  opening  of  the  antrum,  the  removal  of  the  greater  part 
of  the  posterior  wall  of  the  bony  meatus,  the  curetting  and 
clearing  of  the  aditus  (for  this  a bayonet-shaped  dental 
excavator  is  most  useful),  the  construction  of  a wide 
meatal  flap,  and  the  treatment  of  the  bone  cavity  with 
bipp,  which  gives  such  excellent  results  in  mastoid  surgery. 
By  this  operation  drainage  is  provided,  while  the  drum 
and  ossicles  are  left  untouched,  and  the  middle  ear  may 
recover,  with  full  possession  of  its  functions. 

I lately  had  the  opportunity  of  examining  six  cases,  upon 
all  of  which  I had  performed  the  operation  over  two  years 
ago.  The  ear  was  dry  in  five  cases,  and  in  all  cases  hearing 
was  good  (whisper  at  6 feet). 


Leicester  Royal  Infirmary. — On  the  promotion 
of  Dr.  T.  V.  Crosby  to  be  honorary  physician  to  the 
infirmary  two  vacancies  were  offered  for  assistant  phy- 
siciancies,  and  to  these  Dr.  J.  D.  Slight  and  Dr.  Arthur 
Foster  have  been  appointed.  During  the  war  Dr.  Slight 
has  been  in  charge  of  medical  patients,  officers  as  well  as 
other  ranks,  at  the  5th  Northern  General  Hospital,  and 
has  also  acted  as  temporary  physician  to  the  Royal 
Infirmary.  Dr.  Foster  has  been  in  charge  of  medical 
beds  at  the  same  military  hospital.  Mr.  R.  S.  Lawson  was 
at  the  same  time  appointed  assistant  surgeon.  Mr.  Lawson 
has  been  lecturer  in  anatomy  at  Edinburgh  University, 
and  acted  as  assistant  lecturer  and  demonstrator  in  the 
pathological  department  there.  During  the  war  he  was 
operating  surgeon  at  the  Royal  Naval  Hospital,  Chatham, 
and  on  a hospital  ship,  and  since  demobilisation  has  been 
doing  surgical  work  at  Alder  Hey  Military  Orthopaedic 
Hospital. 


A NOTE  ON 

PROPHYLACTIC  QUININE  IN  MALARIA. 

By  A.  H.  GOSSE,  M.D.  Cantau.,  M.R.C.P.  Lono., 

BREVET  MAJOR,  R. A.M.C.  (T.F.). 

It  was  with  an  unbiassed  view  of  its  value  or  otherwise 
that  the  following  investigations  into  the  use  of  prophylactic 
quinine  in  malaria  in  two  units  of  the  Mesopotamian  Expedi- 
tionary Force  were  carried  out,  and  as  they  led  to  definite 
opinions  they  are  now  reported. 

The  Investigation  Described. 

A medical  unit  to  look  after  a thousand  hospital  or  con- 
valescent patients  was  located  at  Mohammerah,  some  25  miles 
from  Basrah,  with  little  or  no  opportunity  for  the  personnel 
to  visit  other  units,  so  that  any  infection  by  the  malarial 
parasite  was  due  to  the  conditions  in  the  camp.  As  these 
conditions  seemed  to  indicate  that  it  was  a suitable  oppor- 
tunity an  investigation  was  undertaken.  The  troops  per- 
manently posted  there  con  sisted  of  three  officers  and  about 
30  N.C.O.’s  and  men,  who  had  only  been  one  month  in  the 
country,  and  had  come  direct  from  England.  During  this 
month  one  man  had  contracted  malaria  while  in  Basrah,  and 
he  was  excluded  from  the  investigation.  None  of  the  others 
had  ever  had  malaria.  No  quinine  was  issued  to  or  taken  by 
any  of  them,  as  I explained  to  them  that  as  it  was  a new 
camp,  and  the  presence  of  mosquitoes  infected  by  the 
malarial  parasite  was  doubtful,  experience  alone  would  show 
whether  it  was  necessary  to  take  quinine  or  not,  as  every 
anopheles  is  not  necessarily  a cafrier  of  malaria.  If  any 
of  us  became  infected  the  administration  of  quinine 
would  be  reconsidered.  For  nine  months,  from  September, 
1916,  to  June,  1917,  no  quinine  was  taken  and  no 
malaria  occurred.  Towards  the  end  of  June  two  of 
the  nursing  orderlies  reported  sick  with  high  fever 
on  the  same  day,  but  it  was  not  till  four  days  later  that  a 
diagnosis  of  malaria  was  made.  On  this  day  a warrant 
officer  reported  sick  and  a blood  film  showed  B.T.  parasites 
present.  Quinine  sulphate,  gr.  v. , in  a mixture  daily  was 
ordered  for  the  remaining  30  as  a prophylactic  measure.  A 
list  of  their  names  was  made  and  each  dose  taken  was 
recorded.  The  men  were  told  that  an  investigation  was 
being  carried  out  and  they  showed  their  interest  by  their 
methodical  attendance  at  the  dispensary  to  take  quinine 
without  any  attempt  to  evade  it.  Three  days  later  one  of 
the  men  went  sick  and  was  also  found  to  have  malaria,  but 
he  must  have  been  infected  some  ten  days  at  least  before 
quinine  was  started  and  5 gr.  daily  was  not  sufficient  to  stop 
an  attack.  During  the  next  three  months  no  further  case  of 
malaria  occurred.  MajorS.  R.  Christophers,  I.M.S.,  visited 
the  camp  during  this  period  to  make  an  examination  for 
anopheles  in  the  area,  and  in  the  first  tent  found  over  a 
dozen.  The  value  of  the  administration  of  prophylactic 
quinine  in  this  camp  seemed  to  be  demonstrated. 

I was  then  transferred  for  duty  to  a hospital  five  miles 
from  Basrah.  The  female  nursing  staff  of  this  hospital 
consisted  of  nine  nursing  sisters,  none  of  whom  had  had 
malaria,  though  several  of  the  orderlies  were  then  sick  with 
it.  I advised  them  all  to  take  quinine,  but  emphasised  the 
importance  I attached  to  being  informed  beforehand  of  the 
names  of  those  who  would  take  it  regularly.  The  matron 
very  kindly  gave  every  assistance  and  the  quinine  mixture 
was  handed  round  at  their  mess,  where  it  was  taken 
regularly  by  five  of  them,  but  the  other  four  declined  it, 
and  these  I regarded  as  controls.  The  five  taking  quinine 
did  not  develop  malaria  then  or  at  any  time  while  they  were 
in  Mesopotamia.  Of  the  other  four,  two  of  them  had  malaria 
with  parasites  demonstrated  in  blood  films  within  a month. 

Shortly  afterwards  four  new  sisters  were  added  to  the 
nursing  staff.  Two  of  them  took  quinine  from  the  first  day, 
while  two  others  preferred  not  to  take  it,  and  were  therefore 
regarded  as  further  controls.  In  less  than  three  weeks  both 
the  controls  developed  a temperature  on  the  same  day,  and 
parasites  "were  found  in  their  blood.  The  two  who  took 
quinine  did  not  develop  malaria.  Experiences  such  as  these 
make  it  impossible  to  accept  the  view  that  prophylactic 
quinine  is  useless  at  all  times. 

Remarks. 

Far  more  elaborate  investigations  than  these  have  been 
frequently  reported,  and  still  the  opinion  for  or  against 


432  The  Lancet,]  DR.  F.  HERNAMAN-JOHNSON : X RAYS  IN  TREATMENT  OF  DYSMENORRHCEA.  [Sept.  6, 1919 


prophylactic  quinine  is  divided.  Why,  then,  this  apparently 
conflicting  evidence?  The  work  of  these  investigators  must 
be  accepted  on  both  sides.  It  appears,  then,  that  the  solu- 
tion can  only  lie  in  the  discovery  of  the  variable  conditions 
under  which  the  conflicting  experiences  have  been  obtained. 
To  explain  my  meaning,  let  me  refer  to  the  opposing  views 
which  in  the  past  have  been  held  over  the  value  of  digitalis 
in  heart  disease.  It  is  now  known  that  the  beneficial  effects 
are  exhibited  in  patients  with  the  rapid  pulse-rate  of 
auricular  fibrillation  or  auricular  flutter,  but  ha3  practically 
no  effect  on  other  cardiac  conditions.  The  solution,  then, 
lay  in  the  discovery  of  the  variable  conditions  under  which 
the  conflicting  experiences  had  been  obtained.  What  are 
these  variable  conditions  in  prophylactic  quinine  ? May  it 
be  in  the  variable  amount  of  the  dose  at  the  time  of  infection, 
or,  in  other  words,  in  the  variable  number  of  bites  received 
in  24  hours  from  infective  anopheles  1 

Mesopotamia  is  not  a very  malarious  country.  Death  from 
uncomplicated  malaria  is  rare.  The  mortality  is  larger 
when  complicated  by  heat  stroke.  The  incidence  of  malaria 
is  not  high  when  compared  with  a badly  malarious  country 
like  Northern  Persia  or  Salonica,  where  prophylactic  quinine 
is  said  to  be  almost  useless.  The  conditions  under  which 
prophylactic  quinine  was  demonstrated  to  be  so  beneficial  in 
the  above  investigations  was  in  a country  where,  as  a rule, 
the  infection  was  not  severe  and  therefore  probably  the 
infecting  dose  was  small — i.e.,  the  numbers  of  bites  from 
infective  anopheles  was  small  in  anyone  day.  It  is  suggested 
that  the  value  of  prophylactic  quinine  varies,  and  the  pro- 
phylactic dose  should  be  in  direct  proportion  to  the  severity 
of  the  infection  in  any  given  area.  There  should  be  an 
optimum  prophylactic  dose  for  that  area.  The  cases  receiving 
an  exceptionally  large  number  of  infective  bites  will  still 
develop  malaria,  but  the  rest  will  be  protected.  In  a very 
malarious  country,  when  one  is  frequently  bitten  in  the  24 
hours  by  infective  mosquitoes,  gr.  v.,  gr.  x.,  or  even  larger 
doses  may  be  insufficient  to  kill  the  parasite  in  all  but  a very 
few  cases,  and  then  prophylactic  quinine  might  be  regarded 
as  useless. 

Conclusion. 

Prophylactic  quinine  in  Mesopotamia  is  of  the  greatest 
benefit,  but  in  certain  other  places  it  is  almost,  if  not  quite, 
useless,  and  it  may  be  that,  provided  the  dose  necessary  is 
not  too  high  for  regular  administration,  an  optimum  pro- 
phylactic dose  will  be  demonstrated  for  every  malarious  area, 
varying  even  with  the  seasons  and  indicated  perhaps  by  the 
rising  or  falling  incidence  of  the  disease. 


X RAYS  IN  THE  TREATMENT  OF  CERTAIN 
FORMS  OF  DYSMENORRHCEA: 

A PLEA  FOR  THEIR  MORE  EXTENSIVE  USE. 

By  FRANCIS  HERNAMAN-JOHNSON,  M.D.  Aberd., 

RADIOLOGIST  TO  THE  FRENCH  HOSPITAL;  PHYSICIAN  TO  THE  X RAY 
DEPARTMENT,  THE  MARGARET-STREET  HOSPITAL  FOR 
CONSUMPTION,  ETC. 

The  object  of  this  article  is  to  call  attention  to  certain 
methods  of  treatment  which  often  succeed  in  cases  of 
menstrual  disturbance,  when  more  orthodox  measures,  medi- 
cal and  surgical,  have  failed.  I hasten  to  say  that  certain 
conditions  should  be  fulfilled  before  any  case  of  such  a 
nature  is  undertaken  by  the  radiologist.  They  are : (1) 
treatment  by  ordinary  medical  methods  (drugs,  regulation 
of  way  of  living,  &c.)  should  have  a fair  trial — by  this  is 
meant  a matter  of  a few  months  ; (2)  surgical  investigation 
must  be  made  to  exclude  any  gross  deformity,  and  any  minor 
surgical  procedure  not  dangerous  to  life — e.g.,  dilatation  of 
the  cervix — tried  if  it  seems  indicated. 

By  this  I do  not  mean  to  convey  that  no  cases  presenting 
any  abnormality  of  an  organic  nature  should  be  accepted. 
Cases  in  which  serious  malposition  of  the  uterus  was  found 
and  surgically  corrected  have  failed  to  benefit,  but  have 
subsequently  been  cured  by  X rays.  The  presence  of  a 
certain  amount  of  congestion  in  the  ovaries  and  uterus  is 
also  not  a bar  to  success  ; but  it  is  important  that  the  radio- 
logist should  know  of  any  condition  which  may,  should  he 
fail,  require  surgical  interference.  Cases  in  which  the 
uterine  contents  are  septic — as  after  abortion — or  where 
large  fibroids  are  present,  are  obviously  suitable  for 
surgical  treatment  only.  On  the  other  hand,  there 


are  those  in  which  nothing  in  the  nature  of  a possible 
organic  cause  can  be  demonstrated.  But,  inevitably,  there 
must  be  borderline  cases  in  which  opinions  will  differ  as  to 
what  treatment  should  be  followed.  In  making  a decision  it 
should  be  remembered  that  X ray  treatment  can  be  con- 
ducted without  risk  ; if  it  fails,  surgery  can  still  be  resorted 
to.  But  operations  for  straightening  out  uterine  kinks  are 
not  wholly  free  from  danger,  and  an  excised  ovary  cannot  be 
replaced. 

Characteristics  of  a Suitable  Case. 

The  type  of  case  most  suitable  for  X rays  presents  the 
following  characteristics  ; (a)  It  is  free  from  gross  organic 
lesions,  (ft)  There  is  excessive  and  prolonged  bleeding  at 
the  menstrual  periods,  which  follow  one  another  with  undue 
rapidity.  (c)  There  is  more  or  less  pain  of  the  usual 
menstrual  type,  and  frequently  headache  and  mental 
depression.  ( d ) Owing  to  the  excessive  loss  of  blood  and 
the  shortness  of  the  intervals  the  patient  never  really  feels  fit. 

Cases  conforming  closely  to  the  above  type  yield  to 
X ray  treatment  with  great  regularity.  A wide  cone 
of  rays  is  used,  filtered  through  3 mm.  of  aluminium, 
so  that  the  ovaries  and  uterus  receive  radiations  more 
or  less  equally  at  each  sitting.  The  external  genitals 
are  protected  by  ray-proof  material  to  prevent  any  possibility 
of  temporary  epilation.  These  patients  are  rarely  able  to 
attend  for  treatment  for  much  more  than  two  weeks  out  of 
four  ; and  endeavour  should  be  made  to  give  at  least  seven 
sittings  during  each  interval.  The  first  period  after  starting 
treatment  is  usually  worse,  and  the  second  may  be  little 
better.  But  if  the  treatment  is  going  to  succeed,  the  third 
should  show  distinct  improvement.  If  it  does  not,  ultimate 
success  is  unlikely.  When  improvement  is  obtained,  X rays 
are  omitted  during  the  fourth  interval,  and  a final  course 
given  during  the  fifth. 

Objections  to  the  Treatment. 

Two  objections  have  been  raised  against  this  form  of 
treatment : (1)  that  there  is  risk  of  sterilisation  ; (2)  that 
the  integrity  of  the  skin  is  endangered.  The  one  question  is 
in  reality  bound  up  with  the  other.  It  is  practically  im- 
possible permanently  to  sterilise  a woman  below  40  without 
injury  to  the  skin.  In  the  literature  on  the  X ray  treatment 
of  uterine  fibroids  great  stress  has  been  laid  upon  a technique 
which  will  produce  sterilisation,  and  in  consequence  the 
method  has  not  been  recommended  for  patients  who 
have  not  completed  their  fourth  decade.  But  in  dealing 
with  young  subjects  who  suffer  from  menstrual  dis- 
turbance no  attempt  is  made  to  carry  the  dosage  beyond 
what  is  necessary  to  restrain  excessive  ovarian  function. 
This  statement  implies  a theory  as  to  the  cause  of  the  type 
of  dysmenorrhcea  under  discussion.  The  theory  is  that  just 
as  excessive  thyroid — or  possibly  thyroid  and  thymus — 
action  is  the  immediate  cause  of  the  symptom-complex 
known  as  Graves’s  disease,  so  does  excess  of  ovarian 
hormone  produce  what  the  present  writer  has  ventured 
to  call  the  “ovarian  syndrome”:  excessive  bleeding, 

prolonged  periods,  diminished  intervals,  headache,  and 
depression.  In  exophthalmic  goitre  the  thyroid  can  be 
“ tamed  ” without  in  any  way  interfering  witlj  its  normal 
function.  In  a similar  way  the  ovary,  regarded  as  a ductless 
gland,  can  be  restrained  from  excessive  exuberance  by  com- 
paratively small  doses  of  X rays.  It  was  proposed  some 
years  ago  by  a well-known  surgeon  that  portions  of  the 
ovaries  should  be  removed  in  such  cases.  This  procedure 
would,  of  course,  be  exactly  on  a par  with  partial  thyroidec- 
tomy for  Graves’s  disease,  and  could  only  be  regarded  as 
justifiable  if  all  other  measures  failed.  Also,  as  regards 
X rays,  their  effect  upon  low  forms  of  inflammation 
in  general  must  not  be  forgotten.  In  chronic  colitis,  for 
instance,  their  beneficial  effects  are  well  established,  and 
therefore  the  lining  of  the  uterus,  if  congested,  is  in  all 
probability  directly  benefited  by  their  application. 

Effects  on  the  Skin. 

As  to  visible  effects  on  the  skin,  a sun-burnt  appearance 
is  generally  produced  about  the  end  of  the  second  course. 
There  should  be  no  redness  or  tenderness ; at  the  most 
a slight  itching  at  night,  which  is  readily  relieved  by 
cold  cream.  This  browning  occurs  only  when  small, 
graduated  doses  are  given,  and  appears  to  be  protective.1 

i I have  found  that  in  treating  cancer  once  this  browning  is  produced 
very  large  doses  are  tolerated  for  months  and  even  years  without  any 
breaking  down. 


The  Lancet,] 


MR.  F.  RANSOM  : IODIDES  AND  THE  THYROID. 


[Sept.  6,  1919  433 


With  the  small  dosage  necessary  in  dysmenorrhoea  cases, 
the  brown  layer  begins  to  peel  oil  in  about  one  month  after 
the  cessation  of  treatment,  leaving  a perfectly  healthy  skin 
surface.  The  skin  is  fully  fit  to  stand  operation,  should  this 
be  necessary,  within  two  months. 

Danger  of  Faulty  Technique. 

That  great  harm  can  be  done  by  faulty  technique  must  be 
admitted  ; but  this  can  be  said  of  most  modern  methods  of 
treatment.  The  risk  in  skilled  hands  is  practically  nil.  And 
it  must  be  remembered  that— if  the  conditions  stated  at  the 
beginning  of  this  article  have  been  fulfilled — either  there  is 
no  alternative,  or  the  alternative  is  a major  operation. 

To  the  majority  of  such  patients  life  is  literally  not  worth 
living,  and  I personally  have  found  no  class  of  sufferers  so 
pathetically  grateful  for  relief  as  women  thus  afflicted.  It  is 
essentially  a disorder  of  young  women,  and  ruins  the  best 
years  of  their  life,  often  preventing  marriage  ; or,  what  is 
worse,  making  it  a failure. 

As  to  choice  of  cases,  the  more  nearly  one  approaches 
to  the  type  described  in  the  early  part  of  this  paper,  the 
more  likely  is  it  to  benefit  by  X ray  treatment.  When  pain 
is  prominent  rather  than  loss  of  blood,  cure  is  less  probable, 
but  a trial  should  be  made. 

Decent  Cases. 

The  present  writer  first  referred  to  this  subject  in  an 
article  published  some  years  ago,  in  which  details  of  several 
cases  were  given.2  Two  more  recent  ones  are  quoted 
below. 

L.  B.,  school-teacher,  30.  First  seen  January,  1918.  All 
her  life  had  been  troubled  by  excessive  loss  at  periods.  Of 
late  years  the  condition  had  become  steadily  worse.  Periods 
lasted  ten  days,  and  the  free  interval  was  less  than  a 
fortnight.  There  was  a good  deal  of  pain  and  headache  at 
the  time,  and  2-3  days  had  to  be  spent  in  bed.  She  was  in 
danger  of  losing  her.  position  and  was  in  a very  depressed 
state,  threatening  suicide.  She  had  had  prolonged  treat- 
ment from  her  medical  attendant  and  was  certified  by  a 
gynaecologist  to  be  apparently  free  from  organic  disease. 
X ray  treatment  at  first  aggravated  the  condition,  and  the 
interval  succeeding  the  commencement  of  treatment  was  so 
short  that  X ray  dosage  was  continued  through  a part  of  the 
second  period— a departure  from  the  usual  procedure.  The 
free  period  following  lasted  three  weeks,  and  the  succeeding 
period— the  third  after  the  commencement  of  treatment— 
was  almost  normal.  A complete  cure  seems  to  have  resulted, 
as  the  patient  wrote  in  December,  1918  (seven  months  after 
stopping  all  treatment),  to  say  that  she  was  quite  well. 

The  above  case  is  typical  of  those  in  which  a large  measure 
of  success  may  reasonably  be  expected.  In  one  such  as  the 
following  less  confidence  can  be  expressed. 

C.  M.,  28,  spinster.  Had  suffered  since  the  age  of  14  from 
painful  menstrual  periods  lasting  6-7  days.  Flow  somewhat 
greater  than  normal.  Headache  severe  for  3-4  davs  at  the 
time  of  periods.  Year  by  year  the  condition  had  become 
worse.  General  health  in  intervals  indifferent,  and  patient 
was  unable  to  follow  any  regular  occupation.  The  uterus 
and  both  ovaries  were  slightly  enlarged  and  tender  to  palpa- 
tion. The  girl  was  very  miserable,  and  a gynaecological 
surgeon  suggested  complete  removal  of  the  organs  if  no  other 
means  of  relief  could  be  found.  As  a final  resort  before  opera- 
tion it  was  decided  to  try  X rays.  The  second  period  after  tbe 
commencement  of  treatment  was  considerably  better,  in  so 
much  that  the  bleeding  was  less  and  that  it  lasted  only 
five  days.  Pain  also  was  not  so  violent.  Two  more 
“interval  courses”  of  X rays  were  given,  but  no  further 
improvement  occurred,  and,  in  view  of  the  possible  final 
necessity  for  operation,  it  was  not  considered  desirable  to 
push  the  treatment.  Result : Periods  reduced  to  five  days 
instead  of  6-7.  Flow  normal.  Pain  more  bearable.  General 
health  improved.  Patient  writes  three  months  after  cessa- 
tion of  treatment  to  say  that,  on  the  whole,  she  remains 
much  better  than  before  she  had  X rays. 

In  the  above  instance  X ray  treatment  succeeded  only  to  a 
limited  degree,  but  it  enabled  the  patient  to  avoid  a serious 
and  mutilating  operation,  at  least  for  the  time.  I am  not  to 
be  taken  as  opposing  the  operation  of  pan-hysterectomy  in 
intractable  cases  of  dysmenorrhcea,  provided  every  other 
possible  means  of  relief  have  been  tried  without  success,  but 
X rays  should  alrcays  be  remembered  as  among  the  most 
j powerful  of  these  means. 

The  radiologist,  holding,  as  it  were,  a position  midway 
between  that  of  the  physician  and  the  surgeon,  has  no  need 
to  encroach  upon  the  domain  of  either.  ‘ The  patient  with 

2 Practitioner,  vol.  xcii.,  p.716. 


dysmenorrhoea  should  first  receive  medical  treatment — the 
term  “ medical  ” being  used  in  its  more  limited  sense.  If 
this  fails,  it  should  be  ascertained  whether  there  is  any 
recognised  surgical  cause  for  the  trouble,  such  as  a contracted 
os,  or  whether  any  condition  exists  dangerous  to  life — e.g., 
septic  endometritis,  large  fibroid,  uterine  cancer,  &c.  Failing 
the  presence  of  any  of  the  above,  X rays  should  be  tried 
before  major  surgery  is  resorted  to. 

The  vexed  question  as  to  the  treatment  of  uterine  fibroids 
I do  not  purpose  entering  on  here,  except  to  say  that  small 
fibroids  associated  with  excessive  bleeding  at  the  menstrual 
periods,  but  not  in  the  intervals,  can  be  successfully  dealt 
with  by  X rays  in  women  near  the  menopause. 

Harleystreet,  W. 

IODIDES  AND  THE  THYROID.1 

By  FRED  RANSOM,  M.D.  Edin., 

READER  IN  PHARMACOLOGY  IN  THE  UNIVERSITY  OF  LONDON. 


The  specific  relationship  between  the  thyroid  gland  and 
iodine  was  first  pointed  out  by  Baumann,  who  discovered 
that  the  normal  thyroid  contains  a considerable  amount  of 
iodine  in  organic  combination.  Iodine  is  a frequent  con- 
stituent of  cells  generally,  but  the  thyroid  contains  relatively 
8-10  times  more  than  any  other  organ. 

Baumann  obtained  from  the  thyroid  by  a somewhat  drastic 
means  a substance  which  he  believed  to  be  the  active 
principle  called  iodothyrin,  and  looking  upon  it  as  the  cause 
of  the  remarkable  effects  upon  metabolism.  Oswald  has, 
however,  shown  that  iodothyrin  is  an  artificial  product,  and 
that  its  mother  substance  is  an  iodised  protein,  iodothyeo- 
globulin,  from  which  iodothyrin  can  only  be  obtained  by 
breaking  up  the  protein  molecule. 

An  extract  of  the  gland  made  with  physiological  salt 
solution  contains  all  the  iodine-containing  substance,  and 
gives  relief  in  hypothyroidismus  ; but  so  do  various  organic 
and  inorganic  preparations  of  iodine,  though  to  a less  degree. 

Considerations  as  to  the  Active  Principle  of  the  Gland. 

Are  we,  then,  entitled  to  consider  that  iodine  is  the  active 
principle  of  the  gland  ! This  theory  has  been  advocated  by 
Swingle,  who  considers  that  the  iodine  plays  the  part  of  an 
hormone,  but  before  accepting  it  certain  points  require  con- 
sideration ; the  presence  of  iodine  in  the  thyroid  is  no  proof 
that  the  activity  of  the  organ  is  dependent  upon  its  iodine- 
content,  for  one  function  of  the  thyroid  may  be  to  absorb 
iodine,  another  to  provide  a specific  internal  secretion. 
Even  the  fact  that  iodine  is  specifically  absorbed  by  the 
thyroid,  and  perhaps  stimulates  secretion,  does  not  prove 
that  iodothyeoglobulin  constitutes  the  internal  secretion  of 
the  gland.  Carlson  and  Woelfel  failed  to  find  iodine  in  the 
lymph  flowing  out  of  the  thyroid.  Moreover,  the  iodine- 
content  of  the  thyroid  is  subject  to  much  variation  and  is 
greatly  influenced  by  the  amount  of  iodine  in  the  food.  The 
thyroid  of  carnivora  contains  little  or  even  no  iodine ; the 
amount  of  iodine  is  greatest  in  herbivora,  omnivora  take  a 
middle  place.  The  thyroid  of  dogs  can  be  made  iodine-free 
by  feeding  on  an  exclusively  flesh  diet,  and  still  the 
functions  of  the  gland  remain  unimpaired.  The  foetal  thyroid 
and  the  thyroids  of  newly  born  infants  contain  no  iodine, 
yet  in  sucking  animals  thyroidectomy,  after  removal  from 
the  mother,  produces  its  characteristic  effects. 

The  iodine-content  of  the  human  thyroid  is  very  variable  ; 
Jolin,  in  extensive  investigations  in  Sweden,  found  these 
variations  so  great  that  he  regards  the  iodine  as  of  quite 
secondary  importance  ; he  was  also  unable  to  detect  any 
connexion  between  iodine-content  and  health.  Abelin 
found  that  a thyroid  extract  containing  much  iodine  did 
not  differ  in  activity  from  one  containing  little.  During  the 
administration  of  an  iodide  the  iodine-content  of  the  gland 
may  rise  to  4-5  times  the  average  normal,  and  yet  in  the 
treatment  of  cretinism  or  myxcedema  iodides  are  not  so 
successful  as  is  the  taking  of  the  gland  itself.  In  view  of 
these  facts  it  appears  at  least  improbable  that  the  iodine 
plays  an  important  primary  role  in  the  activity  of  the 
internal  secretion  of  the  thyroid. 

Is,  then,  the  active  principle  likely  to  be  a protein  ? 
There  are  several  facts  which  tell  against  such  a 

1 Abstract  of  a post- graduate  lecture  delivered  at  the  London  (K.F.H.) 

School  of  Medicine  for  Women. 


434  Th,e  Lancet,] 


CLINICAL  NOTES. 


[Sept.  6,  1919 


hypothesis.  Abderhalden  and  also  Herzfeld  and  Klinger  got 
characteristic  effects  with  protein-free  extracts  of  thyroid. 
Abelin  found  that  thyreoglandol,  a protein  and  lipoid-free 
preparation,  has  the  same  effect  on  metabolism  as  the  gland 
itself  ; indeed,  the  efficacy  of  the  per  os  treatment  with 
the  dried  gland  would  seem  to  indicate  that  the  active 
principle  is  not  a protein.  An  iodised  protein  which 
v.  Fuerth  employed  was  split  up  in  the  cat’s  intestine  so  that 
iodine  appeared  in  the  cells  of  the  gut  wall  and  in  the  blood, 
not  as  iodised  albumin  or  peptone,  but  in  inorganic  form. 
Abelin  considers  it  likely  that  the  active  principle  of  the 
thyroid  is  formed  from  protein  in  the  cell  metabolism  of  the 
gland,  much  as  adrenalin  arises  from  the  protein  of  the 
adrenals.  The  investigations  of  Kendall  go  a long  way  to 
confirm  this  opinion,  for  he  has  obtained  from  thyroid  a 
crystalline  body  of  definite  chemical  constitution  to  which  he 
gives  the  name  thyroxin.  It  is  an  indol  derivative,  trihydro- 
triiodo-a-oxyindol-propionic  acid,  and  Janney,  who  has 
clinical  experience  in  the  use  of  Kendall’s  preparation, 
considers  that  it  is  an  hormone  possessing  the  functions 
ascribed  to  the  thyroid  secretion.  Kendall  does  not  think 
that  the  iodine  is  of  primary  importance,  and  hence  the 
omission  of  any  reference  to  it  in  the  name  which  he  has 
given  to  his  preparation. 

An  Apparent  Paradox. 

There  is,  then,  considerable  probability  that  the  active 
principle  of  the  thyroid  is  a breakdown  product  of  protein 
which  may  be,  but  is  not,  necessarily  iodised.  Iodine,  if 
present,  has  apparently  no  direct  effect  upon  the  activity  of 
the  internal  secretion,  and  yet  there  is  no  doubt  that  when 
that  activity  is  diminished  it  can  often  be  restored  to  a 
certain  extent  by  administration  of  iodides.  Is  there  any 
explanation  of  the  apparent  paradox  ? 

Jobling  and  Petersen  have  shown  that  unsaturated  fatty 
acids  have  a powerful  effect  in  inhibiting  autolysis,  but  that 
in  presence  of  iodine  these  acids  on  becoming  saturated  lose 
their  inhibitory  effect,  so  that  the  ferments  causing  autolysis 
are  free  to  act.  We  have  seen  that  the  active  principle  of 
the  thyroid  is  probably  produced  by  the  breakdown  of  protein 
in  the  gland — i.e  , by  autolysis.  This  process  would, 
according  to  Jobling  and  Petersen,  be  facilitated  by  the 
presence  of  iodine  in  the  gland,  because  the  inhibitory  effect 
of  unsaturated  fatty  acids  in  the  blood  would  be  diminished 
or  done  away  with  owing  to  their  saturation  with  iodine. 

An  inefficiency  of  the  thyroid  secretion  might  oonceivably 
depend  upon  an  excess  of  unsaturated  fatty  acids  in  the 
blood  checking  the  autolysis  by  which  the  thyroid  secretion 
is  formed,  and  in  suoh  cases  the  administration  of  iodides 
would  be  effective  by  promoting  the  saturation  of  the  acids. 
If  the  inefficiency  of  the  thyroid  were  due  to  destruction  or 
removal  of  part  of  the  gland,  the  activity  of  the  remainder 
might  well  be  increased  by  iodides  which  are  specifically 
taken  up  by  the  gland,  and  would  there  favour  the  charac- 
teristic autolysis  by  checking  inhibition. 

Possibly  the  curative  action  of  iodides  in  tertiary  syphilis 
may  be  explained  by  the  thyroid  effect  of  the  drug  in  thus 
favouring  an  increase  in  the  active  secretion  passed  into  the 
blood,  and  so  facilitating  the  absorption  of  lowly  organised 
tissues  such  as  gummata,  &c.  The  same  would  apply  to 
the  use  of  iodides  in  the  treatment  of  enlarged  lymphatic 
glands. 

If  the  above  premises  are  correct  they  suggest  that 
tertiary  syphilis  might  be  at  least  as  successfully  treated 
with  thyroid  as  with  iodides  ; indeed,  one  might  anticipate 
a quicker  result,  and,  moreover,  there  would  be  no  fear  of 
iodism. 

Summary. 

The  action  of  iodides  in  relieving  a condition  in  which  the 
thyroid  secretion  is  deficient  is  due  to  two  facts  : (1)  iodine 
is  specifically  absorbed  by  the  gland  ; (2)  the  iodine  in  the 
gland  in  saturating  the  unsaturated  fatty  acids  of  the  blood- 
supply  favours  the  autolysis  by  which  the  active  principle 
of  the  gland  is  produced.11 

The  efficacy  of  iodides  in  tertiary  syphilis  may  be 
explained  on  these  lines,  and  it  is  anticipated  that  tertiary 
syphilis  may  bg  successfully  treated  with  thyroid. 


* The  usefulness  of  cod-liver  oil  in  tuberculosis  may  be  in  part  due  to 
its  high  content  of  unsaturated  fatty  acids  limiting  to  some  extent  the 
production  of  thyroid  exoretion,  and  so  serving  to  prevent  the  absorp- 
tion of  the  lowly  organised  tubercle  tissue  and  the  setting  free  of  the 
bacillus. 


Clinical  Stoles : 

MEDICAL,  SURGICAL,  OBSTETRICAL,  AND 
THERAPEUTICAL. 


A CASE  OF 

NERVE  TRANSPLANTATION. 

By  Neville  I.  Spriggs,  M.D.  Lond.,  F.R.C.S.  Eng., 

CAPTAIN,  R.A.M.C.  (T.) ; MEDICAL  REFEREE  TO  MINISTRY  OF 
PENSIONS  ; CITY  POLICE  SURGEON,  ETC. 


Nerve  transplantation  now  being  on  its  trial  for  war 
injuries  of  nerves,  the  following  case,  though  only  partially 
successful,  is  deemed  worthy  of  record. 

The  Cate  Described. 

Pte.  S.  was  wounded  in  the  left  arm  on  Jan.  6th,  1916. 
There  was  a fracture  of  the  humerus  with  clinically  com- 
plete musculo-spiral  paralysis.  Several  operations  were 
needed  before  healing  occurred,  and  then  a large  scar 
resulted  very  adherent  to  the  bone.  On  Oct.  1st,  1917,  the 
musculo-spiral  nerve  was  exposed  and  found  to  be  com- 
pletely divided,  with  bulbs  adherent  to  the  bone.  After 
excision  of  the  bulbs  the  nerve  ends  could  not  be  stretched 
to  within  an  inch  of  each  other.  The  external  cutaneous 
nerve  of  the  thigh  was  then  searched  for,  and  found  with 
some  difficulty  as  it  was  abnormally  small.  A length  of 
two  inches  was  removed,  divided  at  its  middle,  and  the  two 
one-inch  lengths  so  formed  were  stitched  into  the  gap  in  the 
musculo-spiral  side  by  side.  A branch  to  the  triceps,  which 
was  also  implicated,  was  at  the  same  time  stitched  in  to  the 
upper  junction.  The  muscle  was  then  stitched  over  the 
bone,  between  it  and  the  bridged  nerve,  and  the  wound 
closed. 

The  wound  healed  well  and  the  man  was  shortly  after  dis- 
charged from  the  Army  and  went  to  reside  nearer  his  home 
in  the  north,  where  he  was  treated  by  electricity  and  massage 
as  an  out-patient.  It  was  thought  that  his  chance  of  recover- 
ing the  function  of  the  injured  nerve  was  very  small. 

He  was  next  seen  by  me  on  May  31st,  1918  (about  eight 
months  after  the  operation).  Epicritic  sensation,  which 
had  been  lost  on  the  outer  side  of  the  forearm  owing  to 
the  low  branching  of  the  nerve,  had  then  recovered.  The 
wasting  of  the  extensors  and  supinators  was  obviously  less. 
There  was  slight  but  definite  action  both  of  the  supinators 
and  of  the  extensors  of  the  wrist.  There  was  no  action  of 
the  extensors  of  the  fingers  and  thumb.  The  grasp  was 
good  and  the  man  was  starting  work.  He  was  supplied  with 
a “ long  cock-up  ” splint  and  told  to  wear  it  at  night  only. 

Result  of  Further  Examination. 

Another  examination  has  been  made  recently  (May,  1919). 
The  patient  has  been  working  since  last  seen.  There  is  fair 
power  in  the  supinators  and  in  the  wrist  extensors,  and  there 
is  slight  power  in  the  long  extensors  of  thumb  and  fingers, 
so  that  one  may  hope  that  the  man  will  still  continue  to 
improve. 

The  scar  in  the  arm  is  still  somewhat  adherent  to  the 
bone,  and  probably  to  the  repaired  nerve  also.  I con- 
sider that  had  more  attention  been  given  to  the  excision  and 
“toilet”  of  this  scar  a more  complete  and  earlier  recovery 
would  have  resulted. 

I am  indebted  to  Colonel  C.  J.  Bond  and  to  Dr.  Annie  C. 
Greenep  for  advice  and  help  in  this  case. 


A CASE  OF  STOMACH  AND  BOWEL  ATONY 
IN  INFLUENZAL  PNEUMONIA. 

By  Norman  Bradly,  M.D. 

In  The  La-ncet  of  March  15th  Mr.  R.  Eccles  Smith  has 
drawn  attention  to  this  condition  in  his  paper  on  “Influenzal 
Intra-abdominal  Catastrophes.  ” The  following  case  is  recorded 
to  show  the  value  of  pituitrin  in  this  condition. 

Account  of  Case. 

Miss  , aged  21,  was  taken  ill  on  March  4th  and 

developed  signs  of  pneumonia  on  the  9th.  Toxaemia  was 
profound,  haemoptysis  was  a recurring  symptom,  and  severe 
cyanosis  was  constant,  the  administration  of  oxygen  being 
almost  continuous.  On  the  15th  occasional  vomiting  of 
altered  blood  commenced  and  the  pulse  became  markedly 
intermittent ; on  the  18th  the  temperature  dropped  to  sub- 
normal. resp. 40-48,  pulse  96;  vomiting  persisted  and  became 


The  Lancet,] 


CLINICAL  NOTES. 


[Sept.  6,  1919  435 


almost  continuous;  everything  by  mouth  was  stopped  and 
replaced  by  salines  per  rectum  ; the  vomiting  became  less 
frequent,  but  recurred  at  once  on  allowing  anything  by  the 
mouth. 

On  the  20th  her  condition  was  desperate  ; temp,  subnormal, 
pulse  very  intermittent  and  infrequent  (50-60),  resp.  40-48, 
deeply  cyanosed,  persistent  vomiting,  petechial  haemorrhages 
under  skin  of  chest ; the  liver  dullness  absent,  upper  part  of 
abdomen  distended,  very  restless  and  no  sleep. 

Six  doses  of  pituitrin  (0  5 c.cm.  intramuscular  and  four- 
hourly)  were  given  ; in  addition  salines  per  rectum,  fomenta- 
tions, and  gentle  massage  to  abdomen.  Forty-eight  hours 
after  the  third  injection  of  pituitrin  the  vomiting  ceased, 
pulse  became  regular  and  more  frequent  (70-80).  Respira- 
tions 20.  The  temperature  had  been  subnormal  for  six 
days,  a rise  to  101°  now  occurred  and  gradually  came  down 
in  a few  days.  The  patient  made  an  uninterrupted  recovery. 
The  condition  was  without  doubt  acute  toxaomic  dilatation 
of  the  stomach  as  seen  in  several  post-mortems  on  these 
cases. 

Remarks. 

“Early  stomach  washing,”  as  suggested  by  Mr.  Eccles 
Smith,  would  no  doubt  have  helped  towards  recovery,  but 
was  quite  impossible  on  account  of  the  extreme  cyanosis  ; 
pituitrin  and  salines  saved  this  patient.  The  irregular,  and 
particularly  infrequent,  heart  action  as  an  additional  sign  of 
this  condition  may  be  worthy  of  note. 

Crowborough,  Sussex. 

A CASE  OF  LETHARGY. 

By  Grace  H.  Giffen  Dundas,  F.R.C.S.  Irel., 
D.P.H.  Camb. 

The  interest  in  this  case  lies  partly  in  the  question  of 
diagnosis — was  it  a case  of  encephalitis  lethargica  1 — and  in 
the  fact  that  the  patient,  being  intelligent,  was  on  con- 
valescing able  to  tell  something  of  her  psychological  state 
during  her  three  weeks’  cataleptic-like  condition.  I have 
permission  from  Dr.  G.  E.  Oates,  medical  superintendent  of 
the  Ilford  Isolation  Hospital,  to  report  the  case. 

Notes  of  Case. 

Previous  history.— Patient,  aged  26,  had  erysipelas  of  face 
and  scalp  four  years  ago;  very  ill,  high  temperature, 
delirium,  &c.  She  is  nervous  and  quick-tempered.  A few 
years  ago  she  took  up  shorthand  and  typewriting,  but  was 
too  “ nervous”  to  continue,  whereupon  she  confined  her- 
self to  housework  at  home,  at  which  she  is  very  energetic. 
She  was  very  nervous  during  air-raids,  trembling  violently. 
Three  months  before  her  present  illness  she  had  a great 
shock  on  hearing  that  a soldier  to  whom  she  had  been 
engaged  for  years  was  killed.  Her  mother’s  illness 
(bronchitis)  greatly  worried  her  during  the  three  months 
preceding  her  own  illness. 

Present  illness  began  on  Jan.  31st  with  a feeling  of  great 
restlessness.  Patient  had  great  difficulty  in  getting  through 
her  work  that  day.  For  a week  previous  to  this  she  had 
headache  and  constipation.  On  Feb.  1st  she  remained  in 
bed  thinking  she  had  “ a nervous  breakdown.”  That  night 
she  went  into  her  sister’s  bedroom,  not  liking  to  be  alone 
and  not  liking  the  dark.  She  got  worse  daily,  and  was 
admitted  to  the  Ilford  Isolation  Hospital  on  Feb.  6th. 

On  admission  patient  lay  supine  without  endeavouring  to 
make  the  slightest  movement.  Limbs  rigid.  Elbows  flexed 
and  forearms  lying  across  chest.  Sweating  profusely.  Sordes 
on  lips;  mouth  dry  and  dirty.  Severe  headache.  Pupils 
reacted  sluggishly  to  light.  Partial  ptosis  of  both  lids.  When 
asked  to  open  her  eyes  she  did  so  with  difficulty.  No  squint, 
no  diplopia,  no  evident  loss  of  vision  or  paralysis  of  accom- 
modation. Mask-like  expression  of  face.  Could  neither 
raise  her  eyebrows  nor  frown  ; could  not  smile  or  close  her 
eyelids  firmly,  or  close  her  lips  (upper  teeth  and  part  of  gum 
exposed) ; could  not  use  muscles  of  mastication.  Understood 
all  that  was  said.  Answered  with  difficulty  and  in  mono- 
syllables ; could  phonate,  but  articulated  badly.  Could  not 
depress  lower  jaw.  It  was  not  possible  to  ascertain  if  there 
was  sensory  paralysis  of  skin.  No  paralysis  of  taste.  Thus 
there  was  no  evident  paralysis  of  third,  fourth,  and  sixth 
nerves,  but  paralysis  of  motor  branch  of  fifth,  seventh, 
eleventh,  and  twelfth.  |Kernig’s  sign  was  absent ; knee- 
jerks  and  Babinski’s  sign  present.  Arms  and  legs  paralysed. 
Patient  gave  not  the  slightest  indication  of  being  aware  that 
one  was  manipulating  her.  The  back  was  red  in  places,  she 
not  having  been  moved  during  the  seven  days  she  had  lain 
m bed.  Menstruation  present,  bad  smelling  discharge. 

Treatment. — Patient  was  placed  on  a water  bed  and  put  on 
two-hourly  milk  feeds,  occasionally  varying  the  milk  with 
Valentine’s  beef  juice.  Mouth  toilet  was  attended  to. 
Catheterisation  and  enemata  were  given  when  required. 


Subsequent  history  until  March  13th,  when  patient  was  dis- 
charged well.  Temperature  dropped  to  normal  after  two 
days;  thereafter  subnormal.  Pulse  gradually  dropped  to 
80-90,  respirations  to  20.  She  slept  deeply  most  of  the  time. 
Bed-sores  occurred  during  the  first  week,  but  rapidly  healed 
when  she  began  to  move  a little.  Retention  of  urine  for 
the  first  few  days,  then  incontinence.  Constipation  was 
extreme.  Epsom  salts,  1 drachm  in  each  feed,  had  no 
result.  Two  large  soap-and-water  enemata  with  1 ounce 
ol.  ricini  were  retained.  The  gut  was  thereupon  washed 
out,  after  which  incontinence  set  in. 

It  was  difficult  to  feed  the  patient,  as  she  could  not  open 
her  jaw.  Fortunately,  one  or  two  teeth  were  absent.  She 
could  manage  nothing  but  fluids  for  the  first  fortnight,  after 
which  she  began  gradually  with  solids.  The  first  bite  of 
bread  and  butter  she  tried  had  to  be  taken  out  of  her  mouth 
again,  neither  the  power  of  mastication  nor  deglutition 
having  returned. 

Gross  tremors  of  the  limbs  formed  a prominent  sign, 
especially  marked  if  the  patient  tried  to  put  out  an  effort 
to  move  the  limb.  Movement  began  three  weeks  after  the 
beginning  of  the  illness,  first  seen  in  the  upper  lip  when 
asked  to  try  to  close  her  lips.  Each  day  thereafter  the 
orbicularis  oris  improved.  The  existing  light  did  not  allow 
of  a series  of  photographs  showing  the  daily  improvement 
in  frowning,  smiling,  &c.  Movement  in  the  arms  next 
came  back,  the  left  being  the  last  to  recover.  Then  followed 
movement  in  neck,  back,  and  lower  limbs,  the  left  leg 
being  the  last  to  recover.  Strychnine  was  cautiously 
exhibited  by  the  time  the  legs  began  to  recover. 

Sensations  of  Patient  during  Illness. 

No  emotional  symptoms  of  any  description  accompanied 
convalescence.  Patient  was  neither  hilarious  nor  depressed. 
She  voluntarily  showed  her  daily  progress  in  movements  and 
expressed  herself  as  grateful  to  the  nurses  for  everything 
done  for  her. 

She  willingly  told  of  her  sensations  during  the  three  weeks 
when  to  all  outward  appearance  she  had  no  sensations.  She 
thought  she  had  lain  five  weeks  without  movement.  There 
was  an  occasional  hiatus  in  her  mind  as  to  the  sequence  of 
events,  which  may  have  been  due,  of  course,  to  deep  sleep. 
When  awake  she  heard  all  that  was  said  and  would  willingly 
have  answered  the  questions  I asked  the  nurse  if  she  had 
had  the  power  to.  She  was  acutely  aware  of  catheterisation, 
incontinences,  &c.  She  had  terrifying  dreams  usually,  of 
someone  trying  to  do  her  a bodily  harm.  Occasionally  she 
had  a distinct  sense  of  well-being,  but  was  unable  to  say  if 
this  sense  followed  on  her  gut  being  emptied  or  what. 

She  had  lost  sense  of  position  and  direction,  having  no 
idea  of  how  her  legs  and  her  left  arm  were  placed.  Eyes 
and  teeth  seemed  misplaced,  her  eyes  up  at  the  roots  of  her 
hair  and  her  teeth  several  inches  in  front  of  her  mouth. 
She  resented  her  friends  trying  to  keep  her  awake  during 
the  visiting  hour.  She  resented  them  “chaffing”  her,  as 
she  “ could  not  chaff  them  back.”  I have  only  to  add  that 
the  ward  sister  resented  the  friends  expressing  surprise  at 
the  cure  nature  had  effected. 

No  case  of  encephalitis  lethargica  has  been  notified  in  this 
sanitary  area.  During  the  last  12  months  two  cases  of 
poliomyelitis  and  one  of  cerebro-spinal  fever  were  notified. 

A fortnight  after  the  patient’s  discharge  from  hospital — 
i.e. , two  months  from  the  commencement  of  her  illness — she 
was  perfectly  well  with  no  untoward  symptom,  either  mental 
or  motor. 


The  Dorset  Education  Committee  has  decided 
to  appoint  an  additional  assistant  medical  officer  at  a salary 
of  £450  per  annum. 

Housing  in  Belfast. — A scheme  has  been  evolved 
in  Belfast  (which,  however,  has  still  to  be  sanctioned  by  the 
Local  Government  Board),  under  which  it  is  hoped  that  the 
first  instalment  of  1500  houses  will  be  built  within  the  next 
year  at  an  estimated  cost  of  £1,000,000.  The  Corporation 
have  had  several  offers  of  sites  for  the  new  houses,  so  that  no 
difficulty  is  likely  to  arise  in  this  respect.  But  how  will 
a workman  pay  a rental  commensurate  with  the  enormous 
cost  of  building  houses?  Will  an  increased  city  rate  be 
acceptable  to  people  who  have  suffered  from  the  war  if  the 
great  industries  which  require  more  houses  contribute  only 
in  the  same  proportion  ? It  is  felt  that  the  ship-building 
companies,  who  have  earned  much  money  during  the  war, 
might  erect  the  houses  themselves  for  their  own  operatives 
as  part  of  their  business.  One  thing  is  clear — owing  to  its 
increasing  population,  Belfast  is  badly  in  need  of  working- 
class  houses. 


436  The  Lancet,] 


REVIEWS  AND  NOTICES  OF  BOOKS. 


[Sept.  6,  1919 


an )>  Itnlias  of 


The  Future  of  Medicine.  By  Sir  James  Mackenzie.  F.R.S., 

F.R.C.P.,  Consulting  Physician  to  the  London  Hospital. 

London  : Henry  Frowde  and  Hodder  and  Stoughton. 

(Oxford  Medical  Publications.)  1919.  Pp.  238.  8s.  6 d. 

Educational  reform  is  an  acknowledged  need  of  the 
present  day  and  the  new  Education  Act  is  an  earnest  and 
well-thought-out  attempt  to  satisfy  that  need  in  so  far  as 
general  education  goes.  If  a nation  is  not  to  drop  behind  in 
humanity’s  race  its  members  must  be  educated,  and  in 
addition,  they  must  be  placed  in  the  best  position  for  profiting 
by  the  education  supplied.  A prime  necessity  for  this 
desirable  condition  is  health,  for  no  sickly,  ill-developed,  or 
unhealthy  learner  can  use  the  knowledge  or  means  of 
knowledge  supplied  by  his  teacher  to  the  best  advantage. 
This  being  so,  the  next  necessity  is  that  that  portion  of  the 
community  in  whose  hands  lies  the  preservation  of  the 
nations  health — namely,  the  medical  profession — should 
learn  how  to  carry  out  the  great  work  entrusted  to  them  in 
the  best  and  most  profitable  manner.  This  is  the  simple 
message  from  Sir  James  Mackenzie  to  his  fellow-students 
contained  in  this  book  Over  and  over  again  it  has  been  said 
in  different  ways  and  with  different  arguments,  so  that  no 
one,  medical  or  lay,  will  be  found  to  dispute  the  proposition  ; 
there  is  plenty  of  room  for  its  enthusiastic  support,  and 
never  has  there  been  provided  finer  advocacy  than  that  of 
Sir  James  Mackenzie. 

Despite  all  the  advances  which  have  been  made  in  medical 
science  during  the  last  50  years,  no  one  realises  more  keenly 
than  do  medical  men  themselves,  that  our  knowledge  of 
disease  practically  only  begins  when  the  patient  is  already 
more  or  less  damaged,  and  that  though  the  ideal  of  medicine 
is  “ pricipiis  obsta,”  yet  only  in  very  few  instances  are  we 
able  to  carry  out  this  precept.  Teaching  is  at  fault,  teachers 
are  at  fault,  examinations  are  at  fault,  and  consequently 
practice  is  hampered  ; even  while  in  this  country  our  tests  are 
fair,  our  examinations  standardised,  and  our  instructors  in  the 
main  keen  and  often  distinguished,  if  poorly-paid  men. 
Sir  James  Mackenzie  treats  in  admirably  simple  language, 
and  with  a wealth  of  illustration,  the  position  outlined  above, 
and  is  able  to  do  so  from  a strong  position,  for  he  has  per- 
sonally triumphed  over  the  difficulties  which  lie  ahead  of  the 
reformer,  and  has  vastly  improved  medical  practice  by  his 
personal  teaching.  His  thesis  includes  three  heads,  which 
seem  obvious  to  absurdity  and  yet  are  apparently  but  little 
realised.  Shortly,  they  are  as  follows  : 1.  If  a problem  is  to 
be  solved,  the  nature  of  the  problem  and  its  difficulties 
should  first  be  comprehended.  2.  Disease  is  only  made 
manifest  by  the  symptoms  which  it  produces,  and  to  get  a 
thorough  understanding  of  disease  we  must  recognise  the 
symptoms  not  merely  by  detecting  their  presence,  but  by 
understanding  the  mechanism  of  their  production  and  their 
bearing  on  the  health  of  the  patient.  3.  He  who  conducts 
the  investigation  should  have  had  the  opportunity  of  seeing 
disease  in  all  its  phases,  and  of  observing  the  various  sym- 
ptoms which  it  produces.  Allow  these  premises,  and  it 
follows  that  only  one  class  of  individual  has  the  opportunity 
for  acquiring  the  knowledge,  and  that  is  the  class  of  the 
general  practitioner.  This  position  leads  Sir  James 
Mackenzie  to  a chapter  upon  medical  education  wherein 
he  puts  his  finger  upon  one  of  the  weak  points  in 
the  present  system  of  medical  education — namely, 
its  divorce  from  the  work  of  the  general  practitioner. 
The  average  teacher  either  has  no  experience  of  the 
difficulties  which  the  majority  of  his  pupils  will  meet  with 
in  their  life’s  work,  or  if  he  has  had  any  experience  of  such 
difficulties  in  his  own  training  he  seems  to  have  forgotten 
them. 

It  must  have  occurred  to  many  persons  of  intelligence— 
both  teachers  and  taught — that  books  written  with  the  idea 
of  instruction  might  well  be  written  not  by  a master  of  his 
subject  alone,  but  in  collaboration  with  an  intelligent  learner. 
The  master  might  write  a chapter  and  then  hand  it  over  to 
the  learner  for  comment  and  the  latter  could  then,  when  he 
came  to  a passage  which  puzzled  him,  say  “What  do  you 
mean  when  you  say  this?”  Written  after  this  manner,  a 
book  would  gain  infinitely  in  value  as  an  educational 
agency,  but  the  teaching  in  hospitals,  which  are  at  present 


I the  only  schools  of  medicine,  cannot  be  conducted  after 
the  same  model.  The  value  of  the  old  apprenticeship  system, 
the  return  of  which  we  are  not  advocating,  was  that  it 
offered  personal  communication  between  the  learner  and  a 
teacher  who  was  living  and  working  under  the  very 
difficulties  which  the  learner  would  one  day  have  to  deal 
with.  At  the  present  day,  says  Sir  James  Mackenzie,  the 
student  is  instructed  by  a number  of  teachers  not  one  of 
whom  has  had  any  experience  of  the  life  he  is  to  lead  as  a 
general  practitioner  ; and,  moreover,  the  general  practitioner, 
who  has  sometimes  suffered  from  a defective  education,  is 
never  consulted  on  educational  matters.  In  the  system  of 
apprenticeship,  however,  there  would  never  be  any  guarantee 
that  the  master  was  able,  or  had  the  leisure,  to  teach  the 
pupil  properly,  so  that  the  system  can  find  no  place  in  a 
standardised  curriculum. 

We  have  said  enough  to  indicate  the  line  of  argument 
which  Sir  James  Mackenzie  pursues,  and  we  think  that  his 
suggestion  that  in  every  school  of  medicine  there  should  be 
one  or  more  teachers  who  have  passed  through  10  to  20 
years  of  general  practice  is  an  admirable  one.  We  can  see  no 
better  method  of  supplying  teachers  who  have  a knowledge 
at  first  hand  of  what  ought  to  be  taught. 


Text-booh  of  Ophthalmology.  By  Hofrath  Ernst  Fuchs, 
former  Professor  of  Ophthalmology  in  the  University  of 
Vienna.  Authorised  translation  from  the  twelfth 
German  edition,  by  Alexander  Duane,  M.D.  Sixth 
edition.  London  and  Philadelphia : J.  B.  Lippincott 
Company.  Pp.  1067.  30*. 

This  text-book  is  too  well  known  to  need  recommenda- 
tion. The  present  edition  is  nearly  a reprint  of  the  fifth 
which  appeared  two  years  ago,  but  the  changes  between  the 
fifth  and  earlier  editions  were  numerous  and  important.  For 
these  Professor  Duane  is  almost  wholly  responsible.  No  new 
German  edition  has  appeared  for  some  years,  and  the  book, 
though  based  on  Fuchs’s  original  text,  tends  to  become  more 
and  more  the  work  of  the  American  translator.  Its  com- 
posite nature  remains,  and  in  most  parts  additions  and 
alterations  are  indicated  by  the  use  of  brackets  and 
the  translator’s  initial  D.  Some  parts  are  rewritten  ; 
for  instance,  the  chapter  on  disturbances  of  motility, 
a subject  which  the  translator  has  made  peculiarly  his 
own.  All  this  tends  to  increase  the  bulk  of  the  volume. 
And  yet  in  parts  it  still  needs  to  be  brought  up 
to  date.  In  the  chapter  on  Glaucoma,  for  example,  we 
find  a good  deal  about  the  older  theories  of  its  pathology, 
but  no  sufficient  directions  for  taking  the  visual  fields,  or  of 
their  importance  in  early  diagnosis.  Again,  the  older 
theories  of  colour  blindness  are  explained  at  considerable 
length,  but  the  newer  ones  nearly  ignored.  For  the 
beginner  we  should  recommend  a smaller  text-book,  but  as 
a book  of  reference  and  for  the  advanced  student,  the  work 
of  Fuchs  will  still  be  deservedly  popular.  The  chapter  on 
Diseases  of  the  Cornea  and  the  sections  on  Pupillary 
Reactions  are  hard  to  beat.  Therefore,  we  say  that  for  anyone 
who  has  time  to  study  the  book  in  its  entirety  it  will 
doubtless  be  of  great  value,  but  he  will  soon  discover  that, 
in  a subject  which  is  alive,  no  single  text-book  can  possibly 
be  sufficient  for  all  that  he  will  need.  Especially  in  the 
chapter  on  Operations,  more  references  would  be  useful,  so 
that  the  full  description  of  any  particular  operation  that 
the  operator  is  at  all  likely  to  require  could  be  easily 
found  at  a library.  The  same  principle  might  perhaps  be 
applied  to  the  rarer  diseases  and  to  important  observations 
relating  to  the  commoner  ones. 


Auto-Erotic  Phenomena  in  Adolescence.  By  K.  Menzies. 

With  a foreword  by  Dr.  Ernest  Jones.  London  : H.  K. 

Lewis  and  Co.,  Ltd.  1919.  Pp.  via.  + 88.  4*.  6 d. 

There  is  so  much  nonsense  written  on  the  subject 
of  masturbation  that  such  an  analytical  study  of  the 
psychology  and  psycho-pathology  of  onanism  as  has  been 
prepared  in  this  small  volume  has  become  an  un- 
pleasant necessity.  Mr.  Menzies  has  real  widely  in  bis 
subject  and  writes  as  a psychologist.  The  mental 
conflict  engendered  by  false  conceptions  of  this  habit  is 
considered  to  be  the  most  serious  aspect  of  the  problem. 
Whether  it  is  necessary  to  invoke  the  aid  of  psycho-analysis 
in  treatment  of  the  numerous  sufferers  is  a question  the 
reader  will  answer  according  to  his  belief  in  this  method  of 


The  Lancet,] 


REVIEWS  AND  NOTICES  OF  BOOKS. 


[Sept.  6,  1919  437 


psychotherapy.  When  once  the  condition  itself  is  properly 
understood,  a little  common  sense  and  a rational  education 
of  the  young  may  well  make  the  somewhat  painful  and 
cumbersome  efforts  of  the  skilled  psycho-analyst  unnecessary. 
But  whatever  we  think  of  Mr.  Menzies’s  views  of  treatment, 
or  of  his  ethical  considerations,  we  cannot  but  be  grateful 
that  he  has  handled  his  subject  in  a sane  way.  In  the 
result  he  has  achieved  nothing  new,  but  he  has  made 
available  in  a small  compass  the  experience  and  conclusions 
of  many  writers  whose  opinions  are  worth  knowing. 


A Short  Practice  of  Medicine.  By  Robert  A.  Fleming, 
M.A.,  M.D.,  F.R.C.P.E.,  F.R.S.E.,  Lecturer  on  Practice 
of  Medicine,  School  of  the  Royal  Colleges,  Edinburgh  ; 
Senior  Lecturer  on  Clinical  Medicine,  Edinburgh  Uni- 
versity ; Physician,  Royal  Infirmary,  Edinburgh.  Third 
edition.  London  : J.  and  A.  Churchill.  1919.  Pp.  676. 
21s. 

The  purpose  of  this  manual  is  to  provide  students  attend- 
ing lectures  on  medicine  with  a general  synopsis  of  that 
subject.  The  author  suggests  that  its  use  will  free  the 
teacher  from  dictating,  year  in  and  year  out,  statements  which 
can  be  mastered  as  well,  if  not  better,  from  a text-book.  It 
is  perhaps  not  surprising  that  the  index  of  a text-book  on 
the  practice  of  medicine  contains  no  reference  to  acidosis 
or  vagotonia,  but  when  one  looks  in  vain  for  colon 
bacilluria  or  encephalitis  lethargica  one  is  forced  to  the 
conclusion  that  the  writer  either  has  Dot  taken  the  full 
advantage  which  a new  edition  offers  for  the  inclusion 
of  new  material,  or  considers  such  subjects  more  suited  to 
oral  instruction.  However  this  may  be,  the  opportunity  has 
been  taken  to  rewrite  and  bring  up  to  date  the  descriptions 
of  many  diseases,  and  various  medical  diseases  met  with 
during  the  war,  such  as  trench  fever  and  trench  nephritis, 
have  received  recognition.  The  book  is  arranged  on  the 
usual  plan  adopted  in  works  of  systematic  medicine.  We 
notice  that  rickets,  scurvy,  and  beri-beri  are  classed  together 
as  diseases  due  to  faulty  nutrition.  Rheumatoid  arthritis 
is  not  very  clearly  distinguished  from  osteo-arthritis  and 
is  found,  with  osteomalacia,  hypertrophic  pulmonary  osteo- 
arthropathy, osteitis  deformans,  and  achondroplasia,  under 
diseases  of  bones  and  joints.  No  mention  is  made,  we 
observe,  of  the  association  between  diabetes  insipidus 
and  morbid  change  in  the  pituitary  body,  but  the  writer  of 
a synopsis  has  to  confine  his  work  within  definite  limits, 
so  that  some  omissions  become  imperative,  the  author 
being  the  arbiter.  The  old  anatomical  terminology  is 
used  throughout  the  book  and  we  think  the  author  is  to  be 
commended  on  its  retention  ; for  the  sake  of  those  who  are 
accustomed  to  the  international  nomenclature  a table  of 
such  equivalent  terms  in  the  two  systems  as  have  been  made 
use  of  in  the  text  is  provided.  Several  new  illustrations 
have  been  added  and  these  now  number  64,  nearly  half  of 
them  occurring  in  the  section  devoted  to  diseases  of  the 
nervous  system. 

The  book  provides  a very  fair  summary  of  the  current 
views  on  medicine,  but  we  are  inclined  to  think  it  is  likely 
to  prove  of  greater  use  to  students  than  to  practitioners. 


A Text-looh  of  Practical  Therapeutics.  By  Hobart  Amory 
Hare,  M.D.,  B.Sc.,  Professor  of  Therapeutics,  Materia 
Medica,  and  Diagnosis  in  the  Jefferson  Medical  College 
of  Philadelphia  ; Physician  to  the  Jefferson  Medical 
College  Hospital.  Seventeenth  edition.  London  : Henry 
Kimpton.  1919.  Pp.  1024.  28s. 

This  work  thoroughly  justifies  its  title  of  “ practical  thera- 
peutics with  especial  reference  to  the  application  of  remedial 
measures  to  disease  and  their  employment  upon  a practical 
basis.”  Although  there  is  of  necessity  a certain  amount  of 
theoretical  discussion  the  practical  element  is  never  lost 
sight  of.  Great  care  has  been  taken  to  bring  this  edition 
fully  up  to  date,  and  so  many  alterations  and  additions  have 
been  found  necessary  that  a large  part  of  it  has  been  reset  in 
new  type.  Though  we  are  dealing  with  a seventeenth 
edition,  it  is  not  an  old  treatise. 

Most  of  the  book  is  taken  up  with  a consideration  of 
“drugs.”  Under  this  heading  the  various  preparations  used 
in  the  practice  of  medicine  are  fully  discussed.  A uniform 
method  is  adopted  throughout.  A description  is  first  given 
of  the  drug,  then  its  physiological  action  is  explained  at 
sufficient  length  to  enable  the  reader  to  appreciate  fully  its 
effect  upon  the  various  systems  of  the  body.  Next,  its 


therapeutic  use  is  considered,  and  the  indications  for  its 
employment.  The  mode  of  administration  is  also  explained, 
and  when  necessary  the  symptoms  of  poisoning  are  also  given. 
In  the  preface  Professor  Hare  remarks  that  “ many  important 
drugs  heretofore  made  in  Germany,  or  under  German 
patents,  are  now  made  in  this  country  and  have  been  given 
names  whereby  they  may  be  properly  designated.”  It  may 
be  that  practitioners  will  not  at  first  recognise  these  names  ; 
for  instance,  the  word  arsphenamine  is  adopted  for  salvarsan 
(although  in  the  full  description  which  follows  the  name 
salvarsan  is  retained  throughout)  ; procaine  is  substituted  for 
novocaine,  and  barbital  for  veronal. 

Experience  during  the  war  has  increased  the  knowledge  in 
relation  to  shock,  and  has  emphasised  the  need  of  careful 
methods  of  intravenous  injection  or  of  direct  transfusion  ; 
therefore  the  technique  of  these  procedures  is  fully  and 
clearly  described.  The  use  of  Dakin’s  fluid  and  dichloramine-T 
by  Carrel’s  methods  is  also  discussed.  We  would  draw 
attention  to  the  valuable  remarks  on  chloroform  and  the 
method  of  its  administration.  The  section  of  the  book 
dealing  with  the  treatment  of  various  diseases  will  be 
appreciated  by  practitioners,  as  will  also  be  the  index  of 
diseases  and  remedies. 

We  believe  that  this  work  will  particularly  appeal  to  those 
in  general  practice,  who  will  find  it  a useful  work  of  refer- 
ence ^ the  material  contained  in  it  is  essentially  practical, 
and  owing  to  the  general  arrangement  of  the  book  the 
information  required  can  be  easily  found. 


Anti-malaria  Worh  in  Macedonia : By  W.  G.  Willoughby, 

M.D.,  and  Louis  Cassidy,  M.B.  With  14  plates. 

London  : H.  K.  Lewis  and  Co.  1918.  Pp.  x.  + 68. 

3s.  6 d.  net. 

The  authors  in  their  preface  to  this  little  book  of  about 
50  pages  of  text  expressly  state  that  it  is  “ not  intended  as 
a scientific  work,”  after  which  we  cannot  expect  the  subject- 
matter  to  be  treated  in  a scientific  way,  though  the  authors’ 
efforts  are  commendable.  But  we  must  express  our  sorrow 
that  it  should  be  necessary  to  issue  a book  of  this  kind  for 
the  use,  apparently,  of  medical  officers.  If  we  may  read 
between  the  lines,  the  authors  appear  to  have  had  to 
struggle  against  “regulations”  and,  indeed,  to  put  it 
bluntly,  against  ignorance,  for  on  p.  65  they  say  cooperation 
in  anti-malarial  measures  is  far  more  satisfactory  when  its 
basis  is  intellectual.  We  see  no  indication  that  the  authors 
lived  in  an  atmosphere  of  research.  What  anopheline  or 
anophelines  were  the  carriers,  what  percentage  of  these 
were  infected,  what  was  the  infection  rate  amongst  the 
indigenous  population  and  the  troops,  what  were  the 
breeding-places  of  the  transmitting  species,  are  not  stated. 
It  is  information  such  as  only  specially  trained  medical  men 
could  give.  We  believe  that  an  anti-mosquito  campaign 
can  only  be  scientifically  and  economically  carried  out  if 
these  factors  are  known,  and  that  it  is  unscientific  to  pro- 
ceed in  the  dark  and  take  measures  against  all  anophelines. 
Suppose,  for  instance,  that  the  main  carrier  is  a species 
restricted  in  numbers  with  restricted  breeding-places,  a 
supposition  that  in  certain  cases  actually  agrees  with  the 
facts,  then  it  is  good  policy,  especially  where  labour  is  a 
difficult  question  or  money  is  scarce,  to  proceed  against  this 
species  first. 

This  book,  then,  gives  the  impression  that  research  was 
not  in  progress  in  the  field  of  malaria  operations  in 
question.  The  authors,  however,  believe  that  the  actual 
anti-malaria  operations  were  successful,  though  the  data 
for  forming  an  independent  opinion  are  not  given. 


Life  and  Its  Maintenance : A Symposium  of  Biological 

Problems  of  the  Day.  London,  Glasgow,  and  Bombay  : 
Blackie  and  Sons,  Ltd.  1919.  Pp.  297.  5s. 

Lectures  on  Sex  and  Heredity , delivered  in  Glasgow , 1917 - 
1918.  By  F.  0.  Bower,  J.  Graham  Kerr,  and  W.  E. 
Agar.  London:  Macmillan  and  Co.,  Ltd.  1919. 

Pp.  120.  5s. 

The  first  of  these  books  is  a volume  of  15  lectures  which 
were  delivered  to  a mixed  audience  at  University  College, 
London,  during  the  spring  of  1918  and  which  were  designed 
to  deal  with  the  vital  war  problems  such  as  the  supply, 
nutritional  value,  and  production  of  food,  the  physiological 
aspects  of  flying,  the  anaerobic  treatment  of  wounds,  and 
industrial  efficiency  and  fatigue,  the  lecturers  being  selected 
from  professorial  chairs  of  the  universities  of  the  country  or 


438  The  Lancet,]  REVIEWS  AND  NOTICES  OF  BOOKS.— SOOlfiTfi  DE  BIOLOGIE. 


[Sept.  6,  1919 


from  important  institutions  for  research  such  as  the  Lister 
Institute  of  Preventive  Medicine.  Although  the  lectures  were 
called  forth  by  the  exigencies  of  war,  they  cannot  but  have 
an  important  bearing  in  times  of  peace,  more  especially 
during  the  reconstruction  period,  in  the  throes  of  which  we 
now  are.  The  Problem  of  Food,  by  Professor  William 
Bayliss,  and  War  Bread  and  its  Constituents,  by  Professor 
F.  G.  Hopkins,  discuss  important  matters  which  expanding 
populations  and  economic  needs  make  vital,  while  Vitamines, 
by  Miss  E.  Margaret  Hume,  is  a subject  equally  urgent  in 
its  bearings.  Professor  Cushny’s  lecture  on  Alcohol  and 
other  Beverages  in  War  Time,  while  not  encroaching  upon 
the  controversy  which  is  engaging  the  attention  of 
America  at  the  present  moment,  and  which  in  the  near 
future  may  react  upon  our  own  country,  inquires  how 
far  beer,  and  incidentally  domestic  beverages,  may  be 
regarded  as  food.  The  Physiological  Aspects  of  FlyiDg,  by 
Lieutenant-Colonel  Martin  Flack,  will  be  read  with  interest 
now  that  the  commercial  possibilities  of  aviation  are  some- 
thing more  than  a dream,  and  the  subjects  of  Efficiency  and 
Fatigue  and  Fresh  Air  and  Efficiency,  respectively  dealt  with 
by  Dr.  H.  M.  Vernon  and  Professor  H.  R.  Kenwood,  are 
matters  with  which  the  new  Ministry  of  Health  will  have 
much  to  do. 

The  lectures  on  Sex  and  Heredity  deal  with  a somewhat 
abstruse  subject  in  simple  language.  Scientific  terms  are jreely 
introduced,  but  their  definition  is  repeated  in  paraphrase 
again  and  again  as  occasion  suggests,  while  abundant  illus- 
trations and  a glossary  further  help  the  reader.  No  indica- 
tion is  given  as  to  where  or  to  what  audience  in  Glasgow  the 
lectures  were  delivered,  but  presumably  they  were  given  in 
the  University,  as  two  of  the  three  lecturers  are  respectively 
Regius  professors  of  botany  and  zoology  there.  The  aim 
is  to  give  the  leading  facts  in  relation  to  sex  in  animals 
and  plants,  together  with  suggestions  bearing  on  the  use 
and  effect  of  sexual  propagation,  and  this  has  been 
abundantly  fulfilled.  The  lectures  make  a simple  and 
admirable  introduction  to  such  subjects  as  race  regeneration 
and  eugenics,  which,  after  the  devastations  of  war,  are  likely 
to  occupy  the  minds  of  thoughtful  people  for  many  years  to 
come. 


The  Urethroscope  in  Diagnosis  and  Treatment  of  Urethritis. 

By  Major  N.  P.  L.  Lumb,  O.B.E.,  R.A.M.C.  (T.C.). 

London  : John  Bale,  Sons,  and  Danielsson,  Ltd.  1919. 

Pp.  52.  10s.  6 d. 

This  book  performs  two  useful  tasks : First,  it 

emphasises  the  necessity  for  the  use  of  the  urethroscope 
in  all  cases  of  urethritis ; and,  secondly,  it  gives  to  the 
practitioner  some  idea  as  to  what  he  may  expect  to  find  by 
looking  through  the  instrument.  The  illustrations,  which 
are  all  coloured,  are  quite  good,  although  perhaps  a little 
diagrammatic  in  places,  but  suffer  from  the  disadvantage 
that  the  references  in  the  text  necessitate  a repeated  turning 
over  of  pages.  Still,  this  is  a minor  point.  The  advantages 
of  the  Wyndham  Powell  aero-urethroscope  are  wisely  taken 
into  account.  The  author  does  not  pretend  that  the  book  is 
complete.  It  is  a useful  contribution  in  that  it  depicts  in 
the  illustrations  the  effect  of  treatment  on  the  pathological 
condition  found  in  cases  of  urethritis. 


Ten  Lectures  on  Field  Sanitation.  By  C.  B.  Moss-Blundell, 
M.D.,  D.P.H.  ; Captain,  R. A.M.C.  (T.F.).  London^ 
Aldershot,  and  Portsmouth  : Gale  and  Polden.  1919 
Pp.  134.  5s. 

This  book,  which  has  a commendatory  introduction  by 
Major-General  Gerald  Cree,  contains  a series  of  lectures 
delivered  by  the  author  at  a school  of  sanitation  in  France  of 
which  he  was  the  commandant,  and  their  object  is  to  teach 
the  practical  side  of  sanitation  in  the  field.  The  lectures 
discuss  the  general  principles  which  underlie  the  sanitary 
problem  in  active  service,  the  details  of  the  syllabus  embracing 
the  dangers  from  horse  manure  and  the  menace  of  flies, 
the  disposal  of  excreta  and  refuse,  the  method  of  dealing 
with  water-supplies,  food,  and  disinfection.  Diagrams 
are  freely  used  in  elucidation  of  the  text.  The  author,  who 
ia  county  medical  officer  of  health  for  Huntingdonshire,  has 
brought  to  the  compilation  of  the  lectures  a wide  experience 
of  sanitary  matters  gained  both  before  and  during  the  war, 
and  his  treatment  of  the  subject  will  prove  valuable,  not 
only  to  R.A.M.C.  officers,  but  also  to  officers  in  other 
branches  of  the  service. 


JOURNALS. 

In  the  Military  Surgeon  for  July,  Colonel  B.  K.  Ashford 
completes  a lecture  on  Field  Hospitals,  in  which  he  tells 
the  newly  arriving  officers  of  the  American  Medical  Corps 
what  they  should  aim  at  in  providing  accommodation 
for  their  wounded.  The  wounded  sent  back  from  the 
advanced  dressing  station  are  examined  at  the  field  ambu- 
lance and  there  sorted  as  to  their  next  destinations.  This 
sorting  or,  as  the  French  call  it,  triage,  must  never  be  done 
except  at  a place  where  there  is  a chance  of  dealing  with 
grave  emergencies.  Therefore,  he  says,  in  action  the  field 
ambulance  must  be  able  to  deal  with  cases  of  haemorrhage, 
shock,  severe  compound  fractures,  chest  and  abdominal 
cases,  all  untransportable,  and  consequently  it  must  be 
strengthened  in  time  of  action  by  an  advanced  surgical 
section  and  a radiologist.  He  discusses  the  French  and 
English  field  hospitals  as  he  has  seen  them,  and  notes 
how  field  ambulances  are  in  turn  taken  out  of  the  line 
and  made  to  do  duty  as  gas  hospitals,  rest  stations, 
hospitals  for  medical,  infectious,  or  scabies  cases.  He 
gives  high  praise  to  the  British  for  cleanliness.  Never, 
he  says,  has  he  smelt  faeces  in  the  British  lines;  their 
latrines  may  never  be  near  their  kitchens,  which,  like 
the  cooks,  are  spotless.  Many  trades  were  represented 
about  the  hospitals  of  rest — tailors,  cobblers,  saddlers. 
Much,  too,  was  done  for  the  comfort  of  the  men,  who 
had  a gymnasium,  library,  entertainments,  theatricals, 
and  plenty  of  open  air,  so  that  80  per  cent,  go  back  to  their 
units.  Colonel  Ashford  expresses  a high  opinion  of  the  French 
Bessoneau  tent,  of  their  mobile  surgical  units,  and  of  their 
hospitals  for  gassed  cases.  He  notices  that  in  one  attack 
only  some  15  of  those  supposed  gassed  were  really  so ; the 
others  were  mentally  and  physically  exhausted,  but  they, 
too,  required  treatment.  In  the  same  issue  Major  G.  A. 
Soper  recounts  the  history  of  the  notorious  “ Typhoid  Mary,'' 
Who  in  18  years  is  believed  to  have  originated  ten  outbreaks 
of  enteric  while  acting  as  a cook  in  various  circumstances. 

Journal  of  the  East  Africa  and  Uganda  Natural  History 
Society.  July,  1919.  London  : Longmans,  Green,  and  Co. 
5s.  4d.  to  non-members. — This  number  contains  two  papers  of 
medical  interest,  Major  C.  E.  Soutbon’s  description  of  plague 
and  its  history,  and  Mr.  R.  E.  Montgomery’s  story  of  insects 
in  relation  to  the  diseases  of  stock.  Dr.  J.  H.  H.  Pirie  has  a 
note  on  the  Eburru  steam  jets  (natural  emanations  of  hot 
aqueous  vapour  from  the  ground),  some  of  which  have  been 
used  for  obtaining  a water-supply,  the  steam  being  condensed 
on  metal  plates.  Mr.  Y.  G.  L.  van  Someren  sends  some  notes 
on  East  African  birds  and  on  the  European  crane,  and  Dr.  R. 
van  Someren  is  responsible  for  a group-picture  of  sacred 
ibis,  cormorants,  and  stone  curlew  on  an  island  on  the 
Victoria  Nyanza.  A contributor  asks  whether  albinism  is 
only  found  among  males  in  South  Africa,  as  in  the  half  a 
dozen  cases  he  has  met  with  he  has  never  seen  an  albino 
woman,  and  another  contributor  describes  an  albino  child 
at  Mlalende,  south-east  of  the  Taita  Hills;  this  boy  was 
about  10  years  of  age,  with  skin  and  hair  quite  white.  The 
eyes  were  of  a watery  blue,  and  he  complained  of  the  bright 
sunlight.  There  were  marks  on  his  face  resembling  very 
large  freckles,  and  his  lips  were  badly  blistered  by  the  sun. 
The  boy  seemed  intelligent,  and  his  father,  mother,  and  two 
sisters  were  all  quite  black. 


SOCIETE  DE  BIOLOGIE,  PARIS. 

At  a meeting  of  this  society  held  on  July  26th  the 
following  papers  were  read  : — 

Dubois. — Pseudo-cellules  Symbiotiques  Anaerobies  et 

Pathogenes. 

On  peut  obtenir  des  pseudo-cellules  pathogenes  et  meme  des  pseudo- 
tissus  parenchymal  eux  avec  des  photobacteries,  mais  eela  ne  peouve 
pas  que  les  cellules  animales  ou  vegetales  en  general  et  en  particulier 
lea  cellules  pathoghnes,  solent  formees  par  des  agglomerations  micro- 
biennes. 

Le  Moignic  et  Sezary.— Lesions  Pulmonaires  Consecutives 
aux  Injections  Intraveineuses  d’Huiles  Vegetales. 

Des  injections  intra-veineuses  uniques  ou  rarement  repetees,  d'une 
dose  d'huile  d'olive  variant  de  0,0  3 c.cm.  a 0,2  c.cm.  par  kilogramme 
d’animal,  ne  determinant  que  des  alterations  legeres  du  poumon.  Des 
injections  repetees  15  a 30  fois  provoquent  une  sclerose  interstitlelle 
diffuse,  enserrant  les  alveoles,  diminuant  notablement  le  champ  de 
l'hematose.  L’incorporation  a l'huile  de  substances  medicamenteuses 
produit  des  lesions  graves  de  bronchopneumonia  necrotique.  L’huile 
camphree  seule  est  bien  toleree  experimentalement. 

Le  Moignic  et  Norero.— Recherches  sur  la  Distribution  des 
Huiles  Injectees  dans  la  Trachde. 

On  injects  a un  gros  chien  par  piqure  de  la  trachea  de  petites 
quantites  d’huile  eoloree  par  des  substances  peu  ou  non  diffusible-. 
Autopsie  apn's  24  heures.  L'huile  ne  se  departit  pas  en  definitive  dans 
tout  le  parenchyme  pulmonaire,  elle  se  rend  surtout  a des  lobules  des 
parties  inferieures  du  poumon  ; il  est  rare  qu’elle  se  distribue  abondam- 
ment  au  lobe  superieur. 


The  Lanoet,] 


THE  FUTURE  OF  LIQUOR  CONTROL. 


[Sept.  6,  1919  439 


THE  LANCET. 


LONDON:  SATURDAY,  SEPTEMBER  G,  1919. 


The  Future  of  Liquor  Control. 

In  view  of  the  approaching  extinction  of  the 
Liquor  Control  Board  and  the  proposed  establish- 
ment, in  its  place,  of  a permanent  authority  directly 
responsible  to  Parliament,  special  interest  attaches 
to  the  speech  delivered  by  Lord  D’Abernon  at 
Carlisle  last  week  dealing  with  the  future  of 
drink  policy  in  this  country.  Lord  D’Abernon 
was  in  the  position  of  being  able  to  point  to  a 
record  of  successful  administration  in  a difficult 
sphere  where  generations  of  reformers  and  legis- 
lators have  failed.  At  a time  when  public  opinion 
is  showing  itself  much  more  alive  to  the  short- 
comings than  to  the  achievements  of  the  State  in 
the  many  unusual  activities  thrust  upon  it  by  the 
war,  the  Liquor  Control  Board  stands  out  as  a 
department  of  the  Government  whose  work  during 
the  national  emergency  has  won  general  recog- 
nition not  merely  for  its  accomplishment  of 
the  immediate  purpose  for  which  it  was  created, 
but  also  as  having  made  a contribution  of 
permanent  value  to  the  solution  of  a notoriously 
difficult  social  problem.  We  know  all  the  direc- 
tions from  which  the  Liquor  Control  Board  has 
been  criticised,  but  the  fact  emerges  that  when 
something  had  to  be  done  the  Board  did  it  success- 
fully. And  readers  of  Lord  D’Abernon’s  speech 
will  not  be  at  a loss  to  find  the  explanation  of  this 
success. 

The  history  of  liquor  legislation  in  the  past  has 
been  marked  by  an  entire  blindness  to  the  fact  that 
the  problem  of  alcoholism  is  in  a very  large  and 
important  measure  a problem  of  pharmacology. 
Lord  D’Abernon,  with  the  intuition  of  statesman- 
ship, and  with  the  even  more  useful  quality  of 
being  able  to  trust  scientific  advice,  grasped  this 
fundamental  and  neglected  truth.  The  potential 
efficacy  of  legislation  against  intemperance  depends 
largely  on  the  fact  that  the  conditions  which 
physiology  indicates  as  necessary  to  prevent  the 
injurious  action  of  alcohol  appear  generally  to  be 
such  as  can  be  adequately  secured  by  legislation 
or  regulative  measures.  When,  for  example,  the 
physiologist  teaches  that  alcohol  gets  into  the 
blood  very  quickly  and  gets  out  of  it  very 
slowly,  and  that  its  persistent  presence  in  the 
system  is  the  main  cause  of  chronic  alcoholic 
poisoning,  the  obvious  precaution  is  the  quite 
feasible  one  of  providing  against  public-houses 
being  open  for  long  continuous  periods.  Similarly, 
when  it  is  shown  that  an  alcoholic  drink  taken  in 
dilution  is  very  much  less  injurious  than  the  same 
dose  taken  in  an  unduly  concentrated  form,  the 
obvious  precaution  is  to  provide  against  the  sale 
of  alcoholic  beverages  at  excessive  strengths,  and 
to  bring  about  effective  dilution  by  encouraging 
the  consumption  of  alcohol  with  meals  instead  of 
offering  dangerous  facilities  for  drinking  on  an 
empty  stomach.  The  regulation  of  the  liquor 
trade  in  accordance  with  these  principles  has 
brought  about  a reduction  of  intemperance  and  a 
consequent  improvement  in  national  health  and 
efficiency  which  a very  few  years  ago  would  have 
appeared  impossible  of  attainment  by  any  prac- 
ticable measures  of  reform,  and  the  accompanying 
interference  with  the  liberty  of  the  subject  cannot 


be  described  as  a counterbalancing  mischief.  The 
lesson  which  Lord  D’Abernon  draws  from  this 
experience  is  that  the  pre-war  prevalence  of 
alcoholism  in  this  country  was  primarily  attri- 
butable to  the  absence  of  any  rational  system  of 
liquor  legislation,  and  that,  should  relapse  to  these 
pre-war  evils  occur,  it  will  similarly  be  the  fault 
of  the  legislation.  In  this  matter  the  immediate 
responsibility  of  the  State  is  clear  and  definite  : 
under  the  existing  licensing  system,  the  retailers  of 
liquor  are  not  traders  in  tbe  ordinary  sense  of  the 
term,  they  enjoy  a monopoly  granted  to  them  by 
the  State,  and  it  is  the  duty  of  the  State  to  regulate 
in  the  public  interest  the  conditions  under  which 
that  monopoly  is  exercised.  In  the  United  States  the 
abuse  of  their  privileges  by  the  liquor  traders  has 
led  the  legislature  to  adopt  the  extreme  policy  of 
absolute  prohibition.  In  this  country  the  experi- 
ence of  the  Control  Board  has  shown  that  more 
moderate  methods  may  be  at  least  as  effectual  in 
safeguarding  public  health  and  order,  while  they 
have  the  additional  advantage — of  no  small 
account  at  the  present  moment— that  they  do  not 
involve  the  sacrifice  of  a source  of  State  revenue 
which  may  be  capable  of  such  development  as 
should  make  it  second  only  to  the  income-tax  in 
productiveness. 

Whether  the  system  of  regulation  by  which 
certain  beneficent  results  have  been  achieved  during 
the  war  can  be  effectively  carried  out  in  peace  time 
without  the  direct  management  of  the  liquor  busi- 
ness by  the  State  is  a question  which  only  experi- 
ence can  decide.  The  answer  will  depend,  no 
doubt,  in  a very  large  measure  on  the  capacity  of 
the  licensed  traders  to  take  an  intelligent  view  of 
their  own  interests.  With  the  example  of  America 
before  them — where  the  intolerable  abuses  of  the 
American  saloon  were  the  chief  argument  for 
prohibition — they  should  be  able  to  appreciate  the 
full  force  of  Lord  D’Abernon’s  epigrammatic  warn- 
ing that  “ the  noisy  advocates  of  unrestricted 
indulgence  are  the  cats-paws  of  Pussyfoot.”  And 
it  is  equally  desirable  that  the  nation  should 
realise  the  immediate  and  inevitable  results  of 
complying  with  the  demands  of  these  advocates. 
If  we  withdraw  reasonable  restrictions  we  shall 
create  almost  a legitimate  demand  for  unreasonable 
ones. 


Some  Housing  Questions. 

The  influence  which  housing  conditions  exercise 
upon  the  incidence,  spread,  and  permanence  of 
disease  is  so  enormous  that  no  apology  is  needed 
for  recurring  notices  of  the  developments  now 
taking  place.  The  housing  problem  is  being  dealt 
with  seriously,  and  upon  what  is  intended  to  be 
a scheme  of  general  application,  for  the  first  time 
in  this  country,  and  this  general  application  is, 
perhaps,  indicated  by  the  absence  of  any  definition 
of  the  class  of  citizen  whose  need  for  accommoda- 
tion is  exercising  the  community  at  large.  A series 
of  questions  has  been  addressed  to  Dr.  Addison 
by  the  Council  of  Rotary  Clubs  of  London, 
and  other  inquiries  have  been  directed  to  this 
point.  Dr.  Addison,  in  reply  to  the  Council  of 
Rotary  Clubs,  said  that  he  had  deliberately  “ and 
obstinately”  refrained  from  defining  “a  work- 
man.” “A  type  of  house,”  he  said,  “is  sanctioned, 
and  it  is  left  to  the  local  authorities  to  use 
their  own  common-sense  as  to  who  shall  occupy 
the  houses.”  Dr.  Addison  was,  however,  betrayed 
into  something  very  like  a definition  such  as 
he  had  obstinately  declined  to  give,  for  he 


440  The  Lancet,] 


DEARER  MILK  AND  BREAD. 


[Sept.  6,  1919 


continued : “ A workman  is  a man  who  works,  and 
it  is  immaterial  to  me  whether  he  works  as  a 
bank  clerk  or  a navvy.”  This  indicates  at  any 
rate  that  the  honourable  term  of  workman  is 
not  to  be  confined  to  manual  labour,  but  it  does 
not  say  with  what  strictness  the  new  dwellings  are 
to  be  confined  to  those  who  “work.”  Are  they  to  be 
denied  to  the  naval  or  military  pensioner  debarred 
by  war  injuries  from  work?  Is  the  widow  of  a 
man  who  has  saved  a little  money  for  her  and 
his  family  to  be  excluded  from  them  ? Will  a 
worker  of  any  sort,  in  receipt  of  wages  which  fairly 
might  enable  him  to  rent  a more  expensive  house, 
be  made  to  do  so  ? This  last  question  was  actually 
answered  by  Dr.  Addison  by  saying  that  rents  will  be 
fixed  according  to  the  type  of  house,  and  cannot  be 
graded  according  to  the  proposed  tenant’s  earnings. 
Where  there  is  competition  for  the  new  houses 
there  will  be  a good  field  for  the  exercise  of  the 
common-sense  with  which  we  are  willing  to  credit 
the  local  authority,  and  for  allotting  the  new  habita- 
tions to  those  for  whose  benefit  they  were  provided. 
From  the  health  point  of  view  this  may  be  of 
importance ; competition  for  the  houses  will  promote 
rivalry  in  keeping  them  decent,  and  once  a neigh- 
bourhood begins  to  pride  itself  upon  being  clean 
half  the  battle  of  public  health  is  won. 

In  London  the  conversion  of  houses  into  working- 
class  flats  will  presumably  be  the  branch  of 
rehousing  which  will  first  show  tangible  results. 
Such  conversion  has  taken  place  before,  but  not  on 
the  large  scale  now  contemplated,  and  the  securing 
of  satisfactory  health  conditions  will  not  always  be 
as  easy  as  the  mere  conversion  itself.  To  turn  a 
house,  built  to  contain  one  middle-class  family, 
into  three  or  four  self-contained  tenements  for 
workmen  may  dispose  of  that  number  of 
families  so  far  as  their  lodging  at  night  is 
concerned,  but  when  streets  or  rows  of  houses  are 
thus  treated  a comparatively  crowded  area  will  take 
the  place  of  one  more  sparsely  populated.  The 
children  have  to  be  considered  in  places  where 
the  children  of  former  occupants  played  in  the 
back  garden  of  the  one  house  belonging  to  or 
rented  by  their  parents  and  gave  no  cause  for 
anxiety  to  anyone.  We  doubt  the  children  of 
four  families  living  in  one  house  sharing  its 
yard  or  garden  harmoniously.  Children  will 
do  better  in  larger  playgrounds,  where  they  can 
find  friends  adapted  to  their  tastes  and  have  some 
kind  of  supervision,  official  or  voluntary,  to 
keep  them  out  of  mischief.  We  hope  that  in 
all  housing  and  building  schemes  the  health  and 
enjoyment  of  the  children  when  out  of  school  will 
be  kept  well  in  view,  and  recognised  as  an  essential 
aid  to  the  well-being  as  well  as  the  happiness  of  the 
population.  The  streets  and  public  roads  in  urban 
districts  are  not  proper  playgrounds  whether  for 
babies  or  for  bigger  girls  and  boys.  A public  park 
or  playground  may  accommodate  thousands  and  be 
an  excellent  place  for  holiday  time,  but  at  half  a 
mile  distance  or  even  less  it  is  of  no  use  for  every- 
day purposes.  Small  playing  areas  for  the  children 
coming  from  ten  up  to  a hundred  houses,  standing 
open  within  easy  reach,  might  make  it  possible  to 
forbid  absolutely  their  enjoyment  of  the  danger  of 
the  highway. 

The  reconstruction  of  houses  into  flats  should 
lead  to  increased  housing  accommodation  more 
quickly  than  the  construction  of  new  buildings, 
but  it  is  to  the  new  buildings  that  the  medical  man 
looks  for  such  a solution  of  the  housing  troubles 
as  may  lead  to  an  actual  improvement  in  public 


health  conditions.  Conversion  of  large  houses 
into  flats  is  an  economical  proceeding  of  itself  and 
should  have  considerable  advantages,  because  the 
quality  of  fabric  is  higher  than  may  be  available 
in  these  days.  But  no  choice  of  site  is  left,  and  it  is 
here  and  in  the  planning  of  the  arrangements  of 
roads  and  approaches  that  we  look  for  the  main 
improvements  in  the  houses  of  the  future.  Much  of 
the  insanitary  horrors  of  the  existing  workmen’s 
dwellings  has  been  due  to  the  absence  of  any 
prevision  in  building ; but  now  that  housing  and 
town  planning  are  being  carried  out  under  the  aegis 
of  a Ministry  of  Health  neglect  of  the  real  sanitary 
outlook  should  not  be  feared. 


Dearer  Milk  and  Bread. 

Great  and  immediate  efforts  are  needed  upon 
the  part  of  all  local  authorities  to  protect  the 
population  against  the  hardships  arising  out  of 
a milk-supply  at  famine  prices.  Mr.  McCurdy, 
the  Parliamentary  Secretary  to  the  Ministry 
of  Food,  in  a speech  delivered  at  a recent 
meeting  of  the  Consumers’  Council,  issued  a warn- 
ing that  it  is  probable  that  the  retail  price  for 
milk  throughout  the  country  next  winter  will  be 
at  least  Is.  a quart,  which  is  an  advance  of 
2d.  per  quart  on  last  winter’s  rates.  This  will 
mean  a heavy  burden  on  the  resources  of  the 
working-class  families  and,  likely  enough,  a serious 
increase  in  the  rate  of  infant  mortality.  “We 
have  to  make  good,”  Mr.  McCurdy  concluded, 
“ the  wastage  of  human  life  that  took  place 
during  the  war.  Our  baby  crop  for  the  years  1914 
to  1919  is  in  danger.  We  must  save  it.”  It  is 
well  to  remind  local  authorities  of  the  powers 
conferred  upon  them  by  an  order  of  the  Ministry 
of  Food  last  year.  Subject  to  such  conditions  as 
might  be  laid  down  by  the  Food  Controller,  any 
local  authority  could  arrange  for  the  supply  of 
milk  for  children  under  5 years  of  age,  and  in 
necessitous  cases  such  milk  might  be  sold  at  less 
than  cost  price,  or  even  supplied  free.  The  dairy 
farmer,  of  course,  must  have  a reasonable  return, 
and  with  the  increased  cost  of  production  and 
shortage  of  hay  and  roots  the  price  of  dairy 
produce  must  rise.  It  is  to  be  hoped  that  the 
Government  are  taking  steps  to  secure  auxiliary 
supplies  in  the  shape  of  dried  milk,  which 
appears  to  meet  the  dietary  requirements  of 
the  infant  quite  well,  and  further  attention  should 
be  given  to  the  possibility  of  imitating  milk 
by  emulsion  mixtures  containing  fat  protein  and 
carbohydrate,  plus,  of  course,  the  vital  accessory 
factors.  Lastly,  the  healthy  adult  should  cut  down 
his  accustomed  supply  of  milk,  particularly  in  tea 
and  coffee,  and  thus  place  a substantial  quantity  of 
milk  at  the  disposal  of  those  who  need  milk  if  they 
are  to  live.  Milk  can  well  be  excluded  from  the 
healthy  grown-up  person’s  diet  without  the  slightest 
dietetic  sacrifice,  and  all  who  thus  penalise  them- 
selves will  be  rendering  the  State  a great  service 
by  foregoing  an  article  of  food  which  belongs 
essentially  to  the  young. 

Less  anxiety,  perhaps,  need  be  felt  in  regard  to 
the  dearer  loaf,  as  the  advance  in  price  is  relatively 
small  and  the  staple  constituent  of  bread — carbo- 
hydrate— can  be  made  good  by  other  commonly 
occurring  articles  of  diet.  It  may  be  remem- 
bered that,  in  dealing  with  the  operative  bakers’ 
grievances,  the  Court  of  Arbitration,  having  regard 
to  the  hours  and  wages  of  the  workers  and  the 
■ factors  governing  the  cost  of  production,  concluded 


The  Lancet,] 


FEES  FOR  PUBLIC  VACCINATION.— HOME  “DOCTORING.” 


[Sept.  6,  1919  44 1 


that  the  demands  of  the  operatives,  which 
were  reasonable,  could  be  met  by  slightly  raising 
the  cost  to  the  consumer  of  the  4 lb.  and  2 lb.  loaf 
by  one  halfpenny  and  one  farthing  respectively. 
This  advanced  price  is  solely  due  to  the  increase  in 
wages  conceded  to  the  baker.  The  new  prices  are 
based  still  on  a State  subsidy,  which  provides  against 
a greater  rise  in  the  price  of  the  loaf.  This  subsidy, 
of  course,  comes  out  of  the  pockets  of  the  tax-payers. 
The  period  of  the  war  showed  that  the  general 
health  of  the  community  was  not  seriously  affected 
by  the  restrictions  placed  on  bread  allowance  or 
by  the  modifications  which  were  enjoined  as 
to  its  composition.  The  shortage  of  carbo- 
hydrate in  the  form  of  bread  was  easily  com- 
pensated by  the  supply,  amongst  other  things, 
of  rice  and  potatoes,  and  this  was  done  with  no 
harm  to  anybody. 

The  adult  can  deal  with  such  a situation 
without  much  inconvenience,  but  not  so  the 
baby.  The  process  of  turning  pasture  into  milk 
involves  greater  economic  interests  than  are 
present  in  the  growth  of  seed  and  the  development 
of  the  tuber  and  cereal.  For  the  latter  source  of 
food-supply  the  home  allotments  should  be  kept 
going,  as  though  the  war  is  over  the  difficulties  of 
food-supply  evidently  remain.  Intensive  home 
cultivation  has  proved  a great  success,  and  no 
hindrance  should  be  put  in  the  way  of  continuing 
the  undoubted  assistance  which  allotments  gave 
to  the  food  resources  of  the  country.  Neither 
should  the  healthy  occupation  which  the  allotment 
involves  be  checked.  But  the  problem  of  milk 
for  children  remains,  and  it  can  best  be  met  by 
rigid  economy  in  its  use  by  adults. 


Fees  for  Public  Vaccination. 

The  Association  of  Public  Vaccinators  of  England 
and  Wales  has  justified  its  existence  in  a number 
of  ways.  It  has  done  much  to  promote  a high 
standard  of  efficiency  in  the  vaccination  service ; 
and  although  primarily  concerned  with  the  interests 
of  public  vaccinators  and  the  conditions  of  service, 
the  association  has  also  been  active  in  the  defence 
of  vaccination  per  se  for  many  years.  A deputa- 
tion received  by  Major  Astor  at  Whitehall  during 
June  stated — not  for  the  first  time — a case  for 
improvement  as  regards  fees  and  conditions  of 
service  for  public  vaccinators,  and  urgently  called 
for  a recision  of  the  Act  of  1907  which  has  been 
the  cause  of  much  neglect  of  vaccination  by  substi- 
tuting a statutory  declaration  for  the  certificate  of 
conscientious  objection  required  under  Section  (2) 
of  the  Vaccination  Act  of  1898.  Major  Astor,  in 
his  reply,  was  by  no  means  unsympathetic,  and 
assured  the  deputation  that  he  would  lay  all  their 
points  before  the  President  of  the  Local  Govern- 
ment Board,  who  would  give  them  his  most  careful 
consideration.  On  July  14th  the  Association 
addressed  a letter  to  the  Minister  of  Health  on  the 
subject  of  the  increase  of  fees  payable  to  public 
vaccinators,  and  Sir  Robert  Morant  replied  on 
July  24th  : — 

“ I am  to  state  that  the  Minister  has  it  in  contemplation 
to  modify  the  existing  Order  by  raising  to  5s.  the  present 
minimum  fee  of  2s.  6 d.  or  3s.  6 d.,  as  the  case  may  be,  for 
primary  vaccination  performed  at  the  residence  of  the 
person.” 

We  congratulate  the  Association  upon  its  success 
in  obtaining  this  concession,  even  though  it  be  not 
immediate,  for  contemplation  in  Government 
•offices  may  take  some  time  to  develop  into  action. 


Annotations. 

" Ne  quid  nlmle.” 

HOME  “DOCTORING”  AND  THE  SPREAD  OF 
INFECTIOUS  DISEASE. 

The  medical  officer  of  health  for  Ealing  has 
recently  presented  to  his  public  health  department 
an  interesting  report  dealing  with  a local  outbreak 
of  scarlet  fever.  Of  25  cases  in  all,  18  were  in 
children  attending  North  Ealing  school,  1 attend- 
ing Drayton  school,  1 a private  school,  and  4 were 
under  school  age.  The  outbreak  began  in  May, 
two  cases  being  notified  in  that  month,  one  on 
May  6th  and  the  other  on  May  9th.  Further  cases 
were  notified  on  June  2nd,  11th,  and  12th. 
To  determine  the  actual  source  of  infection 
Dr.  T.  Orr  arranged  that  on  June  18th  the  hands 
of  all  the  children  in  the  three  classes  in  which 
scarlet  fever  had  occurred  should  be  examined, 
but  no  child  was  found  to  show  evidence  of  infec- 
tivity.  Absentees  were  followed  up  and  one  child 
was  found  whose  hands  were  desquamating,  and 
the  mother  said  that  the  child  had  had  a rash  on 
May  30th.  This  child  was  in  the  same  school  class 
as  the  two  cases  notified  on  June  2nd  and  12th.  On 
June  21st  all  cases  in  the  North  Ealing  area  which 
had  been  notified  during  May  and  June  as  suffering 
from  measles  or  German  measles  were  visited, 
with  the  result  that  one  child  attending  North 
Ealing  School,  notified  as  a case  of  German 
measles,  was  found  to  be  desquamating  in  a 
manner  typical  of  scarlet  fever.  On  June  23rd 
and  24th  every  child  in  the  North  Ealing 
School  was  examined  and  three  children  in 
classes  not  previously  examined  were  found 
to  be  desquamating,  while  one  child,  in  a 
class  already  examined  as  far  as  the  hands,  was 
found  to  be  desquamating  on  the  chest.  All  these 
children  were  sent  home  and  visited,  when  it  was 
found  from  the  mothers  that  in  every  case  the 
children  had  had  a rash  from  two  to  three  weeks 
previously.  Among  the  absentees  who  were  also 
visited  two  other  cases  of  missed  scarlet  fever  were 
found,  making  in  all  eight  cases  which  had  been 
missed,  one  of  these  having  been  notified  as 
German  measles.  After  this  a constant  daily 
supervision  was  kept  over  all  absentees,  who  were 
visited  at  home,  their  parents  being  warned  in  any 
cases  of  suspicious  illness,  with  the  result  that 
three  new  cases  were  discovered  at  an  earlier  date 
than  they  would  otherwise  have  been.  Dr.  Orr 
remarks  upon  the  large  number  of  missed  cases, 
i.e.,  8,  in  comparison  with  the  number  of  notified 
cases,  25.  The  affected  school  is  in  excellent 
sanitary  condition,  but,  continues  Dr.  Orr — - 
“I  have  been  remarkably  struck  on  my  visits  to  some  of 
the  houses  of  the  children  found  to  be  recovering  from 
scarlet  fever  to  find  the  mothers  so  full  of  knowledge  as  to 
what  the  children  suffered  from,  a knowledge  which  was 
pitted  against  mine  in  discussing  the  nature  of  the  condi- 
tion, and  which  was  gleaned  ostensibly  from  some  ‘ Family 
Physician,’  a volume  which  was  handed  to  me  on  two 
occasions  to  see  on  wbat  authority  they  relied.” 

It  is  obvious  that  in  such  conditions  as  Dr.  Orr 
describes  we  have  an  ideal  position  for  the  spread 
of  scarlet  fever  or  any  other  infectious  disease. 
Scarlet  fever  is  sometimes  very  easy  to  diagnose, 
and  sometimes  very  difficult,  or  even  impossible. 
An  untrained  observer,  relying  upon  information 
gained  from  such  a volume  as  Dr.  Orr  mentions,  is 
subjecting  the  community  of  his  or  her  residential 
neighbourhood  to  a criminal  risk. 


442  Thb  Lancet,]  ACUTE  THYROIDITIS.— PLIGHT  OF  HOSPITALS  IN  AUSTRIA  & HUNGARY.  [Sept.  6 1919 


ACUTE  THYROIDITIS. 

To  the  Albany  Medical  Annals  for  June  Dr. 
G.  E.  Beilby  has  contributed  a careful  study  of  a 
very  rare  condition — acute  thyroiditis.  It  might  be 
supposed  that  the  proximity  of  the  pharynx,  tonsils, 
and  lymphatic  structures  of  the  throat  would  pre- 
dispose to  infections  of  the  thyroid  by  lymphatic 
extension.  But  it  has  been  shown  that  there  is  no 
lymphatic  circulation  between  the  structures  of  the 
throat,  which  are  so  commonly  the  seat  of  acute 
infections,  and  the  thyroid  gland.  Cases  in  which 
infection  occurs  by  way  of  the  lymph  vessels  seem 
to  be  always  preceded  by  infection  in  the  upper 
trachea  or  larynx.  Infection  from  the  blood- stream 
appears  to  be  the  most  frequent  cause  of  inflamma- 
tion in  cases  of  tumour  or  hypertrophy  of  the 
thyroid,  the  consequent  processes  of  degeneration 
lowering  the  resistance.  It  is  particularly  in 
adenomata  undergoing  degeneration  and  containing 
free  blood  and  necrotic  material  that  infection 
occurs.  The  following  is  an  example 

A married  woman,  aged  33  years,  the  mother  of  three 
children,  was  admitted  to  the  Albany  Hospital  on  Jan.  10th, 
1919.  She  first  noticed  enlargement'  of  the  neck  four  years 
previously,  just  after  the  birth  of  her  youngest  child.  The 
enlargement  was  gradual  until  about  six  months  ago,  since 
which  time  it  had  been  more  rapid.  Thepressureof  thegrowth 
caused  discomfort,  and  at  times  difficulty  in  breathing. 
About  three  months  before  admission  she  had  a severe  attack 
of  influenza.  Before  she  left  her  bed  her  neck  began  to 
swell  and  to  be  painful,  and  there  was  a rise  of  temperature 
every  day.  On  New  Y’ear’s  day  Bhe  had  a chill  and  from  that 
time  grew  rapidly  worse.  Her  breathing  became  more 
difficult  and  she  lost  her  voice.  On  admission  she  was 
suffering  from  dyspnoea  and  dysphagia.  She  was  pro- 
foundly septic  and  in  a critical  state.  There  was  a large 
and  very  tense  tumour  in  the  median  line  of  the  neck,  a 
little  more  prominent  on  the  left  side.  The  temperature 
was  103-5°  F.  and  the  pulse  120.  Infected  thyroid  adenoma 
was  diagnosed.  Under  local  anaesthesia  the  mass  was 
opened  and  a large  amount  of  purulent  fluid,  mixed  with 
blood  and  broken  down  thyroid  tissue,  escaped.  Free 
drainage  was  instituted.  Cultures  of  the  fluid  yielded  a 
haemolytic  streptococcus.  The  patient  was  very  ill  for  two 
weeks,  but  eventually  was  able  to  leave  hospital  with  a 
small  discharging  sinus.  This  completely  healed  and  she 
slowly  regained  weight  and  strength.  She  was  advised  to 
return  later  for  removal  of  the  adenoma.  The  adenoma 
had  undergone  cystic  degeneration  and  the  infection  was 
undoubtedly  haematogenous  and  part  of  the  general 
influenzal  infection. 

Two  other  cases  are  related  in  which  the  infection 
of  the  thyroid  was  a direct  extension  from  the 
throat,  which  was  inflamed.  The  symptoms  of 
acute  thyroiditis  vary  according  as  the  inflamma- 
tion of  the  gland  is  primary  or  arises  in  some 
lesion  previously  existing.  In  the  former  case 
there  are  usually  chills,  malaise,  and  headache. 
Pain  is  felt  in  the  region  of  the  gland,  more  pro- 
nounced on  one  side,  because  the  process  usually 
begins  in  a single  lobe,  often  radiating  to  the 
ear  and  side  of  the  neck,  lancinating  and  greatly 
aggravated  by  extension  of  the  head.  As  a result 
the  attitude  may  be  somewhat  characteristic,  the 
head  bowed  and  held  very  rigid.  Local  swelling  is 
never  noticed  as  an  early  oi;  a marked  symptom. 
Dyspnoea  and  dysphagia  are  present,  the  degree 
depending  on  the  severity  of  the  infection  and  the 
extent  of  gland  involved.  The  voice  may  be 
affected ; there  may  be  aphonia  and  an  irritative 
cough  with  slightly  blood-stained  expectoration. 
The  diagnosis  is  usually  difficult  and  the  condition 
is  unrecognised  for  a considerable  time  because 
the  usual  signs  of  inflammation  and  suppuration 
are  absent.  The  gland  is  surrounded  by  a closely 
adherent  connective  tissue  capsule  derived  from 
the  pretracheal  layer  of  deep  cervical  fascia.  A 
layer  of  the  capsule  also  encloses  the  larynx  and 


trachea  and  pharynx  and  oesophagus.  Hence  the 
swelling  of  the  gland  produces  its  first  and  most 
marked  effect  upon  the  trachea  and  oesophagus. 
The  cause  of  the  resulting  stenosis  is  usually 
sought  in  the  throat.  But  there  is  a pathogno- 
monic symptom — stony  hardness  of  the  gland  on 
palpation.  As  the  condition  of  the  throat  renders 
administration  of  a general  anaesthetic  difficult  and 
dangerous,  operation  should  be  performed  under 
local  anaesthesia.  A free  opening  should  be  made 
and  drainage  established.  As  little  injury  as 
possible  should  be  done  to  the  gland,  and  no 
extensive  measure,  such  as  partial  excision  or 
removal  of  tumours  or  cysts,  undertaken  in  the 
presence  of  such  serious  infection. 


THE  PLIGHT  OF  HOSPITALS  IN  AUSTRIA  AND 
HUNGARY. 

An  appeal  drawn  up  by  Dr.  Hilda  Clark,  who  has 
recently  joined  Dr.  Hector  Munro  in  Vienna,  brings 
up  to  date 1 the  urgent  conditions  of  want  in  which 
the  hospitals  of  Austria  and  Hungary  find  them- 
selves. In  both  these  countries,  while  the  standard 
of  professional  skill  and  permanent  equipment 
remains  very  high,  the  staff  is  faced  with  the  im- 
possibility of  giving  their  patients  the  treatment 
which  they  require.  In  Vienna,  where  the  hospitals 
are  maintained  by  the  State,  milk  and  eggs  are  only 
provided  for  infants  under  1 year,  as  although  the 
cost  at  which  these  articles  can  be  obtained  in  the 
country  is  lower  at  the  present  rate  of  exchange 
than  the  prices  which  are  paid  for  them  in  England, 
the  State  is  too  poor  to  buy  them  and  other 
requisites.  The  hospitals  have  therefore  to  carry 
on  without  linen,  surgical  dressings,  rubber 
appliances,  drugs,  anaesthetics,  soap,  or  disinfect- 
ants. Paper  clothing  and  bandages  are  everywhere 
in  use,  better  dressings  being  reserved  for  very 
special  cases.  The  shortage  of  coal  and  gas  has 
reduced  the  opportunities  of  sterilisation  far 
below  the  limit  of  safety.  In  Budapest  a sudden 
crisis  in  the  food  position,  which  up  to  that 
time  had  been  better  than  in  Vienna,  was  pro- 
duced by  the  Roumanian  occupation.  The  short- 
age of  hospital  requisites,  including  dressings 
and  drugs,  and  the  limited  opportunities  of  sterilisa- 
tion were,  however,  already  more  acute  in  the 
Hungarian  capital.  Some  spread  of  ^epsis  and  of 
skin  diseases  in  the  general  wards  and  an  increased 
morbidity  rate  in  the  maternity  wards  has  so  far 
been  one  of  the  results.  The  lack  of  anaesthetics 
has  been  partially  met  by  the  extended  use  of  local 
anaesthesia,  but  it  is  obviously  impossible  for  the 
whole  medical  profession  to  acquire  at  a moment's 
notice  the  skill  and  experience  thus  necessitated. 
The  shortage  of  general  anaesthetics  and  of 
morphine  has  been  particularly  felt  in  the  obstetric 
clinics.  The  appeal  suggests  help  in  three  direc- 
tions. The  first  essential  .is  coal,  which  can 
presumably  be  paid  for  on  credit  if  not  in  money ; 
secondly,  some  help  with  the  hospital  supplies  is 
urgently  needed : and  thirdly,  assistance  to  the 
hospitals  and  sanatoriums  to  cope  with  the 
increase  in  tuberculosis,  to  be  continued  until 
industry  regains  a proper  footing.  Another  problem 
which  vitally  affects  the  health  of  the  people  in 
both  countries  is  the  shortage  of  clothing.  The 
supply  of  new  material  on  credit  for  the  manu- 
facture of  clothing  on  the  spot  would,  in  the  opinion 
of  the  signatories,  meet  the  risk  of  demoralising  by 
the  giving  of  help.  Relief  for  all  the  hospitals  in 

1 See  The  Laxcet,  August  2nd.  p.  203. 


TheLanoet,]  MENTAL  DEFICIENCY  IN  PROSTITUTES.— WELFARE  OF  THE  BLIND.  [Sept.  6,1919  44.3 


Austria  and  Hungary  is  being  administered  through 
a representative  medical  committee,  under  the 
chairmanship  of  Professor  Wenckebach,  professor  of 
internal  medicine  in  the  University  of  Vienna,  with 
offices  at  Singerstrasse  16,  Vienna  I. 


MENTAL  DEFICIENCY  IN  PROSTITUTES. 

Lieutenant  Paul  A.  Mertz,  psychological  examiner 
at  Newport  News,  one  of  the  principal  ports  of 
embarkation  and  debarkation  of  the  American 
army,  records1  the  results  of  his  psychological 
examination  of  women  arrested  for  prostitution 
and  similar  offences  in  the  course  of  six  months. 
It  is  noteworthy  that  74  per  cent,  of  the  white 
women  and  79  per  cent,  of  the  coloured  women 
were  found  to  be  infected  with  a communicable 
venereal  disease.  Of  69  women  whose  ages  were 
obtained,  50  per  cent,  were  under  21  years  of  age, 
and  over  half  of  these  were  between  18  and  20.  In 
126  women  in  whom  the  mental  age  was  determined 
by  the  Binet-Simon  scale,  53  per  cent,  had  a mental 
age  of  ten  or  under,  this  figure  closely  agreeing 
with  the  51  per  cent,  feeble-minded  reported  by  the 
Massachussetts  Commission  for  the  Investigation  of 
the  White  Slave  Traffic  in  its  examination  of  prosti- 
tutes. At  the  Chicago  Morals  Court  the  percentage 
of  mental  deficiency  among  126  prostitutes  was  still 
higher — 85'8  per  cent.  Only  10  per  cent,  of  the 
cases,  however,  examined  by  Mertz  were  so 
deficient  as  to  warrant  under  existing  laws  segre- 
gation in  an  institute  for  the  feeble-minded.  In 
addition  to  the  mentally  deficient,  15  per  cent,  of 
the  cases  showed  mental  disorder,  11  being 
emotionally  unstable,  three  epileptic,  one  a drug 
addict,  and  two  subjects  of  dementia  praecox.  As 
only  few  opportunities  were  given  for  detect- 
ing deviations  from  the  normal,  this  number  is 
probably  considerably  understated.  The  ignorance 
of  the  prostitutes,  according  to  Mertz,  was 
appalling,  and  therefore  it  is  not  surprising  to 
learn  that  50  per  cent,  of  the  women  did  not  reach 
the  fifth  grade  at  school. 


THE  FIRST  ANTITUBERCULOSIS  DISPENSARY  AT 
NAPLES. 

On  June  1st  there  was  inaugurated  at  Naples,  in 
the  Piazza  Salerno,  near  the  industrial  quarter, 
the  “ Preventorium  pro  Salute,”  instituted  by  the 
Neopolitan  Antituberculosis  Society.  According  to 
La  Biforma  Medica  this  is  the  first  of  the  three 
dispensaries  that  the  society  intends  to  establish 
in  various  parts  of  the  city;  the  second  will  be 
built  during  the  present  year  on  a suitable  site  in 
the  hospital  area  in  the  centre  of  the  town,  while 
the  third  will  be  erected  next  year  in  the  western 
quarter.  These  represent  part  of  the  social  pro- 
gramme which  has  been  determined  on  in  order  to 
encourage  methods  of  prophylaxis  adapted  to  the 
special  conditions  of  the  city;. later  on  the  other 
preventive  institutions  of  the  society  will  be  added 
— namely,  day  sanatoriums,  floating  sanatoriums, 
country  camps,  and  open-air  schools — leaving  to 
other  antituberculosis  associations  the  task 
of  providing  permanent  sanatoriums  and  sea- 
side hospitals.  It  must  be  acknowledged  that 
the  installation  of  three  dispensaries  in  two 
years  in  a city  where  none  previously  existed 
is  a record  of  rapidity  and  energy  which  has 
only  been  possible  when  the  artificial  barriers 
of  small  committees  have  been  broken  down  and  in 

1 Journal  of  the  American  Meiical  Association,  1919,  lxxii.,  1597-99. 


their  place  a powerful  organisation  set  up,  such 'as 
the  Neapolitan  Antituberculosis  Society  with  its 
committee  composed  of  such  men  as  Professors 
Bianchi,  de  Giaxa,  and  Jemma,  and  a band  of 
commercial  and  industrial  men  and  women  well 
versed  in  practical  philanthropy.  The  dispensary 
consists  of  a central  block  and  two  wings,  the 
former  having  in  front  a large  waiting  hall  com- 
municating by  three  openings  with  a corridor 
leading  respectively  to  bathroom,  surgical  and 
laryngological  rooms.  The  left  wing  contains  an 
office  for  the  registration  of  patients,  a large  labora- 
tory and  X ray  room,  while  the  right,  which  faces  the 
south,  is  occupied  by  the  dispensary,  and  two  ample 
medical  rooms.  In  the  basement  are  washhouses  and 
stoves  for  disinfection  or  destruction.  Over  the 
wings  are  spacious  terraces  for  heliotherapy,  while 
the  whole  front  leads  on  to  a large  garden.  The 
medical  staff,  two  of  whom  are  volunteers,  are 
assisted  by  ladies,  wTho  undertake  the  difficult  task 
of  domiciliary  visiting  for  which  they  are  made 
efficient  by  a special  course  of  lectures  held  at  the 
Institute  of  Hygiene  in  the  University.  The  choice 
of  a locality  for  the  dispensary,  isolated  in  the 
middle  of  a large  open  space  close  to  the  industrial 
quarter,  is  happy,  and  the  beneficence  of  the 
project  and  the  lavishness  of  its  details  have  aroused 
the  most  enthusiastic  approbation  of  all  competent 
judges.  The  sound  organisation  is  the  outcome  of 
the  long  study  of  an  expert  committee  of  manage- 
ment presided  overby  the  superintendent,  Professor 
de  Giaxa.  


THE  WELFARE  OF  THE  BLIND. 

The  welfare  of  the  blind  is  a matter  of  pressing 
importance,  even  more  pressing  to-day  than  hereto- 
fore, on  account  of  the  large  accession  which  has 
been  made  to  the  ranks  of  the  blind  by  the  ravages 
of  war.  Loss  of  sight  is  one  of  the  most  serious 
disabilities  which  can  affect  humanity,  although 
there  are  well-known  instances  of  blind  persons, 
such  as  Milton  and  Henry  Fawcett,  wTho  were  able 
to  do  good  work  after  having  lost  their  sight. 
When  blindness  is  accompanied  by  deafness,  as  too 
often  happens — the  latest  figures  as  given  in  the 
Report  of  the  Advisory  Committee  on  the  Welfare 
of  the  Blind,  dated  June,  1919,  show  that  there 
were  in  England  and  Wales  1009  deaf  blind 
persons,  of  whom  660  were  reckoned  as  “ unemploy- 
able”— the  disability  is  enormously  increased. 
We  therefore  refer  again  with  pleasure  to  the 
publication  of  a circular  by  the  Ministry  of  Health, 
dated  August  7th,  from  which  we  learn  that  an 
estimate  has  been  laid  before  Parliament  for  a 
grant  to  be  distributed  in  aid  of  certain  services 
carried  on  for  the  benefit  of  the  blind.  If  voted  by 
Parliament  this  grant  will  be  appropriated  in  aid 
of  these  services  from  the  period  July  1st,  1919,  to 
March  31st,  1920,  and  thereafter,  subject  to  the 
consent  of  Parliament,  a grant  will  be  payable  in 
respect  of  each  financial  year  ending  March  31st. 
Grants  will  be  payable  to  approved  agencies  (an 
“agency”  is  defined  as  an  institution,  society,  or 
body  engaged  in  work  for  the  blind)  in  respect  of 
the  following  services  : workshops  for  the  blind, 
provision  of  assistance  to  home  workers,  homes 
and  hostels  for  the  blind,  home  teaching,  book 
production,  counties  associations,  miscellaneous. 
In  regard  to  the  first  two  services,  grants  will  be 
allocated  at  rates  not  exceeding  £5  to  £20  per  annum 
per  worker  or  per  blind  person  incapable  of  work 
who  is  cared  for  in  a home.  Provision  is  made 
for  granting  to  any  home  teacher  employed  by 


444  The  Lancet,]  MASSAGE  AND  MASSEURS.— GENERAL  PARALYSIS  AMONG  JEWS. 


[Sept.  6,  1919 


an  agency  a sum  not  exceeding  £78  per  annum, 
and  grants  will  be  made  to  any  approved  agency 
producing  books  and  music  in  embossed  type. 
Under  the  head  of  “Miscellaneous,”  we  see  that  the 
Minister  will  be  prepared  to  consider  applications 
from  an  agency  for  a grant  towards  expenditure 
incurred  or  estimated  for  any  service  other  than 
the  services  mentioned  in  the  regulations,  and  we 
earnestly  hope  that  training  in  music  will  be  con- 
sidered by  the  Minister  as  suitable  for  a grant,  for 
a blind  man  who  can  play  a musical  instrument 
with  skill  is  not  only  a source  of  great  pleasure  to 
himself  but  may  be  so  also  to  his  fellows.  Every- 
one will  remember  Thackeray’s  pathetic  account  of 
George  III. — old,  blind,  and  mad,  solacing  himself 
with  Handel.  If  the  suggestions  made  in  the 
circular  are  carried  out  then  the  lot  of  the  blind  will 
be  made  appreciably  easier  than  we  fear  it  is  at 
present.  


MASSAGE  AND  MASSEURS. 

A petition  to  His  Majesty  in  Council  has  been 
presented  recently  to  the  Board  of  Trade  begging 
that  a charter  may  be  granted  to  a society  to  be 
known  henceforward  as  the  Chartered  Society  of 
Massage  and  Medical  Gymnastics.  The  object  of 
the  proposed  society  is  to  unite  the  older  Incor- 
porated Society  of  Trained  Masseuses,  founded  in 
1894  and  incorporated  in  1900,  with  the  more  recent 
foundation  of  the  Institute  of  Massage  and  Remedial 
Gymnastics,  which  was  founded  in  1916.  Such  an 
application  has  been  in  posse  ever  since  September, 
1918,  and  we  can  but  repeat  what  we  wrote  upon 
the  subject  in  our  issue  of  Sept.  21st,  1918,  that  it 
should  protect  the  title  of  masseur  from  fraudulent 
usurpation ; and  while  the  council  of  the  new 
amalgamation  should  be  empowered  to  coopt  as 
members  all  those  who  can  produce  satisfactory 
evidence  of  training  in  recognised  schools  abroad, 
they  must  take  steps  to  examine  those  whose 
training  appears  deficient.  Only  thus  can  the 
public  be  protected  from  the  danger  of  the  un- 
instructed dabbler  in  remedial  gymnastics,  while 
the  elimination  of  the  quack  will  be  in  the  interest 
of  all  genuine  masseurs. 


GENERAL  PARALYSIS  AMONG  JEWS. 

General  paralysis  of  the  insane  is  stated  to  be  a 
modern  disease  amongst  Jews.  Whilst  epilepsy 
has  been  notoriously  rife  amongst  them  from  an 
early  date,  being  mentioned,  indeed,  by  the  Talmud 
writers,  general  paralysis  has  practically  only 
occurred  in  the  last  50  years.  Sichel 1 finds  the 
reasons  for  this  state  of  things  in  the  social  and 
religious  seclusion  in  which  this  people  lived  from 
mediasval  nearly  up  to  present  times,  and  in 
their  former  habit  of  early  marriage.  The  older 
Jew  was  of  strict  sexual  morality.  It  is  quite 
plausible,  therefore,  that  the  Jew  suffered  less 
often  from  syphilis  and  its  sequelae  than  did  the 
Gentile.  But  if  a change  in  life  conditions 
favoured  and  actually  produced  more  frequent 
syphilitic  infection,  then  conceivably  the  type 
of  the  disease  might  be  more  severe  in  a 
race  long  unfamiliar  with  it.  The  same  con- 
ditions, a pent-up  life  continuing  for  many 
generations,  which  have  resulted  in  familiarity  with 
tuberculosis,  followed  by  some  slight  racial  im- 
munity to  it,  have,  on  the  other  hand,  resulted  in 
unfamiliarity  with  syphilis  and  consequent  lack  of 


resistance  ; in  particular  lack  of  resistance  on  the 
part  of  tiie  cerebral  tissues.  At  any  rate,  the  facts 
of  the  case  will  bear  some  such  interpretation.  In 
the  first  place,  the  increase  of  general  paralysis 
coincides  in  date  with  the  Jew  migration  from  small 
towns  and  villages  into  the  great  cities,  Berlin  now 
containing  a quarter  of  all  the  Jews  in  Germany, 
and  New  York  over  a million  American  Jews.  Big 
cities,  of  course,  offer  opportunities  for  impure 
sexual  commerce,  and  the  life  in  them  is  exhaust- 
ing to  the  nervous  system.  In  Vienna  two  different 
alienists  found  20  per  cent,  of  Jews  among 
their  general  paralytics,  and  the  disease  in  the 
whole  of  Austria  occurred  more  frequently  by 
nearly  a third  in  Jews  than  in  Gentiles.  The 
same  phenomenon  appeared  in  London  (Beadle), 
and  in  Frankfort.  However,  Russian  Jews  have 
(or  perhaps  one  should  say  had)  been  compelled  to 
be  urban  dwellers,  agricultural  pursuits  being  for- 
bidden them.  Yet  general  paralysis  was  rarely 
observed  in  their  community.  The  explanation  of 
this  is  probably  that  the  Eastern  Jew  is  more 
of  the  primitive  national  type  than  his  Western 
brother,  and  keeps  more  strictly  to  Biblical  and 
Talmudic  precepts  as  to  early  marriage  and  pre- 
marital continence.  The  Talmud  enjoins  that 
every  member  of  the  religious  community  shall  be 
married  at  20  years  of  age.  Western  social  life, 
especially  urban,  tends  more  and  more  to  make 
such  a precept,  especially  in  the  upper  classes,  quite 
impossible  of  fulfilment : the  age  of  marriage  is  com- 
monly much  nearer  40  than  20,  and  pre-marital  con- 
tinence is  consequently  very  much  rarer,  syphilitic 
infection  very  much  commoner.  It  is  further  con- 
firmatory that  general  paralysis  in  Jewish  women  is 
as  uncommon  as  in  Gentile  women:  the  increase 
spoken  of  only  occurs  in  males.  Again,  it  is  suspected 
that  alcohol  as  well  as  syphilis  has  a place  in  the 
aetiology  of  general  paralysis — it  may  be  an 
important  place,  for  Mohammedans,  who  are  often 
syphilitic,  but  rarely  alcoholic,  suffer  very  little  from 
paralysis.  Formerly  Jewish  commercial  travellers 
were  those  of  their  nation  who  suffered  most  with 
the  disease,  but  this  well-nigh  exclusive  incidence 
in  one  occupation  has  progressively  declined, 
artisans  and  the  labouring  class  having  become  more 
and  more  affected.  The  disease  is  becoming,  as  it 
were,  popularised.  At  all  events,  the  breaking 
down  of  national  seclusion  and  tradition  has  run 
very  closely  with  the  decline  in  freedom  from 
general  paralysis,  and  the  arguments  advanced  do, 
as  far  as  they  go,  suggest  a certain  measure  of 
causal  connexion  between  the  two  processes. 


KOHLER  S DISEASE  OF  THE  TARSAL  SCAPHOID. 

This  condition  is  described  by  Dr.  F.  W.  O'Brien,1 
of  Boston,  who  reports  a case  in  a girl,  aged 
3 years,  as  probably  a non-infectious  process,  seen 
only  in  children  and  characterised  clinically  by 
swelling  of  the  fooij,  pain  on  palpation  and  weight 
bearing,  usually  without  constitutional  signs  and 
with  some  history  of  trauma.  The  disease  appears 
to  be  due  to  delayed  development  of  the  ossifica- 
tion of  the  scaphoid,  which  is  stimulated  to 
osteogenesis  by  traumatism,  and  the  pain  and 
swelling  may  be  due  to  post-traumatic  osteitis. 
Less  than  20  cases  have  been  recorded  since 
Kohler  first  reported  three  cases  of  the  disease  in 
1908.  It  is  probable,  as  Dr.  O’Brien  remarks,  that 
both  before  and  since  it  was  frequently  mistaken 
for  cold  tuberculous  abscess.  The  diseased  scaphoid 

1 Boston  Medical  and  Surgical  Journal,  1919,  clxxx.,  445-7. 


1 Max  Sichel : Zeitsclirift  fur  Sexualwissenschaft,  June,  1919. 


TdB  Lancet,] 


THE  STUDENTS’  NUMBER.— THE  STING  OF  THE  BEE  AND  WASP.  [SEPT.  6,  1919  445 


presents  the  following  X ray  appearances : 
(1)  It  is  one-half  to  one-quarter  smaller  than 
usual ; (2)  its  form  is  entirely  regular ; (3)  its 

architecture  cannot  be  recognised,  the  cortex  and 
spongy  portion  running  together ; (4)  its  density  is 
increased  two-  to  four  fold.  The  prognosis  is 
invariably  good,  and  recovery  takes  place  in- 
dependently of  treatment,  though  the  disease  may 
last  two  or  three  years.  Rest  or  support  in  some 
form  is  usually  employed. 


THE  STUDENTS'  NUMBER. 

We  wish  to  thank  all  those  who  helped  us  so 
promptly  in  the  production  of  the  Students’  Number 
of  The  Lancet,  which  appeared  last  week.  We 
desired  to  revert  at  the  earliest  opportunity  to  our 
practice  for  the  last  60  years  of  issuing  shortly 
before  the  commencement  of  the  October  session 
an  educational  guide  to  the  medical  profession  for 
the  use  alike  of  those  who  are  joining  it,  those  who 
are  in  it,  and  their  relatives.  Circumstances  will 
compel  us  from  time  to  time  to  add  to  the  state- 
ments made  in  the  last  Students’  Number,  as  many 
things  were  in  course  of  deliberation  and  re- 
arrangement at  the  time  of  issue.  For  example, 
there  were  published  on  Saturday  last  from  the  India 
Office  new  announcements  concerning  appointments 
to  the  Indian  Medical  Service.  The  announce- 
ments include  the  new  rates  of  pay,  and  those 
are  the  same  as  we  were  able  to  publish ; while 
the  information  in  respect  of  the  vacancies  and  of 
the  circumstances  qualifying  the  applications  are 
now  published  in  another  column.  We  regret  as 
yet  to  be  unable  to  publish  the  new  rates  of  pay  in 
the  Army  Medical  Service. 

The  following  corrigendum  has  been  brought  to 
our  attention.  The  Branch  Medical  Council  office 
for  Scotland  of  the  General  Medical  Council  is  now 
situated  at  20,  Queen- street,  Edinburgh,  and  Mr. 
T.  H.  Graham  has  succeeded  Mr.  James  Robertson 
as  Registrar.  


THE  STING  OF  THE  BEE  AND  THE  WASP. 

The  grave  symptoms  which  sometimes  follow 
the  sting  of  a wasp  or  bee  render  the  observations 
of  Mr.  Edward  R.  Speyer,  M.A.,  F.E.S.,  Investigator 
of  Diseases  of  Trees  at  Oxford  University,  in  a 
letter  in  the  Times , of  great  interest.  Little  is 
known  really  of  the  nature  of  the  poison  of  these 
insects,  but  it  was  for  long  accepted  that  the  chief 
toxic  agent  was  formic  acid  and  that,  therefore,  the 
prompt  application  of  an  alkali  to  neutralise  the 
acid,  such  as  ammonia  or  the  blue  bag,  avoided 
serious  consequences.  However  effective  that 
method  may  be  in  the  treatment  of  a bee-sting,  it  is 
not  only  unsound  in  the  case  of  a wasp-sting, 
but  is  likely  to  aggravate  the  toxic  effects  of  the 
subcutaneous  injection,  for  Mr.  Speyer  now  shows 
that  the  sting  of  the  bee  is  decidedly  acid,  while 
that  of  the  wasp  is  distinctly  alkaline.  If,  there- 
fore, the  toxic  factors  are  an  acid  in  one  case  and 
an  alkali  in  the  other,  the  choice  of  a neutralising 
agent  is  clear,  depending  upon  the  particular  insect 
which  discharged  the  venom.  But  it  is  doubtful 
whether  the  issue  is  as  simple  as  this,  for  toxins, 
apart  from  any  question  of  alkali  or  acid,  though 
these  may  respectively  be  effective  vehicles  of  toxins, 
are  not  negatived  by  simple  acid  or  alkaline  appli- 
cations. The  case  of  the  toxin  of  the  serpent  fang 
may  be  quoted.  Still,  the  evidence  is  interest- 
ing that  by  extracting  the  stings  of  wasps  and 
immersing  them  for  a short  time  in  an  acid  no 


ill-effects  resulted  when  they  were  driven  as  deep  as 
possiblo  into  the  flesh.  We  have  ourselves 
observed  that  water  in  which  wasp- stings  had 
been  immersed  becomes  distinctly  alkaline,  and, 
further,  that  the  prompt  application  of  vinegar  as 
the  nearest  acid  in  domestic  service  will  prevent 
inflammation.  Onion  juice,  which  is  acid,  acts 
similarly,  and  no  doubt  other  acid  vegetable  or 
fruit  juices  would  answer  equally  well.  That  the 
bee-sting  is  acidic  and  the  wasp-sting  basic  is  an 
interesting  differentiation  which  should  be  widely 
known,  for  not  uncommonly  the  sting  proves  to  be 
not  a simple  puncture  but  the  beginning  of  a toxic 
process  sometimes  fatal.  A wasp-sting  on  the 
moist  mucosa,  as  in  the  mouth,  invariably  leads 
to  serious  inflammation,  with  most  distressing 
results.  If  the  simple  gargling  or  washing  of 
the  attacked  spot  with  an  acid  fluid  in  such 
a case  keeps  down  the  swelling  lives  may 
well  be  saved.  The  season  of  wasps  is  with  us, 
and  these  observations  are  therefore  opportune. 
Amongst  gardeners  there  is  the  belief  that  the 
wasp  draws  its  venom  from  young  laurel  leaves, 
which  are  rightly  reputed  to  contain  prussic  acid. 
Wasps  certainly  are  fond  of  the  laurel  leaf,  but 
while  it  seems  certain  that  prussic  acid  is  not  the 
business  element  of  their  sting  this  acid  may 
be  the  foundation  of  basic  nitrogenous  bodies  of 
a toxic  nature  passed  on  by  the  sting.  It  will 
be  remembered  also  that  wasps,  different  from 
bees,  are  voracious  flesh  eaters,  and  meat  materials 
easily  enough  give  rise  to  basic  substances. 


The  death  is  announced  of  Dr.  Alexander 
Macalister,  F.R.S.,  professor  of  anatomy  in  the 
University  of  Cambridge,  and  a member  of  the 
Senate  of  Dublin  University. 


Two  cases  of  rabies  have  occurred  in  the 
Colchester  borough,  one  on  August  15th  and  one 
on  August  17th,  and  a third  suspected  case  is  now 
reported.  No  case  of  rabies  has  occurred  in  the 
administrative  county  of  Essex. 


The  Ministry  of  Health  were  notified  orr 
August  19th  by  the  deputy  medical  officer  of 
health  of  the  Port  of  London  Sanitary  Authority 
that  a member  of  the  crew  of  the  s.s.  Clan  Lamont 
was  suffering  from  plague.  The  vessel  was  then 
in  dock,  but  has  since  been  taken  into  the  river 
and  fumigated.  The  clinical  symptoms  of  the 
patient  are  those  of  plague,  but  the  bacteriologist 
of  the  Ministry  has  been  unable  to  verify  the 
diagnosis,  and  no  plague-infected  rats  have  been 
found  on  the  vessel.  No  further  cases  of  illness 
have  occurred  on  board,  and  the  ship  has  sailed 
from  the  Port  of  London. 


National  Physical  Laboratory.  — The  Lord 
President  of  the  Council  has  appointed  Professor  Joseph 
Ernest  Petavel,  D.Sc.,  F.R.S.,  M.I.Mech.E.,  &c.,  to  be 
Director  of  the  National  Physical  Laboratory  in  succession 
to  Sir  Riohard  Glazebrook,  C.B.,  F.R.S.,  who  retires  on 
reaching  the  age  limit  on  Sept.  18th  next.  Professor 
Petavel  is  professor  of  engineering  and  director  of  the 
Whitworth  Laboratory  in  the  University  of  Manchester.  He 
is  a member  of  the  Advisory  Committee  for  Aeronautics  of 
the  Air  Ministry.  He  was  educated  at  University  College, 
London,  and  undertook  scientific  research  at  the  Royal 
Institution  and  at  the  Davy  Faraday  Laboratory  until  1898. 
He  was  elected  John  Harling  Fellow  of  the  Owens  College, 
Manchester,  in  1900,  and  was  scientific  manager  of  the  Low 
Temperature  Exhibit  of  the  British  Royal  Commission  for 
the  St.  Louis  Exhibition,  1904. 


446  The  Lancet,] 


AMERICAN  MEDICAL  GATHERINGS. 


[Sept.  6,  1919 


AMERICAN  MEDICAL  GATHERINGS. 


Three  important  medical  gatherings  were  held  in  the 
United  States  of  America  during  the  month  of  June.  The 
seventieth  annual  session  of  the  American  Medical  Associa- 
tion, which  took  the  form  of  a “victory  meeting”  at 
Atlantic  City,  from  June  9th-13th,  has  already  been  reported 
in  The  Lancet.1  There  remain  for  brief  comment  the 
twentieth  annual  meeting  of  the  American  Therapeutical 
Society,  the  sessions  of  which,  on  June  6th  and  7th, 
preceded  the  victory  meeting  at  Atlantic  City,  and  the 
Congress  of  American  Physicians  and  Surgeons,  of  which 
the  eleventh  triennial  session  occupied  June  16th  and  17th 
at  the  same  city. 

At  the  American  Medical  Association  the  afternoon  of 
June  11th  was  devoted  to  various  aspects  of  industrial 
hygiene  and  their  relation  to  public  health,  and  this  dis- 
cussion, at  which  Dr.  H.  E.  Mock  (Chicago)  presided,  merits 
attention. 

Dr.  \V.  J.  Clarke  (Worcester,  Mass.)  dealt  with 

Preventive  Surgery  as  Demonstrated  by  Industrial  Practice. 

In  the  treatment  and  repair  of  hernia  the  question  often 
arose  whether  the  condition  wa3  to  be  classed  as  an 
industrial  accident.  He  had  found  that  the  sac  was  often 
congenital,  and  there  was  a distinct  racial  suscepti- 
bility. The  question  of  recurrence  was  a difficult  one.  He 
often  saw  a sac  adherent  to  the  cord,  with  a small  neck,  and 
after  amputation  of  the  sac,  although  the  repair  appeared  to 
be  without  a flaw,  yet  the  patient  was  apt  to  come  back 
later  with  a recurrence.  No  man  with  a definite  bulge  should 
be  put  to  do  heavy  work. 

Dr.  W.  S.  Sherman  (Pittsburgh,  Pa.)  said  employers  were 
coming  to  realise  the  impcrtance  of  keeping  their  workers 
fit,  and  the  immense  loss  entailed  to  industry  by  illness. 
Fortunately,  injuries  received  in  the  steel  mills  were  often 
sterile,  as  coal,  coke,  and  iron  did  not  produce  infection. 
Dakin’s  hypochlorite  solution,  used  according  to  the  Carrel 
technique,  had  been  found  a useful  solvent  of  necrotic 
tissue. 

Dr.  O.  P.  Geier  (Cincinnati)  indicated  how  the  industrial 
surgeon  might  stimulate  the  patient  to  seek  early  advice 
from  an  outside  surgeon — e.g.,  in  cases  of  neoplasm  or 
appendicitis. 

The  President  _said  that  the  timely  examination  and 
removal  of  diseased  tonsils  might  save  such  complications 
as  appendicitis  and  gall-bladder  invasion,  and  even  rheu- 
matisms. This  was  an  important  side  of  industrial  pre- 
vention. 

Dr.  J.  W.  Schereschewsky  (U.S.  Public  Health  Service, 
Washington,  D.C.)  stated  his  belief  that  intra-abdominal 
pressure  was  the  result  of  opposition  to  contraction  of  abdo- 
minal muscles.  The  development  of  musculature  had  much 
to  do  with  the  prevention  of  hernia  and  its  recurrence.  With 
impaired  tonus  relapse  must  take  place. 

Dr.  C.  E.  Ford  (New  York)  dealt  with 

Industrial  Medical  Practice  and  Sickness  Prevention  as  a 
Factor  in  Public  Health. 

Some  years  ago  the  employment  of  a physician  was 
regarded  as  benevolence  on  the  part  of  the  employer.  It 
was  now  beginning  to  be  understood  that  industry  would 
best  be  benefited  by  the  employment  of  qualified  physicians. 
Part-time  service  was  of  little  use.  Men  adapted  to  under- 
take this  work  were  those  who  had  seen  at  least  five  years’ 
general  practice,  had  had  experience  in  health  department 
and  dispensary  work,  with  opportunity  of  acquiring  the 
social  view-point.  Sanitation,  nuisances,  garbage  disposal, 
sewage  disposal,  flies,  housing,  prevention  of  infection 
were  all  subjects  of  great  educational  importance.  The 
frank  discussion  of  venereal  disease,  the  control  of  tuber- 
culosis, the  necessity  of  rest,  and  the  like,  were  all  matters 
of  vital  importance.  Educational  films  could  now  be  obtained 
at  a very  moderate  cost.  In  a survey  of  the  funds  spent 
by  99  leading  industries  he  found  that  $2.50  was  being  spent 
per  head  annually  in  this  way. 

Dr.  W.  A.  Sawyer  (Philadelphia)  said  that  there  were 
approximately  30  million  industrial  workers  in  the  United 
States,  and  industrial  medicine  served  to  reach  a class  that 


could  be  reached  by  no  other  means.  There  should  be 
cooperation  between  public  health  workers  and  industrial 
physicians. 

Dr.  D.  L.  Edsall  (Boston)  stated  that  at  the  Massa- 
chussets  General  Hospital  a survey  of  patients  attending  the 
occupational  clinic  showed  that  in  5000  cases,  or  one-tenth 
of  the  total  attending,  occupation  had  something  to  do  with 
the  disability.  The  average  industrial  worker  was  said  to 
lose  eight  days  in  the  year  from  sickness.  The  opportunity 
for  community  service  by  the  industrial  physician  was 
illimitable. 

Dr.  C.  Hastings  (Toronto)  gave  his  experience  of  the 
department  of  industrial  hygiene  started  four  years  ago  in 
that  city.  “ Show,”  he  said,  “ the  employers  of  labour  how 
the  loss  of  10  to  15  per  cent,  of  efficiency  in  the  employee 
could  be  saved,  and  they  would  be  willing  to  put  in  good 
ventilation  or  any  other  desired  improvement.” 

Dr.  A.  Wadsworth  (Albany,  New  York)  spoke  of  the 
need  for  industrial  physicians  to  avail  themselves  of  the 
facilities  offered  by  the  State  for  laboratory  examinations. 
Systematic  examinations  in  the  venereal  diseases  would  be  of 
great  industrial  service,  but  if  a demand  for  the  work  arose 
there  was  no  doubt  that  the  legislature  would  see  fit  to 
appropriate  the  proper  funds. 

Dr.  Schereschewsky  enumerated  six  lines  along  which 
federal  management  of  industrial  medicine  had  been 
planned  : — 

(1)  Extension  of  health  service  in  industries  to  determine  extent  and 
means  of  correcting  health  hazards;  (2)  development  of  system  of 
medical  and  surgical  supervision  of  employees  ; (3)  securing  reports  of 
the  prevalence  of  disease  among  employees  and  sanitary  conditions  in 
industrial  communities;  (4)  establishment  of  minimum  standards  of 
industrial  hygiene  and  prevention  of  occupational  diseases  ; (5)  improve- 
ment of  sanitation  of  industrial  communities  by  cooperating  with  State 
and  local  health  authorities  and  other  agencies  ; (6)  medical  and  sanitary 
supervision  by  public  health  service  of  industrial  establishments  owned 
or  operated  by  Government. 

Dr.  George  A.  Soper  (Sanitary  Corps,  U.S.  Army)  dealt 
with 

The  Efficacy  of  Measures  for  the  Prevention  of  Disease. 

Of  the  three  great  lines  of  effort — namely,  sanitation, 
public  health  administration,  and  personal  precautions — 
only  the  first  two  had  been  developed.  Respiratory  infec- 
tions were  ten  times  as  numerous  as  the  exanthemata,  and 
personal  precautions  were  the  largest  factor  in  this  question. 
Disinfection  had  come  to  take  a secondary  place,  and  proper 
ventilation  and  a high  standard  of  cleanliness  had  been 
found  of  first  importance.  The  soldier  had  been  taught 
how  to  take  care  of  himself.  The  time  to  study  respiratory 
infections  was  before  the  attack  appeared.  It  was  for  the 
individual  to  learn  that  the  lessons  of  the  Army  were  not 
for  the  Army,  but  to  be  appropriated  by  the  whole  world  in 
times  of  peace. 

Colonel  Kramer  (U.S.  Army)  feared  that  unless  the 
medical  profession  approached  industrial  hygiene  in  a more 
scientific  and  thorough  manner  they  might  lose  control 
altogether,  as  the  work  was  being  done  most  efficiently  by 
sanitary  engineers. 

Dr.  L.  I.  Harris  (New  York)  said  it  was  a pity  that  after 
many  enthusiastic  meetings  nothing  was  done.  Resolu- 
tions ought  to  follow  the  matters  discussed  and  the  advice 
obtained  carried  out. 

Dr.  Schereschewsky  said  that  the  responsibility  rested 
with  the  community  itself.  The  State  and  national  boards 
were  there  for  guidance  and  control.  The  individual  citizen 
must  play  his  part  in  demanding  the  best  conditions. 

Dr.  Soper,  in  closing  the  debate,  regretted  that  only  about 
70  per  cent,  of  the  population  were  included  in  the  vital 
statistics  of  the  United  States. 


The  scientific  section  of  the  American  Therapeutic  Society 
on  June  6th  opened  with  an  address  by  Dr.  Douglas 
Yander  Hoof  (Richmond,  Va.),  the  President,  on 

Therapeutics  and  G astro- Intestinal  Disorders. 

In  making  a diagnosis  of  gastro-intestinal  disorders  the 
services  of  the  internist,  the  roentgenologist,  the  oculist,  the 
neurologist,  or  the  surgeon,  were,  he  said,  often  required. 
1000  private  cases  (excluding  definite  lesions  of  the 
alimentary  tract)  in  which  the  patients  complained  of  ‘ ‘ indi- 
gestion ” were  studied  and  the  causative  factors  tabulated. 
Laboratory  analyses  and  X ray  pictures  were  made  in 
all  cases,  and  a Wassermann  test  was  performed.  Where 


1 The  Lancet,  July  12th,  1919,  p.  78. 


The  Lancet,] 


AMERICAN  MEDICAL  GATHERINGS. 


[Sept.  6,  1919  447 


the  presence  of  more  than  one  lesion  was  demonstrated  the 
condition  most  likely  to  be  the  causative  factor  was  tabulated. 
The  most  frequent  cause  was  found  to  be  chronic  appendicitis 
(one-lifth  of  all  cases)  ; this,  with  gall-bladder  lesions  added, 
made  one-third  of  all  causative  factors.  Peptic  ulcer  formed 
one-tenth  of  all  cases.  Kidney  and  heart  involvement,  one- 
tenth.  Cancer  cases  formed  less  than  4 per  cent,  of  the 
whole.  Hypo-acidity  was  present  in  about  one-sixth  of  the 
cases.  As  regards  symptomatology,  loss  of  appetite,  though 
an  important  symptom  in  children  and  in  animals,  was  not 
prominent  in  adults  on  account  of  the  number  of  artificial 
stimulants  to  produce  appetite.  Coated  tongue  exhibited 
no  relationship  to  affections  of  the  stomach.  An  analysis 
showed  that  the  same  proportion  was  found  in  hypo-  and 
hyper-acidity,  and  that  62  per  cent,  of  perfectly  healthy 
persons  had  coated  tongues.  The  causes  seemed  to  be  : (1) 
nasal  obstruction  ; (2)  absence  of  friction  (as  in  liquid  diet) 
and  where  the  arch  of  the  palate  was  very  high  ; (3)  per- 
version of  salivary  secretion,  probably  the  most  common 
cause  and  often  found  in  neurotic  individuals.  Nausea 
and  vomiting  were  common  and  found  to  be  due  to  : (1) 
toxic  states ; (2)  reflex  disturbances  from  eyes  or  ears  ; 

(3)  pharyngeal  irritation  as  in  alcoholics  and  smokers  ; 

(4)  habit  vomiting ; (5)  brain  and  spinal  cord  lesions. 
These  were  not  frequent  in  gastro-intestinal  disease, 
except  in  pylorospasm.  Hsematemesis  indicated  peptic  ulcer 
or  obstruction  of  the  portal  circulation.  Flatulence  was 
due  in  most  cases  to  the  eructation  of  atmospheric  air 
that  had  been  swallowed.  Abnormal  secretion  of  mucus  in 
the  stomach  was  a protective  adaptation  against  irritating 
ingesta.  Similarly,  mucus  in  the  stools  was  a protective 
measure  of  the  intestine  against  the  irritation  of  cathartics. 
The  first  treatment  for  this  condition  was  complete  rest  for 
the  bowel.  Then  treatment  by  belladonna  and  mineral  oil 
would  effect  a cure.  Indigestion  would  be  found  to  be 
caused,  not  so  much  by  the  food  eaten  as  by  the  state  of  the 
gastric  nerves  during  eating.  As  regards  therapeutics,  drugs 
had  their  place  ; belladonna  was  indicated  in  pylorospasm 
and  digitalis  in  chronic  passive  congestion  of  the  liver.  In 
some  cases  psychotherapy  was  called  for. 

Discussion . 

Dr.  T.  F.  Reilly  (New  York)  said  that  the  last  place  to 
look  for  stomach  symptoms  was  in  the  stomach  itself. 

Dr.  Jacob  Diner  (New  York)  spoke  of  kidney  lesions  as 
the  cause  of  indigestion  ; these  were  usually  of  the  chronic 
interstitial  or  parenchymatous  kind.  In  the  very  poorest 
dispensary  class  in  New  York  City  65  per  cent,  of  all  com- 
plaints was  of  indigestion,  and  upon  investigating  the  teeth 
large  pus  pockets  and  alveolar  abscesses  were  frequently 
found.  If  these  people  would  have  their  teeth  looked  after 
the  indigestion  disappeared  of  itself. 

Dr.  0.  T.  Osborne  (New  Haven,  Conn.)  laid  emphasis  on 
the  character  of  the  food  taken.  Many  persons  undoubtedly 
were  eating  wrongly.  In  order  to  gain  weight  young  people 
were  apt  to  drink  milk  as  they  would  water  with  solid  meals, 
thus  putting  too  much  work  on  the  stomach.  The  giving  of 
digestives,  as  such,  outside  of  needed  hydrochloric  acid, 
was  rarely  necessary. 

Dr.  F.  M.  Pottenger  (Monrovia,  Calif.)  discussed  the 
question  from  the  standpoint  of  histology  and  neurology. 
Stimulation  of  the  vagus  nerve  caused  increased  tension 
throughout  the  whole  gastro-intestinal  tract.  Thus,  with 
increase  of  ter  sion  the  whole  syndrome  of  appendicitis  might 
be  produced,  as  well  as  that  of  hyperchlorhydria.  The 
stimuli  did  not  explode  in  all  individuals  at  the  same  time, 
and  appendix  stimulation  might  produce  increased  acid  and 
motility  of  the  stomach  or  intestinal  tract  with  irregular 
contraction  and  pain  in  one  case,  or  it  might  produce 
intestinal  stasis  with  resulting  biliousness  in  another.  A 
large  group  of  people  were  vagotonics.  The  main  point  in 
stomach  indigestion  was  to  find  out  whether  the  case  was 
due  to  sympathetic  or  to  vagus  stimulation. 

The  regular  sessions  of  the  Therapeutic  Society  were 
devoted  to  a discussion  on  Physiological  Researches  in  their 
Relations  to  Therapy,  introduced  by  Dr.  J.  C.  Hemmeter 
(Baltimore)  and  Dr.  R.  T.  Morris  (New  York)  ; on  Glandular 
Therapy,  introduced  by  Dr.  E.  B.  McCready  (Pittsburgh) 
and  Dr.  A.  A.  Lescohier  (Detroit) ; on  Thoracic  Affections 
and  their  Management,  when  papers  were  read  by  Dr.  H.  C. 
Gordonier  (Troy,  N.Y.)  and  Dr.  E.  Zueblin  (Cincinnati)  ; 
and  a symposium  on  Epidemic  Influenza,  to  which  Dr.  F.  E. 


Stewart  and  Dr.  H.  0.  Wood,  jun.  (Philadelphia),  Dr.  J. 
Diner,  and  Dr.  N.  P.  Barnes  (Washington)  contributed. 

The  Present  Teaching  of  Therapeutics. 

At  the  concluding  session  Dr.  S.  L.  Dawes  (New  York) 
gave  an  address  on  the  Present-day  Teachingof  Therapeutics. 
Medicine,  he  said,  had  now  become  a science  more  or  less 
exact,  teaching  being  based  more  upon  careful  statistical 
data,  case-histories,  hospital  records,  laboratory  findings 
than  upon  exposition  of  individual  opinion.  Students  were 
taught  to  carry  out  a Wassermann  reaction,  to  do  a spinal 
puncture  and  examine  stomach  contents,  to  differentiate 
typhoid  and  paratyphoid,  and  to  have  intimate  acquaintance 
with  calories,  opsonins,  and  vitamines  ; but  excepting  in 
surgery  the  cure  of  disease  had  become  a secondary  matter. 
Materia  medica  was  not  taught  and  therapeutics,  with  a 
few  notable  exceptions,  ignored.  The  pendulum  had  swung 
far  from  the  practice  of  polypharmacy  and  “shot-gun” 
prescriptions.  The  first  assault  of  any  magnitude  upon  this 
part  of  the  curriculum  was  made  by  a clique  of  medical 
politicians  who  arranged  the  passage  of  the  Medical  Prac- 
tice Act  of  1909,  when  materia  medica  and  therapeutics 
Wire  removed  from  the  list  of  subjects  in  which  a 
candidate  was  required  to  pass  in  order  to  practise 
medicine,  with  the  result  that  osteopaths  could  practise 
without  any  examination  of  any  kind.  Not  one  of  the 
larger  medical  schools  now  taught  materia  medica,  and 
pharmacological  teaching  consisted  for  the  most  part  in 
studying  the  action  of  drugs  on  animals,  and  did  not  include 
the  properties  and  dosage  of  drugs,  their  methods  of 
administration,  and  their  incompatibilities.  Only  two  of  the 
first-class  medical  schools  taught  applied  therapeutics,  in 
most  of  the  15  it  was  taught  as  an  accessory.  What  wonder, 
therefore,  that  the  practitioner  gave  fever  tablets,  kidney 
pills,  coryza  tablets,  heart  tonics,  hepatic  stimulants,  and 
anti-this  and  anti-that,  while  the  public  crowded  the 
waitiDg-rooms  of  osteopaths,  cheiropractics,  Christian 
scientists  and  charlatans,  or  turned  to  religious  newspapers 
to  read  the  statements  of  ex- Statesmen  and  clerical  incom- 
petents as  to  the  value  of  some  patent  article.  The  full- 
time teacher  had  pushed  out  the  experienced  clinician. 

An  animated  discussion  followed,  in  which  Dr.  Vander 
Hoof,  Dr.  Diner,  Dr.  Reilly,  Dr.  Osborne,  Dr.  C.  E.  de  M. 
Sajous,  Dr.  H.  Wood  (Philadelphia),  and  Dr.  Pottenger 
took  part.  


The  meetings  of  the  Congress  of  American  Physicians  and 
Surgeons  occupied  two  afternoons,  of  which  the  first  was 
devoted  to  the  Surgical,  and  the  seoond  to  the  Medical, 
Aspects  of  Reconstruction. 

Dr.  Simon  Flexner  (New  York)  delivered  the  presidential 
address  on 

Epidemiology  and  Recent  Epidemics , 

basing  his  remarks  on  the  wave  of  poliomyelitis  which  passed 
over  New  York  and  contiguous  States  in  1916,  leaving  its 
mark  on  a portion  of  the  population  during  the  lifetime  of 
the  youngest  individuals.  Medical  literature  afforded  no 
parallel  for  that  epidemic.  20,000  cases  were  recognised,  of 
which  one-fourth  recovered  and  one-half  are  still  suffering 
from  the  consequences  of  the  disease.  In  1917-18  there 
appeared  in  the  camps  of  the  country,  spreading  thence  to 
the  civil  community,  an  epidemic  streptococcus  infection, 
localised  in  the  lungs  and  affecting  the  pleura,  creating  a 
large  amount  of  sickness  and  disability  among  troops,  and 
resulting  in  many  deaths  ; this  infection  increased  in 
severity  as  the  disease  progressed.  But  these  two  visitations 
were  mild  and  inconspicuous  in  contrast  with  the  great 
epidemic  of  influenza,  which  caused  so  many  more  deaths 
than  the  war  that  the  two  calamities  were  hardly  to  be 
compared.  And  yet  the  havoc  of  disease  left  the  great  mass 
of  people  unmoved.  It  was  the  duty  of  the  medical  pro- 
fession to  ensure  that  the  attitude  of  the  people  towards 
disease  calamity  was  similar  to  that  adopted  towards  ill- 
government.  In  regard  to  poliomyelitis  we  had  two  pieces 
of  essential  information — the  nature  of  the  germ  and  its 
dissemination — but  there  were  things  about  the  microbial 
origin  of  this  disease  which  were  still  hidden.  It  was  not 
enough  for  the  germs  to  be  identified,  there  were  qualities  of 
virulence,  subject  to  fluctuations  and  variations,  and  called 
forth  by  circumstances  over  which  we  had  as  yet  no  control. 
These  phenomena  were  by  no  means  incapable  of  being  dis- 
covered, but  results  could  only  go  just  so  far  as  the  public 


448  The  Lancet,] 


MEDICAL  MATTERS  IN  SPAIN. 


[Sept.  6,  1919 


mind  was  ready  to  receive  knowledge  and  to  adopt  measures 
which  flow  therefrom.  In  regard  to  the  epidemic  of 
influenza,  we  were  confronted  with  the  question  whether  of 
that  disease  we  had  the  essential  fundamental  knowledge. 
Epidemics  of  influenza  had  been  recorded  since  about  the 
sixteenth  century.  The  great  outbreak  of  1889-92  coincided 
with  the  discovery  of  the  Pfeiffer  bacillus,  fairly  accepted  by 
the  world  as  the  cause  of  influenza.  But  to-day  the  position  of 
the  Pfeiffer  bacillus  was  not  as  strong  as  it  was  in  1892.  The 
development  of  laboratories  as  accessories  to  medical  practice 
had  brought  a practical  knowledge  of  epidemic  problems 
and  of  the  application  of  knowledge  to  clinical  purposes. 
If  it  had  not  been  for  the  disorganisation  of  forces  due  to  the 
war  there  would  doubtless  have  been  a frontal  and  massed 
attack  on  the  problem.  If  scientific  opinion  was  still  un- 
certain as  to  the  role  of  the  Pfeiffer  bacillus,  the  disease  was 
at  all  events  well  under  investigation,  and  certain  lines  of 
work,  not  yet  published,  were  likely  to  have  a profound 
effect  on  our  views  of  the  microbial  origin  of  the  disease. 
There  was  a movement  towards  the  belief  in  a filterable  or 
invisible  micro-organism,  but  the  evidence  that  this  type  of 
virus  was  related  to  the  disease  should  be  just  as  complete 
as  in  the  case  of  a visible  organism.  The  cause,  whatever  it 
was,  of  influenza  was  mysterious  and  elusive.  It  attached 
itself  to  persons  and  was  carried  about  with  them.  The 
disease  appeared,  disappeared,  and  reappeared.  In  the 
history  of  epidemics  influenza  took  its  origin  in  a region 
somewhere  near  the  Russian  border  of  Turkestan,  spreading 
along  the  trade  routes  as  rapidly  as  transportation  moved. 
In  the  last  epidemic  in  which  the  speed  of  travel  had  been 
greatest  it  spread  East  and  West,  to  Spain  and  to  China, 
and  in  1919  over  the  entire  globe.  Small  numbers  of 
individuals  were  first  affected,  then  larger  numbers,  then 
whole  communities  fell  victims.  A curve  representing  the 
speed  of  travel  of  poliomyelitis,  compared  with  that  of 
influenza,  showed  the  progress  of  the  former  by  weeks  and 
months,  of  the  latter  by  days  and  weeks.  The  curves  were 
extremely  similar,  first  a slow  rise,  then  a steep  rise,  then  a 
level  maintained,  then  a steep  fall  or  decline.  The  seeming 
mystery  was,  in  fact,  due  to  definite  causes,  like  ordinary 
infections.  Particular  organisms,  the  presence  of  which 
might  or  might  not  cause  the  actual  disease,  gained  access 
to  the  body,  the  persons  carrying  it  possibly  being  immune, 
and  yet  transmitting  it  to  others.  Both  these  diseases  had 
homes.  Poliomyelitis  had  an  endemic  home  in  North- 
Western  Europe.  In  1881  it  was  recorded  in  Norway  and 
Sweden,  where  an  epidemic  outburst  preceded  the  general 
spread  to  other  parts  of  the  world  in  1903-5.  If  the  disease 
could  be  arrested  in  the  influenzal  stage  we  should  have  little 
to  complain  of,  but  we  were  confronted  with  the  menace  of  a 
second  disease,  pneumonia,  more  severe,  which  became  grafted 
on  a widespread,  relatively  innocuous  infection.  However 
influenza  germs  entered  the  body,  we  knew  that  the 
pneumonia  organism  entered  by  the  nose  and  throat  and 
spread  under  circumstances  rendering  possible  an  inflamma- 
tion of  the  lungs.  Whatever  we  might  think  concerning 
influenza,  there  was  no  doubt  that  we  should  prevent  that 
most  serious  complication.  What  were  the  proper  measures 
of  eradication  of  these  great  epidemic  calamities  ? We  had 
a splendid  example  of  eradication  of  disease  in  yellow  fever. 
We  did  not  wait  for  the  disease  to  become  epidemic,  it  was 
destroyed  in  its  endemic  home.  The  endemic  focus  of 
influenza  was  somewhere  on  the  eastern  border  of  Russia.  It 
was  not  too  much  for  a reconstructive  medical  profession  to 
conceive  the  cleaning  up  of  such  a region  as  that,  which  by 
its  inaccessibility  and  its  neglect  had  every  25  or  30  years 
originated  waves  of  disease  spreading  over  the  globe.  We 
might  imagine  communities  intelligent  enough  to  hold  their 
officials  responsible  for  control  of  disease,  as  nations  have 
proven  that  they  have  held  their  rulers  responsible  for 
control  in  the  war.  Communities  should  be  so  taxed  for 
public  health  that  they  would  have  the  means  and  power  to 
put  into  office  those  best  qualified  to  carry  out  measures  on 
a parallel  with  knowledge,  holding  them  responsible,  and, 
if  they  did  their  work  ill,  letting  them  suffer  the  con- 
sequences. 

On  the  second  evening  of  the  Congress  Dr.  Frank 
Billings  (Office  of  the  Surgeon-General,  Washington,  D.C.) 
gave  an  address  on  the  Physical  and  Mental  Rehabilitation 
of  Disabled  Soldiers  of  the  United  States  Army,  with  an 
exhibition  of  films  illustrating  physical  reconstruction  in  the 
military  hospitals. 


MEDICAL  MATTERS  IN  SPAIN. 

(From  our  own  Correspondents.) 


Patent  Medicines  in  Spain. 

In  the  interests  of  public  health  and  in  response  to 
numerous  representations  made  by  the  medical  and  pharma- 
ceutical professions  of  the  country  the  Spanish  Government 
has  at  last  undertaken  to  regulate  the  traffic  in  proprietary 
medicines,  and  to  this  effect  it  has  promulgated  an  Order 
dealing  with  the  manufacture  and  sale  of  such  preparations 
equally  applicable  to  national  as  well  as  foreign  products. 

It  defines  a pharmaceutical  specialty  as  “ every  medicament 
of  known  composition,  distinguished  by  the  name  of  its 
originator  or  by  a fancy  appellation,  put  up  in  uniform 
packages  and  destined  for  sale  in  a pharmacy  or  elsewhere. 
Preparations  the  composition  of  which  is  partially  or  totally 
unknown,  as  well  as  those  merely  stating  that  they  ‘ are 
prepared  from, ’are  to  be  regarded  as  secret  remedies,  the 
sale  of  which  is  prohibited.”  Unless  the  preparation 
marketed  as  a proprietary  is  made  in  accordance  with  a 
formula  contained  in  the  Spanish  or  in  a foreign  pharma- 
copoeia, in  which  case  it  must  be  labelled  with  the  official 
title,  and  without  any  additional  qualification,  it  must  be 
registered  with  the  general  inspection  of  the  board  of 
health  before  it  may  be  sold  in  Spain.  Applica- 
tion for  registration  of  a proprietary  medicine  must 
be  accompanied  by  the  package  (in  the  case  of  foreign 
preparations  three  packages  must  be  submitted),  the 
designs  or  proofs  of  the  label,  wrapper,  and  prospectuses 
relating  to  the  preparation,  the  exact  composition,  and  the 
grounds  which  induce  the  manufacturer  to  place  the  product 
on  the  market  in  the  form  of  a proprietary  medicine.  When 
registered  the  preparation  may  only  be  sold  provided  the 
label  and  all  printed  matter  referring  to  it  mention  the 
name  under  which  it  has  been  registered,  the  name  of  the 
maker  and  his  profession,  where  it  is  manufactured,  its 
composition,  the  serial  number,  and  date  of  its  registration. 
Proprietary  medicines  may  only  be  manufactured  by 
pharmacists  or  in  establishments  where  the  director  and  the 
technical  personnel  are  pharmacists.  In  the  case  of  foreign 
specialties  the  professional  qualification  of  the  applicant 
must  be  certified  by  the  competent  health  authority  of  the 
country  of  origin  on  the  back  of  the  application  for 
registration. 

Questions  relating  to  the  therapeutic  or  pharmacological  j 
action  of  a proprietary  medicine  submitted  for  registration 
will  be  referred  to  the  Royal  National  Academy  of  Medicine 
for  its  decision.  The  health  authorities  are  entrusted  with 
the  task  of  supervising  the  sale  of  such  products  and  of 
enforcing  the  observance  of  these  regulations.  If  it  is  found 
that  the  composition  of  a registered  proprietary  has  been 
altered,  and  does  not  correspond  with  that  entered  on  the 
register,  its  sale  will  be  stopped  and  a renewed  application 
for  registration  by  the  same  manufacturer  will  be  refused. 
The  registration  in  each  case  is  strictly  personal,  and  on  the 
death  of  the  holder,  or  in  the  event  of  his  ceding  his  interest 
in  the  preparation  to  another  person,  or  if  the  manufacture 
is  entrusted  to  another  party,  a fresh  application  for  registra- 
tion must  be  made  by  the  new  owner.  Proprietary  medicines 
which  contain  potent  drugs,  defined  as  all  substances  of 
which  the  maximum  initial  dose  ranges  from  a fraction  of  a 
milligramme  to  5 centigrammes,  as  well  as  those  possessing 
a drastic,  antipyretic,  emetic  or  emmenagogue  action,  and, 
in  preparations  for  external  use,  a caustic  or  irritant  effect, 
may  only  be  sold  in  a pharmacy.  If  the  preparation  consists 
solely  of  one  or  more  drugs  answering  this  description,  it  may 
only  be  supplied  on  production  of  a medical  practitioner's 
prescription.  The  manufacture  and  public  advertisement  in 
any  form  of  any  remedies  directly  or  indirectly  destined  to 
prevent  conception,  is  forbidden,  as  well  as  any  references 
to  the  possibility  of  such  use.  In  the  case  of  proprietary 
medicines  at  present  on  sale  in  Spain,  whether  national  or 
foreign,  a period  of  two  years  is  allowed  in  which  registra- 
tion can  be  effected.  All  new  preparations  of  this  class,  as 
well  as  the  importation  of  specialties  not  at  present  on  sale 
in  Spain,  must  comply  with  these  rules  before  their  sale  in 
Spain  is  permitted. 

Marine  Sanatorium  for  Children  Suffering  from  Surgical 
Tuberculosis  at  Gorliz,  Vizcaya. 

Lately  there  was  opened  a magnificent  public  charity, 
which,  it  is  hoped,  will  be  a model  of  its  kind  for  many 


The  Lancet,] 


SOUTH  AFRICAN  NOTES. 


[Sept.  6,  1919  449 


others  in  Spain.  The  writer  first  paid  a visit  to  the  place 
some  six  years  ago,  when  the  sanatorium  was  only  in  the 
early  stage  of  construction.  Founded  by  the  Provincial 
Council  of  Vizcaya  and  aided  by  voluntary  contributions,  its 
progress  to  the  present  state  of  usefulness  has  been  slow, 
but  the  result  is  highly  satisfactory.  For  situation,  plan, 
and  internal  arrangements  it  would  be  difficult  to  beat.  The 
model  is  that  of  Berck-sur-Mer  in  France  and  also,  as  I 
was  later  informed,  the  Marine  Sea  Bathing  Hospital, 
Margate.  The  sanatorium  contains  300  beds  and  is  on  the 
Bay  of  Biscay  some  15  miles  from  Bilbao,  lying  close  to  the 
sandy  shore  of  a little  bay,  facing  due  west.  It  is  surrounded 
by  hills,  which  are  only  broken  in  their  continuity  by  a gap 
which  forms  the  bay.  A more  perfect  arrangement  for  helio- 
therapy it  would  be  difficult  to  plan.  As  a suntrap  the 
aspect  has  been  specially  chosen.  The  wide  verandahs  in 
front  and  behind  each  ward  are  for  morning  and  after- 
noon use  respectively.  The  flat  roof  of  the  central  block 
is  also  designed  for  open-air  treatment.  The  sanatorium 
is  a massive  stone  structure,  cemented,  and  white  in  colour, 
with  square  blue  tiles  arranged  in  bands  near  the  top, 
giving  it  a curious  speckled  appearance  in  Basque  style.  It 
consists  of  three  floors  with  large  wards  identical  in  character, 
the  walls  and  floors  tiled,  but  with  the  angles  duplicated, 
not  rounded,  the  wider  angles  affording  less  lodgment  for 
dust  than  the  gutters  of  the  usual  kinds.  In  all  the  passages 
the  gutter  angle,  however,  prevails.  Each  ward  contains 
space  for  20  cots,  with  a cubic  space  of  50  metres  for  each. 
The  cot  is  of  white  enamelled  iron  fitted  with  a movable 
lattice  tray  suspended  by  hooks  for  the  purpose  of  raising 
or  tilting  the  hair  mattress  upon  it.  A white-enamelled  iron 
and  glass  locker  is  beside  each  cot.  So  far  only  30  little 
patients  are  in  the  hospital,  and  these,  when  I last 
visited  the  place,  were  lying  in  their  cots  on  one  of  the 
spacious  verandahs  outside  the  wards.  They  were  basking 
in  the  afternoon  sun  on  the  western  side  practically  in  a 
state  of  nudity,  many  so  sunburnt  as  to  be  peeling, 
for  the  doctors  believe  in  the  beneficial  effects  of  the  direct 
solar  rays  on  skin  tuberculosis  and  joint  disease.  Even 
dressings  over  open  wounds  were  cast  aside  and  pus  welled 
up  by  the  action  of  kicking  legs.  In  front  of  the  sanatorium 
the  quiet  ripple  of  the  tide  was  creeping  over  the  sand  of  a 
perfect  bathing-place,  where  in  suitable  cases  sea-bathing 
augments  the  cure.  There  is  a complete  installation  for 
X rays  adjoining  the  operating  theatre,  sterilising  apparatus 
of  up-to-date  pattern,  shoots  for  soiled  linen,  and  many 
ingenious  contrivances  of  a sanitary  kind.  The  water-closets 
and  baths  are  provided  by  an  English  firm,  Twyfords.  The 
large  laundry  in  the  basement  is  complete  with  the  latest 
machinery.  The  whole  building  can  be  heated  throughout 
by  steam  radiators.  The  kitchen  is  in  a separate  block  at 
the  back,  and  contains  the  most  modern  kind  of  boilers  and 
cookers,  worked  by  super-heated  steam.  There  are  buildings 
for  the  nursing  staff,  a chapel,  and  a special  separate  block 
called  the  “ lazareto  ” for  cases  of  doubtful  tuberculosis  for 
observation  purposes.  The  cost  of  the  whole  sanatorium 
when  complete  will  be  upwards  of  £170,000. 


SOUTH  AFRICAN  NOTES. 

(From  our  own  Correspondent.) 

A Mild  Recrudescence  of  Influenza. 

The  Union  Department  of  Public  Health  reports  that 
after  the  epidemic  of  October  and  November  last  occasional 
sporadic  cases  and  small  localised  prevalences  have  con- 
tinued to  occur  throughout  South  Africa.  Up  to  the  end  of 
April  last  the  reported  cases  averaged  166  and  the  deaths 
10  per  cent,  of  the  cases.  May  ushered  in  cold  weather  and 
increased  influenza  cases  and  deaths.  It  will  be  seen  from 
the  following  figures  that  there  was  a remarkably  large 
increase  in  the  number  of  cases — though  happily  not  in 
deaths— during  the  last  week  in  June  and  first  week  in  July. 
This  is  the  South  African  mid-winter,  and  it  has  been  a 
singularly  mild  one.  The  figures  have  been  for  the  weeks 
ending — 


Cases.  Deaths.  Cases.  Deaths. 


May  17th  ... 

. 60 

June  14th 

...  1701  . 

. 134 

„ 24th  ... 

...  691  . 

. 56 

,,  21st 

...  1933  . 

. 165 

,,  31st 

...  1363  . 

. 116 

,.  28th  .. 

...  4272  . 

. 163 

June  7th  ... 

...  1297  . 

. 10 

July  5th 

...  5706  . 

. 196 

Many  mild  cases  escaped  notification.  While  some  of  the 
localised  prevalences  have  been  fairly  severe  the  disease, 
generally  speaking,  has  been  of  much  milder  type  than 
during  last  year’s  epidemic,  and  with  less  tendency  to 
pneumonia  or  other  complications.  The  incidence  has  been 
more  severe  on  those  localities  and  classes  of  population 
which  escaped  comparatively  lightly  last  year.  Although 
second  attacks  are  not  uncommon,  persons  who  escaped  last 
year  are  now  the  principal  sufferers.  The  incidence  of  the 
disease  on  children  and  elderly  persons,  formerly  light,  has 
now  become  heavier.  At  Pietermaritzburg,  and  in  certain 
other  districts,  the  schools  have  been  closed.  The  disease 
has  been  particularly  severe  in  the  Heilbron  district,  Orange 
Free  State,  where  there  have  been  over  60  deaths.  The 
severity  is  now  abating,  but  recent  cases  have  much  sooner 
developed  pneumonia  than  previous  ones.  It  is  reported 
that  influenza  in  the  Hekpoort  Valley  and  along  the 
Magaliesberg,  Transvaal,  is  worse  than  it  was  last  year. 
Whole  households  are  down  in  some  cases,  and,  unfortunately, 
without  any  doctor,  nurse,  or  medicine  being  available.  Dr. 
J.  Anderson,  medical  officer  of  health,  Capetown,  reported 
on  July  4th  that  the  influenza  position  in  the  city  is  quite 
satisfactory.  Capetown  suffered  exceptionally  severely  in 
last  year’s  epidemic. 

A Stricken  Transport. 

Epidemic  influenza  occurred  on  H.M.S.  Kursk,  which  left 
Sydney,  Australia,  on  May  4th,  with  a ship’s  complement 
of  213,  military  personnel  109,  and  995  German  internees. 
There  were  three  doctors  and  three  nurses  on  board.  The 
vessel  arrived  at  Durban  on  June  21st,  and  reported  635  cases 
of  influenza  during  the  voyage  ; deaths,  1 guard  and  16 
internees  ; 94  sick  on  arrival,  7 very  seriously.  The  vessel 
was  quarantined.  All  serious  cases  were  landed  and  isolated 
in  hospital,  where  two  died.  The  vessel  was  thoroughly 
cleansed  and  disinfected,  while  the  internees  were  kept  on 
Salisbuiy  Island  and  the  Bluff  ; no  further  cases  occurred, 
and  the  vessel  sailed  for  Europe  on  June  28th. 

Tribute  to  a Lady  Doctor  at  Capetown. 

Dr.  Jane  Waterston,  a medical  practitioner  and  ardent 
social  worker  at  Capetown,  was  presented  on  Friday, 
July  4th,  with  an  illuminated  address,  a letter  case,  and 
cheque,  subscribed  for  by  the  citizens,  as  a small  mark  of 
their  appreciation  of  Dr.  Waterston's  medical,  social,  and 
■missionary  labours  during  the  last  50  years.  Dr.  Waterston 
became  half  a century  ago  a coadjutor  of  Dr.  Stewart  at 
Lovedale  Native  College,  and,  embracing  the  medical  pro- 
fession, was  afterwards  a missionary  in  Nyasaland,  following 
in  Livingstone’s  steps.  For  the  last  30  years  she  has  done  a 
great  social  work  at  Capetown,  especially  for  the  Free  Dis- 
pensary there.  The  Mayoress  of  Capetown  (Mrs.  W.  J. 
Thorne)  presided  at  the  gathering,  and  said  that  the 
example  of  self-sacrifice  and  devotion  to  ideals  of  duty 
displayed  by  Dr.  Waterston  in  South  Africa  would  be  an 
inspiration  to  all  the  women  of  the  country.  A letter  was 
read  from  the  Right  Hon.  John  X.  Merriman,  M.L.A. , the 
G.O.M.  of  South  African  Parliamentary  life,  which  con- 
cluded : — 

“May  God  bless  Dr.  Waterston,  and  may  she  still  live  many  years  to 
shed  the  light  of  her  holy  and  unselfish  life  over  the  dark  places  of 
South  Africa  is  the  heartfelt  wish  of  her  admiring  friend, 

John  X.  Merriman.’’ 

Sir  John  Buchanan,  in  paying  his  tribute  to  Dr.  Waterston, 
said  that  she  had  embraced  the  medical  profession  because 
of  her  enthusiasm  for  the  succour  of  humanity,  and  he  had 
been  credibly  informed  that  she  had  actually  walked 
hundreds  of  miles  on  foot  in  the  interior  of  Africa,  all  in 
the  cause  that  she  had  at  heart.  Dr.  Waterston,  in  acknow- 
ledging the  testimonial,  said  that  it  was  the  most  trying 
time  of  her  life.  She  intimated  that  she  did  not  propose  to 
leave  off  public  work. 

Dr.  Alex.  Ogg  has  accepted  appointment  to  the  chair  of 
Physics  in  the  University  of  Capetown. 


Belfast  Local  Government  Board  Medical 
Inspector. — Dr.  John  McCloy  has  been  appointed  by  the 
Local  Government  Board  their  medical  inspector  in  charge 
of  the  Belfast  district,  in  place  of  Mr.  E.  F.  Stephenson, 
transferred  to  another  area.  This  appointment  will  greatly 
strengthen  the  Local  Government  Board,  as  Dr.  McCloy  has 
a thorough  knowledge  of  modern  pathology  and  bacteriology, 
and  was  up  to  the  date  of  his  present  appointment  senior 
assistant  in  the  work  of  the  tuberculosis  scheme  in  Belfast. 


459  The  Lancet,] 


NOTES  FROM  INDIA.— CONTROL  OF  VENEREAL  DISEASES. 


[Sept.  6,  1919 


NOTES  FROM  INDIA. 

(From  a Regular  Correspondent.) 


Burma  Pasteur  Institute. 

At  the  Burma  Pasteur  Institute  during  1918-19  595 
persons  sought  advice  as  compared  with  426  in  the  previous 
year.  The  number  of  persons  bitten  by  animals  of  proved 
taint  who  submitted  to  the  full  course  of  treatment  fell  from 
183  in  the  previous  year  to  105  in  the  year  under  review. 
There  were  no  deaths  during  the  year  from  hydrophobia 
amongst  those  who  submitted  to  treatment,  whilst  at  least 
four  deaths  from  this  cause  are  reported  to  have  occurred 
amongst  34  individuals  who  declined  to  undergo  treatment. 

Influenza  Recrudescence. 

The  following  communique  has  been  issued  by  the 
Government  of  India  : — 

Outbreaks  of  influenza  are  reported  from  Bombay, 
Calcutta,  Rangoon,  and  Madras.  These  outbreaks  do  not 
(save  in  the  case  of  Bombay)  appear  to  have  attained  serious 
dimensions.  Nevertheless,  they  coincide  in  time  with  the 
preliminary  outbreaks  of  last  year,  and  though  there  is  at 
present  no  reason  to  apprehend  an  epidemic  of  the  same 
proportions  the  measure  of  immunity  conferred  on  any 
individual  by  a previous  attack  is  uncertain.  Accordingly 
the  following  steps  have,  among  others,  been  taken  as  a 
preliminary  precaution. 

The  Government  of  India  have  suggested  to  Maritime 
Governments  the  taking  of  power  to  notify  by  rule  under 
the  Indian  Ports  Act  ship-borne  cases  of  pneumonia,  and 
discretionary  power  similarly  to  deal  with  ship-borne  cases 
of  violent  influenza.  They  have  requested  early  intimation 
of  all  outbreaks  in  order  that  timely  warning  may  be  given 
to  the  authorities  in  neighbouring  areas  and  to  the  public. 

Stocks  of  anti-influenza  vaccine  are  being  made  ready  for 
early  transfer  to  centres  of  infection.  Surgeons  and  adminis- 
trative medical  officers  are  being  invited  to  indent  for 
supplies  to  be  ready  on  the  spot  in  case  of  emergency. 

A specialist  has  been  deputed  to  Bombay  to  deal  with  the 
situation. 

The  Sanitary  Commissioner  with  the  Government  of  India 
has  distributed  widely  a leaflet  dealing  with  influenza  and 
the  course  that  should  be  taken  in  case  of  an  outbreak.  This 
has  been  communicated  to  the  press.  He  has  specially  recom- 
mended the  use  of  an  aniline  nasal  douche  as  an  effective 
prophylactic. 

Though  there  is  no  immediate  cause  for  alarm,  it  has  been 
thoughtadvisable  toinform  the  publicof  these  new  outbreaks 
in  order  that  the  necessary  precautions  may  be  taken  and, 
should  the  disease  show  signs  of  further  extension,  other 
communiques  will  from  time  to  time  be  issued. 

Extra  medical  precautions  have  been  taken  at  Howrah 
station  to  meet  returning  pilgrims  from  Puri.  It  has  been 
ascertained  that  influenza  is  raging  in  epidemic  form  at 
Puri.  At  Howrah  doctors  treated  40  cases  of  influenza  and 
1 case  of  cholera. 

Infant  Welfare  Exhibition  at  Delhi. 

A maternity  and  infant  welfare  exhibition  will  be  held  in 
Delhi  in  February,  1920.  It  will  be  reserved  for  women  on 
certain  days,  but  will  be  open  to  men  at  other  times.  The 
proper  care  of  mothers  and  babies  will  be  shown  by  means 
of  model  exhibits,  leaflets,  lectures,  pictures,  magic-lantern 
slides,  &c.  The  exhibition  will  be  arranged  in  the  following 
sections  : pre-maternity,  maternity,  infant  welfare,  child- 
hood, domestic  hygiene,  and  sanitation,  first  aid  and  home 
nursing.  A baby  show  will  also  be  held.  The  whole  will 
be  under  the  patronage  of  Lady  Chelmsford.  It  is  hoped 
that  this  exhibition  may  be  the  forerunner  of  many  others 
both  in  Delhi  and  in  other  cities  of  India,  and  that  it  may 
lead  to  a great  improvement  in  the  condition  of  childbirth 
and  the  welfare  of  young  children. 

Shortage  of  Medical  Officers. 

A leading  Indian  journal  says  : — 

We  understand  that  the  Government  of  India  are  drawing 
the  attention  of  the  Secretary  of  State  to  tfie  extremely 
serious  shortage  of  regular  officers  of  the  Indian  Medical 
Service  and  urging  recruitment  of  a large  number  of 
European  officers  for  enrolment  permanently.  The  Govern- 
ment of  India  have  also  proposed  that  certain  measures 
recommended  by  the  Medical  Services  Committee  as  likely 
to  increase  the  attractions  of  the  I.M.S.  should  be  announced 
in  England  at  once.  We  further  understand  that  the 
increased  rates  of  pay  for  the  I.M.S.  in  civil  employment  will 
be  announced  very  shortly,  and  that  these  rates  will  take 


effect  from  Dec.  1st,  1918.1  This  action  of  Government  will 
help  to  allay  the  apprehension  created  by  the  grave  state 
of  affairs  to  which  we  have  repeatedly  directed  attention,  and 
it  will  also  no  doubt  afford  some  encouragement  to  over- 
worked officers  of  the  I.M.S.  who  are  almost  at  breaking 
point.  There  is  no  disguising  the  fact  that  the  present 
position  is  well  nigh  desperate.  More  than  60  per  cent,  of 
the  I.M.S.  civil  officers  are  still  in  military  employ,  and 
military  employments  in  India  are  increasing,  not  diminish- 
ing. India  itself  has  been  ransacked  for  doctors  to  makegood 
the  deficiency  and  the  only  hope  now  lies  in  making  the  terms  I 
of  service  so  attractive  that  the  necessary  number  of  men 
will  be  forthcoming  from  the  medical  schools  at  home.  We 
are  glad  to  learn  that  the  Government  of  India  recognise 
that  the  matter  is  one  of  extreme  urgency  and  are  apparently 
determined  to  put  it  right.  But  it  will  not  be  so  easy  as  it 
would  have  been  before  the  war  to  obtain  recruits  by 
improving  the  conditions  of  the  Service.  There  probably 
never  was  a time,  indeed,  when  the  opportunities  open  to 
medical  men  at  home  were  so  favourable  as  they  are  at 
present.  This  is  an  additional  reason  why  there  should  not 
be  a moment’s  unnecessary  delay  in  taking  the  definite 
action  which  the  gravity  of  the  situation  demands. 

War  Gratuity  of  the  Indian  Army. 

Issuable  on  the  British  scale,  the  Government  of  India 
announces  that  it  has  been  decided  to  issue  to  regular  officers 
in  the  Indian  Army,  Indian  Medical  Service,  and  of  the 
British  garrison  in  India,  and  to  departmental  officers  with 
honorary  rank  of  the  Indian  Unattached  List  a gratuity 
for  war  service  on  the  same  conditions  generally  of  those 
announced  for  officers  of  the  British  Army  in  Army  Orders  IV. , 
dated  June  '7th,  1919.  The  gratuity  will  be  payable  in 
the  case  of  officers  still  on  the  active  list  on  August  4th, 
1919,  or  the  termination  of  war  as  defined  by  statutory 
authority,  whichever  is  earlier.  It  is  not  payable  to  any 
officer  commissioned  after  February,  1919.  Officers  who 
have  retired  and  the  legal  representatives  of  officers  who 
have  died  or  been  killed  in  the  war  should  apply  for  a form 
of  claim  to  the  Secretary,  Military  Department,  India  Office,  , 
London,  S.W.  1. 

Nero  Medical  Scholarship. 

Lieutenant-Colonel  W.  D.  Smith,  commandant  of  the 
Madras  Guards,  has  presented  a scholarship  valued  at 
Rs.1200  to  the  Madras  Medical  College  for  students  in 
chemistry  and  drugs. 

Calcutta  University  Commission 
A summary  of  the  report  of  the  Commission  has  been 
published.  It  concludes  as  follows  : — 

We  desire  to  make  it  clear  that  certain  reforms  in  the 
University  of  Calcutta  ought  not  to  be  postponed  whatever 
scheme  be  adopted — namely,  the  provision  of  further  resi-  { I 
dential  accommodation,  the  provision  of  a teachers’  training 
department,  the  provision  of  additional  accommodation  for 
teaching,  and  the  provision  of  measures  for  supervising  and 
improving  the  health  of  the  students. 

August  10th.  


CONTROL  OF  VENEREAL  DISEASES. 


Early  Preventive  Treatment  and  the  N.  C.  C.  V.D. 

A recent  deputation  from  the  National  Council  for 
Combating  Venereal  Diseases,  led  by  Sir  Malcolm  Morris, 
was  received  by  the  Public  Health  Committee  of  the  London 
County  Council.  Its  object  was  to  urge  the  County  Council 
to  make  provision,  through  its  scheme  for  the  diagnosis  and 
treatment  of  venereal  diseases  in  London,  for  early  preventive 
treatment — that  is  to  say,  “ treatment  at  an  approved  centre 
within  a short  time  after  exposure  to  possible  infection." 
The  question  also  arose  of  treatment  before  exposure,  and 
of  the  alleged  objections  to  such  treatment  on  the  side  of 
public  morals.  It  was  stated  by  the  deputation  that  for 
early  treatment  to  be  effectual  in  the  prevention  of  syphilis, 
it  must  be  initiated  within  six  hours  after  exposure  to  risk. 
It  therefore  follows  that  it  would  be  necessary  to  institute  a 
very  large  number  of  early  treatment  centres,  accessible  at 
all  hours  of  the  night  and  day.  The  Public  Health  Com- 
mittee stated  that  with  one  exception  the  committees  of  all 
the  London  hospitals  at  which  venereal  clinics  were  in 
operation  had  definitely  expressed  the  opinion  that  it  would 

1 The  new  rates  of  pay  for  the  military  and  civilian  aides  of  the  Indian 
Medical  Service  were  eiven  in  the  Students’ Number  of  The  Lascxt, 
August  30th,  1919,  p.  393. 


The  Lancet,] 


TUBERCULOSIS. 


[Sept.  6,  1919  45 1 


be  impossible  for  them  to  introduce  early  preventive  treat- 
ment on  these  lines.  The  National  Council  has  made  inquiry 
of  medical  officers  of  health  of  certain  provincial  towns,  but 
apparently  no  steps  have  been  taken  to  provide  opportunities 
for  such  treatment.  The  Public  Health  Committee  came  to 
the  considered  conclusion  that  quite  apart  from  the  moral 
issues  involved,  although  benefit  might  accrue  in  individual 
cases,  yet  this  would  be  nullified  by  the  resultant  increase 
in  the  number  of  cases  exposed  to  infection.  The  Committee 
therefore  recommended  : — 

“ That  in  connexion  with  its  scheme  for  the  diagnosis  and  treatment 
of  venereal  diseases  the  Council  is  not  satisfied  that  the  public  pro- 
vision of  early  preventive  tieatment  as  suggested  by  the  National 
Council  for  Combating  Venereal  Disease  is  desirable,  and  that  the 
National  Council  be  informed  accordingly.” 

We  would  ask  our  readers  to  consider  what  the  result 
will  be  if  this  policy  of  passivity  be  persevered  in. 

1.  If  we  regard  the  question  in  its  bearings  upon  public 
health  we  shall  find  that  a far  larger  number  of  patients 
would  ultimately  require  treatment  for  these  diseases  at  a 
stage  when  it  will  be  much  harder  and  take  more  time  to  effect 
a cure,  whilst  in  some  instances  it  will  be  impossible  for 
them  to  recover.  Many  sufferers  before  they  recognise 
themselves  as  such  will  have  communicated  the  infection  to 
others.  Some  of  these  will  be  visitors  to  the  large  towns, 
who  on  returning  to  their  country  homes  will  find  it  difficult 
to  secure  adequate  treatment  for  themselves  or  their  conjugal 
victims.  Whilst  we  are  endeavouring  to  secure  treatment  for 
venereally-infected  pregnant  women  and  attempting  to  treat 
infants  suffering  from  congenital  syphilis  and  gonorrhoeal 
ophthalmia,  we  shall  be  neglecting  the  obvious  course  of 
trying  to  eliminate  the  factors  responsible  for  the  production 
of  such  lamentable  results — in  other  words,  we  shall  be  pro- 
viding wilfully  a constantly  increasing  and  preventable 
stream  of  maternal  and  infantile  infection. 

2.  The  community  will  achieve  economy  if  those  respon- 
sible for  its  welfare  will  adopt  early  preventive  treat- 
ment. If  they  do  not  institute  such  centres  then  vastly 
increased  sums  will  eventually  be  expended  upon  institu- 
tions at  which  an  increasingly  large  number  of  patients 
suffering  from  the  fully  developed  disorders  will  have  to  be 
treated.  Further,  great  sums  will  be  called  for  to  maintain 
the  army  of  parasyphilitic  patients  in  asylums,  infirmaries, 
&c.  More  medical  men  will  be  required  for  the  efficient 
working  of  curative  clinics  as  apart  from  preventive  ones  ; 
this  will  entail  an  augmented  salary  list  and  deflection  of 
medical  energy  from  other  spheres.  The  loss  to  the  nation 
in  productive  working  power  through  patients  incapacitated 
will  be  as  immense  as  it  will  be  unnecessary. 

Doubtless  the  National  Council  for  Combating  Venereal 
Diseases  will  not  allow  the  position  to  remain  as  it  is,  and 
we  ask  our  readers  to  augment  their  efforts. 

Hostels  for  Gonorrhoeal  Patients. 

Medical  officers  in  charge  of  venereal  clinics  are  now 
faced  with  a variety  of  problems.  A very  difficult  one  is 
represented  by  the  question  as  to  what  to  do  with  patients 
suffering  from  gonococcal  epididymitis  who  are  unable  to 
carry  out  the  required  treatment.  Take  the  case  of  a man 
living  in  a single  room,  without  attendance,  unable  to  obtain 
a supply  of  hot  water,  and  so  on  ; he  is  terribly  handicapped, 
both  as  regards  relief  from  suffering  and  ultimate  recovery. 
His  treatment  entails  more  work  and  a greater  demand  on 
the  resources  of  the  venereal  clinics.  There  is  also  in  these 
cases  a prolongation  of  the  period  of  infectivity  and  a greater 
prospect  of  sterility  ensuing.  The  general  hospitals  to  which 
clinics  are  attached  can  hardly  be  expected  to  give  up  beds 
for  this  purpose  ; but  what  objection  can  be  advanced  to  the 
institution  of  hostels  to  which  clinics  can  send  those  cases 
which  cannot  be  treated  adequately  in  their  own  homes  ? 
The  dictates  of  humanity,  of  national  health,  and  of  economy 
(financial  and  temporal)  demand  such  a step,  which  we 
commend  to  the  Ministry  of  Health.  Once  the  practical 
necessity  is  admitted,  the  question  of  sites,  staff,  and  salaries 
is  capable  of  ready  solution. 

Travelling  Consultants  for  Venereal  Clinics. 

Owing  to  the  rapidity  with  which  venereal  clinics  are  now 
being  formed,  it  follows  of  necessity  that  many  of  the 
medical  officers  in  charge  of  them  are  practitioners  who 
have  as  yet  had  but  small  opportunity  of  gaining  experience 
in  such  work.  Cases  will  be  brought  before  them  which 


call  for  an  opinion,  to  be  acquired  only  by  a large  and  long 
experience.  We  are  assured  that  medical  officers  who  are 
possessed  by  the  desire  to  do  the  best  for  their  patients  and 
to  acquire  knowledge  for  themselves  would  welcome  an 
expert  opinion.  Might  not  the  Ministry  of  Health  select  a 
certain  number  of  experts  from  different  parts  of  the  country 
who  would  be  willing  when  called  upon  to  visit  clinics  on 
the  request  of  the  medical  officer  in  charge  ? Such  experts 
would  naturally  work  under  the  segis  of  the  advisor  or 
advisors  to  the  Ministry  who  have  been,  or  may  be,  appointed. 
Since  these  consultants  would  only  visit  a clinic  on  the 
invitation  of  its  medical  officer,  any  objection  to  such  a 
scheme  on  the  score  of  interference  or  compulsion  would  be 
nullified. 

Systematic  Care  in  the  Sexual  Diseases. 

In  an  article  with  this  title  1 Dr.  James  Bayard  Clark, 
U.S.M.C.,  gives  a practical  account  of  the  organisation, 
equipment,  and  treatment  routine  at  the  Genito-Urinary 
Clinique  at  Camp  Logan.  Medical  officers  in  charge  of 
venereal  treatment  centres  and  those  about  to  assume 
such  command  should  study  this  graphic  description  with 
care.  Hospitals,  municipal  boards,  and  other  bodies  con- 
structively inclined  might  gain  by  assimilating  the  hints 
contained  therein  before  beginning  to  build.  The  descrip- 
tion of  the  department  devoted  to  early  or  prophylactic 
treatment  possesses  a particular  topical  interest  in  view  of 
the  present  tendency  to  initiate  such  “early  treatment 
centres  ” throughout  this  country  in  the  interests  of  civilian 
health. 


TUBERCULOSIS. 


Residential  Treatment  for  Discharged  Sailors  and  Soldiers  : 
Report  of  the  Inter-  Departmental  Committee. 

The  Committee  appointed  last  April  by  the  Minister  of 
Health  and  the  Minister  of  Pensions  “ to  consider  and  report 
upon  the  immediate  practical  steps  which  should  be  taken 
for  the  provision  of  residential  treatment  for  discharged 
soldiers  and  sailors  suffering  from  tuberculosis  and  for  their 
reintroduction  into  employment,  especially  on  the  land,”  has 
issued  its  report  (Cmd.  317,  price  6 d.).  It  is  calculated  that 
about  35,000  ex-Service  men  are  suffering  from  tuberculosis 
traceable  to,  or  aggravated  by,  the  conditions  of  service. 
Of  these,  about  22,000  have  received,  or  are  receiving, 
residential  treatment.  Though  it  is  conceded  that  the 
priority  of  treatment  hitherto  afforded  the  ex-Service  man 
should  continue,  it  is  pointed  out  that  the  problem  of  the 
tuberculous  ex-Service  man  is  only  one  aspect  of  a national 
scourge.  The  present  accommodation  for  institutional 
treatment  is  inadequate,  for  the  number  of  beds  for 
tuberculosis  in  the  United  Kingdom  amounts  only  to 
19,500,  while  only  10,000  to  11,000  of  these  are  avail- 
able for  adult  men.  The  report  recommends  an  immediate 
and  considerable  increase  of  accommodation,  as  well  as  the 
most  effective  use  of  existing  means  of  treatment.  Generally 
speaking,  Army  hutments  are  unsuited  for  the  treatment  of 
tuberculosis,  though  the  best  of  them,  if  used  in  their  present 
position,  may  prove,  at  any  rate,  of  temporary  use.  It  is 
suggested  that  local  authorities  ought  to  secure  these  huts, 
without  charge,  from  the  Government. 

Of  the  many  schemes  submitted  to  it  the  Committee  find 
the  colony  system  the  best.  This  would  provide  (1)  sana- 
torium treatment,  (2)  training,  (3)  permanent  village  settle- 
ment with  employment  under  medical  supervision,  the  three 
sections  being  intimately  correlated  in  the  same  area.  It  is 
suggested  that  the  Government  should  at  once  make  pro- 
vision in  the  Estimates  for  £1,000,000  for  the  finance  of 
village  settlements,  primarily  for  ex-Service  men.  These 
settlements  might  be  provided  by  local  authorities  or 
voluntary  bodies.  In  the  former  case  the  capital  sum  should 
be  provided  by  the  Government.  After,  say,  five  years,  the 
local  authorities  might  contribute  to  the  cost  by  paying  not 
less  than  one-fifth  of  the  capital  expenditure.  The  Com- 
mittee insist  on  the  superiority  of  sanatorium  over  home 
treatment  for  advanoed  cases,  and  urge  local  authorities  and 
large  employers  of  labour  to  provide  special  facilities  for 
employment  of  those  ex-Service  men  for  whom  the  village 
settlement  is  not  a satisfactory  solution  of  their  difficulties. 


1 Journal  of  the  American  Medical  Association,  April  26th,  1919. 


452  The  Lancet,] 


URBAN  VITAL  STATISTICS. 


[Sept.  6,  1919 


Paris;  Post-Graduate  Courses  in  Tuberculosis. 

Three  post-graduate  courses  in  tuberculosis  will  be  given 
in  Paris  during  the  coming  academic  year  under  the  direction 
of  MM.  Bernard,  Bezanr;on,  Calmette,  Kuss,  Letulle,  Rist, 
Sergent,  and  Teissier.  The  courses  will  be  of  six  weeks’ 
duration,  commencing  on  Oct.  20th,  1919,  and  April  15th 
and  June  15th,  1920.  They  will  be  essentially  practical  in 
nature,  and  will  include  pathology,  bacteriology,  physical 
diagnosis,  X ray,  laryngology,  social  welfare  and  dispensary 
administration.  Opportunity  will  be  afforded  to  the  students 
to  work  each  morning  in  a dispensary  or  hospital  under  the 
guidance  of  the  lecturing  physicians.  The  course  will  be 
open  to  graduates  in  medicine  who  are  citizens  of  France  or 
of  allied  and  neutral  countries.  The  Commission  for  the 
Prevention  of  Tuberculosis  in  France  will  grant  subventions 
to  a limited  number  of  French  physicians.  Further  details 
of  the  course  may  be  obtained  from  Dr.  E.  Rist,  5 rue  de 
Magdebourg,  Paris. 

Tuberculosis  in  Norway  and  Sweden. 

Norway's  expenditure  on  tuberculosis. — Since  the  adoption 
of  the  tuberculosis  law  of  1900  Norway  has  contributed 
increasingly  large  sums  to  the  campaign  against  this  disease. 
In  1901  the  State’s  budget  for  tuberculosis  was  Kr. 80, 000. 
Bv  1908  it  had  risen  to  about  Kr. 250, 000 ; by  1914  to 
Kr. 450, 000 ; by  1916  to  Kr.900,000;  by  1917  to  Kr.  1,300,000 ; 
and  by  1918  to  Kr. 1,800, 000.  For  the  year  1919-1920  the 

State  has  budgetted  for  about  Kr.3,225,000.  It  will  thus  be 
seen  that  since  1901  the  funds  officially  provided  for  tuber- 
culosis have  been  multiplied  by  about  40.  This  enormous 
rise  is  partly  connected  with  the  general  rise  of  prices,  but 
the  chief  factor  is  the  State’s  recognition  of  the  necessity  for 
constantly  undertaking  new  campaigns  against  the  disease. 
It  realises  that  the  money  thus  spent  is  a sound  financial 
investment,  directly  and  indirectly.  At  present  it  is 
estimated  that  Norway  loses  every  year  from  tuberculosis  the 
equivalent  of  about  50  million  kroner  in  working  capacity, 
quite  apart  from  the  incalculable  distress  which  the  disease 
brings  to  thousands  of  homes. 

The  Norwegian  National  Association  against  Tuberculosis. 
— The  following  figures  are  illuminating  as  showing  what 
large  sums  a country,  with  a population  of  only  a little  over 
two  million,  can  collect  by  private  initiative  for  the  campaign 
against  tuberculosis.  The  balance-sheet  of  this  association 
for  1918  shows  a total  figure  of  Kr.76,617.  The  income 
for  the  year  was  Kr.66,520,  and  of  the  sums  expended 
Kr.11,786  were  devoted  to  salaries  and  office  expenses, 
Kr.  16,834  to  educational  propaganda,  Kr.12,591  to  the 
education  and  pay  of  nurses,  and  Kr.31,741  to  miscellaneous 
expenses.  Included  under  this  heading  was  expenditure  on 
new  houses  built  to  replace  old  infected  houses. 

The  Swedish  National  Association  against  Tuberculosis. — 
This  association,  which  recently  celebrated  its  fifteenth  anni- 
versary, owes  its  inception  and  organisation  in  large  measure 
to  Sweden’s  chief  administrative  medical  officer,  Dr.  B.  Buhre. 
The  main  feature  of  the  association’s  programme  is  a vigorous 
and  organised  scheme  of  prevention.  Special  attention  is 
devoted  to  the  dispensary  system,  which  provides  for  the 
supervision  of  all  tuberculous  homes  and  takes  every  possible 
measure  to  prevent  spread  of  the  disease  to  the  healthy  from 
the  infected  in  these  homes.  The  association,  which  has  a 
membership  of  17,000,  has  trained  165  nurses  for  this  dis- 
pensary work,  and  it  has  provided  three  homes  for  healthy 
children  taken  from  tuberculous  surroundings.  In  various 
ways  the  association  has  taken  steps  to  prevent  the  infection 
of  1200  children  in  their  homes.  The  income  of  the  associa- 
tion is  entirely  derived  from  private,  independent  sources, 
and  by  the  sale  of  its  various  badges  about  Kr.1,550,000 
have  been  obtained  since  1904.  In  1918  alone  they  brought 
in  Kr.181,000.  In  1917,  in  gifts  and  legacies  alone, 
Kr.  236,630  were  received,  and  interest  on  capital  amounted 
to  Kr. 54,980.  The  total  income  in  1917  was  Kr. 508, 619. 

Mother  of  the  “ May  Flower." — On  Feb.  11th  last  Fru  Beda 
Hallberg  celebrated  the  fiftieth  anniversary  of  her  birthday, 
which  was  the  occasion  of  many  greetings  sent  her  from  the 
various  countries  that  have  adopted  her  idea.  Since  she 
started  the  “ May  Flower  ” in  1907  this  scheme  for  collecting 
funds  for  the  tuberculosis  campaign  has  brought  in  over 
2,000,000  kroner  in  Sweden  alone.  It  was  soon  adopted 
in  Norway,  where  about  Kr.900,000  have  been  contri- 
buted. The  scheme  was  introduced  in  America  by 
Fru  Hallberg’s  sister,  who  founded  the  association 


“ Linnean  ” on  the  200th  anniversary  of  the  Swedish 
naturalist’s  birthday.  Finland  adopted  the  scheme  in  1908, 
Denmark  in  1909.  In  1910  Germany  adopted  it  in  the  form 
of  “Die  Blume  der  Barmherzigkeit,”  large  sums  being  con- 
tributed. Austria  and  Russia  followed  in  1911.  Since  then 
Holland,  Belgium,  France,  Italy,  and  England  have  followed 
suit. 

Tuberculosis  in  Germany. 

A week  after  peace  was  signed  two  Americans,  Miss  Jane 
Addams  and  Dr.  Hamilton,  made  a tour  of  inspection  in 
Germany,  and  according  to  the  report  they  have  issued  tuber- 
culosis has  not  only  become  far  more  prevalent  than 
before  the  war,  but  it  has  also  in  many  cases  assumed 
rapidly  progressive  and  malignant  forms,  previously  regarded 
as  rare  curiosities.  Professor  Kayserling  stated  that  the 
effect  of  partial  starvation  in  promoting  tuberculosis  was 
so  striking  that  German  physicians  have  begun  to  regard  it 
primarily  as  a disease  of  nutrition,-  to  be  controlled  much 
more  by  appropriate  feeding  than  by  the  prevention  of 
infection.  At  present  he  sees  a9  many  cases  of  tuberculosis 
in  children  every  month  as  he  used  to  see  in  the  year.  In 
the  course  of  a visit  to  Professor  Czerny’s  wards  at  the 
Charite,  the  Americans  were  informed  that  fully  half  of  all  the 
children  there  were  tuberculous,  and  they  were  shown  many 
hitherto  rare  cases,  such  as  tuberculosis  of  the  bones  of  the 
head,  including  the  upper  jaw.  At  the  City  Orphanage  in 
Berlin,  where  v.  Pirquet’s  test  used  to  be  positive  only  in 
10  per  cent.,  it  had  become  positive  in  30  percent.  But 
while  infection  has  increased  threefold,  actual  illness  has 
increased  fivefold,  as  shown  by  the  number  of  cases  of 
skin,  gland,  bone,  and  pulmonary  tuberculosis.  In  Halle 
there  is  ten  times  as  much  skin  tuberculosis  as  there  was 
before  the  war.  All  these  effects  of  starvation  cannot  be 
gauged  simply  by  estimates  of  the  death-rate ; most  of  the 
children  infected  with  tuberculosis  will  not  die  at  once  or 
even  show  signs  of  the  disease  for  some  time.  But,  it  is 
estimated,  for  the  next  20  years  the  tuberculous  morbidity 
will  be  much  higher  in  Germany  than  it  has  been  for  many 
decades.  One  of  the  agencies  through  which  relief  work  is 
being  done  is  “Save  the  Children  Fund,”  329,  High 
Holborn,  W.C.  1.  


URBAN  VITAL  STATISTICS. 

(Week  ended  August  30th,  1919.) 

English  and  Welsh  Towns.  -In  the  96  English  and  Welsh  towns, 
with  an  aggregate  civil  population  estimated  at  16,500,000  persons, 
the  annual  rate  of  mortality,  which  had  been  9 7, 10  0,  and  10'0  in  the 
three  preceding  weeks,  was  again  10  0 per  1000.  In  London,  with 
a population  slightly  exceeding  4,000,006  persons,  the  annual  rate 
was  9'6,  and  was  0'8  per  1000  below  that  in  the  preceding  week, 
while  among  the  remaining  towns  the  rates  ranged  from  l-9  in 
Wimbledon,  2 9 in  Oxford,  4 0 in  Cambridge,  and  4'4  in  Hornsey  and  in 
Lincoln,  to  17'1  in  Bournemouth,  18  5 in  Wakefield,  19'6  in  Barnsley,  i 
and  22  2 in  Exeter.  The  principal  epidemic  diseases  caused  317  deaths, 
which  corresponded  to  a rate  of  10  per  1000,  and  included  231  from 
infantile  diarrhcea,  32  from  measles,  29  from  diphtheria,  14  from 
whooping-cough,  6 from  enteric  fever,  and  5 from  scarlet  fever. 
Measles  caused  a death-rate  of  3 5 in  Gateshead.  There  were  1421 
cases  of  scarlet  fever  and  1004  of  diphtheria  under  treatment  in  the 
Metropolitan  Asylums  Hospitals  and  the  London  Fever  Hospital, 
against  1464  and  1063  respectively  at  the  end  of  the  previous  week. 
The  causes  of  21  deaths  in  the  96  towns  were  uncertified,  of  which 
7 were  registered  in  Birmingham  and  2 in  Rotherham. 

Scotch  Toivns.— In  the  16  largest  Scotch  towns,  with  an  aggregate 
population  estimated  at  nearly  2,500,000  persons,  |the  annual  rate  of 
mortality,  which  had  been  10’0,  9 9.  and  10-7  in  the  three  preceding 
weeks,  further  rose  to  10‘9  per  1000.  The  246  deaths  in  Glasgow 
corresponded  to  an  annual  rate  of  11'5  per  1000,  and  included  25  from 
infantile  diarrhcea,  3 from  whooping-cough,  2 from  diphtheria,  and  1 
each  from  measles  and  scarlet  fever.  The  73  deaths  in  Edinburgh 
were  equal  to  a rate  of  11  3 per  1000,  and  included  2 each  from 
measles  and  scarlet  fever,  and  1 each  from  whooping-cough  and  infantile 
diarrhcea. 

Irish  Totons.— The  142  deaths  in  Dublin  corresponded  to  an  annual 
rate  of  18'3  per  1000,  and  inoluded  [37  from  infantile  diarrhoea,  2 
from  scarlet  fever,  and  1 from  diphtheria.  The  131  deaths  in  Belfast 
were  equal  to  a rate  of  17'0  per  1000,  and  included  30  from  infantile 
diarrhoea  and  3 from  scarlet  fever. 


War  Emergency  Fund  of  the  Royal  Medical 
Beneyolbnt  Fund.— At  the  last  meeting  of  the  Committee 
of  this  Fund,  Sir  Alfred  Pearce  Gould,  K.C.V.O.,  in  the 
chair,  applications  for  assistance  were  received  and  grants 
amounting  to  £1250  were  made  to  seven  applicants.  The 
Committee  are  prepared  to  receive  applications  for  assist- 
ance from  demobilised  officers  of  the  R.A.M.C.(T.l  and 
Special  Reserve.  All  communications  should  be  addressed 
to  the  honorary  secretary,  11,  Chandos-street,  Cavendish- 
square,  W.l. 


The  Lancet,] 


THE  SERVICES. 


[Sept  6,  1919  453 


®I)t  Serbices. 


INDIAN  MEDICAL  SERVICE. 

The  Secretary  of  State  for  India  announces  that  204 
medical  men  are  urgently  required  tc  fill  vacancies  in  the 
Indian  ‘Medical  Service.  Of  these  two-thirds  (136)  will  be 
Europeans  and  the  remainder  Indians.  The  appointment 
of  European  candidates  will  be  made  by  nomination  on  the 
recommendation  of  a Selection  Committee  in  England. 
Applications  from  Europeans  and  from  Indian  candidates 
resident  in  this  country  will  be  received  at  the  India  Office. 
Applications  from  all  Indian  candidates  will  be  considered 
together.  Appointment  will  be  by  nomination  on  the  recom- 
mendation of  a Selection  Committee.  Candidates  must  be 
over  21  and  under  32  years  of  age  at  date  of  application. 
Preference  will  be  given  to  candidates  who  are  or  have  been 
serving  with  His  Majesty’s  Forces  during  the  war.  All 
service  rendered  as  a medical  or  combatant  officer,  or  in  a 
position  usually  filled  by  an  officer,  during  the  war  will 
count  both  for  promotion  and  pension  on  appointment  to 
the  Service,  but  not  for  the  gratuity  mentioned  below. 
The  scale  of  pay  has  recently  been  greatly  increased.  A 
Lieutenant  on  appointment  now  receives  Rs.550  a month 
(equivalent  at  the  present  rate  of  exchange,  the  con- 
tinuance of  which  cannot  be  guaranteed,  to  £605  per 
annum).  Those  who  have  had  three  years  or  more  previous 
service  will  enter  in  the  rank  of  Captain  on  Rs.  700  a month 
(or  £770  a year).  An  officer  who  is  appointed  to  the  Service 
in  1919  or  1920  may  claim  to  retire  on  a gratuity  of  £1200  on 
completion  of  eight  years’  service  from  date  of  permanent 
appointment,  provided  he  has  given  notice  of  his  intention 
to  retire  18  months  before  the  date  of  retirement.  An 
officer  so  retiring  will  also  be  eligible  for  a free  return 
passage  to  Europe,  if  claimed  within  three  months  of 
retirement.  Application  forms  and  any  further  particulars 
desired  can  be  obtained  from  the  Secretary,  Military 
Department,  India  Office.  The  correspondence  should  be 
clearly  marked  on  the  top  left-hand  side  of  the  envelope 
“ Medical  Recruitment.” 

The  scales  of  pay  accompanying  the  announcement  were 
published  in  the  Students’  Number  of  The  Lancet  last 

week.  

ROYAL  NAVAL  MEDICAL  SERVICE. 

Surg.  Lieut.-Cmdr.  C.  F.  Willes  is  placed  on  the  retired  list. 

Temporary  Surgeon  Lieutenants  transferred  to  the  permanent  list  of 
Surgeon  Lieutenants : — F.  H.  Vey,  H.  L.  Pridham. 

ARMY  MEDICAL  SERVICE. 

Major-Gen.  (temp.  Lieut.-Gen.)  Sir  C.  H.  Burtchaell,  K.C.B.,  C.M.G., 
relinquishes  his  temporary  rank  on  re- posting. 

Cols.  S.  F.  Clark  and  W.  L.  Gray,  C.M.G.,  retire  on  retired  pay. 

Col.  E.  M.  Hassard  is  placed  on  the  half-pay  list  under  the  provisions 
■of  Article  351,  Royal  Warrant  for  Pay  and  Promotion. 


ROYAL  ARMY  MEDICAL  CORPS. 

The  undermentioned  Lieutenant- Colonels  relinquish  the  temporary 
rank  of  Colonel  on  re-posting  : H.  B.  Fawcus,  T.  C.  MacKenzie. 

Lieut.-Col.  G.  B.  W.  Brazier-Creagh  (retired  pay)  is  granted  the  rank 
of  Colonel  on  ceasing  to  be  re-employed. 

Lieut.-Col.  M.  Boyle  is  placed  on  retired  pay. 

The  undermentioned  relinquish  their  temporary  commissions  on 
re-posting:  Temp.  Col.  M.  G.  Foster,  (R. A. M. C. , T.F.),  Temp.  Lieut.- 
Col.  Sir  T.  C.  English  (Hon.  Colonel  in  the  Army,  R.A.M.C.,  T.F.), 
Acting  Lieut.-Col.  D.  C.  L.  Fitzwilliams  (Captain,  R.A.M.C.,  T.F.), 
Temp.  Major  F.  A.  Hepworth  (Captain,  R.A.M.C.,  T.F.). 

The  undermentioned  relinquish  the  acting  rank  of  Lieutenant- 
Colonel  : Major  E.  B.  Booth,  on  ceasing  to  be  specially  employed ; Major 
F.  L.  Bradish  and  Capt.  W.  W.  MacNaught,  on  ceasing  to  command  a 
Medical  Unit. 

The  undermentioned  relinquish  the  acting  rank  of  Lieutenant- 
Colonel  on  re-posting:  Major  and  Brevet  Lieut.-Col.  R.  B.  Ainsworth; 
Majors  G.  de  la  Cour,  R.  J.  C.  Thompson,  C.  R.  M.  Morris,  E.  M. 
Middleton,  C.  Seaife,  E.  C.  Phelan,  W.  J.  Weston,  W.  E.  C.  Lunn, 
N.  Low,  W.  J.  E.  Bell ; Temp.  Majors  T.  M.  Carter,  H.  M.  Chasseud ; 
Capts.  M.  White,  R.  M.  Davies. 

Major  M.  P.  Leahy  retires,  receiving  a gratuity. 

To  be  acting  Lieutenant-Colonels  : Major  M.  C.  Beatty,  whilst  com- 
manding a Medical  Unit ; Temp.  Capt.  (acting  Major)  R.  Jamison ; 
Temp.  Capt.  and  Brevet  Major  (acting  Major)  W.  E.  P.  Phillip?,  whilst 
specially  employed. 

The  undermentioned  temporary  Captains  relinquish  the  acting  rank 
of  Major:  S.  Brown,  A.  W.  G.  Woodforde,  A.  C.  Profeit,  P.  L.  Watkin- 
Williams,  H.  E.  Rawlence,  C.  G.  Skinner,  A.  F.  Wright,  G.  Marshall. 

Capts.  A.  L.  Krogh  and  A.  S.  Crane  relinquish  the  acting  rank  of 
Major  on  re-posting. 

The  undermentioned  to  be  acting  Majors : Capt.  A.  L.  Krogh.  Whilst 
specially  employed : Capt.  N.  T.  Whitehead  ; Temp.  Capts.  A.  Fletcher, 
J.  A.  Mackenzie,  A.  F.  Wright,  R.  G.  Oram,  N.  L.  M.  Reader,  V.  C. 
Vesselovsky. 

To  be  Captains:  Capts.  W.  O.  Tobias,  D.  S.  Martin,  and  J.  J. 
Molyneaux,  from  the  Special  Reserve;  Temp.  Capt.  G.  O.  F.  Alley. 

To  be  temporary  Captains  : S.  McNair  and  W.  Fletcher-Barrett,  late 
temporary  Captains;  R.  J.  Monahan  ; Temp.  Lieut.  F.  M.  Simmonds. 

Officers  relinquishing  their  commissions  : Temporary  Lieutenant- 
Colonels  retaining  the  rank  of  Lieutenant-Colonel : H.  A.  Kidd.  D.  G. 


Thomson,  Temp.  Maj.  W.  E.  M.  Corbett;  Temporary  Majors  retaining 
the  rank  of  Major:  F.  W.  Broderick,  H.  W.  Wiltshire,  F.  H.  Welsh; 
Temporary  Captains  granted  the  rank  of  Major : F.  F.  Middleweek, 
It.  W.  Sutherland,  G.  E.  Nelegan,  H.  B.  Rawlence,  J.  D.  Gimlett, 
W.  II.  Allen,  E.  W.  Willett,  I*.  W.  Hampton,  P.  A.  Leighton,  C.  S. 
Gideon,  J.  F.  McLay,  O.  J.  Day,  H.  Cordner  ; Temp.  Capt.  and  Bt. 
Major  Fell  retains  the  rank  of  Brevet  Major.  Temporary  Captains 
retaining  the  rank  of  Captain  : W.  T.  Buchan,  J.  B.  Mackay,  A.  G.  B. 
Duncan,  G.  A.  Upcott-Gill,  R.  P.  Garrow,  G.  M.  Vevers,  G.  P. 
Armstrong,  L.  T.  Giles,  It.  C.  L.  Batchelor,  C.  C.  Irvine,  T.  D. 
Cumberland,  P.  Lornie,  D.  M.  Moffat,  A.  E.  Goldie,  It.  W.  E. 
Roe,  C.  H.  Lloyd,  G.  G.  Buchanan,  A.  S.  Richmond,  J.  S. 
Kinross,  E.  H.  Edward,  G.  Stanger,  J.  H.  C.  Began,  H.  P.  Dawson, 
U.  H.  Mofatt,  H.  Quigley,  It.  Puttock,  C.  K.  Cohen,  A.  W.  Mitchell, 

R.  J.  M.  Love,  J.  W.  Flood,  B.  Haigh,  J.  Cruickshank,  W.  G.  Southey, 

S.  A.  Montgomery,  V.  C.  Pennell,  H.  E.  Griffiths,  J.  J.  Healy,  R.  L. 
Barwick,  W.  M.  Stewart,  L.  T.  Wells,  J.  M.  Ross,  J.  II.  Wilson,  P.  D. 
Hunter,  I.  W.  Corkey,  H.  M.  Cade,  A.  M.  A.  James,  H.  F.  Hutchinson, 
F.  M.  Simmonds,  L.  Makin,  S.  Jacob,  F.  P.  Grove,  H.  G.  Carlisle, 
C.  H.  Newton,  A.  N.  Drury,  H.  M.  C.  Green,  J.  S.  Young,  M.  L.  Neylon, 
S.  G.  Trail,  A.  B.  R.  Sworn,  E.  Coleman,  J.  W.  Power,  L.  M.  Markham, 
P.  M.  Shiels,  T.  W.  Sheldon,  G.  H.  H.  Russell,  A.  P.  MacMahon,  W.  T. 
Smith,  M.  T.  W.  Steedman,  G.  K.  Thompson,  W.  Miller,  G.  O'N. 
Waddington,  W.  Brown,  G.  T.  Cregan,  G.  W.  Elder,  H.  M.  Roberts, 
(acting  Major)  G.  W.  S.  Paterson,  H.  N.  Eccles,  F.  B.  Chavasse  ; 
Temp.  Hon.  Capt.  W.  S.  Rutherford  (retains  the  honorary  rank  of 
Captain);  Temp.  Lieut.  J.  G.  Thomson.  Temporary  Lieutenants 
retaining  the  rank  of  Lieutenant : F.  C.  Mann,  F.  W.  P.  Sullivan,  T.  S. 
Macaulay,  II.  E.  Davison,  M.  Baranov,  S.  A.  Bontor,  S.  Bardal,  F.  H. 
Boone. 

Canadian  Army  Medical  Corps. 

Temporary  Majors  to  be  temporary  Lieutenant- Colonels : (Acting 
Col.)  C.  F.  Martin,  (Acting  Lieut.-Col.)  M.  H.  Allen. 

Temp.  Capt.  E.  F.  Risdon  to  be  acting  Major  while  employed  as 
Officer  in  charge  of  Canadian  Section  of  Plastic  and  Facial  Surgery. 

The  undermentioned  temporary  Captains  retire  in  the  British  Isles  : 

E.  Wershof,  J.  P.  Bonfield,  A.  E.  Wood,  H.  C.  Clermont,  H.  L.  Walker, 

F.  A.  O’Reilly,  J.  A.  Houston,  R.  G.  Moffat. 

Temp.  Capt.  J.  P.  S.  Oathcart  to  be  temporary  Major. 

SPECIAL  RESERVE  OF  OFFICERS. 

The  undermentioned  Captains  relinquish  the  acting  rank  of  Lieu- 
tenant-Colonel on  re-posting : J.  R.  R.  Trist,  C.  N.  Gover,  T.  Y. 
Barkley,  S.  Miller. 

Capts.  C.  Armstrong  and  R.  O.  C.  Thomson  to  be  acting  Majors 
whilst  specially  employed. 

The  undermentioned  relinquish  the  acting  rank  of  Major-.  Capts. 
H.  W.  H.  Holmes,  J.  Gossip  ; Lieut.  R.  J.  Patchett. 

Lieut.  J.  Whittingdale  relinquishes  his  commission  on  account  of  ill- 
health  and  retains  the  rank  of  Lieutenant. 

TERRITORIAL  FORCE. 

Lieut.-Col.  (acting  Col.)  T.  F.  Dewar  relinquishes  the  acting  rank  of 
Colonel  on  vacating  the  appointment  of  Assistant  Director  of  Medical 
Services. 

Majors  (acting  Lieut.-Cols.)  relinquishing  the  acting  rank  of  Lieu- 
tenant-Colonel on  ceasing  to  be  specially  employed  : T.  P.  Puddicombe, 
J.  W.  Mackenzie. 

Capt.  (acting  Lieut.-Col.)  J.  Strathern  relinquishes  the  acting  rank 
of  Lieutenant-Colonel  on  ceasing  to  be  specially  employed. 

Capts.  (acting  Majors)  relinquishing  the  acting  rank  of  Major  on 
ceasing  to  be  specially  employed  : J.  C.  Grieve,  G.  W.  C.  Hollist,  C.  H. 
Crawshaw,  W.  W.  Greer,  J.  H.  Robinson. 

Capt.  (Bt.  Major)  (acting  Major)  W.  Brander  relinquishes  the  acting 
rank  of  Major  on  ceasing  to  be  specially  employed. 

Capt.  B.  J.  Alcock  to  be  acting  Major  whilst  specially  employed. 

Capt.  D.  E.  S.  Davies  relinquishes  his  commission  on  account  of  ill- 
health  contracted  on  active  service,  and  retains  the  rank  of  Captain. 

Capt.  H.  W.  Spaight  to  be  Deputy  Assistant  Director  of  Medical 
Services,  and  to  be  acting  Major  whilst  so  employed. 

1st  London  Sanitary  Company  : Capt.  W.  N.  W.  Kennedy  relinquishes 
his  commission  on  account  of  ill-health  contracted  on  active  service, 
and  is  granted  the  rank  of  Major.  Lieut.  P.  R.  Fincher  to  be  Captain. 

Sanitary  Service:  Capt.  (Bt.  Major)  (acting  Major)  C.  M.  Fegen 
relinquishes  the  acting  rank  of  Major. 

4th  Scottish  General  Hospital : Capt.  (acting  Major)  W.  A.  Campbell 
relinquishes  the  acting  rank  of  Major  on  ceasing  to  be  specially 
employed.  Capt.  W.  A.  Campbell  is  restored  to  the  establishment. 

ROYAL  AIR  FORCE. 

Medical  Branch.— Lieut.-Col.  E.  O.  B.  Carbery  (Surg.-Cmdr.,  R.N.) 
relinquishes  his  commission  on  ceasing  to  be  employed. 

C.  P.  V.  MacCormack,  J.  G.  Skeet  (late  Captain  A.I.F.),  G.  M.  Mellor 
are  granted  temporary  commissions  as  Captains. 

Lieut.  C.  Duggan  to  be  acting  Captain  whilst  employed  ss  Captain, 
without  pay  and  allowances  of  that  rank. 

G.  H.  H.  Maxwell  and  T.  H.  K.  MacLaughlin  are  granted  temporary 
commissions  as  Lieutenants. 

The  undermentioned  are  transferred  to  Unemployed  List : Capts. 
J.  W.  Brash,  G.  Sparrow,  N.  C.  Graham,  G.  Visger,  R.  H.  Robbins, 
Lieut.  N.  C.  Cooper. 

Dental  Branch.— W . P.  Bole  is  granted  a temporary  commission  as 
Lieutenant.  

* INDIA  AND  THE  INDIAN  MEDICAL  SERVICE. 
Lieut.-Col.  C.  Duer,  I.M.S.,  has  resigned  the  Service.  Major-Gen. 
P.  Hehir,  I.M.S.,  is  retained  in  the  Service  until  further  orders. 
Lieut.-Col.  E.  F.  G.  Tucker,  I.M.S.,  to  be  Senior  Medical  Officer,  J.  J. 
Hospital,  vice  Lieut.-Col.  A.  Street  proceeded  on  leave.  Major  A.  F. 
Hamilton,  I.M.S.,  to  act  as  Senior  Surgeon,  J.  J.  Hospital,  and  Pro- 
fessor of  Surgery,  Grant  Medical  College,  Bombay.  Lieut.-Col.  R.  M. 
Carter,  I.M.S.,  to  be  Dean,  Grant  Medical  College,  Bombay.  Dr. 
Anandrai  Keshaolal  to  act  as  Senior  Surgeon  J.  J.  Hospital,  and  Pro- 
fessor jof  Surgery,  Grant  Medical  College,  Bombay,  in  relief  of  Major 
Hamilton,  I.M.S.  Dr.  Gopal  V.  Deshmukh  to  act  as  Second  Surgeon, 
J.  J.  Hospital,  and  Professor  of  Clinical  and  Operative  Surgery, 
Grant  Medical  College,  Bombay,  vice  Dr.  A.  K.  Datal.  Lieut.-Col. 


454  The  Lancet,] 


THE  SERVICES. 


[Sept.  6,  1919 


S.  H.  Barnett,  I.M.S.,to  act  as  Surgeon  Superintendent,  St.  George’s 
Hospital,  Bombay,  vice  Lieut.-Col.  T.  Jackson  proceeded  on  leave. 
Major  W.  M.  Houston,  I.M.S.,  to  act  as  Presidency  Surgeon,  First 
District.  Major  A.  D.  Stewart,  I.M.S.,  to  act  as  Surgeon-in  Charge 
Gokeeldas  Te.jpal  Native  General  Hospital,  Bombay.  Major  K.  H. 
Bolt,  I.M.S.,  has  been  recalled  from  military  duty  in  Simla  and  has 
taken  over  from  Sir  James  Roberts  the  Civil  Surgeon  of  Simla,  West. 
Sir  James  Roberts  is  at  present  acting  as  Surgeon  to  the  Viceroy  as 
Lieut.-Col.  Austen  Smith  is  ill.  The  services  of  Lieut.-Col.  D.  W. 
Sutherland,  I.M.S.,  Principal,  King  Edward  Medical  College,  Lahore, 
were  placed  at  the  disposal  of  the  Government  of  India  Department 
from  May  26th.  Lieut.-Col.  J.  N.  Walker,  I.M.S.,  on  return  from  leave 
to  be  Civil  Surgeon,  Lucknow,  vice  Lieut.-Col.  Birdwood,  I.M.S., 
granted  leave.  Lieut.-Col.  G.  T.  Birdwood,  I.M.S.,  Civil  Surgeon, 
second  class,  has  been  appointed  a Civil  Surgeon,  first  class,  vice  Lieut.- 
Col.  J.  M.  Crawford,  I.M.S.  Major  C.  H.  L.  Palk,  I.M.S.,  resigns  the 
Service. 

Major-General  W.  H.  B.  Robinson,  C.B.,  I.M.S,.  is  appointed  an 
Honorary  Surgeon  to  the  King,  vice  Col.  Hormasjie  Edaljie  Banatvala, 

C.S.I.,  I.M.S.,  and  Major-General  W.  E.  Jennings,  I.M.S.,  is  appointed 
an  Honorary  Physician  to  the  King,  vice  Major-General  It.  W.  S. 
Lyons,  I.M.S. 

THE  HONOURS  LIST. 

The  following  awards  to  naval  medical  officers  are  announced  : — 
C.M.G. 

Surg.-Cmdr.  J.  F.  HALL.— For  valuable  services  in  H.M.  A.S.  Australia 
and  H.M.  Hospital  Ship  Soudan,  and  at  the  Medical  Department, 
Admiralty. 

Surg.-Cmdr.  T.  T.  JEANS.— For  valuable  services  in  various  theatres 
of  the  war. 

Surg.-Cmdr.  F.  BOLSTER.— For  valuable  services  in  various  theatres 
of  the  war. 

C.B.E.  (Military  Division). 

Surg.-Capt.  C.  S.  WOODWRIGHT.— For  valuable  services  at  the 
R.N.  Sick  Quarters,  Yokohama,  in  H.M.  Hospital  Ship  Soudan,  and  as 
Principal  Medical  Transport  Officer. 

O.B.E.  (Military  Division). 

Surg.-Lt.-Cmdr.  F.  C.  ALTON. — For  valuable  services  in  H M.  Ships 
during  the  war  and  at  the  R.N.  Hospital,  Gibraltar. 

Surg.-Lt.  C.  H.  F.  ATKINSON.— For  valuable  services  in  H.M.  Ships 
during  the  war  and  at  the  R.N.  Sick  Quarters,  Trevol. 

Surg.-Lt.  S.  S.  BARTON.— For  valuable  services  in  H.M.S.  Dwarjand 
at  the  R.N.  Hospital,  Haslar. 

Surg.-Lt.  T.  BEATON. — For  valuable  services  in  H.M.  Ships  during 
theiwar  and  at  the  R.N.  Hospital,  Chatham. 

Surg.-Lt.  K.  B.  BELLWOOD. — For  valuable  services  in  H.M.S. 
Diligence,  H.M.  Hospital  Ship  Soudan,  and  at  the  R.N.  Hospital, 
Chatham. 

Surg.-Lt.-Cmdr.  J.  C.  BUINGAN. — For  valuable  services  in  several 
of  H.M.  Ships  during  the  war. 

Surg.-Lt.  O.  D.  BROWNFIELD. — For  valuable  services  in  H.M.  Ships 
during  the  war,  at  the  R.N.  Barracks,  Portsmouth,  and  at  the  R.N. 
Hospital,  Haslar. 

Surg.-Lt.  R.  BUDDLE. — For  valuable  services  in  several  of  H.M.  Ships 
during  the  war. 

Surg.-Lt.-Cmdr.  H.  BURNS. — For  valuable  services  in  several  of 
H.M.  Ships  during  the  war. 

Surg.-Lt.  P.  N.  BUTTON.— For  valuable  services  in  H.M.S.  Yarmouth 
and  with  the  3rd  H.M.  Battalion  in  the  Eastern  Mediterranean. 

Surg.-Cmdr.  J.  A.  L.  CAMPBELL — For  valuable  services  in  H.M.S. 
Lancaster  and  as  Senior  Medical  Officer,  R.N.  Depot,  Crystal  Palace. 

Surg.-Lt.  R.  S.  CAREY.— For  valuable  services  in  H.M.  Hospital 
Ships  during  the  war  and  at  the  R.N.  Hospital,  Plymouth. 

Surg.-Cmdr.  H.  CLIFT.— For  valuable  services  in  H.M.S.  Hercules 
and  at  the  R.M.  Barracks,  Chatham. 

Surg.-Lt.  W.  E.  DIXON.— For  valuable  services  during  the  war. 

Surg.-Lt.  W.  A.  S.  DUCK.— For  valuable  services  in  H.M.S.  Biarritz 
and  H.M.  Hospital  Ship  Delta. 

Surg.-Lt.-Cmdr.  S.  F.  DUDLEY. — For  valuable  services  in  H.M. 
Hospital  Ship  Agadir  and  at  the  R.N.  Hospital,  Chatham. 

Surg.-Lt.  (acting  Surg.-Lt.-Cmdr.)  G.  E.  D.  ELLIS.— For  valuable 
services  in  several  of  H.M.  Ships  during  the  war  and  at  H.M.  Dockyard, 
Sheerness. 

Surg.  Lt.  F.  B.  EYKYN.— For  valuable  services  with  the  R.N. 
Division,  at  the  R.N.  Infirmary,  Eastney,  and  at  the  R.N.  Barracks, 
Portsmouth. 

Surg.-Lt.  J.  G.  A.  FAIRBANK.— For  valuable  services  in  H.M.S. 
Bacchante  and  at  the  R.N.  Barracks,  Chatham. 

Surg.-Lt.  M.  FAWKES. — For  valuable  services  in  H.M.  Ships  during 
the  war,  at  the  R.N.  Hospital,  Haslar.  and  at  the  R.N.  Air  Station, 
Barrow. 

Surg.-Lt.  G.  W.  M.  FINDLAY.— For  valuable  services  as  Medical 
Officer  of  the  Royal  Naval  DepSt,  Port  Said. 

Surg.-Lt.  E.  E.  FLETCHER.— For  valuable  services  to  the  R.N. 
Barracks,  Devonport. 

Surg.-Lt.  T.  E FRANCIS. — For  valuable  services  in  H.M.S.  Britannia, 
H.M.  Hospital  Ship  Soudan,  and  at  the  R.N.  Hospitals,  Haslar  and 
Plymouth. 

Surg.-Lt.  W.  L.  M.  GOLDIE.— For  valuable  services  in  H.M.  Ships 
during  the  war,  at  the  R.N.  Hospital,  Chatham,  and  at  the  R.N. 
Infirmary,  Deal. 

Surg.-Lt.  L.  S.  GOSS. — For  valuable  services  in  H.M.  Ships  during 
the  war  and  at  the  R.N.  Seaplane  Station,  Port  Said. 

Surg.-Lt.-Cmdr.  S.  W.  GRIMWADE.— For  valuable  services  in 
H.M.S.  Erebus  and  at  the  R.N.  Hospital,  Malta. 

Surg.-Cmdr.  T.  D.  HALAHAN.— For  valuable  services  In  H.M.S. 
King  George  V.  and  at  the  R.N.  Sick  Quarters.  Shotley. 

Surg.-Lt.-Cmdr.  (acting  Surg.-Cmdr.)  W.  E.  IIARKER. — For  valuable 
services  as  Senior  Medical  Officer,  Tyne  District. 

Surg.-Lt.  A.  E.  HERMAN.— For  valuable  services  in  H.M.  Hospital 
Ships  during  the  war  and  at  the  R.N.  Barracks,  Devonport. 

Surg.-Lt.  E.  C.  HOLTOM  — For  valuable  services  In  several  of  H.M. 
Ships  during  the  war  and  with  the  K.M.  Division,  Chatham. 

Surg.  -Cmdr.  C.  II,  M.  HUGHES.— For  valuable  services  at  the  R.N. 
Hospital,  Chatham. 


Surg.-Lt.-Cmdr.  T.  W.  JEFFERY.— For  valuable  services  in  several 
of  H.M.  Ships  during  the  war. 

Surg.-Lt.  J.  LAMBERT.— For  valuable  services  in  H.M.  Hospital 
Ship  Rewa,  at  the  R.N.  Sick  Quarters,  Shotley,  and  at  the  R.N. 
Barracks,  Devonport. 

Surg.-Lt.  D.  LORIMER.— For  valuable  services  in  H.M.S.  Bacchante 
and  at  the  R.N.  Hospital,  Granton. 

Surg.-Lt.  G.  R.  LYNCH.— For  valuable  services  at  the  R.N.  Hospital, 
Malta,  R.N.  College,  Greenwich,  and  R.N.  Depot,  Crystal  Palace. 

Surg.-Lt.  R.  G.  LYSTER.— For  valuable  services  in  H.M.  Ships 
during  the  war  and  at  H.M.  Dockyard,  Rosyth. 

Surg.-Lt.-Cmdr.  G.  H.  McCOWEN.— For  valuable  services  in  various 
theatres  of  the  war. 

Surg.-Lt.  H.  C.  MANN. — For  valuable  services  fn  H.M.S.  Dimcan,  at 
the  R.N.  Hospitals,  Plymouth  and  Malta,  and  at  the  R.N.  College, 
Osborne. 

Surg.-Lt.  H.  P.  MARGETTS.— For  valuable  services  in  H.M.S. 
Barham,  at  the  R.N.  Barracks,  Portsmouth,  and  in  the  Piraeus. 

Surg.-Cmdr.  W.  L.  MARTIN.— For  valuable  services  in  the  Medical 
Department,  Admiralty. 

Surg.-Lt,  C.  F.  MAYNE.— For  valuable  services  in  H.M.S.  Kildonaii 
Castle,  with  the  R.N.  Division,  and  at  the  R.N.  Hospital,  Chatham. 

Surg.-Cmdr.  C.  W.  MORRIS. — For  valuable  services  at  the  R.N. 
Hospital,  Haslar. 

Surg.-Lt.  A.  C.  MORSON. — For  valuable  services  in  several  of  H.M. 
Ships  and  Hospital  Ships  during  the  war  and  at  the  R.N.  Hospital, 
Haslar. 

Surg.-Lt.-Cmdr.  G.  NUNN. — For  valuable  services  in  various  theatres 
of  the  war. 

Surg.-Cmdr.  W.  E.  ORMSBY. — For  valuable  services  in  several  of 
H.M.  Ships  during  the  war. 

Surg.-Lt.  J.  R.  PALMER. — For  valuable  services  at  the  R.N.  Barracks, 
Chatham. 

Surg.-Lt.  O.  PARKE3. — For  valuable  services  in  H.M.  Hospital  Ships 
during  the  war  and  at  the  R.N.  Hospitals,  Chatham  and  Plymouth. 

Surg.-Lt.  H.  F.  PERCIVAL. — For  valuable  services  in  H.M.  Ships 
during  the  war  and  at  the  R.N.  Barracks.  Portsmouth. 

Surg.-Lt.-Cmdr.  R.  A.  RANKINE.— For  valuable  services  in  con- 
nexion with  anti-malarial  work  at  the  British  Naval  Base,  Corfu. 

Surg.-Lt.  A.  H.  RICHARDSON. — For  valuable  services  in  H.M.S. 
Humber  and  at  the  R.N.  Hospital,  Chatham 
Surg.-Cmdr.  M.  L.  B.  RODD.— For  valuable  services  in  H.M.  Hospital 
Ship  Plassy  and  at  the  R.M.  Infirmary.  Deal. 

Surg.-Lt.  E.  G.  SCHLESINGER. — For  valuable  services  with  the 
R.N.  Division  and  at  the  R.M.  Infirmary,  Deal. 

Surg.-Cmdr.  H.  W.  B.  SHEWELL.— For  valuable  services  in  H.M.S. 
Euryalus  and  at  the  R.N.  Barracks,  Portsmouth. 

Surg.-Lt.  R.  E.  SMITH. — For  valuable  services  in  H.M.  Ships  during 
the  war,  at  the  R.N.  Hospitals,  Gibraltar  and  Plymouth,  and  at  the 
R.N.  Barracks,  Devonport. 

Surg.-Cmdr.  P.  H.  M.  STAR. — For  valuable  services  in  H.M.S. 
Conqueror  and  at  the  R.N.  Hospital,  Queensferry. 

Surg.-Lt.-Cmdr.  (acting  Surg.-Cmdr.)  E.  J.  STEEGMANN.— For 
valuable  services  during  the  war. 

Surg.-Lt.-Cmdr.  H.  E.  R.  STEPHENS. — For  valuable  services  in 
H.M.  Ships  during  the  war  and  at  the  R.N.  Hospital,  Plymouth. 

Surg.-Cmdr.  R.  W.  G.  STEWART.— For  valuable  services  in  the 
Medical  Department,  Admiralty. 

Surg.-Lt.  E.  L.  STURDEE.— For  valuable  services  with  the  R.N. 
Division  and  at  the  R.N.  Hospital,  Plymouth,  R.N.  Barracks,  Devon- 
port. and  R.N.  Depot,  Crystal  Palace. 

Surg.-Cmdr.  P.  T.  SUTCLIFFE. — For  valuable  services  in  H.M. 
Hospital  Ships  during  the  war  and  at  the  Medical  Department, 
Admiralty. 

Surg.-Cmdr.  A.  R.  THOMAS.— For  valuable  services  in  H.M.S.  Talbot 
and  at  the  R.N.  Hospital.  Malta. 

Surg.-Lt.  F.  THOMPSON.— For  valuable  services  at  the  R.N.  Hospital, 
Haslar. 

Surg.-Lt.-Cmdr.  G.  G.  VICKERY. — For  valuable  services  in  several 
of  H.M.  Ships  during  the  war. 

Surg.-Lt.  Li.  R.  WARBURTON. — For  valuable  services  in  H.M.  Ships 
during  the  war  and  with  the  R M.  Division,  Plymouth. 

Surg.-Lt.-Cmdr.  L.  WARREN. — For  valuable  services  in  H.M.  Hos- 
pital Ship  Agadir  and  at  the  R.N.  College,  Dartmouth. 

Surg.-Lt.-Cmdr.  D.  P.  D.  WILKIE.— For  valuable  services  in  H.M.S. 
Glory  and  H.M.  Hospital  Ship  St.  Margaret  of  Scotland. 

Surg.-Lt.-Cmdr.  (acting  Surg.-Cmdr.)  R.  J.  WILLAN,  M.Y.O.— 
For  valuable  services  in  H.M.  Hospital  Ships  during  the  war  and  at  the 
R.N.  Hospital,  Haslar. 

Surg.-Lt.  A.  G.  WILLIAMS. — For  valuable  services  in  H.M.S.  Ebro, 
with  the  R.M.  Division.  Deal,  and  in  Belgium. 

Surg.-Lt.-Cmdr.  (acting  Surg.-Cmdr.)  W.  K.  WILLS. — For  valuable 
services  in  H.M.  Ships  during  the  war. 

Surg.-Lt.  G.  E.  WOOD.— For  valuable  services  at  the  R.N.  Barracks, 
Portsmouth. 

Brought  to  Notice. 

The  names  of  the  following  naval  medical  officers  have  been  brought 
to  the  notice  of  the  Admiralty  for  valuable  services  in  the  prosecution 
of  the  war  :— 

Surg.  Lt.-Cmdr.  A.  D.  Cowburn;  Surg.  Lt.-Cmdr.  H.  L.  Murray; 
Surg.  Lt.-Cmdr.  C.  F.  A.  Hereford ; Surg.-Lts.  R.  St.  L.  Brockman, 
F.  C.  Endean,  J.  C.  Walker,  T.  C.  Blackwell,  H.  Carlill,  W.  A. 
McKerrow,  W.  W.  Rooke,  A.  L.  Sutcliffe,  E.  G.  Fisher.  A.  J. 
MaoDiarmid,  A.  E.  Sanderson,  E.  F.  Fisher,  T.  Norman,  T.  H.  G. 
Melrose,  W.  G.  Robertson,  J.  C.  H.  Allan,  A.  C.  Mooney,  N.  C. 
Carver.  R.  H.  H.  Newton,  C.  M.  Burrell,  D.  A.  Imrie,  F.  C.  Newman, 

D.  McAlpine,  F J.  F.  Barrington,  R.  T.  Bailey.  E.  A.  Green.  G.  E.  S. 
Ward,  I.  H.  Beattie.  W.  O.  Sankey,  E.  A.  Cockayne,  A.  E.  W.  Hird, 
W.  I.  Gerrard,  H.  Chitty,  J.  Lorimer,  E.  P.  Punch,  B.  Cohen,  J R. 
Kay-Mouat,  E.  F.  Murray,  A.  C.  McVittie,  W.  S.  Ollis,  A.  Lawrev, 

E.  J.  Winstanley,  A.  H.  Crook,  M.C. 

The  names  of  the  following  civilian  doctors  have  been  brought  to  the 
notice  of  the  Secretary  of  State  for  War  for  valuable  medical  services 
rendered  in  the  United  Kingdom  in  connexion  with  the  war  : — 

F.  W.  Abbott.  P.  H Abercrombie,  R.  C.  Acland,  W.  G.  P.  Alpin,  C.  M. 
Anderson,  Sir  M.  Abbott-Anderson.  G.  J.  M.  Atkinson,  J.  H.  Badcock, 

E.  G.  Barker,  J.  M.  Barlet,  Sir  T.  Barlow,  J.  H.  Barnard,  F.  S.  Barnett, 

F.  E.  Batten,  H.  Beckett-Overy,  Sir  W.  H.  Bennett,  G.  Blacker,  E.  J. 


MEDICAL  NEWS. 


[Sept.  6, 1919  455 


1'nK  Lancet,] 


Blackett,  J.  Blomlield,  J.  S.  Roden.  0.  Bolton,  E.  C.  Bridges,  J M. 
Bruce,  J.  M Brydone,  C.  «.  Bubi),  W.  Bulloch.  H.  T.  Campkln,  C.  E. 
Carpmael.  A.  A.  Carr,  J.  VV.  Carr,  A.  J.  Carter,  J.  W.Caton,  10.  Card  ley, 
Miss  H.  Chambers,  A.  H.  Cheatlo,  J.  Chute.  H.  N.  Col  tart,  C.  T.  T. 
Comber,  (i.  ,).  Conford,  T.  A.  Ooysh,  J.  VV.  Cropper,  J.  Cunning, 

E.  G.  C.  Daniel,  P.  L.  Daniel,  the  late  Sir  J.  M.  Davidson,  G.  F. 
Dickinson,  T.  V.  Dickinson,  L.  0.  T.  Dobson,  J.  A.  Drake,  M.  A.  Dutch, 
A.  M.  Elliot,  Sir  T.  Crisp  English,  II.  L.  Evens,  J.  W.  II.  Eyre.  E.  11. 
E/.ard,  G.  Paris,  W.  S.  Fenwick.  Sir  I).  Perrier,  A.  II.  Poster,  L.  Puller, 
E P.  Furbor,  P.  Furnivall,  ,T.  Gay,  Miss  G.  Gazdar,  G.  G.  Genge,  H.  T. 
George,  E.  Gillespie,  L.  G Glover,  Sir  K.  VV.  Goadby,  Sir  R.  J. 
Godlee,  W.  A.  Gordon,  H.  T.  Gray,  10.  C.  Greenwood,  A.  .1.  Gregory, 
H.  10.  Griffiths,  H.  B.  Grimsdale,  C.  N.  Groves,  L.  G.  Guthrie,  C.  F. 
Had  field , Miss  E.  Haigh.  J.  Z.  Hanafy,  T.  E.  Harwood,  E.  D.  H.  Hawke, 
K,  It.  Hay,  H.  Heart,  VV.  Hern,  C.  Higgins,  C.  Hodgson,  I).  VV.  C. 
Hood,  G.  H.  J.  Hooper,  It.  J.  Howard,  It.  J.  B.  Howard,  H. 
Huxley,  T.  B.  Hvslop,  Miss  C.  M.  Ironside,  W.  VV.  James, 
T.  H.  Jamieson.  VV  H.  Jewell.  H.  J.  Johnson.  R.  G.  Johnson, 
It.  D.  lvandin,  B.  S.  Kanga,  VV.  N.  Kingsbury,  M.  D.  B.  Kinsella, 
A G.  Lacey.  F.  G.  Langford,  J.  D.  Lawford,  A.  Lawson,  K.  A. 
Lees,  H.  Lett,  VV.  J.  Lindsay,  T.  D.  Lister,  E.  M.  Little,  Miss  A. 
Lloyd,  J.  P.  Lockhart  Mummery,  K.  M.  H.  Low,  K.  F.  Lund,  E.  Lynn, 
C it.  C.  Lyster,  Miss  E.  M.  MacGili.  C.  F.  Marshall,  A.  T.  Marston, 

E.  C.  Masser,  H.  M.  McCrea,  N.  McDonald.  W.  F.  McEwen,  L.  H. 
McGavin,  It.  McKay,  VV.  McLachlan,  J.  H.  Menzies,  J.  Metcalfe,  It.  H. 
Miller,  C.  H Mills,  W.  T.  Mullings,  J.  F.  Nall,  J.  Needham,  E.  M. 
Niali,  G.  P.  Nicolet.  F.  Norman,  G.  Northcroft,  VV.  J.  C.  Nourse, 
Sir  VV.  Osier.  C.  D.  Outred,  A.  W.  Oxford,  J.  I.  Palmer,  J.  G.  Pardop, 
Sir  T.  W.  Parkinson,  H.  J.  Paterson,  L.  J.  Paton,  J.  L.  Payne, 

F.  J.  Pearce,  E.  T.  Piohey.  W.  J.  Potts.  II  J.  Pulling,  A.  J.  Rlce- 
Oxley,  Miss  M.  M.  Richards,  A.  M.  Robertson,  Mrs.  A.  L.  L.  C. 
ltobs'on,  A.  R.  Roche,  A.  Rocyn-Jones.  W.  Rnughton,  S.  H.  Rouquette, 
It.  A.  Rowlands,  N.  Itushworth,  H.  Sainsbury,  E.  A.  Saunders,  R.  E. 
Scholefield,  VV.  Shears,  O.  B.  Sbelswell,  Miss  A.  Sheppard,  D.  A. 
Shields,  J.  Sinclair,  G.  C.  Sneyd,  E.  L.  Sortain,  Sir  J.  P.  Stewart, 
T.  G.  Stewart,  J.  Stirling- Hamilton,  Miss  F.  A.  Stoney,  T.  S.  P. 
Strangeways,  A.  J.  Swallow,  R.  -J.  Swan,  Sir  F.  Taylor,  J.  Taylor, 
E.  G.  Thomas,  G.  C.  Thomas,  T.  Thompson,  J.  D.  Thomson,  Miss  M. 
Thorne,  W.  Thornely,  R.  Thorpe,  S.  A.  Tidey,  W.  Trotter,  J.  Van  den 
Broeck,  J.  W.  T.  Walker,  R.  M Walker,  A.  J.  Walton.  A.  H.  Warde, 
S.  J.  Wareham,  C.  J.  F.  Westman,  C.  P.  White,  E.  F.  White,  Miss 

E.  M.  White,  L.  E Wigram,  J.  C.  Wilkinson,  F.  W.  Wilson,  E.  C. 

Young,  R.  A.  Young.  

Tim.  Territorial  Decoration.— The  King  has  conferred  the  Territorial 
Decoration  upon  the  undermentioned  officers  Royal  Army  Medical 
Corps  : Col.  A.  E.  L.  Wear,  C.M.G.  ; Lt.-Cols.  E.  B.  Dowsett,  A.  C. 
Guilan,  J.  A.  Masters,  J.  H.  Stephen,  C.  It.  Browne,  A.  R.  Tweedie  ; 
Maj.  (Bt.  Lt.-Col.)  R.  Griffith;  Maj.  (acting  Lt.-Col. ) H.  B.  Roderick  ; 
Ma'j.  (temp.  Lt.-Col.)  E.  W.  St.  Vincent-R , an  ; Majs.  S.  W.  Plummer, 
J.  Bruce,  C.  It.  White.  A.  Ehrmann,  W.  T.  Blackledge,  F.  W.  Johnson, 

F.  Grade,  E.  J.  T.  Cory,  A.  Price.  A.  Bird,  F.  W.  Kendle  (attached  to 
R.F.A.);  Capt.  (acting  Maj.)  VV.  II.  Brailey ; Capt.  W.  J.  Rice. 
Territorial  Force  Reserve:  Surg.-Ma.j.  A.  W.  Cuff,  T.F.R..  attached  to 
3rd  West  Riding  Brigade,  R.F.A. ; Surg.-Maj.  A.  R.  Stoddart,  attached 
to  5th  Batn.,  West  Yorkshire  Regt. ; Maj.  R.btarkev-Smith,  attached  to 
R.A.M.C.  ; Maj.  J.  E.  Molson,  attached  to  R.A.M.C. 


Stoical  Stctos. 


Society  op  Apothecaries  op  London. — At 
examinations  heid  recently  the  following  candidates  passed 
in  the  subjects  indicated  : — 

Suri/ery. — J.  F.  E Burns  and  D.  G.  Cossham  (Sects.  I.  fnd  II.), 
Bristol  ; W.  D.  McRae  (Sect  II.),  London  Hosp.  ; and  H.  H.  Selim 
(Sects.  I.  and  II.),  St.  Mary's  Hosp. 

Medicine. — E.  V.  Briscoe  (Sect.  I.),  St.  Mary's  Hosp.;  O.  H.  Brown 
(Sect.  II.).  Charing  Cross  Hosp. ; J.  F.  E Burns  and  D.  G.  Cossham 
(Sects.  I.and  II.),  Bristol;  F.  I.  G.  Edwards  (Sects.  I.  and  II), 
Royal  Free  Hosp.  and  Liverpool;  C.  W.  Lakin  (Sects.  I.  and  II.), 
Guy's  Hosp.  and  Birmingham  ; and  H.  M.  Partridge,  St.  Bart,  s 
Hosp 

Forennc  Medicine. — D.  G.  Cossham  and  .T.  H.  C.  Eglinton,  Bristol  ; 

G.  ap  V.  Jones.  Glasgow;  W.  D.  McRae.  London  H sp  ; H.  M. 
Partridge,  St.  Birt.'s  Hosp  ; and  G.  K.  Reeves,  Guy's  Hosp. 

Midwifery.— C.  C.  Bennett.  Guy's  Hosp.;  E.  V.  Brisaoe,  St.  Mary's 
Hosp. : D.  G.  Cossham.  Bristol;  F.  C.  M.  Gabites,  Edinburgh  ; and 

H.  M.  Partridge,  St.  Bart.’s  Hosp. 

The  Diploma  of  the  Society  was  granted,  to  the  following  candidates, 
entitling  them  to  practice  medicine,  surgery,  and  midwiierv  ; J.  F.  E. 
Burns,  D.  G.  Cossham,  F.  C.  M.  Gabites,  C W.  Lakin,  W.  D.  McRae, 
and  H.  H.  Selim. 

National  Association  for  the  Prevention  op 
Consumption. --The  annual  conference  of  this  association 
will  be  held  at  the  Central  Hall,  Westminster,  on  Oct.  16tb, 
17tb,  and  18th,  the  last  previous  conference  having  been  held 
at  Leeds  in  1914.  The  following  distinguished  foreigners  are 
taking  part  in  the  conference  : from  France,  Professor  Leon 
Bernard,  Professor  Calmette,  Professor  Courmont,  and  Pro- 
fessor Rist ; from  the  United  States,  Dr.  Hermann  Biggs,  of 
New  York,  and  Professor  William  White,  of  the  American 
Red  Cross  (Italy);  from  Italy,  Professor  Poli,  Dr.  Rasponi, 
and  Professor  Ronzoni.  The  full  programme  of  the  con- 
ference is  not  yet  settled,  but  the  main  subject  of 
consideration  at  the  conference  is  the  completion  of 
tuberculosis  schemes  throughout  the  country  in  rela- 
tion to  (1)  the  Ministry  of  Health ; (2)  local  authorities 
and  Insurance  Committees;  (3)  Pensions  Boards  and  Com- 
mittees (Discharged  Sailors  and  Soldiers) ; (4)  general 


practitioners  ; (5)  Red  Cross  and  other  voluntary  activities  ; 
(6)  training  of  doctors  and  nurses.  The  morning  session 
of  the  first  day  will  he  devoted  to  the  consideration  of 
Sections  (1)  and  (2),  the  afternoon  session  being  devoted  to 
Sections  (3)  and  (4).  The  subject  for  consideration  at  the 
morning  session  of  the  second  day,  Oct.  17 th , is  not  yet 
settled,  hut  iu  the  afternoon  Sections  (5)  and  (6)  will  he  dis- 
cussed. The  programme  of  the  third  day  is  as  yet 
unsettled.  Among  those  who  will  address  the  conference 
on  the  first  day  are  Sir  R.  W.  Philip,  President  of 
the  Royal  College  of  Physicians,  Edinburgh,  and  Dr. 
Hermann  Biggs.  Addresses  will  be  given  on  the  second 
day  by  Professor  Sir  William  Osier,  Regius  professor  of 
medicine  in  the  University  of  Oxford,  and  by  Pro- 
fessor Sir  Sims  Woodbead,  professor  of  pathology  in  the 
University  of  Cambridge.  There  will  be  addresses  given 
during  the  third  day’s  session  on  Tuberculosis  Work  for  Red 
Cross  and  other  Voluntary  Workers,  hut  the  speakers  are 
not  yet  arranged.  Among  the  social  functions  a conver- 
sazione will  be  held  on  the  evening  of  the  16th  by  the  Asso- 
ciation, and  on  the  evening  of  the  17th  Lady  Glenconner. 
the  wife  of  the  honorary  treasurer  of  the  Association,  will  be 
At  Home. 

Dr.  John  Robinson  Harper,  O.B.E.,  of  Barnstaple, 
has  received  the  decoration  of  Commander  of  the  Military 
Order  of  St.  Avis,  conferred  by  the  Portuguese  Republic. 

Royal  Devon  and  Exeter  Hospital. — The 
committee  of  this  hospital  has  accepted  a tender  for  £29,201 
for  the  proposed  extension  of  the  hospital,  and  the  work 
will  be  proceeded  with  in  sections.  Up  to  the  present 
over  £10,000  have  been  received  for  the  scheme. 

Dorset  County  Council  and  Tuberculosis. — 
The  Hon.  Gertrude  Pitt  has  presented  Beckford  Lodge, 
Wilts,  .to  the  Dorset  County  Council  for  the  purposes  of 
a sanatorium  for  tuberculosis  patients.  The  estate  is  valued 
at  £7000.  The  county  medical  officer  of  health  considers  the 
premises  suitable  for  the  scheme. 

A Gloucestershire  Centenarian. — Mrs.  Arthur 
Mosley,  who  completed  her  104th  year  last  January,  died  at 
Cheltenham  on  August  15th.  She  was  the  widow  of  the  Rev. 
A.  Mosley,  and  had  nine  brothers  and  sisters  ; the  combined 
ages  of  the  ten  show  an  aggregate  of  907  years. 

Presentations  to  Medical  Men. — The  members 
of  the  Redruth  (Cornwall)  branch  of  the  St.  John  Ambulance 
Nursing  Association  recently  presented  Dr.  Frank  Hichens, 
the  divisional  surgeon,  with  a case  of  surgical  instruments 
in  appreciation  of  his  services  as  honorary  lecturer. — Mr. 
E.  J.  Domville,  consulting  surgeon  to  the  Royal  Devon 
and  Exeter  Hospital,  has  been  presented  by  the  honorary 
medical  staff  with  a silver  bowl  and  four  silver  candlesticks 
in  appreciation  of  his  practical  patriotism  in  filling  the  post 
of  resident  house  surgeon  at  the  hospital  during  three  and  a 
half  years  of  the  war. 

The  late  M>r.  W.  C.  Mence. — William  Charles 
Mence,  L.R.C.P.,  M.R.C.S.,  Temporary  Captain,  R.A.M.C., 
died  recently  at  Axminster  in  his  forty-third  year.  Mr. 
Mence  was  medical  officer  of  health  for  Chard  and  was 
honorary  surgeon  to  the  AxmiDster  Cottage  Hospital.  He 
had  been  in  practice  for  some  years  in  Axminster,  where  he 
was  widely  known  and  respected.  He  joined  the  R.A.M.C. 
shortly  after  the  commencement  of  the  war,  and  had  served 
in  Egypt,  Mesopotamia,  and  France.  He  had  only  recently 
returned  from  active  service.  Much  sympathy  is  felt  locally 
for  his  widow  and  children. 

Diploma  in  Public  Health. — A course  of 
lectures  and  demonstrations,  extending  over  three  months, 
will.be  given  at  the  Western  Hospital,  Seagrave  road, 
Fulham,  S.W.,  by  Dr.  R.  M.  Bruce,  medical  superintendent, 
on  Tuesdays  and  Fridays,  at  5 P.M.,  beginning  Tuesday, 
Sept.  30tb.  The  fee  for  the  course  is  £3  3s.  Medical  men 
desiring  to  attend  the  course  are  required,  before  attending 
at  the  hospital,  to  ray  the  above-mentioned  fee  to  the  Clerk 
to  the  Metropolitan  Asylums  Board  (Sir  T.  Duncombe 
Mann),  Embankment,  E.C.4,  giving  their  full  name  aud 
address. 

Society  for  the  Study  of  Inebriety. — An 
autumn  session  will  be  held  in  the  rooms  of  the  Medical 
Society  of  London  on  Oct.  14th,  preceded  by  a breakfast  at 
8.30  a.m.  at  the  Polytechnic.  The  sessions  commence  at 
j 10  30  a.m.  and  2 P.M.,  followed  at  5.30  P.M.  by  the  eighth 
Norman  Kerr  lecture  at  the  house  of  the  Royal  Society 
of  Medicine  on  the  Relation  of  Alcohol  and  Alcoholism  to 
Maternity  and  Child  Welfare,  by  Mrs.  Mary  Scharlieb, 
C.B.E.,  M.D.  Communications  should  be  made  to  the 
honorary  secretary,  Dr.  T.  N.  Kelynack,  139,  Harley-street, 
London,  W.  1. 


456  The  Lancet,] 


The  conduct  of  labour  and  puerperal  sepsis. 


[Sept.  6,  1919 


Camspnknu. 

" Audi  alteram  partem.” 

THE  CONDUCT  OF  LABOUR  AND  PUERPERAL 
SEPSIS. 

To  the  Editor  of  The  Lancet. 

Sih, — There  are  just  three  points  in  Dr.  R.  L.  Kitching’s 
letter  in  your  issue  of  August  23rd  to  which  I will  briefly  reply. 

1.  The  cause  of  conjunctival  inflammation  during  the  first 
week  of  life  of  the  newly-born  child.  For  this  Dr.  Kitching 
suggests  a chemical  irritant  in  the  vagina,  possibly  lactic 
acid.  We  know  that  in  strengths  of  50  to  75  per  cent, 
solutions  lactic  acid  is  a caustic.  We  shall  therefore  not  be 
far  wrong  if  we  assume  a 10  per  cent,  solution  of  the  acid  in 
the  vaginal  discharge  during  labour  to  be  necessary  for  the 
production  of  actual  inflammation  of  the  conjunctiva.  It  is 
characteristic  of  all  chemical  irritants  that  they  produce 
their  effects  within  a very  short  time  of  application.  It 
therefore  follows  that  ophthalmia  should  declare  itself  in 
the  eyes  of  the  child  at  latest  within  two  or  three  hours  of 
birth.  The  delay  of  from  four  to  seven  days  before  it 
makes  its  appearance  seems  strange  on  this  hypothesis. 
There  is  also  another  difficulty  in  the  way,  and  that  is  the 
presence  of  lactic  acid  itself  in  the  vaginal  discharge  in 
concentration  sufficient  to  produce  the  required  result.  The 
information  which  Dr.  Kitching  would  like  to  have  as  to 
what  numbers  become  infected  after  birth  was  arrived  at 
many  years  ago,  and  was  apparent,  not  only  to  those  who 
attended  labour  in  those  days,  but  also  to  ophthalmic 
surgeons  who  saw  the  end-results  of  ophthalmia  neonatorum 
in  these  eyes.  It  would  be  impossible  to  obtain  statistics 
now  because  we  eradicate  and  suppress  the  evidence  of 
maternal  infection  by  immediate  attention  to  the  eyes  of  the 
newly-born  child.  There  is  also  one  other  fact  that  points 
to  the  maternal  passage  as  the  source  of  infection — and  that 
is,  that  after  the  first  week  of  life  the  susceptibility  of  the 
child  to  acute  inflammatory  infections  of  the  conjunctiva 
vanishes,  although  its  environment  remains  the  same. 

2.  While  admitting  the  soiling  of  the  genital  passages  in 
the  various  ways  that  I pointed  out,  Dr.  Kitching  believes 
that  the  vagina  is  able  to  deal  with  these  organisms  and 
sterilise  itself.  The  vagina,  so  far  as  one  can  see  from  its 
structure,  possesses  no  means  of  defence  against  intruding 
organisms.  It  has  no  adenoid  tissue,  no  glands,  and  it  is 
lined  with  squamous  epithelium.  It  has,  however,  a great 
many  folds  and  recesses,  within  which  organisms  would  find 
a convenient  resting  place.  Nor  has  the  uterus  any  particular 
power,  so  far  as  we  know,  of  destroying  organisms.  The 
spread  of  venereal  disease  shows  the  vagina  is  powerless  to 
deal  with  invading  organisms,  and  the  occurrence  of  gonor- 
rhoeal ophthalmia  in  the  newly-born  child  is  proof  positive 
that  the  vagina  of  the  pregnant  woman  is  equally  defenceless 
The  argument  from  analogy  furnishes  just  as  conclusive 
proof  that  cavities  and  canals  far  more  highly  endowed  by 
Nature  than  the  vagina  to  deal  with  organisms  are  often 
powerless  to  rid  themselves  of  their  invaders.  I need  only 
point  out  the  persistence  of  Klebs-Loffler  bacilli,  meningo- 
cocci, and  pneumococci  in  the  naso-pharynx  for  months  ; of 
Bacillus  typhosus , B.  paratyphosus,  bacillus  of  Shiga,  and 
streptococci  in  the  bowel ; of  Bacillus  coli  and  streptococci 
in  the  urinary  passages. 

3.  The  operation  area  in  a confinement  extends  from  uterus 
to  perineum,  and  the  management  of  a normal  labour  is 
primarily  the  care  of  a wound.  In  an  ordinary  operation 
the  surgeon  inflicts  the  wound  and  is  careful  to  interfere 
with  it  as  little  as  possible.  In  labour  Nature  inflicts  the 
wounds,  and  in  doing  so  pours  out  a serous  exudate  with 
intent  to  sterilise  and  wash  out  the  passage  along  which 
the  foetus  will  pass.  I tried  to  point  out  the  various  ways 
in  which  sepsis  might  be  introduced  into  the  maternal 
passage  before  labour  began,  and  instanced  conjunctival 
infection  of  the  newly -born  child  in  proof  of  my  contention 
of  vaginal  sepsis.  Until  ophthalmia  neonatorum  has  been 
explained  away  and  the  maternal  passage  exonerated  it  is  a 
legitimate  assumption  that  the  operation  area  of  the  medical 
attendant  at  a confinement  may  contain  septic  organisms 
before  labour  begins,  and  that  great  caution  should  be 
exercised  in  the  making  of  internal  examinations.  To  Dr. 
Kitching  this  is  only  worth  a ponderous  joke. 

I am,  Sir,  yours  faithfully, 

Steele’s  road,  N.W.,  August  24th.  1919.  J.  H.  E.  BROCK. 


THE  VERNON-HARCOURT  INHALER. 

To  the  Editor  of  The  Lancet. 

Sir, — In  your  obituary  notice  of  the  late  Mr.  A.  Vernon- 
Harcourt,  F.  R.  S. , you  animadvert  upon  the  chloroform  inhaler 
associated  with  his  name.  I am  sure  the  writer  has  no  wish 
to  prejudice  the  use  of  the  inhaler  by  a rather  disparaging 
criticism  upon  it.  It  is  suggested  that  “ clinical  authorities” 
maintain  : (1)  “that  chloroform  accidents  cannot  be  entirely 
prevented  by  regulating  chloroform  percentages  ” ; (2)  the 
inhaler  proves  useful  for  cases  “in  which  a light  anaes- 
thesia ” is  required  ; (3)  the  risk  of  using  a dosimetric 
inhaler  is  that  while  it  suggests  security  it  may  divert  the 
anaesthetist’s  attention  from  his  patient’s  condition.  Some 
confusion  is  caused  by  mixing  the  findings  of  the  Chloroform 
Committee  with  the  use  of  the  inhaler.  The  Committee  never 
stated  that  any  inhaler  or  method  could  wholly  avert  chloro- 
form fatalities.  It,  however,  contended  that  such  deaths 
were  commonly  the  result  of  employing  concentrations  of 
vapours  the  strength  of  which  could  only  be  guessed  at  by 
the  anaesthetist.  This  applies  alike  to  excessive  or  too 
tenuous  strengths  of  vapour.  The  Committee,  not  Mr. 
Harcourt,  adopted  the  2 per  cent,  value  as  the  usual  maxi- 
mum, following  the  findings  of  Paul  Bert  and  others.  This 
was  done  after  a great  deal  of  careful  experimentation,  the 
protocols  of  which  are  to  be  found  in  the  report.  Mr. 
Harcourt’s  inhaler  can  be  graded  for  any  strength  vapour,  it 
is  a question  of  physics,  but  he  was  requested  to  adopt  the 
2 per  cent,  maximum.  This  was  done,  although  during 
experiments  2 5 per  cent,  and  3 per  cent,  vapours  were  used 
from  the  inhaler.  A simple  device  secured  this. 

Of  course  I do  not  know  what  clinical  authorities  are 
referred  to,  but  I doubt  whether  those  who  criticised  in  the 
way  indicated  had  enjoyed  a wide  experience  of  the  use  of 
the  inhaler,  say  a thousand  or  so  cases.  As  to  the  third 
point,  having  had  a rather  wide  experience  in  the  use  of  the 
Vernon-Harcourt  inhaler,  I may,  perhaps,  be  allowed  to 
quote  from  my  article  dealing  with  the  matter,1  which 
received  the  approval  of  the  Committee.  I wrote  : — 

“ It  cannot  be  too  strongly  insisted  upon  that  the  Vernon  Harcourt 
regulator  is  only  a means  to  an  end.  It  supplies  a fairly  accurate 
method  of  regulating  the  percentage  of  chloroform  presented  to  the 
patient,  but  it  does  not,  nor  can  any  inhaler,' abrogate  the  necessity  for 
a competent  knowledge  of  the  action  of  chloroform  on  the  human 
subject  and  experience  in  administering  that  anaesthetic.  The 
apparatus  need  not,  and  must  not,  detach  the  cldoroformist's  attention 
from  his  patient’s  condition ; it  merely  enables  him  to  increase  or 
decrease  the  dose  of  chloroform  as  may  be  necessary.  Observation  of 
the  patient's  condition  will  indicate  when  the  necessity  arises.” 

Finally,  I should  like  to  suggest  that  the  implication  that 
the  Vernon-Harcourt  inhaler  is  only  useful  when  a light 
anassthesia — i.e.,  a narcosis  below  Snow’s  third  degree— is 
required  is  inaccurate.  It  can  induce  full  anaesthesia  and 
even  a deeper  narcosis  in  cases  of  prolonged  administration. 
This  assuming  that  the  person  using  it  does  so  efficiently. 

I am,  Sir,  yours  faithfully, 

August  29th,  1919.  DUDLEY  W.  BUXTON. 

***  We  had  Dr.  Buxton’s  book  before  us,  and  noted  the 
passage  which  he  quotes.  Other  authorities  disagree  with 
Dr.  Buxton  as  to  the  range  of  utility  of  the  ingenious 
Vernon-Harcourt  inhaler. — Kd.  L. 


THE  INCIDENCE  OF  TUBERCULOSIS  AMONGST 
ASYLUM  PATIENTS. 

To  the  Editor  of  The  Lancet. 

Sir,— The  paper  on  this  subject  by  Dr.  F.  A.  Elkins  and 
Dr.  Hyslop  Thomson  in  your  issue  of  August  9th  and  the 
subsequent  letters  from  Dr.  F.  E.  Tylecote  and  Dr.  H.  K. 
Abbott  have  been  read  by  me  with  great  interest,  for  I was 
chairman  of  the  Tuberculosis  Committee  of  the  Medico- 
Psychological  Association  appointed  in  1901,  and  have  taken 
always  a keen  and  active  interest  in  tuberculosis,  not  only 
among  the  insane,  but  also  among  the  poorer  classes  in  this 
country.  The  Tuberculosis  Committee  of  the  Medico-  ; 
Psychological  Association  was  elected  as  a result  of  an 
excellent  essay  by  Dr.  F.  G.  Crookshank,  which  gained  for 
him  the  medal  of  the  association,  and  which  was  published  ' 
in  the  Journal  of  Mental  Science  in  October,  1899.  Dr. 
Crookshank’s  clear  and  concise  conclusions  were  endorsed 
in  the  Report  of  the  Tuberculosis  Committee,  who  received 
from  medical  superintendents  of  the  asylums  for  the  insane 
in  Great  Britain  invaluable  answers  to  specific  questions. 

1 Anaesthetics,  p.  249, 


The  Lanobt,] 


INJECTIONS  OF  TARTAR  EMETIC  IN  BILHARZIASIS. 


[Sept.  6,  1919  457 


This  Report  was,  unfortunately,  shelved  by  reason  of  minor 
errors  in  the  statistical  figures,  though  it  was  admitted  by 
the  Association  that  these  errors  in  no  way  altered  the  real 
value  of  the  document.  The  Report  was  published,  and  can  no 
■doubt  be  obtained  from  the  secretary  of  the  Medico-Psycho- 
ogical  Association. 

Practically  very  little  has  been  done,  and  the  death-rate  of 
tuberculosis  in  asylums  is  still  increasing.  The  Board  of 
Control  recognise  this  fact,  but  simply  make  recommendations 
and  insist  on  nothing.  If  they  have  no  power  under  the 
Lunacy  Act  of  1890  to  enforce  their  recommendations,  why 
do  not  they  obtain  that  power  or  urge  the  Ministry  of  Health 
to  obtain  it  for  them  ? I have  pointed  all  this  out  in  a recent 
book  of  mine.  Something  more  must  be  done.  A Ministry 
of  Health  is  about  to  open  a campaign  for  the  physical 
improvement  of  the  nation.  To  my  mind  the  whole  question 
of  the  death-rate  of  tuberculosis  in  our  large  asylums  is  a 
standing  disgrace  to  our  country,  and  I earnestly  hope 
something  will  soon  be  done  to  mitigate  this  crying  evil. 

I am,  Sir,  yours  faithfully, 

Bournemouth,  Sept.  1st,  1919.  L.  A.  WEATHERLY,  M.D. 


INJECTIONS  OF  TARTAR  EMETIC  IN 
BILHARZIASIS. 

To  the  Editor  of  The  Lancet. 

Sir, — In  a paper  on  this  subject  published  in  your  issue 
of  August  9th  Dr.  Frank  E.  Taylor  draws  attention  to  the 
risk  of  antimony  poisoning  as  the  results  of  intravenous 
injections.  He  goes  on  to  say  that  the  toxicity  of  arsenic 
has  been  greatly  reduced  by  introducing  it  in  organic 
combination,  and  that  it  would  appear  highly  probable  that 
similar  organic  compounds  of  antimony  could  be  produced 
combining  equal  therapeutic  effects  with  diminished  toxicity. 
As  no  further  allusion  to  any  such  substance  was  made  either 
by  Dr.  Taylor  or  by  Dr.  J.  B.  Christopherson  in  his  letter 
on  the  same  subject  in  the  following  issue,  it  may  interest 
your  readers  to  know  that  Dr.  G.  Caronia,  editor  of 
La  Pediatria,  has  experimented  as  far  back  as  1916  with 
preparations  of  antimony  as  injections  in  external  kala-azar 
and  leishmaniasis.  He  gave  the  preference  to  acetyl-p- 
aminophenyl,  stibiate  of  sodium,  on  account  of  its  greater 
efficacy,  easy  absorption,  and  less  toxicity.  It  is  freely 
soluble  in  distilled  water  and  contains  38  5 per  cent,  of 
antimony,  and  may  be  given  in  doses  up  to  20  eg. 

I am,  Sir,  yours  faithfully, 

T.  Vincent  Dickinson. 

Cadogan  Mansions,  S.W.,  Sept.  2nd,  1919. 

EARLY  MENTAL  HOMES. 

To  the  Editor  of  The  Lancet. 

Sir, — It  was  recently  stated,  in  answer  to  a question  in 
the  House  of  Commons,  that  the  provision  of  convalescent 
homes  for  early  uncertifiable  mental  cases  (without  detention 
and  on  a purely  hospital  basis)  would  come  under  the 
province  of  the  new  health  authority.  It  is  admitted  that 
such  homes  would  be  a great  bcon  in  intercepting  cases 
(especially  those  occurring  among  ex- soldiers)  who  would 
otherwise  be  relegated  to  asylums.  The  Lunacy  Board, 
according  to  its  annual  reports,  has  long  desired  the  institu- 
tion of  “ reception  houses  ” under  its  wing  where  early  cases 
could  be  detained,  say  for  six  months,  without  certification — 
i.e.,  without  any  judicial  investigation  or  appeal.  A Bill 
with  this  object,  entitled  the  “Mental  Treatment  Bill  ” was 
introduced  by  the  Home  Office  in  1915,  but  had  to  be 
withdrawn,  the  House  of  Commons  regarding  it  as  an 
annulling  of  the  safeguards  of  the  Lunacy  Act  and  an 
infringement  of  the  rights  of  the  individual.  From  recent 
indications  it  appears  that  a similar  Bill  is  now  again  in 
contemplation.  The  Lunacy  Board  has,  however,  no  juris- 
diction over  uncertified  and  uncertifiable  persons  ; and  in 
order  that  cases  in  the  very  early  and  most  curable  stages 
should  be  induced  to  enter  these  homes  voluntarily  (as  they 
would  enter  a hospital),  it  is  essential  that  the  homes  should 
have  no  connexion  with  lunacy,  else  they  will  be  regarded 
as  “ half-way-houses”  to  asylums,  and  shunned  by  the  very 
people  for  whom  they  are  intended.  Public  money,  if  sunk 
in  such  homes,  will  be  for  the  most  part  entirely  wasted. 

It  is  a mistake  to  think  that  legislation  is  needed  for  the 
provision  of  sanatoria  which  do  not  involve  detention.  The 
Public  Health  Act,  1875,  has  already  conferred  on  borough 


councils  the  power  to  run  hospitals,  and  similar  powers 
could  be  readily  extended  to  the  London  County  Council 
and  county  councils  generally.  The  cheering  and  hopeful 
atmosphere  produced  by  the  fact  that  the  terms,  both  of 
admission  and  of  stay,  are  voluntary , is  in  itself  a most 
important  factor  in  recovery.  It  is  not  the  existence  of 
legal  safeguards  whioh  creates  “stigma,”  but  the  fact  of 
being  subjected  to  detention.  It  is  in  the  interest  of  the 
public  that  every  case  in  which  restraint  is  applied  should 
be  carefully  investigated  under  judicial  procedure,  and  the 
salutary  provision  contained  in  Section  315  of  the  Lunacy 
Act  ought  to  be  strengthened  and  not  annulled.  On  the 
other  hand,  every  case  proved  to  be  “dangerous  and  unfit 
to  be  at  large,”  ought  to  be  certified,  and  no  trivial  and 
uncertifiable  case  ought  to  be  subjected  by  any  underhand 
method  to  detention. 

I am,  Sir,  yours  faithfully, 

S.  E.  White,  M.B.,  B.Sc. 

Upper  Montagu-street,  W.,  August  21st,  1919. 


THE  .ETIOLOGY  OF  INFLUENZA. 

To  the  Editor  of  The  Lancet. 

Sir,— Captain  G.  E.  Beaumont  in  his  paper  on  this 
subject  in  The  Lancet  of  August  9th  records  that 
examination  of  material  from  influenza  patients  has  shown 
the  presence  of  a “mycotic  organism.”  I do  not  wish  to 
comment  on  his  results  beyond  saying  that  there  must  be 
rigid  proof  before  one  can  accept  “ hyphae,  large  spores, 
coccal  clusters,  small  spores,  tetrads,  mulberry  masses, 
chains  of  cocci,  bacilli  ” as  pleomorphs  of  the  same 
organism.  My  object  in  writing  is  to  point  out  how 
inadequate  from  the  point  of  view  of  a systematist  are 
the  figures  of  fungi  usually  appearing  in  medical  litera- 
ture. In  the  present  instance  it  is  impossible  from  the 
diagram  to  hazard  a guess  as  to  the  fungal  genus  in  which 
the  hyphal  stage  of  the  organism  would  normally  be  placed. 
The  manner  in  which  the  spores  are  borne  is  the  important 
point  in  classification,  and  this  should  be  clearly  shown  in 
any  figures.  This  can  rarely  be  made  out  in  film  prepara- 
tions, but  is  best  studied  by  mounting  the  fungus  in  absolute 
alcohol ; the  preparation  may  be  made  more  permanent  by 
running  in  dilute  glycerine  and  “ringing”  after  a week 
or  so.  I am,  Sir,  yours  faithfully, 

J.  Ramsbottom. 

British  Museum  (Natural  History),  August  26th,  1919. 


THE  RESULTS  OF  COMPLETE  COLECTOMY. 

To  the  Editor  of  The  Lancet. 

Sir, — In  your  issue  of  August  9th  there  is  a letter  from 
Mr.  J.  F.  Dobson,  of  Leeds,  in  reference  to  a paper  of  mine 
on  colectomy,  in  which  he  says  that  the  operation  of  com- 
plete colectomy  will  remain  under  a cloud  as  long  as  those 
surgeons  who  perform  it  are  content  to  support  their  views 
by  the  publication  of  their  cases  in  an  imperfect  manner. 
Mr.  Dobson’s  criticism  is,  up  to  a certain  point,  merited,  in 
that  very  few  details  of  the  after-histories  of  my  cases  were 
appended,  but  the  implication  that  discredit  must,  as  a con- 
sequence, fall  upon  the  operation  because  such  histories 
were  unknown  or  unfavourable,  cannot  pass  without  com- 
ment. At  the  time  of  writing  I was  perfectly  well  aware 
that  the  condition  of  the  patients  to  whom  I referred 
was  satisfactory,  but  I had  not  sufficient  recent  detail  to 
make  it  worth  while  to  do  more  than  indicate  in  a general 
way  that  the  results  of  the  operation  were  good.  Perhaps  I 
took  for  granted  in  my  realisation  of  this  fact  that  critics 
would  accept  it  as  a matter  of  course.  Since  Mr.  Dobson’s 
letter  appeared  I have  communicated  with  my  patients 
again,  and  I hope  that  he  will  agree  that  the  details  supplied 
now  bear  out  the  general  statement  made  in  the  paper. 

Mr.  Dobson  mentions  specially  the  after- progress  of 
Cases  1 and  2.  In  a letter  I have  just  received  from  Case  1 
are  these  remarks:  “ I am  in  good  general  health  ; I get 
no  pain  after  eating,  as  before  the  operation.  I believe  the 
operation  to  be  a great  success.”  He  goes  on  to  say  that  he 
is  employed  in  one  of  the  shipping  lines  in  Liverpool. 
Nearly  two  years  have  elapsed  since  I operated  on  him. 
Case  2 writes  that  he  was  playing  football  ten  weeks  after 
the  operation,  and  that  he  has  had  no  trouble  with  his  bowels, 
although  they  move  three  times  a day.  This  colectomy  was 
done  six  months  ago.  Mr.  Dobson  finally  deplores  the 
absence  of  “a  full  description  of  the  diseased  condition  of 


458  Thk  Lancet,]  THE  ORIGIN  OF  LIFE:  THE  WORK  OF  THE  LATE  CHARLTON  BASTIAN.  [Sept.  6,  1919 


the  rectum  held  responsible  for  the  imperfect  recovery  of 
Case  3.”  But  surely  if  a patient  has  ulcerative  colitis  of 
such  severity  as  to  endanger  his  life — as  stated  in  my  paper 
— and,  if,  after  removal  of  the  colon,  he  still  for  a time 
continues  to  pass  mucus  and  blood  in  his  stools,  it  is  fair  to 
conclude  (without  submitting  the  patient  to  another 
anarsthetic  for  sigmoidoscopy)  that  the  persistence  of  some 
of  the  symptoms  is  explained  by  the  presence  of  ulcers  in 
the  only  remaining  portion  of  the  large  bowel.  This 
inference  is  supported  by  the  statement  made  in  the  descrip- 
tion of  the  case  that  the  symptoms  improved  under  rectal 
lavage  and  vaccine  treatment.  This  patient  has  just  written 
that  he  has  improved  very  much  since  leaving  hospital  six 
months  ago. 

It  is  only  fair  to  add  that  since  my  paper  was  written  I 
have  been  asked  to  see  Case  4 again,  and  have  found  that 
after  18  months  of  perfect  health  she  had  been  taken  ill  with 
headache  and  vomiting.  I discovered  a nodular  enlarge- 
ment of  her  liver,  and  evidence  of  a metastatic  growth  at 
the  base  of  her  skull.  Still,  I think  it  is  surprising  that  she 
remained  well  so  long  after  the  removal  of  such  an  advanced 
cancer  of  the  bowel,  and  I do  not  think  that  anyone  could 
regard  her  present  condition  as  in  any  way  attributable  to 
the  removal  of  her  colon. 

I am  fully  cognisant  of  the  severity  of  the  operation,  and 
agree  that  it  should  be  undertaken  only  to  relieve  a very 
serious  condition.  But  I feel  quite  certain  that  there  are 
many  people  whose  suffering  can  be  relieved  in  no  other 
way,  and  I wrote  the  paper  with  the  object  of  showing  that 
it  was  possible  for  the  operation  to  be  performed  with  a 
moderate  degree  of  safety  even  by  such  a tyro  as  myself. 

I am,  Sir,  yours  faithfully, 

James  Taylor, 

Aldershot,  August  26th,  1919.  Major,  R.A.M.C. 


THE  ORIGIN  OF  LIFE:  THE  WORK  OF  THE 
LATE  CHARLTON  BASTIAN. 

To  the  Editor  of  The  Lancet. 

Sir, — In  your  issue  of  August  16th  Commander  W.  Bastian, 
R.N.,  now  objects  to  the  tubes  used  in  my  experiments. 
I have  stated  that  “the  tubes  employed  were  the  same  as 
those  used  by  Dr.  Bastian,”1 *  but  as  this  seems  insufficient  I 
have  written  to  the  makers,  hence  the  delay.  They  reply  : 
“The  tubes  were  made  no  doubt  from  soft  German  glass 
tubing,  in  every  way  the  same  as  those  supplied  to  Dr. 
Bastian.”  (August  20th,  1919.)  Evidently  Commander 
Bastian  was  misled  by  the  word  “ hard,”  which  was  only 
used  relatively,  not  as  equivalent  to  Jena  glass. 

Commander  Bastian  seems  still  doubtful  whether  the 
experiments  are  not  invalidated  because  some  of  the  tubes 
were  kept  three  years.  I have  explained  that  samples  were 
opened  about  every  three  months,  but  that  Professor  Hopkins 
considered  it  unnecessary  to  give  details  about  the  whole 
100  tubes.  As  a matter  of  fact,  I fail  to  see  why  all  the 
organisms  must  be  dead  in  three  years.  Because  if  the  con- 
ditions were  ever  such  as  to  produce  life,  there  is  no  reason 
for  the  conditions  to  change;  and  “organisms”  would  be 
continually  coming  into  being  and  dying.  Since  the  mass  of 
the  “ organisms  ” is  infinitely  small  compared  with  that  of 
the  salts,  “ live  organisms"  should  be  found  after  any  length 
of  time,  however  short-lived  they  might  be,  because  the 
process  of  formation  would  continue  until  the  salts  were 
exhausted,  or  until  some  harmful  end-product  had  been 
elaborated.  Dr.  Bastian  himself  uses  this  form  of  argument 
to  prove  that  abiogenesis  is  still  taking  place.  “ Relying  on 
the  uniformity  of  natural  phenomena,  we  have  a right  to 

believe  that  the  processes  which  originally  led  to  the 

growth  of  living  matter  would  constantly  tend  to  be  repro- 
duced.”3 I should  like  to  add,  the  object  of  my  experi- 
ments was  to  test  whether  I could  repeat  Dr.  Bastian's 
results.  Therefore  all  possible  precautions  were  taken  to 
reproduce  his  conditions,  by  the  use  of  the  same  samples,  the 
same  tubes,  and  the  same  laborious  method  of  sterilisation. 
I am  fully  aware  of  the  difficulty  of  proving  a negative, 
therefore,  though  others  as  well  as  myself  have  had  negative 
results,  I agree  with  Commander  Bastian  in  hoping  he  may 
have  the  satisfaction  of  seeing  the  work  repeated.  The 
positive  results  of  one  man  can  only  be  disproved  by  the 

1 Pri’c.  Roy.  Soe.,  vol  xc.,  p.  266. 

s “ Origin  of  Life  " p.  7. 


general  consensus  of  opinion  derived  from  a number  of 
negative  results — as  in  the  case  of  the  well-known  N-rays, 
which  have  been  relegated  to  the  category  of  faulty 
observation.  I am.  Sir,  yours  faithfully. 

The  Biochemical  Laboratory.  Cambridge,  H.  ONSLOW. 

August  22nd,  1919. 


LIFE  INSURANCE  AND  WAR  DISABILITIES. 

To  the  Editor  of  The  Lancet. 

Sir, — There  are  many  questions  in  life  insurance  connected 
with  injuries  and  ailments  incurred  during  active  service  on 
which  data  are  required.  As  far  as  mechanical  injuries  go 
there  is  probably  nothing  very  novel.  Limbs  have  been  lost 
and  injuries  by  bullets  sustained  by  so  many  in  previous 
centuries  that  a fairly  clear  actuarial  estimate  can  be  made 
of  their  bearing  on  longevity.  More  pressing  questions  are, 
among  others,  these  : — 

1.  Gassing. — So  far  as  I have  seen  at  present  a man  who 
has  been  badly  gassed  exhibits  objective  signs  in  his  lungs. 

Is  he  going  to  be  more  liable  to  bronchitis,  pneumonia,  &c.‘? 

2.  Trench  nephritis. — Is  this  permanent  in  a majority  or 
minority  of  cases?  and  what  is  the  ultimate  condition 
when  the  albuminuria  does  not  clear  up  ? 

3.  Shell  shock. — Admitting  the  vagueness  of  the  term,  one 
would  wish  to  know  how  far  the  nervous  stability  of  the 
individual  is  likely  to  be  affected  and  whether  there  is  any 
connexion  between  the  severity  of  the  original  condition  and 
the  probable  sequelae. 

4.  V.D.H.  and  D.A.1I. — Of  all  the  unfortunate  legacies 
left  us  by  the  war  I fear  that  few  will  lead,  or  have  led,  to 
more  pitiable  distress  in  the  uneducated  or  even  the  educated 
soldier.  Thousands  of  men  are  leading  valetudinarian  lives 
and  causing  untold  anxiety  to  their  dependants  and  friends 
because  at  some  time  their  hearts  responded  naturally  to  an 
unaccustomed  call  upon  their  reserves.  Once  a man  has  been 
told,  “ There  is  something  wrong  with  your  heart,”  it  makes 
him  in  nine  cases  out  of  ten  a derelict  member  of  society.  < 
In  ninety-nine  cases  out  of  a hundred  there  is  nothing  wrong,  : 
and  in  the  other  case  usually  nothing  that  matters.  An 
examination  of  all  these  cases  by  competent  cardiologists  1 
would  probably  save  tens  of  thousands  of  pounds  and  give 
back  to  thousands  peace  of  mind  and  desire  to  work.  It 
might  do  the  latter  and  it  might  not.  Personally,  I have 
seen  few  cases  in  which  the  individual  libelled  with  one  of 
the  two  tags  could  not  lead  a normal  life,  and  none  that 
believed  me.  What  is  the  best  empirical  test  for  gauging 
cardiac  muscle  condition? 

Other  ailments  will  suggest  themselves,  but  those  I have 
mentioned  are  perhaps  the  commonest.  On  the  three  first  ; j 
any  data  would  be  most  rvelcome  to  those  engaged  in  trying  < 
to  foretell  the  future  of  the  individual. 

I am,  Sir,  yours  faithfully, 

Birchin-lane,  E.C.,  August  26th,  1919.  C.  WYNN  WlRGMAN.  I 

CRYPTOPODIA. 

To  the  Editor  of  The  Lancet. 

Sir, — The  condition  described  by  Dr.  E.  C.  Bousfield  under  [ 
the  name  “ cryptopodia  ” in  The  Lancet  of  August  23  d is 
of  some  interest,  but  I doubt  if  it  should  be  described  as  a 
new  disease,  or  even  as  a disease.  Au  oedematous  swelling 
of  the  feet,  and  sometimes  of  the  legs,  is  not  very  unusual 
in  the  infective  type  of  rheumatoid  arthritis  ; in  patients 
who  sit  for  long  hours  with  their  legs  in  a dependent  positbn 
this  oedema  may  become  marked  and  resemble  that  seen  in 
elephantiasis.  This  swelling  usually  subsides  gradually  if 
the  limbs  are  kept  in  a horizontal  position,  and  more  quickly  | 
if  massage  is  ordered. 

Dr.  Bousfield’s  patient  seems  to  show  this  oedema  in  an 
exceptionally  severe  form  ; it  is,  of  course,  possible  that  in 
his  case  the  condition  is  due  to  some  other  cause,  but  as  he 
states  the  patient  suffers  from  rheumatiod  arthritis  and  does 
not  discuss  the  above  type  of  oedema  in  his  diffe-ential 
diagnosis,  may  1 point  out  the  possibility  of  this  being  a 
simple  explanation  of  the  change. 

I am,  Sir,  yours  faithfully, 

T.  S.  P.  Stbangeways. 

Research  Hospital,  Cambridge,  August  27th,  1919. 

To  the  Editor  of  The  Lancet. 

Sir, — When  Dr.  E.  C.  Bousfield  demonstrated  the  above- 
named  remarkable  case  at  the  recent  meeting  in  Loudon 
(July,  1919)  of  the  Association  of  Physicians  of  Great 
Britain  and  Ireland,  I had  the  good  fortune  to  be  present, 


Thb  Lanoet,] 


THE  TREATMENT  OF  “BORDER-LINE”  PENSIONERS. 


[Sept.  6,  1919  459 


though  his  illustrated  description  in  The  Lancet  of 
August  23rd  gives  one  an  almost  equally  exact  idea  of  the 
condition.  I venture  to  suggest  that  it  represents  an  extreme 
form  of  the  class  of  cases  which  I have  referred  to  under  the 
heading, Baggy  Subcutaneous  Fat  Simulating  Symmetrical 
(Edema  of  the  Legs  ; Disorder  of  Internal  Secretions.”  An 
outline  drawing  by  Mr.  Shiells  illustrates  the  account  of  the 
case,  which  I showed  at  the  Clinical  Section  of  the  Royal 
Society  of  Medicine  on  March  14th,  1913  (Proceedings,  1912- 
1913,  vol.  vi.,  p.  167)  I should  have  spoken  of  “baggy 
subcutaneous  tissue”  rather  than  of  “baggy  subcutaneous 
fat.”  In  my  description  I said  : “ There  is  chronic  swelling 
of  the  subcutaneous  tissue  of  the  legs  below  the  knees  of  one 
or  two  years’  duration.  This  is  symmetrical,  and  in  both 
legs  tends  to  lag  above  the  ankles.  It  either  does  not  pit  at 
all,  or  it  (sometimes)  pits  slightly  on  pressure.”  The  patient 
in  question  was  a woman,  aged  40  years,  in  whom  menstrua- 
tion had  ceased  six  years  previously.  The  thyroid  gland 
could  not  be  distinctly  seen  or  felt.  Unfortunately  an  only 
very  imperfect  trial  of  thyroid  treatment  was  made.  There 
can  be  no  doubt  that  in  similar  cases  obvious  symptoms  of 
thyroidal  disorder  are  sometimes  present. 

I am.  Sir,  yours  faithfully, 

F.  Parkes  Weber,  M.D.,  F.R.C.P. 

London,  W.,  August  23rd.  1919. 

THE  TREATMENT  OF  “BORDER-LINE” 
PENSIONERS. 

To  the  Editor  of  The  Lancet. 

Sir, — The  question  and  answer  reported  in  your  Parlia- 
mentary page  1 regarding  the  treatment  and  accommodation 
of  neurasthenic  and  “ shell  shock  ” pensioners  on  the  border- 
line of  lunacy  call  attention  to  a defect  in  the  present 
administration  which  many  of  us  engaged  in  this  work  have 
constantly  brought  before  us.  A serving  soldier  in  a 
neurological  hospital  can,  if  necessity  arises,  be  transferred 
quietly  and  without  publicity  to  an  asylum,  where  he  is  not 
certified  until  ample  time  has  elapsed  to  make  it  evident 
that  there  is  no  alternative.  What  happens  to  the  un- 
fortunate discharged  soldier  who  is  similarly  situated  1 
Before  he  can  be  admitted  to  an  asylum  he  must  be  certified 
and  be  removed  by  the  Poor-law  authorities — i.e.,  as  a 
pauper.  It  is  true  that  once  admitted  he  is  transferred  to 
the  ‘ 1 Service  patient  ” side,  but  why  should  he  not  be  treated 
similarly  to  the  serving  soldier,  thus  avoiding  the  stigma  of 
certification  and  pauperism. 

Medical  officers  of  neurological  hospitals  are  often 
reluctantly  compelled  to  refuse  cases  such  as  these,  which 
might  benefit  considerably  by  treatment,  owing  to  the 
unavoidable  delay,  publicity,  and  detrimental  effect  on  the 
other  patients  which  ensue  if  it  should  become  necessary  to 
send  them  to  an  asylum  through  the  present  Poor-law 
channels.  Moreover,  a man  may  require  closer  control  than 
the  average  neurological  hospital  can  provide  without  being 
certifiable.  I am,  Sir,  yours  faithfully, 

August  23rd,  1919.  X. 

THE  POSITION  AND  PAYMENT  OF  THE 
PENSIONS  BOARDS. 

To  the  Editor  of  The  Lancet. 

Sir, — I have  noticed  several  letters  in  The  Lancet  com- 
plaining about  the  insufficiency  of  the  rate  of  pay  given  to 
the  members  of  Pension  Boards.  I agree  that  the  pay 
is  quite  insufficient  to  attract  capable  men,  but  there  is  a 
worse  grievance  than  the  pay,  and  that  is  the  conditions 
of  work.  I am  speaking  of  the  boards  at  Westminster,  in 
Clock  Tower  Gardens.  Until  a few  days  ago  we  had  a 
36 

long  form,  either  179  A or  A — ^ to  fill  in  in  duplicate , when 

the  second  copy  could  well  have  been  made  by  a clerk  ; and 
the  chairman  had  to  sign  his  name  an  average  of  eight  times 
in  each  case  examined,  the  members  not  quite  so  often. 
This  was  bad  enough,  but  within  the  last  few  days  the 
card  index  system  has  been  introduced,  and  two  cards  and 
one  long  form  are  now  used  in  each  case.  These  cards 
contain  a resume  of  the  pensioner’s  medical  history,  and 
precis  of  all  previous  medical  boards.  No  doubt  they  will 
be  very  useful,  but  they  should  be  filled  up  in  a quiet 
room  by  a capable  medical  man  some  time  after  the 

1 The  Lancet,  August  23rd,  p.  353. 


board.  While  the  chairman  is  making  out  this  card 
one  of  the  members  is  either  making  out  a duplicate, 
or  is  filling  up  the  long  form,  thus  leaving  the  third 
member  free  to  do  the  examination  of  the  pensioner. 
He  is  hampered  greatly  in  this  work  because  the  chairman, 
in  order  to  fill  up  his  card  correctly,  must  keep  the  docu- 
ments— M.H.S.,  & c. — under  his  eye,  so  that  the  examining 
doctor  has  nothing  to  guide  him  in  the  search  for  a disability. 
La'er  on,  the  card  having  been  filled,  the  documents  are 
released,  and  may  be  consulted,  but  much  valuable  time  has 
been  lost,  and  the  examination  is  necessarily  not  so  complete 
as  if  engaged  in  by  two  or  by  all  of  the  members  of  the 
board. 

Before  this  card  system  was  introduced  each  board  exa- 
mined about  9 cases  ; now  under  the  card  system  only  5 or  6 
can  be  examined  during  a session,  and  even  then  not 
examined  so  carefully  as  before.  The  expense  is  great  and 
the  waste  of  public  money  is  to  be  deplored  when  one  con- 
siders that  there  are  three  members  of  each  board,  with 
supervising  officers  and  clerks,  orderlies,  &c.,  to  be  paid  for. 

I am.  Sir,  yours  faithfully, 

August  20th,  1919.  MEMBER  OF  PENSION  BOARD. 


To  the  Editor  of  The  Lanoet. 

Sir, — I read  “MedicoV’  letter  in  your  issue  of  August  16th 
on  the  status  of  members  of  pensions  boards  with  great  interest. 
Our  fees  are  certainly  inadequate,  but  he  has  omitted  to 
state  that  these  are  always  several  weeks  in  arrears.  We 
were  kept  waiting  till  July  23rd  for  our  June  fees.  Thus  we 
were  seven  weeks  without  any  pay.  We  have  not  yet 
received  any  pay  for  the  month  of  July,  although  it  is,  when 
I write,  approaching  the  close  of  the  month.  We  feel  strongly 
on  this  point.  Payment  should  be  made  when  it  is  due. 

I am,  Sir,  yours  faithfully, 

August  20th,  1919.  DEMOBILISED  MEDICO. 


THE  MARRIAGE  OF  ASSISTANT  MEDICAL 
OFFICERS  AT  ASYLUMS. 

To  the  Editor  of  The  Lancet. 

Sir, — I hope  that  the  letter  of  “ Dismissed  ” in  your  issue 
of  August  9th  will  not  pass  without  proper  notice.  Such 
injustice  cannot  be  too  strongly  condemned.  At  a time 
when  we  have  just  concluded  a war  for  freedom  and 
justice  to  think  of  this  instance  of  man’s  inhumanity  to 
man  and  to  his  rights  as  a citizen  makes  one  rise  in  anger 
and  protest.  What  possible  harm  could  be  done  by 
retaining  a married  man,  especially  as  this  officer  was 
actually  willing  to  allow  his  wife  to  live  away  from  his 
professional  residence,  so  that  his  position  might  not  be 
lost  ? Surely  the  Commissioners  of  the  Board  of  Control 
should  take  action  in  this  matter  and  see  who  is  to  blame — 
the  committee  or  medical  superintendent. 

A spirit  of  antagonism  against  one’s  employers  is  to  be 
deprecated,  but  it  is  not  to  be  wondered  that  organisations 
are  made  to  defend  the  victims  of  such  lack  of  consideration 
and  unjust  treatment.  The  Association  of  Assistant  Medical 
Officers  might  now  be  revived  seeing  that  A.M.O.’s  are  back 
at  their  old  work.  The  advantages  of  being  married  in  the 
case  of  medical  officers  of  asylums,  who  have  to  live  among 
special  environments  and  temptations,  are  so  apparent  that 
no  further  observations  on  the  matter  are  necessary. 

I am  Sir,  yours  faithfully, 

August  20th,  1919.  A MARRIED  A.M.O. 


BOOKS,  ETC.,  RECEIVED. 

Adlard  and  Son,  London. 

Hunterian  Oration  on  British  Military  Surgery  in  the  Time  of 
Hunter  and  in  the  Great  War.  By  Sir  Anthony  Bowlby,  Tempo- 
rary Major-General,  A.M.S.  Pp.  48. 

Aleany  Press,  Bromley-place,  Fitzroy-square,  W. 

Lectures  on  Venereat  Diseases.  By  L.  Myer,  F.R.C.S.  Pp.  88. 
6s.  post  free. 

Macmillan  (The)  Co.,  New  York. 

Elements  of  Pediatrics  for  Medical  Students.  Bv  R.  G.  Freeman 
M.D.  Pp.  290.  10s.  6 d. 

Murray,  John,  London. 

Through  a Tent  Door.  By  R.  W.  Mackenna,  M.D.,  R.A.M.C. 
Pp.  310.  8s. 

Unwin,  T.  Fisher,  London. 

The  Religion  of  a Doctor.  By  T.  Bodley  Scott.  Pp.  98.  5s. 
Bov-Work:  Exploitation  or  Training.  Bv  Rev.  S.  J Gibb 

Pp.  223.  8s.  64. 

Wright,  John,  Bristol. 

National  Health.  By  F.  Rees,  M.D.  Pp.  68.  Is.  64. 


460  The  Lancet,] 


OBITUARY. 


[Sept.  6,  1919 


CHARLES  ARTHUR  MERCIER,  M.D.,  F.R.C.P.  Lond., 
F.R.C.S.  Eng., 

CONSULTING  PHYSICIAN  FOB  MENTAL  DISEASES,  CHARING  CROSS 
H08PITAL  ; LATE  PRESIDENT  OF  THE  MEDICO-PSYCHOLOGICAL 
ASSOCIATION. 

With  the  death  of  Charles  Mercier  at  Bournemouth,  in 
his  sixty-seventh  year,  medicine  has  lost  one  of  its  ablest 
dialecticians,  whose  erudition,  wisdom,  and  humour  enabled 
him  to  make  valuable  contributions  in  that  dim  borderland 
where  psychology  and  insanity  meet. 

Charles  Arthur  Mercier  was  born  in  1852,  the  son  of  the 
Rev.  L.  P.  Mercier,  and  was  educated  at  Merchant  Taylors 
School.  His  family  was  left  in  poor  circumstances  on  the 
death  of  his  father,  and  he  became  a cabin  boy,  in  which 
capacity  he  sailed  to  Mogador,  and  later  a clerk  in  a ware- 
houseman’s office  in  the  City  of  London.  At  this  time, 
fortunately,  he  became  in  a position  to  follow  his  natural 
bent  and  study  medicine.  He  joined  the  London  Hospital 
Medical  School,  and  from  that  school  took  the  M.R.C.S.  in 
1874,  the  L.S.A.  in  1877,  and  the  M.B.  Lond.  in  1878. 
To  these  primary  diplomas  he  subsequently  added  the 
higher  medical  and  surgical  distinctions,  taking  the 
F.R.C.S.  Eng.  in  1878,  being  elected  F.R.C.P.  Lond.  in  1904, 
and  being  awarded  the  M.  D.  Lond. , with  gold  medal  in  mental 
science,  in  1905.  At  the  London  Hospital  he  fell  under  the 
influence  of  that  master  of  scientific  medicine,  Hughlings 
Jackson,  whose  keen  and  intensive  studies  in  neurology 
formed  the  starting  point  of  his  pupil’s  interest  in  the  subject 
of  psychology  in  a wide  sense.  At  first  a close  student  of 
Herbert  Spencer,  Mercier  subsequently  struck  out  a direction  of 
his  own,  based  on  his  personal  work.  He  held  posts  of  medical 
officer  in  two  large  public  asylums,  the  Buckingham- 
shire County  Asylum  at  Stone  and  the  City  of  London 
Asylum,  and  after  relinquishing  these  appointments  he 
became  for  the  greater  part  of  his  life  resident  physician 
at  a private  asylum.  He  made  full  use  of  his  opportunities 
for  a close  study  of  lunacy,  and  from  his  personal  daily  work 
he  evolved  a philosophy  of  life,  which  he  exposed  with 
frankness  and  defended  with  tenacity.  What  proportion 
of  the  world  Mercier  considered  to  be  a little  mad  it 
would  be  hard  to  say,  but  he  was  a very  genuine 
friend  to  the  insane.  It  was  largely  owing  to  his 
unceasing  zeal  that  a Bill  was  introduced  several  times 
in  Parliament  to  legalise  the  treatment  of  insanity  in 
its  early  stages,  and  it  is  regrettable  that  he  did  not 
live  to  see  what  can  hardly  fail  to  be  the  full  fruition  of 
his  and  others’  labours  in  the  near  future.  The  legal  stand- 
ing of  the  lunatic  was  his  particular  care,  and  he  was  a 
valuable  member  of  the  Medico-Legal  Society,  where  his 
early  contributions  were  of  a highly  interesting  nature. 
Some  of  our  readers  may  recall  the  discussion  of  a problem 
arising  out  of  a paper  by  Mercier,  and  illustrated  by  a 
case  tried  at  Stafford.  It  came  out  in  that  debate  that  the 
law  had  overlooked  the  possibility  that  a sane  person  might 
be  prevented,  by  deafness  and  inability  to  read,  from  under- 
standing the  proceedings  in  a court  of  law.  Mercier’s  equal 
facility  on  the  medical  and  legal  side  of  mental  disease  long 
served  the  Medico-Legal  Society  in  good  stead,  while  he 
himself  thoroughly  enjoyed  his  forensic  excursions. 

As  a writer  Mercier’s  genius  found  its  particular  expression. 
From  his  first  contribution  on  a Classification  of  Feelings 
in  Mind  (1884)  to  his  last  work  on  “Crime  and  Criminals” 
(1918)  he  never  wrote  a slovenly  sentence  and  never  spared 
himself  the  most  assiduous  effort  to  make  his  meaning  clear 
and  precise  to  his  readers.  His  “Text-book  on  Insanity,” 
appearing  in  1902,  was  the  first  comprehensive  view  of 
insanity  in  its  practical  aspects.  Within  a moderate  compass, 
available  to  the  student  and  practitioner  of  medicine,  his 
logical  mind  delineated  forms  and  varieties  of  insanity  as 
types,  with  illustrative  examples  culled  from  his  own  abundant 
clinical  experience.  It  speaks  much  for  his  mental  fertility 
that  this  text-book  appeared  almost  at  the  same  time  as  his 
work  on  • ‘ Psychology,  Normal  and  Morbid,”  which  was  largely 
responsible  for  making  his  name  known  as  a writer  in  wider 
circles  of  philosophy.  In  this  book  he  approached  psychology 
from  the  subjective  side,  treating  morbid  conditions  in  the 
light  of  normal  conditions  working  inharmoniously.and  making 
no  attempt  to  connect  the  manifestations  of  mental  alienation 
with  definite  morbid  lesions  of  the  brain.  The  close  and 


accurate  reasoning  and  the  facility  in  the  statement  of 
abstract  propositions  which  characterised  all  his  later  work 
were  present  here.  In  his  last  book  Mercier  turned  again, 
as  was  his  wont,  to  first  principles.  He  proposed  to  discover 
the  foundations  upon  which  criminal  law  rests,  so  as  to  deter- 
mine in  what  directions  improvement  was  possible.  His 
chapters  on  the  prevention,  detection,  and  punishment  of 
crime  are  of  great  general  interest,  and  his  definition  of 
crime  as  “due  to  temptation  or  opportunity,  the  environ- 
mental factor  of  stress,  acting  upon  the  predisposition  of 
the  offender,  the  inherent  or  constitutional  factor,”  is 
a convincing  example  of  Mercier’s  clearness  of  thought 
and  absence  of  acquired  prejudice.  This  able,  useful, 
and  original  book  earned  for  him  for  the  second  time  in 
succession  the  Swiney  prize.  He  also  wrote  a book  on  logic, 
which  failed  to  find  acceptance. 

Mercier  revelled  in  argument,  and  for  a time  he  may  be 
better  remembered  as  a dialectician  than  as  a fine  writer  and 
a constructive  sociologist.  But  the  fame  of  dialectics  is 
transitory,  and,  good  controversialist  as  Mercier  was,  he 
certainly  sacrificed  points  to  a desire  to  score,  and  he 
allowed  his  wit  to  run  away  with  his  judgment.  Often  his 
nimbleness  of  brain  led  him  beyond  the  position  which  could 
be  taken  up  by  strict  logic.  He  had  for  many  years  been  a 
serious  invalid,  and  at  no  time  lately  would  his  death  have 
caused  any  surprise.  We  have  lost  in  Mercier  one  of  the  most 
sheerly  clever  men  who  ever  adorned  the  ranks  of  medicine. 
And  behind  the  cleverness  lay  a mass  of  solid  learning. 


WILLIAM  ANGUS,  M.D.  ABERD.,  D.P.H., 

MEDICAL  OFFICER  OF  HEALTH  FOR  THE  CITY  OF  LEEDS. 

The  untimely  death  of  Dr.  William  Angus,  M.O.H.  for 
the  city  of  Leeds  and  professor  of  public  health  in  the 
University,  cuts  short  a career  of  great  promise. 

William  Angus  was  born  in  Aberdeen  in  1884,  and  was  a 
student  there  as  well  as  at  University  College,  London.  He 
qualified  in  1909  after  obtaining  many  academic  honours, 
including  the  Mather  scholarship  in  medicine.  For  18 
months  he  held  the  position  of  senior  assistant  medical 
superintendent  at  St.  Pancras  Infirmary,  London,  and  in 
January,  1911,  began  his  public  health  work  proper,  being 
in  succession  assistant  medical  officer  of  health  for  Hertford- 
shire, for  Ipswich,  and  for  Leeds.  In  February,  1917,  he 
became  chief  health  officer  for  the  city,  and  in  June  of  the 
same  year  he  volunteered  for  active  service  with  the 
R. A. M.C.,  becoming  A. D.M.S.  (Sanitation),  with  charge  of 
the  sanitary  arrangements  in  connexion  with  the  1st  Echelon 
in  Egypt.  On  returning  to  this  country  in  February  last  he 
threw  himself  into  the  work  of  the  organisations  of  which, 
apart  from  his  official  duties,  he  had  been  a moving  spirit. 
Foremost  among  these  was  the  Maternity  and  Child  Welfare 
Scheme,  for  the  organisation  and  development  of  which  he 
was  largely  responsible.  His  efforts  won  a competitive 
shield  for  the  best  organised  “ Baby  Week  ” throughout  the 
country.  He  also  took  a keen  interest  in  the  organisation 
of  tuberculosis  relief  measures. 

One  of  his  colleagues  (J.  J.  J.)  writes  thus  of  him  : — 

“ When  Angus  came  to  Leeds  in  1913  he  came  full  of 
freshness  and  vigour.  He  had  been  an  athlete  in  his 
student  days  at  Aberdeen  University,  and  his  carriage  and 
bearing  bore  testimony  to  the  excellence  of  his  training. 
The  uprightness  of  his'body  was  an  index  of  the  uprightness 
of  his  mind.  He  was  a true  Scot— straight,  clean,  and 
honest,  conscientious  to  a fault,  firm  to  his  convictions,  and 
loyal  to  his  friends.  He  said  little,  but  what  he  did  say  he 
said  with  a directness  and  precision  which  carried  convic- 
tion ; he  had  no  time  for  superfluity  of  speech.  One  reason  j 
for  his  success  was  the  easy  way  in  which  he  could  grasp 
things  and,  when  once  within  his  grasp,  retam  them.  He 
could  sum  up  a situation  in  a trice,  and  his_  conclusions 
were  invariablv  correct.  Like  the  sons  of  the  North,  he  was 
something  of  a mystic,  a dreamer,  only  in  his  case  his 
dreams  were  not  nebnlous  but  .very  real  things.  He  was  a 
man  of  ideals,  and  his  life  and  work  in  Leeds  furnished  him 
with  scope  enough  for  their  development.  In  his  public 
life  Dr.  Angus  was  imbued  with  the  one  idea  of  serving  his 
fellow  men  faithfullv  and  leaving  the  world  and  the  city  of 
his  adoption  the  better  for  his  life's  endeavours.  For  him- 
self he  desired  nothing,  only  to  fill  the  niche  allotted  to  him 
in  the  world  and  complete  his  appointed  task  in  such  a 
manner  as  to  win  the  approbation  of  his  generation.” 

And  another  (M.  J.  S.)  adds  : — 

“ A man  of  sterling  and  transparent  honesty  and  high 
purpose,  Angus  combined  in  a remarkable  degree  the 


The  Lancet,] 


APPOINTMENTS.— VACANCIES. 


[Sept.  6,  1919  4(j[ 


qualities  of  the  idealist  and  the  man  of  action. . The 
possessor  of  great  executive  ability  and  sound  common 
sense,  he  impressed  all  with  whom  he  came  in  contact  by 
his  breadth  of  vision  and  power  of  grasping  the  essentials 
of  a situation.  He  was  a man  of  few  words,  but  those  well 
chosen,  cogent,  and»to  the  point.  His  clarity  of  expression 
is  well  exemplified  in  his  admirable  report,  just  published, 
on  malaria  in  the  Egyptian  Expeditionary  Force  during 
1918,  a document  of  high  scientific  and  historical  import- 
ance. Of  the  quality  of  Angus’s  professional  work  it  is 
impossible  to  speak  too  highly.  All  of  it  was  done  with 
energy  and  enthusiasm,  and  he  would  tackle  the  biggest  and 
most  difficult  problems  with  the  keenest  possible  zest  and 
determination.  In  the  academic  sphere,  as  professor  of 
public  health  in  the  University  of  Leeds,  he  was  equally 
successful.  He  enjoyed  to  the  full  the  confidence  of  his 
colleagues,  and  one  felt  that  in  these  days  of  change  and 
reconstruction  Angus,  the  steady,  wise,  and  clear  visioned, 
was  the  right  man  in  the  right  place." 

Personally,  William  Angus  was  a most  lovable  man  and  a 
delightful  companion,  and  his  death  leaves  a gap  in  the 
circle  of  his  friends  which  it  will  be  impossible  to  fill.  To 
his  wife  and  two  little  daughters  goes  out  at  this  time  the 
heartfelt  sympathy  of  all  their  friends. 


SKENE  KEITH,  M.B.,  F.R.C.S.  Edin. 

The  death  of  Mr.  Skene  Keith,  which  occurred  on 
August  19th  after  a week’s  illness  from  pneumonia,  follows 
closely  on  that  of  his  brother,  Dr.  George  Keith,  who  died 
last  December  from  the  same  cause.  With  little  outward 
show,  Mr.  Skene  Keith  achieved  no  small  success  as  an 
operating  gynaecologist,  and  his  death  will  be  felt  as  a loss 
over  a wide  circle.  Both  brothers  inherited  something  of 
the  diagnostic  acumen  and  manual  dexterity  of  their  father, 
Dr.  Thomas  Keith,  well  known  in  his  time  as  a pioneer  of 
ovariotomy.  Many  years  ago  Mr.  Skene  Keith  published  his 
first  hundred  cases  of  ovariotomy,  with  a mortality  of  rather 
under  3 per  cent. , and  his  results  improved  still  further  as 
time  went  on.  He  came  to  London  while  still  a young  man 
and  was  appointed  to  the  staff  of  the  Samaritan  Hospital, 
but  returned  shortly  after  to  Edinburgh  to  assist  his  father, 
until  both  came  to  London  at  a later  time.  Mr.  Keith’s 
“ Text-book  of  Abdominal  Surgery  ” (1894)and  his  “Gyneco- 
logical Operations  ” (1900),  the  former  in  collaboration  with 
his  brother,  Dr.  George  Keith,  were  his  principal  published 
works.  

THOMAS  TORKINGTON  BLEASE,  M.R.C.S.  Eng., 
L.S.A.  Lond. 

Thomas  Torkington  Blease  was  born  in  Altrincham, 
Cheshire,  on  Oct.  4th,  1835.  He  was  the  son  of  Thomas 
Blease,  L.S.A.,  who  was  born  at  Altrincham  in  1804, 
and  after  qualifying  practised  there  until  his  death  in 
1883.  Father  and  son  were  together  in  practice  for  27 
years,  then  Mr.  Thomas  Torkington  Blease  carried  on 
the  practice  for  21  years,  when  he  in  his  turn  was 
joined  by  his  only  son,  who  survives  him.  Mr.  Blease 
qualified  in  1856,  after  studying  at  the  Manchester  Royal 
Infirmary  and  the  Pine  Street  School  of  Medicine,  and 
also  in  London.  He  at  once  commenced  practice  in 
Altrincham  and  in  1858  founded  the  Altrincham  Provident 
Dispensary,  which  later  became,  and  still  continues  as, 
the  Altrincham  Provident  Dispensary  and  Hospital.  To 
this  institution,  of  the  success  of  which  he  was  justly  proud, 
he  gave  devoted  service  for  more  than  40  years.  In  May, 
1869,  he  was  appointed  medical  officer  for  the  Altrincham 
district  of  the  Bucklow  union  and  held  this  post  until 
August,  1912.  For  45  years  he  was  medical  officer  to  the 
Great  Central  Railway  Mutual  Provident  Society,  and  on  his 
retirement  in  1908  he  was  the  recipient  of  an  illuminated 
address  from  the  members.  He  also  held  numerous  appoint- 
ments with  other  friendly  societies.  He  most  thoroughly 
approved  of  the  principle  of  these  efforts  of  the  working 
classes  to  help  themselves,  and  won  the  unbounded  esteem  of 
their  members  by  the  way  in  which  he  never  spared  himself 
jn  connexion  with  such  work. 

Until  comparatively  recently  he  enjoyed  remarkably  good 
health  ; when  over  70  years  of  age  no  amount  of  night  work 
seemed  to  make  any  difference  to  his  ability  to  carry  on  as 
usual  during  the  day,  and  by  this  infinite  capacity  for  work 
he  was  able,  while  holding  all  the  above  appointments,  to 
have  for  over  60  years,  first  in  association  with  his  father, 
then  single-handed,  and  later  in  association  with  his  son,  an 
extensive  private  practice  which  alone  was  as  much  as  most 
men  could  have  done  even  for  a much  shorter  period. 


Successful  applicants  for  vacancies,  Secretaries  of  Public  Institutions, 
ana  others  possessing  information  suitable  for  this  column,  are 
invited  to  forward  to  The  Lancet  Office,  directed  to  the  Sub- 
Editor,  not  later  than  9 o’clock  on  the  Thursday  morning  of  each 
week,  such  information  lor  gratuitous  publication. 

Babnes,  H.  W , M.B.,  B.C.  Cantab.,  D.P.H.,  has  been  appointed 
Medical  Officer  of  Health  and  School  Medical  Officer  for  Yeovil 
(Somerset). 

Gunn,  W.,  M.B.,  Medical  Officer  for  the  Wadebridge(Cornwall)  District 
of  the  Bodmin  Union. 

Haycraft,  Guy  F.,  M.R.C.S.,  L.R.C.P.,  Honorary  Ophthalmic  Surgeon 
to  the  Walsall  General  Hospital. 

Langley,  George  Johnson,  B.S.,  M.D.Lond.,  Honorary  Assistant 
Physician  to  Salford  Royal  Hospital. 

Smith,  R.  Wayland,  M.B.,  Ch.B.  Edin.,  Senior  Resident  House 
Surgeon  at  the  Royal  Devon  and  Exeter  Hospital. 

Sturrock,  Alexander  Corsar,  M.A.,  M.D.  Edin.,  M.R.C.P.  Lond., 
Honorary  Physician  to  Salford  Royal  Hospital. 

Sutherland,  R.,  M.B.,  Ch.B. Viet.,  Temporary  Medical  Officer  of 
Health  for  Chard  (Somerset). 

Leicester  Royal  Infirmary:  Crosby,  T.  V.,  M.D.Lond.,  Honorary 
Physician  ; Slight,  J.  D.,  M.D.  Edin.,  and  Foster,  A.,  M.D.  Edin., 
Assistant  Physicians;  Lawson,  R.  S.,  M.B.,  Ch.B.  Edin., 
F.R.C.S.  Eng.,  Assistant  Surgeon. 

Queen  Charlotte’s  Lying-in  Hospital : Davibs,  Trevor  B.,  M.D., 
M.R.C.P.,  F.R.C.S.,  Obstetric  Surgeon  to  Out-patients  ; Dearnley, 
Grace,  M.D.,  Medical  Officer  to  the  Antenatal  Department; 
Willmore,  J.  Graham,  M.R.C.S.,  L.R.C.P.,  Pathologist  and 
Registrar 

Certifying  Surgeons  under  the  Factory  and  Workshop  Acts : Duncan, 
J.  M.,  M.B.,  Ch.B.  Aberd.  (Ascot);  Devine,  J.  A.,  M.D.  Dub. 
(Newhaven)  ; Baker,  J.  E.,  M.D.,  B.Hy.  Durh.  (Tynemouth); 
Babst,  E.,  M.B.,  B.S.  Durh.  (Wallsend-on-Tyne) ; Libbey,  E.  O., 
L.S.A.,  L.M.S.S.A.  (Scarborough) ; Payne,  R.  W.  (Lavenham). 


®raittws. 


For  further  information  refer  to  the  advertisement  columns. 

Aylesbury,  Royal  Bv,ckinghamshire  Hospital. — H.S. 

Barbados  General  Hospital.— Sen.  Res.  S.  £300. 

Battersea  General  Hospital.  Bat'ersea  Park,  S.  TV.— Res.  M.O. 
Birkenhead  Borough  Hospital.— Jun.  H.S.  £170. 

Birkenhead  Union  Infirmary.— Res.  Asst.  M.O.  £300. 

Bridgend  Urban  District  Council,  Penybont  Rural  District  Council.— 
Joint  M.O.H.  £600. 

Brighton,  Royal  Sussex  County  Hospital. — H.P.  £100. 

Bristol  Eye  Hospital.— H.S.  £150. 

Bristol  General  Hospital.— H.S. , Obstet.  O.,  and  H.S.  Also  Two  H.P.  s. 
£175. 

Burnley  Union  Workhouse.— Res.  M.O.  £400. 

Cambridge,  Addenbrooke’s  Hospital.— Hon.  Asst.  P.  and  Hon.  Asst.  S. 
Cancer  Hospital  ( Free ).  Fulham-roal,  S.  W.— Two  H.S.’s.  £150. 

Cardiff,  King  Edward  VII.’ s Hospital.— Hon.  S.  and  Hon.  Asst.  S. 
Central  London  Ophthalmic  Hospital,  Judd-street,  St.  Pancras,  W.C.— 

H.S.  £50. 

Chartham,  near  Canterbury,  Kent  County  Mental  Hospital.— Jun  Third 
Asst.  M.O.  £300. 

Chester  Royal  Infirmary.— H.P.  £150. 

Chichester,  Royal  West  Sussex  Hospital.— B.S.  £200. 

Derbyshire  Royal  Infirmary.— H.P.  £200. 

Devonport,  Royal  Albert  Hospital.— Res.  H.S.  £200. 

Dumfries,  Crichton  Royal.— Asst.  P.  £300. 

Durban,  Government  Hospital.— Asst.  M.O.  £400. 

East  Riding  Education  Authority. — Female  Asst.  Sch.  M.O.  £350. 
Finchley  Urban  District. — M.O.H.  and  Sch.  M.O.  £600 
Glamorgan  County  Asylum,  Bridgend. — Fourth  Asst.  M.O.  £400. 
Glasgow,  Ilawkhcad  Asylum,  Cardonald.—J un.  Asst.  M.O.  £275. 
Glasgow,  Scottish  Western  Asylum  Research  Institute.—  Director.  £600. 
Hackney  and  Stoke  Newington,  Metropolitan  Boroughs  <>/.— Tuberc.  O. 
£500. 

Halifax  Royal  Infirmary.— B.S.  £200. 

High,  Wood,  Brentwood,  Essex.—  Med.  Supt.  £600. 

Hudaersfield  Royal  Infirmary.— Asst.  H.S.  £100. 

Hyde  Borough.— M.O.H.  and  Female  Asst.  M.O.  £700  and  £400 
respectively. 

Italian  Hospital,  Queen-square,  W.C.— Hon.  Oph.  S. 

Leeds  Neurasthenic  Hospital  for  Pensioners.— M.O.  £400. 

Leeds  Public  Dispensary,  North-street.— Res.  M.O.  £200. 

Leicester  Royal  Infirmary.—  H .S.'s.  £250.  Also  Ear  and  Throat  Surg. 
Liverpool  Royal  Infirmary.— Hon.  Asst.  Gynaecol.  S 
Liverpool,  Royal  Southern  Hospital. — Two  H.P.’s  and  Three  H.S.’s. 
£100. 

London  County  Mental  Hospital,  Bexley,  Kent.— Temp.  Asst.  M.O.  7 gns. 
a wk. 

Maidstone,  Kent  County  Ophthalmic  Hospital.— Hon.  Oph.  S. 
Maidstone,  West  Kent  General  Hospital. — Jun.  H.S.  £150. 

Manchester  Northern  Hospital  for  Women  and  Children,  Park-place, 
Cheetham  Hill-road.— H.S.  £150. 

Manchester,  St.  Mary's  Hospitals  for  Women  and  Children.— Two  H.S.’s. 

£100. 

Melbourne  University. — Lecturer  in  Pathology.  £600. 

Metropolitan  Hospital,  Kingsland-road,  E.— H.S.,  Asst.  H.P.,  and  Asst. 
H.S.  £100. 

Newcastle-upon-Tyne,  University  of  Durham  College  of  Medicine  and 
Royal  Victoria  Infirmary  .—Jun.  Demons,  in  Path,  and  Asst,  to 
Pathologist.  £300. 

Northampton  County  Mental  Hospital,  Berrywood. — Jun.  Asst.  M.O. 
£300. 

Northampton  General  Hospital.— Pathologist.  £750. 

Nottingham  Children’s  Hospital.— Female  Res.  H.S.  £250.  Female 
Res.  H.P.  and  Anaesth.  £200. 


462  The  Lancet,]  NOTES,  SHORT  COMMENTS,  AND  ANSWERS  TO  CORRESPONDENTS.  [Sept.  6,  1919 


Nottingham  Oeneral  Hospital.— Two  H.P.’s.  Also  Two  H. S.’s.  £150. 
Queen  Charlotte’s  Lying-in  Hospital,  Marylebone-road,  N.  IK— Diet. 
Res.  M.O.  £80. 

Richmond,  Surrey,  Royal  Hospital. — H.S.  £150. 

Rotherham  Hospital.— Jun.  H.S.  £150. 

Royal  National  Orthopsedic  Hospital, 23/,,  Great  Portland-street,  IV'.— H.S. 

£200. 

St.  Mary's  Hospital  for  Women  and  Children,  Plaistow,  E.— Res.  M.O. 
£200.  Also  Hon.  Gynaecologist. 

St.  Peter's  Hospital  for  Stone,  dec.,  Henrietta-street,  Covent-garden,  W.C. 
Jun.  H.S.  £75. 

Salford  Royal  Hospital.— Hon.  Dent.  S.  Also  Res.  Surg.  O.,  H.P., 
H.S.,  and  Jun.  H.S.  £250,  £200,  £150,  and  £125  respectively. 
Scarborough  Hospital  and  Dispensary.— Two  H.S.’s.  £150. 

Sheffield  City  Education  Committee.— Sch.  Dental  S.’s.  £400. 

Sheffield  Royal  Infirmary.— H.S.  for  Ear,  Nose,  and  Throat.  £150. 
South  Africa,  Mental  Hospital  Service. — Asst.  P.’s.  £380. 

Southampton,  Free  Eye  Hospital.— H.S.  £150  to  £200. 

Southwark  Borough. — Female  Asst.  M.O.H.  £400. 

Swansea  General  and  Eye  Hospital.— H.S.  £250. 

Ulverston,  High  Carley  Sanatorium.—  Asst.  Tsberc.  M.O.  £350. 
University  College  Hospital,  Gower-street.  W.  C.— Asst.  S. 

Wallasey,  Victoria  Central  Hospital.— Hon.  Ophth.  S. 

Wallsall  General  Hospital.— Female  H.S.  and  Anaesth.  £175. 

Wilts  County  Council. — Sch.  Dentist.  £350. 

The  Chief  Inspector  of  Factories,  Home  Office,  S.W.,  gives  notice  of 
vacancies  for  Inspectors  under  the  Factory  and  Workshop  Acts  at 
Killough  and  Luddenden,  Brigg  (Lincoln),  Dartford  (Kent). 

The  Secretary  of  State  for  the  Home  Department  gives  notice  that  in 
consequence  of  the  death  of  Mr.  F.  Wilson,  one  of  the  Medical 
Referees  under  the  Workmen’s  Compensation  Act,  1906,  for  County 
Court  Circuit  No.  28,  the  appointment  held  by  him  is  vacant.  Mr. 
Wilson  was  attached  more  particularly  to  the  Aberystwyth, 
Dolgelly,  Llanidloes,  Machynlleth,  and  Newtown  County  Courts. 
Applications  for  the  post  should  be  addressed  to  the  Private 
Secretary,  Home  Office,  and  should  reach  him  not  later  than 
Sept,  lltb,  1919.  Notice  is  also  given  that  in  consequence  of  the 
resignation  of  Mr.  J.  L.  Russell,  one  of  the  Medical  Referees  under 
the  Workmen’s  Compensation  Act,  1906,  for  County  Court  Circuit 
No.  12,  the  appointment  held  by  him  is  vacant.  Mr.  Russell  was 
attached  more  particularly  to  the  Todmorden  County  Court. 
Applications  for  the  post  should  be  addressed  to  the  Private 
Secretary,  Home  Office,  and  should  reach  him  not  later  than 
Sept.  25th,  1919. 

Uirifes,  JJtarriages,  aid)  f taffa. 


BIRTHS. 

Brooks.— On  August  31st,  at  Beaufort  House,  Grange  Park,  Ealing, 
the  wife  of  Captain  Ralph  St.  John  Brooks,  R.A.M.C.,  of  a son. 
Henry.— Ou  August  19th,  at  The  Croft,  Sandon-road,  Edgbaston,  the 
wife  of  A.  E.  Henry,  B.Sc.,  L.D.S.,  of  a son  (Richard  Montagu). 
Leslie.— On  August  27th,  at  a nursing  home,  the  wife  of  Captain  W. 
Leslie,  M.O.,  R.A.M.C.,  of  a son. 

Osborn.— On  August  21st,  at  Sheet-street,  Windsor,  the  wife  of  Dr. 
A.  G.  Osborn,  of  a son. 

Porteous.— On  August  26th,  at  Drumsheugh-gardens,  Edinburgh,  the 
wife  of  W.  J.  Porteous,  M.B.,  Ch.B.  Edin.,  of  a son. 

Stephens.— On  August  26th,  at  Fair  Elms,  Sandown,  the  wife  of  J.  B. 

Stephens,  M.B.,  B.S.  Lond.,  of  a daughter. 

Whitehead.— On  August  24th,  at  Rougemont,  Salisbury,  the  wife  of 
Brian  Whitehead,  M.R.C.S.  Eng.,  L.R.C.P.  Lond.,  of  a daughter. 


MARRIAGES. 

Debenham  — Archer-Shee.  — On  Sept.  2nd,  Leonard  Snowden 
Debenham,  M.B.,  B.S.,  B.Sc.,  to  Anna,  daughter  of  the  late  Martin 
Archer-Shee,  of  Bristol  and  Nailsworth,  Gloucestershire. 

Elliot— Hamilton. — On  August  27th,  at  St.  Margaret's,  Westminster, 
Captain  W.  E.  Elliot,  M.P.,  M.C.,  R.A.M.C.,  to  Helen  A Hamilton, 
eldest  daughter  of  Lieutenant-Colonel  D.  L.  Hamilton,  R. A. M.C.(T.). 

Ewens— Kelleher.— On  Sept.  1st,  Bernard  C.  Ewens,  M B.  (late 
Captain,  R.A.M.C.),  to  Mary,  daughter  of  the  late  James  Kelleher, 
D.L.,  Bengal  Civil  Service  (retired),  and  of  Mrs.  Kelleher,  Goderich, 
Ontario. 

Gardner— Ponton.— On  August  21st,  at  All  Souls  Church,  Langham- 
place,  W„  Humphrey  D.  Gardner,  Captain,  R.A.M.C.,  to  Phyllis 
Ponton. 

Hunter— Kempson.— On  August  21st,  at  the  Chapel  Royal,  Savoy, 
Captain  (acting  Major)  jJohn  Henderson  Hunter,  M.C',  R.A.M.C. 
(T.F.).  to  Dorothy  Kenelm,  only  daughter  of  the  late  Frank  Kenelm 
and  Mrs.  Kempson,  Kingsbrook  House,  Bedford. 


DEATHS. 

Angus.— On  August  23rd,  at  St.  Cyrus,  Scotland  (very  suddenly),  aged 
36,  William  Angus,  M.D.,  D.P.H.,  Medical  Officer  of  Health  for 
Leeds.  Interred  at  Aberdeen,  August  25th. 

Chevers.— On  August  10th,  at  Southmead  Military  Surgical  Hospital, 
Bristol,  Major  Herbert  L.  G.  Chevers,  R.A.M.C.  (retired), aged  59. 

Fox.— On  August  16th,  at  Panyam,  Nigeria,  John  Crofton,  M.R.C.S., 
L.R.C.P. 

Hewlett. — On  August  26th,  at  Andover,  the  result  of  a cycle  accident, 
George  Hewlett,  Surgeon-Commander,  R.N.,  retired. 

Humphry.— On  August  29th,  Reginald  Humphry,  M.R.C.S.,  L.R.C.P., 
of  Nelson-road,  Southsea,  aged  67. 

Kazanjian.— On  August  10th,  at  Boston,  Mass.,  following  the  birth  of  a 
daughter,  Sophie,  wife  of  Major  V.  Kazanjian,  C.M.G. 

Keith.— On  August  19th,  at  Bryanston-street,  W.,  after  a brief  illness, 
Skene  Keith,  M.B.,  C.M..  F.R.C.S.E.,  aged  61. 

Stevens.— On  August  25th,  at  Gordon  House.  Booking,  Essex,  Percy 
Richard  Stevens,  L.R.C.P.  Lond.,  M.R.C.S.  Eng.,  aged  61. 

Wright.— On  August  28th,  at  Blakesley,  Northants,  Cyril  Haworth 
Wright,  M.B.,  Ch.B.  Edin.,  D.P.H.,  R.C.P.S.,  aged  43. 

N.B.—A  fee  of  6s.  is  charged  for  the  insertion  of  Notices  of  Births, 
Marriages,  and  Deaths. 


Holes,  Sfeort  Comments,  anb  ^nsfoers 
to  Correspondents. 

THE  PERTHSHIRE  UNIT. 

The  following  interesting  letter  from  Nish  has  reached  us 
through  the  kindness  of  “ J.  G.  F.,”  who  has  forwarded  it  to 
us  “ in  the  belief  that  it  will  prove  of  interest  to  readers  who 
have  served  lately  in  Macedonia,  particularly  with  the 
Serbian  Units.” 

The  Perthshire  Unit,  Serbian  Relief  Fund, 

Nish,  Serbia,  July  25th,  1919. 

It  8 hard  to  realise  that  it’s  almost  6 months  since  I left  England,  yet 
it  will  be  on  August  14th.  Although  my  address  says  “ Nish  ’ I’m 
really  40  kilometres  (25  miles)  from  that  town,  out  at  Prokuplje,  which 
is  slightly  north-west  from  Nish.  We  are  right  off  the  railway  line, 
which  at  first  made  us  awfully  cut  off  when  the  weather  was  bad.  Now 
of  course  the  road  is  dry,  so  cars  come  out  to  u9  ofteoer ; so  far  I’ve  not 
one  of  my  own. 

I've  made  a hospital : well  it  has  been  a job,  but  there  is  much  satis- 
faction now  in  looking  over  an  extremely  good  garden  on  to  four  large 
marquees  each  holding  14  beds,  another  of  12  beds  and  a long  one- 
storied building  which  holds  22  beds.  We  have  a funny  little  cottage 
not  half  bad  now  it’s  really  clean  and  for  the  rest  of  the  staff  I’ve  rooms 
outside.  Although  I’ve  only  69  beds,  there  is  much  work  here,  as  there 
is  a very  large  out-patient  department.  This  hospital  supplies  accommo- 
dation for,  or  rather  I should  say,  meets  the  urgent  needs  of  a good  many 
villages,  as  well  as  this  town  with  its  7000  inhabitants.  When  first  we 
got  here  in  the  early  days  of  March  we  at  once  commenced  a soup 
kitchen  from  which  1600  were  fed  daily,  also  we  distributed  clothing. 
But  this  town  itself  has  not  suffered  as  much  as  the  villages.  In  these 
the  picture  of  misery  is  too  awful.  In  view  of  the  facts  that  I’m  soon 
to  begin  a distribution  of  clothes  in  villages  within  a radius  of  30  kilo- 
metres I’ve  been  by  degrees  visiting  a good  many  to  see  for  myself  how 
things  were  and  what  the  most  pressing  needs  were.  In  one  village, 
only  13  kilos  from  here,  I found  only  5 houses  standing,  where  originally 
65  stood  ; all  the  rest  are  in  ruins. 

The  people  there  now  just  live  in  what  was  once  the  cowhouse  below 
the  level  of  the  ground  or  else  in  shelters  built  against  the  steep 
mountain  side  with  neither  light  nor  ventilation.  In  one  small  room  I 
was  told  13  slept,  all  on  a hard  mud  floor.  In  one  comer  there 
was  some  wood  ash,  so  I knew  they  had  had  a fire,  in  fact  I saw  the  small 
black  opening  in  the  roof,  the  only  ventilation,  and  I wondered  what  ■ 
chance  there  was  for  these  poor  people  should  one  fall  a victim  to  the 
all  too  prevalent  disease — tuberculosis. 

I asked  why  there  was  such  crowding  in  view  of  the  fact  that  the 
weather  was  so  pleasant  for  sleeping  out,  but  was  told  that  wolves  . 
came  into  the  village  every  night  which  made  it  impossible  to  sleep 
outside,  in  fact  the  few  animals  that  the  people  possess  are  taken  inside 
as  well  for  fear  of  being  lost. 

Almost  all  the  houses  had  had  the  furniture  removed.  The  village  I 
mention  was  one  quite  near  the  forest,  right  up  towards  a high  moun- 
tain range.  The  people  told  me  what  an  awful  time  they  had  had.  . 
Their  men  were  mostly  with  the  Comitadji,  living  for  three  years  in 
the  forests.  The  Bulgars  occupied  all  the  villages  during  the  day 
and  took  everything  they  could  find,  but  retired  for  the  night,  as  they  : 
were  too  frightened  to  remain  on  account  of  the  Comitadji.  As  : 
soon  as  night  came,  down  came  the  Comitadji,  and  the  women  gave 
them  as  much  food  as  they  had  been  able  to  conceal  from  the  Bulgars. 
Here  in  Prokuplje  the  houses  bear  little  evidence  of  war,  except 
in  one  place  where  a bomb  fell ; also  the  Public  Buildings  are 
riddled  with  shot  holes — here  the  Bulgars  in  occupation  of  the  town  r 
had  to  take  refuge  when  the  Comitadji  from  the  forests  on  our  moun- 
tains  came  down  and  stormed  the  town.  This  they  did  just  after  the  r 
fall  of  Monastir  (December,  1916)  as  they  were  under  the  impression 
that  an  advance  was  then  to  be  made.  They  kept  storming  the  Town 
Hall  for  two  days  and  then  the  Bulgars,  480  of  them,  gave  in;  the 
Comitadji  held  the  town  for  15  days  and  then  were  driven  out  once 
more  by  German  heavy  guns  which  had  been  brought  up.  Then  the 
persecution  of  the  women  began  ; they  were  cut  with  knives,  branded 
with  hot  irons  and  tortured  in  every  possible  way:  the  Bulgars 
demanding  to  be  told  where  the  Comitadji  had  gone.  I have  seen 
many  of  these  women  at  our  Dispensary  with  great  seams  all  round 
their  sides  and  down  their  backs,  and  in  one  case  a woman  came  with 
an  awful  chest  just  one  mass  of  holes,  from  which  pus  was  pouring: 
the  remaining  evidence  of  when  she  had  been  prodded  by  a bayonet ! 
These  things  must  be  seen  to  be  believed.  Beyond  this  lovely  garden 
of  mine,  which  we  just  made  out  of  a rough  field,  I look  across  open 
country  fora  little  way  and  then  a glorious  range  of  mountains  rises : 
on  the  slope  of  a nearer  one*  just  where  now  a cornfield  ripens,  30  or  40 
people  of  all  ages  and  both  sexes  were  done  to  death  every  night  for 
trumped  up  trivial  offences  ! Such  is  war! 

Many  men  have  found  their  families  and  many  of  the  older  soldiers  - 
have  been  demobilised  and  come  home;  but  then  I’ve  met  others  who 
say  they  have  been  to  their  villages  and  have  found  just  a heap  of 
stones  to  show  where  once  a comfortable  home  stood  and  that  no  trace 
of  the  family  or  word  of  their^fate  can  be  found. 

I’m  most  tremendously  interested  in  it  all  and  only  wish  one  could  I 
do  more  and  work  more  rapidly,  but  I suppose  every  little  helps.  Just  i 
now  in  this  place  we’ve  a typhoid  epidemic,  but  during  two  weeks  we 
have  only  had  14  cases.  I’ve  had  to  see  to  the  disinfecting  of  the  houses  t 
where  cases  have  developed  and  have  distributed  soap  and  urged  J 
cleanliness.  I work  here  entirely  with  a Czech  Doctor  and  his  partner,  > 
also  a Czech.  The  senior  is  quite  a capable  man,  he  speaks  only  French,  1 
the  other  German ; however,  we  jog  along ; no  English  doctor  of 
course.  We  get  many  cases  of  malaria,  but  I’ve  never  once  seen  a 
mosquito.  We  all  have  nets  up,  but  have  so  far  not  slept  under  them. 
I'm  afraid  this  is  a very  long  letter,  but  my  pen  runs  away  with  me, 
because  I'm  so  interested  in  my  subject: 

This  interesting  account  provides  ample  evidence  of  the  j 
terrible  sufferings  which  the  poor  country  folk  of  stricken  ‘i 
but  victorious  Serbia  are  undergoing.  Clearly  there  is  &t 


The  Lancet,] 


NOTES,  SHORT  COMMENTS,  AND  ANSWERS  TO  CORRESPONDENTS.  [Sept.  6,  1919  463 


the  moment  a great  demand  for  help,  and  the  demand  will 
last  for  some  time,  and  it  should  not  fail  to  appeal  to  all  of 
us  at  home.  The  devotion  to  the  Serbian  cause  which  our 
women  have  shown  should  stimulate  a material  response. 

THE  CHILDREN’S  COUNTRY  HOLIDAYS  FUND. 

Sir  Horace  B.  Marshall,  the  Lord  Mayor  of  London,  has 
issued  an  appeal  on  behalf  of  this  Fund,  through  the 
agency  of  which  it  is  hoped  that  over  20,000  London  children 
will  be  given  a fortnight’s  holiday  in  the  country.  A 
large  number  of  poor  children  have  already  been  sent  away 
for  a holiday,  but  there  are  hundreds  more  on  the  list,  and 
the  Fund  is  spending  more  rapidly  than  it  receives.  Addi- 
tional donations  are  urgently  required  to  prevent  undue 
depletion  of  the  reserve  fund.  Cheques  made  payable 
to  the  Fund  should  be  sent  to  the  Secretary,  C.C.H.F., 
18,  Buckingham-street,  Strand,  W.C.2. 

THE  FOOD  EDUCATION  SOCIETY. 

The  activities  of  the  Food  Education  Society  (honorary 
secretary,  Mr.  C.  E.  Hecht,  M.A.,  M.C.A.,  Danes  Inn  House, 
265,  Strand,  W.C.  2)  are  to  be  extended  and  the  cooperation 
of  allied  societies  has  been  successfully  invited.  It  has  been 
decided  by  the  society  to  hold  a conference  in  Manchester  in 
1920  on  the  lines  of  the[Guildhall  School  conferences  of  1912 
and  1913,  in  which  problems  connected  with  the  teeth 
figured  prominently.  (See  “ Our  Children’s  Health  at  Home 
and  at  School  ” and  “ Rearing  an  Imperial  Race.”)  A strong 
and  representative  committee  is  in  course  of  formation. 
Steps  are  also  being  taken  to  constitute  committees  in 
Birmingham  and  other  places,  so  as  to  arouse  interest  in, 
and  secure  adequate  representation  at,  the  conference  and 
to  arrange  for  a local  campaign.  Invitations  will  be 
issued  on  a large  scale  throughout  the  United  Kingdom. 
A draft  programme  of  the  conference,  with  tentative 
suggestions  for  a local  campaign,  which  include  a travelling 
exhibition,  and  further  particulars  will  be  sent  on  receipt 
of  a stamped  addressed  envelope,  if  application  be  made  to 
to  Mr.  Chas.  E.  Hecht  at  the  offices  of  the  society. 

LEFT-  AND  RIGHT-HANDED  COUCHES. 

To  the  Editor  of  The  Lancet. 

Sir,— The  modern  couch  sold  as  part  of  a “ suite  ” has  the 
head  at  the  left  end  when  the  back  rail  is  against  the  wall. 
The  effect  of  this  is  that  the  occupant  naturally  reposes  on 
his  right  side.  Couches  many  years  ago  used  to  be  made 
also  with  the  head  at  the  right  end,  so  that  the  occupant 
would  lie  on  his  left  side.  This  kind  of  couch,  I find,  is 
seldom  made  now,  and  I have  a faint  recollection  that  it  was 
condemned  because  lying  on  the  left  side  after  a heavy  meal 
brought  on,  or  was  supposed  to  bring  on,  indigestion  or 
palpitation,  or  something  worse.  I am  rather  curious  to 
know  whether  that  was  the  real  reason  for  the  abandonment 
of  such  couches,  which,  I think,  are  called  “right-handed  ” 
couches.  Perhaps  some  of  your  readers  know  and  could 
inform  me.  I am,  Sir,  yours  faithfully, 

August  25th,  1919.  LAYMAN. 

PHYSICAL  PROGRESS  AND  MENTAL  RETRO- 
GRESSION. 

The  testimony  of  all  military  medical  officers  is  clear 
upon  one  point— namely,  that  although  the  physique  of  the 
last  lot  of  recruits  for  the  fighting  line,  called  up  about  1915- 
1916,  was  poor,  yet  the  physique  of  those  who  had  attained 
the  age  of  17  to  18  in  1917,  and  were  then  called  up  for 
training,  was  extraordinarily  good.  This  fact  was  due  in 
great  measure  to  their  having  been  well  fed  from  the 
age  of  14  or  15,  i.e.,  from  the  beginning  of  the  war. 
Their  parents  had  had  more  money  owing  to  increased 
wages,  and  had  spent  it  wisely  in  giving  the  children 
better  food.  The  same  improved  development  due  to 
the  same  factors  may  be  noted  in  the  children  who  are 
to-day  between  11  and  13.  Physical  development,  however, 
is  not  everything,  as  two  paragraphs  in  the  same  issue  of  the 
Times  showed  one  day  last  week.  One  of  these  deals  with 
the  case  of  a boy,  aged  13,  who  showed  a friend  a small  jar, 
saying,  “ It  is  rat  poison.  I am  going  to  take  it  for  the  sake 
of  a girl  because  she  does  not  like  me.”  He  took  it  and 
eventually  died  from  phosphorus  poisoning.  Evidence  was 
given  that  “ he  was  a boy  for  girls,”  and  the  father  said  that 
his  son  was  strong  willed  and  well  developed  physically. 
He  had  thought  about  telling  his  son  concerning  matters  of 
sex,  but  had  not  done  so.  The  other  paragraph  relates  the 
familiar  story  of  a window  in  a train  being  broken  by  a 
stone,  the  passengers  in  the  carriage  being  covered  with 
glass.  It  was  presumably  thrown  by  a boy,  the  fusion  of  the 
sexes  has  not  yet  got  to  the  point  of  producing  a girl  who 
can  throw  a stone.  Throwing  seems  to  be  a natural  impulse 
in  boys,  or  rather,  we  should  say,  the  desire  to  hit  a moving 
body  with  a missile  is  universal  among  them,  but  the  impulse 
should  be  guided  in  the  direction  of  wickets  rather  than 
trains.  The  suicidal  youth  seems  to  have  been  impelled 
by  sexual  impulses,  which  are  normally  strong  and  also 


unbalanced  at  the  time  of  puberty.  Moreover,  the  condi- 
tions of  the  last  four  years  have  undoubtedly  tended  to 
laxity  in  sexual  matters  and  also  to  opportunity.  It  is  to 
be  feared  that  physical  development  has  not  gone  hand-in- 
hand  with  instruction  as  to  the  necessity  for  keeping  the 
bodily  functions  under  control. 

CURRENT  SEXUAL  DECORUM. 

Qui  s'excuse  s'accuse.  The  number  of  pens  at  work  lately 
(when  there  have  surely  been  plenty  of  other  things  to  put 
in  the  journals)  defending  phenomena  like  new  styles  of 
dancing,  like  mixed  bathing  followed  immediately  by  much 
‘ jazzing,”  like  the  present  fashion  of  scanty  feminine  dress 
both  by  land  and  sea,  sufficiently  demonstrates  a change  in 
public  conduct  in  the  matter  of  sexual  decorum.  Whether 
that  change  arises  from  a spirit  of  mere  licence  and  rebellion, 
or  from  a new  moral  evaluation,  is  uncertain.  Probably — 
aetiology  being  ever  complex — both  motives  operate,  with 
many  others  in  addition.  What  is  invariably  mentioned  as 
a cause  when  this  subject  is  discussed  is  reaction  from  the 
strain  of  war ; but  since  the  change  spoken  of  has  been  notice- 
able, though  not  quite  so  prominent  as  now,  any  time  this  last 
two  or  three  years,  if  not  for  longer,  it  cannot  play  a great 
part.  What  lies  far  deeper  is  the  lowering  of  moral  tone 
brought  about  by  war  itself,  for  great  dangers,  as  Bacon 
remarks,  demand  great  delights,  and  the  spirit  of  the  soldier 
is  in  essence  the  spirit  of  the  adventurer.  War  brings 
excitement,  too,  and  excitement,  especially  in  women, 
easily  runs  over  into  sexual  manifestations.  Again,  women, 
upon  whom  society,  as  well  as  Nature,  imposes  a stricter 
code  of  morality,  have  been  almost  from  the  beginning  of 
the  war  in  a position  of  greater  social  and  economic 
independence  than  formerly.  It  would  be  incorrect  to 
lay  exclusive  stress  upon  factors  like  these,  which  a 
conventional  moralist  would  call  unfavourable.  For  the 
progress  of  human  culture  is  perhaps  showing  that  the 
indispensable  barriers  which  Freud  has  called  “shame, 
loathing,  and  morality  ” are  not  in  their  proper  positions. 
They  may,  even  now,  be  too  narrowly  set,  may  make 
libertines  of  too  many. 

TENACIOUS  ADVERSARIES. 

Mr.  Aylmer  Maude,  a well-known  authority  on  Russian 
affairs  and  literature,  and  the  author  of  a life  of  Tolstoy,  is 
responsible  in  the  columns  of  the  Westminster  Gazette  for 
the  following  story: — 

“A  curious  instance  of  extreme  tenacity  of  life  among  the  lower 
races  was  mentioned  to  me  by  Major  K.  Black,  R.A.M.C.,  now  surgeon 
to  the  Dvina  Force,  and  before  the  war  a well-known  practitioner 
in  the  Midlands.  The  case  occurred  at  Bakaritsa.  Two  friends  of 
Mongolian  origin,  in  a labour  battalion,  played  cards,  and  A won 
more  than  B liked  to  lose.  Thereupon  B got  a sharp  axe  and  drove 
it  through  A’s  skull  and  about  ljin.  into  his  brain.  A was  taken 
to  hospital,  where  Major  Black  trephined  him  and  repaired  his 
brain.  Next  day  A demanded  his  usual  rations,  and  wanted  to 
get  up  and  go  home  to  settle  accounts  with  his  friend.  This  was 
not  allowed,  but  meanwhile  B had  been  arrested,  and,  not  wishing  to 
submit  to  the  Courts  of  the  Western  Barbarian,  he  hanged  himself, 
and,  after  a period  variously  estimated  at  from  five  to  ten  minutes  of 
suspension,  was  cut  down.  The  surgeon  was  again  sent  for,  and  found 
the  Russian  attendants  administering  artificial  respiration  to  the  man 
at  the  rate  of  about  300  per  minute,  and  nearly  played  out  by  their 
labours.  This  he  slowed  down  to  about  20,  and  after  half  an  hour  the 
man  revived  and  was  taken  to  the  hospital  ward  his  friend  was  in,  as  no 
bed  was  available  elsewhere.  On  seeing  him  A became  extremely 
violent,  and  it  required  six  men  to  hold  him  down  and  prevent  his 
exacting  summary  vengeance  on  B,  who  was  still  only  semi-conscious. 
However,  B,  too,  made  a remarkable  recovery,  and  half  an  hour  later  it 
took  12  men,  six  to  each  of  the  combatants,  to  prevent  the  two  patients 
from  fighting.  Huge  and  repeated  doses  of  morphia  had  no  effect  on 
either  of  them,  but  by  arranging  a bed  in  a separate  ward  for  one  of 
them  murder  was  avoided,  or  at  least  deferred." 

Mr.  Maude,  who  is  working  on  the  Dvina  front,  gives  a 
satisfactory  account  of  the  health  of  the  troops. 

“ STAMMERING  AND  VOICE  DEFECTS.” 

To  the  Editor  of  The  Lancet. 

Sir,— Will  you  grant  me  sufficient  of  your  valuable  space 
to  make  a comment  on  Miss  Mabel  Oswald’s  paper  on  the 
above  subject  in  your  issue  of  August  23rd  ? Miss  Oswald  is 
mistaken  in  saying  that  “stammering  and  functional  voice 
defects  have  until  recently  been  looked  upon  as  unfortunate 
disabilities,  and  no  real  scientific  attempt  was  made 
thoroughly  to  deal  with  such  cases,  and  hence  there  was 
no  recognised  cure.”  In  1892  my  father,  the  late  Emil 
Behnke,  was  invited  to  address  the  British  Laryngological 
Association  on  this  subject,  to  demonstrate  cases,  and  to 
explain  his  method.  This  body  of  experts  accepted  his 
system  for  the  treatment  of  stammering  and  speech 
defects  as  being  thoroughly  scientific  and  sound,  and  their 
opinion  has  been  endorsed  and  maintained  by  the  medical 
profession  in  general  in  the  years  that  have  elapsed.  His 
works  on  the  subject,  together  with  those  of  my  mother,  the 
late  Mrs.  K.  Behnke,  are  recognised  text-books. 

I am,  Sir,  yours  faithfully, 

Kate  Emil  Behnke. 

Earl's  Court-square,  S.W.,  August  26th,  1919. 


464  The  Lancet.] 


NOTES,  SHORT  COMMENTS,  ETC.— MEDICAL  DIARY. 


[Sept.  6,  1919 


THE  VALUE  OF  MEDICAL  SERVICE. 

The  City  Life  Assurance  Company,  Limited,  6,  Paul- 
street,  Finsbury,  London,  E.C.,  possess  the  Medical 
Examiners’  Nomination  Form  reproduced  below,  and  have 
endorsed  it  for  the  inspection  of  one  of  our  readers  who 
applied  for  the  medical  fee  of  £2  2s. : — 

Scale  of  Fees. 

For  Assurances  up  to  and  including ) These  Fees  refer 
£50,  2s.  6 d.  to  Industrial 

For  Assurances  exceeding  £50,  5s.  Od.  J Proposals  only. 

For  Assurances  up  to  and  including!  tj,  f 

£50,  5s.  Od.  I These  Fees  refer 

For  Assurances  up  to  and  including1  to  Ordinary 
£200,  10s.  6d.  |P  Bra?ch  , 

For  Assurances  exceeding  £200,  £1  Is.  J Proposals  only. 

Medical  Examiners’  Nomination  Form  : Questions  to 
be  Answered  by  the  Medical  Examiner. 


Questions. 

Answers. 

1.  Should  the  Directors  decide 
to  appoint  you  as  Local 
Medical  Examiner,  will  you 
undertake  the  usual  duties 
connected  therewith  and 
accept  the  Fees  above 
enumerated. 

Note.— In  order  to  save  the 
remittance  of  individual  sums  from 
time  to  time  the  Medical  Fees  will 
be  paid  by  the  Company  Quarterly. 

2.  What  area  is  covered  by 
you  in  connexion  with  your 
present  practice  ? 

3.  Please  name  the  principal 
town  and  villages  so  covered. 

If  occasion  arises  are  you  pre- 
pared to  visit  the  proposers 
at  their  residences? 

4.  Are  you  at  present  acting  as 
Medical  Examiner  for  any 
other  Life  Assurance  Com- 
pany. If  so,  please  mention 
the  Office  or  Offices  repre- 
sented. 

5.  Areyouinany  wayinterested 
in  the  Company,  either  as  a 
Policyholderor  Shareholder? 
If  not,  is  it  your  intention  to 
become  so  interested? 

Note. — The  Directors  desire  it  to  be  distinctly  understood  that  this 
nomination  carries  do  guarantee  as  to  the  number  of  cases  to  be  sub- 
mitted for  examination  or  remuneration  to  be  received,  and  the 
Directors  do  not  hold  themselves  responsible  for  any  promise,  verbal  or 
otherwise,  made  by  the  Company’s  representative.  Any  application  for 
shares,  policies,  &c.,  made  by  any  Medical  Officer  must  be  made  in  the 
ordinary  course  of  business,  as  the  shares  or  policies  applied  for  will  be 
dealt  with  on  this  understanding. 

Name 

Address  in  full 


Qualifications 

Date 191  

Signature  of  Inspector  or  l 

District  Superintendent  ( 

THE  COOL1DGE  DENTAL  RADIATOR  TUBE. 

This  dental  radiator  tube  has  been  designed  for  the 
purpose  of  making  radiographs  of  the  teeth  and  jaw,  and 
is  not  intended  for  general  radiographic  work.  An  important 
feature  of  the  radiator  tube  is  that  it  is  self-rectifying  and 
can  be  used  directly  across  the  terminals  of  either  an  induc- 
tion coil  or  a high-tension  transformer  without  the  necessity 
for  any  auxiliary  rectifying  device,  whereas  the  universal 
Coolidge  tube  must  be  used  on  rectified  current.  The  dis- 
posal of  the  cathode  and  anode  gives  the  following  advantages, 
itis  stated,  for  dental  work  : (1)  the  rays  are  emitted  from  the 
tube  in  a line  with  the  axis  of  the  anode,  rendering  manipula- 
tion and  adjustment  easy ; (2)  the  cathode  circuit  is  grounded, 
so  that  there  is  only  one  high  tension  wire  connected  to  that 
part  of  the  tube  farthest  lrom  the  subject;  and  (3)  it  is 
possible  to  reduce  to  a minimum  the  distance  between  the 
film  and  focal  spot  by  which  satisfactory  radiographs  of  the 
teeth  and  jaws  are  obtained  with  comparatively  short 


exposure.  Further  details  in  regard  to  the  advantages  and 
conveniences  of  this  special  dental  radiator  X ray  tube  are 
furnished  by  the  British  Thomson-Houston  Co.,  Ltd.,  of 
Rugby  and  77,  Upper  Thames-street,  E.C.4,  who  are  the 
patentees. 

THE  RANYARD  NUR8E8. 

The  annual  report  of  the  Nursing  Branch  of  the  Ranyard 
Mission  for  the  year  ending  Dec.  31st,  1918,  shows  that  their 
work  among  the  sick  poor  has  been  carried  on  steadily 
under  difficult  conditions.  The  society  is  one  of  the  oldest 
of  the  Voluntary  Nursing  Associations,  having  been  founded 
in  1868  as  an  off-shoot  of  a mission  to  supply  Biblewomen  to 
the  poorest  and  most  neglected  quarters  of  London.  The 
Ranyard  nurse  attends  patients  of  any  denomination  and 
those  only  who  are  under  a doctor’s  care.  She  must  be  fully 
trained,  and  then  undergoes  a further  period  of  six  months’ 
work  under  an  experienced  sister  at  the  Central  Hostel, 
25,  Russell-square,  W.,  before  she  is  allocated  to  the  London 
district,  where  she  will  eventually  reside  and  work.  The 
staff,  when  complete,  comprises’  84  sisters  and  nurses, 
whose  zeal  and  energy  may  be  estimated  by  the  fact  that 
11,853  cases  were  nursed  during  the  year  1918.  We  are  glad 
to  note  that  the  nurse’s  working  day  averages  eight  hours 
only  and  that  night  work  is  discouraged,  also  that  the 
holiday  conditions  are  good — five  weeks  a year  and  a day  a 
month.  The  estimate  of  £130  a year  for  the  equipment  and 
maintenance  of  each  nurse  hardly  suggests  a lavish  scale  of 
remuneration  under  present  conditions,  but  it  must  be 
remembered  that  the  main  source  of  income  is  voluntary 
contributions,  and  the  balance-sheet  already  shows  a deficit 
of  £1584  for  the  nurses’  fund.  We  trust  that  public  support 
of  this  excellent  society  will  be  generous  enough  to  warrant 
an  increase  of  payment  to  its  staff  as  well  as  an  extension 
in  its  sphere  of  work. 

J.F.  T. — A coroner  has  great  latitude  in  holding  an  inquiry 
as  to  the  cause  of  death,  and,  where  a suicide  is  seen  to  have 
been  precipitated  by  the  act  of  another,  most  coroners  would 
take  serious  cognisance  of  the  fact. 


Utrtrial  for  tty  ensuing  IHeek. 


LECTURES,  ADDRESSES,  DEMONSTRATIONS,  &c. 

LONDON  HOSPITAL  MEDICAL  COLLEGE,  in  the  Clinical  Theatre 
of  the  Hospital. 

A Special  Course  of  Instruction  in  the  Surgical  Dyspepsias  will  be 
given  by  Mr.  A.  J.  Walton  and  others  :— 

Monday,  Sept  8th.— 4.30  p.M.,  Lecture  XI.: — Conditions  Simulating 
Dyspepsia.  (Dr.  Hutchison.) 

Friday.— 4.30  p.m.,  Lecture  XII.:— The  Differential  Diagnosis  of 
Medical  from  Surgical  Dyspepsias.  (Dr.  Hutchison.) 


Communications,  Letters,  Ac.,  to  the  Editor  have 
been  received  from— 

A.— Assurance  Medical  Society,  L. — Mrs.  D.  C.  Lea,  Lond.;  London 
Lond.  School  of  Dental  Mechanics  for 

B — Miss  K.  E.  Behnke,  Lond.;  Dr.  Ladies;  Messrs.  Lawson  and  Co., 

D.  W.  Buxton,  Lond.;  Dr.  A.  T.  Bristol;  Dr.  S.  C.  Lawrence, 

Blease,  Altrincham ; Dr.  G.  Lond.;  Dr.  O.  Langmead,  Lond.; 

Blacker,  Lond  ; Dr.  W.  A.  London  Hospital  Medical  Col- 

Bullough,  Chelmsford  ; Dr.  G.  E.  lege.  Sec.  of. 

Beaumont,  Lond.  M.— Mr.  R.  Mealing,  Badminton; 

C. — Continental  Surgical  Supplies  Dr.  H.  A.  Macewen,  Glasgow  ; 

Co.,  Lond.;  Messrs.  A.  H.  Cox  Dr.  B.  Moore,  Paignton;  Mr. 

and  Co.,  Brighton  ; Dr.  G.  Cobb,  J.  H.  McEwan,  Harrogate;  Dr. 

Lond.;  Pr.  D.  Campos,  Porto  W.  O.  Meek.  Frimley ; Ministry 

Aiegre;  Mr.  J.  Conqueror,  South  of  Health,  Lond.;  Medicus  : Dr. 

Shields;  Chicago  School  of  Sani-  S.  R.  Meaker,  Esher;  Mr.  F.  H. 

tary  Instruction ; Commission  Moore,  Thaxted. 

for  the  Prevention  of  Tubercu-  N. — National  Alliance  of  Employers 
losis  in  France,  Paris,  Director  of.  and  Employed,  Lond. 

D.  — Mr.  R.  Dawson,  Lond.;  Dr.  0. — Miss  M.  V.  O.  Oswald,  Lond._ 

T.  V.  Dickinson,  Lond.  R.  — Dr.  J.  Riviere,  Paris;  Dr.  K. 

E. — Maj.-Gen.  Sir  G.  Evatt ; Dr.  Rogers,  Bromley;  Dr.  W.  C. 

T.  W.  Eden,  Lond.;  Lieut -Col.  Rivers,  Worsboro'  Dale;  Dr. 

W.  McAdam  Eccles,  R.A.M.C.  J.  D.  Rolleston,  Lond.;  Ranyard 

F. — Dr.  E.  R.  Fotbergill,  Hove;  Nurses,  Lond. 

Factories,  Chief  Inspector  of,  S. — Mr.  T.  S.  P.  Strangeways, 
Lond.  Cambridge ; Prof.  M.  J.  Stewart, 

G. — Mr.  T.  H.  Graham.  Edinburgh  ; Leeds;  Prof.  E.  G.  Slesinger, 

Major  H D.  Gillies,  R.A.M.C.;  Lond  : Dr.  W.  D.  D.  Small, 

Dr.  P.  O.  Gibson,  Lond.  Edinburgh  ; Scientific  and  In- 

H. — Capt.  H.  A.  Haig,  ll.A.M  C.;  dustrial  Research  Department, 
Dr.  J.  Haddon,  Denholm  ; Dr.  Lond  , Sec.  of. 

R.  C.  Holt,  Didsbury ; Mr.  J.  J.  T.— Mr.  G.  H.  Thring,  Lond.;  Dr. 
Hemming.  Margate.  W.  J.  Turrell.  Oxford. 

I. — India  Office.  Lond.;  Dr.E.C.  B.  V.— Dr.  P.  C.  Varrier- Jones,  Cam- 

Ibotson,  Corris.  bridge. 

J. — Dr.  J.  J.  Jervis,  Leeds.  W.— Sir  G.  Sims  Woodhead,  Cam- 

K.  — King  Edward  VII.  Welsh  bridge;  Sir  G.  Watson,  Lond.; 

National  Memorial  Association,  Dr.  J.  W.  White.  Glasgow ; Dr. 

Cardiff ; Miss  G.  Keith,  Loud.  L.  A.  We&therlv,  Bournemouth. 

Communications  relating  to  editorial  business  should  be 
addressed  exclusively  to  the  Editor  of  The  .Lancet, 

423,  Strand,  London,  W.C.  2. 


THE  LANCET,  September  13,  1919. 


THE 

tfjtttMmcli  fectures 

ON 

THE  PROBLEM  OF  HYGIENE  IN  EGYPT. 

Being  Three  Lectures  delivered  at  the  Summer  Session,  1019, 

By  ANDREW  BALFOUR,  C.B.,  C.M.G.,  M.D., 

DIRECTOR-IN-CHIEF,  WELLCOME  BUREAU  OF  SCIENTIFIC  RESEARCH  ; 
LATE  PRESIDENT,  EGYPTIAN  PUBLIC  HEALTH  COMMISSION. 


LECTURE  II.— THE  SOLUTION  OF  THE  PROBLEM: 
PAST  AND  PRESENT. 

In  our  last  lecture  we  considered  a number  of  the  more 
obvious  causes  which  go  to  make  up  the  problem  of  hygiene 
in  Egypt.  There  are,  however,  others  equally  important 
though  less  apparent  to  the  mere  onlooker,  which  are  best 
discussed  along  with  the  schemes  that  have  been  evolved  for 
dealing  with  as  difficult  a proposition  as  a sanitarian  was 
ever  called  upon  to  face. 

The  Share  of  the  Central  Government. 

For  the  benefit  of  those  not  familiar  with  the  Orient  it 
may  be  well,  in  the  first  place,  to  furnish  some  explanation 
of  the  predominant  share  which  the  Central  Government  has 
always  had  to  play  in  these  schemes  and  which,  as  you  will 
find,  has  been  allotted  to  it  in  these  lectures,  so  far  as  the 
perfecting  of  its  machinery  is  concerned. 

In  England  health  reform  is  pressed  upon  the  Government 
by  the  public  ; the  movement  originates  amongst  the  more 
intelligent  and  more  active  members  of  the  community ; 
it  is  explained  in  the  scientific  journals,  discussed  in  reviews 
and  the  public  press  ; books  are  published,  societies  formed, 
lectures  and  public  speeches  delivered,  deputations  to 
Ministers  arranged.  By  all  these  means  the  public  is 
aroused  to  the  necessity  of  action  and,  through  Parliament, 
pressure  is  put  upon  the  Government  to  introduce  legislation. 
When  at  last  legislation  is  obtained  it  is  largely  the  public, 
through  local  bodies,  societies,  the  medical  profession,  and 
public-spirited  individuals,  which  sees  to  its  enforcement  ; 
and  it  is  again  public  opinion  which  demands  its  extension 
and  amendment.  The  role  of  the  Government  lies  chiefly  in 
its  sympathetic  assistance  and  in  helping  to  obtain  uniformity 
in  administration. 

How  very  different  in  Egypt  1 There  the  position  is 
entirely  reversed.  Public  opinion  initiates  nothing,  demands 
nothing,  enforces  nothing.  If,  therefore,  any  advance  is  to 
be  made  in  public  health  it  is  the  Government  which  must 
call  attention  to  the  necessity  of  reform,  the  Government 
which  must  initiate  and  press  through  proposals,  the  Govern- 
ment which  must  try  by  education  to  overcome  the  inevitable 
opposition  caused  by  the  natural  conservatism  of  the  popu- 
lation. From  the  public  little  more  can  be  expected  than 
passive  acquiescence  in  the  proposals  of  the  Government.  A 
Central  Government,  therefore,  strong  enough  on  its  health 
side  to  influence  and  arouse  public  opinion,  to  stimulate 
lethargic  local  bodies,  and  to  demonstrate  the  usefulness  of 
health  measures  by  successful  experiment,  is  the  prime 
necessity  of  health  reform  in  Egypt. 

Pioneers  in  Sanitary  Reform. 

The  courageous  person  who  first  undertook  the  work  of 
reform  was  Clot  Bey,  a Frenchman,  who  in  1825,  under  the 
enlightened  rule  of  the  great  Mehemet  Ali,  established  a 
Board  of  Health,  which  was  chiefly  concerned  with  providing 
means  of  treatment  for  sick  and  wounded  civilians.  This 
speedily  led  to  the  founding  of  a School  of  Medicine  and 
Pharmacy  and  also  of  a Maternity  Hospital,  but  it  was  not 
until  1845  that  a Civil  Sanitary  Service  was  inaugurated  in 
addition  to  the  existing  Military  Sanitary  Service,  which 
dated  back  to  1820. 

About  this  time  it  would  appear  that  considerable  activity 
was  displayed  in  abating  nuisances.  Vaccination  was  largely 
practised  and  the  registration  of  deaths  was  efficient. 
Indeed,  a European  Commission  reported  favourably  on 
the  manner  in  which  the  sanitary  department  was  con- 
ducted, a fact  well  worth  remembering  by  those  pessimists 
who  are  inclined  to  say  Egypt  was  always  backward  and 

No.  50J.1. 


will  ever  remain  so.  It  is  significant  that  in  those  days,  for 
a period  of  more  than  12  months,  no  case  of  plague  or 
cholera  occurred  in  the  country. 

Unfortunately,  this  satisfactory  state  of  affairs  did  not 
continue,  and  at  the  time  when  Great  Britain  undertook  to 
rectify  and  control  the  administration  of  the  country  sani- 
tary matters  were  in  a lamentable  condition.  The  causes 
are  not  far  to  seek,  and  as  some  of  them  are  operative  in  the 
problem  of  to-day  they  may  be  briefly  noted. 

The  lethargy  of  the  East  played  an  important  part  ; 
corruption,  with  the  inevitable  cry  for  backsheesh,  was 
rampant ; ignorance,  indifference,  and  lack  of  recognition 
of  all  that  a sound  and  energetic  sanitary  policy  stands  for 
exerted  a baleful  influence.  In  addition,  the  finances  of 
Egypt  were  in  a most  parlous  condition,  and  there  was 
actually  very  little  money  available  for  health  measures.  In 
those  days,  also,  fanaticism  was  more  powerful  than  is  now 
the  case  and  it  was  difficult  to  remedy  the  state  of  the 
mosques,  which  was  often  deplorable  and  afforded  every 
facility  for  the  spread  of  disease. 

The  Department  of  Public  Health. 

In  1883  Mr.  Clifford  Lloyd  created  a Department  of  Public 
Health,  and  its  first  director  was  one  who,  in  later  days, 
delivered  the  Chadwick  lectures  with  much  acceptance, 
Dr.  F.  M.  Sand  with,  a man  who  ever  placed  duty  before 
self  and  who,  as  Lord  Milner  says,  “ was  got  rid  of  by  a 
rather  ignoble  intrigue  due  to  the  excessive  zeal  which  he 
had  shown  in  the  dismissal  of  corrupt  subordinates.” 
Sandwith,  however,  set  the  sanitary  ball  rolling,  and  though 
its  pace  slackened  a fresh  impetus  was  imparted  to  it  when 
Rogers  Pasha,  now  Sir  John  Rogers,  assumed  control.  He 
did  a great  deal  for  sanitation  in  Egypt,  and  his  successor. 
Sir  Horace  Pinching,  carried  on  the  good  work.  It  is 
unnecessary  to  enter  into  particulars  as  regards  the  various 
schemes  put  forward  and  completed  during  the  period 
when  these  two  able  administrators  fought  disease  and  death 
in  Egypt.  Our  theme  is  the  problem  at  the  present  time  for, 
despite  all  they  accomplished,  they  were  very  far  from 
attaining  anything  like  perfection,  and  those  who  followed 
them  found  plenty  to  do  and  left  plenty  to  be 
done.  At  the  same  time,  it  is  necessary  to  note  that 
the  cause  of  hygiene  was  helped  indirectly,  but  very 
effectually,  by  the  manifold  reforms  carried  through  in 
other  departments  of  the  Government  service.  The  fact 
that  Egypt  was  rescued  from  bankruptcy  and  became  finan- 
cially prosperous  aided  sanitation,  the  spread  of  education 
helped  it  in  large  measure,  the  great  development  of  public 
works,  and  especially  of  road-making,  water-supply,  and 
drainage  schemes,  assisted  enormously ; in  other  words, 
sanitation  shared  in  the  benefits  attending  the  general 
quickening,  as  must  ever  be  the  case.  It  is  essential  that 
the  hygienist  should  possess  a spirit  of  sweet  reasonableness 
and  recognise  that  money  expended  on  other  services  than 
his  own  may  often  be  regarded  as  chinking  in  the  sanitary 
coffers,  though  I admit  it  is  not  always  easy  to  cultivate  so 
philosophic  a spirit,  and  that  too  much  complacency  in  this 
direction  is  strongly  to  be  deprecated. 

Shortcomings  of  the  Administrative  Scheme. 

Bearing  all  these  points  in  mind,  and  remembering  that 
lethargy,  corruption,  ignorance,  indifference,  and  intrigue 
are  always  likely  to  hinder  sanitary  progress  in  Egypt,  as 
indeed  they  do  in  other  countries,  let  us  see  in  what  direc- 
tions the  lately  existing  scheme  of  health  administration— 
a scheme,  be  it  noted,  admirable  in  many  respects  and  the 
outcome  of  years  of  experience  and  labour— fell  short  of 
the  ideal  and  thereby  contributed  its  quota  to  the  causes 
which  we  are  considering. 

In  order  to  do  so  it  is  necessary  to  discuss  the  scheme 
itself,  and  I direct  your  attention  to  the  graph.  (Graph  1.) 
As  I have  indicated,  this  scheme,  or  rather  its  execution, 
has  gone  a long  way  towards  solving  health  problems  in 
Egypt,  and  in  its  discussion  attention  will  be  drawn  not  only 
to  its  shortcomings,  such  as  they  are,  but  to  its  virtues, 
while  points  which  may  be  obscure  to  those  unfamiliar  with 
the  land  of  the  Pharaohs  will  be  elucidated  so  far  as  this 
is  possible  in  the  time  at  our  disposal. 

It  will  be  seen  that  the  Department  of  Public  Health  is 
merely  a section  of  the  Ministry  of  the  Interior.  It  does 
not,  so  to  speak,  stand  on  its  own  legs.  In  “ Modern  Egypt  ” 
Lord  Cromer  devotes  a chapter  to  the  interior  and  a sub- 
sidiary chapter  to  its  three  sub-departments.  These  are  : 
L 


466  The  Lancet,] 


DR.  A.  BALFOUR : THE  PROBLEM  OF  HYGIENE  IN  EGYPT. 


[Sept.  13,  1919 


(1)  prisons  ; (2)  slavery  ; (3)  medical  and  sanitary  adminis- 
tration. There  in  a nut-shell  you  have  one  of  the  chief 
causes  of  the  problem  of  hygiene  in  Egypt — lack  of  adequate 
and  fitting  status  for  the  organisation  that  controls  the 
factors  governing  the  health  of  the  nation. 

Subordinate  Position  of  Sanitary  Administration. 

One  need  not  feel  surprised  that  so  notable  an  adminis- 
trator as  the  late  Lord  Cromer  was  content  with  such  a 
situation,  was  satisfied,  or  apparently  satisfied,  to  class  a 
great  sanitary  administration  along  with  the  sections  of 
Government  which  look  after  prisoners  and  slaves.  Lord 
Cromer  belonged  to  a school  which  was  not  greatly  concerned 
with  health  problems,  save  when  waves  of  epidemic  disease 
disturbed  their  peace  of  mind  and  the  well-being  of  the 
community.  Though  by  no  means  indifferent  to  medicine 
and  hygiene  and  a good  friend  to  the  scientist,  he  perhaps 
scarcely  realised  the  full  significance  of  sanitary 
work  in  such  a country  as  Egypt.  I am  quite 
certain  he  was  infinitely  more  interested  in  Greek  odes  than 
in  the  pathogenic  protozoa.  Small  blame  to  him.  The  day 
he  represented  is  only  now  passing  and  it  is  passing  slowly 
and  with  some  reluctance.  The  medical  profession  itself 
is  largely  the  cause  of  a conservatism  which  has  hindered 
progress  in  hygiene,  which  has  obscured  the  truth  enshrined  in 
Emerson’s  famous  dictum,  “ The  first  wealth  is  health.”  The 
Faculty  from  time  immemorial  has  been  much  more  interested 
in  the  cure  than  in  the  prevention  of  disease,  though,  to  its 
honour  be  it  said,  medicine  is  the  profession  above  all  others 
which  cuts  its  own  throat,  which  has  always  endeavoured 
to  efface  itself  by  following  an  unselfish  tradition.  But  it 
is  not  only  the  clinician  who,  by  indifference  and  lack  of 
interest,  has  put  his  spoke  in  the  sanitary  wheel.  The 
hygienist  himself  has  too  often  been  to  blame,  for  how  often 
has  he  asked  for  impossible  things  in  an  impossible  way  1 
His  outlook  has  frequently  been  narrow,  and  it  is  no  wonder 
that  men  like  Cromer,  who  were  accustomed  to  take  a wide 
survey  of  life  and  of  affairs,  who  had  to  weigh  the  claims  of 
many  applicants  for  money,  and  who,  in  addition,  could 
scarcely  be  expected  to  appreciate  fully  how  the  increase  of 
scientific  knowledge  had  placed  new  and  effective  weapons 
in  the  hands  of  the  sanitarian — it  is  not  surprising,  I say, 
that  such  men  were  a little  apt  to  be  suspicious  of  the 
enthusiastic  reformer  whose  constant  cry  was  that  if  he  only 
got  the  funds  he  would  achieve  hygienic  miracles. 

The  difficulties  of  the  administrator  in  this  respect  are 
well  set  forth  in  the  concluding  chapter  of  that  very 
interesting  book  by  Dr.  Malcolm  Watson  “Rural  Sanitation 
in  the  Tropics.”  Therein  he  quotes  the  very  words  of  the 
famous  Egyptian  Pro-Consul  to  good  effect.  It  is,  however, 
at  last  being  understood  that  the  welfare  of  a nation  is 
closely  bound  up  with  the  health  of  its  people.  Nowhere  is 
this  more  true  than  in  Egypt  and  nowhere  is  there  a greater 
necessity  for  establishing  a Ministry  of  Health.  In  this  con- 
nexion let  me  read  you  a portion  of  a valuable  memorandum 
on  the  subject  by  Dr.  Cyril  Goodman,  late  Assistant  Director- 
General  of  the  Egyptian  Public  Health  Department,  and  one, 
truth  to  tell,  who  is  much  better  qualified  to  deliver  these 
lectures  than  I am,  for  he  knows  Egypt  intimately  and  has 
done  much  to  guide  her  health  policy  along  sound  and 
practical  lines.  He  says  : — 

“ As  there  is  no  public  opinion  in  the  country  demanding 
health  reform  the  whole  of  the  driving  force  in  favour  of 
health  measures  must  come  from  within  the  Government 
itself,  or  rather  that  part  of  the  administration  charged  with 
public  health  duties.  The  progress  attained  is  directly  pro- 
portional to  the  influence  which  can  be  brought  to  bear  upon 
the  Government. 

“ As  at  present  constituted  the  Department  of  Public 
Health  has  no  direct  influence  upon  the  policy  of  the 
Government ; it  is  represented  neither  upon  the  Council  of 
Ministers  nor  upon  the  unofficial  Council  of  British 
Advisers  which  wjth  the  High  Commissioner  go  to  make 
up  the  somewhat  informal  system  of  government  in  Egypt. 
The  High  Commissioner,  except  in  so  far  as  he  is  con- 
trolled by  the  Foreign  Office,  is  possessed  of  supreme  autho- 
rity in  so  far  as  he  cares  to  exercise  it,  but  the  representa- 
tive of  the  Public  Health  Department  has  no  right  of  access 
to  him  to  press  forward  public  health  measures  or  to  oppose 
measures  detrimental  to  the  health  of  the  country. 

‘‘The  Public  Health  is  a subordinate  Department  classed 
with  and  often  below  the  Customs,  the  coastguards,  the 
Public  Lands  and  the  Survey  Departments,  which,  how- 
ever important  in  themselves,  have  very  little  concern  with 
the  public  policy  of  the  country.  The  result  of  this  system, 


or  lack  of  system,  is,  as  might  be  expected,  a reign  of  dis- 
organisation and  misunderstanding.  No  opportunity  is  ever 
offered  for  the  consideration  of  the  health  problem  as  a 
whole ; lack  of  coordination  between  the  various  depart- 
ments has  led  to  conditions  injurious  to  health  which 
might  have  been  easily  remedied  at  the  outset;  individual 
public  health  measures  are  presented  and  pressed  forward 
second-  and  very  often  third-  or  fourth-hand  or  not  presented 
at  all— killed  or  mutilated  for  some  unknown  reason  by 
some  unknown  official  of  the  superior  hierarchy ; measures 
with  a strong  public  health  bearing  are  discussed  and 
agreed  to  without  consultation  of  the  department,  which  is 
left  with  the  choice  between  silence  and  a belated  and 
irritating  protest.  In  short,  the  position  of  the  department 
is  very  much  that  of  an  indignant  subscriber  whose  only 
resource  if  he  disagrees  with  the  policy  of  his  paper  is  to 
write  a letter  of  protest  which  his  editor  may  or  may  not 
insert.” 

The  Burden  of  Petty  Detail. 

This  is  a serious  indictment  of  the  Government 
machinery,  but  I believe  it  to  be  fully  justified,  and  I 
should  say  that  this  cardinal  fault  of  lack  of  status  is 
the  chief  of  those  more  obscure  causes  which  to-day 
render  the  question  of  health  in  Egypt  as  paradoxical  as 
is  the  country  itself. 

In  the  past  the  Director-General  has  been  burdened  with 
petty  details,  a state  of  things  which  has  tended  to  prevent 
him  devoting  sufficient  attention  to  larger  questions  of 
policy  and  to  the  bearing  of  scientific  discovery  and 
progress  on  the  affairs  of  his  department.  No  separate 
section  of  medical  intelligence  has  been  available,  and 
though,  as  will  be  seen,  the  Director  of  the  Public  Health 
Laboratories  has  ably  filled  the  post  of  technical  adviser  in 
addition  to  his  other  duties,  it  is  essential  in  these  days  of 
rapid  change  and  widespread  activities  to  have  a properly 
organised  bureau  of  information  attached  to  every  large 
department  of  hygiene.  Egypt  has  suffered  from  the  want 
of  such  an  institution,  and  there  has  also  been  an  absence 
of  means  for  enlightening  both  Government  officials  and 
the  public  generally  as  to  the  nature  and  prevalence  of 
preventable  disease  and  the  measures  which  have  been  and 
should  be  taken  to  combat  it. 

Grouping  of  Sanitary  Administration. 

Turning  again  to  the  graph  and  the  Central  Administra- 
tion, we  see  that  there  are  four  chief  sections  of  work,  each 
controlled  by  a director.  These  are  the  sections  dealing 
respectively  with  general  sanitation,  with  hospitals,  with 
ophthalmic  hospitals,  and  with  epidemics.  It  is  necessary 
to  consider  them  briefly  in  detail. 

I.  Section  of  General  Sanitation. 

Probably  nobody  but  the  director  of  Section  I.  has  any 
real  conception  of  the  multifarious  duties  which  fall  to  his 
share  and  the  difficulties  with  which  he  is  constantly  beset. 
These  difficulties,  though  largely  due  to  the  presence  of  the 
Capitulations,  the  state  of  sanitary  law  in  Egypt,  and  in  some 
instances  to  the  flatness  of  the  land,  its  water-logged  condi- 
tion, and  the  comparative  scarcity  of  fuel,  are  also  caused  by 
an  overloading  of  the  section  with  matters  which  should  be 
dealt  with  elsewhere.  As  a result  the  ill-effects  arising  from 
a chronic  paucity  of  staff  are  intensified.  For  example,  a 
great  deal  of  the  work  concerned  with  cemeteries  is,  strictly 
speaking,  not  sanitary  work  at  all,  and  should  be  relegated 
to  the  State  Domains  Administration  or  at  the  present  time 
to  the  Survey  Department.  Later  on,  when  local  self- 
government  has  become  a power  in  the  land,  as  must  needs 
be  the  case,  the  municipalities  and  village  councils  will 
doubtless  assume  control  of  the  cemeteries  in  their  respective 
districts.  Anyone  versed  in  public  health  administration 
will  wonder  why  the  words  “ medico-legal  work  ” appear  on 
the  list  of  subjects  classed  under  general  sanitation,  and  no 
one  not  conversant  with  Egypt  could  read  the  riddle.  It  is 
no  use  saying  more  about  the  matter  here,  for  the  question 
is  intimately  bound  up  with  the  duties  of  the  Markaz  doctor, 
and  will  be  considered  when  we  discuss  the  role  which  that 
indispensable  person  plays  in  the  provincial  organisation. 

Prostitution  figures  in  the  list,  possibly  with  more  reason, 
for  at  last,  at  long  last,  the  nations  are  beginning  to  under- 
stand all  that  the  results  of  prostitution  cost  them  in  the  way 
of  expense,  inefficiency,  wrecked  homes,  disease,  degradation, 
and  death.  Still,  prostitution  is  so  intimately  bound  up  with 
venereal  clinics  and  hospital  treatment  that  its  sanitary 
control  is  undoubtedly  better  exercised  elsewhere  than  in  the 
company  of  offensive  trades,  insanitary  buildings,  drains, 


The  Lancet,] 


DR.  A.  BALFOUR:  THE  PROBLEM  OF  HYGIENE  IN  EGYPT.  [SEPT.  13,  1919  46? 


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o 


468  The  Lancet, J 


DR.  A.  BALFOUR  : THE  PROBLEM  OF  HYGIENE  IN  EGYPT. 


[Sept.  13,  1919 


water-supplies,  conservancy  arrangements,  and  all  the 
various  matters  which  are  sometimes  for  the  sake  of  con- 
venience, and  not  too  inaptly,  classed  as  nuisances.  A 
possible  objection  to  the  use  of  this  term  may,  however,  be 
found  in  the  fact  that  the  harassed  director  of  this  section 
would  often  gladly  extend  it  to  include  officials  of  the 
Ministries  of  Finance  and  Justice,  who,  possibly  through  no 
fault  of  their  own,  are  brought  sharply  into  conflict  with 
him. 

It  is  undoubtedly  along  the  lines  mentioned  in  this  section 
that  there  has  been  the  least  progress  in  the  past,  and 
it  is  probable  that  general  sanitation  presents  the  most 
difficult  of  all  the  problems  which  have  to  be  solved.  The 
hygiene  of  the  village,  of  the  native  quarters  in  the  cities 
and  large  towns,  the  destruction  of  flies  and  mosquitoes,  the 
control  of  food,  the  sanitary  regulation  of  buildings  are  all 
included  in  this  part  of  the  health  campaign  and,  as  has 
been  hinted  before,  it  is  no  easy  matter  to  hustle  the  East. 

II.  Section  of  General  Hospitals. 

Hospitals,  except  those  for  infectious  diseases,  do  not 
usually  come  under  a public  health  administration,  but  you 
will  see  that  Section  II.  embraces  general  hospitals,  dis- 
pensaries, and  maternity  schools.  The  department  whose 
work  we  are  considering  would  probably  in  other  countries 
than  Egypt  be  termed  the  Department  of  Medical  Services, 
for  it  is  concerned  with  all  matters  affecting  health.  It 
is,  I think,  to  the  credit  of  those  who  christened  it  that 
they  gave  it  a comprehensive  title  and  one  which  brings 
prominently  into  notice  the  hygienic  side  of  the  work.  It  is 
not,  however,  the  best  name.  That,  let  us  hope,  will  soon 
be  applied  and  will  entail  a radical  change  converting  the 
department  into  a ministry — a Ministry  of  Health. 

Most  of  the  general  hospitals  under  the  Public  Health 
Department  are  satisfactory,  but  there  are  not  enough  of 
them.  This  is  specially  true  in  the  case  of  the  larger 
provincial  towns.  The  hospital  is  no  longer  looked  upon 
with  dread  and  suspicion.  Not  so  long  ago  most  of  the 
lower  class  Egyptians  certainly  believed  that  a suitable 
hospital  motto  was:  “All  hope  abandon  ye  who  enter 
here,”  but  happily  that  day  is  past  and  now  the  cry  is  for 
more  beds  and  yet  more  beds.  Hospitals,  however,  cost 
money  and  there’s  the  rub  1 The  Central  Treasury  has  not 
a chest  of  bullion  like  the  widow’s  cruse,  and  yet  money 
must  be  found.  Here,  then,  is  another  problem,  the  only 
solution  of  which  lies  in  the  establishment  of  local  self- 
government  and  local  taxation  ; measures  still  in  their 
infancy  in  Egypt  but  capable  of  great  development. 

When  this  occurs  it  will  be  possible  to  provide  more 
permanent  hospitals  for  infectious  disease.  These  are  badly 
needed,  for  whatever  the  future  may  have  in  store,  it  will  be 
long  before  communicable  disorders  cease  to  be  one  of  the 
plagues  of  Egypt,  and  though  certain  of  them  are,  perhaps, 
best  treated  in  emergency  hospitals  others  require  the 
comfort  and  hygienic  surroundings  associated  with  a per- 
manent building.  Both  classes  of  hospital  suffer  to  some 
extent  from  a lack  of  sufficiently  frequent  and  skilled 
inspection.  Dispensaries,  and  more  particularly  children’s 
dispensaries,  are  amongst  the  most  useful  health  institutions 
in  Egypt,  but  there  are  far  too  few  of  them,  especially  con- 
sidering that  the  provision  for  children’s  beds  in  the  general 
hospitals  is  inadequate.  There  is  also  a lack  of  beds  for 
gynaecological  cases,  and  a great  need  for  women’s  out- 
patient clinics  throughout  the  country.  You  will  see  that 
maternity  schools  figure  in  the  list.  Tnere  are  six  of  these, 
but  that  number  is  not  sufficient.  Owing  to  the  harem 
system  in  Egypt,  the  proportion  of  maternity  cases  attended 
solely  by  midwives  is  very  high,  amounting  almost  certainly 
to  over  90  per  cent.,  and  at  present  the  training  of  the  dayas 
or  midwives  is  most  defective,  while  the  mumarridas,  though 
well  trained  in  nursing  and  midwifery  at  the  Kasr-el-Aini 
Hospital  in  Cairo,  have,  partly  as  the  result  of  having  long 
been  called  hakimas,  been  in  the  habit  of  practising  medicine 
as  well  as  midwifery,  and  certainly  require  to  have  their 
duties  defined  and  their  activities  controlled.  There  is  good 
reason  to  believe  that  they  often  pass  from  a case  of  infectious 
disease  to  a childbirth  without  taking  any  precautions  what- 
soever. The  result  of  such  a state  of  things  can  readily  be 
imagined. 

One  cannot  leave  the  question  of  children’s  dispensaries 
and  maternity  schools  without  paying  a tribute  of  admiration 
to  the  excellent  work  performed  by  the  inspectress  of  the 


Public  Health  Department  in  connexion  with  these  institu- 
tions. Taking  this  hospital  section  as  a whole,  it  may  be 
said  that,  while  a great  deal  has  been  accomplished,  it  yet 
furnishes  a good  many  of  the  causes  which  help  to  make  the 
health  problem  so  pressing  and  so  difficult  to  solve.  There 
are  errors  of  omission,  there  are  errors  of  commission,  and 
at  a later  date  we  will  consider  how  these  may  perhaps  be 
rectified  or  at  least  in  some  measure  minimised. 

III.  Seotion  of  Ophthalmic  Hospitals. 

Turning  to  Section  III.  we  find  we  are  again  concerned 
with  hospitals,  but  with  hospitals  of  a special  class.  We 
are  at  once  in  touch  with  a great  and  beneficent  charity, 
excellently  organised,  admirably  conducted,  which  has 
brought  relief  and  cure  to  thousands,  which  many  have  good 
reason  to  bless,  and  which  no  Britisher  can  study  without  a 
feeling  of  pride  and  satisfaction.  If  the  British  occupation 
of  Egypt  had  resulted  in  nothing  beyond  the  establishment 
of  the  ophthalmic  hospital  system,  it  might  still  have  been 
claimed  for  it  that  it  had  conferred  a great  boon  upon  the 
inhabitants. 

Prevalence  of  trachoma. — This  campaign,  however,  owed 
its  inception  to  private  philanthropy,  for  at  first  the 
expenses  were  defrayed  out  of  a fund  provided  by  Sir 
Ernest  Cassel.  This  was  in  1903,  and  prior  to  that  date 
practically  nothing  was  done  for  eye  diseases  in  Egypt, 
although  no  less  than  4£  per  cent,  of  the  total  population 
was  blind  in  one  or  both  eyes.  At  first  there  was  only  one 
travelling  hospital,  but  the  zeal,  energy,  and  skill  of  the 
director  soon  led  to  a much  larger  organisation,  and  at  the 
present  time  there  are  13  permanent  eye  hospitals  and  five 
travelling  hospitals,  with  a staff  of  29  doctors,  carrying  on  a 
most  beneficent  prophylactic  and  curative  work.  These  hos- 
pitals also  serve  as  training  centres  in  ophthalmic  surgery, 
and  many  medical  men  have  passed  through  the  post-graduate 
courses  held  in  them.  A visit  either  to  a permanent  or 
temporary  ophthalmic  hospital  is,  as  I can  testify,  full  of 
interest.  Women  and  children  form  the  greater  number  of 
the  patients  who  suffer  from  trachoma,  trichiasis,  corneal 
opacities,  cataracts,  and  indeed  every  form  of  eye  affection. 
Let  us  hope  that  those  who  have  still  their  sight  or  whose 
vision — praise  be  to  Allah  1— is  restored  benefit  from  what 
they  see  of  the  cleanliness,  smartness,  and  order  of  these 
model  hospitals.  The  people  flock  to  them,  81,000  patients 
being  now  treated  in  them  annually,  and,  best  sign  of  all,  for 
imitation  is  the  sincerest  flattery,  various  provincial  councils 
have  established  ophthalmic  hospitals  of  their  own,  while  the 
medical  service  of  the  Ministry  of  Waqfs,  a Ministry  which 
controls  large  funds  from  Moslem  sources  earmarked  for 
charitable  purposes,  possesses  a special  eye  hospital  at 
Kalaoun  in  Cairo.  As  the  sectional  director  reports,  “the 
provision  of  means  of  ophthalmic  relief  is  one  of  the  few 
things  besides  education  in  which  the  Egyptian  has  taken 
a keen  interest,  and  it  is  frequently  stated  in  native 
circles  that  the  provision  of  ophthalmic  hospitals  reflects 
more  credit  on  an  individual  or  group  of  individuals 
than  the  building  of  a mosque.”  All  this  is  very  gratifying, 
but  there  is  still  need  of  expansion.  The  provinces  of  Qena, 
Assuan,  and  Qaliubia  have  been  left  out  in  the  cold,  and 
there  the  poorer  classes  suffer,  and  have,  so  far,  little  chance 
of  remedy.  But  the  section  is  not  only  concerned  with 
hospital  work.  Its  activities  have  extended  to  the  Govern- 
ment primary  schools,  for  it  has  been  recognised  how 
important  it  is  to  obtain  trachoma  cases  at  an  early  stage  and 
cure  them  before  irremediable  damage  has  been  done. 
Actually  90  per  cent,  of  the  pupils  show  signs  of  the  disease 
either  in  an  active  or  passive  form.  The  pressing  question 
now  is  to  apply  the  same  methods  of  inspection  and  treat- 
ment to  the  kuttabs,  or  infant  schools.  It  will  cost  £E.40.000 
per  annum  to  do  so,  but  it  is  well  worth  the  money,  which 
should  be  obtainable  from  local  sources. 

Campaign  against  ankylostomiasis. — lTet  another  duty 
devolved  on  the  ophthalmic  section  when  at  the  instance  of 
the  late  Lord  Kitchener  it  undertook  a campaign  against 
ankylostomiasis  not  very  long  before  the  outbreak  of 
war.  As  the  Egyptian  Government  did  contribute  some- 
thing towards  the  expenses  of  this  campaign  the  Britisher 
may  perhaps  view  it  with  feelings  less  mingled  than  those 
with  which  he  regards  other  campaigns  against  the  hook- 
worm in  various  British  Colonies  and  Protectorates,  or, 
indeed,  that  waged  under  the  auspices  of  the  Church 
Missionary  Society  in  Egypt  itself.  In  this  case,  as  elsewhere 


The  LANOBT,] 


DR.  A.  BALFOUR:  THE  PROBLEM  OF  HYGIENE  IN  EGYPT.  [Sept.  13,  1919  469 


throughout  the  world,  Great  Britain  has  been  in  large 
measure  content  to  allow  its  American  cousins,  or  as  one 
now  might  almost  say,  brethren — brothers  in  arms  at  least — 
to  assume  its  responsibilities  and  to  do  work  which,  rightly 
speaking,  it  should  have  done.  Whatever  may  be  our  views 
as  regards  the  utility  of  the  methods  employed  (and  I may 
say  that  not  a few  believe  that  it  would  be  better  to  con- 
centrate attention  on  ankylostome  breeding  places  and  not 
on  the  victims  of  the  disease) — whatever  our  views,  all  honour 
must  be  ascribed  to  the  Rockefeller  Institute  for  what  it  has 
achieved,  not  only  in  the  States  and  in  countries  under  the 
Stars  and  Stripes,  but  in  British  Colonies  and  Protectorates. 
We  owe  it  a debt  of  gratitude,  but  surely  it  is  strange  that 
the  British  Empire,  which  is  not  lacking  in  millionaires  and 
which  stands  in  loco  parentis  to  hundreds  of  thousands  of 
sufferers  from  the  hook-worm,  should  complacently  accept 
this  gift  of  money  and  of  workers  from  America, 
and  do  little  more  than  afford  facilities  for  treatment 
and  research.  I confess  it  has  always  seemed  to  me  an 
attitude  unworthy  of  a world-wide  Empire  which,  thanks 
to  Sir  Patrick  Manson  and  the  presence  of  our  far-flung 
possessions,  was  the  pioneer  nation  in  the  study  and 
treatment  of  ' tropical  diseases.  Let  us  hope  that  once 
we  all  settle  down  this  reproach  will  be  removed,  and 
that  we  will  take  up  such  part  of  the  white  man’s  medical 
burden  as  rightly  falls  to  our  share. 

IV.  Section  of  Epidemic  Diseases. 

We  have  alreaiy  paid  a well-merited  tribute  to  the  efficiency 
of  Section  IV.,  which  controls  epidemic  disease,  and  from 
the  list  you  will  see  the  various  branches  of  the  work  with 
which  it  is  concerned.  Outbreaks  of  typhus  and  relapsing 
fever  are  seasonal  in  Egypt,  and  during  the  epidemic  season 
you  will  find  scattered  about  the  country  the  temporary 
hospitals  or  cordons  run  by  this  section.  They  are  simple 
structures,  but  are  well  designed  to  cope  with  emergencies  and 
they  combine  efficiency  with  economy.  There  can  be  no 
higher  praise.  Similar  hospitals  deal  with  plague  patients, 
while  this  section  has  a special  epidemic  staff  in  the 
provinces,  where  it  also  possesses  disinfectors  and  rat- 
catchers. 

Vaccination,  a most  important  duty,  fa'ls  to  its  share,  and 
it  is  ever  bustling  and  busy,  as  indeed  it  must  be,  for  the 
motto  when  dealing  with  epidemic  disease,  especially  in  a 
country  like  Egypt,  must  ever  be,  “Strike  early,  strike 
quickly,  and  strike  hard.” 

You  will  notice  that  pilgrims  and  passenger  control  figure 
in  the  list,  and  let  me  say  at  once  that  this  has  nothing  to 
do  with  international  quarantine.  The  coatrol  is  exercised 
over  all  passengers  arriving  from  cholera-infected  countries 
once  they  are  safely  ashore.  It  supplements  the  work  of  the 
International  Quarantine  Board,  of  which  it  is  convenient  to 
speak  here,  though  very  briefly.  It  will  be  remembered  in 
our  first  lecture  that  we  began  by  considering  the  part  which 
Egypt  plays  as  a filter  for  communicable  disease.  This 
filtering  action  has  in  the  past  been  conducted,  and  very 
well  conducted,  under  the  segis  of  a somewhat  heterogeneous 
body,  over  which  presided  for  many  years  a man  of  brilliant 
parts,  with  the  pentecostal  gift,  with  many  of  the  qualities  of 
genius  and  an  abundance  of  tact  and  discretion,  a man 
whom,  alas  1 the  sea  which  he  loved  so  well  and  with  which 
he  had  so  many  dealings  claimed  for  its  victim,  as  it  has 
claimed  so  many  in  the  late  war.  I refer  to  Sir  Armand 
Ruffer,  under  whose  guidance  the  Board  guarded  Egypt 
faithfully  and  well.  His  monument  is  El  Tor,  the  great 
quarantine  station  which  he  established  in  the  Sinai 
Peninsula,  and  where  he  encouraged  and  promoted  research 
work  upon  cholera,  plague,  and  dysentery.  In  addition,  the 
Board  carried  out  much  port  work  at  Abu  Saad  near  Jeddah, 
at  Suez,  at  Port  Said,  and  at  Alexandria.  It  may  be  said 
that  it  did  not  control  the  Hedjaz  railway,  which  had 
its  land  lazaret  at  Tebuk,  nor  did  it  look  after  Indian 
pilgrims,  for  whom  the  Indian  Government  provided  a 
quarantine  station  at  Camaran,  a station  wiped  out  by 
the  Turks. 

As  it  acted  under  the  terms  of  the  Paris  Convention  the 
Board  could  only  apply  quarantine  against  cholera-infected 
ports  and  not  countries,  and  yet  a port  might  be  free  and 
part  of  the  country  to  which  it  belonged  infected.  Hence 
the  Epidemic  Section  could  furnish  most  useful  help  by 
inspecting  and  registering  passengers  on  arrival  from  cholera- 
infected  countries.  Pilgrims  also  returning  after  quarantine 


at  El  Tor  were  dealt  with,  and  medical  officers  of  the  places 
to  which  they  were  returning  were  notified  so  that  surveillance 
could  be  instituted,  and,  if  necessary,  specimens  taken  for 
bacteriological  examination. 

Mulids  are  fairs,  and  great  nuisances  as  centres  of  infec- 
tion. The  other  items  do  not  call  for  special  notice  here. 
We  will  meet  with  the  barbers  in  due  course,  while  the 
P’rontier  District  Control  has  to  do  with  new  conditions- 
arising out  of  the  war. 

On  the  whole  it  may  be  said  that  this  section  rather  solves 
than  creates  problems.  It  saves  lives  and  it  saves  money, 
many  lives  and  much  money,  and  few  English  folk  in  Egypt 
outside  the  Public  Health  Department  know  much  about  it  or 
its  work.  The  village  Omdehs  and  Sheikhs,  however,  know 
all  about  it,  and,  I believe,  usually  appreciate  these  mush- 
room hospitals  of  wood  and  matting. 

Other  Services  : Public  Health  Laboratories. 

So  much  for  the  four  sections.  Of  the  other  services 
which  you  observe  also  form  part  of  the  central  administra- 
tion, 1 propose  to  consider  only  two,  the  Public  Health 
Laboratories  and  the  Inspectorate  of  Pharmacies. 

The  laboratories,  which  are  under  a most  capable  director, 
and  which  have  rendered  great  service  to  the  cause  of 
health  in  Egypt,  were  started  in  1896  by  Sir  John  Rogers, 
and  from  modest  beginnings  have  attained  respectable 
proportions.  There  is,  however,  a very  pressing  need  for 
an  extension  in  the  accommodation  provided,  especially  as 
regards  the  chemical  and  bacteriological  laboratories.  At 
present  there  is  no  protozoologist,  and  yet  the  pathogenic 
protozoa  play  no  unimportant  part  in  Egyptian  pathology, 
as  witness  Entamoeba  histolytica  and  Leishmania  tropica, 
the  causes  respectively  of  amoebic  dysentery  and  oriental 
sore. 

You  will  note  that  small-pox  vaccine  is  manufactured 
at  an  institute  attached  to  the  laboratories,  while  there  is 
also  an  Antirabic  Institute — a very  necessary  establishment 
in  a land  where  rabies  is  common  and  where  the  bites 
received  from  rabid  dogs,  wolves,  and  jackals  are  often 
facial  and  severe.  It  is  a very  interesting  place,  this 
institute,  with  its  crowd  of  patients,  mostly  blue-  or  black- 
garbed  fellaheen  or  ragged  slum-dwellers,  but  with  a 
sprinkling  of  all  classes  of  the  community.  The  dexterity 
with  which  the  inoculations  are  given  is  remarkable,  and 
many  patients  must  yearly  be  saved  from  the  horrors  of 
hydrophobia. 

The  Vaccine  Institute,  though  small  and  somewhat  archaic 
in  the  matter  of  special  apparatus,  is  well  run  and  fulfils  a 
very  useful  function.  Buffalo  calves  furnish  the  supply  of 
lymph  which,  from  the  results  obtained,  evidently  possesses 
good  immunising  powers.  In  a country  like  Egypt,  where 
small-pox  is  rife,  such  an  institution  is  essential  and  it 
should  be  kept  up  to  date  in  every  particular. 

Allowing  for  the  value  of  the  vaccine  lymph  produced, 
deducting  the  fees  paid  for  treatment  at  the  Antirabic 
Institute  and  those  received  for  analyses,  the  annual  upkeep 
of  these  excellent  laboratories  only  amounts  to  about 
£E.5000.  As  their  director  has  modestly  stated  : — 

“For  this  sum  the  Government  obtains  a reasonably 
efficient  bacteriological  and  chemical  service,  including  the 
following  regular  services:  1.  Bacteriological  diagnosis  for 
the  whole  of  Egypt  except  Alexandria.  2.  The  diagnosis 
work  of  the  city  of  Cairo.  3.  A regular  bacteriological  and 
chemical  control  of  the  Cairo  water-supplies.  4.  The 
analytical  work  of  the  Inspectorate  of  Pharmacies.  5.  All 
bacteriological  and  chemical  examinations  required  for  the 
General  Sanitation,  Epidemic,  and  Hospital  Sections  of  the 
Department  and  for  the  Cairo  Inspectorate,  the  work  for  the 
latter  including  a regular  milk  control  and  a bacteriological 
control  of  the  Cairo  aerated  water  and  ice  supplies.” 

Here  indeed  is  a worthy  record  of  work,  and,  in  addition, 
research  is  conducted  as  opportunity  offers,  while  the 
director  acts  as  scientific  adviser  to  the  department  which 
he  serves. 

The  Water-Control  Service,  which  comes  under  the 
Laborataries,  is  yet  in  its  infancy,  but  it  is  an  important 
development,  for  if  water  plays  a paramount  part  in  the 
well-beiDg  of  Egypt,  it  is  one  of  the  chief  sources  of  trouble 
from  a hygienic  and  economic  standpoint,  and  water-supplies 
everywhere  require  to  be  regularly  inspected  and  adequately 
controlled.  Moreover,  a careful  study  is  required  of  the 
manifold  problems  connected  with  drinking-water  in  Egypt. 

L 2 


470  Thh  Lanoet,]  DR.  T.  F.  COTTON:  OBSERVATIONS  ON  AORTIC  DISEASE  IN  SOLDIERS.  [Sept.  13,  1919 


Inspectorate  of  Pharmacies. 

It  is,  perhaps,  a little  surprising  to  see  an  inspectorate  of 
pharmacies  figuring  as  an  important  branch  of  public  health 
administration,  but  pharmacies  play  quite  a peculiar  part  in 
Egyptian  life,  and  many  of  them  require  close  supervision. 
Some  day  someone  may  write  a romance  of  Egypt  with 
pharmacies  well  in  the  foreground.  It  is  doubtful  if  per- 
mission could  be  obtained  for  the  publication  of  such  a work, 
but  if  it  ever  saw  the  light  of  day  what  tales  would  be 
forthcoming  about  the  smuggling  of  forbidden  drugs,  about 
opium  and  cocaine,  about  the  sale  of  aphrodisiacs,  aborti- 
facients,  and  patent  medicines,  about  the  trade  in  spices  and 
perfumes,  about  poisons,  and  especially  those  grown  in  Egypt, 
such  as  hyoscyamus  and  datura.  All  kinds  of  abuses  exist, 
for  pharmacists,  ignorant  of  medicine,  usurp  the  duties  of  the 
medical  man,  and  drugs  are  adulterated  or  tampered  with  to 
the  detriment  of  purchasers.  The  Inspector  of  Pharmacies 
has  his  own  problems  to  face,  and  he  will  be  greatly  helped 
when  the  Capitulations  are  abolished,  when  new  legislation 
is  introduced,  when  private  laboratories  are  better  controlled, 
when  facilities  for  the  inspection  of  pharmacies  are  increased, 
and  when  an  official  pharmacopoeia  is  duly  recognised  in 
Egypt. 

Severance  op  Provincial  Organisation. 

The  graph  (No.  1)  would  seem  to  indicate  that  our  proper 
course  would  now  be  to  discuss  the  provincial  organisation, 
but  before  doing  so  it  is  necessary  to  point  out  that  of  late 
years  the  Public  Health  Department  has  suffered  some  loss 
in  efficiency  through  a tendency  towards  the  severance  of 
certain  of  its  services  from  the  Central  Administration. 
In  addition,  some  government  medical  services  in  Egypt 
have  never  been  within  the  fold.  As  examples  of  these 
statements  I may  cite  the  medical  services  of  the  railways, 
police,  prisons,  and  coastguards,  and  what  is  known  as  the 
Central  Medical  Commission,  which  is  concerned  with  the 
medical  examination  of  candidates  for  Government  posts. 

As  the  special  Public  Health  Commission  reported  last 
July  : — 

“ A department  like  that  of  Public  Health  may  be  likened 
to  one  of  the  Great  Powers  with  many  possessions.  So  long 
as  the  central  grip  is  firm  and  the  responsibilities  fully 
recognised  the  component  parts  will  remain  united,  but  the 
first  sign  of  decadence  and  weakness  is  often  a tendency 
towards  disruption." 

The  proposals  submitted  for  checking  this  tendency  and 
remedying  the  existence  of  this  state  of  affairs  will  be  dealt 
with  in  due  course.  Meanwhile,  it  seems  advisable  to  say  a 
few  words  about  the  municipalities  and  local  commissions 
which,  with  the  provincial  councils  to  which  passing  refer- 
ence has  been  made  and  which  are  like  county  councils  in 
England,  form  the  hope  of  local  self-government  and  town 
development  in  Egypt.  On  this  account  it  is  upon  them 
also  that  the  responsibility  of  grappling  with  many  sanitary 
problems  will  assuredly  fall. 

I unctions  of  Municipalities. 

Time  will  not  permit  an  historical  survey  of  the  foundation 
and  progress  of  the  municipalities  and  local  commissions  ; 
they  come  under  the  Ministry  of  the  Interior,  but  are  quite 
distinct  and  separate  from  the  Public  Health  Department. 
Yet  they  are  largely  concerned  with  sanitary  engineering 
and  with  public  works  which  have  a distinct  bearing  on  the 
health  of  the  people — such  works,  for  instance,  as  the  care 
and  maintenance  of  roads  and  cemeteries,  water-supply, 
scavenging,  and  the  superintendence  of  slaughter-houses. 
They  are  also  concerned  with  lighting,  and  let  it  always  be 
remembered  that  a dark  town  is  a dirty  town  in  more  ways 
than  one.  The  municipalities  exercise  their  functions  in 
some  of  the  larger  provincial  towns,  the  local  commissions 
in  35  of  the  smaller  towns  of  Egypt.  They  are  in  some  ways 
analogous  to  municipal  councils  and  town  councils  in  this 
country,  and  are  administered  in  an  able  manner  by  a 
British  director,  who  happens,  fortunately,  to  be  a medical 
man.  Already  they  have  accomplished  much  good  work, 
some  of  which  we  shall  look  at  ia  a moment,  and,  consider- 
ing the  ever-incfreasing  burden  of  expense  in  public  health 
matters,  a load  which  no  Central  Treasury  can  possibly 
shoulder,  it  is  clear  that  the  municipalities  and  local  com- 
missions must  remain  apart  and  form  the  nucleus  of  a future 
scheme  whereby  the  municipalities  will  manage  their  own 
health  affairs  under  the  guidance  and  advice  of  the  Ministry 
of  Health. 


OBSERVATIONS  ON  AORTIC  DISEASE  IN 
SOLDIERS. 

By  THOMAS  F.  COTTON,  M.D.  McGill. 

(A  Report  to  the  Medical  Research  Committee.') 


During  the  past  winter  an  unusually  large  number  of 
soldiers  presenting  signs  of  aortic  disease  were  admitted  to 
the  Sobraon  Military  Hospital,  Colchester.  The  majority  of 
these  were  young  men  who  had  been  passed  fit  for  general 
service,  and  all  but  a few  had  seen  active  service  abroad. 
The  opportunity  seemed  a favourable  one  for  making  a 
careful  study  of  the  symptoms  associated  with  this  form  of 
cardiac  affection,  and  their  significance  ; and  of  the  signs 
used  to  recognise  this  valvular  defect,  and  their  value  in 
estimating  the  stage  of  development  of  the  disease. 

Analysis  of  50  Case  Histories. 

In  dealing  with  the  symptoms  I have  analysed  the  case 
histories  of  50  soldiers  with  signs  of  aortic  insufficiency.  All 
of  them  were  submitted  to  a complete  physical  examination, 
and  the  description  of  the  signs  is  based  on  this  examination. 
The  exercise  tolerance  was  determined  in  these  50,  and  17 
others,  by  observing  their  reaction  to  a simple  exercise  test  ; 
in  8,  graded  exercises  as  employed  in  the  treatment  and 
sorting  of  the  D.A.H.  cases,  were  used  as  a test  of  physical 
fitness.  The  histories  which  these  men  have  given  throw 
considerable  light  upon  the  causation  of  the  symptoms  which 
they  complain  of.  If  they  can  be  interpreted  as  symptoms 
arising  not  from  loss  of  cardiac  reserve,  and  can  be  explained 
by  some  other  cause  than  the  valvular  defect,  then  the 
difficult  task  of  forecasting  the  future  welfare  of  the  patient 
suffering  from  this  heart  malady  becomes  an  easier  one. 

I am  not  concerned  here  with  the  causation  of  the 
symptoms  in  patients  with  advanced  aortic  disease.  These 
observations  refer  to  a group  of  soldiers  with  an  average  age 
of  31  years  ; men  who  have  been  in  the  Army  for  an  average 
period  of  2 years  and  7 months,  including  1 year  and 
7 months’  military  service  overseas.  These  men  presented 
no  signs  of  venous  engorgement,  and  the  pain  which  they 
complained  of  was  not  anginal  in  character  or  distribution. 

In  30  the  average  duration  of  symptoms  was  1 year  and 
7 months ; in  12  the  symptoms  extended  over  a,  longer 
period,  and  were  present  before  enlistment.  Half  of  these 
had  been  in  the  firing  line,  4 had  not  been  abroad,  and  with 
the  remainder  only  light  duty  at  the  base  bad  been  per- 
formed. Before  enlistment  the  occupation  had  been  a heavy 
one  in  36  per  cent.,  moderately  heavy  in  41  per  cent. ; and 
light  work  only  in  23  per  cent. ; 62  per  cent,  played  games 
such  as  football,  cricket,  and  tennis  before  enlistment.  Only 
12,  or  27  per  cent.,  gave  a history  of  rheumatic  fever,  a very 
low  incidence.  One  gave  a history  of  syphilis.  In  35  the 
complement-fixation  test  was  done,  and  of  these  the  reaction 
was  positive  in  8,  or  23  per  cent. ; all  of  these  8 were  over 
the  age  of  40  but  one,  who  was  22. 

Determination  of  Exercise  Tolerance. 

In  27  of  those  with  slight  incompetence  and  16  with 
free  regurgitation  the  exercise  tolerance  was  determined 
by  observing  the  response  after  a brisk  walk  up  and  down  20 
steps  twice.  Distress  after  the  effort  accompanied  by  a rapid 
pulse-rate  with  a slow  return  to  the  pre-exercise  rate  were 
considered  signs  of  poor  exercise  tolerance.  H there  were 
no  complaints,  and  no  obvious  signs  of  distress,  with  a 
moderate  increase  of  pulse-rate,  and  a quick  return  to  the 
pre-exercise  rate — i.e.,  less  than  two  minutes — the  reaction 
was  looked  upon  as  good.  In  24,  12  with  slight  incompetence 
and  12  with  free  regurgitation,  the  symptoms  alone,  after 
the  same  exercise  test,  were  used  in  estimating  the  physical 
fitness ; the  pulse-rates  were  recorded  in  these  with  a 
Mackenzie  polygraph  for  five  minutes  before  the  exercise 
with  the  patient  sitting,  and  the  average  was  taken  as  the 
pre-exercise  rate  immediately  after  the  effort,  and  at  the 
end  of  two  minutes.  In  those  of  the  first  group,  where  the 
tolerance  was  determined  by  the  symptoms  and  the  pulse- 
rate.  14  with  slight  incompetence  of  the  aortic  valve  had 
good  exercise  tolerance,  and  the  average  pulse-rates  were  77 
before  the  test,  128  immediately  after,  and  78  at  the  end  of 
two  minutes;  13  had  poor  exercise  tolerance, and  the  average 
pulse-rates  were  93,  157,  109  ; 10  with  free  regurgitation  had 
good  exercise  tolerance,  and  the  pulse-rates  72,  123,  81 ; 
6 had  poor  tolerance,  and  the  rates  were  84,  166,  113. 
Of  the  second  group,  with  the  tolerance  determined 
by  the  svmptoms  alone.  8 with  slight  incompetence 
had  good  exercise  tolerance,  with  average  pulse-rates 
of  82,  132,  85 ; 4 had  poor  tolerance,  and  the  rates  were 


The  Lanobt,]  DR.  T.  F.  COTTON:  OBSERVATIONS  ON  AORTIC  DISEASE  IN  SOLDIERS.  [Sept.  13,  1919  471 


97,  139,  105  ; 5 with  free  regurgitation  had  good  exercise 
toleranoe,  with  average  pulse-rates  of  89, 137,  94  ; 7 had  poor 
tolerance,  and  the  rates  were  99,  153,  120.  If  these  two 
groups  are  combined,  it  will  be  seen  that  of  the  39  early  cases 
the  reaction  is  good  in  22,  and  the  average  pulse-rates  are 
79,  130,  81 ; the  reaction  is  poor  in  17,  and  the  pulse-rates  are 
94,  153, 108  ; 28  had  free  regurgitation,  with  good  tolerance  in 
15,  and  pulse-rates  of  77,  127,  86 ; 13  poor  tolerance,  and 
pulse-rates  of  92, 159,  116. 

Diagrammatic  Representation  of  Results. 

In  the  diagrams  I have  plotted  these  average  pulse-rates. 
In  Diagram  T.  the  broken  line  and  the  line  with  the  circles 
represent  the  average  pulse-rates  of  the  27  early  cases,  with 
the  tolerance  determined  by  the  symptoms  and  the  pulse- 
rate  ; the  unbroken  line  and  the  line  with  the  black  dots 
represent  the  pulse-rates  of  the  16  with  free  regurgitation 
and  the  tolerance  determined  in  the  same  way.  The  figures 
at  the  side  are  the  pulse-rates.  Where  the  tolerance  is  good 
the  summits  of  the  curves  are  at  approximately  the  same 
height,  and  at  a much  lower  level  than  those  with  poor 
tolerance  ; the  actual  increase  in  rate  after  effort  is  the  same. 


tolerance  is  good  in  56  per  cent,  of  the  former  and  54  per 
cent,  of  the  latter.  When  a comparison  is  made  of  the 
exercise  tolerance  in  all  with  aortic  disease  55  per  cent,  are 
found  to  have  good  tolerance  and  45  per  cent,  poor  tolerance. 
When  the  tolerance  of  the  67  with  aortic  disease  is  com- 
pared with  that  of  25  unselected  D.A.H.  cases,  55  per  cent, 
of  those  with  valvular  disease  are  found  to  have  good 
tolerance,  as  against  56  per  cent,  of  those  with  D.A.H, 

The  points  which  I desire  to  make,  and  which  I think 
these  observations  on  exercise  tolerance  clearly  show,  are 
these : aortic  disease  is  compatible  with  good  exercise 
tolerance ; when  there  is  an  equal  degree  of  distress  after 
effort  the  increase  in  pulse-rate  is  the  same  in  patients 
with  slight  aortic  incompetence,  in  aortic  disease  with  free 
regurgitation  where  there  is  no  venous  congestion,  and  in 
D.A.H.  cases  in  whom  there  are  no  signs  of  structural 
disease. 

Three  Types  of  Aortic  Disease. 

By  the  symptoms  alone  aortic  disease  may  be  divided  into 
three  types  : (1)  aortic  disease  without  symptoms  ; (2)  aortic 


Composite  diagram  showing  average  pulse-rates  before  exercise,  immediately  after,  and  at  the  end  of  two  minutes.  The  broken  line  ( ) 

indicates  slight  regurgitation  aud  good  tolerance;  the  line  with  circles  ( -o ) indicates  slight  regurgitation  and  poor  tolerance;  the 

continuous  line  ( ) indicates  free  regurgitation  and  good  tolerance  ; the  line  with  black  dots  ( — ■ ) indicates  free  regurgitation 

and  poor  tolerance.  I.  Tolerance  determined  by  symptoms  and  pulse-rate.  II.  Tolerance  determined  by  symptoms  alone.  III.  Curves  I. 
and  II.  combined.  IV.  Aortic  disease,  including  those  with  slight  regurgitation  and  free  regurgitation,  with  tolerance  determined  as  in 
I.  and  II.  and  D.A.H.  (the  broken  line  and  the  line  with  circles  indicate  the  D.A.H.  cases ; the  continuous  line  and  the  line  with  black  dots 
indicate  those  with  aortic  disease). 


When  the  tolerance  is  poor  the  increase  in  rate  is  consider- 
ably greater  than  in  thgse  with  good  tolerance,  and  the  rate 
is  at  a higher  level  in  those  with  free  regurgitation  than  in 
the  early  cases. 

In  Diagram  II.  the  pulse-rates  are  those  of  the  24  with  the 
tolerance  determined  by  the  symptoms  alone.  The  summits 
of  the  curves  are  slightly  higher  than  in  Diagram  I.  when 
the  tolerance  is  good,  and  at  a lower  level  when  the  tolerance 
is  poor.  The  high  points  are  not  so  far  apart,  and  the  peaks 
are  lower  in  those  with  poor  tolerance  than  in  Diagram  I. 

In  Diagram  111.  I have  combined  Diagrams  I.  and  II. 
In  those  with  good  tolerance  the  peaks  are  low  and  the  rise 
is  the  same.  In  those  with  poor  tolerance  the  peaks  are 
considerably  higher,  with  a greater  rise  after  effort  in  those  - 
with  free  regurgitation,  and  a fall  after  two  minutes  which 
does  not  reach  the  pre-exercise  rate. 

In  Diagram  IV.  I have  plotted  the  pulse-rates  before  and 
after  exercise  of  67  patients  with  aortic  incompetence — 37 
with  slight  regurgitation  and  30  with  free  regurgitation  ; 
and  also  the  pulse-rates  after  the  same  exercise  of  25 
unselected  D.A.H.  cases,  with  the  exercise  tolerance  deter- 
mined by  the  symptoms  alone,  and  the  pulse-rates  recorded 
with  a Mackenzie  polygraph.  In  those  with  good  tolerance 
the  pulse-rate  rises  to  approximately  the  same  height,  both 
in  the  D.A.H.  case  and  in  the  patient  with  aortic  disease, 
and  at  a much  lower  level  than  in  those  with  poor  tolerance. 
When  the  tolerance  is  poor  the  level  is  slightly  higher  in 
those  with  D.A.H.,  and  the  fall  about  the  same  after  two 
minutes. 

In  those  with  slight  incompetence  of  the  aortic  valve,  as 
compared  with  those  with  free  regurgitation,  the  exercise 


disease  with  a group  of  symptoms  which  we  term  “the 
effort  syndrome  ” ; (3)  aortic  disease  with  venous  engorge- 
ment or  angina  pectoris. 

With  aortic  disease  of  the  first  type  there  are  no  sym- 
ptoms, and  the  condition  is  recognised  by  the  signs  alone. 
Fully  developed  incompetence  of  the  aortic  valves  is  com- 
patible with  good  exercise  tolerance  ; the  severest  form  of 
exercise  can  be  performed  without  greater  distress  than 
that  observed  in  a healthy  untrained  subject.  The  extra 
load  put  upon  the  heart  by  the  reflux  of  blood  through  the 
defective  valve  is  cared  for  by  the  large  reserve  power  which 
a healthy  or  slightly  damaged  myocardium  possesses.  Not 
until  the  cardiac  muscle  has  been  sufficiently  impaired — for 
example,  through  coronary  or  myocardial  disease — does  the 
heart  fail  to  bear  the  extra  work  put  upon  it,  and  with  the 
exhaustion  of  its  reserve  give  rise  to  the  symptoms  of  heart 
failure.  The  uncomplicated  valvular  defect,  the  simple 
crumpling  of  the  aortic  cusps,  is  not  in  itself  of  great 
consequence.  The  reason  that  in  so  many  aortic  disease 
leads  to  heart  failure  is  that  the  coronary  arteries,  or  the 
myocardium,  or  both,  have  been  damaged  by  the  same  agent 
that  has  caused  the  valve  defect. 

The  second  type  presents  the  effort  syndrome  group  of 
symptoms.  Breathlessness  on  exertion  is  always  present  ; 
this  respiratory  distress  is  provoked  by  an  effort  which,  in 
a healthy  person,  would  not  be  complained  of.  It  is  absent 
at  rest  save  in  rare  instances.  Occasionally  it  is  noticed  at 
night  in  bed,  and  is  described  as  a choking  sensation,  a 
feeling  of  suffocation  ; it  is  sudden  in  onset  and  of  short 
duration.  This  is  not  to  be  confused  with  the  nocturnal 
breathlessness  due  to  deficient  aeration  of  the  lungs,  nor 


472  The  Lancet,]  DR.  T.  F.  COTTON:  OBSERVATIONS  ON  AORTIC  DISEASE  IN  SOLDIERS.  [Sept.  13,  1919 


the  paroxysmal  dyspnoea  of  relative  acidosis  in  cardio-renal 
disease.  It  is  as  frequently  met  with  in  the  effort  syndrome 
case  where  there  are  no  signs  of  structural  disease. 
Palpitation  is  a common  complaint.  When  provoked  by 
exercise  it  is  felt  after  the  effort ; it  is  associated  with  an 
overacting  heart  and  persists  as  long  as  the  excessive 
heart-rate  is  maintained.  Emotional  stimuli — excitement, 
fear,  pain,  joy,  &c. — give  rise  to  the  same  sym- 
ptom. Palpitation  is  complained  of  by  many  in  bed 
at  night  ; often,  but  not  always,  it  is  noticed  when  the 
patient  lies  on  the  left  side,  and  disappears  with  a change  of 
position.  In  some  way  it  is  related  to  the  breathlessness  at 
night  for  the  two  symptoms  often  occur  together.  Giddiness 
is  present  in  many.  Sometimes  it  is  felt  after  exercise,  as 
often  with  change  of  position,  as  in  bending  or  suddenly 
assuming  the  erect  posture.  In  a few  there  is  experienced 
in  bed  at  night  a peculiar  sinking  feeling,  a sensation  of 
falling  through  the  bed  or  floor,  or  actual  loss  of  sense  of 
position,  quite  like  the  giddiness  produced  by  effort. 
Observations  upon  the  blood  pressure  and  pulse-rate  have 
been  made  to  explain  this  condition.  This  symptom  is 
caused  in  some  way  by  an  altered  cerebral  circulation  ; the 
mechanism  by  which  it  is  produced  has  not  been  determined. 
Pain  is  an  important  feature  of  the  disease.  It  may  occur 
after  effort,  but  it  is  often  felt  at  rest ; occasionally  it  is  com- 
plained of  at  night.  Some  describe  it  as  a stitch  in  the  left 
chest,  or  a sharp  cutting  pain  in  the  region  of  the  left  costal 
border,  over  the  heart,  or  in  the  back,  while  others  have  a 
dull  boring  pain,  or  soreness  over  the  precordium.  Exhaus- 
tion after  effort  is  much  greater  than  that  experienced  by  a 
healthy  individual,  and  lassitude  in  the  morning  is  a 
common  complaint.  Headaches  are  frequent  ; they 
occur  in  the  morning,  and  are  usually  frontal  in  situa- 
tion. Sweating,  flushing,  mental  irritability  or  depres- 
sion, are  less  constant  symptoms.  The  hands  are  cold, 
clammy,  cyanosed,  and  often  tremulous,  and  drops  of 
sweat  run  down  from  the  axillae.  These  are  the  symptoms 
observed  in  soldiers  with  aortic  disease  before  venous  engorge- 
ment has  made  its  appearance.  Briefly,  the  symptoms  in 
D.A.H.  so-called  and  in  the  aortic  cases  are  identical,  indis- 
tinguishable the  one  from  the  other.  How  are  they  produced 
in  the  aortic  cases?  If  the  symptoms  in  aortic  disease  of 
this  type  arise  from  cardiac  weakness,  and  are  caused  by 
cardiac  inefficiency ; if  they  are  to  be  explained  by  the 
inability  of  the  heart  to  carry  on  its  work  from  myocardial 
weakness,  and  the  added  load  put  upon  it  by  the  reflux  of 
blood  from  a defect  in  the  aortic  valve  ; if  that  is  the  true 
explanation  it  is  difficult  to  account  for  the  symptoms  in  the 
D.A.H.  case  where  we  find  no  signs  of  structural  heart 
disease.  It  might  be  thought  that  the  two  groups  differ  in 
their  onset  of  symptoms.  Now  the  symptoms  in  aortic 
disease  arise  from  a variety  of  causes.  They  appear  in  a 
large  number  after  an  acute  infection — after  rheumatic 
fever,  pneumonia,  bronchitis,  trench  fever,  malaria,  and 
dysentery.  In  some  gas  poisoning  is  the  agent,  in  others 
shell  shock  ; some  date  their  symptoms  from  a severe  effort ; 
in  others  the  symptoms  are  gradual  in  their  onset  and  cannot 
be  associated  with  any  particular  cause.  But  with  the 
D.A.H.  case  the  onset  of  symptoms  are  as  I have  described 
for  aortic  disease  ; acute  infections,  gassing,  shell  shock, 
effort,  and  conditions  of  active  service  or  civil  life,  all  have 
the  same  {etiological  significance  ; this,  we  all  agree,  has 
been  established.  It  seems  fair,  then,  to  ascribe  the 
symptoms  in  the  group  of  aortic  cases  to  the  same  causes, 
when  there  is  an  equally  clear  history.  Do  not  misunder- 
stand me.  I do  not  speak  of  the  causes  of  aortic  disease  ; I 
am  dealing  now  only  with  the  ascribed  causes  of  the 
symptoms.  In  both  the  provocative  agents  are  the  same, 
and  in  both  the  symptoms  are  identical.  Here  let  me  add 
one  word  about  the  {etiology  of  the  two  conditions  ; the 
incidence  of  rheumatic  fever  is  much  higher  in  aortic  disease 
in  those  under  the  age  of  40  than  in  D.A.H.,  and  the 
incidence  of  syphilis  is  higher  in  disease  of  the  aorta  over  the 
age  of  40.  I have  referred  at  some  length  to  the  similarity 
of  the  symptoms  in  the  two  groups.  I do  so  because  I wish 
to  give  you  the  view  which  we  who  have  worked  at  Colchester 
hold  ; that  the  symptoms  of  early  aortic  disease  in  soldiers 
are  not  produced  by  the  extra  work  put  upon  the  heart  by 
the  valvular  defect,  but  are  due  to  the  same  causes  as 
are  the  symptoms  in  D.A.H.  In  other  words,  that 
disease  of  the  aortic  valve  in  itself  gives  rise  to  no 
symptoms. 


Now  of  aortic  disease  of  the  third  type , where  there  is 
venous  engorgement  or  angina  pectoris,  I shall  be  very  brief. 
They  are  not  the  symptoms  of  aortic  regurgitation  but  those 
of  heart  failure.  With  venous  engorgement  we  have  the 
symptoms  of  venous  stasis  in  the  pulmonary  circulation  on 
the  one  hand — cyanosis,  orthopnoea,  and  pulmonary  conges- 
tion ; and  on  the  other,  the  symptoms  arising  from  the 
failure  of  the  heart  to  maintain  the  general  circulation — - 
oedema  of  the  extremities,  general  anasarca  with  disturb- 
ance of  the  renal  and  other  abdominal  visceral  functions, 
cerebral  manifestations,  and  the  final  moribund  state  of  the 
human  organism.  Of  the  characteristic  picture  of  angina 
pectoris  in  advanced  aortic  disease,  I shall  only  say  that 
it  is  rarely  seen  in  the  presence  of  venous  engorgement, 
with  enlargement  of  the  liver,  and  with  the  onset  of  dropsy 
the  pain  disappears. 

The  Value  of  Physical  Signs. 

I have  dealt  only  with  symptoms  and  their  significance  in 
aortic  disease.  The  signs  are  equally  important,  for  they 
are  the  guide  to  diagnosis,  and  assist  us  in  prognosing  the 
future  life  of  the  patient.  By  the  signs  alone  are  we  able 
to  diagnose  incompetence  of  the  aortic  valve.  They  may 
be  classified  as  signs  of  slight  insufficiency  of  the  aortic 
valve,  and  signs  of  aortic  incompetence  with  free  regurgita- 
tion. When  the  disease  has  sufficiently  advanced,  and 
heart  failure  has  set  in,  then  new  signs  are  added.  The 
most  constant  sign  by  which  we  can  recognise  early  aortic 
disease  is  a diastolic  murmur.  This  murmur  is  best  heard 
at  the  left  border  of  the  sternum  at  the  level  of  the  third 
rib  or  third  intercostal  space.  When  heard  over  the  aortic 
cartilage  it  is  more  distant ; the  diagnosis  may  have  to  be 
made  when  no  murmur  is  heard  over  this  area.  During 
this  stage  of  the  disease  the  heart  may  be  slightly  enlarged  ; 
frequently,  however,  there  is  no  increase  in  the  area  of 
relative  cardiac  dullness.  The  pulse  is  not  collapsing  ; there 
is  no  conspicuous  pulsation  of  the  carotids  or  the  brachial 
arteries  ; and  the  blood  pressure  range  is  within  normal 
limits.  With  the  development  of  free  regurgitation  chief 
reliance  should  be  placed  upon  the  character  of  the  pulse  : 
the  collapsing,  water-hammer,  or  corrigan  pulse.  There  is 
throbbing  of  the  carotids  and  brachials,  capillary  pulsation 
is  always  present,  the  pistol  shot  phenomenon  is  commonly 
present,  the  systolic  blood  pressure  is  higher  and  the 
diastolic  is  relatively  low,  and  there  is  material  enlargement 
of  the  heart.  When  venous  engorgement  occurs  the  signs  of 
venous  stasis  are  added.  With  the  progress  of  the  disease 
the  heart  increases  in  size,  its  area  of  relative  cardiac 
dullness  may  extend  to  the  anterior,  mid-axillary  line,  or 
further.  It  is  generally  held  that^the  dilatation  and  hyper- 
trophy is  mainly  that  of  the  left  ventricle,  and  is  produced 
by  the  extra  work  put  upon  this  chamber  by  the  reflux  of 
blood  through  the  incompetent  aortic  valve.  Now  the 
signs  by  which  we  recognise  car^jac  enlargement  are  an 
uncertain  indication  of  the  preponderating  hypertrophy  in 
one  or  other  ventricle.  Increase  in  cardiac  dullness  to  the 
left  does  not  necessarily  mean  left  ventricular  hypertrophy, 
and  epigastric  pulsation  is  a very  unreliable  sign  of 
hypertrophy  of  the  right  ventricle.  The  electro-cardio- 
graph offers  means  of  accurately  determining  the  com- 
parative degree  of  hypertrophy  in  one  or  the  other 
chamber.  One  frequently  observes  in  electro-cardiographing 
patients  with  aortic  disease  that  hypertrophy  is  equally 
borne  by  the  two  ventricles,  so  that  the  normal  relationship 
of  the  two  is  maintained,  and  in  some  the  predominating 
hypertrophy  is  in  the  right  ventricle.  By  weighing  separ- 
ately the  ventricles  of  patients  whom  Lewis  and  I had 
observed  during  life  with  signs  of  aortic  disease  we  were 
able  to  confirm  the  electro-cardiographic  records.1  Such 
observations  do  not  support  the  hypothesis  that  hypertrophy 
in  aortic  disease  is  produced  solely  by  the  regurgitation  of 
blood  through  the  defective  aortic  valve.  Some  other  theory 
must  be  sought  to  explain  the  causation  of  hypertrophy  in 
aortic  disease.  Such  observations  favour  the  view  that 
myocardial  disease  is  the  chief  factor  in  the  production  of 
cardiac  hypertrophy,  and  in  the  causation  of  the  symptomsof 
heart  failure. 

Prognosis  in  Aortic  Disease. 

A difficult  task  awaits  those  who  attempt  to  forecast  the 
duration  of  life  in  aortic  disease  duriDg  the  early  stages  of  its 

1 Cotton  Observations  on  Hypertrophy.  Heart,  vi.,  217. 


The  Lancet,]  DK.  B.  MOORE  : INCREASE  OF  ALKALINITY  OF  BLOOD  IN  SHOCK.  [Sept.  13,  1919  47‘J 


development.  Prognosis  becomes  easier  as  the  disease  pro- 
gresses and  signs  of  cardiac  failure  make  their  appearance. 
There  are  certain  symptoms,  and  of  these  pain  is  one  of  the 
most  important,  which  guide  us  in  estimating  the  number  of 
years  remaining  before  the  final  stage  of  total  disability  has 
been  reached.  Dyspnoea  at  rest  with  cyanosis  and  pulmonary 
congestion,  and  pain  that  is  anginal  in  character  and  dis- 
tribution and  felt  after  slight  effort,  are  symptoms  that  we 
all  recognise  as  indicating  a grave  heart  affection.  The 
disability  here  is  a total  one,  and  our  chief  concern 
is  the  relief  of  distress  of  the  patient.  The  ultimate 
prognosis  is  easily  made  ; the  immediate  one  depends  upon 
the  manner  in  which  the  patient  responds  to  treatment.  A 
large  heart  means  myocardial  mischief.  By  its  size  one 
may  be  helped  in  estimating  the  amount  of  damage  which 
the  myocardium  has  suffered.  The  final  breakdown  is  likely 
to  occur  earlier  where  there  is  great  increase  in  the  heart’s 
size  than  in  those  without  much  cardiac  enlargement.  With 
no  signs  of  heart  failure,  and  only  a moderate  extension  of 
the  left  border  beyond  the  nipple  line,  the  outlook  is  more 
favourable.  The  auscultatory  signs  are  not  of  much  help, 
if  any,  in  prognosing  aortic  disease  in  its  early  stages.  We 
recognise  free  regurgitation  of  the  aortic  valve  by  the 
character  of  the  pulse  ; the  quality  of  the  murmur  tells  us 
little.  It  is  probable  that  the  damage  to  the  valve  is  greater 
where  there  is  free  regurgitation,  as  it  is  certain  that 
more  work  is  puc  upon  the  heart.  It  may  be  that  the 
myocardium  and  the  coronary  arteries  have  been  injured  to 
the  same  degree.  With  the  heart  not  much  enlarged  the 
prognosis  is  less  favourable  when  the  pulse  is  collapsing.  It 
is  difficult  to  prognose  with  any  certainty  when  the  heart  is 
not  enlarged  and  there  are  no  signs  of  failure.  Some  have 
no  symptoms  with  good  tolerance  ; others  have  symptoms 
as  I have  described  them,  with  the  physical  capacity 
so  reduced  that  only  the  slightest  effort  can  be  per- 
formed without  distress.  If  we  are  to  determine  the 
course  of  the  disease  in  these  two  groups  then  we  must 
rely  upon  the  symptoms  alone,  for  the  signs  may  be  identical. 
The  immediate  prognosis — i.e.,  the  present  disability — is 
easily  determined  by  submitting  the  patient  to  a simple 
exercise  test.  Other  factors  must  be  considered  in  arriving 
at  the  ultimate  prognosis,  and  of  these  the  most  important 
is  the  cause  of  the  symptoms.  If  symptoms  in  one  arise 
primarily  from  myocardial  disease,  and  in  another  can  be 
ascribed  to  other  causes  not  primarily  cardiac  in  origin,  then 
we  have  obtained  information  of  great  prognostic  value.  In 
the  absence  of  a known  cause  such  as  a focal  or  general 
infection — chronic  appendicitis,  dysentery,  or  pulmonary 
tuberculosis — it  seems  to  me,  with  our  present  knowledge, 
impossible  in  early  aortic  disease  to  distinguish  between 
symptoms  primarily  cardiac  and  symptoms  due  to  other 
causes.  A test  of  our  knowledge  of  prognosis  in  early  aortic 
disease  will  be  one  based  on  the  after-histories  obtained  from 
a large  number  over  a long  period.  It  may  then  be  possible 
to  state  definitely  that  certain  symptoms  arise  primarily  from 
myocardial  disease,  and  indicate  the  early  onset  of  heart 
failure  ; and  other  symptoms  arise  from  other  causes  and  are 
of  less  consequence  in  prognosing  the  course  of  the  disease. 


Red  Cross  Auxiliary  Hospitals:  Annual  Report. 
— The  report,  which  deals  primarily  with  the  accounts  of 
the  Red  Cross  War  Hospitals  at  home  for  the  year  ended 
Dec.  31st,  1918,  contains  also  a summary  of  their  operations 
■during  the  whole  period  of  the  war.  This  summary  shows 
that,  excluding  private  hospitals— i.e.,  those  not  in  receipt 
of  capitation  grants  from  the  War  Office— 1,260,523  patients 
were  admitted  to  the  auxiliary  hospitals,  and  were  treated 
at  an  average  cost  of  3s.  8'78 d.  per  patient  per  day 
for  maintenance  and  0’83rf.  for  administration,  a total 
average  cost  per  day  throughout  the  war  of  3s.  9'61<7. 
Of  the  total  expenditure,  £7,760,727  was  met  by  Army 
and  Ministry  of  Pensions  allowances,  leaving  over 
£2,500,000  to  be  found  by  voluntary  public  giving.  The 
six  leading  counties  in  the  matter  of  patients  admitted 
were:  Kent,  114,316  ; Lancashire  (East),  83,619 ; Hampshire, 
63,113;  Surrey,  60,324;  Cheshire,  58,117;  Sussex,  49,344. 
The  soundness  of  the  policy,  from  a financial  standpoint, 
of  [running  large  hospitals  is  demonstrated  by  the  fact 
that  whereas  in  hospitals  with  50  beds  or  more  the  average 
daily  cost  of  a patient  was  3s.  ll-85d.,  in  those  with  25  beds 
or  less  it  was  4s.  3 41d.  The  report  has  been  prepared  by 
Mr.  Basil  E.  Mayhew,  F.C.A.,  secretary  of  the  Joint  Finance 
Committee  of  the  Red  Cross,  and  mav  be  obtained  from 
Room  70,  83,  Pall  Mall,  London,  S.W.  1,  for  3s. 


THE  INCREASE  OF  ALKALINITY  OF  THE 
BLOOD  IN  SHOCK. 

By  BENJAMIN  MOORE,  D.Sc.,  F.R.S. 

Tiie  report  of  the  Arris  and  Gale  lecture  on  the  Initiation 
of  Wound  Shock  and  its  Relation  to  Surgical  Shock,  by  Dr. 
E.  M.  Cowell,  D.S.O  , in  The  Lancet  of  July  26th,  is  of 
high  scientific  value,  but  in  addition  one  cannot  read  it 
without  admiring  the  calm  courage  with  which  these 
observations  were  made  in  the  firing  line  and  en  route  to 
the  casualty  clearing  stations. 

Results  of  Reoent  Physiological  Work. 

It  is  in  no  criticising  spirit  therefore,  but  because  this 
report  will  be  yvidely  read  by  surgeons  and  clinicians  who 
have  to  undertake  the  treatment  of  cases  of  shock,  that  I 
venture  to  draw  attention  to  quite  recent  physiological  work 
which  demonstrates  that  there  is  no  enhanced  acidity  of  the 
blood  in  shock  such  as  would  warrant  the  use  of  the  term 
“ acidosis,”  but  rather  a greatly  increased  alkalinity  which 
by  damage  to  heart  and  nerve  centres  leads  to  that 
secondary  shock  which  produces  the  fatal  event.  In  this 
aspect  of  the  subject  Dr.  Cowell  is  quoting  the  observations 
of  others,  and  quotes  them  quite  in  an  orthodox  way,  but 
recent  work  shows  that  they  are  entirely  erroneous  and 
misleading,  and  have  warped  the  treatment  of  shock  into 
wrong  channels. 

It  is  quite  true  that  what  has  been  called  the  “alkaline 
reserve  ” of  the  blood  is  reduced  in  shock  often  enormously, 
that  the  titration  value  of  the  alkali  of  the  blood  to  acids 
by  any  of  the  methods,  such  as  those  of  Galleotti,  Wright, 
Moore  and  Wilsou,  van  Slyke,  &c.,  is  decreased,  so  that  the 
condition  is  described  as  “ acidosis  ” or  “acidaemia.”  But 
this  same  blood  is  much  more  alkaline  than  the  normal,  and 
the  animal  is  shocked  and  dying  because  its  blood  and  tissue 
cells  are  loaded  up  with  alkali. 

It  is  entirely  a wrong  treatment  to  administer  alkalies. 
What  the  organism  requires  is  oxygen,  carbon  dioxide,  and 
warmth,  until  oxidation  in  the  tissues  begins  to  approach  its 
normal  level.  The  organism  has  breathed  off  in  excess  its 
balancing  carbonic  acid  in  its  attempts  to  get  enough  oxygen  ; 
it  has  thereby  alkalised  all  its  cells,  and  this  alkalinity,  by 
its  action  on  the  state  of  aggregation  of  the  molecules  of  the 
bioplasm,  has  disturbed  the  functions  of  heart,  and  nerve 
centres.  It  will  be  one  of  the  most  remarkable  records  in 
medical  science  that  for  a generation  scores  of  workers  in 
Britain,  the  continent  of  Europe,  and  America  went  on 
calmly  working  on  the  assumption  that  pumping  off  carbonic 
acid  left  the  blood  more  acid. 

The  Came  of  Mountain  Shock. 

One  of  the  pioneers  in  the  subject  was  Angelo  Mo3so, 
professor  of  physiology  in  the  University  of  Turin,  who 
carried  out  many  of  his  researches  near  the  summit  of  Mont 
Rosa  in  the  high  Alps,  nearly  16,000  feet  above  sea-level,  in 
the  Capanna  Regina  Margherita,  provided  for  him  by  the 
Queen  of  Italy  of  that  time.  Mosso  and  his  colleagues 
showed  most  clearly  that  mountain  shock  and  sickness  were 
caused  by  the  denudation  of  carbon  dioxide  in  the  blood, 
due  to  excessive  breathing  to  get  in  enough  oxygen.  The 
same  factor  appears  in  the  shock  of  aviators  at  high  level, 
and  has  recently  given  rise  to  investigations  by  Haldane, 
Priestley,  and  others,  showing  conclusively  that  alkalinity  of 
the  blood  is  a predominant  factor.  It  has  also  been  shown 
by  Moore  and  Whitley  that  a slight  increase  in  alkalinity  of 
a saline  perfused  through  an  isolated  heart  leads  to  a typical 
shock,  with  output  reduced  to  one-fifth  of  the  normal,  and 
stoppage  in  a few  minutes. 

Erroneous  Conclusions. 

But  Mosso  and  Galleotti  had  not  this  knowledge,  which 
has  only  dawned  out  in  the  last  few  months.  Galleotti,  at 
Mosso’s  request,  attempted  to  estimate  the  alkalinity  of  the 
blood  where  shock  was  tending  to  appear  at  Mont  Rosa, 
16,000  feet  above  sea-level ; he  did  it  by  titrating  to  phenol- 
phthalein,  and  found  the  blood  was  much  more  acid.  His 
titrations  were  correct,  but  his  conclusion  profoundly  wrong. 
Similar  conclusions  have  been  drawn  everywhere,  for  nearly 
20  years  since  then,  but  they  are  all  erroneous.  They  have 
led  to  patients  being  dosed  with  sodium  bicarbonate  to 
relieve  shock,  and  to  intravenous  injections  of  acid  in 
animals  in  the  attempt  to  study  shock.  In  practically  every 


474  The  Lancet,]  LT.-COL.  F.  E.  FREMANTLE  : THE  HOT  SEASON  IN  MESOPOTAMIA. 


[Sept.  13,  1919 


variety  of  shock  these  reduced  determinations  of  the  alkali 
of  the  blood  show  that  the  animal  is  fighting  a stern  fight 
against  alkalinity. 

“ Acidosis  ” and  “ Alkalosis .” 

What  is  the  explanation  of  this  paradox  of  alltali 
diminished,  alkalinity  increased  ? To  the  physical  chemist 
there  is  no  great  difficulty  in  the  proposition  ; the  difficulty 
comes  in  explaining  it  to  the  biologist,  surgeon,  and  physician. 
The  outlook  upon  the  chemical  conditions  in  shock  is  all 
wrong,  and  this  is  why  the  invariably  underlying  presence  of 
“acidosis,”  to  which  at  first  much  attention  was  given, 
became  later  neglected.  All  cases  of  serious  secondary 
shock  show  so-oalled  “acidosis,”  but  this  acidosis  is  not 
“acidosis”;  it  is  “alkalosis.”  So  all  the  attempts  of 
physiologists  to  mimic  it  have  been  abortive.  What,  then,  is 
acidosis  ? As  defined  by  the  American  physiologists,  it 
must  be  admitted  that  in  shock  there  is  “acidosis”  or 
reduction  of  the  “alkali  reserve.”  The  definition  of 
van  Slyke  and  Cullen  is  that  the  serum  must  be  obtained, 
and  then  in  an  atmosphere  containing  carbon  dioxide  to  the 
extent  of  about  5 per  cent,  of  an  atmosphere  be  set  in 
equilibrium.  Next,  the  volume  of  carbon  dioxide  in  c.cm. 
per  100  c.cm.  of  serum  which  can  be  evolved  from  this  by 
addition  of  strong  acid  is  determined  ; this  gives  the  “alkali 
reserve.”  If  the  alkali  reserve  is  reduced  there  is 

“acidosis”;  if  the  “alkali  reserve”  is  increased  there  is 
“alkalosis.”  The  point  of  difference  is  that  in  individuals 
suffering  from  shock  the  blood  is  not  in  equilibrium  with 
5 per  cent,  of  carbon  dioxide,  but  with  2 or  3 per  cent,  of 
carbon  dioxide.  The  blood  of  a shocked  person  while  within 
the  body  breathes  itself  into  a high  state  of  alkalinity,  and 
the  above  method  of  defining  “ acidosis ” and  “alkalosis ” is 
not  much  better  than  defining  “ black  ” as  “ white.” 

W hen  the  pressure  of  free  carbonic  acid  in  the  blood  is 
decreased  then  alkalinity  rises  and  kidneys  and  tissue  cells 
remove  alkali  from  circulation.  It  is  for  this  reason  that 
the  circulating  bicarbonate  decreases,  and  so  lowered  titration 
figures  are  obtained,  but  the  blood  is  more  alkaline.  A fall 
in  bicarbonate  reserve  to  one-third  of  normal  can  be  caused  by 
a small  fall  in  pressure  of  carbon  dioxide  and  accompanying 
increase  in  alkalinity. 

Prima/ry  Shock. 

When  primary  shock  occurs  from  sudden  heart  failure, 
from  emotional  causes,  haemorrhage,  pain,  or  some  such 
stimulus,  there  is  cerebral  anaemia  and  unconsciousness. 
There  may  be  recovery  from  this  in  a few  minutes,  as  in  an 
ordinary  faint,  but  if  the  condition  continues  for  a longer 
time,  such  as  20  to  30  minutes,  it  is  interesting  to  consider 
the  series  of  events.  The  primary  factor  is  that  there  is  a 
general  cessation  of  metabolic  activity  at  first  and  a shut- 
down later  to  about  one-third  of  the  normal  rate.  Now,  if 
there  be  a closure  down  in  the  tissues  to  one-third,  what 
must  happen  if  the  lungs  go  on  working  at  their  normal  rate 
or  even  at  one-half  their  normal  rate?  The  answer  is  that 
an  excess  of  carbon  dioxide  over  that  produced  must  be 
removed  in  the  lungs  and  the  blood  go  alkaline,  and  this  is 
what  occurs  in  secondary  shock. 

During  the  period  of  fainting  both  heart  and  respiration 
are  held  in  abeyance,  the  heart  perhaps  more  than  the 
respiration,  and  there  is  a venous  condition  which  favours 
recovery,  but  later  there  is  a condition  in  which  respiration 
exceeds  circulation  and  the  blood  becomes  more  alkaline  and 
carries  shock  to  the  nerve  centres  and  heart. 

JSxoessive  Respiration  and  Shock. 

It  has  been  much  disputed  whether  excessive  respiration 
is  a necessary  antecedent  to  shock,  some  have  described  it, 
others  failed  to  find  it,  in  wounded  soldiers  suffering  from 
shock.  It  is  an  instance  of  how  long  it  takes  for  the  obvious 
to  strike  us,  the  balance  depends  on  the  relative  rate 
of  working  of  the  circulatory  and  respiratory  systems. 
If  as  a result  of  a primary  shock  the  circulation  is 
only  working  at  one-third  of  its  usual  speed,  and  the 
respiration  is  going  on  at  usual  rate,  the  amount  of  carbon 
dioxide  produced  will  only  be  one-third  of  the  normal,  while 
elimination  proceeds  at  normal  rate.  The  result  must  be  that 
the  alkalinity  of  the  blood  increases,  and  any  such  increase 
leads  to  heart  failure.  It  is  thus  seen  that  hyperpnoea  need 
not  necessarily  be  an  antecedent  factor  to  surgical  shock, 
and  that  in  the  main  the  condition  depends  upon  relative 
rates  of  circulation  and  respiration,  although  other  condi- 
tions, such  as  toxic  products  from  wounds  and  muscle  injury 
and  fatigue  of  nerve  centres,  undoubtedly  play  a part. 


THE  HOT  SEASON  IN  MESOPOTAMIA.1 

By  F.  E.  FREMANTLE,  F.R.C.P.  Lond., 

LIEUTENANT-COLONEL,  R.A.M.C.  (T.),  D.A.D.M.8.  i SAN.),  MESOPOTAMIA 
EXPEDITIONARY  FORCE. 


There  is  evidently  much  uncertainty  at  home  as  regards 
the  climatic  conditions  of  Mesopotamia.  An  account, 
therefore,  cf  the  hot  season  of  1917  at  Amara  on  the  Tigris 
and  of  the  cases  diagnosed  as  suffering  from  “effects  of 
heat  ” may  be  of  interest.  The  military  population  during 
the  period  under  review  may  be  taken  as  25,000,  one-fourth 
being  British,  and  one-fifth  being  hospital  patients,  mostly 
from  other  areas. 

There  were  seven  general  hospitals,  three  British  with 
2000  beds,  four  “Indian”  with  3000  beds,  and  an  isolation 
hospital  with  200  beds,  besides  British  and  Indian  con- 
valescent depots  for  2000  men. 

Climatic  Bata. 

As  a preface  the  following  facts  are  given  as  to  the 
climatic  records  at  the  same  station  in  June,  September,  and 
December,  1917,  and  in  March,  1918. 


- 

June. 

Sept. 

Dec. 

March. 

Temperature  (dry  bulb). 

Max.  average 

103° 

105° 

62® 

70° 

Highest  

110° 

117° 

76° 

80° 

Min.  average 

78° 

71° 

41° 

52° 

Lowest  

73° 

60° 

26° 

44° 

Wet  bulb  at  4 p.m. 

Average  

72° 

73° 

52° 

57° 

Highest  

79° 

82° 

59° 

64° 

Lowest  

67° 

67° 

44° 

52° 

Humidity  at  4 p.m. 

54 

50 

Average  

— 

— 

Highest  

— 

— 

99 

87 

Lowest  

— 

— 

22 

26 

Daily  wind  movement. 

135 

171 

Average  (miles)  

442 

188 

Highest  ,,  

730 

480 

389 

406 

Rainfall  in  inches. 

Total 

Nil. 

Nil. 

1-43 

1-65 

No.  of  rainy  days 

f, 

»• 

7 

8 

Greatest  in  one  day  

" 

071 

090 

In  fact,  the  first  quarter  of  the  year  is  the  only  rainy 
quarter  and  is  about  as  rainy  as  in  England  ; the  third 
quarter  is  the  unpleasantly  hot  season  ; the  second  is  cooking 
up  for  it  ; the  fourth,  like  the  first — with  the  exception  of 
only  a few  rainy  days — is  delicious. 

The  freshness  of  the  spring  depends  partly  on  the  prevailing 
northerly  winds,  blowing  down  from  the  mountains  of 
Kurdistan  or  occasionally  from  the  neighbouring  Pusht-i- 
Kuh  to  the  north-east ; partly  on  the  floods,  which  must,  by 
evaporation,  help  to  keep  down  the  temperature  in  early 
summer. 

The  floods  depend  more  on  the  height  of  the  Tigris  than  on 
the  local  rainfall ; and  the  height  of  the  Tigris  depends 
firstly  on  rainfall  in  its  upper  reaches,  and  then  on  the 
melting  of  the  snows  in  the  mountains. 

The  river  is  at  its  lowest  here,  from  22  to  23  feet  above 
mean  sea-level  at  Fao,  from  September  to  November ; and 
after  a temporary  rise  of  a foot  in  December,  rises  suddenly 
in  January  to  27  or  28  feet,  and  falls  in  February  to 
24  to  25  feet.  In  mid- March  it  again  rises  to  its  maximum  of 
27  to  28  feet,  and.  with  or  without  a remission  of  a foot, 
remains  constant  till  the  beginning  of  May.  It  then  begins 
its  slow,  steady  fall  from  27  to  22  feet,  spread  over  four 
months. 

Below  the  Diala  there  are  no  tributaries  to  the  river  ; but 
the  Hai  at  Kut,  the  Cbahala  and  Masharrah  at  Amara,  the 
several  canals  and  frequent  irrigation  channels  serve  as 
outlets  which  spread  the  rising  waters  over  the  face  of  the 
land,  mostly  to  be  absorbed  or  evaporated,  while  the 
remainder  enters  the  Tigris  again  below  the  Narrows  or, 
through  the  Euphrates,  joins  the  Tigris  at  Qurnah  to  form 
the  Shatt-al-Arab,  running  out  into  the  Persian  Gulf  at  Fao. 
The  whole  country  to  windward  is  therefore  moist  till 
harvest-time  in  April  and  May.  It  then  dries  and  the  dry 
heat  increases  pitilessly  day  after  day. 

i A paper  read  before  the  Amara  Clinical  Society  in  May,  1918,  and 

revised  in  1919. 


Thb  Lakobt,)  LT.-COL.  F.  E.  FREMANTLE:  THE  HOT  SEASON  IN  MESOPOTAMIA.  [Sept.  13,  1919  475 


Relation  of  Temperature  to  Incidence  of  Cases. 


Predisposing  Causes. 


The  figures  in  the  temperature  chart  prepared  for  this 
paper  were  those  recorded  daily  at  the  Meteorological  Station 
at  8 A.M.  each  morning  for  the  previous  24  hours  and  were 
shown  for  the  day  previous  to  that  on  which  they  were 
reported,  so  as  to  correspond  in  general  to  the  day  on  which 
the  effects  of  heat  occurred.2 3 

This  station  is  in  the  open,  fully  exposed  to  the 
prevailing  N.W.  wind  blowing  right  down  the  upper  reach  of 
the  Tigris.  The  air  here  is  noticeably  cooler  and  probably 
moister  than  elsewhere  ; and  the  figures  are  probably  the 
lowest  in  the  place.  Almost  equally  trustworthy  figures 
taken  in  verandahs  of  hospitals  and  elsewhere  often  showed 
dry-bulb  temperatures  from  6°-10°  higher,  even  up  to  130°, 
and  a trustworthy  assistant  surgeon  at  a marching  post 
recorded  140°  one  day  in  a 160  lb.  tent. 

The  chart  showed  dry-bulb  maximum  varying  in  these 
three  months  from  92°  to  121°,  with  two  intense  spells,  one 
between  110°  and  121°  from  July  7th  to  25th,  the  other 
between  108°  and  121°  from  August  16th  to  Sept.  13th. 

The  curve  showing  cases  of  effects  of  heat  presented  two 
corresponding  rises,  but  more  sharply  marked  and  of  far 
shorter  duration.  In  the  first  spell  no  more  than  three 
cases  occurred  each  day  until  July  14th,  no  case  occurring  on 
the  hottest  day — the  10th.  In  the  second  spell  over  three 
cases  a day  occurred  only  between  August  19th  and 
Sept.  4th,  14  cases  occurring  on  the  day  of  greatest  heat,  and 
18  on  the  following  day,  when  the  maximum  temperature 
was  11°  lower  at  110°.  Nor  did  the  other  two  temperature 
curves  correspond  to  that  of  the  cases  of  effects  of  heat,  for 
the  minimum  dry-bulb  temperature  reached  its  highest  (88°) 
on  July  17th  and  20th,  after  the  case  curve  had  made  its 
chief  rise  ; and  the  wet  bulb  at  4 p.m.  was  highest  (83°  and 
82°)  on  days  when  there  were  1,  10,  and  no  cases  respec- 
tively, fewer  even  in  the  second  instance  than  on  the 
previous  day,  when  the  wet  bulb  read  only  73°  and  there 
were  18  cases. 

There  was,  however,  a certain  correspondence  on  several 
occasions  between  a high  minimum — i.e.,  a hot  night — and 
the  number  of  cases  next  day ; and  there  was  a general 
correspondence  between  the  heat  waves  at  their  height  and 
the  number  of  cases. 

The  number  of  cases  in  June  was  too  rare  to  attract  special 
notice  ; and  it  would  appear  that  it  took  several  days  or 
weeks  of  heat  before  the  susceptible  individuals  succumbed 
to  it ; and  those  remaining  were  more  liable  to  be  imme- 
diately affected  by  the  second  spell  of  extreme  heat  towards 
the  end  of  August. 

The  failure  of  the  wet  bulb  to  give  any  useful  indication 
of  the  danger  suggests,  as  Professor  Leonard  Hill  has 
pointed  out,  that  the  most  important  preventive  factor  is  the 
rapidity  of  cooling,  dependent  on  movement  and  negative 
humidity  of  air  and  its  free  play  over  the  surface  of  the 
body  under  the  clothes.  It  was  to  meet  this  suggestion  that 
the  kata-thermometer  has  been  devised  to  show  rapidity  of 
cooling  ; and  the  readings  on  this  instrument  should  be  most 
carefully  recorded  and  studied  in  every  future  hot  weather. 

Effects  of  Heat. 

The  clinical  facts,  as  complete  as  possible,  were  taken 
from  the  hospital  returns  received  on  the  special  notification 
form  1 and  from  a special  return  of  deaths  due  to  effects  of 
heat.  Cases  were  shown  under  the  day  on  which  they  first 
suffered.  All  cases  diagnosed  in  hospital  as  “effects  of 
heat  ” were  included,  whether  otherwise  diseased  or  not. 
The  cases  occurred  between  July  8th  and  Sept.  11th,  with 
the  addition  of  one  case  marching  up  with  an  echelon  and 
admitted  on  Sept.  21st. 

No.  of  cases  recorded,  353 ; deaths,  49. 

Second  attack  recorded  in  4 cases,  of  which  death  occurred  in  1. 

Third  attacks,  0. 

Officers,  5 ; Indians,  16 ; Arabs  and  others,  0. 


2 A full  chart  of  daily  temperatures  and  cases  of  effects  of  heat,  admitted 
to  hospital,  was  exhibited  with  this  paper  but  was  lost  in  transmission 
home.  It  showed  the  dry  bulb  maximum  and  minimum  and,  in  the 
absence  of  a wet  bulb  maximum  thermometer,  the  wet  bulb  temper- 
ature at  4 p.m.  daily  throughout  July,  August,  and  September,  as  well 
as  the  number  of  cases  each  day. 

3 The  notification  form  set  out  the  following  heads  No.,  rank,  and 
name ; regiment:  unit  to  which  now  attached;  camp,  billet,  aid-post,  Ac, 
from  which  case  admitted ; if  already  a patient,  previous  diagnosis ; 
date  and  hour  of  attack ; occupation  at  the  time  ; whether  constipated  ; 
malarial  history— parasites ; max.  temp,  of  case ; progress  since 
admission  ; remarks. 


(«)  Disease: — Malaria:  History,  64;  B.W.  fever,  1; 
smears  B.T.,  11  ; attack,  3. 

Other  cases  actually  in  hospital  at  the  time  had  been 
admitted  with — 


Sandfly  fever 7 

Anaemia  and  debility 7 

Gastric  or  intestinal  6 

Various  and  N.Y.D 6 

Septic  conditions 5 


Amoebic  dysentery  2 

Enteric  group  2 

Cardiac  2 

Bronchitis  1 

Neuroses 1 


( b ) Constipation  : Yes,  122  ; no,  196. 

Time  of  Commencement  of  Attach. 


00.00-06.00  ... 

...  13  cases,  including  4 on 

16/7/17 

06.00-09.00  ... 

...  21  „ 

„ 4 „ 

23/8/17 

09.00-12.00  ... 

...  56  „ 

» \l” 

16/7/17 

23/8/17 

12.00-15.00  ... 

...  42  „ 

— 

i3:: 

18/7/17 

15.00-18.00  ... 

...  92  „ 

21/7/17 

(l  „ 

22/8/17 

18.00-24.00  ... 

...  27  „ 

— 

Total  ... 

...  251  cases. 

06.00  = 6 A.M. ; 18.00  = 6 P.M.,  &c. 


Attack  came  on  gradually  in  a large  proportion  of  the 
trivial  cases — probably  in  the  great  majority  of  them. 

Types  of  Cases. 

Trivial  (temperature  below  104°),  177. 

Moderate  ( ,,  104°-106'9°),  83. 

Severe  ( ,,  107°  or  above  or  grave  symptoms),  78. 


Hyperpyrexia  (over  105°),  out  of  353  cases  and 
49  deaths : — 


No.  of  cases. 

Deaths. 

• 

No.  of  cases.  Deaths. 

105°- 106° 

18  .... 

109°-110°  . 

14  5 

106°-107° 

23  .... 

..  2 

110O-111O  . 

9 3 

107°-108° 

26  .... 

111° 

108°-109° 

26  .... 

. 6 

117  23 

Occupation  at  time  of  attach 

On  duty 

..  117 

Bathing  ... 

1 

Off  duty 

..  33 

Not  stated 

94 

Resting 



..  108 

Occupation  of  those  attached  15.00-1S.00  (3-6  P.M.). — Of 
92  for  which  occupation  was  recorded  30  were  not  resting, 
and  were  thus  occupied  : — 


Fatigues  and  grave-digging  ...  5 

On  guard  or  police  4 

Parade  (2),  orderly  corporal  ...  3 
Transport,  driving,  grooming...  3 
Butchery,  bakery,  cook  3 


Movement  or  waiting — 

In  sun  on  duty 3 

Duty  not  specified 3 

Office  duty,  mess  duty  2 

R.A.  M.O.  duties 2 

On  steamer  1 

Bazaar  I 


Aid-posts. 

Six  aid-posts  were  established  in  May,  some  on  the  5th 
and  the  rest  by  the  end  of  that  month,  at  important  centres, 
such  as  bridgehead  and  railway  station.  They  were  staffed 
by  23  British  privates  in  charge  of  a R.A.M.C.  corporal, 
succeeded  by  a sergeant,  an  ex-policeman,  under  the 
direct  supervision  of  the  officer  commanding  a sanitary 
section. 

These  aid-posts  were  equipped  with  canvas  bath,  Persian 
cooler  (a  20-gallon.open-mouthed  jar  of  porous  earthenware), 
ice-chest,  and  one  wheel  stretcher,  with  lifter  and  hood  apiece, 
and  were  open  from  May  5th  to  Sept.  16th.  During  this 
season  these  posts  dealt  with  only  39  cases,  since  most  cases 
were  taken  direct  to  a medical  unit  or  dealt  with  tem- 
porarily by  any  medical  officer  in  situ  until  removal  could  be 
effected. 

Consideration  of  Preventive  Measures. 

With  regard  to  the  provision  for  future  hot  seasons — 

(a)  A large  proportion  of  cases  being  due  to  the  direct 
effects  of  the  heat  upon  hospital  patients  with  weakened 
constitution,  it  is  essential  to  protect  roofs  and  walls  of 
hospital  wards  from  the  sun  as  much  as  possible  and  to 
provide  electric  fans  freely.  Much  is  already  done  in 
this  way,  but  a final  survey,  before  the  season  begins,  might 
always  reveal  details  requiring  further  action. 

(5)  Every  case  in  hospital  during  the  hot  season  should 
be  examined  for  malaria  and  should  take  quinine  if  positive. 


476  The  Lancet,]  SURGEON  LT. -COM.  S.  F.  DUDLEY:  A NOTE  ON  B.  INFLUENZA. 


[Sept.  13,  1919 


(<?)  With  regard  to  healthy  troops,  it  should  be  brought 
home  to  every  man  that  constipation  is  dangerous,  and 
medical  officers  in  charge  of  units  should  be  specially  warned 
to  pay  attention  to  this  habit. 

(rf)  The  occupations  of  those  attacked  in  the  afternoon 
suggest  that  a further  warning  is  required  with  regard  to 
fatigues  and  movements  in  the  sun.  Seasoned  officers  still 
frequently  consider  it  manly  to  defy  the  heat,  both  in  regard 
to  clothing  and  duties.  The  late  Sir  Victor  Horsley,  here  in 
Amara,  paid  for  this  heresy  with  his  life.  Greater  folly  and 
cruelty  cannot  be  imagined.  It  may  be  generally  stated  that 
with  a wet-bulb  temperature  of  80°  hard  physical  work  is 
impossible  ; at  90°  all  work  is  impossible  ; and  at  95°  life  is 
impossible. 

Consumption  of  Water  : Clothing. 

(e)  The  facts  that  the  effect  of  heat  must  depend  upon  the 
loss  of  heat  from  the  body,  that  this  depends  on  evapora- 
tion and  this  again  on  the  amount  of  water  consumed  and 
clothes  worn,  require  further  bringing  home  to  all  ranks. 
The  consumption  of  water  should  be  pushed.  Men  should 
be  encouraged  to  count  the  number  of  half-pints  of  fluid  they 
drink  in  the  day,  and  in  the  hottest  weather  this  should  not 
be  less  than  16  (a  gallon),  and  may  be  as  much  as  50  (three 
gallons)  or  more  without  harm. 

{/)  Similar  emphasis  and  publicity  require  to  be  given  to 
the  question  of  clothing  during  the  hot  hours.  The  wearing 
of  coats  and  belts  should  not  even  be  optional  ; it  should  be 
forbidden.  Puttees  retain  much  heat,  and  thin  stockings 
should  be  substituted.  Shirts  should  always  be  worn  outside 
shorts  or  trousers  when  working  or  marching ; this  at  once 
doubles  the  body  surface  available  for  loss  of  heat,  and 
adds  greatly  to  the  men’s  comfort.  The  adoption  of  a shirt- 
tunic  to  be  worn  in  this  way  would  be  ideal  for  the  hot 
weather.  The  blouse  is  already  uniform  in  certain  Indian 
regiments,  and  is  worn  in  this  way  by  their  British  officers. 
Its  only  faults  are  that  it  is  too  thick,  and  that  it  is  not 
open  at  the  neck.  Finally,  shirts  should  be  worn  open  at 
the  neck  although  buttoned,  and  in  case  of  officers  tied 
to  the  level  of  the  top  button,  with  stud  holes  buttoned 
outwards.  This  gives  a smart  appearance  and  adds  vastly 
to  the  comfort  by  allowing  a free  issue  of  steamy  air  from 
inside  the  shirt. 

Other  Suggestions. 

(y)  In  varying  the  official  hours  of  work  according  to  the 
weather,  all  ranks  should  be  encouraged  to  keep  early  hours 
in  the  evening,  with  lights  out  at  10  p.m.  at  latest.  Officers 
and  others  cannot  be  expected  to  be  as  fresh  to  stand  the 
heat  of  the  next  day  with  only  five  or  six  hours’ sleep  in  the 
cool  of  the  night  ; and  influence  in  such  matters  is  con- 
tagious. “Early  to  bed  and  early  to  rise”  should  be  a 
rule. 

( h ) The  notification  forms  should  be  slightly  amended  to 
give  in  future  further  and  more  precise  facts  on  these  lines  ; 
and  if  records  on  similar  lines  could  be  kept  by  the  whole 
Force  each  year  a large  body  of  evidence  would  be  obtained 
of  very  great  practical  importance  for  military  operations — 
and,  indeed,  for  civil  life — in  hot  climates. 

(i)  Further  evidence  of  value  in  this  connexion  would  be 
obtained  from  readings  in  various  comparable  conditions  in 
different  huts,  tents,  and  buildings  by  the  kata-thermometer, 
which  shows  rapidity  of  cooling  from  the  human  body,  and 
so  gives  the  effective  result  of  humidity  and  temperature 
combined.  One  of  these  instruments  h’as  recently  been 
issued  to  the  meteorological  station.  They  should  be  under 
the  charge,  as  here,  of  a medical  officer  with  special  physio- 
logical training  and  an  inquiring  turn  of  mind. 

Hitherto  the  value  of  the  different  types  of  hut  and  tent 
has  been  estimated  by  the  general  sensation  of  a few  workers 
and  a few  patients  and  by  very  few  and  occasional  ther- 
mometric readings.  The  importance  of  the  subject  warrants 
a much  more  extended  and  systematic  inquiry,  and  I submit 
that,  so  long  as  any  medical  officer  can  be  spared  from 
hospital- work,  an  officer  with  special  physiological  training 
should  be  instructed  to  make  a comprehensive  inquiry  on 
these  lines  throughout  the  Force,  say  during  the  months  of 
June  and  July. 

These  suggestions  appear  to  be  the  logical  conclusions  of 
Eastern  experience  and  Western  theory.  In  essential  they 
have  already  for  the  most  part  been  officially  adopted.  It  is 
up  to  every  M.O.  in  the  Force  to  do  his  utmost  to  secure  the 
carrying  out  of  every  detail. 


A NOTE  ON  B.  INFLUENZ2E, 

ESPECIALLY  AS  REGARDS  THE  QUESTION  OF 
“ CARRIERS.” 

By  SHELDON  F.  DUDLEY,  M.B.,  B.S.  Lond., 

SURGEON  LIEUTENANT-COMMANDER,  R.N. 


Between  Oct.  1st,  1918,  and  March  31st,  1919,  368  cases 
of  influenza  were  treated  in  H.M  Hospital  Ship  Agadir. 
These  cases  came  from  110  different  ships  or  establishments 
at  Scapa  Base  ; as  a result  nearly  every  type  and  variety 
of  the  disease  was  seen,  from  the  mildest  to  the  most 
virulent.  Descriptions  of  the  pandemic  one  read  of  else- 
where and  at  first  could  not  agree  with  often  became 
explicable  on  admitting  a fresh  batch  of  cases. 

B.  Influenzas. 

As  was  the  case  a few  years  ago  with  the  meningococcus, 
it  is  essential  to  state  on  what  characteristics  the  organism 
one  calls  B.  influenzas  was  identified.  Colonies  on  Matthews’s 
medium  1 were  circular,  translucent,  and  brownish  by  reflected 
light ; isolated  examples  often  exceeded  4 mm.  in  diameter. 
Films  from  these  colonies  stained  well  with  carbol-fuchsin, 
showing  a Gram-negative  bacillus  that  varied  considerably  in 
its  njorphology  ; some  strains  would  show  quite  loDg  fila- 
ments. Subcultures  (if  they  grew  at  all)  on  to  blood-smeared 
agar  reverted  to  the  text-book  pin-point  colonies,  with  the 
usually  described  characters  of  Pfeiffer’s  bacillus.  On  plain 
agar  there  was  never  any  growth.  As  noted  by  Fildes  and 
Baker.2  using  other  media,  stained  films  from  a four-  or  five- 
day-old  culture  on  Matthews’s  medium  produced  a peculiar 
granular  debris  with  few  distinct  morphological  bacteria. 
The  differences  in  shape,  size,  and  staining  of  bacilli,  and 
the  slight  variation  in  the  appearance  and  emulsifying 
properties  of  the  colonies  indicate  that  the  bacteria  which 
possess  the  above  characters  have  different  strains  or  are 
a group  of  organisms  comparative  to  the  Gram- negative 
diplococci. 

Culture  Media. 

A probable  reason  why  Pfeiffer’s  bacillus  has  Dot  been 
invariably  found  in  the  late  pandemic  is  the  difficulty  of 
being  certain  of  the  media  and  not  realising  this  difficulty. 
Experiences  in  this  ship  with  many  medias  found  Matthews’s 
to  be  the  only  really  satisfactory  one  of  those  tried.  I do 
not  mean  that  Matthews’s  is  better  than  the  other  medias 
used  by  other  workers,  but  that  owing  to  some  unknown 
error  in  technique  or  materials  satisfactory  results  were  not 
obtained  with  other  media  in  this  ship.  For  example, 
10  different  strains  of  B.  influenza  which  grew  well  on 
Matthews's  media  were  planted  on  (1)  blood-smeared  agar, 
with  the  result  six  grew  ; (2)  boiled  blood-water  agar — 
four  grew;  (3)  a bad  batch  of  “K”  media  3— none  took  ; 
(4)  blood  boiled  in  agar — none  took  ; (5)  a media  consisting 
of  a killed,  week-old  culture  of  Staphylococcus  aureus 
in  blood  broth  added  to  agar — in  this  latter  medium 
all  the  strains  grew,  but  though  in  my  hands  this 
medium  was  the  most  satisfactory  after  Matthews’s,  it  was 
not  as  good  as  the  latter,  as  the  following  shows.  B.  influenza 
was  isolated  from  the  naso-pharyDX  from  10  men  using 
Matthews’s  medium,  whereas  with  the  staphylococcus  medium 
B.  influenza  was  only  recovered  three  times  from  the  same 
10  cases.  In  May  and  June.  1918,  I tried  to  isolate 
B.  influenza  from  various  patients,  using  blood-smeared 
agar,  but  did  not  get  a single  success.  I therefore  very 
foolishly  stated  that  I did  not  believe  B.  influenza  was 
present  in  these  cases.  But  I am  now  convinced  if  I had 
been  using  Matthews’s  medium  they  would  have  been  found. 

Direct  Smears  of  Discharges. 

The  case  against  Pfeiffer's  bacillus  as  a causative  factor  in 
influenza  is  often  supported  by  the  absence  of  predominant 
morphological  influenza  bacilli  in  stained  smears  from  the 
patient's  discharges.  From  12  positive  cases  plates  were 
inoculated  and  at  the  same  time  smears  of  the  naso- 
pharyngeal mucus  were  stained  with  polychrome  methylene 
blue  and  also  carbol-fuchsin.  In  the  plates  from  five  cases 
the  colonies  of  B.  influenza  predominated  ; in  the  correspond- 
ing stained  smears  numerous  morphological  B.  influenza 
were  seen  in  three  instances,  but  in  the  other  two  one  would 
not  have  liked  to  say  they  were  present  without  the  con- 
firmatory evidence  of  the  plates.  On  the  remaining  seven 

1 The  Lancet.  Julv  27tb,  1918. 

2 The  Lancet,  Nov.  2^rd,  i9]8.  5 IbiJ. 


The  Lanoet,] 


SURGEON  LT. -COM.  S.  F.  DUDLEY:  A NOTE  ON  B.  INFLUENZAS.  [Sept.  13  1919  477 


plates  many  colonies  of  the  organism  appeared,  but  in  only 
one  of  the  corresponding  films  were  B.  influenza  at  all 
evident.  In  all  the  stained  smears  except  three,  where 
organisms  of  any  kind  were  scarce,  numerous  other  bacteria 
were  present  complicating  the  picture.  Hence,  because 

B.  mduenzce  is  not  obvious  in  stained  films  of  a patient’s 
discharges  it  does  not  follow  it  will  not  grow  luxuriantly  on 
culture. 

Carriers  of  B.  Influenza. 

There  were  many  cases  of  influenza  continually  on  board 
from  October  to  the  middle  of  March,  when  the  number 
steadily  diminished,  until  at  the  end  of  April  only  two  mild 
cases  remained  in  the  ship.  During  this  period  the  nursing 
stall  of  the  ship  were  all  examined  as  regards  the  presence 
of  B.  influenza  in  the  discharges  from  the  naso-pharynx. 

1.  On  Deo.  5th-7th  21  men  produced  19  positives,  90  per  cent. 

2.  ,,  March  13th-15th  22  „ ,,  19  ,,  87 

3.  ,,  „ 27th  20  „ ,,  10  ,,  50 

4.  „ April  27th  22  ,,  ,,  6 „ 27 

Sixteen  of  the  men  were  swabbed  on  all  four  occasions, 
representing  a positive  result  as  -(-  and  absence  of  B.  influenza 
as  - . We  can  classify  them  thus  in  the  order  of  the  above 
dates. 

4 men  + + 4-  + I 4 men  + + - - 

4 + + + — 1 man  + — — — 

1 man  + + — + I 2 men  — + — — 

This  shows  the  infection  died  out  fairly  evenly  in  the 
nursing  staff  as  the  cases  of  influenza  got  fewer. 

The  mercantile  crew  of  a hospital  ship  has  quarters  com- 
pletely separated  from  the  nursing  staff,  and  are,  of  course, 
allowed  no  communication  with  the  patients.  A few  of  the 
crew  were  swabbed  for  comparison  with  the  nursing  staff. 

10  men  on  Dec.  6th  gave  6 positive  results. 

12  „ March  28th  ,,  2 

10  ,,  April  27th  ,,  1 ,, 

* As  regards  the  incidence  of  influenza  among  the  ship’s 
company,  40  per  cent,  of  the  mercantile  crew  got  infected 
(average  strength  52  men)  ; 62  per  cent,  of  the  medical  staff 
had  clinical  influenza  (29  men).  The  whole  29  of  the  medical 
staff  were  examined  at  one  time  or  another,  and  26  were 
proved  to  be  “ carriers.”  Of  the  3 who  were  negative,  2 had 
had  influenza  and  the  other  was  a medical  officer  who  joined 
when  the  epidemic  was  practically  over.  Of  the  positives 

14  never  had  clinical  influenza  previous  to  the  first  positive 
swabbing,  though  4 subsequently  developed  it.  Of  12  who 
had  had  “ flu  ” 2 got  it  again  later. 

By  the  courtesy  of  Surgeon-Commander  H.  S.  Burniston, 

C. M.G.,  I was  allowed  to  examine  20  seamen  and  stokers  of 
H.M.S.  Revenge.  Four  (20percent.)  were  positive  “carriers.” 
The  ship’s  company  of  Revenge  averaged  about  1200  men. 
In  May,  1918,  22  per  cent,  had  clinical  influenza  ; in  October 
21  per  cent,  got  the  disease  (including  roughly  3 per  cent, 
of  those  who  had  had  it  in  May).  Thus  about  half  the 
ship’s  company  had  had  influenza.  Of  the  20  men  swabbed 

15  had  never  had  clinical  influenza,  and  only  1 of  the 
4 men  who  were  “carriers”  had  had  it.  The  latter 
4 cases  were  all  from  widely  separated  parts  of  the 
ship.  It  may  be  guardedly  presumed,  therefore,  that  about 
one-fifth  of  the  crew,  or  240  men,  were  harbouring 
B.  influenza  in  the  naso-pharynx  on  Dec.  11th,  a month  after 
the  last  clinical  case  had  occurred  on  board  on  Nov.  9 th. 

Secondary  Infections. 

Practically  every  pathogenic  organism  has  been  reported 
as  present  in  the  late  pandemic.  The  experience  was  the 
same  in  the  Aqadir — pneumococci  and  streptococci  are  the 
most  obvious  secondary  infections  ; but  B.  typhosus , meningo- 
cocci, diphtheria  bacilli,  and  many  unidentified  bacteria 
were  seen.  This  ship  may  be  said  to  have  dealt  with  about 
100  different  isolated  outbreaks  of  the  disease,  each  of 
which  often  seemed  to  have  its  own  clinical  and  bacterial 
picture.  For  example,  at  Scapa  in  October  and  November 
the  broncho-pneumonias  were  nearly  all  pneumococcic,  as 
proved  by  cultures  from  the  blood  and  pleural  fluids  of  the 
patients,  and  these  cases  tended  to  be  delirious  and  termi- 
nated by  crisis.  By  February  streptococci  had  to  a great  extent 
replaced  the  pneumococci.  The  patients  remained  clear- 
headed to  the  end  and  the  temperature  swung  considerably 
before  settling  down.  It  was  not  until  the  advent  of  the 
streptococcus  that  the  typical  cyanosis  and  pure  blood  expec- 
toration (that  one  read  of  down  South)  became  evident  at 
Scapa.  To  give  another  example,  though  8-3  per  cent,  of 
the  total  cases  had  epistaxis,  in  19  cases  from  one  ship, 
which  were  all  mild  in  other  respects,  9,  or  47  per  cent.,  had 
epistaxis. 


“ Filter  Passers." 

Considerable  evidence  has  been  brought  forward  to  prove 
that  a “filter  passer  ” is  a causal  agent  in  influenza.  The 
most  constant  characteristic  of  this  filter  passer  appears  to 
be  that  of  causing  haemorrhagic  lesions  in  the  lungs  of  experi- 
mental animals.  Yet  in  the  mild  cases  of  influenza,  which 
form  the  great  majority  of  all  cases,  lung  signs  and  even 
cough  are  often  absent,  and  clinically  hmmorrhage  is  really 
not  common  in  influenza  as  a whole.  Altogether  the  evidence 
suggests  the  world-wide  spread  of  an  organism,  fairly  harm- 
less in  itself,  which  prepares'  the  way  for  any  pathogenic 
organism  that  happens  to  be  in  the  environment  at  the  same 
time.  And  'perhaps  this  harmless  organism  (B.  influenza') 
especially  favours  the  spread  of  a filter  passer  which,  though 
extremely  virulent  in  its  presence,  cannot  gain  a footing  in 
the  human  organism  without  the  help  of  Pfeiffer’s  bacillus. 
Since  the  above  paragraph  was  first  written  A.  Orticoni  and 
Barbie 1 have  reported  that  B.  influenza  and  the  filtered 
sputum  from  an  influenza  case  are  harmless  to  guinea-pigs 
separately,  but  together  are  extremely  pathogenic.  Should 
this  observation  be  confirmed,  it  would  go  a long  way  towards 
proving  the  double  setiology  of  influenza  as  due  to  a filter 
passer  plus  Pfeiffer’s  bacillus. 

During  the  time  influenza  was  being  treated  on  board, 
three  or  four  of  the  ship’s  company  complained  of  feeling 
out  of  sorts  ; they  were  not  definitely  ill,  but  suffered  from 
headaches  and  sometimes  felt  shivery.  One  case  of  this 
sort  two  or  three  times  had  to  be  put  to  bed  for  a day 
or  two.  His  temperature  never  rose  above  normal ; his 
pulse,  which  was  rapid  at  first,  soon  settled  down  to  a 
rate  of  about  50  beats  a minute.  B.  influenza  was  present 
in  his  naso-pharynx.  This  class  of  man,  who  never  had 
clinical  influenza,  may  well  have  been  a chronic  ambulant 
type.  Many  of  the  post-influenzal  “neurasthenics”  and 
“debilities”  may  possibly  be  chronic  toxaemias  due  to  the 
influenzal  parasite,  whether  B.  influenza  or  anything  else. 

If  we  grant  B.  influenza  as  a factor  in  the  cause  of 
influenza,  “carriers”  and  missed  cases  such  as  “feverish 
colds  ” and  chronic  ambulant  cases  probably  are  more 
dangerous  and  numerous  than  the  bed  case.  These, 
together  with  the  short  incubation  period,  serve  to  explain 
the  tremendous  rate  of  spread  of  the  disease. 

Individual  Immunity . 

In  a ship  where  50  per  cent,  of  the  ship’s  company  may  be 
infected  in  a week  the  rest  must  be  temporarily  immune. 
The  crew  of  a battleship  sleep  under  circumstances  where 
cubic  space  is  very  limited  and  perfect  ventilation  very 
difficult.  Influenza  will  spread  in  a ward  with  10  feet 
between  bed  centres ; with  hammocks  2 feet  apart,  the 
chances  of  contact  infection  by  spraying  is  125  times  as 
great  as  in  the  ward  if  head-to-foot  “slinging”  is  not 
insisted  on,  and  15  times  as  great  where  it  is  properly  carried 
out.  (The  danger  of  infection  being  inversely  as  the  cube 
of  the  distance.)  From  these  considerations  it  can  only  be 
individual  immunity  that  protects  those  who  escape  infection 
in  the  close  confinement  of  a ship.  That  natural  immunity 
to  influenza  must  vary  considerably  from  time  to  time  in  an 
individual  is  suggested  by  the  incidence  of  the  disease  among 
the  nursing  staff,  60  per  cent,  of  whom  had  influenza.  Though 
in  close  contact  with  the  cases  all  the  time  they  did  not  all  get 
it  together,  as  in  the  ordinary  ship,  but  the  cases  were  spread 
more  or  less  evenly  over  six  months.  The  effect  of  lowered 
vitality  is  well  illustrated  by  the  four  medical  men  on  board  who 
contracted  the  disease.  They  had  all  been  attending  cases 
for  one  or  two  months  before  succumbing  themselves.  In 
each  instance  there  was  a definite  cause  of  lowered  resistance 
about  48  hours  beforehand.  In  two  it  was  the  long  journey 
between  Scapa  and  the  south  ; in  one,  a temperate  man,  a 
larger  quantity  of  alcohol  than  he  was  accustomed  to  ; in  the 
last  case  a long  walk  after  some  weeks’ confinement  in  the  ship. 

Before  concluding,  I should  state  the  examination  of  the 
staff  could  not  be  carried  to  the  logical  conclusion  when  all 
were  free  from  B.  influenza , because  the  ship’s  company  was 
relieved  before  this  was  possible. 

Enough  evidence,  I think,  is  collected  to  make  it  worth 
while  to  investigate  how  many  people  in  normal  times 
harbour  B.  influenza  in  their  naso-pharynx.  Even  if 
B.  influenza  should  be  proved  a harmless  saprophyte,  and  if 
carriers  of  it  are  rare  when  there  is  no  epidemic,  its  almost 
universal  distribution  during  an  epidemic  surely  requires 
some  elucidating. 

4 La  Presse  Medicale,  May  8th,  1919. 


[Sept.  13, 1919 


478  The  Lancet,]  DR.  C.  McK.  CRAIG:  VELDT  SORE  AMONGST  EUROPEAN  TROOPS. 


A STUDY  OF  THE  ETIOLOGY  OF  THE 
“ DESERT,”  SEPTIC,  OR  VELDT  SORE 
AMONGST  EUROPEAN  TROOPS: 

AND  ITS  ASSOCIATION  WITH  FAUCIAL  DIPHTHERIA. 
By  COLIN  McK.  CRAIG,  O.B.E.,  M.D.Manch.,  D.P.H., 

LATE  MEDICAL  SUPERINTENDENT,  MANCHESTER  SANATORIUM, 
ABERGELE;  LATE  CAPTAIN,  R.A.M.C.  ; O.C.  MILITARY 
LABORATORY,  E.E.F. 


During  the  Egyptian  and  Palestine  campaigns  chronic 
sores,  very  resistant  to  local  treatment,  on  uncovered  parts, 
became  a great  scourge,  especially  amoDgst  mounted 
units.  I investigated  these  lesions  in  a field  laboratory, 
established  in  connexion  with  this  force  in  the  desert, 
throughout  the  whole  period  and  have  had  access  to  a very 
large  amount  of  material. 

Most  observers  are  agreed  that  the  “desert”  sore  is  of 
distinct  clinical  type,  that  it  is  associated  with  peculiar 
geographical  and  climatic  conditions,  in  no  way  connected 
with  dermal  leishmaniasis ; and  that  it  must  be  due  to  some 
specific  organism.  I am  of  opinion  that  this  organism  is  the 
true  Klebs-Loffler  bacillus. 

While  my  investigations  were  being  undertaken  a paper  by 
Lieutenant-Colonel O.  J.  Martin,  C.M.G.,  D.S.O.,  F.R.S.,1  set 
forth  the  results  of  his  examination  of  a limited  number  of 
cases  amongst  the  Australian  units,  E.E.F.  He  examined 
hairs  extracted  from  the  vicinity  of  the  lesion  and  noted 
diphtheroid  organisms  in  this  situation.  Later  he  investigated 
one  strain  more  thoroughly  and  found  that  it  gave  the  typical 
reactions  of  the  Klebs-Loffler  bacillus.  This  particular  case 
differed  in  no  wise  from  the  others  and  was  associated  with 
no  obvious  constitutional  disturbances.  He  concluded  that 
the  diphtheria  infection  was  superimposed  upon  some 
pyogenic  coccal  lesion. 

Clinical  Characters  of  the  Sore. 

Under  the  term  “desert  sore”  many  sores  have  been 
loosely  classed,  which  differ  widely  in  their  aetiology.  The 
sore  I refer  to  is  invariably  on  exposed  parts  and  mainly  on 
those  covered  by  hairs — i.e.,  dorsum  of  hands,  forearm, 
around  elbow  and  knee-joints,  on  lower  part  of  thigh,  and 
exposed  part  of  legs.  (At  the  commencement  of  the 
campaign  mounted  units,  as  well  as  infantry,  were 
commonly  clothed  in  drill  shorts.)  In  a small  proportion 
of  cases  the  lesions  occur  on  the  face. 

1.  The  vesicle. — The  onset  is  sudden.  The  first  appearance 
is  one  of  acute  inflammation  round  a hair  follicle  and  in  a 
few  hours  a vesicle  forms  full  of  clear  straw-coloured  fluid, 
varying  from  size  of  a pea  to  half  an  inch  or  more  in  diameter. 
The  pain  is  at  first  quite  out  of  proportion  to  size  of  lesion. 
It  soon  bursts  and  exposes  the  deeper  layers  of  the  cuticle, 
thus  forming  a shallow  ulcer. 

2.  The  primary  shallow  nicer. — In  the  early  stages  the  base 
is  dry,  red,  and  glazed.  It  is  acutely  sensitive.  In  a con- 
siderable proportion  a thin  pearly. grey  membrane  may  form, 
though  its  absence  does  not  indicate  a non-diphtherial  origin. 
The  edges  of  the  surrounding  skin  become  undermined  and 
the  ulcer  commences  to  spread  peripherally. 

3.  The  chronic  stage  of  the  ulcer. — The  appearance  is  quite 
characteristic.  It  is  punched  out  and  circular  in  outline,  with 
undermined  edges  and  thickened  margins.  The  base  of  such 
an  ulcer  is  covered  with  grey-coloured  dfibris,  beneath  which 
one  can  frequently  determine  a tough  and  adherent  mem- 
brane. Such  a deep  ulcer  may  discharge  little  or  no  pus. 

Methods  of  Investigation. 

Scrapings  were  taken  from  the  spreading  edge  of  the  ulcers 
by  a sterile  knife  and  inoculated  directly  on  to  freshly  pre- 
pared Loffler’s  serum.  In  unbroken  vesicles  the  skin  was 
first  washed  with  alcohol  ; the  vesicle  was  then  ruptured  and 
the  fluid  mopped  up  from  the  base,  then  inoculated  on  to 
medium  by  a sterile  swab.  The  base  was  also  scraped. 

The  Results  of  Primary  Culture. 

One  hundred  and  ninety-seven  sores  were  investigated. 
The  micro-organisms  constantly  present  in  the  cultures  were  : 

(1)  staphylococci  (S.  albus ),  rarely  S.  aureus , or  S.  aitreus ; 

(2)  diphtheroid  bacilli,  of  two  morphological  types,  i.e.  : — 

(a)  A small  straight  bacillus,  staining  uniformly  with 
msthylene-blue.  Gram-positive  but  decolourising  with  ease, 

1 Brit.  Med.  Jour.,  June  9th,  1917. 


showing  no  polar  differentiation  with  Neisser’s  stain. 
Usually  these  small  forms  were  present  in  moderate  number 
and  lav  parallel  in  pairs. 

(b)  Forms  morphologically  identical  with  the  true  Klebs- 
Loffler  bacillus. 

I believe  that  type  (a)  is  an  immature  form  of  (5).  Inocu- 
lation experiments  showed  that  the  small  form  was  equally 
as  toxic  as  the  large  and  developed  into  the  latter. 

One  or  other  of  these  types  mas  present  in  129  out  of  197 
sores  examined— 67  -5  per  cent.  I consider  this  percentage 
high  when  the  following  facts  are  considered.  (1)  In  the 
chronic  stage  of  the  sore  the  bacillus  is  in  scanty  numbers 
and  attenuated.  (2)  The  frequent  dressing  of  sores  with  anti- 
septic lotions.  (3)  With  further  cultures  the  positive  findings 
would  probably  have  been  higher.  (4)  The  positive  findings 
compare  favourably  with  results  of  swab  culture  of  clinical 
diphtheria  of  the  throat,  especially  under  field  conditions. 

The  following  are  the  statistics  of  examination  of  swabs  for  Klebs- 
Loffler  bacilli  in  this  laboratory  for  two  months  in  1917 : — Total 
examinations,  5442.  Klebs-Loffler  bacilli  in  throat,  455  (8  3 per  cent.); 
diphtheria  carriers,  34  (0'6  per  cent.) ; contacts,  49  (0'9  per  cent.). 

Association  of  Sores  with  Faucial  Diphtheria. 

During  the  period  of  investigation  diphtheria  both  of 
throat  and  nose  had  been  prevalent  amongst  the  troops. 
The  epidemic  was  distinguished  by  (a)  the  mildness  of  the 
average  case  ; ( b ) the  difficulty  of  tracing  the  source  of 
infection.  The  question  was  to  decide  whether  the  diph- 
theroid bacillus  in  the  ulcers  was  identical  with  the  organism 
found  in  the  throat. 

The  evidence  1 collected  at  that  time  may  be  stated  as 
follows  : there  is  a close  correlation  between  the  incidence 
of  faucial  diphtheria  and  the  occurrence  of  the  “desert” 
sore,  the  causal  agent  in  each  case  being  the  true  Klebs- 
Loffler  bacillus. 

The  common  occurrence  of  diphtheritic  skin  lesions  under 
tropical  conditions,  as  compared  to  their  rarity  in  temperate 
climates,  may  be  explained  as  follows  : ( a ) by  moistness  of 
skin  and  activity  of  sweat  glands,  soddenness  of  epithelium 
providing  an  opportunity  for  entrance  of  bacilli  and  a suit- 
able medium  for  their  multiplication  ; (b)  by  the  environment 
of  the  troops — close  contact  between  man  and  man,  lack  of 
washing  facilities,  and  constant  liability  to  laceration  of 
skin. 

The  clinical  evidence  I have  collected  in  favour  of  this  view 
is  interesting  and  suggestive. 

Association  of  Sores  with  Constitutional  Disturbance  and 
Toxic  Neuritis. 

The  question  arose  as  to  why  constitutional  disturbances 
and  paralysis  of  the  throat  or  limbs  had  not  been  observed.  My 
contention  is  that  cases  of  paralysis  had  occurred,  and  were, 
occurring,  but  that  either  they  had  been  overlooked  or  attri- 
buted to  a presumably  untreated  faucial  diphtheria.  [Cases 
were  here  cited  of  specific  instances  of  typical  diphtheritic 
paralysis  occurring  in  association  with  “desert”  sores.] 
Evidence  on  this  score  will  also  be  found  in  a paper  written 
after  this  work  was  completed  by  Major  F.  M.  R.  Walshe,2 
in  which  he  described  a large  number  of  cases  of  paralysis 
following  “desert  ” sores,  in  one  series  in  27  per  cent. 

Medical  officers  all  appear  impressed  by  the  amount  of 
debility  and  weakness,  especially  of  the  limbs,  which  is 
associated  with  these  ulcers,  and  quite  out  of  proportion  to 
the  size,  number,  or  extent  of  the  lesions.  The  amount  of 
military  inefficiency  was  considerable,  as  these  debilitated 
men  were  the  first  to  fall  out  during  the  heavy  desert 
marching.  The  muscular  weakness  was  probably  due  to 
chronic  absorption  of  the  toxins  in  an  amount  insufficient 
to  cause  paralysis. 

Confirmatory  Bacteriological  Tests. 

The  first  experiments  on  animals  were  made  with  glucose- 
broth  cultures  of  the  small  diphtheroid  organism  obtained 
from  a “desert  ” sore.  The  organisms  were  stained  uniformly 
and  showed  no  polar  differentiation.  2 c.cm.  of  the  broth 
culture  were  then  inoculated  subcutaneously  into  a guinea- 
pig  weighing  300  g.  The  animal  died  in  48  hours,  and  from 
the  necrotic  tissue  at  site  of  injection  typical  polar  staining 
Klebs-Loffler  bacilli  were  obtained. 

Six  strains  of  diphtheroid  bacilli  isolated  from  throat 
lesions  and  five  from  “desert”  sores  were  submitted  to 
animal  and  biochemical  tests.  All  the  strains  produced 
acidity  in  glucose  broth  after  48  hours’  incubation.  Both 

= The  Lancet,  1918,  li.,  232. 


The  Lancet,]  SURG.-LT.  GREY:  COMPULSORY  INOCULATION  AGAINST  INFLUENZA.  [Sept.  13,  1919  479 


cultures  of  the  strains  in  doses  of  2 c.cm.  were  injected 
subcutaneously  into  guinea-pigs  of  approximately  the  same 
weight.  Eleven  control  animals  were  given  a similar  dose 
of  the  organism  with  the  addition  of  1 c.cm.  of  diphtheria 
antitoxin.  [The  results  were  here  set  out  in  tabular  form. 
Of  the  five  strains  from  “desert”  sore,  the  injected  animals 
died  in  24  hours,  24  hours,  36  hours,  24  hours,  and 
30  hours  respectively.  All  the  controls  lived.  Of  the  six 
throat  strains,  five  died  in  36  hours,  48  hours,  80  hours, 
36  hours,  and  60  hours  respectively  ; the  sixth  animal  was 
ill,  but  recovered.  All  the  control  animals  lived.] 

Post-mortem  appearances  of  injected  guinea-pigs. — At  the 
site  of  injection  there  was  intense  congestion  and  oedema  of 
surrounding  tissues  ; in  those  animals  which  survived  for 
more  than  24  hours  also  membrane  formation.  In  all 
animals  an  abundant  straw-coloured  effusion  was  found  in 
the  pleural,  pericardial,  and  abdominal  cavities.  The  supra- 
renal capsules  were  swollen,  plum-coloured,  and  intensely 
congested ; section  showed  haemorrhagic  changes.  The 
spleen,  pancreas,  liver,  and  other  viscera  appeared  normal. 
Klebs-Loffler  bacilli  were  recovered  on  culture  in  every  case 
from  the  site  of  injection — that  is,  from  the  necrotic  tissue. 
Similar  cultures  from  the  heart’s  blood  proved  sterile,  showing 
death  from  toxaemia. 

All  these  typical  post-mortem  appearances  agreed  with  the 
classical  description  of  the  action  of  the  Klebs-Loffler  bacillus 
upon  these  animals. 

The  tendency  to  the  production  of  serous  effusions  by 
diphtheria  toxins  would  explain  the  vesical  formation  of  the 
primary  cutaneous  lesion  and  the  suddenness  of  the  onset  of 
the  “desert ” sore. 

A striking  experiment  was  performed  on  quails,  a bird 
apparently  very  susceptible  to  the  diphtheria  bacillus.  Birds 
were  selected  after  two  months  in  captivity  and  in  very  good 
condition.  2 c.cm.  of  a broth  culture  of  a typical  diphtheria 
bacillus  isolated  from  a “ desert  ” sore  were  injected  into  the 
pectoral  muscles  of  one  bird  ; a second  was  given  a similar 
dose  mixed  with  1 c.cm.  of  diphtheria  antitoxin.  The  first 
bird  died  in  16  hours  ; the  second  exhibited  no  symptoms. 
Considerable  serous  effusion  found  at  site  of  inoculation, 
from  which  the  bacillus  was  recovered ; heart’s  blood  was 
sterile. 

I conclude  that  the  diphtheroid  organism  isolated  from 
“desert”  sores  can  be  none  other  than  the  true  Klebs- 
Loffler  bacillus.  The  question  may  be  raised  why  are  not 
the  cutaneous  lesions  more  frequently  associated  with 
membrane  formation  and  constitutional  disturbances.  The 
answer  is  that  only  a very  small  percentage  of  positive  throat 
cases  presented  lesions  or  constitutional  disturbances  such  as 
are  commonly  associated  with  clinical  faucial  diphtheria. 
Out  of  a series  of  221  positive  cases  I examined  clinically 
only  10  8 per  cent,  presented  such  symptoms. 

The  Results  of  Antitoxin  Treatment. 

Diphtheria  antitoxin  proved  an  absolute  specific  for  the 
chronic  “desert”  sore  of  the  type  described.  This  will 
be  supported  by  the  experience  of  a large  number  of  regimental 
medical  officers,  medical  officers  in  field  ambulances  and 
casualty  clearing  stations.  The  sores  which  have  resisted 
treatment  for  weeks  and  months  heal  in  a few  days  with  an 
average  dose  of  4000  units.  Critics  have  suggested  that  the 
normal  horse  serum  would  have  the  same  effect.  Anti- 
dysenteric  serum  (horse  serum)  had  a partial  protective 
influence,  the  animals  recovered,  but  suffered  considerably 
nevertheless.  The  natural  deduction  is  that  horse  serum 
normally  contains  a certain  amount  of  antitoxin  to  the 
diphtheria  bacillus. 

Prophylaxis  : General  and  Personal. 

General  prophylaxis. — I am  convinced  that  the  human 
carrier  cannot  account  for  the  prevalence  of  diphtheria 
during  this  campaign.  The  bacillus  is  capable  of  a sapro- 
phytic existence.  I suggest  that  one  medium  is  horse 
manure.  From  horse  manure  I isolated  a diphtheroid  bacillus 
morphologically  identical  with  the  Klebs-Loffler,  but  non- 
pathogenic  to  guinea-pigs.  Since  the  troops  have  advanced 
into  the  cultivated  portions  of  Palestine  the  incidence  of 
“ desert  ” sores  has  fallen  to  a negligible  quantity.  These 
facts,  with  the  greater  incidence  of  “desert”  sores  amongst 
mounted  units  suggest  an  intimate  connexion  between  horse 
manure  and  the  causation  of  throat  diphtheria  and  “desert” 
sores.  I would  suggest  further  investigation  on  these  lines. 

Personal  prophylaxis. — The  measures  suggested  are  the 
protection  of  exposed  parts  of  the  body,  and  especially  the 


knees,  from  injury;  the  wearing  of  “shorts”  by  mounted 
units  is  unsuitable.  The  use  of  antiseptic  lotions  to  the 
arms  and  knees  of  the  men,  and  especially  to  any  abraded 
surfaces,  is  to  be  advocated  wherever  possible,  as  well  as 
protection  of  sores  with  a dressing,  and  the  avoidance  of  too 
intimate  a contact  between  man  and  man. 

Conclusions. 

1.  That  this  “ desert  ” or  septic  sore  is  a distinct  clinical 
entity  and  has  a distinct  geographical  distribution. 

2.  That  the  aetiological  factor  is  the  Klebs-Loffler  bacillus, 
which  is  responsible  for  the  specific  characters  of  the  lesion. 

3.  That  this  organism  possesses  a low  virulence,  and  there- 
fore only  produces  constitutional  disturbances  in  specially 
susceptible  individuals. 

4.  That  under  favourable  conditions  these  sores  may  be 
responsible  for  outbreaks  of  faucial  diphtheria. 

Against  these  conclusions  certain  objections  raised  are  : — 

1.  That  the  diphtheria  bacillus  is  but  a secondary  infection 
superimposed  upon  some  pyogenic  lesion.  The  frequency 
with  which  I have  isolated  the  Klebs-Loffler  bacillus  from 
the  primary  lesion  with  appropriate  technique  shows  that  it 
is  a primary  infection. 

2.  The  inability  of  pathologists  at  the  base  hospitals  to 
find  Klebs-Loffler  bacilli  in  the  majority  of  these  sores. 
The  more  chronic  the  sore,  the  greater  the  number  of  pyogenic 
organisms  present,  the  more  difficult  it  is  to  isolate  the 
Klebs-Loffler  bacillus.  Also  in  base  hospitals  a large  pro- 
portion of  these  cases  were  deep-seated  pyogenic  infections 
with  which  I was  not  dealing.  In  this  way  I explain  the 
discrepancy  between  my  results  and  those  published  by 
Warren  Crowe.3 

3.  The  question  of  the  curative  action  of  antidiphtheritic 
serum  I have  dealt  with. 

I desire  to  place  on  record  my  indebtedness  to  Major  A.  R. 
Ferguson,  R.A.M.C.,  for  enabling  me  to  carry  out  part  of 
this  work  in  his  laboratory.  My  thanks  are  also  due  to 
Captains  P.  H.  Bahr,  T.  J.  Mackie,  R.A.M.C.  (T.F.), 
F.  Standish,  R.A.M.C.  (T.F.),  and  J.  G.  Willmore,  R.A.M.C. 
I wish  also  to  thank  Captains  Higgins,  R.A.M.C.,  and 
C.  Newton-Davis,  I.M.S.,  for  providing  me  with  clinical 
histories  of  their  cases. 


COMPULSORY  INOCULATION  AGAINST 
SPANISH  INFLUENZA. 

By  FRANCIS  TEMPLE  GREY, 

SURGEON-LIEUTENANT,  ROYAL  NAVY  ; O.C.  SAMOA  RELIEF 

EXPEDITION,  1918. 


My  experience  in  the  South  Sea  Islands  so  impressed  me 
with  the  value  of  antipneumostreptococcal  inoculation  as  a 
prophylactic  against  Spanish  influenza  that  on  my  return  in 
February,  1919,  to  Australia  (where  the  scourge  had  already 
got  a hold  in  Melbourne,  but  had  so  far  been  kept  out  of 
Sydney)  I urged  the  importance  of  making  it  compulsory. 
But  outside  the  Service  nothing  happened. 

The  following  preliminary  communication  submitted  early 
in  March  to  a semi-scientific  periodical  was  published  six 
weeks  afterwards. 

“ The  vaccine  prepared  by  the  Commonwealth  Serum 
Laboratories  has  in  my  hands  achieved  results  which  are 
nothing  short  of  miraculous.  As  a result  of  my  experience, 
I urge  compulsory  inoculation  on  the  first  signs  of  the 
appearance  of  epidemic  influenza  in  any  community  as  the 
one  efficient  means  of  tackling  the  scourge;  inoculation  to 
be  repeated  every  month  or  six  weeks.  I claim  that  this 
measure  will  (1)  decrease  enormously  the  incidence  of  the 
disease ; (2)  mitigate  its  severity ; (3)  reduce  the  mortality 
to  a low  figure. 

The  following  evidence  in  support  of  my  recommendation 
is,  to  say  the  least  of  it,  impressive. 

(1)  The  entire  ship’s  company  of  the  man-o’-war  which 
took  my  expedition  to  the  islands  were  inoculated.  Com- 
munication with  the  shore  at  the  various  ports  was,  as  far 
as  possible,  avoided,  but  this  ideal  was  not  entirely  attained. 
Not  one  case  developed. 

f2)  Every  member  of  my  expedition  was  inoculated  at 
least  four  times  in  three  months.  Not  a single  case 
developed,  although  the  risk  of  infection  was  no  small  one, 
when  it  is  remembered  that  in  Samoa  alone  one-fifth  of  the 
entire  population  was  wiped  out  by  the  scourge.  Two 
officers  had  an  illness  of  four  to  five  days  not  as  severe  as 
the  so-called  influenza  of  normal  times. 

s The  Lancet,  1918,  ii.,  667. 


480  The  Lancet,]  DR.  A.  R FRASER:  "606’  DERMATITIS  TREATED  WITH  INTRAMINE.  [Sept.  13.  1919 


(3)  An  interesting  experiment  to  test  the  efficacy  of  the 
vaccine  was  provided  by  the  Governor  of  American  Samoa, 
who  sent,  against  the  wishes  of  British  Samoa,  40  natives 
from  Pago  Pago  (a  clean  port)  to  Apia  during  the  progress  of 
the  epidemic.  These  were  isolated,  inoculated,  and  not 
released  until  judged  to  be  in  a positive  phase.  Not  one 
contracted  the  disease,  and  the  Secretary  of  Native  Affairs, 
who  knew  their  names  and  villages,  reported  all  clear  after 
a lapse  of  one  month. 

(4)  Ship's  company  and  passengers  of  the  steamer  which 
brought  the  expedition  from  Suva  to  Sydney  were  inoculated 
without  exception.  We  anchored  in  quarantine  in  Sydney, 
and  on  the  second  day  a case  was  taken  ashore.  We  remained 
on  board,  quarantined  another  week.  Although  the  ship 
was  very  overcrowded  not  another  case  developed. 

(5)  The  naval  depot  at  Williamstown  contains  a floating 
population  of  about  500,  half  of  whom  live  on  shore,  and 
the  rest,  of  course,  have  a fair  amount  of  shore  leave. 
All  hands  have  been  inoculated  twice  in  the  last  three 
months.  There  have  been  only  15  cases,  all  mild  except  two, 
and  no  deaths. 

The  severe  reaction  in  some  cases  to  the  lymph  during  the 
small-pox  epidemic  of  1913  on  aD  unvaccinated  adult 
community  has  done  much  harm  to  what  must  perforce  be 
called  the  ‘cause’  of  vaccination  in  Australia,  seeing  that 
the  public  has  been  taught  nowadays  that  it  is  entitled  to 
an  opinion  on  subjects  it  knows  nothing  about.  It  may 
reassure  these  opinionated  objectors  to  know  that  in  this 
case,  at  any  rate,  there  is  little  or  no  reaction.  I myself 
have  seen  only  one  reaction  in  all  my  inoculations. 

Conscientious  objectors,  if  the  legislature  has  not  the 
courage  to  compel  inoculation,  should  be  isolated  from  the 
rest  of  the  community,  it  being  pointed  out  to  them  that  we 
object  not  so  much  to  their  committing  suicide  as  to  their 
carrying  the  disease  unmitigated  to  those  who  are  not  tired 
of  life.” 

In  the  middle  of  March,  a fortnight  after  my  first  com- 
munication was  submitted,  an  epidemic  broke  out  in  the 
ship  referred  to  in  paragraph  1,  and  by  the  end  of  the 
month  there  were  about  100  cases  with  no  deaths. 
Inoculations  (end  November  and  end  December)  appear, 
therefore,  to  have  given  immunity  up  to  the  middle  of 
March,  and,  when  the  disease  broke  through,  to  have 
rendered  it  non-fatal.  To  deny  mitigation  by  inoculation  in 
this  case  is  to  say  that  the  disease  was  not  Spanish  influenza 
(which  has  a high  mortality),  and,  therefore,  that  the 
immunity  was  absolute. 

Soon  after  my  first  communication  was  submitted  an 
influenzoid  epidemic  broke  out  in  the  naval  depot  at 
Williamstown,  and  within  a fortnight  we  had  100 
cases  (characterised  by  high  infectivity,  extraordinary 
mildness,  and  an  average  age-incidence  of  18i).  I was 
inclined  to  regard  this  as  a separate  clinical  entity,  but  if  it 
were  Spanish  influenza  then  the  case  for  inoculation  is 
rendered  stronger  than  ever. 

From  the  beginning  of  the  year  to  date  (June  20th,  1919) 
2875  ratings  have  been  victualled  at  the  depot  ; there  have 
been  315  cases  of  influenza,  5 with  pneumonic  signs,  and 
no  deaths. 

The  Constituents  of  the  Vaooine. 

A full  dose  of  the  vaccine  used  by  me  contains  125  millions 
of  Miorocoocus  catarrhalis , 50  millions  each  pneumococci, 
streptococci,  and  of  a Gram-positive  diplococcus.  My 
experience  shows  Pfeiffer’s  bacillus  to  be  unnecessary  as  a 
constituent  of  a vaccine  directed  against  this  epidemic,  and, 
in  view  also  of  the  risk  of  a negative  phase,  it  is  clearly 
unwise  to  use  it  in  any  community  where  the  epidemic  is 
already  well  under  way. 

If  Spanish  influenza  be  caused  by  a streptococcus  for 
which  the  way  has  been  prepared  by,  say,  the  bacillus  oi 
Pfeiffer  or  a filter  passer,  and  especially  if  this  last  represent 
a stage  in  the  development  of  the  streptococcus,  an  anti- 
streptococcal  vaccine  should  be,  and  in  my  experience  has 
been,  competent  to  protect. 

On  May  14th  half  the  depot  were  given  a pure  anti- 
streptococcal  vaccine  and  the  other  half  were  given  the 
vaccine  already  mentioned,  with  a resulting  difference  in 
incidence  to  date  of  practically  nil. 

Immunity  begins  to  peter  out  after  the  fifth  week. 
I give  a full  dose  (50  millions  each  pneumococci  and 
streptococci)  every  five  or  six  weeks,  and  never  get  more 
than  the  mildest  reaction.  I do  not  inoculate  children 
or  the  old  unless  requested,  as  these  appear  to  have 
relative  immunity.  The  disadvantage,  from  the  public 
point  of  view,  of  a preliminary  dose,  apart  from  the 
fact  that  it  is  unnecessary,  is  that  the  public  are  apt  to 


think  that  the  preliminary  dose  is  all  that  is  required,  and 
for  this  and  other  reasons  (if  reasons  they  can  be  called)  do 
not  come  up  again,  and  their  non-immunity  is  charged 
against  inoculation.  The  theoretical  objection  to  a full  dose 
without  preliminary— viz.,  that  in  stray  cases  a focus  of 
chronic  suppuration  may  be  lit  up  or  that  a nephritic  may 
stand  it  badly — has  no  weight  against  the  foregoing  con- 
sideration, and  is  in  any  case  the  concern  of  the  individual 
vaccinator,  who,  if  ignorant,  will  damage  this  as  he  has 
damaged  other  causes. 

I have  to  acknowledge  with  grateful  thanks  the  help  and 
encouragement  I have  received  from  Surgeon-Captain  Eames, 
R.N.,  Director  of  Naval  Medical  Services  (Australia);  his 
predecessor,  Surgeon-Commander  Bean,  R.N.  ; Surgeon- 
Lieutenant  Commander  Ramsay  Smith,  R.A.N..  in  medical 
charge  of  the  naval  depot,  Williamstown  ; and  especially 
from  Dr.  Penfold,  director  of  the  Commonwealth  Serum 
Laboratories. 


A CASE  OF  “606”  DERMATITIS  TREATED 
WITH  INTRAMINE, 

WITH  SUBSEQUENT  MULTIPLE  SUBCUTANEOUS 
TUMOUR  FORMATION. 

By  A.  R.  FRASER,  M.D.  Aberd. 


The  following  case  of  exfoliative  dermatitis  occurred  in 
my  wards  at  the  Scottish  Command  Central  Venereal 
Hospital,  Robroyston. 

Account  of  Case. 

The  patient  was  a recruit  of  six  weeks’  service,  attached 
to  a labour  company,  aged  41,  a healthy  man,  but  undersized 
and  slightly  and  slimlv  built,  with  a large  double  inguinal 
hernia.  His  medical  category  was  B 2.  He  had  no  history  of 
previous  venereal  disease.  He  was  admitted  to  hospital  with 
a large  spirocbaetal  chancre  of  three  weeks’  duration.  This 
was  a diamond-shaped  erosion,  with  a moist,  greyish,  finely 
granular  surface.  Very  definite  induration  could  be  made 
out  between  finger  and  thumb.  It  was  somewhat  larger  in 
size  than  a sixpenny-piece,  and  was  situated  on  the  upper 
external  aspect  of  prepuce.  There  was  a marked  inguinal, 
axillary,  epitrochlear,  and  posterior  cervical  adenitis.  A 
scattered,  diffuse,  irregular,  fairly  symmetrical  faint 
macular  rash  was  present  over  the  trunk  and  flexor  aspects 
of  limbs,  being,  however,  most  marked  below  the  scapular 
angles.  The  fauces  were  somewhat  injected,  but  there  was 
no  other  mucous  membrane  lesion.  Lungs,  heart,  and 
the  central  nervous  system  showed  nil  abnormal.  Spiro- 
chaeta  pallida  was  found  present  in  the  sore  on  the  day  of 
admission, and  two  days  later  his  Wassermann  reaction  gave 
a strongly  positive  result  (++). 

He  was  then  put  on  a course  of  neo-kharsivan  intra- 
venously, and  mercurial  cream  (metallic  mercury)  intra- 
muscularly. On  the  day  of  his  third  injection  the  sore  had 
completely  healed,  having  meanwhile  been  locally  treated 
with  calomel  ointment,  30  per  cent.  Seven  days' later  the 
rash  had  disappeared  and  except  for  a slight  adenitis  the 
patient  showed  no  active  signs  of  lues.  His  course  consisted 
of  3-90  g.  neo-kharsivan  intravenously,  and  gr.  7 metallic 
mercury  intramuscularly,  extending  over  a period  of  56  days. 
This  he  underwent  without  incident,  on  no  one  occasion 
showing  the  slightest  reaction.  His  urine  was  free  from 
albumin  throughout  the  course.  On  the  fifty-eighth  day  his 
Wassermann  reaction  gave  a complete  negative  result.'  He 
was  forthwith  discharged  from  hospital. 

On  the  morning  of  his  discharge,  having  drawn  his  kit 
and  prepared  for  the  journey  to  his  depot,  he  complained  to 
me  of  having  a headache  and  generally  feeling  off  colour. 
On  examination  it  was  found  that  a scarlatinal  eruption  had 
appeared  over  both  forearms  on  the  flexor  aspect.  His 
temperature  was  102=  F.  He  was  readmitted  to  the  ward 
and  put  to  bed,  and  adrenalin  1 : 1000  administered  in  10  m. 
doses  every  four  hours.  This  occurred  on  the  sixtieth  day. 
Calomel  gr.  5 followed  by  a saline  was  given.  The  following 
day  the  rash  had  spread  over  the  face  and  neck,  legs  and 
trunk.  It  was  well  marked  on  the  forehead.  At  this  stage 
the  rash  might  have  passed  for  scarlet  fever,  but  later 
blebs  and  pustules  developed,  with  scaling  and  crusting 
on  their  rupture.  There  was  very  considerable  exudation 
into  the  skin,  most  marked  on  the  face  and  head.  The 
cheeks  and  eyelids  became  very  swollen  and  puffy,  the  eyes 
practically  closed.  The  temperature  remained  at  102°.  The 
patient  was  put  on  ichthyol  m.  5 in  cachets,  three  being 
given  daily.  The  application  of  calamine  cream  and  bran 
bathing  failed  to  diminish  appreciably  the  intense  skin 
irritation.  By  the  fourth  day  the  rash  had  become  confluent. 

articularly  over  the  thighs' and  abdomen.  The  tongue  was 

ry  and  very  heavily  coated ; it  was  difficult  to  induce  the 


Thb  Lancet,] 


CLINICAL  NOTES 


[Sept.  13,  1919  4gl 


patient  to  take  even  a little  milk,  ami  he  was  losing  ground 
rapidly  from  loss  of  sleep.  Ho  complained  most  of  pain 
in  the  eyes,  and  a dry,  congested,  choking  feeling  in 
his  throat.  Swallowing  was  obviously  a trying  and 
painful  procedure.  Ichthyol  was  continued  until  the 
eighth  day,  but  no  improvement  could  be  seen  from  its 
employment.  It  was  discontinued.  On  this  day  2 50  c.cm. 
intramine  was  given  intramuscularly.  The  following 
day  the  temperature  dropped  to  99-4°,  the  patient 
expressed  himself  as  feeling  better,  and  exfoliation  com- 
menced over  the  face  and  forehead.  There  was  no  pain  at 
the  site  of  injection,  and  no  local  reaction.  Exfoliation  con- 
tinued, and  four  days  later  a second  injection  of  2-50  c.cm. 
intramine  was  given,  again  causing  no  local  pain.  The  skin 
exudation  had  now  gradually  subsided  and  exfoliation  had 
continued  apace.  A third  and  fourth  injection  of  intramine 
in  similar  doses  followed  at  four-day  intervals,  and  the 
patient  steadily  improved.  The  skin  had  now  become  of  an 
intensely  reddish-brown  tint  and  the  itching  was  very  severe. 
This  gradually  subsided  and  the  skin  became  very  thin  and 
atrophic  and  of  a deeply  pigmented  dull  coppery  hue.  The 
patient’s  general  condition  steadily  improved,  his  voice  was 
stronger,  he  became  interested  in  his  surrounding,  his 
appetite  improved,  and  he  became  much  less  depressed. 

On  the  twenty-seventh  day  a very  large  non-inflamed 
swelling  appeared  suddenly  at  the  lower  end  of  the  sternum 
in  much  the  same  manner  as  a pyaemic  abscess.  By  evening 
it  had  reached  the  size  of  a cricket  ball.  There  was  no 
surrounding  inflammation  and  no  “ pointing.”  The  following 
day  similar  smaller  swellings  had  appeared  over  the  external 
condyle  of  the  left  femur,  the  upper  third  of  the  left  fibula, 
over  the  symphysis  pubis,  the  upper  third  posterior  aspect 
right  thigh,  the  external  surface  upper  third  of  the  right 
tibia,  the  left  epigastrium,  the  back  of  the  left  elbow,  and  on 
the  sacrum.  They  varied  in  size  from  a walnut  to  a large 
plum.  These  were  fluctuating,  non-inflamed,  painful 
swellings.  They  seemed  peculiarly  tender,  ordinary  gentle 
palpation  being  resented  by  the  patient.  The  contents 
proved  to  be  a thick  gelatinous,  slightly  opalescent,  stringy 
mucinoid  substance  which  was  very  difficult  to  draw 
into  a syringe,  even  through  a needle  of  large  lumen. 
There  was  no  pus.  Microscopically  it  showed  no  pus 
cells  and  no  organisms  present.  An  occasional  epithelium 
cell  could  be  seen.  No  organism  could  be  cultured. 
Although  the  patient’s  general  condition  improved,  these 
swellings  continued  to  appear,  until  by  the  fifty-first  day 
they  had  reached  a total  of  72.  In  every  case  the  swelling 
increased  in  size,  remained  for  two  or  three  days,  eventually 
burst,  and  healed  over  in  24  hours  without  a scar.  The 
patient  steadily  lost  weight,  but  otherwise  maintained  his 
general  condition.  He  did  not  look  ill,  and  his  voice  was  that 
of  a strong,  healthy  man. 

The  tumour  formation  continued  without  abatement,  and 
owing  to  lack  of  nursing  facilities  he  was  now  transferred 
to  a general  hospital.  There  he  lost  ground  insidiously,  and 
the  case  terminated  fatally  a few  months  later.  The  post- 
mortem findings  coincided  with  that  condition  described  as 
acute  yellow  atrophy. 

Conclusions. 

It  is  extremely  difficult  to  suggest  any  definite  cause  for 
this  extraordinary  process  of  tumour  formation.  Pyasmic 
abscesses  containing  definite  pus  occur  in  severe  cases  of 
“ 606  ” dermatitis.  Here,  however,  the  absence  of  pus  and 
the  sterility  of  the  tumour  contents,  together  with  the  non- 
inflammatory nature  of  the  swelling,  makes  it  extremely 
difficult  to  draw  any  analogy.  The  process  seemed  to  be  of 
the  nature  of  a subcutaneous  myxomatous  degeneration.  In 
all  probability  salvarsan  was  the  exciting  cause.  There 
seems  nothing  to  suggest  that  the  intramine  was  in  any  way 
responsible  for  the  condition.  On  the  contrary,  I think  this 
drug  was  beneficial,  and  essentially  non-toxic. 

The  immediate  improvement  following  the  administration 
of  intramine  was  very  marked.  The  fall  of  temperature,  the 
early  exfoliation  and  the  appreciable  improvement  in  the 
general  condition  coincided  with  the  first  and  second 
intramine  injections.  In  spite  of  the  patient’s  very  poor 
cachectic  condition  its  intramuscular  administration  caused 
no  pain  or  discomfort  whatever. 

Although  no  such  condition  has  been  described,  it  seems  a 
possible  suggestion  that  his  syphilis  was  in  itself  the  exciting 
cause.  One  feels,  however,  that  this  is  unlikely,  since  his 
disease  had  reached  a “ latent  ” condition.  It  is  extremely 
probable  that  in  both  “ 606”  jaundice  and  dermatitis  the 
benzene  or  amino  group,  and  not  the  arsenic,  is  the 
causative  agent,  and  as  this  condition  has  never  been 
observed  as  caused  by  arsenic  apart  from  this  chemical 
combination,  the  amino  radical  may  also  in  this  case  have 
been  the  causative  agent. 

Aberdeen. 


MEDICAL,  SURGICAL,  OBSTETRICAL,  AND 
THERAPEUTICAL. 

« 

THREE  UNUSUAL  CASES  OF  INTESTINAL 
OBSTRUCTION. 

By  W.  H.  C.  Romanis,  M.B.,  M.C.  Cantab., 
F.R.C.S.  Eng., 

SURGEON  TO  OUT-PATIENTS,  ST.  THOMAS’S  HOSPITAL;  SURGEON,  CITY  OF 
LONDON  HOSPITAL  FOR  DISEASES  OF  THE  CHEST. 

Intestinal  obstruction  may  justly  be  regarded  as  one 
of  the  more  interesting  forms  of  acute  abdominal  disease, 
both  from  the  point  of  view  of  the  diagnosis  of  its  cause 
and  no  less  from  the  consideration  of  the  various  problems 
involved  in  its  surgical  treatment.  The  three  cases  recorded 
below  are  not  only  instances  of  obstructions  from  rare 
causes,  but  one  at  least  presented  a complex  problem  in 
surgical  treatment. 

Case  1. — A woman,  aged  45,  after  some  weeks  of  ill-health 
and  constipation,  was  suddenly  seized  with  acute  abdominal 
pain  and  vomiting,  which  rapidly  became  dark  and  evil- 
smelling. When  seen  four  days  later  the  pain  and  vomiting; 
were  unaltered,  the  abdomen  was  very  distended,  and  visible 
coils  of  bowel  were  present,  especially  in  the  right  iliac  fossa, 
where  a large,  resonant,  rounded  mass  was  present.  The 
bowels  bad  not  been  opened  for  four  days,  and  her  pulse 
and  general  condition  were  poor.  Laparotomy  was  per- 
formed, and  the  first  organ  that  presented  itself  was  the 
caecum,  distended  to  a diameter  of  7 inches  and  com- 
pletely green  and  gangrenous,  the  gangrene  extending 
up  the  colon  to  the  hepatic  flexure.  All  the  intestines 
were  very  distended,  especially  the  large  bowel,  and  low 
down  in  the  pelvic  colon  was  a small  movable  ring  carcinoma 
causing  complete  obstruction  ; the  ciecum  was  in  no  way 
twisted,  and  had  evidently  become  gangrenous  from  the 
tension  of  its  walls  caused  by  its  distended  condition.  The 
gangrenous  caecum  and  ascending  colon  were  removed,  but 
the  patient’s  condition  was  not  sufficiently  good  to  permit  of 
the  growth  (which  was  operable)  being  also  resected,  while 
the  distended  and  friable  condition  of  the  bowel  rendered 
any  attempt  at  an  intestinal  anastomosis  hazardous.  Paul’s 
tubes  were  therefore  tied  into  the  lower  end  of  the  ileum 
and  the  upper  end  of  the  ascending  colon  and  the  abdomen 
closed.  The  patient  made  a rapid  and  uninterrupted 
recovery,  was  not  troubled  with  soreness  and  digestion  of 
the  skin  round  the  enterostomy  wound,  and  gained  weight. 
Some  weeks  later  the  growth  was  resected  and  a double 
anastomosis  done,  the  two  ends  of  the  pelvic  colon  being 
united  by  end-to-end  suture  and  the  divided  end  of  the  ileum 
implanted  in  the  side  of  the  transverse  colon. 

Case  2. — A woman,  aged  62,  was  admitted  with  a history 
of  no  previous  ill-health,  but  of  five  days  intense  pain  and 
vomiting  of  sudden  onset.  The  bowels  had  not  been  opened 
and  the  vomiting  was  incessant,  and  consisted  of  black  and 
foul-smelling  matter.  The  abdomen  was  very  little 
distended,  but  visible  intestinal  coils  were  present,, 
and  in  the  left  iliac  fossa  a round  and  very  hard 
movable  mass  the  size  of  a large  chestnut  could  be  felt. 
It  was  thought  that  this  was  probably  a ring  carcinoma 
causing  the  obstruction.  The  abdomen  was  opened  and  a 
large  gall-stone  was  found  firmly  impacted  in  the  ileum 
2 feet  above  the  ileo-caeoal  valve.  The  bowel  above  was 
extremely  distended,  and  the  condition  of  its  wall  at  the 
point  where  the  stone  was  and  for  a foot  or  two  above  was 
very  bad,  and  gangrene  appeared  to  be  imminent.  The  stone 
was  extracted  through  an  incision  in  the  bowel  wall,  the 
bowel  resutured  and  covered  with  an  omental  graft,  the 
patient  recovering  rapidly.  Examination  at  the  time  when 
the  abdomen  was  opened  showed  that  no  further  gall-stones 
were  present,  but  there  were  many  old  adhesions  round  the 
gall-bladder  and  duodenum,  though  on  inquiry  afterwards 
the  patient  stated  that  she  had  never  had  any  pain  or 
symptoms  that  could  in  any  way  have  been  caused  by  the- 
presence  of  gall-stones. 

From  these  two  cases  it  appears  that  distension  of  the 
bowel  alone  without  any  direct  strangulation  of  its  blooeb 
supply  can,  if  allowed  to  continue  loDg  enough,  go  beyond 
the  stages  of  congestion,  oedema,  and  infiltration  of  the 
bowel  wall,  and  lead  to  actual  gangrene  of  the  whole 
thickness  of  the  intestine.  Perforation  of  stercoral  ulcers 
in  the  distended  colon  above  an  obstruction  is  by  no  means 
uncommon,  but  distension-gangrene  of  the  whole  caecum  is  a 
considerable  rarity. 


482  The  Lancet,] 


CLINICAL  NOTES. 


[Sept.  13,  1919 


Case  3.— A soldier,  aged  20,  was  admitted  with  a history 
that  14  hours  previously  he  ran  a seven  mile  race,  and  for  12 
hours  had  had  acute  abdominal  agony  of  sudden  onset,  with 
intense  vomiting.  His  bowels  had  been  well  opened,  and 
on  examination  his  pulse  was  70,  his  abdomen  retracted, 
board  like  and  dull  in-  the  flanks.  Laparotomy  was  per- 
formed at  once  and  the  abdomen  was  found  full  of  a 
blood-stained  purple  fluid,  a large  number  of  black 
gangrenous  coils  of  ileum,  in  places  already  turning 
green,  presenting  themselves.  It  was  found  that  many 
feet  of  ileum  had  passed  through  a small  hole  in  the 
lower  part  of  the  mesentery,  and  that  not  only  was  the 
portion  of  bowel  that  had  passed  through  the  mesentery 
gangrenous,  but  the  pressure  had  produced  gangrene  of  that 
part  of  the  ileum  in  whose  mesentery  the  aperture  was,  the 
gangrenous  portion  extending  down  to  within  2 inches  of  the 
CEecum.  The  whole  gangrenous  portion  was  resected  almost 
down  to  the  caecum,  the  ends  closed,  and  a lateral  union  made 
with  two  layers  of  silk  sutures  between  the  lower  end  of  the 
ileum  and  the  side  of  the  caecum.  On  subsequent  examina- 
tion the  resected  portion  was  found  to  consist  of  14  feet  of 
ileum,  all  black  and  gangrenous,  but  the  patient  was  too 
bad  on  the  table  for  any  investigation  as  to  the  amount  of 
ileum  remaining.  He  made  an  uninterrupted  recovery,  and 
after  the  first  week  rapidly  put  on  weight  until  in  four 
weeks  he  was  heavier  than  before  the  operation.  At  first 
there  were  six  or  seven  loose  motions  daily,  but  when  seen 
four  months  after  the  resection,  he  was  having  two  soft 
motions  daily  and  doing  his  full  day’s  work  with  ease. 

Other  Recorded  Cases. 

There  have  been  many  and  prolonged  controversies  as  to 
the  amount  of  ileum  necessary  for  the  maintenance  of 
normal  nutrition.  Probably  the  longest  resection  recorded 
is  a case  of  Brenner’s  referred  to  in  Moynihan’s  “Abdominal 
Operations,”  in  which  17£  feet  were  removed,  the 
woman  dying  2£-  years  later  of  marasmus.  Several  other 
cases  of  resection  of*  more  than  14  feet  appear  to  have 
lived  without  any  signs  of  malnutrition,  whereas  other 
cases  in  which  only  8 or  9 feet  have  been  removed,  have 
suffered  from  and  even  died  of  malnutrition,  and  it  appears 
that  individual  peculiarities  exist  which  render  any  dogmatic 
statement  quite  impossible. 


VESICAL  PAPILLOMA  SIMULATING  VESICAL 
TUBERCULOSIS. 

By  Rolf  Creasy,  M.R.C.S.,  L.R.C.P.  Lond. 

I venture  to  publish  the  notes  of  this  case  as  they  may 
prove  both  interesting  and  instructive. 

] f Previous  history. — T.  H.,  46  years.  Primary  hsematuria  in 
December,  1917,  frequency  of  micturition  following  soon 
after.  Discharged  from  the  Army  in  March,  1918,  for 
“ tuberculosis  of  testicles  and  bladder.”  Attended  as  an  out- 
patient for  17  months  (April,  1918,  to  August,  1919)  at  one  of 
our  largest  London  hospitals  under  treatment  for  tuber- 
culosis of  bladder  and  testicles.  Between  May  and  July  he 
attended  at  the  R.C.S.  examinations  three  times,  being 
shown  as  a case  for  diagnosis  (in  the  light  of  subsequent 
events  one  wonders  if  any  luckless  candidate  was  ploughed 
for  not  diagnosing  T.B.  of  bladder).  Was  examined  four 
times  to  January,  1919,  by  pensions  board  and  diagnosis 
confirmed. 

~Z Condition  on  admission. — The  patient  was  admitted  in 
August  to  All  Saints’  Hospital  for  Genito-Urinary  Diseases, 
when  his  condition  was  as  follows  : Testicles  wasted ; nodules 
felt  in  both  epididymes  and  thickening  of  both  cords. 
Prostate  normal ; vesicles  rather  thickened.  Cvstoscopic 
examination  revealed  a cherry-sized,  innocent  papilloma 
springing  from  the  bladder  wall  just  above  the  right 
ureteric  orifice.  Bladder  walls  quite  healthy,  showing  no 
signs  of  tubercle.  Both  ureteric  orifices  normal,  with  good 
efflux.  Trigone  normal.  A test  dose  of  old  tuberculin, 
0-0005  c.cm.,  gave  marked  positive  reaction,  local  and  general. 

Points  of  Interest. 

The  points  of  interest  in  this  case  are  : — 

1.  The  improper  assumption  of  tuberculous  bladder 
because  of  the  tubercle  elsewhere.  It  is  surely  a grave 
reflection  on  the  study  of  urology  in  our  London  hospitals 
that  no  cystoscopic  examination  was  made  in  the  case  of 
this  man  complaining  for  over  two  years  of  htematuria  and 
frequency  of  micturition.  The  case  emphasises  also  the 
necessity  for  early  cystoscopic  examination  in  all  cases  of 
hsematuria.  The  cod-liver  and  malt  prescribed  in  hospital 
for  his  condition  naturally  benefited  in  no  way  the  papilloma 
in  his  bladder. 

2.  The  prompt  treatment  of  his  papilloma  by  Mr.  Canny 
Ryall  by  diathermy  fulguration. 


3.  The  positive  reaction  to  the  tuberculin  test  (which  test 
should  without  doubt  be  applied  to  all  cases  of  suspected 
tuberculosis  of  the  genito-urinary  system),  enabling  the 
treatment  t>y  tuberculin  injections  to  be  at  once  started. 

In  regard  to  the  last  point,  with  the  assistance  of  Mr.  Ryall 
and  Dr.  Camac  Wilkinson  I am  carrying  out  a series  of  some 
20  cases  of  genito-urinary  tuberculosis  treated  by  tuberculin 
injections,  the  result  of  which  I hope  to  publish  in  due  course. 

Graf  ton-street,  W. 


A CASE  OF  BACILLARY  DYSENTERY 

IN  WHICH  FLEXNER-Y  WAS  RECOVERED  FROM  THE 
BLOOD  STREAM  DURING  LIFE. 

By  J.  S.  K.  Boyd,  M.B.,  Ch.B.  Glasg., 

CAPTAIN,  R.A.M.C.  (T.C.)  ; FORMERLY  OFFICER  IN  CHARGE,  BRANCH 
HO.  — , MOB.  BACT.  LAB.,  B.S.F. 


It  is  a general  experience  that  dysentery  bacilli  have  been 
rarely  recovered  from  the  blood  during  life.  Glynn  and  his 
collaborators1  (1917)  have  collected  from  the  literature  15 
cases,  viz.  : B.  dysent.  Shiga,  2 ; B.  dysent.  Flexner,  1 ; 
inagglutinable  B.  dysent.  Flexner,  1 ; and  B.  dysent.  Y,  11. 
In  12  other  cases  the  bacilli  were  found  in  the  blood  after 
death — viz.,  Shiga,  6 times  ; Flexner,  4 ; Y,  2.  Maera  (1918) 
has  since  recorded  the  presence  of  B.  dysent.  Shiga  in  the 
blood  of  a soldier  in  the  East,  who  subsequently  died. 
Caussade  and  Marbais3 4  (1919)  described  a remarkable  case 
of  acute  dysentery  with  pyrexia,  which  was  fatal  in  a week. 
The  stools  were  examined  three  times,  with  negative  results, 
for  amoebae  and  pathogenic  bacteria.  Typical  Shiga  bacilli, 
however,  were  isolated  from  the  blood  post  mortem.  The 
patient’s  blood  also  gave  positive  agglutination  to  Shiga 
1-100.  The  large  intestine  was  inflamed  and  the  epithelium 
necrosed,  but  there  was  no  definite  ulceration.  L.  Rosenthal* 
(1903)  isolated  agglutinable  Shiga  bacilli  from  the  heart 
blood  and  spleen  of  a male,  aged  20,  who  died  after 
four  days’  acute  dysentery ; there  was  typical  dysenteric  1 
thickening  of  the  large  intestine  and  the  mesenteric  glands, 
which  were  one  and  a half  times  the  normal  size  and  con- 
tained much  blood. 

While  serving  with  the  Salonika  Force  in  the  summer  of  : 
1917  I encountered  another  case,  the  seventeenth  ; here 
Flexner-Y  was  the  organism. 

L.-Cpl.  K.  was  admitted  to  C.C.S.  complaining  that  four 
davs  previously  he  “ turned  ill  with  sickness,  vomiting,  and 
diarrhoea”;  the  latter  symptoms  progressively  became 
worse.  On  admission  his  bowels  were  moving  “ every  few 
minutes  ” and  he  was  passing  small  stools  of  blood  and 
mucus.  He  had  severe  general  abdominal  pain.  He  was 
flushed,  but  had  no  typhoid  facies.  The  tongue  was  dry  and 
heavily  furred,  the  abdomen  sunken.  No  rash  was  observed, 
and  the  spleen  was  not  palpable.  The  temperature  was 
100°  F.  and  pulse  98.  The  patient  had  not  been  inoculated 
against  dysentery. 

Stools. — These"  presented  macroscopically  and  micro- 
scopically the  typical  appearances  of  bacillary  dysentery— 
i.e.,  they  were  small  stools  consisting  altogether  of  glairy 
mucus  streaked  with  blood  and  contained  many  leucocytes 
and  a moderate  number  of  red  blood  corpuscles,  desquamated 
and  degenerating  epithelial  cells.  Plated  on  MacConkey’s 
medium  an  almost  pure  culture  of  an  organism  with  the 
following  cultural  characters  grew.  Glucose— acid,  no  gas; 
mannite — acid,  no  gas ; maltose,  lactose,  and  cane- 
unchanged.  The  organism  was  agglutinated  to  the  full 
titre,  1-1500,  by  Lister  Institute  Flexner-Y  antiserum. 

Hamoculture  was  performed  in  the  usual  way  on  the  day 
of  admission,  2 per  cent,  bile-salts  in  distilled  water  being 
used.  In  36  hours  an  organism  was  recovered  from 
this  which  gave  the  same  cultural  and  agglutinative 
characteristics  as  that  isolated  from  the  stool. 

Before  the  special  interest  of  the  case  was  recognised  the 
patient  had  recovered  sufficiently  to  be  evacuated  to  the 
base,  and  was  consequently  lost  sight  of. 

It  will  be  noted  that  the  organism  is  of  the  “Y”  type, 
and  that  the  symptoms  show  no  unusual  variation  from  the 
ordinary  acute  dysentery. 

I have  examined  about  12  other  apparently  similar  cases 
of  acute  bacillary  dysentery  in  about  the  same  stage  of  the 
disease  with  the  same  htemoculture  technique,  but  the 
results  were  negative. 

1 Glynn.  E.  E.,  Ac. : Report  upon  2350  Enteritis  " Convalescent'," 
Medical  Research  Committee,  Report  No.  V.,  Special  Report  Series 
No.  7.  2 Maer  : Brit.  Med.  Jour.,  1918.  vol.  L,  p.  84. 

s Caussade.  G.,  and  Marbais,  S.  : Bull.  Soc.  Med.  des  Hdpitaux  de 

Paris,  1919.  No.  7-8,  p.  145.  „ 

4 Rosenthal,  L. : Deutsch.  Med.  Woch.,  1903,  No.  6,  p.  98. 


The  Lancet,] 


REVIEWS  AND  NOTICES  OF  BOOKS. 


[Sept.  13,  1919  483 


anb  Itatices  d gooks. 


Human  Infection  Carriers.  By  Charles  E.  Simon,  B.A., 
M.  D.,  Professor  of  Clinical  Pathology  in  the  University 
of  Maryland  School  of  Medicine.  Philadelphia  and-  New 
York  : Lea  and  Febiger.  Pp.  250. 

The  problem  of  the  human  carrier  of  bacterial  infection  is 
assuming  ever  greater  importance.  Professor  Simon  regards 
all  such  individuals  as^  a menace  to  society.  He  “ wants  to 
make  your  flesh  creep.”  He  refers  to  “ the  hidden  foe,”  and 
estimates,  on  figures  of  doubtful  validity,  that  there  must 
have  been  at  least  2679  carriers  of  the  B.  diphtheria  in  New 
York  in  1915,  and  that  the  same  city  may  be  assumed  to 
harbour  some  25  000  typhoid  carriers  ; though  he  is  led  to 
express  some  surprise  that,  in  such  circumstances,  typhoid 
fever  is  not  much  more  prevalent  than  is  actually  the  case. 
Viewed  in  this  light,  as  the  case  for  the  prosecution,  the 
book  makes  instructive  reading,  though  it  is  difficult  to 
withhold  some  measure  of  sympathy  from  the  carrier  in 
the  dock,  and  one  is  left  with  a feeling  that  a conviction 
on  all  counts  would  hardly  be  obtained  on  the  evidence 
submitted.  As  a critical  survey  of  the  carrier  problem  the 
work  cannot  compare  with  that  of  Ledingham  and  Arkwright 
published  seven  years  ago,  to  which,  strangely  enough, 
Professor  Simon  does  not  once  refer.  Much  recent  work 
in  connexion  with  poliomyelitis,  cerebro-spinal  fever,  and 
pneumococcal  and  streptococcal  infections  is  included  in 
the  chapters  dealing  with  these  subjects.  Many  of  the 
more  important  facts  which  have  recently  come  to  light 
in  connexion  with  the  epidemiology  of  meningococcal 
infections  are,  however,  omitted  or  passed  lightly  over. 
Certain  errors  and  omissions  are  probably  the  result  of  haste 
in  preparation  and  will  be  corrected  in  a subsequent  edition. 
The  most  glaring  examples  occur  in  the  table  of  fermenta- 
tion reactions  on  p.  94. 

A strong  plea  is  put  forward  for  the  control  of  con- 
valescents from  infectious  diseases,  based  on  bacterio- 
logical findings,  and  for  the  rigid  quarantine  of  all  detected 
carriers,  whether  convalescent,  contact,  or  non-contact. 
Where  this  is  obviously  impossible  the  strict  limitation  of 
their  activities  is  suggested  as  the  most  desirable  alternative. 
Several  large  assumptions  are  made : that  practically  all 
carriers  derive  the  organisms  which  they  harbour  directly 
or  through  a series  of  contacts  from  a case  of  the  disease 
in  question  ; that  the  efficient  control  of  the  patient  would 
largely  prevent  the  occurrence  of  carriers  ; that  our  technique 
is  sufficiently  accurate  to  enable  us  to  detect  such  individuals 
by  a practicable  routine ; and  that  a thorough  campaign 
carried  out  along  these  lines  would  eventually  eliminate  the 
carriers  and  hence  the  diseases  which  they  spread.  Almost 
all  these  basic  assumptions  may  be,  and  have  been,  doubted. 
In  the  case  of  cerebro-spinal  fever  the  rise  in  the  carrier-rate 
has  clearly  been  shown  to  precede  the  epidemic.  Once  this 
has  started  many  carriers  will  be  produced  by  direct  or 
indirect  contact  with  actual  cases  ; yet  it  may  be  that  the 

I actual  case  is  often  the  final  product  of  a process  in  which 
the  passive  carrier  and  the  atypical  case  mark  successive 
stages.  The  numerous  statistical  results,  which  have  been 
obtained  as  regards  repeated  examinations  of  individual 
carriers  over  long  periods,  do  not  tend  to  strengthen  our 
confidence  in  our  ability  to  eliminate  these  unfortunate 
persons  by  practicable  measures.  The  widespread  dissemina- 
tion of  the  meningococcus  among  the  healthy  population,  so 
clearly  brought  out  by  the  work  of  Eastwood,  Griffith,  and 
others  in  this  country,  is  hardly  compatible  with  the  belief 
that  any  scheme  of  quarantine  will  avail  to  rid  us  of  carriers  of 
this  organism,  and  observers  of  repute  have  expressed  a definite 
opinion  that  efforts  along  these  lines  are  useless  in  this  disease. 
The  book  is  marred  in  some  respects  by  being  written  too 
exclusively  from  the  point  of  view  of  the  clinical  pathologist, 
and  certain  fundamental  facts  of  epidemiology  are  misstated 
or  ignored.  Twice,  at  least,  is  the  suggestion  made  that 
epidemics  started  by  carriers  may  spread  until  suitable  soil 
is  no  longer  available.  In  the  sense  that  an  epidemic  ceases 
because  all  su'Ceptibles  have  been  attacked,  this  view  has 
been  shown  by  numerous  authorities  to  be  untenable. 
The  mischievous  activity  of  certain  types  of  carriers  has 
been  demonstrated  to  the  satisfaction  of  almost  all  those 


who  have  studied  the  question,  and  Professor  Simon  presents 
us  with  several  new  histories  illustrating  this,  including 
the  latest  chapters  in  the  life  of  the  famous  “Typhoid 
Mary.” 

Among  the  most  interesting  features  of  this  work  is  the 
appended  summary  of  the  State  laws  and  regulations  per- 
taining to  infection  carriers  ; and  it  would  be  hard  to  find  a 
better  text  from  which  to  preach  the  urgency  of  further 
inquiry  into  the  whole  matter.  Most  of  the  laws  and  regu- 
lations are  new.  While  16  States,  at  least,  have  given  no 
definite  rulings  on  this  question,  one  hopefully  includes 
scarlet  fever  in  a list  of  diseases  in  which  carriers  shall  be 
liable  to  special  control.  Illinois  strikes  a practical  note  in 
prohibiting  typhoid  convalescents  from  engaging  in  the  pre- 
paration or  handling  of  foodstuffs  or  milk  until  the  excreta 
are  certified  to  be  free  from  bacilli,  and  in  imposing  a fine  of 
not  more  than  $200  or  imprisonment  in  the  county  gaol 
for  not  more  than  six  months,  or  both,  as  a penalty  for  each 
offence.  The  effort  to  deal  with  a problem  of  such  real 
importance  along  legislative  and  administrative  lines  reflects 
great  credit  on  the  activity  of  the  health  authorities 
of  the  United  States,  and  is  full  of  interest  to  ourselves 
in  a year  marked  by  the  birth  of  the  Ministry  of  Health. 
The  problem  is  exactly  one  where  the  new  Ministry  will 
require  sound  medical  guidance.  Are  detection  and  quaran- 
tine, involving  an  enormous  amount  of  bacteriological  inves- 
tigation and  the  control  of  many  thousands  of  apparently 
healthy  persons,  the  only  or  the  best  ways  to  deal  with  the 
position?  Or  is  it  possible  that  more  will  be  accomplished 
by  less  rigorous  methods  combined  with  a determined 
attempt  to  lessen  overcrowding  and  to  educate  the  public 
in  the  ways  of  cleaner  and  more  healthy  living  ? How 
much,  again,  can  we  expect  from  widespread  schemes 
of  preventive  inoculation,  and  to  how  many  diseases  can 
this  method  be  usefully  extended  ? If  we  are  to  succeed  in 
those  plans  for  the  gradual  diminution  of  infective  disease, 
in  which  our  hopes  are  so  largely  centred,  we  must  secure 
the  hearty  cooperation  of  the  population  in  general.  This 
might  well  be  lost  by  restrictive  legislation  applied  without 
clear  proof  of  its  necessity.  Unpopularity  should  never  be  an 
excuse  for  inactivity  when  the  facts  are  clear,  but  we  should 
do  well  to  build  carefully  and  on  sure  foundations. 

Professor  Simon's  book  serves  to  impress  upon  us  that  action 
cannot  be  indefinitely  delayed.  If  we  could  learn  that  the 
financial  outlay  involved  in  a thorough  and  systematic  survey 
of  the  whole  subject  would  probably  save  us  from  endless 
mistakes,  and  some  possible  disasters  in  the  not  far- distant 
future,  we  should  have  gained  much. 


Praotioal  Obstetrios.  By  E.  Hastings  Tweedy,  F.R.C.P.I., 
Professor  of  Obstetrics,  Royal  College  of  Surgeons  in 
Ireland,  Past  Master  of  the  Rotunda  Hospital  ; and  G.  T. 
Wrench,  M.D.,  late  Assistant  Master.  Fourth  edition. 
London  : Henry  Frowde  (Oxford  University  Press). 

1919.  Pp.  557.  21s. 

This  edition  is  particularly  interesting,  as  in  the  absence 
of  the  master,  Dr.  Henry  Jellett,  on  war  service,  the  governors 
of  the  Rotunda  Hospital  asked  three  past  masters  to  carry 
on  the  work.  Dr.  Hastings  Tweedy  therefore  has  had 
exceptional  opportunities  of  renewing  his  acquaintance  with 
the  clinical  teaching  of  that  institution  which  is  embodied 
in  the  present  volume.  The  demand  for  a fourth  edition 
in  so  short  a space  of  time  shows  the  practical  success  of 
the  work,  which  is  founded  upon  the  experience  gained  in 
what  is,  taken  all  round,  the  best  lying-in  hospital  in  the 
United  Kingdom.  We  may  not  all  of  us  agree  with  some 
of  the  details  of  the  teaching  of  the  Dublin  school,  but  that 
the  “Rotunda”  opinion  upon  any  matter  in  the  science  and 
art  of  obstetrics  must  be  seriously  accepted  no  one  could  be 
found  to  deny. 

In  view  of  the  interest  the  subject  is  exciting  at  present  the 
results  of  the  observations  of  Dr.  J.  R.  Freeland  and  Dr.  B. 
Solomons  on  twilight  sleep  are  important.  Their  report  is,  on 
the  whole,  in  favour  of  the  method,  but  it  must  be  noted  that 
they  gave,  as  a rule,  relatively  small  doses  and  only  10  out 
of  their  100  cases  appear  to  have  exhibited  complete 
analgesia.  The  authors  believe  that  the  results  obtained 
by  scopolamine- morphia  injections  demonstrate  that  so-called 
secondary  uterine  inertia  is  in  reality  not  due  to  a “tired- 
out  uterus”  but  to  a “tired-out  woman,”  and  that  the 


484  The  Lancet,] 


REVIEWS  AND  NOTICES  OF  BOOKS. 


[Sept.  13,  1919 


appearance  of  strong  labour  pains  in  the  early  stages  of 
labour  is  due  to  an  hysterical  condition  of  exaggeration  and 
alarm  in  a hypersensitive  woman.  The  very  constant  effect 
twilight  sleep  has  in  producing  secondary  uterine  inertia 
must,  however,  be  borne  in  mind,  and  we  regard  the 
teaching  that  there  are  two  conditions  of  primary  and 
secondary  uterine  inertia  and  a third  one  of  obstructed 
labour  to  be  the  more  correct. 

The  section  dealing  with  the  treatment  of  eclampsia  is  a 
very  good  one,  and  the  fact  that  in  an  appendix  the  authors 
have  reprinted  a paper  read  by  one  of  them  before  the  Interna- 
tional Medical  Congress,  1911,  and  also  a paper  by  Stroganoff, 
gives  the  reader  additional  information  in  regard  to  the 
methods  described  in  the  text,  methods  which  certainly  give 
extremely  good  results.  The  two-bladed  cephalotribe  is  at 
the  present  time  old-fashioned,  and,  we  imagine,  seldom 
used.  If  a practitioner  attempted  to  use  the  instrument 
according  to  the  description  given  by  the  authors  he  would 
certainly  fail  in  a difficult  case — that  is,  if  we  are  right  in 
assuming  that  Braxton  Hicks's  instrument  is  referred  to. 
The  authors  still  favour  plugging  in  the  treatment  of  rupture 
of  the  uterus,  and  quote  six  cases  successfully  treated  by 
this  method.  It  is  a pity  they  do  not  state  whether  these 
were  cases  of  complete  or  incomplete  rupture.  But  in  spite 
of  these  slight  differences  of  opinion  between  us  and  the 
authors,  we  regard  their  book  as  a very  good  one  and  one 
which  can  be  most  highly  recommended  both  to  students 
and  practitioners  as  thoroughly  sound  in  its  teaching. 


Venereal  Diseases  ; a Practical  Handbook  for  Students.  By 
C.  H.  Browning,  M D.,  D.P.H.,and  David  Watson, 
M.B.,  C.M.  London  : Henry  Frowde  and  Hodder  and 
Stoughton.  1919.  Pp.  336.  16s. 

In  order  that  students  should  benefit  to  the  greatest 
advantage  from  any  treatise  three  conditions  must  be  fulfilled. 
The  presentation  of  the  subject  must  be  systematic,  clearness 
and  brevity  must  go  hand  in  hand,  and  the  information 
afforded  should  be  stimulating. 

This  volume  is  divided  into  two  parts,  the  first  treating 
of  syphilis  and  the  second  of  gonorrheea.  In  Section  I. 
(Syphilis)  the  foregoing  conditions  are,  on  the  whole, 
admirably  satisfied.  From  the  student’s  point  of  view  the 
pathological  teaching  is  extremely  good.  We  can  find  little 
which  calls  for  adverse  criticism,  much  that  deserves  eulogy. 
The  illustrations  are  on  the  whole  good,  but  we  think  that 
the  plates  (2,  3,  and  4)  illustrative  of  different  chancres 
might  be  much  more  definite.  More  space  might  have  been 
allotted  to  the  differential  diagnosis  of  penile  and  other 
chancres. 

It  is  not  necessary  or  desirable  for  anyone  to  attempt  to 
carry  out  the  Wassermann  test  unless  he  is  justified  by  long 
experience  in  doing  so.  Every  practitioner,  however,  should 
understand  its  rationale,  and  therefore  we  are  sorry  to  find 
that  the  explanation  of  this  reaction  is  not  as  clear  as  it 
might  be.  Now  that  the  importance  of  the  pre-natal  treat- 
ment of  syphilis  is  recognised,  it  is  to  be  regretted  that  no 
more  than  2j  lines  are  devoted  to  this  subject. 

It  would  have  been  more  satisfactory  if  the  authors  had 
given  their  readers  more  definite  ideas  as  to  the  comparative 
value  of  the  various  substances  which  are  now  being  used  for 
the  administration  of  intravenous  injections.  We  consider 
that  the  paragraph  devoted  to  the  “contra-indications”  to 
the  administration  of  salvarsan  should  at  least  give  some 
definite  information  for  the  benefit  of  students  as  to  the 
course  to  be  adopted  with  a patient  who  is  suffering  from 
chronic  Bright’s  disease,  acute  nephritis,  or  aortic  disease. 
The  statement  that  “there  are  no  absolute  contra- 
indications to  the  administration  of  the  drug  ” is  one  that 
will  not  commend  itself  generally  to  syphilologists.  If 
it  is  necessary  to  devote  half  a page  to  the  illustration  of 
an  apparatus  for  giving  int  ravenous  injection  by  pressure,  it  is 
desirable  to  afford  some  explanation  of  its  methods  of  action. 
Lastly,  after  calling  attention  to  the  emergencies  contingent 
upon  the  administration  of  salvarsan  treatment,  it  is  advisable 
to  give  the  student  information  as  to  how  to  combat  the 
same.  We  are  purposely  pointing  out  what  we  think  to  be 
weak  spots  in  a valuable  section  of  the  treatise. 

But  while  we  believe  that  the  first  part  of  this  book  is,  as 
a whole,  admirably  suited  to  subserve  the  purpose  of  its 
existence  as  “a  practical  handbook  for  students,’’  the 
same  can  hardly  be  said  of  the  second  section  on 


“ Gonorrhoea.”  It  is  not  systematic,  and  therefore  it  is  not 
clear.  We  are  certain  that  the  student  knowing  nothing  of 
his  subject  who  comes  to  this  volume  for  instruction  will 
leave  it  in  a mentally  nebulous  condition.  The  aim  of  a 
work  of  this  nature  should  be  to  instruct  a student  how  to 
examine  and  treat  a case  of  gonorrhoea  in  a methodical 
fashion.  In  this  respect  the  authors  have  failed,  and,  further, 
their  teaching  is  not  always  in  agreement  with  the  best  views. 
In  regard  to  the  treatment  of  acute  anterior  urethritis  the 
authors  warn  the  students  with  respect  to  injections  as  given 
by  a syringe.  “ No  force  must  be  used,  otherwise  a minute 
quantity  of  gonococcus-laden  pus  may  be  forced  into  the  pos- 
terior urethra  and  an  acute  posterior  urethritis  incited.  This 
is  an  accident  which  frequently  happens  in  cases  treated  by 
this  method.”  On  pages  190-191  the  authors  advise  what 
they  term  “ urethro- vesical  lavation  ” (generally  termed  pos- 
terior irrigation).  They  advise  that  the  reservoir  containing 
the  antiseptic  fluid  should  be  placed  at  a height  of  44  feet  above 
the  level  of  the  patient’s  pelvis.  We  feel  assured  that  the 
danger  which  they  aim  at  preventing  when  using  the  syringe 
will  be  lavishly  present  if  the  above  method  of  “lavation  ” be 
used  in  a case  of  anterior  urethritis.  Again,  in  dealing  with 
the  subject  of  chronic  gonococcal  urethritis  the  authors  fail 
to  emphasise  sufficiently  the  value  of  digital  examination  of 
the  prostate  and  of  the  vesicles.  This  we  regard  as  a serious 
omission  ; in  fact,  we  consider  it  most  necessary  to  impress 
upon  students  the  need  which  exists  for  the  valuable 
information  which  is  to  be  obtained  from  the  constant- 
examination  of  prostate  and  vesicles.  For  there  is  no  doubt 
that  the  rectal  is  the  high  road  which  leads  to  success  in 
both  the  diagnosis  and  treatment  of  chronic  posterior 
urethritis. 

The  consideration  of  the  subject  of  strictures,  their 
diagnosis  and  treatment,  is  inadequate,  and  when  it  is  con- 
sidered what  can  be  effected  by  careful  dilatation  and  the 
resultant  avoidance  of  urethrotomy  the  omission  is  a 
serious  one.  Insufficient  attention  is  given  to  the  technique 
involved  in  urethroscopic  examination.  We  regret,  also,  that 
we  are  unable  to  find  any  reference  to  the  necessity  of 
making  a systematic  examination  of  every  patient  before  he 
is  discharged  from  treatment.  The  authors  suggest  that 
“ any  persons  who  have  previously  suffered  from  gonorrhoea 
should  submit  to  an  expert  medical  examination  before 
marriage.”  This  is  not  enough.  Every  patient  who  has 
been  under  treatment  for  gonorrhoea  should  be  systemati- 
cally examined  before  he  is  discharged,  whether  married, 
about  to  be  married,  or  without  any  idea  of  marriage.  From 
a sociological  point  of  view  the  man  who  has  no  idea  of 
marriage  is  likely  to  prove  the  most  dangerous  to  the  com- 
munity if  he  is  discharged  from  treatment  without  a thorough 
examination. 

We  are  sure  that  the  authors  can  make  a valuable  treatise 
out  of  their  work  if  they  will  boldly  throw  over  altogether  the 
teaching  of  the  schools  where  it  conflicts  with  recent  clinical 
experience,  and  will  bear  in  mind  that  the  present-day 
student  must  be  equipped  on  every  hand  for  a medico-social 
conflict.  

Through  a Tent  Door.  By  Robert  William  Mackenna, 

M.D.,  R.  A..M.C.  London:  John  Murray.  1919.  Pp.  310. 

8s.  net. 

This  book  of  war  essays  has  none  of  the  robustness 
and  rollicking  humour  of  others  of  its  kind,  though  it  is 
possibly  none  the  worse  for  that.  Incidents  of  the  war  as 
seen  from  a field  hospital  form  the  basis  of  the  book,  but 
one  feels  that  the  author  would  hive  been  just  as  happy 
had  his  vantage  point  been  an  English  provincial 
hospital,  for  he  comments  on  life  rather  than  on 
action.  He  is  interested  in  books,  religion,  and  human 
nature — in  fact,  in  things  in  general ; and  it  is  merely  an 
accident  that  he  happens  to  have  thought  and  written  in 
Flanders.  Dr.  Mackenna  has  a pleasant,  gentle  style,  some- 
what reminiscent  of  Elia,  and  on  the  whole  his  work  reaches 
a high  level.  Were  we  called  upon  to  select  any  one  essay 
for  special  praise  it  would  be  the  one  entitled  “ Through  a 
Tent  Door,”  but  many  others  are  ahnost  equally  succ-ssful. 
“The  Visitant,”  a work  of  pure  imagination,  pleased  us  least: 
and  “ Margarine  and  Cafe-au-lait,”  a desultory  discourse  on 
books,  might  well  have  been  omitted  ; the  kind  of  thing 
has  been  done,  and  done  better,  elsewhere.  Dr.  Mackenna's 
public  may  not  be  large,  but  it  will  be  appreciative,  for  his 
work  is  thoughtful  and  sincere. 


Ths  Lanoht,] 


THE  ERADICATION  OF  EPIDEMIC  DISEASES. 


[Sect.  13,  1919  485 


THE  LANCET. 


LONDON:  SATURDAY,  SEPTEMBER  13,  1919. 


The  Eradication  of  Epidemic 
Diseases, 

Can  the  great  epidemics  of  disease  which  from 
time  to  time  sweep  over  the  whole  or  a great  part 
of  the  earth’s  surface  be  prevented  by  human 
effort  ? Will  it  ever  prove  possible  to  trace  them 
to  their  place  of  origin,  and  by  appropriate  measures 
applied  there  destroy  the  cause  of  each  disease  at 
its  very  source  ? In  the  case  of  a large  number  of 
infectious  diseases  human  effort  can,  and  does  to 
a great  extent,  control  the  spread  of  an  infection 
once  introduced,  and  limit  its  disastrous  effects  on 
the  community.  But  the  aim  of  the  epidemiologist 
and  public  health  administrator  is  something  higher 
than  this.  To  them,  even  more  than  to  the  clinician, 
prevention  is  infinitely  to  be  preferred  to  cure, 
for  while  he  deals  with  single  lives  they  are 
dealing  with  lives  in  countless  numbers.  When 
the  recent  truly  terrible  epidemic  of  influenza 
(we  use  the  words  deliberately,  for  the  deaths 
caused  by  that  epidemic  outnumbered  immeasur- 
ably those  caused  by  four  and  a half  years  of  the 
greatest  war  in  history)  swept  over  the  world,  how 
many — or  how  few — persons  were  saved  from  its 
attacks  by  individual  or  by  communal  measures  of 
precaution  ? The  medical  profession  cannot  claim 
that  the  course  of  the  epidemic  was  seriously 
affected,  still  less  stayed,  by  any  such  measures. 
Had  it  proved  possible  to  detect  from  the  outset  the 
place  of  origin  of  the  disease  and  to  destroy  the 
infection  then  and  there,  or  at  least  to  prevent  its 
spread  beyond  local  limits,  the  millions  of  lives 
thus  sacrificed  might  have  been  saved  ; one  more — 
and  perhaps  the  greatest  of  all — would  have  been 
added  to  the  list  of  triumphs  of  preventive 
medicine ; and  the  very  course  of  history  itself 
might  have  been  changed.  And  if  this  is  true  of 
influenza,  it  is  no  less  true  of  other  and  allied 
epidemic  diseases. 

We  have  been  led  along  this  line  of  thought 
by  the  instructive  presidential  address  delivered 
by  Dr.  Simon  Feexner  before  the  recent  Congress 
of  American  Physicians  and  Surgeons.  The  address 
covered  much  ground,  and  we  only  here  refer  to  one 
or  two  of  its  salient  points,  as  they  appear  in  the 
abstract  printed  in  our  issue  of  last  week.  As  Dr. 
Flexner  points  out,  in  the  case  of  one  disease  at 
least,  the  aim  we  have  tried  to  formulate  above 
has  been  actually  attained.  “ We  have,”  he  says, 
“ a splendid  example  of  eradication  of  disease  in 
yellow  fever.  We  did  not  wait  for  the  disease  to 
become  epidemic ; it  was  destroyed  in  its  endemic 
home.”  But  in  the  case  of  influenza  the  problem  to 
be  solved  is  more  complex  than  in  that  of  yellow 
fever,  and  more  complex  perhaps  than  Dr. 
Flexner’s  remarks  (of  necessity  much  concen- 
trated in  our  abstract)  seem  to  imply.  “ In  the 
history  of  epidemics,”  he  says,  “influenza  took 
its  origin  in  a region  somewhere  near  the  Russian 
border  of  Turkestan,  spreading  along  the  trade 

routes  as  rapidly  as  transportation  moved 

The  endemic  focus  of  influenza  is  somewhere  on 
the  Eastern  border  of  Russia.”  Consequently  he 
holds  that  it  is  not  too  much  for  a reconstructive 


medical  profession  to  conceive  the  clearing  up  a 
region  which  by  its  inaccessibility  and  its  neglect 
has  every  25  or  30  years  originated  waves  of 
disease  spreading  over  the  globe.”  We  should 
share  this  hope  more  willingly  were  we  con- 
vinced of  the  correctness  of  the  geographical 
premise.  In  the  great  pandemic  of  1889  and  sub- 
sequent years  there  was  strong  evidence  to  show 
that  the  outbreak  did  in  truth  take  its  origin  on  the 
borders  of  European  and  Asiatic  Russia.  The 
evidence  was  set  forth  in  two  articles 1 published 
in  The  Lancet  by  Dr.  F.  G.  Clemow  in  1894,  and 
was  based  on  original  and  unpublished  reports 
made  by  Russian  doctors  in  the  regions  in  question 
to  the  Medical  Department  of  the  Russian  Ministry 
of  the  Interior  at  the  time  of  the  epidemic.  But 
that  evidence  was  restricted  to  one  particular  out- 
break of  the  disease,  and  we  are  not  aware  that  it  has 
ever  been  claimed,  or  that  the  historical  facts 
would  lend  any  support  to  such  a claim,  that 
influenza  epidemics  always  or  even  frequently  arise 
in  the  regions  indicated.  The  so-called  “ Spanish 
influenza  ” of  1918-19  arose  we  know  not  where. 
The  records  of  its  course,  owing  to  the  state  of  the 
world  at  the  time,  were  far  more  imperfect  than 
those  of  the  1889  pandemic ; and,  so  far  as  they  are 
available,  they  do  not  seem  to  show  the  same  clear 
progress  from  one  well-defined  centre  to  the  rest 
of  the  globe.  In  this  respect  influenza  must 
always,  save  perhaps  on  rare  occasions,  offer  great 
difficulties  to  those  who  would  aim  at  destroying 
it  at  its  source.  But  the  aim  need  not  for  that 
reason  be  lost  sight  of.  The  interests  at  stake 
and  the  rewards  of  success  in  preventing  even  one 
single  pandemic,  such  as  that  of  1889  or  1918, 
are  on  too  colossal  a scale  for  a policy  of  despair  ; 
and  we  fully  share  the  hope  that,  when  order  once 
more  reigns  in  Russia,  a careful  watch  may  be  kept 
on  the  regions  which  gave  birth  to  at  least  one 
great  epidemic  of  influenza,  and  may  yet  give  rise 
to  another. 

But  while  a massed  attack  on  an  endemic  focus 
seems  as  yet  too  sanguine  a prospect  where 
influenza  is  in  question,  the  conditions  sur- 
rounding the  origin  of  the  great  cholera  epi- 
demics offer  more  hope  for  the  attainment  of  the 
aim.  The  endemic  home  of  cholera  is  universally 
believed  to  lie  in  Lower  Bengal — in  the  Sundarbans 
and  the  delta  of  the  Ganges.  The  problem  of  the 
eradication  of  this  disease,  therefore,  is  not  com- 
plicated by  uncertainty  as  to  its  place  of  origin. 
The  real  difficulties  arise  here  when  the  practical 
measures  necessary  for  such  eradication  come  to  be 
considered.  The  large  size  of  the  area  in  question, 
the  engineering  difficulties,  and  the  cost,  with  no 
direct  financial  profit,  of  draining  and  “ sanitating  ” 
this  vast  region  all  stand  in  the  way  of  a radical  solu- 
tion of  the  cholera  problem.  But  these  are  not  in 
truth  insuperable  difficulties.  In  a world  awake  to 
the  blessings  of  health  can  any  cost  be  deemed  too 
great  or  any  obstacles  be  thought  insuperable  where 
the  saving  of  millions  of  human  lives  and  the  preven- 
tion of  incalculable  suffering  will  be  the  rewards  of 
success  ? Each  of  the  great  epidemic  diseases 
presents  its  own  special  problems,  and  preventive 
medicine  can  already  claim  a wonderful  series  of 
triumphs  in  discovering  the  causes  of  most  of 
these  diseases  and  pointing  the  way  to  their 
control.  It  may  no  less  proudly  claim  to  have 
opened  the  eyes  of  modern  statesmen  and  adminis- 
trators to  the  overwhelming  importance  to  the 

1 Recent  Pandemic  of  Influenza,  its  Place  of  Origin  and  Mode  of 
Spread,  The  Lancet,  Jan.  20th  and  Feb.  10th,  1894. 


486  The  Lasoet,] 


THE  TEACHING  OF  OBSTETRICS  IN  LONDON. 


[Sept.  13,  1919 


State  and  the  people  of  dealing  seriously  with  the 
problems  of  disease  prevention.  To-day  large, 
costly,  and  far-seeing  measures  with  this  object 
occupy  a place  in  practical  politics.  But  we 
like  to  picture  a world  where  the  prevention  and 
eradication  of  all  diseases  that  can  be  prevented  or 
eradicated  should  be  the  aim — even  the  first  aim — 
of  national  and  international  policy  and  effort ; 
where  measures  having  as  their  object  the  saving 
of  millions  of  human  lives  would  be  thought  as 
worthy  of  a great  statesman’s  energies  and  of  the 
interest  of  the  public  as  Free  Trade,  bimetallism, 
and  the  nationalisation  of  railways.  It  may — and, 
indeed,  we  are  not  optimistic  enough  to  doubt 
that  it  must — take  many  long  years  to  reach 
this  ideal.  But  in  the  meantime  much  may, 
and  should,  be  done ; and  we  hold  that  it  should 
prove  quite  feasible  to  trace  some,  if  not  all,  of  the 
great  pandemic  diseases  to  their  source  and  to 
make  a serious  effort  to  stifle  them  in  their  cradle.* 
We  do  not  hide  from  ourselves  the  vastness  of  the 
task  or  the  practical  difficulties  to  be  overcome, 
but  modern  science  exults  in  difficulties.  When 
the  smoke  and  noise  of  war  have  cleared  away, 
and  the  nations  are  really  at  peace  again,  the 
statesmen  of  the  world  could  find  no  higher  or 
more  stimulating  aim  for  their  energies  than  the 
cleansing  of  epidemic  breeding  grounds. 


The  Teaching  of  Obstetrics  in 
London. 

No  one  who  has  read  the  report  of  the  Committee 
of  the  Section  of  Obstetrics  and  Gynajcology  of  the 
Royal  Society  of  Medicine,  appointed  to  consider 
this  subject,  can  fail  to  agree  with  their  conclusions 
that  the  present  methods  of  teaching  midwifery  are 
very  defective.  There  has  been  little  alteration  in 
these  methods  for  a long  time  past,  and  while  it  is 
true  that  the  establishment  of  midwifery  wards  of 
recent  years  in  certain  of  the  hospitals  has  done 
something  towards  reform,  the  main  and  gravest 
defect  still  remains.  We  refer  to  the  fact,  strongly 
emphasised  by  the  Committee,  that  the  student 
learning  clinical  midwifery  is  completely  out  of 
touch  with  his  senior  teachers,  as  he  does  not  see 
them  actually  engaged  in  the  work  he  is  trying 
to  learn  and  seldom  has  the  advantage  of  their 
supervision  and  guidance.  This  is  certainly  true 
of  those  hospitals,  the  great  majority  in  London, 
which  have  no  midwifery  ward,  and  even  in  those 
which  have  it  is  true  to  a very  large  extent.  It  is 
generally  impossible  for  the  senior  members  of  the 
staff  to  be  present  at  any  normal  labours,  and  it  is 
no  exaggeration  to  say  that  in  most  hospitals  they 
are  not  there  even  when  a case  of  abnormal  labour 
is  being  conducted,  and  the  most  the  student  can 
expect  to  see  is  the  performance  of  the  Caesarean 
section  by  one  of  the  visiting  staff,  a class  of  case 
he  will  seldom  meet  with  and  an  operation  he  will 
probably  never  attempt.  The  result  of  this  is  that 
while  in  medicine  and  surgery  the  student  has  the 
great  advantage  of  receiving  most  of  his  clinical 
teaching  from  the  visiting  physicians  or  surgeons, 
in  midwifery,  just  as  important  a subject,  the 
teaching  is  mainly  in  the  hands  of  junior 
residents  or  registrars. 

This  being  the  case,  it  is  little  wonder  that  the 
reputation  of  the  London  School  of  Obstetric 
Medicine  is  but  a poor  one,  and  that  research  in 
the  subject  is  practically  non-existent.  It  is  high 
time  that  some  change  was  made  and  that  the 


whole  matter  was  put  upon  a more  satisfactory 
basis.  Not  only  is  the  clinical  teaching  of  mid- 
wifery in  London  very  deficient,  but  the  small 
number  of  beds  available  for  lying-in  cases  is 
almost  scandalous.  In  these  days  the  medical 
student  no  longer  should  be  dependent  upon 
attendance  in  the  extern  maternity  department  for 
his  experience  in  midwifery  practice.  In  the 
unsuitable  surroundings  that  obtain  in  the  homes 
of  the  poor  it  is  quite  impossible  for  antiseptic  or 
aseptic  methods  of  conducting  a confinement  to  be 
efficiently  carried  out,  and  if  they  cannot  be 
properly  practised  they  cannot  be  properly  taught, 
as  they  should  be  by  example  and  not  merely  by 
precept.  One  of  the  pressing  needs  of  London,  and, 
indeed,  of  every  other  town  in  the  country,  is  a 
more  adequate  provision  of  lying-in  beds.  It  should 
be  possible  for  every  woman  who  desires  to  do  so 
to  be  admitted  to  a properly  equipped  lying-in 
hospital,  and  it  should  be  just  as  great  a scandal  to 
conduct  a difficult  case  of  midwifery,  possibly 
necessitating  an  operation,  in  the  utterly  un- 
suitable surroundings  of  a tenement  house  as 
it  would  be  to  carry  out  even  a simple 
surgical  operation  amid  such  surroundings.  And 
yet  this  is  happening  every  day  in  the  week  and 
almost  every  hour  in  the  day.  In  the  ratio  that 
exists  between  the  number  of  beds  available  and 
the  number  of  beds  required  for  lying-in  cases,  we 
imagine  that  London  is  in  a worse  position 
than  any  other  large  city  in  the  world.  It  is 
to  be  hoped  that  the  new  Ministry  of  Health 
will  take  this  matter  in  hand  and  will  insist  that 
the  provision  of  lying-in  beds  in  the  large  hospitals 
with  medical  schools  should  be  such  as  to  render  it 
possible  to  admit  other  cases  than  merely  those 
which  are  sent  in  from  the  maternity,  district  or 
by  medical  practitioners  because  they  require 
operative  interference.  The  fact  that  a woman 
who  has  to  undergo  an  obstetric  operation 
frequently  runs  a greater  risk  than  one  who  has 
to  undergo  an  ordinary  major  operation  of  surgery 
should  be  made  quite  clear  to  the  public,  and  it  is 
not  just  or  fair  that  in  these  circumstances  she 
should  be  terribly  penalised  because  sufficient 
accommodation  is  not  to  be  found  in  the  large 
voluntary  hospitals.  The  fact  that  neither  the 
majority  of  the  medical  staffs  nor  the  managing 
committees  of  many  hospitals  appear  to  recognise 
the  necessity  for  such  a provision  is  becoming: 
a strong  argument  for  placing  the  hospitals  under 
State  control. 

But  when  the  beds  needed  have  been  provided 
they  will  be  useless  from  the  student’s  point  of 
view  unless  a very  radical  change  is  brought  about 
in  the  present  methods  of  teaching.  The  crux  of 
the  whole  question  lies  in  the  provision  of  some 
means  whereby  the  student  can  receive  his  teaching 
in  theoretical  and  practical  midwifery  from  teachera 
of  a class  comparable  to  those  who  are  engaged  in 
teaching  him  medicine  and  surgery.  As  we  have 
pointed  out,  at  present  this  is  only  true  as  regards 
systematic  instruction  in  midwifery,  the  practical 
teaching  being  mainly  in  the  hands  of  junior 
teachers  occasionally  but  seldom  above  the  rank 
of  a registrar.  In  the  near  future,  perhaps, 
several  of  the  medical  schools  in  London  will  have 
whole-time  properly  paid  teachers  in  medicine  and 
surgery,  and  no  one  who  has  given  any  atten- 
tion to  the  needs  of  medical  education  can  doubt 
that  this  step  will  tend  not  only  to  advance  and 
improve  the  theoretical  and  clinical  teaching,  but 
that  it  will  tend  also  greatly  to  the  advancement  of 


The  Lancet,] 


MIND  AND  MEDICINE. 


[Sept.  13,  1919  4^7 


research  in  these  two  subjects.  An  appointment  in 
obstetrics  on  these  lines— namely,  a whole-time 
properly  paid  teacher  provided  with  paid  assistants 
ami  with  adequate  laboratory  accommodation  for 
the  carrying  out  of  research — is  urgently  needed, 
and  is  one  of  the  chief  recommendations  of  the 
Committee  whose  report  we  are  considering. 
Whether  such  a teacher  should  be  the  head 
of  a separate  institution  on  the  lines  of  the 
Rotunda  Hospital  in  Dublin,  or  whether  he 
should  be  closely  associated  with  one  of  the 
existing  medical  schools  and  take  charge  of 
a greatly  enlarged  obstetrical  and  gynaecological 
department  in  the  associated  hospital  is  largely  a 
matter  of  convenience  and  detail ; the  principle 
remains  the  same  in  either  case.  Until  an  appoint- 
ment of  this  kind  is  made  by  which  the  student  will 
be  taught  his  theoretical  midwifery  and  be  able  to 
see  clinical  midwifery  practised  and  obstetrical 
operations  carried  out  as  they  should  be  carried  out, 
in  suitable  surroundings  by  a master  of  the  art,  the 
teaching  of  midwifery  will  never  make  any  appreci- 
able progress  in  London,  and  the  reproach  that 
research  in  this  subject  in  London  is  a negligible 
quantity  will  never  be  overcome.  We  have  said 
little  about  the  teaching  of  the  London  student  in 
gynaecology,  because  on  the  whole  it  is  satisfactory, 
the  same  difficulties  do  not  surround  it,  and  no 
modifications  are  really  required,  but  the  two 
subjects  cannot,  and  should  not.  be  divorced.  They 
should  be  taught  together  in  a single  institute,  and 
under  the  same  roof  should  be  located  a corre- 
sponding maternity  and  child-welfare  centre. 
» 

Mind  and  Medicine. 

The  truism  that  history  repeats  itself  is  suggested 
by  the  reading  of  a lecture  with  this  title  delivered 
in  the  John  Rylands  Library  by  Dr.  W.  H.  R. 
Rivers,  Praelector  in  Natural  Sciences  at  St.  John's 
College,  Cambridge.  Continual  progress  and  fresh 
scientific  discoveries  notwithstanding,  an  impartial 
scanning  of  the  phases  or  trends  of  medicine 
at  various  epochs  in  world  history  points  to  the 
conclusion  that  the  human  mind  in  its  rela- 
tion to  the  practice  of  medicine  moves  through 
cycles  in  which  time  is  measured  not  by  years 
but  by  centuries.  Primitive  associations  of  medicine 
with  religion  and  with  magic  seem  in  the  fullness 
of  time  to  be  replaced  by  modern  associations 
not  widely  differing  in  essence.  Subsequent  search 
for  a material  basis  for  disease  in  a humoral 
theory  is  paralleled  by  a not  much  more  scientific 
conception  of  the  interrelation  of  the  endocrine 
glands  and  their  bearing  on  many  morbid  states. 
To  the  student  of  medicine  the  succession  of 
animism  by  materialism,  and  of  the  latter  by  deeper 
appreciation  of  the  mental  factor  in  disease  does 
not,  however,  represent  the  historical  facts  other 
than  superficially.  At  no  time  has  either  the 
mental  or  the  material  factor  been  predominant  to 
the  complete  exclusion  of  the  other ; as  long  as  a 
dual  conception  of  man’s  being  has  existed,  so  long 
has  medical  opinion  oscillated  between  one  and 
other  aspect  of  it,  and  so  will  it  continue  to 
oscillate.  A system  of  healing  styled  “ New 
Thought”  is  in  reality  very  old  thought ; while  the 
organisms  of  the  germ  theory  are  the  counterpart 
of  the  worms  and  snakes  of  savage  medicine. 

What  is  new  is  the  determination  of  the  precise 
scope  of  the  psychological  factor  in  disease,  and 
the  laying  down  of  the  principles  of  psychotherapy. 
For  the  time,  we  may  say,  the  growing  point  of  the 
study  of  nervous  disease  is  in  the  direction  of 


applied  psychotherapy,  thanks  to  the  immense 
impetus  afforded  by  the  silent  appeal  of  the  phalanx 
of  sufferers  from  war  neuroses  and  psychoneuroses. 
Behind  the  therapy  looms  large  the  desire  to  probe 
further  into  the  why  and  the  wherefore,  hence  the 
renewed  investigation  of  psychical  theories  of 
disease,  and,  as  Dr.  Rivers  justly  concludes,  the 
willingness  of  the  great  majority  of  students  to 
consider  the  position,  and  to  accept,  in  part  at 
least,  the  doctrine  of  pioneers  such  as  Freud. 
Appreciation  of  the  importance  of  psycho-analysis 
as  a means  of  discovering  what  lies  behind  the 
external  phenomena  of  functional  nervous  disease 
implies  no  acceptance  of  the  Freudian  attribution 
of  all  neurosis  to  disordered  sexuality ; for  that 
matter,  there  is  no  finality  of  interpretation  of  the 
symbols,  which,  in  Freudian  doctrine,  constitute 
a large  proportion  of  the  stuff  of  the  mind, 
still  less  of  the  motives  laid  bare  by  such  tech- 
nique. Thus  should  a hidden  spring  of  action 
be  shown  to  be  linked  with  some  “ woman  in  the 
case  ” it  would  not  thereby  necessarily  bear  only  a 
sexual  interpretation.  In  one  of  his  University 
sermons  the  late  Principal  Edward  Caird  laid 
stress  on  the  love  of  knowledge  for  its  own  sake 
as  one  of  the  potent  dynamic  forces  stirring  the 
mind  of  man  to  action,  and  should  this  be  given 
fuller  effect  by  one  in  his  love  for  his  partner,  its 
tingeing  with  an  added  colour  does  not  alter  its 
essentially  non-sexual  nature. 

As  the  working  man  insists  on  his  war  bonus  being 
permanently  incorporated  in  his  wages,  so  the 
advances  recently  made  in  the  understanding  of  the 
unseen  trends  of  the  human  mind  will  be  perma- 
nently embodied  in  medical  doctrine.  There  can 
be  no  going  back  to  the  barren  psychology  of  the 
schools.  We  have  learned  too  much  of  the 
significance  of  the  affective  or  emotional  aspects  of 
functional  nervous  disease  to  rest  content  with 
what  is  little  less  than  therapeutical  “ bluff.”  The 
casual  patient,  it  must  frankly  be  admitted, 
knows  not  merely  much  about  venereal  disease 
that  was  hidden  from  his  father ; he  has  heard  of 
blood -tests,  and  demands  treatment  by  injections;  he 
also  knows  more  than  some  physicians  may  suspect 
of  how  “ nerves  ” should  be  treated  and  will  not 
submit  to  be  put  off  by  an  airy  reassurance.  If  the 
modern  hospital  is  to  earn  or  enhance  a reputation 
for  healing  the  sick  it  must  take  cognisance  of  all  the 
ills  to  which  flesh  is  heir  and  organise  a neurological 
department  for  the  benefit,  among  others,  of  the 
sufferer  from  functional  nervous  disease,  presided 
over  by,  or  including  on  its  staff,  someone  trained  in 
the  recent  acquisitions  of  knowledge  and  convinced 
that  psychological  disorders  deserve  psychological 
treatment.  This  investigation  of  the  underworld 
of  conflicting  impulses,  desires,  and  instincts  must 
lead  also  to  the  medical  man’s  playing  a greater 
part  in  the  solution  of  the  problems  of  criminology. 
The  criminal  deserves  psychological  study  at  least 
as  much  as,  if  not  more  than,  legal.  Social  and 
political  problems,  too,  are  in  their  turn  based  on 
deeper  problems  of  the  trends  of  the  social  mind 
which  provide  a fit  subject  for  patient  research. 
We  should  not  claim  mere  psychological  analysis 
to  be  a panacea  for  the  disorders  of  the  body 
politic,  but  we  are  frequently  reminded  by  intelli- 
gent publicists  of  the  real  roots  of  social  unrest  in 
feelings  and  impulses  that  are  essentially  only 
half-expressed,  and  therefore  potential  mischief- 
makers  unless  dealt  with  as  the  psychologist  deals 
with  the  impulses  of  the  individual.  In  all  this  we 
see  a ripe  field  for  systematic  investigation  by 
competent  workers. 


488  The  Lanoht,] 


OFFICERS  FOR  THE  R.A.M.C.  : THE  NEW  CONTRACT. 


[Sept.  13,  1919 


^nnotatians. 


“Ne  quid  nlmls." 

OFFICERS  FOR  THE  R.A.M.C.:  THE  NEW 
CONTRACT. 

In  the  recent  Students’  Number  of  The  Lancet 
we  regretted  the  inability  to  publish  the  rates  of 
pay  that  would  be  contained  in  the  new  contract 
which  the  Army  Medical  Service  was  prepared  to 
offer  to  medical  practitioners,  though  we  were  able 
to  announce  that  these  terms  would  be  of  a very 
advantageous  sort.  This  week  the  new  contract  has 
been  made  public,  and  the  conditions  under  which 
the  War  Office  is  prepared  to  accept  the  services  of 
medical  practitioners,  including  those  who  have 
been  demobilised,  will  be  found  set  out  on  page  503 
of  this  issue.  The  contract,  it  will  be  seen,  is 
in  many  ways  a great  improvement  on  the  old 
one.  The  pay  is  increased  for  lieutenants  and 
captains,  so  that  the  pecuniary  start  which  the 
young  man  receives  by  qualifying  for  a commission 
in  the  R.A.M.C.  is  now  a distinctly  good  one.  There 
are  allowances  for  foreign  service,  and  specialist  or 
charge  pay  is  available  in  certain  conditions.  As 
directorates  in  pathology  and  in  hygiene  have  now 
been  created  within  the  Army  Medical  Department, 
specially  selected  men  can  rise  through  all  the 
ranks  of  the  Army  to  Major-General  on  the 
strength  of  their  scientific  work,  and  we  have 
before  now  insisted  on  the  attractive  nature  of  the 
outlook  which  is  thus  provided  for  the  scientifically 
minded  man.  Applications  for  commissions  should 
be  addressed  to  the  Secretary,  War  Office,  Cornwall 
House,  Stamford- street,  London,  S.E.  1,  The  full 
regulations  for  admission  and  form  of  application 
will  be  found  in  the  Students’  Number  of 
The  Lancet,  August  30th,  1919,  p.  397. 


THE  MEDICAL  ASPECTS  OF  STATE  SCIENTIFIC 
AND  INDUSTRIAL  RESEARCH. 

The  report  of  the  Committee  of  the  Privy  Council 
for  Scientific  and  Industrial  Research  for  the  year 
1918-19,  issued  last  week,  claims  for  the  work  of 
the  department  over  this  period  a steady  growth 
both  in  usefulness  and  in  amount.  This  is  the 
fourth  annual  report  of  their  proceedings,  and 
a review  of  the  detailed  work  of  the  Advisory 
Council,  which  forms  the  executive  of  the  depart- 
ment, fully  justifies  this  claim.  The  personnel  of 
this  Council  includes  authorities  of  the  highest 
standing  on  the  manifold  subjects  investigated, 
whilst  the  assessors  to  the  Council,  responsible  for 
the  departmental  work  and  organisation  of 
research,  are  all  experts  in  the  various  Govern- 
ment Departments  which  they  officially  repre- 
sent. The  outcome  is  an  official  compilation  of 
progressive  work  in  research  and  industry,  the 
results  of  which  deeply  concern  the  future  industrial 
welfare  of  the  nation.  The  solvency  of  the  nation 
may  well,  indeed,  depend  upon  the  earnestness 
with  which  the  lessons  conveyed  by  this  work  are 
absorbed. 

Scientific  and  industrial  research  are  wide  terms 
of  reference,  and  the  scope  of  inquiry  includes, 
as  will  be  anticipated,  medical  matters  of  in- 
sistent interest.  Such,  for  example,  are  mine 
rescue  apparatus,  the  preparation  and  preserva- 
tion of  foods,  cold  storage  and  its  effect  on  meat, 
oxygen  research,  industrial  fatigue,  the  rendering 


of  “ power  alcohol  ” undrinkable,  and  the  patent 
laws,  in  so  far  as  they  affect  discoveries  which 
concern  the  health  and  life  of  the  people.  It  is 
interesting  to  learn  that  the  Advisory  Council 
recognise  the  strong  professional  tradition  of  the 
medical  profession  in  this  country  in  regard  to 
the  patenting  of  inventions  of  genuine  value  for 
the  preservation  of  health  or  of  life,  and  the 
Council  have  provisionally  decided  that  applica- 
tions for  patents  within  this  category  should 
be  refused.  It  is  admitted,  however,  that  the 
whole  question  needs  careful  watching  and  dis- 
cussion by  those  best  able  to  form  a judgment. 
There  seems  to  be  a suggestion  that  the  State 
should  take  over  such  inventions  and  reward  the 
inventor  on  a scale  which  would  compare  reason- 
ably with  that  compensation  which  he  would  gain 
by  patent  protection.  The  scale  of  remuneration 
by  the  State  in  such  a case  would  form  an  interesting 
contrast  with  the  enormous  profits  made  from  the 
sale  of  secret  remedies  based  on  no  discovery  at  all; 
these  profits,  in  the  main,  are  mercenary  exploita- 
tions purely  and  simply.  Such  preparations  are  in 
no  sense  patented  medicines,  for  in  that  case  they 
could  not  be  secret  remedies,  as  a patent  implies 
the  publication  and  protection  of  their  composition. 
The  Government  compels  the  use  of  a stamp  in 
the  sale  transactions,  which  means  no  more  than  the 
stamp  on  a receipted  bill  exceeding  £2  in  value. 
In  other  words,  the  stamp  is  a duty  and  in  no  sense 
a guarantee  that  the  preparation  is  an  approved 
therapeutic  agent.  This  official  procedure,  how- 
ever, no  doubt  helps  materially  the  sale  of 
many  nostrums.  We  hope  the  Government  will 
introduce  a much-needed  reform  on  the  lines 
suggested  in  the  admirable  report  of  the  Select  > 
Committee  of  Patent  Medicines,  which  was  ordered 
by  the  House  of  Commons  to  be  printed  on  the 
very  day  war  broke  out.  Since  then  nothing  has 
been  done.  The  Committee  of  the  Privy  Council 
for  Scientific  and  Industrial  Research  might  note 
these  things.  It  is  a body  with  great  prestige,  and 
its  constitution,  which  lias  recently  come  under 
acute  criticism,  may  put  it  out  of  sympathy  with 
pure  research,  but  should  enable  it  to  act  forcibly 
in  the  cause  of  practical  reforms. 


A CASE  OF  LETHARGY. 

The  case  related  by  Dr.  Grace  H.  Giffen  Dundas 
in  our  issue  of  last  week  presents  features  of 
interest  and  rarity.  The  illness  from  which  the 
patient,  a young  woman,  suffered  had  an  acute 
onset,  with  rise  of  temperature,  increase  of  pulse 
and  respiration,  headache,  sweating,  and  other  signs 
pointing  clearly  to  a toxi-infective  condition.  These 
general  symptoms  were  coupled  with  others  of 
localising  significance,  including  paresis  or  paralysis 
of  various  motor  cranial  nerves  (though  Dr.  Dundas 
excludes  the  third  nerves  she  specially  mentions 
sluggish  pupil  reactions  and  partial  double  ptosis', 
resulting  in,  among  other  things,  a mask-like  facies 
and  inability  to  depress  the  lower  jaw.  The  arms 
and  legs  were  rigid  and  motionless,  and  there 
was  a double  extensor  response.  Bladder  and 
rectal  control  were  greatly  impaired.  The  patient 
slept  deeply  most  of  the  time.  There  can 
be  little  doubt  that  the  correct  neurological 
diagnosis  is  encephalitis  lethargica,  which  is  usually 
characterised  by  general  symptoms  of  cerebral 
toxaemia  and  localising  symptoms  pointing  to  mes- 
encephalic involvement,  precisely  as  in  this  case. 
The  lower  motor  cranial  nerves  were  rather  more 


The  Lancet,]  EROSION  OF  GREAT  VESSELS  OF  NECK  IN  SCARLATINAL  ABSCESS.  [Sept.  13,  1919  489 


involved  than  the  upper,  as  occasionally  occurs ; 
the  limb  paralysis  is  an  index  of  the  severity  of  the 
attack,  but  does  not  necessarily  signify  a structural 
change  in  the  cortico  spinal  paths  or  centres ; an 
extensor  response  may  occur  where  no  change  in 
structure  is  demonstrable.  An  examination  of  the 
spinal  fluid  by  lumbar  puncture  would  doubtless 
have  been  of  considerable  help  in  diagnosis  if  only 
for  the  exclusion  of  other  conditions  with  which  the 
case  might  be  confused.  It  is  not  quite  clear  whether 
the  patient  showed  atrue  catatonia  or  not — a common 
symptom  in  lethargic  encephalitis ; Dr.  Dundas 
speaks  of  the  cataleptic-like  condition,  but  does 
not  state  whether,  for  instance,  the  limbs  remained 
in  any  position  in  which  they  were  put ; as  there 
was  no  voluntary  movement  the  test  would  have 
had  to  be  made  by  lifting  the  arms  passively  off  the 
bed.  One  of  the  distinctly  unusual  features  is  the 
loss  of  the  sense  of  position  in  the  limbs  ; the  fact 
that  the  patient  did  not  know  her  limbs  were  being 
manipulated  may  also  be  taken  to  indicate 
cutaneous  loss  of  sensibility,  and  there  is  no 
a priori  reason  why  such  might  not  occur  in 
encephalitis.  On  the  other  hand,  however,  she 
was  aware  of  her  incontinence  and  knew  when  the 
catheter  was  being  passed,  so  that  it  is  possible 
the  loss  of  position  and  direction  was  an  index  of 
the  cerebral  apathy.  To  this  suggestion  it  might 
with  justice  be  replied  that  were  such  the  case  she 
would  probably  also  have  been  indifferent  to  her 
incontinence.  Of  considerable  scientific  interest 
are  the  peculiar  hallucinations,  as  exemplified 
by  “ her  eyes  up  at  the  roots  of  her  hair  and 
her  teeth  several  inches  in  front  of  her  mouth.” 
Some  alienists  have  insisted  that  hallucinations  of 
the  muscular  sense  in  the  insane  are  of  unfavourable 
prognostic  import  as  compared  with  those  of  other 
senses  (sight,  hearing),  and  indicative  of  a greater 
degree  of  cortical  defect.  Be  this  as  it  may,  Dr. 
Dundas’s  patient  made  a perfect  and  on  the  whole 
rather  quick  recovery  considering  the  acuteness  of 
the  illness.  One  might  hazard  a conjecture  that 
the  ignorance  of  the  position  of  the  limbs  and  the 
erroneous  references  in  respect  of  other  parts  of 
the  body  (eyes,  teeth)  were  both  the  expression  of 
a disturbance  of  the  “ sense  of  attitude,”  which  is 
something  more  than  mere  impairment  of  sense  of 
position.  


EROS.ION  OF  THE  GREAT  VESSELS  OF  THE 
NECK  IN  SCARLATINAL  ABSCESS. 

Ceevical  adenitis  with  abscess  formation  is  a 
common  complication  of  scarlet  fever.  A very  rare 
consequence  is  erosion  of  one  of  the  great  vessels 
of  the  neck,  with  serious  and  even  fatal  haemor- 
rhage. In  the  Johns  Hopkins  Hospital  Bulletin  for 
August  Mr.  T.  M.  Rivers  has  reported  the  following 
case.  On  Dec.  1st,  1916,  a girl,  aged  years, 
vomited  and  had  slight  fever.  Two  days  later  a 
practitioner  was  called  in,  found  a small  membrane 
on  the  right  tonsil,  and  administered  15,000  units 
of  diphtheria  antitoxin.  About  Dec.  5th  the  cervical 
glands  began  to  swell,  she  became  stuporous,  and  did 
not  pass  urine  for  56  hours  ; then  a small  amount  of 
urine  containing  much  albumin  was  passed.  In  the 
third  week  a diffuse  maculo-papular  rash  appeared 
and  she  was  admitted  to  hospital  three  days  later. 
The  temperature  was  99°F.  and  the  pulse  110.  She 
was  drowsy  and  emaciated.  The  tongue  was  heavily 
coated  and  the  breath  foul.  Part  of  the  tonsil,  soft 
palate,  and  posterior  pillar  on  the  right  side  had 
sloughed,  leaving  a ragged  hole  lined  with  greenish- 


white  pus.  The  cervical  glands  were  enlarged. 
There  was  a fluctuating  mass  of  the  size  of  a 
lemon,  deeply  situated,  below  the  right  angle  of  the 
jaw.  The  liver  extended  two  fingers -breadth  below 
the  ribs.  Over  the  body  was  worm-eaten  desquama- 
tion. The  palms  and  soles  were  very  dry  and  later 
desquamated  in  a way  typical  of  scarlet  fever.  A 
throat  culture  was  negative  for  diphtheria  bacilli, 
but  showed  long  chains  of  streptococci.  The  urine 
contained  3 g.  per  litre  of  albumin,  hyaline  and 
granular  casts,  pus  cells,  red  blood  corpuscles,  and 
epithelial  cells.  The  abscess  was  punctured  and 
2 oz.  of  pus  escaped,  from  which  a haemolytic 
streptococcus  was  grown.  She  seemed  to  be  doing 
well  until  11  p.m.  on  Dec.  26th,  when  she  was  found 
in  a pool  of  blood,  exsanguine,  pulseless,  and  gasp- 
ing for  breath.  The  bleeding  had  stopped  and  the 
wound  was  not  disturbed.  A subcutaneous  injection 
of  300  c.cm.of  saline  solution  was  given  and  an  intra- 
venous inj  ection  of  225  c.cm.  of  citrated  blood  obtained 
from  the  mother.  There  was  another  haemorrhage 
of  about  2 oz.  at  7 a.m.  and  at  11  A.M.  Blood  began 
to  spurt  from  the  wound  at  1 p.m.  Dr.  Dandy,  the 
resident  surgeon,  enlarged  the  incision  into  the 
abscess  and  found  erosion  of  the  lingual  and 
external  carotid  arteries  and  internal  jugular  vein, 
the  haemorrhage  coming  from  all  three  sources. 
The  common  carotid  was  ligatured  and  the  bleeding 
from  the  jugular  was  controlled  by  packing.  The 
child  was  greatly  exsanguinated,  and  was  given 
150  c.cm.  of  citrated  blood  which  had  been  kept 
on  ice  since  the  transfusion  the  previous  night. 
She  rallied  immediately,  but  the  pulse  remained 
irregular  for  weeks.  On  the  28th  the  haemoglobin 
was  40  per  cent.  On  the  29th  she  received 
200  c.cm.  of  citrated  blood.  On  the  30th  her 
hajmoglobin  was  58  per  cent.  Both  ear  drums 
were  punctured,  releasing  pus.  On  Jan.  1st 
there  was  another  large  haemorrhage.  Evidently 
the  carotid  ligature  had  sloughed.  The  bleeding 
was  controlled  by  pressure  and  150  c.cm.  of  citrated 
blood  were  given.  General  oedema,  insensibility  to 
pain,  waxy  flexibility,  exaggerated  reflexes,  double 
ankle  clonus,  and  loss  of  memory  for  recent  events 
developed.  She  gradually  improved  and  the  wound 
healed  slowly  under  Dakin’s  solution.  Recovery 
ensued.  Mr.  Rivers  could  find  recorded  only  about 
50  cases  of  erosion  of  the  great  vessels  of  the  neck 
after  scarlet  fever.  Curiously  the  great  majority  are 
old,  only  one  being  reported  subsequently  to  1885. 
Two  were  recorded  in  our  columns  in  18701 — one  by 
Lovegrove,  in  which  the  patient  bled  to  death  in  a 
short  time  through  ear,  nose,  and  mouth,  and  the 
other  by  Hymes,  in  which  the  patient  bled  to 
death  through  ear  and  mouth.  Is  the  absence  of 
cases  in  recent  years  due  to  diminished  virulence 
of  the  disease  ? Veins  and  arteries  have  been 
involved  about  equally.  The  bleeding  may  come 
from  an  opened  abscess,  from  the  ear,  or  through 
the  mouth  and  nose.  Most  cases  have  been  fatal. 


MEDICAL  EDUCATION  IN  THE  UNITED  STATES. 

•The  annual  educational  number  of  the  Journal 
of  the  American  Medical  Association  (issue  of 
August  16th)  contains  an  interesting  summary  of 
the  facilities  for  medical  study  offered  in  the 
United  States  of  America  for  the  year  ending 
June  30th,  1919.  It  is  well  known  that  the  United 
States  had  at  one  time  more  medical  schools  than 
the  rest  of  the  world  put  together,  the  supply  far 
exceeding  the  needs  of  the  country.  Reduction  in 

1 The  Lancet,  1870,  i.,  729,  and  ii„  431. 


490  TtiK  L^OET,]  PELLAGRA  AMONG  TURKISH  PRISONERS  OF  WAR  IN  EGYPT. 


[Sept.  13,  1919 


the  number  to  one-half  has  been  one  of  the  principal 
signs  of  progress  in  the  last  15  years,  and  the 
reduction  is  still  going  on.  Of  the  13.052  students 
studying  medicine  (578  less  than  in  1918)  the  very 
large  majority — 94  per  cent. — were  doing  so  in  ‘ non- 
sectarian  ” colleges.  Homoeopathic  colleges  scored 
an  attendance  of  397,  “ eclectic  ” colleges  of  86, 
while  310  students  were  obtaining  their  instruction 
at  a group  of  colleges, 2 of  them  “semi-osteopathic” 
and  outlawed  in  their  own  State  of  Missouri,  the 
third  “ eclectic  ” and  not  subject  to  a set  curriculum. 
It  is  evident  that  in  the  United  States  the  tendency 
is  now  prevailing  towards  a standardisation  of 
medical  training  on  broad,  orthodox  lines.  2656 
students  graduated  in  medicine  during  the  year, 
44  per  cent,  of  them  being  already  graduates  of 
colleges  of  liberal  arts,  witness  of  a growing 
appreciation  of  the  value  to  medical  practice  of  a 
sound  preliminary  training.  Compared  with  con- 
ditions ruling  here,  it  is  surprising  to  note  what  a 
small  proportion  of  their  cost  of  training  is 
paid  by  medical  students  themselves.  Financial 
reports  from  82  schools  show  an  average  annual 
expenditure  per  student  of  #419,  of  which  the 
student  only  pays  #150.  A State-controlled  medical 
service  should  not  be  difficult  to  introduce  in  a 
country  in  which  the  State  already  contributes, 
directly  or  by  endowment,  60  per  cent,  or  more  of 
the  cost  of  medical  training.  In  regard  to  the 
character  of  the  training,  the  most  important 
change  noted  is  the  gradual  replacement  of 
lectures  and  lecture  clinics  by  bedside  training 
in  small  group  clinics.  Thus  in  all  important 
respects  the  medical  curriculum  this  side  and  that 
side  of  the  Atlantic  is  converging  towards  a 
common  objective. 


PELLAGRA  AMONG  TURKISH  PRISONERS  OF  WAR 
IN  EGYPT. 

A valuable  contribution  to  the  literature  of 
pellagra  has  recently  been  published  at  Alexandria 
by  the  military  authorities,  dealing  with  the  occur- 
rence of  the  disease  among  captured  Ottoman 
troops.  A prevalence  of  pellagra  having  been 
reported  among  the  Turkish  prisoners  of  war 
interned  at  Kantara,  in  Lower  Egypt,  the  D.M.S. 
Egyptian  Expeditionary  Force  appointed  a com- 
mittee to  investigate  whether  the  disease  in  ques- 
tion was  in  reality  true  pellagra,  and,  if  so,  whether 
the  prisoners  of  war  were  generally  infected  before 
or  after  their  capture ; whether  the  disease  was 
increasing ; and,  if  so,  was  it  spreading  by  infec- 
tion from  case  to  case  or  by  infection  due  to 
location  or  local  conditions ; or  whether,  on  the 
other  hand,  it  was  due  to  some  defect  in  diet  or  to 
other  general  conditions.  Further,  the  committee 
was  to  investigate  the  aetiology  of  the  malady  in  its 
relation  to  bacteria,  protozoa,  blood  conditions, 
pathology,  and  food.  The  committee  consisted  of 
Colonel  F.  D.  Boyd,  C.M.G.,  A.M.S.,  consulting 
physician  to  the  E.E.F.,  and  Lieutenant-Colonel 
P.  S.  Lelean,  C.B.,  R.A.M.C.,  assistant  professor  of 
hygiene,  R.A.M.  College,  along  with  six  collabo- 
rators, each  an  expert,  respectively,  in  pathology, 
bromatology,  protozoology,  biochemistry,  haemato- 
logy, and  bacteriology.  The  inquiry  was  begun  on 
Oct.  7th,  and  the  report1  is  dated  Dec.  31st,  1918. 
The  conclusions  of  the  committee  of  inquiry 
may  be  summed  up  as  follows : The  disease  was 
true  pellagra  and  the  patients  were  generally 

1 Keport  of  a Committee  of  Enquiry  regarding  the  Prevalence  of 
Pellagra  among  Turkish  Prisoners  of  War.  Published  at  Alexandria. 
(Not  on  sale.) 


pellagrous  before  capture.  The  great  majority 
of  the  cases  that  were  systematically  questioned 
stated  that  they  had  similar  symptoms  before 
capture,  while  amongst  those  examined  shortly 
after  they  were  made  prisoners  many  were  found 
suffering  from  the  fully  developed  disease.  For 
example,  in  one  batch  of  1300  prisoners  seen  on 
their  arrival  direct  from  the  front,  18  per  cent,  had 
the  malady  fully  developed.  There  was  no  evidence 
of  case-to-case  infection,  and  none  pointing  to  loca- 
tion or  local  conditions  having  had  anything  to  do 
with  the  causation  or  spread  of  the  disease.  The 
camps  at  Kantara  left  little  to  be  desired  as  regards 
their  situation  and  hygienic  condition.  As  regards 
diet,  judged  by  existing  standards,  the  food  issued 
to  both  non-labour  and  labour  prisoners  provided  an 
ample  margin  over  the  requirements  of  healthy  men 
and  gave  a suitable  balance  of  proximate  food  prin- 
ciples. Any  increase  in  the  disease  has  not  been  due 
to  other  general  conditions  than  those  unavoidable 
for  prisoners  in  monotonous  confinement  in  an  alien, 
hot,  and  arid  country,  with  no  stimulus  to  check  the 
inevitable  decline  in  their  physiological  resistance. 
Pellagra  as  a primary  or  immediate  cause  of  death 
played  an  insignificant  part  in  the  series  of  cases 
that  were  examined.  As  a contributory  cause  its 
influence  was  shared  by  other  debilitating  diseases, 
of  which  chronic  dysentery  was  the  worst.  After 
thorough  investigation  by  the  various  experts,  no 
evidence  was  found  as  to  the  aetiological  relation- 
ship of  the  disease  to  bacteria,  protozoa,  or  to  blood 
conditions.  With  regard  to  food,  the  committee 
found  so  constant  an  association  between  the 
biological  protein  value  of  diet  and  the  occurrence 
of  pellagra  that  they  considered  that  the  lack  of 
sufficient  biological  value  of  protein  stands  in 
setiological  relationship  to  pellagra,  certainly  as  an 
exciting  factor,  and  possibly  as  the  determining 
factor.  The  report  states  that  the  deficiency 
in  biological  value  of  protein  may  be : first, 

absolute,  as  determined  by  the  standard  for 
normal  persons,  or,  secondly,  relative,  as  deter-  . 
mined  by  individualistic  correlation  between  food 
assimilation  and  energy  expenditure,  and  thus 
modified  by  ill-health  and  idiosyncrasy.  A large 
proportion  of  the  cases  showed  helminthic  and 
flagellate  infections  of  the  intestines.  These  cannot 
be  regarded  as  causal  factors,  but  merely  contribu- 
tory to  digestive  disturbance  and  malnutrition. 
Pellagra  produces  loss  of  resistance  to  the  invasion 
of  bacterial  and  protozoal  disease,  and  this  is, 
therefore,  a contributory  factor  to  a high  rate  of 
mortality.  The  recommendations  made  by  the 
committee  were : — 1.  In  view  of  the  pellagra 
admission  rates  having  remained  approximately 
constant  in  non-labour  camps  during  the  last  two 
months,  and  having  diminished  so  markedly  in 
labour  camps  in  the  present  month  (December),  it 
is  considered  that  the  full  authorised  diets  are 
adequate,  and  that  it  is  not  necessary  at  present  to 
introduce  any  cardinal  change.  2.  Full  variety 
should  be  given  under  the  alternatives  of  the 
existing  ration  scales,  and  close  supervision  should 
be  exercised  over  preparation  and  cooking  of  food, 
with  special  regard  to  pulses  in  both  respects. 

3.  Any  increase  in  pellagra  should  be  met  by  an 
increase  in  animal  protein ; the  occurrence  of 
oedema  should  be  met  by  an  increase  in  fat.  It 
may  be  added  that  over  2000  German,  Austrian,  and 
Bulgarian  prisoners  of  war  occupied  a compound 
immediately  adjoining  that  occupied  by  6000 
Ottoman  prisoners.  Both  compounds  had  been 
living  under  precisely  the  same  conditions,  but 


The  Lancet,] 


GREAT  MAURITIANS.— THE  MORBID  ANATOMY  OF  MALARIA.  [Sept.  13,  1919  49] 


not  a single  case  developed  among  the  Germans, 
Austrians,  or  Bulgars,  whereas  there  were  some 
300  cases  among  the  Turks  in  the  adjoining  com- 
pound. No  case  of  pellagra  occurred  among  the 
British  troops.  The  Turkish  prisoners  for  long 
periods  prior  to  capture  had  been  on  rations  con- 
siderably below  the  value  of  those  they  received 
after  arrival  at  Kantara,  and  also  below  the  standard 
of  minimal  needs,  and  had  been  subjected  to  great 
physical  strain  and  privations. 


GREAT  MAURITIANS. 

Mauritius,  whose  fate  is  in  some  places  under 
question,  although  only  three  times  the  size  of  the 
Isle  of  Man,  is — with  its  370,000  inhabitants — more 
than  twice  as  densely  populated.  With  an  oceanic 
climate  and  a mean  temperature  of  74°  F.,  it 
consists  of  highly  fruitful  valleys  separated  by 
wooded  spurs  running  up  to  over  2500  feet  in 
height  in  several  places.  The  island  has  changed 
hands  more  than  once.  Occupied  by  the  Dutch  in 
1598,  it  was  abandoned  by  them  in  1710,  when  the 
French  took  possession,  until  precisely  a century 
later  it  fell  to  the  British,  whose  tenure  was  con- 
firmed by  the  Treaty  of  Paris  in  1814.  French  is 
the  current  language  of  the  “ Isle  of  France,”  while 
English  is  officially  used  in  the  courts  of  law.  Dr. 
Joseph  Riviere,  of  Paris,  whose  name  heads  an 
appeal  on  behalf  of  his  fellow  Mauritians  to  the 
Prime  Ministers  of  England  and  France,  recalls  the 
names  of  a number  of  famous  Mauritian  creoles, 
using  the  term  in  the  strict  French  sense.  One  of 
these,  Charles  Edward  Brown- Sequard,  son  of  a sea 
captain  of  Galway  origin  and  born  in  Port  Louis 
in  1817  of  a Provencal  mother,  was  an  ornament 
alike  to  medicine  and  to  his  island  home.  Plis 
whole-hearted  devotion  to  the  cause  of  experi- 
mental physiology,  for  which  he  renounced  a pro- 
fessorship in  Virginia,  a fashionable  practice  in 
London,  and  an  easy  competence  in  New  York, 
entitles  him  to  a place  by  the  side  of  Claude 
Bernard,  with  whom  he  shares  the  honour  of 
demonstrating  the  existence  of  a nervous  mechanism 
presiding  over  the  physics  of  the  circulation. 
Brown-Sequard’s  cosmopolitan  origin  made  it  appro- 
priate for  him  to  preside  over  the  Societe  de  Biologie 
in  Paris  at  the  same  time  as  he  was  the  recipient 
of  the  Baly  medal  of  the  Royal  College  of  Physicians 
of  London.  He  died  in  Paris  in  1894. 


THE  MORBID  ANATOMY  OF  MALARIA. 

Dr.  Leonard  Dudgeon  and  Dr.  Cecil  Clarke  made 
a notable  contribution  to  our  knowledge  of  the 
pathology  of  malaria  when,  in  1917,  they  published 
in  The  Lancet  an  account  of  their  observations  on 
cases  of  paludism  in  Macedonia,  and  more  espe- 
cially on  the  severe  fatty  degeneration  of  the 
cardiac  muscle  which  they  had  been  able  to 
demonstrate  in  a certain  number  of  cases  of 
pernicious  infection.  In  a second  paper,  which 
appeared  in  the  July  number  of  the  Quarterly 
Journal  of  Medicine , they  record  the  results  of 
“ An  Investigation  on  Fatal  Cases  of  Pernicious 
Malaria  caused  by  Plasmodium  falciparum 
in  Macedonia.”  The  material  on  which  the 
investigation  is  based  was  collected  with  the 
definite  object  of  correlating,  as  far  as  possible,  the 
clinical  history  with  the  microscopical  examina- 
tions, and  throughout  the  paper  this  useful  method 
of  correlation  has  been  followed.  When  dealing  in 
this  communication  with  the  condition  of  the 


cardiac  muscle  previously  described,  and  which  was 
found  to  be  a diffuse  fatty  degeneration  similar  to 
what  is  met  with  in  acute  diphtheritic  toxaemia, 
the  authors  point  out  that  the  effects  of  a long 
period  of  hot  weather  acting  on  men  unaccustomed 
to  such  heat,  and  the  fact  that  the  military  situa- 
tion prevented  the  necessary  degree  of  rest  being 
obtained,  undoubtedly  played  a part  in  the  mtiology 
of  the  condition.  Other  matters  to  which  special 
attention  is  directed  are  the  hajmorrhages  into  the 
pulmonary  alveoli  and  the  pathological  changes 
seen  in  the  suprarenals.  As  regards  the  latter,  the 
most  constant  lesion  has  been  the  reduction  of  the 
fatty  lipoids  of  the  cortical  layers.  In  a few 
instances  other  important  histological  changes 
are  noted,  but  the  authors  consider  it  would  be 
incorrect  to  attribute  the  fatal  result  in  these 
cases  to  a disturbance  of  the  functions  of  the 
adrenals.  This  is  important  from  the  point  of  view 
of  treatment,  as  experience  has  shown  that  the 
administration  of  adrenalin  in  such  cases  produces 
no  permanent  beneficial  effects.  This  is  to  be 
expected,  for  the  action  of  the  drug  rapidly  passes 
off,  while  the  gross  changes  in  the  glands  are 
already  established.  There  are  other  points  of 
interest  in  this  paper,  which  merits  the  close  atten- 
tion of  all  interested  in  the  pathology  of  malaria. 
It  may  be  mentioned  that  the  authors  found  no 
evidence  of  any  intracellular  form  of  the  malarial 
parasite.  They  purpose  publishing  further  observa- 
tions on  the  tissue  changes  in  chronic  malaria 
associated  with  grave  anaemia. 

SYPHILIS  IN  THE  NEGRO. 

In  an  article  based  on  the  general  experience  of 
one  of  the  authors  in  dealing  with  syphilis  in  the 
Southern  States,  and  upon  the  intensive  study  of  300 
consecutive  cases  of  syphilis  occurring  in  negro 
soldiers,  Major  Loyd  Thompson  and  Lieutenant 
Lyle  B.  Kingery  1 state  that  in  the  negro  syphilis  is 
contracted  on  an  average  at  an  earlier  period  of  life 
than  in  the  white  race.  Twenty  per  cent,  of  the  300 
cases  were  patients  with  chancres,  ranging  in  dura- 
tion from  a few  days  to  several  months.  A striking 
characteristic  was  that  of  indolence.  In  the  great 
majority  of  cases  the  chancre  had  been  in  existence 
for  a much  longer  time  than  was  usually  found  to 
be  the  case  with  similar  lesions  in  the  white  race. 
This  occurrence  is  attributed  by  the  writers,  who 
have  made  a careful  collation  of  the  existing 
scanty  literature  on  the  subject,  to  the  fact 
that  during  the  period  of  sexual  activity  the 
average  negro  has  a succession  of  penile  lesions. 
As  regards  the  secondary  manifestations,  the 
writers  agree  with  Hazen  that  macular  and 
maculo-papular  eruptions  are  not  common.  On  the 
other  hand,  the  annular  lesions  of  early  syphilis 
are  remarkably  common  and  may  be  said  to  be 
almost  peculiar  to  the  coloured  race.  Involvement 
'of  the  mucous  membrane  appears  to  be  more  frequent 
in  the  negro  and  is  often  characterised  by  hyper- 
trophic tendencies.  The  general  lymphadenitis, 
which  is  confirmatory  evidence  of  syphilis  of  some 
weight  in  the  white,  is  so  frequently  found  in  the 
non- syphilitic  negro  as  to  be  of  doubtful  value  in 
diagnosis.  Although  there  is  a general  consensus 
of  opinion  that  the  osseous  system  of  the  negro  is 
more  frequently  involved  than  that  of  other  races 
in  syphilis,  the  writers  met  with  only  four  cases  in 
their  series,  but  explain  this  discrepancy  by  the 


1 American  Journal  of  Syphilis,  1919,  iii.,  384-397. 


492  The  Lancet,] 


MEDICAL  ABSTRACTS  AND  REVIEWS. 


[Sept.  13,  1919 


fact  that  their  cases  consisted  of  young  individuals 
in  whom  only  the  secondary  type  of  lesion,  if  any, 
would  be  likely  to  be  found.  The  same  reason 
accounted  for  the  absence  of  any  visceral  involve- 
ment in  their  cases.  As  regards  prognosis,  the 
chances  for  recovery  in  the  negro  are  not  so 
favourable  as  in  the  white,  as  the  large  majority  of 
the  coloured  race  are  totally  indifferent  to  the  fact 
that  they  have  syphilis  when  no  lesions  are 
manifest,  and  only  submit  to  treatment  while 
outward  evidence  of  the  disease  is  present.  On  the 
other  hand,  the  negro  is  less  prone  than  the 
white  to  develop  complications  involving  the 
central  nervous  system,  especially  paresis  and  tabes, 
although  arteritis  and  aortitis  are  quite  common 
and  frequently  fatal.  The  writers  have  been 
unable  to  confirm  the  statement  that  the  negro 
more  frequently  shows  a severe  reaction  to 
salvarsan  than  the  white,  as  out  of  several 
hundreds  of  injections  in  the  present  series 
only  two  or  three  reactions  occurred,  none  of 
which  could  be  termed  severe. 

MEDICAL  ABSTRACTS  AND  REVIEWS. 

Next  month  appears  the  first  number  of  Medical 
Science  : Abstracts  & Reviews,  published  for  the 
Medical  Research  Committee  by  the  Oxford  Uni- 
versity Press.  This  publication  is  the  lineal 
successor  of  the  Medical  Supplement  to  the  Daily 
Review  of  the  Foreign  Press,  issued  by  .the  General 
Staff  of  the  War  Office,  which  made  its  appearance 
privately  in  January,  1918,  with  a view  of  keeping  our 
Army  Medical  Staff  intouch'with  useful  enemy  inven- 
tions and  discoveries,  soontotakeonawider  character 
and  to  become  a work  of  reference  to  foreign  litera- 
ture accessible  to  the  medical  profession  as  a whole. 
The  Medical  Supplement  ceased  with  the  issue  of 
April,  1919,  and  the  index  to  this  truncated  volume 
is  in  our  hands.  Serviceable  as  it  was  in  the  special 
circumstances  of  the  time,  the  format  was  of  a 
makeshift  kind,  and  not  a little  unworthy  of  its 
contents.  That  is  all  to  be  made  good  in  Medical 
Science.  The  first  number  contains  130  pages  of 
agreeable  size  (9£  X 6 inches),  the  printing 
easy  to  read,  well  arranged  and  spaced.  The 
choice  of  different  varieties  of  type  for  the 
names  of  authors  and  periodicals  and  for  the 
titles  of  articles  is  judicious  and  might  well  become 
the  standard  for  such  things.  It  has,  we  believe, 
been  in  the  minds  of  those  who  have  spent  much 
time  and  thought  on  such  apparent  trifles  that 
their  efforts  might  result  in  an  increasing  homo- 
geneity in  the  publication  of  scientific  matter. 
The  contents  consist  of  a series  of  “ reviews  ” 
or  critical  summaries  of  articles  on  a common 
subject  culled  from  various  sources.  Some  of 
these,  taken  at  random,  are : spina  bifida,  habitual 
or  recurrent  dislocation  of  the  shoulder,  typhoid 
and  paratyphoid  diseases,  dysentery,  lethargic 
encephalitis.  They  occupy  two-thirds  of  the  first 
issue,  the  remainder  being  “ abstracts,”  or  similar 
critical  reviews  dealing  with  a single  paper  or 
article.  In  either  case,  the  referring  is  done  by 
men  widely  conversant  with  their  subjects. 
The  names  on  the  title  page  of  those  giving 
editorial  superintendence  in  the  subjects  named 
are : surgery,  Mr.  W.  G.  Spencer ; medicine, 

Dr.  J.  D.  Rolleston ; pathology  and  bacteriology, 
Dr.  W.  Bulloch ; neurology,  Dr.  F.  M.  R.  Walshe  ; 
radiology,  Dr.  W.  S.  Lazarus-Barlow  and  Dr. 
Sydney  Russ.  In  most  cases  we  gather  from  the 
initials  that  they  have  actually  done  the  work 


themselves  and  not  merely  superintended  the  work 
of  others.  We  have  dealt  with  these  external 
tbings  in  detail,  for  the  publication  is  a 
novelty ; how  great  a novelty  is  shown  by  the 
fact  that  no  familiar  English  words  occur  to  the 
mind  to  represent  the  various  sections.  “Review” 
can,  of  course,  well  be  used  in  the  sense  of  a 
Sammelreferat,  but  it  is  in  common  use  for 
the  critical  examination  of  a single  book. 
What  term  other  than  Referent  suggests  itself 
for  the  person  who  reviews  and  abstracts  ? 
Is  there  any  equivalent  in  our  tongue  for 
Format?  All  this  goes  to  show  that  what  is 
being  attempted  by  the  Medical  Research  Com- 
mittee is  something  which  has  hitherto  hardly 
been  attempted  in  this  country  in  relation  to 
medical  science  as  a whole.  There  are  those 
who  contend  that  the  Centralblatt  is  a growth 
which  flourishes  only  in  continental  soil.  But 
its  foundation  should  be  laid  in  industry  and 
fair-mindedness,  and  these  are  qualities  which 
we  should  like  to  think  are  indigenous.  We  wish 
every  success  to  our  contemporary. 


THE  BRITISH  ASSOCIATION  FOR  THE  ADVANCE- 
MENT OF  SCIENCE. 

The  last  meeting  of  the  British  Association  for 
the  Advancement  of  Science  was  held  at  New- 
castle in  1916,  when  the  proceedings  were  devoted 
entirely  to  the  discussion  of  a limited  number  of 
scientific  papers.  In  the  spring  of  1917,  when  the 
general  outlook  was  black,  the  Council,  after  con- 
sultation with  the  local  committee,  decided  to  cancel 
the  summer  meeting  which  was  arranged  to  take 
place  at  Bournemouth,  this  being  the  first  time  in 
the  history  of  the  Association  that  an  annual  meeting 
was  not  held.  The  annual  event  was  resumed 
at  Bournemouth  on  Tuesday  last,  marking  the 
passing  of  the  great  ordeal.  The  President,  Sir 
Charles  A.  Parsons,  D.Sc.,  F.R.S.,  delivered  an 
interesting  address  on  the  future  opportunities, 
position,  and  welfare  of  the  nation.  We  are 
gathered  together,  he  said,  at  a time  when, 
after  a great  upheaval,  the  elemental  conditions 
of  organisation  of  the  world  are  still  in  flux, 
and  we  have  to  consider  how  to  influence  and 
mould  the  recrystallisation  of  these  elements 
into  the  best  forms  and  most  economic  rearrange- 
ments for  the  benefit  of  civilisation.  The  address 
presented  an  absorbing  review  of  the  events 
of  the  war  in  the  light  of  scientific  develop- 
ments and  applications.  The  subjects  traversed 
related,  naturally  enough,  to  those  great  tech- 
nical issues,  to  which  Sir  Charles  Parsons  has 
devoted  intensive  study.  The  position  of  the 
power  resources  of  the  nation  was  clearly  brought 
forward,  and  the  direction  in  which  its  energies 
should  be  concentrated  in  the  future  outlined 
in  plain  and  convincing  terms.  In  regard  to  fresh 
sources  of  power,  Sir  Charles  Parsons  revived  his 
suggestion  of  tapping  volcanic  power  by  sinking  a 
shaft  to  a depth  of  12  miles,  which  would  take 
85  years  to  complete,  at  an  estimated  cost  of 
£5,000,000.  The  addresses  of  the  presidents  of 
the  various  sections  were  delivered  on  Tuesday 
morning,  and  the  usual  reading  of  scientific  papers 
followed.  In  these  communications  the  speakers 
by  common  consent  referred  mainly  to  the  oppor- 
tunities presented  to  science,  as  accelerated  in 
scope  and  processes  by  the  war.  for  obtaining  official 
recognition.  The  proceedings  come  to  a close  to-day 
(Sept.  13th) 


Thb  Lanokt,] 


AN  INDUSTRIAL  MEDICAL  SERVICE. 


[Sept.  13,  1919  493 


AN  INDUSTRIAL  MEDICAL  SERVICE.* 1 


III. — The  Means  of  Promoting!  the  Service. 

Our  distinguished  contemporary,  the  Times , has  recently 
done  good  service  in  pointing  out,2  as  we  had  already  done, 
the  development  which  is  taking  place  in  relation  to  indus- 
trial medicine.  We  have  no  doubt  that  employers  are 
beginning  to  recognise  the  value  of  this  new  branch  of 
preventive  medicine  ; nor  have  we  any  doubt  that  the 
workers  will  welcome  the  appearance  of  the  factory 
medical  officer.  We  also  entirely  agree  with  the  Times  as 
to  the  training  and  knowledge  required  by  those  who 
undertake  the  work ; but  we  feel  some  doubt  as  to 
the  suggestions  put  forward  that  the  General  Medical 
Council  should  “ found  ” a diploma  in  industrial 
medicine,  and  that  the  Royal  Society  of  Medicine 
should  forthwith  form  a section  devoted  to  this  subject. 
Industrial  medicine  must  prove  itself  by  deeds,  and  by 
showing  employers  of  labour  its  economical  value,  and  the 
workers  its  capacity  for  increasing  efficiency  and  diminishing 
suffering.  By  such  spade  work  only  can  foundations  be 
laid.  There  is  no  royal  road  to  construct  a building  by 
commencing  with  specious  decorations. 

What  Need  is  there  for  a State-recognised  Diploma  ? 

On  the  side  of  curative  medicine  we  do  not  find  a diploma 
for  the  ophthalmic  surgeon,  another  for  the  gynaecologist,  for 
the  rhinologist,  the  dermatologist,  the  bacteriologist,  and  the 
Xray  operator.  Nor  in  preventive  medicine  is  a special  diploma 
demanded  from  the  tuberculosis  officer,  the  school  medical 
officer,  or  the  officer  of  the  maternity  and  child- welfare  clinic. 
The  Diploma  of  Public  Health  as  it  exists  to-day,  though  the 
scope  of  its  requirements  might,  as  Sir  G.  Newman  has 
pointed  out,  be  advantageously  widened,  is  a sufficient 
portal  of  entry  to  preventive  medicine.  By  all  means  let 
teaching  authorities  grant  additional  certificates  to  those 
who  have  benefited  by  special  courses  of  instruction  ; this  has 
long  been  the  custom  in  curative  medicine,  and  Manchester 
has  already  acted  in  this  way  in  relation  to  industrial  hygiene. 
Let  us  follow  this  example  and  avoid  multiplication  of  portals 
of  entry.  Let  us  strive  to  obtain  for  industrial  medicine 
recognition  in  the  D.P.H.  course  and  also  in  the  earlier 
training  of  the  medical  student.  The  latter  is  a stronghold 
to  attack,  for  the  battlements  are  manned  by  the  teaching 
consultants  whose  knowledge  of  general  practice  and  of  the 
life  of  the  people  is  not  conpicuous,  while  their  acquaintance 
with  factory  life  and  the  occupations  of  their  hospital 
patients  is  woefully  deficient.  How  many  ophthalmic 
surgeons  have  been  down  a coal  mine  ? Yet  they  teach  on 
miners’  nystagmus.  How  many  dermatologists  have  been  in 
an  engineering  factory  to  justify  their  comments  on  lubricant 
dermatitis  ? How  many  physicians  have  inspected  the  con- 
ditions under  which  lead-poisoning  is  contracted  ? In  fine, 
what  example  do  these  teachers  give  to  students  in  investi- 
gating at  the  fountain  head  the  causation  of  even  the 
obviously  occupational  diseases  that  come  before  them  ? 
Joseph  Bells  are  indeed  scarce. 

The  proceedings  of  sections  of  medical  associations  are 
liable  to  become  far  too  select  and  specialised  to  recommend 
without  urgent  need  the  multiplication  of  sections  ; and 
industrial  medicine  to-day  needs  to  excite  interest,  not  to 
retire  into  seclusion.  Further,  anyone  who  has  watched  the 
proceedings  of  the  Epidemiological  and  State  Medicine 
Section  of  the  Royal  Society  of  Medicine  must  have  noted 
that  ample  opportunity  has  been  given  for  the  discussion  of 
industrial  problems ; among  others,  phthisis  in  industry  ; 
T.N.T.  jaundice  ; industrial  accidents  have  recently  occupied 
the  section,  but  the  attendance  at  the  meetings  has  not  been 
such  as  to  justify  a new  section. 

Bringing  Conviction  to  the  Employer. 

A more  healthy  line  of  advance  is  being  followed  in  the 
United  States,  as  may  be  seen  from  our  report  of  the 
American  Medical  Association  held  in  June  last.  Stress 
was  laid  on  the  value  of  medical  service  to  industry  from 
examples  of  what  has  already  been  done.  “Show,”  said 


1 Previous  articles  appeared  under  this  heading  in  The  Lancet  of 
June  28th,  The  Need  of  an  Industrial  Medical  Service,  and  July  5th, 
How  to  Start  an  Industrial  Medical  Service. 

2 The  Times  Trade  Supplement,  August  23rd,  1919. 


Dr.  Hastings  (Toronto)  “the  employers  of  labour  how  the 
loss  of  10  to  15  per  cent,  of  efficiency  in  the  employee  could 
be  saved,  and  they  would  be  willing  to  put  in  good  ventila- 
tion or  any  other  desired  improvement.”  Another  American 
writer  elsewhere  3 : “ One  of  the  greatest  expenses  in  industry 
is  the  cost  of  labour  turnover,  and  nearly  4500  new 
employees  were  examined  to  keep  3000  positions  filled. 
In  one  department  the  work  is  of  such  a character  that 
it  costs  $100  to  teach  a new  employee  to  become  efficient.” 
Greenwood  has  shown4  that  in  this  country  labour  turnover 
is  much  the  same  as  in  the  States.  We  have  about 
8 millions  employed  in  factories  alone  ; let  us  take  the 
annual  migration  of  workers  at  rather  less  than  the  probable 
cent,  per  cent.,  say  at  6 millions  ; and  the  cost  of  engage- 
ment and  training  at  only  £1  a head  ; we  arrive  at  an 
annual  charge  on  industry  due  to  the  present-day  trial  and 
error  method  of  engagement  of  6 million  pounds.  Greenwood’s 
investigation  further  indicated  that  careful  selection  and 
supervision  of  workers  can  divide  this  turnover  by  three. 
Four  millions  so  saved  would  far  more  than  cover  the  total 
cost  to  industry  of  an  adequate  medical  service  ; and  this 
matter  of  turnover  is  only  one  of  many  ways  in  which  the 
service  would  benefit  industry,  and  through  it,  as  no  other 
medical  service  can,  the  health  of  the  community. 

Avoidance  of  State  Control. 

What  is  required  to-day  is  to  interest  employers  as  the 
Americans  are  doing.  A letter  appearing  in  our  correspond- 
ence columns  from  the  director  of  the  Industrial  Welfare 
Society  suggests  that  a nucleus  for  this  interest  is  already 
existent.  A further  need  is  to  avoid  stereotyping  functions, 
the  result  of  State  “recognition,”  at  too  early  a stage. 
From  this  industrial  medicine  is  suffering  to-day  ; and  one 
fence  to  be  surmounted  is  the  employer's  disgust  with  the 
work  of  the  certifying  factory  surgeon  who  is  called  upon 
by  the  State*  to  undertake  for  6 d.  work  worth  six 
times  that  sum,  and  who,  therefore,  does  badly  what  he 
was  not  originally  called  into  existence  to  perform.  Once 
birth  certification  was  established  the  post  of  certifying 
surgeon  should  have  been  abolished  ; it  has  only  lingered  on 
to  the  harm  of  medical  progress.  Let  the  State  even  at  this 
eleventh  hour  abolish  the  post,  step  aside,  and  allow  the 
factory  medical  officer  to  evolve  naturally,  his  appointment 
being  made  and  his  services  remunerated  according  to  the 
laws  of  supply  and  demand. 

We  note  with  satisfaction  that  the  new  Ministry  of  Health 
shows  no  inclination  to  take  a hand  here.  Those  who  direct 
the  policy  are  clearly  too  wise  and  far-seeing.  Knowledge 
must  always  precede  progress,  and  industry  wi'l  resent  any 
medical  service  forced  on  it.  But  once  employers  know  its 
value  there  will  be  no  need  for  State  action,  unless  it  be  to 
assist.  Such  assistance  was  recognised  during  the  war  when 
the  salary  of  a factory  medical  officer  was  allowed  to  be 
charged  as  a working  expense  when  calculating  excess 
profits  duty.  No  more  was  needed  or  is  needed  to-day. 
Industrial  medicine  is  too  vigorous  a child  to  require  the 
swaddling  clothes  of  a diploma  or  the  supporting  irons  of 
State  orders  to  enable  it  to  grow  to  a sturdy  manhood. 

2 Medical  Inspection  of  Factory  Employees,  M.  A.  Austin,  M.D., 
Journal  of  Industrial  Hygiene,  June,  1919. 

4 Final  Report,  Health  of  Munition  Workers  Committee.) 


Pensions  and  Allowances  for  Disabled  Men. 

— The  revised  scale  of  disablement  pensions  for  the  higher 
ranks  affecting  soldiers  and  airmen  comes  into  force  as  from 
Sept.  3rd.  It  provides  an  increase  of  17  per  cent,  to  19  per 
cent.,  varying  with  the  rank,  on  the  previous  rate  (including 
bonus)  for  total  disablement,  in  addition  to  allowances  in 
respect  of  wife  and  children.  Various  alterations  and  adjust- 
ments have  also  been  made  for  widows  of  men  in  all  services. 
The  nbw  rates  will  continue  for  at  least  three  years,  and 
thereafter  will  be  subject  to  readjustment  according  to  the 
cost  of  living,  but  in  any  case  they  will  not  be  lowered  by 
more  than  20  per  cent.,  or  under  the  previous  rates  (including 
bonus).  The  Ministry  of  Labour  and  the  Ministry  of 
Pensions  make  the  following  announcement 

1.  War  Pensions  Committees  are  authorised,  where  recommended  by 
the  medical  referee,  to  continue  to  pay  allowances  to  disabled  men  in 
training  under  the  Ministry  of  Labour,  over  and  above  the  training 
allowances  which  they  are  receiving  from  the  Ministry  of  Labour  for 
(a)  ‘‘constant  attendance ” and  (6)  special  diet. 

2.  The  divisional  directors  of  the  Ministry  of  Labour  are  not 

responsible  for  the  granting  or  payment  of  these  allowances,  which 
come  under  the  heading  of  treatment,  and  any  disabled  men  who  desire 

their  continuation  or  authorisation  should  apply  to  their  War  Pensions 
Committees. 


494  The  Lancet,] 


THE  TEACHING  OF  OBSTETRICS  IN  LONDON. 


[Sept.  13,  1919^ 


THE  TEACHING  OF  OBSTETRICS  IN 
LONDON. 


The  following  is  an  abstract  of  the  report  made  by  a 
committee  to  the  Council  of  the  Section  of  Obstetrics  and 
Gynaecology  of  the  Royal  Society  of  Medicine  on  the 
Teaching  of  Obstetrics  and  Gynaecology  to  Medical  Students 
and  Graduates  in  London. 

Under  their  terms  of  reference  the  work  of  the  committee 
fell  into  two  parts  : — -(1)  The  present  methods  of  teaching 
midwifery  and  gynaecology  to  medical  students  and  graduates 
in  London.  (2)  The  changes  required  to  make  it  more 
efficient.  The  committee  point  out  the  great  importance  of 
the  subjects  they  were  called  upon  to  examine,  not  only  to 
the  medical  profession  but  through  it  to  the  women  of  the 
country  and  to  the  community  in  general.  The  provision  of 
doctors  more  highly  trained  in  practical  midwifery  work,  and 
the  provision  of  adequate  hospital  facilities  for  dealing  with 
serious  complications  of  pregnancy,  labour,  and  the  lying-in 
period,  are  matters  which  are  intimately  related  to  one 
another,  and  are  of  equal  importance  to  the  public  health. 
A large  increase  in  the  present  hospital  accommodation  for 
midwifery  cases  in  London  is  as  urgently  needed  as  an 
improvement  in  the  training  of  medical  students.  And, 
further,  if  by  suitable  arrangements  better  training  in  the 
management  of  infants  could  be*associated  with  midwifery 
training:,  a great  advance  would  be  made  in  dealing  with 
the  difficult  problem  presented  by  the  high  rate  of  infant 
mortality. 

A. — The  Present  System  : Midwifery. 

Systematic  teaching.— Systematic  lectures  are  given  In  all  the 
hospitals  by  the  obstetric  physicians,  usually  in  the  summer  term— i.e., 
once  a year  only : the  number  of  lectures  varies  frt>m  20  to  40.  A 
“practical  midwifery”  couise,  which  includes  operative  demonstra- 
tions on  the  dummy,  is  also  given  either  by  the  obstetric  physician  or 
by  the  tutor.  In  the  latter  case  it  is  combined  with  the  tutorial  class. 
In  most  hospitals  the  regulations  provide  that  students  attend  the 
systematic  lectures  and  the  practical  midwifery  course  before  being 
allowed  to  attend  cases  of  labour.  Tbe  Dean  of  the  school  may,  and 
sometimes  does,  suspend  this  rule. 

The  tutorial  or  revision  classes  are  held  each  term  by  the  tutor,  and 
are  attended  mainly  by  the  students  then  preparing  for  the  examina- 
tion in  midwifery  and  gynaecology.  Attendance  at  the  systematic  and 
practical  midwifery  courses  is  compulsory  under  the  regulations  of  the 
examining  bodies.  Attendance  at  the  tutorial  classes  is  optional,  but 
in  practice  all  students  do  attend. 

Clinical  instruction  in  normal  and  abnormalpregnancy.— Systematic 
instruction  is  given  in  the  gynaecological  wards  and  out-patients’ 
departments  of  all  hospitals  on  the  diagnosis  and  management  of 
pregnancy,  the  clinical  material  consisting  of  such  women  as  present 
themselves  for  one  reason  or  another  during  pregnancy.  Pregnant 
women  who  desire  to  be  attended  at  their  own  homes  are  usually 
required  to  present  themselves  at  the  hospital  for  examination  before- 
hand. They  are  seen,  usually,  by  an  obstetric  physician  or  by  the 
tutor,  and  any  students  who  care  to  attend  are  present  and  are  allowed 
to  examine  the  patients ; the  attendance  of  students  is,  however,  not 
as  a rule  compulsory,  and  in  practice  sufficient  U6e  is  not  msde  of  this 
department  for  purposes  of  teaching.  Exespt  in  the  case  of  hospitals 
with  a midwifery  ward,  this  is  all  the  provision  which  is  made  for 
instruction  in  normal  and  abnormal  pregnancy. 

Clinical  instruction  in  the  conduct  of  labour. — In  four  hospitals 
midwifery  wards  are  established  for  the  instruction  of  medical  studentB  ; 
others  have  a midwifery  ward  which  is  used  chiefly  for  training  mid- 
wives ; for  the  purposes  of  this  report  these  are  of  no  value.  The 
remaining  hospitals  have  no  midwifery  wards  at  all  at  the  present 
time.  In  every  hospital  serious  complications  of  labour  can  be  admitted 
to  the  gynecological  beds,  where  they  come  under  the  charge  of  the 
obstetric  physicians  ; in  many  cases,  however,  the  registrar  actually 
deals  with  them. 

In  the  case  of  hospitals  with  no  midwifery  win!  the  training  of 
students  in  the  actual  conduct  of  labour,  normal  and  abnormal,  is 
practically  non-existent.  In  order  t > attend  the  20  cases  required  bv 
the  regulations  of  the  examining  b idies  the  student  is  attached  to  the 
maternity  district  of  his  hospital ; previous  to  this  he  has  attended  the 
lectures  mentioned  above,  and,  in  addition,  in  some  hospitals  special 
demonstrations  are  given  by  the  tutor  or  the  resident  obstetric  officer 
to  each  batch  of  students  before  going  on  the  district.  As  a rule,  how- 
ever, the  students  of  hospitals  with  no  midwifery  ward  have  never  seen 
women  in  labour  before  going  on  the  district  to  attend  them. 

Every  hospital  has  a regulation  that  the  student  is  to  be  accompanied 
to  the  first  case  or  the  first  two  cases  by  the  R.O.O  , but  this  regulation 
cannot  in  all  Instances  be  carried  out,  and  the  student  not  infrequently 
goes  to  his  first  case  alone.  It  is  assumed  that  he  needs  no  assistance 
after  the  first  two  cases  in  conducting  a normal  labour,  but  he  is  under 
instructions  to  report  at  once  to  the  K O.O.  any  abnormal  conditions 
which  he  may  discover.  His  ability  to  detect  abnormal  conditions  is. 
however,  very  small  from  lack  of  training.  At  one  hospital  a trained 
midwife  in  the  service  of  the  hospital  is  also  present  at  every  labour, 
and  gives  the  student  assistance  ; as  a rule  the  student  conducts  normal 
cases  without  any  assistance,  even  in  respect  of  the  toilet  of  the  infant. 
Abnormal  conditions  are  frequently  dealt  with  by  the  R.O.O.  in  the 
patient's  home  ; practically  all  hospitals  have  a rule  that  serious  com- 
plications, such  as  ante-partum  haemorrhage  or  eclampsia,  should  be 
at  once  transferred  to  the  hospital,  where  they  are  almltted  under  the 


supervision,  usually  indirect,  however,  of  the  obstetric  physicians. 
There  the  student  is  able  to  take  part  in  their  management,  and  to  see 
any  obstetric  operations  which  are  required. 

The  student  continues  to  attend  his  district  cases  during  the  first 
seven  to  ten  days  after  the  puerperium,  under  the  same  instructions  to 
report  any  abnormal  conditions  which  may  arise  regarding  either  the 
mother  or  tbe  child.  It  must  be  recollected  that  unless  he  has 
previously  attended  the  midwifery  ward  the  student  has  received  no 
practical  instruction  whatever  in  the  management  of  infants;  as  a 
rule  his  work  is  done  without  any  systematic  supervision  during  the 
puerperium. 

In  some  hospitals  the  number  of  cases  available  in  the  district  is 
insufficient  to  allow  20  for  each  student ; a certain  number  of 
students  from  these  hospitals  are  sent  to  the  lying-in  hospitals, 
where  they  can  be  “signed  up”  for  20  cases  in  if  days  (Queen 
Charlotte's),  21  days  (York-road),  or  14  days  (City  of  London).  In  some 
instances  the  student  goes  for  a fortnight  to  the  Lying-in  Hospital, 
and  then  serves  for  a fortnight  on  the  district  of  his  own  hospital. 

In  the  case  of  the  hospitals  having  a midwifery  ward  for  students, 
the  conditions  require  separate  notice.  The  number  of  beds  in  these 
midwifery  wards  varies  from  8 to  24  ; the  number  of  cases  admitted 
per  annum  varies  from  180  to  550  to  600  ; the  number  of  cases  admitted 
per  student  trained  varies  from  3 to  11  or  12.  The  number  of  cases 
actually  delivered  by  medical  students  in  the  ward  is  limited,  in  all 
but  one  hospital,  by  the  fact  that,  not  being  in  residence  in  or  near  the 
hospital,  they  only  attend  the  deliveries  which  occur  in  the  daytime. 
The  instruction  is  given  in  part  by  the  visiting  physicians,  but  mainly 
by  the  registrar  or  the  resident  officers.  The  period  of  attendance  in 
the  midwifery  ward  is  four  weeks,  and  the  student  is  not  permitted  to 
begin  attending  cases  in  the  district  until  he  has  conducted  a certain 
number  of  deliveries  in  the  ward  and  received  a certain  amount  of 
practical  instruction.  After  this  he  attends  his  district  cases  alone,  as 
do  the  students  of  the  other  hospitals. 

Maternity  and  infant-welfare  centres. — These  centres,  where  they 
exist,  provide  opportunities  for  instruction  in  the  care  of  the  nursing 
mother,  in  infant  feeding,  and  in  the  general  management  of  the 
infant  during  the  first  year  of  life.  The  midwifery  department  of  a 
hospital  ceases  to  be  concerned  with  the  average  normal  case  in 
10  to  14  days  after  delivery;  the  work  of  these  centres  is  a continuation 
of  the  work  of  the  obstetrician,  and  its  utility  from  the  point  of  view 
of  preventive  medicine  is  generally  recognised  as  being  very  great. 
It  is  of  the  first  importance  that  these  centres  should  be  made  use  of 
in  training  students  in  continuation  of  their  midwifery  work,  yet  only 
five  hospitals  have  a maternity  and  infant-welfare  centre  in  connexion 
with  them.  Others  are  soon  to  be  started. 

B — The  Defeats  of  the  Present  Methods  of  Teaching 
Midwifery . 

The  systematic  instruction  given  is,  generally  speaking,  satis- 
factory, and  is  in  the  hands  of  the  obstetric  physicians.  The  prac- 
tical instruction  leaves  very  much  to  be  desired,  and  in  some  respects 
merits  emphatic  condemnation.  We  desire,  however,  to  acknowledge  the 
great  improvement  which  has  followed  the  establishment  of  midwifery 
wards  for  the  instruction  of  medical  students.  The  change  is  of  recent 
date  and  is  at  present  operating  in  only  four  hospitals  ; but  its  great 
usefulness  is  apparent  and  will  receive  general  acknowledgment.  The 
case  of  the  hospital  having  no  midwifery  ward  f ir  students  is  the  least 
satisfactory ; the  additional  experience  which  may  be  obtained  when  the 
student  also  goes  to  a lying-in  hospital  for  a short  time  is  most  unsatis- 
factory. The  following  considerations  must  be  borne  in  mind  : — 

(1)  The  hospital  without  a students'  midwifery  ward.— The  grave 
defects  of  this  system  may  be  set  out  as  follows  : 

(а)  Students  learn  to  deliver  vvomm  only  under  conditions  in  which 
surgical  cleanliness  is  extremely  difficult  to  secure.  Under  a satisfactory 
Bystem  the  same  principle  should  be  followed  as  obtains  in  general 
surgery — viz.,  they  should  be  taught  upon  the  highest  plane  of  efficiency 
which  it  is  possible  to  attain,  not  upon  the  lowest,  which  can  be  reached 
without  unjustifiable  risk  to  life.  A not  unfair  analogy  would  be  for 
surgeons  to  teach  students  the  technique  of  abdominal  operations  under 
conditions  where  they  would  be  deprived  of  adequate  light,  ventilation, 
and  the  means  of  cleanliness. 

(б)  Students  who  are  taught  thus,  under  makeshift  conditions,  will 
absorb  the  impression  that  careful  and  exact  precautionary  measures 
are  unnecessary.  Tne  effect  of  such  an  impression  upon  their  future 
work  in  private  practice  can  only  be  disastrous,  and  may  be  related 
directly  to  the  incidence  of  puerperal  fever  in  the  country  as  a whole. 

(c)  Unless  complications  occur  in  his  district  cases,  he  will  never  see 
the  obstetric  physicians  dealing  with  labour  at  all  ; and  even  when 
patients  are  transferred  to  the  hospital  the  control  of  the  obstetric 
physician  is  often  inllrect.  and  is  exerted  through  the  registrar  or 
R.O.O.  who  actually  deal  with  the  cases  themselves  after  asking  his 
advice.  The  student,  therefore,  learns  extremely  little  of  abnormal 
labour;  he  may  not  see  a forceps  delivery  during  his  month,  an f in 
occasional  in.tvices  may  go  up  fur  his  final  examination  without  having 
seen  this  procedure  except  upon  the  dummy. 

(d)  It  follows  from  (e)  that  the  student  learning  clinical  midwifery 
is  completely  out  of  touch  with  his  senior  teachers ; he  does  not  see 
them  actually  engaged  in  the  work  h«  is  trying  to  learn,  and  never  has 
the  advantage  of  their  supervision  and  guidance. 

(e)  That  a student  should  conduct  deliveries  in  the  district  is 
undoubtedly  useful,  for  the  single-handed  conduct  of  cases  of  labour 
maybe  assumed  to  develop  his  sense  of  resp  onsibility.  a valuable  aspect 
of  liis  training  as  a doctor.  But  this  should  come  after  and  not  before 
he  has  been  made  acquainted  with  the  nature  of  his  task.  In  the  case 
of  the  student  of  average  ability,  to  thrust  responsibility  upon  him 
before  he  has  been  taught  his  work,  will  be  more  likely  to  hinder  thau  to 
help  him  in  learning. 

( f ) Attendance  upou  20  to  30  cases  of  midwifery  ought  to  afford 
invaluable  opportunities  of  instruction  and  experience  in  the  manage- 
ment of  the  normal  puerperium,  of  minor  disorders  of  the  puerperium. 
and  of  infant  feeding.  Under  the  district  system  these  opportunities 
are  completely  wasted,  owing  to  the  total  lack  of  systematic  supervision 
of  the  students  when  at  work. 

(2)  The  lying-in  hospital. — The  great  defect  here  is  that  no  direct  pro- 
vision is  made  for  the  instruction  of  medical  students  atthese  hospitals. 


Thb  La  no  hit  ] 


THE  TEACHING  OF  OBSTETRICS  IN  LONDON. 


[Sept.  13,  1919  495 


They  attend  the  practice  of  the  hospital  in  order  to  be  “signed  np,”  but 
no  one  is  responsible  for  teaching  them.  The  visiting  physicians  pay 
regular  visits  to  the  lying-in  wards,  where  they  are  followed  by  a 
mixed  class  of  graduates,  students,  and  pupil-midwlves,  to  whom  they 
give  what  instruction  is  possdile  in  the  circumstances  upon  the  puer- 
perium  and  the  management  of  infants.  They  rarely,  if  ever,  conduct 
a case  of  normal  labour,  and  are  seldom  in  the  labour  wards  except  for 
difficult  cases  which  require  their  presence.  “ Waiting  cases  " which 
present  abnormal  conditions  are  usually  seen  by  the  visiting  physicians, 
who  may  demonstrate  them  to  the  students  ; but  under  the  rules  of  the 
hospital  the  visiting  physicians  do  not  undertake  any  responsibility  for 
the  instruction  of  medical  students.  It  has  been  already  stated  that 
the  student  does  not  actually  deliver  all  the  patients  he  is  certified  to 
have  “attended”;  it  suffices  if  he  is  present  at  the  delivery  as  a 
spectator.  The  number  he  actually  delivers  is  variable  and  depends 
upon  the  goodwill  of  the  R.O.O.  and  the  resident  midwives,  either  of 
whom  may  supervise  his  work.  Instruction  of  students  is,  however, 
no  part  of  t heir  duty  to  the  hospital  and  they  are  under  no  obligation 
to  take  pains  in  giving  it.  Some  students  may  be  allowed  by  the 
R.O.O.  to  conduct  a forceps  delivery  under  supervision,  but  this  depends 
entirely  upon  the  goodwill  of  the  R.O.O.  himself. 

(3)  The  hospital  with  a students'  midwifery  ward.— This  system 
undoubtedly  marks  a great  advance  in  the  training  of  students,  but 
certain  defects  are  inherent  in  it.  Only  four  hospitals  have  such  a 
ward  in  actual  working ; its  Bize  varies  from  8 to  24  beds.  The 
greater  number  of  cases  admitted  are  normal  cases.  Students  are 
attached  to  the  ward,  in  ail  cases  exclusively,  for  a period  of  four  weeks. 
They  come  into  close  touch  with  the  obstetric  physicians,  who  demon- 
strate cases  to  them  and  give  general  clinical  instruction  on  their 
regular  visiting  days.  The  women  are  delivered  by  the  R.O.O.  or  the 
resident  sister  midwife,  under  both  of  whom  the  students  work,  and  by 
whom  they  are  personally  instructed  in  the  conduct  of  normal  labour. 
The  Btudents  are  not  in  residence  except  in  the  case  of  one  hospital, 
and,  as  a rule,  only  the  daytime  labours  are  seen  by  them.  It  must  be 
pointed  out.  however,  that  the  visiting  physicians  take  little  or  no  part 
in  teaching  the  conduct  of  normal  labour,  that  the  more  serious  cases  of 
abnormal  labour  are  not  all  seen  by  them,  and  even  when  conducted 
under  their  supervision,  they  are  not  necessarily  delivered  by 
them. 

The  small  size  of  the  midwifery  ward  is  one  of  its  chief  defects.  It 
suffices  to  allow  each  student  to  conduct  a small  number  of  normal 
deliveries  before  commencing  his  work  on  the  district;  this  number 
could  with  advantage  be  much  increased.  The  more  serious  abnormal 
cases  from  the  hospital  district  are  sent  in  to  the  midwifery  ward,  but 
it  is  impossible  for  these  wards  to  deal  with  large  numbers  of  abnormal 
cases,  and  there  is  no  doubt  that  the  students'  opportunities  of  seeing 
difficult  labour  dealt  with  are  inadequate.  • 

The  non-continuous  character  of  the  student’s  attendance,  in  all  but 
one  hospital,  is  a grave  disadvantage.  A large  proportion  of  all 
deliveries  occur  at  night,  when  the  student  is  not  there  to  see  them. 
Complicated  cases  may  occur  at  any  time,  and  from  their  nature  the 
great  ma  jority  must  be  dealt  with  promptly.  As  a rule,  they  cannot  be 
left  over  until  the  hours  of  the  student's  attendance  come  round,  and 
thus  invaluable  opportunities  of  instruction  are  lost.  To  tell  the 
student  all  about  a difficult  case  the  day  after  it  has  been  dealt  with  is 
not  a satisfactory  method  of  clinical  instruction.  The  time  the  student 
devotes  to  the  midwifery  ward  (four  weeks)  is  quite  inadequate,  if  his 
attendance  is  only  in  the  day  time,  and  even  that  may  be  broken  up  by 
other  duties. 

The  bulk  of  the  practical  teaching  in  the  midwifery  wards  is  given 
by  the  registrar  and  the  R.O.O.,  particularly  in  regard  to  the  conduct 
of  normal  labour ; whereas  the  student  ought  to  be  taught  both  normal 
and  abnormal  conditions  by  senior  obstetric  officers  of  greater  expe- 
rience and  higher  standing  than  the  average  registrar.  The  major  part 
of  the  student’s  clinical  teaching  in  surgery  is  given  him  by  surgeons 
and  assistant  surgeons,  and  this  is  universally  regarded  as  being 
necessary.  It  is  equally  necessary  that  he  should  be  taught  his  clinical 
midwifery  by  men  of  simi'ar  standing.  In  the  nature  of  midwifery 
work  this  would  involve  the  presence  in  resident  control  of  the  mid- 
wifery ward  of  senior  officers,  wbo  would  be  always  available,  would 
personally  supervise  the  work  of  the  labour  wards,  and  would  themselves 
deal  with  abnormal  cases  at  whatever  hour  they  might  arise. 

0. — The  Present  System : Gynceoology. 

A certain  small  number  of  systematic  lectures  in  gynecology  are 
given  by  the  obstetric  physicians  either  as  a part  of  the  course  of 
midwifery  or  separately.  As  a rule  the  student  clerks  for  one  to  two 
months  in  the  gyc: ecological  department;  although  the  regulations 
of  the  majority  of  the  examining  bodies  require  him  to  spend  three 
months  at  clinical  gyncecology,  the  hospitals  do  not  all  enforce  it.  In 
some  instances  his  gynaecological  clerking  is  done  in  the  same  month  as 
he  attends  his  midwifery  cases  on  the  district.  The  number  of  gyneco- 
logical beds  in  the  various  hospitals  varies  from  11  to  34,  the  average 
being  about  20.  In  the  wards  the  clerk  is  taught  by  the  registrar  or  the 
R.O.O.  to  take  the  history  of  a gynaecological  case,  and  is  usually  taken 
over  the  physical  examination  by  the  same  officer.  lie  follows  the 
obstetric  physician  in  his  rounds,  and  is  present  at  the  operations  which 
take  place  during  his  clerkship.  His  attendance  in  the  wards  may  be 
much  restricted  if  he  is  at  the  same  time  doing  his  midwifery  cases  on 
the  district.  In  the  w'ards  he  gets  certain  opportunities  of  making- 
pelvic  examinations  under  ansestheda,  anl  of  personally  assisting  as 
operations.  The  operations  and  the  operation  specimens  are  demon- 
strated more  or  less  fully,  according  to  the  custom  of  each  operator  and 
the  amount  of  work  he  may  haam  to  get  through.  In  the  case  of  hospitals 
with  only  10  to  20  gynecological  beds  the  number  and  variety  of  cases 
seen  in  a month  is  necessarily  very  limited,  and  is,  in  fact,  quite 
inadequate  as  a course  of  clinical  training. 

Among  gynaecological  out-patients,  the  student  usually  sees  a large 
number  of  minor  cases,  and  isallowel  to  examine  a fair  proportion  of 
them.  He  needs  close  supervision  and  a good  deal  of  assistance  in 
learning  to  make  the  bi- manual  examination,  and  in  the  case  of  a large 
out-patient  clinic  the  number  of  cases  which  have  to  be  seen  precludes 
the  out-patient  physician  from  devoting  close  attention  to  the  student. 
In  a small  clinic  the  number  and  variety  of  the  cises  seen  by  the  student 
in  one  month  is  quite  inadequate.  As  a rule,  the  out-patient  physician 
is  assisted  by  the  R.O.O.,  but  it  is  rare  to  find  any  system  operating  for 
the  sifting  of  cases,  so  that  those  most  suitable  for  teaching  may  be 


passed  at  once  to  the  out  patient  physician.  Usually  the  R.O.O.  sees 
all  the  old  cases  and  the  out-patient  physician  all  the  new  ones 
irrespective  of  their  clinical  Importance. 

Deficiencies  in  gymccological  training. -It  is  in  the  clinical  training 
of  the  students  that  defects  are  most  apparent.  These  deficiencies  can 
be  traced  mainly  to  two  causes  : (1)  The  very  inadequate  number  of 
gynaecological  beds  In  all  the  hospitals;  (2)  the  very  inadequate  amount 
of  time  which  the  student  devotes  to  the  subject.  With  regard  to  the 
number  of  beds  it  must  be  recollected  that  midwifery  anil  gynaecology 
together  form  one-third  part  of  the  final  examination,  and  are 
associated  on  equal  terms  with  medicine  and  with  surgery.  The 
combined  number  of  gynaecological  and  midwifery  beds  available 
for  teaching  is  less  than  one-third  of  the  number  allotted  either  to 
medicine  or  to  surgery.  This  policy  of  cramping  the  work  of  the 
obstetric  physician  is  due  partly  to  the  failure  of  colleagues  to  realise 
the  importance  of  these  subjects  to  the  medical  practitioner  and  to  the 
community  and  partly  to  the  relatively  low  level  of  the  requirements  of 
most  of  the  examining  bodies.  In  both  medicine  and  surgery  the 
student  is  obliged  to  clerk  for  six  months,  while  to  clinical  midwifery 
and  gynaecology  combined  he  does  not  devote  more  than  three  months 
at  most  hospitals. 

D.  — The  Consequences  of  Detective  Training  in  Midwifery 

and  Gynaecology . 

(a)  The  training  of  medical  students  is  a matter  of  the  first  import- 
ance to  the  State,  for  efficient  doctors  are  necessary  to  the  maintenance 
of  ihe  public  health.  In  the  early  years  of  his  private  practice 
midwifery  and  the  minor  ailments  of  women  and  infants  form  a large 
proportion  of  the  young  doctor’s  work,  and  yet  these  are  probably  the 
subjects  in  which  his  practical  training  has  been  most  deficient. 

(b)  Since  the  great  majority  of  students  learn  to  conduct  labour  only 
under  conditions  in  which  surgical  cleanliness  cannot  be  enforced, 
they  carry  with  them  into  practice  the  impression  (perhaps  sub- 
consciously) that  surgical  cleanliness  is  not  ot  the  same  importance 
in  midwifery  as  in  surgery.  The  makeshift  methods  with  which  they 
begin  their  experience  tend  to  become  stereotyped  in  their  minds,  and 
the  effect  of  this  upon  their  work  in  private  practice  must  be  very 
bad. 

(c)  The  bearing  of  this  point  upon  the  incidence  of  death  from  child- 
bearing in  the  country  cannot  be  overlooked.  During  the  period  1891 
to  1914  this  death-rate  of  childbirth  for  Great  Britain  and  Ireland  was 
almost  stationary,  the  fall  being  only  from  5 8 to  5 08  per  1000  births. 
This  can  only  be  regarded  as  extremely  unsatisfactory,  for  it  shows  that 
during  a period  in  which  surgical  training  made  such  rapid  advances 
midwifery  training  male  none.  Indeed,  in  all  divisions  of  the  country 
except  Ireland  the  death-rate  actually  rose  in  the  quadrennium 
1911-1914.  The  conclusion  cannot  be  avoided  that  both  medical 
students  and  midwives  are  being  imperfectly  trained. 

(d)  The  student  has  been  accustomed  to  pay  only  perfunctory 
attention  to  the  puerperium,  for  he  has  been  left  largely  to  himself  at 
this  period  while  attending  his  cases  on  the  district  ; he  therefore 
cannot  be  expected  to  realise  its  importance  from  the  point  of  anew  of 
the  health  and  working  efficiency  of  the  mother. 

(e)  The  average  newly  qualified  doctor  has  had  little  or  no  clinical 
training  in  the  management  of  the  infant  and  usually  leaves  it  entirely 
to  the  nurse.  Even  in  the  case  of  the  well-to-do  the  nurse  often 
regards  the  infant  as  her  patient,  and  feeds  it  or  doses  it  without 
reference  to  the  medical  attendant.  Mothers  also  come  to  think  that 
this  is  the  proper  arrangement  and  to  prefer  the  advice  of  the  nurse. 
There  is  no  doubt  that  many  infant  lives  are  lost  owing  to  the  fact  that 
medical  students  receive  insufficient  clinical  training  in  this  subject. 

(/)  It  is  the  personal  experience  of  all  the  members  of  your  com- 
mittee that  medical  practitioners  do  not  consider  it  necessary  to  obtain 
the  services  of  a specialist  or  of  a hospital  in  the  emergencies  of 
midwifery  to  the  same  extent  as  they  undoubtedly  do  in  the  case  of 
general  surgery.  This  is  largely  duo  to  the  fact  that  they  have  not, 
during  their  training,  seen  such  cases  dealt  with  by  the  senior  obstetric 
officers  in  the  way  that  they  have  seen  serious  surgical  cases  dealt  with 
by  surgeons.  Their  custom  is  to  call  in  a neighbouring  practitioner 
and  to  do  the  best  they  can. 

( g ) The  lack  of  hospital  accommodation  for  women  in  labour  and 
the  lack  of  public  means  of  transporting  patien  ts  to  hospital  tend  to 
confirm  the  practitioner  in  this  attitude. 

f/i)  The  close  relation  which  subsists  between  bad  midwifery'and 
pelvic  disease  in  women  is  well  recognised.  A sound  practical  training 
in  the  recognition  and  treatment  of  pe’vic  disease  is  as  important  as 
the  midwifery  training  itself.  Young  medical  practitioners  are  prob- 
ably less  able  to  recognise  common  forms  of  gynecological  disease  than 
they  are  common  forms  of  medical  or  surgical  diseise.  The  results  are 
very  serious  in  regard  not  only  to  the  life,  but  also  to  the  health,  working 
efficiency,  and  subsequent  capacity  for  child-bearing  of  the  women  of 
the  country. 

E.  — The  Bases  of  an  Efficient  Training  in  Midwifery  and 

Gynaecology. 

(1)  Owing  to  their  intimate  relationships  these  subjects  should  be 
taught,  as  is  the  British  practice,  by  the  same  teachers,  and  the  training 
of  students  in  them  should  run  concurrently. 

(2)  Midwifery  training  should  he  extended  in  one  direction  (ante- 
natally)  so  as  to  comprise  a fuller  study  of  the  whole  course  and 
management  of  pregnancy,  and  in  the  other  (post-natally)  so  as  to 
comprise  the  management  of  the  whole  nursing  period  and  the 
management  of  the  infant. 

(3)  The  management  of  labour  should  be  taught  as  a surgical  pro- 
cedure ; this  can  only  be  done  in  hospital,  under  surgical  conditions, 
with  adequate  equipment,  and  a highly  trained  staff  of  teachers. 
Owing  to  the  peculiar  nature  of  the  work  the  senior  officers  upon 
whom  the  ultimate  responsibility  rests  should  be  resident  in  the 
hospital,  or  should  be  available  at  any  time  their  presence  may  be 
required. 

(4)  There  should  be  adequate  hospital  accommodation  in  all  large 
centres  of  population  to  allow  of  all  serious  obstetric  emergencies  being 
immediately  admitted  for  treatment ; this  is  recognised  as  being 
necessary  in  respect  of  surgical  conditions,  and  it  is  equally  necessary 
in  respect  of  midwifery. 


496  The  Lancet,] 


THE  TEACHING  OF  OBSTETRICS  IN  LONDON. 


[Sept.  13, 1919 


(5)  From  (41  it  follows  that  the  number  of  beds  available  for  cases  of 
midwifery  must  be  very  largely  increased,  allowing  due  provision  to  be 
made  for  the  emergencies  which  so  frequently  arise. 

(6)  Medical  students  and  midwives  cannot  be  suitably  trained  in  the 
same  institution  unless  in  separate  classes. 

(7)  The  proportion  of  beds  allotted  to  midwifery  and  gynaecology  is 
quite  inadequate  to  the  importance  of  the  subject  from  the  point  of 
view  of  the  public  health  ; the  number  should  bear  a definite  proportion 
to  the  total  number  of  beds  in  the  hospital ; at  the  present  time  the 
average  proportion  is  less  than  one-twentieth  of  the  total  in  the 
12  teaching  hospitals ; this  proportion  should  be  increased  to  at  least 
one-tenth.  A considerable  number  of  gynaecological  cases  are  dealt  with 
by  the  Burgeons  in  the  surgical  wards,  which  are  largely  lost  for  teaching 
purposes. 

(8)  The  requirements  of  the  examining  bodies  in  both  subjects 
should  be  strengthened  so  as  to  enforce  (a)  an  adequate  period  of 
clinical  training  during  which  the  student  should  be  allowed  to  under- 
take no  other  work;  (6)  the  provision  of  suitably  arranged  and 
sufficiently  large  facilities  for  clinical  work. 

(9)  The  extent  to  which  the  student’s  training  is  influenced  by  the 
nature  of  the  qualifying  examination  must  not  be  overlooked,  and  the 
present  Bystem  of  examination  in  midwifery  and  gynzecologv  urgently 
needs  amendment.  The  examination  of  the  Conjoint  Board,  for 
example,  is  very  unequal  owing  to  the  large  number  of  examiners  from 
different  teaching  hospitals  in  London  and  from  provincial  universities, 
who  often  set  widely  different  standards.  And  the  absence  of  a clinic  il 
examination  in  both  subjects  leads  the  student  to  neglect  his  clinical 
work  and  to  underrate  its  importance. 

The  examining  authorities  should  be  urged,  whenever  it  is  possible, 
to  recognise  the  principle  that  the  student  should  be  examined  by  his 
own  teacher  with  a second  examiner  as  assessor,  and  that  clinical 
examinations  should  be  accorded  the  same  importance  as  in  the  case  of 
medicine  and  surgery. 

F. — Sketch  of  a Satisfactory  Scheme. 

(I.)  There  are  two  different  lines  upon  which  fully  equipped  depart- 
ments, of  adequate  size,  for  the  teaching  of  midwifery  and  gyntecology 
could  be  organised  : — 

(a)  Certain  of  the  larger  teaching  hospitals  might  provide  for  a 
great  expansion  of  their  existing  midwifery  wards,  from  which,  with 
their  associated  gynaecological,  pathological,  and  other  services,  a mid- 
wifery department  could  be  formed  capable  of  providing  for  the 
training,  not  only  of  their  own  students,  but  also,  If  necessary,  of 
students  from  other  hospitals  where  there  is  no  midwifery  ward  in 
existence. 

(b)  New  centres  might  be  found  in  outlying  districts  where 
there  is  at  present  no  adequate  maternity  service.  These  new  centres, 
though  not  in  proximity  to  existing  teaching  hospitals,  might  be 
affiliated  to  certain  of  them  which  were  unable  to  develop  fully 
equipped  maternity  departments  of  their  own,  and  which  might  send 
their  students  to  the  new  centre  for  training.  These  new  centres  could 
be  made  use  of  for  training  not  only  students  but  also  post  graduates, 
and  in  addition  they  would  afford  much-needed  facilities  for 
research. 

(II.)  Departments  developed  out  of  existing  maternity  wards  at  a 
teaching  hospital  (Subsection  I.a)  ought  to  provide  a minimum  of  75 
beds,  of  which  50  would  be  for  midwifery  and  25  for  gynaecology.  Of 
the  midwifery  beds  a certain  number  would  be  allocated  to  ante-natal 
conditions  and  puerperal  complications.  “ Departments  ” developed  in 
connexion  with  the  larger  teaching  hospitals,  which  have  greater 
facilities  for  expansion,  might  exceed  these  figures  if  students  from 
other  hospitals  were  received  in  addition  to  their  own. 

In  the  opinion  of  the  committee  a midwifery  department  containing 
less  than  50  beds  cannot  be  satisfactory  for  the  teaching  of  students,  as 
it  will  not  afford  them  an  opportunity  of  seeing  all  the  ordinary  diffi- 
culties and  complications  of  pregnancy  and  labour  during  the  limited 
period  of  time  in  which  they  are  attending  the  department.  It  would 
be  impossible  for  every  one  of  the  existing  teaching  hospitals  to  supply 
Buch  a large  number  of  beds  for  midwifery.  So  it  is  obvious  t hat  under 
this  scheme  some  form  of  concentration  would  be  necessary — that  is, 
that  some  of  the  hospitals  should  provide  midwifery  departments 
which  would  be  attended  by  their  own  students  and,  in  addition,  by 
students  from  the  hospitals  which  were  unable  to  provide  such 
departments. 

(III.)  Newly  founded  centres  (Subsection  1.6)  would  probably  be 
much  larger  than  the  “departments”  on  account  of  the  urgent 
public  need  which  exists  for  increased  hospital  accommodation  for 
midwifery  cases.  They  could  provide  about  200  beds  each,  of  which, 
roughly,  20  would  be  for  ante  natal  conditions,  100  for  labour,  20  for 
infective  cases  (Isolation),  and  60  for  gynaecological  cases.  The 
provision  of  a certain  number  of  such  centres  as  these  in  selected  out- 
lying districts  would  form  a most  valuable  contribution  to  the 
provision  of  an  efficient  maternity  service  for  London.  It  is  obviously 
of  great  importance  that  full  use  for  teaching  purposes  should  be  made 
of  such  new  centres  when  they  come  into  existence. 

The  provision  of  a proportion  of  gynaecological  beds  in  the  centre  is 
an  essential  feature  ot  the  scheme.  It  would  be  needed  to  meet  the 
medical  requirements  of  the  district,  and,  further,  it  would  allow  the 
student  to  do  his  practical  work  in  the  two  subjects  together  and 
under  the  same  teachers;  knowledge  of  either  subject  is  incomplete 
without  the  other,  and  the  student  learns  them  together  much  more 
readily  than  separately. 

(IV.)  The  medical  staff  required  to  work  the  “centre”  also  involves  a 
new  departure.  Reasons  have  been  advanced  for  the  view  that  a much 
larger  proportion  of  the  teaching  in  the  conduct  of  normal  and 
abnormal  labour  should  be  given  by  senior  obstetric  officers,  than  is  the 
case  at  present.  This  involves  senior  officers  being  either  in  residence 
at  the  centre  or  on  duty  during  certain  definite  hours  of  the  day  and 
night.  Such  services  could  not  be  required  of  them  without  payment 
upon  an  adequate  scale.  Next  to  them  would  be  required  assistants  in 
residence,  of  the  status  of  the  present  registrar  or  tutor,  whose  whole 
time  would  be  required,  and  who  also  must  be  adequately  paid. 

(V.)  “ Departments  ” developing  out  of  existing  midwifery  wards  at 
teaching  hospitals  (Subsection  II. a)  would  probably  be  best  staffed  as 
follows : — 


(1)  A staff  of  two  or  more  visiting  obstetric  physicians  (or  surgeons) 
who  would,  in  rotation,  undertake  the  duties  appertaining  to  the 
director  or  chief  of  the  department,  for  definite  periods  as  might  be 
most  suitable. 

(2)  A resident  “chef  de  Clinique ,"  appointed  for  a term  of  years, 'who 
must  be  a whole-time  officer,  and  who  would  have  charge  of  the  depart- 
ment under  the  visiting  staff.  His  professional  status  should  be  above 
that  of  an  obstetric  registrar— i.e.,  comparable  with  that  of  a resident 
assistant  surgeon  or  a resident  assistant  physician. 

(3)  One  or  two  resident  senior  assistants  of  the  status  of  the  registrar, 
who  would  direct  the  students  personally  in  their  work  in  the  labour 
wards,  the  lying-in-wards,  and  on  the  district,  and  a number  of  resident 
assistants  (house  surgeons).  These  would  also  be  whole-time  officers. 

Departments  such  as  these  would  probably  eventually  develop 
into  “ units  ” with  professors  of  midwifery  and  gynaecology,  on  the  lines 
of  the  units  of  medicine  and  surgery  which  are  about  to  be  founded. 
Such  professors  of  midwifery  and  gynaecology  should  not  be  “whole- 
time” professors,  but  should  remain  in  touch  with  consulting  practice. 

(VI.)  New  centres  formed  inoutlylngdistricts(3ubsection  II.  6)  would 
probably  be  best  worked  by : — 

(1)  A resident  director  or  superintendent,  who  might  be  appointedjfor 
a term  of,  say,  five  to  seven  years.  He  would  be  of  the  status  of  an 
obstetric  physician  at  the  teaching  hospital.  He  would  be  responsible 
for  the  control  of  the  work  of  the  institution  generally,  and  would  take 
a large  share  in  operative  work,  in  teaching,  and  in  research.  The 
director  should  not  be  a “whole-time”  officer,  but  should  remain  in 
touch  with  consulting  practice. 

(2)  One  or  more  resident  assistant  directors, 

(3)  Working  under  (1)  and  (2)  a sufficient  number  of  resident 
assistants  to  direct  the  students  personally  in  their  work  in  the  labour 
wards,  the  lying-in  wards,  the  gynaecological  wards,  and  in  the  district. 
They  would  also  be  responsible  for  the  clinical  pathology  of  the  centre, 
and  would  carry  out  research  under  the  supervision  of  the  director  and 
the  assistant  director. 

These  appointments  when  first  instituted  would  afford  an  oppor- 
tunity for  the  teaching  hospitals  affiliated  to  the  centre  to  be  repre- 
sented upon  its  teaching  Btaff,  and  thus  keep  the  students  in  touch 
with  their  own  hospital  staff. 

It  must  be  borne  in  mind  that  outlying  districts  which  are  in  need 
of  a midwifery  hospital  service  require  general  hospitals  as  well ; these 
would,  no  doubt,  eventually  be  established,  and  thus  proside  for  the 
association  of  pathological  and  other  services  with  the  new  centres. 

(VII.)  In  the  opinion  of  the  committee  the  requirements  of  the 
students'  training  can  only  be  completely  met  under  the  scheme  of 
new  “ centres,”  on  account  of  the  necessity  which  has  been  already 
emphasised  of  the  senior  teachers  taking  a considerably  larger  part 
than  at  present  in  the  work  of  clinical  instruction.  Under  the  alter- 
native scheme  of  “departments”  at  existing  teaching  hospitals  the 
senior  teachers  would,  in  effect,  not  take  any  larger  part  in  teaching 
than  they  do  now. 

(VIII.)  Students  belonging  to  hospitals  with  a fully  equipped  mid- 
wifery department  (Subsection  I.  a)  should  be  attached  to  the  depart- 
ment for  a period  of  four  months,  during  which  their  whole  time  would 
be  devoted  to  midwifery  and  gynaecology.  and  they  would  be  in  residence 
for,  at  any  rate,  a part  of  the  time.  Students  fr  jm  other  hospitals  would 
probably  come  to  the  department  for  practical  midwifery  only ; they 
would  be  in  residence  for  at  least  one  month.  In  the  second  month 
they  would  attend  their  cases  on  the  district  of  their  own  hospital 
under  the  supervision  of  their  own  medical  staff,  and  would,  in  addition, 
continue  to  attend  the  department  for  clinical  teaching,  operations,  &c. 
These  students  would  receive  their  gynaecological  training  at  their  own 
hospitals,  as  at  present. 

(IX.)  The  midwifery  districts  of  the  teaching  hospitals  would,  there- 
fore, be  continued,  for  it  is  of  great  importance  that  the  student  should 
have  experience  of  district  wo  k during  the  latter  part  of  his  training, 
as  long  as  it  is  under  proper  supervision  In  the  case  of  certain 
hospitals  the  district  could  not  provide  sufficient  cases  to  enable  each 
student  to  attend  the  required  number.  Arrangements  could,  perhaps, 
be  made  for  a proportion  of  the  students  from  these  hospitals  to  do 
their  district  work  elsewhere— i.e.,  in  the  district  of  another  hospital. 

(X.)  Each  teaching  hospital  should  provide  means  of  properly  super- 
vising its  students  in  their  work  on  the  district.  Under  the  present 
system  the  assistant  obstetric  physician  is  in  nominal  charge  of  this 
work,  with  the  assistance  of  the  registrar  and  the  K.O.O.  The  control 
of  the  assistant  obstetric  physician  should  be  made  effective  under  the 
rules  of  each  hospital,  and  the  duties  of  the  registrar  should  include  the 
Instruction  of  each  student  in  the  management  of  his  district  cases 
during  the  puerperium. 

(XI.)  Students  attending  a new  centre  (Subsection  1.6)  would  be 
attached  to  it  for  a period  of  four  months,  during  which  their  whole 
time  would  be  devoted  to  midwifery  and  gynaecology,  and  they  would 
be  in  residence  for,  at  any  rate,  a part  of  that  time. 

G. — First  Steps  to  be  Taken.. 

(I.)  While  the  committee  are  of  opinion  that  eventually  the  foundation 
of  new  “centres " will  be  necessary  for  the  proper  training  of  students 
in  midwifery  and  gynaecology,  it  is  recognised  that  it  will  probably  be 
some  time  before  such  a scheme  could  be  put  into  operation.  The 
necessity  of  taking  steps  promptly  to  effect  the  most  urgently  needed 
improvements  is,  however,  obvious,  and  the  formation  of  “depart- 
ments" at  existing  teaching  hospitals  (F,  Subsection  II. a)  could  be  put 
into  operation  without  prejudice  to  the  later  formation  of  new 
"centres.”  In  this  way  the  two  schemes  could  be  developed  side 
by  side,  and  there  is  no  doubt  that  the  one  found  by  experience  to 
be  best  suited  to  the  special  requirements  of  London  would  eventually 
prevail. 

(II.)  It  is  of  great  importance  that  a ' department  ''  of  the  size 
indicated,  formed  at  a teaching  hospital,  should  in  addition  to  their 
own  students  receive  a certain  number  of  students  from  one  or  more 
hospitals  which  have  no  midwifery  ward.  If  this  plan  were  carried 
out  the  existing  inequality  of  the  training  in  practical  midwifery  in 
London  which  results  from  the  absence  of  a midwifery  ward  in  many 
teaching  hospitals  would  be  to  a great  extent  obliterated,  and  the 
general  level  of  midwifery  training  would  be  at  once  appreciably 
raised. 


The  Lanoet,]  A MONTHLY  RECORD  OF  ATMOSPHERIC  POLLUTION.  [Sept.  13,  1919  497 


(III.)  As  hospitals  without  a fully  equipped  midwifery  department 
would  continue  to  train  their  own  students  in  gym-ecology  as  at  present, 
an  Immediate  Increase  in  the  number  of  gynaecological  beds  at  these 
hospitals  Is  urgently  required  for  the  reasons  which  have  been  already 
stated. 

(IV.)  The  first  steps  to  be  taken  would  probably  be  to  Inquire  into 
the  following  points  : — 

i 1 (a)  The  possibility  of  the  hospital  designated  being  able  to  allot  the 
required  number  of  beds  to  midwifery. 

r>(6)  The  willingness  of  other  hospitals  to  make  use  of  the 
‘‘.department  ” for  training  their  students. 

' *t(c)  Suitable  financial  arrangements  being  made  between  the  affiliated 
hospitals,  assisted  by  a Government  grant. 

(V.)  Another  development  which  might  be  put  into  immediate  opera- 
tion is  the  much  greater  utilisation  of  ante-natal  and  infant-welfare 
clinics  for  the  instruction  of  students. 

(VI.)  It  is  also  very  desirable  that  all  teaching  hospitals  should,  as  far 
as  possible,  compel  their  students  to  give  up  a minimum  of  four  months 
solely  to  midwifery  and  gynaecology,  and  the  examining  bodies  should 
he  moved  to  alter  their  requirements  in  this  sense. 

H. — The  Teaching  of  Graduates. 

Midwifery. 

(1)  There  is  no  doubt  that  it  is  very  desirable  that  provision  should 
be  made  for  the  clinical  instruction  of  graduates  in  midwifery  : there  is 
a considerable  demand  for  it  now,  and  this  demand  is  likely  to  be 
greater  in  the  future. 

(2)  The  essential  conditions  for  the  practical  instruction  of  graduates 
in  midwifery  are  -.  (a)  an  institution  able  to  receive  large  numbers  of 
cases,  and  making  special  provision  for  difficult  and  operative  labours ; 
(6)  resident  teachers  of  status  and  experience. 

(3)  The  case  of  the  medical  student  is  in  our  opinion  more  urgent 
than  that  of  the  graduate  and  should  be  dealt  with  first.  When  large 
central  institutions  on  the  lines  indicated  above  have  been  set  up  there 
will  be  no  difficulty,  in  addition  to  meeting  the  needs  of  the  students, 
to  provide  the  clinical  material,  the  teachers,  and  the  laboratory 
facilities  which  are  requisite  for  the  instruction  of  graduates. 

(4)  Under  the  conditions  which  exist  at  present  it  is  practically 
impossible  to  organise  post-graduate  instruction  upon  satisfactory 
lines.  Certain  suggestions  for  improving  the  existing  facilities  at 
lying-in  hospitals  will  be  found  in  Appendix  D. 


Gynxcology. 

(1)  The  abundant  clinical  material  of  the  special  hospitals  for  women 
is  largely  lost  for  teaching  purposes  under  the  present  conditions.  A 
certain  number  of  clinical  assistants  (qualified)  are  usually  attached 
to  thorn  who  attend  out-patients  and  operations,  but  there  are  no 
systematic  arrangements  for  clinical  teaching  upon  a considerable 
scale. 

(2)  Those  hospitals  would  be  of  invaluable  service  in  providing  clinical 
teaching  for  graduates,  and  this  appears  to  be  their  proper  educational 
sphere. 

(3)  The  three  principal  hospitals  (Chelsea  Hospital  for  Women, 
Samaritan  Free  Hospital,  Soho  Hospital)  should  be  affiliated,  so  that 
graduates  taking  a course  would  be  entitled  to  follow  the  practice  of  ail 
of  them.  In  this  way  graduates  taking  a course  of  clinical  gynaecology 
could  be  continuously  employed  in  out-patient  departments,  wards, 
operating  theatres,  and  laboratories. 

(4)  Courses  of  instruction  lasting  for  six  to  eight  weeks  should 
be  provided — viz,  (a)  clinical  gynaecology;  (6)  operative  gynaecology  ; 
(C)  gynaecological  pathology. 

Clinical  gynxcology. — Demonstrations  on  selected  cases  should  be 
given  in  the  in-patient  and  out-patient  departments,  and  the  senior  and 
junior  members  of  the  staff  should  take  part  in  the  teaching  in  both 
departments.  Facilities  should  be  afforded  to  each  graduate  to 
acquire  a knowledge  of  the  bimanual  methods  of  examination  by 
repeated  practice  while  the  patient  is  anaesthetised ; to  acquire  a 
knowledge  of  the  instruments,  appliances,  See.,  used  in  the  practice  of 
gynaecology.  Case-taking  cards  should  be  provided  in  both  in-  and 
out  patient  departments. 

Qynxcological  pathology. — Instructions  should  be  given  in  (a)  recent 
specimens,  (6)  microscopic  preparation,  (c)  bacteriology,  (cl)  specimens 
in  the  Museum  of  the  Royal  College  of  Surgeons. 

(5)  Advanced  courses  might  be  arranged  for  those  who  desire  to 
specialise  in  gymeeology,  and  opportunities  afforded  them  both  in  the 
wards  and  in  the  laboratory  for  research. 

(6)  Clinical  assistantships  might  still  be  available  for  those  who, 
having  taken  a post-graduate  course,  desire  to  continue  their  work  at 
the  hospital. 

The  report  is  signed  by  Dr.  T.  W.  Eden  (chairman  of  the 
committee).  Dr.  H.  R.  Andrews,  Dr.  G.  F.  Blacker,  Dr.  J.  S. 
Fairbairn,  Dr.  F.  J.  McCann,  and  Mr.  Gordon  Ley  (secretary). 


A MONTHLY  RECORD  OF  ATMOSPHERIC  POLLUTION. 


Meteorological  Office  : Advisory  Committee  on  Atmospheric  .Pollution  : Summary  of  Reports  for  the  Months 

ending 

Oot.  31st , 1918.  Nov.  30th , 1918. 


Metric  tons  of  deposit  per  square  kilometre. 

Metric  tons  of  deposit  per  square  kilometre. 

Place. 

.2  « 
u 

— ■ +3 

•3  i 

Insoluble  matter. 

Soluble 

matter. 

Included 
in  soluble 
matter. 

.5  a> 
s- 

■5  * 

Insoluble  matter. 

Soluble 

matter. 

2 

Included 
in  soluble 
matter. 

c| 

«E 

Tar. 

Carbon - 
aceous  . , 
other  Ash' 
than  tar 

Loss  on 
ignition. 

Ash. 

0 

"3 

0 

H 

Sulphate 
as  (S03). 

Chlorine 

(Cl). 

Ammonia 

(NH*). 

Place. 

a B 

rt  ~ 

85  S 

Tar 

Carbon- 
aceous 
other 
jthan  tar 

Ash. 

Loss  on 
ignition. 

Ash. 

0 

3 

0 

H 

Sulphate 
as  (SO3). 

Chlorine 

(Cl). 

Ammonia 

(NH8). 

England. 
London — 
Meteorological 
Office1  

England. 
London — 

M e t e 0 r 0 logical 
Office 1 

Embankment 
Gardens  

22 

0-05 

1-44 

2-29 

7-21 

15-57 

26-57 

6-39 

1-91 

o-u 

Embankment 
Gardens  

28 

0-09 

1-21 

1-69 

3-45 

10-92 

17-36 

5-27 

1-02 

0-22 

Finsbury  Park  ... 

65 

o-io 

1-06 

2-77 

4-45 

907 

17-45 

5-04 

4.00 

0-13 

Finsbury  Park  ... 

52 

008 

1-56 

5-41 

4-69 

7-70 

19-44 

4-83 

1-20 

0-08 

Ravenscourt  Park 

28 

0-02 

0-55 

0-67 

1-41 

3-44 

6-09 

1-28 

0-66 

0-09 

Ravenscourt  Park 

54 

0-03 

1-24 

2-24 

3-92 

5-63 

13  05 

3-12  0-74 

012 

Southwark  Park 

31 

0'05 

1-32 

2-74 

3-51 

5-70 

13-32 

3-86 

0-61 

0-30 

Southwark  Park... 

50 

0-07 

1 58 

2-95 

5-87 

11-22 

21-68 

7-25 

0-99 

0-28 

Victoria  Park  ... 

30 

Tr. 

0-66 

2-05 

1-14 

3-45 

7-29 

1-73 

0-35 

0-07 

Victoria  Park 

40 

0-03 

0-97 

2-50 

2-37 

6-92 

12-78 

363 

0-54 

o-io 

Wandsworth  Com." 

Wandsworth  Com. 

19 

o-oo 

0-01 

0-15 

0 52 

1-77 

2 46 

0-87 

0-1E 

0 04 

Golden  Lane 

31 

0-04 

2-55 

3-80 

099 

3-84 

11-23 

1-51 

0-55 

0-12 

Golden  Lane 

50 

0-07 

3-63 

4-37 

1-40 

5-38 

14-84 

2 21 

0 76 

0-18 

Malvern" 

— 

— 

— 

— 

— 



— 

— 

— 



Malvern 

39 

Nil 

0-33 

1-36 

0-61 

2-24 

4-55 

0-90 

0-23 

001 

Manchester— 
Whitworth  Street 
(garden) 

25 

10-40 

Manchester— 
Whitworth  Street 
(garden) 

38 

15-80 

,,  (roof  of 
College) 

27 









11-30 

,,  (roof  of 

College)  

49 

_ 

_ 

_ 

15-70 





_ 

Newcastle  - on-Tyne 

55 

0-12 

4-36 

5-91 

1-85 

2-94 

15-19 

1-61 

0-39 

0-18 

Newcastle-on-Tyne 

39 

0-10 

3-16 

9-05 

1-79 

4-42 

18-5! 

2-05 1 0-42 

0-09 

Rochdale 

— 

— 

— 

— 

— 

— 

23-16 

— 

— 



Rochdale  

— 

— 

— 

— 

— 

— 

23-16 

— 

— 

— 

St.  Helens  

72 

0-14 

2-87 

5'34 

2-88 

6-12 

17-36 

3-32 

1-82 

006 

St.  Helens  

38 

0-09 

1-58 

2-02 

3-22 

10-33 

17-25 

4-43  2-46 

0-04 

Southport— 
Hesketh  Park  ... 

83 

0-02 

019 

0-23 

0-62 

2-83 

3-89 

0-93 

0-79 

001 

Southport— 
Hesketh  Park  ... 

52 

0 07 

1-95 

5-42 

1-29 

4-60 

13-33 

1-56 

0-62 

o-oi 

Woodvale  Moss... 

61 

— 

— 

' 

— 



2-73 





Woodvale  Moss... 

35 

— 

— 



— 

— 

5-73 

— 

— 

— 

Scotland. 
Coatbridge  

117 

0T1 

1-76 

4-70 

3-52 

7-46 

17-55 

3-97 

1-29 

0-35 

Scotland. 
Coatbridge  

83 

0-16 

380 

10-20 

3-47 

6-80 

24-43 

4-93 

0-76 

0-22 

Glasgow— 
Alexandra  Park... 

83 

0-09 

2-66 

4-92 

2-29 

4-65 

14-61 

2-64 

0-28 

0-20 

Glasgow — 
Alexandra  Park... 

75 

o-u 

1-56 

4-24 

3-31 

6-90 

16-12 

2-59 

0-57 

0-12 

BellahoustonPark" 

BellahoustonPark* 

Blythswood-sq.  ... 

129 

0T6 

2-58 

4-28 

1-76 

9-14 

17-92 

3-49 

0-38 

0-34 

Blvthswood-sq. ... 

96 

0-19 

1-80 

5-25 

1-95 

5-85 

15  04 

4-18,0-69 

0-19 

Botanic  Gardens3 

127 

0-14 

2-07 

4'98 

11-88 

1519 

34-26 

691 

1-59 

0-25 

Botanic  Gardens  111 

0-14 

2-26 

4-16 

4-95 

9-04 

20-55 

5-80;  0-78 

0-20 

Richmond  Park* 

Richmond  Park* 

Ruchill  Park 

133 

01b 

1-75 

2'93 

3-20 

6-80 

14-83 

3-89 

0-35 

0-28 

Ruchill  Park 

108 

0-14 

1-60 

3 15 

2-53 

5-40 

12-82 

3-71 

0-65 

0-14 

South  Side  Park. 

131 

0-12 

2-27 

4-84 

3-62 

8-94  19  79 

3-20 

0 42 

0-24 

South  Side  Park.. 

92 

0-09 

1-62 

2-48 

3-15 

5-33 

12-67 

3-09  0-63 

0-21 

Tollcross  Park*... 

Tollcross  Park*  ... 

Victoria  Park  * ... 

— 

— 

— 

~ 

— 

— 

— 

- 

— 

Victoria  Park*  ... 

— 

— 

— 

— 

— 

— 

— 

— 1 

— 

— 

* No  returns.  1 Bottles  overflowed.  2 The  water  was  dark  violet  in  colour.  Tr.  = trace. 


“Tar”  includes  all  matter  insoluble  in  water  but  soluble  in  CS2.  “Carbonaceous”  includes  all  combustible  matter  insoluble  in  water  and 
In  CS  j.  “Insoluble  ash”  includes  all  earthy  matter,  fuel,  ash,  &c.  One  metric  ton  per  sq.  kilometre  is  equivalent  to:  (a)  Approx.  91b.  per 
acre;  (6)  2‘56  English  tons  per  sq.  mile;  (c)  1 g.  per  sq.  metre;  ( d ) 1/1000 mm.  of  rainfall. 

The  personnel  of  public  health  authorities  concerned  in  the  supervision  of  these  examinations  and  of  the  analytical  work  involved  remains  the 
same  as  published  in  previous  tables.  The  analyses  of  the  rain  and  deposit  caught  in  the  gauge  at  the  Meteorological  Office  are  made  in 
The  Lancet  Laboratory. 


493  The  Lancet,]  BELGIAN  DOOTORS’  AND  PHARMACISTS’  RELIEF  FUND.— PARIS. 


[Sept.  13, 1919 


THE  BELGIAN  DOCTORS’  AND 
PHARMACISTS’  RELIEF  FUND. 

A meeting  of  the  Executive  Committee  of  the  Belgian 
Doctors’  and  Pharmacists’  Relief  Fund  was  held  on  Thursday, 
July  31st,  at  the  offices  of  The  Lancet,  when  the  following 
final  balance-sheet  was  presented  by  Dr.  Des  Yceux,  the 
honorary  treasurer  : — 


BELGIAN  DOCTORS'  AND  PHARMACISTS'  RELIEF  FUND. 

Treasurer’s  Cash  Statement  from  Commencement  to  Close  of 
Fund,  July  Sith,  1919. 


£ s. 

(i. 

£ «. 

d. 

Donations  and  sub- 

Kelief 

25,766  4 11 

scriptiona  

25,790  11 

6 

Loans  not  repaid  ... 

97  8 

n 

Interest  received  ... 

1,143  12 

7 

Drugs 

250  16 

8 

Clothes  

344  17 

0 

Auditors'  fees 

16  16 

0 

Printing  and  stationery  199  14 

3 

Postages  and  sundry 

expenses 

Balance  for  final  dis- 

46  19 

2 

tribution 

211  8 

1 

26,934  4 

1 

26,934  4 

1 

We  have  examined  the  above  account  with  the  books  and  vouchers 
of  the  Fund  and  certify  it  to  be  correct  according  to  the  books.  In  our 
opinion  the  receipts  and  payments  have  been  fully  recorded,  and  we 
have  compared  the  receipts  with  the  published  acknowledgments  and 
have  had  certificates  of  the  balance  produced  to  us  from  time  to  time. 
The  above  account  incorporates  the  periodical  accounts  which  we 
have  previously  certified. 

Crewdson,  Youatt,  and  Howard,  Chartered  Accountants. 

70a,  Basinghall-street,  London,  E.C.  2,  24th  July,  1919. 

It  will  be  seen  that  the  Committee,  by  judicious  invest- 
ment and  husbanding  of  their  resources,  were  enabled  to 
maintain  the  Fund  in  its  charitable  capacity  while  actually 
disbursing  £800  more  than  was  received  from  subscribers. 

The  Committee  decided  to  pass  no  resolution  at  the  time 
with  regard  to  the  disposal  of  the  small  balance  remaining 
in  the  treasurer’s  hands,  as  certain  expenses  of  printing  and 
publication  might  yet  have  to  be  incurred. 

Dr.  Squire  Sprigge,  the  honorary  secretary,  offered  to  keep 
the  papers  and  books  having  reference  to  the  Fund  at  the 
offices  of  The  Lancet  for  the  present. 


THE  POSITION  AND  PAYMENT  OF  THE 
PENSIONS  BOARDS; 

DEPUTATION  TO  THE  MINISTRY  OF  PENSIONS. 


As  will  have  been  made  clear  by  communications  to  our 
correspondence  columns  for  some  time  past,  medical  men 
serving  on  Pensions  Boards  are  not  altogether  satisfied 
with  the  conditions  of  service  and  with  the  remuneration 
offered.  On  Sept.  4th  a deputation  from  the  British 
Medical  Association  waited  on  the  Minister  of  Pensions  at 
Westminster  House  to  bring  these  matters  before  his  notice. 
The  deputation  included  the  responsible  officers  of  the 
Association,  and  was  received  by  Sir  L.  Worthington  Evans, 
with  whom  were  Lieut. -Colonel  A.  L.  Webb,  Dr.  R. 
Cunyngham  Brown,  and  Mr.  J.  F.  Christie. 

Dr.  T.  W.  H.  Garstang,  as  spokesman  of  the  deputation, 
said  that  there  were  six  main  points  which  it  had  been 
decided  to  bring  to  the  notice  of  the  Minister.  These 
were : — 

1.  That  the  fees  for  doctors  attending  boards  under  the  Ministry  of 
Pensions  should  be  raised  from  the  present  standard  of  1 guinea  to 
2 guineas.  2.  That  the  specialists’  fee  be  advanced  pro  rata.  3.  That 
the  number  of  cases  to  be  seen  in  an  individual  session  should  not 
exceed  eight.  4.  That  the  length  of  the  session  should  not  exceed 
2J  hours.  5.  That  payment  to  doctors  attending  on  these  boards  be 
made  more  promptly  than  at  present.  6.  What  was  the  policy  of  the 
Ministry  as  regards  throwing  open  the  posts  of  medical  referees  to  men 
who  had  returned  from  the  Services,  and  when  was  this  policy  iikely  to 
be  carried  out  ? 

Dr.  Garstang  and  several  other  members  of  the  deputa- 
tion explained  the  general  feeling  of  the  medical  profession 
that  the  1 guinea  fee  was  inadequate,  and  that  it  had  only 
been  accepted  as  a temporary  measure,  owing  to  the  anxiety 
of  the  profession  to  help  the  country  during  the  war.  Now 
that  the  war  was  over  the  Ministry  could  not  expect  to  have 
this  work  done  at  an  admittedly  inadequate  rate  and  still 
retain  a choice  of  the  best  men.  Chapter  and  verse  were 
given  for  the  other  grievances  alleged. 


Sir  L.  Worthington  Evans,  while  assuring  the  deputa- 
tion of  the  careful  consideration  of  all  their  points,  indi- 
cated that  the  suggested  increase  in  the  sessional  fee  to 
2 guineas  would  probably  cost  the  country  over  £1,000,000 
a year — an  increase  in  expenditure  not  to  be  lightly 
undertaken.  As  regards  the  number  of  cases  examined 
in  a session,  it  was  found  that  the  average  had  for  some 
time  been  7'2  cases,  and  latterly  even  less,  and  he 
thought  that  if  that  was  so  it  should  be  considered 
as  having  met  the  point  submitted.  He  was  entirely 
in  agreement  as  to  the  length  of  the  session  being 
2T  hours,  though  he  pointed  out  that  there  would  every 
now  and  then  be  occasions  on  which,  for  the  sake  of 
dealing  with  a case  which  might  have  come  some  distance, 
the  members  of  the  board  should  be  willing  to  extend  the 
time  of  the  session  a little.  He  considered  that  there  must 
be  some  give  and  take  in  the  matter.  He  offerred  to  look 
into  the  question  of  prompt  payment,  as,  in  his  opinion, 
there  should  be  no  arrears  such  as  had  been  mentioned.  As 
regards  the  posts  of  medical  referees,  the  District  Commis- 
sioners had  been  instructed  some  time  back  that,  as  soon  as 
they  knew  that  practically  all  the  doctors  had  returned  who 
were  likely  to  apply,  the  posts  should  be  thrown  open, 
preference  being  given  in  the  following  order  : — 

(a)  Service  overseas. 

( b ) Service  in  this  country. 

(c)  Men  who  had  already  held  the  posts. 

Action,  he  added,  had  been  somewhat  delayed  owing  to  the 
rearrangement  of  the  administrative  areas  of  the  Ministry, 
but  in  Scotland  this  was  now  complete,  and  the  procedure 
mentioned  would  be  put  into  operation  almost  at  once  ; 
Wales  would  shortly  follow  suit.  Similar  action  would  be 
taken  in  other  districts  as  soon  as  the  District  Commissioners 
reported  that  the  bulk  of  the  men  had  returned. 


PARIS. 

(From  our  own  Correspondent.) 

A Monument  to  Medical  Men  Killed  during  the  War. 

A proposal  has  just  been  made  to  commemorate  by  a 
monument  those  medical  men  who  have  been  killed  by 
enemy  action.  M.  Landouzy,  the  dean  of  the  Paris  Faculty 
of  Medicine,  has  had  their  names  engraved  on  a tablet  on 
the  walls  of  the  great  hall  of  the  faculty  since  1915. 
A form  of  monument  had  actually  been  proposed,  consisting 
of  names  engraved  on  a wall,  framed  by  plaques  of  mosaic, 
and  surrounding  a statue  representing  military  courage. 
Since  then,  however,  the  number  of  victims  has  increased 
considerably.  The  French  Medical  Corps  consider  that  the 
monument  should  be  proportionate  to  the  magnitude  of 
the  sacrifice  and  the  number  of  the  heroes.  The  idea 
is  to  honour  the  dead  not  only  of  Paris  but  of 
the  whole  of  France,  and  new  projects  are  on  foot. 
One  suggestion  was  the  erection  of  a monument  on  the 
Boulevard  St.  Germain,  in  front  of  the  entrance  to  the 
Faculty  of  Medicine,  but  this  was  thought  to  be  lacking  in 
originality  and  possibly  in  discretion.  Up  to  the  present 
nothing  has  been  decided  except  the  main  principle  of 
opening  a subscription  list  among  medical  men  in  France, 
and  including  also  old  students  of  French  universities  now 
living  abroad.  The  scheme  most  likely  to  be  adopted  is  that 
supported  by  the  present  dean  of  the  faculty,  Professor 
Roger,  which  comprises  the  rebuilding  of  the  old  eighteenth- 
century  amphitheatre  of  the  School  of  Surgery  on  a more 
suitable  site  near  the  faculty.  This  old  building  is  doomed 
to  destruction,  and  the  beauty  of  its  architecture  would 
justify  its  reconstruction  in  the  form  of  a small  temple,  with 
marble  slabs  on  which  could  be  engraved  the  names  of 
medical  men  who  had  fallen  in  the  service  of  their  country. 

Influence  of  Orientation  on  the  Physiology  of  Man  and 
Animals. 

A curious  c mnmunication  by  M Jules  RegDault  to  the 
French  Society  of  Comparative  Pathology  again  brings  up 
the  question  of  the  effect  of  the  earth’s  magnetism  on  the 
physiology  of  living  animals.  Some  such  influence  has  been 
suspected  from  the  earliest  times.  In  1845  Reichenbach 
observed  that  certain  people  experience  real  discomfort 
when  facing  east,  even  when  unaware  of  their  position. 
During  the  last  two  years  M.  Regnault,  following  up 


Thb  Lancet,] 


URBAN  VITAL  STATISTICS.— OBITUARY. 


[Ski't.  13,  1919  499 


the  experiments  of  Abrams,  has  convinced  himself  that 
if,  after  having  percussed  out  liver  and  heart  with 
the  subject  facing  west,  the  observer  repeats  the  per- 
cussion with  the  subject  facing  north,  east,  or  south,  the 
area  of  dullness  is  found  to  be  perceptibly  smaller.  Other 
experiments  show  that  visceral  reflexes  react  most  strongly 
to  electro-magnetic  or  electric  stimuli  when  the  subject  faces 
west.  These  facts  correspond,  moreover,  with  those  recorded 
by  M.  Raphael  Dubois  on  the  orientation  of  development  in 
bacterial  colonies. 

Foreign  Doctors  Practising  in  France. 

This  question  is  causing  some  perturbation  among  French 
doctors  who  return  from  the  war  to  find  their  practice 
absorbed  by  foreign  doctors.  These  latter  are  still  present  in 
large  numbers,  especially  in  Paris  and  the  big  towns.  The 
situation  was  tolerated  during  the  war  because  the  civil 
population  was  really  short  of  medical  aid  ; moreover,  the 
intrusion  of  some  of  the  foreigners  was  condoned  because  of 
services  rendered  by  them  to  wounded  in  hospitals.  Now, 
however,  the  medical  societies  are  moving  in  the  matter  and  are 
agitating  for  the  return  to  the  normal  interpretation  of  the 
laws  regulating  medical  practice  in  France  and  requiring  the 
possession  of  a State  diploma  as  distinguished  from  that  of 
a university  diploma.1  Many  petitions  have  been  sent  to  the 
Government  by  medical  men  with  Spanish  or  South  American 
or  other  degrees,  claiming  exemption  from  these  laws  on  the 
grounds  of  service  rendered  during  the  war.  On  the 
representation  of  the  Paris  medical  societies  all  except  12  of 
these  applications  have  been  refused.  The  exceptions  for  the 
most  part  have  been  made  for  Canadian  medical  officers  of 
French  origin.  In  the  Bulletin  des  Syndioats  M.  le  Filliiitre 
approves  of  this  exception,  and  even  suggests  that  it  maybe 
extended  so  as  to  allow  all  Canadian  doctors  to  practise  in 
France,  assuming  that  French  doctors  are  granted  a 
reciprocal  concession  in  Canada. 

Sept.  8th.  

1 The  Lancet,  1919,  i.,  477. 


URBAN  VITAL  STATISTICS. 

(Week  emied  Sept.  6th,  1919.) 

English  and  Welsh  Towns. — In  the  96  English  and  Welsh  towns, 
with  an  aggregate  civil  population  estimated  at  16,500,000  persons, 
the  annual  rate  of  mortality,  which  had  been  10  0 in  esch  of  the 
three  preceding  weeks,  rose  to  10’7  per  1000.  In  London,  with 
a population  slightly  exceeding  4,000,000  persons,  the  annual  rate 
was  10-5,  and  was  0'9  per  1000  above  that  in  the  preceding  week, 
while  among  the  remaining  towns  the  rates  ranged  from  4 0 in 
Swindon,  4 5 in  Acton,  4 6 in  Enfield,  and  4 9 in  Coventry,  to  14  8 in 
Plymouth,  14  9 in  Gateshead,  171  in  West  Bromwich,  and  20'1  in 
Middlesbrough.  The  principal  epidemic  diseases  caused  345  deaths, 
which  corresponded  to  a rate  of  11  per  1000,  and  included  251  from 
infantile  diarrhcea,  31  from  measles,  30  from  diphtheria,  16  from 
whooping-cough,  13  from  scarlet  fever,  and  4 from  enteric  fever. 
Measles  caused  a death  rate  of  1-2  in  Newcaatle-on-Tyne,  13  in 
Barrow-in-Furness,  and  2‘2  in  Gateshead.  There  were  1454  cases  of 
scarlet  fever  and  1006  of  diphtheria  under  treatment  in  the  Metro- 
politan Asylums  Hospitals  and  the  London  Fever  Hospital,  against 
1421  and  1004  respectively  at  the  end  of  the  previous  week.  The 
causes  of  16  deaths  in  the  96  towns  were  uncertified,  of  which 
3 were  registered  in  Liverpool  and  3 in  Gateshead. 

Scotch  Towns. — In  the  16  largest  Scotch  towns,  with  an  aggregate 
population  estimated  at  nearly  2,500,000  persons,  the  annual  rate  of 
mortality,  which  had  been  9 9,  10'7,  and  10  9 in  the  three  preceding 
weeks,  fell  again  to  10'8  per  1000.  The  223  deaths  in  Glasgow 
corresponded  to  an  annual  rate  of  10  4,  and  included  18  from  infantile 
diarrhoea,  4 from  whooping-cough,  3 from  meaBles,  and  1 from  diph- 
theria. The  78  deaths  in  Edinburgh  were  equal  to  a rate  of  121, 
and  included  2 each  from  infantile  diarrhoea,  scarlet  fever,  and  diph- 
theria, and  1 from  measles. 

Irish  Towns. — The  153  deaths  in  Dublin  corresponded  to  an  annual 
rate  of  19  7,  and  Included  24  from  infantile  diarrhcea,  and  1 each 
from  enteric  fever  and  measles.  The  112  deaths  in  Belfast  were  equal 
to  a rate  of  14  6,  and  included  12  from  infantile  diarrhoea,  2 from 
Bcarlet  fever,  and  1 each  from  enteric  fever  and  diphtheria. 


The  King  of  the  Belgians  has  been  pleased  to 
grant  the  M^daille  du  Roi  Albert  to  the  following  medical 
men  for  medical  services  rendered  to  Belgian  refugees 
Sir  Rickman  J.  Godlee,  Bart.,  K.C.V.O.,  Sir  Frederick  Taylor,  Bart., 
Dr.  C.  St.  Aubyn  Farrer,  Dr.  S.  Squire  Sprigge,  Dr.  Chittenden 
Bridges,  Dr.  Neville  Hart,  Dr.  J.  H.  Philpot,  Dr.  W.  E.  Robinson,  Dr. 
Arthur  C.  Roper,  Dr.  R.  M.  H.  Randell.and  Dr.  L.  Vintras. 

Royal  Institute  of  Public  Health  : Tubercu- 
losis Department. — A course  of  lectures  for  candidates 
desirous  of  obtaining  positions  as  tuberculosis  officers,  for 
general  practitioners  and  others,  will  be  given  in  October, 
November,  and  December,  on  successive  Thursdays  at  5 P.M., 
beginning  Oct.  9th,  at  the  Institute,  37,  Russell-square, 
London,  W.C.  1.  Further  particulars  can  be  obtained  from 
the  secretaries.  The  individual  lectures  will  be  announced 
in  the  Medical  Diary. 


THOMAS  PICKERING  PICK,  F.R.C.S., 

I.ATE  VICK- PRESIDENT  OF  THE  ROYAL  COLLEGE  OF  SURGEONS  OF 
ENGLAND  ; INSPECTOR  OF  ANATOMY  FOR  ENGLAND  AND  WALES; 

CONSULTING  SURGEON  TO  ST.  GEORGES  HOSPITAL. 

We  regret  to  announce  the  death,  which  occurred  at  Great 
Bookham,  Surrey,  on  Saturday  last,  of  Mr.  Thomas  PickeriDg 
Pick,  the  well-known  surgeon  and  anatomist,  whose  connexion 
with  the  Royal  College  of  Surgeons  of  England  for  so  many 
years  as  an  examiner  made  him  a familiar  figure  in  educational 
circles. 

A Liverpool  man,  he  came  to  St.  George’s  Hospital  in 
the  days  when  Prescott  Hewett,  Timothy  Holmes,  George 
Pollock,  and  the  two  Lees  adorned  the  staff,  and  obtained  his 
first  diploma  in  1862.  He  held  the  junior  appointments 
at  the  hospital,  proceeding  to  the  Fellowship  of  the 
Royal  College  of  Surgeons  of  England  in  1866.  In  1869 
he  was  elected  assistant  surgeon  to  the  hospital,  having 
previously  been  an  extremely  successful  demonstrator  of 
anatomy.  Indeed,  it  is  as  a teacher  of  anatomy  that  Pick  is 
always  recalled  to  the  memory  of  his  pupils.  As  a lecturer 
on  his  subject  he  was  rapid  and  correct,  but  not  very 
inspiring,  for  he  followed  the  lines  of  Gray’s  Anatomy  so 
closely  that  he  was  popularly  reported  among  the  students  to 
know  that  elaborate  treatise  by  heart  ; he  was,  of  course, 
its  most  painstaking  and  capable  editor  for  many  years. 
But  as  a demonstrator  Pick  was  thoroughly  in  his 
element,  and  he  went  on  demonstrating  in  an  informal  way 
many  years  after  he  had  become  the  lecturer  on  the 
subject.  In  talking  to  a class  of  students  he  made  the 
dry  bones  live,  and  showed  the  relations  of  a dissection 
in  a manner  which  made  the  topography  of  the  region  for 
ever  a part  of  the  pupil’s  personal  knowledge.  For  many 
years  he  was  examiner  in  anatomy  at  the  Royal  College  of 
Surgeons  of  England,  where  a dignified  presence  and  a 
courteous  manner  concealed  to  some  extent  from  the 
students  the  fact  that  his  standard  of  exact  anatomical 
knowledge  was  a very  high  one.  He  was  possibly  responsible 
for  rejections  which  the  disappointed  candidate  put  down  to 
examiners  of  a less  agreeable  address.  He  was  at  the  time 
of  his  death  Inspector  of  Anatomy  for  England  and  Wales. 

In  1879  he  became  full  surgeon  to  the  hospital.  He 
hardly  made  the  same  mark  as  a surgeon  or  lecturer 
on  surgery  that  he  had  made  as  an  anatomist,  but 
his  date  was  decidedly  a difficult  one.  The  theory 
of  antiseptics  was  universally  accepted,  but  only  after 
discussions  in  which  many  of  Pick’s  immediate  superiors 
were  not  found  on  the  progressive  side  ; while  the 
technique  of  what  in  the  early  eighties  was  still  regarded  as 
a completely  new  thing,  called  for  much  perfecting.  Pick 
was  not  quite  flexible  enough  to  assimilate  the  Listerian 
doctrine,  nor  had  he  a sufficiently  scientific  outlook  to  enable 
him  to  see  its  tremendous  promises.  He  remained  the 
absolutely  capable  surgeon  of  his  time,  conforming  to  the 
antiseptic  creed,  but  unable  to  forget  that  only  a few  years 
ago  he  had  passed  successfully  tests  in  his  professional 
subjects  without  requiring  any  knowledge  of  germ  influence. 
He  wrote,  however,  a good  little  treatise  on  fractures  and 
dislocations,  exclusive  of  fractures  of  the  skull,  as  well  as 
a treatise  on  surgery  for  practitioners.  Each  book  was  the 
outcome  of  personal  experience,  as  well  as  a record  of  the 
principles  of  surgery  as  he  had  learnt  them  and  practised 
them.  He  also  edited  Holmes’s  “ Principles  and  Practice  of 
Surgery,”  which  was  for  many  years  one  of  the  most 
popular  manuals  with  English  and  American  students.  The 
handbook,  however,  was  not  kept  up  to  date,  and,  indeed,  the 
years  when  Pick  was  its  editor  were  so  marked  with  surgical 
developments  that  the  work  would  have  required  almost 
annual  re-issue  if  it  was  not  to  fall  behind,  as  well  as  steady 
collaboration  with  younger  men. 

Pick’s  connexion  with  the  Royal  College  of  Surgeons  of 
England  was  a long  and  honourable  one,  though  he  failed  to 
be  elected  President.  Appointed  to  the  Board  of  Examiners 
in  Anatomy  and  Physiology  in  1876,  he  continued  to  be  a 
member  of  the  Court  of  Examiners  until  1894.  In  this 
year,  as  Hunterian  Professor,  he  delivered  at  the  College  an 
interesting  series  of  lectures  on  Diseases  of  the  Ends  of 
the  Long  Bones  in  Children,  which  were  published  in 
these  columns,  and  display  their  author  as  a sound  surgeon 


500  The  Lancet,] 


OBITUARY. 


[Sept.  13,  1919 


with  a great  knowledge  of  pediatrics.  In  1898  he  delivered 
the  Bradshaw  lecture,  taking  as  his  subject  the  Union  of 
Wounds,  and  in  1903  he  became  Vice-President  of  the 
College.  No  doubt  the  failure  to  be  elected  President  of  the 
Corporation  for  which  he  had  worked  so  long  and  loyally 
was  a great  disappointment  to  him. 

ALEXANDER  MACALISTER,  M.A.,  M.D.  Camu.,  M.D., 
D.Sc.  Dub.,  LL.D.  Glasg.,  Montreal,  & Edin.,  F.R.S., 

PROFISSOR  OF  ANATOMY  IN  THE  UNIVERSITY  OF  CAMBRIDGE. 

By  the  death  of  Alexander  Macalister  Cambridge  loses  one 
of  her  most  ardent  spirits  and  devoted  servants,  for  though 
he  had  been  educated  elsewhere  and  had  made  his  reputa- 
tion before  he  migrated,  no  one  of  her  sons  was  more  loyal 
than  was  Macalister  to  the  home  of  his  adoption,  or  brought 
to  bear  on  the  duties  of  the  professoriate  a wider  and  riper 
experience  of  men  and  affairs.  Looking  back  on  the  many 
and  prominent  parts  he  played,  it  can  be  realised  how 
profound  and  beneficial  has  been  his  influence  in  the 
moulding  of  the  character  and  work  of  his  pupils. 

Alexander  Macalister  was  born  in  Dublin  in  1844,  the 
second  son  of  Robert  Macalister,  and  grandson,  on  his 
mother’s  side,  of  Colonel  James  Boyle  of  Dungiven. 
Educated  at  Trinity  College,  Dublin,  he  took  his  first 
medical  qualification  in  1862,  and  became  in  succession 
demonstrator  of  anatomy  at  the  College  of  Surgeons,  and 
professor  of  zoology,  and  then  of  anatomy  and  chirurgery  in 
the  University  of  Dublin.  During  this  period  he  published 
an  introduction  to  “ Animal  Morphology”  (1876)  and  the 
“Morphology  of  Vertebrate  Animals  ” (1878),  and  entered 
very  fully  into  the  life  of  the  University,  becoming  a member 
of  the  Senate. 

Macalister  came  to  Cambridge  in  1883  in  that  great  period 
of  evolution — almost  of  revolution— inaugurated  by  Coutts- 
Trotter,  Humphry,  George  Paget,  Michael  Foster,  and 
Latham,  their  survivor— men  who,  though  not  always  pulling 
together,  launched  a new  and  vigorous  medical  school  on  the 
main  stream  of  comparative  anatomy,  embryology,  and 
physiology.  Succeeding  Sir  George  Humphry,  Macalister 
had  assigned  to  him  the  task  of  reorganising  the  work  of  the 
department  of  anatomy  and  of  remodelling  the  teaching  of 
his  subject.  How  far  he  succeeded  in  adapting  modern 
scientific  teaching  and  methods  to  the  requirements  of  the 
university  is  now  a matter  of  history ; for  though  it  is 
sometimes  maintained  that  his  teaching  was  not  sufficiently 
“surgical”  to  meet  the  requirements  of  the  student  of 
medicine,  he  built  up  a department  that,  ample  enough  at 
the  time  it  was  planned,  is  already  inadequate  to  the  demands 
made  upon  its  resources  and  accommodation.  It  may  be 
that  if  the  passing  of  professional  examinations  outside  the 
university  by  his  pupils  be  made  the  stand  of  his  success 
it  was  not  so  complete  as  was  that  of  some,  but  if  the 
thorough  grounding  of  men  in  the  principles  of  anatomy  be 
taken  as  the  test,  his  was  the  more  solid  and  lasting  educa- 
tion. Macalister’s  exceptional  powers  and  abilities  could 
never  have  found  sufficient  outlet  in  any  single  branch  of 
anatomical  investigation  and  teaching;  archaeology,  crani- 
ology,  and  comparative  anatomy  all  claimed  a share  of  his 
energies,  his  attention  to  detail  and  marvellous  thoroughness 
ensuring  the  success  of  his  researches  in  all  these  fields, 
whilst  the  same  attention  to  detail,  the  wealth  of  illustra- 
tion he  always  had  at  command,  his  directness  and  inde- 
pendence of  thought,  combined  with  his  devotion  to 
the  interests  of  his  pupils,  rendered  his  teaching 
not  instructive  merely  but  intensely  stimulating  and 
highly  suggestive.  Only  those  who  know  how  willingly 
and  lavishly  he  gave  of  his  time  and  strength  to  the  advance- 
ment of  his  subject  and  in  the  training  of  those  working 
under  him  on  broad  scientific  lines  can  have  any  idea  of  the 
success  of  his  teaching,  and  how  sorely  colleagues  and 
students,  young  and  old,  will  miss  the  quiet  persuasive 
manner,  calm,  well-balanced  judgment,  wide,  almost 
encyclopiedic,  but  profound,  knowledge,  and  dry  humour 
that  characterised  his  dealings  with  them.  His  deep 
religious  feeling  and  acute  moral  sense  account  for  the 
keen  interest  he  took  in  missionary  work  and  the  call  to 
which  he  responded  so  joyously  to  visit  the  Far  East,  there 
to  advise,  help,  and  encourage  those  labouring  in  the 
China  mission-field.  One  of  the  most  highly  equipped  of 
our  intellectuals  he  was  modesty  and  humility  personified  in 
his  respect  for  the  opinions  of  others  and  in  his  attitude 


towards  religion,  which  with  him  was  no  superficial  thing,  but 
was  woven  into  the  very  web  of  his  being,  animating,  guiding, 
and  controlling  his  whole  scheme  of  life. 

One  of  his  old  demonstrators  (E.  R.  T.  C.)  -writes : 

“ Macalister  was  an  outstanding  example  of  a man  officially 
associated  with  the  exposition  of  one  subject  (human 
anatomy),  but  capable,  in  virtue  both  of  his  intellectual 
powers  and  actual  knowledge,  of  assuming  an  equally 
eminent  position  to  any  of  several  other  spheres  of  learning 
(zoology,  philosophy,  archaeology).  From  all  these  provinces 
of  thought  Macalister  drew  deeply  wherewith  to  enrich,  to 
exemplify,  and  to  integrate  his  teaching  of  human  anatomy. 
His  draughtsmanship  was  inimitable,  and  his  executancy  as  a 
dissector  that  of  a master  craftsman,  most  excellent  to 
witness.  Many  old  Cambridge  students  will  regretfully  miss 
the  kindly  reminiscent  welcome  which  was  theirs  when,  on 
rare  visits,  they  looked  in  at  ‘ the  Rooms.’  ” 

Professor  Macalister  married  a daughter  of  James  Stewart, 
of  Perth,  who  predeceased  him.  He  leaves  two  daughters, 
one  of  whom  is  the  wife  of  Sir  Donald  MacAlister,  and  a 
son,  Dr.  R.  A.  S.  Macalister,  who  is  professor  of  Celtic 
archaeology  in  Dublin.  G.  S.  W. 

ARCHIBALD  HENRY  HOGARTH,  M.A.,  M.D.  OxoN., 
D.P.H., 

MEDICAL  OFFICER  OF  HEALTH  FOR  BUCKINGHAMSHIRE. 

The  death  of  Dr.  A.  H.  Hogarth  at  Quainton  on  Sept.  5th, 
in  his  42nd  year,  leaves  a gap  in  the  Public  Health  Service 
which  it  will  be  difficult  to  fill. 

Archibald  Henry  Hogarth  was  educated  at  Westminster 
School  and  Christ  Church,  Oxford,  where  he  graduated  in 
1901.  Going  on  to  St.  Bartholomew’s  Hospital,  he  obtained 
the  Conjoint  qualification  in  1903,  and  the  M.B.,  B.Ch.Oxon. 
in  the  following  year.  He  then  acted  for  some  time  as 
assistant  medical  officer  to  the  Port  of  London,  where  the 
housing  problems  could  hardly  fail  to  arrest  the  attention  of 
a man  of  his  bent,  and  his  first  considerable  contributions  to 
social  medicine  were  in  the  form  of  comprehensive  reports  to  [ 
the  Mansion  House  Council  on  Health  and  Housing,  to 
which  for  some  time  he  acted  as  secretary.  Leaving  the 
Port  and  its  sanitary  problems  to  join  the  educational  staff 
of  the  London  County  Council,  Hogarth  met  the  second  great 
pre- occupation  of  his  busy  life,  and  set  to  work  to  establish 
legislation  on  school  hygiene,  his  pioneer  book  on  “Medical 
Inspection  of  Schools”  (1909),  which  had  a wide  circulation, 
doing  much  to  form  public  opinion.  He  then  became  the 
first  medical  officer  of  health  for  the  county  of  Bucking- 
ham, where  he  had  special  care  for  all  health  matters 
throughout  the  countryside,  particularly  in  attention  to  J 
dental  care  for  children,  to  infancy  and  maternity  nursing, 
and  later  to  schemes  for  venereal  disease  control. 

Whilst  an  Oxford  undergraduate  Hogarth  served  through 
the  Boer  War  with  his  regiment,  the  Queen’s  Own  Oxford- 
shire Hussars,  and  gained  the  D C.M.  On  the  outbreak  of 
the  recent  war  he  rejoined  his  regiment  and  went  to  France 
as  regimental  surgeon,  and  after  the  armistice  he  was  again 
sent  out,  this  time  by  the  Air  Ministry,  on  a special  mission 
to  the  Eastern  Mediterranean,  where  he  worked  among  the 
influenza-stricken  camps  in  the  Levant.  On  his  return 
voyage  an  attack  of  Vincent’s  angina  lowered  a constitution 
at  no  time  robust,  and  he  never  regained  his  strength. 

Hogarth  was  a tremendous  worker  and  inspired  with  some- 
thing of  his  own  zeal  those  who  worked  with  him.  No  one  who 
saw  the  organisation  of  public  health  work  in  Buckinghamshire 
could  have  guessed  that  its  organiser  was  living  in  London 
and  riding  most  of  his  old  hobbies  there.  Whatever  he  was 
at,  he  collected  his  information  and  examined  questions  with 
thorough  and  scientific  method  ; he  had  a great  contempt  for 
all  shams  or  pretence,  and,  drawing  his  own  conclusions, 
went  forward  in  a strenuous  and  impetuous  way.  He  thus 
accomplished  much  and  always,  whether  in  peace  or  war, 
fought  the  good  fight.  His  writings  resembled  his  actions, 
and  from  the  time  when  he  edited  his  hospital  journal  to  his 
latest  works  on  administrative  health  problems,  the  same 
eager  note  was  characteristic  of  them  and  a freshness  which 
his  official  position  did  nothing  to  spoil. 

Of  Hogarth’s  attitude  to  public  health  administration 
something  should  be  said,  for  he  breathed  a spirit  in  which 
generous  rivalry  flourished  while  controversy  faded.-  A whole- 
time officer  himself,  he  fully  recognised  the  claims  of  part- 
time  service.  He  saw  that  reconstruction  of  medical  worn 


The  Lancet,] 


THE  UNIFICATION  OF  THE  ARMY  MEDICAL  SERVICE. 


[Sept.  13, 1919  501 


in  rural  areas  must  be  to  a large  extent  organised  on  a part- 
time  basis.  The  likely  solution  of  efficient  rural  hygiene 
was  not  to  him  the  parcelling  out  of  the  country  into  areas 
conveniently  worked  by  whole-time  officers  on  Whitehall 
lines,  but  rather  a happy  combination  of  part-time  medical 
service  under  local  sanitary  committees,  with  administrative 
control  by  whole-time  county  council  officials.  In  a memo- 
randum which  he  drew  up  for  the  Labour  Party’s  Advisory 
Committee  on  Public  Health,  he  proposed  the  delegation  by 
county  and  county  borough  councils  of  their  powers  and 
duties  to  six  statutory  committees,  dealing  respectively  with 
asylums  and  mental  deficiency ; sanitation  and  housing  ; 
maternity  and  child  welfare  ; industry,  social  welfare,  and 
pensions  ; sanatoriums  and  hospitals ; insurance  and  domi- 
ciliary treatment ; each  with  the  duty  laid  upon  it  of 
appointing  an  independent  and  responsible  whole-time 
medical  officer.  It  is  lamentable  that  death  should  have 
prevented  him  seeing  the  further  working-out  of  this  attrac- 
tive scheme  in  his  own  county,  where  already  the  Public 
Health  and  Insurance  Committees  were  acting  in  complete 
unison. 

Dr.  Hogarth  married  Margaret  MacDonald,  M.B.  Aberd., 
formerly  London  County  Council  medical  inspector  of  schools, 
and  leaves  one  son. 


FREDERICK  WALTER  LOWNDES,  M.R.C.S.  Eng.,  L.S  A., 

CONSULTING  SURGEON,  LIVERPOOL  LOCK  HOSPITAL. 

We  regret  to  announce  the  death  of  Mr.  Frederick  Walter 
Lowndes  at  the  advanced  age  of  81.  Born  in  Liverpool, 
where  his  family  had  for  many  years  held  a prominent 
position,  Lowndes  spent  his  whole  life  in  the  city  of 
his  birth,  working  hard  there  as  doctor,  philanthropist, 
and  official.  He  did  not  intend  in  the  first  instance 
to  adopt  a medical  career,  but  at  the  age  of  23  he  gave 
up  a clerkship  in  a commercial  house  and  went  to  Edinburgh 
to  study  what  he  rightly  felt  to  be  his  vocation.  In  1865, 
having  obtained  his  qualifications,  he  returned  to  his  native 
city  to  practise,  and  during  the  greater  part  of  his  early 
career  he  was  frankly  a poor  man’s  doctor.  The  experience 
which  he  thus  gained,  as  well  as  the  insight  which  he 
obtained  of  the  exact  way  in  which  the  poor  live, 
made  him  a zealous  worker  for  all  medical  charities, 
and  especially  was  he  one  of  the  earliest  champions 
of  the  Hospital  Sunday  Fund.  In  this  connexion  he 
became  the  close  ally  of  Dr.  James  Wakley,  at  that  time 
Editor  of  The  Lancet  and  one  of  the  founders  of  the  Fund, 
and  the  result  of  their  meeting  was  that  Lowndes  became 
for  a long  period  of  years  a member  of  the  editorial  stafE  of 
this  paper.  In  our  columns  and  in  those  of  the  Liverpool 
Courier  he  wrote  many  forcible  articles  on  the  position  of 
the  voluntary  hospitals,  and  the  need  for  concerted  effort 
among  the  public  in  support  of  these  charities  unless  their 
voluntary  character  was  to  be  exchanged  for  the  position 
of  the  rate-aided  institutions. 

Other  questions  of  a medico-public  nature  in  which  he  was 
particularly  interested  were  burial  reform  and  the  medical 
conduct  of  inquests.  A pamphlet  which  he  wrote  setting 
out  the  reasons  why  the  office  of  coroner  should  be  held  by 
a member  of  the  medical  profession  ran  through  several 
editions,  and  is  an  admirable  piece  of  pleading.  But 
Lowndes  was  not  a bigot  in  his  views.  He  held  that  the 
appointment  of  coroner  rightly  belonged  to  his  profession 
because  the  medical  element  in  the  evidence,  so  frequently 
the  most  important  one,  was  very  hard  for  a layman  to 
explain  to  a lay  jury  ; but  he  always  granted  that  the 
lawyer’s  method  of  procedure  might  smooth  the  course  of 
justice.  And  he  had  considerable  legal  knowledge.  He  was 
for  many  years  medical  officer  to  the  Liverpool  Constabulary, 
gave  evidence  in  various  important  trials,  and  had  an  intimate 
acquaintance  with  criminology.  He  was  a walking  encyclo- 
paedia of  information  concerning  famous  cases. 

Db.  G.  A.  Batchelor,  of  Pretoria. — Dr.  George 
Arthur  Batchelor,  Government  district  surgeon,  of  Rayton, 
Transvaal,  who  recently  died  at  Pretoria  Hospital,  was 
born  in  India  64  years  ago.  He  stttdied  medicine  at 
Aberdeen  and  the  London  Hospital,  taking  the  M.R.C.S. 
m 1877,  the  M.B.,  C.M.  Aberd.  in  1879,  and  M.D.  in  1895. 
He  also  took  a D.P.H.  and  was  awarded  the  M.D.  Cape 
University.  Before  settling  in  the  Transvaal  he  practised 
for  a,  time  at  Cradock,  Burghersdorp,  Aliwal  North,  and 
Sea  Point,  in  Cape  Colony.  He  leaves  a son  of  the  same 
name  in  practice  at  Dogies,  Transvaal. 


ftffrrespwbme. 

" Audi  alteram  partem.” 


THE  UNIFICATION  OF  THE  ARMY  MEDICAL 
SERVICE  AND  ITS  RELATION  TO  “ TEAM 
PRACTICE”  IN  CIVIL  LIFE. 

To  the  Editor  of  The  Lancet. 

Sir, — When  I entered  the  A.M.S.  some  53  years  ago  it 
represented  individual  and  personal  practice  in  a very 
definite  way,  and  “team  practice,”  as  the  cooperation  of 
medical  men  is  now  called,  was  practically  unknown.  The 
unification  of  the  A.M.S.,  which  1 helped  to  achieve,  is  a 
definite  model  to-day  of  “team  practice,”  but  no  doubt 
much  remains  to  be  done  to  tighten  the  bonds  of  the 
unification  idea.  Thirty  years  of  stress  and  strain  will 
pave  the  way  to  better  conditions,  and  in  1949  the  civil 
medical  profession  will  have  taken  definite  form  as  a 
“ team  ” organisation.  To-day  we  have  made  the  physician 
a tradesman  selling  cures  ; in  1949  he  will  be  a scientific 
official  guarding  life.  Army  medical  unification  was  not 
achieved  even  in  its  present  incomplete  condition  without 
personal  discomfort  and  at  times  actual  suffering,  hence  the 
need  of  care  and  anxious  study  and  investigation  of  pro- 
posed schemes  of  medical  reform. 

The  primary  function  of  the  State  in  helping  on  medical 
unity  will  be  the  provision  of  increased  local  educational 
facilities,  brought  to  the  very  thresholds  of  the  medical  men 
of  the  new  era.  Large  sums  of  money  will  be  needed  to 
achieve  this  end,  and  not  a farthing  of  the  money  will  go  to 
the  individual  medical  man  as  a bribe  or  personal  benefit. 
A central  library,  a central  laboratory,  facilities  to  spread 
broadcast  the  diplomas  in  public  health,  and  leave  of 
absence  for  rest  and  leisure  guaranteed  by  the  State, 
together  with  sick  leave  with  State  pay  in  case  of  illness — by 
these  tempting  boons  we  may  draw  into  “union”  the 
highly  individualised  medical  profession  of  to-day.  Grants 
in  aid  for  retiring  pensions  will  gradually  creep  in,  and  age 
retirement  with  pension  may  follow  on  our  Army  lines.  The 
central  municipal  dispensary,  selling  medicine  at  cost  price, 
will  no  doubt  be  a feature  in  the  new  organisation  of  public 
health  in  its  widest  sense,  and  that  boon  will  relieve  many 
anxieties  that  exist  to-day  in  private  practice.  The  presence 
of  State-paid  “district  consultants,”  who  will  be  available 
for  consultative  work  at  quite  moderate  fees  to  patients,  will 
gradually  appear,  and  any  interferences  with  the  routine  of 
private  practice  by  these  consultants  will  be  forbidden  by 
definite  rules. 

Just  as  we  grant  forage  and  horse  allowance  to  medical 
officers  in  large  districts,  so  grants  in  aid  for  the  transport  of 
the  medical  man  will  be  quite  usual.  The  life  of  the  medical 
student  and  his  facilities  for  complete  study  will  be  aided  in 
a degree  to-day  undreamed  of,  and  this  alone  would  be  a real 
boon.  The  wretchedly  defective  literary  and  scientific 
examination  that  admits  badly  educated  men  into  colleges  as 
medical  students  will  be  sure  to  be  dealt  with,  and  a General 
Medical  Council  full  of  progressive  ideas  will  replace  the 
antiquated  machine  which  now  blocks  the  pathway  of 
progress. 

The  reforms  to  be  made  will  creep  on  with  such  almost 
imperceptible  steps  that  it  will  appear  as  if  nothing  was 
doing,  but  at  the  end  of  every  decade  progress  will  be  com- 
pletely visible,  and  in  a generation  victory  will  be  evident. 
During  the  whole  of  these  years  of  stress  and  strain  that  are 
to  come  men  will  appear  who  “ want  all  at  once.”  Such 
men  appear  in  all  movements  of  progress,  but  they  have  to 
be  borne  with,  and  eventually  they  find  their  place  in  the 
column  of  march.  What  makes  me  sad  is  that  splendid  men 
with  whom  I worked,  the  latchet  of  whose  shoes  I was 
unworthy  to  let  loose,  and  who  hoped  and  dreamed  of 
progress  in  all  its  splendour,  perished  by  the  roadside  and 
never  even  saw  the  Promised  Land.  When  I think  of  these 
splendid  men,  who  never  lived  into  the  sunshine,  then,  indeed, 

I feel  regret.  Civil  reformers  will  have  to  endure  the  same 
sorrows  and  will  have  to  hope  for  the  same  joys  of  success. 

I say  now,  as  I said  to  others  then,  “ Fight  the  good  fight ; 
victory  is  sure  to  come.”  The  man,  the  woman,  and  the  child, 
constituting  as  they  do  “the  Trinity  of  Humanity,”  will 
surely  come  into  their  own  as  civilisation  advances.  The 
pity  of  it  all  is  that  Edmund  Parkes,  with  his  beautiful  face, 


502  The  Lancet,] 


CRYPTOPODIA— DIFFUSE  FIBROMATA  OF  THE  FEET. 


[Sept.  13,  1919 


charming  ways,  and  splendid  science,  is  no  longer  with  us  ; 
that  Florence  Nightingale,  a veritable  tower  of  strength  in 
health  matters,  and  hidden  and  concealed  by  her  nurse’s 
dress,  has  “ gone  West  ” ; that  Sir  William  Muir,  the  lion  of 
unification,  is  at  rest  ; that  William  Johnston,  the  brilliant 
organiser  who  looked  down  into  the  valley  of  unification 
but  never  sat  by  the  waters  and  rested — all  these  have  passed 
away.  We  must  never  forget  the  names  of  these  brilliant 
workers  in  the  new  work  that  is  now  coming  on. 

I am,  Sir,  yours  faithfully, 

George  Evatt,  M.D., 
Major-General  (retired),  A.M.S. 

Junior  United  Service  Club,  London,  Sept.  8th,  1919. 

CRYPTOPODIA— DIFFUSE  FIBROMATA  OF 
THE  FEET. 

To  the  Editor  of  The  Lancet. 

Sir, — On  Oct.  2nd,  1906,  I made  an  exploratory  incision 
into  the  dorsum  of  a child’s  foot,  which  was  the  seat  of  a 
condition  probably  similar  to  that  of  Dr.  E.  C.  Bousfield’s 
patient,  described  in  The  Lancet  of  August  23rd  last. 
The  following  are  the  brief  notes  of  the  case,  written  at  the 
time : — 

R.  H.,  aged  15  months,  had  a diffuse  symmetrical  fibroma 
on  the  whole  of  the  dorsum  of  each  foot.  The  condition  was 
congenital,  but  the  swellings  had  grown  and  formed  large 
pads  which  overhung  the  toes.  Another  child  of  the  same 
parents,  and  now  aged  3 years,  has  one  foot  similarly 
affected,  and  these  two  are  the  only  children  of  the  family. 
An  incision  was  made  into  the  dorsum  of  one  foot,  and 
showed  dense  smooth  fibrous  tissue,  from  which  oozed 
much  clear  fluid.  The  fibrous  layer  of  the  skin  was  con- 
tinuous with  the  tumour  (i.e.,  there  was  no  subcutaneous 
fat).  An  X ray  examination  showed  the  bones  of  the  feet  to 
be  normal,  and  a microscopic  examination  of  a piece  of  the 
tissue  removed  showed  it  to  be  composed  of  fibrous  tissue 
containing  blood-vessels  with  thickened  walls. 

I know  nothing  of  the  subsequent  history  of  the  children, 
and  I have  seen  no  other  case  like  it. 

I am,  Sir,  yours  faithfully, 

Wm.  Robinson,  M.S.,  F.R.C.S.  Eng., 

Sept.  6tb,  1919.  Senior  Surgeon,  Royal  Infirmary,  Sunderland. 


THE  TERRITORIAL  FORCE  MEDICAL 
OFFICERS’  ASSOCIATION. 

To  the  Editor  of  The  Lancet. 

Sir, — As  it  is  not  possible  to  send  notices  to  individual 
officers,  I shall  be  obliged  if  you  will  allow  me  to  announce 
in  The  Lancet  that  the  dinner  of  the  Territorial  Force 
Medical  Officers’  Association  will  take  Diace  on  Thursday, 
Oct.  30th,  at  7.30  P.M.,  at  the  Holborn  Restaurant. 

The  charge  for  tickets  is  12s.  6d. , not  including  wine.  All 
Territorial  medical  officers  can  attend  and  bring  guests. 
Application  for  tickets  should  be  made  to  me  at  this  address, 
the  office  of  the  association. — I am,  Sir,  yours  faithfully, 

D.  L.  Hamilton, 

Lieutenant-Colonel.  Honorary  Secretary. 

37,  Russell-equare,  London,  W.C.  1,  Sept.  8th,  1919. 

ANTIVIVISECTION  SHOPS. 

To  the  Editor  of  Tiie  Lancet. 

Sir, — One  of  the  antivivisection  societies  lately  opened  a 
shop,  for  three  weeks,  in  Oxford,  and  will  probably  open  it 
elsewhere,  moving  it  from  place  to  place.  There  were  many 
of  these  shops  in  the  years  before  the  war,  and  I shall  ba 
grateful  if  anybody  in  whose  neighbourhood  the  shop  appears 
will  immediately  let  me  know  of  it,  so  that  arrangements 
may  be  made  for  the  distribution  of  leaflets  t:>  counteract  its 
influences.  I am,  Sir,  yours  faithfully, 

Stephen  Paget, 

Hon.  Sec.,  Research  Defence  Society. 

11,  Chandos-street,  Cavendish  square,  London,  W.  1, 

Sept.  8th,  1919. 

INDUSTRIAL  WELFARE  WORK. 

To  the  Editor  of  The  Lancet. 

Sir, — During  the  last  three  years,  inspired  by  the  efforts 
of  far-seeing  firms,  the  welfare  movement  has  made  very 
rapid  strides  in  this  country,  and  the  wide  recognition  now 
being  given  to  it  by  employers,  workers,  and  public  men 


leaves  little  doubt  but  that  within  a few  years  it  will  occupy 
a very  prominent  position  in  the  industrial  world.  So  far  no 
real  attempt  has  been  made  either  by  State  or  voluntary 
agencies  to  collate  information  regarding  various  phases  of 
the  work  ; in  fact,  the  names  of  firms  interested  in  the 
movement  are  not  even  recorded  in  any  place.  The 

Industrial  Welfare  Society  is  anxious,  for  the  benefit  of 
industry  generally,  to  collect  from  the  pioneers  of  this 
movement  information  regarding  their  doings  in  connexion 
with  welfare  work.  I shall  therefore  be  grateful  if  those 
firms  who  are  willing  to  assist  in  this  way  will  apply  for 
particulars  of  the  information  desired  to  the  Industrial 
Welfare  Society,  33,  Tothill-street,  Westminster,  S.W.  1. 

I am.  Sir,  yours  faithfully, 

Robert  R.  Hyde, 

Sept.  9tb,  1919.  Director. 

KERATODERMIA  BLENNORRHAGICA. 

To  the  Editor  of  The  Lancet. 

Sir, — The  case  recorded  by  Dr.  S.  C.  Dyke  in  The  Lancet 
of  August  23rd  presents  points  of  great  interest.  Kerato- 
dermia  blennorrbagica  is  generally  considered  a somewhat 
rare  disease,  having  been  first  described  in  1893  by  Vidal 
and  first  in  England  by  Sequeira1  in  1910.  Possibly  cases 
would  be  more  often  observed,  as  McDonagh  2 suggests,  if 
the  soles  of  the  feet  were  examined  in  all  cases  of  gonor- 
rhoea—for  he  says  that  three  cases  a year  are  seen 
at  the  London  Lock  Hospital.  Histologically,  the  growth 
resembles  gonorrhoeal  warts  It  is  thought  that  the  gono- 
coccus possibly  invades  the  skin,  and  in  support  of  this  view 
the  case  recorded  by  Dr.  W.  E.  M.  Armstrong  in  The  Lancet 
of  May  17th,  1913,  is  of  interest.  Here  wart-like  growths 
appeared  on  the  face  in  a man  who  had  had  previously  an 
acute  conjunctivitis  secondary  to  gonorrhoea.  The  secretion 
had  overflowed  on  to  his  cheeks,  and  he  had  also  rubbed 
them  to  improve  his  colour,  as  he  thought  he  looked  pale. 
This  condition,  as  in  Dr.  Dyke’s  case,  was  rapidly  cured  by 
vaccines.  Further,  Armstrong  determined  the  opsonic  index  t 
of  the  blood  for  the  gonococcus  before  and  after  inducing 
congestion  in  th’e  face,  and  found  a swing  indicating  an 
active  gonococcal  infection.  Keratodermia  plantae  is  known 
to  be  associated  with  neuritis  in  cases  of  arsenic  poisoning  ; 
gonorrhoea  may  cause  peripheral  neuritis,  the  sciatic  nerve 
beiDg  most  often  affected. 

These  cases  are  probably  due  to  the  gonotoxin  and  not  to 
direct  invasion  by  the  gonococcus.  It  would  be  interesting 
to  know  whether  there  were  signs  of  peripheral  neuritis  in 
Dr.  Dyke’s  case,  for  if  so  possibly  keratodermia  blennor- 
rhagica  may  fall  into  line  with  arsenical  keratodermia,  and 
both  be  secondary  to  a toxic  neuritis  affecting  especially  the 
trophic  nerves  of  the  skin. 

I am,  Sir,  yours  faithfully, 

Avonmore-roart,  W.,  Sept.  1st,  1919.  G.  E.  BEAUMONT. 


1 Sequeira  : Brit.  Journ  of  Dermatology,  1910,  p.  139. 

2 McDonagh : Biol,  and  Treatment  of  Venereal  Diseases,  1915. 


Vital  Statistics  of  Scotland. — A remarkably 
high  marriage-rate,  together  with  low  birth-  and  death-rates 
form  the  most  notable  features  of  the  statistics  published 
for  Scotland  for  the  second  quarter  of  the  year  1919.  The 
marriage-rate,  9 5,  is  the  highest  quarterly  rate  on  record, 
while  the  birth-  and  death-rates  are  the  lowest  recorded  for 
the  corresponding  quarter  of  any  year. 

National  Association  for  the  Prevention  of 
Infant  Mortality.— A course  of  elementary  lectures  on 
infant  care,  for  teachers,  infant  welfare  workers,  and  others, 
will  be  held  at  1,  Wimpole-street,  London,  W.,  on  Mondays, 

5.30  to  6.30  P.M.,  from  Sept.  29th  to  Dec.  15th  inclusive,  in 
preparation  for  the  elementary  certificate  of  the  association. 
The  examination  is  open  to  all  students  who  attend  eight  or 
more  out  of  the  12  lectures.  The  fee  for  the  whole  course  is 
5s. — A course  of  elementary  lectures  on  infant  care,  especially 
intended  for  creche  nurses  and  probationers,  will  be  held  at 
the  Essex  Hall,  Essex-street,  London,  W.C.,  on  Thursdays, 

7.30  to  8.30  P.M.,  from  Sept.  25th  to  Dec.  11th,  inclusive, 
in  preparation  for  the  Creche  Nurses’  Certificate,  now 
instituted  by  the  Association  and  the  National  Society  of  Day 
Nurseries.  The  fee  for  this  course  is  10s. — Tickets  for 
either  course  can  be  obtained  from  Miss  Halford,  Secretary, 
National  Association  for  the  Prevention  of  Infant  Mortality, 
4,  Tavistock-square,  London,  W.C.  1. 


The  Lancet,] 


THE  SERVICES. 


[Sept,  13,  1919  503 


ffbc  Strikes, 


R.A.M.C.  TEMPORARY  OFFICERS. 

The  War  Office  is  prepared  to  accept  the  services  of 
medical  practitioners,  including  those  who  have  been 
demobilised,  who  are  desirous  of  undertaking  duty  with 
the  Army. 

Candidates  who  have  served  before  will  be  commissioned  in  their 
previous  rank.  Lieutenants  who  have  completed  one  year’s  satisfactory 
service  as  such  will  be  commissioned  as  Captains.  Those  who  have  not 
served  previously  will  be  commissioned  as  Lieutenants 
The  period  of  engagement  will  be  for  six  months,  and  the  contract 
will  not  be  terminable  by  either  party  prior  to  the  expiration  of  that 
period,  except  for  misconduct,  inefficiency,  or  medical  unfitness. 

Pay  to  be  at  the  rate  of — Lieutenants  £600  perannum,  Captains  £650 
per  annum,  and  in  addition  the  following  will  be  l9suable  : — 

(1)  Pay  at  the  rate  of  £50  per  annum  when  serving  elsewhere  than  in 
Europe. 

(2)  nations  or  an  allowance  in  lieu  thereof  (present  rate  2s.  Id.  per 
diem) 

(3)  Specialist’s,  or  charge  pay,  when  holding  a position  for  which  the 
issue  of  such  is  aut  horised. 

(4)  Officers  holding  higher  acting  or  substantive  rank  than  that  of 
Captain  will,  if  desirous,  be  granted  the  pay  and  allowances  of  their 
rank. 

Kit  and  outfit  allowance  will  be  issued  to  candidates  who  have  not 
previously  received  such  allowance. 

All  candidates  must  be  fit  for  general  service  or  garrison  duty  abroad, 
and  will  require  to  undergo  a medical  examination  prior  to  being 
accepted. 

Applications  should  be  addressed  to  the  Secretary,  War 
Office,  Cornwall  House,  Stamford-street,  London,  S.E.  1. 

EOYAL  NAVAL  MEDICAL  SERVICE. 

Surgeon  Lieutenants  (temp.) : A.  Ritchie  to  Valiant  ; A.  McCallum 
to  Malaya ; H.  A.  L.  Guthrie  to  Prince  George ; and  T.  H.  It. 
McKlernan  to  Pekin.  Temporary  Surgeon  Lieutenants  transferred  to 
permanent  list  of  Surgeon  Lieutenants  : W.  P.  Vicary,  H.  Hurst,  H 
Morrison.  Surg.  Lieut.  Cmdr.  K.  Willan  to  Renown.  Surg.  Lieut.- 
Cmdr.  R.  A.  Rankins,  O.B.E.,  has  been  allowed  to  withdraw  from  the 
R.N.  Medical  Service  with  a gratuity. 

ROYAL  VAVAL  VOLUNTEER  RESERVE. 

Surg.  Litut.  (temp.)  VV.  C.  Murray  to  Victory. 

ARMY  MEDICAL  SERVICE. 

Col.  A.  W.  Bewley,  C.M.G.,  retires  on  retired  pay. 

Temp.  Col.  W.  A.  Turner,  C.B.,  M.D.  (Major,  R.A.M.C.,  T.P.), 
relinquishes  his  temporary  commission  on  re-posting. 

ROYAL  ARMY  MEDICAL  CORPS. 

Major  C.  M.  Drew,  D.S.O.,  to  be  acting  Lieutenant-Colonel  whilst 
commanding  a Medical  Unit. 

The  undermentioned  to  be  acting  Majors : Capts.  E.  Catford 
J.  Biggam,  C.  F.  Burton;  Temp.  Capts.  C.  C.  Harrison,  C.  C.  Chance’ 

A.  Brown,  O.B.E.,  R.  Brown,  W.  H.  D.  Smith,  E.  R.  C.  Cooke,  J.  S. 
Lloyd,  S.  J.  W.  Donald,  R.  Thomson,  R.  H.  Alexander,  W.  Montgomery 
W.  L.  Hay,  H.  L.  Mann,  W.  A.  Todd,  G.  W.  Rea. 

To  be  Captains:  Capts.  W.  Potheringham,  M.C.  (from  Special 
Reserve),  W.  H.  Elliott,  M B E.  (from  Special  Reserve);  Temp.  Capt 
(acting  Major)  W.  S.  Martin,  M.C.;  Temp.  Capts.  H.  Mitchell’ 

P.  Carney,  M.O.,  R.  H.  Alexander,  M.C.) 

The  undermentioned  Lieutenanrs  (temporary  Captains)  to  be 
Captains  : C.  H.  C.  Byrne,  G.  C.  Robinson,  C.  A.  Slaughter  W L A 
Harrison.  T.  P.  Buist,  P.  H.  Wells. 

Late  temporary  Captains  to  be  temporary  Captains : J.  G.  Garson 
E.  Duke,  J.  Cameron,  W.  Gartou,  C.  E.  Dolling,  P S.  MacLaren 
J.  Cunningham,  R.  Stephens,  E.  S Hall,  J.  A.  Marsden. 

To  be  temporary  Captains:  A.  E.  Wood  and  M.  P.  D.  Graham. 

H.  J.  Brink  to  be  temporary  Lieutenant. 

Captain  K'  N'  P’  Martland  (frotn  Special  Reserve)  to  be  temporary 

The  undermentioned  temporary  Lieutenants  to  be  temporary 
Captains:  (Acting  Major)  T.  E.  Coulson,  T.  M.  Richardson  H j 
Cundell,  L.  Milburn,  R.  Lawrencg,  A.  Leigh,  W.  K.  Anderson. 

G.  A.  Fothergill,  late  temporary  Lieutenant,  to  be  temporary 
Lieutenant. 

The  undermentioned  temporary  Captains,  from  the  Home  Hospitals 
Reserve,  to  be  temporary  Captains  : A.  G.  Price,  G.  A.  Skinner. 

Lieut.-Col.  G.  A.  T.  Bray,  D S.O.,  relinquishes  the  temporary  rank 
of  Colonel  on  ceasing  to  be  specially  employed. 

Major  and  Brevet  Lieut.-Col.  A.  McMunn,  O.B.E.,  relinquishes  the 
temporary  rank  of  Lieutenant-Colonel  on  re-posting. 

Captain  A.  J.  Hickey,  M.C.,  relinquishes  the  acting  rank  of  Lieu- 
tenant-Colonel on  re-posting. 

Capt.  F.  R.  H.  Mollan,  M.C.,  relinquishes  the  acting  rank  of  Major 
on  re-posting. 

Capt.  K.  P.  Mackenzie  relinquishes  the  acting  rank  of  Major  on 
ceasing  to  be  specially  employed. 

The  undermentioned  relinquish  the  acting  rank  of  Major  — Capts  C 
Kelly,  P.  A.  Opie. 

Temporary  Captains  relinquishing  the  acting  rank  of  Major: 

C.  S.  Dodson,  H.  M.  Grey  (on  ceasing  to  be  specially  employed),  A.  H 
Coleman,  O.B.E.,  A.  C.  Maeay,  D.  Cowin,  L.  T.  Giles,  C.  C Chance 
R.  S.  Barker,  E.  B.  Smith,  J.  N.  Wheeler,  E.  R.  C.  Cooke,  R Brown’ 

P.  W.  Matheson.  ’ 

Lieut.-Col.  K.  B.  Barnett  retires  on  retired  pay. 

Capt.  C.  Robb  retires,  receiving  a gratuity. 

Major  D.  F.  Mackenzie,  D.S.O.,  relinquishes  the  acting  rank  of 
Lieutenant-Colonel  on  ceasing  to  command  a Medical  Unit 
Temp  Li?ut-‘Co1-  -Sir  Jbhn  Bland-Sutton,  Kt.  (Major, 

R.A.M.C.,  T.I.),  relinquishes  his  temporary  honorary  commission  on 
re-posting. 


Officers  relinquishing  their  commissions : Temp.  Lieut. -Col.  II  J 
Shirley  (retains  the  rank  of  Lieutenant-Colonel,) ; Temp.  Majors  T.  W 
Buckley,  D.  B.  King,  and  W.  E.  N.  Dunn  (retain  the  rank  of  Major)  • 
Temp.  lion.  Majors  T.  G.  M.  Hine  and  A.  G.  Paterson  (retain  the  honorary 
rank  of  Major) ; Temp.  Major  and  Bt.  Lieut.-Col.  A.  W.  Robertson  (retains 
the  Bt.  rank  of  Lieutenant-Colonel)  ; Temp.  Capt.  J.  O.  Egan  (granted 
the  rank  of  Lieutenant-Colonel) ; Temporary  Captains  granted  the  rank 
of  Major:  L.  G.  McCune,  C.  A Weller,  W.  A.  Wheeldon,  J.  A.  W 
Watts,  0.  G.  McAdam,  R.  V.  Dolbey,  II.  L.  Nell,  B.  W.  Armstrong, 
lemp.  Capt.  (acting  Major)  A.  O.  Hancock  (relinquishes  the  pay  and 
allowances  ot  his  acting  rank),  O.  K.  Henderson,  R M.  Penn  ; Temporary 
Captains  retaining  the  rank  of  Captain : W.  M.  McDonald,  W.  11.  Knobel 
W.  Thomas,  H O.  H.  May,  S.  E.  Denyer,  C.  W.  Cunnington,  D.  II.’ 
KurrJ’,,  S.  Sheppard- J ones,  J.  Gilchrist,  A.  Buchanan,  M.C  , J.  A M 

Bligh,  H.  M Jackson,  J.  A.  Clarke,  N.  V.  Mitton,  J.  W.  McDonald  (cii 
account  of  ill  health  contracted  on  active  service),  B.  J.  Mullins,  M C (on 
account  of  ill-health  caused  by  wounds),  V.  M.  Fisher,  E.  Mar  joribanks- 
Marcar,  J.  E.  Rutheriurd,  M.C.  (on  account  of  ill-health  contracted  on 
active  service),  L.  A.  Moran,  O.  N.  Vaisey,  T.  H.  Holrovd  O K 
Tett"^T0nt;  A’  ',£j  £ras<:r'  H-  £ Lucey.  W.  H.  D.  Smith,  J.  M.  Rhhwo'rth’, 
T.  M.  Newton,  D.  Cowin,  G.  R. Wilson,  V.  C.  Martyn,  G.  D.  McLean,  R F 
Young,  W.  Dawson,  D.S.O.,  C.  J.  Armstrong-Dash,  R.  C.  Monnington! 
B.  R.  G.  Russell  (on  account  of  ill-health),  W.  E.  M.  Armstrong  H p 
Gibb,  W.  H.  A.  Elliott,  P.  P.  Montgomery,  H.  D.  Wyatt,  J.  Young,  E O 
Hughes,  A.  M Bell,  P.  Savill,  J.  Leach,  D L.  Hutton,  M.  J T Wallis 
£’irK\,M’,Bre?a?;  G’  S’  Metlnie-  G-  H.  Dart.  J.  P.  Lowson! 

F.  Heatherley,  A.  McEwan,  L.  P.  West,  J.  Hepburn,,  R.  A.  H.  Fulton 

vf'  t W-  Allison,  J.  G.  Slade  (on  account  of  ill-health)', 

I.  M.  Johnstone  (on  ceasing  to  serve  with  the  South  African  Native 
Labour  Corps),  W.  Parsons,  H.  Goodale,  W.  G.  Ridgway,  11.  C.  Phelps 
ww-;<.Simioh»V12*  J*0111,00’  L Thornton,  A.  Verling,  H.  Kirkland- 
Whittaker,  M.  L.  Loveless,  C.  P.  Charles,  H.  E.  H.  Tracey,  J.  E.  T.  Jones 

G.  W.  Anderson,  A.  J.  Partridge,  H.  B.  Wilkinson,  H.  L.  Shelton,  C.  m! 
Smith,  L.  M.  Smith,  J.  S.  Buchanan,  D.  S.  Jones,  J.  E.  P.  Sbera  J J 
Hughes,  J.  C. l Jones,  W.  D.  A.  King,  F.  H.  Nixey,  W.  TudhopeVon 
account  or  ill-health  contracted  on  active  service),  A.  B.  S.  Todd  F K 
Wilson,  C.  M.  Stubbs,  E.  G.  von  B.  Bergh,  J.  P.  Jones,  L.  r!  h'  p’ 
Marshall,  O.B.E.,  A.  P.  Potter,  A.  H.  Davidson,  H.  North,  D Clark 
G.  C.  Gaynor,  H.  P.  Bodvel-Roberte,  H.  M.  Gray,  J.  B.  Wilkie,  R.  j! 
Ledlie,  L.  J.  Lock,  J.  A.  Glover.  M.  R.  Mackey,  J.  R.  Burnett.  J. 
Glaister,  D.  Y.  Buchanan,  W.  H.  Hart  (on  account  of  ill-health  caused 
by  wounds),  R.  Stipe,  L.  B.  Cane;  Temp.  Lieut.  G.  E.  Froggatt  (granted 
the  rank  of  Major). 

Temp.  Lieut.  J.  B.  McGranahan  relinquishes  his  commission  and 
retains  the  rank  of  Lieutenant. 

Lieut.-Col.  L.  A.  Mitchell  is  placed  temporarily  on  the  half-nav 
list  on  account  of  ill  health. 

Canadian  Army  Medical  Corps. 

Temp.  Major  (acting  Lieut.-Col.)  P.  E.  Watts  to  be  temporary 
Lieutenant- Colonel.  J 

The  undermentioned  temporary  Captains  (acting  Majors)  relinquish 
the  acting  rank  of  Major:  C.  W.  Johnston,  D.  A.  Morrisou,  C Kerr 
F.  A.  Brockenshire,  A.  N.  Aitken.  " ’ 

The  undermentioned  retire  in  the  British  Isles  : Temp.  Capts  W A 
McClelland,  A.  N.  Aitken,  A.  R.  Campbell,  Hon.  Capt.  J.  0.  McClure. 

SPECIAL  RESERVE  OF  OFFICERS. 

Capt.  W.  McN.  Walker  relinquishes  his  commission  on  account  of 
ill-health  contracted  on  active  service,  and  is  granted  the  rank  of 
Major. 

The  undermentioned  Captains  relinquish  their  commissions  on 
account  of  ill-health,  and  retain  the  rank  of  Captain  : R.  G Waddv 

H.  Chadwick,  G.  T.  Roche.  y' 

Capt.  M.  P.  Murphy  relinquishes  his  commission. 

The  undermentioned  Captains  relinquish  the  acting  rank  of  Major  • 

R.  P.  A.  Kirkland,  W.  B.  Cathcart,  D.  G.  Stoute. 

Capt.  (acting  Major)  W.  McM.  Chesney  relinquishes  the  pay  and 
allowances  of  his  acting  rank. 

The  undermentioned  Captains  to  be  acting  Majors  R P Fagan 
R.  P.  Starkie,  W.  McM.  Chesney.  S ’ 

The  undermentioned  Lieutenants  to  be  Captains  : B J.  S Bonnett 
r.  Patterson,  S.  A.  Withers,  A.  M.  Dugan,  P.  R.  G.  Heif,  C.  Simpson! 

D.  C.  Lamont,  E.  D.  D.  Dickson,  G.  R.  Ross. 

TERRITORIAL  FORCE. 

Officers  relinquishing  their  acting  rank  on  ceasing  to  be  specially 
employed  — r J 

Major  (Bt.  Lieut.-Col.)  (acting  Col.)  D.  Rorie,  D.S.O.,  relinquishes  the 
acting  rank  of  Colonel  on  vacating  the  appointment  as  Assistant 
Director  of  Medical  Services. 

Major  (Bt.  Lieut.-Col.)  (acting  Lieut.-Col.)  J.  Wilson  relinquishes  the 
acting  rank  of  Lieutenant-Colonel. 

Majors  (acting  Lieut.-Cols.)  T.  Donovan  and  A.  R.  Henchley,  D S O 
relinquish  the  acting  rank  of  Lieutenant-Colonel. 

Capt.  A.  C.  Herne,  O.B.E.,  relinquishes  his  commission  on  ceasing  to 
be  employed,  and  is  granted  the  rank  of  Lieutenant-Colonel. 

Capts.  (acting  Lieut.-Cols.)  J.  Young.  D.S.O.,  A.  G.  Hendley,  J H 
Thomas,  D.S.O.,  relinquish  the  acting  rank  of  Lieutenant-Colonel 
Capts.  (acting  Majors)  G.  T.  Willan,  D.S.O.,  G.  H.  H.  Manfield 
C.  D.  Law,  J.  J.  E.  Biggs,  O.B.E.,  L.  H.  Wootton,  M.C.,  P.  B.  Spurgin’ 

H.  T.  Jones,  R.  W.  Aitken,  W.  N.  P.  Williams.  s ’ 

Capts.  G.  E.  Martin,  H.  W.  Browne,  M.C.,  and  A.  G.  Hendley  to  be 
acting  Majors  whilst  specially  employed. 

2nd  London  General  Hospital : Major  (Bt.  Lieut.-Col.)  T.  D.  Aoland 
is  seconded  for  duty  with  the  Special  Military  Surgical  Hospital 
Shepherd’s  Bush. 

3rd  Northern  General  Hospital : Capt.  P.  A.  Hepworth  is  restored  to 
the  establishment  on  ceasing  to  hold  a temporary  commission  in  the 
R.A.M.C. 

4th  Northern  General  Hospital : Capt.  (acting  Major)  J.  J.  Rainforth 
relinquishes  the  acting  rank  of  Major  on  ceasing  to  be  specially 
employed,  and  is  restored  to  the  establishment. 

lBt  Southern  General  Hospital : Lieut.-Col.  F.  W.  Ellis  is  seconded 
for  duty  with  the  2/lst  Southern  General  Hospital. 

2nd  Southern  General  Hospital:  Capt.  (Bt.  Major)  E.  W.  H.  Groves 
is  restored  to  the  establishment. 

3rd  Southern  General  Hospital : Capt.  J.  A.  Gunn  and  Major  A,  T, 
Waterhouse  are  restored  to  the  establishment. 


504  The  Lancet,] 


MEDICAL  NEWS.— APPOINTMENTS.— VACANCIES. 


[Sept.  13, 1919 


3rd  Western  General  Hospital : Major  (Bt.  Lieut. -Col.)  (acting  Lieut. - 
Col.)  E.  J.  Maclean  relinquishes  the  acting  rank  of  Lieutenant-Colonel 
on  ceasing  to  be  specially  employed.  Lieut. -Col.  (Hon.  Surg.-Col.)  I). 
Hepburn,  C M.G..  V.D.,  relinquishes  his  commission  on  account  of 
ill  health  and  retains  bis  rank. 

2nd  South  Midland  Mounted  Brigade  Field  Ambulance:  Capt.  A.  G. 
Htndley  to  he  acting  Lieutenant-Colonel  whilst  specially  employed. 

3rd  East  Anglican  Field  Ambulance  : Lieut.-Col.  H.  T.  Challis  to  be 
an  Assistant  Director  of  Medical  Services,  and  to  be  temporary 
Colonel  whilst  so  employed. 

TERRITORIAL  FORCE  RESERVE. 

Lieut.-Col.  (temp.  Col.)  H.  T.  Challis,  from  3rd  East  Anglican  Field 
Ambulance,  to  be  Lieutenant-Colonel  on  vacating  appointment  aB 
Assistant  Director  of  Medical  Services. 

HOYAL  AIK  FORCE. 

Medical  Branch.— Major  G.  D.  Bateman,  O.B.E.,  to  be  Lieutenant- 
Colonel. 

Capt.  (acting  Major)  A.  P.  Bowdler  to  be  acting  Lieutenant-Colonel 
whilst  so  employed. 

Temp.  Capt.  A.  E.  Panter  is  granted  the  acting  rank  of  Major  whilst 
specially  employed. 

The  undermentioned  Lieutenants  to  be  Captains  : H.  F.  Squire,  J.  J. 
O'Mullane,  E.  11.  L.  Le  Clezlo,  N.  Eumboll,  V.  A.  T.  Spong,  H.  B.  B. 
Green,  S.  A.  Neild-Faulkner. 

R.  W.  Ryan  is  granted  a temporary  commission  as  Captain. 

The  undermentioned  are  transferred  to  unemployed  list Major  W.  G. 
Mitchell,  Capts.  P.  O.  Moffat,  A.  Leitch,  Lieuts.  G.  n.  Johnston,  G. 
Bourne,  J.  G.  Bird.  G.  H.  W.  Randal,  Flying  Officer  Hughes. 

The  undermentioned  Captains  relinquish  their  commissions  on 
account  of  ill-health,  and  are  permitted  to  retain  their  rank : T.  E. 
Mulvany,  E.  H.  Hogg,  C.  P.  Strong. 

Capt  A.  Gleeson  (Captain,  R.A.M.C.)  relinquishes  his  commission  on 
account  of  ill-health  contracted  on  active  service. 

The  initial  of  Capt.  O.  Gleeson  (Captain,  R.A.M.C.)  is  as  now 
described,  and  not  “ A.” 

Dental  Branch.— Lieut.  L.  G.  Smith  to  be  Captain. 

T.  H.  Jones  is  granted  a temporary  commission  as  Flying  Officer. 

INDIAN  MEDICAL  SERVICE. 

Temporary  Lieutenants  to  be  Temporary  Captains : Richard  Ronald 
Htoon  Oo  Tha,  Vasant  Dinnath  Madgavakar,  Khuda  Baksh  Awan, 
Durgadas  Sanyal,  Mool  Singh  Bazaz,  Roshan  Lai  Kbera,  Narayan 
Raghunath  Shahane,  Ajit  Kumar  Sen,  Dwijendra  Nath  Bhaduri,  H.  H. 
Colwell,  Thakurdas  Parmanand  Vaswani,  Vatackal  Thomas  Ninan, 
Kunjuni  Thirupod,  Govinda  Sankaran  Tampi,  Gopal  Gangadhar 
Limaye. 

Major  A.  E.  Grisewood  to  be  acting  Lieutenant-Colonel  while 
holding  command  oi  an  Indian  Clearing  Hospital  from  March  7th, 
1916,  to  Jan.  4th,  1917. 

The  King  has  approved  the  grant  of  the  temporary  rank  of  Lieu- 
tenant in  the  Indian  Medical  Service  to  Rahmat  Ullah  Qureslii. 

The  King  has  approved  the  relinquishment  of  temporary  rank  in 
the  Indian  Medical  Service  and  Indian  Defence  Force  uy  Capt. 
Villupurani  Rajaratna  Nateson. 


Httbital  Betas. 


We  call  the  attention  of  our  readers  to  a letter 
on  p.  502  from  Mr.  Stephen  Paget,  the  honorary  secretary  of 
the  Research  Defence  Society.  Mr.  Paget  asks  for  early 
warning  as  to  the  opening  of  antivivisection  shops,  so  that 
he  may  counteract,  through  the  Research  Defence  Society, 
the  mischievous  misrepresentations  to  which  these  places 
give  concrete  form. 

Dr.  John  Cahill,  who  died  on  Saturday  last,  was  a 
member  of  the  Egyptian  Government  Medical  Commission, 
and  during  the  war  had  been  acting  as  assistant  physician  to 
St.  George’s  Hospital. 

Dr.  Charles  Cameron  Slorach,  of  Dumbarton, 
was  killed  last  week  in  the  Mount  Vernon  district,  near 
Glasgow,  through  the  motor-car  in  which  he  was  riding 
coming  into  collision  with  a traction  engine.  His  wife  and 
son,  who  accompanied  him,  were  injured. 

The  St.  Thomas’s  Hospital  Old  Students’  dinner 
will  take  place  at  the  Connaught  Rooms,  Great  Queen-street, 
W.C.,  on  Wednesday,  Oct.  1st,  at  7 o’clock  for  7.30.  The  chair 
will  be  taken  by  Sir  George  Makins,  President  of  the  Royal 
College  of  Surgeons  of  England. 

The  Lunacy  Board  of  Control  : Fifth  Annual 
Report. — The  report  shows  a continued  decrease  in  the 
number  of  notified  persons  under  care  in  England  and 
Wales.  The  total  was,  last  New  Year’s  day,  116,703,  and  the 
actual  decrease  from  year  to  year : 1918-19,  9138  ; 1917-18,  8188  ; 
1916-17,  3159.  In  the’ 80  asylums  which  continued  to  receive 
patients  throughout  the  year  the  death-rate  was:  males 
25*2  per  cent.,  and  females  16-4  per  cent.,  being  a further 
increase  of  3'7  and  2-4  per  cent,  respectively  on  the  high 
mortality  of  the  previous  year,  and  attributed  in  the  main  to 
influenza  and  tuberculosis.  6577  mental  defectives  were 
resident  in  certified  institutions.  The  total  expenditure  for 
the  year  on  the  upkeep  of  county  and  borough  asylums  was 
£4,062,752,  being  an  increase  on  the  year  of  £295,717.  The 
average  weekly  cost  of  maintenance  per  head  was  14s.  5$d., 
a rise  of  Is.  9 d.  on  the  cost  of  the  previous  year. 


Royal  Dental  Hospital  of  London.  — The 

annual  dinner  of  the  staff  and  past  and  present  students  of 
the  hospital  will  be  held  at  the  Connaught  Rooms,  Great 
Queen-street,  W.C.,  on  Saturday,  Nov.  22nd,  at  7 P.M.,  Sir 
Harry  Baldwin  in  the  chair.  This  being  the  first  post-war 
reunion,  it  is  hoped  a large  number  of  those  interested  will 
find  it  convenient  to  be  present. 

Failure  of  Londonderry  Water-supply. — An 
Irish  Correspondent  writes:  The  authorities  of  such  an 
old  and  important  Irish  city  as  Londonderry  cannot  be 
congratulated  that,  owing  to  their  continued  procrastina- 
tion, the  water-supply  has  practically  failed.  On  Sept.  2nd 
bakeries  were  carried  on  with  difficulty,  picture-houses 
had  to  be  closed,  and  no  public  and  only  two  private 
houses  had  electric  light.  The  citizens  have  been 
warned  to  use  what  remains  of  the  water-supply  only 
for  cooking  and  washing,  as  it  is  now  in  their  ’ hands 
to  prevent  a famine.  On  Sept.  2nd  the  thousands  of 
shipyard  and  factory  workers  who  turned  cut  in  the 
morning  as  usual  for  work  had  to  be  sent  home  again 
because  it  was  discovered  that  no  water  was  coming  into 
the  tanks  at  the  electric  station  from  the  reservoir  from 
which  the  station  draws  its  supply,  with  the  result  that-the 
shipyard  engineer  had  no  other  alternative  but  to  cut 
off  the  supply  to  the  industries,  as  there  was  an  absence 
of  electric  power.  A gallon  of  water  per  head  each  day 
would  enable  the  engineer  to  provide  the  necessary  power. 
Until  the  corporation  make  up  their  minds  what  is  to  be 
done  in  the  serious  crisis  that  has  arisen,  all  supplies  of 
water  for  industrial  and  business  purposes  are  discontinued, 
and  establishments  found  using  water  are  to  be  prosecuted. 
A similar  crisis  arose  in  1911  in  Londonderry,  but  in  the 
interval  the  population  has  increased  by  8000,  and  the  ship- 
yard has  to  be  considered.  At  a meeting  of  the  corpora- 
tion on  Sept.  4th  a deplorable  situation,  as  regards 
the  water-supply,  was  revealed  by  the  city  engineer, 
who  said  that  “ if  they  kept  the  water  they  had 
for  domestic  purposes  only,  they  could  maintain’  about 
five  weeks’  supply  at  the  very  outside,  provided  the  citizens 
exercised  the  most  rigid  economy  and  used  only  the  very 
minimum.”  He  was  prepared  to  supply  the  electric  station 
with  the  necessary  water  (to  begin  on  Sept.  8th)  to  enable 
the  necessary  power  to  be  provided  to  carry  on  industry, 
although  he  would  be  taking  considerable  risks  in  doing  so, 
but  he  could  not  supply  water  for  trade  purposes  or 
for  laundries,  and  he  could  only  give  water  to  factories 
for  sanitary  purposes,  and  even  that  could  not  be 
guaranteed  at  any  particular  time ; and  on  the  above 
recited  conditions  he  was  prepared  to  resume  a ten  days’ 
trial  of  supplying  water  for  electric  power.  No  wonder 
the  daily  press  regard  such  a condition  of  affairs  as  a 
grave  crisis  for  an  old  city  whose  population  at  the  last 
census  was  40,779.  In  Belfast,  as  reported  on  Sept.  4th 
to  a meeting  of  the  Water  Commissioners,  the  water  in 
store  on  August  28th  was  1103  million  gallons,  which  is 
501  million  gallons  less  than  the  quantity  in  store  on  the 
corresponding  date  of  1918.  The  city  has  been  put  on  a 
diminished  supply,  none  flowing  into  the  cisterns  at  night, 
a practice  of  little  use,  as  people  simply  fill  their  baths  and 
other  receptacles  during  the  day.  Unless  rain  comes  in 
large  quantity  a serious  crisis  may  also  arise  in  Belfast  from 
the  deficient  water-supply. 


^ppcrinfttunts. 


Chisholm,  John,  M.B.,  Ch.B.  Bdin..  has  been  appointed  Registrar  to 
the  Jessop  Hospital  for  Women,  Sheffield. 

Sussex  Throat  and  Ear  Hospital : Hutchison,  A.  J.,  Honorary  Con- 
sulting Surgeon  ; Rigby,  Morris,  and  Crow,  Douglas  a.. 
Assistant  Honorary  Surgeons. 


©acanms. 


For  further  information  refer  to  the  advertisement  columns. 

Alexandra  Hospital  for  Crippled  Children,  Queen-square,  Bloomsbury 
W.  C.— Res.  Med.  Supt.  at  Country  Hospital  near  Reading.  £4(X). 
Aylesbury.  Royal  Buckinghamshire  Hospital.— H.S. 

Barbados  General  Hospital.— Sen.  Res.  S.  £300. 

Birkenhead  Borough  Hospital.— Jun.  H.S.  £170. 

Birkenhead  Union  Infirmary. — Res.  Asst.  M.O.  £300. 

Brentwood  Mental  Hospital,  Essex.— Loc.  Tenens  Asst.  M.O.  £7  7 s.  p.w. 
Bridgend  Urban  District  Council,  Penybont  Rural  District  Council.— 
Joint  M.O. H.  £600. 

Brighton,  Royal  Sussex  County  Hospital.— Asst.  H.S.  £80. 

Cancer  Hospital  (.Free).  Fulham-roa  i,  S.  IF.— Two  H.S.'s.  £150. 

Central  London  Ophthalmic  Hospital,  Judd-slreet,  St.  Pancras,  W.C.— 
H.S.  £50. 

Chartham,  near  Canterbury,  Kent  County  Mental  Hospital. — Jun.  Third 
Asst.  M.O.  £300. 

Cheltenham  Eye,  Ear,  and  Throat  Free  Hospital.— Asst.  S.  £400. 
Chester,  Cheshire  County  Council.— Dist.  Tuberc.  O.  £400. 

Chester  Royal  Infirmary.— H.P.  £150. 


The  Lancet,] 


BIRTHS,  MARRIAGES,  AND  DEATHS.— MEDICAL  DIARY. 


[Sept.  13,  1919  505 


Derbyshire.  Roy  at  Infirmary.— H.S.  and  H.P.  £200  each. 

Durban,  Government  Hospital.—  Asst.  M.O.  £400. 

Fast  Ruling  Education  A uthority.— Female  Asst.  Soh.  M.O.  £350. 
Glamorgan  County  Asylum,  Bridgend.— Fourth  Asst.  M.O.  £400. 
■H«C£500  and  Stoke  Newington,  Metropolitan  Boroughs  of.— Tubere.  O. 

Hyde  Borough.— M.O.H.  and  Female  Asst.  M.O.  £700  and  £400 
respectively. 

Lambeth  Metropolitan  Borough. — Tubere.  O.  £600. 

Leeds  General  Infirmary.— Res.  M.O.  £150.  Res.  Obstet.  O.  £50. 
Also  Res.  M.O.  at  Ida  and  Robert  Arthlngton  Hospitals.  £60 
Two  H P.’s  and  Two  U.S.’s. 

Leeds  Indoor  Institutions,  Beckett-streel.—  Sec.  Asst.  M.O.  £300. 
Leeds  Public  Dispensary,  North-street.— Res.  M.O.  £200. 

Lincoln  County  Hospital.— Jun.  H.S.  £150. 

Liverpool  City  Infectious  Diseases  Hospital—  Two  Asst.  Res.  M.O.’s. 
£200. 

Liverpool  Infirmary  for  Children.—' Two  Res.  H.  P.  and  Res.  H.  S £90 
Liverpool,  Royal  Southern  Hospital.—' Two  H.P.’s  and  Three  H.S.'s. 
£100. 

Liverpool  Stanley  Hospital.— H.  P.  and  H.  S.  £150. 

Maidstone,  Kent  Education  Committee—  School  Med.  Inspector.  £300 
Maidstone,  l Vest  Kent  General  Hospital.— Jan.  H S.  £150. 

Manchester,  Ancoats  Hospital.— Res.  Surg.  O.  £200.  Also  H.S.  £100 
Manchester  Northern  Hospital  for  Women  and  Children,  Park-place 
Cheetham  Hill-road.— H.S.  £150. 

Manchester  Royal  Infirmary.— Path,  and  Med.  Registrars.  £350  and  £75 
respectively. 

Manchester,  St.  Mary’s  Hospitals  for  Women  and  Children.— Two  H.S.’s 
£100. 

Melbourne  University—  Lecturer  in  Pathology.  £600. 

Mothers’  Hospital,  153-163,  Lower  Clapton-road,  E.— Res.  M O 
Newport  Borough  Asylum,  Caerleon,  Mon.— Asst.  M.O.  £40C. 
jVei£900W(A  Wales,  Department  of  Public  Instruction. — Prinpl.  M.O 

Norwich,  Jenny  Lind  Hospital  for  Children.— Female  Res.  M.O.  £150. 
Nottingham  General  Hospital.—' Two  H.P.’s.  Also  Two  HS’s  £150 
Queen  Mary’s  Hospital  for  the  East  End,  Stratford,  E. — H.S  £150  ’ 
Rotherham  Hospital.- Jun.  H S.  £150. 

Royal  London  Ophthalmic  Hospital,  City-road,  E.C.— Curator  and 
Librarian.  £200. 

Royal  Westminster  Ophthalmic  Hospital,  King  William- street.  West 
Strand.  W.C.—  Asst.  H.S.  £40. 

St-  Mm’U's  Hospital  for  Women  and  Children,  Plaistow,  E.— Res.  M.O. 
£200.  Also  Hon.  Gynaecologist. 

St.  Mary’s  Hospital.  Paddington,  IF.— Asst.  Surg.  for  Diseases  of  the 
Ear,  Nose,  and  Throat.  Also  Hon.  Anassth. 

St.  Peter’s  Hospital  for  Stone,  &c.,  Henrietta-street,  Covent-garden,  W.C. 
— Jun.  H.S.  £75. 

Salford  Royal  Hospital.— Hon.  Dent.  S.  Also  Res  Surg  O HP 
H.S.,and  Jun.  H.S.  £250,  £200,  £150,  and  £125  respectively. 
■Salisbury  General  Infirmary—  H.S.  and  Asst.  H.S.  £200  and  £150 
1 respectively. 

Scarborough  Hospital  and  Dispensary— Two  H.S.’s.  £150. 

Seamen  s Hospital , Greenwich. — House  appointments 
Serbian  R lief  Fund,  5,  Cromwell-road,  S.  rr.-Female  Doctor  for  Hos- 
pital  or  Out-station  work  in  Serbia. 

Sheffield  Royal  Infirmary.— H.S.  for  Ear,  Nose,  and  Throat  £150 
Southampton,  Free  Eye  Hospital.— H.S.  £150  to  £200 
Swansea  General  and  Eye  Hospital.— H.S.  £250 
Truro,  Royal  Cornwall  Infirmary.—  H.S.  £170. 

Wakefield,  West  Riding  Asylum'.— Asst.  M.O.  £400. 

Wolverhampton  and  Staffordshire  General  Hospital. — H S £200 
Wrexham,  Borough  and  Rural  District  of.—' Temp.  M.O.  £550.  ’ 

The  Chief  Inspector  of  Factories,  Home  Office,  S.W.,  gives  notice  of 
vacancies  for  Inspectors  under  the  Factory  and  Workshop  Acts  at 
Belper  (Derby),  Birmingham  (East)  and  Erdington  (Warwick). 
JIailsham  (Sussex),  Hanley  (Stafford),  and  Uleeby  (Lincoln). 

Harrises,  ant  gatfcs. 

BIRTHS. 

Dickinson.— On  Sept.  6th,  at  Newcastle-upon-Tyne,  the  wife  of  W H 
Dickinson,  M.B.,  D.P.H.,  of  a son. 

Fuxler.— On  Sept.  4th,  at  Priory  Cottage,  Freshwater.  I.W.,  the  wife 
of  Capt.  R.  Annesley  Fuller,  M.C.,  R.A.M.C.,  of  a son. 
tfiCALiuNE.-On  Sept.  10th,  at  Cranbrook,  Prestwich,  Manchester  the 
wife  of  Jas.  B.  Macalpine,  F.R.C.S.,  of  a daughter. 


MARRIAGES. 

DUNN-JACKSON  -On  Sept.  3rd,  at  St.  James’  Church,  Edgbaston, 
M^°irI'aoaht0n  ?unn’  B-A.M.O.,  to  Ethel  Violet,  daughter  of  Mr 
and  Mrs.  George  Jackson,  of  Glewstone  Court,  Herefordshire. 

1ivS~5Io  R^AN’— °n  Sept-  9th,  in  London,  Hugh  Richard  Phillips 
M.D.,  of  2,  Cavendish  Court,  Cavendish-square,  to  Phyllis  Morgan! 

DEATHS. 

2ahill.— On  Sept.  6th,  at  Pinkneys  Lodge,  Pinkneys  Green,  the  resi- 
s“c®  of  his  brother-in-law,  Mr.  Stanley  Keith,  John  Cahill  M D 
b-Iing"  of  Sevitle-street,  Lowndes- square,  S.W.,  aged  62  ” 

CKp.  On  Sept  6th,  at  The  Nook,  Great  Bookham,  Surrey,  Thomas 

HospTtalfLoodon.  C S'’  consultina  to  St.  George’s 

N.B.—A  fee  of  5s.  is  charged  Jor  the  insertion  of  Notices  of  Births 
Marriages , and  Deaths. 


Iltofcal  far  tjre  enswitj  ®eek. 

LECTURES,  ADDRESSES,  DEMONSTRATIONS,  &c. 

LONDON  HOSPITAL  MEDICAL  COLLEGE,  in  the  Clinical  Theatre 
of  the  Hospital. 

A Special  Course  of  Instruction  In  the  Surgical  Dyspepsias  will  be 
given  by  Mr.  A.  J.  Walton  and  others  : — 

Wednesday,  Sept.  17th.-4.30  p.m..  Lecture  XIII.:— ^Etiology  and 
Pathology  of  Carcinoma  and  Sarcoma  of  the  Stomach. 

FR1© ay. —4.30  p.m.,  Lecture  XIV.: — Symptoms  and  Treatment  of 
Carcinoma  and  Sarcoma  of  the  Stomach. 

Communications,  Letters,  &c.,  to  the  Editor  have 
been  received  from— 


A. — Dr.  F.  P.  Atkinson,  Bexhill 
on-Sea. 

B. — Messrs.  J.  Bibby  and  Sons, 
Liverpool;  British  Red  Cross 
Society,  Lond.;  British  Associa- 
tion for  the  Advancement  of 
Science,  Lend.;  Mrs.  C.  Brereton, 
Lond.;  Dr.  A.  Balfour,  C.M.G., 
Lond.;  Sir  John  Bland-Sutton, 
Lond.;  Col.  R.  J.  Blackham ; 
Mr.  C.  K.  Bond,  Brighton ; 
Prof.  D.  T.  Barry,  Cork ; Dr.  G. 
Blacker,  Lond. 

C.  — Dr.  E.  L.  Collls,  Lossiemouth  ; 
Dr.  E.  R.  T.  Clarkson,  Peters- 
field  ; Colonial  Office,  Lond.;  Mr. 
A.  Cooke,  Lond. 

D.  — Dr.  A.  Distaso,  Whitchurch  ; 
Mr.  C.  Dewdney,  Chingford; 
Dr.  O.  T.  Dinnick,  Lond. 

E.  — Mr.  R.  Eager,  Exminster. 

F.  — Dr.  E.  R.  Fothergill,  Hove; 
Factories,  Chief  Inspector  of, 
Lond. 

G.  — Dr.  P.  C.  Gibson.  Lond. ; Lieut.- 
Col.  E.  Goodall,  R.A.M.C.;  Dr. 
H.  E.  Gibson,  Lond. 

H.  — Mr.  J.  T.  Henderson,  Pieter- 
maritzburg ; Lieut.-Col.  A.  F. 
Hurst,  R.A.M.C.;  Dr.  C.  T.  W. 
Hirsch,  Lond.;  Mr.  F.  Hubbard, 
Lond.;  Capt.  H.  A.  Haig, 
R A.M.C.;  Lieut.-Col.  D.  L. 
Hamilton,  R.A.M.C.;  Mr.  R.  S. 
Hopkins,  Lond, 

I. — Industrial  Fatigue  Research 
Board,  Lond.;  Industrial  Welfare 
Society,  Lond.,  Director  of. 

K.— Dr.  A.  Kidd,  Kilrea;  Dr.  E.  H. 
Kettle,  Lond.;  Dr.  J,  Kerr, 


Lond.;  Dr.  H.  C.  Kidd,  Broms- 
grove. 

L. — Corporation  of  London,  Town 
Clerk  of;  League  of  Red  Cross 
Societies,  Geneva ; Dr.  G.  C. 
Low,  Lond.;  Mr.  B.  B.  Leech, 
Manchester;  Mr.  H.  Lacombe, 
Paris. 

M.  — Mr.  O.  F.  Maclagan,  Rugby; 
Ministry  of  Health,  Lond.;  Dr. 
H.  Martel,  Paris;  Dr.  J.  B. 
Mennell,  Lond. 

N. — Newspaper  Proprietors’  Asso- 
ciation, Lond.;  National  Associa- 
tion for  the  Prevention  of  Infant 
Mortality ; National  Party, 
Lond.,  Sec.  of. 

P.  — Dr.  R.  H.  A.  Plimmer,  Lond. 

R. — Dr.  J.  W.  Roberts,  Thirsk ; Dr. 
J.  D.  Rolleston,  Lond.;  Dr. 
W.  C.  Rivers,  Worsboro’  Dale ; 
Mr.  W.  Robinson,  Sunderland ; 
Royal  Institute  of  Public  Health, 
Lond.;  Research  Defence  Society, 
Lond.,  Hon.  Sec.  of. 

S. — Mr.  A.  C.  Schnelie,  Lond.;  Prof. 
E.  G.  Slesinger,  Lond.;  Dr.  K. 
Simpson,  Hounslow;  Miss  M. 
Sheepshanks,  Lond.;  Dr.  H.  K.  V. 
Soltau,  Bletchingley. 

T. — Dr.  O.  T.  Todd.  O.B.E.,  Llan- 
beris;  Dr.  W.  W.  C.  Topley, 
Lond. 

G.— United  Water  Softeners,  Lond. 
W.— War  Work  Council,  Y.W.C.A., 
New  York;  Mr.  R.  Warren, 
Lond.;  Mr.  H.  G.  Watkins,  Chep- 
stow ; Dr.  R.  c.  Watts,  Cairo; 
Sir  G.  Sims  Woodhead,  K.B  E., 
Conway ; Dr.  F.  J.  Waldo, 
Lond. 


Lh^.ST  ,we®k  an  announcement  appeared  in  this 
■l  A ¥np°  Mthl  marriage  of  Captain  W.  E.  Elliot,  M.C., 
M£“beJrof  parliament  for  Lanark,  and  Miss  Helen 
lamnton.  The  tragic  sequel  has  been  widely  noted  in  the 
noun?nrfu3-  • MrS-  £llio*  fel1  some  hundreds  of  feet  while 
?er  Ib  igu?  ,Sky0-  dragging  her  husband  down  with 

^atsevemlyinlSd011  ' Sp0t  and  Captain  Elliot  some' 


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506  The  Lancet,]  NOTES,  SHORT  COMMENTS,  AND  ANSWERS  TO  CORRESPONDENTS.  [Sept.  13,  1919 


Holes,  S(rort  Comments,  anb  ^nskrs 
to  Correspondents. 

PLAGUE  AND  INFLUENZA  IN  INDIA. 

For  more  than  half  a century  the  Government  of  India 
have  issued  annually  a Blue-book  entitled  “Statement 
Exhibiting  the  Moral  and  Material  Progress  and  Condition 
of  India.”  The  fifty-fourth  of  these  statements,  dealing 
with  the  year  1917-18,  has  recently  been  presented  to  Parlia- 
ment, and  included  in  its  various  contents  are  the  following 
remarks  on  local  self-government  tested  by  disease  and 
scarcity : — 

As  a symptom  of  the  vitality  of  the  institutions  of  Iccal  self- 
government  in  India,  it  may  be  mentioned  that  they  rendered 
excellent  service  in  seconding  the  efforts  of  the  central  and  provincial 
governments  in  grappling  with  two  of  the  most  important  administra- 
tive problems  which  occurred  during  the  period  under  review— namely, 
the  incidence  of  epidemics  and  the  high  prices  of  commodities. 

Plague. 

The  monsoon  of  1917  was  exceptionally  abundant  and,  partly  perhaps 
in  consequence  of  this,  plague  made  its  Appearance  in  serious  degree 
during  the  year.  Between  July.  1917,  and  June,  1918,  the  total  number 
of  deaths  from  plague  was  over  800,000.  Although,  fortunately,  there 
is  reason  to  believe  that  the  incidence  of  the  disease  in  India  is  on  the 
wane,  the  distress  and  dislocation  caused  by  this  mortality  was  very 
great.  In  addition  to  the  influence  of  the  plague  epidemic  the  year  as 
a whole  was  very  unhealthy,  and  a high  death-rate  occurred  both  from 
cholera  and  malaria.  Relief  measures  were  undertaken  by  the  local 
administrations,  the  provincial  sanitary  and  medical  officers  laboured 
with  the  utmost  zeal,  and  the  number  of  hospitals  and  travelling  dis- 
pensaries was  evervwbere  increased.  Preventive  measures  in  the  way 
of  evacuation  of  infected  areas  were  undertaken  in  many  places,  and 
inoculations  were  carried  out  on  a larger  scale  than  was  previously 
known. 

Influenza. 

Bad  as  were  the  general  conditions  of  public  health  in  India 
during  the  year  1917,  those  of  1918  were  infinitely  worse.  In  the 
month  of  June,  1918,  came  the  first  intimation  that  influenza  in 
a virulent  form  was  attacking  India.  In  the  city  of  Bombay 
towards  the  end  of  that  month  many  employees  of  offices,  banks,  and 
so  forth  were  incapacitated  by  fever.  The  disease  began  to  spread  over 
India,  and  before  long  the  mortality,  at  first  low,  began  to  rise  in  an 
alarming  degree.  In  the  city  of  Bombay  itself  the  mortality  reached 
its  maximum  on  Oct.  6th,  on  which  day  768  deaths  were  recorded.  The 
full  force  of  the  outbreak  was  felt  by  the  central,  ndi-thern,  and  western 
portions  of  India,  in  comparison  with  which  Bengal,  Burma,  Bihar, 
and  Orissa,  Madras,  and  Assam  suffered  but  lightly.  During  the  last 
quarter  of  1918  India  seemed  to  have  suffered  more  severely  than 
any  other  country  in  the  world  ; and  influenza  was  responsible  in 
British  India  alone  for  a death  roll  of  approximately  5 millions. 
Detailed  information  with  regard  to  the  incidence  of  the  disease  in  the 
Indian  States  is  not  available,  but  it  is  unlikely  that  the  influenza 
mortality  therein  fell  short  of  1 million.  Within  the  space  of  four  or 
five  months  influenza  was  thus  responsible  for  the  deaths  of  2 per  cent, 
of  the  total  population  of  British  India.  In  some  places— the  Central 
Provinces  for  example  -two  months  of  influenza  caused  twice  as  many 
deaths  as  22  years  of  plague.  In  Bombay,  between  Sept.  10th  and 
Nov.  10th,  the  total  average  mortality  was  326  deaths  a day.  Had 
mortality  continued  at  this  rate  throughout  the  year  the  death-rate  of 
the  city  would  have  been  over  120  per  1000  of  the  Census  population. 
The  Punjab  also  suffered  very  severely. 

Efforts  to  Cope  with  the  Disease. 

The  provincial  administrations  and  the  local  bodies  to  whom  is 
mainly  entrusted  the  maintenance  of  sanitation  and  public  health 
made  whole-hearted  endeavours  to  ameliorate  the  sickness  and  suffering 
occasioned  by  the  outbreak.  The  epidemic  struck  India  at  a time 
when  she  was  least  prepared  to  cope  with  a calamity  of  such 
magnitude.  War  demands  had  depleted  her  sanitary  and  medical 
personnel,  which  at  best  is  inadequate  when  considered  in  rela- 
tion to  the  i ize  of  her  population  and  of  the  tenacity  with 
which  the  population  clings  to  domestic  oustoms  injurious  to 
public  health.  The  overworked  staff  that  remained  was  struck  down 
in  large  numbers  Still  more  serious  were  the  effects  of  the  almost 
total  failure  of  the  monsoon,  which  exercised  a disastrous  influence 
practically  throughout  the  country.  The  staple  food  grains  were  at 
famine  prices,  and  the  scarcity  of  fodder  reduced  the  quantity  of 
mdk  available.  Although  there  is  no  reason  to  suppose  that  the 
epidemic  originated  in  malnutrition,  it  was  particularly  un- 
fortunate that  the  price  of  nourishing  food,  and  also  of 
Buch  comforts  as  blankets  and  warm  clothing  was  extremely  high. 
In  all  the  larger  towns,  where  severe  epidemics  occurred,  many 
additional  dispensaries  were  opened  by  the  looal  authorities,  and 
numerous  agencies  were  employed  for  the  free  distribution  of  drugs 
and  milk.  In  some  towns  municipal  grain  shops  were  opened  which 
supplied  grain  below  the  market  rates.  Endeavours  were  made  by  all 
administrations  to  instruot  the  people  as  to  the  nature  of  the  malady, 
as  to  measures  for  its  prevention,  and  as  to  measures  to  be  adopted 
when  it  had  set  in.  The  efforts  of  official  bodies,  whether  provincial  or 
local,  were  nobly  seconded  by  non-officials,  by  philanthropic  societies, 
by  educational  es'ablishments,  and  by  a host  of  voluntary  workers. 
Everything  that  could  have  been  done  with  the  agency  available  was 
done.  But  with  a population  as  vast  as  is  that  of  India  to-day,  with  a 
relatively  low  standard  of  living,  the  control  of  so  virulent  an  epidemic 
is  completely  outside  the  present  scope  of  human  endeavours. 

The  magnitude  of  the  task  which  the  administration 
was  called  upon  to  face  may  be  gauged  from  the  fact 
that,  according  to  the  report,  it  has  been  estimated 
that  from  50  to  80  per  cent,  of  the  total  population 


of  India  has  recently  suffered  from  influenza.  It  is  un- 
deniable that  the  catastrophe  was  rendered  more  complete 
by  the  generally  insanitary  conditions  under  which  the 
major  portion  of  the  population  of  India  live  their  lives; 
and  the  necessity  of  redoubling  the  efforts  of  the  administra- 
tion, both  central  and  provincial,  to  secure  the  improve- 
ment of  those  conditions,  has  become  more  than  ever 
apparent. 

MEDICAL  WOMEN  IN  CONFERENCE  ON  SOCIAL 
PROBLEMS. 

An  International  Conference  of  Women  Physicians, 
promoted  by  the  War  Work  Council  of  the  Y.W.C.A.,  is  tc 
be  opened  in  New  York  on  Sept.  15th,  and  will  sit  for  six 
weeks.  Some  50  representative  medical  women  from 
various  parts  of  Europe  have  accepted  the  invitation  to 
the  Conference ; doctors  from  India  and  China,  South 
America  and  Canada,  are  also  expected,  and  delegates  from 
the  United  States  themselves  will  doubtless  be  numerous. 
The  general  purpose  is  to  learn  the  attitude  towards  social 
education  in  health  and  sex  problems  taken  up  by  the 
various  countries  of  the  more  or  less  civilised  world,  and  to 
discuss  individual  national  problems.  After  the  more 
technical  aspects  of  these  problems  have  been  dealt  with 
by  the  Conference,  selected  members  of  the  lay  public  will 
be  invited  to  join  the  medical  women  during  the  last  week 
of  their  session.  The  object  of  this  general  conference  will 
be  to  reach  a common  ground  of  understanding  upon  which 
to  base  cooperative  methods  in  dealing  with  social  problems 
affecting  the  women  of  the  world.  The  tentative  programme 
submitted  to  us  suggests  that  the  proceedings  of  tbie 
gathering  are  likely  to  be  of  great  interest. 

THE  ETHICS  OF  ADVERTISING. 

AN  editorial  article  in  the  Journal  of  the  American  Medica. 
Association  of  August  9th  contains  some  shrewd  remarks 
on  this  subject.  What  is  there  about  advertising  having 
a medical  “slant”  that  so  often  causes  the  advertiser 
to  abandon  the  principle  of  honesty  and  common  sense 
Products  which  are  sufficiently  good  to  stand  on  their  own 
merits  and  which,  when  advertised  in  a non-medical  way. 
are  described  truthfully,  when  they  enter  the  medical  or 
quasimedical  field  are  presented  to  the  public  in  such 
a way  as  to  cast  discredit  on  the  whole  field  of 
advertising.  “These  thoughts  are  provoked,”  says  our 
contemporary,  “by  an  advertisement  that  has  recently 
appeared  in  certain  medical  journals  on  ‘ Adams  Chewing 
Gum.’  The  product  itself  is  one  that  certainly  needs  no 
misstatements  or  quibbling  to  stimulate  its  sale.  The 
advertisement  in  question  is  entitled  ‘ The  Care  of  the 
Mouth,’ and  is  made  up  largely  of  what  purports  to  be  a 
quotation  from  an  article  by  a ‘ pediatrician.’  There  are  two 
things  wrong  with  the  advertisement.  First,  the  reader 
given  the  impression  that  the  quoted  article  has  appeared 
comparatively  recently  ; it  appeared  about  eight  years  age. 
Second,  the  quotation  has  been  garbled  and  the  writer  is 
made  to  say  things  that  he  never  said.  The  parallel  indicate; 
the  liberties  that  have  been  taken  ; 

Original  Article.  As  Quoted  in  Advertisement 

‘The  child  naturally  rebels  1 A child  naturally  rebels  ag«int‘ 
against  the  cleansing  process  mouth  cleansing  while  It  is  ill  or 
while  it  is  vert  ill  and  theref  ire  peevish,  and  toerefore  If  some 
if  some  more  attractive  and  more  attractive  and  efficient  way 
efficient  way  can  be  found  to  can  be  found  to  accomplish  the 
accomplish  the  same  result,  we  same  result,  we  ought  to  take 
ought  to  take  advantage  of  it.  advantage  of  it. 

The  use  of  chewing  gum  seems  ‘Adams  Pepsin  Chewing  ecv 
to  offer  the  best  relief.  It  is  seems  to  offer  the  best  relief.  It 
attractive  to  the  child ,’  etc.  is  attractive  to  the  child ' etc. 

The  portions  that  fail  to  coincide  have  been  put  in  smi- 
capitals.  Aside,  altogether,  from  the  medical  aspects  of  the 
case,  and  aside  from  the  morality  or  ethics  of  the  matter,  the 
liberties  which  the  Adams  Chewing  Gum  concern  nave  taken 
with  the  article  have  weakened  rather  than  strengthened 
the  ‘ copy.’  These  advertisements  were  for  medical  journals. 
The  average  physician,  in  reading  the  advertisement  as  it 
appeared,  would  immediately  have  his  suspicion  arousei. 
This  in  itself  is  bad  advertising.  The  reader,  knowing 
that  the  average  physician  does  not,  in  scientific  articles 
appearing  in  medical  journals,  generally  recommend  pro- 
prietary products,  would  jump  to  the  conclusion  that,  if  such 
an  article  wae  written,  it  probably  had  a venal  origin,  or  else  f 
it  was  probably  written  by  a man  of  little  repute.  Toe  s 
chewing  gum  concern  would  have  made  a stronger  appt-S; 
had  they  quoted  from  the  article  verbatim,  and  then  aided  ‘ 
their  own  comment  to  the  effect  that  if  the  profession  wanted  •' 
a chewing  gum  here  was  one  the  manufacturers  coaid 
recommend.”  . . :: 

The  editor  of  the  Journal  of  the  American  Medical  .Utnct*  it 
tion  will  find  it  impossible  to  make  his  would-be  advertisers  j, 
believe  the  plain  truth  of  his  words. 

F.  St.J.  S. — The  condition  can  hardly  be  prescribed  for  on 
so  brief  a description  ; can  more  particulars  be  given 


THE  LANCET,  September  20,  1919. 


THE 

Cjwbtokk  ledum 

ON 

THE  PROBLEM  OF  HYGIENE  IN  EGYPT. 

Being  Three  Lectures  delivered  at  the  Summer  Session , 1919, 

By  ANDREW  BALFOUR,  C.B.,  C.M.G.,  M.D., 

DIRECTOR-IN-CHIEF,  WELLCOME  BUREAU  OF  SCIENTIFIC  RESEARCH  ; 
LATE  PRESIDENT,  EGYPTIAN  PUBLIC  HEALTH  COMMISSION. 


LECTURE  III.— THE  SOLUTION  OF  THE  PROBLEM  : 
PRESENT  AND  FUTURE. 

In  our  first  lecture  we  considered  the  more  obvious  causes 
which  produce  the  problem  of  hygiene  in  Egypt;  in  our 
second  we  discussed  those  which  are  more  obscure  and 
which,  being  intimately  bound  up  with  the  form  of  central 
administration  that  is  in  vogue,  led  to  a review  of  the  latter. 
We  will  now  turn  our  attention  to  the  provincial  organisa- 
tion and  see  not  only  what  problems  it  furnishes  but  how  it 
meets  the  needs  of  health  in  the  towns,  in  the  villages,  and 
in  the  rural  parts  of  the  Mudiriyas,  as  the  provinces  are 
termed  in  the  Arabic  of  Egypt. 

Provincial  Organisation  in  the  Present. 

It  is  usually  a relief  to  leave  a city  like  Cairo  or 
Alexandria  and  fare  forth  into  the  green  of  the  Delta.  The 
air  is  fresh,  the  sky  is,  as  a rule,  blue  and  cloudless,  and 
though  the  scenery  is  monotonous  the  rural  life  is  interesting 
and  there  are  many  spots  which  are  eminently  picturesque. 
In  Upper  Egypt  one  is  not  often  far  from  the  Nile  and  the 
Father  of  Waters  rarely  fails  to  please  the  eye  and  quicken 
the  imagination. 

If  there  is  not  very  much  to  entrance  the  botanist  and 
the  zoologist,  at  least  compared  with  some  other  Eastern 
lands,  there  is  always  something  in  Egypt  to  catch  the 
sanitary  eye  and  too  often  something  also  to  titillate  the 
sanitary  nose.  The  sanitarian  views  a reedy  water  channel, 
and  while  he  thinks  of  it  turning  the  black  alluvial  soil  into 
the  richest  of  muds  and  benefiting  the  patient  cultivator, 
he  knows  that  as  a source  of  drinking  water  it  is,  to  say  the 
least,  doubtful  ; for  may  it  not  in  parts  be  full  of  cercarire 
or  constitute  a medium  wherein  typhoid  or  dysentery  bacilli 
lurk,  or,  given  the  opportunity,  may  it  not  harbour  the 
cholera  vibrio?  He  notes  the  rich  mud  and  the  fellaheen 
ankle-deep  at  work  in  it  and  wonders  whether  or  not  the 
larvae  of  ankylostomes  are  busy  finding  their  way  through 
the  skin  of  the  peasant  farmers.  A grove  of  stately  date 
palms  confronts  him,  and  while  he  admires  them  for  their 
beauty  and  their  fruitfulness  he  cannot  forget  the  filthy 
manner  in  which  agwa  is  prepared.  His  eye  roves 
over  the  picturesque,  nondescript  village  huddling  on  its 
little  mound  hard  by  the  birka  with  its  green  scum 
and  countless  frogs,  and  though  he  admits  it  has  a 
beauty  of  its  own,  he  cannot  but  recall  its  flies  and  their 
breeding  places,  its  rats  and  their  fleas,  its  inhabitants  and 
their  lice,  and  instinctively  he  thinks  of  dysentery,  of  plague, 
of  typhus,  and  relapsing  fever.  And  so  on  and  so  forth’. 
\ou  will  doubtless  say  what  a very  unpleasant  mind  your 
sanitarian  must  have  ! It  is  one  thing  to  find  sermons  in 
stones  and  books  in  the  running  brooks,  but  surely  to  conjure 
up  parasites  and  disease  in  well-nigh  every  feature  of  the 
landscape  is  a dismal  form  of  mental  recreation,  a morbid 
type  of  fancy.  I grant  you  such  is  in  some  measure 
the  case,  but  the  pity  is  that  there  is  good  cause  for 
these  imaginings.  And  yet  the  sanitarian  is,  as  a 
rule,  no  pessimist.  He  knows  these  evils  exist,  but  he 
also  knows  that  they  are  one  and  all  preventable,  and  his 
ambition  is  to  remedy  them  so  far  as  it  lies  within  his 
power  to  do  so.  Their  presence  arouses,  or  should  arouse, 
the  fighting  spirit  in  him,  and,  believe  me,  there  is  some- 
thing stimulating  and  satisfying,  as  well  as  disheartening, 
in  waging  war  against  the  forces  of  disease  and  death 
in  such  a country  as  Egypt. 

Divisional  Inspectors. 

That  is  one  reason  why  we  are  always  likely  to  find  able 
young  men  eager  to  take  up  the  work  of  divisional  inspectors 

No  5012  V 


who,  as  you  will  see  from  the  graph  (Graph  1,  Lecture  II.), 
head  the  list  of  those  who  fight  the  battle  of  health  in  the 
Egyptian  provinces. 

One  reason  why  the  contest  has  not  been  so  victorious  as 
might  have  been  hoped  is  to  be  found  in  the  paucity  of  the 
numbers  of  these  divisional  inspectors.  There  are  14- 
provinces  in  Egypt,  many  of  them  large,  most  of  them 
exceedingly  populous.  The  number  of  inspectors  has  in 
the  past  been  woefully  few,  and  during  the  war  it 
diminished  almost  to  vanishing  point.  Furthermore,  the 
inspectors  were  nob  resident  in  their  districts.  As  a rule, 
they  were  constantly  on  the  move,  and  so  were  not  in  the 
best  position  for  getting  into  close  touch  with  the  populace 
and  the  prevailing  conditions.  Their  duties  also  were  far 
from  being  merely  sanitary,  as  they  had  to  exercise  a 
supervision  over  the  provincial  hospitals,  the  medico-legal 
work  of  the  Markaz  doctors,  and  all  the  hundred  and 
one  matters  which  are  intimately  bound  up  with  health 
problems  in  the  provinces. 

Provincial  Hospitals. 

A glance  at  Graph  1 shows  that  the  provincial  work  is 
divided  into  that  concerned  with  hospitals  and  that  which  is 
directly  under  the  charge  of  the  Markaz  and  outpost  doctors 
and  which  is  a regular  olla-podrida  of  widely  differing 
duties.  The  question  of  provincial  hospitals  need  not  detain 
us.  In  discussing  Section  II.  of  the  Central  Administration 
we  saw  the  problems  they  present.  It  is  time  to  turn  to  the 
Mudiriya  health  inspectors,  who  are,  for  the  most  part,  stout, 
worthy,  and  elderly  Egyptians  who  form  the  link  between 
the  English  divisional  inspectors  and  the  Markaz  doctors, 
and  are  virtually  the  medical  officers  of  health  of  the 
provinces.  Being  as  a rule  advanced  in  years,  they  are  not 
generally  energetic,  they  are  not  sufficiently  well  paid,  and 
few  of  them  do  much  in  the  way  of  private  practice.  Their 
chances  of  promotion  are  very  small,  and  they  tend  to 
become  inactive  and  to  concern  themselves  chiefly  with 
office  work.  Here  and  there  you  will  find  a keen  and  able 
man,  but,  for  the  most  part,  the  Mudiriyah  health  inspectors 
may  be  described  as  genial  anachronisms. 

The  Markaz  Doctor. 

And  now  we  come  to  one  of  the  most  important  props  of 
the  health  fabric  in  Egypt — the  Markaz  doctor — a Markaz 
being  a section  or  district  of  a province.  It  may  be  a 
populous  and  prosperous  district,  so  much  so  that  one 
solitary  medical  officer  may  have  as  many  as  100,000  people 
nominally  under  his  charge.  In  such  a case  the  majority 
die  what  the  old  Highlander  called  “natural  deaths,”  for 
the  doctor  cannot  get  anywhere  mar  them  when  they  are 
ill.  All  the  same  he  probably  enjoys  a most  lucrative  private 
practice  to  which  his  government  duties  may  or  may  not 
play  second  fiddle.  On  the  other  hand,  the  Markaz  may  be 
poor  and  sparsely  peopled,  no  great  catch  for  the  young  and 
pushing  graduate  from  the  Kasr-el-Aini  School  of  Medicine 
who  finds  himself  in  such  a district  with  very  poor  official 
pay,  say  £E.12  a month,  and  but  little  opportunity  of 
supplementing  it  in  any  way. 

Whether  his  Markaz  is  good  or  bad,  however,  he  is 
expected  to  perform  the  manifold  duties  set  forth  on  the 
list  shown  in  Graph  1.  One  has  only  to  read  the  long 
column  to  realise  that  in  the  great  majority  of  cases  the 
Markaz  doctor  is  set  an  impossible  task,  at  least  while  his 
numbers  remain  as  limited  as  they  are  at  present.  He  is 
supposed  to  deal  with  infectious  diseases  both  from  the  clinical 
and  the  preventive  aspects,  much  of  his  time  is  occupied 
with  medico-legal  work,  of  which  there  is  a super- 
abundance in  Egypt,  and  which  often  proves  remunerative 
in  several  directions,  and  he  is  expected  to  control  general 
sanitation.  Consider  what  this  means  in  a large  district 
studded  with  villages  and  seamed  by  canals  and  irrigation 
channels.  Oo  an  ambliDg  ass  the  Markaz  doctor,  surmounted 
by  his  red  tarboosh,  jogs  hither  and  thither,  often  covering 
many  miles  a day.  He  may  have  to  see  that  a birka  is 
filled  up,  he  may  have  to  inspect  a school.  The  water-supply 
of  a mosque  requires  his  attention,  he  has  to  furnish  a 
report  on  the  sanitary  condition  of  a Government  buildiDg. 
Questions  of  the  regulation  of  water  intakes  fall  to  his 
share,  as  do  those  of  street  cleaning,  slaughtering 
places,  the  enclosure  of  waste  lands,  and  the  selection 
of  sites  on  which  town  refuse  and  fosse  contents  can  be 
dumped. 


M 


508  The  Lancet,] 


DR.  A.  BALFOUR:  THE  PROBLEM  OF  HYGIENE  IN  EGYPT. 


[Sept.  20,  1919 


1 


His  Multifarious  Duties. 

As  if  all  this  were  not  enough,  he  has  still  to  keep  an  eye 
on  offensive  trades  in  his  district,  see  to  the  registration  of 
births  and  deaths,  superintend  the  vaccination  of  the  com- 
munity, attend  to  the  dispensary,  examine  prostitutes  in 
places  where  there  are  no  hospitals,  carry  out  various  duties 
connected  with  cemeteries,  in  one  or  other  of  which  he  must 
surely  sometimes  wish  he  were  quietly  at  rest.  Moreover, 
he  attends  the  meetings  of  the  local  commission  as  public 
health  delegate,  he  investigates  contraventions  against  the 
law  regarding  the  practice  of  medicine,  he  looks  after 
pilgrims,  and  keeps  an  eye  on  such  incomers  to  his  district 
as  are  under  the  passenger  control  regulations.  He  is  respon- 
sible for  the  sanitary  state  of  fairs,  he  examines  and  reports 
on  sick  Government  employees,  he  also  examines  the 
village  police,  and  finally  inspects  the  bodies  of  those 
who  die  uncertified.  In  addition,  he  usually  earns  his 
living  by  private  practice,  and  presumably  he  eats,  drinks, 
and  sleeps  1 

But  you  will  say,  “The  poor  man  must  have  a large  staff 
under  him  to  aid  him  in  these  multifarious  duties.”  Not  at 
all.  Look  at  the  graph.  It  is  true  that  the  Omdahs  and 
Sarrafs,  head-men  of  the  villages,  register  the  births  and 
deaths,  but  I fear  they  often  give  the  conscientious  Markas 
doctor  more  trouble  than  assistance.  It  is  true  the  barber, 
if  he  happens  to  be  efficient,  may  render  considerable  aid  ; 
but,  after  all,  who  is  the  barber?  He  is  merely  an  un- 
qualified person  who  in  all  probability  has  inherited  his 
office,  and  though  he  may  be  highly  intelligent  and  carry  out 
his  own  minor  duties  of  vaccination,  cupping,  and  so  forth, 
in  a satisfactory  manner,  he  cannot,  in  the  nature  of  things, 
take  much  of  the  load  off  the  shoulders  of  the  Markaz  doctor. 
There  is  no  one  else,  for  the  Daya,  as  we  have  seen,  if  not 
negligible,  is  usually  dangerous.  It  is  only  when  epidemics 
occur  that  our  harassed  friend  gets  special  help  and  even 
that  is  only  in  one  particular.  In  the  strict  sense  of  the 
term  there  is  no  sanitary  staff  whatever  and  rural  Egypt  lies 
largely  at  the  mercy  of  the  microbe,  the  helminth,  and  the  fly. 

Administration  in  the  Governoratss. 

You  will  note  that  under  the  heading  Provincial  Organisa- 
tion mention  is  made  of  the  health  administration  in 
the  Governorates — that  is  to  say,  in  Cairo,  Port  Said, 
Suez,  and  Damietta.  Cairo  and  Port  Said  have  medical 
officers  of  health  ; Suez  and  Damietta  so-called  health 
inspectors. 

We  considered  the  conditions  in  Cairo  in  our  first  lecture 
and  need  not  recapitulate.  Of  late  years  things  have 
altered  greatly  for  the  better  in  certain  localities,  thanks 
to  hard  work  on  the  part  of  a very  capable  medical  officer 
of  health  and  to  the  partial  completion  of  the  great  drainage 
scheme,  the  sewers  of  which  cast  their  contents  upon  the 
desert  far  from  the  city  and  cause  it  to  blossom,  if  not 
like  the  rose,  at  least  like  a nosegay,  for  the  trees  and 
verdure  of  the  sewage  farm  now  form  a feature  of  the 
landscape,  and  there  was  never  yet  a sewage  farm  without 
an  aroma. 

Recently,  also,  the  Public  Works  Department  has  been 
erecting  public  conveniences  in  the  streets,  and  these,  well- 
designed  and  with  the  latest  sanitary  improvements,  must  be 
regarded  as  a very  considerable  hygienic  advance.  There 
still  remains,  however,  a great  necessity  for  public  drinkin°-- 
fountains  supplying  pure  water.  The  latter  is  available,  for 
there  is  a large  installation  of  mechanical  filters,  but 
it  is  not  to  any  extent  at  the  service  of  the  poorer 
parts  of  the  populace. 

Cairo , Port  Said,  and  Alexandria. 

The  Qism  medical  officers  whom  you  see  mentioned  on 
Graph  1 are  really  analogous  to  the  Markaz  doctors  of  the 
provinces  so  far  as  their  work  is  concerned.  Each  looks 
after  a division  or  district  of  the  city,  and  though  he  has  not 
to  traverse  great  distances  like  his  country  confrere,  he  has 
more  or  less  the  same  cheerful  variety  of  duties  and  has  very 
little  leisure  to  devote  himself  to  what  we  may  call 
pure  sanitation.  At  the  same  time  he  has  assistance 

which  the  Markaz  doctor  lacks,  for  there  are  properly 
organised  disinfecting  gangs  and  the  rudiments  of  a sani- 
tary staff.  Cairo,  indeed,  has  really  made  a start  in  the  right 
direction,  though  it  is  still  a very  long  way  from  a hygienic 
millennium. 


Port  Said  is  also  somewhat  progressive,  for  under  the 
British  medical  officer  of  health  there  is  a senior  medical 
man  who  devotes  himself  almost  entirely  to  sanitary 
work,  while  his  junior  is  entrusted  with  purely  medical 
duties. 

Very  different  is  the  state  of  matters  in  Alexandria,  which, 
as  we  have  stated,  is  a municipality  and  hitherto  has  been 
almost  entirely  a law  unto  itself.  In  other  words,  it  has  not 
been  controlled  by  the  Public  Health  Department.  The  latter 
has  merely  had  the  power  to  intervene  when  some  epidemic 
raging  in  the  city  threatens  danger  to  other  places,  a fine 
example  of  shutting  the  stable-door  when  the  steed  has 
been  stolen.  The  Qism  doctors  who  are  supposed  to  safe- 
guard the  public  health  in  Alexandria  are  not  trained 
sanitarians  and  are  permitted  to  engage  in  private  practice. 
Though  there  is  a medical  officer  of  health,  there  is  no 
expert  control.  There  are  no  qualified  sanitary  inspectors. 
Indeed,  the  whole  health  administration  of  this  wealthy 
port  is  radically  wrong,  and  it  is  no  wonder  that  the  insani- 
tary conditions  we  described  in  our  first  lecture  have  been 
the  subject  of  adverse  comment  in  the  press,  and  that 
repeated  outbreaks  of  typhus  fever  have  evoked  well-merited 
criticism  and  a clamour  for  reform. 

Future  Sanitary  Organisation. 

Our  review  of  existing  health  problems  in  Egypt  is  now  at 
an  end,  and  we  turn  to  the  future.  Shortly  after  the  retiral 
of  the  last  Director-General  of  the  Public  Health  Depart- 
ment, the  High  Commissioner  appointed  a Commission  to 
inquire  into  the  future  organisation  and  work  of  that  depart- 
ment. Very  nearly  a year  ago  the  Commission  began  its 
sittings,  examined  many  witnesses,  studied  much  docu- 
mentary evidence,  carded  out  numerous  inspections,  and  in 
the  fullness  of  time  was  delivered  of  a report,  with  the  salient 
features  of  which  we  shall  now  deal.  Whether  or  not  the 
problem  of  hygiene  in  Egypt  will  be  solved  if  the  recom- 
mendations of  the  Commission  are  adopted  and  carried 
into  effect  no  one  can  say.  Egypt  being  Egypt,  it  is 
quite  possible,  nay  probable  indeed,  that  the  proviso  will 
never  be  forthcoming,  at  least  in  toto.  Still,  it  may 
be  said  that  the  council  of  four1  constituting  the  Com- 
mission found  themselves  in  complete  unanimity  and  that 
what  public  opinion  exists  in  Egypt,  generally  speaking, 
approves  their  findings. 

A Ministry  of  Health. 

What  are  the  findings  ? I direct  your  attention  to  a new 
graph  (No.  2)  and  you  will  note  at  once  the  words  “Ministry 
of  Health.”  Despite  some  evidence  to  the  contrary,  the 
Commissioners  were  persuaded  that  the  establishment  of 
such  a Ministry  was  essential.  The  reasons  for  this  belief 
have  already  been  recorded  in  the  weighty  words  of  Dr. 
Cyril  Goodman,  who  further  states  : — 

“ The  reorganisation  of  Egypt  on  constitutional  lines, 
rendered  necessary  by  the  Protectorate,  offers  a peculiarly 
favourable  opportunity  of  giving  public  health  a place  in 
the  constitution  commensurate  with  its  importance  to  the 
country.  Public  order,  finance,  irrigation,  agriculture, 
education  and  public  health  constitute  the  six  principal 
interests  of  Egypt  and  the  six  principal  duties  of  Great 
Britain  towards  its  Protectorate.  The  present  scheme  of 
government  includes  in  its  governing  body  representatives 
of  each  of  these  interests,  with  the  exception  of  public  health. 
If  the  policy  of  Great  Britain  towards  Egypt  is  to  be  placed 
on  the  broadest  basis  of  material,  mental,  and  physical 
advancement  of  the  people  then  public  health  must  be  given 
without  delay  representation  on  the  Council  of  Ministers, 
on  the  Council  of  Advisers,  and  it  must  be  recognised  as  the 
direct  adviser  of  the  High  Commissioner  on  matters  of 
public  health. 

It  must  be  frankly  stated  that  those  who,  while  expressing 
sympathy  with  the  idea,  urge  delay  in  its  execution  must 
be  considered  as  inimical  to  the  movement  itself,  for  a 
successful  public  health  policy  must  grow  with  the  funda- 
mental institutions  of  the  country.  It  must  be  built  into, 
not  be  grafted  on,  the  constitution.  If.  therefore,  the 
importance  of  public  health  in  Egypt  is  sufficiently  great  to 
justify  its  inclusion  as  a Ministry  amongst  those  which 
direct  the  policy  of  the  country,  then  it  is  clear  that  during 
and  not  after  the  remodelling  of  the  institutions  of  the 
country  is  the  proper  time  for  that  inclusion.” 


1 The  Commission  was  composed  as  follows: — President:  Lieutenant- 
Colonel  Andrew  Balfour.  C.B. , C.  M.G.,  R.  A. M.C.  M mbers  Lieutenant- 
Colonel  G.  E.  F.  Stammers.  R.A.M.C.  ; Mr.  E.  S.  Crispin,  Director. 
Medical  Department,  Sudan  Government ; and  Dr.  Charles  Todd. 
O.B.K.,  Director  of  Laboratories,  Department  of  Public  Heahh 
Secretary  ; Mr  H Sheridan 


The  Lanobt,] 


DR.  A.  BALFOUR : THE  PROBLEM  OF  HYGIENE  IN  EGYPT. 


[Sept  20,  1919  _509 


PROVINCIAL  ORGANIZATION.  CENTRAL  ORGANIZATION. 


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510  The  Lancet,] 


DR.  A.  BALFOUR:  THE  PROBLEM  OF  HYGIENE  IN  EGYPT. 


[Sept.  20,  1919 


The  Head  of  the  Ministry. 

It  remains  to  be  seen  how  such  a Ministry  should  be 
constituted.  At  its  head  there  must,  of  course,  be  a Minister 
— an  Egyptian — and  he  must  bean  official  thoroughly  versed 
in  public  affairs,  interested  in  the  welfare  of  the  people,  in 
social  problems,  and  in  scientific  progress.  It  is  not 
impossible  to  find  such  a man  in  Egypt,  and,  once  found, 
his  words  would  carry  great  weight  in  the  C mncil  Chamber. 
He  need  not  of  necessity  be  a medical  man.  Indeed,  the 
appointment  of  a layman  would  possess  certain  advantages, 
as  it  would  ensure  that  the  Minister  of  Health  was  on  the 
same  footing  as  other  Ministers,  was  appointed  for  the  same 
political  reasons,  and  would  be  interchangeable  with  them  if 
a Ministerial  rearrangement  was  required.  In  immediate 
command  it  is  essential  to  have  a British  Under-Secretary 
of  State,  a medical  man,  who  must  needs  possess  a long  and 
intimate  knowledge  of  health  matters  in  Egypt  and  be  con- 
versant with  the  intricacies  of  governmental  machinery  in 
that  country.  He  will  control  the  sanitary,  epidemic,  and 
medical  work  of  the  Ministry.  As  a glance  at  the  graph 
shows,  there  will  be  a Department  of  Medical  Educa- 
tion under  him,  a new  departure  and  one  necessi- 
tated by  the  present  state  of  Egyptian  affairs.  His  duty 
will  be  to  frame  future  policy  and  indicate  how 
health  legislation  should  best  be  carried  out,  to  see 
that  the  work  is  conducted  upon  a souud  scientific  brsis 
and  that  scientific  research,  which  alone  can  point  the  way 
to  reform,  receives  due  encouragement.  He  must  also  be 
capable  of  taking  that  broad  view  on  which  so  much  depends 
and  possess  those  qualities  of  tact  and  firmness  which  count 
for  so  much  in  Eastern  lands.  Finally,  as  the  Commission 
reported,  “it  is  essential  that  he  should  have  direct  access 
to  the  High  Commissioner,  so  that,  armed  with  the  weapons 
of  an  expert,  he  may  be  able  to  plead  his  cause  to  good 
effect.” 

The  main  driving  force  of  the  Ministry  will,  howe’er, 
undoubtedly  be  the  Director-General,  who  should  not  be  to) 
old  a man.  Public  health  work  is  a campaign  against  Field- 
Marshal  Death  and  his  redoubtable  generals — to  wit.  Dirt, 
Destitution,  Disease,  Ignorance,  Superstition,  and,  by  no 
means  the  least  doughty,  the  fighter  with  the  double-barrelled 
name,  General  Vested-Interests  1 Hence,  as  in  war,  the 
commander  must  unite  a certain  degree  of  youthful  energy 
and  vigour  with  the  experience  and  powers  of  judgment 
which  are  so  necessary.  Not  only  must  he  be  a capable 
organiser,  but  he  must  combine  strength  and  sympathy 
in  his  work,  for,  lacking  sympathy,  he  will  probably 
fail  in  a land  like  Egypt. 

The  Technical  Adviser. 

The  next  post  is  a new  one,  though  it  exists  unofficially. 
It  is  that  of  Technical  Adviser  and  Director  of  Medical 
Intelligence.  I am  not  sure  but  that  it  is  the  most  important 
of  all,  and  though  the  duties  of  the  post  would  be  chiefly 
advisory,  its  holder  would  not  be  wholly  divorced  from 
administrative  work,  for,  as  you  will  observe,  he  would 
control  the  scientific  side  of  the  Health  Ministry  in  so  far  as 
hygiene  is  concerned.  Here  is  what  the  Commission  say 
about  this  appointment  : — 

“ We  consider  a post  of  this  nature  to  be  of  the  very 
greatest  importance.  The  Technical  Adviser  would  not 
only  act  in  that  capacity  to  both  the  Under  Secretary  and 
the  Director-General,  but  he  would  conduct  a Bureau  of 
Information.  Controlling  the  main  library,  keeping  himself 
closely  in  touch  with  what  goes  on  in  other  countries,  study- 
ing the  vast  literature,  corresponding  with  similar  depart- 
ments of  other  Governments,  he  would  be  in  a position  to 
furnish  invaluable  information  to  the  chiefs  of  the  various 
Sectious,  and,  by  issuing  instructive  pamphlets  and  circulars 
both  to  Public  Health  officials  and  to  the  medical  profession 
in  Egypt,  he  might  speedily  make  the  Ministry  of  Health  a 
real  power  in  the  laud.  Moreover,  he  would  collect  and 
collate  information  from  local  sources,  so  that  at  any  time 
he  would  be  in  a 'position  to  advise  on  problems  arising  in 
Egypt  itself.  The  lack  of  a bureau  of  this  kind  in  the 
Medical  Department  of  the  British  War  Office  has  made 
itself  severely  felt  in  the  various  tropical  and  subtropical 
areas  of  hostilities.  Such  work,  properly  carried  out,  effects 
great  saving  in  both  time  and  money,  and  possibly  does  more 
than  anvthiug  else  towards  making  a Government  Depart- 
ment really  efficient  and  up-to-date.” 

A Museum  of  Medicine  and  Hygiene. 

A further  proposal  of  the  Commission  is  the  establishment 
of  an  Egyptian  Museum  of  Medicine  and  Hygiene,  which 


would  be  of  an  educational  nature,  and,  under  the  guidance 
of  the  Technical  Adviser  to  the  Health  Ministry,  should  prove 
itself  a stimulus  towards  sanitary  reform.  It  is  not  sug- 
gested that  this  should  be  a Government  undertaking.  So 
truly  national  a project  may  well  find  support  amongst  the 
wealthy  and  influential  of  Egypt.  As  the  Commissioners 
remark  : — 

“There  is  undoubtedly  a need  for  some  such  institution  in 
Egypt,  where,  in  a graphic  manner,  information  will  be 
furnished,  both  to  officials  and  to  the  populace  generally,  as 
regards  the  diseases  of  Egypt,  the  insanitary  conditions  pre- 
vailing in  the  country,  methods  of  dealing  with  epidemics, 
and  means  of  rendering  towns  and  villages  clean  and  healthy. 
The  work  of  hospitals  and  dispensaries  would  be  illustrated, 
the  role  of  insects  in  disease  explained,  the  danger  from 
faulty  and  deficient  dietaries  set  forth,  together  with  measures 
of  prevention  and  cure.  In  fact,  a great  centre  of  instruction 
would  be  established— a school  where  one  might  learn  with 
little  effort,  where  interest  would  be  excited  and  sympathy 
aroused.” 

Sections  oe  the  Central  Administration. 

At  this  point  I may  mention  that  the  Commission  recom- 
mended a Board  of  Health  for  Egypt,  a body  which 
undoubtedly  would  be  of  benefit  in  many  directions.  The 
results  of  its  deliberations,  as  suggested  by  Dr.  Goodman, 
should  be  published  for  the  information  of  the  public.  We 
need  not  here  enter  into  the  question  of  its  constitu- 
tion, but  will  continue  our  consideration  of  the  Central 
Administration  under  the  new  scheme.  Three  of  the 
sections  we  previously  discussed  become  departments  and 
one  disappears,  the  ophthalmic  section  being,  for  purposes 
of  economy  and  facility  in  administration,  attached  to  the 
Department  of  Medical  Services,  which  is  the  old  hospital 
section. 

The  new  Department  of  Sanitary  Services  will  require  a 
director  intimately  acquainted  with  Egyptian  conditions. 
His  duties  have  been  set  out  in  rather  more  detail  than  were 
those  of  the  director  of  Section  I.,  and  the  only  one  of  them 
to  which  reference  need  now  be  made  is  that  indicated  by 
the  term  sanitary  training  centres.  As  will  in  due  course 
be  seen,  these  are  intended  as  schools  of  sanitation  for 
training  certain  inspectors  of  nuisances  whom  it  is  proposed 
to  create  for  the  purpose  of  dealing  with  village  sanitation. 
The  latter,  which,  as  you  will  see,  heads  the  list,  is 
perhaps  best  considered  under  the  proposals  for  provincial 
administration. 

The  Department  of  Epidemic  Services  shows  little  change 
from  Section  IV.,  save  that  the  suggestion  is  made  to  bring 
sea  quarantine  under  it.  This  is  a difficult  matter,  for  it 
involves  complex  international  questions,  and  no  one  can  say 
how  it  will  yet  be  settled.  Inland  water  transport  is 
mentioned,  as  it  plays,  or  may  play,  an  important  part  in 
the  spread  of  plague  and  cholera  when  these  diseases  are 
epidemic  in  Egypt. 

The  Hospital  Section  becomes  the  Department  of  Medical 
Services,  and  the  shortcomings  which  have  been  mentioned 
indicate  the  measures  required  for  their  remedy.  In  addition 
to  an  increase  in  general  and  infectious  hospitals  and  a 
new  policy  as  regards  the  treatment  of  prostitutes  in  the 
former,  it  is  essential  that  technical  inspectors  be  appointed 
to  visit  periodically  the  23  general  Government  hospitals  and 
to  reside  in  them  from  time  to  time  for  limited  periods.  In 
some  of  these  hospitals,  also,  post-graduate  courses  might 
with  advantage  be  instituted. 

Absorption  of  Other  Medical  Services. 

The  medical  service  of  the  Ministry  of  Education  might 
with  advantage  be  brought  under  the  control  of  the  Ministry  of 
Health.  The  medical  inspection  of  school  children  in  Egypt 
is  of  the  highest  importance  and  requires  to  be  developed 
with  the  help  of  technical  inspectors.  It  will  be  seen  that 
those  medical  services  which  have  been  outside  the  fold  or 
have  strayed  from  it  are  to  be  shepherded  into  it,  so  that 
the  whole  health  work  of  the  country  may  be  properly 
coordinated,  while  the  medico-legal  work  no  longer  figures 
under  general  sanitation,  but  is  brought  into  this  department. 
It  would,  indeed,  be  well  if  some  of  the  burden  of  this  class  of 
work  could  be  borne  by  the  Ministry  of  Justice,  but  the 
question  is  a difficult  one,  and  the  Commission  had  to 
content  itself  with  expressing  some  pious  hopes  in  that 
direction.  Certainly  a great  deal  of  the  time  of  the  Markaz 
doctors  is  taken  up  with  duties  which  are  nearly  as  much 
legal  as  melical. 


The  Lancet,] 


DR.  A.  BALFOUR:  THE  PROBLEM  OF  HYGIENE  IN  EGYPT. 


[Sept.  20,  1919  511 


The  medical  control  of  prostitution  and  venereal  diseases 
has  been  relegated  to  this  department,  and  only  those  who 
have  carefully  studied  the  problem  in  other  countries  can 
appreciate  all  that  it  involves.  More  lock  hospitals  are 
required,  clinics  for  the  treatment  of  venereal  diseases  must 
be  established,  the  populace  must  be  instructed,  and  facilities 
for  preventive  treatment  provided.  The  whole  question 
bristles  with  difficulties,  but  we  know  that  these  exist  to  be 
overcome,  and  money  and  determination,  and  above  all 
things  common-sense,  can  work  wonders. 

Provision  for  Incurables  anil  Lepers. 

As  regards  provision  for  incurables  and  lepers,  I cannot  do 
better  than  quote  again  from  the  Commission’s  report  :■ — 

“Homes  for  incurables  would  meet  a great  need  in  Egypt. 
The  country  is  full  of  crippled  and  debilitated  mendicants, 
for  whom  little  or  nothing  is  done.  The  tekiyas  of  the 
Ministry  of  Waqfs  deal  with  a few  incurable  cases,  but  the 
number  of  these  establishments  is  quite  inadequate.  These 
unfortunate  individuals  are  often  beggars,  are  liable  to 
become  foci  of  infection,  and  present  a problem  which  can 
only  be  solved  by  making  provision  for  them.  Even  then, 
only  a certain  proportion  of  them  can  be  housed,  but  this 
will  help  in  some  measure.  So  far  as  Cairo  and  its 
neighbourhood  is  concerned,  the  proposed  transference  of 
Qasr  el  ’Aini  hospital  from  its  present  site  would  leave 
vacant  a suitable  building  for  a hospital  for  incurables; 
others,  however,  are  required  in  various  parts  of  Egypt. 
This  is  not  the  work  for  the  Ministry  of  Health,  except  as  a 
controlling  and  inspecting  body. 

“ It  would  appear  to  be  the  privilege  of  the  Waqfs  Medical 
Services  to  make  such  provision.  Amongst  charities,  that 
which  benefits  the  aged,  the  infirm,  and  those  who  are 
beyond  the  skill  of  the  physician  and  surgeon  surely 
holds  a high  place.  It  is  true  that  some  waqfs  are 
allotted  by  their  donors  for  definite  purposes,  but  we 
are  assured  that  there  are  ample  funds  on  which  there 
is  no  reservation  and  which  might  well  be  devoted  to  this 
good  cause. 

“ Closely  associated  with  the  question  of  incurables  is  that 
of  lepers.  We  have  been  unable  to  obtain  any  reliable 
statistics  as  regards  the  present  prevalence  of  leprosy  in 
Egypt,  but  there  are  undoubtedly  a number  of  lepers  in 
certain  places— for  example,  Damietta.  There  is  nothing  to 
prevent  them  from  handling  foodstuffs  intended  for  sale ; 
and  though  leprosy  does  not  appear  to  spread  much  in 
Egypt,  and  though  the  channels  of  communication  from  the 
sick  to  the  sound  are  not  fully  known,  such  risks  should 
certainly  not  be  permitted.  Even  if,  from  the  public  health 
point  of  view,  it  may  not  seem  very  necessary  to  segregate 
lepers  in  Egypt,  there  is  the  humanitarian  aspect  of  the  case 
to  be  considered,  and  an  asylum  is  undoubtedly  required  for 
maimed  and  helpless  lepers,  as  well  as  for  those  who  are 
probably  an  active  source  of  infection.  A leper  colony  in 
which  work  could  to  some  extent  be  carried  out  on  the 
land  would  be  a wise  provision,  and  the  attention  of  the 
Ministry  of  Waqfs  might  well  be  drawn  to  this  charitable 
objeot. 

It  will  be  seen  that  the  lunatic  asylums  should  form  a 
section  of  the  Health  Ministry  under  a Director  of  Lunacy. 
This  is  in  accord  with  the  modern  trend  of  thought  as 
regards  the  work  of  the  alienist.  'Lunatic  asylums  are,  how- 
ever, so  specialised  that  they  cannot  be  grouped  with  other 
hospitals,  but  must  form  a separate  department. 

Medical  Education  in  Egypt. 

And  now  we  reach  a very  important  subject— that  of 
medical  education  in  Egypt,  which,  however,  can  only  be 
very  briefly  considered.  We  saw  that  the  Kasr-el-Aini  School 
of  Medicine  owed  its  foundation  to  Clot  Bey.  It  has  proved, 
especially  of  late  years,  a most  useful  institution  both  in  the 
way  of  teaching  and  of  research,  and  its  professoriate  has 
included  men  of  European  reputation.  Unfortunately,  the 
school  is  now  too  small  to  meet  the  needs  of  the  country, 
and  though  it  attracts  the  intellectual  elite  from  the 
secondary  schools  the  Ministry  of  Education  has  to  refuse 
many  applications  owing  to  lack  of  accommodation.  The 
vast  majority  of  the  students  who  pass  through  the  school 
find  employment  in  the  Public  Health  Service,  and  in  the 
absence  of  any  University  system  in  Egypt  it  is  deemed 
advisable  to  bring  medical  education  into  the  Ministry 
of  Health,  there  to  be  placed  under  the  control  of  a 
director,  who  must  of  necessity  be  given  a free  hand  not 
only  as  regards  medical  education,  but  with  respect  to  the 
training  of  dentists,  pharmacists,  nurses,  midwives,  and 
dayas.  Medical  research  work,  demanding  access  to  clinical 
material  and  requiring  the  calm  of  academic  surround- 
ings for  proper  development,  would  be  conducted  in 


the  laboratories  of  the  school  of  medicine  and  would 
be  distinct  from  the  applied  research  work  of  the  public 
health  laboratories,  which  is  of  a different  type  though 
equally  important. 

The  curriculum  of  the  school  can  be  improved  in  certain 
directions,  as  by  establishing  instruction  in  diseases  of 
children  and  in  protozoology.  A chair  of  hygiene 

should  undoubtedly  be  instituted  and  a diploma  granted, 
either  in  public  health  alone  or  in  tropical  medicine  and 
hygiene.  Like  the  medical  school,  the  great  teaching 
hospital  of  Kasr-el-Aini  requires  extension  and  improvement. 
Indeed,  a new  building  on  a new  site  has  long  figured  on  a 
programme  which  has  never  been  fulfilled.  Facilities  for 
dispensary  work  might  prove  valuable,  and  the  question  of 
training  Egyptian  women  doctors  is  one  meriting  serious 
consideration. 

In  Egypt  there  is  also  great  need  for  a powerful 
board  to  control  the  practice  of  medicine,  dentistry,  and 
pharmacy,  and  to  deal  with  all  questions  of  malpraxis  and 
vivisection. 

It  will  be  seen  from  the  graph  (No.  2)  that  it  is  proposed 
in  certain  respects  to  expand  the  work  of  those  public  health 
laboratories.  Protozoology  requires  more  attention  than 
hitherto,  and  food  control  and  sewage  control  services  must 
be  established.  As  will  be  noticed,  there  is  a plan  to 
decentralise  the  work  in  some  measure  by  means  of  pro- 
vincial laboratories,  while  the  existing  quarantine  labora- 
tories should  be  brought  under  the  sway  of  the  Director  of 
Medical  Intelligence.  The  chief  sanitary  engineer  of  the  old 
graph  becomes  a Director  of  Sanitary  Engineering,  a subject 
which  will  undoubtedly  become  increasingly  important  as 
schemes  for  drainage,  water-supply,  disinfection,  and  so 
forth  develop. 

The  Solution  of  Provincial  Administration. 

Such  are  the  main  recommendations  of  the  Commission  as 
regards  central  organisation.  Let  us  see  how  it  proposes  to 
solve  the  problem  in  the  provinces.  Recognising  that  there 
are  far  too  few  divisional  inspectors,  it  recommends  an 
ample  increase  in  their  numbers  and  insists  that  they  should 
live  in  their  districts,  be  housed,  well  paid,  and  given  every 
facility  for  getting  about  rapidly.  Opportunities  should 
also  be  afforded  them  for  seeing  in  rotation  something  of 
the  Central  Administration  and  gaining  an  insight  into  the 
work  of  those  departments  of  the  Ministry,  the  chief 
posts  in  which  some  of  them  will  one  day  fill. 

Introduction  of  the  Sanitary  Inspector. 

There  is  nothing  very  novel  in  these  recommendations, 
but  an  entirely  new  idea,  so  far  as  Egypt  goes,  is  voiced 
by  the  suggestion  to  introduce  qualified  British  sanitary 
inspectors,  one  of  whom  would  be  attached  to  each 
divisional  inspector  to  aid  him  in  his  work  and,  under 
certain  conditions,  to  train  those  inspectors  of  nuisances 
whom  we  have  mentioned  and  who  figure  in  the  graph. 
There  can  be  no  doubt  that  intermediaries  of  this  kind  are 
greatly  needed.  If  the  right  class  of  man  is  obtained — and 
he  should  be  forthcoming  in  greater  numbers  now  the  war 
is  at  an  end — he  should  go  a long  way  towards  solving  some 
of  the  problems  I have  mentioned,  for  efficient  inspection 
means  everything  in  this  kind  of  sanitary  work.  Qualified 
sanitary  inspectors  of  this  type  have  proved  their  value  in  the 
Sudan.  They  are  employed  under  the  Colonial  Office  adminis- 
tration in  various  parts  of  Africa,  and  I hope  to  see  the  day 
when  it  will  be  possible  to  train  them  in  the  rudiments  of 
tropical  hygiene  before  they  leave  this  country  for  their 
posts  abroad.  Their  ordinary  training  is  excellent  so  far  as  it 
goes,  but  at  present  time  is  wasted  after  they  reach  the 
tropics  in  giving  them  instruction  in  antimosquito  measures, 
in  native  habits  and  customs,  in  conservancy  methods  in 
vogue  in  hot  countries,  in  new  aspects  of  the  fly  question,  in 
those  improvisations  which  form  so  great  a part  of  the 
sanitarian’s  outfit  abroad,  and  in  all  those  minutiie  which 
mean  so  much  and  which  can  perfectly  well  be  imparted  to 
them  by  one  having  experience.  It  is  true  that  many  have 
become  an  fait  with  these  matters  during  the  war,  but  we 
have  to  think  of  the  future,  and  the  sooner  this  training  is 
instituted  the  better  for  the  Empire.  It  has  been  too  long 
delayed. 

We  need  not  again  consider  the  strictly  medical  work  in 
the  provinces,  but  from  what  has  been  already  said  it  is  clear 
that  the  Mudiriya  health  inspectors  should  be  better  paid 
and  have  better  prospects.  The  posts  should  be  filled  by 
M 2 


512  The  Lancet,] 


DR.  A.  BALFOUR  : THR  PROBLEM  OF  HYGIENE  IN  EGYPT. 


[Sept.  20,  1919 


younger  and  more  energetic  men  who  may  be  expected  to 
take  an  active  interest  in  their  duties,  especially  if  they  are 
diploinates  in  public  health. 

Two  Categories  of  Markaz  liuotor. 

And  now  we  come  again  to  our  friend  the  Markaz 
doctor.  What  is  to  be  done  about  him  and  his  manifold 
perplexities?  Two  courses  may  be  followed.  The  ideal 
scheme,  and  one  which  eventually  must  be  adopted,  is 
to  divide  the  Markaz  doctors  into  two  categories  according 
to  the  work,  sanitary  and  medical,  as  shown  in  the  subjoined 
table  : — 

Markaz  Doctor  in  charge  of  Public 
Health  Work  (excluded  from 
private  practice). 

General  sanitation. 

Etablissements  insalubres. 

Communicable  diseases  (public 
health  aspect). 

Vaccination  and  vaccination  in- 
spections. 

Pilgrims. 

Quarantine. 

Passenger  control. 

Mdleds. 

Schools  and  kuttabs  (sanitation). 

Prison  lock-ups  (sanitation). 

Cemeteries. 

Registration  of  births  and  deaths. 

Public  health  delegate  on  Local 
Commission. 

Public  health  representative  on 
the  Markaz  Sanitary  Commission. 

Contraventions  against  public 
health  laws  and  regulations. 

The  Markaz  doctor  engaged  on  sanitation  would  not  be 
allowed  private  practice,  would  be  freed  from  medico-legal 
work,  and  would  have  an  initial  salary  of  £E. 25-30  a month. 
He  would  also  be  pensionable.  From  this  category  the 
Mudiriya  health  inspectors  would  be  chosen. 

The  Markaz  doctor  engaged  on  medical  work  would  be  paid 
as  at  present,  would  carry  out  the  official  duties  listed  in  the 
above  table,  and  would  be  on  contract  until  found  satis- 
factory. He  could  then  be  placed  on  the  cadre.  As  at 
present,  his  chief  prospects  would  be  in  the  direction  of 
private  practice. 

Provisional  Measures. 

Unfortunately,  at  present  this  scheme  cannot  be  carried 
into  effect,  for  there  are  not  enough  Markaz  doctors  in 
Egypt,  there  are  not  enough  private  practitioners,  there  are 
not  sufficient  medical  graduates.  Still,  it  might  be  tried  on 
a small  scale  in  certain  districts,  a course  the  Commission 
recommended. 

The  second  plan  is  to  multiply  the  number  of  doctors  in 
each  Markaz,  strictly  defining  their  respective  areas,  and 
making  no  change  in  the  nature  of  their  work  or  in  their 
pay.  Even  this  simple  solution  of  the  problem  will  be 
difficult  of  realisation  until  the  medical  school  is  enlarged 
and  is  able  to  cope  with  the  medical  needs  of  the  country. 
How  true  is  the  old  proverb,  “Things  move  slowly  in  the 
Nile  Valley  ! ” “ Haste,”  however,  we  know,  “is  begotten 

of  the  devil,”  and  if  we  can  only  combine  the  slowness  with 
sureness  no  great  harm  will  be  done,  provided  that  slowness 
does  not  degenerate  into  sluggishness,  a very  different 
affair. 

The  Inspector  of  Nuisances  and  Sanitary  Barter. 
Inspectors  of  nuisances  may  be  recruited  from  the  ranks  of 
the  better  educated  sanitary  barbers  or  from  men  of  the 
artisan  or  mechanic  class,  or  possibly  even  from  ex-non- 
commissioned  officers  of  the  Egyptian  Army.  Trained  by 
the  sanitary  inspectors,  paid  out  of  local  funds,  in  close 
touch  with  the  people,  the  inspector  of  nuisances  would 
supervise  the  scavenging  and  cleansing  of  villages,  and,  if 
village  latrines  and  incinerators  prove  feasible,  he  would  see 
that  they  are  properly  used  and  kept  in  repair.  He  would 
inspect  water-supplies,  markets,  birkas,  and  other  mosquito- 
breeding places.  He  would  endeavour  to  show  the  people 
how  their  villages  could  be  improved  and  how  they  could  live 
in  more  cleanly  and  also  more  comfortable  surroundings. 
He  should  have  some  knowledge  of  building  construction, 
and  of  the  role  of  flies  in  the  spread  of  disease. 

The  sanitary  barber,  who  should  also  be  paid,  would,  in 
addition  to  his  present  duties,  furnish  information  on  matters 
of  public  health  interest  occurring  in  the  village,  while  a 
conservancy  staff  would  represent  the  lowest  rung  in  the 
sanitary  ladder. 

The  Working-out  of  the  Scheme. 

Here,  then,  is  a definite  system,  providing,  apparently,  for 
all  contingencies,  costly  no  doubt  but  not  unduly  so,  and 


avoiding  too  heavy  a strain  upon  the  central  treasury.  It 
remains  to  be  seen  if  it  will  be  adopted  in  its  entirety  and, 
if  adopted,  how  it  will  serve  the  medical  needs  of  Egypt. 
It  has  been  said  that  the  report  of  the  Commission  afforded 
cause  for  complaint  by  the  Egyptian  Nationalists  inasmuch 
that,  save  in  the  case  of  the  Minister,  all  the  higher  posts  in 
the  Health  Ministry  were  allotted  to  Britishers.  The  state- 
ment is  doubtless  true,  but  requires  to  be  qualified,  for, 
owing  to  the  lack  of  technical  training  which  has  been 
mentioned,  there  are  at  present  no  Egyptian  doctors  capable 
of  holding  these  posts.  Furthermore,  I would  like  to  point 
out  that  the  Commission  expressly  recommended  an  improve- 
ment in  the  status  and  pay  of  the  Egyptian  Mudiriyah  health 
inspectors  and  advocated  their  advance  to  divisional  inspector- 
ships as  soon  as  possible.  Their  report  also  provides  for  a 
large  increase  of  Markaz  doctors  and  the  creation  of  a new 
class  of  Egyptian  employees — namely,  the  inspectors  of 
nuisances.  The  national  aspect  of  the  question  was  duly 
and  sympathetically  considered  and,  as  has  been  stated, 
recommendations  were  made  which,  if  carried  into  effect, 
will  create  a body  of  Egyptian  hygienists  capable  of  serving 
their  country  to  the  best  advantage  in  the  interests  of  the 
public  health. 

Application  to  Urban  Areas. 

In  the  case  of  the  individual  towns  measures  closely 
resembling  those  just  detailed  must  be  applied.  Cairo 
requires  qualified  sanitary  inspectors  and  inspectors  of 
nuisances.  So  does  Alexandria.  The  latter  city  must  no 
longer  be  permitted  to  act  as  a law  unto  itself  in  public 
health  matters.  The  Commission  recommend  that  a Con- 
troller be  appointed  by  the  Ministry  of  Health,  which 
itself  should  approve  all  public  health  appointments.  The 
Qism  doctors  should  not  be  allowed  private  practice  and 
should  devote  their  whole  time  to  public  health  duties,  in 
which  they  should  be  specially  trained.  In  short,  a radical 
change  is  needed  if  the  stigma  now  resting  on  the  city  is 
to  be  removed  and  the  health  of  its  populace  safeguarded. 
At  the  same  time,  it  is  only  fair  to  state  that  the  chief 
engineer  of  the  municipality  has  been  busy  with  schemes 
for  replacing  the  echeches  of  which  I spoke  in  the  first 
lecture,  by  model  dwellings.  Building  regulations  have 
also  been  framed  and  a town  plan  introduced,  so  that  the 
outlook  is  distinctly  more  hopeful.  As  regards  other  towns, 
the  method  in  vogue  at  Port  Said  may  be  followed  with 
advantage  until  such  time  as  each  is  able  to  work  out  its 
own  sanitary  salvation  on  a sound  basis  of  local  self- 
government. 

Time  does  not  permit  a discussion  of  other  points  con- 
sidered by  the  Commission,  such  as  the  future  of  the  medical 
services  of  the  Ministry  of  lYaqfs,  that  department  which 
controls  large  funds  earmarked  for  charitable  purposes, 
the  amendment  and  progress  of  public  health  legislation, 
the  dissemination  of  information,  and  the  great  desirability 
of  lay  officials  taking  a real  interest  in  sanitary  reform  and 
keeping  themselves  acquainted  with  what  is  happening  in 
the  hygienic  world  of  Egypt. 

The  Removal  of  a Reproach. 

It  all  sounds  very  simple,  but  in  reality  how  hard  it  is  to 
make  headway  against  ignorance,  inertia,  and  prejudice ! 
Let  us,  however,  hope  for  the  best. 

Along  with  this  reform,  or  rather  advance,  in  public 
health  administration  an  active  campaign  should  be  instituted 
against  these  three  deadly  enemies  of  the  fellaheen— 
bilharziasis,  ankylostomiasis,  and  pellagra.  Leiper  and  his 
colleagues  have  already  thrown  much  light  on  the  first- 
named,  we  know  a great  deal  about  the  second,  the  third 
alone  remains  a mystery.  Given  money  and  research  on 
sound  lines,  the  mystery  will  assuredly  vanish,  and  given 
funds  and  a progressive  sanitary  policy  the  people  of  Egypt 
will  be  freed  from  the  burden  of  all  three  diseases. 

I have  spoken  in  vain  if  it  is  not  apparent  that  the  sanitary 
condition  of  Egypt  still  remains  in  many  respects  a byword 
and  a reproach.  Great  Britain  has  declared  that  ancient 
land  a Protectorate,  and  has  protected  it  from  the  Teuton 
and  the  Turk  on  the  east  and  the  Senussi  and  the  Turk  on 
the  west.  There  are,  however,  other  foes  of  its  own  house- 
hold, and  unless  this  country  realises  its  responsibilities  and 
undertakes  to  rout  the  forces  of  disease  which  hold  Egypt  m 
thrall,  it  will  have  failed  in  its  duty,  and  one  day  there 
will  be  written  of  it,  as  there  was  of  Belshazzar  of  Babylon, 
" Mene,  mene,  tekel,  upharsin  ” — Thou  art  weighed  in  the 
balances  and  art  found  wanting. 


Markaz  Doctor  in  charge  of  medical 
work  (allowed  private  practice). 

Communicable  diseases  (clinical). 
Medicolegal  examinations  and 
reports. 

Dispensary. 

Prostitutes. 

Medical  Commission  work  : — 
Examination  of  sick  Govern- 
ment employees. 

Examination  of  ghajirs. 

Prisons  (in  certain  places). 

Schools  (medical). 


The  Lancet,] 


DK.  G.  R.  PIRIK  : A STUDY  OF  HYPER-ADRENALISM. 


[Sept.  20,  1919  5]  3 


A STUDY  OF  HYPER-ADRENALISM: 

ITS  INFLUENCE  IN  PRODUCING  CONGENITAL  PYLORIC 
HYPERTROPHY  AND  SUBSEQUENT  OBSTRUCTION. 

By  GEO.  R.  PIRIE,  M.B.  Tor.,  M.R.C.P.  Lond., 

MEDICAL  REGISTRAR  AND  PATHOLOGIST,  RESIDENT  MEDICAL  SUPER- 
INTENDENT. AND  CASUALTY  MEDICAL  OFFICER  FOR  THE  PERIOD 
OF  THE  WAR  TO  THE  HOSPI  TAL  FOR  SICK  CHILDREN, 

GREAT  ORMOND  STREET. 


From  the  time,  over  20  years  ago,  when  John  Thomson 
and  Finkelstein  began  to  associate  specific  signs  and  sym- 
ptoms in  babies  with  a large  thickened  pylorus  (until  then 
recognised  only  in  the  post-mortem  room),  there  have  been 
several  theories  advanced  and  much  discussion  has  taken 
place  as  to  the  pathogenesis  of  this  condition. 

In  the  typical  case  there  is  undoubted  true  hypertrophy. 
There  is  an  increase  in  both  the  number  and  size  of  the 
circular  muscle  fibres,  as  has  been  repeatedly  demonstrated. 
It  is  concerning  the  cause  of  this  hypertrophy  that  there  has 
been  so  much  speculation.  The  explanation  most  commonly 
offered  has  been  that  the  hyperplasia  of  the  musculature  of 
the  pylorus  is  caused  by  an  error  in  its  development.  Apart 
from  the  fact  that  it  is  very  difficult  to  conceive  of  any  error 
in  development  resulting  directly  in  true  hypertrophy,  there 
is  neither  corroborative  evidence  nor  any  analogous  condi- 
tion to  substantiate  this  theory.  The  natural  explanation  of 
hypertrophy  is  overaction  or  spasm.  Still  and  Thompson 
were  inclined  to  attribute  it  to  spasm  induced  by  a lack  of 
coordinate  action  between  stomach  and  pylorus. 

Hyper-adrenalism,  before  Birth  as  the  Chief  Cause  of  the 
Spasm. 

It  is  the  purpose  of  this  paper  to  suggest  that  the  spasm 
inducing  hypertrophy  is  primarily  due  to  hyper-adrenalism 
before  birth,  and  that  other  subsidiary  post-natal  causes 
determine  the  persistence  or  recurrence  of  the  spasm.  This 
condition  is  due  to  a lack  of  balance  between  the  secretions 
of  the  various  endocrinic  organs  in  the  process  of  their 
development  and  involution,  which  may  result  either  in  a 
relative  or  an  absolute  hyper-adrenalism. 

Whether  this  condition  is  congenital  or  not  is  also  a much 
discussed  point.  The  balance  of  evidence  seems  to  indicate 
that  it  must  be  congenital.  It  is  true  that  the  majority  of 
cases  first  show  symptoms  at  about  the  third  week.  It  is 
equally  true  that,  in  many  instances,  the  child  forcibly  ejects 
the  first  and  every  subsequent  feed.  Moreover,  at  operation, 
the  hypertrophy  is  usually  found  to  be  so  marked  that  it  is 
difficult  to  believe  that  it  could  have  arisen  during  extra- 
uterine  life.  Further,  many  babies  are  presented  for  exa- 
mination and  treatment  exhibiting  gastric  peristalsis  and 
projectile  vomiting.  In  the  absence  of  a palpable  tumour, 
congenita]  pyloric  stenosis  should  not  be  the  diagnosis.  A 
careful  history  and  observation  will  show  that  varying 
amounts  of  food  pass  through  the  pylorus,  inasmuch  as  there 
are  occasional  periods  without  vomiting  and  with  normal 
stools.  The  symptoms  are  due  to  improper  feeding,  gastritis, 
or  phimosis  among  many  other  causes.  The  child  Is  treated 
empirically,  by  regulation  of  its  feeding,  proper  management 
of  the  gastritip,  or  the  performance  of  circumcision.  Thus 
the  symptoms  are  relieved  without  any  apparent  permanent 
change  having  taken  place  in  the  muscle  of  the  pylorus.  If 
the  spasm  persisted  for  a long  time,  as  it  does  in  many 
instances,  hypertrophy  sufficient  to  warrant  surgical  inter- 
vention might  result,  This  never  happens  in  practice. 
Therefore  it  must  take  a great  deal  longer  for  spasm  to 
produce  hypertrophy  than  many  have  hitherto  thought. 

From  these  considerations,  then,  one  is  forced  to  the  con- 
clusion that  the  hypertrophy  in  the  cases  under  consideration 
exists  from  before  birth,  and  that  whatever  influence  has 
been  at  work  to  produce  this  change  must  have  existed  for  a 
long  time.  This  being  so,  one  must  look  for  some  ante-natal 
force  which  is  capable  through  its  prolonged  action  of  pro- 
ducing this  change.  It  is  not,  then,  the  occurrence  of 
hypertrophy  some  time  after  birth  which  determines  the 
onset  of  symptoms.  This  may  exist  in  widely  varying 
degrees,  and  it  is  the  degree  of  added  spasm  from  one  of 
many  causes  which  will  determine  the  time  of  appearance 
and  severity  of  the  symptoms  in  those  cases  where  the 
amount  of  hypertrophy  at  birth  is  not  excessive. 

Swale  Vincent,  Sharpey  Schafer,  Priestly,  Elliott,  and 
many  others  have  shown  how  important  from  a develop- 
mental point  of  view  are  the  endocrinic  organs  and  how 
finely  adjusted  is  the  balance  between  their  hormones. 


Medical  literature  is  full  of  reports  as  to  the  breaking  down 
of  this  balance  in  adult  life.  If  this  is  so,  how  much  more 
readily  may  one  accept  the  possibility  of  a lack  of  balance 
at  birth  and  before,  when  developmental  requirements  are 
urgent  and  physiological  processes  so  active.  If  this  dis- 
turbance in  balance  results  in  a relative  or  absolute  excess 
of  the  suprarenal  medullary  hormone,  spasm  of  any  non- 
striated  muscle  may  result.  Keith  has  shown  that  both  the 
pylorus  and  the  medulla  of  the  suprarenal  gland  become 
differentiated  at  about  the  third  month  of  intrauterine  life. 
Since  excessive  suprarenal  secretion  produces  spasm  in  non- 
striated  muscles,  this  would  allow  plenty  of  time  for  spasm 
induced  by  any  excessive  suprarenal  secretion  to  bring  about 
hypertrophy.  He  also  states  that  before  birth  the  gland  is 
larger  than  the  kidney,  and  at  birth  may  be  the  same  size. 
After  that  it  rapidly  reaches  its  normal  relative  size. 

Sharpey  Schafer,  in  his  blood  pressure  experiments  with 
adrenalin,  noted  that  spasm  of  the  pylorus  was  produced 
when  he  injected  the  secretion  into  the  suprarenal  vein.  It 
is  not  claimed  for  a moment  that  adrenalin  has  a selective 
action  on  the  muscle  of  the  pylorus.  The  same  experiments 
showed  that  spasm  was  produced  at  many  places  in  the 
gastro-intestinal  tract — e.g.,  the  ileo-ciecal  valve  and  the 
junction  of  the  pelvic  with  the  rectal  colon.  The  fact  that 
untoward  results  of  this  spasm  are  noted  so  rarely  in  situa- 
tions other  than  the  pylorus  is  explained  by  the  peculiar 
anatomical  and  secretory  relations  existing  between  the 
stomach,  pylorus,  and  duodenum.  This  relationship  favours 
the  establishment  of  secondary  vicious  circles  which  would 
determine  the  persistence  or  recurrence  of  spasm.  The 
objection  might  be  raised  that  if  hyjm -adrenalism  can  exist 
in  the  ante-natal  condition  we  should  see  more  frequent 
evidence  of  its  effects  after  birth.  The  reason  that  we  do  not 
is  that  the  degree  of  hyper-adrenalism  can  never  be  constant, 
and  only  those  cases  would  show  symptoms  where  it  is 
marked.  In  the  post-mortem  room  one  has  noted  many 
times  slight  thickening  of  the  pyloric  muscle  in  the  bodies  of 
babies  who  have  died  without  any  clinical  evidence  of 
obstruction  at  the  outlet  of  the  stomach.  This  thickening  is 
quite  apart  from  the  apparent  hypertrophy  which  sometimes 
occurs  just  at  death,  and  is  noted  in  bodies  from  which  rigor 
mortis  has  passed  off.  Whether  this  thickening  is  congenital 
or  not  is,  of  course,  pure  conjecture.  It  may  have  been 
due  to  prolonged  spasm  from  one  of  the  several  causes 
mentioned  elsewhere.  Both  in  these  cases,  and  in  those 
dying  with  true  hypertrophic  stenosis,  has  vain  search 
been  made  for  any  abnormal  or  unusual  appearance  of  the 
suprarenal  gland.  If  the  assumption  of  ante-natal  hyper- 
adrenalism  is  correct,  there  need  be  no  abnormality  of  the 
gland  apparent  after  birth.  As  most  of  the  examinations  are 
made  when  the  infant  is  at  least  several  weeks  old,  the 
process  of  involution  would  be  complete  and  only  the  effects 
of  the  plus  secretion  before  birth  would  remain.  Moreover, 
a gland  which  undergoes  such  marked  changes  in  its  develop- 
ment and  involution  may  easily  have  had  its  balance  with  the 
other  glands  of  internal  secretion  upset  a long  time  before 
birth,  with  resulting  hyper-adrenalism.  This  may  exist  in 
widely  varying  degrees  and  would  determine  the  amount  of 
hypertrophy  present  at  birth.  It  cannot  be  claimed  that  in 
all  cases  the  hyper-secretion  is  controlled  by  changes  in  the 
gland  itself.  The  ready  response  of  its  secretion  to  stimuli 
from  the  semilunar  ganglion  would  lead  one  to  expect  that  in 
some  cases  there  is  hyper-adrenalism  following  excessive 
stimulation  of  the  splanchnics.  Tyrrell  Gray  and  Parsons 
have  shown  the  effect  of  excessive  stimuli  passing  to  the  sym- 
pathetics.  Their  work  gives  a possible  explanation  of  the 
added  pyloric  spasm  in  the  frequently  associated  condition 
of  phimosis.  If  the  development  of  the  suprarenal  gland 
may  be  excessive  or  its  involution  unduly  delayed,  one  would 
expect  sooner  or  later  to  find  an  abnormally  large  gland 
associated  with  hypertrophy  of  the  pylorus  or  other  non- 
striated  muscle. 

Recently  there  was  admitted  to  Dr.  G.  F.  Still’s  ward  at 
the  Great  Ormond  Street  Hospital  a boy  aged  8 weeks. 
Although  the  mother  was  ill  throughout  her  pregnancy, 
the  child  was  born  at  full  term  and  was  apparently 
healthy.  He  was  breast  fed  and  never  gained.  He  was 
constipated  and  had  vomited  at  irregular  intervals  practi- 
cally from  birth.  The  mother  brought  him  to  hospital 
because  of  the  vomiting  and  wasting,  and  also  because  of  a 
very  distended  abdomen.  Examination  on  admission  showed 
marked  wasting.  The  abdomen  was  too  distended  to  permit 
of  any  satisfactory  examination,  and  dilated  coils  of  intestine 
bulged  through  the  abdominal  wall  like  the  rungs  of  a 


514  The  Lancet,] 


DR.  G.  R.  PIRIE  : A STUDY  OF  HYPER-ADRENALISM. 


£Sept.  20,  1919 


ladder.  There  was  stenosis  of  the  urinary  meatus  and 
marked  phimosis  of  the  type  described  below— that  is,  a 
well-developed  penis  with  the  prepuce  stretched  tightly  over 
the  glans.  Before  the  clinical  investigation  could  be  com- 
pleted the  child  died.  At  the  post-mortem  examination  rigor 
mortis  had  passed  off,  and  the  external  features  as  noted 
above  were  confirmed.  There  was  stenosis  of  the  oesophageal 
and  pyloric  openings  of  the  stomach,  and  a slight  hour-glass 
constriction  about  the  middle  of  the  viscus.  The  stenosis 
was  not  extreme,  but  there  was  definite  thickening  of  the 
muscle  at  the  pyloric  orifice  and  to  a lesser  degree  at  the 
oesophageal  opening.  The  duodenum  and  the  upper  part  of 
the  jejunum  were  contracted  and  small.  From  this  point 
down  there  was  a gradual  increase  in  the  calibre  of  the  gut, 
which  was  considerably  dilated  in  the  lower  part  of  the 
ileum,  and  the  whole  colon  as  far  as  the  junction  of  the 
pelvic  with  the  rectal  portions.  At  this  point  there  was 
another  definite  constriction.  Below  this  point  the  bowel 
again  bulged  out,  to  end  in  a narrowed  and  constricted 
anus.  The  ureters  as  they  entered  the  bladder  appeared 
small,  but  the  upper  two-thirds  of  both,  as  well  as  the  pelvis 
of  both  kidneys,  were  dilated.  This  was  obviously  a case  of 
early  hydronephrosis  secondary  to  a uarrowed  and  constricted 
urinary  outlet.  The  right  suprarenal  gland  appeared  normal, 
but  the  left  was  enlarged  to  about  one-third  the  size  of  the 
kidney. 

Sections  of  the  enlarged  suprarenal  gland  were  made,  and 
Dr.  T.  R.  Elliott  expressed  an  opinion  upon  them.  He 
thought  the  enlargement  was  entirely  confined  to  accessory 
cortical  cells,  and  was  not  of  any  importance. 

The  significant  feature  of  this  case  is  that  there  was 
stenosis  at  points  in  the  gastro-intestinal  tract  other  than 
the  pylorus.  This  would  indicate  that  the  influence  at  work 
did  not  emanate  from  th^  immediate  vicinity  of  any  one  of 
these  points,  and  that?  the  spasm  producing  the  stenosis 
must  have  been  the  result  of  some  general  physiological 
disturbance  affecting  all  the  orifices.  The  only  influence  we 
know  of  from  experimental  investigation  which  will  cause 
spasm  of  the  above  nature  is  hyper-adrenalism.  There  was 
nothing  in  the  appearance  of  the  gland  with  which  these 
changes  could  be  associated.  The  gland  evidently  proceeded 
along  its  normal  course  of  involution,  leaving  only  the  results 
of  ante-natal  hyper-secretion.  It  is  unjustifiable  to  insist  that 
hyper-adrenalism  is  the  cause  of  congenital  pyloric  hyper- 
trophy, because  it  cannot  be  proved.  There  is,  however, 
sufficient  evidence  to  justify  one  in  holding  it  to  be  the  most 
reasonable  explanation. 

Contributory  Causes  of  Spasm. 

As  has  been  suggested  above,  the  amount  of  hypertrophy 
present  at  birth  is  insufficient,  except  in  rare  instances,  to 
cause  symptoms  of  obstruction.  This  is  clearly  evident  from 
the  clinical  history  of  the  great  majority  of  cases.  But  there 
are  certain  conditions  which  will  cause  spasm  after  birth 
sufficient  to  complete  the  obstruction  in  an  already  stenosed 
orifice.  This  combination  determines  the  onset  and  severity 
of  the  symptoms.  That  some  of  these  cases  recover  without 
surgical  intervention  is  due  to  the  fact  that  the  subsidiary 
conditions  are  amenable  to  palliative  treatment,  and  are  of 
greater  moment  in  producing  obstruction  by  added  spasm 
than  the  congenital  stenosis  itself.  And  there  is  sufficient 
evidence  to  justify  the  opinion  that  the  two  chief  con- 
tributory causes  of  spasm,  phimosis  and  secretory  inhibition, 
are  directly  associated  with  the  congenital  hypertrophy. 

1.  Phimosis. — The  association  of  phimosis  is  very 
interesting.  That  phimosis  in  itself  may  cause  spasm  we 
know. 

In  1914  there  were  admitted  to  Dr.  W.  S.  Colman’s  ward  at 
Great  Ormond-street,  three  baby  boys  who  showed  gastric 
peristalsis  and  projectile  vomiting.  No  tumour  was  palpable, 
therefore  no  diagnosis  of  congenital  stenosis  was  made. 
They  were  all  markedly  phimosed,  and  circumcision  per- 
manently relieved  the  symptoms  in  all  three. 

Moreover,  in  cases  of  true  congenital  stenosis  circum- 
cision without  any  other  form  of  treatment  has  relieved  the 
symptoms  immediately  for  varying  periods  of  time.  Further, 
an  analysis  of  the  last  84  cases  admitted  at  Great  Ormond- 
street  showed  only  13  girls  and  not  one  Jew.  This  in  itself 
is  an  observation  of  marked  significance  as  to  the  association 
of  phimosis  with  congenital  stenosis  of  the  pylorus. 
Whether  it  is  an  associated  condition,  or  the  cause  of  the 
added  spasm,  or  both,  is  difficult  to  say.  Certainly  it  may 
be  a potent  cause  of  spasm.  A large  majority  of  boys  in 
this  series  of  cases  showed  phimosis  of  a definite  character. 
There  is  not,  as  a rule,  a long  prepuce  with  a narrow  opening 
covering  a small  penis,  but  a prepuce  stretched  tightly  over 
the  glans  of  a particularly  well-developed  penis.  In  other 


words,  “ the  penis  is  too  large  for  the  prepuce.”  Up  to  the 
present  investigators  consider  that  it  is  the  cortex  of  the 
suprarenal  gland  with  which  is  connected  development  of 
the  sexual  organs.  The  association  of  precocious  sexual 
development  with  malignant  hyper-nephromata  is  in  itself 
significant.  It  may  well  be  that  there  is  a definite  relation 
between  a slow  involution  of  the  suprarenal  gland  and 
phimosis  of  this  particular  type.  The  way  in  which 

phimosis  may  produce  pyloric  spasm  has  been  shown  by 
Tyrrell  Gray  and  Parsons,  and  will  be  referred  to  more  fully 
in  the  joint  paper  which  follows  this  article. 

2.  Secretory  inhibition. — The  most  important  factor  in 
producing  added  spasm  at  the  pyloric  orifice  is  a secretory 
disturbance  directly  attributable  to  the  obstruction.  Under 
normal  conditions  the  acid  content  of  the  stomach,  passing 
through  the  pylorus  and  over  the  duodenal  mucous  membrane, 
stimulates  the  formation  of  secretin.  This  is  absorbed  into 
the  blood  and  is  carried  to  the  pancreas,  stimulating  the 
formation  of  the  external  secretion  of  this  gland.  This 
phenomenon  had  been  investigated  by  many  physiologists, 
and  the  correctness  of  the  observation  was  finally  demon- 
strated by  Bavliss  and  Starling.  They  also  determined  that 
the  amount  of  pancreatic  secretion  exhibited  varied  directly 
with  the  amount  of  acid  chyme  passing  through  the  pylorus. 
Normally,  acid  chyme  in  the  stomach  opens  the  pylorus  and 
in  the  duodenum  closes  it.  In  the  absence  of  a sufficient 
supply  of  the  alkaline  pancreatic  secretion,  the  acid  chyme 
is  much  longer  being  neutralised.  During  this  time  the 
pylorus  remains  closed.  Given  an  already  stenosed  orifice, 
there  is,  in  the  absence  of  any  other  cause,  a diminished 
supply  of  pancreatic  secretion.  This  very  lack  in  secretion 
will  keep  the  orifice  closed,  with  still  less  room  for  stomach 
contents  to  escape,  and  thus  still  less  pancreatic  secretion. 

In  this  way  a vicious  circle  is  set  up  which  effectively  obstructs 
the  already  narrow  stomach  outlet.  There  are  several 
reasons  for  thinking  that  there  is  pancreatic  insufficiency. 
Even  under  ordinary  circumstances  clinicians  know  that  ' 
babies  cannot  digest  the  more  complex  forms  of  starches. 
From  this  one  deduces  diminution  or  absence  of  certain 
starch-splitting  ferments  in  the  pancreatic  secretion.  Again, 
it  is  a noteworthy  fact  that  babies  with  congenital  pyloric 
stenosis  do  better  on  a diet  of  pancreatinised  milk  than  on 
any  other  food.  Moreover,  after  relief  from  obstruction 
either  by  palliative  or  by  surgical  treatment,  the  child, 
though  fed  on  peptonised  milk,  has  loose,  frequent,  greasy 
stools  for  several  days.  This  has  been  noted  by  several 
observers,  and  Still  has  pointed  out  the  grave  danger  of 
“diarrhoea,”  in  the  early  post  operative  period,  in  those  cases 
where  surgical  intervention  became  necessary.  These  loose,  , 
frequent,  greasy  stools  are  not  the  result  of  any  inflam- 
matory charge  in  the  mucosa,  but  are  due  to  the  presence  of 
incompletely  digested  fats.  Still  has  also  noted  in  these 
cases  that  babies  tolerate  fats  in  their  diet  very  badly. 
Even  when  the  obstruction  is  relieved  the  child  will  still 
do  better  on  a diet  of  peptonised  milk  low  in  fats  for  the 
first  couple  of  weeks.  The  reason  suggests  itself.  A gland 
like  the  pancreas,  whose  function  has  been  inhibited  for 
any  length  of  time  by  pyloric  obstruction,  will  not  resume 
its  maximum  function  the  moment  the  obstruction  is 
relieved,  but  will  take  a coriesponding  length  of  time  before 
it  secretes  sufficient  ferments  to  digest  the  proteids  and 
fats.  Then,  again,  the  small,  hard,  dry  stool  so  characteristic 
in  these  cases  is  due  as  much  to  the  lack  of  secretions  as  to 
the  small  quantity  of  food  passing  through  the  pylorus.  | 
Thus  there  is  clinical  evidence  to  show  that  there  is  , 
pancreatic  insufficiency  in  cases  of  congenital  stenosis.  Add 
to  this  the  evidence  of  Sharpey  Schafer  that  the  suprarenal 
gland  is  antagonistic  to  the  pancreas,  and  it  would  seem 
that  hyper-adrenalism.  relative  or  absolute,  would  inhibit 
pancreatic  secretion.  There  is  then  good  reason  for  justify-  j 
ing  the  assumption  of  pancreatic  insufficiency,  which  we 
know  is  a powerful  factor  in  producing  pyloric  spasm. 
Given  hyper-adrenalism,  there  is  at  once  sufficient  cause 
for  the  primary  hypertrophy  induced  by  spasm  and  for  the  j 
perpetuation  or  reinduction  of  this  spasm  by  pancreatic  I 
insufficiency. 

Effect  of  Changes  in  the  Stomach. 

Nothing  has  been  mentioned  about  the  effect  on  the 
stenosed  pyloric  orifice  of  charges  in  the  stomach  itself. 
Any  local  irritative  conditions  or  inflammatory  changes  will, 
of  course,  produce  swelling  of  the  mucosa.  In  many  of  the  ( 
c ises,  perhaps  all,  there  is  some  change  of  the  nature 
produced  by  the  undue  retention,  and  thus  fermentation,  of  j 


The  Lancet,]  MR.  TYRRELL  GRAY  k DR.  PIRIE  : HYPERTROPHIC  STENOSIS  OF  PYLORUS.  [Sept.  20,  1919  515 


food.  Ordinarily  these  changes  would  not  cause  obstruc- 
tion, but  added  to  congenital  pyloric  stenosis,  they  hasten 
the  formation  of  the  vicious  circle,  and  the  perpetuation  of 
the  obstruction  is  due  to  the  more  rapid  secretory  arrest. 
It  is  also  likely  that  phimosis,  while  in  itself  an  important 
cause  of  spasm,  hastens  the  appearance  of  symptoms  of 
obstruction  in  the  same  way. 

Relation  to  Treatment. 

The  recognition  of  these  phenomena  has  a most  important 
bearing  upon  treatment,  palliative  or  surgical.  In  my 
joint  paper  with  Mr.  H.  Tyrrell  Gray  we  have  studied 
the  application  of  this  theory  to  the  treatment  and  indica- 
tions for  operation.  The  results  obtained  and  the  observa- 
tions we  have  been  able  to  make  justify  one  in  thinking  that 
this  theory  of  the  pathogenesis  of  congenital  pyloric  stenosis 
as  outlined  above  is  based  on  sound  deductions. 

Importance  of  Internal  Secreting  Glands  in  the  Study  or 
Diseases  of  Children. 

The  experimental  evidence  available  shows  that  only  one 
condition  will  produce  spasm  of  unstriped  muscle,  and  that 
is  hyper-adrenalism.  An  effort  has  been  made  to  present  to 
the  profession  the  application  of  this  condition — the  result  of 
an  ante-natal  lack  of  balance  between  the  internal  secretory 
glands — to  the  pathogenesis  of  congenital  hypertrophic 
pyloric  stenosis.  This  study,  of  course,  opens  up  a very 
wide  field  for  investigation.  If  hyper-adrenalism  may  exist, 
why  not  hypo-adrenalism  1 One  may  yet  have  to  reconsider 
the  aetiology  of  the  whole  question  of  intestinal  stasis  from 
this  point  of  view.  Again,  Rachford  has  reported  the 
post-mortem  examinations  of  six  children  who  died 
from  pyloric  stenosis  where  no  possible  cause  of  death 
could  be  found  other  than  an  abnormally  large  thymus 
gland.  Experimental  physiologists  have  shown  that 
in  extirpation  of  the  thyroid  gland  hypertrophy  of  the 
thymus  ensues.  The  thyroid  secretion  is  antagonised  by  the 
suprarenal  secretion.  How  far  may  one  go  in  one’s  deduc- 
tion? This  fact  is  clear,  we  must  not  study  children  as 
young  adults.  Their  physiology  is  entirely  different,  and 
their  symptoms  should  not  be  measured  by  similar  symptoms 
in  adults.  Many  of  the  problems  they  exhibit  must  be 
studied  from  the  developmental  point  of  view,  and  in  this 
connexion  none  of  their  organs  are  more  important,  or  so 
easily  upset  by  faulty  interaction  during  the  course  of  their 
development  and  involution,  than  the  internal  secreting 
glands.  

CONGENITAL  HYPERTROPHIC  STENOSIS 
OF  THE  PYLORUS: 

ITS  DIAGNOSIS  AND  TREATMENT. 

A CLINICAL  STUDY. 

By  H.  TYRRELL  GRAY,  M.A.,  M.C.  Cantab., 
F.R  C.S.  Eng., 

BURGEON  TO  OUT-PATIENTS  TO  THE  WEST  LONDON  HOSPITAL  ; SURGEON 

TO  THE  HOSPITAL  FOB  SICK  CHILDREN,  GREAT  ORMOND  STREET, 

TO  THE  ITALIAN  HOSPITAL,  AND  TO  THE  INFANTS’  HOSPITAL, 
VINCENT  SQUARE;  HUNTERIAN  PROFESSOR  (LATE  ARRIS 
AND  GALE  LECTURER)  R.C.S.,  ETC.  ; 

AND 

GEO.  R.  PIRIE,  M.B.  Tor.,  M.R.C.P.  Lond., 

MEDICAL  REGISTRAR  AND  PATHOLOGIST,  RESIDENT  MEDICAL  SUPER- 
INTENDENT, AND  CASUALTY  MEDICAL  OFFICER  FOR  THE  PERIOD 
OF  THE  WAR  TO  THE  HOSPITAL  FOR  SICK  CHILDREN, 

GREAT  ORMOND  STREET. 


I. — Diagnosis. 

There  are  very  few  diseases  of  infants  in  which  opinions 
as  to  the  diagnosis  and  treatment  differ  so  widely  as  in  con- 
genital hypertrophic  stenosis  of  the  pylorus.  The  mortality 
is  generally  so  high,  indeed  so  amazingly  high,  in  undoubted 
cases,  that  it  has  led  the  writers  to  make  a special  joint  study 
of  this  condition  for  the  past  few  years.  One  of  the  first 
conclusions  to  which  we  have  been  led  is  that  the  unsatis- 
factory results  obtained  from  various  lines  of  treatment 
advocated  are  largely  to  be  attributed  to  the  fact  that  such 
treatment  has  been  empirical  rather  than  based  on  a full 
appreciation  of  the  aetiology ; while  the  extraordinary 
variability  of  the  figures  published  by  competent  authorities 
is  explained  by  the  difficulty  of  certain  diagnosis  in  doubtful 
cases,  and  therefore  by  the  different  standards  adopted  in 
establishing  such  a diagnosis  in  any  given  case.  Thus  some 
observers  do  not  consider  the  presence  or  absence  of  a 


palpable  tumour  an  important  point  in  diagnosis,  though  we 
place  this  first  and  foremost  as  the  most  important  diagnostic 
feature. 

It  must  be  clear,  we  think,  that  the  repudiation  of  such  an 
important  point  must  of  necessity  lead,  in  any  series,  to 
the  inclusion  among  true  and  undoubted  cases  of  congenital 
hypertrophic  stenosis  of  mild  or  doubtful  ones  ; or  even  of 
cases  which  only  resemble  the  condition  under  discussion  in 
their  clinical  manifestations  and  do  not  really  come  into  the 
same  category.  Such  figures  are  not  only  useless  but  mis- 
leading. The  first  point,  therefore,  to  be  made  quite  clear 
in  such  a study  is  the  clinical  picture  on  which  the  diagnosis 
of  congenital  hypertrophic  stenosis  is  based.  The  signs  and 
symptoms  upon  which  such  a diagnosis  is  to  be  founded  are  : 
1.  The  presence  of  a palpable  tumour  in  the  region  of  the 
pylorus.  2.  Visible  gastric  peristalsis.  3.  Projectile  vomit- 
ing. Associated  with  these  are  nearly  always  varying  degrees 
of  : 4.  Constipation.  5.  Phimosis.  As  the  symptoms  in  the 
great  majority  of  cases  first  appear  at  a fairly  constant 
period  in  the  child’s  life  some  consideration  in  making  a 
diagnosis  must  be  given  to  : 6.  The  age  of  onset.  The 
general  appearance  of  the  child  in  long-standing  cases  is 
characteristic  of  marasmic  children  whatever  the  cause  of 
wasting,  and  will  not  be  discussed. 

1.  A palpable  pyloric  tumour. — First  in  importance  in 
making  a diagnosis  of  true  congenital  hypertrophic  pyloric 
stenosis  is  the  detection  of  the  tumour.  It  is  the  one  certain 
sign.  Failure  to  find  the  tumour  must  always  leave  the 
diagnosis  in  grave  doubt.  It  is  said  that  it  cannot  be 
demonstrated  in  every  case,  but  we  believe  that  repeated 
examinations,  with  the  child  under  favourable  conditions, 
should  reveal  its  presence.  It  is  usually  found  just  outside 
the  outer  border  of  the  right  rectus  muscle  in  the  trans- 
pyloric  plane.  Deep  palpation  is  necessary  as  it  may  lie 
well  back,  often  tucked  in  beside  the  vertebrae.  Occasionally 
it  is  higher,  when  care  must  be  exercised  to  exclude  Riedl’s 
or  an  enlarged  quadrate  lobe  of  the  liver.  Sometimes  also 
it  is  situated  lower  in  the  abdomen,  in  cases  where  there  is 
extreme  gastric  dilatation.  Often  a clue  to  its  situation  may 
be  obtained  by  locating  the  right  limit  of  the  peristaltic 
waves.  When  found  it  gives  a very  characteristic  sensation  ; 
it  feels  like  a marble  which  rolls  away  from  the  examining 
finger  as  it  is  touched.  Examination  of  the  tumour  in  the 
operating  and  post-mortem  rooms  has  shown  that  there  is 
considerable  variation  in  its  size  and  appearance.  The 
majority,  however,  fall  into  two  groups  : 

(1)  A large  hard  avascular  type.  — At  operation  this  kind 
appears  as  a hard,  smooth,  glistening,  oval  or  cylindrical, 
white,  and  almost  bloodless,  swelling  about  the  size  of  a 
large  acorn. 

(2)  A small  hard  vascular  type. — In  this  instance  the  size 
is  less  than  the  preceding  ; there  are  more  blood-vessels 
evident,  but  otherwise  it  presents  almost  the  same  appear- 
ance. This  variation  in  size  sometimes  accounts  for  the 
difficulty  in  finding  it,  the  smaller  ones  naturally  presenting 
the  greater  difficulty.  Other  reasons  for  missing  it  may  be  : 

(a)  Dilatation  of  the  stomach. — In  this  case  the  dilated 
stomach  overlaps  the  pylorus  and  makes  its  detection 
impossible  until  the  dilatation  has  been  somewhat  relieved 
by  palliative  treatment. 

(h)  There  is  often  difficulty  in  getting  the  examining 
finger  behind  the  lower  border  of  the  liver  and  in  palpating 
deeply  enough. 

(o)  The  age  of  the  child. — In  older  children  of  2 or  3 months 
the  better-developed  abdominal  muscles  increase  the 
difficulty  of  palpation.  Moreover,  the  coils  of  intestine  are 
somewhat  distended,  as  they  have  been  functioning  longer. 

The  most  favourable  time  for  examination  is  while  the 
child  is  being  fed.  The  food  when  it  reaches  the  stomach 
drags  on  the  fundus  and  uncovers  the  pylorus.  Moreover, 
the  peristalsis  induced  by  the  presence  of  food  in  the 
stomach  makes  it  more  apparent.  Sometimes  it  is  necessary 
to  postpone  the  examination  until  after  repeated  lavage, 
when  the  dilatation  is  sufficiently  relieved  to  permit  of  easier 
palpation.  Where  difficulty  with  the  liver  or  a deeply-placed 
pylorus  is  encountered  it  is  a good  plan  to  turn  the  baby  on 
its  face,  allowing  the  slightly  flexed  body  to  rest  on  the 
palm  of  the  band.  In  this  position  the  abdominal  walls  are 
more  relaxed,  and  the  child  cannot  resist  examination  as  much. 
The  viscera  fall  forward,  and  the  fingers  can  be  more  easily 
pressed  behind  the  liver  and  explore  the  whole  region.  The 
examination  should  always  be  made  with  the  thoroughly 
warmed  left  hand  from  the  left  side  of  the  patient. 
m 3 


516  Thi  Lanobt,]  MR.  TYRRELL  GRAY  & DR.  PIRIE:  HYPERTROPHIC  STENOSIS  OF  PYLORUS.  [Sept.  20,  1919 


2.  Visible  gastric  peristalsis. — This  is  evidence  that  the 
tumour,  palpated  as  above,  is  sufficient  to  cause  a marked 
degree  of  obstruction  at  the  outlet  of  the  stomach.  By 
itself  it  is  not  of  paramount  importance.  In  Case  14  no 
peristalsis  was  seen  until  the  child  was  on  the  operating 
table  under  deep  anaesthesia,  although  it  was  believed  that 
the  tumour  had  previously  been  palpated.  On  the  other 
hand,  pure  spasm  without  congenital  hypertrophy  may  cause 
gastric  peristalsis  and  projectile  vomiting.  The  following 
case  illustrates  the  point : — 

A boy  (Case  18),  age  nine  weeks,  was  admitted  to  the 
hospital.  Visible  gastric  peristalsis  and  projectile  vomiting 
were  demonstrated,  and  the  child  was  markedly  wasted. 
There  was  also  a very  tight  phimosis.  No  tumour  was 
palpated,  therefore  no  diagnosis  of  congenital  stenosis  was 
made.  The  only  treatment  carried  out  was  that  of  circum- 
cision. Subsequent  to  this  operation  there  was  no  more 
peristalsis  seen,  nor  did  the  child  vomit  again.  Some  60 
hours  later  he  suddenly  collapsed  and  died.  Post-mortem 
examination  showed  considerable  dilatation  of  the  stomach, 
but  no  abnormal  thickening  of  the  pyloric  muscle  whatever. 

The  three  cases  admitted  under  Dr.  Oolman,  mentioned  in 
the  previous  paper  (G.R.P.),  also  show  that  gastric  peristalsis 
may  be  visible  without  congenital  stenosis.  If  this  sign  is 
not  obvious  it  can  often  be  elicited  by  gently  stroking  the 
epigastrium  or  by  giving  a feed. 

3.  Projectile  vomiting. — This  symptom  is  of  similar 
diagnostic  importance  to  visible  gastric  peristalsis.  When 
characteristic,  the  food  is  forcibly  ejected  across  the  cot  on 
to  the  floor,  and  will  also  appear  streaming  from  the  nostrils. 
Usually  the  baby  is  not  otherwise  disturbed,  and  appears 
quite  happy  about  it.  It  may  occur  after  every  feed,  or  at 
infrequent  intervals.  Sometimes  the  food  is  returned  before 
the  child  has  finished  suckling,  and  at  other  times  one  or 
two  hours  later.  The  character  of  the  vomits  will,  of 
course,  depend  on  how  long  the  food  has  remained  in  the 
stomach,  but  it  is  never  bile-stained.  Infrequent  vomiting 
must  not  always  be  regarded  favourably,  because,  with 
increasing  dilatation  of  the  stomach,  two  or  more  feeds 
may  be  retained  before  the  whole  is  ejected.  This  will 
account  for  the  frequent  history  that  the  child  “vomits 
more  than  it  takes.”  The  vomiting  is  not  always  projectile. 
Under  palliative  treatment  it  may  become  much  less  forcible 
if  no  less  frequent.  As  has  been  shown  above,  it  may 
occur  also  where  there  is  no  congenital  stenosis. 

These  are  the  three  cardinal  features  to  be  considered  in 
making  a diagnosis.  Taken  together,  their  presence  will 
indicate  congenital  hypertrophic  stenosis  with  a high  degree 
of  obstruction.  Taken  separately,  the  first  only  is  of 
paramount  importance.  There  is  sufficient  evidence 
to  show  that  the  other  two  may  occur  where  pylorospasm 
exists  alone.  There  is  a great  variation  in  the  published 
statistics  of  this  condition.  Many  observers  have  reported 
brilliant  results  in  long  series  of  cases  under  medical  treat- 
ment. From  the  above  conclusions  we  consider  that,  in 
many  such  instances,  the  diagnosis  has  been  made  on  entirely 
insufficient  grounds,  and  that  the  number  of  cases  of  true 
congenital  pyloric  stenosis  is  but  a fraction  of  those  reported. 
A positive  diagnosis  may  never  be  made  without  finding  the 
pyloric  tumour. 

4.  Constipation. — This  is  usually  marked.  In  typical 
instances  the  motions  are  small,  hard,  and  infrequent.  Its 
relation  to  the  primary  condition  is  evident.  If  very  little 
food  passes  the  pylorus  there  will  remain  even  less  to  be 
evacuated.  Reference  has  been  made  in  the  previous  paper 
to  the  associated  secretory  inhibition.  This  lack  of  secretion 
explains  the  hard  consistence  of  the  stool.  The  diagnostic 
importance  rests  on  the  fact  that  the  size  of  the  stool  will, 
in  a measure,  indicate  the  degree  of  obstruction  at  the  outlet 
of  the  stomach,  while  its  consistence  will  indicate  the  degree 
of  secretory  inhibition. 

5.  Phimosis. — In  males  phimosis,  or  an  adherent  prepuce, 
is  constantly  associated  with  congenital  pyloric  stenosis.  Its 
frequency,  character,  and  possible  relation  to  the  primary 
condition  have  been  dealt  with  in  the  previous  paper.  That 
marked  phimosis  may  be  sufficient  to  produce  pylorospasm 
reflexly  is  evident  from  the  cases  reported  above  and 
subsequently. 

It  has  been  shown  1 how  definitely  a powerful  afferent 
stimulus,  in  its  efferent  response,  not  only  involves  the 
sympathetic  system  as  a whole,  but  does  so  particularly  in 

1 Tyrrell  Gravand  Parsons,  Arris  and  Gale  Lectures,  Roy.  Coll.  Sure., 
1912. 


the  splanchnic  system,  and  that  such  an  efferent  response 
in  the  splanchnic  system  not  only  involves  the  vascular 
distribution  of  the  sympathetic,  but  also  its  intestinal 
muscular  supply.  Thus,  it  was  pointed  out  that  a reflex, 
acting  both  through  the  higher  centres  and  also  through  the 
segments  involved,  might  induce  a powerful  stimulus  result- 
ing in  an  inhibition  of  the  intestinal  muscle.  The  sphincters 
in  the  intestinal  tract,  however  (i.e.,  pyloric  and  ileo-csecal), 
appear  to  have  an  inverse  innervation,  so  that  a stimulus 
which  inhibits  the  bowel  musculature  causes  a con- 
traction of  the  sphincters.  The  powerful  afferent  stimulus 
arising  from  the  prepuce  is  well  known,  and  it  is  not  difficult 
to  appreciate  that  the  constant  series  of  small  stimuli  arising 
from  the  prepuce  in  a subject  of  phimosis  may  well  induce, 
in  this  way,  a spasm  of  the  pylorus.  It  is  possible  that  such 
a spasm  may  arise  either  from  direct  nerve  stimulation  or 
from  excessive  stimulation  of  the  suprarenal  hormone,  or 
from  both  of  these. 

6.  Age  of  onset. — The  age  at  which  these  babies  are 
usually  brought  for  advice  is  from  four  to  eight  weeks.  We 
are  then  told  that  the  vomiting  and  wasting  have  gone  on 
for  from  one  to  five  weeks.  So  that  the  symptoms,  in  the 
great  majority  of  cases,  appear  about  the  third  week. 
Occasionally  one  does  not  see  the  child  until,  perhaps,  the 
third  month,  and  true  cases  have  been  reported  as  showing 
symptoms  from  the  third  month  only.  These  cases  are  some- 
times not  easy  to  diagnose  because  of  the  difficulties  in 
physical  examination  mentioned  above. 

On  rare  occasions  examination  under  an  anaesthetic  may  be 
necessary  before  a diagnosis  can  be  made. 

A history  of  projectile  vomiting  beginning  about  the  third 
week,  which  is  unrelieved  by  the  ordinary  methods  of  treat- 
ment, is  highly  suggestive,  and  should  lead  to  a detailed 
examination  in  respect  of  the  above  signs  and  symptoms. 
Then  an  opinion  can  be  formed  as  to  whether  the  condition 
is  one  of  pylorospasm  or  congenital  hypertrophic  pyloric 
stenosis. 

II. — Sex  Incidence. 

It  is  a remarkable  fact  that  all  published  statistics  show  a 
very  large  preponderance  of  boys.  In  the  series  we  quote,  ’ 
of  84  cases,  there  were  only  13  girls.  The  male,  being  vago- 
tonic, might  be  expected  to  show  spasm  sufficient  to  cause 
hypertrophy  more  often  than  the  sympathetico-tonic  female. 
But  this  cannot  account  for  the  total  difference.  Certainly 
girls  do  suffer  from  congenital  stenosis,  but  we  are  able  to 
show  their  behaviour  to  be  different.  They  are  slower 
developing  the  characteristic  symptoms  of  obstruction,  and 
therefore  usually  come  under  observation  at  a somewhat 
later  age.  (Vide  Cases  4,  14,  and  15.)  That  they  will 
also  show  a correspondingly  slower  recovery  than  boys  is 
particularly  well  illustrated  by  Cases  14  and  15.  These 
cases  will  be  referred  to  again  in  more  detail,  when  these 
factors  will  be  emphasised. 

As  has  been  stated  previously,  thickening  of  the  pylorus 
has  been  noted  in  many  post-mortem  examinations  of 
children,  both  male  and  female,  who  showed  no  symptoms 
of  obstruction  during  life.  It  was  also  shown  that  the  inci- 
dence of  these  symptoms  depended  upon  the  relationship 
existing  between  the  degree  of  congenital  hypertrophy  and 
the  severity  of  the  added  spasm.  In  girls  the  more  urgent 
cause  of  spasm — phimosis — does  not  exist. 

We  are  thus  led  to  believe  that  many  children,  boys  and 
girls,  are  born  with  some  degree  of  pyloric  hypertrophy  who 
never  develop  pyloric  obstruction.  And  we  conclude  that 
the  sex  difference  is  more  apparent  than  real.  That  is  to 
say,  apart  from  the  slight  excess  in  the  number  of  males, 
possibly  due  to  their  vago-tonicity,  the  sex  incidence  is  about 
equal. 

It  would  be  interesting  to  know  the  relative  number  of 
boys  and  girls  in  Jewish  children  who  develop  pyloric 
obstruction.  Our  deductions  from  the  present  study  would 
lead  us  to  expect  that,  in  Jewish  subjects  of  pyloric  hyper- 
trophy, clinical  symptoms  of  obstruction  would  be  manifested 
in  as  many  girls  as  boys.  Further,  that  progress  would  be 
identical  in  both  sexes  under  palliative  or  operative 
treatment. 

111.  — Operative  Treatment. 

Criticism  of  operative  procedures. — In  estimating  at  their 
value  the  effects  of  different  forms  of  treatment  in  a par- 
ticular disease  there  are  several  factors  which  are  essential 
to  a sound  judgment.  Foremost  amongst  these  is  the 
necessity  for  every  case  to  be  studied  under  conditions  of 


The  lancet,]  MR.  TYRRELL  GRAY  & DR.  PIRIE  : HYPERTROPHIC  STENOSIS  OF  PYLORUS.  [Sept.  20,  1919  517 


medical  attention,  after  treatment,  nursing,  housing, 
temperature,  &c.,  as  nearly  constant  as  possible.  Only 
under  such  conditions  can  the  vitiation  of  results  by  outside 
influences  be  excluded,  and  the  intrinsic  value  of  any  opera- 
tion be  accurately  estimated.  For  this  reason  the  value  of 
this  study  would  be  much  diminished  if  it  included  cases 
seen  in  a number  of  other  hospitals  as  well  as  in  private 
practice,  since  such  a lack  of  uniformity  would  prejudice 
the  value  of  observations  intended  to  support  or  disprove  a 
definite  hypothesis.  It  is  well  known  that,  up  to  the  present, 
the  results  of  surgical  treatment  of  congenital  hypertrophic 
stenosis  are  markedly  inferior  in  hospital  to  private  practice, 
whatever  operation  may  be  performed.  Thus  we  can  record 
successes  both  with  Loreta’s  operation  (divulsion),  and  with 
gastro-enterostomy  in  apparently  hopeless  cases,  in  private 
practice,  when  undivided  individual  attention  and  every 
possible  facility  were  available.  But  at  Great  Ormond- 
street,  up  to  April,  1918,  when  we  first  initiated  the 
Rammstedt  operation  as  a routine  procedure,  there 
had  never  been  a single  instance  of  recovery  after 
surgical  intervention.  A second  feature  of  importance 
in  ascertaining  the  best  surgical  procedure,  and  the  indica- 
tions for  its  adoption,  is  that  different  methods  should  be 
given  a trial  by  the  same  surgeon  ; for  the  fact  that  one 
surgeon  obtains  the  best  results  with  one  particular  opera- 
tion, while  another  similarly  perfects  himself  by  practice 
with  a different  one,  from  which  he  deduces  his  figures,  is  of 
limited  value  in  helping  the  profession  to  judge  which 
method  is  to  be  generally  adopted  as  the  most  hopeful.  In 
order,  therefore,  to  arrive  at  impartial  results  we  have 
practised  for  the  last  few  years  three  kinds  of 
operation : (1)  gastro-enterostomy,  (2)  Loreta’s  operation, 
(3)  Rammstedt’s  operation.  It  is  feared  that  the  number 
of  cases  available  is  not  large,  because  surgical  results  have 
been  so  unsatisfactory  that  it  has  been  difficult  to  get 
physicians  to  allow  cases  to  be  operated  upon  ; while,  on 
other  occasions,  when  the  surgeon  has  been  called  in,  their 
condition  has  been  such  that  surgery  has  rarely  been 
afforded  a fair  trial. 

However,  since  the  same  disadvantages  obtained  when  the 
operation  of  Rammstedt  was  first  practised,  the  comparison 
of  results  in  these  three  procedures  is  tolerably  fair.  The 
first  point  of  importance,  then,  is  the  decision  as  to  which 
variety  of  operation  is  the  best  and  based  on  the  soundest 
principles. 

Pyloroplasty  will  not  be  discussed,  because,  though  it  may 
be  possible  to  do  this  operation  successfully  in  a limited 
number  of  cases,  it  is  only  necessary  to  see  and  feel  some  of 
the  hard,  almost  cartilaginous,  tumours  so  often  met  with,  to 
appreciate  the  fact  that  the  adoption  of  any  plastic  method 
is  impossible  with  any  degree  of  certainty  or  security. 

The  operation  of  Lor  eta,  though  it  has  been  attended  with 
such  a great  measure  of  success  in  the  hands  of  Mr.  F.  F. 
Burghard,  has  disadvantages  which  cannot  be  ignored.  In  the 
first  place,  this  procedure  is  unsound  in  principle  because  it 
lacks  precision.  Thus  the  object  is  to  rupture  the  hypertrophied 
and  spastic  circular  fibres  without  damage  to  the  mucous 
membrane,  and,  if  possible,  without  rupturing  the  peritoneal 
coat.  That  this  object  is  attained  only  by  violent  measures 
is  true,  however  carefully  and  slowly  the  dilators  are  intro- 
duced, and  whatever  length  of  time  is  allowed  to  elapse 
while  each  dilator  rests  in  the  pylorus  before  the  next  size 
is  employed.  Secondly,  it  is  not  always  a simple  matter  to 
gauge  the  exact  amount  of  dilatation  required  to  rupture 
the  muscular  coat,  though,  when  rupture  has  occurred,  the 
gap  can  usually  be  felt  with  the  fingers  of  the  left  hand  as 
they  grasp  the  pylorus  during  these  manipulations.  It  is 
easy  to  avoid  damage  to  the  mucous  membrane  ; indeed, 
with  the  most  ordinary  precautions,  it  is  impossible  to  do 
harm  in  this  way.  There  is  no  certainty  at  any  time  that 
the  peritoneum  will  not  split  when  the  muscular  coat  gives 
way,  for  it  is  so  thin,  friable,  and  adherent  to  the  tumour 
that,  in  many  instances,  the  rupture  of  both  may  take  place 
simultaneously.  Thirdly,  this  very  lack  of  precision  leads 
to  overstretching  or  to  insufficient  stretching,  leaving  to  the 
surgeon’s  instinct  and  experience  alone  the  estimation  of  the 
amount  required.  Recurrences  of  obstruction  in  the  latter 
eventuality  are  to  be  expected.  In  the  absence  of  full  statistics 
no  estimate  of  the  percentage  of  recurrences  can  be  given,  but 
it  does  undoubtedly  occur.  Fourthly , such  an  operation  on  an 
obstructed  stomach  is  more  liable  to  be  a septic  one  on  account 
of  the  retained  contents  and  consequent  changes  in  the  gastric 


mucosa,  since  the  stomach  has  to  be  opened  in  order  to 
introduce  dilators  ; and  a certain  amount  of  infection,  how- 
ever mild,  must  add  to  the  severity  of  the  operation  in  so 
small  a subject,  in  spite  of  every  care  to  avoid  soiling. 
Fifthly,  the  operation  cannot  be  performed  carefully  and 
gently  in  less  than  15  minutes,  most  of  the  time  being 
consumed  in  allowing  each  dilator  to  rest  a short  time  in  the 
pylorus  as  larger  sizes  are  used.  Such  a length  of  time  in 
an  operation  of  violence  on  a young  subject,  together  with 
the  addition  of  the  necessary  sepsis  entailed  by  opening 
the  stomach,  combine  to  make  the  operation  a severe  one. 
Sixthly,  the  exact  site  of  the  rupture  can  never  be  predicted 
with  certainty. 

It  follows  naturally  that  Loreta’s  operation  is  only  avail- 
able for  early  cases,  when  the  nature  of  the  condition  is 
established  soon  after  the  onset  of  symptoms,  and  before  the 
baby  is  markedly  wasted.  In  later  cases,  when  the  subject 
is  wizened  and  marantic,  or  almost  moribund  from  loss  of 
fluid,  this  operation  is  doomed  to  failure  and  cannot  be 
advocated  generally  as  a means  of  saving  life.  Now  we 
submit  that  any  operation  of  the  severity  and  risk  entailed 
in  the  surgical  treatment  of  so  dangerous  a condition  should, 
if  the  immediate  operation  risks  are  survived,  at  least  be  one 
that  offers  a certain  cure  with  no  risk  of  recurrence.  This 
cannot  be  claimed,  we  believe,  from  Loreta’s  operation. 
Further,  it  must  be  practised  on  early  cases  of  fair  physique 
to  offer  a reasonable  chance  of  success.  If  this  principle 
be  adopted  as  a routine,  we  believe  that,  though  a definite 
proportion  of  cases  will  be  operated  upon  successfully, 
in  accordance  with  ordinary  surgical  risks,  even  favourable 
cases  will  sometimes  succumb  to  Loreta’s  operation. 
Amongst  these  will  be  numbered  a certain  proportion  who 
would  have  recovered  by  palliative  measures  alone.  For 
these  reasons  we  are  of  opinion  that  the  ideal  operation  to 
be  advocated  generally  is  one  which  offers  the  chance  of  a 
certain  cure,  while  being  applicable  to  cases  in  which 
palliative  treatment  has  been  given  a trial  and  failed.  It 
is  from  this  standpoint  that  we  have  made  a study  of 
congenital  pyloric  stenosis.  In  following  this  study  we 
would  ask  our  readers  to  bear  in  mind  that,  in  every  instance, 
operations  have  been  performed  only  on  infants  with  whom 
palliative  measures  had  definitely  failed  and  the  child  was 
losing  ground.  In  no  instances  have  operations  been 
performed  without  giving  such  preliminary  measures  a fair 
chance.  Further,  we  emphasise  the  fact  that,  had  we  been 
aiming  at  good  statistics  alone,  many  cases  would  not  have 
been  operated  upon  ; and  still  further,  that  in  no  single 
instance  has  operation  been  declined  owing  to  the  feebleness 
of  the  subject.  As  a result  life  has  been  saved  on  more  than 
one  occasion  in  an  apparently  hopeless  case,  though 
naturally  our  actual  figures  suffer. 

(1)  Gastro-enterostomy. — The  obvious  drawbacks  in  Loreta’s 
operation  led  us  to  try  gastro-enterostomy  as  an  alternative 
method.  Successful  gastro-enterostomy  has,  at  least,  the 
merit  of  certain  cure.  This  operation  was  attended  in  the 
past  with  such  a high  mortality  that,  by  common  consent, 
it  had  been  abandoned  as  a routine  method.  But  we 
wished  to  try  this  method  under  spinal  anassthesia.  The 
number  of  cases  is  too  small  to  allow  of  statistical  deduc- 
tions, but  the  reasons  for  the  abandonment  of  this  procedure 
are  of  importance.  Briefly,  gastro-enterostomy  has  been 
performed  on  four  cases  ; three  were  operated  upon  under 
spinal  anaesthesia  and  one  under  warm  ether  anaesthesia. 
The  posterior  no-loop  operation  was  performed  on  all  the 
cases.  Two  were  operated  on  at  Great  Ormond-street  and 
both  died  within  48  hours.  Two  were  operated  on  elsewhere 
and  both  recovered.  One  of  these,  in  excellent  condition, 
with  no  adverse  symptoms  after  the  operation,  developed  a 
fatal  pneumococcal  meningitis,  by  extension  from  the  middle 
ear,  about  a fortnight  later.  The  other  was  alive  and  well 
some  few  months  ago,  three  and  a half  years  after  operation. 
There  can  be  no  doubt  that  spinal  anesthesia  improves  the 
outlook  from  this  operation,  which  can  be  performed  easily 
and  securely  in  a total  time  of  15-20  minutes.  With  figures 
showing  50  per  cent,  recoveries  in  all  cases,  it  might  appear 
that  there  was  no  justification  for  abandoning  this  procedure. 
The  figures,  however,  do  not  represent  the  whole  case,  and 
the  reasons  for  discarding  gastro-enterostomy  are  as  follows. 

The  two  most  favourable  cases  were  those  at  Great 
Ormond-street,  where  everything  appeared  in  favour  of 
recovery,  yet  both  died.  Of  the  two  babies  who  recovered, 
one  appeared  practically  moribund,  the  other  seemed 


518  Thb  Lanoht,]  MR.  TYRRELL  GRAY  Sc  DR.  PIRIE : HYPERTROPHIC  STENOSIS  OF  PYLORUS.  [Sept.  20,  1919 


hopelessly  wasted  and  feeble  ; both  owe  their  recovery  to  the 
most  constant  devotion  and  attention  of  doctor  and  nurse, 
and  even  so  their  condition  was  quite  critical  for  some  days. 
Again,  though  the  operation  can  be  quietly  and  gently  per- 
formed under  favourable  conditions  in  15  minutes,  this  end 
will  only  be  attained  by  perfect  team  work  between  anaes- 
thetist, sister,  assistant,  and  surgeon,  and  allows  no  margin  for 
surgical  accidents,  small  delays,  &.C. , and  the  hundred-and-one 
small  events  which  contribute  towards,  or  militate  against,  a 
smooth  and  rapid  operation.  Finally,  even  when  everything 
has  gone  perfectly,  without  a hitch,  the  child’s  condition 
immediately  afterwards  is  always  bound  to  be  critical  ; while, 
in  the  presence  of  any  adverse  circumstances,  a fatal  result 
is  almost  sure.  It  was  concluded,  therefore,  that  though 
many  recoveries  might  be  obtained  with  gastro-enterostomy, 
even  in  late  cases,  there  would  always  be  too  great  an 
element  of  “ luck,”  and  the  prognosis  must  always  be  too 
doubtful  to  justify  its  routine  adoption.  There  is  another 
point  which  deserves  mention.  It  has  been  shown  in  a post- 
mortem performed  on  one  of  these  cases  many  months  after 
gastro-enterostomy  (death  had  occurred  from  other  causes) 
that,  though  symptoms  are  definitely  cured  and  the  child  is 
apparently  normal  in  every  respect,  the  pyloric  tumour 
remains.  In  other  words,  gastro-enterostomy  does  not  cure 
the  congenital  hypertrophy  of  the  pylorus,  but  only  short- 
circuits  the  site  of  obstruction.  (Vide  Rammstedt’s  opera- 
tion (3).)  Finally,  since  the  aim  of  any  operation  should  be, 
if  possible,  directed  primarily  at  the  cause  of  the  evil,  we 
trust  that  our  study  will  show  that  gastro-enterostomy  is  a 
measure  which  aims  only  at  circumventing  the  gastric 
obstruction,  and  does  not  attack  the  origin  of  such  obstruc- 
tion. It  is  a little  difficult  to  account  for  the  inferior 
immediate  results  obtained  by  gastro-enterostomy  compared 
with  those  following  Loreta’s  operation,  for  the  time  taken 
by  this  operation  is  no  longer  (indeed,  it  is  often  shorter)  ; 
while  the  operation  itself  is  of  a gentler  nature  involving  less 
manipulation.  Nevertheless,  it  seemed  clear  that,  in  spite  of 
the  apparent  certainty  of  cure,  gastro-enterostomy  ought  to 
be  abandoned  as  a routine  method.  Loreta’s  operation  was 
therefore  reverted  to  in  cases  where  palliative  treatment  had 
definitely  failed. 

(2)  Lor  eta' s operation. — This  operation  has  been  performed 
on  four  occasions  at  Great  Ormond-street  ; all  were  fatal. 
We  record  a total  of  7 cases  with  one  recovery.  In  all  cases 
a feed  was  introduced  into  the  duodenum  as  recommended 
by  Mr.  Burghard.  The  first  two  cases  were  operated  upon 
under  spinal  anaesthesia,  one  male  and  one  female  ; both 
were  6 weeks  old  ; both  died.  In  one  of  them  the  child  did 
well  for  11  days  and  gained  4 ounces  in  weight,  and  then 
commenced  to  go  downhill  and  began  to  vomit.  Subsequent 
to  operation  visible  peristalsis  was  never  seen.  In  the  other 
case  no  cause  of  death  is  stated  in  the  notes  ; but  it  may  be 
stated  that  spinal  anaesthesia  was  abandoned  in  these  very 
wasted  and  feeble  infants,  owing  to  the  frequency  of  massive 
collapse  of  the  lungs  to  which  there  is  a great  liability.  Of 
the  other  two  infants  who  died  after  Loreta’s  operation,  one 
is  of  special  interest. 

The  child  was  a male  of  4 months,  in  whom  vomiting 
commenced  at  2-1  months.  It  was  a weakly  infant  of  6A  lb. 
Loreta’s  operation  was  performed  under  open  ether  anaes- 
thesia and  lasted  under  15  minutes.  The  muscular  coat  was 
ruptured  by  a No.  10  Hegar’s  dilator,  which  was  left  in  situ 
for  a few  seconds.  The  pulse  remained  excellent  throughout, 
but  breathing  became  spasmodic  during  the  dilatation,  and 
continued  so  for  some  time  after  returning  to  the  ward. 
There  was  an  occasional  vomit  during  the  first  few  days,  but 
the  child’s  condition  improved  for  the  first  13  days,  with  a 
gratifying  gain  in  weight.  (Chart  1.)  Diarrhoea  and  vomiting 
supervened,  and  though  this  was  controlled  at  times  the 
child  gradually  sank  and  died  one  month  after  the  operation. 

The  two  features  to  be  noted  in  connexion  with  this  case 
are  : 

(a)  The  spasmodic  breathing  inaugurated  by  the  dilatation 
of  the  pylorus.  ( b ) The  occurrence  of  vomiting  after  the 
operation. 

(«)  The  first  of  these  two  has  been  noted  by  us  on  several 
occasions  during  Loreta’s  operation,  and  is  attributable,  we 
think,  to  a violent  afferent  vagus  stimulus  initiated  by  the 
violent  stretching  (and  persisting  for  some  time  afterwards), 
which  inhibits  inspiration  in  much  the  same  way  as  a •'  blow 
in  the  wind.” 

(>)  The  occurrence  of  vomiting  after  Loreta’s  operation 
was  noted  in  all  three  cases  which  recovered  from  the 


operation.  Four  cases  definitely  died  from  the  operation, 
while  two  died  witbin  a month,  as  already  detailed.  One 
case  recovered  and  is  alive  to-day.  In  the  last  three  cases 
vomiting  was  noted  after  operation  ; it  was  not  forcible  in 
character,  and  visible  peristalsis  was  not  present.  This 
feature  is,  we  think,  to  be  explained  by  the  fact  that,  though 
the  circular  muscular  coat  is  completely  ruptured  by  the 

Chart  1. 


The  arrow  indicates  the  day  of  operation. 

passage  of  the  dilators,  this  manipulation  induces  a swelling 
and  hypersemia  of  the  mucosa  which  partially  closes  the 
pylorus  until  this  new  factor  subsides.  It  is  not  due  to 
insufficient  dilatation,  for  in  each  case  the  split  in  the 
muscle  was  definitely  felt,  and  there  were  no  signs  of  gastric 
obstruction  such  as  could  be  observed  before  operation,  while 
the  vomiting  was  in  no  instance  of  a projectile  character. 
We  have,  of  course,  too  few  cases  to  allow  us  to  say  how 
often  this  feature  is  to  be  noted  after  Loreta’s  operation  ; 
but,  in  view  of  our  small  experience,  we  should  expect  it  to 
be  fairly  common. 

The  one  case  which  recovered  was  of  considerable  interest 
in  that  it  was  due  to  this  experience  that  Loreta's  was 
abandoned  in  favour  of  Rammstedt’s  operation.  In  this 
case,  during  the  final  dilatation,  the  muscular  and  peritoneal 
coats  were  both  split  over  a distance  of  about  half  an  inch. 
The  gap  was  closed  by  a catgut  stitch,  since  any  attempt  at 
invagination  was  out  of  the  question,  owing  to  the  hard  and 
cartilaginous  nature  of  the  tumour.  Contrary  to  expecta- 
tion, the  child  made  a good  recovery,  and  it  was  this  fact 
which  overcame  a natural  disinclination  to  divide  these  two 
coats  of  the  pylorus  deliberately  from  the  outside  and  leave 
them  open  with  the  mucous  membrane  exposed. 

(3)  Rammstedt' s operation. — This  operation  aims  at  the 
relief  of  the  pyloric  obstruction  without  at  any  time 
opening  the  gastric  mucous  membrane.  This  procedure 
seems  to  have  been  adopted  with  success  by  Rammstedt, 
whose  name  is  attached  to  the  operation,  in  1913.  The 
credit,  however,  for  devising  a method  of  relieving  the 
obstruction  without  opening  the  gastric  mucosa  must,  we 
think,  be  given  to  an  Englishman,  Mr.  Russell  Coombe,  of 
Exeter.  This  surgeon  published  a recovery  in  1911  (Annals 
of  Surgery)  by  an  extra-mucous  pyloroplasty,  and  in  the 
same  paper  suggested  a modification  (which  has  since  been 
practised  with  success)  designed  to  facilitate  the  introduc- 
tion of  the  necessary  sutures.  Rammstedt’s  operation 
surpasses  in  speed,  simplicity,  and  certainty  every  other 
operation  for  the  relief  of  hypertrophic  pyloric  stenosis,  by 
eliminating  every  unessential  detail.  The  essential  principle 
of  the  operation  is  the  recognition  of  the  fact  that  the  mucous 
membrane  of  the  pylorus  is  sufficiently  thick  and  redundant 
to  provide  by  itself  adequate  protection  for  the  peritoneum 
against  leakage  and  infection  from  the  gastric  contents.  The 
realisation  of  this  all-important  fact  naturally  suggests  the 
simplest  of  all  measures  for  the  relief  of  the  obstruction — 
namely,  the  longitudinal  division  of  the  hypertrophied 


Thh  Lanoht,]  MR.  TYRRELL  GRAY  ic  DR.  PIRIE:  HYPERTROPHIC  STENOSIS  OF  PYLORUS.  [Sept.  20,  1919  519 


pylorus  down  to  mucous  membrane ; this  constitutes 
Rammstedt’s  operation.  It  might  appear  that  such  a simple 
operation  offers,  in  its  actual  performance,  little  for  the 
surgeon  to  learn  ; but  experience  has  shown  that  this  is  not 
the  case,  and  this  study  will  serve  a more  useful  purpose  if 
we  briefly  describe  some  of  the  points  of  interest  in  the  cases 
on  which  this  operation  has  been  performed.  We  have  per- 
formed Rammstedt’s  operation  on  17  occasions  at  Great 
Ormond-street,  with  seven  deaths  and  ten  recoveries,  giving 
a mortality  of  411  per  cent.  Two  facts  must  be  noted  : — 

1.  Pre-  and  post-operative  treatment  has  been  practically 
identical  in  all  cases. 

2.  In  no  instance  have  we  declined  operation  on  account 
of  the  bad  condition  of  the  patient,  whatever  the  reason.  In 
other  words,  every  case,  without  exception,  when  palliative 
measures  definitely  failed,  was  afforded  the  chance  of  a cure 
by  operation. 

CaseI. — M.  Age9weeks.  Symptoms  present  for  four  weeks. 
The  onild  rapidly  went  downhill,  and  vomiting  increased 
until  at  the  time  of  admission  the  description  is  that  of  a 
very  wasted  baby,  with  drawn  face,  lying  with  eyes  and 
mouth  half  open,  fontanelle  depressed,  presenting  classical 
symptoms  and  signs  of  hypertrophic  pyloric  stenosis.  In 
spite  of  infusion,  the  child  when  first  seen  was  grey  and 
semi-conscious,  with  slow  intermittent  gasping  respirations, 
for  which  it  was  placed  in  a mustard  hath.  Operation  was 
temporarily  declined  unless  improvement  took  place  with 
subcutaneous  infusion  of  saline  and  2 per  cent,  glucose. 
This  was  continued  for  36  hours,  when  it  was  considered 
that  operation  offered  a faint  chance  of  recovery.  As  it  was 
thought  that  any  of  the  more  recognised  operations  offered 
little  hope  of  success,  Rammstedt’s  operation  was  performed 
for  the  first  time.  At  the  first  incision  the  skin  and  sub- 
cutaneous tissues  were  cedematous  with  saline  which  oozed 
as  if  a local  anassthethic  had  been  given,  while,  on  opening 
the  peritoneum,  fluid  poured  out  as  in  a case  of  ascites.  The 
pylorus  was  brought  up  into  the  wound  and  an  incision 
rapidly  made  through  the  hypertrophied  area  through  all 
coats  down  to  the  mucosa.  The  pylorus  was  then  returned 
to  the  abdominal  cavity  and  the  wound  closed  in  layers. 
Temperature  rose  to  105°  F.  the  same  evening,  but  com- 
menced to  fall  rapidly  the  following  day.  This  child,  though 
apparently  quite  a hopeless  case,  made  an  uninterrupted 
recovery.  There  was  no  post  operative  vomiting.  Loose 
motions  were  noted  for  a short  time  after  operation. 
(Chart  2.V 

' Chart  2. 


The  arrow  indicates  the  day  of  operation. 

Case  2. — M.  Age  8 weeks.  Symptoms  started  at  3 weeks. 
This  case  was  booked  for  operation  on  the  same  afternoon  as 
Case  1.  Loreta’s  operation  had  been  contemplated,  but  the 
simplicity  and  rapidity  of  the  Rammstedt  was  so  inviting 
that  it  was  performed  on  this  case  also.  In  spite  of  the 
fact  that  medical  treatment  had  been  persisted  in  for  over 
three  weeks,  with  no  relief  of  projectile  vomits,  the  condi- 
tion of  the  child  was  much  better  than  in  Case  1.  The 
temperature  rose  to  104°  the  evening  of  the  operation, 


falling  to  100°  the  following  day.  Recovery  was  uninter- 
rupted and  there  was  a small  vomit  on  the  ninth  and  another 
on  the  tenth  day  after  operation.  Loose  motions  were  noted 
occasionally  for  the  first  11  days. 

Case  3. — M.  Age  8 weeks.  Symptoms  commenced  at  5 
weeks.  Medical  treatment  for  a fortnight,  when  vomiting 
became  more  frequent  and  14  oz.  in  weight  had  been  lost. 
Incidentally  the  temperature  rose  to  102°  on  the  seventh  day, 

Chart  3. 


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71 

6_. 

... 

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5 .. 

i_ 

..... 

The  arrow  indicates  the  day  of  operation. 

or  a week  previous  to  operation.  Kammstedt’s  operation 
was  followed  by  an  uninterrupted  recovery.  Temperature 
rose  to  105°  on  the  evening  after  operation.  There  was  one 
vomit  on  the  second  day.  Stools  were  formed  on  the  tenth 
day,  when  there  were  seven  loose  motions,  which  improved 
with  a rectal  wash-out,  and  a steady  gain  in  weight  super- 
vened. (Chart  3.) 

Case  4. — F.  Age  8 weeks.  Symptoms  commenced  at  5 
weeks.  Rammstedt’s  operation  performed  the  day  after 
admission.  Uninterrupted  recovery.  The  points  to  note  in 
this  case  are  the  frequency  of  stools  the  two  days  before 
operation  and  the  absence  of  “ diarrhoea  ” after  operation. 
This  observation  has  a bearing  on  the  different  behaviour  of 
girls,  to  which  reference  is  made  later.  Post-operative  tem- 
perature only  rose  to  101-4°,  but  it  is  worthy  of  remark  that 
in  this  oase  the  pre-operative  temperature  showed  a variation 
of  97°  to  98-8°.  (Vide  Case  3.) 

Case  5. — M.  Age  8 weeks.  Symptoms  started  at  5 weeks. 
Baby  wasted  and  had  lost  much  fluid ; skin  loose  and  inelastic. 
Rammstedt’s  operation  was  well  borne  and  recovered  from, 
and  feeds  were  well  taken.  Gastric  lavage  the  evening  after 
operation  showed  a quantity  of  undigested  milk  and  mucus. 
Forty-eight  hours  after  operation  the  child  developed  some 
abdominal  pain,  and  died  suddenly  an  hour  later.  Post- 
mortem examination  showed  that  the  incision  into  the 
hypertrophied  part  of  the  pylorus  had  not  been  continued 
sufficiently  far  on  the  stomach  side — in  other  words,  the 
incision  had  been  deep  enough  to  sever  all  coats  down  to  the 
mucosa,  but  had  not  completely  divided  all  the  hyper- 
trophied portion  in  the  most  important  situation.  The 
lesson  to  be  learned  from  this  case,  therefore,  was  that  the 
hypertrophied  portion  must  be  divided  throughout  its  whole 
length  down  to  the  mucous  membrane.  This  seemed  to  be 
essential  to  the  complete  relief  of  the  gastric  obstruction  ; 
for,  though  the  child  was  in  good  condition  after  the  opera- 
tion, the  presence  of  mucus  and  undigested  milk  in  the 
stomach  shows  that  the  obstruction  was  not  completely 
relieved. 

Case  6. — M.  Age  6 weeks.  Symptoms  dated  from  first 
week,  becoming  typical  at  3 weeks,  and  culminating  in 
frequent  projectile  vomits.  Rammstedt’s  operation  per- 
formed two  days  after  admission,  during  which  time  the 
temperature  varied  from  97-4°  to  99°  and  101°.  Recovery 
was  uninterrupted  and  there  was  no  vomiting.  The 
temperature  rose  to  104°  on  the  evening  of  operation,  and  to 
105°  on  the  following  day,  falling  to  normal  three  days  later. 
“Diarrhoea"  was  noted  on  the  second  day.  Steady  gain  in 
weight  was  noted  from  the  fifteenth  day. 

Case  7. — M.  Age  6 weeks.  Premature  baby  born  at 
74  months  and  weighing  5i  lb.  Child  very  feeble  and  weak. 
Symptoms  dated  from  nine  days  ago,  and  were  severe  in 
character.  Medical  treatment  for  17  days  with  no  improve- 
ment. Rammstedt’s  operation  was  followed  by  death  the 
same  evening. 


520  Thb  Lancet,]  MR.  TYRRELL  GRAY  & DR.  PIRIE:  HYPERTROPHIC  STENOSIS  OF  PYLORUS.  [Sept.  20,  1919 


Case  8. — This  case  is  of  special  interest  in  view  of  the 
lesson  learnt  from  a study  of  the  result.  M.  Age  5 weeks. 
In  good  condition.  Medical  treatment  for  five  days  yielded 
no  improvement  in  the  vomiting,  while  the  child  steadily 
lost  ground.  Rammstedt’s  operation  was  performed  on  the 
seventh  day  after  admission.  The  temperature  rose  to 
102-8°  on  the  day  following  operation,  and  showed  from  that 
time  the  usual  steady  fall  up  to  the  third  morning.  On  the 
third  afternoon  the  temperature  rose  again  to  102°,  and  was 
accompanied  by  five  vomits.  Subsequent  to  this  diarrhcea 
and  rapid  respirations  developed  ; the  temperature  rose  to 
104°,  and  the  child  died  at  midnight,  or  nearly  four  days 
after  operation. 

Commentary . — Now  the  interest  in,  and  instruction  from, 
this  case  lie  in  the  following  facts  : In  Case  5 the  obstruc- 
tion was  insufficiently  relieved  owing  to  the  imperfect 
division  of  the  pylorus  on  the  stomach  side.  In  the  sub- 
sequent cases,  therefore,  special  efforts  were  made  to  ensure 
that  the  division  should  be  complete ; and  in  this  case 
(Case  8)  the  incision  was  carried  too  far  down  towards  the 
first  part  of  the  duodenum.  The  mucous  membrane  was 
punctured  at  the  lowest  part  of  the  incision,  and  had  to  be 
closed  by  sutures,  The  child  did  well  for  three  days,  when 
leakage  occurred  and  was  followed  by  death.  Post-mortem 
examination  showed  that  leakage  and  peritonitis  were  the 
cause  of  death.  (At  this  point  in  our  experience  the  same 
incident  occurred  in  private  practice.  Fortunately,  however, 
in  this  case  the  wound  in  the  mucosa  was  more  securely 
closed,  no  leakage  occurred,  and  the  child  recovered.) 

Lessons  Learned  from  Cases. 

The  lessons  we  learned  from  these  cases  were  as  follows:— 

1.  The  mucous  membrane  beneath  the  hypertrophied 
pylorus  is  not  only  redundant,  but  is  also  very  thick,  and 
loosely  connected  with  the  muscular  coat.  It  is  this 
anatomical  fact  which  renders  it  so  easy  to  divide  the  two 
external  coats  without  damaging  the  mucous  coat  over  the 
obviously  hypertrophied  portion.  The  mucous  membrane 
under  the  muscular  coat  of  the  stomach  immediately  adjoin- 
ing the  hypertrophied  pylorus  is  also  loosely  attached  ; and 
it  is  easy,  therefore,  to  divide  well  into  normal  stomach  wall 
without  fear  of  injury  to  the  mucosa  or  of  subsequent  leak- 
age. On  the  duodenal  side,  however,  the  mucosa  is  not  only 
very  thin,  but  it  is  firmly  attached  to  the  muscular  coat,  so 
that  any  prolongation  of  the  incision  below  the  hypertrophied 
portion  is  almost  certain  to  wound  the  normal  mucosa  of  the 
first  part  of  the  duodenum. 

2.  We  also  learned  that  the  hypertrophy  ends  abruptly  on 
the  duodenal  side  in  a peculiar  manner,  but  on  the  gastric 
side  it  merges  gently  into  the  normal  structures. 

The  peculiar  configuration  of  the  hypertrophied  pylorus  in 
the  duodenal  portion  is  of  the  highest  importance.  Thus, 
there  are  three  features  to  be  noted  by  the  operator. 

(1)  The  mucous  membrane  is  firmly  adherent  to,  and  very 
thin  and  friable  over,  the'  terminal  hypertrophied  muscular 
coat  at  a.  (Fig.  1.) 

Fig.  1. 


(2)  This  terminal  hypertrophy  projects  into  the  lumen  of 
the  duodenum,  and  the  adherent  mucous  membrane  bends 
back  with  it  towards  the  stomach  to  join  the  normal 
duodenal  wall,  where  it  is  also  firmly  attached  at  b. 

(3)  It  is  clear  that  to  divide  the  hypertrophy  completely 
on  the  duodenal  side  as  far  as  a , the  incision  must  be 
carried  as  far  as  c.  But  it  is  equally  evident  that  this 
cannot  be  done  without  just  traversing  the  lumen  of  the 
duodenum.  The  impossibility  of  complete  division  of  the 
hypertrophied  portion  of  the  pylorus  by  Rammstedt’s  opera- 
tion might,  at  first  sight,  appear  to  constitute  an  important 
point  in  favour  of  Loreta’s  method  ; such  a conclusion  is 
unjustified.  For  not  only  is  the  final  obstruction  due  to 
spasm  at  the  gastric  end  (and  not  at  the  duodenal  end)  of 
the  pylorus,  but  the  thin  and  elastic  duodenal  wall  in  itself 
allows  too  much  play  for  mechanical  obstruction  to  occur  at 


this  outlet.  Thus  the  hypertrophied  distal  portion  cannot 
and  does  not  form  an  element  in  the  obstruction,  and  there 
is  no  need  for  the  division  to  be  carried  to  its  termination. 

The  practical  lesson,  therefore,  was  that  the  incision  must  be 
carried  well  beyond  the  hypertrophied  pylorus  on  the  stomach 
side  where  the  main  responsibility  for  the  obstruction  lies ; 
while,  on  the  duodenal  side,  it  does  not  matter  very  much  if 
the  division  is  a little  incomplete,  since  the  main  obstruction 
is  not  at  this  situation.  Moreover,  in  the  post-mortem  room 
it  can  be  demonstrated  that  water  can  be  forced  from  the 
duodenum  through  the  hypertrophied  pylorus  into  the 
stomach,  but  not  in  the  reverse  direction.  In  subsequent 
cases,  therefore,  the  stomach  side  has  been  given  special 
attention  ; and  the  landmark  adopted  for  determining  the 
upper  limits  of  the  incision  was  the  point  at  which  (1)  the 
muscular  coat  becomes  thin,  (2)  the  muscular  coat  becomes 
vascular.  In  other  words,  we  now  make  a point  of  ensuring 
that  the  incision  stops  exactly  at  a point  where  venous 
oozing  commences.  On  the  duodenal  side  we  stop  just  short 
of  the  point  where  the  white  avascular  coat  merges  into 
the  normal  vascular  structures  of  the  duodenum.  In  all 
subsequent  cases  these  lessons,  learned  from  disappointing 
experience,  have  been  faithfully  applied.  The  practical 
justification  of  these  deductions  becomes  increasingly  evident. 

Case  9. — M.  Age  7 weeks.  Symptoms  commenced  at 
3 weeks.  Medical  treatment  for  five  days  produced 
some  improvement  in  symptoms  for  a day  or  so,  but 
subsequently  the  child  became  rapidly  worse.  Rammstedt’s 
operation  was  followed  by  slow  recovery,  the  delay  being 
attributable  to  the  sloughing  of  the  skin  at  the  site"  of  one 
of  the  subcutaneous  saline  injections.  Temperature  rose  to 
104°  in  the  evening  of  the  operation,  but  fell  to  99°  the 
following  morning.  No  vomiting  from  the  day  following 
operation,  but  “ some  diarrhcea  ” was  noted  for  the  first  ten 
days. 

Cases  10  and  11. — These  two  cases  may  be  dismissed 
shortly  as  offering  no  basis  for  study.  Both  were  submitted 
to  Rammstedt’s  operation,  as  they  were  going  downhill  under 
medical  treatment.  Both  were  operated  upon  on  the  same 
day,  during  the  persistence  of  influenzal  bronchitis.  It  may  1 
be  questioned  whether  these  two  children  were  given  the  ■ i 
best  chance  of  recovery  by  operating  under  such  adverse  , 
conditions,  but  after  careful  consideration  we  decided  that 
the  pyloric  stenosis  was  the  greater  menace  and  acted 
accordingly.  Had  we  been  considering  statistics  only  we 
should  have  refused  to  operate  in  both  instances.  Both 
cases  ended  fatally  from  purulent  bronchitis,  as  evidenced 
by  post-mortem  examination,  while  the  abdomen  in  each 
instance  showed  nothing  abnormal.  We  propose,  therefore 
(as  we  think  we  are  justly  entitled  to  do  so),  to  exclude  these 
two  cases  from  our  study. 

Case  12. — M.  Age  4 weeks.  Symptoms  dated  from  1 

2 weeks.  Medical  treatment  for  eight  days  resulted  in  a 
steady  loss  of  weight  of  5 oz.  Rammstedt’s  operation  was 
performed  on  the  eighth  day  after  admission.  The  tempera- 
ture rose  to  103-4°  on  the"  day  after  operation,  when  the 
gradual  fall  was  interrupted  by  repeated  convulsions, 
cyanosis,  and  rigidity,  ending  in  death  three  days  after 
operation.  There  was  no  post-operative  vomiting,  while 
the  child  bore  the  operation  excellently,  and  subsequently 
took  its  feeds  well.  Post-mortem  examination  revealed 
nothing  abnormal.  In  fact,  this  case  is  one  of  the  only  two 
instances  in  our  series  in  which  a fatal  result  cannot  be 
explained  satisfactorily. 

Case  13. — M.  Age  4 weeks.  Symptoms  dated  from 

3 weeks.  Medical  treatment  persisted  in  for  eight  days 
without  improvement.  The  child  weighed  8 lb.  at  3 weeks 
and  6 lb.  6 oz.  at  the  time  of  operation.  Rammstedt’s 
operation  was  followed  by  uninterrupted  recovery.  Post- 
operative temperature  rose  to  105-2°,  but  fell  gradually  to 
normal  on  the  third  day.  There  was  no  vomiting  after  the 
first  day. 

Case  14. — This  case  presented  features  of  unusual  interest. 

F.  Age  3 months.  Full-time  child,  weighing  8 lb  at  birth. 
Vomits  started  a few  days  after  birth  and  gradually  got 
larger,  more  frequent,  and  more  forcible.  Child  was 
admitted  to  Great  Ormond-street  at  3 months  of  age.  The 
abdomen  was  always  distended  ; the  pylorus  could  never  be 
felt  with  certainty,  and  we  were  never  able  to  see  gastric 
peristalsis.  A series  of  X ray  examinations  after  the  taking 
of  bismuth,  carried  out  on  "two  occasions,  showed  that  a 
small  quantity  of  bismuth  escaped  through  the  pylorus  soon 
after  it  was  taken,  but  that,  after  this  small  quantity  had 
passed,  the  rest  remained  in  the  stomach  for  48  hours  (after 
which  the  examination  ceasedl.  Vomiting  persisted  in 
spite  of  medical  treatment  carried  out  for  a month,  during 
which  time  the  child  steadily  lost  ground.  In  spite  of 


The  Lancet,]  MR.  TYRRELL  GRAY  & DR.  PIRIE : HYPERTROPHIC  STENOSIS  OF  PYLORUS.  [Sei-t.  20,  1919  521 


almost  daily  infusions  of  salino  and  glucose  the  weight  fell 
from  7 lb.  8 oz.  to  6 1b.  4oz.  Rammstedt’s  operation  was 
performed  and  was  followed  by  immediate  improvement  in 
the  symptoms,  while  a return  to  the  normal  and  pro- 
gressive gain  of  weight  was  slow  and  delayed  for  some 
weeks,  and  was  characterised  by  fatty  stools  for  a consider- 
able time.  The  temperature  after  operation  rose  to  105'2° 
on  the  second  day,  falling  to  normal  on  the  fourth  day. 
There  was  no  frequency  of  stools  and  no  vomiting  subse- 
quent to  operation.  One  point  of  interest  in  this  case  con- 
sists in  the  fact  that,  though  under  the  most  careful  and 
constant  supervision  for  a month  previous  to  operation,  the 
pylorus  could  never  be  felt  with  certainty  and  we  never 
succeeded  in  seeing  peristalsis,  yet  directly  the  child  was 
anaesthetised  for  operation  peristalsis  was  clearly  present  to 
a marked  degree. 

Effect  of  A nasthetio. 

We  have  already  suggested  that  powerful  or  constantly 
recurring  afferent  stimuli  evoke  an  efferent  sympathetic 
response,  and  have  pointed  out  that  the  splanchnic  nerves 
share.tn  this  phenomenon  to  a marked  extent.  The  result  of 
such  impulses  is,  therefore,  a corresponding  stimulation  of 
the  splanchnic  nerves,  with  two  main  results  so  far  as  this 
study  is  concerned. 

( a ) Direct  stimulation  to  contraction  (i.e.,  spasm)  of  the 
pyloric  sphincter. 

( b ) A corresponding  excess  of  absorption  of  suprarenal 
secretion  into  the  blood,  with  an  accompanying  increase  in 
pyloric  spasm.  The  increased  contraction  of  the  pylorus  is 
not  only  accentuated  with  peristalsis,  but  such  a contracted 
pylorus  is  rendered  more  easily  palpable.  In  this  case  the 
stimulus  of  the  ansesthetic,  aided  by  the  relaxation  of  the 
abdominal  walls,  seems  to  be  the  explanation  of  this 
phenomenon.  Support  is  lent  to  this  explanation  by  the 
frequency  with  which  early  anaesthesia  induces  visible  gastric 
peristalsis. 

Case  15. — F.  Age  11  weeks.  Breast-fed,  started  vomiting 
at  2 weeks.  Brought  up  to  hospital  at  4 weeks.  Kept  on 
the  breast  with  daily  lavage,  and,  as  there  was  no  improve- 
ment, supplementary  feeds  were  given.  Patient  showed  a 
steady  but  slow  loss  of  weight  for  eight  weeks  on  medical 
treatment.  Rammstedt’s  operation  performed  on  admission, 
pituitrin  mxx.  being  administered  previous  to  operation. 
Recovery  uninterrupted,  but  progress  slow.  Temperature 
rose  to  104°after  operation,  and  fell  to  normal  on  the  third  day. 
No  post  operative  vomiting  and  no  diarrhoea.  This  child 
was  in  excellent  condition  before  operation  and  remained  so 
afterwards.  The  subsequent  history  of  this  case  is  inter- 
esting. Peptonised  milk  was  given  until  the  twelfth  day, 
during  which  time  the  weight  fluctuated  round  a fairly  even 
figure.  Subsequently  citrated  milk  was  substituted,  with 
the  result  that  5 oz.  in  weight  was  lost  in  four  days.  A steady 
increase  in  weight  immediately  followed  the  return  to  feeds 
of  peptonised  milk. 

Case  16. — M.  Age  6 weeks.  Brought  to  surgical  out- 
patients because  of  difficulty  in  passing  water,  and  sickness. 
Onset  sudden  at  4 weeks.  Projectile  vomiting,  visible 
peristalsis,  a palpable  tumour,  and  constipation  completed 
the  picture ; while  phimosis  (of  the  type  referred  to)  was 
well  exemplified.  Circumcision  two  days  later  was  followed 
by  a cessation  of  projectile  vomiting,  and  the  passage  of 
copious  greasy  stools.  Loss  of  weight  ceased  on  the  fourth 
day,  and  symptoms  continued  to  be  relieved  until  the  ninth 
day,  when  the  recurrence  of  projectile  vomiting  demanded 
radical  treatment.  Rammstedt’s  operation  was  followed  by 
immediate  relief  of  all  symptoms,  and  the  passage  again  of 
copious  fatty  stools.  There  was  no  post-operative  vomiting. 
Points  worthy  of  comment  are  : — (1)  This  was  the  largest 
pylorus  on  which  we  have  ever  operated  ; (2)  there  was  a 
gain  in  weight  of  11  oz.  in  the  first  six  days. 

These  points  indicate  : — (1)  That  the  infant  was  born  with 
a pyloric  hypertrophy  so  excessive  that  the  orifice  was 
nearly  closed ; (2)  the  deciding  factor  in  the  final  closure 
was  the  added  spasm  from  phimosis  which  induced  a very 
mild  degree  of  secretory  inhibition ; (3)  circumcision 
relieved  the  added  spasm  to  some  extent,  but  not  sufficiently 
to  re-establish  normal  conditions,  owing  to  the  excessive 
hypertrophy. 

Briefly,  the  congenital  hypertrophy  was  the  preponderating 
feature,  and  therefore  the  case  was  only  amenable  to 
radical  treatment.  The  fact  that  secretory  inhibition  played 
a small  part  is  evidenced  by  the  immediate  post-operative 
gain  in  weight. 

Case  17. — M.  Age  5 weeks.  A very  poor,  weakly,  wasted 
infant  with  classical  symptoms.  Vomiting  began  about  the 
twenty-fifth  day.  Phimosis  was  well  marked  and  of  the 
usual  type.  Circumcision  was  followed  by  no  improvement 
in  the  symptoms  in  three  days.  As  the  child  had  no  reserve 


power  to  draw  upon,  and  added  spasm  was  clearly  playing  a 
minor  r61e  in  the  obstruction,  we  did  not  wait  longer,  but 
decided  on  operation.  Rammstedt’s  operation  was  followed 
by  immediate  relief  of  vomiting  and  the  passage  of  the  usual 
loose,  fatty  stools.  The  pylorus  was  exceedingly  large. 
There  was  no  post-operative  vomiting  after  12  hours,  and 
the  child’s  condition  continued  to  improve  daily.  Sudden 
death  from  unexplained  causes  on  the  fifth  day  surprised 
everyone.  Post-mortem  examination  of  a most  detailed 
character  failed  to  show  any  cause  of  death.  (Vide  Cases  18 
and  19.) 

In  addition  to  these  cases  on  which  Rammstedt’s  opera- 
tion was  performed,  we  have  selected  two  cases  in  which 
circumcision  so  completely  relieved  the  obstructive  symptoms 
that  they  are  worthy  of  note.  If  we  do  not  report  in  detail 
all  cases  where  the  results  of  circumcision  might  support  our 
contention  that  phimosis  is  the  most  important  cause  of 
added  spasm,  it  is  only  because  we  do  not  wish  unduly  to 
labour  the  point. 

Case  18. — A male  child,  with  symptoms  of  projectile 
vomiting,  constipation,  and  wasting.  Phimosis  of  the  usual 
type  was  marked.  Visible  peristalsis  was  noted,  but  no 
tumour  was  felt.  Circumcision  was  followed  by  immediate 
cessation  of  vomiting  and  the  passage  of  copious  greasy 
stools.  This  amelioration  of  symptoms  continued  until 
sudden  death  occurred  60  hours  later.  Post-mortem  examina- 
tion showed  no  pyloric  hypertrophy,  and  the  cause  of  death 
is  unexplained. 

Case  19. — This  is  of  exceptional  interest.  A male  infant, 
in  whom  visible  peristalsis  and  a palpable  tumour,  added  to 
the  characteristic  history,  established  the  diagnosis.  The 
usual  type  of  phimosis  indicated  circumcision,  which,  with 
one  relapse,  gradually,  but  completely  and  permanently, 
relieved  vomiting  and  constipation.  Gain  in  weight  com- 
menced on  the  eighth  day,  and  stools  were  becoming  normal 
about  the  eleventh  or  twelfth  day.  On  the  thirteenth  day, 
five  loose,  green,  undigested  stools  were  passed  containing 
mucus.  On  the  fourteenth  day  7 oz.  in  weight  were  quickly 
lost,  and  the  baby  died  quite  suddenly. 

In  this  case  all  the  symptoms  of  pyloric  obstruction  were 
relieved  by  circumcision,  and  the  definite  improvement  in  the 
stools  at  about  the  eleventh  or  twelfth  day  (together  with  the 
preceding  steady  gain  in  weight)  supports  our  experience — 
i.e.,  that  pancreatic  function  begins  to  be  re-established 
about  this  time  after  the  relief  of  the  pyloric  obstruction.  It 
is  possible  that  this  child,  already  weakened  by  starvation, 
could  not  withstand  even  the  slight  toxaemia  which  may  have 
accompanied  a mild  infective  diarrhoea.  The  stools  were 
normal  for  the  24  hours  preceding  death. 


Details  of  Operation  Performed . 

A study  of  these  17  cases  teaches  much  in  connexion  with 
the  actual  performance  of  the  operation,  and  as  our  expe- 
rience has  shown  us  that  the  success  of  the  operation 
depends  in  no  small  measure  on  apparently  insignificant 
details,  the  procedure,  as  we  now  practise  it,  should  be 
described.  The  essence  of  the  operation  is  its  simplicity 


Fig.  2. 


blunt  separator-. 


serrated 
ringer  slot 


and  rapidity  ; and  this,  being  the  case,  there  is  no  neces- 
sity for  hurry.  It  can  be  quietly  and  comfortably  per- 
formed with  care  and  deliberation  in  a minimum  of  five 
minutes  and  a maximum  of  seven  minutes.  If  everything 
goes  smoothly  the  latter  figure  need  never  be  exceeded.  A 
special  knife  has  been  made  by  Messrs.  Allen  and  Hanburys 
in  order  to  combine  rapidity  with  safety.  It  is  exceedingly 
simple  and  consists  of  semicircular  cutting  blade  on  one 
side  with  a blunt  separator  on  the  other,  so  designed  that 
there  are  no  sharp  points  in  the  cutting  part  which  could 
inadvertently  damage  the  gut.  (Fig.  2.) 

This  knife  is  held  like  a pen,  the  cutting  side  being  used 
first,  and  then  the  knife  turned  over  and  the  blunt  separator 
employed  for  completing  the  division.  The  abdomen  is 
opened  by  an  incision  about  1£  in.  long,  about  £ in.  below 
the  costal  margin,  at  about  the  junction  of  the  outer  and 
middle  thirds  of  the  right  rectus.  The  incision  is  continued 


522  The  Lanobt,]  MR.  TYRRELL  GRAY  & DR.  PIRIE  : HYPERTROPHIC  STENOSIS  OF  PYLORUS.  [Sept.  20,  1919 


through  the  rectus  fascia  and  the  muscle  is  split.  The 
peritoneum  is  opened  for  about  1 in.  in  length  and  a pair  of 
artery  forceps  clipped  on  it  at  either  extremity.  Such  an 
incision  usually  exposes  the  liver  in  about  the  upper  two- 
thirds  of  its  length.  The  liver  is  gently  rotated  upwards  and 
the  stomach  wall  lifted  out  of  the  wound  by  picking  it  up 
with  a pair  of  forceps.  The  stomach  is  caught  with  the 
finger  and  thumb  of  the  right  hand  and  lifted  gently  upwards 
and  to  the  left.  At  this  point  there  often  may  be  experi- 
enced a little  difficulty  in  presenting  the  pylorus  in  the 
wound.  We  have  observed  that  any  degree  of  traction 
influences  (sometimes  to  a marked  extent)  the  respirations, 
and  so  the  child’s  general  condition.  In  order,  therefore,  to 
avoid  traction  we  find  that  the  best  manoeuvre  is  to  hold  the 
stomach  wall  near  the  pylorus  out  of  the  wound  with  the 
right  hand,  while  with  the  left  finger  and  thumb  the 
abdominal  wall  is  pressed  back  behind  the  pylorus  rather 
than  the  pylorus  brought  up  to  the  abdominal  wall.  There 
is  much  less  disturbance  to  the  respirations  if  this  simple 
manoeuvre  is  remembered  and  practised.  The  left  hand  now 
holding  the  pylorus,  the  incision  is  made  longitudinally  with 
the  cutting  part  of  the  knife  in  the  whole  length  of  the 
hypertrophied  part,  stopping  just  short  of  the  normal  bowel 
on  the  duodenal  side,  but  carried  well  up  into  normal 
stomach  wall.  (In  the  white,  large,  avascular  type  the 
commencement  of  oozing  is  the  indication  that  normal 
tissue  is  reached.) 

The  site  of  the  incision  deserves  a word.  This  should  be 
placed  as  far  back  as  can  be  comfortably  arranged,  since  it 
then  falls  into  alignment  with  the  plane  of  the  lesser  curva- 
ture. In  the  large  avascular  type  this  plane  is  easily 
recognised  as  an  area  short  of  which  the  termination  of  the 
circular  vessels  can  be  clearly  seen,  and  therefore  as  the 
situation  of  choice  for  the  incision.  In  the  small  vascular 
type  this  area  can  only  be  selected  in  a speculative  way  by 
placing  the  incision  as  nearly  in  a plane  with  the  lesser 
curvature  as  possible  ; or,  in  other  words,  as  far  back  as  can 
be  managed  comfortably.  The  incision  is  deepened  with 
the  knife  edge  in  the  middle  of  the  tumour  until  the  pearly 
mucosa  is  seen,  and  when  this  is  exposed,  towards  either 
extremity,  just  short  of  the  termination  of  the  hypertrophied 
area.  The  knife  is  now  inverted  and  the  remainder  of  the 
operation  completed  with  the  blunt  separator.  The 
division  in  the  stomach  side  is  carried  by  a cutting  move- 
ment of  the  blunt  separator  until  the  mucosa  is  seen  lying 
beneath  the  thin  and  normal  stomach  wall.  Finally,  when 
the  mucosa  has  been  exposed  over  the  whole  length  of  the 
original  incision,  the  blunt  separator,  by  a side-to-side  move- 
ment, combined  with  a little  pressure  of  the  instrument  and  a 
little  squeezing  with  the  left  finger  and  thumb  grasping  the 
pylorus,  completely  frees  the  mucosa  from  the  muscular  wall, 
and  allows  it  to  protrude  a short  distance  into  the  severed 
outer  coats.  These  manoeuvres  take  longer  to  describe  than  to 
practise.  The  pylorus  and  antrum  are  then  returned  to  the 
abdomen  and  the  abdominal  wound  sutured  in  layers.  The 
whole  operation  can  be  performed  quietly  and  comfortably 
in  5-7  minutes,  and  can  always  be  guaranteed  to  last  no 
longer  than  ten  minutes.  The  simplicity  and  rapidity  must 
appeal  to  every  surgeon  once  it  is  recognised  that  such  a 
wound  in  the  gut  can  be  left  open  with  impunity.  The  most 
important  point  to  remember  is  the  adequate  division  of  the 
sero-muscular  coat  on  the  stomach  side  ; Case  5 illustrated 
the  necessity  for  full  division  on  the  stomach  side  until 
normal  stomach  wall  is  reached.  In  confirmation  of  this 
may  be  quoted  a case  of  Mr.  L.  E.  Barrington-Ward’s  at  Great 
Ormond-street.  This  child  after  operation  had  persistent 
vomiting,  which  was  so  characteristically  of  the  obstruc- 
tive type  that  Mr.  Barrington-Ward  operated  a second  time, 
completing  the  division  of  the  hypertrophied  portion  on  the 
stomach  side.  Vomiting  ceased  and  the  child  recovered. 

Mortality. 

It  will  be  evident  that  our  first  four  cases  gave  high  hopes 
of  a safe  operation  with  small  risk.  Subsequent  experience 
was  less  fortunate  so  far  as  our  figures  were  concerned,  but 
very  valuable  for  the  purpose  of  establishing  this  operation 
as  the  method  of  choice  in  all  cases.  Our  total  mortality  in 
all  cases  of  Raramstedt’s  operation  is  41 T percent.,  a marked 
improvement  on  the  previous  100  per  cent.  LTp  to  January, 
1919,  the  total  figure  in  hospital  worked  out  at  38  8 per  cent. 
In  order,  however,  to  ascertain  the  intrinsic  value  of  this 
operation  in  uncomplicated  cases,  it  is  only  fair  that  Cases  10 


and  11  should  be  excluded,  since  they  both  died  of  purulent 
bronchitis  after  an  operation  performed  (as  offering,  in  our 
opinion,  the  only  chance  of  recovery)  during  an  attack  of 
influenza  and  bronchitis  then  prevalent.  This  gives  us  15  cases 
with  5 deaths,  or  a mortality  of  33  3 per  cent.  Of  the  4 
remaining  deaths,  2 (Cases  5 and  8)  are  attributable  to  lack 
of  experience— i.e.,  to  easily  avoidable  causes.  For  while 
Case  5 died  from  insufficient  division,  Case  8 died  as  the 
result  of  dividing  too  much.  Any  fair  estimate  of  the 
intrinsic  mortality  of  Rammstedt’s  operation,  therefore,  will 
be  one  which  excludes  deaths  attributable  to  inexperi- 
ence. Excluding  these  two  cases,  we  have  13  cases  with 
3 deaths,  or  a mortality  of  23  per  cent.  It  will  be  seen 
that,  with  thd  operation  conducted  as  we  describe  it 
(together  with  the  indications  for  operation,  palliative  and 
post-operative  treatment,  which  we  shall  shortly  describe), 
the  operative  mortality  of  all  uncomplicated  cases  (however 
poor  their  condition)  works  out  at  23  per  cent.  We  have 
only  had  two  unexplained  deaths  in  children  operated  on 
in  good  condition,  for  the  other  two  remaining  fatalities 
(Cases  7 and  17)  were  both  very  minute,  sickly,  and 
marantic  infants.  Therefore,  while  we  estimate  the  mor- 
tality in  all  uncomplicated  cases  at  23  percent.,  we  feel 
justified  in  saying  that  mortality  in  favourable  or  early  case) 
is  represented  in  our  series  by  11  cases  and  1 death,  or  a 
mortality  of  9 per  cent.  A mortality  of  9 per  cent,  in 
hospital  practice,  even  with  all  unfavourable  cases  excluded, 
represents  a striking  plea  for  the  adoption  of  this  operation. 
Finally,  we  wish  to  lay  stress  on  the  fact  that  whereas  the 
recovery  of  our  first  four  cases  was  surely  due  in  a large 
measure  to  good  fortune,  the  lessons  of  our  subsequent 
failures  have,  so  far  as  in  us  lay,  been  turned  to  good 
account.  Thus  our  results  are  improving  steadily,  as 
evidenced,  not  only  by  the  recovery  of  seven  out  of  the  last 
eight  consecutive  cases,  but  by  the  rarity  of  post-operative 
vomiting  in  the  later  cases.  We  feel  we  can  confidently 
predict  a marked  improvement  in  the  figures  in  the  near 
future. 

Post-operative  Temperature. 

There  is  one  point  in  connexion  with  this  operation  which 
is  of  great  interest — namely,  the  post-operative  temperature. 
We  append  a typical  chart  in  one  of  our  series  where  the 
child  made  an  uninterrupted  recovery.  (Chart  4.)  It  will 


be  seen  that  the  temperature  rose  on  the  evening  of  operation 
to  105  2°,  an  ice-bag  being  applied  to  the  head  whenever  the 
temperature  rose  above  i.04Q.  Finally,  two  of  our  series 
(Cases  12  and  17)  died  somewhat  suddenly  and  unexpectedly 
(when  their  excellent  progress  had  placed  them  out  of 
obvious  danger)  three  and  four  days  respectively  after  opera- 
tion. Progress  had  been  eminently  satisfactory  and  unaccom- 
panied by  vomiting.  Post-mortem  examination  showed  no 
obvious  cause  of  death  ; and  our  view  that  these  deaths 


Th*  Lanobt,]  MR.  TYRRELL  GRAY  & DR.  PIRIE  : HYPERTROPHIC  STENOSIS  OF  PYLORUS.  [Sept.  20,  1919  523 


were  independent  of  the  operation  is  supported  by  a case 
(Case  18)  of  pyloric  spasm  where  circumcision  alone  pro- 
duced complete  relief  of  symptoms.  60  hours  later  the 
baby  died  suddenly.  Post  mortem  no  cause  of  death  could 
be  found,  and  no  hypertrophy  of  the  pylorus  was  present. 
Case  19  is  another  similar  instance  in  a case  of  hypertrophy, 
where  circumcision  relieved  the  obstruction.  A study  of  nine 
cases  which  recovered  shows  that  the  highest  temperatures 
reached  were  respectively  105°,  104°,  105°,  101-4, 105°,  104°, 
103  4°,  105°,  and  104°.  Thus  in  only  two  instances  did  the 
chart  fail  to  register  104°  at  least.  The  curious  fact  in 
this  connexion  is  that  the  babies  did  not  seem  ill ; and  in 
several  instances  the  observer  would  not  have  realised  such 
an  abnormal  temperature  from  the  child’s  appearance.  The 
patients  seemed  to  be  none  the  worse,  and  the  temperatures 
always  fell  to  near  normal  on  the  second  to  the  fourth  day. 
We  have  been  unable  to  find  any  satisfactory  explanation  of 
this  phenomenon.  It  is  not  due  to  any  infection  at  the 
site  of  the  pyloric  incision,  for  the  post-mortem  examina- 
tions never  showed  signs  of  peritonitis,  with  the  exception 
of  Case  8.  Three  of  the  cases  showed  a variable  tempera- 
ture previous  to  operation  (from  97°  to  101°  or  102°),  but 
this  may  have  been  influenced  by  saline  and  glucose 
infusion,  and  will  not  help  to  explain  the  abnormally 
high  temperature  after  operation  in  practically  all  cases. 
The  rise  of  temperature  is  of  no  importance,  and  we  think 
it  is  probably  central  in  origin.  The  application  of  an  ice- 
bag  to  the  head  quickly  reduces  the  hyperpyrexia.  The 
other  feature  shown  in  this  series  is  that  vomiting  only 
occurs  exceptionally  (and  is  not  projectile  in  character)  if 
the  operation  has  been  properly  performed. 

Advantages  of  Rammstedt's  Operation. 

From  our  study,  up  to  the  present,  therefore,  we  do  not 
hesitate  to  advocate  Rammstedt's  operation  when  surgical 
interference  is  necessary  ; and,  in  our  opinion,  it  will  in  the 
near  future  take  the  place  of  every  other  surgical  method 
devised  for  the  cure  of  hypertrophic  stenosis  of  the  pylorus. 
In  further  support  of  this,  Rachford  also  reports  a post- 
mortem examination,  six  months  after  Rammstedt’s 
operation,  where  the  child  had  died  from  other  causes.  In 
this  case,  contrary  to  his  experience  after  gastro-enterostomy 
(vide  supra),  no  trace  of  the  tumour  could  be  found.  Our 
own  experience,  both  clinical  and  post  mortem,  has  shown 
that  after  Rammstedt’s  operation  the  pyloric  hypertrophy 
rapidly  disappears.  For  in  Case  17  five  days  after  operation 
the  hypertrophy  had  diminished  by  at  least  two-thirds  of  its 
former  extent,  and  the  mucous  membrane  lay  almost 
smoothly  round  the  incision.  Further,  so  clearly  and 
smoothly  had  the  incision  been  sealed  over  by  organised 
lymph,  that  it  was  difficult  to  reopen  the  wound  in  the 
sero-muscular  coat. 

IV. — Treatm  ent. 

It  is  a regrettable  fact  that  the  net  results  of  treatment 
by  all  methods  in  all  cases  have  not  been  good.  During  the 
years  1915-16-17  54  cases  were  admitted  to  Great  Ormond- 
street.  The  majority  of  these  were  treated  without  opera- 
tion, and  in  those  where  operation  was  performed  various 
methods  other  than  the  Rammstedt’s  were  employed.  The 
total  mortality  was  80  5 per  cent.  The  mortality  of  those 
operated  upon  was  100  per  cent.  There  are  three  explana- 
tions of  this  fact  : — 

(a)  The  lack  of  an  ideal  operative  technique  where  opera- 
tion was  indicated. 

(b)  The  insufficient  appreciation  of  any  reasoned  indications 
for  operations  owing  to 

(o)  Failure  to  realise  the  true  mechanism  of  the  pyloric 
obstruction. 

(a)  A detailed  analysis  of  the  various  operative  procedures 
has  been  given,  and  it  has  been  shown  that  Rammstedt’s 
operation,  by  virtue  of  its  simplicity  and  applicability  to  all 
cases  (both  early  and  late),  is  the  only  one  to  be  advocated 
when  palliative  treatment  has  definitely  failed  and  surgical 
intervention  is  indicated.  Thus,  at  Great  Ormond-street 
during  the  past  year,  when  this  operation  was  first  performed, 
the  mortality  of  our  cases  operated  upon  was  41 -1  per  cent, 
while  the  total  mortality  showed  a proportionate  decrease. 

(b)  and  (c)  Until  the  present  no  rational  explanation  has 
been  offered  of  the  nature  of  the  pyloric  obstruction.  Thus, 
failing  a sound  basis  for  treatment,  such  treatment  has  been 


largely  empirical,  or  dependent  only  on  individual  judgment. 
In  a previous  communication  on  the  pathogenesis  of  pyloric 
stenosis  an  explanation  has  been  offered  of  the  occurrence  at 
birth  of  varying  degrees  of  pyloric  hypertrophy.  It  was 
shown  that  in  the  large  majority  of  these  cases  certain  sub- 
sidiary conditions  added  to  the  stenosis  produced  by  ante- 
natal hypertrophy,  and  initiated  the  symptoms  of  obstruction. 
These  are : — 

(1)  Inhibition  of  pancreatic  secretion  dependent  upon 
the  original  hypertrophy,  or  upon  the  superadded  con- 
ditions of  (2)  gastritis,  (3)  spasm  due  to  phimosis,  (4)  spasm 
from  unknown  causes. 

(1)  The  normal  sequence  of  events  in  which  the  amount  of 
pancreatic  secretion  varies  directly  with  the  amount  of  acid 
chyme  passing  through  the  pylorus  and  over  the  duodenal 
mucosa  has  been  shown  by  experimental  physiologists.  It 
has  also  been  shown  that,  until  such  time  as  acid  chyme  has 
been  neutralised  by  alkaline  pancreatic  secretion,  the  pylorus 
remains  closed.  We  believe  that  the  pancreatic  function, 
antagonised  originally  by  hyper-adrenalism,  is  at  least 
diminished,  so  that  the  balance  between  these  two  fluids  is 
disturbed.  This  results  in  a prolongation  of  the  time  during 
which  the  duodenal  contents  remain  acid,  and  thus  during 
which  the  pylorus  remains  closed.  The  function  of  the 
gland  never  can  have  been  entirely  abolished,  but  the  forma- 
tion of  its  external  secretion  would  have  to  be  stimulated 
indirectly  by  acid  chyme  in  the  duodenum.  It  follows  that 
a diminishing  amount  of  acid  chyme  passing  through  the 
pylorus  results  in  the  exhibition  of  still  less  alkaline 
secretion,  and  there  is  the  increasing  tendency  of  the  pylorus 
to  remain  closed.  So  the  vicious  circle  is  established. 

It  must  be  conceded  then  that,  when  the  amount  of 
pyloric  hypertrophy  existing  at  birth  is  sufficient  in  itself  to 
cause  obstruction,  the  amount  of  pancreatic  secretion 
exhibited  will  be  the  minimum.  In  this  instance  the  vicious 
circle  is  established  at  once.  Again,  when  there  is  a 
moderate  degree  of  congenital  hypertrophy  the  vicious 
circle  will  take  longer  to  become  established  unless  some 
other  added  cause  results  in  a more  rapid  closure  of  the 
orifice.  And,  again,  where  there  is  only  a slight  degree  of 
congenital  hypertrophy  there  may  be  sufficient  acid  chyme 
passing  through  the  pylorus  to  satisfy  physiological  require- 
ments. In  this  instance  the  child  would  never  show  sym- 
ptoms of  obstruction  unless  there  were  added  some  other 
cause  of  spasm  severe  enough  to  complete  the  closure. 
And,  finally,  we  must  draw  attention  to  those  cases  where 
there  was  no  ante-natal  hyper-adrenalism,  and  therefore  no 
congenital  hypertrophy,  but  where  obstruction  may  result 
from  severe  pylorospasm  alone.  In  this  instance  the 
obstruction  is  completely  relieved  by  the  removal  of  the 
cause  of  the  spasm. 

Such  cases  should  never  be  considered  in  the  same 
category  with  congenital  hypertrophic  pyloric  stenosis. 

(2)  Gastritis. — Food  remaining  in  the  stomach  an  undue 
length  of  time  will  set  up  a retention  gastritis,  with  con- 
sequent swelling  and  hypersemia  of  the  gastric  mucosa. 
This  clearly  contributes  towards  the  closure  of  an  already 
stenosed  pyloric  orifice.  The  urgency  of  the  symptoms  will 
depend  upon  the  relation  between  the  degree  of  hyper- 
trophy and  jhe  amount  of  gastritis. 

(3 ) Phimosis. — It  has  already  been  shown  how  phimosis, 
or  preputial  adhesions,  may  produce  spasm  of  the  pylorus. 
We  believe  this  to  be  the  most  potent  cause  of  added  spasm. 
This  explains  the  fact  that  the  great  majority  of  babies 
presented  for  treatment  on  account  of  pyloric  obstruction 
are  boys. 

It  will  be  shown  that  these  statements  as  to  the  relation  of 
phimosis  and  gastritis  with  pyloric  hypertrophy  are  amply 
borne  out  by  the  results  of  treatment. 

(4)  Spasm  from  unknown  causes. — It  cannot  be  claimed  that 
gastritis  and  phimosis  are  the  only  causes  contributing 
towards  the  complete  closure  of  the  pyloric  orifice.  John 
Thomson  reports  cases  that  have  been  cured  by  the 
administration  of  sedatives  such  as  chloral  hydrate  ; and  we 
realise  that  there  may  be  many  unrecognised  causes  of 
pylorospasm,  which,  according  to  the  relation  between 
their  severity  and  the  amount  of  hypertrophy,  might  con- 
tribute towards  closure  of  the  outlet. 

It  will  now  be  seen  that,  apart  from  extreme  congenital 
hypertrophy,  we  are  in  a position  to  gauge  the  urgency  of  the 


524  The  Lancet,]  MR.  TYRRELL  GRAY  & DR.  PIRIB : HYPERTROPHIC  STENOSIS  OF  PYLORUS.  [Sept.  20,  1919 


obstruction  by  the  degree  of  secretory  inhibition.  This 
cannot  be  estimated  accurately,  but  there  are  certain  indica- 
tions upon  which  conclusions  may  be  based.  Thus,  when 
insufficient  food  for  physiological  requirements  passes  the 
pylorus,  there  are,  in  addition  to  the  signs  and  symptoms 
upon  which  the  original  diagnosis  rested,  loss  of  weight  and 
infrequent,  hard,  dry  bowel  motions.  The  consistence  of 
the  motion  depends  upon  the  absence  of  secretion,  its  size 
on  the  amount  of  food  passing  the  pylorus.  Soon  after  the 
obstruction  is  relieved,  in  addition  to  the  cessation  of 
vomiting  and  gastric  peristalsis,  the  stools  become  more 
bulky,  loose,  greasy,  and  more  frequent.  The  motions  are  of 
this  character  because,  although  the  gastric  secretion  has  a 
slight  lipolytic  action,  pancreatic  secretion  is  inhibited,  and 
most  of  the  fats  are  coming  through  incompletely  changed. 
A reference  to  all  our  cases  in  which  symptoms  of  obstruction 
were  relieved  with  or  without  operation  will  support  this 
statement.  The  digestion  of  the  proteids  we  can  accomplish, 
in  a measure,  by  peptonising  the  milk,  but  the  fats  we 
cannot  sufficiently  modify.  Emulsification  and  saponifica- 
tion cannot  proceed  in  the  absence  of  pancreatic  secretion. 
As  soon  as  this  function  has  been  re-established  the  stools 
will  resume  their  normal  consistence  and  the  child  will  gain 
more  rapidly  in  weight.  It  is  against  reason  that  the 
function  of  the  pancreas,  which  has  been  inhibited  for  vary- 
ing lengths  of  time,  should  be  resumed  the  moment  the 
obstruction  is  relieved.  Accordingly  we  have  found  that  the 
length  of  time  necessary  for  the  pancreatic  secretion  to  be 
re-established  is  almost  directly  proportionate  to  the  length 
of  time  it  was  in  abeyance.  Thus,  children  whose  pyloric 
obstruction  had  been  relieved  by  operative  or  palliative 
treatment  ceased  to  vomit  and  began  to  gain  in  weight  in 
from  10-14  days  from  the  beginning  of  treatment.  The 
stools  in  some  still  showed  incompletely  changed  fat,  and  in 
them  improvement,  as  evidenced  by  gain  in  weight,  was  not 
marked  until  the  stools  became  normal.  A reference  to  the 
charts  of  our  cases  will  bear  this  out. 

The  only  exception  to  this  is  in  the  case  of  girls.  In  them 
the  onset  of  symptoms  was  more  gradual,  and  the  improve- 
ment consequently  much  slower.  Reference  in  this  connexion 
should  be  made  to  Cases  14  and  15.  This,  again,  supports 
our  contention  that  phimosis  is  the  most  potent  cause  of 
added  spasm.  Girls  being  exempt  from  this  influence  are 
much  slower  developing  complete  closure.  In  consequence 
of  this  the  pancreatic  gland,  functionating  incompletely  for 
a long  time,  will  take  a proportionately  long  time  in  regain- 
ing its  function.  It  is  only  after  due  appreciation  of  all  the 
factors  contributing  to  pyloric  obstruction  that  we  may  now 
consider  ourselves  in  a position  to  place  the  treatment  on  a 
rational  basis.  There  are  very  definite  indications  as  to  the 
line  of  treatment  to  be  advocated  : (1)  It  must  be  radioal 
when  the  secretory  inhibition  is  established  at  once  by  a 
maximum  amount  of  congenital  hypertrophy  at  birth,  and  a 
minimum  effect  from  added  causes.  (2)  It  will  be  palliative 
until  we  have  determined,  by  treatment  of  the  added  causes 
of  closure,  whether  their  influence  was  the  preponderating 
one  or  not.  (3)  We  have  a critical  point  in  the  progress  of 
the  treatment  at  which  we  know  whether  the  obstruction  has 
been  relieved  by  the  removal  of  one  or  more  of  these  added 
causes.  There  are  three  general  considerations  in  the  treat- 
ment, common  to  all. 

1.  Diet. — In  all  cases  the  food  given  should  be  peptonised 
milk.  This  is  not  the  place  to  establish  the  value  of  milk 
as  the  best  artificial  food,  and  we  shall  not  labour  the  point. 
Breast-fed  babies  admitted  to  the  hospital  are  given  as  many 
feeds  from  the  breast  as  practicable  and  complemental  feeds 
of  peptonised  milk.  From  the  preceding  observations  it  natu- 
rally follows  that  the  milk  should  be  peptonised.  With  one 
of  the  various  media  for  pancreatisation  we  have  the  means 
of  compensating  for  (at  least  as  far  as  the  proteids  are  con- 
cerned) the  deprivation  of  pancreatic  secretion.  There  is  a 
25  per  cent,  dilution  of  the  milk  in  the  process  of  peptonisa- 
tion,  and  it  is  clearly  superfluous  to  dilute  further  a milk 
whose  proteid  is  already  prepared  for  absorption.  The  fats  and 
carbohydrates  are  well  below  3 per  cent,  and  require  no 
further  dilution.  Although  we  know  that  fats  are  not  well 
tolerated,  it  is  not  wise  to  eliminate  them  entirely, 
since  their  very  presence  in  the  duodenum  may  help  to 
provoke  the  exhibition  of  lipolysins.  We  have  not  found  it 
necessary  to  modify  the  quantity  or  the  feeding  interval. 
The  usual  amount  for  the  weight  and  age  of  the  child  should 
be  given,  with  no  more  than  nine  feedings  in  the  24  hours. 


2.  Gastric  lavage.— In  all  cases  gastric  lavage  should  be 
employed.  This  treatment  is  based  on  the  knowledge  of 
the  importance  of  gastritis  as  a contributory  factor  to  com- 
pleting pyloric  obstruction.  A mildly  alkaline  solution  is 
used  through  a nasal  or  oesophageal  tube.  It  should  be 
carried  out  once  or  twice  a day,  depending  upon  the  severity 
of  the  local  symptoms.  After  operation  it  may  be  dis- 
continued, since  the  obstruction  has  been  relieved,  and  the 
re-establishment  of  normal  drainage  is  all-sufficient.  Other- 
wise, it  is  continued  until  the  wash-out  is  free  from  mucus. 
Lavage  is  never  stopped  abruptly,  but  the  intervals  between 
the  treatments  are  gradually  lengthened  until  they  can  be 
dispensed  with  altogether. 

3.  Constipation. — Recognising  the  cause  of  constipation 
to  be  lack  of  bulk  as  well  as  of  secretion  due  to  pyloric 
obstruction,  no  cathartic  should  ever  be  given.  A small 
oil  enema  or  rectal  lavage  is  all  that  is  necessary.  Apart 
from  general  considerations,  the  treatment  will  naturally 
fall  into  divisions : (1)  Urgent  treatment,  (2)  palliative 
treatment,  (3)  radical  treatment. 

(1)  Urgent  treatment. — Although  we  have  demonstrated 
above  that  there  is  a critical  point  up  to  which  we  may 
safely  pursue  palliative  treatment,  there  are  two  groups  of 
cases  which  must  be  considered  as  presenting  urgent 
indications  for  radical  treatment. 

( a ) Extreme  congenital  hypertrophy. — In  this  small  group 
the  amount  of  hypertrophy  present  at  birth  is  sufficient  to 
cause  obstruction.  The  babies  forcibly  eject  the  first  and 
every  subsequent  feed,  and  gastric  lavage  with  (in  boys) 
circumcision  fails  to  relieve  the  symptoms,  even  temporarily. 
These  cases  are  to  be  considered  as  surgical  emergencies, 
and  should  be  operated  upon  as  soon-  as  the  diagnosis  is 
established. 

( h ) Frail , puny  babies. — Some  babies  are  not  presented 
for  treatment  until  the  wasting,  consequent  upon  the 
obstruction,  is  extreme.  They  have  practically  no  reserve 
strength  to  face  a possible  operation.  If  their  history  is 
that  of  group  (a)  they  are  treated  in  the  same  way.  If  the 
symptoms  date  from  later  in  life  some  factor  has  contributed 
to  the  closure  of  the  pylorus.  They  are  treated  in  the 
routine  way  with  gastric  lavage  and  fed  with  peptonised 
milk.  Their  strength  is  further  fortified  by  the  subcutaneous 
injection  of  2 per  cent,  glucose  in  saline  solution.  In  boys, 
if  phimosis  or  preputial  adhesions  exist,  circumcision  is 
performed.  Unless  there  is  immediate  (within  two  or  three 
days)  cessation  of  vomiting  and  the  evacuation  of  larger, 
greasy  stools  operation  takes  place  at  once.  If  improvement 
is  not  obtained  it  may  mean  that  the  effect  of  hypertrophy 
preponderates  over  that  of  any  added  cause.  These  babies 
are  so  frail  that  we  cannot  afford  to  wait  for  the  critical 
point — i.e. , 10-12  days  from  the  commencement  of  treat- 
ment. These,  too,  are  to  be  regarded  as  surgical  emer- 
gencies and  operated  upon  immediately.  In  this  connexion 
reference  should  be  made  to  Case  17.  It  is  thus  seen  that 
urgent  treatment  means  operation  upon  certain  cases  within 
the  tenth  to  twelfth  day  limit. 

(2)  Palliative  treatment. — (a)  Secretory  inhibition. — It  has 
been  shown  that  the  ultimate  effect  of  stenosis  of  the 
pyloric  outlet  is  suppression  of  the  pancreatic  secretion, 
which  very  suppression  in  itself  contributes  to  the  closure 
of  the  orifice.  This  condition  can  only  be  treated  in  one 
way.  There  must  be  sufficient  acid  chyme  in  the  duodenum 
to  stimulate  the  pancreas  to  normal  activity.  This  can  only 
be  accomplished  by  relieving  the  pyloric  obstruction.  Thus, 
if  by  10-12  days  the  routine  treatment  of  eliminating  any 
other  cause  of  added  spasm  has  not  succeeded  in  securing  a 
cessation  of  vomiting  and  the  appearance  of  the  character- 
istic stools,  operation  is  indicated.  We  may  say  here,  and 
this  will  also  apply  to  any  similar  circumstance,  we  do  not 
demand  an  absolute  cessation  of  vomiting.  There  may  be  an 
occasional  non-projectile  vomit,  but  this  is  of  no  moment  if 
the  stools  show  that  a fair  amount  of  food  is  passing  the 
pylorus  and  there  is  ever  so  slight  a gain  in  weight.  Our 
observations  have  taught  us  that  all  babies,  in  whom  every 
contributory  cause  of  closure  has  been  eliminated  and  in 
whom  symptoms  of  obstruction  persist,  come  to  operation. 
It  has  been  shown  that  in  no  other  way  can  the  pancreas  be 
stimulated  to  renewed  function.  Reference  in  this  connexion 
should  be  made  to  Cases  16  and  17. 

(b)  Gastritis. — It  is  probable  that  in  most  cases  of  pyloric 
obstruction  a certain  amount  of  retention  gastritis  with 


The  Lancet,]  MR.  TYRRELL  GRAY  k DR.  PIRIE:  HYPERTROPHIC  STENOSIS  OF  PYLORUS.  [Sept.  20,  1919  5 25 


consequent  swelling  and  hyperasmia  of  the  mucosa  is 
present.  Where  this  is  sufficient  to  complete  the  closure 
of  the  pyloric  orifice  its  relief  should  result  in  the  removal 
of  the  obstruction.  Thus,  in  the  case  of  a male  infant 
recently  admitted  under  Dr.  Still  the  diagnosis  was 
established  in  the  usual  way.  There  were  neither  phimosis 
nor  preputial  adhesions,  therefore  circumcision  was  not 
performed.  He  was  fed  on  peptonised  milk,  and  his 
stomach  was  washed  out  daily.  About  the  twelfth  day,  the 
vomiting,  which  had  been  variable,  ceased  altogether  ; the 
stools,  which  had  been  occasionally  loose,  became  more 
bulky,  greasy,  and  more  frequent,  and  he  began  to  gain  in 
weight.  His  improvement  has  been  progressive  ever  since. 
In  the  case  of  Ivy  M.,  the  same  procedure  was  followed, 
with  similar  results.  Thus,  gastritis  in  itself  may  be  the 
determining  factor  in  producing  closure  of  the  pylorus.  If 
successful  results  are  not  obtained  by  this- routine,  and  the 
possible  effects  of  phimosis  in  boys  have  been  eliminated, 
only  one  cause  of  obstruction  remains — the  preponderating 
element  of  hypertrophy  with  its  attendant  secretory 
suppression,  for  which  operation  is  the  only  remedy. 

We  have  referred  elsewhere  to  the  fact  that  girls  do 
not  behave  in  quite  the  same  manner  as  boys.  Uninfluenced 
by  phimosis,  the  most  potent  cause  of  added  spasm,  they 
are  slower  developing  symptoms  of  obstruction,  and  they 
will  be  correspondingly  slower  in  showing  improvement 
following  relief  from  obstruction.  For  this  reason  we  are 
disposed  to  wait  longer  than  the  10-12  days  before 
deciding  that  operation  is  indicated  upon  girls.  We 
advocate  this  because  the  pancreas  may  be  slower  in 
regaining  its  function.  Thus,  if  at  the  end  of  10-12  days 
from  the  commencement  of  treatment  there  is  still  an 
occasional  vomit  with  constipated  motions,  we  do  not 
operate  unless  there  is  marked  or  progressive  loss  in 
weight.  We  wait  until  a period  of  time  has  elapsed 
corresponding  with  that  during  which  the  symptoms  of 
obstruction  were  developed. 

( o ) Phimosis. — We  shall  not  again  enter  into  a discussion 
of  the  relation  of  phimosis  to  pyloric  stenosis.  It  is  sufficient 
to  repeat  that  we  consider  it  the  most  potent  cause  of  added 
spasm  in  boys.  If  babies  in  whom  the  diagnosis  of  con- 
genital hypertrophic  pyloric  stenosis  has  been  established 
show  phimosis  or  preputial  adhesions  they  should  be  circum- 
cised, or  the  adherent  prepuce  separated  at  once.  In 
Case  16  circumcision  was  immediately  followed  by  complete 
cessation  of  vomiting,  and  the  appearance  of  characteristic 
motions.  Within  a few  days,  however,  the  symptoms  of 
obstruction  began  to  reappear,  and  were  well  established  by 
the  tenth  day.  In  this  case  phimosis  was  only  a contributory 
cause  of  spasm,  and  was  not  the  only  one.  Gastritis  was 
eliminated  by  the  failure  of  lavage  to  relieve  the  symptoms, 
since  these  reappeared.  There  remained  the  only  cause  of 
obstruction — hypertrophy  plus  secretory  inhibition,  for  which 
operation  was  performed  and  gave  relief.  And  in  support 
we  may  again  call  attention  to  the  fact  that  the  child  showed 
the  largest  pylorus  we  have  ever  seen. 

Again,  in  Case  19,  under  Dr.  Colman,  circumcision  was 
performed.  There  followed  occasional  vomits  and  loose 
motions.  After  the  tenth  day  the  patient  did  not  Vomit  again. 
On  the  eleventh  and  twelfth  days  there  were  the  frequent, 
bulky,  greasy  motions,  and  he  began  to  gain.  His  improve- 
ment was  progressive  up  to  the  time  when  sudden  death 
occurred,  as  already  reported. 

There  is  also  a child  under  the  care  of  Dr.  Colman  who  is 
now  under  similar  treatment,  and  appears  to  be  following  a 
most  satisfactory  course.  In  these  cases  phimosis  itself  was 
the  predominant  factor  in  completing  closure  of  the  stenosed 
pylorus.  On  the  other  hand,  Case  17,  admitted  under  Dr. 
Poynton,  was  circumcised  without  any  subsequent  relief  from 
the  symptoms.  As  it  came  under  Group  I.  operation  was 
performed  at  once  with  immediate  relief  from  the  symptoms. 
In  this  instance  phimosis  had  nothing  to  do  with  the  closure 
of  the  pylorus. 

(<2)  Unknown  causes  of  spasm. — We  must  admit  that  there 
may  be  a very  small  group  of  cases  where  some  unrecognised 
cause  of  spasm  determines  the  closure  of  the  stenosed  pyloric 
orifice.  We  cannot  satisfy  ourselves  that  we  have  found  any 
in  our  experience.  But  such  good  observers  as  John  Thomson 
have  had  success,  in  some  cases,  by  the  administration  of 
sedatives  such  as  chloral  hydrate.  Such  cases  must  be  very 
few  in  number,  and  only  the  results  of  treatment  such  as  we 
are  advocating  could  differentiate  them. 


(3)  Radical  treatment. — The  treatment  becomes  radical — 
that  is,  the  pylorus  is  operated  upon — when  palliative  treat- 
ment definitely  fails  to  relieve  the  symptoms  of  obstruction 
by  the  twelfth  day.  This  failure  would  mean  that  all 
causes  of  obstruction,  other  than  the  hypertrophy  itself,  had 
been  removed  ; the  only  relief  now  is  operation.  During 
the  twelfth  day  interval  the  symptoms  may  fluctuate.  The 
vomiting  may  be  non-projectile  and  less  frequent.  Gastric 
peristalsis  is  seen  only  occasionally.  The  stools  are  some- 
times constipated  and  sometimes  loose.  The  weight  will 
vary  between  small  gains  and  losses.  The  subcutaneous 
injections  of  saline  and  glucose  will  prevent  any  marked 
wasting.  These  fluctuations  are  of  no  moment  before  the 
twelfth  day,  but  after  this  point  they  would  indicate  the 
inability  of  the  pylorus  to  relax  permanently.  We 
do  not  say  that  all  babies  left  longer  than  12  days 
will  not  recover,  but  we  do  think  that  there  is 
sufficient  evidence  to  show  that  if  they  are  to  recover 
under  palliative  treatment  they  should  usually  indicate 
definite  evidence  of  doing  so  by  the  end  of  the  twelfth  day. 
(We  make  an  exception,  as  mentioned  above,  in  the  case  of 
girls.)  We  consider  that,  after  this  point,  the  risk  from 
operation  is  much  less  than  the  risk  from  a more  or  less 
permanent  inhibition  of  pancreatic  function  becoming  estab- 
lished, owing  to  prolonged  pyloric  obstruction.  If  this 
happened,  even  operation  would  be  of  no  avail,  and  the 
children  would  die  from  marasmus.  Moreover,  a relapse 
might  occur  when  operation  would  have  to  be  performed 
under  far  less  advantageous  circumstances.  (Vide  Case  7.) 
The  treatment,  then,  of  babies  in  whom  symptoms  of  obstruc- 
tion persist  beyond  the  twelfth  day  is  surgical,  and  Ramm- 
stedt’s  operation  should  be  performed. 

With  regard  to  the  prevention  of  sudden  deaths  from 
unexplained  causes,  it  is  very  difficult  to  suggest  any  way 
in  which  this  definite  percentage  of  losses,  with  or  without 
operation,  can  be  obviated.  Similar  accidents  are  reported 
in  America  and  are  well  recognised.  We  have  not  yet  made 
trial  of  blood  transfusion  previous  to  or  after  operation,  but 
we  propose  trying  a series  of  cases  in  this  way,  and  com- 
paring the  results  obtained  with  the  figures  we  have  already 
given. 

V. — Post-operative  Treatment. 

When  the  child  is  returned  to  bed  from  the  operating 
theatre  it  should  be  kept  warm  with  wool  wrapped  about  the 
extremities  and  preferably  nursed  on  a water  bed.  If  there 
is  no  shock  we  prefer  the  semi-upright  position.  There  is 
sometimes  a mild  degree  of  post-operative  bronchitis,  which 
can  be  treated  better  in  this  position. 

Diet. — This  is  an  important  detail.  We  have  shown  that 
the  period  of  time  necessary  for  the  pancreas  to  regain  its 
function  is  from  10  to  12  days.  During  this  time  peptonised 
milk  should  be  given.  Our  practice  is  to  give  one  ounce 
four  hours  after  the  operation,  and  a similar  amount  every 
four  hours  for  the  first  24  hours.  The  second  24  hours  an 
ounce  and  a half  is  given  every  three  hours.  After  this  an 
amount  is  given  according  to  the  weight  and  age  of  the  child. 
We  have  never  found  it  necessary  to  feed  smaller  quantities. 
When  the  stools  cease  to  show  incompletely  changed  fats 
(usually  about  the  tenth  to  twelth  day)  the  food  is  changed 
to  citrated  modified  milk.  This  change  in  the  stools  would 
indicate  a return  to  the  normal  outflow  of  pancreatic  secre- 
tion. Beyond  this  point  they  are  fed  as  normal  babies.  We 
make  an  exception  to  the  10  to  12-day  limit  for  this  change 
of  food  in  the  case  of  girls.  As  shown  before,  in  them  the 
pancreas  is  slow  to  regain  its  secretory  function  for  reasons 
already  indicated,  and  therefore  the  peptonised  milk  usually 
will  have  to  be  continued  longer  than  12  days.  Case  15 
illustrated  this.  At  the  twelfth  day  the  stools  were  still 
rather  loose  and  greasy,  and  she  was  gaining  very  slowly. 
Citrated  modified  milk  was  given.  The  stools  became  more 
undigested  and  she  began  to  lose  weight.  The  food  was 
again  changed  to  peptonised  milk  and  she  immediately 
began  to  gain.  The  stools  were  still  loose,  but  were  free 
from  curds.  She  is  still  on  peptonised  milk,  which  will  be 
discontinued  as  soon  as  there  is  no  evidence  of  undigested 
fat  in  the  stools. 

During  the  first  few  days  after  operation,  while  the  child 
is  taking  insufficient  food,  we  continue  the  saline  and 
glucose  infusions.  At  first  eight  ounces  a day,  and  later 
four  a day,  may  be  given.  The  infusion  should  never  be 
repeated  unless  the  one  previously  given  has  been  com- 
pletely absorbed.  If  absorption  is  unduly  slow  it  may  be 


526  Th®  Lanobt,]  SIR  G.  SIMS  WOODHEAD  & MR.  VARRIER-J*ONES : COLONY  TREATMENT,  ETC.  [8ept.  20, 1919 


expedited  by  the  hypodermic  injection  of  a ^ c.cm.  of  pituitrin. 
The  combined  saline-glucose  infusion  with  pituitrin  treat- 
ment is  doubly  useful,  in  that  it  combats  post-operative 
shock,  and  replaces,  in  a measure,  the  food  which  must  at 
first  be  withheld.  We  have  said  nothing  about  medicinal 
treatment,  and  we  think  there  is  seldom  any  indication  for 
the  administration  of  drugs.  The  only  fear  after  operation 
is  shock,  and  this  is  best  treated  in  the  manner  described. 
Brandy  might  be  advocated,  but  our  experience  has  taught 
us  that  it  may  cause  vomiting.  As  most  of  these  small 
patients  are  in  a precarious  condition,  they  are  not  able  to 
withstand  the  extra  demand  on  their  reserve  made  by 
vomiting.  The  work  recently  done  od  direct  blood  trans- 
fusion has  suggested  to  us  its  employment  on  the  more 
feeble  of  these  patients.  In  a further  series  of  cases  it  is 
intended  to  practise  this  at  the  time  of  operation.  In  cases 
which  do  not  come  to  operation,  we  think  this  might 
advantageously  be  employed  about  the  end  of  the  second 
week,  since  two  or  three  children  have  died  from  unexplained 
causes  about  this  time,  although  the  symptoms  of  obstruction 
had  been  relieved. 


Summary  of  Conclusions  on  Both  Contributions. 

1.  Congenital  pyloric  hypertrophy  is  the  result  of  pro- 
longed ante-natal  spasm  induced  by  hyper-adrenalism. 

2.  Pyloric  obstruction  is  completed  by  two  secondary 
influences  : (a)  retention  gastritis  with  consequent  swelling 
of  the  mucosa  ; (£)  added  spasm  due  to  several  causes  ; fore- 
most by  phimosis. 

3.  The  final  results  in  the  closure  of  the  pyloric  orifice  are  : 
(a)  absence  of  acid  chyme  in  the  first  part  of  the 
duodenum,  leading  to  ( b ) failure  of  secretin  formation, 
leading  to  (o)  suppression  of  pancreatic  secretion.  These 
factors  themselves  further  induce  (d)  inhibition  of  the 
normal  pyloric  relaxation  and  establishment  of  the  “ vicious 
circle.” 

4.  Positive  diagnosis  should  never  be  made  without  the 
demonstration  of  a palpable  tumour. 

5.  Rammstedt’s  operation  is  the  operation  of  choice. 

6.  Fulminating  cases  demand  immediate  operation. 

7.  In  all  other  cases  palliative  treatment  should  first 
be  adopted  as  follows : — (1)  Feeds : peptonised  milk  in 
appropriate  quantities  ; (2)  gastric  lavage  ; (3)  circumcision  ; 
(4)  subcutaneous  infusion  of  saline  and  2 per  cent,  glucose 
when  necessary  ; and  possibly  (5)  administration  of  chloral 
hydrate. 

8.  Duration  of  palliative  treatment : (a)  Very  wasted  and 
weakly  infants.  If  there  is  no  relief  of  symptoms  in  48  hours 
operation  should  be  performed  without  delay.  ( b ) In  the 
majority  of  cases  palliative  treatment  is  to  be  persevered 
with  for  from  10  to  12  days. 

9.  The  critical  time  at  which  failure  or  success  of  pallia- 
tive treatment  can  be  gauged  is  from  10  to  12  days  from 
the  commencement  of  treatment,  and  coincides  with  the 
re-establishment  of  pancreatic  function  in  successful  cases. 

10.  Failure  to  improve  after  this  point  constitutes  an 
indication  for  operation  in  boys,  but  not  necessarily  in  girls. 

11.  Sex  incidence  is  about  equal ; phimosis  being  the 
determining  factor  in  the  onset  and  severity  of  sympt  >ms  in 
a large  proportion  of  male  subjects  of  pyloric  hypertrophy. 

12.  Post-operative  diet  snould  consist  of  peptonised  milk 
until  pancreatic  functions  have  been  re-established. 

Finally,  we  cannot  conclude  this  study  without  expressing 
our  thanks  to  the  staS  of  the  Great  Ormond-street  Hospital 
for  their  courtesy  in  placing  at  our  disposal  their  cases  and 
the  hospital  notes. 


Child  Welfare  in  British  Guiana. — The  Baby 
Saving  League  of  British  Guiana  was  started  five  years  ago. 
We  have  now  received  the  (fifth)  annual  report  for  the  year 
1918.  Such  an  institution  appears  to  be  greatly  needed,  for 
the  infant  mortality-rate  is  extremely  high.  For  the  year 
1918,  for  the  whole  colony,  it  was  223  per  1000;  for  the 
Portuguese,  157 ; for  the  East  Indian  race,  241 ; for  the 
Chinese,  143  ; and  for  the  black  races,  235.  The  need  for  a 
larger  population  in  British  Guiana  is  an  urgent  one.  It  is 
pointed  out  in  the  report  that  East  Indian  immigration  is 
likely  to  be  abolished,  and  a larger  supply  of  labour  is 
needed  in  order  to  develop  the  resources  of  the  interior  and 
to  maintain  the  industries  which  are  already  established  on 
the  coast.  Shortage  of  the  labour  supply  is  already  reflected 
in  the  diminished  acreage  under  sugar,  notwithstanding  the 
enhanced  prices  due  to  the  world-war. ; 


FURTHER  EXPERIENCES  IN  COLONY 
TREATMENT  AND  AFTER-CARE. 

By  Sir  G.  SIMS  WOODHEAD,  K.B.E.,  V.D.,  M.A., 
M.D.,  LL.D., 

FELLOW  OF  TRINITY  HALL,  AND  PROFESSOR  OF  PATHOLOGY,  UNIVERSITY 
OF  CAMBRIDGE  ; 

AND 

P.  C.  VARRIER-JONES,  M. A.  Camb.,  M.R.C.S., 
L.R.C.P.  Lond., 

FOUNDATION  SCHOLAR,  ST.  JOHN’S  COLLEGE,  CAMBRIDGE;  HONORARY 
MEDICAL  OFFICER,  CAMBRIDGESHIRE  TUBERCULOSIS  COLONT  ; 

AND  TUBERCULOSIS  OFFICER  FOR  THE  COUNTY 
OF  CAMBRIDGE. 


III.1 

The  incidence  of  the  new  problem  involved  in  the  treatment 
of  the  discharged  tuberculous  soldier  and  sailor  has  so  shaken 
our  old  beliefs  and  jarred  our  prejudices  that  we  are  in  danger 
of  attempting  to  grasp  at  an  idea  which  we  imagine  may  help 
us  in  the  solution,  while  failiDg  to  evaluate  the  idea  in  that 
its  fundamental  principles  are  not  understood.  From  the 
number  of  inquiries  received,  and  from  conversations  with 
many,  both  lay  and  medical,  who  have  visited  Papworth 
Colony — interested  in  the  problem  of  the  treatment  of  tuber- 
culosis— it  has  been  brought  home  to  us  that  even  amongst 
those  who  have  given,  or  are  giving,  attention  to  the  matter 
there  is  a welter  of  opinion  which  must  be  rescued  from 
chaos  and  carefully  arranged  and  classified  before  any 
concerted  action  can  be  taken. 

Chances  of  Sucoess  in  Change  of  Employment. 

The  simple  and  oft-repeated  formula,  “Seek  a job  in  the 
open  air,”  glibly  offered  to  the  middle-aged  mechanic,  and 
the  equally  casual  advice  “to  take  things  easy  for  the  next 
three  months  or  so  ” given  to  a man  with  a wife  and  six 
children  to  support,  indicate  only  too  clearly  that  little 
mental  effort  can  have  been  brought  to  bear  on  the 
actualities  of  the  situation.  If  there  is  one  thing  that  expe- 
rience of  colony  work  has  made  clear  it  is  that,  as  a rule,  it 
is  futile,  and  will  now  be  criminal  to  give  the  above  advice, 
unless  it  is  realised  that  if  there  is  one  form  of  occupation 
more  unsuitable  than  any  other  for  the  consumptive  it  is  a 
job  as  an  unskilled  farm  labourer. 

The  job  in  the  open  air — the  utopian  dream  of  the 
unthinking  adviser— may  be  either  Scylla,  Charybdis,  or 
both,  but  usually  threatening  the  consumptive  with 
destruction.  The  idyllic  summer  holiday  at  a farm, 
with  its  peace  and  rest,  its  plain  but  nourishing  milk 
and  eggs,  its  new  and  temporary  interests,  and  its 
gentle  exercises  in  the  open  air,  is  very  different  from 
the  strenuous  and  exacting  life  of  a farm  labourer, 
even  at  an  enhanced  wage  of  40s.  per  week.  The  un- 
skilled hand,  the  untrained  eye,  and  the  inexperienced 
brain  are  of  little  value  to  the  farmer,  and  certainly  cannot 
be  profitably  employed.  Though  many  members  of  the 
medical  profession,  and  the  vast  army  of  voluntary  workers, 
who  so  frequently  give  this  advice  do  not  realise  its  futility, 
it  is  a matter  to  which  the  consumptive  is  fully  alive.  It 
is  only  necessary  to  talk  to  these  men  and  to  obtain  their 
confidence  to  have  it  brought  home  to  one  that  they  know 
better  than  their  advisers  that  to  set  an  unskilled  man 
to  work  at  any  skilled  trade  is  not  only  economically 
unsound,  but  physically  detrimental  and  morally  and 
socially  delusive.  To  bring  the  matter  home  to  ourselves  we 
have  merely  to  imagine  how  sorry  would  be  the  plight  in 
which  most  of  us  would  find  ourselves  were  it  necessary  for 
us  to  give  up  our  profession  and  seek  pastures  new.  Why, 
then,  give  advice — fortunately  rarely  followed,  or  if  followed 
quickly  given  up — which  nine  times  out  of  ten  can  only  be  a 
source  of  disappointment  to  all  concerned  ? The  question  : — 
How  many  men  can  be  trained  in  agriculture  in  the  course  of 
six  months  ? can  only  be  put  by  a town-bred  man  with  no 
knowledge  of  country  life,  and  as  it  is  impossible  in  six 
months  to  train  a healthy  man  to  follow  a complicated 
industry  such  as  agriculture,  how  much  less  is  this  possible 
in  the  case  of  a 50  per  cent,  man  suffering  from  tuberculosis. 
Had  the  colony  committee  the  changing  of  a man’s  occupa- 
tion from  that  of  an  artisan  or  clerk  to  that  of  a farm 
labourer,  or  even  a small-holder,  for  its  objective  it  must 

1 Part  I.  was  published  in  The  Lancet  of  Nov.  24th,  1917,  and 
Part  II.  in  The  Lancet  of  August  3rd,  1918. 


The  Lancet,]  SIR  G.  SIMS  WGODHBAD  Sc,  MU.  VARRIER-JONES : COLONY  TREATMENT,  ETC.  [Sept.  20, 1919  527 


jnevitably  court  failure.  A genuine  case  of  pulmonary 
tuberculosis  with  a definite  and  progressive  lung  lesion 
will  undoubtedly  benefit  by  a prolonged  stay  under 
ideal  colony  conditions,  but  very  few  will  ever  be  able  to 
stand  alone,  and,  working  from  morning  till  night,  live  on  the 
produce  of  a small  holding.  The  arrested  condition  of  the 
disease  in  these  cases  is  so  unstable  that  the  proposition 
Cannot  be  a paying  one,  and  this  instability  is  the  main 
medical  cause,  not  taking  into  consideration  economical  and 
psychological  factors  of  failure,  and  must  necessarily  remain 
so  until  some  method  of  stabilising  the  arrest  is  attained. 
One  of  the  difficulties  met  with  in  dealing  with  such  a vast 
problem  as  that  of  tuberculosis  is  that  exceptional  results 
which  do  not  appear  to  bear  out  general  experience  crop  up 
now  and  again  ; but  as  a rule,  if  these  exceptional  results  are 
carefully  analysed,  it  will  be  found  that  the  principles  on 
which  the  colony  treatment  is  based  are  sound  and  have  not 
been  violated,  and  that  other  special  factors  have  come  into 
play  and  have  altered  the  course  of  events.  In  some  cases 
change  of  employment  has  undoubtedly  been  attended  with 
success,  but  these  successes  are  few  and  far  between,  and 
have,  as  a rule,  been  associated  with  a group  of  such  favour- 
able contributory  conditions  that  the  truth  of  the  general 
proposition  is  in  no  way  countered.  For  example,  a sympa- 
thetic employer  may  be  an  important  factor  in  the  deter- 
mination of  an  apparently  exceptional  success  fundamentally 
altering  the  patient’s  whole  economic  condition.  He  permits, 
nay  ensures,  the  working  of  shorter  hours,  later  morning 
rising,  more  prolonged  noonday  rest,  with  ample  time  for 
meals,  and  one  of  the  prime  factors  in  success — the  feeling  of 
the  absence  of  competition  is  assured.  The  feeling  “ I shall 
not  get  the  sack  even  if  I slack  a little  when  I feel  weary  ” 
affords  great  psychological  comfort.  It  must  be  remembered, 
however,  that  such  philanthropy  does  not  flourish  freely  in 
the  largest  concerns  and  in  the  limited  liability  companies  : 
but  the  colony  having  learned  much  from  the  sympathetic 
employer,  takes  his  place,  and  must  strive  to  provide  for  all 
cases  of  tuberculosis  not  only  the  above  conditions,  but  in 
addition  suitable  dwellings,  good  food,  and  protection  from 
the  economic  struggle — the  salvation  of  the  consumptive 
working  man.  The  exceptions  proving  the  rule  therefore, 
instead  of  militating  against  the  general  proposition,  are  of 
the  greatest  service  as  indicating  the  proper  method  of 
tackling  the  general  problem.  It  is  not  so  much  the  change 
of  occupation  that  ensures  the  favourable  reaction,  nor 
certainly  is  it  the  mere  fact  that  the  patient  becomes  a farm 
labourer  ; for  there  is  no  magic  in  that  occupation.  Nor, 
again,  is  a light  open-air  job  a panacea  for  the  disease. 
Patients  working  at  either,  or  both,  unless  carefully  watched 
and  guided  become  steadily  worse  and  inevitably  head  for 
disaster.  We  must  realise  the  actual  economic  conditions 
that  are  assured  when  a sympathetic  employer  has  the  case 
in  hand,  and  also  that  these  are  necessary  for  the  success  of 
the  undertaking.  These  fundamentals,  these  economic  con- 
ditions assured,  we  are  afraid  to  disturb  them  in  any  way,  and 
the  problem  seems  to  us  so  vast  that  we  are  almost  afraid 
to  do  or  say  anything  that  might  lead  to  such  disturbance. 

Reason  for  Labour's  Laok  of  Sympathy, 

Has  it  ever  struck  us  how  extraordinarily  unsympathetic 
the  mass  of  labour — “the  labour  world” — is  toward  all 
schemes  of  sanatoriums  and  the  like,  and,  if  so,  has  it 
ever  occurred  to  us  to  seek  the  reason  for  this  ? It  is  obviously 
the  same  reason  that  underlies  the  apathetic  attitude  of  labour 
to  the  Government’s  training  schemes  for  disabled  sailors  and 
soldiers,  which  are  little  more  than  camouflage,  the  mere 
tinkering  with  a huge  problem.  What  should  we,  as  medical 
men,  say  if,  owing  to  a shortage  of  doctors,  it  was  seriously 
proposed  to  give  men  a six  months,  or  even  a 12  months 
intensive  course  in  medicine  and  surgery  in  the  large 
hospitals  and  then  turn  the  recruits  loose  to  practise  medi- 
cine and  surgery  on  the  community  ? It  may  be  argued  that 
this  is  not  an  exact  parallel,  but  it  is  sufficiently  exact  if  we 
leave  out  of  account  the  question  of  danger  to  the  public 
and  consider  only  the  amount  of  knowledge  which  the  man 
could  acquire  from  such  a course.  For  the  training  of  an 
efficient  workman  the  present  course  as  recommended  and 
provided  is  absurd,  and  the  working  man  knows  it.  That  the 
skilled  artisan  does  not  wish  his  trade  to  be  exploited  by  an 
untrained  person  is  another  aspect  of  the  question,  but  one 
of  equal  importance.  If  we  are  simply  patching  up  a 
patient  in  order  that  he  may  return  to  his  original  surround- 
ings, where  he  may  infectr  other  working  men,  small  wonder 


that  the  plan  of  utilising  the  sympathetic  employer  receives 
but  scant  consideration  from  the  working  man,  who  is  thus 
called  upon  to  run  the  risk  not  only  of  infection  but  also  of 
diminished  earnings  due  to  the  business  being  burdened  by 
the  introduction  of  the  invalid. 

The  insufficiency  of  the  training  that  can  be  given  to  a 
man  disabled,  whether  by  the  loss  of  a limb  or  a lung,  is 
very  fully  appreciated  by  the  intelligent  working  man  ; not 
so  fully  by  those  called  upon  to  advise,  treat,  and  train  him. 
The  medical  profession  does  not  fully  appreciate  that  there 
can  be  no  other  criterion  of  a patient’s  “ cure  ” or  of  the 
arrest  of  his  disease  than  that  of  earning  capacity,  more  or 
less  permanent.  It  is  obviously  of  vital  importance  that  the 
earning  capacity  of  a consumptive  should  be  restored  to  as 
nearly  a normal  level  as  possible.  To  alter  a man’s  occupa- 
tion, when  the  earning  capacity  of  such  a man  is  the 
standard  of  success,  is  no  easy  matter.  Here  earnings  are 
of  prime  importance  and  a moment’s  thought  will  make  it 
clear  that  in  the  majority  of  cases  of  pulmonary  tuberculosis, 
those  with  well-developed  disease,  it  is  impossible  for  the 
earning  power  of  the  consumptive  to  be  more  than 
50  per  cent,  of  his  normal — for  him  to  be  more  than  a 
50  per  cent.  man.  That  some  become  75  per  cent,  men  is 
an  encouraging  fact,  but  we  recognise  that  it  is  only  under 
very  special  conditions  that  such  a percentage  is  obtained. 
Consumptive' s Hopeless  Handicap  in  the  Open  T,abour  Marhei. 

If  it  be  accepted  that  a “middle  case”  of  consumption 
is  unable  to  work  for  more  than  six  hours  per  day 
at  a trade  which  is  not  too  laborious  and  not  too 
technical,  and  is  paid  at  a full  trade-union  rate  of  wages  for 
those  six  hours,  it  is  obvious  that  the  man  cannot  earn 
during  those  restricted  hours  of  work  a sufficient  sum  to 
keep  himself  and  his  family  in  decent  circumstances.  In 
the  ordinary  workaday  world  an  employer  cannot  be 
expected  to  take  into  his  shops  or  factory  a consumptive 
with  a working  capacity  of  only  50  per  cent,  and  pay  him 
above  the  trade-union  rate  of  wages.  There  would  soon  be 
a general  upheaval  in  that  factory  or  shop,  and  a state  of 
unrest  such  as  that  we  have  witnessed  arising  out  of  the 
exorbitant  rate  of  wages  paid  to  munition  workers.  Our 
hypothetical  employer  would  have  to  be  a philanthropist 
indeed  who  could  or  would  consent,  or  dare,  to  adopt  such  a 
course.  It  is  obvious,  therefore,  that  even  if  we  could  find 
a sufficient  number  of  sympathetic  employers  who  would 
guarantee  a full  wage  for  a 50  per  cent,  worker  our 
difficulties  would  not  be  at  an  end.  A further  subsidy  is 
required,  a subsidy  that  must  come  from  the  Government  or 
State,  as  it  is  impossible  to  throw  such  a burden  on  the 
industrial  employer  of  labour.  As  a rule,  an  employer  asked 
to  employ  a consumptive  answers  that  he  would  prefer  to 
give  a donation  or  subscription  to  some  charitable  institu- 
tion, hospital,  or  sanatorium  and  have  done  with  the 
matter.  The  disorganisation  of  business  which  would  arise 
out  of  the  employment  of  a consumptive  on  the  only 
adequate  basis,  that  of  the  maintenance  of  health  of  a 
patient  and  his  family,  is  sufficient  to  undermine  the  whole 
scheme.  Occasionally  an  employer  willing  to  run  the  risk 
may  be  and  is  found,  but  the  arrangement  entered  into  does 
not  as  a rule  last  long.  The  danger  of  infection  from  the 
presence  of  a tuberculous  worker  is  hinted  at  and  rapidly 
passes  through  the  shop.  Moreover,  if  concessions  as  to 
hours,  &c.,  are  made  to  an  apparently  healthy  man  (the 
wound  in  the  lung  is  not  visible)  it  is  with  difficulty  that  the 
other  workers  are  prevented  from  expecting  and  demanding 
similar  concessions.  The  difficulties  and  obstructions  set 
up  by  the  trade-unions  are  equally  great,  in  many  cases 
debarring  the  consumptive  from  finding  suitable  employ- 
ment. The  embargo  of  the  union  is  decisive  unless 
the  patient  is  a skilled  workman,  who  in  many  trades  must 
have  served  his  full  apprenticeship.  This  indeed  is  the 
fatal  bar  to  the  training  of  a consumptive  in  any  new  skilled 
trade.  A few  months  spent  in  specially  fitted-up  shops  at  a 
colony  is  quite  inadequate  to  obtain  his  admission  into  any 
skilled  trade,  in  which  wages  are  high,  and,  for  the  most  part, 
adequate,  and  the  corresponding  trade-union,  even  should 
he  have  the  ability  to  perform  the  work  at  the  end  of  such 
a short  period  of  training.  From  all  points  of  view,  then, 
the  difficulty  of  training  a consumptive  in  a new  trade,  to  be 
carried  on  in  the  open  market,  is  enormous,  and  there  remain 
but  the  inadequately  paid  casual  occupations,  where  the  work 
is  heavy  and  the  remuneration  poor,  both  factors  to  be  avoided 
if  success  is  to  be  attained  or  expected. 


528  Thh  Lanobt,]  SIR  G.  SIMS  WOODHKAD  & MR.  VARRIER  JONES  : COLONY  TREATMENT,  ETC.  [Sept.  20, 1919 


Return  of  the  Consumptive  to  His  Orvn  Trade. 

The  myth  of  a “light  job  in  the  country  ” is  exploded.  The 
training  of  a consumptive  in  a “ light  remunerative  calling  ” 
is  not  practical  politics.  There  remain  but  two  alternatives  : 
(1)  the  consumptive  must  return  to  his  own  trade,  or  (2)  he 
must  become  a permanent  colonist.  The  former  is  the  one 
usually  adopted  for  the  consumptive  ; it  is  at  present  the  only 
course  open  to  him,  though  in  the  majority  of  cases  it 
must  end  in  disaster.  The  economic  conditions  of  com- 
petitive labour  are  against  the  man,  and  are  fatal  to  success. 
The  philanthropic  employers  who  are  willing  to  eliminate 
these  fatal  competitive  conditions  are  few  and  far  between, 
but  to  their  sympathy  and  action  we  owe  the  cases  which 
appear  to  provide  exceptions  to  the  rule  ; apparent  excep- 
tions only,  but  they  serve  as  examples  of  methods  which, 
if  followed  on  a large  scale,  spell  general  success. 

The  nature  of  this  method,  call  it  after-care  or  any  name 
which  may  indicate  its  nature,  has  as  yet  been  but  in- 
adequately appreciated.  The  problem  has  almost  invariably 
been  viewed  from  the  “ individual  cure  ” point  of  view,  one 
small  factor  after  another  being  takeD  and  insisted  upon. 
The  new  idea,  which  is  the  outcome  of  the  colony  as 
advocated  at  Papworth,  is  admirably  expressed  by  Dr.  H.  A. 
Pattison  in  his  study,  “ The  Agricultural  and  Industrial 
Community  for  Arrested  Cases  of  Tuberculosis  and  their 
Families,”  published  by  the  Federal  Board  for  Vocational 
Education,  Washington,  1919.  “ Industrial  communities,” 

he  says,  “ have  developed  rapidly  in  the  country.  Many  of 
them  have  grown  about  a single  industry  for  the  sake  of  that 
industry,  such  as  a steel  mill,  coal  or  mineral  mine,  &c.  The 
converse  proposition  is  the  one  I wish  to  offer,  the  develop- 
ment of  industries  around  a community  for  the  sake  of  that 
community.”  The  same  idea  has  been  expressed  as  follows  : 
“Let  communities  be  started  in  which  our  consumptive 
soldier  can  live  in  his  own  home,  shielded  from  the  fierce 
competition  of  the  outside  world,  a self-respecting  worker, 
an  economic  asset.  Let  employment  be  found,  the  model 
factory  erected,  the  hours  of  toil  properly  regulated,  a fair 
wage  paid.”  2 

In  other  words,  the  role  of  the  colony  is  that  of  the 
philanthropic  but  unfettered  employer,  with  his  factory  open 
for  the  admission  of  those  who  cannot  find  work  elsewhere, 
and  where  the  mode  of  life — if  a serious  relapse  is  to  be  avoided 
— must  be  carefully  regulated.  That  the  disease  will  progress 
there  can  be  little  doubt,  but  the  rate  of  its  advance  may 
be  so  controlled  that  the  patient  may  yet  enjoy  many 
years  of  useful  work  and  pleasant  recreation,  instead  of 
having  to  engage  in  a brief  struggle  against  over- 
whelming odds,  the  while  seeing  his  family  dragged 
down  to  poverty  and  want.  In  the  model  village  the 
amenities  of  life  are  such  that  the  wife  and  child  are 
protected  from  all  massive  infection,  and  in  time  the  latter 
will  be  free  to  compete  in  the  world  at  large,  unhandicapped 
by  intervening  years  of  want,  malnutrition,  and  consequent 
lowered  resistance.  There  may  be  little  hope  of  altering  at 
a stroke  of  the  pen  imperfect  economic  conditions  in  the 
world  at  large,  but  we  now  have  ample  evidence  that  small 
communities  may  be,  and  have  been,  inaugurated,  where 
the  conditions  of  existence  may  in  time  constitute  a model 
for  the  workaday  world  outside.  Such  communities  realise 
the  dream  of  all  social  workers,  and  embody  the  aim 
and  end  sought  by  the  consumptive  workers  of  the 
world,  who  desire  the  priceless  privilege  of  living  in 
surrroundings  that  will  compensate  for  their  segregation, 
while  helping  to  protect  the  communities  outside  against 
dangerous  sources  of  infection. 

Essential  Features  of  Consumptive  Industries.  * 

The  features  essential  for  the  industries  specially  run  for 
consumptives  are  many  and  complex,  but  the  idea  that  such 
industries  can  be  only  those  carried  on  in  the  open  air  must 
be  abandoned  as  a practical  proposition,  and  this  for  one 
reason  among  others,  that  enormous  tracts  of  land  would  be 
required  on  which  to  carry  them  out.  On  an  acre  of  ground, 
unless  very  highly  and  intensively  cultivated,  few  people  can 
be  employed.  An  ordinary  farm  of  200  acres  would  afford 
employment  for  a number  of  hands  infinitesimal  as  compared 
with  the  number  of  cases  awaiting  admission.  It  is,  there- 
fore, of  primary  importance  that  industries  should  be  started 
capable  of  absorbing  a greater  number  of  workers  per  acre 
of  ground.  It  is  accepted  that  it  is  impossible  to  train  a 

3 Varrler-Jones  ■.  "A  Plea  for  the  Consumptive  Soldier,"  lleveille* 
No.  2,  19X8. 


man  in  a new  trade  in  the  short  space  of  time  allotted,  so 
it  is  obviously  inadvisable  to  select  an  occupation  in  which 
elaborate  training  must  of  necessity  take  place ; but  from  the 
munition  works  we  have  acquired  experience  which  should  be 
applied  with  great  success  in  the  employment  of  the  consump- 
tive. Strenuous  and  prolonged  physical  manual  labour  must 
be  avoided  and  the  use  of  modern  machinery  enables 
us  to  do  away  with  such  severe  manual  toil.  It  is  now  no 
longer  necessary  to  set  consumptives  to  work  at  carpentry, 
say,  with  a plane  and  a saw,  and  instruct  them  in  the  per- 
formance of  labour  which  in  all  modem  businesses  is  done 
by  machinery.  (Little  wonder  that  on  the  old  methods 
our  goods  could  not  compete  in  the  open  market.) 

In  a well-ventilated  workshop  with  good  aspect,  fitted 
with  modern  machinery,  the  hours  of  toil  regulated  to  a 
nicety  by  a sympathetic  management,  it  is  possible  for 
consumptives  to  earn  a reasonable  rate  of  wages.  That  the 
wage  earned  is  insufficient  to  keep  the  man  and  his  family 
goes  without  saying,  for,  as  already  pointed  out,  a full 
trade-union  rate  of  wages  for  the  short  hours  worked 
is  insufficient  to  provide  for  that  standard  of  comfort 
which  is  essential  for  the  well-being  of  the  patient.  We 
are  dealing  with  the  50  per  cent,  capacity  man,  and  no 
speeding-up  machinery  brought  into  play  can  do  other  than 
leave  the  percentage  unaltered,  but  it  does  relieve  the  patient 
of  much  too  strenuous  exertion.  The  8tate  must  come  to  the 
rescue,  and  for  its  protection  against  infection  must  con- 
tribute a subsidy  equivalent  to  some  percentage  of  the 
patient’s  earning  capacity.  When  once  an  industrial  colony 
has  been  started  it  will  be  possible  to  employ  numbers  of 
subsidised  patients  at  various  trades,  and  an  encouraging 
vista  of  employment  will  be  opened  up  to  our  consumptives. 
All  we  have  to  do  is  to  find  out  and  provide  the  necessary 
conditions,  and  make  rules  and  regulations  whereby  the  most 
suitable  working  hours  are  ensured  and  excessive  toil 
eliminated.  Given  these  things,  the  labour  of  the  consump- 
tive may  be  made  so  remunerative  that,  while  some  subsidy 
will  be  necessary,  it  need  not  be  large  and  will  be  well 
applied,  especially  when  the  advantages  to  the  general 
community  are  taken  into  consideration.  These  applied 
elementary  principles  of  colony  treatment,  common  to  all 
workers  amongst  the  tuberculous,  indicate  a distinct  advance 
along  lines  hitherto  but  little  explored.  Organisation 
is  needed  in  order  that  these  principles  may  be  applied 
logically  in  the  domain  of  practical  politics  in  the  near 
future.  Here  we  must  have  organisation  of  the  home  life  ; 
there  must  also  be  a coordinated  attack  upon  the  disease, 
its  effects  and  its  causes,  primary  and  predisposing  ; a full 
appreciation  of  the  factors  in  the  spread  of  the  disease  ; and 
a realisation  of  the  fact  that  all  measures  to  be  successful 
must  be  continuous,  well-directed,  and  prolonged.  Sir 
Arthur  Newsholme,  in  his  foreword  to  Dr.  Chapman’s 
report  on  colonies,  appreciates  the  position  exactly,  except 
that  he  does  not  refer  to  the  control  of  infection  outside  the 
home.  “ The  greater  part  of  the  consumptive’s  life  is  spent 
at  home,  often  under  unsatisfactory  conditions  both  for  the 
patient  and  his  family,  and  the  supervision  of  his  home  life 
by  the  tuberculosis  officer  and  the  health  visitor,  even  when 
this  is  frequent  and  sympathetic,  does  not  completely  meet  his 
needs.  If  the  patient  is  to  have  the  best  possible  prospect  of 
recovery,  and  if  his  family  are  to  be  safeguarded  against 
infection,  in  many  cases  he  will  need  (a)  improved  housing  ; 
( b ) occupation  adapted  to  his  physical  capacity.  &.c.  ; (o)  the 
family  income  will  need  to  be  supplemented.  These  require- 
ments for  many  patients  have  not  hitherto  been  met.” 

Some  System  of  Segregation  Required. 

They  have  not  been  met,  and  for  the  reasons  given  in  the 
earlier  part  of  this  paper  they  are  not  likely  to  be  fully  met 
until  some  system  of  segregation  is  thought  out  and 
organised.  The  problem  of  occupation  under  private 
employers  working  for  profit  is  not  likely  to  be  solved  ; it  is 
impracticable,  and,  moreover,  it  may  be  prejudicial  to  the 
health  of  the  other  workers  to  have  subsidised  consumptives 
working  alongside  the  non-tuberculous.  With  the  provision 
of  separate  workshops  and  separate  dwellings  the  difficulties, 
though  not  by  any  means  removed,  are  minimised.  Indeed, 
our  thoughts  directed  into  this  channel,  the  colony  idea 
acquires  an  entirely  new  significance.  Formerly  it  meant  the 
advocacy  of  open-air  occupation,  and  the  provision  of  those 
special  conditions  that  were  available  for  the  wealthy  few  : 
it  is  not  until  we  can  get  the  public  to  view  the  matter 
from  an  entirely  different  angle  that  the  full  significance  of 
the  new  colony  idea  becomes  evident.  From  the  fresh  stand- 


Thb  Lancet,]  DR.  F.  W.  B.  YOUNG  : TREATMENT  OF  SEPTIC  WOUNDS  BY  IONISATION.  [Sept.  20,  1919  529 


point  facts  which  seem  to  have  no  place  in  our  system  assume 
a new  importance,  and  fit  in  with  the  general  scheme,  helping 
to  bind  it  into  a concrete  whole. 

No  scheme  for  the  control  of  the  tuberculous  can  be 
regarded  as  satisfactory  which  does  not  embrace  the  whole 
life  of  the  consumptive  patient.  But  what  scheme  can 
control  the  whole  life  of  a consumptive  in  our  crowded 
cities,  and  where  can  an  organisation  be  found  to  throw  its 
tentacles  into  every  yard  and  alley  7 

Recommendations?  of  the  Inter- Departmental  Committee. 

In  the  past  we  have  gained  a knowledge  of  the  facts,  but 
we  have  failed  to  view  them  from  the  right  angle.  Turn  the 
picture  round  ; let  us  get  rid  of  preconceived  notions,  and 
build  on  the  firm  rock  of  experience  and  tried  methods.  Then, 
and  then  only,  will  progress  be  made  and  success  attained. 

We  now  note  with  interest  that  the  Inter- Departmental 
Committee  on  Tuberculosis  appointed  in  April,  1919,  “to 
consider  and  report  on  the  immediate  practical  steps  which 
should  be  taken  for  the  provision  of  residential  treatment 
for  discharged  soldiers  and  sailors  suffering  from  tuberculosis 
and  for  their  reintroduction  into  employment,  especially  on  the 
land,”  has,  as  a result  of  its  inquiries,  and  reporting  very 
promptly,  recommended  that  the  Papworth  Colony,  with  its 
various  departments,  should  be  adopted  for  development 
in  various  centres  all  over  the  country.  That  it  may  be 
improved  and  developed  we  recognise  very  fully.  That 
there  are  difficulties  to  be  overcome  we  have  ample 
experience.  But  that  it  is  based  on  sound  lines  we  are 
satisfied,  and  for  this  reason,  and  not  because  it  has  been 
built  up  in  Cambridge,'  we  welcome  the  recommendations  of 
the  Inter-Departmental  Committee. 


TREATMENT  OF  SEPTIC  WOUNDS  BY 
IONISATION. 

By  F.  W.  BAKER  YOUNG,  M B.,  Ch.B.  Manch., 

CAPTAIN,  R.A.M.C.  (T.F.). ; HONORARY  ASSISTANT  SURGEON,  CANCER 
AND  SKIN  HOSPITAL,  LIVERPOOL. 


Cases  were  treated  at  a general  hospital  at  the  request  of 
Colonel  G.  W.  Crile,  M.C.,  U.S.A.,  to  demonstrate  the 
effect  of  ionisation  in  rendering  wounds  aseptic  for  delayed 
primary  suture. 

Account  of  Experiments. 

The  action  of  the  metallic  ions  on  suppurating  wounds, 
particularly  zinc,  is  well  known,  and  I decided  to  try  the 
effect  of  the  chlorine  ion.  Several  laboratory  experiments 
were  carried  out  to  show  that  the  chlorine  ion  was  detri- 
mental to  the  growth  of  bacteria.  Although  several 
observers  have  described  the  effect  of  the  electrolytic  current 
on  bacteria,  I can  find  no  description  of  apparatus. 
Accordingly  apparatus  were  devised  for  my  purpose.  In 
one  experiment  a glass  tube  about  1§  inches  in  length  is 
closely  fitted  at  each  end  with  a carbon  electrode  which  is 
fitted  into  a rubber  tube.  The  rubber  tube  acts  as  a cork 
and  as  a non-conducting  cover  for  the  wires  leading  to  the 
milliamp.  meter.  Before  use  the  rubber,  glass  tube,  and 
electrodes  were  sterilised  by  boiling.  The  solutions  to  be 
tested  were  placed  in  the  glass  tube,  which  was  then  placed 
in  a water  bath  kept  at  blood  temperature  by  a lamp. 

Experiment  1. — An  emulsion  of  Staphylococcus  aureus 
and  albus  was  prepared  with  a normal  saline  solution 
at  blood  heat.  The  electrode  and  rubber  tube  were 
removed  from  one  end  of  the  glass  tube  and  the  tube 
was  almost  filled  with  emulsion.  A drop  was  then  taken 
with  a loop  and  smeared  on  agar-agar  in  a test-tube 
as  a control.  The  electrode  and  rubber  tube  were  then 
placed  tightly  into  the  glass  tube  and  the  whole  placed  in  the 
water  bath.  Currents  were  passed  of  5 ma.  for  5 minutes, 
10  minutes,  and  15  minutes  respectively.  At  the  end  of 
each  period  of  time  a drop  was  taken  by  a platinum  loop 
dipped  into  emulsion,  and  a smear  was  made  on  marked 
tubes  containing  agar-agar. 

A second  series,  in  which  10  ma.  were  passed  for  5 minutes 
and  10  minutes  respectively,  was  also  taken.  The  tubes  were 
then  placed  in  an  incubator  for  18  hours  with  the  following 
result : — 

First  series.  Tube  A control.— Profuse  colonies  of  Staphylococcus 
aureus  and  albus  covering  entire  media. 

Tube  1.  5ma.  x 5 minutes. — Profuse  colonies  of  Staphylococcus  aureus 
and  albus,  not  so  abundant  as  on  control. 

Tube  2.  5 ma.  x 10  minutes. — Colonies  of  Staphylococcus  aureus  and 
albus  discrete,  small,  and  fewer  than  in  tube  1. 


Tube  3.  5 ma.  x 15  minutes.— Agar-agar  practically  sterile,  only  one 
small  colony  survived. 

Second  scries.  Tube  A.  10  ma.  x 5 minutes.— Colonies  dlscreto  and 
Identical  in  appearance  with  tube  2. 

Tube  5.  10  via.  x 10  minutes.—  Agar-agar  sterile.  No  growth. 

Deduction. — Electrolysis  with  sodium  chloride  will  inhibit 
the  growth  of  Staphylococcus  aureus  and  albus  with  a short 
exposure  and  with  a low  current  strength.  10  ma.  given 
for  10  minutes  is  sufficient  to  render  a culture  sterile. 

Experiment  2. — A microscope  slide  is  prepared  with  a 
plasticine  cell  and  the  walls  of  the  cell  are  perforated  by 
the  platinum  wire.  A drop  of  emulsion  of  staphylococcus 
aureus  and  albus  was  placed  in  the  cell  with  a few  drops  of 
normal  saline.  The  cell  was  then  placed  on  a warm  stage, 
which  was  kept  at  blood  heat  by  siphonage  of  warm  water. 
The  electrodes  were  then  connected  with  the  milliamp. 
meter.  The  warm  stage  was  then  placed  on  a microscope 
stage  and  a current  of  2 ma.  passed.  There  was  an 
immediate  activity  of  the  cocci  and  a general  flocking 
towards  the  positive  pole.  The  current  was  increased  to 
4 ma. , when  the  bacteria  arranged  themselves  in  apparently 
three  layers  around  this  pole.  At  the  end  of  five  minutes  all 
movement  of  cocci  had  ceased. 

Experiment  3. — Similarly  prepared  with  plasticine  cell.  A 
smear  of  living  culture  of  gonococcus  was  placed  in  cell. 
A few  drops  of  fresh  human  blood  were  then  dropped  on  the 
gonococci  and  the  whole  covered  with  a cover-glass  and 
placed  on  a warm  stage  and  connected  up  with  the  milliamp. 
meter  as  before.  0 5 ma.  was  then  passed  for  10  minutes. 
Gas  was  given  off  at  the  negative  electrode  and  a small  drop 
of  blood  escaped  at  the  point  where  the  electrode  passed 
through  the  plasticine.  The  cover-slip  was  removed  and  the 
plasticine  lifted  off  slide.  The  blood  clot  was  carefully 
washed  off  with  normal  saline,  the  slide  was  then  fixed  with 
heat  and  stained  with  methylene  blue,  covered  with  a slip, 
and  examined  under  high  power  with  oil  immersion.  It  was 
observed  that  complete  phagocytosis  had  occurred.  Practically 
every  leucocyte  was  crowded  with  gonococci.  A few  gono- 
cocci were  extra-cellular. 

Deduction.  — Phagocytosis  is  probably  stimulated  by  a small 
current  passed  for  a short  time. 

Clinical  Results. 

I determined  to  use  sodium  chloride  in  treating  wounds 
as  likely  to  cause  less  irritant  effect  on  the  tissues  than  the 
metal  ions.  The  average  administration  was  10  ma.  for 
20  minutes  daily,  the  wound  afterwards  being  dressed  with 
sterile  gauze  soaked  in  normal  saline.  No  other  antiseptic 
was  used.  In  a few  cases  of  cellulitis  where  the  oedema  was 
very  marked  one  hot  pack  was  applied  at  night-time.  By 
this  means  the  skin  was  never  rendered  sodden. 

Six  cases  were  treated  and  sutured,  4 with  success  and 
1 with  only  partial  success.  The  sixth  case  broke  down  and 
was  evacuated  to  England  owing  to  pressure  on  hospital 
accommodation. 

Twelve  cases  of  cellulitis  were  treated,  and  these  were 
entirely  successful.  The  pain  was  considerably  lessened, 
and  the  final  result,  even  in  cases  in  which  tendon  and 
tendon-sheaths  were  involved,  showed  fewer  signs  of  con- 
tracting scar  tissue  than  generally  occurs  following  septic 
infection  of  the  tendon-sheaths. 

Other  types  of  cases  were  through  gunshot  wounds  of 
extremities. 

Three  cases  were  treated  with  a view  of  preparing  the 
surface  for  skin-grafting,  and  in  one  case  periosteum  was 
grafted  on  an  exposed  tibia. 

Four  cases  in  which  a joint  was  exposed  and  septic  were 
treated,  one  with  complete  success.  The  remaining  three 
cases  (two  elbows  and  one  knee)  had  multiple  wounds,  and 
the  patients  were  in  such  a feeble  general  condition  that 
treatment  with  ionisation  was  not  carried  out  on  account  of 
the  lowered  vitality  due  to  multiple  wounds. 

Technique. — Where  it  was  possible  to  immerse  the  limb  the 
injured  part  was  placed  in  a porcelain  bath  with  a carbon 
electrode.  The  inert  electrode  was  placed  either  under  the 
patient’s  buttocks  or  strapped  to  an  uninjured  limb.  Where 
immersion  was  impossible  several  thicknesses  of  lint  were 
wrung  out  in  a 1 per  cent,  sodium  chloride  solution  and 
Carrel’s  tubes  were  placed  in  contact  with  the  wound  and 
covered  with  the  lint,  leaving  the  open  end  of  the  tube  free. 
An  electrode  was  then  bandaged  to  the  lint.  By  means  of  the 
Carrel’s  tubes  it  was  possible  to  keep  up  a fresh  solution 
through  a sterile  glass  syringe  while  the  treatment  was 
carried  on. 


530  The  Lanoht,] 


CLINICAL  NOTES. 


[Sept.  20,  1919 


Several  cases  were  examined  bacteriologically  ; examina- 
tion was  made  previous  to  the  operation.  [A  series  of  cases 
was  here  given  supporting  the  statements  in  the  text.] 
Conclusions. 

Ionisation  with  chlorine  or  zinc  does  not  possess  any 
advantage  over  other  methods  for  sterilising  a wound  for  the 
purpose  of  delayed  primary  suture. 

Oases  of  cellulitis  show  a marked  improvement  when 
treated  with  ionisation,  both  in  the  relief  experienced  by 
patient  and  in  the  final  result,  which  in  every  case  treated 
was  extremely  satisfactory,  cicatricial  contractures  being 
practically  unseen. 

The  fact  that  one  septic  joint  recovered  indicates  that  the 
treatment  is  well  worth  trying  in  similar  cases. 

My  thanks  are  due  to  Lieutenant-Colonel  R.  B.  Ainsworth, 
D.S.O.,  R.A.M.C.,  for  allowing  me  to  carry  out  these 
investigations,  and  to  Colonel  Crile  for  supplying  the  cases 
and  apparatus  and  for  his  extremely  helpful  suggestions 
and  advice. 


(tlmiral  Stotts: 

MEDICAL,  SURGICAL,  OBSTETRICAL,  AND 
THERAPEUTICAL. 


AN  UNUSUAL  CASE  OF  RETROVERSION  OF 
THE  GRAVID  UTERUS. 

By  R.  Burton  Eccles,  L.R.C.P.,  M.R.C.S. 

The  following  unusual  case  of  retroversion  of  the  gravid 
uterus  deserves  record  : — 

I was  sent  for  to  attend  a woman,  the  message  saying  that 
a piece  of  bowel  10  inches  or  more  in  length  bad  been  pro- 
truding for  a week,  and  there  had  been  no  evacuation  of  the 
bowels  for  the  same  period,  although  large  doses  of  castor 
oil,  cascara,  and  Epsom  salts  had  been  taken. 

On  arrival  I found  the  patient,  a woman,  aged  27  years,  in 
bed,  looking  very  ill,  and  complaining  of  great  pain  in  the 
back  and  lower  part  of  her  body.  The  history  I got  from  her 
was  that  14  days  previous  to  my  coming  she  had  a sudden 
pain  in  the  lower  part  of  the  body  and  the  back,  with  frequent 
desire  to  micturate.  Then  the  abdomen  gradually  began 
to  enlarge.  Though  she  had  constant  dribbling  for  14  days, 
she  had  been  able  to  pass,  each  day,  a few  ounces  of  clear- 
coloured  urine,  and  she  passed  clear  urine  while  I was  in 
attendance. 

On  examination  I found  the  abdomen  very  greatly  enlarged, 
giving  me  the  impression  at  first  sightthat  she  was  probably 
in  the  eighth  or  ninth  month  of  pregnancy.  The  body  was 
hard  and  dull  on  percussion,  the  dullness  extending  above  the 
umbilicus  to  the  ensiform  cartilage.  The  right  thigh  and  leg 
were  enormously  swollen  and  oedematous,  also  the  vulva,  the 
right  labia  forming  a large  cushion  reaching  up  to  and 
completely  obliterating  the  anal  aperture  ; serous  fluid  was 
oozing  from  both  labia.  I then  passed  a catheter  and  drew 
off  104  oz.  of  dark  bloody  urine.  Per  vaginam  I felt,  with  great 
difficulty,  the  cervix  pushed  high  up  behind  the  symphysis. 
The  posterior  fornix  was  obliterated  by  a large,  elastic, 

f lobular  swelling,  which  filled  up  the  vagina.  Per  rectum 
felt  a large  substance,  which  was,  in  fact,  a retroverted 
uterus.  I ascertained  from  the  patient  that  she  had  last 
menstruated  three  and  a half  months  ago,  and  came  to 
the  conclusion  that  I had  an  incarcerated,  retroverted,  gravid 
uterus  to  deal  with. 

I first  tried  to  replace  the  uterus  bi-manually  and  failed. 
As  I did  not  care  to  use  bullet  forceps  on  so  oedematous  and 
congested  a cervix,  I replaced  the  uterus  by  the  knee-elbow 
position,  the  patient  at  once  remarking,  “What  a great 
comfort,”  and  that  she  was  now  free  from  pain.  1 then 
introduced  a Smith-Hodge  pessary  to  keep  the  uterus  ante- 
verted.  There  was  complete  atony  of  the  bladder,  and  a 
catheter  was  passed  every  six  hours  for  eight  days.  A 
mixture  of  hexamine,  sodium  benzoate,  and  tincture  of  nux 
vomica  was  given  every  four  hours. 

The  patient  made  an  excellent  recovery.  At  the  end  of  the 
fifth  month  of  pregnancy  I removed  the  pessary.  Four 
months  afterwards  she  gave  birth  to  a fine,  healthy  male 
child,  the  labour  being  quite  normal. 

The  points  in  this  case,  unusual  in  my  experience  of 
country  practice,  are  the  absence  of  serious  complications, 
such  as  sloughing  of  the  bladder  or  septic  cystitis,  and  the 
fact  that  the  woman  went  on  to  full  term  of  pregnancy  and 
gave  birth  to  a healthy  child. 

Driffield,  East  Yorks. 


SPONTANEOUS  CURE  OF  STRANGULATED 
INGUINAL  HERNIA. 

By  W.  Fletcher  Stiell,  L.R.C.P.,  M.R.C.S., 

RESIDENT  MEDICAL  OFFICER,  COUNTV  HOSPITAL,  LINCOLN. 


I am  taking  the  opportunity  of  recording  this  case,  not  as 
a plea  to  wait,  watch,  and  expect  such  a happy  result  to 
ensue  from  so  serious  a condition,  but  more  as  a surgical 
curiosity. 

A man,  aged  37,  had  been  suffering  from  a swelling  in  the 
left  groin  for  about  five  years.  He  had  during  this  period 
consulted  several  doctors,  who  had  unanimously  wisely 
advised  cure  of  the  hernia  by  operation.  The  patient  was, 
however,  of  the  procrastinating  type  and  had  failed  to  follow 
the  advice  given.  On  Feb.  4th,  1918,  the  patient  attended 
the  Lincoln  County  Hospital  on  account  of  a painful  swelling 
in  the  left  groin.  He  gave  the  following  history:— 

History.— He  had  noticed  the  swelling  for  about  five  years, 
he  “knew  it  was  a rupture,”  and  as  he  had  never  had  any 
difficulty  in  effecting  reduction  of  the  hernial  contents,  did 
not  think  an  operation  necessary.  In  December,  1917,  the 
tumour  had  suddenly  increased  in  size,  had  become  both 
painful  and  tender,  and  could  never  again  be  reduced.  There 
was  at  that  time  some  generalised  abdominal  discomfort, 
but  no  vomiting,  constipation,  or  other  symptoms  to  suggest 
any  intestinal  obstruction. 

At  the  actual  time  of  admission  to  hospital  all  abdominal 
symptoms  had  disappeared  and  there  were  no  abnormal 
physical  signs  in  the  abdomen.  In  the  region  of  the  left 
cord,  just  below  the  external  ring,  there  was  a well-defined, 
bard,  non-cystic  tumour,  which  was  neither  painful  nor 
tender.  The  mass  was  fairly  freely  movable  from  side  to 
side,  but  was  fixed  in  a vertical  direction.  It  was  found 
impossible  therefore  to  reduce  it,  either  into  the  abdomen  or 
into  the  scrotum.  The  testicle  itself  was  unaltered,  and  a 
normal  vas  deferens  could  be  traced  upwards  behind  the 
tumour. 

Differential  diagnosis. — The  differential  diagnosis  at  this 
stage  of  examination  rested  between  : (a)  an  omental  plug  in 
an  incarcerated  inguinal  hernia;  (b)  fibroma  of  the  cord; 
(c)  an  organised  hsematoma  of  the  cord  from  forcible 
attempts  at  reduction  by  taxis  on  the  part  of  the  patient 
himself. 

Operation. — Operation  was  performed  on  Feb.  5th,  1918. 
The  actual  technique  and  procedure  of  the  operation  were 
in  a large  measure  similar  to  an  ordinary  radical  cure 
for  inguinal  hernia,  so  that  it  is  unnecessary  to  describe 
them  in  detail.  The  tumour  was  occupying  the  inguinal 
canal  with  the  aponeurosis  of  the  external  oblique  and 
the  external  abdominal  ring  stretched  tightly  over 
its  anterior  surface.  The  tumour  itself  was  everywhere 
surrounded  by  a thickened  peritoneal  investment,  to  which 
it  was  closely  attached  by  old-standing  and  somewhat 
vascularised  adhesions.  The  various  constituents  of  the 
cord  were  lying  posterior  to  the  tumour,  and  were  abnor- 
mally adherent  to  its  peritoneal  lining.  When  traced  in  an 
upward  direction  the  peritoneal  coat  of  the  tumour  gradually 
merged  into  a small  strand  of  dense  fibrous  tissue,  and  the 
internal  ring  was  solidly  and  absolutely  occluded.  The 
cord  was  thoroughly  isolated,  the  tumour,  together  with  its 
peritoneal  investment,  removed,  and  the  operation  com- 
pleted, as  in  Halstead’s  method  of  radical  cure.  Con- 
valescence was  uneventful  and,  although  no  peritoneal  neck 
to  the  sack  could  be  ligatured  at  the  internal  ~'ng,  there  has 
been  no  recurrence  of  the  hernia  after  18  mouth  . 

Microsccrpic  examination. — Microscopic  exat  d nation  of  the 
tumour  was  performed  by  a pathologist,  who  was  inten- 
tionally given  no  information  of  the  case,  and  his  findings 
are  therefore  of  interest.  He  stated  that  “ this  is  a mass  of 
fat  showing  fibrous  alveolation.  It  is  undergoing  fibrous 
degeneration  and  inflammatory  infiltration.  No  evidence  of 
tubercle  or  new  growth.  There  is  no  evidence  to  show  how 
it  has  originated.” 

Remarks. — Taking  into  consideration  the  history  of  the 
case,  the  findings  at  the  operation  and  the  histological 
examination,  there  can  be  little  doubt  that  the  tumour 
owed  its  origin  to  an  omental  plug  in  the  strangulated 
inguinal  epiplocele,  which  had  undergone  a process  of 
aseptic  ulceration  at  the  internal  abdominal  ring,  with 
subsequent  complete  stenosis  of  the  ring.  The  tumour, 
therefore  consisted  of  a mass  of  omentum  which,  at  the  time 
of  operation,  possessed  no  actual  anatomical  connexion 
with  the  main  mass  of  the  great  omentum. 

For  permission  to  publish  this  case  I am  much  indebted 
to  Major  D.  J.  G.  Watkins,  R.A.M.O  (T.F.),  who  performed 
the  operation. 


The  Lancet,] 


REVIEWS  AND  NOTICES  OF  BOOKS. 


[Sept.  20,  1919  531 


anfr  Notices  d 


War  Neuroses  and  Shell  Shook.  By  Sir  Frederick  W.  Mott, 
M.D.,  LL.D.,  F.R.S.,  Brevet-Colonel,  R.  A.M.C.  (T.),  &c. 
With  Preface  by  the  Right  Hon.  Christopher  Addison, 
M.P.,  Minister  of  Reconstruction.  London:  Henry 
Frowde  and  Hodder  and  Stoughton.  1919.  Pp.  348.  16s. 

With  a good  deal  of  Sir  Frederick  Mott’s  excellent  and 
comprehensive  volume  on  war  neuroses  the  profession  has 
already  become  acquainted  through  previous  publication 
in  the  form  of  lectures  or  otherwise,  not  infrequently  in 
our  own  columns.  To  have  at  hand,  however,  a useful 
“ body  ” of  doctrine  on  the  functional  neurology  of  war 
is  almost  a sine  qua  non  for  the  practitioner,  in  view 
of  the  large  number  of  functional  cases  still  requiring 
at  least  a modicum  of  treatment.  In  Sir  Frederick 
Mott’s  book  will  be  found  all  he  needs  on  the  practical 
side,  for  treatment  is  discussed  in  detail,  together  with 
clinical  studies  of  the  multifarious  types  of  war  neuroses 
and  interesting  analyses  of  the  pathogenesis  of  such  dis- 
orders. The  author  is  catholic  enough  to  appreciate  the 
value  of  the  Freudian  theory  where  affections  of  the 
psyche  are  concerned,  but  he  points  out  the  inadequacy 
of  certain  Freudian  contentions  in  the  case  of  the  typical 
war  neurotic,  and  emphasises  the  importance  of  the  corn- 
motional  element,  introducing  material  that  formed  part 
of  his  Lettsomian  lectures1  on  “The  Effects  of  High 
Explosives  on  the  Central  Nervous  System.”  He  goes 
beyond  the  commotion,  however,  to  elaborate  the  greater 
importance  of  the  emotional  shock  in  the  perpetuation  of 
symptoms,  and  furnishes  numerous  confirmatory  clinical 
illustrations.  A section  of  the  book  is  devoted  to  study  of 
the  phenomena  of  gas  poisoning,  both  on  the  clinical  and 
on  the  pathological  side.  We  do  not  suppose  the  practi- 
tioner is  likely  to  observe  any  variety  of  symptom  or 
symptom-complex  of  a functional  sort,  nervous  or  mental, 
which  is  not  at  least  touched  on  in  this  book  ; nor  need  he 
be  at  a loss  how  to  deal  with  such  cases,  for  Sir  Frederick 
Mott  devotes  many  pages  to  a discussion  of  the  means  of 
promoting  convalescence  and  of  establishing  an  atmosphere 
of  cure. 

In  comparatively  small  compass  the  results  of  five  years’ 
familiarity  with  the  problems  of  functional  war  disorders 
have  been  garnered,  sifted,  and  offered  for  consideration, 
and  we  agree  with  Dr.  Addison  that  a book  which  is  the 
outcome  of  such  unusual  experience  cannot  fail  to  be  of 
great  value. 


Psychoses  of  the  War,  including  Neurasthenia  and  Shell  Shock. 
By  H.  C.  Marr,  Lieutenant-Colonel,  R.A.M.C.,  M.D., 
Neurological  Consultant  to  the  Scottish  Command,  &c! 
London  : Henry  Frowde  and  Hodder  and  Stoughton. 
1919.  Pp.  292.  16s. 

Dr.  Marr  bases  his  interesting  volume  on  material 
derived  from  the  observation  of  no  less  than  18,000 
officers  and  men,  of  whom  approximately  one-half  were 
sufferers  from  shell  shock  and  neurasthenia,  and  one-half 
from  more  definite  mental  disorders.  The  book,  however,  is 
not  a mere  precis  of  information  on  war  psychoses,  inasmuch 
as  its  author  devotes  some  space  to  general  observations  on 
the  pathogenesis  of  mental  disease,  to  its  types  and  their 
clinical  expression,  to  cerebral  anatomy  and  mental  patho- 
logy, and  to  infantile  mental  deficiency.  Further,  there  are 
sections  on  the  classification  of  mental  affections,  on  mental 
case-taking,  and  on  the  cerebro-spinal  fluid.  Not  a few  of 
the  useful  clinical  photographs  reproduced  are  of  cases  of 
mental  disorder  in  the  female  sex  and  of  mental  defectives 
who  can  never  have  been  in  the  Army.  We  might,  in  fact, 
suggest  to  Dr.  Marr  that  his  title  is  rather  misleading  and 
unnecessarily  restricted ; his  book  really  constitutes  a concise 
and  readable  compendium  of  mental  diseases,  illustrated  by 
a large  number  of  clinical  records  derived  from  military 
material. 

Dr.  Marr  divides  his  subject  into  the  four  main  groups  of 
infantile  mental  deficiency,  adolescent  mental  enfeeblement, 
toxic  (confusional)  psychoses,  and  organic  psychoses.  The 
respective  percentages  of  these  in  3755  cases  of  mental 
affection  in  soldiers  were  42  31,  8-92,  36-73,  and  12  04.  It 
is  somewhat  surprising  to  learn  that  42  per  cent,  of  the 

1 The  Lancet,  1916,  i„  331,  441,  and  545. 


soldiers  admitted  to  mental  hospitals  were  found  to  have 
been  weak-minded  from  infancy,  but  an  adequate  explana- 
tion is  forthcoming  in  the  fact  of  the  capacity  for  manual 
routine  labour  of  all  kinds  exhibited  by  the  mental  defective, 
at  least  under  direction  and  supervision  ; their  docility  and 
usefulness  leads  to  their  being  employed  on  work  for  which 
they  are  quite  unsuitable,  with  the  inevitable  result.  Dr.  Marr 
charitably  exonerates  the  authorities  from  blame  ; the  mental 
defective  shows,  as  a rule,  no  gross  bodily  physical  defect,  his 
mental  state  does  not  obtrude  itself  except  in  the  face  of 
responsibility,  and  in  doubtful  cases  expert  medical  investiga- 
tion is  not  likely  to  be  always  at  hand.  His  second 
group  comprises  primary  mania,  melancholia  and  dementia, 
as  also  alternating  insanity  and  idiopathic  epilepsy — condi- 
tions in  which  inherent  neuronic  weakness  is  unable  to  resist 
the  united  strain  of  adolescence  and  military  service.  The 
third  group,  the  second  largest,  includes  the  psychoses  of 
both  known  and  unknown  toxic  agents,  the  presence  of 
which  in  the  circulation  “ acts  as  a veil  between  the  mental 
functions  and  the  external  world.”  The  fourth  group  deals 
mainly  with  neurosyphilis,  but  also  with  trauma,  arterio- 
sclerosis, and  cerebral  tumour. 

Dr.  Marr’s  selected  clinical  cases  are  described  in  a fresh 
and  informative  fashion,  which  adds  to  the  attractiveness  of 
a useful,  unpretentious  exposition  of  the  main  facts  of 
mental  disease,  wonderfully  complete  for  its  size,  well 
illustrated,  and  with  a good  index. 


Psycho-Analysis  and  its  Place  in  Life.  By  M.  K.  Bradby. 

London  : Henry  Frowde  and  Hodder  and  Stoughton. 

1919.  Pp.  266.  8s.  6d. 

Miss  Bradby’s  standpoint  is  that  of  the  trained  psycho- 
logist, who  is  also  a humanist,  and  impressed  by  the 
possibilities  of  life  in  general  which,  she  believes,  seem  to 
open  up  as  a consequence  of  the  discoveries  in  the  realm  of 
thought  of  Freud  and  Jung.  Her  role  is,  in  part,  that  of  the 
expositor,  to  the  educated  man  or  woman,  of  the  meaning 
of  psycho-analysis,  but  she  also  makes  a persuasive  appeal 
to  the  psychologist  to  interest  himself  at  least  as  much  in 
feeling  and  willing  as  in  knowing,  and  to  the  Freudian 
psycho-analyst  not  to  ignore  such  ruling  passions  of  humanity 
as  are  not  embodied  in 'sexuality. 

The  reader  will  find  much  that  is  admirable  in  Miss 
Bradby’s  presentation  of  her  subject,  which  is  marked  by 
erudition  and  independent  thinking  and  by  a freshness  of 
exposition  and  originality  of  view  which  will  impress  those 
of  us  who  may  confine  our  attention  too  strictly  to  the 
volumes  of  the  medical  profession  proper. 

Miss  Bradby  at  the  outset  correlates  the  knowledge  of  the 
unconscious  mind  derived  from  psycho-analytic  investiga- 
tion with  that  of  the  nature  and  development  of  mind  in 
primitive  man  and  with  our  knowledge  of  the  mind  of  the 
child.  The  mode  of  working  of  the  unconscious  mind  is 
sketched  and  Freudian  theory  more  or  less  accepted.  The 
Freudian  interpretation  of  dreams  is  favourably  reviewed 
and  various  dreams,  historical  and  private,  are  analysed.  The 
author  then  considers  the  application  to  social  and  indi- 
vidual conduct  of  the  knowledge  of  hidden  and  unconscious 
motives  acquired  by  psycho-analytic  procedures,  and  ends  on 
a note  of  enthusiastic  hope  for  future  progress,  especially  in 
the  sphere  of  education,  as  the  result  of  such  self-knowledge. 

It  will  be  understood  that  Miss  Bradby  deals  mainly 
with  the  application  of  psycho-analysis  to  the  normal 
mind,  and  only  incidentally,  and,  we  may  suppose,  at 
secondhand,  with  mental  disease.  She  is  not  on  sure 
ground  when  she  speaks  of  “ perfectly  natural  normal  homo- 
sexuality,” repressed  into  the  unconscious  “in  sensitive  and 
upright  minds,  with  results  that  are  always  injurious  to 
health  and  often  to  sanity.”  Assuming  the  facts,  they  are 
capable  of  a quite  other,  medical,  interpretation.  Other 
statements  that  have  a bearing  on  medicine  require  more  sub- 
stantiation than  is  given  them,  which  is  perhaps  unfortunate, 
for  the  lay  reader  may  be  inclined  to  accept  as  proven  what 
are  not  specified  by  Miss  Bradby  as  psycho-analytic  assump- 
tions. More  generally  we  get  the  impression  that 
there  is  a certain  tacit  disregard  of  the  significance  of 
the  conscious  life,  as  being  of  less  value  than  unconscious 
mental  activity,  and  we  feel  that  there  is  also  an  unwitting 
minimising  of  moral  upbringing  and  the  formation  of  good 
habits  by  influence  from  without,  as  though  knowledge  of 
the  unconscious  self  were  somehow  to  make  men  all 
that  they  should  be.  But  is  there  any  dynamic  force  in 


532  TheLancbt,] 


REVIEWS  AND  NOTICES  OF  BOOKS. 


[Sept.  20,  1919 


such  self-knowledge,  assuming  it  can  be  acquired  by  psycho- 
analysis? Has  it  any  driving  power  for  good  as  against  evil  1 
Will  the  dragging  of  unconscious  motives  and  impulses  into  the 
full  light  of  consciousness  of  itself  make  us  pursue  the  good  ? 
It  may  be  pointed  out,  further,  that  springs  of  action  are  far 
from  being  always  as  deep  down  and  as  hidden  as  Miss 
Bradby’s  reading  of  the  Freudian  position  suggests. 


What  is  Psycho. Analysis?  By  Isador  H.  Coriat,  M.D., 
Physician  for  Diseases  of  the  Nervous  System,  Boston 
City  Hospital.  London  : Kegan  Paul.  1919.  Pp.  124.  3.1!.  6 d. 
From  the  preface  we  learn  that  this  little  volume,  on  the 
question-and-answer  system,  is  intended  for  “ physicians, 
clergymen,  social  workers,  and  laymen  ” who  are  interested 
in  psycho-analysis  from  the  point  of  view  of  its  aim,  purpose, 
and  field  of  usefulness  as  a therapeutic  procedure.  The 
deduction  is  allowable  that  Dr.  Coriat  sees  no  disadvantage 
in  individuals  becoming  familiar  with  psycho-analysis  (as  a 
therapeutic  procedure)  who  can  have  no  trained  knowledge 
whatever  of  organic  or  functional  nervous  disease.  It 
appears  to  us  that  the  important  distinction  between 
psycho-analysis  as  a method  of  investigation  of  the 
mind,  normal  or  abnormal,  and  as  a means  of  treating 
functional  nervous  disorders,  is  thereby  in  danger  of  becoming 
eliminated.  Many  psychologists,  many  workers  in  cognate 
branches  of  science,  are  legitimately  studying  the  applic- 
ability of  Freudian  technique  to  their  own  subject,  but  it  is 
a long  step  from  this  to  the  handling  of  the  mind  diseased, 
unless  we  are  to  be  content  to  let  the  opportunity  slip  and 
allow  non-medical  intervention  in  therapeusis  an  even 
larger  scope  than  it  has  already.  No  one  who  is  familiar 
with  the  results  of  misdirected,  because  ignorant,  lay 
treatment  can  view  the  prospect  with  equanimity. 

Dr.  Coriat  follows  conventional  Freudian  doctrine  in  his 
little  sketch,  minimising  the  difficulties  and  avoiding  as  far  as 
may  be  the  contentious  aspects.  Like  Freud,  he  maintains 
that  under  no  circumstances  does  the  element  of  suggestion 
enter  into  psycho-analysis,  notwithstanding  the  obstacles  in 
the  way  of  the  acceptance  of  this  statement.  It  is  a counsel 
of  perfection  to  say,  as  Dr.  Coriat  does,  that  “ no  explana- 
tions or  suggestions  are  made  to  the  patient  during  the 
course  of  treatment,”  for  in  another  section  he  declares  that 
“the  ethical  value  of  psycho-analysis  depends  upon  telling  a 
patient  the  truth,”  in  other  words,  explanation.  In  one 
answer  we  find  the  statement  that  “libido  means  vital 
energy  or  instinct ; it  is  not  always  sexual,  since  the  instinct 
may  be  hunger  or  nutritional.”  Two  pages  farther  on  we 
read  that  “the  sexual  instinct  displays  itself  very  early  in 
the  child,  first  as  the  sucking  or  nutritional  instinct” — a 
contradiction  illustrating  the  preconceptions  of  the  crystal- 
lised Freudian  mind.  We  are  glad  to  be  assured,  however, 
that  “ if  psycho-analysis  be  properly  carried  out  it  refers  less 
to  sexual  activities  than  does  the  usual  medical  history  of  an 
organic  illness.  ” 

Shell  Shock , Commotional  and  Emotional  Aspects.  By  Andre 
Leri,  Professor  in  the  Faculty  of  Paris.  With  Preface  by 
Professor  Pierre  Marie.  Edited,  with  Preface,  by  Sir 
John  Collie,  M.D.,  C.M.G.  London  : University  of 
London  Press.  1919.  Pp.  249.  Is.  6 d. 

We  gave  a favourable  review  of  this  book  on  its  original 
appearance  in  the  Horizon  Series  of  military  manuals  pub- 
lished by  Messrs.  Masson,  of  Paris.  It  is,  in  our  opinion, 
one  of  the  very  best  of  all  the  productions  bearing  on  shell 
shock,  and  we  are  confident  that  its  reception  in  English 
form  will  corroborate  this  opinion.  When  Charcot  was 
congratulated  on  the  lucidity  of  his  lectures  by  a foreign 
confrere  well  qualified  to  do  so,  he  replied  deprecatingly  : 
“Ah,  Monsieur,  it’s  our  language.”  It  is  not,  however,  a 
question  of  language  merely  ; the  Gallic  mind  has  the  power 
of  expressing  itself  with  unusual  clarity,  consecutiveness, 
and  conciseness.  All  these  qualities  are  found  in  Professor 
L6ri’s  excellent  monograph. 


Vegetative  Neurology  : The  Anatomy , Physiology , Pharmaco- 
dynamics, and  Pathology  of  the  Sympathetic  and  Autonomic 
Nervous  Systems.  By  Dr.  Heinrich  Higier,  of  Warsaw. 
Authorised  translation  by  Walter  M.  Krads,  M.D., 
New  York.  New  York : Nervous  and  Mental  Disease 
Publishing  Co.  1919.  Pp.  144.  $2. 

Dr.  Higier’s  monograph  appeared  originally  in  the 
Ergebnisse  der  Neurologic , which  came  to  an  untimely  end, 


after  only  three  or  four  issues  had  appeared,  on  the  outbreak 
of  the  war.  The  edition  published  in  English  is  a faithful 
translation  of  the  original,  but  the  illustrations  are  not, 
this  time,  in  colours — somewhat  of  a drawback,  as  some  of 
them  are  very  complicated.  No  student  of  neurology  wish- 
ing to  keep  abreast  of  knowledge  should  be  without  this 
monograph,  in  which  the  author,  collating  from  the  widest 
sources  data  bearing  on  his  subject,  has  organised  his  material 
into  a revue  d' ensemble  which  is  a model  of  what  such  reviews 
should  be.  It  is  not  a rival  but  complementary  to  such  a 
study  as  Gaskell’s  “ Involuntary  Nervous  System  ” ; it  does 
not  contain  personal  original  work,  but,  on  the  other  hand, 
it  represents  a laborious  marshalling  of  facts  and  an  able 
selective  skill  on  the  part  of  the  author.  The  translator 
has  spared  us  Americanisms,  but  a painful  number  of 
slips  have  been  allowed  to  escape  the  proof-reading — 
e.g.,  sphincter  anus,  rami  communicanti,  was  deferens  and 
prostrate,  nerve  bundles  or  plexi,  different  than,  mucus 
colitis,  &c.  “Unreactibility”  (p.  79)  is  not  an  Americanism  : 
it  is  a monstrosity. 


A Conspectus  of  Recent  Legislation  on  Venereal  Disease  in  the 
British  Dominions  and  United  States  of  America.  By 
Douglas  White,  M.D.  London:  Published  by  the 
National  Council  for  Combating  Venereal  Disease. 

We  welcome  this  pamphlet  not  only  on  account  of  the 
systematic  presentation  of  the  recent  legislation  on  venereal 
disease  in  the  countries  mentioned,  but  also  by  reason  of  the 
interesting  statements  as  to  the  results  which  have  accrued 
from  such  legislation. 

This  valuable  pamphlet,  under  the  heading  of  “Con- 
clusion,” contains  some  most  suggestive  remarks  by  Dr. 
White  on  the  subject  of  legislation  in  Great  Britain,  with 
reference  to  the  Act  of  Parliament  of  1917.  ‘ 1 How 

much  further,  and  in  what  direction,”  he  pertinently 
asks,  “are  we  prepared  to  move”?  He  then  considers 
the  questions  of  : (1)  notification  ; (2)  penalisation  of  the 
conscious  transmission  of  disease  ; (3)  the  active  repression 
of  prostitution ; (4)  the  safeguarding  of  marriage  against 
disease. 

Dealing  with  the  subject  of  prophylaxis  in  the  U.S.A., 
Dr.  White  writes  : “No  reference  is  made  to  this  method  in 
any  laws  or  regulations.  All  the  bureaus  of  health,  who 
have  replied  to  a query  on  this  matter,  express  distrust  and 
disapproval  of  prophylactic  • packets  ’ as  likely  to  defeat 
the  object  in  view.  Some  go  further  and  include  in  their 
disapproval  ‘ early  preventive  treatment.  ’ Some  express 
approval  of  the  latter  method,  but  it  has  not  apparently  been 
instituted,  unless  sporadically,  except  by  the  military 
authorities  in  the  area  of  the  camps.  In  these,  however, 
good  results  have  been  obtained.” 

The  author  has  dealt  successfully  with  each  of  the  four 
subjects  indicated  above  and  may  be  congratulated  on  the 
attainment  of  his  professed  objective — namely,  to  give 
information  succinctly  and  to  stimulate  thought. 


Injuries  to  the  Head  and  Neck.  By  H.  Lawson  Whale, 
M.D.  Cantab.,  F.R.C.S.  London  : Bailliere,  Tindall,  and 
Cox.  1919.  Pp.  320.  15s. 

The  title  of  this  book  is  misleading,  as  the  injuries 
described  are,  without  exception,  those  due  to  gunshot 
wounds  about  the  head  and  neck  ; injuries  such  as  those 
found  in  civilian  practice  are  not  dealt  with.  Injuries  to 
the  vault  of  the  skull,  the  brain,  and  the  eye  are  not 
described,  the  book  dealing  only  with  injuries  to  those 
parts  which  come  within  the  province  of  the  oto-laryngo- 
logist  ; to  which  is  added  a chapter  upon  prosthesis  and 
plastic  operations  after  severe  injuries  to  the  face  and  jaws. 

The  book  contains  full  records  of  numerous  interesting 
cases,  which  illustrate  the  signs,  symptoms,  and  method  of 
treatment  of  injuries  in  this  region  of  the  body.  This  is 
not  a text-book  for  students,  but  Mr.  Whale  has  produced 
a volume  which  should  appeal  to  the  practitioner  who  is 
interested  in  the  broad  lines  of  treatment  which  have  been 
employed  in  the  treatment  of  war  injuries  of  the  head  and 
neck.  The  plastic  work  upon  the  face  is  new,  describing 
the  procedures  necessitated  by  war  conditions,  but  the 
recognised  methods  of  civil  surgery  have  been  modified 
to  suit  the  special  cases  treated.  The  book  is  written 
in  a pleasant,  discursive  style,  and  is  well  and  fully 
illustrated. 


Thh  Lancet,] 


MALARIA  IN  ENGLAND. 


[Sept.  20,  1919  533 


THE  LANCET. 


LONDON:  SATURDAY,  SEPTEMBER  20,  1919. 


Malaria  in  England. 

Malaria  at  one  time  was  endemic  in  England, 
and  traces  of  its  presence  could  still  be  found  in 
some  London  hospitals  as  late  as  the  early 
“ seventies,”  patients  being  sometimes  admitted 
from  Essex  and  other  districts  for  the  treatment  of 
enlarged  spleens  or  “ ague  cakes.”  The  prevalence 
of  laudanum- drinking  among  the  agricultural 
population  of  the  low-lying  districts  of  Lincolnshire 
as  late  as  50  years  ago  was  explained  as  being  due 
to  the  need  for  taking  an  anodyne  to  mitigate  the 
discomforts  of  their  recurring  attacks  of  ague. 
Of  late  years,  however,  there  has  been  a general 
impression  that  draining  and  bringing  under  culti- 
vation of  much  marshy  and  waste  ground  has  led 
to  the  disappearance  of  endemic  malaria  in  the 
affected  parts  of  England.  Up  to  the  outbreak  of 
the  war  little  notice  was  taken  of  imported  malaria 
cases,  it  being  assumed  by  many  persons  that  our 
local  mosquitoes  were  not  likely  to  act  as  carriers 
of  the  infection.  But  when  our  soldiers  began  to 
be  invalided  home  as  the  result  of  malaria  con- 
tracted mostly  in  the  Eastern  war  zones,  and  espe- 
cially in  Macedonia,  the  Local  Government  Board 
entered  into  communication  with  the  medical 
departments  of  the  Navy  and  Army  in  order  that 
joint  action  might  be  taken  to  meet  the  danger. 
Surgeon-Captain  P.  W.  Bassett-Smith,  directed 
measures  on  behalf  of  the  Navy,' and  Sir  Ronald 
Ross,  consultant  in  malaria  to  the  War  Office,  on 
behalf  of  the  Army.  The  measures  against  civilian 
infection  were  directed  by  Lieutenant-Colonel  S.  P. 
James,  adviser  on  malaria  to  the  Local  Govern- 
ment Board,  and  Lieutenant-Colonel  E.  Wilkinson, 
late  Sanitary  Commission  for  the  Punjab,  medical 
inspector  of  the  Local  Government  Board,  with 
whom  was  associated  a skilled  entomologist,  Mr. 
A.  J.  Grove,  M.Sc. 

A report  on  malaria  in  England  during  1917  has 
already  been  published.  Quite  recently  another 
report,1  for  1918,  has  been  issued  with  an  intro- 
duction by  Dr.  G.  S.  Buchanan,  first  assistant 
medical  officer  to  the  Local  Government  Board, 
summarising  clearly  the  results  of  action  taken 
against  the  risks  of  a spread  of  malaria  in 
this  country.  From  this  report  it  appears  that 
there  are  at  least  three  species  of  anophelines, 
the  malaria-carrying  mosquitoes,  to  be  found 
at  present  in  this  country,  and  it  is  stated 
that  evidence  has  been  found  that  there  are  a 
few  areas  in  England  where  £t  mild  form  of  true 
indigenous  malaria  still  persists.  Special  inquiries 
were  made  into  the  cases  of  subjects  who  were  said 
to  have  contracted  malaria  in  England  during  1917 
and  1918.  The  total  number  of  such  cases  was  330, 
of  which  38  occurred  in  the  Navy,  224  in  the 
Army,  and  68  in  the  civil  population.  Of  the 
civil  cases  42  occurred  in  1917  and  24  in 
1918 ; the  majority  in  both  years  occurred  in 

1 Reports  to  the  Local  Government  Board  on  Public  Health  and 
Medical  Subjects,  New  Series,  No.  123;  Reports  and  Papers  on  Malaria 
contracted  in  England,  1918.  H.M.  Stationery  Office.  1919.  Pp.  51. 
Price  Is.  6 d.  net. 


the  county  of  Kent,  in  an  area  at  the  mouth  of 
the  Thames,  including  the  towns  of  Sheerness 
and  Queenborough.  All  the  locally  contracted 
malaria  cases  were  due  to  infection  with  the  benign 
tertian  parasite,  and  none  died.  In  the  military 
malaria  cases,  in  which  the  infection  had  been 
contracted  in  England,  their  source  of  origin  was 
attributable  to  the  presence  in  their  immediate 
neighbourhood  of  relapsing  cases  of  malaria  among 
soldiers  invalided  home  from  the  Eastern  war  zones. 
In  the  naval  cases  the  origin  was  not  in  all  cases 
so  obvious,  but  some  of  them  occurred  in  the  Kent 
area  already  mentioned.  Among  the  civilian 
population  the  origin  of  the  cases  was  generally 
due  to  relapses  in  returned  malarious  soldiers; 
but  a local  outbreak  in  the  civil  popula- 
tion of  Queenborough  included  cases  whose 
illness  appeared  to  be  attributable  to  infection  from 
civilians  in  their  immediate  vicinity.  The  clinical 
characters  of  these  last-mentioned  cases  were  less 
severe  than  those  in  which  the  infection  was 
derived  from  returned  soldiers,  and  this  suggests 
that  they  were  possibly  due  to  an  indigenous  strain 
of  the  benign  tertian  parasite  instead  of  the  more 
virulent  strain  recently  imported  from  the  Eastern 
war  areas.  There  is  a probability  that  the  hot 
weather  in  September  of  the  present  year  may 
favour  the  breeding  and  development  of  anophelines 
in  districts  which  have  not  as  yet  taken  satisfactory 
steps  to  reduce  the  breeding-places  of  these  mos- 
quitoes. We  understand  that  in  1919  both  at 
Sheerness  and  Queenborough  malaria  cases,  locally 
contracted,  have  again  been  reported.  In  the 
Fletton  urban  district,  in  the  county  of  Huntingdon, 
not  far  from  Peterborough,  a boy  who  had  never 
been  out  of  the  district  is  reported  to  have  developed 
an  attack  of  malaria.  It  is  probable  that  other 
instances  not  recorded  as  yet  in  the  press  have  also 
occurred. 

The  action  taken  by  the  Local  Government  Board 
to  prevent  the  spread  of  malaria  in  the  civil  popu- 
lation seems  to  have  been  sufficiently  compre- 
hensive. Its  policy  was  based  primarily  on  the 
early  detection  of  all  malaria  cases  and  carriers, 
followed  by  thorough  treatment,  protection  from 
mosquitoes,  along  with  special  supervision  and 
control.  In  selected  areas  this  action  was  supple- 
mented by  anti-mosquito  measures  directed  specially 
against  the  breeding-places  of  these  insects.  Notifi- 
cation of  malaria  was  made  compulsory  in  certain 
districts.  Since  the  Armistice  other  measures  have 
been  added,  in  consultation  with  the  Ministry  of 
Pensions  and  the  National  Health  Insurance 
Department,  for  the  treatment  of  malaria  in 
demobilised  men.  A pamphlet  entitled  “ Sug- 
gestions for  the  Care  of  Malaria  Patients,”  was 
prepared  by  Lieutenant-Colonel  James,  in  collabo- 
ration with  Sir  Ronald  Ross,  and  this  was  dis- 
tributed to  medical  practitioners  throughout  the 
country.  In  January,  1919,  the  Local  Govern- 
ment Board  issued  an  Order,  “ Public  Health  (Pneu- 
monia, Malaria,  Dysentery,  &c.)  Regulations,  1919,” 
which,  among  other  things,  imposed  on  local 
authorities  and  their  officers  certain  new  powers 
and  duties  in  regard  to  malaria  prevention.  All 
practical  assistance  was  given  by  the  expert  officers 
of  the  Local  Government  Board  to  medical  officers 
of  health  and  medical  practitioners ; in  all  cases 
where  indigenous  malaria  was  suspected  and  where 
no  other  arrangement  had  been  made  for  the 
examination  of  blood  films,  this  duty  was  under- 
taken by  the  experts  belonging  to  the  Board’s 
Medical  Department. 


534  The  Lancet,] 


A SHORTER  WORKING  DAY. 


[Sept.  20,  1919 


A Shorter  Working  Day. 

At  the  meeting  of  the  British  Association  interest 
was  manifested  by  a large  attendance,  which 
overstrained  the  accommodation  provided,  in 
the  possibilities  of  reduction  in  hours  of  labour, 
with  special  reference  to  Lord  Leverhulme’s  pro- 
posal of  a six-hour  day.  The  subject  was  intro- 
duced by  Dr.  H.  M.  Vernon,  who  spoke  from  his 
unique  knowledge  of  output  under  different 
periods  of  employment,  as  ascertained  by  him  in 
a variety  of  industries  during  the  war  on  behalf  of 
the  Health  of  Munition  Workers  Committee,  and 
since  then  for  the  Industrial  Fatigue  Research 
Board.  Mr.  Sargant  Florence  told  of  the  work  now 
being  carried  on  by  the  National  Research  Council 
in  the  United  States;  while  Professor  E.  L.  Collis, 
Sir  Hugh  Bell,  and  Professor  A.  D.  Waller  also 
presented  different  aspects  of  the  case.  Every  social 
movement  which  affects  a considerable  portion  of 
the  community  calls  for  close  attention,  but  the 
present  position  in  the  industrial  section  of  the 
community,  which  forms  so  large  a portion  of 
the  whole,  and  upon  which  the  whole  is  finally 
dependent,  requires  to  be  watched  with  par- 
ticular interest  by  the  medical  profession.  The 
workers  are  demanding  and  are  obtaining  a 
great  reduction  in  their  hours  of  labour  with 
no  reduction  in  their  earnings.  These  hours  have 
up  to  the  present  remained  (except  for  miners) 
practically  unaltered  since  1850,  when  they  were 
limited  by  the  Factory  Acts  to  56?  per  week  for 
textile  workers  and  60  for  other  operatives;  these 
limits,  it  is  true,  only  apply  to  “protected”  labour — 
i.e.,  juveniles  and  females — but  the  hours  of  the 
unprotected  adult  male  have  been  largely  deter- 
mined by  these  legal  limits. 

Every  community  is  alive  and  reacts  as  a living 
organism  to  the  influences  to  which  it  is  sub- 
jected ; and  its  reactions  are  to  be  measured  by 
the  collective  behaviour  of  the  units  of  which  it  is 
composed,  as  indicated  by  vital  statistics.  Such 
records  show  that  epidemics  of  disease,  like  influenza 
or  plague,  come  and  go,  ruffling  the  waves  of  the 
advancing  or  receding  tide  of  health,  but  not 
materially  affecting  the  total  rise  or  fall  over 
long  periods.  Three  main  influences  affect  life — 
the  air  we  breathe,  the  food  we  eat,  the  work  we  do. 
The  effect  of  the  air  does  not  now  concern  us, 
although  data  are  accumulating  which  support  the 
contention  that  impurities  poured  into  the  air  of 
great  cities  and  industrial  centres  have  an  impor- 
tant and  harmful  influence.  The  importance  of  the 
food  supply  has  long  been  recognised,  particularly 
since  Malthus  early  last  century  pointed  out  that 
increase  or  decrease  of  population  followed  the  food- 
supply  rather  than  the  birth-rate  ; and  we  have  just 
seen  how  food-supply  has  been  the  dominant  factor 
in  the  Great  War,  controlling  the  amount  of  energy 
the  Belligerents  had  at  their  disposal — i.e.,  the  amount 
of  work  they  could  do.  But  the  importance  of 
the  work  itself  has  hardly  been  fully  appreciated ; 
the  importance  upon  the  health  of  the  community 
of  modern  industrial  life ; even  though  Sir  James 
Paget  laid  it  down  that  “ fatigue  (too  much  work) 
has  a larger  share  in  the  promotion  or  permission  of 
disease  than  any  other  causal  condition  you  can 
name.”  Fewer  hours  of  work  should  mean  less 
fatigue ; and  the  health  of  the  nation  is  bound  to 
react,  though  several  years  must  elapse  before  the 
reaction  can  be  measured.  Health  has  reacted  to 
the  social  changes  brought  about  by  the  sudden 
advance  in  civilisation  of  the  last  200  years,  and 


more  particularly  of  the  last  80  years,  which  has 
resulted  from  industrial  development  guided  by 
intellectual  progress.  The  food-supply  has  increased 
and  the  population  has  increased,  as  Malthus  said 
it  should.  Vital  statistics  indicate  a diminution  in 
our  exposure  to,  and  an  increase  in  our  capacity  for 
resisting,  the  onset  of  disease  ; and  in  no  case  has 
this  been  more  manifest  than  in  the  decline  in 
mortality  from  tuberculosis.  What  reaction  will 
follow  the  present  movement  which  should  elimi- 
nate much  industrial  fatigue  ? 

Dr.  Vernon  traced  the  present  possibilities  of 
the  six-hour  day,  and  showed  by  instances  taken 
from  the  iron  and  steel  industry,  and  the  tinplate 
industry,  that  the  rate  of  output  per  worker  cannot 
always  be  increased  in  proportion  to  the  reduced 
hours.  He  chiefly  dealt  with  the  economic  question 
of  output,  which  is  fundamental  in  the  industrial 
world ; for  industry  must  obtain  a surplus  of  out- 
put ; that  is,  a greater  output  per  working  unit  than 
that  unit’s  requirements  necessitate,  if  the  social 
circulation  which  supplies  him  with  materials, 
and  absorbs  his  output,  is  to  be  maintained. 
Hours  of  labour  and  conditions  of  work  have  to 
be  arranged  to  ensure  this  surplus  of  output 
which  is  wealth,  the  blood-stream  of  industry. 
JSsop’s  fable  of  the  limbs  and  the  stomach  is 
still  a useful  parable ; the  stomach  must  be 
fed  for  nourishment  to  reach  the  limbs.  The  con- 
stitution of  the  State  has  in  the  past  been  showing 
signs  of  greediness  and  of  an  overloading  of  its 
metaphorical  stomach ; dyspeptic  symptoms  have 
followed — nightmares  of  unrest;  and  somewhat 
unwieldy  corporations  have  developed,  while  the 
work  a day  limbs  have  suffered  from  unequal  dis- 
tribution of  nourishment.  But  if  the  hands  go  on 
strike  and  refuse  to  feed  the  stomach,  they  in  their 
turn  can  receive  no  nourishment  and  must  starve. 
Recently  a tendency  for  more  equal  distribution 
has  manifested  itself,  but  for  this  to  be  main- 
tained output  must  be  maintained,  and  not  only 
maintained  but  increased.  Can  this  be  effected 
by  adopting  the  six-hour  day  ? Dr.  Vernon’s  data 
show  that  so  far  as  certain  dexterous  processes  are 
concerned  the  answer  is  “ Yes,”  but  that  in  regard 
to  the  majority  of  automatic  processes  the  answer 
is  a definite  “ No.”  Modern  industry  has  developed 
on  a longer-day  basis  and  has  not  yet  organised 
itself  to  meet  the  requirements  of  an  eight-hour 
day,  even  though  this  modification  has  for  years 
been  demanded  by  the  workers.  If  ever  the  six- 
hour  day  proposed  by  Lord  Leverhulme  is  to  be 
generally  adapted — and  from  the  point  of  view  of 
health  and  welfare  it  has  much  in  its  favour — 
industry  must  have  due  notice.  Labour-saving 
devices  must  be  invented,  and  processes  brought 
more  under  the  control  of  the  workers’  own 
dexterity. 

These  things  can  probably  be  done,  but  not  in  a 
moment,  and  to-day  each  process  must  be  considered 
on  its  merits.  We  must  encourage  in  every  way 
a reduction  of  hours  by  permitting  multiple  short 
shifts,  which  to-day  are  discouraged,  if  not  rendered 
impossible,  for  protected  labour  by  the  inelastic 
provisions  of  the  Factory  Acts.  If  short  shifts 
prove  an  economic  success,  which  can  only 
result  through  energetic  action  on  the  part 
of  employers,  and  more  especially  of  the  workers, 
then  industry  will  adopt  them  without  com- 
pulsion, and  will  organise  itself  so  that  they 
can  be  introduced  where  to-day  they  could  only 
prove  an  economic  failure.  Legal  action  at  present 
should  be  limited  to  fixing  some  maximum  period 


Thb  Lancet,] 


MARKING  TIME  IN  PSYCHIATRY. 


[Sept.  20,  1919  535 


for  employment,  say  eight  hours  a day,  or,  better, 
a 48-hour  week,  and  should  leave  to  industry  every 
possible  latitude  to  work  out  its  own  salvation 
within  this  limit.  The  step  would  be  a great 
advance,  for  it  must  be  remembered  there  is  no  legal 
limit  to-day  (except  for  miners)  to  the  hours  of  adult 
male  labour.  At  some  future  time,  in  the  light 
of  experience  gained,  a further  reduction  of  the 
maximum  might  be  found  of  value  to  the  health 
and  wealth  of  the  State  ; but  in  the  light  of  present 
knowledge  with  industry  organised  as  it  is  to-day 
there  are  at  least  three  dangers  in  adopting  a 
universal  six-hour  day:  (1)  health  might  be 

impaired  by  too  little  activity,  for  work  is  even 
more  necessary  to  health  than  rest ; (2)  the  un- 
occupied time  might  be  spent  unprofltably  and 
harmfully,  since  the  working-class  population  have 
not  been  accustomed  to  having  leisure  hours  to 
devote  to  mental  and  physical  recreation ; and 
(3)  surplus  of  output  might  not  be  obtained,  when 
economic  circulation  would  cease. 

, » 

Marking  Time  in  Psychiatry. 

In  common  with  other  Government  departments, 
the  Board  of  Control  has  been  seriously  hampered 
in  its  activities  by  the  conditions  obtaining  during 
the  war,  which  not  only  depleted  its  staff  but  also 
thrust  upon  it  a number  of  emergency  duties  of  a 
difficult  and  responsible  character,  notably  in  con- 
nexion with  the  adaptation  for  use  as  war  hospitals 
of  certain  asylums  under  its  supervision.  The 
present  report,  though  it  appears  several  months 
after  the  termination  of  hostilities,  inevitably  bears 
traces  of  this  preceding  period  of  stress,  and  can 
hardly  be  expected,  therefore,  to  come  quite 
up  to  the  standard  of  fullness  and  accuracy 
which  may  reasonably  be  looked  for  in  normal 
times  in  the  reports  of  a State  authority 
responsible  for  such  important  duties  in  regard 
to  the  care  and  treatment  of  the  insane.  Even, 
however,  when  full  allowance  has  been  made  for 
the  difficulties  of  the  moment,  it  cannot  be  said  that 
the  inadequacy  of  the  Board’s  last  report  is  entirely 
accounted  for.  In  the  first  place,  the  statistical 
information  which  the  report  contains  is  very 
defective,  even  for  a war-time  publication,  and  it  is 
badly  arranged;  there  are  no  details  as  to  the  age 
distribution  of  patients  on  first  admission  and 
on  recovery;  there  is  only  one  meagre  table  show- 
ing the  percentage  distribution  of  deaths  from 
certain  causes  at  three  different  age-periods,  which, 
in  the  absence  of  any  figures  indicating  the  age  dis- 
tribution of  the  whole  asylum  population,  is  quite 
useless ; no  particulars  are  given  as  to  the  assigned 
causation  of  insanity  or  as  to  the  clinical  forms 
of  disease  in  patients  admitted  to  care.  If  the 
omission  of  any  reference  to  these  latter  points 
could  be  explained  by  scepticism  on  the  part  of  the 
Commissioners  regarding  the  value,  in  the  present 
state  of  knowledge,  of  any  attempt  to  classify  the 
forms  of  mental  disease  or  to  distinguish  their 
setiological  factors,  it  would  perhaps  be  a com- 
prehensible position;  but  in  point  of  fact  the  Board 
has  had  in  use  for  many  years  past  a most  minute 
and  complex  table  of  classification  with  an  equally 
complex  table  of  alleged  causes  of  insanity,  and 
the  statistical  information  collected  every  year 
from  all  the  asylums  in  the  country  has  to  be 
furnished  in  accordance  with  these  schedules.  If 

1 Report  of  the  Board  of  Control  (Lunacy  and  Mental  Deficiency)  for 


this  system  is  too  elaborate  and  too  artificial  to  be 
of  any  use  in  practice,  as  may  well  be  the  case, 
and  if  it  is  not  possible  to  substitute  for  it  some 
provisional  scheme  of  a simpler  and  less  ambitious 
character,  it  should,  at  least,  be  feasible  to  show 
the  statistical  movement  of  a number  of  the 
generally  recognised  clinical  groups  of  mental 
disease,  as,  for  instance,  general  paralysis,  the 
insanity  associated  with  epilepsy,  and  the  insanities 
of  child-birth.  Meanwhile  the  lack  of  information 
of  this  sort  renders  it  the  more  necessary  to 
provide  statistics  regarding  such  matters  as  the  age 
at  onset  of  attack  and  the  age  distribution  of  the 
asylum  population.  If  space  is  a consideration,  it 
would  be  easy  to  find  room  for  the  inclusion  of 
these  really  important  data  by  omitting  details 
about  trivial  administrative  points,  such  as  the 
extension  of  a certificate  to  allow  an  institution  to 
increase  its  accommodation  by  one  bed,  or  the 
purchase  of  3i  acres  by  a county  asylum.  Such 
matters,  if  worth  recording  at  all,  might  well  be 
relegated  to  an  appendix ; they  are  quite  out  of  place 
in  the  text  of  the  report.  It  is  desirable  to  make 
these  criticisms  at  the  outset,  because  the  absence 
of  adequate  statistical  data  imports  a large  element 
of  uncertainty  into  the  interpretation  of  the  two 
main  facts  disclosed  in  the  report — viz.,  the  high 
death-rate  amongst  asylum  inmates  and  the 
increase  in  the  number  of  admissions  to  asylum 
care  during  1918. 

On  Jan.  1st,  1919,  the  number  of  notified 
insane  persons  under  care  in  England  and  Wales 
was  116,703 — 49,936  males  and  66,767  females — 
showing  a decrease  of  9138  as  compared  with  the 
number  under  care  on  the  corresponding  date  in 
1918,  and  a decrease  of  23,763  since  the  beginning 
of  the  war.  The  number  of  patients  placed  under 
care  last  year  was  21,765 — 10,078  men  and  11,687 
women.  Of  this  number,  8835  men  and  9726 
women  had  not  previously  been  under  asylum 
treatment.  The  admissions  for  the  year  show  an 
increase  in  both  sexes  as  compared  with  the 
figures  for  1917,  and  the  number  of  first  admissions 
of  women  is  higher  than  any  previously  recorded. 
It  should  be  noted  that  the  figures  do  not  include 
3000  to  4000  patients  under  observation  in  military 
hospitals,  many  of  whom  will  ultimately  be 
certified.  During  the  year  5907  patients  were 
discharged  recovered,  being  a percentage  of 
recoveries  to  admissions  of  27'14 — the  lowest  on 
record.  The  decrease  in  notification  has  been  due 
in  the  main  to  the  abnormally  high  death-rate, 
which,  calculated  on  the  daily  average  number  of 
patients,  amounted  last  year  to  19  56  per  cent.,  as 
compared  with  16‘86  per  cent,  in  1917  and  with 
9'43  in  the  pre-war  year  1913.  This  excessive 
mortality  was  the  subject  of  a special  inquiry 
by  a committee  of  the  Board,  who  reported 
that  its  main  cause  was  the  reduction  in 
quantity  and  deterioration  in  quality  of  the 
food  supplied  to  patients.  The  unpleasant  impres- 
sion which  this  statement  makes  will  not  be 
lessened  when  it  is  observed,  from  Statistical 
Table  YI.  in  Part  II.,  that  the  increase  in  the  death- 
rate  was  confined  to  institutions  receiving  paupers, 
and  did  not  affect  the  registered  hospitals  which 
deal  only  with  private  patients.  Further  informa- 
tion on  this  matter  is  clearly  desirable,  especially 
as  to  whether  the  rationing  of  asylum  patients 
was  scientifically  adjusted  to  their  needs  as  sick 
people.  The  Commissioners,  as  a result  of  their 
investigations,  judged  it  necessary  to  make  a series 
of  suggestions  to  the  asylum  authorities,  and  it  is 


536  The  Lancet,]  IRISH  PUBLIC  HEALTH  COUNCIL. — THE  RODENT  MENACE 


[Sept.  20,  1919 


a little  surprising  to  find  that  their  first  recom- 
mendation is  to  the  effect  “ that  patients  should  be 
weighed  at  least  quarterly  and  a record  kept.”  Is 
it  to  be  inferred  from  this  that  there  are  institu- 
tions for  the  insane  where  patients  are  not 
periodically  weighed,  and  that  it  is  only  after  a 
disastrous  experience  of  excessive  rationing  that 
the  utility  Of  such  weighing  is  discovered  ? The 
other  recommendations  of  the  Commissioners  refer 
mainly  to  precautions  against  the  spread  of  com- 
municable diseases,  especially  tuberculosis  and 
dysentery,  which  became  much  more  prevalent  in 
the  asylum  population  during  the  war.  The 
measures  advised  are  generally  sound  and  prac- 
tical, but  the  Board  of  Control  can  hardly  be  called 
progressive  scientifically.  The  financial  statistics 
reveal  the  interesting  and  illuminating  fact  that 
in  the  year  ending  March  31st,  1918,  the  expendi- 
ture on  county  and  borough  asylums  for  the  insane 
amounted  to  considerably  over  £4,000,000,  and  the 
expenditure  for  scientific  research  in  connexion 
with  mental  disease  was  £375. 

It  will  be  seen  that  the  report  does  not  give  a 
very  encouraging  view  of  the  present  position  of 
insanity  in  this  country,  and  that  it  is  likely  to 
strengthen  the  growing  sense  of  dissatisfaction 
with  our  existing  methods  of  dealing  with  the 
insane.  The  very  tone  of  the  report,  with  its 
constant  insistence  on  the  purely  custodial  and 
administrative  side  of  asylum  work,  points  to  what 
is  amiss : it  is  the  failure  to  recognise,  in  practice 
as  well  as  in  profession,  that  insanity  is  a disease 
which  must  be  studied  and  treated  in  the  spirit  and 
by  the  methods  of  medical  science.  The  reforms 
which  the  Commissioners  themselves  advocate, 
such  as  the  establishment  of  clinics  for  mental 
disease  in  connexion  with  general  hospitals  and  the 
amendment  of  the  law  to  allow  of  the  treatment  of 
cases  of  insanity  in  the  incipient  and  more  curable 
stages,  will,  it  may  be  hoped,  do  something  to 
remedy  the  defects  of  the  present  system,  but  it  is 
evident  that  more  radical  changes  will  be  needed  if 
psychiatry  is  to  be  freed  from  the  influences  which 
now  impede  its  progress,  and  is  to  be  brought  into 
contact  with  the  main  current  of  medical  thought 
and  practice.  


^nnotatians. 

"Ne  quid  nlmls.” 


IRISH  PUBLIC  HEALTH  COUNCIL. 

The  Chief  Secretary  for  Ireland,  acting  under 
Section  10  of  the  Ministry  of  Health  Act,  1919, 
nas  nominated  the  following  to  be  the  medical 
members  of  the  Irish  Public  Health  Council : — Dr. 
E.  Coey  Bigger,  now  Medical  Commissioner  to  the 
Local  Government  Board  for  Ireland,  to  be  chair- 
man of  the  Council ; Sir  John  W.  Moore,  president 
of  the  Royal  Academy  of  Medicine  of  Ireland  and 
chairman  of  the  Public  Health  Committee  of  the 
General  Medical  Council ; Dr.  Robert  J.  Rowlette, 
nominated  by  the  Irish  Medical  Committee  and 
the  Irish  Medical  Association ; Dr.  Alice  Barry, 
medical  superintendent  of  the  Child  Welfare 
Work  Branch  of  the  Women’s  National  Health 
Association,  nominated  by  the  Irish  Medical  Com- 
mittee. The  non-medical  nominated  members  of 
the  Council  are : Countess  of  Kenmare,  chairman 
of  the  Advisory  Council  for  Ireland  of  the  Queen 
Victoria  Jubilee  Institute ; Mrs.  J.  McMordie, 
member  of  the  Tuberculosis  Committee  of  the 
Belfast  Corporation,  and  of  the  Belfast  Insurance 


Committee ; Sir  James  M.  Gallagher,  ex-Lord 
Mayor  of  Dublin  and  ex-chairman  of  the  Dublin 
Joint  Hospital  Board;  Mr.  J.  Ewing  Johnston, 
M.R.C.V.S.,  president  of  the  North  of  Ireland 
Veterinary  Medical  Association;  Rev.  P.  Kerlin, 
C.C.,  nominated  by  the  (Irish)  National  Associa- 
tion of  Insurance  Committees ; and  Mr.  John 
Drennan,  representing  the  approved  insurance 
societies.  It  will  be  remembered  that  the  Vice- 
President  and  two  other  Commissioners  of  the  Local 
Government  Board  for  Ireland ; the  chairman  and 
two  other  Irish  Insurance  Commissioners ; the 
Registrar- General  of  Births,  Deaths,  and  Marriages 
in  Ireland,  are  ex-officio  members  of  the  Council. 
Major  George  A.  Harris,  of  the  Local  Government 
Board  for  Ireland,  has  been  appointed  secretary 
to  the  Council,  the  offices  of  which  will  be  at 
33,  St.  Stephen’s  Green,  North  Dublin.  The  first 
meeting  of  the  new  Council  will  be  held  on 
Thursday,  Oct.  2nd.  

THE  RODENT  MENACE. 

Civilisation  is  daily  teaching  us  that  we  are 
members  one  of  another,  and  this  applies  especially 
to  our  failings  and  failures,  and  even  to  our  diseases, 
for  one  carries  the  germ  and  another  catches  it.  On 
the  animal  kingdom  we  are  still  more  intimately 
dependent,  for  they  frequently  act  as  hosts  to  our 
infections  during  inhospitable  intervals.  What  should 
we  know  of  malaria  if  it  was  not  for  the  mediation 
of  the  mosquito,  or  of  plague  if  it  was  not  for  the 
rat  ? And  the  rat  is  becoming  ever  more  and  more 
suspect.  In  regard  to  protozoal  parasites  it  has  been 
long  known  to  harbour  the  Trypanosoma  lewisi,  an 
apparently  harmless  guest.  The  Japanese  have 
shown  the  rat  to  be  the  host  of  two  other  protozoa 
which,  while  harmless  to  itself,  are  capable  of 
causing  serious  illness  in  man.  These  are  the 
Spirochceta  icterohcemorrhagice  Inada  and  the 
Sp.  morsus  muris  Futaki.  The  work  of  Inada,  Ido, 
Hoki,  Kaneko,  and  Ito,  on  the  first-named  has  since 
been  confirmed  by  the  demonstration  of  rat  carriers 
in  France,  Belgium,  Algeria,  and  the  United  States 
of  America.  In  England  the  presence  of  the  specific 
spirochaste  of  haemorrhagic  jaundice  in  the  rat  was 
not  fully  proved  until  the  investigation  of  Major 
A.  G.  R.  Foulerton,  carried  out  in  the  Hygiene 
Department  of  University  College,  London,  and 
recently  printed  at  the  instance  of  the  Public  Health 
Department  of  the  Corporation  of  London.  Major 
Foulerton  examined  101  rats  caught  within  the  City 
and  Metropolitan  area,  and  in  4 of  them  found  a 
spirochaBte  which  killed  a guinea-pig  on  the  twelfth 
day  with  all  the  characteristic  appearances  of 
spirochastal  jaundice.  Three  of  these  rats  were  from 
a batch  of  12  caught  at  a general  store  in  the  City 
last  November ; the  fourth  from  a batch  of  7 from 
another  part  of  London.  Dr.  A.  C.  Coles  stated  in 
our  columns  1 last  year  that  he  had  found  spiro- 
chaetes  resembling  the  Sp.  icterolusmorrhagicB  in 
9 out  of  100  rats  caught  in  the  neighbourhood  of 
Bournemouth,  and  gave  excellent  micro-photographs 
of  the  protozoa,  but  he  did  not  proceed  to  confirm 
his  results  by  animal  inoculation.  Major  Foulerton 
discusses  the  method  of  transmission  of  the 
protozoon  from  rat  to  rat  and  rat  to  man,  inclining 
in  the  first  case  to  accidental  inoculation,  in  the 
latter  to  the  infection  of  food  and  drinking  water. 
For  the  present  the  rat-flea  has  nothing  to  say  to 
this  matter. 

In  a presidential  address,  delivered  last  year 
before  the  Royal  Society  of  New  South  Wales  and 


1 The  Lascet,  1918,  i.,  468. 


Thh  Lancet,] 


THE  MEDICAL  DEFENCE  UNION.— THE  POSOLOGY  OF  EMETINE.  [Sept.  20,  1919  537 


since  reprinted  and  circulated,  Dr.  J.  Burton 
Cleland  pointed  out  that  a town  that  lets  its 
rats  multiply  is  exposed  to  a menace  that  may 
lead  to  enormous  financial  losses  and  possibly  a 
heavy  death  roll.  Rats  live  a communal  life  in 
direct  contact  with  each  other,  and  thus  the 
passage  of  any  pathogenic  organism  is  facilitated, 
while  in  the  passage  the  pathogenicity  of  the  less 
lethal  forms  is  probably  increased.  He  went  on  to 
discuss  rat  leprosy,  which  is  widely  distributed, 
though  of  relatively  rare  occurrence,  its  incidence 
among  the  rat  population  in  New  South  Wales 
being  much  about  the  same  as  the  incidence  of 
leprosy  amongst  the  human  population.  From 
investigations  on  its  occurrence  in  rats  it  might  be 
inferred  that  there  is  one  diseased  rat  in  Sydney  for 
every  100,000  examined,  whilst  in  New  South  Wales 
there  is  approximately  one  leper  to  80,000  inhabi- 
tants. The  question  arises  as  to  whether  there  is 
any  possible  connexion  between  the  two  diseases, 
whether,  indeed,  they  are  not  due  to  the  same 
organism.  Dr.  Cleland  sketches  the  phylogenetic 
history  of  the  tubercle  bacillus,  showing  that  it  was 
originally  a saprophyte,  as,  for  instance,  the  acid- 
fast  timothy-grass  bacillus  is  still ; the  next 
stage  being  its  accidental  introduction  by  the 
alimentary  canal  or  through  wounds  into  the  tissues 
of  vertebrates,  where  it  has  found  itself  capable  of 
living  and  multiplying,  even  though  in  such  an 
unusual  environment;  finally,  being  given  frequent 
opportunities  of  escape  from  its  host  through 
ulceration  of  the  lungs  and  of  introduction  con- 
sequently to  fresh  individuals,  its  pathogenicity 
has  been  increased  and  its  saprophytic  qualities 
have  been  diminished  or  lost.  The  rat  leprosy 
bacillus  may,  he  suggests,  be  in  somewhat  the  same 
transition  stage. 

These  are  new  aspects  of  the  rodent  menace 
about  which  sufficient  is  known  to  demand  the  more 
active  measures  of  suppression  in  this  country. 
The  Rats  Orders  of  1918  and  1919  gave  local  authori- 
ties the  liberty  to  organise  local  campaigns.  Several 
county  councils  have  appointed  official  rat- 
catchers. In  Leicestershire  a summer  campaign 
resulted  in  the  death  of  125,223  rats,  for  which 
a sum  of  £1525  was  paid  out.  The  Board  of 
Agriculture  has,  in  harmony  with  a growing  habit, 
suggested  a “ rat  week  ” for  Oct.  20th-27th,  in 
which  village  communities  should  compete  one 
against  the  other  in  baiting,  trapping,  and  ferreting. 
All  this  is  to  the  good,  but  we  doubt  the  attainment 
of  the  end  in  view  so  long  as  slack  authorities  are 
not  gently  urged  by  legislative  action ; for  rats 
harried  on  one  side  of  a boundary  can  take  refuge 
on  the  other  side  where  the  human  community  is 
more  lenient.  We  regret  that  Lord  Aberconway’s 
Rat  Destruction  Bill  did  not  become  law.  It  is  for 
the  Ministry  of  Health  to  devise  appropriate  legis- 
lative action  which  shall  not  be  held  up  by  lack 
of  time  or  interest  in  the  Chamber. 


THE  MEDICAL  DEFENCE  UNION. 

The  annual  general  meeting  of  the  Medical 
Defence  Union  was  held  in  the  board- room  of  the 
Public  Medical  Service  at  Leicester,  under  the 
presidency  of  Sir  John  Tweedy,  when  the  report 
presented  began  by  recording  the  great  loss  to  the 
Union  incurred  by  the  death  in  April  last  of  the 
general  secretary,  Dr.  A.  G.  Bateman.  Dr.  Bateman’s 
services  were  largely  instrumental  in  safeguarding 
the  rights,  liberties,  privileges,  duties,  and  ethical 
obligations  of  medical  men  in  their  relations  with 
each  other  and  with  the  public,  and  the  appoint- 


ment of  his  successor,  Dr.  James  Neal,  with  a long 
experience  behind  him  as  deputy  medical  secretary  of 
the  British  Medical  Association,  promises  a continu- 
ation of  Dr.  Bateman’s  activities.  During  the  year 
123  cases  were  referred  to  the  Union’s  solicitor,  Mr. 
W.  E.  Hempson,  24  being  libel  and  slander  actions, 
prosecuted  or  defended ; 15  malapraxis  actions, 
defended;  8 prosecutions  of  unqualified  persons; 
76  arbitration  and  personal  matters.  The  out-of- 
pocket  expenses  for  litigation  amounted  to  £278,  and 
the  total  law  charges  to  £1136.  No  action  conducted 
by  the  Union  has  been  lost  during  the  last  two  years. 
The  profit  and  loss  account  for  the  year  shows  a 
credit  balance  of  £2016  at  the  beginning  and  £2830 
at  the  end  of  the  year.  The  most  interesting 
feature  of  the  report  is  the  record  of  a difference 
of  opinion  which  has  arisen  between  the  Union- 
and  the  General  Medical  Council  in  regard  to 
requests  addressed  by  the  Council’s  acting  registrar 
to  members  of  the  Union  inquiring  their  reasons 
for  refusing  medical  attendance  in  certain  cases  in 
regard  to  which  complaint  had  been  received  by 
the  Council.  The  reply  of  the  Penal  Cases  Com- 
mittee of  the  Council,  justifying  the  Council’s 
action,  is  given  at  length  in  the  report.  The 
Union  takes  the  view  that  a continuance  of  this 
new  procedure  can  only  lead  to  a conflict  between 
the  General  Medical  Council  and  registered  medical 
practitioners.  The  number  of  members  on  the 
register  of  the  Union  is  now  8719. 

THE  POSOLOGY  OF  EMETINE. 

At  a recent  discussion1  on  the  posology  of  emetine 
at  the  Societe  de  Therapeutique,  Paris,  Dr.  Chauffard 
stated  that  he  preferred  giving  subcutaneous  injec- 
tions of  the  drug  as  being  less  painful  than  intra- 
muscular. He  never  used  rectal  injections,  as  they 
were  liable  to  cause  a recrudescence  of  dysentery. 
In  moderately  severe  cases  of  amoebic  dysentery 
he  gave  two  injections  daily  of  3-5  eg.  of  emetine 
hydrochloride.  The  patient  received  a series  of 
injections  for  from  six  to  eight  days,  followed 
by  a week  to  a fortnight’s  rest.  The  injections 
were  then  resumed  if  necessary.  Dr.  Dopter 
stated  that  injections  of  emetine  might  give  rise 
to  toxic  symptoms,  such  as  cardiac,  digestive, 
and  nervous  disturbance,  which  was  sometimes 
fatal.  The  toxicity  of  emetine  was  favoured  by 
its  accumulation  in  the  system  and  by  its 
slight  degree  of  daily  elimination.  In  practice, 
therefore,  it  was  advisable  not  to  exceed  a total 
dose  of  1 g.,  the  daily  dose  being  8-10  eg.  If  toxic 
symptoms  developed  before  the  total  dose  of  1 g. 
was  reached,  treatment  should  be  suspended.  If 
several  courses  of  emetine  treatment  were 
required  for  relapses  of  amoebiasis,  before 
undertaking  a second  series  it  would  be  neces- 
sary to  wait  for  complete  elimination  of  the 
drug  from  the  first  course — i.e.,  40  to  60  days. 
Major  F.  Noc  advocated  the  following  treatment  of 
amoebic  dysentery:  (1)  an  injection  of  emetine  in 

doses  of  4 eg.  daily  for  four  days  ; (2)  an  intravenous 
injection  'of  0'30  g.  neosalvarsan  on  the  first  or 
second  day ; (3)  milk  as  a drink  throughout  the 
duration  of  treatment ; (4)  small  doses  of  extract 
of  ipecacuanha  (5  or  10  eg.),  in  pills,  three  times  a 
week  ; (5)  one  or  two  injections  of  emetine  every 
week  or  fortnight,  according  to  the  frequency  of 
relapses  and  the  number  of  cysts  in  the  stools ; 
(6)  reinjection  of  small  doses  of  neosalvarsan 
(0'30  g.)  at  fairly  long  intervals  concurrently  with 
the  injections  of  emetine. 

1 Bulletin  de  la  Societe  de  Therap.,  4e  Serie,  xxiv.,  1919,  pp.  125-136. 


538  The  Lancet,] 


THE  IDEAL  ATMOSPHERE.— A PROGRESSIVE  MOVE. 


[Sbpt.  20,  1919 


THE  IDEAL  ATMOSPHERE. 

The  chemistry  of  the  air  was  established  with 
some  degree  of  certainty  a good  many  years  ago. 
The  essential  constituent,  of  course,  for  the  main- 
tenance of  animal  life  is  oxygen  absorbed  in  the 
process  of  respiration  and  passed  on  to  the  tissues 
by  way  of  the  circulatory  system.  These  are 
elementary  facts.  The  physics  of  the  air  has  only 
comparatively  recently  received  promising  study. 
It  is  well  to  remember  that  the  chemistry  of  the 
air  does  not  vary,  while  the  physics  of  the  air  does 
considerably  in  ways  which  affect  the  well-being 
of  the  individual.  As  is  well  known,  the  great 
and  important  organ,  the  skin,  is  susceptible  to 
the  fluctuations  in  the  physical  conditions  of  the 
atmosphere.  Terms  such  as  stuffy,  oppressive, 
heavy,  thundery,  fresh,  bracing,  are  constantly  used 
as  expressing  certain  varying  conditions  of  the  air 
we  continually  experience,  but  all  through  these 
phases  its  chemical  constitution  remains  the  same. 
We  may  disregard  the  chemistry  of  the  air,  as  that 
is  assured  to  us  as  a constant  in  all  ordinary 
circumstances — we  are  taking  no  regard,  of 
course,  of  added  impurity.  The  physics  of  the 
air,  on  the  contrary,  is  an  ever-varying  factor  which 
determines  its  adaptability  to  the  physiological 
convenience  of  the  individual.  The  progressive 
studies  of  the  physical  conditions  of  the  air  are 
rapidly  modifying  our  views  on  questions  of 
indoor  warming  and  ventilation:  these  refer  to 
the  correct  estimate  of  a healthy  aerial  environ- 
ment independently  of  chemical  purity  or 
composition. 

In  this  connexion  it  is  interesting  to  recall  that 
as  far  back  as  1892  a Report  of  The  Lancet 
Sanitary  Commission  on  the  Ventilation  of  Theatres 
and  Places  of  Public  Assembly  was  published  in  our 
columns.  This  report  referred  mainly  to  the  steps 
that  were  being  taken  in  regard  to  the  ventilation 
of  the  great  amphitheatre  of  the  Paris  Sorbonne. 
The  task  was  entrusted  to  an  eminent  architect 
and  hygienist,  M.  Emile  Trelat,  who  had  already 
consummated  a scheme  at  the  Vienna  Opera  House 
which  had  given  great  satisfaction.  This  scheme 
took  for  its  ideal  of  well-being  in  regard  to  indoor 
ventilation  the  conditions  prevailing  on  a fine 
autumnal  day  when  the  air  is  cold  and  crisp, 
but  when  the  rays  of  the  sun  are  still  warm. 
M.  Tr&lat  maintained  that  the  colder  the  air  the 
greater  the  internal  oxidation  in  breathing,  and 
therefore  the  greater  the  internal  warmth.  Accord- 
ing to  these  views  if,  while  breathing  cold  air,  the 
body  can  be  preserved  from  external  cold  by  the 
radiation  of  heat  from  the  sun  or  other  sources, 
there  follows  the  most  healthy  and  the  most  enjoy- 
able state  of  physical  existence.  These  views 
receive  confirmation  to-day,  for  practically  the  same 
conclusion  has  been  reached  by  Dr.  Leonard  Hill 
in  his  admirable  series  of  researches  on  the  subject. 
In  his  recent  report  on  “The  Science  of  Venti- 
lation and  Open  Air  Treatment  ” to  the  Medical 
Research  Committee  (Special  Report  Series,  No.  32, 
published  by  His  Majesty’s  Stationery  Office), 
he  repeats  his  statement  that  the  ideal  method 
of  warming  and  ventilating  rooms  would  give 
radiant  heat,  a warm  floor,  and  agreeable  movement 
of  cool  air — the  conditions,  he  adds,  of  a sunny 
spring  day  out-of-doors.  Except  that  M.  Trelat 
speaks  of  a fine  autumnal  day,  whereas  Dr.  Hill 
speaks  of  a sunny  spring  day,  these  investigators 
appear  to  have  arrived  at  the  same  ideals.  The 
weather  of  these  islands  does  not  always  approach 


these  ideals,  but  the  suggestion  plainly  is  that  the 
favourable  conditions  described  should  be  imitated 
as  nearly  as  possible  in  regard  to  indoor  heat- 
ing and  ventilation.  The  appeal  to  scientific 
instruments  for  guidance  in  these  matters  has 
hitherto  been  of  little  value,  and  particularly 
does  this  apply  to  the  ordinary  thermometer, 
for,  as  Dr.  Hill  rightly  observes,  the  healthy 
aerial  environment  is  not  a question  of  actual 
temperature,  but  (1)  of  the  cooling  power  of 
the  air,  that  depending  not  only  on  the  tempera- 
ture, but  far  more  on  the  movement  of  the 
air ; (2)  the  radiant  energy  of  the  sun  or 
other  source  received  by  the  skin ; and  (3)  the 
drying  power,  depending  upon  humidity,  move- 
ment of  the  air,  and  radiant  energy  received, 
which  affects  the  cutaneous  nerve-endings  by 
varying  the  difference  between  the  temperature 
of  the  surface  and  the  blood  temperature  in  the 
deeper  layers  of  the  skin. 

Towards  determining  the  physics  of  the  air, 
particularly  in  regard  to  its  cooling  and  evapora- 
tive power,  the  kata-thermometer  has  been  devised 
by  Dr.  Hill.  This  is  an  alcohol  thermometer 
designed  primarily  for  the  measurement  of  its 
own  rate  of  cooling,  when  its  temperature 
approximates  to  that  of  the  human  body.  The 
classic  wet-  and  dry-bulb  thermometer  is  thus 
superseded  where  measurements  in  behalf  of  the 
human  body  are  concerned,  and  the  records 
given  by  the  dry  and  wet  kata-thermometers 
form  a well-begun  means  of  differentiation  as 
to  what  is  and  what  is  not  a healthy  aerial 
environment.  In  his  observations  in  our  last  issue 
on  the  hot  season  in  Mesopotamia,  Dr.  F.  E. 
Fremantle  dwelt  on  the  value  of  the  kata-thermo- 
meter  in  determining  the  conditions  under  which 
the  white  man  can  continue  to  exist  in  tropical 
climes.  Scientific  measurements  of  this  kind  are 
interesting,  though  their  lessons  sometimes  seem 
late  in  supporting  long-established  convictions. 
Cool,  clear  air  has  for  long  been  accepted  as  most 
congenial  to  healthy  respiration,  but  the  comfort  of 
the  body  needs  to  be  sustained  by  artificial  warmth 
in  chilly  times.  The  individual  who  shivers  is 
miserable,  and  his  suffering  may  well  denote  the 
beginning  of  disturbance  of  health. 


A PROGRESSIVE  MOVE. 

In  the  advertisement  pages  of  this  week's  issue 
of  The  Lancet  appears  a notice  indicating  an 
interesting  departure  by  the  authorities  of  the 
Hospital  for  Nervous  Diseases,  Maida-vale.  The 
advertisement  invites  applications  for  the  post  of 
psychologist  to  the  hospital,  from  which  we  assume 
the  hospital  is  about  to  establish  the  nucleus  of 
what  should  develop  into  a psychological  depart- 
ment. From  the  report  of  the  medical  registrar  of 
the  hospital  for  the  last  year  it  appears  that  there  is 
much  material  awaiting  investigation,  for  of  the 
4000  patients  treated  at  the  hospital  in  1918  nearly 
half  are  classified  as  suffering  from  functional 
nervous  disorders.  Apart  from  the  treatment 
of  these  patients  and  the  opportunity  for 
original  work,  much  can  be  done  for  many 
of  the  patients  who  are  classified  as  suffering 
from  organic  nervous  disease,  but  who  also  show 
faulty  mental  adjustment,  and  the  appointment  of 
a psychologist  displays  the  intention  to  place  the 
facilities  of  the  hospital  at  the  disposal  of  those 
competent  to  carry  out  original  investigation  in 
psychotherapy. 


The  Lancet,] 


TUBERCULOUS  INFECTION  IN  SCHOOL  CHILDREN. 


[Sept.  20, 1919  539 


TUBERCULOUS  INFECTION  IN  SCHOOL 
CHILDREN. 

Dr.  Alexander  Arnfinsen 1 lias  tested  80  school 
children  between  6 and  18  years  of  age  at 
Trondhjem,  in  Norway,  with  von  Pirquet’s  reaction, 
and  found  that  it  was  positive  in  only  37'8  per  cent. 
Although  Trondhjem  is  an  old  city,  tuberculosis 
until  comparatively  recently  was  almost  unknown 
there.  The  surrounding  country,  from  which  the 
city  partly  draws  its  population,  had  been  relatively 
protected  from  infection  up  to  1850,  when  the  con- 
struction of  railways  and  good  highroads  brought 
about  a change  in  the  situation.  In  spite  of  the 
low  percentage  of  the  tuberculin  test,  the  mortality 
from  tuberculosis  is  higher  at  Trondhjem  than  in 
other  Norwegian  cities.  The  writer,  therefore, 
suggests  that  the  greater  the  dissemination  of 
tuberculous  infection  the  lower  is  the  mortality 
from  the  disease  owing  to  the  population  having 
acquired  a relative  immunity.  The  state  of 
nutrition  of  the  children  is  very  good,  probably 
owing  to  the  fact  that  82  per  cent,  had  been  breast- 
fed up  to  the  age  of  3 months  or  more.  Children 
from  tuberculous  homes  showed  a positive  cuti- 
reaction  in  68  and  64  per  cent,  for  boys  and  girls 
respectively.  


PERFORATION  OF  THE  LUNG  A SEQUEL  OF 
PERFORATION  OF  THE  STOMACH. 

In  the  American  Journal  of  the  Medical  Sciences 
for  August  Dr.  J.  Friedenwald  has  reported  a very 
rare  sequel  of  gastric  perforation — subphrenic 
abscess  perforating  through  the  lung.  A man, 
aged  51  years,  was  seen  in  consultation.  He  com- 
plained of  gastric  symptoms  for  35  years,  mainly 
fullness  after  meals  and  belching.  For  the  past  eight 
or  ten  years  there  were  periodic  attacks  lasting 
three  or  four  weeks  to  several  months,  characterised 
by  pain  in  the  stomach  appearing  two  hours  after 
meals,  and  relieved  by  soda  and  rest.  Pyrosis  and 
hunger  pain  frequently  occurred.  He  vomited  at 
times,  but  there  was  no  history  of  haematemesis  or 
melaena.  After  an  attack  lasting  some  weeks 
he  was  seized  with  agonising  pain  in  the 
upper  abdomen  requiring  injections  of  morphine. 
The  abdomen  was  distended  and  there  was  a tender 
epigastric  area.  Next  day  there  was  dull  pain  in 
the  left  kidney  region  which  radiated  towards  the 
epigastrium.  The  pain  lasted  ten  days,  and  was 
accompanied  by  a temperature  ranging  from  101°  to 
103°  F.  Cough  and  hiccough  developed  and  purulent 
expectoration  followed.  During  the  first  day  he 
expectorated  about  a quart  of  pus.  When  the 
expectoration  began  the  temperature  and  pain 
diminished.  He  was  admitted  to  hospital.  On 
examination  he  was  thin  and  pale.  The  tongue 
was  coated,  and  there  was  marked  pyorrhoea 
alveolaris.  In  the  chest  only  some  impairment  of 
the  percussion  note  in  the  region  of  the  right 
scapula  could  be  detected.  Auscultation  was 
negative.  The  abdomen  was  somewhat  distended, 
and  the  recti  were  spastic.  There  was  a tender 
area  in  the  epigastrium  and  left  lumbar  region,  over 
which  was  a burn  caused  by  hot  applications.  The 
liver  extended  a finger-breadth  below  the  costal 
margin.  X ray  examination  showed  a high  stomach 
with  rapid  expulsion  and  defect  at  the  pyloro- 
duodenal  junction  (revealing  an  ulcer),  dilatation 
of  the  bronchi,  and  cloudy  infiltration  below 
the  right  clavicle.  The  temperature  was  100°. 

1 Norsk  Magazin  for  Laegevidenskaben,  1919,  lxxx.,  508-530. 


On  the  first  day  in  hospital  he  expectorated 
about  a pint  of  pus.  The  expectoration  rapidly 
diminished  and  ceased  in  a week.  The  pus 
was  creamy  and  of  a putrid  odour.  It  con- 
tained colon  bacilli  and  streptococci  in  abundance. 
Recovery  quickly  took  place.  Evidently  the  attack 
of  abdominal  pain  indicated  gastric  perforation, 
which  was  followed  by  subphrenic  abscess,  and 
finally  by  perforation  of  the  lung.  The  complete 
evacuation  of  the  abscess  led  to  recovery.  In  gastric 
perforation  producing  subphrenic  abscess  the  pus 
usually  accumulates  rapidly  and  the  symptoms  are 
very  acute.  There  is  often  sudden  severe  pain  in 
the  epigastrium  or  hypochondrium  radiating  to  the 
shoulders  with  dyspnoea  due  to  pressure  on  the 
diaphragm.  There  are  usually  vomiting,  hiccough 
and  weakness,  and  acceleration  of  the  pulse.  Fever, 
with  chills  and  sweating,  is  not  uncommon.  Dr. 
Friedenwald  could  find  recorded  only  four  cases — 
all  German — In  which  perforation  of  a gastric  ulcer 
was  followed  by  rupture  through  the  lung. 


INTELLIGENCE  TESTS. 

It  was  announced  some  months  ago  that  the 
authorities  of  Columbia  College,  New  York,  had 
resolved  to  replace  their  matriculation  examination 
from  July  last  by  a series  of  psychological  tests  for 
the  selection  of  those  candidates  for  admission  who 
could  profit  most  by  a University  course  of  study. 
For  many  years  past  the  utility  of  special  mental 
tests  has  been  gaining  increasing  recognition. 
Their  value  was  finally  established  during  the  war, 
and  nowhere  so  conclusively  as  in  the  United 
States  Army,  in  which  they  were  applied  to  about 
one  and  a half  million  recruits.  A brief  report  of  the 
methods  adopted  for  measuring  intelligence  by  these 
Army  mental  tests  has  now  been  issued  from  the 
Government  Press, Washington,  showing  also  some  of 
the  results  obtained  and  the  practical  applications 
secured.  Men  of  too  low-grade  intelligence  were 
rejected,  while  those  of  superior  intelligence  were 
considered  for  advancement,  the  most  suitable 
being  selected  for  special  training  or  for  specific 
Army  duties.  On  the  basis  of  these  tests  endeavours 
were  made  to  provide  each  unit  (save  in  certain 
arms  of  the  Service)  with  its  proportion  of  superior, 
average,  and  inferior  men,  instead  of  leaving  the 
proportion  to  chance.  In  this  way  were  formed 
units  of  uniform  mental  strength  which  could  be 
trained  at  a uniform  rate.  Intelligence,  of  course, 
is  only  one  of  the  factors  in  military  efficiency,  but 
it  is  probably  the  most  important  single  factor. 
The  results  obtained  from  intelligence  tests  and 
from  other  mental  tests  by  the  United  States  Army 
and  by  our  own  Admiralty  during  the  war  are  clear 
indications  of  their  future  value  in  the  work  of 
human  selection  and  vocational  guidance. 


ANTHROPOLOGY  AS  AN  IMPERIAL  STUDY. 

The  Mackie  Anthropological  Expedition  to 
Uganda,  postponed  for  obvious  reasons  on  the 
outbreak  of  the  war,  is  now  to  get  to  work. 
Under  the  direction  of  the  Royal  Society,  the 
mission  will  be  in  the  personal  charge  of  the 
Rev.  John  Roscoe,  whose  thorough  acquaintance 
with  the  subject  and  long  residence  in  Uganda  as 
a missionary,  constitute  exceptional  qualifications. 
The  original  idea  was  that  the  Colonial  Office 
should  finance  the  scheme,  but  Mr.  Lewis 
Harcourt,  upon  full  consideration,  did  not 
concur.  Accordingly,  Mr.  P.  Jeffrey  Mackie,  of 


540  The  Lancet,] 


THE  INDUSTRIAL  EMPLOYMENT  OF  MOTHERS. 


[Sept.  20,  1919 


Glenreasdell,  a well-known  Scotch  distiller,  was 
approached  and  he  undertook  to  defray  the  entire 
cost.  We  hope  that  the  results  of  his  generosity 
will  provide  a valuable  contribution  to  our  know- 
ledge upon  a subject  hitherto  unduly  neglected. 
Anthropological  study  is  of  particular  importance 
to  the  British  Empire,  to  which  has  fallen  the 
charge  of  so  great  and  various  a collection  of  the 
human  race.  The  expedition  could  not  be  in  better 
hands  than  those  of  Mr.  Roscoe,  lecturer  to  the 
University  of  Cambridge  in  African  Anthropology, 
and  author  of  an  authoritative  work  on  the  folk- 
lore of  the  Baganda. 


THE  OPENING  OF  THE  WINTER  SESSION. 

A welcome  sign  of  the  return  to  more  normal 
conditions  of  life  is  the  renewed  foregathering  of 
past  and  present  members  of  London  medical 
schools  at  the  commencement  of  the  winter  session. 
The  social  dinners  which  one  by  one  have  been 
dropped  during  the  war  are  again  to  take  place,  and 
will  bring  together  for  the  first  time  men  and  women 
whose  medical  duties  have  taken  them  to  the  ends 
of  the  earth,  and  given  them,  in  a brief  year,  more 
than  the  normal  experience  of  a life-time.  Some 
of  the  London  schools  of  medicine  are,  as  usual, 
giving  their  newcomers  the  opportunity  of  hearing 
the  stimulating  experience  of  veterans  in  the 
profession.  


Dr.  Wilfrid  Ombler  Meek  died  with  tragic 
suddenness  on  Sept.  14th  at  the  Brompton  Hos- 
pital Sanatorium,  Frimley,  where  he  had  long 
been  resident  medical  officer.  He  was  in  his 
fortieth  year.  


The  inaugural  sessional  address  at  the  Pharma- 
ceutical Society  of  Great  Britain  will  be  given  on 
Wednesday,  Oct.  1st,  at  3 p.m.,  by  Mr.  W.  J.  Uglow 
Woolcock,  M.P.,  at  the  School  of  Pharmacy, 
17,  Bloomsbury-square,  London,  W.C. 


University  of  London:  Lectures  in  Advanced 
Physiology,  1919-1920. — The  following  are  recognised  as 
advanced  lectures  which  a candidate  at  the  B.Sc.  Honours 
examination  may  name  for  part  of  his  examination.  Kind’s 
College,  1st  term  Dr.  Da  Fano:  Histology  of  the  Nervous 
System.  Ten  lectures  at  4.30  p.m.  on  Tuesdays,  beginning 
Oct.  7th.  King’s  College  for  Women,  3rd  term  : — Dr.  E. 
Mellanby:  Nutrition.  Eight  lectures  at  5 p.m.  on  Mondays 
and  Wednesdays.  St.  Bartholomew’s  Hospital,  2nd  term  : — 
Mr.  J.  W.  Trevan  : The  Reaction  of  the  Blood  and  Acidosis. 
Eight  lectures  at  4.30  p.m.,  on  Wednesdays.  Guy’s  Hospital, 
2nd  term:-  Dr.  M.  S.  Pembrev  and  Dr.  J.  H.  Kyffel:  The 
Regulation  of  Respiration.  Eight  lectures  at  4.30  p.m.  on 
Thursdays.  The  precise  dates  of  delivery  will  be  announced 
later,  as  will  also  the  place  of  delivery  of  the  following: 
2nd  term  : — Mr.  W.  L.  Symes  : Physiologically  Balanced 
Solutions.  Eight  lectures  at  5 p.m. on  Tuesdays.  3rd  term: — 
Mr.  J.  A.  Gardner:  The  Bio-chemistry  of  Sterols.  Eight 
lectures  at  5 p.m.  on  Tuesdays.  At  the  imperial  College  of 
Science  and  Technology  during  the  1st  term  Professor  A.  D. 
Waller  will  deal  with  the  Energy  Balance  of  the  Human 
Body  and  Electrical  Signs  of  Emotive  Phenomena  at  5 p.m. 
on  Wednesdays,  beginning  on  Oct.  15th,  but  these  lectures 
do  not  count  for  examination.  Intercollegiate  courses  also 
approved  for  the  Honours  B.Sc.  examination  will  be 
delivered  at  University  College  during  the  1st  term  by 
Professor  Bayliss  on  Physical  Chemistry  in  Relation  to 
Physiology  ; and  during  the  3rd  term,  at  King’s  College,  by 
Professor  Halliburton  and  Dr.  Rosenheim,  on  Advanced 
Chemical  Physiology;  at  Bedford  College,  on  Advanced 
Practical  Histology ; at  St.  Bartholomew’s  Hospital,  by 
Professor  F.  A.  Bainbridge,  on  Electrical  Changes  on  Skeletal 
and  Cardiac  Muscle  (practical  work) ; and  during  the  2nd 
term  at  Guy’s  Hospital,  on  Practical  Work  on  Respiration. 
Further  information  may  be  obtained  from  the  heads  of  the 
laboratories  in  which  the  lectures  are  given,  and  in  the  case 
of  courses  by  Professor  Waller,  Mr.  Gardner,  and  Mr.  Symes, 
from  Professor  Waller,  Physiological  Laboratory,  University 
of  London,  South  Kensington,  S.W.  7. 


THE  INDUSTRIAL  EMPLOYMENT  OF 
MOTHERS: 

FRENCH  AND  GERMAN  EXPERIENCES. 


An  account  has  been  given  of  the  steps  which  were  taken 
during  the  war  for  protecting  the  welfare  of  the  children  of 
women  employed  in  factories  in  France  and  Germany  in  a 
report  which  was  issued  a short  time  ago,  and  which  was 
prepared  in  the  Intelligence  Department  of  the  Local 
Government  Board.  The  infant  welfare  work  which  has 
been  done  in  these  countries  is  suggestive.  A short  descrip- 
tion of  it  may  be  useful  so  as  to  enable  a comparison  to  be 
made  with  similar  work  in  England. 

France. 

In  France,  as  in  this  country,  women  were  extensively 
employed  in  factories  and  on  munition  work,  and  attention 
was  aroused  to  the  dangers  of  such  employment  for 
the  health  of  the  mothers  and  infants.  Statistics  compiled 
from  the  weekly  bulletins  of  municipal  statistics  for  Paris 
showed  that  during  the  second  year  of  the  war,  as  com- 
pared with  the  first,  there  wa3  an  increase  in  the  percent- 
age of  stillbirths  and  cases  of  maternal  mortality,  and  in  the 
number  of  abandoned  infants.  The  number  of  premature 
births  had  also  increased.  There  was  a vigorous  discussion 
on  the  subject  in  the  Academy  of  Medicine  in  December, 
1916,  as  an  outcome  of  which  a committee  was  appointed  to 
consider  the  matter.  The  resolutions  which  were  passed  were 
strongly  supported  by  the  Ministry  of  Labour,  the  Ministry 
of  the  Interior,  and  the  Ministry  of  Munitions.  The  need 
was  emphasised  for  the  compulsory  establishment,  in  every 
war  factory  where  women  were  employed,  of  a nursing 
room  furnished  with  cradles  and  reserved  exclusively  for 
breast-fed  infants.  It  was  held  that  the  mothers  should  be 
allowed  to  attend  to  their  infants  during  working  hours 
without  any  loss  of  wages.  They  should  be  employed  on 
day  shifts  only.  There  should  be,  in  addition,  a creche  for 
artificially-fed  infants  and  a day  nursery  for  children  up  to 
4 years  of  age  attached  to  each  factory,  or  to  a group  of 
factories,  and  in  factories  where  a number  of  women  were 
employed  a welfare  supervisor  should  be  appointed,  whose 
duties  and  functions  should  be  similar  to  those  of  welfare 
workers  in  English  factories. 

The  vital  need  for  breast-feeding  was  so  well  recognised 
that  in  August,  1917,  a law  was  passed  under  which 
certain  amendments  were  made  in  and  clauses  added  to 
the  second  book  of  the  Industrial  Code.  These  clauses 
provided  that  two  periods  of  30  minutes  each  were  to 
be  allowed  during  working  hours,  and  in  addition  to 
the  usual  rest-periods,  to  nursing  mothers  to  breast-feed 
their  infants  up  to  1 year  of  age,  and  they  were  to  be 
allowed  to  attend  to  their  infants  on  the  premises.  Whether 
this  law  was  complied  with  was  a debated  point.  M.  Pinard 
reported  to  the  Academy  of  Medicine  that  the  effect  was 
nil  and  that  the  measures  for  the  protection  of  expectant 
mothers  existed  only  “on  paper.” 

The  need  for  creches  and  day  nurseries  for  the  children 
of  women  workers  was  also  recognised.  In  1897  the  creche 
was  legally  defined  as  “an  establishment  for  the  hygienic 
and  moral  care  of  infants  until  they  have  reached  their  third 
year.”  Creches  might  be  opened  only  on  the  authorisation 
of  the  prefect,  and  were  to  be  subject  to  inspection  by 
persons  appointed  for  the  purpose,  either  by  the  Minister  of 
the  Interior  or  by  the  prefect.  A report  on  the  working  of 
the  creche,  and  a medical  report,  had  to  be  submitted  to  the 
prefect  each  year,  and  he  had  power  to  order  a creche  to  be 
closed  if  he  considered  the  arrangements  defective.  Later 
in  the  same  year  it  was  made  obligatory  for  every  creche  to 
be  supervised  by  a doctor  ; and  no  infant  could  be  received 
at  a creche  without  a medical  certificate  showing  that  it  was 
free  from  infectious  disease.  During  the  war  the  creches  in 
France  have  had  to  contend  with  many  difficulties  and 
anxieties,  among  which  were  scarcity  of  milk,  high  price  of 
food  and  coal,  lack  of  funds,  difficulties  in  arranging 
for  medical  supervision  owing  to  the  mobilisation  of  so  many 
of  the  doctors,  and  difficulties  in  finding  a working  staff 
which  was  adequate  in  number  and  competence.  In  various 
industrial  regions,  however,  creches  were  established  in 
connexion  with  a factory  or  group  of  factories,  to  a very 
large  extent  by  the  employers  themselves.  Among  those 
specially  mentioned  in  the  report  are  Messrs.  Schneider  at 


Thb  Lancet,] 


SCHOOL  MEDICAL  INSPECTION,  1918. 


[Sept.  20,  1919  541 


Creusot,  the  Chattillon-Commentry  Works  at  Montluyon, 
the  ‘‘Comit6  des  Forges” — a federation  of  nearly  60 
employers’  associations  representative  of  the  metal,  electrical, 
mechanical  construction,  railway  material,  and  other 
industries — and  other  employers  in  Basse  Indre,  Saint 
Etienne,  in  the  india-rubber  industry  of  Auvergne,  Clermont, 
Thiers,  and  the  neighbouring  district.  A group  of  firms 
formed  an  association  at  Levallois  Ferret  and  Neuilly,  and 
erected  a model  building,  the  cost  of  the  building  beiDg 
met  by  the  employers  themselves.  Similar  measures  were 
carried  out  elsewhere.  The  manner  in  which  the  employers 
have  organised  and  assisted  in  providing  these  institutions 
is  remarkable. 

The  creches  receive  grants  from  the  State,  Department,  or 
Municipality,  from  two,  or  even  from  all  three  ; some,  how- 
ever, receive  no  grant  from  public  funds.  In  many  creches 
a small  charge  is  made  to  the  mothers  for  each  child  cared 
for,  more  as  a matter  of  principle  than  for  the  money 
obtained.  Children  of  2 years  of  age  can  be  sent  to 
infant  schools  or  cared  for  in  day  nurseries  (garderies). 
A day  nursery  becomes  an  infant  school  if  any  instruction  is 
given,  and  is  subject  to  inspection  by  the  education  authority, 
and  becomes  a creche  if  children  under  2 years  are 
admitted. 

The  French  working  woman  appears  to  be  more  prejudiced 
than  her  English  sister  where  creches  and  similar  institu- 
tions are  concerned,  preferring,  in  many  cases,  to  leave  her 
children  with  foster-mothers.  Some  thick  the  infants 
would  thus  be  better  cared  for,  others  regard  it  as  more 
respectable  to  leave  their  children  with  neighbours  than  take 
them  to  a free  creche. 

French  women  have  long  been  accustomed,  as  a rule,  to 
send  their  children  to  be  cared  for  in  country  villages  by 
foster  mothers,  often  arranging  for  them  to  be  breast-fed. 
The  mortality  among  these  children  was  at  one  time  extremely 
high,  and  for  their  protection  in  1874  the  “ Loi  Roussel” 
was  passed,  which,  among  other  provisions,  stipulated  that  a 
record  should  be  kept  of  all  facts  connected  with  the  board- 
ing-out of  infants,  and  that  the  children  should  be  examined 
medically  from  time  to  time.  It  was  realised,  however,  that 
the  protection  afforded  by  this  law  was  not  sufficient,  and 
infant  welfare  consultations  were  set  up  in  a number  of  Depart- 
ments to  which  foster-mothers  wereencouraged  tobringchildren 
under  their  care  for  medical  supervision,  advice,  and  help. 
In  the  Department  of  Seine  et  Oise  there  were  in  1914  nearly 
100  consultations.  In  1917  a report  for  this  department  stated 
that  of  4893  infants  attending  only  192  died  before  reaching 
1 year  of  age — a mortality  rate  of  39  per  1000,  the  general 
infant  mortality  rate  for  the  department  in  1916  beiDg  67  per 
1000,  as  compared  with  73  per  1000  in  1913.  In  estimating 
the  value  of  these  consultations  it  should  be  realised  that, 
where  attendance  is  voluntary,  the  best  mothers  and  foster- 
mothers  attend  in  greater  numbers  than  others,  and  among 
their  children,  or  the  children  in  their  care,  the  infant 
mortality-rate  would  naturally  be  lower  than  the  general 
infant  mortality-rate  of  the  Department. 

Germany. 

The  infants  of  mothers  working  in  factories  in  Germany 
have  usually  been  cared  for  in  creches  or  infants’  homes  and 
the  children  below  school  age  in  day  nurseries,  whilst  for 
children  of  school  age  “ day  shelters  ” were  provided  where 
they  could  spend  their  free  time  until  their  mothers  returned 
from  work.  During  the  war  the  number  of  creches  and  day 
nurseries  greatly  increased.  Many  were  carried  on  by 
municipal  authorities,  and  creche  associations  and  other 
organised  bodies  made  considerable  efforts  to  extend  the 
existing  accommodation  and  open  new  creches.  In  many 
cases  it  was  found  necessary  to  open  the  creches  earlier  and 
close  them  later,  and  often  to  keep  them  open  all  night. 
Among  the  many  difficulties  experienced  were  the  scarcity 
of  food,  soaps,  and  rubber  teats.  At  the  end  of  1916  the 
“ Central  Office  for  Women’s  Employment”  was  set  up  within 
the  War  Bureau  and  placed  under  the  direction  of  an 
experienced  medical  woman.  Amongst  the  duties  attached 
to  the  office  was  that  of  suggesting  and  carrying  out 
measures  for  the  protection  and  well-being  of  the  women, 
and  of  seeing  that  the  children  did  not  suffer  on  account  of 
the  employment  of  their  mothers. 

The  large  associations  interested  in  welfare  work  among 
women  and  children  were  appealed  to,  and  in  January,  1917, 
was  formed  the  “National  Committee  for  Women’s  War 


Work,”  which,  together  with  the  “Central  Office  for  Women’s 
Employment  ” and  various  local  committees,  was  responsible 
for  much  of  the  welfare  work  which  was  carried  out  during 
the  war.  In  Germany  the  general  feeling  appeared  to  be  in 
favour  of  boarding-out  the  children  in  suitable  foster  homes 
rather  than  of  placing  them  in  institutions.  The  creches, 
day  nurseries,  and  day  shelters  received  financial  support 
from  (1)  private  contributions  ; (2)  payments  by  mothers  ; 
(3)  municipal  grants  (many  creches  being  supported 
entirely  by  municipalities,  who  in  their  turn  received 
Imperial  and  State  aid) ; (4)  Imperial  funds  (half  to  two- 
thirds  of  any  expenditure  on  war  relief)  ; (5)  State  aid  ; 

(6)  State  insurance  institutions,  &c.  (fire  insurance  societies 
have  contributed  on  the  ground  that  children  left  at  home 
without  supervision  are  frequently  the  cause  of  fires)  ; and 

(7)  contributions  from  employers.  Under  the  Imperial 
Industrial  Law  women  workers  in  factories  were  forbidden  to 
work  on  night  shifts,  their  working  day  was  limited  to  ten 
hours,  and  they  could  not  be  employed  for  a fortnight  before 
or  six  weeks  after  confinement.  By  an  emergency  law  of 
August  4th,  1914,  the  Imperial  Chancellor  was  given  power 
to  suspend  some  of  the  provisions  of  the  industrial  law, 
among  others  those  relating  to  women’s  labour.  The 
result  appears  to  have  been  very  serious,  long  hours, 
and  night  shifts  becoming  general,  and  in  some  cases  it  was 
stated  that  women  were  being  kept  at  work  in  factories  for 
24  hours  at  a stretch,  and  in  mines  for  36  hours,  without  a 
proper  rest.  Representations  to  the  Government  seem  merely 
to  have  called  forth  circulars  from  the  War  Bureau  at 
intervals  in  1917,  urging  the  responsible  officials  in  various 
districts  to  do  all  they  could  to  bring  about  improvements. 
The  condition  of  women  workers  appears  to  have  been  much 
worse  in  Germany  than  either  in  France  or  England. 

The  original  report  contains  an  immense  amount  of 
information  and  a wealth  of  detail,  and  is  well  worth 
careful  study. 


SCHOOL  MEDICAL  INSPECTION,  1918. 


Birmingham — Bristol — Hull — Liverpool — 
Nottingham — Sheffield. 

For  the  city  of  Birmingham  the  report  of  the  medical 
officer  dealing  with  health  conditions  in  schools  is  very  brief, 
owing  to  conditions  connected  with  the  war.  The  total 
number  of  children  medically  examined  was  35,269  ; 2314 
were  treated  for  scabies  and  1021  for  throat  affections 
(enlarged  tonsils  and  adenoids).  A school  for  physically 
defective  children  and  an  open-air  school  at  Uffculme  have 
been  carried  on  with  much  benefit  to  the  children  admitted. 
Dr.  Lewis  Graham  alludes  in  his  report  to  the  important 
results  likely  to  be  obtained  in  the  nursery  schools,  for  the 
accommodation  of  children  between  2 and  5 years  of  age,  that 
are  to  be  established  according  to  Section  19  of  the  Educa- 
tion Act  (1918).  It  is  stated  that  “ the  number  of  children 
reported  as  necessitous  and  in  need  of  food  ” decreased 
during  1918.  Actual  ratios  of  malnutrition  are  not  supplied. 
Considering  the  circumstances  of  the  times  this  is  to  be 
regretted. 

At  Bristol  the  work  has  been  considerably  interfered  with 
by  changes  in  the  medical  staff,  due  to  the  war ; school 
attendance  was  also  interrupted  by  an  outbreak  of  influenza 
in  October  and  November.  On  the  other  hand,  by  an 
augmentation  of  the  nursing  staff  more  frequent  supervision 
in  the  schools,  and  a better  following  up  of  the  children  at 
their  homes  has  become  possible.  A new  central  clinic  has 
been  opened,  which  is  stated  to  be  a great  improvement  on 
former  arrangements.  Routine  inspection  of  infants  had  to 
be  given  up,  only  special  cases  of  “ailing  children  ” brought 
forward  by  the  head  teachers  being  examined.  The  total 
number  examined  in  the  code  groups(intermediate  and  leavers) 
was  9121.  The  nutrition  of  the  children  appears  to  have  been 
satisfactory;  only  Oil  per  cent,  were  considered  to  be 
actually  badly  nourished,  and  3-43  per  cent,  “below  normal.” 
The  clothing  and  footgear  were  also  satisfactory  in  all  except 
1-32  per  cent,  for  the  former  and  186  for  the  latter. 
Cleanliness  was  satisfactory  in  98  95  per  cent,  for  the  body, 
and  96-70  per  cent,  for  the  head.  A new  clinic  has  been 
opened  for  minor  ailments  in  Portland-square,  which  has 
already  proved  to  be  of  great  benefit,  27,109  attendances 
having  been  recorded  during  the  year.  Dr.  Percy  Stocks,  the 


542  The  Lancet,] 


SCHOOL  MEDICAL  INSPECTION,  1918. 


[Sept.  20, 1919 


acting  school  medical  officer,  draws  attention  to  the 
prevalence  of  tuberculosis,  of  which  503  cases  among 
school  children  had  been  treated  during  the  year  at  the 
Tuberculosis  Dispensary,  410  being  pulmonary  ; the  propor- 
tion found  at  the  routine  inspection  was  0 72  per  cent. , the 
lungs  being  affected  in  0 69  percent.  ; an  increase  in  open- 
air  school  accommodation  is  recommended,  and  measures  are 
now  being  taken  to  carry  this  out.  Open-air  classes  where 
practicable,  summer  camps,  and  organisation  of  boy  scout 
troops  in  connexion  with  the  schools  are  other  excellent 
recommendations.  The  only  epidemic  prevalence  of  import- 
ance was  that  of  influenza  ; 70  cases  were  fatal.  Scabies 
was  diagnosed  in  only  10  children  at  the  routine  examina- 
tions (O  il  per  cent.),  but  491  other  children  of  various  ages 
were  found  to  be  suffering  from  the  disease  and  were  treated 
at  the  clinics  ; in  1915  there  had  been  only  53  cases 
altogether.  Impetigo  also  increased  from  228  cases  treated 
in  1915  to  752  cases  in  1918. 

At  Hull  the  number  of  children  examined  in  the  code 
groups  was  9769  ; the  nutrition  is  considered  to  have  been 
“extremely  satisfactory,”  0 26  per  cent,  only  having  been 
classed  as  “ bad  ” and  11  24  per  cent,  as  below  normal.  These 
figures  should  be  compared  with  those  of  1913,  just  before 
the  war,  when  0 27  per  cent,  were  found  to  be  badly 
nourished  and  14-12  below  normal.  Dinners  were  provided 
according  to  an  excellent  diet  table ; on  account  of  the 
coupon  difficulty  no  meat  was  given,  but  a menu  of  soup, 
suet  pudding,  lentil  pie,  &c.,  gave  a daily  average  of  proteid 
0 6 oz.,  fat  1-6  oz.,  and  carbohydrate  3-3  oz.  per  head.  The 
education  committee  now  provide  spectacles  for  any  child 
that  requires  them  if  they  have  not  been  obtained  within 
three  months  of  the  examination  when  the  eyesight  was  found 
to  be  defective  ; in  the  case  of  necessitous  parents  no  charge 
is  made,  in  other  cases  the  cost  is  recovered.  A large  number 
of  cases  (541)  of  ringworm  of  the  scalp  were  treated,  a con- 
siderable increase  on  the  number  (317)  in  the  previous  year  ; 
398  children  were  cured,  with  an  average  treatment  through 
ten  weeks  (if  the  attendance  was  regular).  A great  increase 
of  scabies  has  occurred  ; in  1914  there  were  296  cases,  in 
1917  there  were  1056,  and  in  1918,  1442  cases  ; the  average 
period  of  absence  from  this  cause  was  85  weeks;  the  inter- 
ference with  education  is  obvious.  Disinfection  of  the  houses 
and  bedding  has  been  carried  out,  but  there  is  no  power  to 
insist  on  the  treatment  of  any  person  over  school  age,  and, 
of  course,  reinfection  occurs.  Pulmonary  tuberculosis  was 
found  in  16,  and  suspected  in  61  children  in  the  three  code 
groups  ; in  addition,  21  children  specially  examined  were  con- 
sidered to  be  positively  affected,  and  77  others  were  suspected 
to  be  suffering  from  the  disease.  Two  epidemics  of  influenza 
occurred  in  1918,  one  in  June  and  July,  the  second  (more 
severe)  in  October  and  November,  causing  great  disturb- 
ance of  school  work.  Dr.  James  Fraser,  the  school  medical 
officer,  does  not  consider  school  closure  to  be  of  use  in 
limiting  spread  of  the  disease. 

The  work  of  medical  inspection  in  Liverpool  schools  was 
considerably  interfered  with  by  a severe  outbreak  of  influenza 
in  the  autumn,  necessitating  school  closure  for  four  weeks  ; 
medical  treatment  was  only  slightly  interrupted.  The  total 
number  of  children  examined  in  the  code  groups  was  24,252. 
Actual  malnutrition  was  only  present  in  0-132  per  cent.  ; in 
0-334  per  cent,  the  child’s  nutrition  was  not  satisfactory, 
without  being  actually  in  need  of  treatment.  Scabies  is 
stated  to  have  been  very  prevalent  (1179  cases,  as  compared 
with  512  in  1916  and  851  in  1917,  p.  5 of  report  ; in 
Table  II.,  p.  17,  it  is  stated  that  44  cases  were  found  among 
the  code-group  children  and  49  among  those  specially 
examined) ; the  need  for  suitable  facilities  for  treatment  is 
urgent.  Baths  and  disinfectants  are  required.  “Approxi- 
mately 500  children  were  away  from  school  at  the 

end  of  the  year  with  this  disease The  gain  in 

increased  Government  grant  would  probably  more  than 
make  up  for  the  cost  of  installation  and  administrative 
expenses  of  the  special  centre  or  centres.”  Arrangements 
were  made  for  the  special  inspection  of  children  absent 
from  school  for  a long  time,  such  as  cases  of  ringworm,  of 
phthisis  or  other  tuberculous  infection,  &c.  3988  children 

were  examined,  of  whom  1111  were  found  fit  to  attend 
school.  With  regard  to  operation  for  adenoids  and  enlarged 
tonsils,  Dr.  E.  W.  Hope,  who  presents  this  report,  notes  that 
in  37  cases  (4  per  cent.)  haemorrhage  occurred,  and  in  11 
instances  it  was  necessary  to  keep  the  children  at  the  clinic 
for  two  nights  instead  of  one.  “Experience  has  proved 


the  desirability  of  not  allowing  any  children  to  return  home 
until  the  following  day,  as  it  is  quite  impossible  to  forecast 
which  children,  if  any,  are  likely  to  suffer  from  haemorrhage 
or  collapse.”  This  is  a very  wise  precaution,  not  always 
adopted.  Two  outbreaks  of  influenza  during  the  year  made 
the  closing  of  several  schools  necessary— 16  in  July,  27  in 
September ; and  at  the  beginning  of  October  all  the 
elementary  schools  in  the  city  were  closed  for  a month. 

In  an  introductory  letter  to  the  education  committee  of  the 
corporation  of  Nottingham,  Dr.  Philip  Boobbyer,  the  medical 
officer  of  health  for  the  city  and  superintendent  medical 
officer  of  schools,  refers  to  the  need  for  radical  improvement 
in  the  conditions  of  life  of  the  industrial  classes,  especially 
in  the  densely  populated  urban  districts,  which  has  been 
brought  home  to  everyone  by  the  large  proportion  of  men  of 
military  age  who  have  been  found  unfit  for  military  service. 
This  is  largely  the  result  of  heredity,  but  improvements  in 
the  conditions  of  the  working  classes  in  our  great  cities  are 
more  practicable  at  the  present  time  than  any  attempt  at 
restrictions  on  matrimony  for  eugenic  reasons.  The  pro- 
vision of  better  dwellings  is  of  the  first  importance,  and  as 
regards  the  elementary  school  child  the  open-air  schools 
have  done  excellent  service.  The  number  of  children 
inspected  in  the  code  groups  was  5137,  all  entrants,  no 
leavers  being  examined.  This  was  on  account  of  ill-health 
of  the  staff,  the  prevalence  of  epidemic  disease,  and  school 
closure  for  various  reasons  ; but  a large  number  of  other 
children  (7255)  were  examined  as  special  cases  at  the 
clinics.  Malnutrition  was  present  in  132  cases  (2-56  per 
cent.),  and  in  addition  210  per  cent,  were  not  con- 
sidered satisfactory  in  this  respect.  Scabies  was  not 
excessively  prevalent  (58  cases,  1-12  per  cent.)  in 
the  children  of  the  age-group  examined,  but  altogether 
843  children  were  under  treatment,  of  whom  72  per 
cent,  were  cured.  Dr.  E.  M.  Wyche,  the  senior  school 
medical  officer,  refers  tc  the  difficulties  attending  treatment, 
and  the  immense  loss  of  school  time  involved,  chiefly  owing 
to  repeated  reinfection  at  the  home.  The  matter  is  of 
serious  importance  : the  total  number  of  children  excluded 
school  for  all  causes  during  1918  was  1650,  with  a loss 
of  83,369  school  days.  841  of  these  children  were  excluded 
for  scabies,  and  39,652  actual  school  days  were  lost  for  this 
reason,  involving  a loss  of  £413  attendance  grant.  This  is 
an  excellent  use  of  the  argumentv.m  ad  orumenam,  which 
might  well  be  applied  to  the  negligent  parents.  Ringworm 
has  been  most  successfully  treated  by  the  education  com- 
mittee’s X ray  department,  192  children  having  been  treated 
during  the  year  without  a single  failure  : radiant  heat  has 
been  used  to  restore  the  growth  of  the  hair,  also  for  alopecia 
areata.  Open-air  education  is  carried  on  in  several  of  the 
recreation  grounds  and  open  spaces  in  the  city,  and  seven 
open-air  class  rooms  have  been  erected  for  specially  selected 
delicate  children.  The  work  of  medical  inspection,  treat- 
ment, and  after-care,  is  evidently  carried  out  with  great 
thoroughness  and  enthusiasm  in  the  city  of  Nottingham. 

Owing  to  the  absence  of  12  medical  officers  on  military 
service  routine  medical  inspection  was  suspended  in  Sheffield 
during  1918,  but  16,956  “ selected  cases  ” were  examined  in 
school,  as  well  as  over  25,000  at  the  various  clinics.  Mal- 
nutrition was  only  found  in  28  children,  and  in  six  others 
the  nutrition  was  not  satisfactory.  Dr.  Thomas  Cbetwood, 
the  school  medical  officer,  referring  to  this  question  of  nutri- 
tion, states  that  during  1918  there  was  a decided  improve- 
ment, as  shown  by  the  weights  of  the  children  (taken 
regularly  every  six  months).  The  total  number  of  dinners 
and  breakfasts  served  at  the  feeding  and  school  centres  was 
89,733,  being  a decrease  of  54,474  on  the  number  provided 
in  1917.  Scabies  is  reported  in  2304  children.  The  method  of 
treatment  is  described  by  Dr.  E.  F.  Skinner.  It  was  extremely 
thorough  and  yet  simple.  The  parent  is  instructed  to  attend 
at  the  cleansing  station  at  a fixed  time  and  to  bring  a set  of 
clean  underclothing  (in  addition  to  the  clothes  worn  by  the 
child).  The  child  is  undressed,  and  both  sets  of  clothing  sub- 
mitted to  steam  sterilisation  for  an  hour  while  the  child  is  being 
treated.  After  rubbing  down  with  soft  soap  the  child  is  placed 
in  the  bath  for  20  minutes  and  well  rubbed  with  a loofah  ; 
after  the  bath  the  skin  is  rubbed  with  sulphur  ointment,  the 
cleansed  and  sterilised  clothing,  powdered  with  sulphur,  is 
put  on,  and  the  child  leaves,  taking  another  set  of  sterile 
clothes  with  it.  Printed  instructions  and  sulphur  ointment 
and  powder  are  given  to  the  parent,  who  is  told  to  repeat  the 
process  each  day.  The  children  are  seen  by  the  doctor  at 


The  Lancet,] 


SCOTLAND. 


[Sept.  20,  1919  543 


the  end  of  a week,  and,  if  fit,  are  sent  back  to  school.  “ The 
treatment  is  simple,  and  its  efficiency  has  been  abundantly 

proved  by  this  year’s  experience The  average  time  of 

exclusion  is  only  1198  days.”  With  ordinary  treatment  at 
home  with  ointment,  the  average  absence  has  been  56  days. 
The  secret  of  successful  treatment  is  to  take  all  the  infected 
children  in  a family  at  the  same  time,  but  a large  measure  of 
success  depends  on  the  efficacy  of  the  rubbing. 


SCOTLAND. 

(From  our  own  Correspondent.) 

The  Public  Health  ( Pneumonia , Malaria , Dysentery , fio. ) 

Regulations  ( Scotland ),  1919. 

This  Order  is  closely  similar  to  that  issued  in  February 
last  by  the  English  Local  Government  Board.1  It  makes 
notifiable  all  cases  of  malaria,  dysentery,  trench  fever, 
acute  primary  pneumonia,  and  acute  influenzal  pneumonia. 
Notification  is  not  required  in  cases  of  malaria,  dysentery, 
or  trench  fever,  which  to  the  practitioner’s  knowledge  have 
been  already  notified  within  the  preceding  six  months. 
The  medical  officer  of  health  for  the  district,  on  receiving 
the  notification,  is  to  take  any  necessary  steps  to  prevent 
the  spread  of  the  disease.  He  is  to  forward  to  the  Board  the 
name  and  address  of  the  patient  in  cases  of  (a)  trench  fever  ; 
(b)  malaria,  where  the  infection  was  apparently  contracted 
in  this  country  ; and  (0)  dysentery.  The  Order  proceeds  : — 

Malaria.—  The  M.O.H.  is  to  take  steps  to  see  that  the  person 
affected  is  supplied  with  efficient  mosquito  netting,  receives  necessary 
quinine  treatment,  receives  proper  advice  as  to  the  continuation  of 
quinine  treatment  in  order  to  prevent  relapses,  and  advice  as  to 
precautions  to  prevent  the  spread  of  infection.  On  the  occurrence  of 
two  or  more  cases  in  a district  where  the  disease  appears  to  have  been 
locally  contracted  the  local  authority  may,  and  if  required  by  the 
Board  shall,  appoint  and  pay  an  approved  medical  practitioner  to 
make  systematic  visits  to  houses  where  the  disease  has  occurred,  and 
offer  to  examine  therein  persons  suspected  of  being  infected  with 
malaria,  examining  the  blood,  and  further  making  certain  that  proper 
treatment  and  preventive  measures  are  being  carried  out. 

Dysentery. — The  M.O.H.  may  give  notice  in  writing  that  until 
further  written  notice  the  person  specified  shall  discontinue  any 
occupation  connected  with  the  preparation  or  handling  of  food 
or  drink  for  human  consumption,  that  children  of  or  in  the 
care  of  the  said  person  shall  not  be  sent  to  school,  and 
that  certain  specified  measures  are  taken  for  the  destruction  of 
excreta  and  prevention  of  infection.  If  the  M.O.H.  suspects  that  any 
person  employed  in  the  preparation  or  handling  of  food  or  drink  for 
human  consumption  is  a carrier  of  dysentery  he  may  give  notice  In 
writing  to  the  manager  of  the  trade  or  business  concerned,  certifying 
that  for  prevention  of  the  spread  of  disease  he  considers  it  necessary 
to  make  a clinical  examination  of  such  suspected  person,  and  the 
manager  and  all  other  persons  concerned  shall  give  to  the  M.O.H.  all 
reasonable  assistance.  If  the  suspected  person  be  found  to  be  a 
dysentery  carrier  notice  may  be  given  to  the  person  and  to  the 
manager  of  the  trade  or  business,  with  a view  to  preventing  the 
employment  of  the  said  person  in  that  or  any  other  business  con- 
cerned with  the  preparation  or  handling  of  human  food  for  a specified 
period. 

Trench  fever.— Special  measures  are  to  be  taken  for  the  destruction  of 
lice,  and  inmates  of  the  house  may  be  temporarily  segregated  until  their 
clothing  has  been  completely  freed  from  vermin. 

In  the  case  of  enteric  fever  the  regulations  are  the  same  as 
for  dysentery.  Where  typhus  fever  or  relapsing  fever  is 
found,  the  names  of  infected  persons  are  to  be  transmitted 
to  the  Board,  and  the  same  measures  for  the  destruction  of 
lice  as  in  trench  fever  are  applicable.  Expenses  incurred  by 
the  Medical  Officer  of  Health  are  to  be  defrayed  by  the  local 
authority  concerned,  and  they  may  also  provide  medical 
assistance  where  necessary  in  cases  of  the  diseases  specified. 

Organised  Health  in  Edinburgh. 

Some  extremely  interesting  facts  and  figures  are  contained 
in  a report  prepared  by  Councillor  J.  A.  Young,  L.D.S., 
convenor  of  the  Public  Health  Committee  of  Edinburgh 
Town  Council,  on  the  progress  of  health  administration  in 
the  city.  The  first  record  available  regarding  public  health 
work  is  dated  1812-13,  when  the  Police  Commissioners 
undertook  the  scavenging  of  the  city,  the  watering  of  the 
streets,  and  the  building  and  maintenance  of  public  con- 
veniences. The  cholera  epidemics  in  the  early  part  of  the 
century  seem  to  have  been  dealt  with  by  voluntary  workers 
in  special  hospitals,  but  it  was  not  until  the  outbreak  of  1866 
that  a hospital  was  provided  at  public  expense.  There  was 
not  until  1870  any  public  provision  for  the  treatment  of 
infectious  diseases,  and  at  that  date  it  was  only 
furnished  for  cases  of  small-pox.  The  late  Sir  Henry 

1 The  Lancet,  1919,  i.,  303,  309. 


Littlejohn  was  appointed  medical  officer  of  health 
in  1862,  and  immediately  undertook  a thorough  survey 
of  the  sanitation  of  the  city.  His  report  was  published  in 
1865,  and  taking  the  figures  for  1863,  it  gives  a picture  of 
the  actual  condition  of  affairs  at  the  time  of  the  formation  of 
the  department.  In  1861  the  population  of  the  city  was 
170,444,  and  the  death-rate  25  88  per  1000;  in  1911  the 
figures  were  320,829  and  14  39  respectively,  this  reduction 
in  the  death-rate  being  equivalent  to  the  saving  of  3673  lives 
per  annum  on  the  increased  population.  Deaths  under 
5 years  of  age  show  an  enormous  reduction,  from  93  -29  per 
1000  living  in  1863  to  33  6 per  1000  in  1913.  In  1863  the 
death-rate  from  zymotic  diseases  was  equal  to  6-23  per 
1000;  in  1913  to  0-87;  many  of  the  diseases  then 
chiefly  responsible — cholera,  typhus,  &c. — have  now  practi- 
cally disappeared.  The  phthisis  death-rate  in  1863  was 
2-54  per  1000  ; in  1913  the  figure  was  1-13.  The  general 
sanitary  condition  of  the  city  shows  corresponding  im- 
provement. In  1863  the  most  densely  crowded  district  had 
a population  of  646  persons  per  acre ; the  highest  figure 
at  the  present  day  being  343.  The  internal  condition  of  the 
tenements  in  1863  was  in  many  instances  appalling.  Sir 
Henry  Littlejohn  mentions  one  known  as  Middle  Mealmarket 
Stair,  in  which  248  persons  were  housed,  and  which  was 
unprovided  with  sink  or  water-closet.  Of  171  cow-byres 
then  existing,  110  were  below  human  dwellings,  and  many 
of  them  filthy  and  overcrowded,  with  the  cows  dying  off 
from  pleuro-pneumonia.  A comparison  of  the  finance  of  the 
department  shows  an  average  expenditure  for  the  last  nine 
years  of  £36,778,  as  compared  with  an  average  for  the  ten 
years  to  1889  of  £5365. 

Edinburgh  Royal  Infirmary  : Retirement  of  Professor  Willia/m 
Russell  and  Dr.  Graham  Brown. 

At  the  meeting  of  managers  held  on  Sept.  8th  special 
minutes  were  passed  expressing  regret  at  the  retirement  of 
Professor  William  Russell  and  Dr.  Graham  Brown,  and 
placing  on  record  the  valuable  services  which  these  gentle- 
men have  rendered  to  the  institution.  Professor  Russell 
first  became  a member  of  the  staff  in  1888,  when  he  was 
appointed  pathologist  to  the  infirmary,  a position  which 
he  held  for  four  years.  In  1891  he  became  assistant 
physician,  and  in  1907  full  physician  in  charge  of  wards. 
In  1913  he  was  appointed  by  the  University  the  first 
occupant  of  the  Moncrieff-Arnott  chair  of  Clinical  Medicine. 
In  all  these  positions  he  performed  his  duties  with  efficiency 
and  zeal,  and  in  consideration  of  his  eminent  services  the 
managers  of  the  Royal  Infirmary  have  appointed  him  a con- 
sulting physician  to  the  institution.  Professor  Russell’s 
successor  as  Moncrieff-Arnott  professor  of  Clinical  Medicine 
is  Dr.  F.  D.  Boyd,  whose  appointment  has  been  previously 
announced.  Dr.  Graham  Brown  was  appointed  assistant 
physician  to  the  infirmary  in  1897,  and  full  physician  in  1912. 
He  has  also  held  the  position  of  lecturer  on  neurology  in  the 
University  for  a number  of  years,  and  is  well  known  for  his 
special  ability  in  this  branch  of  medicine.  In  recognition  of 
his  services  to  the  institution  Dr.  Graham  Brown  was 
appointed  a consulting  physician  to  the  Royal  Infirmary. 

Criminal  or  Spontaneous  Abortion  ? 

On  Sept.  9th  and  10th,  in  the  High  Court  of  Justiciary  at 
Edinburgh,  a woman  was  tried  for  causing  the  death  of  a 
young  clerkess  by  performing  an  illegal  operation.  The  case 
is  of  interest  from  the  fact  that  the  deceased,  who  was  about 
four  months’  pregnant,  had  placenta  prasvia,  and  also  because 
of  the  absence  of  any  wound  of  the  private  parts,  and  the 
assertion  of  the  Crown  that  the  attempted  abortion  had  been 
made  by  means  of  an  injection  into  the  womb  from  a 
Higginson’s  syringe.  At  the  post-mortem,  made  by  Professor 
Littlejohn  and  Dr.  Haig  Ferguson,  there  was  found  dilatation 
of  the  os  and  cervix,  absence  of  the  usual  plug  of  mucus 
in  the  cervix,  and  partial  detachment  of  the  placenta  around 
the  internal  os.  There  was  evidence  of  considerable  loss  of 
blood,  and  the  medical  witnesses  ascribed  death  to  haemorrhage 
and  shock.  All  the  internal  organs  were  healthy,  and  no 
other  conditions  to  account  for  death  were  found.  The 
deceased  went  by  arrangement  to  the  house  of  the  prisoner 
one  evening  about  5.30  ; she  was  then  in  good  health,  and 
there  was  no  history  of  previous  illness  or  haemorrhage.  She 
was  quite  well  at  9 P.M.  except  for  slight  sickness,  alleged 
to  be  due  to  some  strawberries  and  cream  which  she  had 
eaten  a short  time  earlier.  At  9 P.M.  deceased  went  to  bed 
and  the  prisoner  spent  a quarter  of  an  hour  with  her  alone. 


544  The  Lancet,] 


CANADA.— PUBLIC  HEALTH. 


[Sept.  20,  1919 


The  young  woman  then  became  ill,  vomited,  and  was 
collapsed,  and  died  about  11  P.M.  A Higginson’s  syringe  in 
a basin  of  water  was  seen  in  the  room  immediately  after 
the  prisoner  had  been  with  her.  Three  obstetricians 
who  appeared  for  the  defence  contended  that  the 
appearances  were  quite  consistent  with  impending  spon- 
taneous abortion.  The  jury  unanimously  found  the  prisoner 
guilty  of  culpable  homicide  and  she  was  sentenced  to 
five  years’  penal  servitude. 

Sept.  15th.  


CANADA. 

(From  our  own  Correspondent.) 

The  Health  Department  of  Canada. 

The  Hon.  Newton  W.  Rowell  has  been  placed  in  charge  of 
the  organisation  of  Canada’s  Department  of  Health,  author- 
ised by  special  legislation  at  the  last  session  of  Parliament. 
Dr.  John  Amyot,  who  has  been  appointed  Deputy  Minister, 
was  formerly  professor  of  hygiene  and  public  medicine  in 
the  University  of  Toronto.  The  new  department  is  taking 
over  from  other  departments  of  Government  administration 
those  branches  which  concern  the  health  of  the  people, 
such  as  quarantine,  marine  hospitals,  the  health  of  the 
Indians.  Immigration  was  the  first  to  be  brought  over  to  the 
new  department.  The  question  of  cooperation  with  the 
various  boards  of  health  of  the  different  provinces  is  claim- 
ing the  particular  attention  of  the  Deputy  Minister  with  a 
view  to  cooperation  in  the  campaign  against  venereal 
diseases.  The  policy  of  the  department  will  be  shortly 
announced  to  the  public. 

Hospitals  in  Montreal  and  Toronto. 

A number  of  citizens  have  become  interested  in  a new 
hospital  scheme  for  Montreal.  It  is  to  be  known  as  the 
St.  Mary’s  Memorial  Hospital,  and  is  to  perpetuate  the 
memory  of  relatives  who  lost  their  lives  in  the  Great  War. 
The  hospital  will  be  open  to  all  classes  and  creeds  in  the 
community.  An  appeal  for  funds  will  be  made  in  October. 
Many  Montreal  families  have  already  promised  to  endow 
beds.  Montreal  is  in  great  need  of  enlarged  hospital 
accommodation. 

Mr.  William  Ramsay,  formerly  a Toronto  wholesale 
merchant  and  director  of  many  commercial  concerns,  died 
recently  in  Scotland.  He  left  over  half  a million  dollars  to 
Toronto  charities — the  General  Hospital,  §10,000  a year  ; 
Home  for  incurables,  $5,000. 

Public  Welfare  in  Alberta. 

The  Department  of  Public  Health  of  Alberta  province, 
under  the  responsible  Minister,  Hon.  A.  G.  Mackay,  and 
Deputy  Minister,  Dr.  J.  T.  Norman,  has  recently  been  given 
power  by  the  Legislature  to  prevent,  mitigate,  or  suppress 
disease.  It  can  deal  with  all  epidemics,  and,  if  necessary, 
order,  in  the  case  of  small-pox,  general  vaccination  of  all 
communities  affected.  It  is  handling  the  venereal  diseases 
problems,  and  it  is  seeing  that  the  provisions  of  the  Pro- 
vincial Health  Act  are  applied  when  necessary. 

The  war  being  over,  the  Canadian  Public  Health  Association 
is  showing  signs  of  new  life.  Dr.  H.  E.  Young,  secretary  of 
the  Provincial  Board  of  Health  of  British  Columbia,  was 
elected  president  at  the  last  annual  meeting,  held  for  the 
present  year  in  Toronto.  Edmonton,  Alberta,  was  chosen  as 
the  place  of  meeting  in  1920.  Alberta  has  more  trouble  in 
health  matters  with  the  33  6 percent,  foreign- born  popula- 
tion than  with  the  remaining  66  4 per  cent.  British-born, 
owing  to  the  foreigners  holding  to  their  traditions  and 
refusing  to  adopt  up-to-date  methods  in  vogue  in  Canada. 

Toronto,  Sept.  1st. 


Educational  Grants  for  ex- Service  Men. — 
Under  the  Government  scheme  of  financial  assistance  for 
the  higher  education  of  ex-Service  officers  and  men  the  total 
number  of  grants  awarded  by  the  Board  of  Education  now 
amounts  to  9500,  including  4000  officers  and  5500  men.  The 
courses  in  respect  of  which  grants  have  been  awarded  include 
more  than  2500  for  engineering  and  technological  subjects, 
between  800  and  900  for  classics,  philosophy,  and  literature, 
and  about  1200  for  pure  science  and  mathematics.  Applica- 
tions are  still  being  received  in  large  numbers,  and  are  being 
dealt  with  at  the  rate  of  more  than  100  a day. 


Mi t 


REPORT  OF  THE  LONDON  COUNTY  COUNCIL’S 
MEDICAL  OFFICER  OF  HEALTH  AND  SCHOOL 
MEDICAL  OFFICER  FOR  THE  YEAR  1918. 


Dr.  W.  H.  Hamer’s  annual  report  on  the  health  of  the 
metropolis  during  1918  contains  a great  deal  of  interesting 
material.  It  appears  that  in  1918,  for  the  first  time  in 
records  going  back  nearly  a century,  the  deaths  in  London 
exceeded  the  births.  Two  causes  contributed  to  this  result— 
namely,  the  reduction  in  births  brought  about  by  the  war 
and  the  large  number  of  deaths  from  the  two  epidemics  of 
influenza.  The  deaths  among  civilians  alone  during  the  year 
outnumbered  the  births  by  nearly  5000,  and  to  this  figure 
must  be  added  a number  of  deaths  among  Londoners  on 
active  service.  In  the  first  week  of  November,  when  the 
second  epidemic  of  influenza  reached  its  height,  the  death- 
rate  in  London  was  55 ’5  per  1000.  This  is  the  highest  rate 
recorded  in  any  week  since  the  cholera  year  of  1849,  in  the 
thirty-sixth  week  of  which  3183  deaths  were  registered, 
giving  a rate  of  over  72  per  1000.  The  total  number  of 
deaths  among  civilians  in  1918  numbered  nearly  76,000,  and 
of  this  total  it  is  estimated  that  not  fewer  than  18,000  were 
due  to  the  influenza  epidemics.  The  infant  mortality  was 
108,  showing  a slight  increase  on  the  rate  of  104  per  1000 
births  in  1917. 

Notifiable  Infectious  Diseases. 

The  remarkably  low  prevalence  of  notifiable  infectious 
diseases  in  London  in  recent  years  was  maintained  in  1918. 
Several  groups  of  small-pox  cases,  however,  gave  cause  for 
anxiety,  but  happily  in  each  instance  prompt  measures  of 
isolation  were  effective  in  limiting  the  spread  of  the  disease. 
Diphtheria  was  less  prevalent  than  in  1917,  and,  while  there 
was  a slight  increase  in  the  number  of  cases  of  scarlet  fever, 
the  total  was  nevertheless  far  below  the  average.  There  was 
an  increase  in  the  deaths  from  dysentery,  which  amounted  to 
313,  as  compared  with  290  in  1917,  the  increase  beiDg  in 
female  deaths,  while  the  male  deaths  showed  a decline. 
There  were  no  recognised  outbreaks  due  to  importation  of  the 
disease  from  abroad,  such  as  occurred  in  two  boroughs  in 
1917.  The  incidence  of  typhoid  fever  was  very  low. 
Cerebro-spinal  fever  was  less  prevalent  than  in  1917,  and 
polioencephalitis  and  poliomyelitis  were  at  a comparatively 
low  ebb.  There  were,  however,  a few  cases  of  encephalitis 
lethargica  which  might  formerly  have  been  described  as 
polioencephalitis.  There  was  some  increase  in  the  number  of 
cases  of  pulmonary  tuberculosis  notified,  both  among  males 
and  females,  mainly  in  the  first  half  of  the  year.  The 
mortality  was  also  higher  than  in  1917,  but  this  increase  was 
largely  due  to  the  influenza  epidemics. 

Fleas  and  Scarlet  lever. 

In  recent  annual  reports  by  Dr.  Hamer  the  relationship  of 
scarlet  fever  to  rainfall  and  flea  prevalence  was  discussed. 
The  present  report  contains  a diagram  showing  the  seasonal 
prevalence  of  fleas  over  a series  of  years  and  the  incidence  of 
scarlet  fever  and  diphtheria  in  the  corresponding  period. 
The  diagram  is  divided  into  two  sections  ; the  first  shows 
the  monthly  prevalence  of  fleas  in  relation  to  the  monthly 
case  rates  of  scarlet  fever  and  diphtheria  during  the  ten 
years  1909-18.  A small  inset  diagram  gives  the  mean 
monthly  rates  for  the  ten  years,  and  as  the  maximum 
seasonal  incidence  of  scarlet  fever  cases  is  about  one  month 
later  than  the  maximum  prevalence  of  fleas  the  case-rates 
are  ante-dated  one  month  to  facilitate  comparison.  The 
second  section  of  the  diagram  is  designed  to  illustrate  how 
far  a deviation  from  the  average  quarterly  incidence  of  flea 
prevalence  is  associated  with  a corresponding  deviation  from 
the  average  quarterly  incidence  of  scarlet  fever,  as  well  at  all 
ages  as  in  certain  age-groups  ; the  average  for  diphtheria  at 
all  ages  beiDg  also  shown.  The  contour  of  flea  prevalence  is 
based  upon  figures  which  post-date  by  one  month  the  figures 
for  scarlet  fever  and  diphtheria.  The  first  section  of  the 
diagram  shows  a greater  measure  of  association  of  annual 
prevalence  of  fleas  with  scarlet  fever  than  with  diphtheria. 
The  three  years  of  highest  prevalence  of  scarlet  fever  and 
fleas  (1913-15)  are  followed  by  three  years  of  relatively  low 
incidence,  but  in  diphtheria  the  correspondence  is  not  so 
close.  In  some  years  there  is  a secondary  prevalence  of 


The  Lancet,] 


URBAN  VITAL  STATISTICS. —THE  SERVICES. 


[Sept.  20,  1919  545 


diphtheria  following  the  normal  autumn  incidence,  and  in 
1914  the  February  case-rate  of  diphtheria  exceeded  the 
normal  autumnal  maximum  of  the  preceding  October.  There 
is  no  evidence  of  any  similar  secondary  prevalence  in  the 
case  of  scarlet  fever,  although  the  decline  after  the  normal 
autumnal  maximum  is  not  equally  regular  in  all  years. 

In  the  second  section  of  the  diagram  the  average  figures 
for  each  quarter  are  taken  as  a basis  in  order  to  eliminate 
the  wide  fluctuations  of  monthly  records.  The  diagram  shows 
the  extent  of  deviation  in  any  first  quarter  from  the  average 
of  nine  first  quarters  in  the  period  1910-18,  and  so  on  for 
other  quarters.  The  general  similarity  of  the  contours  of 
the  flea  and  scarlet  fever  prevalences  is  significant,  especially 
in  view  of  the  less-marked  correspondence  shown  in  the 
case  of  diphtheria.  In  view  of  the  interval  of  about  a month 
between  the  maxima  of  flea  and  scarlet  fever  prevalence, 
the  question  arises  whether  the  interval  points  to  the  fact 
that  there  are  two  distinct  phenomena  controlled  by  one 
factor  (such,  for  instance,  as  meteorological  conditions),  or 
whether  a part  of  the  interval  can  be  talren  to  represent 
evolution  of  a scarlet' fever  germ.  In  either  case  the  facts, 
in  Dr.  Hamer’s  opinion,  imply  that  the  conditions  which 
favour  flea  prevalence  are  either  identical  or  intimately  asso- 
ciated with  those  influencing  prevalence  of  scarlet  fever, 
and  a presumption  is  raised  that  steps  directed  to  the  elimi- 
nation of  fleas  may  loosen  the  foothold  of  scarlet  fever. 
Effect  is,  as  far  as  practicable,  being  given  to  this  view  in 
London  at  the  present  time.  There  was,  for  example, 
prevalence  of  scarlet  fever  in  Southwark  in  the  summer  of 
last  year.  The  outbreak  occurred  at  a time  when  the  amount 
of  scarlet  fever  in  London  as  a whole  was  relatively  small. 
The  area  affected  was  veay  limited,  but  the  incidence 
within  the  area  was  very  high.  Application  was  made  to 
the  borough  council  to  disinfect  the  infants’  department  of 
the  council’s  school  central  to  the  area,  the  records  of  which 
showed  a greatly  excessive  proportion  of  flea-bitten  children. 
This  was  done,  and,  in  addition,  the  officers  of  the  borough 
council  visited  homes  and  disinfected  rooms  and  bedding 
associated  with  scarlet  fever  cases.  This  action  was  followed 
by  marked  reduction  of  prevalence  of  scarlet  fever. 

Influenza. 

A special  report  on  the  three  widespread  influenza 
epidemics  of  1918-19  is  given  in  the  appendix.  The 
report  is  divided  into  two  parts — namely  : (1)  a review  of 
recent  epidemic  prevalences  ; and  (2)  a study  of  the  light 
thrown  on  these  epidemics  by  earlier  prevalences,  with  a 
summary  view  of  the  epidemiology  of  the  influenzal  group  of 
diseases.  If  the  subject  is  to  receive  adequate  treatment, 
Dr.  Hamer  urges  the  necessity  for  “ extensive  and  peculiar  ” 
knowledge  of  the  epidemiology  of  past  epidemics  of  influenza 
in  London,  and  expresses  the  opinion  that  the  subject  must 
be  approached  from  the  natural  history  point  of  view.  As 
Creighton  has  said  in  another  connexion,  the  older  or 
Hippocratic  method  must  be  applied.  This  is  one  which 
“ took  account  of  gradations,  modifications,  affinities,  being 
careless  of  symmetry,  of  definitions,  or  clear-cut  nosological 
ideas,  or  the  dividing  lines  of  a classification.”  The  attempt 
to  comply  with  such  conditions  will  involve  reference  to  the 
sweats,  agues,  spotted  fevers,  and  lethargies  of  the  earlier 
centuries  ; then,  throughout,  to  obscure  pneumonias,  certain 
outbreaks  of  “ typhus  ” and  various  “ new  diseases.”  The 
special  report  on  influenza  contains  many  valuable 
suggestions,  and  is  -worthy  of  the  careful  consideration  of  all 
epidemiologists.  


URBAN  VITAL  STATISTICS. 

(Week  ended  Sept.  13th,  1919.) 

Enylish  and  Welsh  Towns.— In  the  96  English  and  Welsh  towns, 
with  an  aggregate  civil  population  estimated  at  16.500,000  persons, 
the  annual  rate  of  mortality,  which  had  been  10  0,  10  0,  and  10  7 in  the 
three  preceding  weeks,  fell  to  10'4  per  1000.  In  London,  with 
a population  slightly  exceeding  4,000,000  persons,  the  annual  death-rate 
was  10'9,  or  0 4 per  1000  above  that  recorded  in  the  previous  week, 
while  among  the  remaining  towns  the  rates  ranged  from  5'6  in 
Wallasey,  5'9  in  Huddersfield,  and  6 0 in  East  Ham  and  in  Bury,  to 
163  in  Tynemouth,  17'1  in  South  Shields,  and  19’3  in  West 
Hartlepool.  The  principal  epidemic  diseases  caused  313  deaths, 
which  corresponded  to  a rate  of  TO  per  1000,  and  included  241  from 
infantile  diarrhcea,  26  from  diphtheria,  17  from  whooping-cough, 
15  from  measles,  11  from  scarlet  fever,  and  3 from  enteric  fever. 
Measles  caused  a death-rate  of  13  in  Barrow-in-Furness  and  in 
Gateshead.  There  were  1504  cases  of  scarlet  fever  and  1057  of  diph- 
theria under  treatment  in  the  Metropolitan  AsylumB  Hospitals  and 
the  London  Fever  Hospital,  against  1454  and  1006  respectively  at  the 


end  of  the  previous  week.  The  causes  of  16  deaths  in  the  96  towns 
were  uncertified,  of  which  4 were  registered  in  Liverpool,  3 in  Tyne- 
mouth, and  2 in  Birmingham. 

Scotch  Towns— In  the  16  largest  Scotch  towns,  with  an  aggregate 
population  estimated  at  nearly  2,500,000  persons,  the  annual  rate  of 
mortality,  which  had  been  10'7,  10  9,  and  10'8  in  the  three  preceding 
weeks,  fell  to  10  2 per  1000.  The  222  deaths  in  Glasgow  corresponded 
to  an  annual  rate  of  10'3  per  1000,  and  included  20  from  Infantile 
diarrhoea,  4 from  diphtheria,  3 from  whooping-cough,  2 from  measles, 
and  1 from  scarlet  fever.  The  68  deaths  in  Edinburgh  wore  equal  to 
a rate  of  10'5  per  1000,  and  included  a fatal  case  each  of  measles  and 
diphtheria. 

Lrish  Towns. — The  134  deaths  in  Dublin  corresponded  to  an  annual 
rate  of  17  3,  or  2 4 per  1000  below  that  recorded  in  the  previous  week, 
and  Included  7 from  infantile  diarrhcea,  and  1 each  4rom  enteric 
fever  and  diphtheria.  The  100  deaths  in  Belfast  were  equal  to  a rate 
of  13  0 per  1000,  and  included  10  from  infantile  diarrhoea,  and  2 
each  from  enteric  fever  and  scarlet  fever. 


Sk  Serbkes. 

G 

THE  HONOURS  LIST. 

The  following  awards  to  medical  officers  in  connexion  with  military 
operations  in  India  and  in  Persia  are  announced 

C.l.E. — Capt.  J.  B.  Hanafin,  I.M.S. , Lt. -Col.  J.  B.  Jameson,  I. M.S. 
(ret.);  Maj.  L.  Hirsch,  I.M.S. ; Lt.-Col.  S.  J.  Rennie,  R.A. M.C.  (ret.) ; 
Lt.-Col.  J.  W.  Watson,  I.M.S. 

C.S.I.— Col.  A.  E.  Tate,  C.M.G.,  A.M.S. 

C.B.E.— Map  and  Bt.  Lt.-Col.  (temp.  Col.)  F.  A.  F.  Barnardo,  C.I.E., 
I.M  S. 

O.B.E  — Capt.  (femp.  Maj.)  A.  F.  Babonau,  I.M.S.;  Temp.  Capt.  J. 
Cairns,  R.A. M.C.  (T.  CM  ; Capb.  (temp.  Maj. ) F.R.  Coppinger,  R.A.M.C.; 
Maj.  (temp.  Lt.-Col.)  J.  K.  S.  Fleming,  I.M.S  ; Map  G.  D.  Franklin. 

I. M.S.;  Maj.  A.  T.  Frost,  R.A. M.C. ; Capt.  W.  A.  Frost,  R.A. M.C.  ; 
Capt.  T.  B.  Heaton,  R.A. M.C.  (S.tt.) ; Maj.  D.  P.  Johnstone,  R.A.M.C.; 
Maj.  T.  W.  Minty,  I.M.S.;  Lt.-Col.  P.  St.C.  More,  IMS.  ; Maj.  R.  B. 
Nicholson,  M.C.,  I.M.S. ; Maj.  H.  W.  Pierpoint,  I.M.S. ; Lt.-Col.  J.  J.  W. 
Prescott,  D.S.O.,  R.A.M  C. ; Capt.  C.  H.  Smith,  I.M.S. ; Capt.  (temp. 
Maj.)  J.  R.  D.  Webb,  I.M.S. 

M.B.E. — Lt.  (temp.  Capt.)  P.  X.  Godinho,  I.M.S. 

Military  Cross. — Temp.  Lt.  Mahomed  Nawaz,  I.M.S.  ; Capt.  R.  R.  M. 
Porter,  I.M.S. 

To  he  Brevet  Lieutenant-Colonel.— Maj.  N.  W.  Mackworth,  I.M.S. 

To  be  Brevet  Major.— Capt.  J.  A.  A.  Kernaban,  I.M.S. ; Capt.  (temp. 
Lt.-Col.)  J.  V.  Macdonald,  M.C.,  I.M.S.,-  Capt.  (temp.  Maj.)  M.  A. 
Rahman,  I.M.S.;  Capt.  (temp.  Maj.)  E.  E.  Doyle,  I.M.S.;  Capt.  (temp. 
Maj.)  C.  Ryles,  R.A. M.C. ; Capt.  (temp.  Maj.)  W.  R.  Stewart,  I.M.S. 

ARMY  MEDICAL  SERVICE. 

Major-General  Sir  M.  T.  \Tarr,  C.B.,  K.C.M.G.,  to  be  Inspector  of 
Medical  Services  (temporary),  vice  Major-General  Sir  W.  Babtie,  V.C., 
K.C  M.G.,  C.B  , K.H.S. 

Temp.  Cols.  Sir  T.  C.  English,  K.C.M.G.  (Captain,  R.A.M.C.,  T.F.), 
and  Sir  C.  A.  Ballance,  K.C.M.G.,  C.B.,  M.V.O.  (Captain.  R.A.M.C., 
T.F.),  relinquish  their  temporary  commissions  on  re-posting. 

ROYAL  ARMY  MEDICAL  CORPS. 

Lieut.-Col.  O.  W.  A.  Eisner  relinquishes  the  temporary  rank  of 
Colonel  on  re-posting. 

The  undermentioned  relinquish  the  acting  rank  of  Lieut.-Col.  on 
re-posting:  Majors  G.  H.  Stevenson,  T.  F.  Ritchie,  P.  J.  Marett; 
Temp.  Capts.  J.  Scott,  D.  Miller. 

The  unoermentioned  to  be  acting  Lieut. -Colonels  whilst  command- 
ing Medical  Units  : Capt.  (acting  Major)  R.  G.  Shaw ; Capts.  E. 

Perciva),  T.  S.  Eves;  Temp.  Capts.  (acting  Majors)  H.  C.  Watson,  J.  P. 
Davidson ; Temp.  Capt.  G.  Jackson. 

Temp.  Major  E.  W.  H.  Groves  (Captain,  R.A.M.C.,  T.F.)  relinquishes 
his  temporary  commission  on  re-posting, 

The  undermentioned  relinquish  the  acting  rank  of  Major  : Capt. 

J.  E.  Hepper  (on  ceasing  to  be  specially  employed);  Temp.  Capts.  A.  W. 
Tabuteau.  L.  ap.  I.  Davies,  W.  II.  Clements,  J.  M.  Morris,  W.  J.  J. 
Arnold,  C.  Roche,  A.  L.  Krogh  (on  re-posting);  Temp.  Lieut.  G.  E. 
Froggatt. 

To  be  acting  Majors  whilst  specially  employed  : Capts.  S.  H.  Smith, 

F.  Worthington,  R.  E.  Todd,  H.  F.  Joynt;  Capt.  and  Bt.  Major  T.  A. 
Weston  ; Temp.  Capts.  H.  G.  Gillies,  A.  L.  Robinson,  S.  S.  Dunn, 

G.  Cooper,  H.  M.  Anderson,  C.  E.  Waldron. 

Capt.  T.  D.  Inch  resigns  his  commission. 

Temp.  Capt.  (acting  Major)  R.  Jamison  to  be  acting  Lieutenant- 
Colonel  whilst  specially  employed. 

Temp.  Capts.  J.  H.  G.  Hunter  and  J.  McFadden  to  be  Captains. 

The  undermentioned  late  temporary  Captains  to  be  temporary 
Captains  -.  L.  Gibbons,  R.  A.  Flynn,  T.  F.  Griffin,  J.  Joule,  C.  L.  Driscoll. 

Officers  relinquishing  their  commissions : Temp.  Lieut.-Col.  and 
Hon.  Lieut.-Col.  W.  I.  de  C.  Wheeler  (retains  the  rank  of  Lieutenant- 
Colonel)  ; Temp.  Lieut.-Col.  B.  J.  Moore,  Temp.  Lieut.-Cols.  G.  E.  Miles 
and  C.  T.  Parsons  (retain  the  rank  of  Lieutenant-Colonel);.  Temp. 
Hon.  Lieut.-Cols.  G.  S.  Buchanan  and  J.  Robertson  (retain  the 
honorary  rank  of  Lieutenant-Colonel),  Temp.  Hon.  Lieut.-Col.  H.  R. 
Kenwood  (Major,  R.A.M.C.,  T.F.)  (relinquishes  his  temporary  com- 
mission (Ton  re-posting).  Temporary  Majors  retaining  the  rank  of 
Major:  T.  M.  Kendall,  P.  J.  A.  Seceombe.  Temporary  Captains 
granted  the  rank  of  Major  : J.  Crawford,  R.  E.  Cree.  Tempo- 
rary Captains  retaining  the  rank  of  Captain : A.  W.  George,  D. 
Corry,  W.  E.  Morgan,  W.  F.  Thompson  (acting  Major),  J.  E.  L.  A. 
Turnley,  R.  M.  Gordon,  F.  F.  C.  Willington,  W.  G.  Shaw,  J.  G. 
Shanklin,  G.  L.  Keynes,  C.  J.  Glasson,  J.  M.  Christie.  S.  C.  H.  Moberly, 
E.  R.  Wheeler,  E.  M.  Brown,  J.  A.  Wilson,  F.  W.  Jones,  C.  J.  Heaton, 
J.  D.  Carroll,  R.  A.  Banbury,  A.  Poole,  P.  B.  Whitington,  J.  C. 
Fergusson,  J.  Prichard,  W.  D.  Lawrie,  W.  McFarlane,  G.  Hoffmann,  C. 
Gray.  H.  C.  Hinwood,  W.  C.  P.  Barrett;  Temp.  Hon.  Capt.  W.  A. 
Pride  (retains  the  honorary  rank  of  Captain);  Temp.  Lieuts.  R.  M.  D. 
Devereux  and  W.  H.  Newton  (retain  the  rank  of  Lieutenant). 


546  The  Lanoet,]  THE  BRITISH  FEDERATION  OF  MEDICAL  AND  ALLIED  SOCIETIES.  [Sept.  20,  1919 


Canadian  Army  Medical  Corps. 

Temporary  Lieutenant-Colonels  (acting  Colonels)  to  be  temporary 
Colonels:  C.  P.  Templeton,  K.  L.  Stone. 

Temporary  Majors  (acting  Lieutenant- Colonels)  to  be  temporary 
Lieutenant-Colonels : J.  S.  Jenkins,  C.  Hunter,  W.  T.  Lockhart,  C.  F.  L. 
Haszard. 

Temp.  Major  (acting  Lieut.-Col.)  L.  H.  McKirn  relinquishes  the 
acting  rank  of  Lieutenant-Colonel. 

The  undermentioned  temporary  Captains  (acting  Majors)  relinquish 
the  acting  rank  of  Major:  J.  G Shaw.  J.  Pullar. 

The  undermentioned  temporary  Captains  (acting  Majors)  to  be 
temporary  Majors  : D.  S.  Lewis.  S.  Sprague,  G.  O.  Scott,  H.  W.  Wadge, 
P.  .1.  S.  Bird,  J.  I).  Jones,  J.S.  Fitzsimmons,  J.  W.  Hunt,  A.  B.  Wilkes, 
B.  R.  Almquqst. 

Temp.  Capts.  (acting  Majors!  E.  F.  Kisdon  and  R.  A.  Thomas 
relinquish  the  acting  rank  of  Major. 

Temp.  Major  N.  G.  Cooperand  Temp.  Capt.  H.  W.  Bell  retire  in  the 
British  Isles. 

South  African  Medical  Corps. 

The  undermentioned  relinquish  their  commissions  and  retain  the 
rank  of  Captain:  Capt.  J.  McL.  Hendry;  Temp.  Capts.  E.  W.  Dyer, 
J.  I.  de  Villters,  E.  Wolff,  A.  S.  Wilson,  G.  H.  Coke. 

GENERAL  RESERVE  OF  OFFICERS. 

T.  D.  Inch,  late  Captain  R.A.M.C.,  to  be  Captain. 

SPECIAL  RESERVE  OF  OFFICERS. 

Capts.  L.  C.  Rudd  and  E.  R.  Chambers  relinquish  their  commissions. 

Capt.  R.  T.  C.  Robertson  relinquishes  the  acting  rank  of  Lieutenant- 
Colonel  on  ceasing  to  command  a Medical  Unit. 

Captains  relinquishing  the  acting  rank  of  Major  on  ceasing  to  be 
specially  employed  : U.  C.  G.  Pedler,  R.  O.  C.  Thomson. 

Captains  to  be  acting  Majors:  D.  McIntyre,  J.  J.  McL  Shaw  (whilst 
specially  employed). 

TERRITORIAL  FORCE.* 

Major  M.  G.  Foster  is  restored  to  the  establishment  on  ceasing  to 
bold  a temporary  commission  in  the  Army  Medical  Service. 

Capts.  (acting  Lieut.-Cols.)  J.  Barkley,  D.S  O.,  and  W.  D.  Sturrock 
relinquish  their  acting  rank  of  Lieutenant-Colonel  on  ceasing  to  be 
specially  employed. 

Capts.  (acting  Majors)  J.  L.  M.  Symns  and  L.  E.  Hughes  relinquish 
their  acting  rank  of  Major  on  ceasing  to  be  specially  employed. 

4th  London  General  Hospital:  Major  W.  A.  Turner  is  restored  to  the 
establishment  on  ceasing  to  hold  a temporary  commission  in  the  Army 
Medical  Service. 

2nd  London  Sanitary  Company : Capt.  (acting  Major)  A.  G.  G. 
Thompson  relinquishes  the  acting  rank  of  Major  on  ceasing  to  be 
specially  employed. 

ROYAL  AIR  FORCE. 

Medical  Branch.— Capt.  (acting  Major)  C.  J.  G.  Taylor  (Surgeon- 
Lieut.,  R.N.V.R.)  relinquishes  his  commission  on  ceasing  to  be 
employed. 

The  undermentioned  are  transferred  to  the  unemployed  list : Capts. 
Wm.  S.  T.  Connell,  T.  R.  Hunter,  W.  H.  Cam. 


INDIAN  MEDICAL  SERVICE. 

To  be  acting  Lieutenant-Colonels  while  commanding  Medictl  Units 
in  the  Field  : Majors  F.  H.  Stewart,  S.  H.  L.  Abbott,  Capts.  A.  G. 
Coullie,  J.  B.  Lipsley.  J.  Portelli  to  be-temporary  Lieutenant. 

DEATHS  IN  THE  SERVICES. 

Fleet  Surgeon  George  Hewlett,  R.N.,  died  on  August  26th  at 
Andover  as  a result  of  a collision  between  the  motor-bicycle  he  was 
riding  and  a motor-car  four  days  previously.  As  a student  in 
Edinburgh  he  surprised  some  by  graduating  after  four  years'  study 
with  first  ela“s  honours,  but  he  was  very  shrewd,  had  an  alert  mind 
and  a retentive  memory.  A Cornishman,  he  went  at  once  to  sea, 
first  in  the  merchant  service,  and  later  in  the  Navy,  where  he  did  a 
great  deal  to  keep  a friendly  spirit  alive  in  the  ships  in  which  he 
served.  His  loss  will  be  keenly  felt  by  his  old  shipmates.  He  was 
by  nature  a man  of  the  wild,  and  after  leaving  the  service  spent  a year 
fishing  and  shooting  in  British  Columbia.  His  alternative  employ- 
ment was  the  sailing  of  his  yacht  about  the  Channel.  For  three  years 
of  the  war  he  served  as  fleet  surgeon  of  Portsmouth  Dockyard. 


The  late  Mr.  Edwin  O.  Sachs,  F.R.S.E., 
Chairman  of  the  British  Fire  Prevention  Committee. 
— Mr.  Sachs,  who  died  at  his  residence  in  Portland-place  on 
Sept.  9th  at  the  early  age  of  49,  practised  for  several  years  as 
an  architect  and  was  the  author  of  a standard  work,  “ The 
Modern  Opera  House  and  Theatre.”  He  was  the  first  in 
England  to  apply  electrical  power  to  the  working  of  the 
stage,  and  the  “ Sachs  System  ” has  been  adopted  bv  Covent 
Garden  Opera  House  and  the  Theatre  Royal,  Drurv-lane.  It 
is,  however,  by  his  keen  interest  in  regard  to  fire  protection 
that  he  will  be  most  remembered.  Realising  that  the  great 
loss  of  human  life  and  property  due  to  lire  might  be  much 
reduced  by  legislation  and  ordinary  measures  of  precaution,  he 
devoted  his  time  to  propaganda  work  in  this  direction,  and 
helped  to  procure  preventive  legislation  by  which  loss  of 
infant  life  due  to  the  use  of  inflammable  clothing  could  be 
minimised.  His  activities,  which  were  entirely  voluntary, 
extended  to  mauy  other  countries  besides  the  British  Isles, 
and  he  ,vas  vice-president  of  the  International  Fire  Service 
Council.  During  the  war  the  committee  of  which  he  was 
chairman  made  arrangements  for  a voluntary  survey  force 
for  over  2000  war  hospitals,  camps,  and  factories.  He 
initiated  or  guided  work  of  high  importance  to  the  nation 
in  circumstances  of  ill-health  attended  by  much  suffering. 


Cornspnktue. 

“ Audi  alteram  partem." 


THE  BRITISH  FEDERATION  OF  MEDICAL  AND 
ALLIED  SOCIETIES. 

To  the  Editor  of  The  Lancet. 

Sir, — A letter  from  Dr.  E.  R.  Fotbergill  was  published 
under  the  title  “The  Cult  of  Individualism”  in  the 
issue  of  the  British  Medical  Journal  dated  Sept.  13th. 
That  communication  contained  so  many  inaccuracies 
and  mis-statements  that  we  would  request  space  in  your 
valued  columns  to  correct  any  false  impressions  that 
may  have  been  occasioned  by  it.  Seeing  that  no  issue 
exists  between  the  British  Medical  Association  and  the 
Federation  of  Medical  and  Allied  Societies  (late  Medical 
Parliamentary  Committee),  of  the  former  of  which 
we  are  also  members,  we  are  not  concerned  with  the 
defence  of  the  body  we  represent.  In  the  first  place  we 
do  not  subscribe  to  the  wholesale  condemnation  of  the 
Association  contained  in  the  fourth  paragraph  of  Dr. 
Fothergill’s  letter.  And  we  cannot  agree  that  the  British 
Medical  Association  “ is  now  recognised  by  all  departments 
in  the  State  as  the  mouthpiece  of  the  profession,”  much  as 
we  might  wish  it  to  be.  Apart  from  the  fact  that  the 
Medical  Directory  contains  the  names  of  twice  the  number 
of  medical  men  that  the  membership  of  the  Association 
embraces,  there  are  several  other  professional  bodies  that  the 
Government  departments  consult  direct.  The  policy  of  the 
Federation  can  in  no  way  be  construed  as  making  for  rivalry 
with  the  Association  ; the  aims  of  the  former  are  definite 
in  extent.  It  provides  a permanent  “round  table”  at  which 
representative  doctors,  of  all  shades  of  opinion  and  engaged 
in  all  branches  of  medical  work,  may  meet  and  confer  with 
one  another  and  with  the  representatives  of  lay  bodies  whose 
activities  are  ancillary  to  medicine  ; it  aims  at  obtaining 
support  for  the  profession  from  a much  larger  section  of  the 
public  than  any  purely  medical  body  can  hope  to  obtain  ; it 
constitutes  a “reference  library  ” on  matters  affecting  the 
public  health,  and  by  being  in  a position  to  supply  informa- 
tion to  the  profession  and  the  public,  on  the  one  side,  and  to 
those  guiding  legislation,  on  the  other,  it  is  truly  a “ liaison 
committee.”  Thus,  in  place  of  overlapping  and  confusion  in 
policy,  the  Federation  offers  a real  prospect  of  unity  in 
thought  and  action. 

Dr.  Fothergill  has  a great  deal  to  say  regarding  schisms 
in  the  ranks  of  the  profession  : it  will  therefore  interest  him 
to  know  that  the  three  bodies  he  mentions  and  whose 
existence  he  deplores  are  amongst  those  who  have  taken 
part  in  the  formation  of  the  Federation,  so  that  already 
far  greater  unity  exists  than  was  the  case  prior  to  the 
formation  of  the  Medical  Parliamentary  Committee.  It 
will  be  time  enough  to  discuss  the  objection  raised 
regarding  individual  subscriptions  when  the  Federation 
asks  for  them. 

It  would  be  well  if  Dr.  Fothergill  could  understand 
that  there  are  others  besides  himself  who  are  working  dis- 
interestedly for  the  good  of  the  profession  and  the 
community. — We  are,  Sir,  yours  faithfully, 

Malcolm  Morris, 

Chairman. 

Charles  Buttar, 

Honorary  Secretary. 

N.  Howard  Mummery. 

Organising  Secretary. 

The  British  Federation  of  Medical  and  Allied  Societies, 

20,  Hanover-square,  W.,  Sept.  15th,  1919. 


CONTROL  OF  VENEREAL  DISEASE. 

To  the  Editor  of  The  Lancet. 

Sir, — In  the  account  given  in  The  Lancet  of  Sept.  6th  of 
the  recent  deputation  of  the  National  Council  for  Combating 
Venereal  Diseases,  and  the  reply  thereto  of  the  Public  Health 
Committee  of  the  London  County  Council,  the  recommenda- 
tion of  the  last-named  body  is  merely  stated  without  the 
addition  of  the  detailed  reasons  on  which  it  was  presumably 
based.  The  Lancet  account  proceeds  to  comment  on  the 
London  County  Council’s  recommendation  as  indicating  a 
“ policy  of  passivity”  in  relation  to  the  preventive  treatment 
of  venereal  diseases,  and  apparently  regards  the  National 


The  Lancet,] 


PROPHYLACTIC  QUININE  IN  MALARIA. 


[Sept.  20,  1919  547 


Council’s  proposal  of  “treatment  at  an  approved  centre 
within  a short  time  after  exposure  to  possible  infection,” 
and  its  further  statement  that,  for  the  effectual  prevention 
of  syphilis , “treatment  must  be  initiated  within  six  hours 
after  exposure  to  risk,”  as  embodying  the  only  possible 
scheme  of  medical  prevention. 

I desire  to  point  out  that  the  National  Council’s  scheme 
in  respect  to  syphilis  (as  reported)  gives  a very  wide  and 
dangerous  margin  of  safety  in  its  mention  of  “within  six 
hours  ” and  says  nothing  of  the  safety  margin  in  the  case  of 
gonorrhoea,  which  is  overwhelmingly  more  widespread  than 
syphilis.  It  is  scarcely  to  be  supposed  that  the  six-hour 
margin  is  meant  by  the  Council  to  apply  to  both  cases  1 
Further,  the  National  Council’s  scheme  ‘'not  only  is  of 
very  doubtful  efficiency,  but  also  involves  an  increased 
expenditure  of  public  money  out  of  all  proportion  to  the 
slight  amount  of  good  it  might  possibly  bring  about. 

Is  it  not  probable,  if  not  certain,  that  it  is  owing  to  such 
objections  as  these  that  the  London  County  Council’s  Pub'ic 
Health  Committee  “ is  not  satisfied  that  the  public  provision 
of  early  preventive  treatment  as  suggested  by  the  National 
Council  for  Combating  Venereal  Disease  is  desirable  ” ? Or  is 
The  Lancet’s  implication  that  the  County  Council’s  Com- 
mittee is  indifferent  to  the  question  of  preventing  the  spread 
of  venereal  diseases  to  be  preferred  ? 

I am  Sir,  yours  faithfully, 

Sept,  nth,  1919.  H.  Bryan  Donkin. 


PROPHYLACTIC  QUININE  IN  MALARIA. 

To  the  Editor  efTHE  Lancet. 

Sir, — During  a stay  of  three  months  in  Aden  I had  a great 
deal  of  trouble  with  my  servant.  He  was  a Somali,  who 
understood  no  English  and  no  Hindustani,  and  who  spoke 
worse  Hindustani,  if  possible,  than  I did  myself.  Heated 
misunderstandings,  no  doubt  aggravated  by  the  fact  that  I 
was  suffering  at  the  time  from  repeated  attacks  of  mild 
malaria,  naturally  resulted,  and  our  relations  became  more 
and  more  strained. 

The  first  step  on  the  road  to  reconciliation  was  taken  when 
I found  that  I could  with  absolute  certainty  keep  myself  free 
from  malaria  by  taking  5 gr.  of  quinine  daily.  I then  found 
to  my  shame  one  evening  that  my  unfortunate  servant  was 
excusing  himself  for  his  shortcomings  in  a fearful  jumble  of 
tongues  on  the  grounds  that  he  was  sick  in  the  same  way 
that  “master”  had  been  sick  himself.  Five  grains  of  quinine 
daily  transformed  him  into  an  intelligent  and  efficient  valet. 
To  save  trouble  I used  to  give  him  my  own  tabloids,  and 
when  we  parted,  the  best  of  friends,  he  begged  me  to  tell 
him  where  they  could  be  purchased.  I explained  to  him, 
in  the  code  we  had  established,  that  they  were  beyond  his 
means  and  he  must  go  to  the  civil  hospital. 

Nothing  will  ever  persuade  this  Somali  boy  or  myself  that 
in  certain  circumstances  there  is  not  a type  of  malaria 
which  can  with  certainty  be  prevented  by  quinine,  and  which 
will  with  equal  certainty  recur  if  the  quinine  is  discontinued. 

In  view  of  the  above  domestic  incidents  I have  read  with 
much  interest  Major  A.  H.  Gosse’s  article  on  quinine 
prophylaxis  in  your  issue  of  Sept.  6th. 

I am.  Sir,  yours  faithfully, 

Kensington,  W„  Sept.,  12th,  1919.  J.  E.  SANDILANDS. 


EROSION  OF  THE  GREAT  VESSELS  OF  THE 
NECK  IN  SCARLATINAL  ABSCESS. 

To  the  Editor  of  The  Lancet. 

Sir, — This  condition  may  not  be  so  rare  as  is  implied  in 
the  annotation  in  your  issue  of  last  week.  During  an  epidemic 
of  scarlet  fever  in  South  Wales  in  1887  I saw  two  cases  in  a 
fortnight,  both  in  young  children,  and  both  rapidly  fatal. 
One  burst  externally,  and  I concluded  that  it  was  the 
external  carotid  which  was  eroded. 

I am,  Sir,  yours  faithfully, 

Bournemouth,  Sept.  14th,  1919.  E.  CURTIN. 


CRYPTOPODIA. 

To  the  Editor  of  The  Lancet. 

Sir, — Mr.  T.  S.  P.  Strangeways  has  overlooked  the  fact 
that  the  arthritis  began  10  years  later  than  the  enlargement 
of  the  feet,  and  I may  add  that  there  is  no  trace  of  it  in  the 
lower  limbs.  Moreover,  for  more  than  10  years  past  the 


patient  has  .been  bedridden — i.e.,  living  under  the  very 
conditions  which  Mr.  Strangeways  lays  down  as  essential  to 
cure.  In  the  face  of  the  very  remarkable  blood-count  it  is 
hard  to  deny  the  right  of  the  condition  to  be  regarded  as  a 
disease,  and  even  a specific  one.  I especially  hope  that  the 
blood-count  will  receive  the  attention  that  it  deserves. 
With  reference  to  Dr.  Parkes  Weber’s  remarks,  I distinctly 
stated,  and  believe  that  I demonstrated  to  Dr.  Parkes 
Weber  personally,  the  very  ready  and  deep  pitting  on 
pressure  in  the  case  under  notice.  This  differentiates  it 
sharply,  on  his  own  showing,  from  the  case  described  by 
him  at  the  Royal  Society  of  Medicine.  How  my  case  can 
possibly  have  anything  in  common  with  one  in  which  the 
enlargement  consisted  of  “ dense  fibrous  tissue,”  as  described 
by  Mr.  W.  Robinson  in  your  last  issue,  I fail  to  see. 

For  the  present,  my  description  of  my  case  by  a new  name, 
and  as  a new  disease,  has  not  been  in  any  way  shown  to  be 
unwarranted.  I am,  Sir,  yours  faithfully, 

De  Crespignv  Park.  Denmark  Hill,  S.E.,  E.  C.  BOUSFIELD. 

Sept.  15th,  1919. 


THE  RESULTS  OF  COMPLETE  COLECTOMY. 

To  the  Editor  of  The  Lancet. 

Sir, — In  reference  to  Mr.  J.  E.  Adams's  letter  in 
The  Lancet  of  August  23rd,  in  which  he  criticises  me 
for  not  giving  fuller  details  of  my  cases,  I plead  guilty, 
since  I might  have  mentioned  that  he  was  the  surgeon  who 
performed  the  third  operation  on  Case  B. 

I am.  Sir,  yours  faithfully, 

James  Taylor. 

Cambridge  Hospital,  Aldershot,  Sept.  12th,  1919. 

MINI)  AND  MEDICINE. 

To  the  Editor  of  The  Lancet. 

Sir, — The  adhesion  of  a prominent  psychologist  to  one 
of  Freud’s  main  principles,  noticed  lately  in  your  journal, 
reminds  us  that  not  so  long  ago  a leading  alienist  wrote 
that  psycho-analysis  was  dead  in  England,  thanks  to  Dr.  C. 
Mercier.  A continental  observer,  if  told  of  this,  would 
likely  enough  have  seen  in  it  merely  the  common  spectacle 
of  a man  of  talent  attacking  a man  of  genius.  Now,  it  is 
certain  that  Dr.  Mercier  was  a man  of  talent,  but  not  quite 
certain  yet  that  Freud  has  genius.  Contemporary  estimates 
are  notoriously  unreliable,  and,  moreover,  inevitably  so,  or 
mankind,  which,  as  was  long  ago  pointed  out,  whether  or 
not  it  wishes  to  act  rightly,  mostly  desires  correct  knowledge, 
would  have  improved  ere  this  its  powers  of  criticism  of  a 
current  event  or  opinion.  Sometimes  posterity  endorses 
contemporary  verdicts,  but  oftener  reverses  them.  How  will 
it  be  with  Freud’s  work  ? The  testimony  already  mentioned 
may  furnish  an  indication,  as  also  the  appearance  of 
paragraphs  on  “repression”  in  the  daily  press — a pheno- 
menon, this  latter,  of  complete  unimportance  had  it 
happened  when  Freud’s  name  first  crossed  the  Channel 
(or  rather  the  North  Sea),  but  of  considerable  significance 
now,  after  the  lapse  of  years  and  the  consequent  test  of  time. 

What  more  than  his  obscurity  of  style  and  the  poorness  of 
his  translators  has  spoiled  Freud’s  reception  over  here  is  the 
British  ignorance  that  there  is  such  a study  as  sexuology — or 
perhaps  one  had  better  say,  after  the  last  International 
Medical  Congress  in  London,  the  Biitish  “ conspiration  ” (as 
I have  seen  it  nlisspelt  in  a foreign  journal)  of  silence.  That 
ignorance  or  that  conspiracy  is  perforce  beginning  to  dis- 
appear now  ; still,  in  this  country  we  have  only  yet  got  to 
the  antivenereal  campaign  and  sexual  pedagogy,  and  to 
these  only  fairly  recently ; although  in  different  book- 
lets on  the  latter  subject  have  appeared  in  such 
numbers  as  to  suggest  that  their  production  is,  if  one 
may  help  oneself  to  a metaphor  from  the  illustrious 
physician  of  Chinon,  as  easy  as  wetting  the  bed.  The 
best  book  of  Freud’s  to  begin  with — in  fact  his  countrymen 
say  his  best  book  altogether — is  the  “ Psycho-pathology  of 
Everyday  Life.”  The  assertion  is  ventured  that  a single 
perusal  of  this  work  would  make  a good  many  partial 
converts.  When  a man  sees  that  by  the  help  of  Freud,  and 
of  nobody  else,  he  can  account  for  missed  trains,  undated 
cheques,  and  other  seemingly  fortuitous  slips  of  his  daily 
life,  he  is  impressed.  Not  that  the  dreaded  sexual  element 
is  absent.  This  book,  too,  is  not  one.  to  leave  about.  Sex 
occupies  in  it  nearly  as  much  space  as  in  human  thought 


548  The  Lancet,] 


OBITUARY. 


[Sept.  20,  1919 


and  conduct.  One  secretly  fearing  that  his  mistress  has 
conceived  makes  an  ordinary  slip  of  the  tongue  in  ordinary 
conversation  ; but  it  is  enough  for  the  psycho-analyst  to 
guess  his  secret  by.  Well,  these  things  happen  and  will  go 
on  happening;  better  to  study  than  to  snigger  over  them,  or 
pretend  they  are  non-existent. 

Probably  the  strongest  impeachment  comes  from  the  man 
who  first  in  this  country  mentioned  Freud’s  work,  and  to 
whom  the  latter  paid  the  compliment  of  writing  to  regret 
that  psycho-analysis  did  not  meet  with  his  full  approval. 
That  impeachment  was,  that  the  line  of  inquiry  is  full  of 
risk  of  error  ; for  sexual  symbolism,  which  is  central  to  the 
argument  of  Freud’s  chief  work,  can,  like  any  other 
symbolism,  be  rather  easily  carried  to  an  excess,  become 
far-fetched,  strained,  intolerably  overweening.  In  its 
simpler  applications  it  will  probably  convince  most  un- 
prejudiced minds,  particularly  in  presence  of  the  high 
standard  of  investigation  some  Freudian  disciples  attain. 
Take,  for  instance,  an  article  in  Imago , on  the  sexual 
symbolism  of  the  fish,  by  a lesser  known  one.  In  this  paper 
proofs,  often  pictorially  reproduced,  are  drawn  from  pre- 
historic drawings,  down  through  classic  art,  through 
mythology,  anthropology,  etymology,  literature  and  folk- 
lore, to  a quotation  (about  Montenegrin  water- bailiffs)  from 
Country  Life , of  all  sources — and  the  editors  in  a fine  spirit 
of  team  work  add  others.  It  is  difficult  to  doubt,  after 
reading  this  multifarious  evidence  of  the  world-wide 
association  of  the  fish  with  erotic  deities,  and  those 
presiding  over  increase  and  fertility,  as  also  with 
marriage  ceremonies,  that  the  author  has  made  out  a 
strong  case.  Again,  others  besides  Freud  rely  on  sexual 
symbolism.  In  view  of  the  mention  of  religion  in  your 
article  the  following  two  instances  come  in  well.  A 

reviewer  in  The  Expository  Times  has  written:  “ 

the  Bible  is  full  of  symbols  and  we  have  lost  their 
language.  We  are  very  prosaic.  The  writers  of  the  Old 
Testament  and  of  the  New  were  very  imaginative.  Between 
us  there  is  a gulf  fixed  of  which  we  are  aware  only  in 
unquiet  moments.”  Now  a much  less  orthodox,  but  not 
Freudian,  writer  in  another  Continental  journal  has  recently 
tried  to  interpret  the  symbolism  in  the  familiar  story  of 
Samson.  It  is,  he  says,  a story  of  a rude,  primitive  time, 
containing  little  of  morality,  and  turning  on  the  three 
motives  of  strength,  love,  and  rustic  wit.  To  trace  the 
second  motive  he  has  recourse  to  the  sexual  symbolism 
undoubtedly  present  in  the  narrative  ; and  when  he  recalls 
how  the  Romans  at  the  Cerealia  let  loose  in  the  circus  foxes 
with  firebrands  at  their  tails,  and  the  rite  at  Carseoli  of 
covering  foxes  with  grass,  setting  fire  to  them,  and  letting 
them  run  over  the  fields,  the  fox  being  regarded  as  the 
Genius  of  the  Crops,  and  kindred  Arabian  and  Japanese 
rites,  it  at  least  puts  one  strongly  in  mind  of  the  way  in 
which  early  civilisations  connected  phallic  symbols  with  the 
earth’s  fertility.  Exegesis  of  this  kind  will  be  allowed  much 
significance  ; and  not  only  this,  but  also  some  of  the  simpler 
interpretations  of  sexual  symbolism  in  dreams  and  neuroses. 
But  with  more  highly  developed  ones  a feeling  of  dubiety 
begins.  One  perceives  that  the  logical  razor  of  Occam, 
never  very  sharp  in  Austro-Germany,  would  make  short  work 
of  many  of  them.  And  that,  then,  is  the  danger,  that 
sexual  symbolism  is  a risky  business.  You  never  know  how 
far  to  trust  it,  how  far  to  go  with  it. 

Mr.  Havelock  Ellis,  perhaps  the  rarest  mind  in  the  British 
medical  profession,  further  pronounces  Freud  to  be  an  artist. 
Certainly  he  is  one  of  the  few  who  are  at  home  either  in  the 
literary  or  the  scientific  camp,  two  positions  between  which 
there  has  been  small,  but  for  various  reasons  must  in  the 
future  be  more,  communication.  It  is  a bold  thing,  however, 
to  say  that  the  artistic  imagination  can  serve  the  purpose 
of  scientific  investigation,  and  a statement  unwarranted 
by  history.  What  might  be  nearer  the  truth  is  that  Freud 
has  the  specific  faculty  of  the  great  investigator,  the  gift  of 
“superb  guessing”  (which,  after  all,  is  essentially  recon- 
structive, not  creative),  but  has  it  in  exuberant  degree  ; 
like,  for  instance,  Kepler  the  astronomer.  Of  his  amazing 
reconstructions  of  the  infant  mind  he  offers  hardly  a trace 
of  verification.  The  length  of  his  inductive  leaping  pole  is 
dangerous,  but  the  reach  of  his  theories  impressive.  And  if 
it  be  true  that  he  has  opened  a new  window  giving  upon  the 
wonderland  of  the  human  mind,  then  it  is  not  fitting  to 
complain  of  the  view.. — I am,  Sir.  yours  faithfully, 

Sept.  15tb,  1919.  CADUCEUS. 


JOHN  CAHILL,  M.D.  Durh.,  F.R.C.S.  Eng. 

Dr.  John  Cahill,  whose  death  on  Saturday,  Sept.  6th,  was 
alluded  to  in  The  Lancet  last  week,  was  the  only  son  of 
the  late  Dr.  Thomas  Cahill,  of  Albert  Gate,  Knightsbridge. 

A Catholic,  he  was  born  in  1857  and  educated  at 
Beaumont  College,  and  then  for  two  years  in  Germany. 

He  joined  the  medical  school  of  St.  George’s  Hospital 
in  1877,  but  in  the  year  of  his  qualification  as  M.R.C.S. 

— namely,  in  1881 — his  father  died.  Cahill  remained  at 
the  hospital  discharging  the  junior  appointments,  and 
took  the  F.R.C.S.  Eng.  in  1884,  when  he  decided  to  go  into 
private  practice  in  the  neighbourhood  where  his  father  and 
his  family  were  still  well  remembered.  This  he  did,  and  for 
over  30  years  he  practised  in  Seville-street,  Lowndes-square, 
his  success  being  alike  due  to  his  high  professional  attain- 
ments and  his  kind  and  cultivated  personality.  At  first  his 
practice  was  distinctly  surgical,  and  for  some  years  he  was 
surgeon  to  the  Hospital  of  St.  John  and  St.  Elizabeth,  but 
later  he  proceeded  to  the  M.D.  Durham,  and  confined  himself 
to  general  practice.  He  was  medical  adviser  to  the  Egyptian 
Civil  Service  and  a member  of  the  Egyptian  Government 
Medical  Commissioners  Board,  his  knowledge  of  French  and 
German  standing  him  in  good  stead  in  such  appointments. 

Cahill  always  took  a deep  interest  in  the  organisation  and 
material  prospects  of  St.  George’s  Hospital,  which  to  him 
was,  of  course,  not  only  his  old  educational  centre,  but  an 
important  local  institution.  The  perplexities  which  have 
beset  the  hospital  in  the  midst  of  the  various  rumours  with 
regard  to  the  sale  of  the  site  were  under  discussion  by 
the  committee  of  management  of  the  charity  at  a time 
when  be  was  a member  of  the  committee,  and  on  that  body 
no  one’s  voice  was  more  readily  heard,  both  on  domestic 
matters  and  larger  schemes.  During  the  shortage  of  the 
medical  staff,  caused  by  the  calling  up  of  all  available 
men  to  serve  with  the  forces,  Cahill  did  arduous  and 
unselfish  work  as  temporary  assistant  physician  to  the 
hospital,  and  his  death  from  heart  disease,  while  still  in 
middle  age,  can  undoubtedly  be  referred  to  the  strain  of 
professional  overwork  aggravated  by  deep  sorrow  caused  by 
the  death  of  his  son. 

In  1887  he  married  Lucy  Keith,  youngest  daughter  of  the 
late  Thomas  Keith,  C.B.,  Accountant  General  at  the  India 
Office,  and  had  two  daughters  who  survive  him,  as  well  as 
an  only  son,  Captain  Archibald  Cahill,  M.C.,  of  the  Royal 
Berkshire  Regiment,  who  was  killed’ in  action  in  1917.  F'or  < 
40  years  Cahill  was  a well-known  man  to  all  connected  with 
St.  George’s  Hospital,  and  he  leaves  behind  him  a reputation 
for  accomplishment,  industry,  and  courtesy  which  all  might  i 
envy.  

RICHARD  FRANCIS  TOBIN,  F.R.C.S.I., 

PAST  PRESIDENT  OF  THE  IRISH  MEDICAL  ASSOCIATION. 

Mr.  Richard  F.  Tobin,  of  Dublin,  died  suddenly  at  his 
club  on  August  31st  at  the  age  of  76  years.  A native  of 
Waterford,  he  was  educated  at  Clongowes  Wood  College 
and  Dublin,  and  after  obtaining  his  lidnce  from  the  Royal 
College  of  Surgeons  of  Ireland  in  1864  at  the  age  of  21  he 
entered  the  Army  Medical  Service.  He  had  a dis- 
tinguished career,  and  in  1880  was  appointed  assistant 
professor  of  surgery  in  the  Army  Medical  School.  In 
1885  he  took  part  in  the  Sowakin  Expedition,  subsequently 
contributing  an  account  of  his  experiences  to  tbe  Trans- 
actions of  the  Royal  Academy  of  Medicine  in  Ireland.  He 
retired  from  the  Army  Medical  Service  soon  afterwards  with 
the  rank  of  Brigade  Surgeon,  and,  settling  in  Dublin,  was 
appointed  a surgeon  to  St.  Vincent's  Hospital.  He  held  this 
post  until  a few  years  ago,  and  earned  the  reputation  of  a 
sound  and  careful  surgeon,  taking  a special  interest  in 
diseases  of  the  prostate.  In  later  years  he  suffered  much 
from  deafness,  and  some  three  years  ago  he  retired  from  active 
work.  He  continued,  however,  to  hold  the  posts  of  Inspector 
of  Anatomy  in  Ireland  and  secretary  of  the  Board  of 
Superintendence  of  Dublin  Hospitals.  He  was  for  a time 
President  of  the  Irish  Medical  Association,  and  was  surgeon 
to  the  Marquis  of  Aberdeen  during  the  period  of  his  vice- 
royalty. He  wrote  a “ Synopsis  of  Surgery,”  and  contributed 
many  articles  to  the  professional  journals. 


The  Lancet,] 


MEDICAL  NEWS. 


[Sept.  20,  1919  f>49 


Tobin  lost  his  only  son  in  the  Dardanelles,  and  the  grief 
for  this  loss,  together  with  his  own  personal  affliction  of 
deafness,  would  have  embittered  many  men,  but  with  him 
sorrow  only  brought  out  more  strongly  his  native  kindliness. 
A few  months  after  his  son’s  death  it  fell  to  Tobin’s  lot  to 
minister  professionally  to  the  wounds  of  James  Connolly,  the 
rebel  leader  of  Easter  week,  in  the  interval  between  his 
surrender  and  his  execution.  A friendship  sprang  up  between 
the  two  men  so  curiously  unlike — the  aristocrat  and  the 
revolutionary,  the  loyal  veteran  soldier  and  the  avowed  rebel. 
After  Connolly’s  death  Tobin  made  himself,  it  is  believed, 
responsible  for  the  expense  of  educating  the  labour  leader’s 
son.  The  incident  is  illustrative  of  the  gentleness,  the  sim- 
plicity, and  the  Christianity  of  Tobin.  He  brought  the  same 
gentleness  and  charming  courtesy  into  every  relation  of  life, 
and  no  surgeon  in  Ireland  enjoyed  moi  e fully  the  love  and 
friendship  of  his  students  and  professional  colleagues. 


St  tins. 


National  Hospital  for  Diseases  of  the  Heart, 
Westmoreland-street,  W. — Systematic  courses  of  instruc- 
tion are  given  from  time  to  time  in  morbid  anatomy, 
pathology,  diagnosis,  and  treatment  of  diseases  of  the  heart 
and  circulation.  Practical  instruction  in  electrocardio- 
graphy and  graphic  methods  is  also  given.  Post-graduate 
students  are  admitted  to  the  clinical  practice  of  the  out- 
patient department  and  wards,  and  application  should  be 
made  to  Captain  R.  G.  E.  Whitney,  the  secretary  of  the 
hospital. 

The  War  Office  lias  addressed  to  Sir  Arthur 
Stanley,  the  chairman,  Joint  War  Committee,  British  Red 
Cross  Society  and  Order  of  St.  John,  a letter  conveying  the 
appreciation  of  the  Army  Council  of  the  inestimable  service 
rendered  by  the  British  Red  Cross  Society  and  the  Order  of 
St.  John  of  Jerusalem  in  England.  In  this  letter  the  Council 
recognise  the  high  value  of  the  work  done  by  the  organisa- 
tions and  the  hospitals  formed  under  their  auspices.  “ The 
preparations,”  they  say,  “ made  in  time  of  peace,  and  the 
energy  and  efficiency  displayed  when  put  to  the  test  of  war, 
have  greatly  assisted  in  the  restoration  of  life  and  health  to 
the  sick  and  wounded,  and  have  contributed  in  no  small 
measure  to  the  achievement  of  victory.”  Sir  Arthur  Stanley 
is  finally  requested  to  convey  the  thanks  of  the  Army  Council 
to  the  various  branches  of  the  two  organisations  whose 
members  have  unstintingly  devoted  their  resources  to  the 
services  of  the  sick  and  wounded. 

Boating  Accident  on  Belfast  Lough.— The 
bodies  of  the  three  victims  of  the  boating  accident  of 
August  29th  have  now  been  recovered.  Mr.  Thomas  Huston, 
L.R.C.P.  & S.  Edin.,  aged  48,  of  Woodville  House,  Hounslow, 
London,  his  12-year-ohl  son,  and  Mr.  Frank  Huston,  son  of 
Dr.  James  Huston,  Carrickfergus,  a medical  student,  started 
for  a sail  on  Belfast  Lough,  nothing  more  being  heard  of 
them  until  the  boat  was  seen  drifting  empty.  In  the  course 
of  the  last  week  the  bodies  were  found  floating  at  sea  and  an 
inquest  followed. 

Presentation. — The  governors  of  the  Royal 
Devon  and  Exeter  Hospital  recently  presented  Mr.  E.  J. 
Domville,  consulting  surgeon  to  the"  charity,  with  a grand- 
father clock  and  an  illuminated  address,  as  a mark  of 
appreciation  for  his  services  in  performing  the  duties  of 
resident  house  surgeon  for  a period  of  three  and  a half  years 
during  the  period  of  the  late  war. 

Bristol  Royal  Infirmary. — A strong  appeal  is 
being  made  for  increased  financial  support  for  the  Bristol 
Royal  Infirmary.  The  deficit  is  £22,170.  The  president, 
Mr.  H.  H.  Wills,  has  offered  £5000  conditionally  upon  the 
adverse  balance  being  cleared  off  by  the  end  of  the  year. 

Messrs.  Henry  Frowde  and  Hodder  and  Stoughton 
have  in  preparation  a “Practice  of  Medicine  in  the  Tropics” 
by  many  eminent  authorities,  edited  by  Dr.  W.  Byam  and 
Dr.  R.  G.  Archibald,  Majors,  R.A.M.C.  The  number  of 
contributors  is  75,  drawn  from  many  parts  of  the  world. 

Donations  and  Bequests. — The  late  Mr.  Robert 
Anderson,  of  Glasgow,  has  bequeathed  £1000  each  to  the  Glas- 
gow Royal  Infirmary,  the  Western  Infirmary,  the  Glasgow 
Samaritan  Hospital  for  Women,  and  the  Royal  Hospital  for 
Sick  Children  ; and  £500  each  to  the  Victoria  Infirmary  and 
the  Orphan  Homes  of  Scotland.— By  the  will  of  the  late  Mrs. 
Sarah  Finnie,  of  Kilmarnock,  the  testatrix  left  £1000  each 
to  the  Zenana  Mission  of  the  Church  of  Scotland  and  to  the 
Kilmarnock  Infirmary,  and  £350  to  the  Kilmarnock  Nursing 
Association. 


Guy’s  Hospital  Biennial  Dinner. — The  Guy's 
biennial  dinner  will  take  place  at  the  Connaught  Rooms 
on  Tuesday,  Oct.  28th,  at  7 i*.m.,  Dr.  Lauriatou  Shaw  in  the 
chair.  All  Guy’s  men  who  have  not  received  an  invitation 
to  the  dinner  are  asked  to  communicate  with  Mr.  F.  J. 
Steward,  98,  Portland-place,  London,  W.  1. 

University  College  Hospital.  — The  old 
students’  dinner  will  be  held  at  the  Imperial  Restaurant, 
Regent-street,  ou  Friday,  Oct.  3rd,  Sir  J.  Rose  Bradford  in 
the  chair.  Tickets  15s.  (exclusive  of  wine)  may  be  obtained 
from  the  honorary  secretary,  Dr.  A.  M.  H.  Gray,  30,  New 
Cavendish-street,  W.  1. 

It  has  been  decided  to  erect  and  partially  endow 
a cottage  hospital  for  Helston  (Cornwall)  as  a war  memorial. 
The  cost  of  the  scheme  is  estimated  at  £4000,  and  the  building 
will  contain  eight  beds.  About  £1600  has  been  subscribed, 
and  it  is  thought  that  the  amount  required  will  be  easily 
obtained. 

The  Local  Government  Board  has  published 
what  is  to  all  intents  and  purposes  a directory  of  maternity 
and  infant-welfare  centres  in  England  and  Wales.  The  list 
includes  all  the  municipal  and  voluntary  maternity  and 
child-welfare  centres  known  to  the  Board  on  April  1st,  1919. 
The  names  and  addresses  of  the  secretaries  of  voluntary 
centres  are  also  given,  and  appended  is  an  index  of  the  towns 
and  villages  containing  centres.  It  is  a most  useful  little 
book  of  reference  for  all  who  are  engaged  in  this  class  of 
work,  but  from  the  point  of  view  of  the  doctor  it  would  be 
still  more  useful  were  it  to  contain  as  well  the  name  of  the 
medical  officer  who  is  in  charge  of  each  centre.  Such  a 
directory  would  prove  of  immense  help,  and  we  believe 
that  one  containing  this  information  has  not  as  yet  been 
published.  The  Local  Government  Board  list  can  be  pro- 
cured through  any  bookseller  or  from  H.M.  Stationery 
Office  under  the  title,  “ Maternity  and  Child- Welfare  Centres 
in  England  and  Wales.” 

Isolation  Accommodation  in  North  Devon. — 
The  question  of  isolation  accommodation  has  again  arisen 
in  North  Devon.  Dr.  W.  A.  Valentine,  medical  officer 
of  health  for  Barnstaple  Port  Sanitary  Authority, 
reported  on  Sept.  13th  last,  at  their  meeting  in  Barnstaple, 
that  he  had  visited  the  hospital  ship  with  Dr.  H.  A. 
Macewen,  from  the  Ministry  of  Health,  and  that  they  found 
the  ship  was  no  longer  suitable  for  the  reception  of  patients. 
It  was  suggested  by  some  of  the  members  that  a couple  of 
Army  huts  should  be  obtained  and  placed  between  Instow 
and  Fremington.  At  a subsequent  meeting  of  the  Barnstaple 
rural  council  a letter  was  read  from  the  Lynton  urban 
council  stating  that  the  latter  were  willing  to  join  in  a 
scheme  with  neighbouring  authorities  for  the  provision  of 
an  isolation  hospital.  The  chairman,  Mr.  W.  T.  Bucking- 
ham, said  that  their  chief  difficulty  lay  in  the  absence  of 
power  to  remove  patients  to  hospital.  They  had  cases  and 
carriers  of  diphtheria  in  the  district  with  whom  they  could 
not  deal.  He  pointed  out  the  function  of  a hospital  in  the 
prevention  of  epidemics.  The  hospital  ship  had  prevented 
the  spread  of  small-pox  in  Appledore  when  two  cases 
occurred  there  20  years  ago. 

Post-Graduate  Study  in  French:  Opportunity 
at  Laval.— Speaking  at  the  recent  meeting  of  the  Canadian 
Medical  Association,  Professor  S.  Grondin,  of  Laval  Univer- 
sity, Quebec,  stated  that  his  university  would  be  glad  to 
receive,  free  of  charge,  any  young  English-speaking  doctors 
of  the  Dominion  who,  having  passed  their  degree  in  their  own 
universities,  would  like  to  come  to  Quebec  and  follow  during 
one  year  the  lectures  given  at  the  university  and  the  clinics  in 
the  hospitals.  They  would,  he  said,  receive  a hearty  welcome, 
and  after  six  months  would  have  learned  how  to  speak  French . 
Laval  was  asking  in  return  from  the  English  universities  the 
same  privilege  for  its  young  French  doctors.  Professor 
Grondin  went  on  to  recall  his  own  stay  of  six  months  in  the 
Rotunda  Hospital  at  Dublin,  ascribing  thereto  his  ability  to 
deliver  an  address  in  English.  We  have  no  doubt  that  the 
Laval  offer  would  be  extended  to  medical  graduates  from  this 
country  who  desired  to  acquire  a working  knowledge  of 
medical  French  within  the  borders  of  a university  of  the 
Empire.  


BOOKS,  ETC.,  RECEIVED. 

Bailliere,  Tindall,  and  Cox,  London. 

Handbook  of  Gyneecology.  By  Bethel  Solomons,  M.D.  Pp.  xii.  + 236 
10,?.  6 d. 

Frowde,  H.,  and  Hodder  and  Stoughton,  London. 

Fractured  Femurs.  By  M.  G.  Pearson,  M.B.,  B.Sc.,  and  J.  Drummond, 
M.D.  Pp.  92.  10s.  6d. 

Kimpton,  Henry,  London. 

The  Op;rations  of  Obstetrics.  By  F.  E.  Leavitt.  M.D.  Pp.  466.  30s. 
A Stereoscopic  Atlas  of  Plastic  Surgery  oi  the  Face,  Head,  and  Neck, 
with  Case  Reports.  BylJ.  C.  Beck,  M.D  , and  I.  Frark.  With 
Stereoscope.  35s. 


550  Tbe  Lancet,]  APPOINTMENTS  —VACANCIES.— BIRTHS,  MARRIAGES,  AND  DEATHS.  [Sept.  20.  1919 


^pointmenls. 


Successful  applicants  Jor  vacancies,  Secretaries  o]  Public  Institutions, 
and  others  possessing  information  suitable  Jor  this  column,  are 
invited  to  forward  to  The  Lancet  Office,  directed  to  the  Sub- 
Editor,  not  later  than  9 o'clock  on  the  Thursday  morning  oj  each 
week,  such  information  for  gratuitous  publication. 

Adams,  J.,  has  been  appointed  Certifying  Surgeon  under  the  Factory 
and  Workshop  Acts  at  Bishop's  Castle. 

Campbell,  A S . Certifying  Surgeon  under  the  Factory  and  Workshop 
Acts  at  Dundee. 

Chubb,  Elsie  M.,  M.D.  Lond.,  D.P.H.,  Government  Medical  Inspector 
of  Schools  in  the  Cape  Province,  South  Africa. 

Davis,  Harry,  M.R.C.S.,  L.R.C.P.,  L.S.A.,  DP.H.Camb.,  Medical 
Officer  for  the  No.  7 District  by  the  Liskeard  (Cornwall)  Board  of 
Guardians. 

Fitzgerald,  Charles  Conway,  L.R.C.P.  &S.  Kdin.,  Chief  Tuberculosis 
Officer  for  the  county  of  Antrim. 

Langram,  William,  L R.C.S.,  L.M.  Edin.,  L.A.H.  Dub.,  Temporary 
District  Medical  Officer  by  the  Axminster  (Devon)  Rural  District 
Council. 

McKenna,  T.  H.,  Medical  Officer  of  the  Forkhill  Dispensary 
District. 


iarancus. 


For  further  information  refer  to  the  advertisement  columns. 
Barbados  General  Hospital.— Sen.  Res.  S.  £300. 

Battersea  General  Hospital,  Battersea  Park,  S.  IE.— Res.  M.O.  £200. 
Bedford  County  Hospital.— Res.  M .O.  £150. 

Belgrave  Hospital  Jor  Children,  Clapham-road,  S.  W.— Two  Asst.  P.’s 
Bermondsey  Infirmary,  Lower-road,  Rotherhithe,  S.E.— First  Asst.  M.O. 
£350. 

Be1  hie  in  Royal  Hospital,  Lambeth-road,  S.E.— Hon.  Neurologist.  Also 
Jun.  Asst.  P.  £350. 

Birkenhead  Borough  Hospital.— Jun.  H.S-  £170. 

Birmingham,  Lodge-road  War  Pensioners  Hospital. — Asst.  M.O.  £350. 
Birmingham  Municipal  Anti-Tuberculosis  Centre.— Sen.  Asst.  Tuberc- 
O.  £650. 

Bridge  of  Weir,  near  Glasgow,  Consumption  Sanatoria  of  Scotland.— 
Asst.  M.O.  £200. 

Brighton,  Royal  Sussex  County  Hospital.— Asst.  H.S.  £80. 

Cardiff,  King  Edward  VII.’s  Hospital.— H.S.  £200. 

Central  London  Ophthalmic  Hospital,  Judd-street,  St.  Pancras,  W.C. — 
H.S.  £60. 

Cheltenham  Eye,  Ear,  and  Throat  Free  Hospital.— Asst.  S.  £400. 
Chester,  Cheshire  County  Council. — Dlst.  Tuberc.  O.  £400. 

Crowlhorne,  Berks,  Broadmoor  State  Asylum.— Asst.  M.O.  £300-£350. 
Cumberland  Education  Committee.—  Two  School  Dentists.  £350. 
Dunfermline,  Carnegie  Dunfermline  Trust.— Sch.  M.O.  £400. 

Durham  County  Council. — Five  Asst.  School  M.O.'s.  £600. 

Eastbourne.  Princess  Alice  Hospital.— R.M.O.  £175. 

East  Riding  Education  Authority.— Female  Asst.  Sch.  M.O.  £350. 
Sch  Dent.  £350. 

Evelina  Hospital  for  Children,  Southwark,  S.E.—  H.S.  and  H.P.  £160. 
German  East  Africa  Occupied  Territory. — M.O.’s.  £400-£20-£500. 
Glamorgan  County  Asylum,  Bridgend.— Fourth  Asst.  M.O.  £400. 
Glasgow,  Hawkhead  Asylum,  Cardonald.— Jun.  Asst.  M.O.  £275. 
Glasgow,  Scottish  Western  Asylums'  Research  Institute. — Director.  £600. 
Glasgow,  Victoria  Infirmary. -Visiting  P.  and  Visiting  S. 

Grimsby  and  District  Hospital. — H.S.  £300. 

Guy's  Hospital.  S.E.—  Hon.  Anaest. 

Hackney  and  Stoke  Newington,  Metropolitan  Boroughs  of.— Tuberc.  O. 
Hatfield  Union.— M.O.  £75. 

Hospital  for  Consumption  and  Diseases  of  the  Chest.  Brompton. — 
H P.  30  guineas. 

Hospital  for  Epilepsy  and  Paralysis.  Maula  Vale,  W.— Hon.  Psycho- 
logist, Hon.  Ophth.  S.,  and  Hon.  Asst.  P. 

Hospital  for  Sick  Children,  Great  Ormond-strcet,  W.C.— Res.  Med.  Supt. 

£;00.  Also  Asst.  Cas.  M.O.,  H.S.,  and  H.P.  All  £50. 

Huddersfield  Royal  Infirmary.— Asst.  H.S.  £100. 

Ip-wich,  East  Suffolk  and  Ipswich  Hospital.—  H.P.  £250. 

Italian  Hospital,  Queen-square,  W.C. — Hon.  Ophth.  Surg. 

Lambeth  Metropolitan  Borough.— Tuberc.  O.  £600. 

Leamington,  iVameford,  Leamington,  and  South  Warwickshire 
General  Hospital.— Res.  H S.  £200. 

Leeds  General  Infirmary.— Res.  M.O.  £150.  Res.  Obstet.  O.  £60. 
Also  Res.  M.O.  at  Ida  and  Robert  Arthington  Hospitals.  £60. 
Two  H P.'s  and  Two  U.S.'s. 

Leeds  Public  Dispensary,  North-street.— Res.  M.O.  £200. 

Lincoln  County  Hospital.— Jan.  H.S.  £150. 

Liverpool,  Hospital  for  Consumption  and  Diseases  of  the  Chest,  Mount 
Pleasant.—  Asst.  M.O.  and  Pathologist.  £175. 

Liverpool  Infirmary  for  Children. — Two  Res.  H.  P.  and  Res.  H.  S.  £90. 
Maldon  Union.— M.O.  and  Pub.  Vac.  £100. 

Manchester,  Ancoats  Hospital.— Res.  Surg.  O.  £200.  Also  H.S.  £100. 
Manchester  Northern  Hospital  for  Women  and  Children,  Park-place, 
Clieetham  Hill-road.— Hon.  Asst.  P. 

Manchester  Royal  Infirmary.— Path,  and  Med.  Registrars.  £350  and  £75 
respectively. 

Metropolitan  Hospital,  Kingsland-road,  E.— H.S.,  Asst.  H.P.,  and 
Asst.  H.S.  £100  each. 

Middleton  in- Wharfedalc  Sanatorium,  near  Ilkley.— Asst.  Res.  M.O. 
£325. 

Mothers'  Hospital,  MS- 10  . Loner  Clapton- road,  E.— Res.  M.O. 


National  Hospital  jor  the  Paralysed  and  Epileptic,  Queen  square , 
W.C. — Radiologist. 

Newcastle-upon-Tyne,  Hospital  for  Hick  Children.— Jun.  Res.  M.O. 

£200. 

Newport  Borough  Asylum,  Caerleon,  Mon.— Asst.  M.O.  £400. 

New  South  Wales,  Department  of  Public  Instruction.— Prinpl.  M.O. 
£900. 

Norwich  Poor-law  Institution.— Res.  M.O.  £350. 

Preston,  Lancashire  County  Council.— Asst.  Disp.  Tuberc.  O.  £550. 
Prince  of  Wales's  General  Hospital,  Tottenham,  N.— H.P.  and  H.S. 

£200.  Also  Jun.  H.S.  and  Jun.  H.P.  £120. 

Queen  Charlotte's  Lying-in  Hospital,  Marylebone-road,  N.W.—  DUt. 
Res.  M.O.  £80. 

Queen  Mary's  Hospital  for  the  East  End.  Stratford,  E. — H.S.  £150. 
Reading,  Berks  Education  Committee.— Sch.  Dent.  £400. 

Rotherham  Hospital.— Jun.  H.S.  £150. 

Royal  Free  Hospital.  Gray’s  Inn-road,  W.C.— Hon.  Anaest.  Also  Cas.  O. 
(£100)  and  Registrar. 

Royal  London  Ophthalmic  Hospital,  City-road,  E.C.— Curator  and 
Librarian.  £200. 

Royal  National  Orthopedic  Hospital,  2.14,  Great  Porlland-streel,  W. — 
Surg.  Registrar. 

Royal  Westminster  Ophthalmic  Hospital,  King  William-street,  West 
Strand,  W.C. — Non-Res.  Asst.  H.S.  £40. 

Salisbury  General  Infirmary.— H.S.  and  Asst.  H.S.  £200  and  £150 
respectively. 

Seamen’s  Hospital,  Greenwich.— House  appointments. 

Serbia.  Serbian  Relief  Fund  Hospitals.— Surg. 

Sheffield  Royal  Infirmary. — H.S.  for  Ear,  Nose,  and  Throat.  £150. 
Southend-on-Sea  County  Borough.— Tuberc.  O.  £600. 

Sunderland  Royal  Infirmary.— Sen.  H.S.,  Two  Jun.  H.S.’s,  and  H.P. 

£250  and  £200  respectively. 

Swansea  General  and  Eye  Hospital.— H.S.  £250. 

Taunton  and  Somerset  Hospital.— Res.  Asst.  H.S.  £150. 

Truro,  Royal  Cornwall  Infirmary. — H.S.  £170. 

Weston-super-Mare,  Somerset  County  Education  Committee.—  Schoo 
Oculist  and  Med.  Inspec.  £450. 

Whitehaven  and  West  Cumberland  Infirmary.— Res.  H.S.  £180. 
Wolverhampton  and  Staffordshire  General  Hospital.— H.S.  £200. 

The  Chief  Inspector  of  Factories,  Home  Office,  S.W.,  gives  notice  of  a 
vacancy  for  a Certifying  Surgeon  under  the  Factory  and  Workshop 
Acts  at  Malton  (York). 


Ht images,  anb  featfcs 


BIRTHS. 

Brimblecombe.— On  Sept.  10th.  at  Willow  Bank,  Martock,  Somerset, 
the  wife  of  S.  L.  Brimblecombe,  M.R.C.S.,  L.R.C.P.,  of  a son. 

Dent. — On  Sept.  9th,  at  21,  Endslelgh-street,  to  Lieutenant  R.  W- 
Dent,  H.M.T.S.  Monarch,  and  Dr.  Patricia  Dent  (rUe  Barnes),  of 
Okeburn,  Ambleside  Avenue,  Streatham,  a daughter. 

Doll.— On  Sept.  8th,  at  Hill-street,  Knightsbridge,  the  wife  of  Dr. 
H.  William  Doll,  of  a son. 

Oram.— On  Sept.  11th,  at  St.  Michael’s  Lodge,  Deepcut,  Famborough, 
Hants,  the  wife  of  Captain  A.  R.  Oram,  M.C.,  R.A.M.C.,  of  a bod. 
(Richard).  

MARRIAGES. 

Bboughton-Head—  Bland.— On  Sept.  10th,  at  Christ  Church, 
Brondesbury  Park,  London,  N.W.,  Leslie  Charles  Broughton-Head, 
M.B.,  L.D.S.  Eng.,  to  Dorothy,  elder  daughter  of  George  R. 
Bland,  Brondesbury  Park,  N.W. 

Connan— Mackintosh. — On  Sept.  11th,  at  Trinity  Presbyterian 
Church.  Donald  Murray  Connan,  M.B.,  B.S..  to  Annie  Dorothy, 
second  daughter  of  Rev.  Eneas  and  Mrs.  Mackintosh,  of  Temuka, 
Alton,  Hants. 

Harvey— Dohertt.— On  Sept.  15th,  1919,  at  St.  Pancras  Parish  Church  , 
London,  by  the  Vicar,  Rev.  E.  L.  Metcalfe,  M.A.,  and  the  Rev. 
E.  Harvey.  M.A.,  brother  of  the  bridegroom,  Joseph  Harvey, 
Captain,  R.A.M.C.  (T.C.),  youngest  son  of  the  late  Mr.  John 
Harvey  and  Mrs.  Harvey,  Ratbmmes,  Dublin,  to  Winifred 
Eleanor,  fifth  daughter  of  Mr.  and  Mrs.  W.  Doherty,  Claremont. 
Western  Australia. 

Stiell— Holland. — On  Sept.  15th,  at  Nettleham  Parish  Church . 
Lincoln,  by  the  Rev.  C.  K.  Watkins,  William  Fletcher  Stiell  • 
M.R.C.S.,  L.R.C.P.,  younger  son  of  Dr.  aod  Mrs.  Stiell,  of 
Clapham,  London,  S.W.,  to  Margaret,  younger  daughter  of  Mr. 
George  Holland  and  the  late  Mrs.  Holland,  of  ' Kelvin,’’  Lime  Tree 
Avenue,  Retford. 

Wright— Dean.— On  Sept.  9th.  at  Metheringham,  Charles  Samue 
Eric  Wright,  M.B.,  to  Kathleen  Mary,  only  daughter  of  Mr.  and 
Mrs.  J.  H.  Dean,  Heath  House,  Nocton,  Lincoln. 


DEATHS. 

Eccles. — On  Sept.  9th,  at  Upper  Norwood,  William  Soltau  Eccles. 
M.R.C.S.  Eng.,  aged  76  years. 

Macxab.— On  Sept.  12th.  at  Lansdown-place  East,  Bath,  Robert 
Macnab,  M.D.  Glasg.,  F.R.C.S.  Edin.,  aged  78  years. 

Meek.— On  Sept.  15th,  suddenly,  at  Frlmley,  Wilfrid  Ombler  Meek, 
M.B.,  B.S.  Loud.,  in  his  40th  year. 

Rankin.— On  Sept.  14th,  at  The  Orchard,  Helford,  Cornwall,  Guthrie 
Rankin,  M.D.,  F.R.C.P..  and  of  9,  Harley  street,  London. 

N.B.—A  fee  of  5s.  is  charged  Jor  the  insertion  of  Notices  of  Births » 
Marriages,  and  Deaths. 


Thk  Lancet,] 


MEDICAL  DIARY.— NOTES,  SHORT  COMMENTS,  ETC. 


[Sept.  20,  1919  55  1 


SUbital  far  % ensuing  Week 


LECTURES,  ADDRESSES,  DEMONSTRATIONS,  &c. 

LONDON  HOSPITAL  MEDICAL  COLLEGE,  in  the  Clinical  Theatre 
of  the  Hospital. 

A Special  Course  of  Instruction  in  the  Surgical  Dyspepsias  will  be 
given  by  Mr.  A.  J.  Walton  : — 

Monday,  Sept.  22ml.— 4.30  p.m..  Lecture  XV.: — Foreign  Bodies, 
Rupture  of  the  Stomach,  Gastric  Adhesions,  Acute  Dilatation 
of  the  Stomach. 

Friday.— 4.30  p.m.,  Lecture  XVI.: — Technique  and  Complications 
of  Gastric  Operations. 


Communications,  Letters,  &c.,  to  the  Editor  have 
been  received  from—  ■ 


A.  — Army  Medical  Service,  Lond., 
Director-General  of;  Dr.  H.  W. 
Armit,  Sydney. 

B.  - Surg.-Commdr.  W.  Bastian, 
R.N.;  British  Fire  Prevention 
Committee,  Lond.;  Dr.  E.  C. 
Bousfield,  Lond.;  British  Organo- 
therapy Co.,  Lond.;  Dr.  D.  T. 
Barry,  Cork ; British  Federation 
of  Medical  and  Allied  Societies, 
Lond.;  Dr.  G.  Blacker,  Lond.; 
Dr.  E.  F.  Barton,  Lond.;  Major 
W.  Byam,  O.B.E. 

C. — Mr.  B.  F.  Conolly,  Lond.; 
Mr.  F.  B.  Cornell,  Whitley  Bay; 
Dr.  E.  F.  Cyriax,  Lond.;  Mr.  A. 
Crafu,  Worthing  ; Charing  Cross 
Hospital  Medical  School,  Lond., 
Governors  and  Staff  of. 

D.  — Sir  H.  B.  Donkin,  Isieworth ; 
p’  Dr.  P.  W.  Diack,  Lond. 

E. — Dr.  R.  Eager,  Exminster; 
Dr.  J.  Elliott,  O.B.E.,  Chester; 
Dr.  R.  B.  Eocles,  Driffield. 

F.  — Factories,  Chief  Inspector  of, 
Lond.;  Food  Education  Society, 
Lond.,  Hon.  Sec.  of. 

G. — Mr.  H.  T.  Gray,  Lond.;  Dr. 
A.  M.  H.  Gray,  Lond. 

H. — Mrs.  Hogarth,  Quainton  ; Dr. 
C.  T.  W.  Hirsch,  Lond.;  Dr.  H. 
Head,  Lond. 

I. — Dr.  H.  Ilioway,  New  York. 

J.  — Prof.  F.  W.  Jones.  Lond. 

K. — Dr.  H.  C.  Kidd,  Bromsgrove. 


L. — Dr.  G.  C.  Low,  Lond.;  Mrs.  O. 
Langmead,  M.B.,  Loud.;  Dr. 

R.  B.  Low,  C.B.,  Lond. 

M.  — Dr.  F.  H.  Morison,  Carlisle  ; 
Ministry  of  Health,  Lond.;  Major 
E.  F.  W.  Mackenzie;  Dr.  C.  S. 
Myers,  Etchingham;  Mr.  A.  E. 
Mahood,  Bristol ; Dr.  I.  Moore, 
Lond. 

N. — Dr.  H.  P.  Newsholme,  Ripon  ; 
Dr.  L.  E.  Napier,  Reading ; 
National  Board,  Young  Women's 
Christian  Association,  New 
York. 

P. — Pharmaceutical  Society  of 
Great  Britain,  President,  Vice- 
President,  and  Council  of. 

R.  — Dr.  Roland,  Paris;  Lieut.- 
Col.  Sir  L.  Rogers,  I.M.S.;  Dr. 
J.  D.  Rolleston,  Lond.;  Mrs.  E. 
Riach,  Lond.;  Dr.  W.  C.  Rivers, 
Worsboro'  Dale  ; Mr.  T.  H.  Robin- 
son, Melton  Constable. 

S. — St.  Mary's  Hospital  Medical 
School,  Lond.,  Medical  Staff  and 
Lecturers  of  ; Dr.  F.  J.  Steward, 
Lond.;  Dr.  W.  C.  Sullivan, 
Lond.;  St.  Marylebone  General 
Dispensary,  Sec.  of. 

T. — Dr.  D.  Turner,  Edinburgh ; 
Major  J.  Taylor,  R.A.M.C. 

V.  — Dr.  R.  M.  Vick,  Lond. 

W.  — Mr.  L.  J.  Webb,  Winchester; 
Mr.  W.  B.  Woollam,  Buxton ; 
Dr.  J.  Wilson,  Belfast. 


Communications  relating  to  editorial  business  should  be 
addressed  exclusively  to  the  Editor  of  The  Lancet, 
423,  Strand,  London,  W.C.  2. 


MANAGER'S  NOTICES, 

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I 

States,  Styart  Camments,  anh  ^nsfoers 
ta  Correspondents. 

THE  ECONOMICS  OF  NIGHT  CALLS. 

It  was  recently  recorded  in  the  obituary  notice  of  a well- 
known  north-country  practitioner  that  throughout  his  long 
and  active  professional  life  he  was  able  to  attend  to  a series 
of  night  calls  without  deterioration  of  his  day-time  work. 
This  ability  must  surely  be  passing  with  the  brave  age  of 
heroes.  The  present-day  practitioner  is  of  commoner  clay, 
and  there  must  be  few  who  do  not  experience  some  loss  of 
attention  or  of  interest  in  their  work  after  a bite  out  of  the 
night’s  sleep.  The  matter  has  its  bearing,  too,  from  the 
patient’s  point  of  view  ; a jaded  doctor,  even  if,  as  we  are 
assuming  here,  his  night-watching  is  the  result  of  profes- 
sional engagements,  is  not  worth  as  much  as  a fresh  one. 
The  Federation  of  Ratepayers  Associations  at  Johannesburg 
recently  discussed  the  question,  debating  whether  suitable 
provision  could  not  be  made  for  procuring  medical  attention 
and  medicines  during  the  night  time.  Dr.  E.  P.  Baumann, 
senior  physician  to  the  Johannesburg  Hospital,  attended  by 
invitation  to  submitthe  pointof  viewof  medical  practitioners. 
He  urged  that  though  the  question  of  fees  was  a consideration 
it  was  not  the  primary  one,  and  he  suggested  that  some 
steps  be  taken  to  form  a panel  of  junior  practitioners  to 
whom  night  work  would  be  a welcome  introduction  to  the 
public.  His  estimate  that  99  9 per  cent,  of  night  calls 
were  futile  and  not  cases  of  necessity  may  have  been 
intentionally  picturesque,  but  he  went  on  very  justly  to  point 
out  the  physical  strain  of  night  calls  upon  a practitioner  who 
had  spent  a busy  day.  A subcommittee  was  appointed  to 
discuss  the  question  with  the  local  medical  profession  and 
to  report  to  the  Federation.  Something  instructive  may 
come  of  it. 

“STAMMERING  AND  VOICE  DEFECTS.” 

To  the  Editor  of  The  Lancet. 

Sir, — With  reference  to  Miss  Emil  Behnke’s  comment  on 
the  statement  I made  in  my  paper  on  the  above  subject  in 
your  issue  of  August  23rd,  may  I say  that  I think  my 
meaning  was  rather  misunderstood. 

I know  the  late  Mrs.  Behnke’s  books  on  the  subject  well, 
and  have  in  the  past  obtained  valuable  help  from  them.  By 
saying  that  “stammering  and  functional  voice  defects  have 
until  recently  been  looked  upon  as  unfortunate  disabilities, 
and  no  real  scientific  attempt  was  made  thoroughly  to  deal 
with  such  cases,  and  hence  there  was  no  recognised  cure,”  I 
mean  that  stammering  and  functional  voice  defects  have  not 
until  recently  been  regarded  as  an  evidence  of  a disease 
which  required  specialised  medical  treatment  in  addition  to 
specialised  speech  treatment.  As  a rule,  stammering,  Ac., 
patients  were  sent  to  teachers  of  elocution  or  speech 
specialists — the  cure  being  left  to  them  entirely — and  the 
symptom  alone  was  treated.  Now,  however,  it  is  generally 
accepted  that  the  symptom — i.e.,  stammering,  &c.— cannot 
permanently  be  cured  until  the  underlying  psychic  cause 
has  been  dealt  with,  and  this  latter  can  only  successfully  be 
accomplished  by  those  trained  in  psychological  medicine. 
My  paper,  of  course,  only  referred  to  functional  and  not  to 
organic  voice  defects. 

I am,  Sir,  yours  faithfully, 

Blackheath.  S.E.,  Sept.  10th.  1919.  MABEL  V.  O.  OSWALD. 

COLONIAL  HEALTH  REPORTS. 

Basutoland. — The  report  on  this  territory  for  1917-18 
states  that  typhus  fever,  which  had  been  prevalent  for 
more  than  a year  in  certain  districts  of  Cape  Colony, 
appeared  in  August,  1917.  The  early  cases  were  nearly  all 
among  the  Tembu  of  the  Quthing  and  Mohales  Hock 
districts.  Later,  cases  occurred  in  the  Qacha’s  Nek  district. 
Energetic  measures  were  at  once  taken  to  control  the 
epidemic.  Infected  areas  were  strictly  quarantined. 
Recruiting  for  mines  and  other  purposes  was  prohibited 
in  the  southern  districts  and  every  means  taken  to  dis- 
courage the  movements  of  natives  from  one  place  to  another. 
All  infected  huts  were  destroyed  by  fire,  and  olothing  and 
other  personal  effects  disinfected  by  boiling.  The  death- 
rate  was  high — about  50  per  cent. — but  this  resulted  in  the 
people,  who  were  thoroughly  scared,  cooperating  actively 
with  the  authorities  in  enforcing  quarantines.  This 
would  not  have  been  the  case  had  the  disease  been 
attended  with  a low  mortality.  From  August  14th,  when 
the  first  cases  were  noted,  till  Dec.  31st,  there  were  215 
cases  with  100  deaths.  No  Europeans  were  affected.  There 
was  no  ease  of  small-pox.  A good  many  men  suffering  from 
malarial  fever  came  under  the  notice  of  the  medical  officers. 


552  The  Lancet,]  NOTES,  SHORT  COMMENTS,  AND  ANSWERS  TO  CORRESPONDENTS.  [Sept.  20,  1919 


They  were  all  imported  cases,  chiefly  returned  general 
service  boys  from  German  East  Africa.  Syphilis  is  still 
very  prevalent,  and  a proposal  is  under  consideration  to 
inaugurate  free  treatment  for  the  disease.  The  general 
difficulty  in  dealing  with  the  problem  of  syphilis  in  a native 
territory  is  the  indifference  of  the  people.  Most  cases  have 
a non-venereal  origin  (only  16  cases  of  chancre  were  seen 
during  the  year) ; the  initial  lesion  is  often  overlooked, 
mucous  patches  on  the  mouth  follow,  and  the  infection 
spreads  from  one  member  of  a family  to  another,  and  whole 
villages  may  be  rapidly  infected.  In  a great  many  instances 
the  secondary  symptoms  subside  without  treatment,  but  not 
before  the  patient  has  passed  infection  on  to  many  others. 
Dysentery  was  again  prevalent,  but  much  milder  in  type 
than  in  recent  years.  There  were  a few  cases  of  meningitis, 
mostly  tubercular  in  origin.  The  general  health  of  the 
community  has  been  above  the  average.  1997  in  patients 
and  32,347  out-patients  were  treated  at  the  Government 
hospitals  and  dispensaries.  On  April  1st,  1917,  there  were 
181  male  and  182  female  inmates  of  the  Leper  Asylum,  and 
during  the  year  ended  March  31st,  1918,  52  new  cases  were 
admitted.  One  patient  was  discharged  as  a possibly  arrested 
case  ; there  were  29  deaths  and  8 births.  Of  43  deserters  all 
but  two  returned  to  the  settlements.  There  has  been  an 
improvement  in  the  general  health  of  the  inmates. 

Nyasaland. — In  1917-18  the  health  of  the  Protectorate 
was  not  satisfactory  owing  to  the  extensive  movement  of 
natives  necessitated  by  the  military  operations.  Small- 
pox, which  in  the  previous  year  was  confined  to  the 
Dowa  and  Lilongwe  districts,  made  its  appearance  in 
seven  other  areas.  It  was  found  impossible  to  entirely 
restrict  the  movements  of  natives  with  a view  to 
checking  the  spread  of  the  disease,  as  the  increasing 
military  demands  for  labour  had  to  be  made.  Owing  to  the 
lack  of  medical  officers  sleeping  sickness  investigations  had 
to  be  suspended.  Twenty-eight  cases  of  plague  were  reported 
from  Karonga  in  the  North  Nyasa  district,  the  outbreak 
being  merely  a continuance  of  the  one  reported  in  the 
previous  year.  The  extermination  of  rats,  inoculation,  and 
other  preventive  measures  which  were  adopted  not  only 
checked  the  local  spread  of  the  disease,  but  prevented  its 
gaining  an  entry  into  other  parts  of  the  Protectorate.  As  in 
the  case  of  plague,  cerebro-spinal  meningitis  was  introduced 
into  Nyasaland  from  German  East  Africa.  It  was  first 
observed  among  the  native  German  prisoners  of  war  who 
were  sent  to  Zomba  for  internment.  Sixty-seven  cases  were 
recorded  during  the  year  ; the  case  mortality  was  high,  but 
of  the  three  Europeans  who  contracted  the  disease  only  one 
died.  The  number  of  Europeans  resident,  including  officials 
and  non-officials,  but  excluding  the  military,  was  463  males 
and  215  females.  The  Asiatic  population  amounted  to  422. 
The  native  population  is  estimated  at  1,227,442— approxi- 
mately 559,810  males  and  667,632  females. 

NOCTURNAL  ENURESIS. 

To  the  Editor  of  The  Lancet. 


following  day  in  which  the  pertinent  warning  is  given  that 
some  opticians  are  not  to  be  trusted,  though  others  are 
excellent  scientific  workers. 

THE  SURGEON  AND  HIS  FAMILY. 

The  patria  potestas  was  accurately  defined  by  the  Roman 
Code,  but  in  modern  civilisation  the  duties  and  privileges  of 
the  father  of  the  family  towards  his  own  household  are 
determined  rather  by  broad  views  of  equity  and  by  the  force  of 
accumulated  public  opinion  than  by  statute.  Many  of  these 
duties  are  common  to  all  ranks  of  society  and  to  all  kinds 
of  occupation,  but  there  are  special  privileges  attaching 
to  fathers  who  possess  special  qualifications.  The  school- 
master helps  his  son  at  home  with  his  school  lessons ; 
the  bootmaker  patches  the  shoes  which  otherwise  go  out 
to  be  done;  the  public  hygienist  exerts  in  his  private 
family  that  speoial  supervision  in  the  prevention  of 
disease  for  which  his  larger  experience  qualifies  him.  It 
would  be  absurd  to  exclude  the  surgeon  from  the  position  of 
special  helpfulnees  to  his  own  household.  The  question  has 
been  recently  discussed  in  the  daily  press  in  the  light  of  a 
tragic  incident.  The  scanty  story  relates  to  a man  who, 
after  receiving  serious  injuries  in  a shooting  accident,  was 
taken  to  a county  hospital  where  his  father,  a consulting 
surgeon,  performed  an  operation  upon  him,  but  was  unable 
to  save  his  son’s  life.  No  details  were  given  in  regard  to  the 
urgency  of  surgical  intervention  nor  what  opportunity  of 
assistance  or  consultation  were  open  to  the  surgeon.  But  on 
general  grounds  the  propriety  of  a father  operating  upon  his 
son  has  been  apparently  called  in  question.  The  argument 
seems  to  rest  upon  the  assumption  that  a surgeon  in  the 
position  of  a near  relative  cannot  offer  to  his  patient  the 
same  skill  which  he  could  give  to  a stranger.  It  overlooks  the 
fact  that  the  whole  course  of  medical  training  is  directed 
towards  transforming  the  emotion  of  pity  into  the  instinct 
of  helpfulness.  Were  this  mutation  incomplete  no  medical 
man  would  trust  himself  to  be  arbiter  of  human  life  at  all. 
To  the  surgeon  his  art  has  no  affective  tone.  Blood  is  simply 
a corpuscular  fluid  with  certain  chemical  and  physical 
properties.  Small  casualties  occurring  in  the  house  of  the 
medical  practitioner  are,  of  course,  dealt  with  as  a matter  of 
ordinary  routine,  the  more  so  probably  as  the  medical  man 
suffers  under  the  disability  of  not  being  allowed,  in  most 
instances,  to  pay  the  colleague  whom  he  calls  in.  On  this 
account,  as  well  as  for  convenience,  the  practitioner  frequently 
gives  the  anaesthetic  to  any  member  of  his  family  when  a 
larger  surgical  intervention  is  needed.  What  is  to  be  regarded 
as  a major  operation  depends  on  the  skill  of  the  surgeon.  In  a 
report  recently  received  from  a hospital  in  India  paracentesis 
abdominis  and  curettage  are  classed  as  such.  The  hospital 
surgeon  in  this  countrv  possesses  the  skill  which  makes  the 
so-called  major  operation  to  him  an  ordinary  everyday  task. 
To  deprive  him  of  the  privilege  of  offering  his  services  to 
members  of  his  family  in  urgent  need  would  be  stupid  ; his 
call  is  often  no  less  clear  than  that  of  Abraham  to  use  the 
knife  on  his  own  son. 


Sir,— Can  any  of  your  readers  suggest  treatment  for  a boy, 
aged  9,  who  suffers  from  incontinence  of  urine  both  by  day 
and  night?  By  constant  supervision— telling  him  to  pass 
water  every  two  hours  or  so— he  can  be  kept  dry.  He 
apparently  has  no  “call”  when  the  bladder  is  full,  as  he  has 
been  known  to  declare  that  he  did  not  wish  to  pass  water 
during  the  very  act  of  micturition,  he  not  being  aware  of  the 
fact  that  he  was  passing  water.  He  is  a well-nourished 
and  apparently  healthy  boy  except  that  he  is  a bad 
stammerer.  I am,  Sir,  yours  faithfully, 

9,  Welbeck-street,  Cavendish-square,  W.  1,  F.  St.  J.  S. 

Sept.  10th,  1919. 

OCULIST  AND  OPTICIAN. 

The  following  letter,  signed  “ F.,”  appears  in  the  Times 
of  Sept.  10th 

"Even  more  important  than  opticians' prices  is  the  verification  of 
opticians’  work.  My  oculist  ordered  me  a change  of  lenses.  I took 
the  prescription  to  an  optician  of  repute,  recommended  by  my  oculist, 
but  the  new  glasses,  luckily  for  me,  pained  my  eyeB,  and  I went  back 
to  the  oculist.  He  found,  to  his  intense  indignation,  that  the  prescrip- 
tion had  been  incorrectly  carried  out.  The  optician  made  the  usual 
excuse  of  war  conditions,  and  later  had  the  impudence  to  send  me 
an  additional  bill  for  putting  the  glasses  right,  which  of  ourse  I flatly 
refused  to  pay.  There  should  be  a regular  system  of  verification. 
Without  it  the  skill  of  the  oculist  may  be  all  in  vain,  and  the  patient's 
oyes  may  suffer  irreparable  injury.  It  would  be  a little  more  trouble 
for  the  oculist  to  see  his  patient  again,  but  he  would  sometimes  be  as 
surprised  and  indignant  as  my  friend  was." 

We  have  had  ocoasion  to  point  out  that  the  work  of  the 
ophthalmologist  may  be  entirely  disorganised  by  a lack  of 
conscience  or  knowledge  on  the  part  of  the  optician,  adding 
that  in  our  experience  most  opticians  do  their  work,  as  such, 
extremely  well.  The  real  message  to  the  public  contained 
in  " F.’s  ” letter  is  that  it  is  dangerous  to  resort  to  the  optician 
for  a prescription  for  glasses.  In  " F.’s  " case,  by  falling  back 
on  the  qualified  ophthalmologist,  the  source  of  his  trouble 
was  detected.  A rejoinder  to  “ F.’s"  letter  appeared  on  the 


A TAR-SPRAYING  FATALITY. 

The  death  is  reported  from  pustular  dermatitis  of  a 
labourer  employed  in  tar-spraying  the  road.  It  is  stated 
that  some  of  the  tar  spray  came  into  contact  with  his  face 
and  neck.  Inflammatory  conditions  of  the  skin  have  been 
known  to  be  set  up  amongst  the  workers  engaged  on  moulding 
pitch  into  “ patent  fuel,”  and  pitch,  of  course,  is  related  to 
tar.  “ Pitch  cancer  ” was  a matter  of  inquiry  by  the  Home 
Office  some  years  ago,  and  certain  protective  measures  were 
recommended  which  the  manufacturers  agreed  to  adopt 
(vide  The  Lancet,  Sept.  6th,  1913).  It  seems  desirable  that 
similar  precautions  should  be  taken  by  tar-pavers,  particu- 
larly as  the  process  is  conducted  on  a very  large  scale  on  our 
roadways. 


RHEUMATOID  ARTHRITIS  OF  THE  SPINE. 

Spe a writes  : — I have  a patient  who  suffers  severe  pain 
which  I can  onlv  relieve  by  morphia  injections— everything 
else  tried  has  failed  to  alleviate.  Can  anyone  who  has  had 
similar  cases  give  me  any  help  by  suggestions 


J.  B.  D.—lt  is  usual  in  cities  (and  a commendable  practice) 
to  carrv  out  the  work  of  cleaning  and  tidying  the  streets  m 
the  small  hours  of  the  morning  when  the  traffic  is  at  its 


awest. 

Temp.  Major—  Temporary  officers  of  the  Royal  Army 
ledical  Corps  are  not  entitled  to  any  gratuity  on  demobilisa- 
ion  other  than  the  bonus  of  £60  a year  granted  to 
nder  the  terms  of  their  contract,  except  in  the  case  of  those 
rho  have  for  a period  of  six  months  or  longer  held  acting 
ank  higher  than  that  of  Captain,  and  have  drawn  the  Army 
iav  and  allowances  of  the  higher  rank,  in  which  case  they 
re  awarded  the  gratuity  equal  to  that  allowed  uhcei 
article  497  of  the  Royal  Warrant,  less  any  gratuity  which 

nav  have  already  been  drawn  under  the  provisions  as  set 
orth  in  the  contract  for  the  award  of  £60  on  completion  of 
ach  year’s  service. 


THE  LANCET,  September  27,  1919. 


IJrcsibcittial  ^bktss 

ON 

THE  DIFFERENTIATION1  OF  MANKIND  INTO 
RACIAL  TYPES. 

Delivered  before  the  Anthropological  Section  of  the  British 
Association  for  the  Advancement  of  Science 

By  Prop.  ARTHUR  KEITH,  M.D.  Aberd., 
LL.D.,  F.R.S., 

HUNTERIAN  PROFESSOR  AND  CONSERVATOR  OF  THE  MUSEUM,  ROYAL 
COLLEGE  OF  SURGEONS  OF  ENGLAND. 


Ladies  akd  Gentlemen, — For  a brief  half-hour  I am  to 
try  and  engage  your  attention  on  a matter  which  has  excited 
the  interest  of  thoughtful  minds  from  ancient  times — the 
problem  of  how  mankind  has  been  demarcated  into  types  so 
diverse  as  the  Negro,  the  Mongol,  and  the  Caucasian  or 
European. 

Explanations,  Ancient  and  Modern. 

For  many  a day  the  Mosaic  explanation — the  tower  of 
Babel  theory — was  regarded  as  a sufficient  solution  of 
this  difficult  problem.  In  these  times  most  of  us  have 
adopted  an  explanation  which  differs  in  many  respects  from 
that  put  forward  in  the  book  of  Genesis  ; Noah  disappears 
from  our  theory  and  is  replaced  in  the  dim  distance  of 
time  by  a “ common  ancestral  stock.” 

Our  story  now  commences,  not  at  the  close  of  a historical 
flood,  but  at  the  end  of  a geological  epoch  so  distant  from  us 
that  we  cannot  compute  its  date  with  any  degree  of  accuracy. 
Shem,  Ham,  and  Japheth,  the  reputed  ancestors  of  the  three 
great  racial  stocks  of  modern  times — the  white,  black,  and 
yellow  distinctive  types  of  mankind — have  also  disappeared 
from  our  speculations  ; we  no  longer  look  out  on  the  world 
and  believe  that  the  patterns  which  stud  the  variegated 
carpet  of  humanity  were  all  woven  at  the  same  time  ; some 
of  the  patterns,  we  believe,  are  of  ancient  date  and  have 
retained  many  of  the  features  which  marked  the  “ common 
ancestral  ” design  ; others  are  of  more  recent  date,  having 
the  ancient  pattern  altered  in  many  of  its  details. 

We  have  called  in,  as  Darwin  has  taught  us,  the  whole 
machinery  of  evolution — struggle  for  existence,  survival  of 
the  fittest,  spontaneous  origin  of  structural  variations,  the 
inheritance  of  such  variations — as  the  loom  by  which  Nature 
fashions  her  biological  patterns.  We  have  replaced  the 
creative  finger  by  the  evolutionary  machine,  but  no  one  is 
more  conscious  of  the  limitations  of  that  machine  than  the 
student  of  human  races. 

We  are  all  familiar  with  the  features  of  that  racial  human 
type  which  clusters  round  the  heart  of  Africa  ; we  recognise 
the  Negro  at  a glance  by  his  black,  shining,  hairless  skin, 
his  crisp  hair,  his  flattened  nose,  his  widely  opened  dark 
eyes,  his  heavily  moulded  lips,  his  gleaming  teeth  and  strong 
jaws.  He  has  a carriage  and  proportion  of  body  of  his  own  ; 
he  has  his  peculiar  quality  of  voice  and  action  of  brain.  He 
is,  even  to  the  unpractised  eye,  clearly  different  from  the 
Mongolian  native  of  North-Eastern  Asia  ; the  skin,  the  hair, 
the  eyes,  the  quality  of  brain  and  voice,  the  carriage  of  body 
and  proportion  of  limb  to  body  pick  out  the  Mongol  as  a 
sharply  differentiated  human  type.  Different  from  either  of 
these  is  the  native  of  Central  Europe — the  Aryan  or  Caucasian 
type  of  man  ; we  know  him  by  the  paleness  of  his  skin  and 
by  his  facial  features- -particularly  his  narrow,  prominent  nose 
and  thin  lips.  We  are  so  accustomed  to  the  prominence  of 
the  Caucasian  nose  that  only  a Mongol  or  Negro  can  appre- 
ciate its  singularity  in  our  aryanised  world.  When  we  ask 
how  these  three  types — the  European,  Chinaman,  and  Negro 
— came  by  their  distinctive  features,  we  find  that  our  evolu- 
tionary machine  is  defective  ; the  processes  of  natural  and  of 
sexual  selection  will  preserve  and  exaggerate  traits  of  body 
and  of  mind,  but  they  cannot  produce  that  complex  of 
features  which  marks  off  one  racial  type  from  another. 
Nature  has  at  her  command  some  secret  mechanism  by 
which  she  works  out  her  new  patterns  in  the  bodies  of  man 
and  beast — a mechanism  of  which  we  were  almost  ignorant 
in  Darwin’s  day,  but  which  we  are  now  beginning  to  perceive 
and  dimly  understand.  It  is  the  bearing  of  this  creative  or 
morphogenetic  mechanism  on  the  evolution  of  the  modern 
races  of  mankind  which  I propose  to  make  the  subject  of 
my  address. 

No.  5013 


The  Endocrine  Glands  as  Growth-controlling 
Structures. 

Hid  away  in  various  parts  of  the  human  frame  is  a series 
of  more  or  less  obscure  bodies  or  glands,  five  in  number, 
which,  in  recent  times,  we  have  come  to  recognise  as  parts 
of  the  machinery  which  regulate  the  growth  of  the  body. 
They  form  merely  a fraction  of  the  body — not  more  than 
l/180th  part  of  it;  a man  might  pack  the  entire  series  in  his 
watch-pocket.  The  modern  medical  student  is  familiar 
with  each  one  of  them — the  pituitary  body,  about  the  size  of 
a ripe  cherry,  attached  to  the  base  of  the  brain  and  cradled 
in  the  floor  of  the  skull ; the  pineal  gland,  also  situated  in 
the  brain,  and  in  point  of  size  but  little  larger  than  a wheat- 
grain  ; the  thyroid  in  the  neck,  set  astride  the  windpipe, 
forms  a more  bulky  mass  ; the  two  suprarenal  bodies  situated 
in  the  belly,  capping  the  kidneys,  and  the  interstitial  glands 
embedded  within  the  substance  of  the  testicle  and  ovary, 
complete  the  list.  The  modern  physician  is  also  familiar 
with  the  fact  that  the  growth  of  the  body  may  be  retarded, 
accelerated,  or  completely  altered  if  one  or  more  of  these 
glands  become  the  seat  of  injury  or  of  a functional  disorder. 

Acromegaly  and  Giantism. 

It  is  33  years  now  since  first  one  woman  and  then  another 
came  to  Dr.  Pierre  Marie  in  Paris  seeking  relief  from  a 
persistent  headache,  and  mentioning  incidentally  that  their 
faces,  bodies,  hands,  and  feet  had  altered  so  much  in  recent 
years  that  their  best  known  friends  failed  to  recognise  them. 
That  incident  marked  the  commencement  of  our  knowledge 
of  the  pituitary  gland  as  an  intrinsic  part  of  the  machinery 
which  regulates  the  shaping  of  our  bodies  and  features.  Dr. 
Marie  named  the  condition  acromegaly.  Since  then  hundreds 
of  men  and  women  showing  symptoms  similar  to  those  of 
Dr.  Marie’s  patients  have  been  seen  and  diagnosed,  and  in 
every  instance  where  the  acromegalic  changes  were  typical 
and  marked  there  has  been  found  a definite  enlargement  or 
tumour  of  the  pituitary  body.  The  practised  eye  recognises 
the  full-blown  condition  of  acromegaly  at  a glance,  so 
characteristic  are  the  features  of  the  sufferers.  Nay,  as  we 
walk  along  the  streets  we  can  note  slight  degrees  of  it — 
degrees  which  fall  far  short  of  the  border-line  of  disease  ; we 
note  that  it  may  give  characteristic  traits  to  a whole  family 
— a family  marked  by  what  may  be  named  an  acromegalic 
taint. 

The  pituitary  gland  is  also  concerned  in  another  dis- 
turbance of  growth — giantism.  In  every  case  where  a 
young  lad  has  shot  up,  during  his  late  “ teens,”  into  a 
lanky  man  of  seven  feet  or  more — has  become  a giant — it 
has  been  found  that  his  pituitary  gland  was  the  site  of 
a disordered  enlargement.  The  pituitary  is  part  of  the 
mechanism  which  regulates  our  stature,  and  stature  is  a 
racial  characteristic.  The  giant  is  usually  acromegalic  as 
well  as  tall,  but  the  two  conditions  need  not  be  combined  ; 
a young  lad  may  undergo  the  bodily  changes  which  charac- 
terise acromegaly  and  yet  not  become  abnormally  tall,  or  he 
may  become — although  this  is  rarely  the  case — a giant  in 
stature  and  yet  may  not  assume  acromegalic  features. 

There  is  a third  condition  of  disordered  growth  in  which 
the  pituitary  is  concerned — one  in  which  the  length  of  the 
limbs  is  disproportionately  increased — in  which  the  sexual 
system  and  all  the  secondary  sexual  characters  of  body  and 
mind  either  fail  to  develop  or  disappear — where  fac  tends  to 
be  deposited  on  the  body,  particularly  over  the  buttocks  and 
thighs — where,  in  brief,  a eunuchoid  condition  of  body 
develops. 

In  all  of  these  three  conditions  we  seem  to  be  dealing  with 
a disordered  and  exaggerated  action  of  the  pituitary  gland  ; 
there  must  be  conditions  of  an  opposite  kind  where  the 
functions  of  the  pituitary  are  disordered  and  reduced.  A 
number  of  cases  of  dwarfism  have  been  recorded  where  boys 
or  girls  retained  their  boyhood  or  girlhood  throughout  life, 
apparently  because  their  pituitary  gland  had  been  invaded 
and  partly  destroyed  by  tumours.  We  shall  see  that  dwarfism 
may  result  also  from  a failure  of  the  thyroid  gland.  On  the 
evidence  at  our  disposal,  evidence  which  is  being  rapidly 
augmented,  we  are  justified  in  regarding  the  pituitary  gland 
as  one  of  the  principal  pinions  in  the  machinery  which 
regulates  the  growth  of  the  human  body  and  is  directly 
concerned  in  determining  stature,  cast  of  features,  texture  of 
skin,  and  character  of  hair — all  of  them  marks  of  race. 
When  we  compare  the  three  chief  racial  types  of  humanity 
— the  Negro,  the  Mongol,  and  the  Caucasian  or  European — 
we  can  recognise  in  the  last  named  a greater  predominance 
N 


554  The  Lancet,]  PROF.  A.  KEITH  : DIFFERENTIATION  OF  MANKIND  INTO  RACIAL  TYPES.  [Sept.  27,  1919 


of  the  pituitary  than  in  the  other  two.  The  sharp  and  pro- 
nounced nasalisation  of  the  face,  the  tendency  to  strong 
eyebrow  ridges,  the  prominent  chin,  the  tendency  to  bulk  of 
body  and  height  of  stature  in  the  majority  of  Europeans,  are 
best  explained,  so  far  as  the  present  state  of  our  knowledge 
goes,  in  terms  of  pituitary  function. 

The  Genital  Glands  in  Relation  to  Growth. 

There  is  no  question  that  our  interest  in  the  mechanism 

growth  has  been  quickened  in  recent  years  by  observa- 
tions and  discoveries  made  by  physicians  on  men  and 
women  who  suffered  from  pituitary  disorders,  but  that  a 
small  part  of  the  body  could  influence  and  regulate  the 
growth  and  characterisation  of  the  whole  was  known  in 
ancient  times.  For  many  centuries  it  has  been  common 
knowledge  that  the  removal  of  the  genital  glands  alters  the 
external  form  and  internal  nature  of  man  and  beast.  The 
sooner  the  operation  is  performed  after  birth  the  more 
certain  are  its  effects.  Were  a naturalist  from  a unisexual 
world  to  visit  this  earth  of  ours  it  would  be  difficult  to 
convince  him  that  a brother  and  a sister  were  of  the  same 
species,  or  that  the  wrinkled,  sallow-visaged  eunuch  with  his 
beardless  face,  his  long  tapering  limbs,  his  hesitating 
carriage,  his  carping  outlook  and  corpulent  body,  was 
brother  to  the  thick-set,  robust,  pugilistic  man  with  the 
bearded  face. 

The  discovery  that  the  testicle  and  ovary  contain, 
scattered  throughout  their  substance,  a small  glandular 
element  which  has  nothing  to  do  with  their  main  function 
— the  production  of  genital  cells — was  made  70  years  ago, 
but  the  evidence  which  leads  us  to  believe  that  this  scattered 
element — the  interstitial  gland — is  directly  concerned  in  the 
mechanism  of  growth  is  of  quite  recent  date.  All  those 
changes  which  we  may  observe  in  the  girl  or  boy  at  puberty 
— the  phase  of  growth  which  brings  into  full  prominence 
their  racial  characteristics -depend  on  the  action  of  the 
interstitial  glands.  If  they  are  removed  or  remainjin  abey- 
ance the  maturation  of  the  body  is  both  prolonged  and 
altered.  In  seeking  for  the  mechanism  which  shapes  man- 
kind into  races  we  must  take  the  interstitial  gland  into  our 
reckoning.  I am  of  opinion  that  the  sexual  differentia- 
tion— the  robust  manifestations  of  the  male  characters — is 
more  emphatic  in  the  Caucasian  than  in  either  the  Mongol 
or  Negro  racial  types.  In  both  Mongol  and  Negro,  in  their 
most  representative  form,  we  find  a beardless  face  and 
almost  hairless  body,  and  in  certain  Negro  types,  especially 
in  Nilotic  tribes,  with  their  long,  stork-like  legs,  we  seem  to 
have  a manifestation  of  abeyance  in  the  action  of  the 
interstitial  glands.  At  the  close  of  sexual  life  we  often 
see  the  features  of  a woman  assume  a coarser  and  more 
masculine  appearance. 

The  Suprarenal  Bodies. 

Associated  with  the  interstitial  glands,  at  least  in  point 
of  development,  are  the  suprarenal  bodies  or  glands.  Our 
knowledge  that  these  two  comparatively  small  structures, 
no  larger  than  the  segments  into  which  a moderately  sized 
orange  can  be  separated,  are  connected  with  pigmentation 
of  the  skin  dates  back  to  1894,  when  Dr.  Thomas  Addison, 
a physician  to  Guy’s  Hospital,  London,  observed  that  gradual 
destruction  of  these  bodies  by  disease  led  to  a darkening  or 
pigmentation  of  the  patient’s  skin,  besides  giving  rise  to 
other  more  severe  changes  and  symptoms.  Now  it  is  150 
years  since  John  Hunter  came  to  the  conclusion,  on  the 
evidence  then  at  his  disposal,  that  the  original  colour  of 
man’s  skin  was  black,  and  all  the  knowledge  that  we  have 
gathered  since  his  time  supports  the  inference  he  drew. 
From  the  fact  that  pigment  begins  to  collect  in  and  thus 
darken  the  skin  when  the  suprarenal  bodies  become  the 
seat  of  a destructive  disease  we  infer  that  they  have  to  do 
with  the  clearing  away  of  pigment,  and  that  we  Europeans 
owe  the  fairness  of  our  skins  to  some  particular  virtue 
resident  in  the  suprarenal  bodies. 

That  their  function  is  complex  and  multiple  the  researches 
of  Sharpey-Schafer,  of  T.  R.  Elliott,  and  of  W.  B.  Cannon 
have  made  very  evident.  Fifteen  years  ago  Bulloch  and 
Sequeira  established  the  fact  that  when  a suprarenal  body 
becomes  the  site  of  a peculiar  form  of  malignant  over- 
growth in  childhood  the  body  of  the  boy  or  girl  undergoes 
certain  extraordinary  growth  changes.  The  sexual  organs 
became  rapidly  mature,  and  through  the  framework  of 
childhood  burst  all  the  features  of  sexual  maturity — the 
full  chest,  muscularity  of  limbs,  bass  voice,  bearded  face, 


and  hairy  body — a miniature  Hercules— a miracle  of  trans- 
formation in  body  and  brain.  Corresponding  changes  occur 
in  young  girls — almost  infants  in  years — with  a tendency  to 
assume  features  which  characterise  the  male.  Professor 
E.  E.  Glynn 1 has  recently  collected  such  cases  and 
systematised  our  knowledge  of  these  strange  derangements 
of  growth. 

There  can  be  no  doubt  that  the  suprarenal  bodies  consti- 
tute an  important  part  of  the  mechanism  which  regulates 
the  development  and  growth  of  the  human  body  and  helps  in 
determining  the  racial  characters  of  mankind.  We  know 
that  certain  races  come  more  quickly  to  sexual  maturity 
than  others,  and  that  races  vary  in  development  of  hair  and 
of  pigment,  and  it  is  therefore  reasonable  to  expect  a satis- 
factory explanation  of  these  characters  when  we  have 
come  by  a more  complete  knowledge  of  the  suprarenal 
mechanism. 

The  Pineal  Gland. 

During  the  last  few  years  the  totally  unexpected  discovery 
has  been  sprung  upon  us  that  disease  of  the  minute  pineal 
gland  of  the  brain  may  give  rise  to  a train  of  symptoms 
very  similar  to  those  which  follow  tumour  formation  of  the 
cortex  of  the  suprarenal  bodies.  In  some  instances  the 
sudden  sexual  prematurity  which  occurs  in  childhood  is 
apparently  the  immediate  result  of  a tumour-like  affection  of 
the  pineal  gland.  We  have  hitherto  regarded  the  pineal 
gland,  little  bigger  than  a wheat-grain  and  buried  deeply  in 
the  brain,  as  a mere  useless  vestige  of  a median  or  parietal 
eye,  derived  from  some  distant  human  ancestor  in  whom 
that  eye  was  functional,  but  on  the  clinical  and  experimental 
evidence  now  rapidly  accumulating  we  must  assign  to  it  a 
place  in  the  machinery  which  controls  the  growth  of  the 
body. 

The  Thyroid  Gland. 

We  come  now  to  deal  with  the  thyroid  gland,  which,  from 
an  anthropological  point  of  view,  must  be  regarded  as  the 
most  important  of  all  the  organs  or  glands  of  internal 
secretion.  Here,  too,  in  connexion  with  the  thyroid  gland, 
which  is  situated  in  the  front  of  the  neck,  where  it  is  so  apt 
to  become  enlarged  and  prominent  in  women — I must  call 
attention  to  a generalisation  which  I slurred  over  when 
speaking  of  the  pituitary  and  suprarenal  glands.  Each  of 
these  glands  throws  into  the  circulating  blood  two  sets  of 
substances — one  set  to  act  immediately  in  tuning  the  parts 
of  the  body  which  are  not  under  the  influence  of  the  will 
to  the  work  they  have  to  do  when  the  body  is  at  rest  and 
when  it  is  making  an  effort.  Another  set  of  substances — 
which  Professor  Gley  has  named  morphogenetic — has  not 
an  immediate  but  a remote  effect ; they  regulate  the 
development  and  coordinate  the  growth  of  the  various  parts 
of  the  body. 

Now,  so  far  as  the  immediate  function  of  the  thyroid  is 
concerned,  our  present  knowledge  points  to  the  gland  as  the 
manufactory  of  a substance  which,  when  circulating  in  the 
body,  regulates  the  rate  of  combustion  of  the  tissues.  When 
we  make  a muscular  effort,  or  when  our  bodies  are  exposed 
to  cold,  or  when  we  become  the  subjects  of  infection,  the 
thyroid  is  called  upon  to  assist  in  mobilising  all  available 
tissue-fuel.  If  we  consider  only  its  immediate  function  it 
is  clear  that  the  thyroid  is  connected  with  the  selection  and 
survival  of  human  races.  When,  however,  we  consider  its 
remote  or  morphogenetic  effects  on  growth  its  importance 
as  a factor  in  shaping  the  characteristics  of  human  races 
becomes  even  more  evident.  In  districts  where  the  thyroid 
is  liable  to  that  form  of  disease  known  as  goitre  it  has  been 
known  for  many  a year  that  children  who  were  affected 
became  cretins — dwarf  idiots  with  a very  characteristic 
appearance  of  face  and  body.2 

Disease  of  the  thyroid  stunts  and  alters  the  growth  of 
the  body,  so  that  the  subjects  of  this  disorder  might 
well  be  classed  as  a separate  species  of  humanity.  If 
the  thyroid  becomes  diseased  and  defective  after  growth 
of  the  body  is  completed,  then  certain  changes,  first 
observed  by  Sir  William  Gull  in  1873,  are  set  up  and  give 
rise  to  the  disordered  state  of  the  body  known  as  myxcedema. 
“ In  this  state,”  says  Sir  Malcom  Morris,3  “ the  skin  is  cold, 
dry  and  rough,  seldom  or  never  perspires,  and  may  take  on  a 
yellowish  tint  ; there  is  a bright-red  flush  in  the  malar 

1  Quart.  Journ.  of  Med.,  1912,  vol.  v..  p.  157. 

2  The  story  of  the  discovery  of  the  action  of  the  thyroid  gland  is  told 
hv  Professor  G.  M.  Murray,  Brit.  Med.  Jour.,  1913.  ii.,  163. 

3  Brit.' Med.  Jour.,  1913.  i.,  1033. 


ThhLanoht,]  PROF.  A.  KEITH:  DIFFERENTIATION  OF  MANKIND  INTO  RACIAL  TYPES.  [Sept.  27,  1919  555 


region.  The  skin  as  a whole  looks  transparent ; the  hair  of 
the  scalp  becomes  scanty;  the  pubic  and  axillary  hair,  with 
the  eyelashes  and  eyebrows,  often  falls  out  ; in  many  cases 
the  teeth  are  brittle  and  carious.  All  these  appearances 
disappear  under  the  administration  of  thyroid  extract.” 

We  have  here  conclusive  evidence  that  the  thyroid  acts 
directly  on  the  skin  and  hair,  just  the  structures  we  employ 
in  the  classification  of  human  races.  The  influence  of 
the  thyroid  on  the  development  of  the  other  systems  of  the 
body,  particularly  on  the  growth  of  the  skull  and  skeleton, 
is  equally  profound.  This  is  particularly  the  case  as  regards 
the  base  of  the  skull  and  the  nose.  The  arrest  of  growth 
falls  mainly  on  the  basal  part  of  the  skull,  with  the  result 
that  the  root  of  the  nose  appears  to  be  flattened  and  drawn 
backwards  between  the  eyes,  the  upper  forehead  seems 
projecting  or  bulging,  the  face  appears  flattened,  and  the 
bony  scaffolding  of  the  nose,  particularly  when  compared  to 
the  prominence  of  the  jaws,  is  greatly  reduced. 

Now  these  facial  features  which  I have  enumerated  give 
the  Mongolian  face  its  characteristic  aspect,  and,  to  a lesser 
degree,  they  are  also  to  be  traced  in  the  features  of  the  Negro. 
Indeed,  in  one  aberrant  branch  of  the  Negro  race — the 
Bushman  of  South  Africa — the  thyroid  facies  is  even  more 
emphatically  brought  out  than  in  the  most  typical  Mongol. 
Yrou  will  observe  that,  in  my  opinion,  the  thyroid — or  a 
reduction  or  alteration  in  the  activity  qf  the  thyroid — has 
been  a factor  in  determining  some  of  the  racial  character- 
istics of  the  Mongol  and  the  Negro  races.  I know  of  a 
telling  piece  of  evidence  which  supports  this  thesis.  Some 
years  ago  there  died  in  the  East  End  of  London  a Chinese 
giant — the  subject,  we  must  suppose,  of  an  excessive  action 
of  the  pituitary  gland — the  gland  which  I regard  as  playing 
a predominant  part  in  shaping  the  face  and  bodily  form  of 
the  European.  The  skeleton  of  this  giant  was  prepared 
and  placed  in  the  museum  of  the  London  Hospital  Medical 
College  by  Colonel  T.  H.  Openshaw,  and  any  one  inspecting 
this  skeleton  can  see  that,  although  certain  Chinese  features 
are  still  recognisable,  the  nasal  region  and  the  supra-orbital 
ridges  of  the  face  have  assumed  the  more  prominent 
European  type. 

Achondroplasia  and  Mongolism. 

There  are  two  peculiar  and  very  definite  forms  of  dwarfism 
with  which  most  people  are  familiar,  both  of  which  must  be 
regarded  as  due  to  a defect  in  the  growth  regulating 
mechanism  of  the  thyroid.  Now,  one  of  these  forms  of 
dwarfism  is  known  to  medical  men  as  achondroplasia, 
because  the  growth  of  cartilage  is  particularly  affected,  but 
in  familiar  language  we  may  speak  of  the  sufferers  from  this 
disorder  of  growth  as  being  of  the  “ bulldog  breed  ” or  of 
the  “dachshund  breed.”-  In  the  dachshund  the  limbs  are 
greatly  shortened  and  gnarled,  but  the  nose  or  snout  suffers 
no  reduction,  while  in  the  bulldog  the  nose  and  nasal  part 
of  the  face  are  greatly  reduced  and  withdrawn,  showing  an 
exaggerated  degree  of  Mongolism.  Among  achondroplastic 
human  dwarfs  both  breeds  occur,  but  the  “ bulldog  ” form  is 
much  more  common  than  the  “dachshund”  type.  The 
shortening  of  limbs  with  retraction  of  the  nasal  region  of  the 
face — pug-face  or  prosopia  we  may  call  the  condition — has  a 
very  direct  interest  for  anthropologists,  seeing  that  short 
limbs  and  a long  trunk  are  well-recognised  racial  charac- 
teristics of  the  Mongol. 

In  the  second  kind  of  dwarfism,  which  we  have  reason  to 
regard  as  due  to  a functional  defect  of  the  thyroid,  the 
Mongolian  traits  are  so  apparent  that  the  sufferers  from 
this  disorder  are  known  to  medical  men  as  “Mongolian 
idiots,”  for  not  only  is  their  growth  stunted,  but  their 
brains  also  act  in  a peculiar  and  aberrant  manner.  Dr. 
Langdon  Down,  who  gave  the  subjects  of  this  peculiar  dis- 
order the  name  “Mongolian  idiots”  55  years  ago,  knew 
nothing  of  the  modern  doctrine  of  internal  secretions,  but 
that  doctrine  has  been  applied  in  recent  years  by  Dr.  F.  G 
Crookshank4  to  explain  the  features  and  condition  of 
Mongoloid  imbecile  children. 

Some  years  ago  5 I brought  forward  evidence  to  show  that 
we  could  best  explain  the  various  forms  of  anthropoid  apes 
by  applying  the  modern  doctrine  of  a growth -controlling 
glandular  mechanism.  In  the  gorilla  we  see  the  effects  of  a 
predominance  of  the  pituitary  elements  ; in  the  orang,  of 
the  thyroid.  The  late  Professor  Klaatsch  tried  to  account 
for  the  superficial  resemblances  between  the  Malay  and  the 


orang  by  postulating  a genetic  relationship  between  them  ; 
for  a similar  reason  he  derived  the  Negro  type  from  a 
gorilline  ancestry.  Occasionally  we  see  a man  or  woman 
of  supposedly  pure  European  ancestry  displaying  definite 
Mongoloid  traits  in  their  features. 

We  have  been  in  the  habit  of  accounting  for  such  mani- 
festations by  the  theory,  at  one  time  very  popular,  that  a 
Mongoloid  race  had  at  one  time  spread  over  Europe,  and 
that  Mongoloid  traits  were  atavistic  recurrences.  An  ex- 
amination of  the  human  remains  of  ancient  Europe  yields 
no  evidence  in  support  of  a Turanian  or  Mongol  invasion  of 
Europe. 

The  Mechanism  of  the  Control  of  Growth. 

All  of  these  manifestations  to  which  I have  been  calling 
your  attention — the  sporadic  manifestation  of  Mongoloid 
characters  in  diseased  children  and  in  healthy  adult 
Europeans,  the  generic  characters  which  separate  one  kind 
of  ape  from  another,  the  bodily  and  mental  features  which 
mark  the  various  races  of  mankind — are  best  explained  by 
the  theory  1 am  supporting — namely,  that  the  conformation 
of  man  and  ape  and  of  every  vertebrate  animal  is  deter- 
mined by  a common  growth-controlling  mechanism  which  is 
resident  in  a system  of  small  but  complex  glandular  organs. 
We  must  now  look  somewhat  more  closely  into  the  manner 
in  which  this  growth-regulating  mechanism  actually  works. 

That  we  can  do  best  by  taking  a glimpse  of  a research 
carried  out  by  Bayliss  and  Starling  in  the  opening  years  of 
the  present  century.  They  were  seeking  to  explain  why  it 
was  that  the  pancreas  poured  out  its  digestive  juice  as  soon 
as  the  contents  of  the  stomach  commenced  to  pass  into  the 
first  part  of  the  duodenum.  It  was  then  known  that  if  acid 
was  applied  to  the  lining  epithelial  membrane  of  the 
duodenum,  the  pancreas  commenced  to  work  ; it  was  known 
also  that  the  message  which  set  the  pancreas  into  operation 
was  not  conveyed  from  the  duodenum  to  the  pancreas  by 
nerves,  for  when  they  were  cut  the  mechanism  was  still 
effective.  Bayliss  and  Starling  solved  the  puzzle  by  making 
an  emulsion  from  the  acid-soaked  lining  epithelium  of  the 
duodenum  and  injecting  the  extract  of  that  emulsion  into 
the  circulating  blood.  The  result  was  that  the  pancreas  was 
immediately  thrown  into  activity.  The  particular  substance 
which  was  thus  set  circulating  in  the  blood  and  acted  on  the 
pancreas  and  on  the  pancreas  alone,  and  which  thus  served 
as  a messenger  or  hormone,  they  named  secretin.  They  not 
only  cleared  up  the  mechanism  of  pancreatic  secretion,  but 
at  the  same  time  made  a discovery  of  much  greater  import- 
ance. They  had  discovered  a new  method  whereby  one  part 
of  the  human  body  could  communicate  with  and  control 
another. 

The  Theory  of  Hormones. 

Up  to  that  time  we  had  been  like  an  outlandish  visitor  to 
a strange  city,  who  believed  that  the  visible  telegraph  or 
telephone  wires  were  the  only  means  of  communication 
between  its  inhabitants.  We  believed  that  it  was  only  by 
nerve  fibres  that  intercommunication  was  established  in  the 
animal  body.  Bayliss  and  Starling  showed  that  there  was  a 
postal  system.  Missives  posted  in  the  general  circulation 
were  duly  delivered  at  their  destinations.  The  manner  in 
which  they  reached  the  right  address  is  of  particular  import- 
ance for  us ; we  must  suppose  that  the  missive  or  hormone 
circulating  in  the  blood  and  the  recipient  for  which  they  are 
intended  have  a special  attraction  or  affinity  for  each  other 
— one  due  to  their  physical  constitution — and  hence  they, 
and  only  they,  come  together  as  the  blood  circulates  round 
the  body. 

Secretin  is  a hormone  which  effects  its  errand  rapidly  and 
immediately,  whereas  the  growth  or  morphogenetic  hormones, 
thrown  into  the  circulation  by  the  pituitary,  pineal,  thyroid, 
suprarenals,  and  genital  glands,  act  slowly  and  remotely. 
But  both  are  alike  in  this  : the  result  depends  not  only  on 
the  nature  of  the  hormone  or  missive,  but  also  on  the  state 
of  the  local  recipient.  The  local  recipient  may  be  specially 
greedy,  as  it  were,  and  seize  more  than  a fair  share  of  the 
manna  in  circulation,  or  it  may  have  “sticky  fingers  ” and 
seize  what  is  not  really  intended  for  local  consumption. 

We  can  see  that  local  growth — the  development  of  a 
particular  trait  or  feature — is  dependent  not  only  on  the 
hormones  supplied  to  that  part,  but  also  on  the  condition  of 
the  receptive  mechanism  of  the  part.  Hence  we  can  under- 
stand a local  derangement  of  growth — an  acromegaly  or 
giantism  confined  to  a finger  or  to  the  eyebrow  ridges,  to  the 
nose,  to  one  side  of  the  face,  and  such  local  manifestations 


4 The  Universal  Medical  Record,  1913,  vol.  iii.,  12. 

5 Jour,  of  Anat.  and  Physiol.,  1913. 


556  The  Lancet,] 


DRS.  PERKINS.  YOUNG.  & MEEK  : “ HETEROSEROTHERAPY.” 


[Sept.  27,  1919 


are  not  uncommon.  It  is  by  a variation  in  the  sensitiveness 
of  the  local  recipient  that  we  have  an  explanation  of  the 
endless  variety  to  be  found  in  the  relative  development  of 
racial  and  individual  features. 

Regulation  of  Muscular  Effort. 

Some  ten  years  after  Starling  had  formulated  the  theory 
of  hormones  Professor  W.  B.  Cannon,  of  Harvard  University, 
piecing  together  the  results  of  researches  by  Dr.  T.  R. 
Elliott  and  by  himself  on  the  action  of  the  suprarenal  glands, 
brought  to  light  a very  wonderful  hormone  mechanism— one 
which  helps  us  in  interpreting  the  action  of  growth-regulating 
hormones.  When  we  are  about  to  make  a severe  bodily 
effort  it  is  necessary  to  flood  our  muscles  with  blood,  so  that 
they  may  have  at  their  disposal  the  materials  necessary 
for  work — oxygen  and  blood-sugar — the  fuel  of  muscular 
engines. 

At  the  beginning  of  a muscular  effort  the  supraienal 
glands  are  set  going  by  messages  passing  to  them  from  the 
central  nervous  system  ; they  throw  a hormone — adrenalin — 
into  the  circulating  blood,  which  has  a double  effect ; 
adrenalin  acts  on  the  flood-gates  of  the  circulation,  so  that 
the  major  supply  of  blood  passes  to  the  muscles.  At  the 
same  time  it  so  acts  on  the  liver  that  the  blood  circulating 
through  that  great  organ  becomes  laden  witb  blood-sugar. 

We  here  obtain  a glimpse  of  the  neat  and  effective  manner 
in  which  hormones  are  utilised  in  the  economy  of  the  living 
body.  From  that  glimpse  we  seem  to  obtain  a clue  to  that 
remarkable  disorder  of  growth  in  the  human  body  known  as 
acromegaly.  It  is  a pathological  manifestation  of  an  adapta- 
tioDal  mechanism  with  which  we  are  all  familiar.  Nothing 
is  better  known  to  us  than  that  our  bodies  respond  to  the 
burden  they  are  made  to  bear.  Our  muscles  increase  in  size 
and  strength  the  more  we  use  them  ; increase  in  the  size  of 
our  muscles  would  be  useless  unless  our  bones  also  were 
strengthened  to  a corresponding  degree.  A greater  blood- 
supply  is  required  to  feed  them,  and  hence  the  power  of  the 
heart  has  to  be  augmented  ; more  oxygen  is  needed  for  their 
consumption,  and  hence  the  lung  capacity  has  to  be  increased; 
more  fuel  is  required — hence  the  whole  digestive  and  assimi- 
lative systems  have  to  undergo  a hypertrophy,  including  the 
apparatus  of  mastication. 

Such  a power  of  coordinated  response  on  the  part  of  all  of 
the  organs  of  the  body  to  meet  the  needs  of  athletic  training, 
presupposes  a coordinating  mechanism.  We  have  always 
regarded  such  a power  of  response  as  an  inherent  property  of 
the  living  body,  but  in  the  light  of  our  growing  knowledge  it 
is  clear  that  we  are  here  dealing  with  a hormonic  mechanism, 
one  in  which  the  pituitary  gland  is  primarily  concerned. 

Production  of  Acromegaly . 

When  we  study  the  structural  changes  which  take  place 
in  the  first  phase  of  acromegaly, 6 we  find  that  not  only  are 
the  bones  enlarged  and  overgrown  in  a peculiar  way,  but  so 
are  the  muscles,  the  heart,  the  lungs,  the  organs  of  digestion, 
particularly  the  jaws  ; hence  the  marked  changes  in  the  face, 
for  the  form  of  the  face  is  determined  by  the  development  of 
the  upper  and  lower  jaws.  The  rational  interpretation  of 
acromegaly  is  that  it  is  a pathological  disorder  of  the 
mechanism  of  adaptational  response ; in  the  healthy  body 
the  pituitary  is  throwing  into  the  circulation  just  a sufficiency 
of  a growth-regulating  substance  to  sensitise  muscles,  bones, 
and  other  structures  to  give  a normal  response  to  the  burden 
thrown  on  the  body.  But  in  acromegaly  the  body  is  so 
flooded  with  this  substance  that  its  tissues  become  hyper- 
sensitive and  respond  by  overgrowth  to  efforts  and  move- 
ments of  the  slightest  degree.  It  is  not  too  much  to  expect, 
when  we  see  how  the  body  and  features  become  transformed 
at  the  onset  of  acromegaly,  that  a fuller  knowledge  of  these 
growth  mechanisms  will  give  us  a clue  to  the  principles  of 
race  differentiation. 

The  Path  of  Future  Inquiry. 

There  must  be  many  other  mechanisms  regulated  by 
hormones  with  which  we  are  as  yet  totally  unacquainted. 
1 will  cite  only  one  instance — that  concerned  in  regulating 
the  temperature  of  the  body.  We  know  that  the  thyroid 
and  also  the  suprarenal  glands  are  concerned  in  this 
mechanism  ; they  have  also  to  do  with  the  deposition  and 
absorption  of  pigment  in  the  skin,  which  must  be  part  of 
the  heat-regulating  mechanism.  It  is  along  such  a path  of 
inquiry  that  we  expect  to  discover  a clue  to  the  question  of 
race  colour. 


This  is  not  the  first  occasion  in  which  the  doctrine  of 
hormones  has  been  applied  to  biological  problems  of  the 
British  Association.  In  his  Presidential  address  to  the 
Zoological  Section  at  Sheffield  in  1910  Professor  G.  C. 
Bourne  applied  the  theory  to  the  problems  of  evolution  : its 
bearing  was  examined  in  more  detail  in  an  address  to  the 
same  section  by  Professor  Arthur  Dendy  during  the  meeting 
at  Portsmouth  in  1911.  At  the  meeting  of  the  Association 
at  Newcastle  in  1916  Professor  MacBride  devoted  part  of  his 
address  to  the  morphogenetic  bearings  of  hormones.  Very 
soon  after  Starling  formulated  the  hormone  theory,  Dr.  J.  T. 
Cunningham  applied  it  to  explain  the  phenomena  of 
heredity.7  Nay,  rightly  conceived,  Darwin’s  theory  of 
Pan-genesis  is  very  much  of  the  same  character  as  the 
modern  theory  of  hormones. 


“HETEROSEROTHERAPY”  IN  PULMONARY 
TUBERCULOSIS. 

By  J.  J.  PERKINS,  M.B.,  F.R.C.P., 

PHYSICIAN  TO  ST.  THOMAS'S  AND  THE  BROMPTON  HOSPITALS  ; 

R.  A.  YOUNG,  M.D.,  F.R.C.P., 

PHYSICIAN  TO  THE  MIDDLESEX  AND  BROMPTON  HOSPITALS  ; 

AND 

W.  0.  MEEK,  M.B., 

MEDICAL  SUPERINTENDENT,  THE  FRIMLEY  SANATORIUM. 

( From  the  Brompton  Hospital  Sanatorium,  Fri/nley,  Surrey.') 

An  attack  of  acute  pleurisy  with  serous  effusion  occurring 
in  the  course  of  chronic  pulmonary  tuberculosis,  with 
subsequent  spontaneous  absorption  of  the  effused  fluid,  is 
followed  not  infrequently  by  a prolonged  period  of  improved 
health  and  a marked  amelioration  of  pre-existing  svm- 
ptoms.  This  improvement  has  been  ascribed  to  the 
mechanical  action  of  the  effusion  in  compressing  and 
immobilising  the  subjacent  lung,  an  action  comparable  to 
that  of  gas  artificially  introduced  into  the  pleural  cavity  for 
this  purpose  or  to  that  of  the  accumulated  serous  fluid  in 
a case  of  hydro-pneumothorax.  This  explanation  seems 
doubtful  in  view  of  the  fact  that  the  duration  of  an  inter- 
current attack  of  pleurisy  with  effusion  is  usually  limited  to 
a period  of  three  weeks,  sometimes  less.  It  entirely  fails  to 
explain  the  improvement  witnessed  in  those  cases  where  the 
effusion  has  occurred  on  the  side  of  the  sounder  or  (in 
instances  of  unilateral  disease)  the  apparently  sound  lung. 

Of  late  years  the  treatment  of  tuberculous  serous  pleural 
effusion  has  become  more  conservative  and  paracentesis  is 
reserved  by  many  for  those  cases  where  the  accumulated 
fluid  is  dangerous  in  virtue  of  its  bulk  or  where  natural 
absorption  is  unduly  delayed.  In  fact,  it  is  becoming  recog- 
nised that  the  patient  gains  “ something  ” from  his  effusion  ; 
it  is  difficult  to  be  more  explicit. 

One  of  us  (W.  O.  M.)  1 has  pointed  out  elsewhere  that  the 
amount  of  specific  antibody  (as  estimated  by  means  of  the 
“complement-fixation  reaction”)  in  the  blood-serum  of  a 
consumptive  individual  may  show  marked  fluctuations  during 
an  intercurrent  attack  of  acute  pleurisy  with  effusion.  R.  C. 
Paterson,2  whose  work  throws  fresh  light  on  the  subject  of 
the  tuberculous  serous  effusion,  concludes  that  “clinical 
pleural  effusions  are  caused  by  the  infection  of  an  allergic 
pleura.”  V.  Gilbert 3 of  Geneva,  in  1896,  published  details  of 
the  treatment  of  sero-fibrinous  pleurisy  by  “ autoserotherapy.” 
He  advocated  the  withdrawal  of  a small  amount  of  fluid  from  the 
pleural  cavity  and  the  inoculation  of  2 c.cm.  into  the  patient's 
own  subcutaneous  tissue.  He  stated  that  this  procedure  was 
followed  by  ( a ) a reaction  evidenced  by  a transient  rise  of 
temperature  of  1^-2°,  (i)  increased  diuresis  with  a fall  of 
temperature,  and  ( c ) rapid  absorption  of  the  effusion  in  from 
six  to  ten  days.  A.  Jousset,' in  1912,  while  not  admitting 
the  value  of  “ autoserotherapy,”  suggested  the  employment 
of  “ heteroserotherapy  ” in  the  treatment  of  chronic  tuber- 
culous pleurisy,  stating  that  tuberculous  pleural  effusion 
fluid  may  be  protective  to  guinea-pigs.  He  recommended 
that  the  fluid  withdrawn  from  cases  of  acute  serofibrinous 
pleurisy  should  be  allowed  to  clot  and  the  serum  be  pipetted 
off  and  sterilised  by  heating  to  55°  C.  on  three  successive 
days.  This  sterile  serum  was  to  be  employed  in  doses  of 
from  20-50  g. , by  subcutaneous  inoculation,  in  the  treatment 
of  other  patients  suffering  from  chronic  tuberculous  pleurisy. 


6 See  Keith,  The  Lancet,  1911,  ii.,  993 ; 1913,  i.,  305. 


" Dr.  J.  T.  Cunningham,  Proc.  Zoo.  Soc.,  London,  39C8,  p.  431. 


Thu  Lancet,] 


DUS.  PERKINS,  YOUNG,  & MEEK:  “ HKTERO, SEROTHERAPY.” 


[Sept.  27,  1919  5,77 


Details  of  Treatment. 

In  1917-18  we  employed  the  method  of  “heterosero- 
therapy ” in  the  treatment  of  a few  cases  of  pulmonary 
tuberculosis.  The  following  is  a brief  account  of  our 
experience : — 

Source  of  the  tuberculous  effusion  fluid  employed. — Fluid 
from  five  cases  of  pleurisy  was  used  : (a)  Two  cases  of 
“primary”  tuberculous  pleurisy  with  effusion,  from  the 
wards  of  St.  Thomas’s  Hospital,  diagnosed  on  clinical 
grounds  and  on  cytological  examination  of  the  aspirated 
fluid.  ( b ) Three  cases  of  acute  pleurisy  with  effusion  com- 
plicating “ open  ” pulmonary  tuberculosis  in  patients  at  the 
Frimley  Sanatorium. 

Collection  and  preparation  of  the  fluid. — The  effused  fluid 
was  withdrawn  from  the  “donors’”  chests  by  the  usual 
method,,  with  aseptic  precautions,  into  flasks  containing  a 
2 per  cent,  solution  of  sodium  citrate  in  normal  saline,  the 
final  proportion  of  pleural  fluid  to  citrated  saline  being 
roughly  as  3 to  1.  The  fluid  was  examined  cytologically, 
and  in  some  instances  a rough  estimation  of  the  number  of 
lymphocytes  to  the  cubic  centimetre  was  made.  Sterilisation 
was  effected  by  adding  to  the  fluid  one-tenth  its  volume  of  a 
5 per  cent,  solution  of  carbolic  acid,  the  addition  being  made 
gradually  with  constant  stirring.  Even  so,  some  coagulum 
forms,  but  it  is  small  in  amount  and,  if  the  fluid  is  shaken 
before  use,  the  slight  flocculent  deposit  is  insufficient  to 
block  a moderately  stout  hypodermic  needle.  Finally,  the 
fluid  was  stored  in  the  cold  in  convenient  hermetically 
sealed  vessels.  From  the  above  it  will  be  seen  that  all  the 
constituents  of  an  unheated  effusion  were  employed  for 
inoculation. 

Dosage. — The  fluid  was  administered  by  inoculation  into 
the  subcutaneous  tissues.  For  obvious  reasons  the  initial 
dose  was  small  (1  2 c.cm.).  The  amount  was  increased 
gradually  up  to  10,  15,  or  even  25  c.cm.  At  the  commence- 
ment of  a course  of  injections  they  were  given  twice  or  three 
times  weekly  ; when  the  larger  doses  were  reached,  as  a rule 
at  weekly  intervals.  The  injections  never  caused  any  dis- 
quieting symptoms.  Occasionally  a transient  small  rise  was 
noted  in  the  evening  temperature  on  the  day  of  administra- 
tion. This  occurred  with  some  regularity  in  Case  C alone 
of  the  eight  cases  treated.  In  another  instance,  where  the 
temperature  had  fallen  to  normal  during  treatment,  a dose 
was  sometimes  followed  by  an  evening  temperature  of  99°  F. 
In  no  instance  was  a sudden  marked  rise  of  temperature, 
comparable  to  that  produced  by  an  overdose  of  tuberculin, 
witnessed.  Where  improvement  in  the  patient’s  condition 
coincided  with  the  administration  of  the  pleural  fluid,  it  was 
most  marked  when  a dose  of  about  10  c.cm.  had  been 
reached. 

Selection  of  oases  for  treatment. — As  will  be  seen  from  the 
subjoined  clinical  abstracts,  all  the  cases  treated,  with  the 
exception  of  D,  had  extensive  active  disease  of  the  lungs, 
and  in  all.  with  the  same  exception,  the  outlook  seemed  very 
grave.  The  patients,  C,  G,  and  H appeared  to  us  to  be 
moribund  at  the  time  treatment  was  commenced.  All, 
except  Case  C,  were  undergoing  sanatorium  treatment  at 
the  Frimley  Sanatorium  and  had  been  there  for  some  months 
previous  to  the  administration  of  the  pleural  fluid.  In  every 
instance  tubercle  bacilli  were  present  in  the  patient’s 
sputum. 

Details  of  Cases  Treated. 

(A)  Male,  39,  eight  years’  history.  Admitted  June  6th, 

1917.  Extensive  active  bilateral  disease  and  extensive 
laryngeal  ulceration.  Evening  temperature  100:-101°  F. 
Very  distressing  laryngeal  symptoms.  Rest  in  bed  for  two 
months  effected  no  improvement,  and  his  condition  steadily 
deteriorated.  On  August  13th  injections  of  pleural  fluid 
were  commenced  with  a dose  of  1 c.cm.  gradually  increased 
up  to  15  c.cm.  by  the  end  of  September  and  continued  until 
Oct.  16th,  when  they  were  omitted.  During  this  period  the 
temperature  fell  gradually  and  remained  about  normal,  the 
laryngeal  symptoms  disappeared  in  a remarkable  manner, 
the  patient  gained  some  weight  and  was  well  enough  to  be 
up  and  about.  His  condition  remained  satisfactory  until 
Nov.  22nd,  when  the  temperature  again  rose  to  100°  F. 
Injections  of  10  c.cm.  of  pleural  fluid  were  recommenced  and 
continued  until  the  patient  was  discharged  on  May  8th,  1918. 
During  the  second  course  of  injections  the  temperature 
fell  rapidly  and  remained  satisfactory,  not  reaching  100°  F. 
again,  and  only  twice  exceeding  99°  F.  He  returned  to  light 
work  at  his  home  and  reported  in  August,  1919,  that  he  had 
been  constantly  at  work  with  continued  improvement  in  his 
health. 


(B)  Male,  21,  12  months’  history.  Signs  of  active  disease 
throughout  the  right  lung,  with  infiltration  of  the  upper 
lobe  of  the  left  lung.  Admitted  May  2nd,  1917.  Evening 
temperature  about  lOO’F.  After  10  weeks’  rest  in  bed  the 
general  condition  showed  no  improvement  and  the  tempera- 
ture was  higher.  On  July  19th  a right-sided  artificial 
pneumothorax  was  induced,  and  compression  of  the  lung 
kept  up  until  August  24th.  The  lung  collapsed  readily,  and 
the  pneumothorax  was  apparently  complete.  (No  X ray 
examination.)  This  having  no  effect  upon  the  pyrexia  or 
other  symptoms,  injections  of  pleural  fluid  (1  c.cm.)  were 
commenced  on  August  13th.  The  amount  was  increased 
gradually  up  to  25  c.cm.  on  Nov.  5th,  on  which  date  the 
injections  were  discontinued.  The  temperature  began  to  fall 
when  a dose  of  7 c.cm.  was  reached,  and  after  a few  doses  of 
10  c.cm.  rapidly  assumed  a more  favourable  type,  being 
practically  normal  by  Sept.  27th,  and  from  this  date  until 
Nov.  20th  rarely  exceeded  99°  F.  and  was  never  higher  than 
99-4°  F.  During  this  period  the  patient  gained  12  lb.  in  weight, 
was  able  to  get  up  for  most  of  the  day,  and  the  symptoms 
and  general  condition  were  improved.  On  Nov.  20th,  21st, 
and  22nd  the  evening  temperature  was  99°  or  99-2°  F.,  and 
injections  of  10  c.cm.  of  pleural  fluid  were  recommenced 
and  continued  until  Feb.  8th,  1918.  During  this  time  the 
temperature  remained  satisfactory,  weight  was  maintained, 
and  the  patient  was  well  enough  to  be  up  all  day  and  to  take 
exercise.  He  relapsed  subsequent  to  discharge,  and  in  June, 
1919,  was  reported  to  be  going  downhill. 

(C)  Male,  16,  two  months’  history.  Seen  Feb.  12th,  1918. 
Acute  caseous  tuberculosis  of  both  lungs.  Tuberculous 
laryngitis.  Pyrexia  (temperature  up  to  103°  F.).  After  two 
months’  rest  in  bed  the  temperature  improved  (ranging  up  to 
100°  or  101°  F.),  he  had  gained  a few  pounds  in  weight,  and  the 
general  condition,  while  still  grave,  showed  slight  improve- 
ment. Between  April  7th  and  June  12th  he  had  23  doses 
of  pleural  fluid  from  2 to  10  c.cm.  During  this  period  the 
temperature  fell  further,  the  general  condition  improved, 
he  gained  10  lb.  in  weight,  and  became  well  enough  to  go  to 
a sanatorium.  Subsequently  the  laryngeal  disease  increased, 
and  he  died  about  Christmas,  1918.  In  this  case  the  adminis- 
tration of  the  earlier  doses  of  pleural  fluid  was  followed 
frequently  by  a slight  elevation  of  temperature  with  a 
subsequent  fall. 

(D)  Male,  48.  Admitted  Dec.  28th,  1916.  Seven  years’ 
history.  Chronic  tuberculosis  of  right  lung.  Recent  activity. 
Slight  pyrexia  and  constant  haemoptysis  of  small  amount. 
In  March,  1917,  acute  bilateral  tubercular  epididymitis 
developed.  One  testicle  was  removed  in  April  and  the 
second  in  June.  This  was  followed  by  a prolonged  period 
of  slight  pyrexia,  with  occasional  rises  of  temperature  to 
100°  or  101°  F.,  and  persistent  slight  haemoptysis.  From 
Dec.  24th,  1917,  to  May  3rd,  1918,  he  had  35  injections  of 
pleural  fluid  in  doses  of  from  2 to  10  c.cm.  (346  c.cm.  in  all). 
By  February  the  temperature  had  fallen  to  98-4°  F.or  below, 
and  thereafter  remained  stable.  The  haemoptysis  ceased  at 
the  end  of  this  month  and  did  not  recur.  The  pulmonary 
symptoms  were  reduced  to  a minimum,  and  in  May  he  was 
well  enough  to  resume  active  work  and  has  remained  well 
ever  since. 

(E)  Male,  24.  Admitted  May  16th,  1917.  A few  weeks’ 
history. — Acute  bilateral  disease.  Continuous  pyrexia  and 
frequent  haemoptysis.  By  November  the  general  condition 
had  improved  slightly,  the  evening  temperature  ranging  up 
to  101°  F.  From  Nov.  13th,  1917,  to  March  1st,  1918,  he  had 
35  inoculations  of  pleural  fluid  (300  c.cm.  in  all).  During  the 
administration  the  temperature  fell  and  remained  much 
more  stable,  though  he  did  not  become  actually  afebrile. 
(Average  evening  temperature  99°  F.)  The  improvement  in 
general  health  was  marked.  In  April,  1918,  a prolonged 
period  of  fever  set  in  and  the  temperature  remains  unstable 
at  the  time  of  writing,  though  the  improvement  in  general 
condition  has  been  maintained. 

(F)  Male,  23.  Admitted  Sept.  26th,  1917.  Nine  months’ 
history.  Extensive  disease  of  the  right  lung  and  ulceration 
of  the  larynx.  Slight  pyrexia  with  irregular  rises  of 
temperature  up  to  102°  F.  From  Nov.  21st,  1917,  to  Jan.  15th, 

1918,  had  18  injections  of  pleural  fluid  (1  c.cm.  to  10  c.cm.). 
There  was  no  apparent  effect  on  temperature  or  general 
condition.  He  subsequently  improved  and  reported  in  June, 

1919,  that  he  had  returned  to  America  and  was  in  better 
health. 

(G)  Male,  47.  Admitted  Nov.  14th,  1917.  Eighteen  months’ 
history.  Extensive  bilateral  disease  with  advanced  laryngeal 
and  pharyngeal  tuberculosis.  Apparently  moribund.  From 
Jan.  18th,  to  Feb.  28th,  1918,  had  14  doses  of  pleural  fluid 
(3  c.cm.  to  10  c.cm.).  They  had  no  effect,  and  the  patient 
died  in  April. 

(H)  Female,  21.  Admitted  Nov.  30tb,  1917.  Eighteen  months’ 
history.  Extensive  bilateral  disease.  Pyrexia.  In  February, 
1918,  there  was  evidence  of  marked  extension  of  disease,  and 
the  general  condition  deteriorated.  From  May  1st  to 
July  5th  12  doses  of  pleural  fluid  were  given  (110  c.cm.  in 
all)  with  no  effect.  The  patient  continued  to  go  rapidly 
downhill,  and  died  in  the  winter. 


558  Thk  Lancet, J DR.  R.  EAGER  : THE  EARLY  TREATMENT  OF  MENTAL  DISORDERS.  [Sept.  27,  1919 


Summary. 

In  three  (F,  G,  and  H)  of  the  above  eight  cases  the 
administration  of  the  pleural  fluid  was  without  any  apparent 
effect  upon  the  symptoms  or  course  of  the  disease.  In  two 
(C  and  E),  where  improvement  coincided  with  treatment,  it 
must  be  admitted  that  these  two  patients  had  shown  signs 
of  improvement  before  it  was  commenced.  Two  (A  and  B) 
were  going  steadily  downhill  in  spite  of  other  measures  of 
treatment ; in  both  the  use  of  pleural  fluid  was  followed  by 
rapid  and  marked  improvement,  in  both  the  cessation  of 
the  injections  was  followed  by  a tendency  to  relapse,  and  in 
both  renewed  improvement  followed  their  resumption.  Both 
these  patients  received  injections  of  the  same  pleural  fluid 
(from  a case  of  “primary  ” tuberculous  pleurisy)  used  within 
a few  weeks  of  its  preparation. 

In  the  remaining  case  (D),  though  the  patient’s  general 
condition  was  good  throughout,  troublesome  symptoms 
which  had  persisted  for  months  disappeared  within  a few 
weeks  of  the  administration  of  the  pleural  fluid. 

While  well  aware  of  the  difficulty  of  correlating  cause  and 
effect  in  a case  of  tuberculosis  of  the  lungs,  we  are  of  opinion 
that  the  use  of  “heteroserotherapy”  in  this  disease  is  worthy 
of  further  investigation,  and  that  the  results  obtained  in 
Cases  A,  B,  and  D may  be  ascribed  fairly  to  the  effect  of  the 
inoculated  pleural  fluid. 

References.— 1.  Meek,  W.  O. : The  Immune-body  Content  of  the 
Blood-serum  in  Pulmonary  Tuberculosis,  Journal  of  Hygiene,  xiv., 
No.  1.,  April,  1914.  2.  Paterson,  R.  C.  : The  Pleural  Reaction  to 
Inoculation  with  Tubercle  Bacilli  in  Vaccinated  and  Normal  Guinea- 
pigs,  American  Review  of  Tuberculosis,  i..  No.  6,  August,  1917.  3. 
Gilbert,  V.  : L'autoserotherapie  de  la  pleuresie  serofibrineuse,  Rev. 
Medicate  de  la  Suisse  Rom.,  Geneve,  1910,  xxx.,  24-35.  4.  Jousset,  A.  : 
Sur  l'autoserotherapie  dans  la  pleuresie,  Journal  de  med.  et  chir. 
pratique,  Paris,  1912,  Ixxxiii.,  91-94. 


THE  EARLY  TREATMENT  OF  MENTAL 
DISORDERS. 

By  R.  EAGER,  M.D.  Aberd., 

SENIOR  ASSISTANT  MEDICAL  OFFICER  AND  DEPUTY  MEDICAL  SUPER- 
INTENDENT, DEVON  MENTAL  HOSPITAL,  EXMINSTER  ; MAJOR, 
R.A.M.C  (T.)  ; LATE  O.  i/C.  MENTAL  DIVISION,  THE 
LORD  DERBY  WAR  HOSPITAL,  WARRINGTON. 


At  the  present  time,  when  articles  are  constantly  being 
published  with  regard  to  the  extraordinary  good  results 
obtained  in  the  treatment  of  the  psychoneuroses  in  special 
neurological  hospitals,  I think  it  will  not  be  out  of  place  to 
record  the  results  obtained  amongst  the  psychoses. 

The  Material  Examined. 

I am  taking  my  figures  from  the  admissions  to  the  Mental 
Division  of  the  Lord  Derby  War  Hospital  for  the  first  two 
years.  There  were  during  this  period  4695  admissions,  all 
of  whom  were  soldiers  in  a state  of  acute  mental  disorder, 
and  by  far  the  majority  came  from  the  Expeditionary  Forces 
overseas. 

Amongst  this  vast  number  of  cases  of  acute  mental  break- 
down all  types  were  met  with.  Speaking  generally,  there 
was  nothing  very  noticeable  in  the  way  of  symptoms  pre- 
sented to  differentiate  them  from  those  seen  in  pre-war 
experience.  I have  already  recorded  the  individual  types  of 
psychoses  met  with  in  a paper  published  in  the  Journal  of 
Mental  Science  of  July,  1918,  and  will  therefore  not  enter 
into  the  discussion  of  individual  cases  in  this  article. 

A survey  of  the  numbers  of  admissions  and  discharges  at 
the  end  of  two  years’  work  discloses  the  fact  that  the  recovery 
rate  stands  at  56  per  cent.,  and  I think  this  is  sufficiently 
encouraging  to  call  attention  to,  seeing  that  the  percentage 
of  recoveries  amongst  male  admissions  to  county  and  borough 
asylums  in  England  for  the  10  years  1902  to  1911  inclusive 
was  only  32  per  cent.1  A statistical  record  of  the  admissions 
from  the  French  Expeditionary  Force  will  be  found  in 
Table  III. 

Of  the  1000  cases  in  hospital  at  the  end  of  two  years’ 
admissions  only  200  had  been  resident  six  months  or  over, 
and  during  this  period  the  deaths  totalled  only  40,  or 
0-8  per  cent. 

Over  330  cases  who  had  developed  a mild  psychosis  under 
exceptionally  trying  conditions  were  considered  sufficiently 
recovered  to  justify  their  return  to  military  duty  under  the 
proviso  that  they  were  kept  on  home  service  for  12  months. 


This  step  was  so  far  justified  that  a great  number  of  these 
ultimately  again  went  to  the  front,  the  wisdom  of  which, 
however,  is  a question  for  speculation. 

Review  of  Treatment  Adopted : 1.  Early  Observation. 

I propose,  therefore,  to  review  the  treatment  adopted  in 
dealing  with  this  vast  number  of  cases  of  acute  mental 
disorder. 

In  the  first  place,  I think  an  important  point  is  that  all 
were  brought  under  observation  at  the  earliest  possible 
period  of  their  trouble  and  placed  under  medical  officers 
with  special  experience  of  such  conditions.  At  the  same 
time,  this  segregation  was  as  far  as  possible  relieved  of 
any  stigma.  No  patient  was  under  any  certificate,  and  no 
legal  formalities  had  to  be  gone  through  before  he  was 
placed  under  the  special  treatment.  As  soon  as  possible, 
after  his  condition  improved  sufficiently,  he  was  allowed 
parole  and  all  the  privileges  of  a case  in  the  surgical  or 
medical  wards  of  the  hospital.  The  Lord  Derby  War 
Hospital  was,  in  fact,  a general  hospital  with  medical, 
surgical,  and  mental  divisions,  of  which  the  latter  comprised 
1000  beds.  Apart  from  the  fact,  therefore,  that  his  mental 
condition  prevented  it,  just  as  a case  in  the  surgical  or 
medical  wards  might  be  similarly  prevented  by  his 
disability,  a patient  was  as  soon  as  possible  allowed  to  mix 
freely  with  patients  from  other  parts  of  the  hospital.  Any 
distinction  was  avoided. 

The  bringing  of  these  cases  under  early  observation  was 
helped  considerably  by  the  facilities  in  detecting  premonitory 
symptoms.  If  a soldier  in  the  army,  who  has  been  previously 
up  to  the  average  standard,  is  noticed  to  be  unable  to  stand 
properly  to  attention  on  parade,  or  does  not  form  fours 
properly,  or  in  any  other  way  does  not  seem  up  to  his  usual 
standard,  it  is  almost  certain  that  this  will  be  reported  by 
his  N.C.O.  to  a superior  officer,  who  will  ultimately  send  him 
to  be  examined  by  the  medical  officer.  Even  off  duty,  when 
in  billets  or  barracks,  he  is  more  or  less  under  observation, 
and  by  night  more  especially  so.  It  is  therefore  likely  that 
any  strange  action  will  be  noticed  and  reported.  In  civil 
cases,  on  the  other  hand,  this  early  detection  of  symptoms 
is  much  more  difficult,  and  patients  are  much  more  likely  to 
be  able  to  conceal  their  symptoms.  This  point  has  been  brought 
out  by  my  colleague,  Captain  O.  P.  N.  Pearn,  R.A.M.C.,  in 
his  article  on  the  Psychosis  in  the  Expeditionary  Forces, 
recently  published  in  the  Journal  of  Mental  Science.-  I feel 
sure  that  the  patient,  as  a civilian  under  present  conditions, 
knows  that  by  disclosing  his  feelings  he  will  be  brought 
before  a medical  man,  who  will  probably  call  in  the  assist- 
ance of  a magistrate,  that  he  will  deprive  him  of  his 
freedom,  and  at  the  same  time  subject  him  to  the  stigma  of 
certification  and  all  its  necessary  legal  accompaniments. 
Under  such  conditions  symptoms  are  concealed  as  long  as 
possible,  and  in  the  early  stages,  as  a rule,  the  patient  does 
not  find  much  difficulty  in  “pulling  himself  together” 
sufficiently  to  pass  muster  in  his  office  as  a clerk,  or  what- 
ever occupation  he  may  perform.  In  a city  he  probably  does 
not  return  home  to  his  midday  meal  or  tea,  but  has  these  at 
a restaurant,  where  it  is  no  one’s  business  in  particular  if  he 
does  anything  strange.  He  probably  returns  home  late  at 
night,  and  spends  little  time  in  the  company  of  his  friends  or 
relations.  This  sort  of  thing  often  goes  on  for  months  or 
even  years  undetected,  until  he  ultimately  commits  some  act 
against  the  conventions  of  society  by  which  he  gets  into  the 
hands  of  the  police.  In  the  soldier,  on  the  other  hand,  as 
treated  during  the  war,  no  stigma  was  attached  to  the  fact 
that  he  became  insane.  He  was,  as  far  as  practicable, 
treated  as  any  other  casualty,  and  if  he  reported  his 
symptoms  voluntarily,  was  taken  to  a hospital  in  the  same 
way  as  if  he  were  suffering  from  any  other  illness. 

2.  Adequate  Medical  Staff. 

Another  point  is  the  importance  of  having  e.n  adequate 
medical  staff  in  dealing  with  cases  at  this  stage.  A glance 
at  Table  I.,  which  shows  the  monthly  admission  and 
discharge  rate  during  the  two  years  under  consideration, 
will  indicate  the  necessity  for  a large  medical  staff  to  deal 
with  such  numbers  alone.  At  the  opening  of  this  special 
psychiatric  section  it  was  strongly  urged  that  the  relative 
strength  of  medical  officers  should  be  no  less  than  1 to 
every  100  patients. 

Apart  from  the  question  of  dealing  with  large  numbers  it 
must  be  remembered  that  if  patients  are  to  have  adequate 
treatment  in  the  early  stages  of  mental  disorder,  the  relative 


The  Lanoet,]  DR.  R.  EAGER:  THE  EARLY  TREATMENT  OK  MENTAL  DISORDERS.  [Sept.  27,  1919  559 


TABLE  1 


number  of  doctors  must  be  increased  much  above  that  which 
is  customary  in  present-day  asylum  practice.  From  the 
experience  I have  had  I would  advocate  that  there  should  be 
no  less  than  1 medical  officer  for  every  50  patients,  if  all 
that  is  possible  is  to  be  done  for  such  cases. 

In  making  this  statement  I am,  of  course,  intending  it  to 
apply  to  a hospital  dealing  solely  with  early  cases  of  mental 
disorder,  and  am  not  supposing  that  the  chronic  cases  will  be 
included  or  retained,  if  admitted. 

To  undertake  work  which,  if  carried  out  properly,  meant 
spending  many  hours  a week  with  individual  cases,  was  quite 
out  of  the  question  with  a staff  of  only  1 in  100,  in  addition 
to  the  fact  that,  at  times,  when  medical  officers  were  urgently 
needed  elsewhere,  even  this  proportion  could  not  be  main- 
tained. As  much  as  possible,  however,  was  done. 

A great  deal  has  been  written  lately  about  the  treatment 
of  the  psychoneuroses  by  suggestion  and  persuasion,  using 
these  terms  to  cover  all  the  different  modifications,  such  as 
hypnotism  and  treatment  with  the  aid  of  electricity,  which 
comes  under  their  meaning.  Also  the  amount  of  individual 
attention  and  time  that  has  to  be  given  to  each  case.  The 
same  applies  to  the  treatment  of  the  psychoses,  and  in  many 
cases  is  the  sole  means  of  saving  them  from  running  a chronic 
course.  It  is  true  that  some  cases  appear  to  recover  with 
li  quiet  and  rest,”  and  treatment  by  what  Dr.  T.  E.  K. 
Stansfield3  has  called  “rational  ” lines,  but  there  are  a great 
number  in  which  every  means  of  suggestion  and  persuasion 
must  be  exercised  with  tact  and  perseverance  and  untiring 
patience  upon  the  part  of  the  medical  officer.  In  these  cases 
— more  so  than  in  the  psychoneuroses — comes  the  importance 
of  psycho-analysis,  using  this  term  in  its  widest  sense  and 
not  necessarily  meaning  Freudian  psycho-analjsis,  as  is  so 
commonly  concluded  by  those  opposed  to  this  method.  I 
am  certain  that  individual  attention  and  analysis,  as  a rule, 
fully  justified  the  expenditure  of  time  necessary  for  such 
methods,  the  principles  of  which  have  been  so  aptly  and 
ably  described  by  Bernard  Hart,4  who  teaches  that  it  is 
becoming  more  and  more  certain  that  the  mental  factor 
forms  the  most  important  link  in  the  chain  of  causation  in 


the  psychoneuroses  and  has  drawn  attention  to  the  under- 
lying conflict  between  the  instinct  of  self-preservation  and 
the  sense  of  duty  and  patriotism  in  the  case  of  the  soldier,  t <j 

As  has  been  pointed  out  by  Eder,5  “ psycho-analysis  is  the 
only  method  that  enables  the  patient  to  deal  with  the  under- 
lying state,  and  not  merely  with  the  symptom.  In  psycho- 
analysis the  patient  learns  for  himself  the  real  significance 
of  his  disease,  a privilege  only  acquired  by  a bitter  self- 
realisation.  The  ‘ rest  cure  ’ affords  the  ideal  conditions  for 
retirement  from  life’s  duties,  and  strengthens  the  patient’s 
motives  for  remaining  ill,  but  by  psycho-analysis  the  uncon- 
scious mind  is  explored  and  the  energy  hitherto  wasted  in 
internal  conflict  is  made  available  for  the  purpose  of  life.” 

Usual  Procedure  on  Admission. 

On  admission  of  patients  to  the  Mental  Section  of  the 
Lord  Derby  War  Hospital,  they  were  taken  straight 
to  the  admission  ward,  where  clerks  obtained  par- 
ticulars for  the  admission  and  discharge  book.  Each 
medical  officer  was  provided  with  a private  room  in 
his  wards,  where,  at  his  convenience,  he  could  interview 
each  patient  separately,  with  the  full  assurance  that  his 
statements  would  be  treated  as  confidential.  The  case 
sheets  of  each  patient  in  the  ward  were  kept  in  this  room 
under  lock  and  key  as  confidential  documents,  and  not  hung 
up  with  the  chart  over  the  patient’s  bed,  as  in  ordinary  hos- 
pital wards.  Everything,  in  fact,  was  done  to  inspire  con- 
fidence between  the  patient  and  the  doctor,  and  it  is  only  in 
this  way  that  one  can  expect  such  cases  to  really  enter  freely 
into  examination,  to  cooperate  with  the  doctor  and  interpret 
their  feelings,  as  the  result  of  which  the  benefits  of  psycho- 
therapy become  very  strikingly  obvious.  It  is  not  to  be 
expected  that  such  can  be  carried  out  either  in  an  open  ward 
with  numbers  of  other  patients  listening  to  everything  said, 
or  in  a room  in  which  anyone  else  is  present  except  the 
physician  and  the  patient.  Beds  in  the  open  air  were  pro- 
vided for  those  to  whom  it  was  thought  rest  in  bed  would  be 
beneficial,  and  as  soon  as  possible  patients  were  allowed  to 
have  freedom  from  lock  and  key. 


560  The  Lancet,]  DR.  R.  EAGER:  THE  EARLY  TREATMENT  OF  MENTAL  DISORDERS.  [Sept.  27,  1919 


No  selection  as  to  the  type  of  case  admitted  was  possible. 
Amongst  such  a vast  number  of  admissions  it  is  not  surprising 
therefore  that  the  number  of  cases  of  general  paralysis  alone 
came  to  197. 

The  above  facts  must  be  borne  in  mind  when  considering 
the  recovery-rate,  in  addition  to  which  I should  add  that 
the  number  of  cases  of  congenital  mental  defect  reached  no 
small  figure.  Even  in  these  cases,  however,  many  showed 
acute  symptoms  superimposed  on  this  congenital  defect.  A 
number  of  cases  received  had  been  previously  in  special 
neurological  hospitals,  and  were  transferred  to  the  mental 
section  as  they  had  not  improved.  These  admissions  also 
tended  to  reduce  the  percentage  of  recoveries. 

Cases  found  to  have  been  previously  under  asylum  care  in 
peace-time,  all  epileptics,  and  cases  of  G.P.I.  were  certified 
and  transferred  to  asylum  care  as  soon  as  the  diagnosis  had 
been  confirmed.  Similarly  all  cases  who  had  been  resident 
nine  months  without  showing  any  appreciable  signs  of 
improvement,  were  so  transferred,  and  in  this  way  the 
hospital  was  kept  as  free  as  possible  from  chronic  cases  and 
an  atmosphere  of  cure  was  prevalent.  The  total  transferred 
to  asylums  was  452  (or  9 per  cent.). 

A number  of  cases  were  transferred  to  other  hospitals  in 
Scotland,  Wales,  or  Ireland  so  as  to  be  nearer  their  relatives 
for  visiting  purposes,  and  a larger  number  of  Colonials  were 
repatriated  to  the  Colonies  for  final  disposal.  A large  pro- 
portion of  these  cases  were  well  on  the  road  to  convalescence 
before  they  left,  but  as  their  final  condition  was  not  deter- 
mined, they  have  not  been  included  in  the  percentage  of 
recoveries.  Whilst  under  treatment,  any  man  having  a 
special  trade  was  given  facilities  for  working  at  this  in 
hospital  workshops  during  his  period  of  convalescence  prior 
to  his  discharge,  and  in  this  way  prepared  himself  for  the 
work  he  would  be  taking  up  when  leaving  the  hospital.  This 
helped  in  a large  measure  to  establish  the  man’s  confidence. 
Other  cases,  numbering  about  100  daily,  were  encouraged  to 
work  on  the  farm  and  in  the  grounds.  Idleness  was  dis- 
couraged, but  absolute  rest  in  bed  in  certain  cases  of 
exhaustion  psychoses,  on  the  other  hand,  was  insisted  on  for 
purposes  of  treatment. 

3.  An  Abundant  Diet. 

Next  I should  like  to  draw  attention  to  the  question  of 
diet.  A liberal  nourishing  diet  is  of  the  greatest  importance 
in  treating  all  cases  of  acute  mental  disorder.  The  diet  as 
issued  to  the  patients  in  the  Mental  Division  of  Lord 
Derby  War  Hospital  will  be  seen  laid  out  for  the  week  in 
Table  II.  The  allowances  are  much  more  liberal  than  those 


Table  II .—Specimen  Dietary  for  Patients  on  Ordinary  Diet. 


- 

Breakfast. 

Dinner. 

Tea. 

Supper. 

Sunday. 

Tea,  bread  and 
margarine, 
with  boiled 
bacon  (4  oz. 
uncooked). 

ltoast  beef  (8  oz.  un- 
cooked). potatoes 
(12  oz.)  and  green  peas 
(2  oz.),  and  milk 
pudding. 

Tea,  bread, 
margarine, 
and  currant 
cake. 

Coffee 
or  cocoa 
and 
cheese 
(i  oz.). 

Monday. 

Tea,  bread  and 
margarine, 
with  one  egg; 

Meat  pie3  (beef,  8 oz. 
uncooked),  potatoes 
(12  oz.),  and  haricot 
beans  (i  oz.),  with  milk 
pudding. 

Tea,  bread, 
margarine, 
and  .jam 
<1J  oz.). 

Tuesday. 

Porridge, 
milk,  tea, 
bread,  and 
margarine. 

Hot  boiled  bacon  (6  oz. 
uncooked),  potatoes 
(12  oz.),  sufficient 
cabbage,  and  milk 
pudding. 

Wednesday. 

Tea,  bread, 
margarine, 
and  sausage 
<43  oz.). 

Steamed  fish  (12  oz. 
uncooked),  potatoes 
and  boiled  suet  pudding 
(ginger,  college,  or 
jam  roll). 

Thursday. 

Tea,  bread  and 
margarine, 
with  one  egg. 

Roast  beef  (8  oz.  un- 
cooked), potatoes,  and 
sufficient  fresh  vege- 
tables and  milk  pudding. 

Tea,  bread, 
margarine, 
with 

currant  bun 
or  scone. 

Friday. 

Tea,  bread  and 
margarine, 
with  sausage 
(4§  oz.). 

Hot  pot  (beef.  8 oz.  un- 
cooked), peas  pudding 
(split  peas,  2 oz.), 
with  milk  pudding. 

Tea,  bread, 
margarine, 
and  jam 
(la  oz.). 

** 

Saturday. 

Tea,  bread  and 
margarine, 
with  one  egg. 

Ilot  boiled  bacon  (6  oz. 
uncooked),  potatoes, 
and  sufficient  cabbage, 
with  milk  pudding. 

N otes. — Daily  allowances : Bread,  12  oz. ; margarine,  1 oz. ; sugar, 
li  oz. ; milk,  9 oz.,  with  15  oz.  tor  milk  puddings  and  10  oz.  with 
porridge.  Tea,  1 oz.  per  day ; coffee,  i oz.,  or  cocoa,  i oz. 


allowed  by  the  average  civil  asylum  scale.  The  cost  of  this 
dietary  alone  in  a civil  institution  would  probably  exceed  13s. 
per  head  per  week  on  pre-war  prices,  whereas  the  average 
cost  of  maintenance  up  to  the  end  of  1918,  in  civil  asylums 
in  this  country,  was  only  14s.  5| d.,  and  this  is  stated  to  be 
a rise  of  Is.  9 d.  on  the  cost  of  the  previous  year.0  It  must 
also  not  be  forgotten  that  this  cost  of  maintenance  includes 
provision  for  the  salaries  of  the  staff  for  these  institutions. 

In  addition  to  the  above  standard  dietary,  in  some  cases, 
patients  were  put  on  milk  and  eggs  as  extras,  but  the 
necessity  for  this  did  not  often  arise  with  such  a substantial 
diet  as  a foundation. 

4.  facilities  for  Specialist  Treatment. 

Another  special  feature  which  I should  mention,  and 
from  which,  I am  certain,  many  patients  derived  much 
benefit,  was  the  facility  that  existed  for  any  patient  being 
seen  in  consultation  by  a specialist  for  practically  any  bodily 
disorder  of  which  he  might  complain.  A spirit  of  confidence 
therefore  existed  amongst  the  patients  that  every  complaint 
would  at  once  receive  thorough  investigation.  Numbers  of 
cases  on  this  account  were  sent  to  special  departments  of  the 
hospital  for  examination  or  treatment.  I would  especially 
mention  the  eye  department,  the  ear,  nose,  throat,  X ray, 
electro-therapeutics,  and  massage.  If  any  patient  made  a 
complaint  with  regard  to  physical  symptoms,  it  was  the 
invariable  rule  to  call  the  medical  officer  in  charge  of  the 
medical  or  surgical  divisions  of  the  hospital  in  consultation, 
and  similarly  with  other  special  branches  in  order  that  the 
patient  should  receive  the  best  possible  treatment  or  advice. 
The  London  Hospital  scheme  of  appointing  a whole-time 
salaried  physician  of  the  highest  standing  instead  of  the 
honorary  appointment,  where  visits  are  made  periodically, 
has  already  been  introduced  in  some  hospitals,  as  it  was  felt 
that  the  best  results  could  only  be  obtained  under  conditions 
where  the  doctor  was  on  the  spot.  It  was  certainly  most 
helpful  in  dealing  with  large  numbers  of  acute  psychoses.  ' 

A specially  trained  masseur  was  employed  in  the  mental 
section  to  attend  cases  having  surgical  disabilities  com- 
plicated by  a psychosis.  There  were  numerous  cases  of  this 
kind,  as  would  be  expected,  seeing  that  most  of  the  admis- 
sions came  direct  from  the  firing  line  or  front-line  area. 
Cases  in  a generally  debilitated  exhausted  state  were  also 
treated  with  general  massage  in  some  instances.  There  were 
18  of  these.  About  an  hour  was  devoted  to  each  case  at  a 
sitting,  and  treatment  was  given  three  days  a week,  ; 
extending  in  some  instances  to  three  months  in  duration. 
The  improvement  in  general  condition  was  very  striking,  and 
in  all  cases  the  mental  condition  improved  with  accom- 
panying psychotherapy. 

Surgical  Cases. 

Amongst  the  surgical  cases  special  investigations  were  ! 
made  into  a hundred  cases  of  head  injury  with  accompany-  1 
ing  mental  symptoms,  which  I have  made  the  subject  of 
another  article. 

No  corroborative  evidence  was  found  to  substantiate 
Hollander's  7 statements  that  loss  of  intelligence  occurs  in 
frontal  injuries,  melancholia  in  parietal  injuries,  mania  in 
temporal  injuries,  or  that  in  the  case  of  occipital  injuries 
the  gregarious  instinct  is  especially  effected.  On  the 
contrary,  it  was  clearly  shown  from  27  cases  of  frontal 
injury  that  there  was  no  uniformity  in  the  mental  symptoms 
that  may  follow  injuries  to  this  part  of  the  head,  and  this 
statement  is  applicable  to  the  skull  generally. 

A large  number  of  cases  of  epilepsy  occurred  in  gross 
lesions  of  the  parietal  region  of  the  skull,  and  my  results  in 
this  respect  agree  with  those  of  Roeper.”  The  preponderance 
of  cases  of  amnesia  were  found  in  frontal  injuries,  but,  with 
these  exceptions,  no  symptoms  could  be  definitely  associated 
with  injuries  to  any  special  region  of  the  skull. 

Cases  of  Venereal  Disease. 

Amongst  other  cases,  about  which  some  special  considera- 
tion might  be  made,  are  the  cases  of  venereal  disease. 
There  were  305  cases  suspected  of  being  so  infected,  and 
tested  by  the  Wassermann  method.  Of  this  number  249 
gave  a positive  blood  reaction  and  172  a positive  reaction  in 
the  cerebro-spinal  fluid.  The  globulin  test  was  positive  in 
123,  and  in  109  there  was  an  increased  cell  count. 

Prior  to  the  discovery  of  this  method  of  testing  a patient’s 
bodily  fluids  it  was,  in  many  cases,  mere  guess-work  to  say 
whether  this  or  that  person,  at  some  time  or  other,  had  or 
had  not  suffered  from  syphilis.  Any  expressions  of  opinion 


Thb  Lanoet,]  DR.  R.  EAGER:  THE  EARLY  TREATMENT  OF  MENTAL  DISORDERS.  [Sept.  27,  1919  561 


as  to  the  role  of  syphilis  in  the  causation  of  mental  disease 
must  have  been  merely  speculative.  At  the  present  time, 
however,  it  must  be  accepted  that,  provided  the  Wassermann 
test  is  performed  by  a specially  trained  pathologist,  who  has 
had  special  experience  in  its  technique,  the  percentage  of 
positive  Wassermann  reactions  in  active  syphilis  is  so  high 
that  the  test  may  for  all  practical  purposes  be  looked  upon 
as  decisive. 

Major  C.  F.  White  and  Captain  A.  T.  McWhirter  and  Captain 
H.  Barber,11  as  a result  of  their  experience  of  5800  Wasser- 
mann tests,  say  that  they  are  satisfied  that  syphilitic  serum 
gives  a positive  result  and  non-  syphilitic  a negative  in  such  an 
overwhelming  majority  of  cases  that  any  apparent  exceptions 
must  be  very  closely  studied  before  they  are  accepted.  A 
full  course  of  606  injections  was  given  in  11  cases  in  which 
the  blood  only  was  positive.  Nine  of  these  cases  were 
ultimately  discharged  recovered  from  their  mental  sym- 
ptoms. The  complete  conversion  of  the  positive  Wassermann 
reaction  in  the  blood  was,  however,  only  obtained  in  four 
of  these  cases.  It  must  be  remembered,  however,  that  the 
history  of  infection  was  at  a very  remote  period,  and  that, 
apart  from  the  mental  symptoms,  there  were  no  active  signs 
of  syphilis. 

The  method  of  treatment  adopted  was  to  give  salvarsan 


or  its  equivalent  combined  with  mercury 

as  follows  : — 

Salvarsan 

Mercury. 

1st  day 

0-3  g.  . 

1 gr. 

4th  „ 

0'3  „ . 

0 ,, 

8th  „ 

0-3  ,,  . 

1 ,, 

15th 

0 .,  . 

1 „ 

22ud  ,, 

0-4  „ . 

1 ,, 

29th 

0-5  „ 

1 „ 

36th 

0 ,, 

1 ,, 

43rd  ., 

0-5  „ 

1 „ 

50th 

0-5  ,. 

1 ,, 

The  606  injections  were  given  intravenously  by  the  gravity 

method,  and  the 

mercury  injections 

were  given  intra- 

muscularly  into  the  buttocks.  On  the  52nd  day  the  blood 

was  again  tested,  and,  if  negative,  treatment  was  suspended. 

In  cases  where  the 

reaction  was  still  positive,  however,  a 

course  of  pot.  iod. 

was  given  till  the 

68th  day  and  then 

the  following  injecti 

ons  : — 

Salvarsar 

Mercury. 

69th  day 

0 3 g. 

1 gr. 

76th 

0'4  „ 

1 ,, 

83id  „ 

0-5  „ 

1„ 

If  the  blood  was  still  positive  after  this,  chronic  mercurial 
treatment  was  advised.  The  derivatives  of  salvarsan  used 
were  kharsivan  and  arsenobillion,  and  the  solutions  were 
freshly  prepared  immediately  before  injection.  In  no  case 
was  there  any  dermatitis  or  other  untoward  symptoms. 

The  treatment  of  syphilis  of  the  nervous  system  by  pro- 
longed intravenous  injection  of  neosalvarsan  has  been 
shown  by  Henry  Head  10  to  have  given  good  results  in  cases 
where  the  lesion  is  situated  in  parts,  such  as  the  meninges 
and  vessels  (meningo-vascular  type),  easily  reached  by  a 
drug  circulating  in  the  blood.  He  states  that  not  only  is 
the  disease  afEected  favourably,  but  the  Wassermann 
reaction,  if  positive  in  the  c.s.  f. , may  become  negative 
within  a few  months  after  treatment,  and  the  pleocytosis 
greatly  reduced.  In  most  cases  this  change  was  effected 
by  three  doses  of  0 9 g.  of  neosalvarsan,  but  in  a few 
instances  even  relatively  smaller  doses  of  salvarsan  were 
used.  On  the  other  hand,  in  cases  which  do  not  improve 
with  this  treatment,  he  considers  the  affection  is  deeper- 
seated  and  out  of  reach  of  the  arsenical  compounds 
employed  by  that  method.  The  conclusions  arrived  at  by 
Head  were  that  it  is  impossible  by  bedside  examination  to 
determine  whether  the  patient  is  suffering  from  dementia 
paralytica  or  syphilitic  encephalitis.  Cases  of  syphilis 
meningo-vascularis  cerebralis  may  be  distinguishable  from 
dementia  paralytica  solely  by  the  fact  that  the  cerebro- 
spinal fluid  from  the  first  gives  a negative  reaction.  But 
if,  as  so  commonly  happens,  intraspinal  complication  is 
present  the  cerebro-spinal  fluid  in  both  may  be  equally 
positive. 

General  Paralysis. 

With  regard  to  the  cases  of  general  paralysis,  there  were 
in  all  197  cases  admitted  under  my  care.  Ten  of  these  died 
before  their  transfer  to  asylum  care  could  be  carried  out. 
Transfer  to  an  asylum  was  the  method  of  disposal  of  all 


these  cases  as  soon  as  the  diagnosis  had  been  confirmed  by 
the  laboratory  findings.  In  180  cases  in  which  records  of 
the  reactions  were  made  168,  or  94  per  cent.,  gave  a positive 
blood  Wassermann  reaction  and  12  a negative.  Amongst  the 
latter,  however,  the  negative  blood  reaction  was  associated 
in  four  cases  with  a positive  reaction  in  the  c.s.f. , a positive 
globulin  reaction  and  an  increased  cell  count,  leading  to  the 
supposition  that  the  bloods  had  been  converted  by  treatment, 
and  in  only  two  cases  were  all  the  results  negative.  The 
c.s.f.  reaction  was  positive  in  93  per  cent.,  the  globulin 
reaction  in  94  per  cent.,  and  there  was  a pleocytosis  in 
87  per  cent.  The  cell  count  in  some  cases  reached  as  high 
as  400  per  c.mm.,  but  anything  over  10  per  c.mm.  was  looked 
upon  as  abnormal. 

Captain  Barker  Charnock,  R.A.M.C.,  pathologist  to  the 
hospital,  has  very  kindly  given  me  the  following  brief 
observations:  “In  general  paralysis  of  the  insane  it  is  my 
experience  that,  as  a routine,  the  blood  serum  and  the 
cerebro-spinal  fluid  should  be  examined,  together  with  the 
globulin  content  and  the  cell  estimation  of  the  latter.  As  an 
aid  to  the  differential  diagnosis  of  general  paralysis,  cerebral 
syphilis,  and  tabes,  Lange’s  colloidal  gold  reaction  is  of  great 
use  ; tne  only  difficulty  being  the  preparation  of  the  water 
triply  distilled  from  glass.  A good  glass  still  is  required  in 
the  up-to-date  laboratory.  In  spite  of  what  is  said  to  the 
contrary,  I have  found  that  the  routine  globulin  reaction  has 
been  useful  in  early  cases.  It  has  been  my  experience  that 
the  globulin  reaction  may  appear  before  the  positive 
Wassermann  reaction  in  the  cerebro-spinal  fluid.  As  a 
reliable  test  the  Pandy  method  gives  good  results  and  is 
free  from  the  obnoxious  odour  associated  with  the  Noguchi 
reactions.  The  Alzheimer  method  has  been  of  great  use  in 
demonstrating  the  plasma  cells  diagnostic  of  G.P.  I.  The 
quantitative  method  of  performing  the  Wassermann  test  has 
been  useful  in  judging  the  effects  of  treatment.  This  method 
has  been  controlled  by  the  modified  complement-fixation 
tests  with  and  without  the  destruction  of  complement. 
Observations  based  upon  the  modified  tests  pointed  out  that 
the  sera  possessing  the  most  potent  complement  usually 
reacted  best  to  arsenical  treatment.” 

These  reactions  are  of  the  greatest  importance  in  dealing 
with  incipient  cases  of  general  paralysis  of  the  insane,  the 
correct  diagnosis  of  which  in  this  stage  cannot  be  given 
unhesitatingly  without  their  aid.  In  quite  a number  of  cases 
the  reactions  to  these  tests  changed  from  a negative  to  a 
positive  finding  whilst  the  patients  were  under  observation, 
showing  the  early  stage  in  which  the  condition  existed.  On 
the  other  hand,  in  cases  in  which  the  medical  history  sheet 
(A.F.  187)  covered  that  period,  the  date  of  primary  infection 
could  be  shown  to  be  as  long  as  15  years  before  the  onset  of 
the  symptoms. 

A few  of  the  early  cases  of  general  paralysis  of  the  insane 
were  give  intrathecal  injections  of  mercurialised  serum,  but 
in  no  case  was  a positive  converted  into  a negative  fluid 
reaction  by  this  treatment,  and  hence  no  success  can  be 
claimed  for  it  as  far  as  my  experience  goes.  All  types  of 
general  paralysis  of  the  insane  were  met  with,  and  the  im- 
pression gained  was  that  the  symptoms  developed  more 
rapidly  than  in  the  cases  seen  in  pre-war  days.  A few  died 
in  a state  of  acute  mania,  with  little  to  justify  the  diagnosis 
had  not  the  reactions  of  the  blood  and  fluid  been  tested,  and 
I feel  sure  that  many  cases  in  the  past  who  have  died  from 
so-called  “acute  delirious  mania  ” belong  to  this  category. 

Lumbar  Puncture. 

The  importance  of  performing  a lumbar  puncture  and 
testing  the  spinal  fluid  reactions,  especially  in  cases  which  in 
any  way  cause  one  to  suspect  incipient  symptoms  of  general 
paralysis,  cannot  be  over-emphasised.  Up  to  the  present 
cases  are  rarely  diagnosed  before  the  brain  has  undergone 
extensive  and  irreparable  damage.  Sir  Charles  Ballance  and 
Dr.  H.  Campbell 11  have  recently  published  an  instructive 
article  on  this  subject  advocating  treatment  by  introduction 
of  salvarsanised  serum  into  the  lateral  ventricles  in  the  pre- 
clinical  stage  of  the  disease.  They  point  out  also  that  the 
demobilisation  of  the  British  Army  and  the  probable  increase 
of  syphilis  in  this  country  make  it  highly  desirable  that  any 
means  which  may  have  a remedial  influence  on  syphilitic 
infections  of  the  nervous  system  should  receive  careful  study. 

This  all  tends  to  emphasise  the  importance  of  any  insti- 
tution dealing  with  early  cases  of  mental  disorder  being 
in  close  association  with  an  up-to-date  laboratory  and 
N 2 


562  The  Lancet,]  DR.  R.  EAGER:  THE  EARLY  TREATMENT  OF  MENTAL  DISORDERS.  [Sept.  27,  1919 


pathologist  especially  experienced  in  the  technique  necessary 
to  perform  this  work.  It  also  shows  the  importance  of  any 
institution  for  the  early  treatment  of  mental  diseases  being 
provided  with  adequate  means  for  treating  syphilitic  affec- 
tions by  modern  methods,  and  the  need  for  closer  coopera- 
tion between  clinician  and  pathologist  than  has  been 
customary  in  the  past. 

Table  III. — Showing  Total  Admissions  of  Cases  from,  the  French 
Expeditionary  Force  Classified  according  to  their  Mental 
Diseases,  and  their  Disposal,  [a)  June,  1916-17 ; ( b ) June, 
1917-18. 


Totals. 

'C 

>4 

© 

Form  of  mental 
disease. 

*3 

A . 
o * 

cfl 

A 

home 

-t- 

c 

a 

S 

3 

■5. 

A -3 
O Cb 

'O 

© 

S 

6 

5 

•2 

aS 

a 

© "3 

SC  3 

— © 
P*> 

n 

5 

m £ 

t- 

A 

o 

tu 

OT 

A 

5 

a 

b 

a 

b 

a 

b 

a 

b 

a 

b 

a 

b 

N.A.D.  mental 

20 

16 

1 

— 

— 

14 

ii 

4 

4 

- 

— 

2 

— 

36 

Neurasthenia 

145 

64 

71 

51 

4 

— 

11 

8 

27 

3 

- 

— 

32 

2 

209 

Psychasthenia 
Concussion  of  the 

— 

13 

— 

7 

— 

— 

— 

1 

— 

— 

— 

— 

— 

5 

13 

brain  

1 

— 

1 

— 

— 

— 

— 

— 

— 

— 

— 

— 

— 

— 

1 

Tumour  of  the  brain; 

1 

i 

1 

Epilepsy 

20 

5 

14 

5 

- 

- 

— 

- 

4 

- 

- 

- 

2 

- 

25 

Hysteria  and 

4 

6 

3 

5 

— 

- 

— 

1 

1 

10 

Shell  shock  

63 

12 

25 

8 

— 

— 

6 

4 

20 

— 

i 

~ 

11 

— 

75 

Locomotor  ataxia ... 

1 

1 

Mental  deficiency* 

233 

190 

89 

104 

2 

15 

14 

42 

14 

4 

— 

1 

114 

24 

423 

Mania 

135 

81 

37 

55 

3 

5 

12 

9 

16 

7 

5 

4 

62 

1 

216 

Melancholia  

309 

143 

111 

84 

4 

16 

18 

24 

31 

5 

- 

3 

142 

11 

452 

Mental  stupor 

33 

16 

3 

9 

2 

— 

7 

6 

1 

— 

- 

- 

20 

1 

49 

Delusional  insanity 

242 

102 

73 

39 

5 

25 

20 

26 

17 

2 

- 

1 

127 

9 

344 

Epileptic  insanity.. . 

11 

7 

6 

5 

- 

2 

1 

4 

- 

18 

Moral  insanity 

3 

10 

2 

6 

— 

1 

— 

2 

- 

- 

- 

- 

1 

1 

13 

Impulsive  insanity 

3 

1 

— 

— 

- 

— 

1 

1 

2 

4 

Acute  delirium 

14 

5 

6 

2 

- 

— 

— 

— 

1 

1 

- 

2 

7 

— 

19 

Insanityt 

Clonf  usion'a  I in- 

— 

2 

1 

1 

2 

sanity  

179 

182 

60 

121 

— 

5 

18 

30 

29 

9 

1 

2 

71 

15 

361 

Alcoholic  insanity 

19 

10 

5 

6 

1 

1 

4 

2 

2 

- 

- 

— 

7 

2 

29 

Cerebral  syphilis  ... 

3 

2 

1 

2 

- 

— 

— 

— 

— 

- 

2 

- 

— 

- 

5 

G.P.I 

78 

50 

4 

3 

48 

35 

2 

3 

— 

— 

1 

4 

23 

5 

128 

Mental  instability 

39 

21 

21 

14 

2 

2 

3 

2 

4 

1 

- 

— 

9 

2 

60 

Dementia  praecox... 

127 

97 

26 

27 

6 

36 

13 

22 

9 

1 

- 

1 

73 

10 

224 

Secondary  dementia 

20 

8 

9 

5 

- 

3 

2 

— 

— 

- 

- 

- 

9 

- 

28 

N.Y.D 

1 

— 

— 

— 

- 

— 

— 

— 

— 

— 

— 

- 

1 

- 

1 

Morphinism  

- 

1 

- 

1 

- 

- 

- 

- 

- 

- 

- 

- 

- 

- 

1 

Totals  

1704 

1044 

570 

560 

77 

146 

146 

194 

183 

37 

11 

19 

717 

88 

2748 

* Including  feeble-mindedness,  idiocy,  and  imbecility, 
t Associated  with  acute  infective  disease. 


Correction  of  Refractive  Errors. 

A large  number  of  cases  complaining  of  persistent  head- 
ache were  sent  to  the  ophthalmic  department  of  the  hospital 
for  special  examination,  and  on  the  refractive  errors  being 
corrected  rapid  improvement  resulted  in  the  accompanying 
mental  symptoms. 

Captain  R.  Richards,  R.A.M.C.,  ophthalmic  surgeon  to 
the  hospital,  has  very  kindly  given  me  the  following 
particulars  with  regard  to  129  cases  examined.  Of  these 
cases,  he  states  that  “myopia  accounted  for  7 ; hyper- 
metropia,  15  ; simple  astigmatism,  11,  myopic  astigmatism, 
14  ; hypermetropic  astigmatism,  15  ; mixed  astigmatism, 
26  ; anisometropia,  41.  In  addition  to  the  above  9 cases 
of  presbyopia  were  corrected.  The  41  cases  specified  under 
anisometropia  were  of  a more  or  less  pronounced  character, 
but  there  were  others  which  showed  a much  lesser  degree  of 
unequal  refraction.  Examination  of  the  fundi  revealed  in 
many  of  the  eyes  conditions  associated  with  pathological 
and  traumatic  factors,  such  as  choroiditis,  retino-choroiditis, 
choroidal  atrophy,  opaque  nerve  fibres,  macular  changes  due 
to  high  myopia,  ruptured  choroid,  and  myopic  crescents. 
There  were  also  cases  of  nystagmus,  corneal  nebulae,  corneal 
scars  following  perforating  wounds,  occlusion  of  pupil,  &c. 
The  cases  proved  quite  an  interesting  series,  and  it  is  satis- 
factory to  find  that  the  improvement  in  the  visual  acuity  of 


those  corrected  added  to  their  well-being  and  corresponding 
improvement  in  their  mental  condition.  Ophthalmoscopic 
examination  under  the  best  conditions  is  not  an  easy  matter, 
and  one  would  be  quite  justified  in  coming  to  the  conclusion 
that  it  would  be  much  more  difficult  in  patients  mentally 
afflicted.  This  conclusion  was,  however,  completely  falsified  ; 
for,  with  only  a very  few  exceptions,  the  very  best  of 
cooperation  and  assistance  was  obtained.” 

In  the  cases  with  refractive  error  I have  little  doubt  that 
an  error  of  refraction  which  had  previously  caused  no  trouble 
had  given  rise  to  severe  headache,  and  superimposed  mental 
symptoms  in  a man  whose  nervous  system  was  exhausted  as 
the  result  of  active  service. 

Conclusions. 

I should  like  to  lay  stress  again  on  the  benefit  derived  by 
the  system  of  parole  which  was  granted  to  convalescing 
cases.  Although  in  the  period  of  the  two  years  on  the 
average  300  cases  daily  were  getting  parole,  only  one  case  of 
concealed  delusions  managed  to  escape  detection  by  the 
system  adopted.  I am  quite  certain  that  could  such  facilities 
be  granted  to  convalescing  patients  in  civil  asylums  and 
mental  hospitals  throughout  the  country  a much  healthier 
atmosphere  would  be  created  in  these  institutions.  The 
granting  of  permission  to  these  patients  to  go  out  for  walks, 
not  under  supervision,  for  a couple  of  hours  in  the  afternoon, 
would,  I am  certain,  promote  mental  “well-being”  and 
hasten  convalescence.  It  would  be  looked  upon  as  a privilege 
and  would  be  seldom  abused  if  sufficient  care  was  exercised 
as  to  whom  it  was  extended. 

The  experience  I have  gained  by  dealing  with  such  a vast 
material  of  early  mental  cases  has  convinced  me  more  than 
ever  of  the  importance  of  early  treatment.  The  fear  of  being 
certified  and  sent  to  an  asylum  existed  as  a prominent  feature 
in  many  cases,  and  I cannot  help  feeling  that  a step  in  the 
right  direction  will  be  made  if  the  lunacy  laws  are  so  amended 
as  to  allow  of  the  treatment  of  early  cases  occurring  amongst 
civilians  on  similar  lines  prior  to  certification.  If  this  were 
possible,  and  such  institutions  were  under  the  control  of 
specially  experienced  medical  men,  I feel  sure  that  a large 
number  of  cases  of  early  mental  disease  would  be  provided 
with  a much  needed  opportunity  of  obtaining  advice  and 
treatment  at  a time  when  there  were  some  prospects  of  it 
being  of  some  value.  It  was  remarkable  to  see  how  cases 
cleared  up  with  individual  attention. 

As  things  exist  at  present,  however,  a patient  suffering 
from  early  mental  trouble  is  denied  treatment  by  a doctor 
who  has  specialised  in  that  branch  of  medicine,  for  it  rests 
with  the  private  practitioner,  with  no  special  knowledge  of 
the  subject,  to  certify  the  patient.  This,  in  the  early  stages, 
he  naturally  never  does,  owing  to  the  stigma  attached  to  such 
a procedure.  The  result  is  that  such  cases  drift  on  from  bad 
to  worse  for  months  or  even  years,  and  are  prevented  from 
being  able  to  obtain  the  advice  of  those  interested  in  their 
condition  until  the  certificate  stage  is  reached.  In  the 
case  of  the  majority  the  damage  has  been  done  by  this  time. 
There  was  a similar  state  of  affairs  with  consumptive 
disease  in  the  old  days,  before  the  local  authorities 
were  given  the  power  to  appoint  specially  trained  men  to 
treat  this  condition  in  its  early  stages.  I strongly  maintain 
that  the  need  is  just  as  great  now  for  the  “ mental  clinic," 
especially  as  we  are  face  to  face  with  a tremendous  reduc- 
tion of  the  male  population  of  the  country  through  the 
ravages  of  war  and  also  an  emotional  epidemic,  which  is 
quite  common  after  a period  of  stress  and  strain  such  as  the 
world  has  recently  been  through.  Are  all  these  cases, 
which  might  be  directly  or  indirectly  attributed  to  the 
war,  to  be  deprived  of  treatment  until  they  are  so 
advanced  as  to  be  recognised  as  certifiable  by  the  general 
practitioner  ? 

No  progress  can  be  made  in  psychiatry  in  this  country  till 
Receiving  Hospitals  for  psychoses  in  the  early  stages  are 
introduced  as  a preliminary  step  to  certification.  It  will  be 
in  these  hospitals  that  the  curable  cases  should  be  treated. 
The  chronic  cases  should  be  sent  to  asylums,  which  have 
already  become  vast  store-houses  of  chronic  mental  condi- 
tions. An  atmosphere  of  cure,  which  is  all-important  in  the 
early  stages  of  treatment,  is  not  possible  in  such  an  institu- 
tion where  the  powerful  force  of  imitation  and  suggestion  by 
contact  with  chronic  cases  can  only  have  harmful  influence 
To  detach  such  a department  from  the  soil  in  which  it  has 
grown  for  generations,  and  to  effect  a considerable  change 


Thbi  Lanoet,] 


DR.  G.  H.  WINCH:  “TWILIGHT  SLEEP'’  IN  GENERAL  PRACTICE.  [Sept.  27,  1919  563 


in  procedure  which  has  hitherto  been  in  vogue  for  so  many 
years  in  order  to  bring  this  about,  is  going  to  be  no  easy 
matter.  But  if  it  is  agreed  that  the  task  is  worth  under- 
taking, these  difficulties  must  be  overcome,  and  now,  when 
the  Ministry  of  Health  Act  is  in  its  infancy,  the  time  seems 
favourable  for  considering  these  changes  seriously.  For 
acute  cases  every  modern  method  of  psycho-therapeutic 
treatment  should  be  available  in  order  to  hasten  the  return 
of  the  patient’s  mental  condition  to  the  normal.  We  want 
the  best  surroundings  we  can  get  with  free  access  to  con- 
sultative advice  in  all  the  other  special  branches  of  medicine, 
for  it  is  only  after  a searching  clinical,  as  well  as  psycho- 
logical, examination  that  the  particular  lines  of  treatment  for 
individual  cases  can  be  determined.  For  the  chronic  cases, 
on  the  other  hand,  nothing  more  can  be  done  than  to  place 
them  in  as  comfortable  conditions  as  circumstances  will 
permit.  For  the  latter,  there  already  exists  a plentiful 
supply  of  asylums,  which  in  this  country  rank  amongst  the 
best  in  the  world  for  care  and  comfort,  but  for  the  former 
there  is  at  present  almost  nothing  at  all. 

References.— 1.  Sixty-sixth  Report  of  Commissioners  in  Lunacy, 
Part  ii.  2.  The  Psychoses  in  the  Expeditionary  Forces,  by  O.  P.  Napier 
Pearn,  M.R.C.S.,  Journal  of  Mental  Science,  April,  1919.  3.  Proceedings 
of  the  Royal  Society  of  Medicine,  Discussion  on  Shell  Sh  «k.  4.  The 
Psychology  of  Insanity,  Bernard  Hart,  Cambridge  University  Press. 
5.  War  Shock,  by  Eder,  published  by  W.  Heinemann.  6.  Fifth  Annual 
Report  “Board  of  Control."  7.  Mental  Symptoms  of  Brain  Disease, 
by  Bernard  Hollander.  S.  The  Daily  Review  of  the  Foreign  Press, 
April  1st,  1918.  9.  The  Wassermann  Test : A Criticism  of  its  Reliability, 
The  Lancet,  March  29th,  1919.  10.  The  Clinical  Aspect  of  Syphilis  of 
the  Nervous  System  in  the  Light  of  the  Wassermann  Reaction  and 
Treatment  with  Neosalvarsan,  Brain,  vol.  xxxvii.,  p.l,  September,  1914. 
11.  The  Lancet,  April  12th,  1919. 


“TWILIGHT  SLEEP”  IN  GENERAL 
PRACTICE. 

By  G.  HAMILTON  WINCH,  M.B.,  Ch.B.  Edin. 

Having  administered  scopolamine-morphine  anesthesia  to 
a series  of  435  cases  of  parturition  in  private  practice,  I now 
record  my  results  and  experience  of  this  treatment  from  a 
general  practitioner’s  point  of  view.  These  cases  were 
attended  by  me  during  a period  of  five  years  and  nine  months. 
During  the  first  two  years  I was  in  a country  practice  in  the 
Midlands,  and  during  the  remainder  of  the  time  I was  in  a 
London  practice. 

The  method  employed  of  producing  aneesthesia  was 
that  developed  by  Gauss  of  Freiburg,  which  has  become  the 
standard,  and  to  which  he  applied  the  term  of  “ Diimmer- 
schlaf  ” (twilight  sleep).  The  object  of  this  method  is  to 
obtain  not  only  a condition  of  analgesia,  but  also  one  of 
amnesia,  or  loss  of  memory  for  recent  events.  The  import- 
ance of  amnesia  is,  that  it  saves  the  mothers  from  physical 
and  mental  suffering  and  from  fear  of  a succeeding  labour. 
This  state  of  amnesia  does  not  cause  loss  of  memory  for 
previous  events,  but  only  an  inability  to  remember  what  is 
happening  while  the  patient  is  under  the  influence  of  this 
anaesthesia. 

Technique. 

It  is,  of  course,  necessary  to  know  the  general  condition  of 
the  patient,  her  pelvic  measurements,  and  the  position  and 
presentation  of  the  child.  The  only  absolute  contra- 
indication to  this  form  of  anaesthesia  is  primary  uterine 
inertia.  Contracted  pelvis,  dry  labours,  rigid  cervix, 
eclampsia,  and  heart  disease  are  not  contra-indications. 
On  the  contrary,  in  some  of  my  complicated  cases,  where 
operative  treatment  demanded  chloroform,  I very  definitely 
found  that  much  less  was  needed  than  in  cases  where 
“twilight  sleep”  was  not  used.  Junker’s  apparatus  has 
always  been  used  by  me  in  midwifery  cases,  and  careful 
notes  of  the  amount  of  chloroform  used  were  taken.  The 
amount  used  in  “ twilight  ” cases  was,  on  an  average,  half 
the  amount  used  in  non-twilight  cases. 

As  soon  as  labour  begins  the  patient  is  put  in  the  room 
chosen  for  her  labour.  When  labour  pains  have  caused 
dilatation  of  the  cervix  to  the  extent  of  admitting  two 
fingers,  and  recur  every  five  minutes  in  primiparas,  and  not 
less  than  every  seven  in  multiparas,  the  treatment  is  com- 
menced. First,  the  room  is  darkened,  and  the  patient’s  ears 
are  plugged  with  cotton-wool  in  order  to  help  in  the  exclu- 
sion of  any  disturbing  sounds.  The  first  hypodermic 


injection  is  then  administered,  consisting  of  morph, 
hydrochlor.  gr.  I and  scopolamine  hydrobromide  gr.  1/150. 
Here  one  may  mention  that  it  is  important  to  use  freshly 
prepared  solutions  of  these  drugs,  which  should  be  absolutely 
pure.  I used  tablets  made  by  the  following  firms  : Messrs. 
Evans,  Sons,  Lescher,  and  Webb,  Messrs.  Burroughs  and 
Wellcome,  and  Messrs.  I’arke,  Davis  and  Co.,  and  always 
found  them  reliable.  After  this  injection  has  been  given, 
as  a rule,  in  20  minutes  time  the  patient  becomes  drowsy 
and  sleeps  between  the  pains.  During  the  pains  she  may 
still  complain,  but  less  so  than  before.  At  this  stage  it  is 
advisable  to  carefully  watch  the  patient’s  condition  and 
frequently  auscultate  the  foetal  heart  sounds.  All  being  well, 
the  second  injection  is  given  about  one  hour  after  the  first ; 
this  and  all  succeeding  ones  consist  of  scopolamine  hydro- 
bromide gr.  1/450  only.  In  this  series  of  cases  I found  that 
these  subsequent  injections  were  required  every  one  or  two 
hours,  the  interval  becoming  longer  as  the  number  of 
injections  increased. 

The  Memory  Test. 

The  method  of  determining  the  depth  of  the  amesthesia 
and  the  need  of  a further  injection  was  the  application  of 
the  memory  test.  This  was  carried  out  as  follows  : One 
wishes  to  find  out  the  stage  at  which  the  patient’s  memory 
for  present  events  is  absent,  but  on  the  verge  of  returning. 
The  patient’s  temperature  was  taken  in  the  axilla,  and  a few 
minutes  later  a pretence  of  taking  it  in  the  same  way  was 
made.  If  on  inquiry  immediately  after  the  pretended  act 
she  did  not  remember  the  previous  real  act,  she  was  deemed 
to  be  sufficiently  “under.”  The  least  sign  of  returning 
memory  indicates  another  injection.  The  number  of  these 
subsequent  injections  is  of  no  importance.  I have  given 
14  in  one  case  without  any  harmful  effect. 

Important  Points  Noted  During  the  Ancesthesia. 

In  the  great  majority  of  cases  the  patient’s  face  was 
decidedly  flushed,  and  dryness  of  the  throat  was  common. 
The  latter  condition  was  treated  by  administering  frequent 
sips  of  water.  In  practically  all  the  cases  the  patients  never 
expressed  any  desire  to  pass  urine.  This  was  due,  I think, 
to  the  fact  that  the  amount  of  analgesia  present  nullified 
any  pain  caused  by  bladder  distension.  It  is  necessary, 
therefore,  to  note  the  condition  of  the  patient’s  bladder  and 
use  a catheter  when  required. 

The  first  stage  of  labour  in  these  cases  was  nearly  always 
definitely  shortened  as  compared  with  non-twilight  cases, 
especially  in  primiparas.  My  experience  is  that  this  form  of 
anaesthesia  promotes  dilatation  of  the  cervix.  On  the  other 
hand,  the  second  stage  of  labour  was  nearly  always  prolonged  ; 
most  of  the  delay  occurring  after  the  head  had  reached  the 
perineum.  This  delay  was  not  found  to  be  in  any  way 
harmful  to  mother  or  child,  even  if  of  five  or  six  hours’  dura- 
tion. In  fact,  owing  to  the  gradual  dilatation  of  the  vaginal 
outlet,  lacerations  of  the  perineum  were  distinctly  fewer  than 
in  non-twilight  cases.  In  many  of  the  cases  I terminated 
the  labour  either  by  the  use  of  the  forceps  or  by  the  intra- 
muscular injection  of  pituitary  extract.  The  former  opera- 
tion was  in  most  of  my  cases  carried  out  withottt  the  use  of 
chloroform,  and  was  done  slowly  and  carefully.  With  regard 
to  those  cases,  terminated  by  injection  of  pituitary  extract, — I 
always  used  pituitrin  (P. , D.  and  Co.),  \ c.cm.  in  an  ampoule 
— injecting  a £ c.cm.  at  first,  and  repeating  it  if  necessary. 
It  was  distinctly  observed  that  pituitary  extract  had  not  the 
same  powerful  effect  in  causing  uterine  contractions  in  these 
cases  that  it  has  in  non-twilight  cases.  No  bad  effects  on 
the  foetal  heart  sounds  were  noted — that  is  to  say,  in  none  of 
my  cases  did  the  foetal  heart-rate  become  unduly  rapid 
(above  170)  or  unduly  slow  (below  100).  Some  of  the 
patients  exhibited  a certain  amount  of  restlessness  and 
slight  delirium,  but  not  of  sufficient  account  to  interrupt 
the  administration. 

Birth  of  the  Child. 

As  soon  as  the  child  was  born  and  the  cord  had  been  tied 
and  separated  it  was  removed  to  another  room  in  order  that 
its  crying  should  not  disturb  the  mother.  This  was  always 
done  when  the  child  was  born  not  cyanosed  nor  apnoeic,  but 
breathed  and  cried  out  spontaneously  ; in  this  series  of 
cases  such  were  in  the  majority.  A comparatively  small 
number — 11 '9  per  cent. — were  born  cyanosed,  and  some 
were  treated  by  artificial  respiration  ; they  all  recovered. 
I found  in  a few  of  the  cases  where  the  baby  was  born 


564  Thh  Lancet,]  DR.  H.  WILTSHIRE:  HYPERKERATOSIS  OF  HAIR  FOLLICLE8  IN  SCURVY.  [Sept.  27, 1919 


cyanosed  that  if  simply  left  alone  it  returned  to  a normal 
condition  after  a considerable  time. 

Third  Stage  of  Labour. 

The  mother  was  always  carefully  watched  for  atonic  post- 
partum hajmorrhage,  but  this  condition  only  occurred  in 
3-03  per  cent.  Two  were  cases  of  partially  adherent 
placenta,  where  manual  extraction  was  necessary.  One 
other  case  occurred  in  a transverse  presentation,  where  the 
version  necessitated  a good  deal  of  manipulation  and  also 
the  administration  of  chloroform  in  addition  to  the 
“ twilight  sleep.”  In  all  three  the  bleeding  was  controlled 
and  good  recoveries  ensued.  These  cases  were  all  multi- 
part, the  average  number  of  injections  per  case  being  three. 
Perineal  tears  were  remarkably  few,  the  percentage  being  : 
primiparae,  12  61  per  cent.  ; multipart,  4 03  per  cent. 
When  they  did  occur  they  were  immediately  sutured 
without  the  use  of  chloroform. 

Puerperinm. 

In  the  majority  of  the  cases  of  this  series  the  mother  slept 
well  for  from  two  to  six  hours  immediately  after  the  comple- 
tion of  labour.  The  absence  of  shock  was  a most  noteworthy 
feature  in  these  cases.  I was  particularly  struck  by  the 
excellent  general  condition  of  the  mothers  24  hours  after 
delivery.  Lactation,  and  involution  proceeded  quite  as 
normally  as  in  non-twilight  cases,  and  apparently  were  in 
no  way  affected  by  the  drugs  administered  ; no  other  bad 
effects  of  this  form  of  anaesthesia  on  the  mothers  were 
observed. 

Conclusions. 

“Twilight  sleep  ” is  of  great  value  in  obstetric  practice, 
provided  that  it  is  administered  in  strict  accordance  with 
the  technique  laid  down  by  Gauss  of  Freiburg.  It  certainly 
saves  the  mother  from  much  pain,  fright,  and  from  shock. 
There  are  no  ill-effects  to  mother  or  child. 

Having  been  able  to  follow  up  the  after-history  of  my 
cases,  both  as  regards  mother  and  child  for  a period  of  four 
years,  I can  confidently  assert  that  I have  not  seen  any 
harmful  effects  on  either  the  mother’s  or  the  child’s  health 
which  could  be  attributed  to  the  use  of  this  “twilight  sleep  ” 
method. 

The  main  disadvantage  of  the  method  in  private  practice 
is  that  it  requires  far  more  time  and  careful  personal  atten- 
tion than  are  needed  in  ordinary  labour  cases.  It  has  always 
seemed  to  me,  however,  that  the  extra  time  and  trouble  are 
well  spent,  for  surely  any  woman  has  the  right  to  be  pro- 
tected from  unnecessary  pain  and  suffering  during  parturi- 
tion. I am  not  in  agreement  with  those  who  state  that 
labour  is  a normal  physiological  process  and  should  be  left 
to  Nature  as  much  as  possible.  Modern  civilisation  has  so 
changed  the  average  woman  of  to-day  that  parturition  is  no 
longer  the  easy  process  it  was  reputed  to  be  in  less  civilised 
times.  I am  quite  convinced  that  “ twilight  sleep  ” can  be 
just  as  efficiently  carried  out  in  the  patient’s  own  home  as  in 
a hospital  or  nursing  home.  The  following  case,  as  being 
unique  in  many  respects,  is  quoted  in  full  : — 

Mrs.  , primipara,  age  43  years.  Healthy.  Pelvic 

measurements  normal.  Labour  commenced  at  9 a.m.  on 
Sept.  29th,  1917.  Examination  revealed  normal  position  of 
child  ; vertex  presentation  ; L.O.A.  At  11  a.m.,  when  pains 
recurred  every  five  minutes  and  cervix  admitted  two  fingers, 
the  first  injection  was  given.  Twenty  minutes  later  patient 
was  drowsy  and  sleeping  between  pains,  but  moaning  during 
pains.  The  following  injections  were  given  after  memory 
test:  second,  at  11.45;  third,  at  1.5p.m.  (patient  at  this 
stage — face  flushed,  very  little  thirst,  and  during  uterine 
contractions  quiet);  fourth,  at  2.35  (patient’s  condition  as 
above) ; fifth,  at  4 p.m.  ; sixth,  at  5.45 ; seventh,  at  7.15 ; 
eighth,  at  8 p.m.  ; ninth  and  last,  at  10  p.m.  Baby  girl  born 
at  10.30  p.m.  Placenta  11  p.m.  No  forceps  or  pituitrin 
used.  No  post  partum  hmmorrhage.  No  perineal  laceration. 
Baby  breathed  and  cried  out  spontaneously.  Mother  slept 
for  six  hours  after  completion  of  labour. 

The  chief  interest  of  this  case  was  the  fact  that  during  the 
latter  part  of  the  labour — i.e.,  from  about  7.30  p.m.  onwards 
— one  of  the  worst  enemy  air-raids  over  this  district  of 
London  was  taking  place,  and  some  bombs  were  dropped 
within  a short  distance  of  this  particular  house.  Careful 
inquiry  from  the  patient  afterwards  revealed  the  fact  that 
she  did  not  know  until  some  hours  after  her  labour  was  over 
that  an  air-raid  had  taken  place.  Mother  and  child  made 
splendid  progress,  and  at  the  present  time  are  both  in 


excellent  health.  The  baby  is  now  1 year  and  7 months  old. 
[A  photograph  of  the  child  was  submitted  bearing  out  this 
statement.] 

“ Twilight  Sleep”  Statistical  Table. 


Total  number  of  cases 

Numberof  primipara 

,,  ,,  multipara; 

Average  age  of  primiparae 

,,  ,,  multipara 

Maternal  mortality  

Fretal  „ 

Vertex  presentation  

Breach  ,,  

Face  ,,  ' 

Transverse  ,,  

Average  duration  of  labour  in  primiparae 

•i  ,,  ,,  multiparae 

Average  number  of  injections  in  primioarae  

••  ,,  „ multiparae  

Average  interval  between  injections  

Highest  number  of  injections  in  1 case,  14  (in  a primipara) 
Lowest  ,,  „ „ 1 (in  a multipara) 


435 

179 

256 

25  years. 
32  ,, 
Nil. 

Nil. 

422 

8 

2 

3 

184  hours 
8i  ,. 

9 

4 

14  hours 


Cases  in  which  “twilight  sleep"  was  successfully 
obtained— i.e. .amnesia  aud  analgesia  were  complete ... 
Cases  where  amnesia  was  imperfect,  but  analgesia  was 

marked 

Cases  of  partial  analgesia  only 

Cases  of  complete  failure— i.e.,  neither  amnesia  nor 

analgesia  obtained  

Condition  of  child  at  birth— 

(1)  Breathed  and  cried  out  spontaneously  in  

(2)  Cyanosed  in  

Perineal  lacerations  in  primipara 

■i  „ multipara 

Placenta  delivered  half  an  hour  after  birth  of  child  in  ... 
Placenta  delivered  by  Crede’s  method  in  

,,  manually  extracted  in  

Post-partum  haemorrhage  severe  in  

i,  ,,  slight  in  

Labour  completed  by  use  of  forceps  in 

.,  ,.  injection  of  pituitary  extract 

Chloroform  used  as  an  additional  anaesthesia  in  

Lactation- 

Mothers  with  good  supply  of  milk  and  able  to  nurse  .. 
>,  ,,  ,,  unable  to  nurse 


76  per  cent. 

17  „ 

5 

2 

88T 

11-9 

1261  „ 

403  ,. 

66 
33  2 
08 

3-03  ,. 

515 

18 

22 

701  „ 

69 

31 


HYPERKERATOSIS  OF  THE  HAIR 
FOLLICLES  IN  SCURVY. 

By  HAROLD  WILTSHIRE,  O.B.E.,  D.S.O.,  M.D.,  F.R.C.P., 

PHYSICIAN  TO  KING'S  COLLEGE  HOSPITAL  ; LATE  ASSISTANT 
CONSULTING  PHYSICIAN,  B.S.F. 


In  dealing  with  some  3000  cases  of  scurvy  which  occurred 
amongst  Serbian  troops  it  was  noticed  that  a condition  of 
hyperkeratosis  of  the  hair  follicles  was  commonly  present,  in 
addition  to  those  skin  changes  which  are  generally  described 
as  proper  to  this  disease.  The  latter  are  : («)  an  increase  in 
dryness  and  roughness  of  the  whole  skin  ; and  (b)  a petechial 
rash  due  to  small  hemorrhages  occurring  mainly  in  connexion 
with  the  hair  follicles. 

Occurrence  of  the  Skin  Changes. 

Frequency. — The  frequency  of  these  follicular  changes  in 
scurvy  is  shown  by  the  following  analysis  of  78  consecutive 
cases,  which  were  under  special  observation  with  reference 
to  another  point 1 : — 

Changes  of  petechial  type  only  9 per  cent. 

„ keratotic  „ 32  „ 

Both  petechial  and  keratotic  types  present  in  ) „ 

same  individual  •• 

No  abnormal  follicles  4 „ 

From  this  it  is  seen  that  the  proportion  showing  follicular 
hyperkeratosis  amounted  to  no  less  than  87  per  cent. 

Distribution. — The  follicles  which  showed  this  change 
were  usually  limited  to  the  lower  extremities,  the  favourite 
sites  being  the  front  and  inner  aspects  of  the  thighs  and  the 
upper  parts  of  the  legs.  When  they  were  numerous  in  these 
regions — and  in  some  instances  nearly  every  follicle  was 
affected — those  of  the  pubic  hairs  were  often  affected  as  well 
(20  per  cent,  of  the  cases  mentioned  above),  and  sometimes 
those  of  the  backs  of  the  wrists  and  forearms  (2 -5  per  cent.). 

The  individual  follicle. — Each  affected  follicle  presented  a 
hard  conical  swelling  about  the  size  of  a pin’s  head,  owing 
to  a collection  of  horny  epithelial  debris  which  had  accumu- 
lated at  the  follicle  mouth.  In  some  a thin  atrophic  hair, 
or  a broken  hair  stump,  projected  from  the  summit  of  this 
cone  ; in  others,  the  hair  was  wanting,  having  been  shed 
or  broken  off  flusn  with  the  surface.  When  dirt  was 
present  it  tended  to  be  incorporated  with  the  material 
forming  the  cone,  which  then,  on  superficial  examination, 


The  lancet,]  DR.  H.  WILTSHIRE  : HYPERKERATOSIS  OF  HAIR  FOLLICLES  IN  SCURVY.  [Sept.  27, 1919  565 


resembled  an  ordinary  sebaceous  comedo.  By  degrees  the 
conical  projection  flattened  down  into  a scale,  under  which, 
on  examination  with  a lens,  a new  developing  hair  could  be 
seen  coiled  up  like  a watch  spring.  At  this  stage,  also, 
the  appearance  on  casual  examination  resembled  that  of 
a comedo.  Later  the  flattened  scale  was  shed,  the  new 
hair  erupted  and  was  seen  to  be  growing  from  a pink 
recovering  follicle.  These  changes  were  not  simultaneous 
in  all  the  follicles.  When  a patient  was  admitted  to  hos- 
pital it  was  the  rule  to  find  some  follicles  in  the  stage  of 
conical  swelling  with  the  hair  still  present,  some  in  the  stage 
of  flattened  scale  covering  a new  developing  hair,  and  others 
in  intervening  stages  of  broken  or  shed  hairs. 

Duration.  — The  whole  process  took  place  gradually  and 
was  spread  over  many  weeks.  Owing  to  the  fact  that  these 
changes  caused  no  symptoms  and  never  attracted  the  patient’s 
attention  their  duration  before  admission  could  not  be 
ascertained.  Since,  however,  it  was  common  to  find  some 
follicles  in  the  stage  of  new  developing  hair  when  the 
patient  came  into  hospital,  it  must  be  concluded  that  the 
abnormal  process  had  commenced  a month  or  even  six  weeks 
before.  Under  treatment  recovery  was  gradual.  As  a rule, 
at  the  end  of  six  or  eight  weeks,  when  the  patients  passed 
from  observation,  all  the  scales  were  shed,  and  young 
hairs  could  be  seen  growing  from  pink  healthy  follicles. 
It  is  probable  that  a further  period  of  six  to  eight  weeks 
elapsed  before  the  normal  condition  became  fully  re- 
established, the  whole  process  thus  taking  from  four  to 
six  months  in  a marked  case. 

Degree  of  recovery. — Though  it  is  possible  that  some  few 
follicles  were  permanently  destroyed,  complete  recovery 
must  be  the  rule.  All  those  which  were  watched  in  1918 
were  seen  to  recover  to  the  stage  of  commencement  of  a new 
hair,  and  no  deficiency  of  leg  hairs  was  ever  noticed  to  follow 
the  severe  epidemic  of  scurvy  from  which  the  Serbians 
suffered  in  1917. 

Carnation  and  Vaiue  in  Diagnosis. 

The  cause  of  hyperkeratosis  of  the  follicle. — The  question 
was  raised  whether  these  keratotic  changes  could  be  due  to 
a minute  haemorrhage  having  taken  place  into  the  deep  part 
of  the  follicle,  sufficient  to  impair  its  nutrition,  but  too  small 
to  be  recognised  as  a haemorrhage  upon  the  surface.  In  the 
follicles  of  the  petechial  type  the  appearances  were  quite 
diSerent.  In  these  the  follicle  formed  the  centre  of  an  intra- 
dermal  haemorrhage  which  showed  as  a flat  round  spot, 
1 or  2 mm.  in  diameter,  bright  red  in  colour  when  recent, 
fading  to  a dull  brown  later.  Although  the  hair  of  this 
follicle  might  be  thin  and  atrophic  or  shed,  there  was  never 
any  heaping  up  of  epithelium  or  keratosis,  the  spot  remain- 
ing flat.  Intervening  types  between  the  petechial  and  the 
keratotic  were  not  seen,  and  the  presence  of  haemorrhage 
could  never  be  demonstrated  in  one  of  the  latter,  so  that  it 
is  safest  to  conclude  that  the  keratosis  was  caused  by  a 
simple  scorbutic  impairment  of  the  nutrition  of  the  follicle. 

Friction  and  irritation  from  dirt  were  taken  into  considera- 
tion as  possible  contributing  causes  and  both  dismissed. 
Friction  seems  to  be  ruled  out  by  the  frequency  with  which 
the  pubic  hairs  were  affected  and  by  the  fact  that  the 
infantry  suffered  as  much  as  mounted  troops.  As  regards 
cleanliness,  the  skins  of  these  men  were  as  well  kept  as 
those  of  any  other  troops  on  active  service. 

Value  in  diagnosis. — When  this  follicular  hyperkeratosis 
had  been  recognised  as  occurring  in  the  vast  majority  of 
cases  of  undoubted  scurvy  it  was  searched  for  in  patients 
admitted  for  other  diseases  and  at  other  seasons,  as  a 
result  of  which  it  was  found  that:  1.  Follicular  hyper- 
keratosis was  unusual  except  during  the  scurvy  season 
(January  to  June).  When  seen  at  other  times  it  was 
usually  in  conditions  involving  marked  wasting  and 
debility,  such  as  chronic  dysentery,  in  which  a deficiency 
of  antiscorbutic  vitamine  might  well  have  existed.  2.  During 
the  scurvy  season,  when  the  Serbian  Army  as  a whole 
was  suffering  from  deficiency  of  antiscorbutic  vitamine, 
follicular  hyperkeratosis  was  found  to  be  present  in  a 
large  proportion  of  patients  admitted  for  other  diseases. 
This  was  most  striking  in  the  case  of  men  admitted  to  the 
surgical  side  for  conditions  which  had  not  impaired  the 
general  health,  such  as  gunshot  wounds,  hernia:,  frac- 
tures, &c.  Although  these  men  might  have  no  other  signs 
or  symptoms  of  the  disease,  we  came  to  regard  them  as 
definitely  scorbutic,  and  my  surgical  colleague,  Major  R.  V. 


Slattery,  postponed  operating  upon  them,  whenever  possible, 
until  they  had  received  some  weeks  of  antiscorbutic  treat- 
ment. 

In  consideration  of  these  two  points,  and  of  the  fact  that 
most  definite  cases  of  scurvy,  though  admitted  within  a 
few  days  of  the  onset  of  symptoms,  show  a stage  of  kera- 
tosis which  must  have  taken  some  weeks  to  develop,  it 
seems  obvious  that  the  presence  of  this  follicular  hyper- 
keratosis may  afford  a valuable  means  of  early  diagnosis. 
I am  under  the  impression  that,  given  another  scurvy 
epidemic  among  Serbian  troops,  it  would  be  possible  to 
pick  out  most  of  the  men  who  were  on  the  road  to  clinical 
scurvy  by  a brief  inspection  of  the  hair  follicles  of  their 
legs,  and  to  do  this  in  the  pre-symptomatic  stage  when 
preventive  measures  would  still  have  time  to  succeed. 

The  relation  of  hyperkeratosis  to  shin  nutrition  in  general. — 
Dr.  A.  Whitfield  tells  me  that  he  recognises  general  dryness 
and  roughness  of  the  skin  with  follicular  changes  similar 
to  those  described  above  as  occurring  in  all  sorts  of  mal- 
nutritional  states,  but  most  commonly  in  association  with 
wasting.  He  regards  it  as  a general  stagnation  process 
which  shows  most  in  the  follicles,  the  cells  being  in- 
completely matured  and  consequently  cohering  to  make  a 
flake  which  is  shed  en  masse,  instead  of  by  individual  cells 
as  an  imperceptible  process. 

As  noted  by  Johnson  Smith,2  wasting — that  is  to  say, 
simple  loss  of  fat  and  muscle — does  not  occur  in  uncompli- 
cated scurvy.  Certainly  some  of  my  cases  which  showed 
these  follicle  changes  in  marked  degree  were  amongst  the 
finest  specimens  of  physical  manhood  I have  ever  seen  ; 
and,  excluding  complicating  factors  such  as  dysentery  and 
malaria,  the  majority  were  above  rather  than  below  the 
average  of  physical  development.  In  the  case  of  these 
Serbians  it  seemed  that  nothing  was  lacking  save  anti- 
scorbutic vitamine — a fact  which  invites  speculation  con- 
cerning the  pathogeny  of  the  similar  skin  condition  which 
occurs  in  other  malnutritional  states. 

It  is  to  be  remembered  that  with  our  modern  habits  of 
cooking  the  intake  of  antiscorbutic  vitamine  of  the  average 
individual  falls  considerably  below  the  ration  which  was 
intended  by  nature. 

Conclusions. 

1.  Follicular  hyperkeratosis  occurs  in  the  vast  majority  of 
cases  of  clinical  scurvy. 

2.  In  a large  proportion  of  cases  it  formed  the  first 
recognisable  sign  of  the  scorbutic  tendency,  and  would  have 
enabled  a diagnosis  to  be  made  before  the  onset  of 
symptoms. 

3.  It  is  similar  in  appearance  to  the  hyperkeratosis  of 
follicles  which  occurs  in  other  malnutritional  states. 

4.  It  appears  to  be  due  to  altered  nutrition  of  the  follicle 
produced  by  simple  deficiency  of  antiscorbutic  vitamine. 

I am  indebted  to  Dr.  Whitfield  for  information  concerning 
follicular  hyperkeratosis  in  general  malnutrition,  and  to  Miss 
Ahern  for  careful  clinical  notes  of  the  cases  quoted. 

References. 

1.  Wiltshire : The  Value  of  Germinated  Beans  in  the  Treatment  ot' 
Scurvy.  The  Lancet,  1918,  ii.,  811. 

2.  Johnson  Smith:  Article,  Scurvy,  Allbutt  and  Kolleston,  System 
of  Medicine,  2nd  ed.,  vol.  v..  886. 

Welbeck-street,  W. 


Centenarians. — Mr.  W.  C.  Vivian  died  on 
August  29th  at  his  residence,  Reskadinnick,  Camborne 
He  celebrated  the  one  hundredth  anniversary  of  his  birthday 
on  June  6th  last. — Miss  8.  E.  Selden,  daughter  of  the  late 
Mr.  W.  C.  Selden,  M.R.C.8.,  of  Melksham,  died  recently  at 
Bath.  She  was  born  in  Bath  on  Feb.  3rd.  1819. 

Guy’s  Hospital  War  Memorial. — The  fund  for 
the  Guy’s  Hospital  Memorial  will  be  closed  at  the  end  of  the 
present  month  and  a general  meeting  of  the  subscribers  will 
be  held  in  October  to  decide  upon  the  form  or  forms  which 
the  memorial  shall  take.  The  first  charge  on  the  fund  will 
be  the  education  of  the  children  of  Guy’s  men  who  have 
fallen  in  the  war,  should  such  help  be  required,  as  well  as 
assistance  to  widows  and  to  Guy’s  men  permanently  dis- 
abled. Fortunately  the  help  required  in  this  direction  will 
not  demand  much  of  the  fund,  and  it  is  proposed  to  devote  a 
portion  of  the  subscriptions  to  a War  Memorial  Clinical 
Ward,  the  adornment  of  the  Dining  Hall  of  the  College,  and 
the  formation  of  a nucleus  for  endowment  of  a Dental 
Research  Scholarship. 


566  The  Lancet,]  MR.  IRWIN  MOORE  : FOREIGN  BODIES  IN  THE  (ESOPHAGUS  ETC. 


[Sept.  27,  1919 


FOREIGN  BODIES  IN  THE  OESOPHAGUS 
AND  RESPIRATORY  PASSAGES. 

REMARKS  ON  THE  DANGERS  ARISING  FROM  THEIR 
IMPACTION  AND  SOME  DIFFICULTIES  WHICH 
MAY  BE  MET  WITH  IN  THEIR  REMOVAL  : 

A PLEA  FOR  THE  ABOLITION  OF  THE  COIN-CATCHER, 
THE  BLIND  USE  OF  THE  BOUGIE  AND  PROBANG,  AND 
THEIR  REPLACEMENT  BY  THE  DIRECT  ENDOSCOPIC 
METHODS  OF  EXTRACTION. 

By  IRWIN  MOORE,  M.B.,  C.M.  Edin., 

SURGEON  TO  THE  THROAT  HOSPITAL,  GOLDEN  SQUARE,  W. 

It  is  very  well  known  that  many  obsolete  methods  of  treat- 
ment persist  in  various  departments  of  medicine  and  surgery  at 
the  present  day  and  are  still  described  in  recent  text-books. 
In  the  case  of  foreign  bodies  in  the  air-  and  food-passages 
the  use  of  such  out-of-date  instruments  as  the  coin-catcher, 
bougie,  and  probang  still  persists,  much  to  the  chagrin  of 
the  specialist,  whose  preaching  of  the  dangers  and  risks  of 
such  unsurgical  methods  of  treatment  by  blind  working  in 
the  dark  appears  in  many  instances  to  have  passed  unheeded. 
Though  old  habits  die  hard,  yet  it  appears  incomprehensible 
how  such  procedures  can  still  continue  in  the  face  of  the 
accumulated  experience  and  repeated  warnings  of  the 
entire  body  of  laryngologists.  Since  improvement  in  the 
“direct  vision”  method  of  per-oral  endoscopy  has  placed 
at  our  disposal  the  more  exact  means  of  treating  such 
cases,  one  would  have  thought  that  the  coin-catcher  at 
least  would  have  been  banished  from  our  instrumentarium 
once  and  for  all.  The  following  cases,  however,  show  that 
this  haphazard  and  dangerous  instrument  is  still  being  used, 
often  with  disastrous  results. 

The  Blind  Use  of  the  Coin-Catcher  and  its  Dangers. 
A Halfpenny  accidentally  Swallowed  and  Impacted  in  the 
(Esophagus  for  Six  Days,  Removed  by  the  ( Esophtpgoscope , 
after  Repeated  Attempts  with  a Coin-  Catcher  had  Failed. 
Though  this  case  is  only  one  of  many  others,  in  which  coins 
and  various  foreign  bodies  have  been  successfully  removed 
by  endoscopic  technique,  yet  it  would  appear  to  be  of 
sufficient  interest  to  merit  publication  in  view  of  the 
importance  of  the  discussion  to  which  it  gave  rise  when 
reported  at  a meeting  of  the  Laryngological  Section  of  the 
Royal  Society  of  Medicine.1 

On  August  8th,  1915.  at  4 P.M.,  a little  girl,  aged  4 years,  was  taken  to 
a suburban  general  hospital,  having  swallowed  a halfpenny  at  mid-day 
whilst  playing  with  it  in  her  mouth.  With  the  exception  that  she  had 
been  sick  three  or  four  times  there  weie  no  other  symptoms  Examina- 
tion showed  no  difficulty  in  breathing  and  as  the  patient  appeared  to 
be  quite  comfortable  she  was  sent  home.  The  following  morning  she  was 


in  front  of  it.  (Fig.  24.)  On  withdrawal  of  the  tube  and  again  passing 
it  carefully  down  the  posterior  wall  the  coin  was  easily  located  and 
removed  without  any  difficulty  with  forceps.  The  child  returned  home 
next  day,  and  no  complaints  were  afterwards  made  of  soreness  of  the 
throat,  difficulty  in  swallowing,  or  any  other  symptom.  Fortunately, 
in  this  case  no  damage  had  been  done  to  the  oesophageal  wall  by  the 
coin-catcher. 

The  case  gave  rise  to  considerable  discussion  at  the  above 
meeting  in  connexion  with  the  dangers  of  this  old-fashioned 
and  out-of-date  instrument.  Mr.  D.  R.  Paterson  referred  to 
the  case  of  a child  who  had  been  sent  to  a general  hospital  with 
a coin  in  its  oesophagus,  and  because  a coin-catcher  “ failed  to 
\ bring  anything  away  ” the  child  was  sent  home.  It  was  not 
until  18  months  later,  when  “ tracheal  symptoms  ” arose,  that 
the  case  came  under  his  notice.  The  coin  was  discovered  in 
the  gullet  by  oesophagoscopy  and  was  safely  removed.  He 
remarked  that  these  cases  were  now  common,  and  he  thought 
it  was  time  that  the  authorities  at  general  hospitals  recog- 
nised that  the  direct  method  was  the  proper  one,  and  that 


Fig.  1.— Skiagram  showing  a halfpenny  impacted  in  the  oesophagus  of  : 
a child  aged  four  years.  Posterior  view. 

such  cases  should  not  be  submitted  to  a coin-catcher.  Sir 
William  Milligan  associated  himself  with  Mr.  Paterson’s 
remarks.  He  thought  that  hospitals  should  give  definite 
instructions  to  house  surgeons  not  to  use  the  coin-catcher,  and  . 
that  it  was  lamentable  the  state  the  oesophagus  was  brought 
into  sometimes  by  the  inexperienced  trials  at  removal  of 
foreign  bodies.  He  had  several  times  seen  fatal  cases  as  the 
result  of  the  wall  of  the  oesophagus  being  torn  by  the  coin- 
catcher. If  these  cases  were  at  once  sent  to  the  proper  depart- 
ment the  right  method  would  be  used.  He  suggested  that  a 


!/'  Fig.  2.— Out-of-date  coin-catcher-  (A)  Combined 

II  probang  and  coin-catcher  with  whalebone  or 

i /,'  metal  stem  and  screw  in  centre  for  portability. 

iSa'  (B)  Tbe  Howard  Marsh  coin  extractor. 


Fig.  3.— Semi-diagrammatic 
view  of  acoin  impacted  against 
the  posterior  wall  of  the  oeso- 
phagus, leaving  sufficient 
room  in  front  for  a coin- 
catcher to  pass  up  and  down 
without  touching  the  coin. 


brought  back  to  the  hospital  as  she  had  been  sick  during  the  night,  and 
was  unable  to  swallow  anything  but  liquid  food.  On  this  occas  on  she 
was  admitted  and  X rayed  by  Dr.  David  Arthur,  when  the  coin  was  j 
distinctly  seen  to  be  Impacted  in  the  oesophagus  at  the  level  of  the 
seventh  cervical  vertebra— i.e.,  just  below  the  cricoid  cartilage.  (Fig.  1.) 
Three  or  four  attempts  to  extract  the  coin  with  a coin-catcher  (Mg.  2) 
without  a general  anaesthetic  failed.  It  was  not  till  six  days  later  that 
it  was  considered  advisable  to  send  for  a laryngologist,  and  the  writer 
was  asked  to  attend.  The  child  was  placed  under  chloroform  anaesthesia,  ! 
an  endoscopic  tube  of  10  mm.  diameter  was  passed  into  the  oesophagus, 
but  tbe  coin  could  not  at  first  be  seen,  since  the  lube  had  passed  down 

1 Proo.  Roy.  Soc.  Med.,  1915,  ix.  (Larvngol.  Sect.),  pp.  39-41 


resolution  should  be  framed  and  forwarded  to  the  various  | 
teaching  hospitals  in  this  country.  Mr.  W.  Howarth  related  a j 
case  which  occurred  at  his  hospital,  illustrating  Sir  William 
Milligan’s  remarks,  where  attempts  were  made  to  extract  a 
halfpenny  from  a child’s  oesophagus  by  means  of  a coin- 
catcher.  The  child  bit  the  coin-catcher,  broke  off  the  end, 
and  this  was  swallowed.  It  became  impacted  in  the  pylorus 
and  had  to  be  removed  by  laparotomy,  and  the  coin,  which  j 
remained  impacted  in  the  oesophagus,  was  removed  by  the  | 
direct  method.  Since  this  occurrence  the  coin-catcher  had  j 


Thb  Lanohit,] 


MR.  IRWIN  MOORE  : FOREIGN  BODIES  IN  THE  (ESOPHAGUS,  ETC.  [Sept.  27,  1919  567 


been  banished  from  the 
casualty  department  at 
his  hospital.  Dr.  F.  de 
Havillaod  Hall  expressed 
his  opinion  that  it  was 
very  desirable  that  the 
members  of  the  Section 
of  Laryngology  should 
draw  up  a communica- 
tion and  send  it  to  the 
members  of  general  hos- 
pital staffs  — that  the 
time  had  come  for  pro- 
nouncing that  the  direct 
method  should  be  em- 
ployed in  these  cases 
instead  of  using  the  coin- 
catcher. 

Some  Reported  Cases 
shorcing  the  Disastrous 
Results  fo  Homing 
Attempts  at  the  Blind 
Extraction  of  Foreign 
Bodies. 

The  following  are  a few 
of  many  cases  reported 
in  the  medical  press 
which  are  here  referred 


to  in  order  still  further  to 
emphasise  the  disastrous 
results  of  the  blind 
probing  in  the  dark  with 
forceps,  the  coin-catcher, 
or  probang  : — 

Chevalier  Jackson2 3  (Phila- 
delphia) mentions  that  he 
had  seen  a child,  aged 
2 years,  who  had  a penny  lodged  in  the  oesophagus  five  days 
previously  and  where  forceps  had  been  blindly  passed  without  an 
cesophagoscope,  which  he  considered  an  “ utterly  unjustifiable  pro- 
cedure." When  seen  “ the  temperature  was  104°  and  the  pulse 
uncountable,  sloughs  were  being  vomited,  and  the  child  was  sinking 
away  in  the  profound  shock  of  a traumatic  oesophagitis.  Its  death 


Fig.  4.— The  cricoidal-pharynx  and 
upper  part  of  oesophagus  seen  from 
behind.  A portion  of  the  p >sterior 
wall  has  been  removed  to  show  the 
coin-catcher  which  has  caught  a coin, 
but  on  withirawal  has  itself  been 
caught  under  the  posterior  inferior 
edge  of  the  cricoid  cartilage,  so  that 
neither  the  coin-catcher  nor  the  coin 
can  be  extracted. 


Fig.  5. — The  same  in  sagittal  section.  The  coin  is  seen  lying  in  the 
posterior  half  of  the  coin-catcher,  whilst  the  anterior  portion  has  been 
caught  under  the  lower  projecting  edge  of  the  cricoid  cartilage. 

Thomas  Guthrie4  (Liverpool)  reports  a case  in  which  a halfpenny 
was  impacted  in  the  oesophagus  and  a previous  unsuccessful  attempt 
at  removal  with  the  coin-catcher  failed.  On  examination  with  the 
eesophagoscope  the  coin  was  found  to  have  been  forced  upwards  and 
buried  under  the  mucous  membrane  at  about,  the  level  of  the  cricoid. 
Removal  V as  performed  by  tearing  through  the  mucous  membrane,  but 
recovery  was  fortunately  uneventful. 

E.  D.  Davis  s supplies  the  following  notes  of  two  cases  not  yet 
recorded : — (1)  A girl,  aged  41.,  swallowed  a halfpenny,  which  became 
impacted  in  the  gullet  immediately  below  and  overlapped  by  the  lower 
edge  of  the  cricoid  cartilage.  Several  unsuccessful  attempts  were  made 


Fig.  6.— This  diagram  shows  the  disadvantageous  and  strained  position  commonly  employed  for  the  passage  of  endoscopic  tubes 
through  the  buccal  cavity,  pharynx,  and  cesophagus,  with  over-extension  of  the  head  and  neck,  causing  anterior  curvature  of  the 
cervical  vertebra- ; it  also  shows  the  faulty  position  of  the  tube  in  the  middle  line  of  the  mouth  and  in  contact  with  the  incisor  teeth 


was  really  due  to  the  absolute  ignorance  of  the  family  physician, 
who  had  never  heard  of  oesophagoscopy  and  its  safety  in  trained 
hands.” 

Logan  Turner  3 (Edinburgh)  refers  to  a case  where  a halfpenny  had 
remained  in  the  oesophagus  for  only  one  week,  and  the  patient  died  as 
a result  of  the  injury  caused  by  the  old-established  method  used 
for  the  removal  of  the  coin,  and  not  from  the  presence  of  the  coin 
itself. 


2  Journ.  Amer.  Med.  Assoc.,  1909,  liii  , p.  1C09. 

3  Proc.  Scot.  Otol.  and  Laryngol.  Soc.,  Nov.  22nd,  1913  ; Abstract 

Journ.  Laryngol.,  Rhinol.,  and  Otol  , 1914,  xxix.,  p.  98. 


to  remove  it  by  experienced  and  skilful  surgeons  accustomed  to  the  use 
of  the  coin-catcher.  The  c in  was  finally  removed  without  difficulty  by 
cesopbagoscopy.  (2)  Report  of  an  inquest  in  the  lav  press  on  a boy 
where  the  oin-catcher  was  used  to  extract  a penny.  The  coin-catcher 
broke  and  the  child  died  with  the  penny  and  piece  of  the  coin-catcher 
fixed  in  the  gullet. 

Norman  Patterson*)  gives  the  particulars  of  an  unreported  case  which 
occurred  at  one  of  the  Loudon  hospitals.  A child,  aged  4 years,  had  a 


4  Liverpool  Med.  Chir.  Journ.,  1912,  xxxii.  ; Abstract  Journ. 
Laryngol.,  Rhinol..  and  Otol.,  1913,  xxviii.,  p.  219. 

5  6 Personal  communication  to  the  author. 


568  ThbLanoht,]  MR.  IRWIN  MOORE:  FOREIGN  BODIES  IN  THE  (ESOPHAGUS,  ETC. 


[Sept.  27,  1919 


halfpenny  impacted  In  its  icsophagus  at  the  level  of  the  cricoid  cartilage 
— as  Bhown  by  X rays.  During  attempts  to  move  it  with  the  coin-catcher 
the  basket  portion  broke  off  from  the  stem  and  passed  into  thestomach. 
Both  coin  and  coin-catcher  had  to  be  removed  the  same  evening  by 
gastrotomy.  The  coin-catcher  employed  had  been  in  use  at  this 
hospital  for  20  years,  and  had  become  weakened  by  rust  and  old  age. 

G-  L.  Richards7  (Fall  River,  Mass.),  at  a meeting  of  the  American 
Laryngological  Association  in  1909,  in  describing  the  coin-catcher  as 
almost  obsolete,  mentions  that  a child  of  2 or  3 years  of  age  was 
brought  to  one  of  his  colleagues  with  a coin  in  the  oesophagus,  and  he 
used  the  coin-catcher.  After  catching  the  coin  and  trying  to  remove 
it,  he  found  this  was  impossible  on  account  of  urgent  symptoms  of 
suffocation.  He  had  to  do  a tracheotomy  first,  and  was  then  able,  but 


Donald  Armour9  refers  to  the  case  of  a boy,  aged  .5  years,  who 
swallowed  a coin,  which  was  seen  by  X rays  lodged  in  the  pyriform 
fossa.  A house  surgeon  passed  a coin-catcher  and  engaged  the  coin, 
but  on  traction  being  made  to  remove  it  the  coin-catcher  broke  off  at 
the  junction  of  the  metal  part  with  the  whalebone  handle.  The 
portion  of  the  coin  catcher,  5 inches  in  length,  passed  down  and 
lodged  in  the  lower  end  of  the  oesophagus.  The  coin  was  easily 
extracted  through  the  mouth  with  a pair  of  forceps,  whilst  it  was 
necessary  to  perform  laparotomy  and  gastrotomy  in  order  to  remove 
the  portion  of  the  coin-catcher. 

Gordon  Kingio  (New  Orleans,  U.S.A.)  protests  against  the  indis- 
criminate use  of  the  coin-catcher,  which  he  says  may  be  the  cause  of 
Berious  injury  to  the  (esophagus.  He  cites  a case  reported  by  Sebileau 


Fig.  7.— This  diagram  shows  the  correct  position  for  the  easy  insertion  and  passage  of  endoscopic  tube  into  the  oesophagus  when  the 
upper  two-thirds  are  under  examination. 


Fig.  8.— The  same  when  the  lower  third  of  the  oesophagus  is  under  examination  : the  head  being  lowered  by  means  of  the  movable 
table  flap,  the  axis  of  the  endoscopic  tube  is  brought  into  line  with  and  parallel  to  the  oesophagus  in  the  horizontal  plane. 


with  difficulty,  to  remove  the  coin-catcher,  since  it  had  got  caught 
under  the  cricoid  cartilage  (Figs.  4 and  5 have  been  specially  drawn  for 
the  writer  to  illustrate  how  this  danger  can  occur). 

Chevalier  Jackson  * (Philadelphia),  in  a discussion  which  followed, 
said  he  was  6orry  to  say  the  coin-catcher  was  not  an  obsolete  insiru 
ment.  A patient  was  brought  to  his  hospital  a few  weeks  previously 
with  a penny  in  the  oesophagus.  A coin-catober  had  been  previously 
passed  down  to  take  out  the  penny,  the  position  of  which  was  demon- 
strated by  a radiogram,  but  the  coin-catcher  entered  the  trachea  and 
on  being  drawn  out  had  torn  out  the  inside  of  the  larynx.  The  child 
was  in  a very  serious  condition.  It  took  him  but  a moment  to  remove 
the  penny  safely  and  easily  by  aid  of  the  oesophagoscope. 


of  death  occurring  from  tearing  through  the  oesophageal  wall  in  efforts 
to  extract  acoin.  Healso  cited  another  case  reported  by  Felizet,  where 
the  basket  end  had  been  broken  off  and  lodged  in  the  gullet. with  the 
coin. 

Frequency  of  Lodgment  of  Foreign  Bodiet. 

Statistics  show  that  the  lodgment  of  foreign  bodies  in  the 
air  and  food  passages  is  much  more  common  than  generally 
supposed,  especially  amongst  children,  on  account  of  their 
habit  of  placing  things  in  their  mouth,  and  these  foreign 
bodies  are  exceedingly  likely  to  make  their  way  into  the 


Trans.  Amer.  Laryngol.  Assoc.,  1909,  xxxi.,  p.  371. 
6 Discussion  on  G.  R.  Richards's  case,  ibid.,  p.  372. 


» Rept.  Soc.  Study  Dis.  Child.,  1904,  iv„  p.  116. 
Tram.  Amer.  Laryngol.  Assoc.,  1905,  xxvii.,  p..203. 


The  Lancet,] 


MR.  IRWIN  MOORB:  FOREIGN  BODIES  IN  THE  (ESOPHAGUS,  ETC.  [Sept.  27,  1919  569 


Pig.  9. — Approach  to  the  lower 
sphincter  orifice  of  the  pharynx 
(closed)  as  seen  through  Hill's 
18  mm.  diameter  osophsgo- 
scope. 


Fig.  10. — The  lower  pharyngeal  orifice  partially  open.  Note 
the  alteratb  n in  the  shape  of  Killian's  lip.  The  pharyngo- 
esophageal junction  and  the  mouth  of  the  oesophagus  is  out 
of  sight  in  deep  shadow.  Note  also  the  pharyngeal  “ lip  " 
forming  a distinct  ledge  posteriorly.  Hill  has  pointed  out 
that  Killian  inaccurately  described  this  lip  as  forming  the 
posterior  boundary  of  the  mouth  of  the  (esophagus. 


Fig  11.— View  of  the  cervical 
and  upper  thoracic  oesophagus 
after  passage  of  the  tube  through 
the  lower  sphincter  orifice  of  the 
pharynx. 


(esophagus.  Though  in  some  cases  a coin  when  it  has 
entered  the  oesophagus  may  safely  pass  through  the  alimentary 
tract  and  be  evacuated  without  causing  any  symptoms,  few 
foreign  bodies,  if  inspired  into  the  respiratory  tract,  are 
voluntarily  expectorated.  It  has  been  shown  by  innumer- 
able cases  that  the  risk  of  the  sojourn  of  a foreign  body  is 
greater  than  the  risk  of  early  per-endoscopic  removal. 
Therefore  when  the  fact  of  the  accidental  swallowing  of  a 
foreign  body  is  recognised  no  time  should  be  unnecessarily 
lost  before  it  is  sought  for  and  removed,  since  if  not  removed 
as  soon  as  possible  it  may  give  rise  to  local  irritation,  cedema, 
septic  infiltration,  ulceration,  perforation,  and  death. 


Pre-endosoopio  Days. 


A.  E.  Durham  11  refers  to  Adelman's 12  analysis  of  314  untreated  cases 
of  foreign  bodies  in  the  oesophagus  during  the  pre-endoscopic  days,  in 

109  of  which  cases  fatal  results 
ensued.  In  31  of  the  fatal 
eases  death  was  due  to  per- 
foration either  of  the  heart, 
aorta,  or  one  of  the  great 
vessels  ; in  43  to  lesions  of  the 
respiratory  organs  ; and  in  25 
to  ulceration  of  the  oesophagus 
and  septic  inflammation  set  up 
in  the  neighbouring  Darts. 

Chevalier  Jackson  l;!  states 
that  105  deaths  were  recorded 
in  North  America  alone  in  five 
years  from  foreign  bodies  in 
the  air  and  fond  passages,  from 
ill-advised  efforts  at  removal— 
e.g.,  blind  groping  with  forceps 
or  bougies.  McKinney 14  adds  : 
“ There  are  also  many  more 
unrecognised  and  unreported 
cases  which  would  increase  the 
high  mortality  rate.” 

Brilliant  Results  of 
Endoscopy. 

The  introduction  o f 
straight  endoscopic  tubes 
has  placed  at  our  com- 
mand the  means  by  which 
removal  of  foreign  bodies 
from  the  air  and  food 
passages  can  now  be 
efficiently  carried  out  by 
expert  endoscopists  under  direct  vision  bv  lo  cps  with 
hardly  any  risk  to  the  patient  ; and  in  this  w^y  the  death- 
rate  has  been  greatly  reduced  so  that  many  valuable  lives 


Fig.  12. — Coin  impacted  partly  in  the 
ericoidal-pharynx  aDd  partly  in  the 
cervical  oesophagus  (after  Guisez). 


have  been  saved. 


Chevalier  Jackson 15  gives  the  mortality  and  results  of  bronchoscopy 
in  the  removal  of  foreign  bodies  from  the  air  passages  during  recent 
years  as  ranging  from  5'3  to  1'7  per  cent.,  while  that  of  CESophagoseopy 
as  3 per  cent,  to  nil.  He  states  that  in  his  own  clinic  in  182  cafes  of 
bronchoscopy  the  foreign  body  was  removed  in  177  cases,  whilst  in  201 
cases  of  cesophagoscopy  the  foreign  body  was  removed  in  198  cases,  and 
escaped  downwards  in  8.  There  were  only  4 deaths,  1 due  to  chronic 
disease  of  the  kidneys,  the  other  3 the  result  of  previous  laceration  due 
to  improper  attempts  at  extraction. 

Friedbergi6  (Chicago),  from  the  analysis  of  50  cases  of  foreign  bodies 
in  the  oesophagus  since  the  introduction  of  endoscopic  methods,  shows 
that  the  age  period  varies  from  7 months  to  63  years,  but  that  the  greater 
number  —viz.,  42— occurred  between  the  ages  of  7 months  and  10  years,  13 
of  which  were  between  1 and  2 years  of  age.  Of  the  50  cases  of  foreign 


11  Foreign  Bodies  in  the  (Esophagus,  Holmes’s  Surgery,  1883,  i.,  p.  789. 
12  Vierteljahrsch.  fiir  Prakt.  Heilkunde,  1867. 

12  Journ.  Amer.  Med.  Assoc.,  1909,  liii.,  p.  1009. 
i*  Ibid. 

15  Trans.  XVIIth.  Internat.  Cong.  Med.,  London,  1913  (Laryngol. 
Sect.),  p.  3. 

1<;  Ann.  Otol.,  Rhinol.,  and  Laryngol.,  1917,  xxvii.,  p.  772. 


Fig.  13. — The  cervical  oeso- 
phagus with  its  lumen  open 
(during  the  inspiratory 
stage). 


Fig.  15.— The  same  with  the 
endoscopic  tube  tilted 
anteriorly. 


Fig.  17.— The  oesophagus  in  the 
cervical  or  thoracic  region 
opening  in  its  upper  and 
closing  in  its  lower  part  during 
respiration . To  the  left  is  seen 
a loose  fold  of  the  oesophageal 
wall,  pushed  downwards  by 
the  tube. 


Fig.  14.— The  same  closed 

(during  the  expiratory  stage) 
with  the  endoscopic  tube 
centralised. 


Fig.  16. — The  same,  showing 
extreme  closure  (stellate 
rosette)— uncommon.  


Fig.  18.— The  thoracic  oeso- 
phagus seen  during  the 
inspiratory  stage  more  widely 
open  and  its  lumen  more 
circular  than  in  the  cervical 
region. 


bodies  it  is  interesting  to  note  that  29  were  coins  or  disc-shaped  bodies, 
and  that  40  were  impacted  below  the  criopharyngeus  and  only  4 above 
— i.e.,  in  the  deep  pharynx.  Successful  extraction  by  endoscopy 
occurred  in  47  cases  and  only  2 became  dislodged  and  passed  into  the 
stomach.  The  only  fatal  eases  amongst  these  50  foreign  bodies  was 
in  that  of  an  impacted  coin  in  which  considerable  traumatism  had 
previously  been  caused  by  indirect  methods,  resulting  in  death  from 
infection  following  a trachea- (esophageal  fistula. 

That  the  medical  profession  in  general  have  not  yet  fully 
recognised  the  dangers  which  may  accrue  from  the  swallowing 
of  foreign  bodies,  nor  realised  the  brilliant  results  obtained 
by  cesophagoscopic  and  bronchoscopic  methods,  is  shown  by 
many  cases  of  death  reported  in  the  lay  press.  For  example, 


570  The  Lancet,]  MR.  IRWIN  MOORE:  FOREIGN  BODIES  IN  THE  (ESOPHAGUS,  ETC. 


[Sept.  27,  1919 


Fig.  19. — Tbe  fame  during  tbeexpiratory  stage; 
incompletely  closed — i.e.,itdoes  not  close  as 
completely  in  tbe  thoracic  as  in  tbe  cervical 
region  during  endoscopy. 


Fig.  22.— The  endoscopic  appearance  of  the 
inflamed  (edematous  lumen  of  the  oesophagus 
just  above  the  position  of  an  impacted  coin. 
Note  the  dark  transverse  slit. 


Fig.  20  — Mid  - thoracic  region 
showing  bulging  of  left 
bronchus. 


Fig.  23. — Appearance  of  upper 
edge  of  a coin  when  1 icate  t by 
“the  endoscopic  tube. 


Fig.  21.— Lower  end  of  thoracic  gullet  showing 
the  phrenic  or  diaphragmatic  constriction. 


Fig.  24.— Semi-diagrammatic  view  of  a coin  lying 
on  the  posterior  wall  of  tne  oesophagus,  the 
flaccid  anterior  wall  being  stretched  as  the  tube 
descends  allowing  endoscopic  tubes  to  pass  in 
front  of  the  coin. 


in  the  same  week  as  the  writer's  case  previously  referred  to 
there  was  reported  17  the  “ Death  from  misadventure  ” of  a 
child  aged  11  years,  who,  while  playing  with  her  father 
and  performing  a conjuring  trick,  accidentally  swallowed  a 
penny  which  stuck  in  its  throat.  Attempts  on  the  part  of 
the  father  to  remove  the  coin  having  failed,  the  child  was 
taken  to  a cottage  hospital,  where  it  died  some  days  later  of 
“septic  poisoning.”  At  the  inquest  it  was  stated  that 
there  was  a difficulty  in  obtaining  the  services  of  an  X ray 
expert  to  locate  the  coin  1 Though  the  use  of  the  Roentgen 
rays  may  prove  of  great  service  both  in  settling  the 
presence  of  a foreign  body  and  in  determining  its  exact 
position,  yet  if  it  is  not  available  there  is  no  reason  why 
the  endoscopic  tube  alone  should  not  be  used  to  locate  and 
extract  a foreign  body  so  long  as  it  is  passed  under  direct 
vision.  The  X rays  should  only  be  considered  as  an 
accessory  in  endoscopic  work  and  not  as  an  absolute 
necessity.  It  is  important  to  remember,  however,  that  a 
button  if  made  of  vegetable  ivory  and  some  kinds  of 
vulcanite  may  not  be  revealed  by  X rays.  Again,  “Death 
by  misadventure  ” was  the  verdict 18  recently  given  at 
another  of  the  many  inquests  on  children  who  have  died 
from  swallowing  foreign  bodies — in  the  case  of  a two-year- 
old  child  who  swallowed  a halfpenny.  The  coin  perforated 
an  internal  organ  and  set  up  inflammation  of  the  lungs.  A 
more  correct  verdict,  the  author  suggests,  would  have  been 
“ Manslaughter”  for  neglecting  to  send  for  an  experienced 
endoscopist. 

The  Danger  of  Foreign  Bodies , with  reference  especially  to 

Coins  in,  the  (Esophagus  and  some  Difficulties  which  may 
be  met  with  in  tkeir  Extraction  by  Endoscopy. 

Since  this  article  is  mainly  concerned  with  the  use  and 
abuse  of  the  coin-catcher,  reference  has  been  chiefly  confined 
to  cases  of  coins  and  allied  circular  bodies. 

(Esophageal  measurements. — The  oesophagus  is  10  inches 
long  in  the  adult.  It  commences  just  below  the  lower 
border  of  the  cricoid  cartilage — i.e.,  below  the  lower 
sphincter  orifice  of  the  pharynx,  its  opening  or  mouth  being 
in  the  adult  about  6 inches  distant  from  the  upper  incisor 
teeth.  From  the  latter  to  the  crossing  of  the  aortic  arch  the 
distance  is  10  inches,  whilst  to  the  level  of  the  diaphragm  it 
is  16  inches.  These  measurements  vary  somewhat  in  adults, 
and  in  children  may  be  reduced  to  one-half. 

The  so-called  mouth  of  the  oesophagus  is  often  described 
as  a transverse  slit  bounded  in  front  by  the  lower  border  of 


s7  News  of  the  World,  August  29th,  1915. 
“ Ibid.,  May  19th,  1918. 


® 

Fig.  26. — The  same,  showing  a 
later  stage  of  folding  of  ihe' 
s <r  o 1 1 e n post  • oesophageal  j 
mucosa  over  the  upper  edge 
and  sides  of  an  impacted  coin,' 
which  is  securely  grasped, and 
almost  completely  hidden 
from  view, 

the  cricoid  cartilage  and  behind  by  the  vertebral  column,  but, 
as  emphasised  by  William  Hill,19  this  is  usually  confused 
with  the  lower  sphincteric  orifice  of  the  pharynx. 

The  average  measurements  of  this  orifice  in  the  adult 
cadaver  are  23  mm.  in  the  transverse  and  17  mm.  in  the 
sagittal  diameter.  The  average  transverse  diameter  of  the 
unstretched  cesophagus  in  the  living  adult  is  25  mm.  (1  inch) 
all  the  way  down  ; the  antero-postedor  diameter  varying 
from  19  mm.  (J  inch)  at  the  cricoid  to  25  mm.  (1  inch)  at  the 
cardia.  The  oesophageal  lumen,  however,  is  capable  of  much 
greater  distensibility  both  in  the  infant  and  adult,  as  shown 
by  the  passage  of  circular  foreign  bodies — e.g. , coins, 
buttons — of  much  larger  diameter. 

D.  R.  Paterson  20  (Cardiff)  has  safely  removed  from  the  cesophagus  of 
a soldier  bv  means  of  a 20  mm.  tube  the  disc  of  a bully  beef  tin 
measuring  35  mm.  (lg  inch) — i.e.,  rather  larger  than  a half-a-crown, 
which  was  impacted  at  the  level  of  tbe  sternal  notch,  whilst  Whale*1 
had  previously  reported  an  exactly  similar  disc  with  the  same  diameter 
which  he  was  obliged  to  remove  by  cesophagotomy. 

Luscbka  22  reported  a post-mortem  case  where  the  oesophagus  was 
dilated  to  46  cm.  in  length  (ISA  inches)  and  30  cm.  (12  inches)  in  circum- 
ference at  its  widest  part — i.e.,  a diameter  of  3j  inches.  This  case  is 
interesting  in  so  far  that  it  shows  to  what  an  enormous  extent  the 
oesophagus  may  become  pathologically  dilated. 

The  chief  sites  of  impaction  of  foreign  bodies  in  the  ■ 
cesophagus  and  adjacent  portion  of  the  deep  pharynx. — 

1.  In  the  post-cricoidal  pharynx,  or  hypopharynx — i.e., 

19  Journ.  Laryngol.,  Rhinol..  and  Otol.,  1916,  xxxi.,p.  164. 

20  Proc.  Roy.  Soc.  Med.,  1916.  ix.  (Laryngol.  Sect.),  p.  41. 
st  Ibid.,  1915,  viii.  (Laryngol.  Sect.),p.  70. 

22  Archiv.  f.  Path.  Anat.  (Virchow),  1868,  xlii.,  pp.  473-477. 


Fig.  25.— The  same,  showing 
commencing  folding  of  the 
swollen  post  - oesophageal 
mucosa  over  an  impacted  c in. 
The  anterior  wall  is  seen  well 
distended  by  the  endoscopic 
tube. 


— * Lanoht,]  MR  IRWIN  MOORE  : FOREIGN  BODIES  IN  THE  ESOPHAGUS,  ETC.  [Sept.  27,  1919 


Fia.  27.- 


above  the  lower  sphincter  orifice  of  the 
pharynx.  2.  At  the  junction  of  the 
pharynx  and  oesophagus,  being  partly 
in  each.  3.  The  loose  cervical  portion 
of  the  gullet  entirely  below  the  sphincter. 

4.  At  the  constriction  in  the  thoracic 
gullet  where  the  left  bronchus  crosses 
it.  5.  According  to  Stark  there  is  a 
constriction  where  the  aorta  crosses  it. 

6.  At  or  just  above  the  phrenic  level 
where  there  is  narrowing  of  the  gullet. 

The  Bireet  Endoscopic  Method  of 
Extraction  of  Foreign  Bodies. 

In  examining  the  oesophagus  it  is 
advisable  to  employ  as  large  a tube 
as  possible,  since  not  only  a more 
extensive  view  of  the  field  may  be  seen, 
but  also  there  is  more  room  for  the 
manipulation  of  instruments,  and  con- 
sequently more  successful  results  may 
be  obtained  with  celerity  and  certainty,  especially  when 
dealing  with  foreign  bodies.  Experience  has  shown  that 
much  larger  tubes  than  those  first  employed  may  be  used 
with  safety  and  without  causing  traumatism,  provided  the 
operator  has  acquired  the  necessary  skill  and  technique. 

While  Chevalier  Jackson  employs  endoscopic  tubes  of 
/ mm.  in  infants  and  10  mm.  as  the  largest  size  in  adults 


571 


-Briinings  s endoscopic  tube  with  spatula-shaped  extremity. 


Fig.  28.— Killian's  endoscopic  tube  with  plane  (i.e.,  non-bevelled 
distal  extremity. 


Fig.  29.— Semi-diagrammatic  sectional  view  of  the  cesophagus  showing 
how  a small-sized  endoscopic  tube  may  override  a loose  fold  of  the 
posterior  wail,  which  may  conceal  and  partly  cover  a foreign  body- 
vision  ° The  foreign  body  1S  consequently  out  of  the  line^ of 


and  its  upper  edge  is  easily  seen  and  seized  by  forceps.  8 


for  oesophageal  work,  Briinings » uses  tubes  that  are  larger 
and  considers  that  the  largest  should  not  exceed  14  mm 

™ nPTVn  exPandin&  ^be  to  30  mm! 
(1  3/16  inch)  D R Paterson  has  shown  that  much 
arger  tubes  of  18  and  20  mm.  diameter  may  be  passed 
with  safety,  and  are  especially  to  be  commended  in  the 
removal  of  large  foreign  bodies.  His  opinion  has  been 
confirmed  by  Wil  iam  Hill,  who  has  used  and  advocated 
iarger  tubes  up  to  18  mm.  diameter  for  some  years. 

When  using  a small  or  medium-sized  tube  its  distal  end 

ihn  nrl  emTd  a^°Ufc  from  side  to  side  and  orientated 
in  order  to  thoroughly  expose  the  oesophageal  walls  and 

foreign  bodies  are  likely  to  be  overlooked,  whereas  the 
passage  of  a large  tube  circular  on  section  or  as  recom 

thenwallsby  Hl0ShH:  Til  Section’  causes  distension  of 
the  walls,  and  as  the  tube  is  advanced  any  transverse  folds 

in  the  walls  are  obliterated  (Figs.  29,  30,  31),  and  the 
oesophagus  may  be  seen  standing  open  for  some  inche« 
ahead  of  the  tube.  The  tubes  should  never  be  passed 
except  under  the  direct  vision  of  the  eye  and  no  force 
whatever  should  be  used.  It  is  harder  to  insert  a large 
tube  past  the  cricoid,  but  the  difficulty  is  easily  overcome 
if  the  patient  is  placed  in  the  proper  posture,  so  that  the 
buccal  cavity  and  neck  are  in  a straight  line  with  the 
thoracic  portion  of  the  oesophagus. 

Position  of  Patient  for  (Esophagoseopy . 

thJhep^°rSf1fbeCUtnl?e“t  P°sition  with  sliShfc  extension  of 

Sr  th?d  -he  °<?Clplt°‘autl0ld  j°int  is  the  correct  position 
for  the  easy  insertion  of  the  tube.  (Fig.  7 ) This  Dositinn 

was  first  described  by  William  Hill'  in*  Iflii,  who  Towed 

that  the  a^is  of  the  cesophagoscope  more  nearly  approaches 

an  angle  of  45°  with  the  horizontal  when  the  upper  two- 
thirds  of  the  gullet  are  under  examination.  (Fig-  7 He 
points  out  that  in  endoscopy  of  the  lower  fourth  of  the 

hodzonfaT  f**  bfomeS  dories" 

Horizontal.  (Fig,  8.)  If  the  lumen  of  the  tube  is  not  seen 

"es  ahead  are  not  in  the  right  axis,  and  the 
head  may  require  raising  or  lowering,  according  as  to 

posterior  <*soPhagosooPe  <•  "P  .gains!  the  anterior  or 

I-Phio6  j6®  ln  the  natural  recumbent  position  on  the 

table—the  head  is  extended  by  placing  the  finger  in  the 
mouth  and  making  traction  on  the  upper  alveolar  region 

f-0m  the  head  of  table  ; this  extends 
the  head  at  the  occipito-atloid  joint  without  interfering  with 
the  position  of  the  cervical  spine  which  slopes  gently  down- 
wards. This  extension  of  the  head  without  Altering  The 
curve  of  the  cervical  and  upper  dorsal  spine  serves  to  bring 
the  axis  of  the  bucco-pharyngeal  cavity  into  line  with  that  of 
he  upper  half  or  two- thirds  of  the  oesophagus,  and  it  is  then 
an  easy  matter  to  pass  an  endoscopic  tube  and  all  obstruc- 
Jl°n  1S,a^°lded  (Hill),2-1  whereas  if  the  tube  is  passed  in 
the  middle  line  it  will  hitch  against  the  teeth  Palso  the 
SW  SS01  posterior. surface  of  the  cricoid  plate 
( g.  o.)  The  head  can  be  raised  or  lowered  as  necessary 

flaplngTWesTsSaage  °1  thefftube  mea-  a movable  table 
flap'  Thls  1S  a much  better  posture  than  the  Rose  position 

p -yiireet  Laryngoscopy,  Bronchoscopy,  and  (Esophagoseopy.  1912, 

*3  ?roe  ?°y-  Soe;  Med.,  1916,  ix.  (Laryngol.  Sect  ) n 41 
Journ  Laryngol.,  Ehinol.,  and  Otol.,  1916,  xxxi.,’p.  107 


572  The  Lancet,]  MR.  IRWIN  MOORE  : FOREIGN  BODIES  IN  THE  (ESOPHAGUS,  ETC. 


[Sept.  27,  1919 


or  the  modified  Rose  position  of  Boyce  and  Jackson,  where 
the  posterior  part  of  the  vertex  and  occiput  is  hanging  over 
the  end  of  the  table  and  occupies  a lower  plane  than  the 
trunk — causing  anterior  curvature  of  the  cervical  vertebra 
and  over-prominence  of  the  sixth  cervical  vertebra — so 
obstructing  the  passage  of  the  tubes.  To  get  over  the 
difficulties  of  this  position  some  operators  employ  an  assistant 
to  raise  or  lower  the  head  while  it  is  extended — at  the 
oceipito-atlantal  joint — this  not  only  brings  the  air  passages 
into  line,  but  also  the  cervical  vertebrae  parallel  to  the 
oesophagus  in  the  horizontal  plane.  This  latter  is  termed 
the  Boyce  position,  and  is  used  by  Chevalier  Jackson. 

Introduction  and  Passage  of  the  GIsophagoscope . 

The  tube  should  be  inserted  through  the  right  angle  of  the 
mouth,  advancing  by  the  right  side  of  the  tongue  through 
the  buccal  cavity  and  pharynx  to  the  right  pyriform  fossa, 
then  through  the  hypo-pharynx  or  post-cricoidal  pharynx  to 
its  lower  sphincteric  orifice.  This  orifice,  as  previously 
stated,  has  been  wrongly  referred  to  in  the  past  as  the 
mouth  of  the  oesophagus,  and  is  often  described  as  a trans- 
verse slit,  bounded  in  front  by  the  lower  border  of  the 
cricoid  cartilage  and  behind  by  the  vertebral  column,  but,  as 
so  frequently  emphasised  by  William  Hill,  this  is  really  the 
lower  sphincter  orifice  of  the  pharynx,  and  the  mouth  of  the 
oesophagus  is  situated  immediately  below. 

Coins  or  similar  circular  bodies,  such  as  large  buttons  or 
discs,  when  accidently  swallowed,  are  not  always  easy  to 
find.  They  generally  enter  the  oesophagus  flat,  being  so 
directed  by  the  transverse  shape  of  the  lower  sphincter 
orifice  of  the  pharynx  (Fig.  9),  and  almost  invariably 
retain  their  original  position  as  they  descend — i.e.,  lie  flat 
against  the  vertebral  column,  so  that  when  they  become 
impacted  they  are  found  lying  against  the  posterior  wall 
(Figs.  23  and  24)  or  in  a band  or  recess  of  the  oesophagus — 
anywhere  from  the  cricoid  to  the  cardia  (Figs.  25  and  26), 


Fig.  32.— Shows  a halfpenny  encysted  in  the  post-u  sophageal  wall  of  a 
child  aged  1 year  and  10  months.  The  dotted  circle  represents  the 
position  of  the  buried  coin.  In  the  specimen  the  trachea  and  anterior 
wall  of  the  (Esophagus  have  been  slit  open  from  the  front  exposing 
the  coin  lying  in  its  bed.  The  dotten  line  represents  the  buried 
circumference  of  the  coin.  Note  the  irregular  folds  of  the  oesophageal 
wall  surrounding  and  nearly  completely  hiding  the  coin,  only  1/5  of 
the  centre  being  seen.  The  remarkable  distensibilitv  of  the 
(esophagus  at  this  age  is  also  well  seen.  (Mr.  Jewell’s  case,  from  a 
life  sized  drawing  specially  made  for  the  author,  from  the  specimen, 
by  kind  permission  of  Mr.  Jewell.) 

and  forceps  must  open  antero-posteriorly  in  order  to  grasp 
them.  The  exact  opposite  occurs  when  they  are  aspirated 
into  the  trachea,  the  antero-posterior  position  of  the  vocal 
cords  causing  them  to  enter  the  trachea  edge  on — i.e.. 
antero-posteriorly — in  which  position  they  are  generally 
found. 

The  appearance  of  the  oesophagus,  as  seen  through  the 
tesophagoscope,  not  only  varies  somewhat  in  different 


Fig.  33.— Shows  portion  of  halfpenny  which  has  perforated  the  post- 
tesophageal  wall  into  the  posterior  mediastinum.  This  illustration  is 
from  a photograph  showing  posterior  view  of  Fig.  32.  (Mr.  Jewell's 
case.) 

individuals,  but  also  according  as  to  whether  a large  or 
small  tube  is  used  in  the  examination.  It  also  varies 
according  to  the  position  of  the  tube — i.e.,  of  its  distal 
end — for  at  one  time  the  lumen  may  appear  centralised 
(Fig.  14),  whilst  at  others  it  may  be  seen  in  the  anterior 
part  of  the  field  with  a considerable  area  of  the  posterior 
wall  showing  posteriorly  (Fig.  15),  or  vice  versa.  That  is 
to  say,  in  examination  of  the  oesophagus  we  necessarily 
obtain  a composite  view.  When  an  endoscopic  tube  is 
passed  down  into  the  hypo-pbarnyx  or  cricoidal  pharynx, 
the  lower  sphincter  orifice  is  seen  to  be  closed  and  is 
represented  by  a slit  consisting  of  an  anterior  and  posterior 
lip,  the  latter  being  more  prominent.  (Fig.  9 ) A short 
delay  may  occur  here  on  account  of  spasm.  There  is  a 
depression  behind  on  the  upper  surface  of  the  posterior  lip 
(of  Killian)  against  which  the  posterior  edge  of  the  tube 
may  rest  and  pressure  on  which  may  increase  the  sphincteric 
spasm  and  cause  the  advancing  tube  to  be  held  up.  By 
gentle  pressure  downwards  and  anteriorly  the  spasm  becomes 
relaxed  and  the  sphincter  opens  (Fig.  10),  allowing  the 
examining  tube  to  enter  the  cervical  oesophagus.  This 
entrance  is  the  narrowest  part  of  the  oesophagus  in  the 
living  subject. 

Figs.  9,  10,  11  represent  composite  extended  endoscopic 
views  of  the  lower  pharynx  and  oesophagus,  drawn  from 
life,  by  orientation  of  the  distal  end  of  the  largest  calibre 
oesophagoscopic  tube  (18  mm.  diameter). 

A coin  impacted  below  the  sphincteric  orifice  may  have  its 
upper  edge  hidden  by  the  projecting  forward  of  the  posterior 
pharyngeal  wall — i.e.,  by  Killian's  lip.  This  is  due  to  the 
spasmodic  contraction  of  the  lower  sphincter  of  the  pharynx 
— i.e.,  the  lower  horizontal  bundle  of  fibres  of  the  inferior 
constrictor  muscle  (crico-pharyngeus),  which,  as  before 
stated,  is  situated  just  above  the  oesophageal  mouth.  As  the 
endoscopic  tube  enters  the  sphincteric  orifice  it  tends  to  ride 
down  over  this  lip  and  may  easily  pass  in  front  of  a foreign 
body  which  remains  out  of  the  line  of  vision.  Chevalier 
Jackson  in  his  latest  work  “ Per-oral  Endoscopy,”  1915, 
shows  an  oesophagoscopic  view  of  a coin  wedged  in  this 


The  Lancet,] 


MR.  IRWIN  MOORE  : FOREIGN  BODIES  IN  THE  (ESOPHAGUS,  ETC.  [Seft.  27,  1919  573 


position,  with  forceps  retracting  the  subjacent  crico- 
pharyngeal fold,  preparatory  to  removal  of  the  coin. 
(Plate,  iii. , No.  10,  p.  708.) 

After  passing  through  the  pharyngeal  sphincter  the  tube 
enters  the  cervical  oesophagus,  the  lumen  of  which  in  the 
normal  condition  may  be  seen  to  contract  and  expand  more 
or  less  with  the  respiratory  movements — i.e..  opening  during 
inspiration  (Fig.  13)  and  closing  during  expiration  (Fig.  14), 
the  latter  having  the  appearance  of  a small  dark  rosette 
which,  according  to  the  position  of  the  tube,  may  be  either 
centrally  or  peripherally  situated.  (Figs.  14  and  15.) 

Below  the  top  of  the  sternum  as  far  as  the  cardiac  orifice 
of  the  stomach,  the  expansion  and  contraction  of  the  thoracic 
oesophagus  is  usually  found -to  be  more  marked  than  in  the 
cervical  region.  In  consequence  of  opening  wider  during 
inspiration  (Fig.  18)  it  may  be  possible  to  see  ahead  for  some 
distance  ; especially  is  this  the  case  when  a large  tube  is 
employed,  for  the  movements  of  the  oesophagus  are  less 
active  because  of  stretching  of  its  walls,  and  the  oesophagus 
stands  open  for  a distance  of  an  inch  or  two  beyond  the  end 
of  the  tube  before  it  narrows  down  to  the  customary 
expiratory  contracture  (central  rosette). 

In  the  thoracic  region  the  closure  of  the  oesophagus  is 
not,  as  a rule,  so  complete  as  it  is  usually  in  the  cervical 
region  (Figs.  14  and  19),  when  tubes  of  moderate  calibre  are 
employed. 

These  oesophagoscopic  views  have  been  carefully  drawn 
from  life,  during  the  examination  of  a large  number  of  cases 
and  with  various  sized  endoscopic  tubes.  I am  much  indebted 
to  my  friend,  Dr.  William  Hill,  for  material  and  for  assistance 
in  my  endeavours  to  attain  pictorial  correctness. 

When  a coin  has  passed  the  pharyngo-sphincteric  constric- 
tion there  is  a tendency  for  it  to  be  caught  and  impacted  in 
the  loose  and  collapsed  walls  of  the  cervical  oesophagus 
before  it  reaches  the  second  constriction  caused  by  the 
crossing  of  the  left  bronchus. 

James  E.  Logan  26  (Kansas,  U.S.  A.)  states  that  foreign  bodies  usually 
lodge  at  the  second  constriction  of  the  oesophagus,  and  there  is  nodoubt 
that  this  is  the  commonest  situation  in  children. 

Scanes  Spicer27  6ays  "it  is  remarkable  that  foreign  bodies  such  as 
coins  should  pa  s the  lower  sphincter  orifice  of  the  pharynx  and  yet 
get  lodged  in  a wider  part  of  the  gullet  just  below.  It  was,  no  doubt, 
the  prominence  of  the  first  dorsal  vertebra  behind  the  manubrial 
notch  in  front,  and  the  first  ribs  externallo,  which,  forming  the 
superior  O'ifiee  of  the  thorax,  provided  a sufficiently  narrow  channel 
at  the  best  of  times  when  picked  with  the  trachea,  gullet,  thyroid 
gland,  great  vessels,  nerves,  and  lymphatic  glands.” 

If  a coin  becomes  so  impacted,  and  this  applies  equally  to 
the  thoracic  oesophagus,  on  approaching  it  with  the  endo- 
scopic tube  the  normal  opening  and  closing  of  the  lumen  is 
seen  to  have  disappeared,  and  its  place  taken  by  a dark 
horizontal  slit  (Fig.  22)  somewhat  similar  to  that  seen  at 
the  pharyngo-sphincter  constriction.  (Fig  9.)  This  dark 
slit  is  caused  by  the  coin  stretching  and  holding  apart  the 
oesophageal  walls.  When  this  is  observed  we  know  that  the 
coin  is  close  by,  and  a careful  search  should  be  made  espe- 
cially along  the  posterior  wall.  The  upper  edge  of  the 
coin  may  be  hidden  by  a folding  over  of  the  swollen  or 
collapsed  mucous  membrane  of  the  posterior  and  lateral 
walls  (Figs.  25  and  26),  so  that  it  is  possible  for  the 
examining  tube  to  ride  over  and  slip  past  it  without  it  being 
observed  or  even  touched  by  the  tube,  just  as  may  occur  at 
the  pharyngeal  sphincter.  Especially  is  this  the  case  when 
a tube  with  a spatula  extremity  is  used  (Fig.  27),  the  upper 
edge  of  the  coin  being  either  imperfectly  seen  or  not  seen 
at  all,  and  it  is  therefore  impossible  to  grasp  it  with  forceps. 
When,  however,  a tube  with  plane  or  non-bevelled  extremity 
is  used  (Fig.  28),  and  of  the  largest  size  that  can  be  passed 
with  safety,  as  it  descends  it  straightens  out  any  loose  folds, 
thus  tilting  the  upper  edge  of  the  coin  forwards  and  causing 
it  to  become  more  central  and  to  appear  across  the  opening 
of  the  tube,  when  it  can  be  easily  seized. 

This  was  well  exemplified  in  a case  where  I was  recently 
asked  to  assist  a colleague. 

A child,  aged  1 year  and  3 months,  swallowed  a bone  button  the  same 
size  as  a halfpenny— i.e.,  25  mm.  diameter.  It  had  been  impacted  for 
threedays  in  the  cerv'cal  oesophagus  and  its  upper  edge  was  so  covered 
by  the  loose  folds  of  the  posterior  wall  that  it  was  found  impossible, 
after  many  attempts  with  a spatula-shaped  tube,  to  see  the  coin  properly 
and  to  grasp  it.  The  following  day  a short  tube  of  12  mm  diameter, 
with  non-bevelled  extremity  was  used,  with  the  desired  effect  of  stretch- 
ing  out  the  folds,  so  that  the  upper  edge  of  the  button  at  once  pre- 

26  Trans.  Amer.  Laryngol.  Assoc.,  1905,  204. 

57  Discussion  on  Tilley’s  case  of  a penuy  removed  from  the  gullet  in 
a young  girl  aged  14.  Proc.  Roy.  Soc.  Med.,  1910,  iii.  (Laryngol.  Sect.), 
p.  135. 


sented  in  front  of  the  tube  and  was  easily  removed.  A stricture  caused 
by  a foreign  body  may  require  to  be  dilated  before  the  foreign  body  can 
be  readied  and  removed. 

In  some  cases  the  swollen  and  oedematous  mucous 
membrane  may  cover  an  impacted  coin  so  as  to  hide  it 
not  only  partially  but  completely,  or  the  coin  may  become 
encysted. 

Tappey28  reports  the  case  of  a child,  2j  years  of  age,  with  a silver 
quarter  of  a dollar  in  the  (esophagus.  The  presence  of  the  coin  had 
caused  hyperplasia  of  the  wall  In  which  the  coin  had  become  embedded. 
It  was  removed  by  a-Bophagotomy. 

Halsted  2’J  (Syracuse,  N.Y.)  refers  to  the  case  of  a chi’rl,  aged  5 years, 
who  had  swallowed  a penny  during  infancy.  It  was  found  encysted  in 
the  post -(esophageal  wall,  and  was  only  released  after  curetting  the  wall 
through  t he  endoscopic  tube. 

Munro  3,1  mentions  a case  in  which  a halfpenny  was  retained  in  the 
(esophagus  of  a boy  for  three  years.  After  death  from  consumption  the 
coin  was  found  closely  embraced  by  the  gullet. 

Jewell 81  reported  the  very  interesting  case  of  a child,  aged  22  months, 
who  swallowed  a halfpenny  ten  days  before  admission  to  hospital,  and 
it  became  impacted  against  the  post-o  sophageal  wall.  The  coin  was 
located  by  X rays  just  below  the  sterno  clavicular  articulation,  but  all 
attempts  to  remove  it  both  by  forceps  and  hooks  failed,  nor  could  it  eve 


Fig.  34. — Skiagram  showing  lateral  view  of  a farthing  impacted  partly 
in  the  cricoidal-pharynx  and  partly  in  the  cervical  (esophagus  of  a 
child  aged  2 years. 

be  moved  from  its  bed.  Death  occurred  on  the  thirteenth  day  after  the 
swallowing.  Post  mortem  examination  showed  that  the  coin  had  become 
almost  completely  embedded  in  the  post-oesophageal  wall,  the  circum- 
ference of  the  coin  and  four-fifths  of  its  anterior  surface  being 
enveloped  by  folds  of  swollen  mucous  membrane  (Fig.  32).  and  that  it 
had  c uised  death  by  perforation  into  the  posterior  mediastinum. 
(Fig.  33.) 

Kent  Hughes  32  had  a case  in  which  a halfpenny  was  swallowed  by  a 
child  live  months  previously,  and  the  patient  was  brought  to  a 
children’s  hospital  on  account  of  broncho-pneumonia.  There  was  a 
history  that  something  had  been  swallowed,  and  X rays  showed  a half- 
penny in  the  posterior  mediastinum,  and  it  had  ulcerated  through  the 
right  posterior  wall  of  the  oesophagus.  He  managed  to  remove  it  by 
cutting  away  part  of  the  clavicle  and  two  ribs.  The  child,  however, 
died  of  the  pre  existirg  broncho-pneumonia. 

McKinney33  (Memphis,  U.S. A.)  reports  the  case  of  a girl,  aged 
2 years,  who  swallowed  a button  (the  same  diamenter  as  a halfpenny) 
three  or  four  days  previously.  Fluids  only  could  be  swallowed  and  with 
great  difficulty.  It  was  impacted  just  above  the  sternal  notch  and 
caused  considerable  congestion  and  swelling  of  the  oesophageal  mucosa 
followed  by  oedema  of  the  glottis  and  death. 

Friedberg34  (Chicago)  reports  the  case  of  a boy,  aged  3,  from 
whom  a nickel  and  two  pennies  (U.S. A.)  were  removed  from  the 
oesophagus  at  the  same  time,  as  they  were  all  stuck  together. 
A foreign  body  may  also  be  hidden  from  view  by  particles  of  impacted 


28  Cited  by  Shurley,  “ Dis.  of  Throat,  Nose  and  Ear, ”1900,  p.  664 
29  Laryngoscope,  1912,  xxii.,  p.  1227. 

30  Cited  by  Durham  in  Holmes’s  Surgery,  1883,  i.,  p.  788. 

31  Proc.  Roy.  Soc.  Med.,  1915,  viii.  (Laryngol.  Sect.),  p.  108. 

32  Journ.  Laryngol.,  Rhinol.,  and  Otol.,  1916,  xxxi.,  pp.  150-151 
33  Laryngoscope,  1912,  xxii.,  p.  1227. 

34  Ann.  Otol.,  Rhinol.,  and  Laryng.,  1914,  xxii.,  p.  123. 


574  The  Lanokt,]  MR.  IRWIN  MOORE:  FOREIGN  BODIES  IN  THE  (ESOPHAGUS.  ETC. 


[Sept.  27,  1919 


food— e g.,  H.  J.  Davis30  reported  a case  where 
a penny  was  impacted  in  the  oesophagus  of  a 
woman  aged  25  The  patient  was  unable  to 
swallow  anything  for  four  days.  The  coin  was 
hidden  by  grape  skins  which  obscured  its  view', 
and  was  firmly  grasped  by  the  oesophageal  wall. 

After  removai  of  the  grape  skins  the  coin  was 
successfully  removed  by  oesophagoscopy. 

The  frequent  impaction  of  small 
coins  — e.g.,  farthings  — accidentally 
swallowed,  which  have  a diameter  of 
only  10  mm.,  shows  that  it  is  not  always 
the  size  of  the  foreign  body  that  deter- 
mines its  stoppage  and  lodgment : — 

Tilley  315  reports  a case  where  he  removed  by 
the  oesopbagotcope  a farthing  which  had  been 
impacted  for  five  horns  in  the  (esophagus  of  a 
boy  aged  5 years. 

H.  J.  Davis 37  reports  a similar  case  in  a child  aged  2 years. 

Edward  I)  Davis 38  mentions  a third  case  in  a child  aged  9 months, 
where  a farthing  was  impacted  in  the  oesophagus  at  the  level  of  the 
bifurcation  of  the  trachea  for  one  month.  The  child  appeared  to  be 
unwell,  was  wheezy,  and  frequently  vomited.  By  X rays  the  coin  was 
localised  and  by  means  of  the  cesophagoseope  was  easily  extracted. 

The  writer  has  removed  a farthing  in  a child,  aged  2 years,  which  had 
been  impacted  at  the  level  of  the  second  dorsal  vertebra  for  13  days. 
(Pig.  34.)  Neither  liquids  nor  solids  could  be  swallowed  for  the  first 
seven  days,  everything  being  regurgitated  ; during  the  last  six  days, 
however,  the  child  was  able  to  swallow  milk,  and  even  bread  and  milk 
with  perfect  ease,  and  there  was  no  regurgitation.  Beyond  being  very 
fretful  and  constantly  crying,  the  child  appeared  to  be  quite  well. 

Such  cases  show  that  the  oesophagus  may  so  adapt  itself 
to  foreign  bodies  that  food  may  pass  by  without  giving  rise 
to  any  marked  trouble. 


Pig.  37.— Extraction  of  coin,  second  position. 

Figs.  36  and  37  show  the  extraction  of  a coin  by  the  non  slipping 
forceps  with  a spatula  extremity  endoscopic  tube. 

Tolerance  of  the  Oesophagus  to  Foreign  Bodies. 

That  the  mucous  membrane  of  the  oesophagus  is  most 
tolerant  to  foreign  bodies,  and  especially  to  pieces  of  money, 
is  shown  by  the  length  of  time  a foreign  body  may  be 
impacted  without  doing  any  material  harm  or  causing  any 
marked  symptoms.  Though  coins  may  have  been  impacted 
for  months  and  even  years  with  only  slight  inconvenience, 
and  the  disturbance  caused  by  them  attributed  to  other 
causes,  yet,  on  the  other  hand,  serious 
complications  may  occur — i.e. , oesophag- 
itis, peri-oesophageal  abscess,  medias- 
tinitis,  ulceration  and  perforation  of  the 
tracheo- oesophageal  wall,  contractures 
and  strictures  (from  long-continued 
presence). 


Monro  41  reports  a case  (previously  referred  to)  in  which  a halfpenny 
wa9  retained  in  the  oesophagus  of  a boy  for  three  years. 

Kellock 42  has  removed  a halfpenny  with  the  coin-catcher  from  the 
oesophagus  of  a little  girl  which  had  been  impacted  for  three  years,  and 
had  caused  no  symptoms. 

D.  K.  Paterson  43  reports  a case  where  a halfpenny  had  been  in  the 
oesophagus  for  18  months,  and  when  removed  by  oesophagoscopy  it 
looked  as  if  it  had  been  dug  out  of  a Roman  ruin  ; j et  it  had  given  rise 
to  no  ulceration. 

Walker  Downie44  had  a similar  case,  where  he  removed  bv  cesopha- 
goscopy  a halfpenny  lodged  in  the  oesophagus  of  a child.  When  6rst 
swallowed  the  story  was  not  believed,  since  nothing  passed  per  rectum, 
and  it  was  not  till  18  months  later  that  the  case  came  into  his  hands, 
and  the  X ray  was  used  and  licated  the  coin.  No  permanent  injury  to 
the  oesophagus  was  observed. 

Singletary 45  has  reported  the  case  of  a child,  aged  2 years  and 
3 months,  who  swallowed  a 5-cent  piece  (21  mm.  diameter),  which 
became  impacted  in  the  lower  part  of  the  pharynx  and  gave  rise  to  two 
or  three  attacks  of  pneumonia  yearly  for  eight  years.  Finally,  a large 
amount  of  blood  and  pus  was  vomited  and  the  coin  passed  per  anum, 
eight  years  and  two  months  after  it  had  been  swallowed. 

Porter  4«  reported  the  case  of  a boy,  aged  11  years,  who  had  complained 
of  indefinite  gastric  symptoms  for  three  weeks.  He  was  small  for  his 
age,  po  >rly  developed  and  weighed  only  2st.  10  lb.  The  father  stated 
that  the  boy  had  swallowed  a halfpenny  at  the  age  of  4,  and  had 
never  been  the  same  since.  An  X ray  showed  the  coin  lying  between 
the  fifth  and  sixth  dorsal  vertebra.  Un  introducing  forceps  it  slipped 
away,  passed  into  the  stomach,  aud  was  evacuated  later  in  the  „t.wis. 
On  careful  endoscopic  inspection  no  lesion  or  ulceration  of  the 
oesophageal  wall  could  be  detected.  In  two  weeks  the  boy  improved  so 
markedly  in  health  that  he  had  put  on  5 lb.  in  weight. 

Perforation  of  the  oesophagus  and  aorta  by  foreign  bodies. — 
Are  not  very  rare.  Adelmann  47  has  recorded  14  such  cases, 
Poulet  17,  and  Krause  21.  Fatal  laceration  of  the  oesophageal 
walls  and  perforation,  especially  of  the  aorta,  has  occurred 
in  from  a few  days  to  four  years.  Early  perforation,  however, 
according  to  Poulet,  is  very  rare,  only  2 cases  having  been 
recorded.  Generally  the  foreign  body  wounds  the  oesophagus, 
or  as  a result  of  continued  pressure  may  excite  inflammation, 
followed  by  ulceration,  suppuration,  and  perforation. 

Tilley  43  described  a case  in  which  a halfpenny  had  lodged  just  below 
the  cricoid  region  in  the  gullet  for  five  days.  On  direct  examination 
the  coin  was  seen  lying  in  an  ulcerated  area,  surrounded  by  oedematous 
granulations  It  was  removed  with  little  difficulty,  but  the  child  died 
the  same  night  from  collapse.  Post-mortem  showed  that  the  oesophagus 
had  ulcerated  right  through  into  the  trachea,  and  this  had  occurred  in 
five  days. 

Wishart 49  (Toronto)  states  that  a 5 centime  piece  has  caused  per- 
foration of  the  oesophagus  within  24  hours. 


Fig 


Guisez :is  (Paris)  reports  the  case  of  a 10- 
centime  coin  which  he  extracted  by  means  of 
the  cesophagoseope,  and  which  had  been  in  the 
oesophagus  tor  four  years.  (Fig.  12.) 

Halstead  4«  mentions  the  case  (previously 
referred  to)  of  a child  aged  5 years,  from  whom 
he  extracted  a 1-cent  piece  (penny,  U.S  A.) 
which  had  been  impacted  in  the  oesophagus 
since  infancy.  It  had  become  absorbed  to  such 
an  extent  that  it  had  lost  25  per  cent,  in 
weight,  and  was  not  more  than  two-thirds  of  its  normal  thickness. 
It  had  lodged  in  the  posterior  wall  of  the  cardiac  end  of  the  oesophagus 
and  had  become  embedded  or  encysted.  At  the  rate  of  absorption 
it  might  have  been  absorbed  in  20  years.  In  this  ease  but  for  the 
X rays  the  cause  of  the  obstruction  could  never  have  been  discovered , 
since  the  cesophagoseope  failed  to  show  it  until  the  wall  covering  the 
coin  was  removed. 


33  Proc.  Roy.  Soc.  Med.,  1913,  vi.  (Clinical  Sect.),  p.  152. 

3<i  Ibid.,  1914,  vii.  (Laryngol.  Sect.),  p.  20. 

37  Proc.  Roy.  Soc.  Med.,  1914,  vii.  (Laryngol  Sect.),  p.  20. 

<»  Ibid.,  1910,  iii.  (Laryngol.  Sect.)  p 136;  The  Lancet,  1914,  ii.,  p.  493. 

39  Maladies  de  I'CEsopbage,  1911,  p.  270. 

1908  ^ariC8KCS0°Pe'  1909’  X'X"  P'  520;  Trans’  Amer.  Laryngol.  Assoc., 


The  author’s  foreign  body  forceps,  showing 
the  blades  reversed. 


41  Cited  by  Durham  in  Holmes's  Surgery.  1883,  i.,  p.  78S. 

43  Trans.  Mel.  Soc.  Lone.,  1911.  xxxiv..  p.  454. 

43  Proc.  Roy.  Soc.  Med.,  1915, ix.  (Laryngol.  Sect.),  p.  40. 

44  Proc.  Scot.  Otol.  and  Laryngol.  Soc.,  Nov.  22nd,  1913;  Abstract 
Journ.  Laryngol.,  Rbinol.,  and  Otol.,  1914,  xxix.,  p.  98. 

45  Louisville  Med.  News.  vol.  x.,  p.  254,  cited  by  Bosworth,  Diseases  of 
Nose  and  Throat,  1892,  p.  322. 

4,1  Proc.  Scot.  Otol.  and  Laryngol.  Soc.,  Nov.  22nd.  1913;  Abstract 
Journ.  Larj  ngol,  Rbinol..  and  Otol.,  1914,  xxix.,  pp.  97-98. 

47  (junted  by  H.  Chiari,  Berl.  Klin.  Woch.,  Jan.  5th,  1914. 

43  Proc.  Roy.  Soc.  Med..  1912,  vi.  (Laryngol.  Sect.),  p.  42. 

49  Corps  Strangers  du  Tube  Digestal,  St.  Pierre  l’t'nion  Medicale  du 
Canada.  December,  1914. 


The  Lancet,] 


MR.  IRWIN  MOORE:  FOREIGN  BODIES  IN  THE  CESOl'HAGUS,  ETC.  [Sept.  27,  1919  575 


Urey  Turner  50  reports  a case  where  a halfpenny  was  impacted  in  the 
oesophagus  of  a boy,  aged  4 years,  for  1 year  and  10  months,  the  boy 
being  able  to  take  his  ordinary  food  and  having  no  difficulty  in 
swallowing.  The  coin  ultimately  perforated  the  aorta  and  death  from 
hsemorrlmge  ensued. 

li.  D.  Davis  51  reports  the  case  of  a child,  aged  2 years,  who  swallowed 
a halfpenny.  Five  years  later  a little  blood  was  vomited,  followed  the 
same  night  by  a profuse  haemorrhage  and  death  occurred.  Poet  moitem 
it  was  found  that  the  coin  had  caused  ulceration  into  the  aorta.  Also  he 
reports  another  case52  where  a child,  aged  5,  swallowed  a halfpenny. 
One  week  later  a radiogram  showed  the  coin  in  the  gullet.  It  was 
removed  by  a skillod  ocsophagoscopist,  but  ulceration  had  already 
occurred  into  the  left  bronchus,  and  the  child  died  from  broncho- 
pneumonia. . 

Bradley53  records  the  case  of  a man  who  swallowed  a counterfeit 
half-crown.  Eight  months  afterwards  death  occurred  from  sudden 


Fig.  39. — Semi-diagrammatic  sectional  view  of  the  cesophagus,  showing 
the  forceps  with  reversed  blade  insinuating  itself  between  an 
(esophageal  fold  and  an  impacted  coin, 
profuse  harmorrbage.  and  the  coin  was  found  to  have  produced 
ulceration  of  the  gullet  extending  into  the  aorta. 

In  Jewell’s54  esse,  already  referred  to  (Figs.  32  and  33),  a coin 
perforated  through  the  oesophageal  wall  into  the  posterior  medi- 
astinum in  13  days,  and  caused  death  A counterfeit  coin55  has 
been  reported  which  was  impacted  for  12  months  in  the  oesophagus 
of  a convict  and  caused  ulceration  and  perforation  of  the  aorta. 

(t  Kollnek  50  refers  to  the  case  of  a lead  weight— the  diameter  of  which 
was  just  that  of  a halfpenny— impacted  low  down  in  the  oesophagus. 
It  ulcerated  through  and  formed  an  abscess  in  the  mediastinum, 
eventually  causing  death  in  10  days.  He  also  had  a case  where  a button 
had  been  swallowed,  and  within  10  days  it  had  caused  perforation  of 
the  aorta. 

While  it  is  easy  to  understand  why  sharp  or  angular  foreign 
bodies  may  give  rise  to  inflammatory  and  destructive  changes 
in  the  oesophagus,  it  is  not  easy  to  explain  why  smooth  and 
circular  objects,  such  as  coins,  should  in  some  cases  cause 
ulceration  and  perforation  and  in  others  remain  harmless 
and  give  rise  to  no  symptoms,  even  though  worn  and  corroded 
by  long  sojourn.  It  is  likely  that  impaction  in  the  neigh- 
bourhood of  the  constrictions,  and  especially  the  dangerous 
regions  of  the  aortic  arch,  along  with  excessive  spasm  of 
the  oesophageal  walls,  may  be  the  chief  predisposing  causes 
A septic  condition  of  the  foreign  body  and  alteration  in  the 
secretions  may  also  be  a determining  factor.  D’Este  Emery,  " 
in  discussion,  has 
suggested  that  the 
chemical  composi- 
tion of  the  substance 
impacted  may  have 
something  to  do 
with  the  condition 
set  up,  and  he  con- 
siders that  whereas 
copper  is  a strong 
antiseptic,  as 
shown  by  the  fact 
that  typhoid  cultures 
placed  in  a vessel  of  pure  copper  become  sterile  in  a few 
hours,  in  the  case  of  lead  this  would  not  be  so.  It  is 
interesting  to  note,  however,  that  metallic  poisoning  may 
occur  owing  to  the  impaction  of  copper  coins,  as  shown  by 
the  following  cases  : — 

Lee  58  reports  the  case  of  a child,  aged  5 years,  who  swallowed  a half- 
penny. It  was  forced  into  the  stomach  with  a bougie.  Enteritis 
followed  and  death,  which  was  due  to  the  mechanical  irritation  pro- 
duced by  the  passage  of  the  coin  through  the  intestine  and  to 
poisoning  by  the  copper,  evidence  of  the  existence  of  the  latter  in 
considerable  quantities  being  discovered  on  testing  the  mucous  mem- 
brane and  contents  of  the  intestines. 

Faucon  59  (Paris)  records  a similar  case. 

50  The  Lancet,  1910,  i..  p.  1335. 

51  Proc.  Eoy.  See.  Med..  1915,  viii.  (Laryngol.  Sect.)  p. 

52  The  Lancet,  1914,  ii.,  p.  493. 

53  Med.  Times,  1868,  ii.,  p.  447,  cited  by  Durham  in  Holmes's  Surgery, 
3883,  i.,  p.  787. 

54  Proc.  Roy.  Soc.  Med.,  1915,  viii.  (Laryngol.  Sect..),  p.  108. 

55  New  York  Med.  Jour.,  Dec.  10th,  1869,  p.  335. 

56  Trans.  Med.  Soc.  Lond.,  1911,  xxxiv.,  p.  454. 

st  Ibid. 

58  St.  George’s  Hosp.  Reports,  1869,  iv.,  p.  219. 

39  Bull,  de  la  Soc.  de  Chir.,  1877,  iii.,  p.  158. 


DistensibiUty  of  the  Infantile  (Bsophagus. 

lb  is  remarkable  what  large  objects  may  be  introduced 
even  into  the  infantile  oesophagus,  and  the  extent  to  which 
its  walls  are  distensible,  as  shown  in  the  cases  reported. 
The  oesophagus  of  a child  aged  4 years,  which  is  no  wider 
than  10  or  12  mm.  (|  to  1 inch),  can  be  so  distended  that  it 
is  capable  of  admitting  an  object  of  much  greater  diameter — 
e.g. , a halfpenny,  which  measures  25  mm.  (1  inch) — whilst 
in  addition  it  will  permit  the  free  passage  of  a metal  tube  of 
10  mm.  (|  inch)  diameter,  and  even  one  of  11  or  12  mm. 
This  is  not  unusual  and  is  possible  even  with  larger  coins 
and  at  a much  earlier  age. 

In  Halstead’s60  case  of  a child,  aged  5 years  (already  referred  to), 
from  whom  he  extracted  a one  cent  piece  measuring  20  mm.  in 
diameter,  it  was  impacted  at  the  cardiac  end  of  the  oesophagus.  The 
child  had  swallowed  it  during  infancy,  and  was  supposed  to  be  Buffering 
from  a congenital  stenosis  which  had  caused  constant  regurgitation  of 
fool  and  almost  starvation  since  infancy.  The  coin  was  so  encysted 
I hat  it  was  necessary  to  curette  the  posterior  (esophageal  wall  before 
it  was  possible  to  seize  the  coin  with  forceps. 

McKinney  81  also  reports  the  case  of  a halfpenny  removed  from  the 
oesophagus  of  a child,  aged  15  months.  It  had  been  firmly  impacted 
just  above  the  suprasternal  notch  for  six  davs,  and  only  liquids  could 
be  swallowed.  It  required  considerable  force  to  dislodge  it. 

Rate  of  Passage  of  JYon-impacted  foreign  Bodies. 

In  those  cases  where  foreign  bodies  do  not  become 
impacted,  but  safely  pass  through  the  food  passages,  it  is 
interesting  to  note  their  rate  of  passage. 

Mosher62  refers  to  the  case  of  a baby,  aged  1 year,  who  swallowed  a 
button  measuring  25  mm.  (1  inch)  in  diameter.  It  travelled  through 
the  entire  (alimentary  canal,  safely  negotiated  the  pylorus,  and  in  24 
hours  was  evacuated  per  rectum.  It  took  three  days  from  the  time  it 
was  swallowed  before  it  was  discharged.  He  also  records  another  case63 
where  a mother-of-pearl  button,  measuring  27  mm. — i.e.,  1 1/16  inch — 
diameter,  was  swallowed  by  a child  8 years  of  age,  which  passed  in  a few 
days  and  gave  rise  to  no  svmptoms.  Also  a metal  button  in  a child  aged 
1 year  and  7 months,  which  remained  at  the  level  of  the  clavicle  for  three 
days,  was  dislodged  by  the  endoscopic  tube,  delayed  at  the  cardiac 
orifice  of  the  stomach,  and  entered  the  stomach  in  24  hours.  In 
48  hours  it  had  passed  the  pylorus  and  was  at  the  brim  of  the  pelvis. 
Here  it  was  delayed  for  three  days  and  was  then  discharged. 


Fig.  40. — The  Kahler  electroscope  adapted  by  the  author  for  use  with  Briimngs's 
or  Hill’s  tubes.  Showing  Irwin  Moore's  non-slipping  extraction  forceps  in 
position.  A,  Fixation  screw  for  removable  handle.  B,  Slot  for  fixing  handle 
in  the  straight  position.  C,  Reflector  lever  and  spring.  D,  Mouth  of  endo- 
scopic tube.  E,  Lamp  with  focussing  lens  F,  Contact  lever  for  electric 
current.  G,  Removable  handle  of  electroscope,  H,  Cords  for  attachment  to 
electric  current.  I,  Adjusting  screw  of  reflector.  K,  Concave  reflector. 

M,  Handle  of  forceps,  n,  Screw  for  fixing  forceps  revolving  shaft  to  handle. 

Chevalier  Jackson  64  reports  the  case  of  a penny  located  at  the  level 
of  the  cricoid  cartilage,  dislodged  by  examination  with  the  examining 
tube,  and  passed  per  rectum  in  nine  days. 

It  would  appear  that  coins  lodge  longest  of  all  at  the 
level  of  the  cricoid  cartilage,  next  in  the  region  of  the 
clavicles,  and,  lastly,  at  the  upper  and  lower  parts  of  the 
intestinal  canal.  They  seldom  stop  at  the  cardiac  orifice, 
and  pass  easily  and  quickly  through  the  pylorus.  It  is 
easy  to  understand  why  they  stick  at  the  back  of  the  cricoid 
whilst  at  the  sternal  level,  the  thymus  gland  or  arch  of  the 
aorta  causes  constriction  of  the  gullet  and  may  hold  them  up 
in  this  situation. 

These  cases  show  the  serious  dangers  of  delay,  even  though 
in  many  instances  serious  symptoms  have  been  long 
postponed,  and  that  no  time  should  be  lost  before  steps  are 
taken  before  their  removal  by  endoscopic  methods. 

(To  be  continued.) 


, 40. 


60  Laryngoscope,  1909,  xix..  p.  520. 

64  Ibid.,  1912,  xxii.,  p.1226. 

62  Ibid.,  1909,  xix.,  p.  414. 

63  Ibid. 

64  Cited  by  Ballenger  : Diseases  of  Throat  and  Ear,  1908,  p.  566. 


576  The  Lancet,] 


DR.  S.  OTABE:  WHEAT  CULTURE-MEDIA. 


[Sept.  27,  1919 


WHEAT  CULTURE-MEDIA. 

By  SHOZABURO  OTABE,  M.D.  Bale, 

MEDICAL  SUPERINTENDENT  (TEMPORARY),  NATIONAL  SANATORIUM, 
BENKNDKN,  KENT;  FORMERLY  ASSISTANT  MEDICAL  OFFICER, 
KENSINGTON  INFIRMARY,  LONDON;  ASSISTANT,  BACTERIO- 
LOGICAL INSTITUTION,  TOKIO  CHARITY  HOSPITAL 
MEDICAL  COLLEGE. 


Since  Pasteur 1 and  Koch 2 suggested  the  use  of  malt 
extract  for  culture-media,  many  bacteriologists  have  made  a 
trial  of  the  same,  but  this  has  not  been  successful  and  malt 
extract  has  not  come  into  general  use.  My  own  studies  of 
the  employment  of  grain  extracts  cover  a period  of  nearly 
10  years.  Wheat  is  not  only  much  cheaper  than  meat,  but 
it  is  more  convenient  to  get  and  to  carry  about.  It  is  neces- 
sary, too,  to  keep  in  mind  the  sporadic  influence  of  patho- 
genic bacteria  and  to  prepare  both  vaccine  and  immune 
serum,  if  possible,  at  the  place  where  the  epidemic  broke 
out  and  from  the  actual  strain  of  bacteria  which  caused  the 
epidemic  at  that  locality.  For  this  purpose  the  first  requisite 
is  to  get  suitable  culture-media.  In  some  places  it  is  difficult 
to  get  meat  or  its  extract,  though  it  is  easy  to  preserve 
them,  while  wheat  can  readily  be  obtained  almost  everywhere 
and  as  readily  preserved.  My  experimental  results  show 
that  there  is  no  more  value  in  meat-extract  culture-media 
than  in  wheat-extract  culture-media. 

Method  of  Making  Wheat  Media. 

1.  Wheat  broth. — A.  Roast  the  wheat  (with  or  without 
husk)  in  an  iron  pan  until  it  becomes  brown.  B.  Put 
1 lb.  of  the  roasted  wheat  without  washing  into  1600  c.cm. 
of  distilled  water.  C.  Boil  this  in  Koch’s  boiler  for 
half  an  hour.  D.  Strain  through  a clean  cloth.  E.  Make 
up  to  1000  c.cm.  with  distilled  water  if  under  this  quantity. 
F.  Add  0 5 g.  of  taka-diastase  or  ordinary  diastase  and 
shake  the  flask  well.  The  temperature  of  the  contents  at 
this  time  should  be  maintained  at  30°  to  40°  C.  fur  half  an 
hour.  G.  Filtration.  The  resultant  fluid  ought  to  be  quite 
transparent  with  yellowish  colour,  almost  the  same  as 
ordinary  meat  broth.  The  fluid  has  a sweet  smell,  the 
reaction  being  slightly  alkaline.  H.  As  we  make  usual 
broth,  add  5 g.  of  sodium  .chloride  and  10  g.  of  peptone 
albumin,  then  boil  and  filter. 

2.  Wheat  agar. — Add  15  g.  (in  winter)  or  20  g.  (in  summer) 
of  agar  to  the  above  quantity.  For  the  rest  the  preparation 
is  almost  the  same  as  that  of  meat  agar  as  usually  prepared. 
Many  special  culture-media  can  be  made  of  the  wheat  broth 
and  agar  media. 

Cultural  and  Agglutination  Tests. 

To  compare  the  rate  of  bacterial  growth  on  the  various 
media  I used  Staphylococci  albus  and  aureus , B.  coli , 
B.  typhosus , B.  dysenteries,  Vibr.  cholercs , and  others,  and 
found  almost  the  same  growth  in  each  case  on  the  different 
media. 

The  difference  of  agglutination  reaction  of  the  bacteria 
cultivated  on  two  different  culture  media  was  then  tested. 


Staphylococcus.  B.  coli. 


Dilution  of 
serum. 

Cultured  on — 

Dilution  of 
serum. 

Cultured  on  — 

Wheat 

agar. 

Meat 

agar. 

Wheat 

agar. 

Meat 

agar. 

10 

+ 

+ 

25 

+ 

+ 

50 

+ 

+ 

50 

+ 

+ 

100 

+ 

+ 

10 

+ 

+ 

200 

+ 

+ 

200 

+ 

+ 

300 

- 

- 

400 

+ 

+ 

600 

- 

- 

Agglutination  positive,  + ; negative,  — . 


For  therapeutic  purposes  I have  made  autogenous  vaccines 
from  cultures  of  the  above-mentioned  bacteria  on  wheat 
media  and  observed  good  results. 

Summary. 

The  experimental  results  given  prove  that  wheat  can  be 
used  instead  of  meat  for  culture  media.  As  the  wheat- 

1 Etudes  sur  la  Mire,  Paris. 

3 Mitth.  a.  d.  K.  Gsndlitamte.,  i.,  I.,  Berlin. 


A B C D 


Growth  of  B.  coli  on  wheat  culture  media  and  ordinary  meat  media 
compared.  A,  Wheat  broth;  B,  Ordinary  broth;  C,  Ordinary  agar; 
D,  Wheat  agar. 

extract  culture-media  contains  maltose,  they  can  be  used  as 
special  media  for  particular  bacteria  and  for  diagnostic 
purposes. 


$Uhietos  anb  ftatices  cf  ^oobs. 


Trench  Fever;  a Louse-borne  Disease.  By  W.  Byam, 

J.  H.  Cabroll,  J.  IT.  Churchill,  Lyn  Dimond,  V.  E. 
Sorapure,  R.  M.  Wilson,  and  Ll.  Lloyd.  With  an 
Introduction  by  Sir  T.  H.  Goodwin,  K.C.B.,  a Foreword 
by  Sir  David  Bruce,  and  a Summary  of  the  Report  of 
the  American  Trench  Fever  Commission  by  R.  H.  Vercoe. 
London  : Henry  Frowde  and  Hodder  and  Stoughton.  i 
1919.  Pp.  196.  10*.  6 d. 

The  findings  of  the  War  Office  Trench  Fever  Investigation 
Committee  have  now  been  made  available  in  an  attractive 
volume  of  the  Oxford  Medical  Publications.  The  committee, 
under  the  chairmanship  of  Sir  David  Bruce,  was  composed  of 
the  following  workers  : Lieutenant-Colonel  D.  Harvey,  Mr. 

A.  W.  Bacot,  Major  W.  Byam,  Lieutenant- Colonel  H. 
French,  Mr.  J.  A.  Arkwright,  Sir  W.  M.  Fletcher.  Lieu- 
tenant A.  F.  Hird,  and  the  late  Professor  H.  Plimmer ; their 
results  are  adequate  testimony  to  the  great  possibilities  of 
well-coordinated  research  work.  It  is  certainly  true  that 
much  remain?  b?  found  out  about  trench  fever.  We  are 
still  complete'/  ^norant  of  the  causal  organism,  as  of  any 
efficient  meaut  of  treatment,  but  the  positive  incrimination 
of  the  louse  as  the  carrier  of  the  disease  puts  us  well  on  the 
road. 

It  has  been  argued  that  trench  fever  is  a war  disease  and 
will  perish  unaided  when  the  trenches  are  filled  in.  Sir 
Charles  Burtchaell,  in  a recent  address  dealing  with  disease 
as  affecting  success  in  war,  said:  “With  the  cessation  of 
hostilities  the  disease  [trench  fever],  for  the  moment  at  all 
events,  ceased  to  be  of  any  immediate  practical  importance, 
as  it  was  only  under  the  conditions  of  trench  life  that  there 
were  real  difficulties  in  keeping  troops  free  from  lice.”  The 
authors  do  not  agree  with  this  view.  There  is  evidence,  they 
say,  that  the  disease  has  existed  since  the  twelfth  century, 
and  certainly  so  long  as  lice  are  allowed  to  dwell  in  security 
among  men  there  will  always  be  the  danger  of  its  reappear- 
ance. Neither  can  we  afford  to  overlook  the  possibility  of 
the  human  race  being  again  confronted  with  the  horrors  of 
warfare,  minor  as  well  as  major. 

In  a foreword  written  in  May,  1918,  Sir  David  Bruce 
reviews  the  research  work  carried  out  in  England.  France, 


The  Lancet,] 


REVIEWS  AND  NOTICES  OF  BOOKS. 


[Sept.  27,  1919  577 


and  Germany  up  to  that  date,  and  shows  that  no 
satisfactory  evidence  on  tire  transmission  of  the  disease 
had  been  brought  forward  when  the  British  and  American 
commissions  began  their  task  at  the  end  of  1917.  He  pays  a 
warm  tribute  to  the  courage  of  those  who  volunteered  as 
experimental  subjects,  and  without  whose  self-sacrifice  no 
progress  could  have  been  made.  The  account  of  these 
experiments  in  the  chapter  on  transmission  makes  romantic 
reading.  By  means  of  the  very  exact  work  done  in  the 
laboratory  at  Hampstead  several  conclusions  of  vital  import- 
ance to  prophylaxis  were  finally  arrived  at.  Trench  fever 
is  not  a disease  caused  by  normal  lice,  but  the  excreta  from 
pediculi  fed  on  trench-fever  patients,  applied  to  an  abraded 
skin  area,  are  capable  of  producing  a febrile  illness  similar 
in  its  relapsing  character  and  general  clinical  picture  to  the 
disease  at  present  known  as  trench  fever.  Louse  excreta 
may  be  virulent  without  the  presence  of  vermin,  and  this 
virulence  is  retained  in  the  excreta  even  after  so  long  a 
period  as  120  days.  The  infection  is  not  communicable  by 
the  mouth,  but  it  has  taken  place  through  the  unbroken 
conjunctiva.  The  excreta  can  infect  when  introduced  sub- 
cutaneously, and  although  the  causative  organism  has  not 
been  isolated  the  outline  of  its  life-history  is  beginning  to 
take  shape.  When  lice  are  fed  on  patients  during  an 
afebrile  stage  of  the  disease  they  become  capable  of  con- 
veying the  infection.  This  infection  is  therefore  present  in 
the  peripheral  blood  of  the  human  subject  during  the 
afebrile  intervals.  It  is  also  claimed  that  the  number  of 
trench  fever  organisms  passed  by  the  lice  increases  as  the 
time  from  the  infecting  blood-feed  lengthens.  The  incuba- 
tion period  in  the  human  subject  was  never  less  than  seven 
days,  but  varied  up  to  16  days  as  the  infecting  dose  was 
decreased. 

The  chronic  disease  is  carefully  described,  particular 
attention  being  devoted  to  the  vagal  disturbances  of  the 
circulation.  There  is  a short  chapter  on  prognosis  which 
should  be  useful  to  members  of  pensions  boards.  The 
main  suggestions  in  regard  to  treatment  are  concerned  with 
prophylaxis,  and  as  the  most  important  measure  of  prophy- 
laxis is  the  extermination  of  lice  this  chapter  has  a wider 
application  than  any  other  part  of  the  book.  It  will,  for 
example,  be  read  with  interest  by  those  who  are  at  present 
engaged  in  suppressing  typhus  in  Central  Europe. 

The  report  of  the  Commission  of  the  American  Red 
Cross  Research  Committee  on  Trench  Fever — a review  of 
which  appeared  in  The  Lancet  of  Oct.  12th  last  year — is 
summarised  by  Lieutenant  R.  H.  Vercoe  in  the  concluding 
appendix.  That  the  louse  is  the  main  astiological  factor 
in  trench  fever  is  common  to  the  conclusions  of  both  British 
and  American  Commissions,  but  whereas  the  British  regard 
the  louse-bite  as  an  uncommon  mode  of  .nfection,  this  is 
looked  upon  as  the  most  frequent  origin  of  the  disease  by 
the  American  Commissioners.  The  agreement  is,  however, 
more 'important  to  preventive  medicine  than  the  difference. 
The  publication  of  this  work  should  stimulate  thought  and 
lead  to  further  important  discoveries. 


Massage  and,  the  Original  Swedish  Movements.  By  the  late 
Kurre  W.  Ostrom.  Edited  by  P.  Silfyerberg,  G.D. 
Eignth  edition,  illustrated.  London  : H.  K.  Lewis  and 
Co.,  Ltd.  1919.  Pp.  X.-196.  5.«.  net. 

The  author  admits  that  “several  movements  belonging  to 
the  Swedish  system  have  been  omitted,”  and  so  the  reader  of 
this  little  book  will  not  expect  to  find  in  its  pages  all  that  is 
to  be  known  of  Swedish  massage  and  movements.  It  is,  in 
fact,  a compendium  of  elementary  lectures.  The  funda- 
mental positions  and  Swedish  exercises  described  are  clearly 
expressed  and  well  illustrated.  But  in  other  respects  the 
medical  man  will  find  much  to  criticise.  For  example, 
almost  equal  space  is  devoted  to  what  can  only  be  described 
as  “ beauty  massage  ” and  to  the  treatment  of  all  types  of 
recent  injury,  while  the  elementary  doctrine  of  inhibiting 
the  action  of  antagonistic  muscles  when  treating  a case  of 
paralysis  is  referred  to  as  a “ recent  experiment.”  The  best 
section  is  that  which  deals,  very  shortly,  with  spinal  curva- 
ture, but  differentiation  is  lacking  between  cases  of  advanced 
scoliosis  and  static  or  postural  curvatures.  A short  chapter 
on  massage  treatment  in  America  leads  the  reader  to  the 
conclusion  that  the  sooner  some  recognised  standard  of 
training  is  established  the  better  it  will  be  for  the  general 
public.  The  bibliography  is  unusually  full  and  satisfactory. 


Essentials  of  Surgery . By  Archibald  L.  McDonald,  M.D. , 
The  Johns  Hopkins  University,  Lecturer  on  Surgery, 
Nurses’  Training  School,  St.  Luke’s  Hospital,  Duluth, 
Minnesota.  With  46  illustrations.  London  and  Phila- 
delphia : J.  B.  Lippiucott  Company.  1919.  Pp.  265. 
8s.  6 d.  net. 

This  volume  is  an  addition  to  the  Lippincott  Nursing 
Manuals.  It  is  designed  for  the  use  of  senior  nurses  and  is 
written  in  the  belief  that  a nurse  can  assist  in  the  care  of 
her  patient  more  intelligently  if  she  be  primarily  equipped 
with  a reasonable  knowledge  of  the  injuries  and  diseases 
with  which  she  is  likely  to  meet.  The  notes  make  no 
attempt  to  discuss  technical  nursing  details  or  to  provide  an 
elaborate  treatise  on  anatomy,  physiology,  or  bacteriology. 
The  advantage  of  this  is  seen  in  the  fact  that  in  so  small  a 
volume  the  author  is  able  to  deal  adequately  with  the 
essentials  of  surgical  disease. 

The  diagrams  are  very  simple  and  clear,  the  subject 
matter  is  laid  out  well,  according  to  systems.  At  the  end  of 
each  chapter  is  a list  of  demonstrations  suitable  for  illustra- 
tion of  the  various  points  detailed  therein  which  will  be  of 
great  practical  value  to  those  who  lecture  to  nurses.  A 
brief  but  useful  glossary  of  medical  terms  is  to  be  found  at 
the  end  of  the  volume. 

To  compile  a book  of  this  nature  requires  knowledge  of 
nurses  as  well  as  nursing.  It  is,  moreover,  a matter  of 
difficulty  to  strike  the  happy  medium  between  a treatise  on 
surgery  and  a guide-book  to  the  intelligent  nursing  and 
treatment  of  disease.  In  our  opinion  the  author  has 
succeeded  in  both  these  respects.  The  nurse  who  is  really 
keen  will  be  able  to  satisfy  her  thirst  for  knowledge  of 
surgery  in  this  book  alone  ; while  to  the  surgeon  who  is 
called  on  to  give  lectures  to  nurses  this  book  will  be  invalu- 
able for  both  junior  and  senior  courses. 


A Manual  of  Gynecology.  By  John  Cooke  Hirst,  M.D., 
Associate  in  Obstetrics,  University  of  Pennsylvania. 
With  175  illustrations.  London  and  Philadelphia  : 
W.  B.  Saunders  Company,  Ltd.  1918.  Pp.  466.  12s. 

In  this  little  manual  the  author  has  presented  the  arrange- 
ment of  the  subject  he  has  used  for  the  last  20  years  in  his 
teaching.  The  book  contains  a considerable  amount  of 
information  in  a concise  and  clear  form.  We  may  not 
agree  with  all  the  author’s  teaching  or  methods  of  treat- 
ment, but  the  work  is  a good  example  of  its  kind  and  should 
prove  helpful  to  the  students  for  whom  it  has  been  written. 
Whether  it  is  wise,  or,  indeed,  necessary,  to  increase  the 
size  of  such  a book  by  including  chapters  on  diseases  of  the 
breast,  the  urinary  tract,  and  the  rectum  is  a matter  upon 
which  there  may  well  be  some  difference  of  opinion  ; we  do 
not  think  it  is.  The  illustrations  are  fair,  and  the  index  is 
a good  one. 


The  Exact  Diagnosis  of  Latent  Cancer.  By  O.  C.  Gruner, 
M.D.  London:  H.  K.  Lewis  and  Co.,  Ltd.  1919. 
Pp.  79.  Is.  6 d. 

This  book  is  essentially  one  for  the  clinician  and  clinical 
pathologist,  but  in  many  places  the  meaning  is  obscure  from 
the  arbitrary  use  of  newly-coined  technical  terms.  Although 
it  would  be  impossible  without  voluminous  quotations  to  give 
a summary  of  Dr.  O.  C.  Gruner’s  book,  we  must  remark  that 
statements  such  as  “lymphocytosis  indicates  relative 
alkalinity,  lymphopenia  relative  acidity,  of  the  serum,”  are 
freely  introduced  without  evidence  to  support  them.  The 
author  is  an  enthusiast,  but,  we  fear,  has  little  prospect  of 
becoming  a pioneer  until  he  enshrines  his  views  in  less 
cumbrous  language,  and  is  more  detailed  in  his  evidence. 


Freemasons’  Hospital  for  Paying  Patients. — 
Under  the  presidency  of  the  Lord  Mayor  a meeting  was  held 
at  the  London  Mansion  House  on  Sept.  19th  to  discuss  a 
scheme  for  the  utilisation  of  the  Freemasons’  War  Hospital 
(formerly  the  Chelsea  Hospital  for  Women)  as  a nursing 
home  for  paying  patients  of  limited  means  who  are  members 
of  their  craft  and  their  families.  It  was  decided  to  submit 
the  matter  to  a meeting  of  representatives  of  the  lodges 
which  had  taken  part  in  the  founding  of  the  war  hospital, 
and  other  supporters,  to  be  held  at  the  Mansion  House  on 
Oct.  10th,  at  4 p.m. 


578  The  Lancet,] 


FRENCH  SUPPLEMENT  TO  THE  LANCET. 


[Sept.  27,  1919  '• 


FRENCH  SUPPLEMENT  TO  THE  LANCET 

Under  the  Editorial  Direction  of 

Professor  CHARLES  ACHARD,  AND  Dr.  CHARLES  FLANDIN,  D.S.O., 

PROFESSOR  OF  PATHOLOGY  AND  THERAPEUTICS  IN  THE  CHEF  DE  CLINIQUE  A LA  FACULTE  DE  PARIS. 

UNIVERSITY  OF  PARIS. 


DYSIDROSIS:  ITS  PARASITIC  NATURE. 

By  J.  DARIER, 

PHYSICIAN  AT  THE  HOSPITAL  OF  ST.  LOUIS;  MEMBER  OF  THE 
ACADEMY  OF  MEDICINE. 

During,  the  war  I have  noticed  that  whenever  a soldier, 
either  from  the  armies  or  the  interior,  presented  himself  at 
a dermatological  consultation  for  a vesiculo-bullous  or 
squamous  eruption  limited  to  the  hands  and  feet,  three 
diagnoses  were  usually  considered : eczema,  occupational 
dermatitis,  or  dysidrosis  ; very  exceptionally  a parasitic 
mycotic  affection  was  thought  of. 

It  is  necessary,  first  of  all,  to  examine  what  these  diagnoses 
mean.  What  is  understood  by  eczema  ? Standing  by  itself, 
this  term  entirely  lacks  precision.  Do  we  mean  true  or 
diathetic  eczema , which  I have  suggested  calling  eczema- 
tosis  ? It  would  then  be  a matter  of  a disturbance  of 
metabolism,  thanks  to  which  the  skin  possesses  an 
exaggerated  vulnerability  aDd  reacts  in  eczematous  form  to 
the  slightest  and  most  various  irritants.  It  must  be 
remarked  that  this  morbid  state  is  hardly  ever  found  in  the 
case  of  adults  enjoying  good  general  health,  and  that  there 
is  no  reason  for  the  eruption  to  be  confined  to  the  extremities. 

Have  we  got  seborrhwio  eczema  in  our  mind  ? It  prefers 
to  localise  itself  on  the  head  and  trunk,  and  only  reaches  the 
palmar  and  plantar  regions  exceptionally,  never  exclusively. 
On  the  other  hand,  the  professional  eczemas,  whether  caused 
by  medicaments  or  otherwise,  grouped  under  the  name  of 
artificial  dermatites,  have  their  seat  in  the  hands,  and  are  far 
rarer  on  the  feet.  It  is  well  known  that  the  particularly 
exposed  professions  are  those  of  mechanic,  factory,  and 
laundry  hands,  scullions,  masons,  painters,  photographers, 
hairdressers,  grocers,  and  gardeners ; that  these  artificial 
dermatites  can  be  provoked  by  a crowd  of  irritant  substances, 
such  as  the  various  forms  of  mercury,  phenol,  antiseptics 
generally,  reducing  agents,  distilled  oils,  &c.  The  initial 
topography  of  the  lesions  and  inquiry  about  the  occupation 
of  the  patient  very  quickly  make  it  clear  whether  one  can 
stop  at  this  interpretation.  Very  rarely  one  will  have  to  deal 
with  intentionally  provoked  dermatitis,  the  origin  of  which 
is  concealed  by  the  patient.  As  for  Tilbury  box's  dysidrosis, 
Hutchinson's  chiropompholyx , or  simply  pompholyx , it  is  a 
vesiculo-bullous  dermatitis,  later  on  squamous  in  type,  which 
has  as  essential  character  its  limitation  to  the  hands  and 
feet.  According  to  the  authors,  the  eruption  comes  on  in 
recurring  attacks,  especially  in  spring  and  summer.  It 
appears  symmetrically  on  both  hands  or  both  feet,  or  on  all 
four  extremities  at  once  ; it  announces  itself  by  a feeling 
of  “ burning  or  tingling.”  It  often  comes  on  after  profuse 
perspirations,  violent  exercise,  or  a nervous  shock,  in  both 
sexes  and  in  adolescents  and  adults.  The  authors'  very 
generally  make  it  appear  that  dysidrosis  patients  are  almost 
always  overworked,  dyspeptic,  neurasthenic,  nervously 
depressed  people.  According  to  these  data  dysidrosis  would 
be  a particular  kind  of  eczema  arising  from  sudation  or  a 
hyperidrosis  in  subjects  predisposed  to  it  by  their  general 
state. 


Characteristics  of  Eczema  and  Differential  Diagnosis. 

The  following  characteristics  are  specially  given  as 
distinctive  marks  of  “eczema”:  the  topography  of  the 
eruption  ; the  deep  seat  of  the  vesicles,  which,  especially  on 
the  lateral  faces  of  the  fingers,  resemble  “ boiled  sago 
grains  embedded  in  the  skin  ” ; the  fact  that  the  vesicles, 
and  the  blisters  resulting  from  their  coalescence  on  an  only 
slightly  inflamed  basis,  have  little  tendency  to  burst,  do  not 
rnn  plentifully  when  opened,  but  on  the  contrary  dry  up 
within  10  or  15  days,  leaving  circles  or  polycyclic  surfaces 
edged  with  an  epidermic  collar.  The  relation  which  T.  Fox 
believed  to  exist  between  the  vesicles  and  the  sudoriparous 
canals  has  been  shown  to  be  only  accidental  by  Hutchinson, 
Robinson,  R Crocker,  W.  Williams,  and  myself.  In  none  of 
the  publications  with  which  I am  acquainted  is  any  mention 
made  of  the  state  of  the  nails,  which  I have  always  found 
intact  in  cases  labelled  dysidrosis. 

Within  the  last  15  years  it  has  been  found  that 
various  epidermomy coses  can  more  or  less  exactly  imitate 
dysidrosis  and  the  eczemas  of  the  extremities.  There  is 
firstly  palmar  and  plantar  trichophytosis,  which  Djelaleddin 
Mouktar  was  the  first  to  describe  clearly  to  the  French 
Society  for  Dermatology  and  in  the  Annales  de  Dermatologic 
in  1892,  based  on  the  cases  which  he  had  observed  when 
working  under  our  master,  Professor  A.  Fournier.  As  marks 
distinguishing  it  from  dysidrosis  he  indicates  the  following  : 
habitual  unilateralness,  vesicles  less  numerous  and  less 
scattered,  less  pruritus  ; in  the  period  of  desquamation 
extensive  erythemato-squamous  blotches  clearly  circum- 
scribed, edged  with  a very  clean  epidermic  collar,  with 
frequent  reproduction  of  some  vesicles  within  the  area  of  the 
blotches  or  on  their  circumference.  Finally,  and  above  all, 
microscopic  examination  of  the  roof  of  the  vesicle  and  the 
squamous  cells  reveals  the  presence  of  a sporular  mycelium, 
sometimes  very  abundant,  sometimes  hard  to  discover.  In 
short,  this  palmar  and  plantar  trichophytosis  presents  itself 
in  a very  special  aspect ; it  ordinarily  resembles  psoriasis 
or  the  syphilides  usually  found  in  those  regions  rather 
than  dysidrosis.  Then  there  is  epidermophytosis,  with 
which  the  works  of  Sabouraud  from  1907  to  1910 
have  made  us  acquainted.  This  mycosis  is  due  to  a 
parasite  nearly  allied  to  the  tricophyton,  the  Epidermo- 
phyton  inguinale  sex  intertriginis,  which  does  not 
attack  the  hairs.  Epidermophytosis  has  two  favourite 

seats.  In  the  groin  and  at  the  top  of  the  thigh  it  causes 
the  eruption  known  as  Hebra's  eczema  marginatum;  there 
are  bright  rosy,  round  or  polycyclic  patches,  extending 
rapidly,  with  clear  edges,  scalloped  and  often  delicately 
vesicular.  This  eczema  marginatum  may  invade  the 
abdomen,  the  arm-pits  and  other  parts  of  the  trunk,  but 
this  is  not  common.  The  other  very  common  habitat  of  the 
epidermophyton  is  the  interdigital  space  between  the  toes. 
It  produces  what  is  known  as  intertrigo  of  the  toes  or 
intertriginous  eczema  of  the  toes , and  betrays  itself  by  a 
macerated  epidermis,  covering  a red  base  and  sometimes 
raised  by  vesioles  and  blisters.  In  his  article  in  the  Annates 
de  Dermatologic , June,  1910,  Sabouraud  points  out  that, 
starting  from  this  centre,  the  lesions  may  reach  the  instep 
in  eczematous  form,  but  according  to  him  they  would  not 
invade  the  smooth  epidermis  of  the  fore  part  of  the  foot ; 
they  are  endless  in  duration.  He  believes  epidermophytosis 
to  be  much  rarer  on  the  hands ; it  betrays  itself  on  the 
lateral  faces  of  the  fingers  by  irregular  vesicles,  scattered, 
disorderly,  without  forming  any  trace  of  a circle ; their 
appearance  is  so  exactly  like  eczema,  and  in  some  cases 
like  dysidrosis,  that  the  differential  diagnosis  with  eczema 
and  dysidrosis  can  only  be  established  by  microscopical 
examination.  This  reveals  in  the  squamas  and  in  the  roof 


The  Lancet,] 


FRENCH  SUPPLEMENT  TO  THE  LANCET. 


[Sept.  27,  1919  579 


Photographs  illustrating  Trichophytosis  and  Dysiduosis  of  Different  Types. 


Fig,  1. — Palmar  trichophytosis. 


Fig.,2.— Parasitic  dysidrosis  of  the  sole  of  the  foot,  vesiculo-bullous  type. 


Fig.  4.— Mycelium  of  the  trichophyton  in  the  squamous  cells  of  the 
epidermis. 


580  The  Lancet,] 


FRENCH  SUPPLEMENT  TO  THE  LANCET. 


[Sept.  27,  1919 


of  the  vesicles  delicate  filaments  of  mycelium,  slightly 
cloisonne , or  on  the  contrary  divided  into  short,  almost 
cubical  elements,  sometimes  very  numerous,  sometimes  rare 
and  hard  to  find.  In  short,  the  lesions  of  epidermophytosis 
of  the  extremities  bear  slight  resemblance  to  those  of  tricho- 
phytosis, but  great  resemblance  to  those  of  eczema  and 
dysidrosis. 

During  the  war  the  setiological  conditions  to  which  dys- 
idrosis is  attributed  have  been  realised  on  a large  scale.  A 
huge  number,  young  and  adult,  of  all  temperaments,  from 
all  classes  of  society,  have  been  subjected  year  in  year  out  to 
repeated  exertions,  with  profuse  sudations,  and  in  a word  to 
prolonged  overwork  ; moreover,  the  causes  of  dyspepsia  have 
not  been  wanting,  any  more  than  occasions  of  nervous  shock 
or  depression  of  spirits.  In  such  circumstances  one  might 
expect  to  meet  with  numerous  cases  of  dysidrosis,  especially 
in  certain  groups  which  have  been  particularly  overworked. 
Now  this  has  not  been  the  case. 

Experimental  Investigation  of  Typical  Skin  Lesions. 

Amongst  soldiers  attacked  by  vesiculo-bullous  or  squamous 
eruptions  on  hands  or  feet  I have  found  : 1.  A huge  majority 
of  secondary  eczema  due  to  scabies,  sometimes  to  pediculosis, 
often  to  boils,  ecthyma,  impetigo,  and  suppurating  wounds. 
2.  A fairly  hieh  number  of  professional  dermatites  explained 
by  the  occupations  of  the  patients.  3.  Some  exceptional 
cases  of  palmar  triohopkytosis,  an  example  of  which  I 
reproduce  here  (Fig.  1),  verified  by  microscopic  examina- 
tion and  culture,  in  which  I was  never  able  to  find  out  the 
origin  of  the  contagion.  4.  Finally,  a respectable  number 
of  cases  of  eruption  reproducing  the  picture  of  dysidrosis. 
When  I observed  them  these  cases  affected  one  of  the 
following  types : — 

(«)  Vesicular  and  bullate  type. — On  the  hands  there  were 
generally  delicate,  clear  vesicles  scattered  or  vaguely 
grouped  on  the  palmar  and  lateral  faces  of  the  fingers,  on 
the  palm,  and  sometimes  also  on  the  back  of  the  hand  ; 
lenticular  or  bullous  vesicles,  often  with  puriform  contents, 
occupying  the  fore  part  or  the  whole  sole  of  the  foot,  as  in 
the  case  depicted  here  (Fig.  2).  Sometimes  blisters  may 
have  been  burst  on  the  march,  and  I have  seen  some  of 
them  become  the  origin  of  lymphangitis. 

( b ) Vesicnlo- squamous  type. — The  lesions  consist  of 
erythemato-squamous  blotches,  multiple  and  scattered,  or 
confluent  into  sheets,  circinate  in  certain  places  only,  and 
usually  with  crumbling  edges  ; these  blotches  are  sprinkled 
and  surrounded  with  a few  vesicles  or  small  brownish  crusts 
resulting  from  the  drying  up  of  the  vesicles. 

(c)  Squamous  type.—  There  are  dry  circumscribed  desquama- 
tions, delicately  lamellar  or  thicker,  disclosing  rosy  and 
smooth  or  squamous  epidermic  surfaces  ; it  is  an  exception 
when  their  shape  is  circinate  or  polycyclic,  being  usually 
irregular,  with  wavy  edges,  which  recalls  that  of  eczema 
rather  than  that  of  a parasitic  affection.  (Fig.  3.)  On  the 
feet  erythemato-squamous  blotches  fill  the  fore  part  of  the 
foot,  often  the  back  of  the  toes  and  the  neighbouring  region, 
as  also  the  plantar  arch,  more  rarely  the  heel.  They 
constantly  coincide  with  intertrigo  of  the  toes. 

The  three  types,  which  I mention  here  separately  in  order 
to  emphasise  the  various  aspects  which  I have  met  with,  are 
evidently  only  stages  in  the  evolution  of  the  same  eruption, 
but  these  stages  can  coexist  at  various  points  of  the  same 
extremity.  Further,  it  seemed  to  me  certain  that  every 
desquamation  does  not  necessarily  follow  on  a visible 
vesicular  process,  and  that  the  affection  can  persist  and 
progress  in  the  form  of  dry  desquamation.  Is  this  dermatosis 
reallyT.  Fox’s  dysidrosis,  Hutchinson’s  pompholyx?  Is  there 
not  amongst  these  dysidrosiform  or  eczematoid  eruptions  a 
certain  number  of  cases  of  epidermic  mycoses,  and  especially 
of  epidermophytosis?  In  order  to  find  out  I have  submitted 
the  roofs  of  the  vesicles  or  the  squamre  of  these  dysidrosi- 
form eruptions  on  hands  and  feet  to  microscopic  examination 
as  often  as  possible.  Besides  negative  cases  I have  found 
positive  ones,  exactly  identical  with  the  others,  in  which  I 
have  found,  either  easily  or  sometimes  with  great  difficulty, 
a mycelium  analogous  to  that  on  Fig.  4. 

All  the  examinations  were  made  by  me  or  under  my 
control  in  my  own  laboratory.1  When  the  first  attempt 

1 I desire  to  thank  Miss  Eliascheff,  my  assistant,  whose  experience 
and  devotion  have  been  invaluable  to  me  in  these  investigations. 


proved  negative  we  adopted  the  following  method  : The 
shreds  of  epidermis  were  fixed  and  the  fat  removed  in 
alcohol-ether,  then  separated  with  needles  in  acetic  acid, 
finally  cleared  on  the  slide  in  40  per  cent,  caustic  potash 
with  gentle  heat.  It  was  sometimes  necessary  for  success 
to  make  several  examinations  at  an  interval  of  some  days 
and  to  spend  several  hours  in  examining  the  preparations. 

I have  kept  a record  of  the  cases  from  February  onwards.  My 
return  refers  to  20  patients,  three-quarters  of  whom  presented 
themselvesduring  June,  July, and  August.  In  5 of  them  all  four 
extremities  were  affected,  9 had  dysidrosiform  lesions  of  the 
hands,  and  6 dysidrosiform  lesions  of  the  feet.  The  total 
positive  results  were  11  to  14  for  hands  and  6 to  11  for  feet.  I 
must  draw  attention  to  the  fact  that  negative  results  became 
more  and  more  rare  in  proportion  as  we  employed  improved 
technique  and  greater  patience  in  our  investigations ; in 
fact,  since  September  we  have  only  had  positive  cases,  one 
of  which  required  altogether  four  hours  of  work.  If  I were 
asked  what  my  general  impression  is,  I should  say  that 
I believe  to-day  that  T.  Fox’s  dysidrosis  does  not  exist  as  a 
distinct  cutaneous  disease  with  a nosological  individuality  ; 
that  the  clinical  picture  portrayed  with  great  perfection  by 
Fox  and  Hutchinson  corresponds  to  a parasitic  dermatosis — 
epidermophytosis  of  the  extremities.  It  will  be  necessary, 
however,  for  further  investigations  to  confirm  or  upset  this 
conclusion,  which  I fully  acknowledge  at  present  goes  beyond 
the  range  of  the  facts  observed  by  me.  It  will  also  be 
necessary  to  make  sure  by  cultural  methods  which  is  the 
parasite  in  question  and  whether  it  always  belongs  to  one  and 
the  same  species  or  not.  The  morphological  aspect  of  the 
mycelium  in  the  squamae  does  not  allow  of  settling  the 
question  ; this  is  true  of  the  one  depicted  in  Fig.  4,  which 
is  taken  from  my  “ Pr6cis  de  Dermatologie.  ” Sabouraud 
himself,  whom  I consulted  on  this  point,  told  me  that  he 
could  not  say  whether  it  is  the  mycelium  of  an  epidermo- 
phyton  that  is  in  question  or  some  species  of  trichophyton, 
which  alone  would  certainly  be  the  case  if  we  are  in  presence 
of  a mycosis  of  the  epidermis. 

Mycotic  Nature  of  so-called  Dysidroses. 

I should  like  to  close  by  pointing  out  how  the  hypothesis 
set  up  by  me  as  to  the  probably  constantly  mycotic  nature  of 
the  so-called  dysidroses  fits  in  with  the  clinical  facts  and,  on 
the  other  hand,  with  the  classic  data  of  dysidrosis  and 
epidermophytosis.  It  is  said  that  attacks  of  dysidrosis 
usually  last  for  from  10  to  20  days  and  often  recur  in  the  same 
subject.  This  is  true  of  epidermophytosis  of  the  extremi- 
ties, but  it  must  be  added  that  one  also  sees  continuous  or 
subintrant  attacks  prolonged  for  six  months  or  more.  I have 
met  soldiers  who  have  been  made  useless  for  more  than  half 
the  war  by  parasitic  dysidrosis.  Of  the  aetiological  conditions 
to  which  dvsidiosis  is  attributed,  those  which  relate  to  the 
nervous  state,  overwork,  or  djspepsia  are  too  banal  to  be 
considered.  The  influence  of  the  seasons  and  the  effect  of 
profuse  perspiration  might  consist  in  the  fact  that  they 
favour  parasitic  vegetation.  As  for  the  topographical  dis- 
tribution of  the  lesions,  epidermophytosis,  like  dysidrosis, 
attacks  hands,  feet,  or  all  four  extremities  symmetrically  at 
the  same  time.  Epidermophytosis  has  in  addition  a favourite 
seat  in  the  interdigital  spaces  of  the  toes,  where  it  is  very 
common  ; it  may  persist  there  for  very  many  years,  causing 
only  slight  annoyance  or  even  without  the  patient  being  at 
all  aware  of  its  existence  ; thence  it  proceeds  to  invade  the 
rest  of  the  feet  and  doubtlessly  the  hands  also  by  auto- 
contagion,  thus  producing  dysidrosiform  attacks  under  the 
influence  of  occasional  causes.  The  inguinal  site  of 
epidermophytosis,  where  it  betrays  itself  by  Hebra’s  eczema 
marginatum,  is  perhaps  nourished  from  the  same  source ; 
but  the  fact  that  this  eczema  marginatum  often  occurs  in 
the  form  of  small  epidemics  in  boarding-schools,  asylums, 
agglomerations  of  young  people,  seems  to  indicate  that  it  is 
due  rather  to  hetero-contagion  by  the  linen  or  the  water- 
closets.  But  it  must  be  remarked  that  if  the  coexistence 
of  eczema  marginatum  in  the  groin  with  parasitic  dysidrosis 
on  the  hands  and  feet  is  not  very  common,  its  coexistence 
with  parasitic  intertrigo  of  the  toes  is,  as  a rule,  nearly 
general. 

Lesions  of  the  nails  have  not  been  noticed  in  dysidrosis, 
nor  have  I observed  them  either  in  epidermophytosis  of  the 
hands  and  feet,  save  as  chance  coincidence.  But,  on  the 
contrary,  it  is  noticed  that  the  nails  are  very  commonly 
affected  in  eczemas  and  professional  dermatites  of  the 


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FRENCH  SUPPLEMENT  TO  THE  LANCET. 


[Sept.  27,  1919  581 


extremities.  It  follows  that  the  good  or  bad  state  of  the 
nails  can,  in  my  view,  serve  as  a retrospective  diagnosis  of 
a dysidrosiform  attack  which  would  be  healed  at  the  time 
of  seeing  the  patient. 

As  for  the  treatment  of  dysidrosis  internal  medication  is 
advised,  using  tonics,  and  especially  arsenic,  which  can 
obviously  only  be  intended  to  improve  the  general  state  ; 
soothing  dressings  and  refreshing  or  slightly  disinfectant 
ointments  are  recommended.  Epidermophytosis,  on  the 
contrary,  demands  repeated  rubbing  for  several  weeks  with 
iodised  alcohol  (from  1 in  60  to  1 in  30)  or  strong  chrysarobin 
ointment  (from  1 in  300  to  1 in  100),  together  with  persistent 
removal  of  the  desquamating  epidermis.  I have  been  able 
to  assure  myself  that  the  treatment  with  iodised  alcohol  has 
relieved,  and  even  cured,  cases  of  dysidrosiform  eruption  in 
which  we  have  not  found  the  mycelium,  probably  for  lack  of 
enough  perseverance  in  our  microscopical  investigations. 

Conclusion. 

T.  Fox’s  dysidrosis  or  Hutchinson’s  pompholyx  is  not  a 
distinct  illness  ; what  has  been  called  by  that  name  is  only  a 
clinical  picture,  a symptom-complex  which  may  be  called 
dysidrosiform.  When  they  are  not  artificial,  professional,  or 
medicamental  dermatitis,  the  dysidrosiform  eruptions  are 
mostly,  and  probably  always,  of  mycotic  nature,  and  due  to 
the  epidermophyton  ; careful  and  sometimes  very  laborious 
microscopical  examination  will  provide  the  proof  ; they  must 
be  treated  as  such.  If  we  want  to  retain  the  term  dysidrosis 
it  must  not,  be  considered  as  giving  a precise  diagnosis,  but 
must  be  completed  by  some  qualifying  term,  as  done,  for 
example,  with  the  term  sycosis.  Therefore,  when  one  is 
faced  with  a dysidrosiform  eruption,  the  problem  is  to  decide 
between  the  following  two  diagnoses  : (1)  parasitic 

epidermophytosic  dysidrosis  ; (2)  non-parasitic  dysidrosis  or 
occupational  dysidrosiform  dermatitis. 


THE  CONTAGIOUSNESS  OF  FAYUS  IN  MAN. 

By  R.  SABOURAUD. 


Most  doctors  and  all  dermatologists  are  acquainted  with 
the  name  and  symptoms  of  tinea  favosa,  its  persistence,  the 
characteristics  of  its  straw-coloured  crusts,  forming  a rocky 
protuberance  on  the  scalp  and  in  consistence,  appearance, 
and  method  of  crumbling  away  suggesting  baked  earth  or 
dry  clay. 

I am  not  going  to  dwell  on  the  clinical  description  of  this 
malady,  as  I should  like  to  consider  it  from  another  point 
of  view.  The  problem  of  the  contagiousness  of  human  favus 
and  its  prophylaxis  has  presented  itself  in  a specially  urgent 
way  during  the  war  on  account  of  the  utilisation  of  African 
colonial  troops,  amongst  whom  favus  is  of  frequent  occur- 
rence. It  is  therefore  not  without  interest  to  face  this 
question  as  it  actually  presents  itself,  not  according  to 
theories  or  preconceived  ideas,  but  according  to  the  facts. 

Nowadays,  when  the  parasite  causing  the  disease  is  known 
by  all,  one  is  always  inclined  to  conclude  that  because  it  is 
parasitic  this  disease  is  very  contagious.  But  one  must  not 
pre-] udge  a question,  one  must  judge  it.  History  tells  us 
that  the  contagious  character  was  just  as  much  in  doubt 
before  as  after  the  discovery  of  the  parasite. 

In  general — in  our  country  and  colonies  and  adjacent 
territories,  at  least — what  one  sees  are  sporadic  cases 
scattered  amongst  an  immune  population,  amongst  which 
there  have  always  been  a few  cases.  And  if  we  call  to  mind 
the  astiological  conditions  in  the  midst  of  which  the  cases 
arise,  it  is  poverty,  filth,  promiscuousness,  and  destitution 
which  seem  to  constitute  the  usual  environment  necessary 
to  bring  them  about. 

When  one  examines  an  accumulation  of  crusts,  or  pits, 
of  favus,  and  sees  under  the  microscope  the  enormous  felted 
mycelium  which  forms  them,  when  one  thinks  what  an 
amount  of  seed  such  crusts  could  produce  to  create  new 
cases,  the  conclusion  is  inevitable  that  favus  is  very  slightly 
and  very  rarely  contagious,  and  that  it  calls  for  very  special 


and  very  rare  circumstances  for  it  to  be  able  to  implant 
itself  in  the  human  skin.  In  the  midst  of  a rural,  pastoral, 
poor  population,  where  no  ideas  of  hygiene  exist,  and  where 
the  human  being  lives  very  much  in  the  same  way  as  his 
domestic  animals,  10  or  15  cases  may  be  seen,  and  the  number 
hardly  increases.  These  cases  are  scattered.  If  a single 
family  will  sometimes  produce  two  or  three,  there  will  usually 
be  also  healthy  children  in  the  very  same  family  who  will 
escape  contagion.  Most  frequently  some  direct  ancestor, 
father,  mother,  or  grandfather,  will  be  found  who  has  been 
affected  with  favus  for  30  or  50  years,  and  has  been  the 
origin  of  the  contagion.  In  this  way  small  centres  exist 
from  generation  to  generation,  and  no  doubt  one  might  find 
families  in  which  favus  has  continued  for  several  centuries 
without  having  brought  any  real  epidemic.  This  means  that, 
when  not  treated,  favus  is  of  illimitable  duration.  The  favus 
patient  who  is  not  treated  for  the  disease  will  die  a favus 
patient  ; and  in  the  course  of  an  illness  of  30  years  or  more 
the  patient  will  have  created  one  or  two  new  cases.  But 
these  are  just  the  conditions  which  favour  the  endemicity 
and  perpetuity  of  the  malady.  Each  case  lasts  indefinitely, 
and  produces  one  or  two  others  in  its  neighbourhood.  Going 
back  a century  one  would  find  practically  the  same  picture 
in  the  same  families.  In  this  connexion  nothing  is  more 
instructive  than  Ciarrochi’s  most  circumstantial  work  on 
favus  in  the  Transtiberine  region.1  On  turning  over  the 
pages  of  the  register  of  the  hospital  of  San  Gallicano 
he  was  able  to  ascertain  that  5374  cases  of  favus  were 
treated  there  during  the  whole  of  the  nineteenth  century, 
all  these  cases  coming  from  the  province  of  Rome,  and  nine- 
tenths  of  them  from  the  south-eastern  part  of  the  province 
situated  below  the  Tiber.  Nearly  all  of  them  came  from 
rural  districts.  Two-thirds  of  the  patients  were  boys,  one- 
third  girls.  The  age  of  contagion,  the  second  stage  of 
infancy ; extreme  cases  from  2 to  18  years.  In  this  way 
Ciarrochi  has  traced  families  which  have  been  producing 
cases  of  favus  for  three  generations.  And  this  country 
which  has  given  birth  to  5374  cases  of  favus — evidently  an 
incomplete  return — had  at  the  end  of  the  century  just  about 
as  many  as  at  its  beginning.  Extend  Ciarrochi’s  survey  and 
you  will  have  the  normal  story  of  favus  all  over  the  world. 
It  is  always  the  same  whenever  observations  are  made. 

Rare  Occurrence  of  Contagious  Type. 

But  can  we  say  ‘'always”?  To  speak  the  truth,  no,  not 
always  ; and  I must  describe  the  very  rare  occasions  when 
I have  been  able  to  see  favus  of  a contagious,  and  even  very 
contagious  and  epidemic  type.  And  as  on  all  three 
occasions  the  story  has  been  identically  the  same,  it 
is  probable  that  it  will  be  found  in  a similar  form 
again.  But  it  must  be  emphasised  that  the  facts  have 
been  seen  only  three  times  in  30  years  of  close  and 
daily  observation.  They  are  therefore  exceedingly  rare. 
Even  if  he  gives  special  attention  to  these  questions, 
a specialist  might  never  have  met  with  similar  cases. 
They  are  so  rare  that  some  experienced  dermatologists 
who  have  not  witnessed  such  facts  will  be  inclined  to  doubt 
them.  But  I can  guarantee  their  absolute  correctness.  A 
6 to  12  years  old  child  is  brought  to  the  doctor  for  a crust 
adhering  to  the  middle  of  the  scalp  and  refusing  to  dis- 
appear. This  crust,  grey,  flat,  as  thin  as  the  nail,  without 
relief,  very  adherent,  cannot  be  moved  to  and  fro  on  the 
skin.  If  you  make  a fold  in  the  skin  the  crust  breaks  and  a 
little  serous  fluid  exudes  through  the  cracks.  The  colour  of 
this  crust  is  an  ash-grey,  recalling  the  colour  of  wasps’  nests 
in  the  woods.  It  is  from  a to  1 mm.  thick.  If  it  is  removed 
with  the  curette,  it  leaves  beneath  it  the  red,  moist,  bleeding 
skin,  similar  to  what  is  found  beneath  the  old  conglomerated 
cups  of  favus.  Examination  of  this  crust  in  small  portions 
under  the  microscope  shows  that  it  is  formed  exclusively  of 
felted  mycelium  like  the  cup.  Culture  gives  the  common 
Schonlein’s  Achorion,  without  any  peculiarity  to  explain  the 
strange  behaviour  of  this  clinical  form,  for  its  behaviour 
does  indeed  differ  widely  from  ordinary  favus.  This  crust, 
which  is  2,  3,  or  even  5 cm.  across  at  its  greatest 
diameter,  is  formed  in  a few  weeks  and  increases  visibly 
from  day  to  day.  When  you  meet  with  this  clinical  type 
you  may  rest  assured  that  in  the  school  to  which  the 


i G.  Ciarrochi : La  repartition  geographique  du  favus  dans  la 
province  de  R ime.  C.  R.  du  IVfrne  Congres  international  de  dermato- 
logic, Paris,  1900,  p.  439. 


582  Thh  Lancet,] 


FRENCH  SUPPLEMENT  TO  THE  LANCET. 


[Sept.  27,  1919 


child  goes  you  will  see  five,  six,  ten  cases  of  con- 
tagion arise,  ten  cases  which  will  develop  with  the  same 
rapidity.  If  the  disease  is  allowed  to  extend,  the  crust  will 
thicken  at  isolated  points  which  will  be  miliary  cups,  and  later 
on  there  will  be  a rock  of  crusts.  It  is  therefore  a squamous 
favus  at  the  outset.  If  favus  always  behaved  like  that  it 
would  be  the  most  formidable  of  tineas.  Nothing  could  be 
more  contagious.  But  these  cases  are  so  exceptional  and 
abnormal  that  if  I had  not  seen  them  with  my  own  eyes  I 
should  be  tempted  to  charge  this  description  with  being 
exaggerated. 

Under  certain  undetermined  conditions,  then,  common 
favus  may  give  place  to  this  papyroid  type,  very  contagious 
amongst  children  and  extending  rapidly.  And  as  one,  so 
to  say,  never  sees  favus  at  its  very  beginning,  it  might  be 
that  it  begins  in  this  way  more  often  than  one  thinks  and 
that  an  old  case  of  favus  can  pass  through  a period  of 
reproduction  after  a long  period  of  apparent  stagnation. 
But  that  is  only  a hypothesis.  We  know  nothing  of  the 
precise  conditions  which  govern  the  cases  of  which  I have 
just  been  speaking,  any  more  than  of  the  conditions  which 
cause  the  habitual  inertia  of  the  others.  In  any  case  it 
must  be  clearly  noted  that  these  facts  have  never  been 
observed  except  in  children,  and  that  this  form  of  favus 
seems,  like  all  favus,  to  be  contagious  only  in  the  case  of 
children. 

The  rare  cases  in  which  one  can  surprise  favus  at  its 
beginning  are  mostly  cases  of  favus  on  the  body  with  circles 
recalling  ringworm,  on  the  circumference  of  which  little 
golden-yellow  cups  are  scattered.  But  nearly  always  in  such 
cases  an  animal  favus  of  a special  species  is  concerned. 
Now,  nobody  has  ever  seen  a single  case  of  favus  of  the 
scalp  caused  in  human  beings  by  any  other  achorion  than 
Schonlein’s  achorion,  human  species.  Consequently  these 
accidental  inoculations  of  favus  from  animals  to  man,  which 
may  be  observed  even  in  adults,  are  of  little  practical 
importance. 

Importance  of  Age  and  Hygienic  Conditions  in  Favus 
Contagion. 

I must  again  insist  on  the  importance  of  age  in  favus 
contagion.  Since  we  have  to  deal  with  a disease  of  indefinite 
duration  and  we  find  it  in  adults  or  even  old  men,  we  might 
think  that  every  individual  at  every  age  can  contract  favus. 
That  is  a mistake.  Ask  all  the  patients  you  meet  and  they 
will  all  tell  you  that  they  contracted  favus  at  school  age. 
From  this  special  point  of  view  of  the  age  of  contagion,  favus 
belongs  therefore  to  that  class  of  tineas  the  inoculations  of 
which  into  the  scalp  are  not  found  after  puberty.  Doubtless 
animal  favuses  are  an  exception,  such  as  the  animal  tricho- 
phytoses, but  they  are  found  only  on  the  body,  where  they 
are  easily  curable.  When,  therefore,  it  is  considered 
necessary  to  isolate  soldiers  attacked  with  favus,  for  fear 
that  they>  might  infect  their  comrades,  it  seems  to  be  a pre- 
caution which  may  appear  a luxury  in  time  of  war.  It  would 
be  more  logical  to  cure  them  after  the  war,  before  they 
return  home,  rather  than  to  deprive  the  army  of  men  who 
are  otherwise  normal,  for  they  will  not  spread  contagion 
amongst  their  adult  comrades.  I am  not  aware  of  a single 
exception  to  this  rule  having  been  observed  amongst  all  our 
North  African  troops,  or  of  a single  case  of  the  transmission 
of  favus  having  been  discovered  in  adults. 

Another  general  remark,  not  without  importance,  results 
from  observation  of  our  North  African  Colonial  troops.  In 
those  regions  tinese  are  hardly  found  except  amongst  the 
poor  and  subject  populations,  both  Arab  and  Jewish  ; they 
are  not  found  amongst  white  colonists,  not  by  reason  of  any 
immunity,  but  on  account  of  the  different  hygienic  condi- 
tions. In  Fez  and  South  Morocco  tine®  are  innumerable  and 
favus  very  common.  For  until  we  occupied  the  country  they 
were  considered  incurable  and  were  not  treated  at  all.  The 
number  is  now  decreasing  daily.  Favus  is,  therefore,  more 
than  other  tineas,  a morbid  type  which  civilisation  ought  to 
remove  gradually.  Our  municipal  dispensary  in  Fez,  installed 
by  my  collaborator  and  friend,  Dr.  Noire,  is  a model  from 
this  point  of  view.  Three  radiotherapeutic  apparatus  are 
permanently  at  work,  and  the  natives  now  present  them- 
selves for  treatment  of  their  own  accord.  If  this 
practice  is  continued  there  will  not  be  a single  case 
of  tineas  in  all  the  region  a few  years  hence. 

It  is  not  intended  in  this  place  to  study  the  treatment  of 
favus,  but  this  much  may  be  recalled.  The  treatment. 


briefly,  involves  local  prophylaxis  in  the  shape  of  scraping 
with  the  curette  and  1 per  cent,  iodine  in  alcohol.  Super- 
ficial cleansing  having  been  thus  performed,  one  passes  on 
to  curative  treatment  by  means  of  X rays  and  1 per  cent, 
chrysophanic  ointment,  when  it  can  be  borne  without  irrita- 
tion. It  must  not  be  forgotten  that  in  favus,  when  the  hair 
grows  again  after  application  of  X rays,  some  hairs  still 
remain  affected  with  the  parasite,  so  that  complementary 
epilation  in  detail  is  necessary.  This  can  be  performed  with 
tweezers,  for  the  eye  of  a skilled  worker  can  distinguish  the 
doubtful  hairs  (centring  in  a red  point)  amongst  the  healthy 
growth.  But  I will  not  pursue  the  matter  further,  for  this 
is  not  a therapeutic  article  but  a simple  note  laying  down  the 
conditions  ordinarily  governing  the  transmission  of  favus 
and  the  considerations  which  must  guide  its  prophylaxis. 


The  French  Supplement  to  The  Lancet — under  the 
Editorial  Direction  of  Professor  Charles  Achard,  Professor 
of  Pathology  and  Therapeutics  in  the  University  of  Paris; 
and  Dr.  Charles  Flandin,  D.S.O.,  Medecin-Major  de  2me 
Classe,  Chef  de  Clinique  a la  Faculte  de  Paris — has  appeared 
on  the  dates  given  in  the  following  list,  which  sets  out 
the  titles  and  authors  of  the  contributions  : — 

Sept.  21st.  1918:  (1)  The  Microbic  Diversity  of  the  Enteric 
Fevers,  by  Professor  Achard.  (2)  Post-Typhoid  Atony  of  the 
Caecum,  by  Maurice  Loeper,  Professor  of  the  Faculty  of 
Medicine  and  Physician  to  the  Paris  Hospitals. 

Oct.  19th,  1918:  (1)  What  the  War  has  Taught  Us  about 
Tetanus,  by  Louis  Bazy.  (2)  Tetanus  Consecutive  to  Super- 
ficialWounds  and  to  Trench  Foot : Treatment  and  Prevention, 
by  Professor  Raymond,  Medecin  Principal  de  2me  Classe. 

Nov.  30th,  1918 : (1)  General  Review  of  French  Cardio 
Pathology  during  the  War,  by  Ch.  Laubry,  Physician  to  the 
Paris  Hospitals,  Medecin  Major  de  2me  Classe.  (2)  Methods 
of  Estimating  Augmentation  in  Depth  of  Volume  of  Left 
Ventricle,  by  Dr.  Bordet,  Director  of  the  Radiological  Labo- 
ratory of  the  Centre  of  Cardiology  of  Professor  Vaquez, 
Hopital  St.  Antoine. 

Jan.  11th,  1919 : (1)  Gunshot  Concussion  of  the  Spinal 
Cord,  by  Henri  Claude,  Professor  in  the  Paris  Faculty  of 
Medicine,  Physician  to  the  Paris  Hospitals ; and  Jean 
Lhermitte,  formerly  Chef  de  Clinique  in  the  Paris  Faculty 
of  Medicine.  (2)  Contribution  to  the  Study  of  the  Manifes- 
tations of  Emotional  Shock  on  the  Battlefield,  by  Cl.  Vincent, 
Physician  to  the  Paris  Hospitals,  formerly  Medical  Officer 
to  the  46th  and  98th  R.I.  and  to  the  44th  B.C.P. 

March  1st,  1919  : The  Surgical  Complications  following 
Exanthematic  Typhus,  by  Dr.  Paul  Moure  and  Dr.  Etienne 
Sorrel,  Prosectors  to  the  Faculty  of  Medicine,  Paris,  Medecins 
Aide-Majors  de  ler  Classe,  Surgeons  to  the  French  Hospital 
at  Jassy. 

April  5th,  1919 : (1)  Nervous  Complications  of  Exanthe- 
matic Typhus,  by  A.  Devaux,  formerly  Interne  of  the  Paris 
Hospitals,  Medecin-Major  de  2me  Classe.  (2)  Note  on  the 
Epidemic  Diseases  Observed  in  Rumania  during  the 
Campaign  of  1916-17,  by  Dr.  Henri  Vuillet,  late  Interne  of 
the  Paris  Hospitals. 

May  3rd,  1919  : (1)  Malaria  During  the  War,  by  G.  Paisseau, 
Medecin-Major  de  2me  Classe.  (2)  Distribution  of  Soldiers, 
Temporarily  Unfit  through  Malaria,  in  Agricultural  Colonies, 
by  Professor  E.  Jeanselme.  (3)  Studies  on  Renal  Function 
in  Chronic  Nephritis,  thesis  by  Pasteur  Vallery-Radot. 
reviewed  by  Professor  Charles  Achard. 

.Tune  21st,  1919  : (1)  Recent  WTork  on  Cerebro-spinal  Fever, 
by  C.  Doptsr,  Professor,  Val-de-Grace,  Medecin-Chef  to  an 
Infantry  Division.  (2)  Meningococcal  Rheumatism  and 
Arthritis,  by  Dr.  Paul  Sainton.  Physician  to  the  Paris 
Hospitals. 

Aug.  23rd,  1919:  Radiological  Examination  of  Pseud- 
arthroses  before  and  after  Operations  of  Bony  Grafts,  by 
Paul  Aubourg,  Professor  Agrege,  Cuneo's  Laboratory  for 
Radiology.  (Centre  for  Surgery  of  Bones.  Hospital  75, 
Cannes.) 

THE  LANCET  can  be  ordered  through  any  Library  in  France,  or 
through  the  following  special  agents  : — 

PARIS. — Masson  et  Cie,  120,  Boulevard  St.  Germain. 

Emile  Bougault,  48,  Rue  des  Ecoles. 

Ch.  Boclange,  14,  Rue  de  l'Ancienne  Comedie. 

Felix  Alcan,  10S,  Boulevard  St.  Germain. 

M.  Choisnet,  30,  Rue  des  St.  Peres. 

H.  Le  Soudier,  174,  Boulevard  St.  Germain. 

Maloine  et  Fils,  27,  Rue  de  l'Ecole  de  Medecine. 

Vigot  Freres,  23,  Rue  de  l'jscole  de  Medecine. 

MARSEILLES.— Tacusskl  and  Lombard,  54,  Rue  Paradis. 

TOCLOl'SE.— Edouard  Privat,  14,  Rue  des  Arts. 


The  Lancet,] 


TEMPORARY  OFFICERS  IN  THE  R.A.M.C.  : THE  NEW  CONTRACT.  [Sept.  27,  1919  583 


THE  LANCET. 


LONDON:  SATURDAY,  SEPTEMBER  27,  1919. 


Temporary  Officers  in  the  R.A.M.C. : 
The  New  Contract. 

We  published  recently  the  terms  upon  which  the 
War  Office  is  willing  to  accept  the  services  of 
medical  practitioners,  including  those  who  have 
been  demobilised,  who  are  desirous  of  undertaking 
duty  with  the  Army.  These  terms  are,  to  our 
thinking,  so  favourable  that  we  have  no  hesitation 
in  recommending  young  medical  men  to  apply  to 
the  Secretary,  War  Office,  Cornwall  House,  Stamford- 
street,  London,  S.E.,  for  prompt  temporary  engage- 
ment. There  are,  indeed,  two  reasons  why  we 
bring  forward  the  invitation  of  the  War  Office 
in  what  is  meant  to  be  a marked  manner.  The 
first,  which  we  have  already  alluded  to,  is 
the  satisfactory  nature  of  the  terms.  Having 
only  the  recently  qualified  man  in  our  mind, 
we  would  point  out  that  if  his  application  for 
employment  for  six  months  or  a year  is  successful, 
he  will  have  at  the  expense  of  his  country  an 
admirable  opportunity  for  travel ; he  will  have 
nothing  to  pay ; and  he  will  find  himself  at  the  end 
of  a short  period  with  £300  or  £600  to  his  credit.  It 
is  difficult  to  imagine  a pleasanter  as  well  as  a more 
instructive  way  of  beginning  professional  life.  But 
secondly,  there  is  to  our  mind  upon  some  of  the 
newly  qualified  men  almost  an  onus  to  assist  their 
country  in  this  way.  The  medical  staffs  in  India, 
Mesopotamia,  and  Egypt  are  distinctly  short,  and 
the  result  is  that  the  medical  officers  of  the 
R.A.M.C.,  both  Temporary  and  Territorial,  have 
to  be  retained  in  these  areas.  Many  of  these 
men  have  surrendered  practices  at  home  to 
serve  their  country  abroad,  and  they  cannot 
return  to  those  practices  until  efficient  sub- 
stitutes have  been  found  for  them.  This  is  a 
very  hard  position  for  them,  as  well  as  for  the  War 
Office,  whose  sympathy  for  the  practitioners  in  exile 
is  quite  sincere.  Those  at  the  head  of  the  Royal 
Army  Medical  Corps  frankly  feel  the  unfairness  of 
keeping  these  practitioners  month  after  month,  and, 
indeed,  year  after  year,  away  from  home,  iamily, 
and  a suspended  career.  The  situation  is  unavoid- 
able for  the  moment,  as  the  men  cannot  be  spared 
until  they  are  replaced  by  others.  The  strain  is 
probably  temporary,  new  men  only  being  urgently 
required  for  six,  or  perhaps  12,  months ; but  for 
such  a period  they  are  needed.  Some  of  the  newly 
qualified  men,  who  have  not  served  in  the  Army, 
were  absolved  from  combatant  service  in  order  to 
obtain  their  medical  qualifications,  the  idea  certainly 
being  that,  when  they  were  qualified,  they  would 
be  at  the  disposal  of  the  country.  A large  propor- 
tion of  these  may  be  fairly  expected  to  take 
temporary  commissions  now  in  order  to  relieve 
their  seniors  in  the  profession,  many  of  whom  have 
served  during  the  last  four  or  five  years  at  great 
personal  sacrifice  and  in  circumstances  of  high 
risk.  This  is  still  a patriotic  call,  for  the  position 
in  the  R.A.M.C.,  as  elsewhere,  depends  on  the  fact 
that  war  conditions  do  not  and  cannot  cease  at  the 
moment  of  the  declaration  of  peace. 


A Defence  of  Urbanisation. 

Urranisation  has  been  credited  with  many  ills. 
At  every  period  of  life  it  has  been  blamed — and, 
doubtless,  rightly  blamed— for  its  maleficent  influ- 
ence. In  infancy,  for  a heightened  mortality  from 
zymotic  enteritis  and  the  exanthems ; at  school 
age,  for  affections  of  the  nose  and  throat,  and  for 
dirt  diseases  in  general ; in  adolescence,  for  the 
rapid  spread  of  venereal  maladies ; in  adult  life, 
for  alcoholism,  hyperpiesis,  neurasthenia,  and 
phthisis.  It  takes  some  courage,  therefore,  to 
break  a lance  in  favour  of  urbanisation,  as  has 
been  done  by  Lieutenant-Colonel  A.  G.  Love, 
U.S.M.C.,  and  Professor  Charles  B.  Davenport  in 
the  Archives  of  Internal  Medicine  for  August,  1919, 
who  boldly  contend  that  life  in  urban  communities 
produces  a general  resistance  to  disease.  This 
opinion  is  based  upon  a study  of  the  immunity  of 
city-bred  recruits  observed  during  the  last  four 
months  of  1917  in  the  16  large  army  camps  of  the 
United  States  of  America.  It  rests  upon  no  mere 
general  impression,  but  upon  the  records  now 
available  in  the  Medical  Department  of  the  U.S. 
Army,  which  they  have  analysed  with  the  equip- 
ment of  practised  statisticians. 

The  population  of  the  camps  consisted  of  men  at 
ages  from  21  to  30  years,  taken  from  their  homes 
and  placed  in  barracks  where  they  slept  in  beds 
only  some  few  yards  apart,  or  in  tents  where  they 
often  had  an  average  floor  space  of  less  than  six 
square  yards.  Men  from  rural  districts  had,  for  the 
most  part,  never  lived  thus  congestedly,  and  it  was 
to  be  expected  that  their  reaction  to  the  new 
environment  should  be  different  from  that  of  town 
dwellers.  The  authors  report  in  detail  on  the  inci- 
dence of  the  six  principal  communicable  diseases — 
measles,  mumps,  pneumonia,  cerebro  spinal  fever, 
scarlet  fever,  influenza — in  the  various  camps  accord- 
ing to  their  “ urbanity,”  that  is  to  say,  according  to 
the  proportion  of  their  population  drawn  from  urban 
communities.  The  results  were  similar  in  each 
case.  We  give  the  actual  words  of  the  report  in 
regard  to  measles,  which  within  three  months 
provided  47,000  cases  to  study  among  the  enlisted 
men : — 

“ the  incidence  of  measles  varied  greatly  in  the 

different  camps.  This  ranged  in  1917  all  the  way  from  a 
mean  annual  admission-rate  of  500  per  1000  at  Camp 
Wheeler,  Ga.,  to  about  1 at  Camp  Wadsworth,  S.C.  The 
climatic  and  housing  conditions  at  these  two  National  Guard 
camps,  located  about  only  100  miles  apart,  were  very  similar. 
Measles  was  present  at  both  camps.  The  tremendous 
difference  in  the  history  of  the  epidemic  seems  clearly  to  be 
due  to  a difference  in  the  constitution  of  the  population.  The 
soldiers  at  Camp  Wadsworth  were  seasoned  National  Guard 
troops  from  New  York  City  and  vicinity.  The  soldiers  at 
Camp  Wheeler  were  mainly  newly  inducted  National  Guard 
troops  from  Alabama,  Florida,  and  part  of  Virginia,  sparsely 
settled  States.” 

Put  into  technical  language,  the  correlation 
between  (1)  the  proportien  of  men  in  the  Army 
born  in  any  State  who  were  admitted  to  sick 
report  for  measles,  and  (2)  the  urbanity  of  their 
respective  native  States,  was  found  to  be  — 0'80 
— a high  correlation  as  correlations  go,  but  inverse 
(as  the  minus  sign  signifies),  meaning  that  the 
more  urban  the  native  State  the  less  susceptible  to 
measles  its  native-born  sons  in  the  Army.  The 
correlation  figures  for  the  other  epidemic  diseases 
were  found  to  be : mumps,  — 0'58 ; pneumonia, 
— 0'37  ; cerebro- spinal  fever,  — 0'44.  What  held 
for  measles  held  in  large  degree  for  the  other 
members  of  the  group. 

Turning  to  the  explanation,  the  obvious  hypo- 
thesis is  the  one  formulated  by  Surgeon-General 


584  The  Lancet,] 


NURSE  ANAESTHETISTS. 


[Sept.  27,  1919 


Gorgas  himself  that  (almost  in  the  words  of  the 
old  riddle)  the  recruits  coming  from  densely 
populated  areas  were  immune  from  measles  and 
mumps  because  they  had  had  them.  Good  so  far 
as  it  goes,  but  inapplicable  to  scarlatina,  pneu- 
monia, and  cerebro-spinal  fever.  The  second  hypo- 
thesis, that  a selective  elimination  of  susceptible 
individuals  has  occurred  in  the  urban  areas,  is  also 
turned  down  by  the  authors  as  not  fitting  mumps. 
Mumps  does  not  bill  off  New  York  children.  A 
third  hypothesis  of  increased  susceptibility  in  the 
south  for  exanthems,  as  for  malaria  and  hookworm, 
has  no  basis  in  experience  or  experiment.  The 
only  remaining  hypothesis  is  that  to  which  the 
authors  give  their  adherence,  and  which  we  have 
already  enunciated : a general  increased  resist- 
ance to  disease  enjoyed  by  urban  dwellers.  They 
go  on  to  give  a closely  reasoned  support  of 
the  related  assumption  that  any  one  of  the 
communicable  diseases  leaves  the  body  in  a 
state  of  heightened  resistance  to  all  micro-para- 
sites. Arising  out  of  the  work  of  J.  W.  Jobling 
and  W.  Petersen  1 in  America  it  will  be  fresh  in  the 
minds  of  our  readers  that  Sir  Almroth  Wright2 
drew  this  “ collateral  ” immunisation  as  one  of  the 
pathological  lessons  of  the  war,  a conclusion  to 
which  experience  had  been  pressing  him  ever  since 
the  allegation,  made  before  the  Indian  Plague  Com- 
mission 20  years  ago,  that  antiplague  inoculation 
had  cured  eczema,  gonorrhoea,  and  other  ills.  A 
number  of  quite  trite  observations  point  in  the 
same  direction:  the  city  dweller’s  immunity 

from  habitual  catarrh  which  attacks  him  at  once 
on  his  return  from  a long  holiday  in  pure  air ; the 
added  risk  of  a post-mortem  prick  at  the  end  of  the 
long  vacation.  It  may  not  be  much,  but  urbanisa- 
tion has  something  to  be  said  for  it 
» — 

Nurse  Anaesthetists, 

To  use  the  best  that  was  available  was  the  war 
maxim,  and  among  other  directions  the  maxim  has 
been  applied  to  anaesthetics,  with  the  result  that  on 
many  occasions  it  has  proved  expedient  to  utilise 
the  services  of  the  nurse  as  anaesthetist.  Con- 
cerning this  procedure,  in  Teply  to  a query,  “ What 
do  you  think  of  nurse  anaesthetists  ? ” addressed 
by  Brigadier-General  Finney  and  Colonel  G.  W. 
Crile  to  the  American  Base  Hospital  staff,  the 
answers  received  were:  Very  satisfactory,  25;  satis- 
factory, 8 ; unsatisfactory,  1 (for  prolonged  opera- 
tions). It  may  fairly  be  deduced  that  the  makeshift 
gave  results  agreeable  to  American  surgeons  under 
war  conditions.  In  America,  Switzerland,  Uganda, 
the  nurse  anesthetist  is  accepted ; she  found  a 
place  in  some  of  our  own  hospitals  during  the  war. 
Is  this  the  beginning  of  a practice  which  may 
become  the  rule  ? There  is  no  question  that  the 
usual  rule-of-thumb  technique  can  be  acquired 
by  any  nurse  of  average  intelligence,  and  that  after 
proper  instruction  she  can  learn  to  induce  anaes- 
thesia slowly,  to  prevent  respiratory  complications, 
to  maintain  regularity  of  dose  and  therewith  of  depth 
of  anaesthesia,  and  to  give  the  needed  relaxation.  Is 
this  enough  for  the  safety  of  the  patient  and  for  the 
ease  of  mind  essential  for  the  operator,  if  he  is  to 
exercise  all  his  skill  ? An  anaesthetist  is  a pilot, 
who  steers  the  ship  of  life  over  a reef-abounding 
sea  to  the  port  of  safety.  His  eyes  must  be 
trained  to  detect  dangers  at  a distance  and,  ever 
on  the  alert,  he  must  spy  out  rocks  before  the 

1 Journ.  A.M.A..  June  3rd.  1916  ; Arch.  Int.  Med..  June.  1917. 

The  Lancet.  March  29th,  1919. 


vessel  has  touched  them.  His  motto  should  be  : 
“ Me  duce,  tutus  eris.”  Kismet  has  no  place  in 
his  vocabulary.  Can  the  non-medical  though 
trained  nurse  reach  this  standard?  If  not,  is  it 
wise  to  introduce  a less  equipped  order  of  prac- 
titioners, as  nurse  anaesthetists  would  be,  when,  if 
proper  encouragement  were  given,  a sufficient 
number  of  qualified  doctors,  men  and  women, 
would  take  up  anaesthetics  as  a specialty  ? 

In  support  of  the  claims  of  the  trained  nurse  as  an 
anaesthetist  it  has  been  pointed  out  that  although 
nitrous-oxide-oxygen  as  a routine  anaesthetic  for 
long  operations  counts  as  dangerous,  yet  Crile  and 
Lower  report  close  on  35,000  cases  without  a 
fatality,  a nurse  in  most  cases  administering  the 
anaesthetic.  In  1916  the  authorities  of  Charing  Cross 
Hospital,  having  decided  to  broaden  the  basis  of  the 
nursing  curriculum,  introduced  a series  of  lectures 
on  anaesthetics,  including  the  preparation  and 
observation  of  patient,  general  principles,  methods, 
post -anaesthetic  sequelae  complications  and  their 
treatment.  These  lectures  have  since  been  published 
in  book  form,1  and  mark  a move  in  the  right 
direction  of  education,  although  difference  of 
opinion  may  arise  in  regard  to  the  remark : 

“It  is  a question  whether  surgical  sisters  should  not  have 
practical  instruction  in  administering  anaesthetics.  We  move 
slowly  here  and  guardedly.  Our  laws  are  strong  to  endure, 
but  hard  to  alter.  Many  signs  seem  to  me  to  indicate  the 
approach  of  a day  when  chosen  nurses  will,  in  their  final  year, 
be  taught  not  only  the  science  but  the  art  of  anaesthesia.” 

No  one  would  doubt  the  desirability  of  teaching  the 
nurse  to  give  an  emergency  anaesthetic  in  case  a 
professional  administrator  should  be  unprocurable, 
and  the  example  of  Charing  Cross  Hospital  might 
with  advantage  be  noted  in  the  curriculum  of  the 
Central  Midwives  Board.  When  a midwife  obtains 
medical  aid  for  difficult  labour,  she  gives  the 
anaesthetic,  but,  be  it  remembered,  whatever  her 
ability  the  doctor  is  responsible.  Some  measure 
of  instruction  for  the  midwife  would  stand  him  in 
good  stead  here,  but  those  who  advocate  the 
innovation  are,  we  hope,  not  blind  to  the  risky 
side  of  the  advice. 

The  administration  of  anaesthetics  is  not  merely 
the  putting  of  a patient  to  sleep.  The  selection  of  the 
method  and  means  to  be  employed  in  a surgical  case 
are  now  arrived  at  after  an  exchange  of  opinion 
between  operator  and  anaesthetist.  The  surgeon 
states  what  he  wishes  to  do,  and  the  anaesthetist, 
after  examination  of  the  patient,  suggests  how  he 
proposes,  with  due  regard  to  the  patient’s  condi- 
tion, to  meet  the  surgeon’s  needs.  The  operator, 
engrossed  in  his  own  work,  cannot  watch  the 
progress  of  the  anaesthesia  ; for  this  the  anaesthetist 
is  responsible.  Even  so  casualties  do  occur, 
and  at  trivial  operations.  Would  they  not  be  more 
frequent  with  a less  skilled  type  of  administrator  ? 
The  position  may  perhaps  be  put  fairly  thus : 
Trained  nurse  anaesthetists  would  do  in  England 
as  excellent  work  as  they  have  done  in  the  States 
or  elsewhere ; complications  must,  however,  occur  ; 
with  these  the  doctor  anaesthetist  must  be 
able  to  deal  more  efficiently  than  the  nurse. 
Extreme  advocates  for  the  latter  have  said  in 
effect:  Doctors  order  medicines,  but  they  do  not 
administer  the  dose  themselves ; with  the  infer- 
ence. the  operator  orders  chloroform  or  ether,  it 
can  be  dropped  on  a bit  of  gauze  held  over  the 
patient’s  face  by  a nurse  under  the  surgeon's 
direction.  There  may  be  surgeons  who  still  desire 
to  be  chief  of  the  anaesthetic,  as  well  as  of  the 

I Anesthesia  and  the  Nurses'  Duties,  by  the  late  A.  de  Prenderville. 
LL  .B..M.K.C.S. 


The  Lancet,] 


MALARIA  IN  THE  UNITED  STATES. 


[Sept.  27,  1919  5*5 


operating  field,  but  they  must  be  very  few.  So  few 
that  the  argument  falls.  The  tendency  of  the  time 
is  to  give  high  credit  to  the  anaesthetist's  function, 
and  the  suggestion  that  there  is  a widespread  wish 
to  follow  the  procedure  of  certain  American  centres 
is  ill-founded.  On  the  contrary,  American  and 
continental  doctors  have  expressed  their  admira- 
tion for  English  methods  of  anaesthesia.  At  a well- 
known  throat  hospital  three  American  specialists 
recently  stated  that  they  employed  local  anaesthesia 
for  submucous  resection  because  of  the  difficulty 
and  danger  of  a general  one.  They  admitted  that 
the  operation  could  be  done  much  more  thoroughly, 
as  it  was  in  England,  the  patient  being  uncon- 
scious. In  an  address  delivered  in  May,  1915,  at 
Cincinatti,  Dr.  Emmet  F.  Hoeine  remarked  that 
many  men  in  America  were  beginning  to  devote 
all  their  time  to  the  study  and  administration  of 
anaesthetics,  as  had  been  done  in  England  for 
many  years,  with  far-reaching  results.  It  is, 
of  course,  possible  that  with  such  intensive 
study  the  traps  and  pitfalls  of  anaesthesia 
may  be  removed  and  the  way  smoothed  for  the 
less  expert.  Analogy  does  not  make  this  likely. 


^nnotalians. 

" Ne  quid  nimls.” 


MALARIA  IN  THE  UNITED  STATES. 

A pamphlet  dealing  with  various  aspects  of  the 
malaria  problem  in  America  has  recently  been 
published  by  F.  L.  Hoffman,  LL.D.,  statistician  to 
the  Prudential  Insurance  Company  of  America,  and 
chairman  of  the  Subcommittee  on  Statistics  of  the 
National  Malaria  Commission,  who  is  already  known 
as  the  author  of  “A  Plea  and  a Plan  for  the  Eradica- 
tion of  Malaria  throughout  the  Western  Hemi- 
sphere.” The  pamphlet  is  a consolidation  and 
revision  of  a number  of  papers  read  by  the  author 
before  certain  public  bodies  during  the  last  two 
years  in  the  course  of  a campaign  against 
malaria  in  the  United  States.  He  gives  a 
number  of  interesting  facts  and  figures  con- 
cerning the  disease  and  the  measures  he  advo- 
cates for  its  suppression.  It  appears  that  there 
are  three  principal  well-recognised  endemic  areas 
of  malaria  in  the  United  States — one  large  and 
two  small.  The  first  and  largest  covers  the  whole 
south-eastern  portion  of  the  States,  its  southern 
boundary  being  the  Gulf  of  Mexico  ; its  western 
boundary  is  a line  drawn  from  Eagle  Pass  on  the 
Rio  Grande  to  Leavensworth,  Kansas  ; the  Atlantic 
seaboard  is  its  eastern  boundary,  and  its  northern 
is  a line  drawn  from  Leavensworth,  Kansas, 
eastward  some  distance  north  of  the  Ohio 
river  and  extending  to  the  Atlantic  on  a 
line  with  the  northern  boundary  of  Maryland. 
The  second  area  includes  a section  of  the 
northern  part  of  New  Jersey,  southern  New 
York  State,  Connecticut,  Rhode  Island,  and  part 
of  Massachusetts.  The  third  is  situated  in 
California  and  comprises  the  Sacramento  and 
San  Jaquin  Valleys.  Dr.  Hoffman  endorses  the 
statement  that  the  success  of  malaria  prophylaxis 
is  very  largely  a question  of  local  conditions  and 
the  assistance  given  by  the  local  and  central  health 
authorities.  He  sets  out  four  different  methods 
which  should  be  applied  in  conformity  with  the 
variations  in  the  local  conditions,  since  a method 
which  may  be  most  useful  in  one  locality  may  not 


be  so  useful  in  another.  The  methods  recom- 
mended, not  necessarily  in  the  order  here  given, 
are  the  usual  ones : (1 ) the  prevention  of  the  develop  - 
ment  of  the  plasmodia  in  man  and  their  destruction 
in  infected  individuals — both  of  these  aims  are 
accomplished  by  the  administration  of  quinine 
(that  is,  quinine  prophylaxis)  ; (2)  destruction  of 
the  mosquitoes  transmitting  malaria  ; (3)  protection 
of  man  from  the  bites  of  mosquitoes;  and  (4)  educa- 
tion of  the  public  regarding  malarial  prophylaxis. 
In  recent  years,  fortunately,  the  mortality  from  this 
disease  in  America  has  been  on  the  decline.  The 
case  mortality  rate  is  higher  in  the  coloured  popu- 
lation than  among  the  whites.  For  the  two-years’ 
period  1915  and  1916  the  fatality  rates  were  1’2  per 
cent,  for  the  coloured  and  0’7  per  cent,  for  the 
whites.  In  order  to  get  better  control  of  malaria, 
Dr.  Hoffman  strongly  advocates  compulsory  notifi- 
cation. Some  boards  of  health  have,  indeed,  made 
its  notification  obligatory,  but  these  are  a small 
proportion  of  the  whole.  So  far  reliance  has  had 
to  be  placed  for  the  collection  of  morbidity 
statistics  relating  to  the  disease  upon  the 
procedure  of  the  United  States  Public  Health 
Service,  which  issues  return  postcards  to  medical 
practitioners  asking  for  a monthly  statement 
of  the  number  of  cases  of  malarial  fever  treated 
by  them,  giving  particulars  as  to  race,  type 
of  disease,  and  whether  the  diagnosis  has  been 
microscopically  confirmed.  The  result  is  as  unsatis- 
factory as  such  postal  returns  always  are.  Hitherto 
only  about  13  per  cent,  of  those  receiving  these  post- 
cards have  sent  replies,  and  the  answers  received 
from  some  districtsaremuch  more  complete  than  the 
replies  from  others.  The  fuller  information  may  be 
due  either  to  the  greater  activity  of  the  local  health 
department  or  to  the  greater  interest  in  the  public 
welfare  on  the  part  of  the  local  practitioners.  Where 
the  State  boards  of  health  are  efficient, better  results 
are  obtained.  In  Dr.  Hoffman’s  opinion  the  complete- 
ness of  the  notification  of  disease  may  be  taken  as  a 
fairly  dependable  index  of  the  efficiency  of  the 
Health  Department  and  of  the  sanitary  knowledge 
and  training  of  its  personnel.  He  regards  the 
neglect  of  notification  by  general  practitioners  as 
a very  serious  dereliction  of  duty,  and  those  who 
thus  fail  in  the  discharge  of  what  is  a public 
service  “ should  be  punished  according  to  law  to 
the  fullest  extent.”  He  would  treat  with  equal 
severity  any  local  or  State  board  of  health  which 
is  unwilling  to  enforce  the  notification  of  malaria 
or  other  communicable  disease,  and  adds  that 
“incompetent  officials  should  be  dealt  with  accord- 
ing to  their  deserts.”  He  further  states  that  owing 
to  the  regrettable  inadequacy  of  the  notification 
returns  of  malaria  the  data  published  by  the  Public 
Health  Service  in  their  present  forms  cannot  be 
utilised  to  much  practical  advantage.  There  is 
much  that  is  useful  and  instructive  in  Dr.  Hoffman’s 
pamphlet. 

INDUSTRIAL  FATIGUE  AND  ACCIDENTS. 

Two  further  reports1  have  just  been  issued  by 
the  Industrial  Fatigue  Research  Board.  Dr.  H.  M. 
Vernon’s  illustrated  description  of  the  millmen’s 
work  in  tinplate  manufacture,  his  investigations 
into  the  influence  of  hours  of  work  and  of  venti- 
lation on  the  output,  and  his  suggestions  of 
improvements  in  factory  appliances  and  methods 

1 Rep  irts  of  the  Industrial  Fatigue  Research  Board.  No.  1 : The 
Influence  of  Honrs  of  Work  and  of  Ventilation  on  Output  in  Tinplate 
Manufacture.  No.  4 : The  Incidence  of  Industrial  Accidents  upon 
Individuals,  with  Special  Reference  to  Multiple  Accidents.  Published 
by  H.M.  Stationery  Oflice.  1919.  Price  6d.  each  net. 


586  The  Lancet,] 


GANGRENE  DUE  TO  CARBON  MONOXIDE  POISONING. 


[Sept.  27,  1919 


and  in  clothing,  all  indicate  very  clearly  not  only 
how  arduous  a task  is  the  making  of  steel  sheets, 
but  also  what  can  be  done  by  employers  to 
increase  production  and  at  the  same  time  to  reduce 
the  discomfort,  the  fatigue,  and  the  dangers  to 
health  of  the  employees.  He  finds  an  increase 
in  total  output  of  8'3  per  cent,  when  six-hour 
instead  of  eight-hour  shifts  are  worked.  His  data 
indicate  the  possibility  of  still  greater  improve- 
ment in  output  by  the  installation  of  thoroughly 
efficient  ventilation.  He  points  out  that  the  men 
stream  with  sweat  within  a very  few  minutes 
of  starting  work,  that  they  are  far  more  subject  to 
rheumatism  and  neuralgia  than  various  other 
classes  of  manual  workers,  and  that  throughout  the 
shift  they  wear  the  same  trousers  and  pants  in  which 
they  journey  to  and  from  the  works.  He  suggests 
several  improvements,  already  adopted  in  certain 
American  mills,  which  would  conduce  to  diminu- 
tion in  needless  physical  effort  and  to  lessened 
fatigue.  One  of  the  recognised  consequences  of 
undue  fatigue  is  an  increase  in  the  frequency  of 
factory  accidents.  Dr.  Major  Greenwood  and 
Miss  H.  M.  Woods,  however,  find  in  their  report 
evidence  of  another  factor  in  the  determination 
of  such  accidents  which  has  hitherto  escaped 
attention.  Certain  workers  are  found  to  show  a 
special  susceptibility  to  accidents.  They  should, 
for  their  own  sake  and  for  that  of  their  fellow 
workers,  be  transferred  to  less  risky  occupations. 
Further  inquiry  is  obviously  needed  to  discover 
what  are  the  reasons  and  the  remedy  for  such 
susceptibility.  It  may  be  that  the  individuals  in 
question  are  unusually  careless,  nervous,  or  clumsy. 
At  present  we  are  quite  ignorant  of  the  cause  pr 
causes.  The  psychological  examination  of  the 
susceptible  worker  would  prove  an  interesting  and 
valuable  piece  of  future  research. 


THE  PRINTED  LIE 

Lately  a distinguished  layman,  reviewing  the 
results  of  the  war,  remarked  that  the  chief  thing  it 
had  proved  was  the  power  of  the  lie  to  mould 
public  opinion.  This  hardly  comforting  finding 
might  have  been  foreseen.  In  the  sphere  of  science 
error  wilfully  propagated  is  rare,  but  in  the  trouble- 
some business  of  governing  men  it  is,  up  to  date, 
almost  inevitable ; as  mordantly  shown  by  Swift, 
and  (to  put  the  lady  in  very  good  company)  in 
Vernon  Lee’s  account  of  “ vital  lying.”  One  reason 
why  science  is  so  much  freer  from  falsehood  than 
politics  is  that  those  interested  in  the  former,  being 
better  educated,  are  much  less  credulous  of  what 
they  see  in  print — having,  indeed,  constantly  before 
them  the  garbling  of  scientific  matters  in  the  daily 
press.  But  the  ordinary  citizen,  who  has  time  and 
inclination  for  one  newspaper  only,  believes  its 
calumny  by  commission  and  omission  just  as  readily 
as  its  reports  of  football  matches.  Again,  in  science, 
dealing  as  it  does  with  exact  and  rational  matters, 
truth  prevails  much  more  quickly  than  in  the 
uncertain  domain  of  the  human  heart  and  will. 
Nevertheless,  the  lie  has  been  met  with  in 
medicine.  The  not  rare  phenomenon  of  patronised 
professors  writing  to  order  is  little  seen,  although 
some  perviousness  to  social  influences  may  exist. 
But  there  is  danger  of  it  when  millionaires 
endow  and  maintain  a large  organisation  for 
research,  especially  considering  the  direction  of 
the  sociological  trend  of  sanitary  science.  Merciful 
deceiving  of  a moribund  patient  is  not  an 
instance  in  point,  if  only  that  every  wise 


practitioner  safeguards  himself  by  enlisting  the 
cooperation  of  the  patient’s  relatives,  whom  he 
leaves  in  no  doubt  as  to  the  facts  of  the  case. 
Where  the  written  lie  is  chiefly  operative  is  on  the 
commercial  side.  Very  few  baseless  medical 
certificates  of  physical  incapacity  for  war  service 
came  to  light,  although,  of  course,  some  must  have 
remained  undetected,  the  responsibility  for  them 
occasionally  being  on  the  shoulders  of  men  of 
high  professional  position.  The  public  estimation 
of  medical  certificates  is,  indeed,  on  the  whole,  high. 
Articles  written  ostensibly  to  serve  research,  but 
really  in  the  interests  of  the  vendors  of  some  drug, 
appliance,  or  bacterial  derivative,  have  been  dealt 
with  by  medical  organisations  in  more  than  one 
country.  Such  communications  cannot  be  hard  to 
detect  by  the  fairly  experienced,  but  they  do  much 
harm.  The  sacred  thirst  for  truth  is  the  motive 
of  all  fruitful  research,  and  although  an  upholder 
of  a dying  theory  or  remedy  (generally  the  latter! 
may  write,  as  Samuel  Johnson  sometimes  talked, 
“ for  victory,”  it  is  mostly  unconscious,  not 
deliberate,  mental  bias  which  puts  a man  into 
this  posture.  In  science,  which  represents  a high 
triumph  of  human  culture  over  nature — which  is, 
of  course,  non-moral  to  the  core — truth  reigns  as 
nowhere  else.  Here  especially  does  the  American 
writer’s  epigram  hold  good  that  truth  will  survive 
being  run  over  by  a locomotive,  while  error  dies  of 
lockjaw  if  it  pricks  its  little  finger.  And  although 
these  last  five  years  have  indeed  shown  that  to 
political  lying  and  vital  lying  must  be  added  a third 
variety,  to  wit,  war  lying,  yet  happily  from  the 
severe  injuries  truth  has  sustained  she  is  now 
slowly  making  sure  recovery. 


GANGRENE  DUE  TO  CARBON  MONOXIDE 
POISONING. 

In  the  • Journal  of  the  American  Medical  Associa- 
te of  August  30th  Dr.  J.  E.  Briggs  has  reported  a 
case  of  a very  unusual  complication  of  carbon 
monoxide  poisoning.  The  case  is  of  interest  not 
only  on  account  of  the  rarity  of  the  complication, 
but  because  it  shows  the  danger,  which  is  not 
generally  recognised,  of  exposure  to  the  exhaust 
gases  of  the  internal  combustion  engine.  Three 
brothers  went  for  a fishing  trip  in  a motor-boat. 
Before  starting  the  exhaust  pipe  had  been  dis- 
connected preparatory  to  installing  another  muffler. 
The  exhaust  was  ordinarily  carried  out  along  the 
bottom  of  the  boat,  but  the  pipe  was  disconnected 
within  3 feet  of  the  engine,  leaving  the  open 
exhaust  in  the  cabin,  which  was  15  by  7 feet.  One 
of  the  brothers  went  to  the  cabin  and  lay  down. 
After  a time  another  went  to  arouse  him,  but  after 
15  minutes  had  not  returned,  and  the  third  noticed 
through  the  open  door  that  he  had  suddenly  fallen 
forwards.  He  shut  off  the  engine  and  rushed  in. 
He  found  the  first  brother  lying  on  the  floor 
about  8 feet  from  the  engine,  and  the  second 
about  4 feet  from  it  and  dead.  The  first, 
who  was  breathing,  was  carried  out  of  the 
cabin,  and  efforts  were  made  to  revive  him. 
At  first  he  talked  incoherently.  He  was  taken  to 
hospital  and  treated  for  what  appeared  to  be  second 
degree  burns  of  both  hands  and  feet.  His  back, 
as  well  as  that  of  the  dead  man,  was  covered 
with  large  tense  blebs.  These  were  punctured, 
trimmed,  and  dressed  with  boric  ointment.  He 
was  discharged,  but  the  affected  areas  enlarged 
and  extensive  gangrene  followed.  A month  after 
the  accident  he  was  admitted  to  hospital  under 


The  Lancet,] 


THE  CENTENARY  OF  THE  HUNTERIAN  SOCIETY. 


[Sept.  27,  1919  f,H7 


Dr.  Briggs’s  care.  There  was  gangrene  of  the 
entire  three  middle  fingers,  one-half  of  the  inner 
border  of  the  thumb,  and  an  extensive  area  of 
the  little  finger  of  the  right  hand.  In  the  left 
hand  gangrene  affected  the  distal  phalanges  of  the 
four  fingers  and  the  flexor  surface  of  the  thumb. 
There  were  also  on  the  right  side  gangrenous  areas 
on  the  outer  border  of  the  tibial  region,  the 
external  malleolus,  the  outer  border  of  the  dorsum 
of  the  foot,  and  small  patches  on  three  toes.  On 
the  left  foot  were  gangrenous  areas  at  the  distal 
end  of  two  toes.  The  location  and  character 
of  the  lesions  showed  that  they  could  not  have 
been  due  to  exposure  to  heat.  The  gangrene 
was  dry,  and  affected  skin,  muscle,  tendon, 
periosteum,  and  bone,  and  extended  into  several 
joints.  Lines  of  demarcation  were  well  established. 
Amputation  of  the  three  fingers  of  the  right  hand 
at  the  metacarpo  phalangeal  joints  and  of  the  four 
fingers  of  the  left  hand  at  the  middle  of  the  second 
phalanx  was  performed.  Two  similar  cases  have 
been  recorded.  Alberti 1 has  reported  a case  of 
extensive  gangrene  of  the  musculature  of  the  throat 
and  paralysis  of  the  left  leg  after  carbon  monoxide 
poisoning.  The  patient  was  overcome  by  the  gas 
escaping  from  a stove.  He  awoke  with  pains  in  the 
head,  and  on  attempting  to  rise  fell  unconscious. 
Paralysis  of  the  right  foot  and  painful  swelling  of 
the  right  elbow,  pain  in  the  arm,  and  stiffness  of 
the  neck  followed.  On  the  right  side  of  the  neck 
a dry,  brownish-black,  mummified  area  of  the  size  of 
the  palm  appeared.  A line  of  demarcation  formed. 
It  was  necessary  to  incise  to  a depth  of  2 cm.  before 
blood,  mixed  with  dark-brown  fluid,  appeared. 
The  gangrenous  areas  extended  and  he  died  26  days 
after  the  poisoning.  A.  Maclean  2 has  reported  the 
case  of  a patient  found  unconscious  in  his  room 
with  a small  gas  burner  open,  in  which  the  flame 
had  been  accidently  extinguished.  The  gas  con- 
tained 7 per  cent,  of  carbon  monoxide.  A week 
later  he  complained  of  pain  in  the  feet  and  legs, 
and  was  admitted  to  hospital  because  they  were 
swollen  and  discoloured  in  patches  below  the 
knee.  During  the  next  two  weeks  the  pain  con- 
tinued, the  legs  became  cedematous,  and  the  dis- 
colourations  became  gangrenous.  Both  legs  had 
to  be  amputated.  Recovery  ensued. 


THE  CENTENARY  OF  THE  HUNTERIAN  SOCIETY. 

The  Hunterian  Society  was  founded  in  the  year 
1819,  and  even  in  its  early  days,  judging  from  the 
reports  in  our  own  columns,  the  discussions  seem 
to  have  been  attended  with  a vivacity  unknown  at 
other  medical  societies  of  London.  To  give  a 
single  example : At  the  Hunterian  Society  in  May, 
1826,  a Mr.  Waller  related  to  a critical  audience  his 
personal  experience  of  transfusion  in  the  treat- 
ment of  conditions  of  dangerous  haemorrhage.  His 
remarks  were  not  well  received,  and  the  presi- 
dent, in  summing  up,  commented  on  the  fact 
that  the  speaker  had  omitted  to  employ  one  import- 
ant remedy — namely,  “ glysters  of  chicken-broth." 
More  recent  meetings,  although  curtailed  by  war 
conditions,  have  dealt  with  equally  live  topics,  and 
a full  programme  is  planned  for  the  coming  winter 
session.  Meetings  will  be  held  on  the  second  and 
fourth  Wednesdays  in  the  month  from  October  to 
April  at  9 p.m.  at  the  School  of  Oriental  Languages 
(formerly  the  London  Institution)  in  Finsbury- 
circus.  A special  address  by  Professor  Arthur 

1 Deutsch.  Ztschr.  f.  Chir.,  1884,  p.  476. 

= Journ.  American  Med  Assoc  , May  20th,  1911,  p.  1465. 


Keith,  F.R.S.,  will  be  given  on  Oct.  8th  in  the  Hall 
of  the  Society  of  Apothecaries.  The  Centenary 
Dinner  takes  place  on  Oct.  22nd,  when  Sir  Norman 
Moore  will  propose  the  health  of  the  Society.  Sir 
William  Osier  has  undertaken  to  deliver  the  annual 
oration.  The  present  officers  of  the  Society  are 
Dr.  W.  Langdon  Brown,  president,  Dr.  F.  Howard 
Humphris  and  Dr.  R.  L.  Mackenzie  Wallis,  honorary 
secretaries.  We  wish  the  centenarian  City  medical 
society  a renewed  youth  and  vigour. 


THE  OPENING  OF  THE  WINTER  SESSION. 

The  new  session  of  the  London  Schools  of 
Medicine  which  is  upon  us  is  likely  to  be  note 
worthy  in  one  particular  especially.  It  will  see 
the  inauguration  of  research  clinics  in  several 
schools  with  a recognised  authority  at  the  head  of 
each,  who  will  devote  the  whole  of  his  time  and 
interest  to  the  advancement  of  his  special  subject. 
At  University  College  Hospital  Dr.  T.  R.  Elliott  is 
mentioned  as  the  director  of  the  medical  clinic; 
at  St.  Thomas’s  Hospital  Sir  Cuthbert  Wallace 
has  been  made  responsible  for  the  establishment  of 
a surgical  unit ; St.  Bartholomew’s  Hospital  is 
fortunate  in  finding  men  like  Sir  Archibald  Garrod 
and  Mr.  G.  E.  Gask  to  preside  over  the  medical 
and  surgical  research  departments  respectively. 
It  is  too  early  to  presage  the  kind  of  development 
to  which  these  appointments  will  give  rise,  although 
it  is  certain  that  they  will  enhance  the  reputation 
of  the  London  School  of  Medicine  as  a research  and 
teaching  centre.  A substantial  step  will  have  been 
taken  towards  founding  that  solid  basis  of  under- 
graduate and  graduate  study  in  London  which  is 
befitting  to  a city  of  the  size  and  position  of  the 
metropolis.  


A NEW  MEDICAL  JOURNAL.1 

The  Journal  of  Industrial  Hygiene  combines 
two  innovations.  This  is  the  first  serial  publica- 
tion devoted  to  occupational  health,  that  branch 
of  preventive  medicine  which  is  so  rapidly 
coming  to  the  front.  Contributions  to  industrial 
medicine  have  heretofore  appeared  in  publica- 
tions dealing  with  general  hygiene,  medicine,  or 
surgery;  they  have  nowhere  been  collated,  and  those 
interested  in  the  subject  have  had  to  watch  all 
journals  or  run  the  risk  of  missing  important 
papers.  Secondly,  it  has  an  international  editor- 
ship, American  and  British.  This  cooperation 
between  two  of  the  greatest  industrial  countries 
in  the  world  is  admirable,  and  is  a sign  of 
scientific  friendship  from  which  only  good 
can  come.  The  two  nations  are  bound  to  be 
industrial  rivals,  but  friendly  rivalry  is  good  for 
both ; and  joint  action  wfill  assist  in  keeping  it 
friendly,  stimulate  a proper  emulation  in  effort  to 
improve  the  health  of  both  peoples,  and  stand  ever 
in  the  way  of  jealous  animosity.  From  both  points 
of  view  this  new  venture  deserves  success.  The 
journal,  which  in  the  excellence  of  its  printing 
and  of  its  reproductions  of  diagrams  and  illustra- 
tions holds  out  a challenge  to  many  of  our 
home  publications,  is  produced  by  the  Macmillan 
Company  in  America ; hence  we  presume  the 
predominance  in  the  first  two  numbers  of 
American  contributions.  The  names,  however, 
of  those  in  this  country  who  cooperate  in  the 
editorship  should  ensure  in  future  numbers 

i The  Journal  of  Industrial  Hygiene,  Macmillan  Company,  Fifth 

Avenue,  New  Yorfr. 


588  Thb  Lancet,] 


THE  COMPLEAT  MASSEUR. 


[Sept.  27, 1919 


adequate  representation  of  British  thought  and 
research.  The  first  number  makes  its  bow 
with  an  article  by  Dr.  Mock,  who  traces 
the  development  of  industrial  medicine  in 
the  States,  and  points  out  the  stimulus  it 
received  during  war-time.  In  this  country,  too, 
through  the  action  of  the  Ministry  of  Munitions, 
war-time  employment  gave  great  impetus  to  the 
movement  which  we  hope  may  hereafter  be  duly 
recorded.  The  writer  sums  up  : “ Thus,  in  the 
course  of  one  short  decade  broad  humanising 
principles,  combined  with  scientific,  medical,  and 
surgical  work,  have  permanently  established  in  the 
medical  profession  this  far-reaching  health  service 
— industrial  medicine  and  surgery.”  Both  the  first 
and  second  numbers  contain  contributions  from 
Dr.  Alice  Hamilton,  who,  in  an  interesting,  if  some- 
what discursive,  way,  deals  with  her  own  specialty 
— industrial  poisons  ; but  in  attempting  to  cover 
intoxication  from  lead,  zinc,  copper,  brass,  arsenic, 
antimony,  mercury,  carbon  bisulphide,  phosphorus, 
and  carbon  monoxide  in  two  articles,  she  hardly 
does  justice  to  her  subject  or  herself.  The  most 
important  paper  is  undoubtedly  that  of  Dr. 
Spaeth  on  the  “ Problem  of  Fatigue.”  It  is  the 
best  exposition  of  present  knowledge  on  the 
subject  we  know,  and  is  accompanied  by  an 
excellent  and  exhaustive  bibliography.  The  author 
summarises  laboratory  experimental  research  and 
chemical  knowledge  of  vital  activity ; and  then 
proceeds  to  discuss  practical  methods  of  investiga- 
tion in  the  industrial  world  by  testing  individuals 
and  by  measuring  output,  accidents,  lost  time,  and 
sickness,  all  of  which  he  holds  may  be  expected  to 
throw  further  light  on  definite  aspects  of  the  subject. 
Psycho-physiological  tests  are  condemned  as  im- 
practicable under  industrial  conditions ; but  research 
into  reflexes  and  objective  tests  is  recommended  as 
likely  to  prove  of  value.  The  relation  of  hours 
of  labour  to  efficiency  is  held  to  establish  the 
superiority  of  a shorter  working  week,  at  any  rate 
so  far  as  the  eight-hour  and  ten-hour  shift  systems 
are  concerned ; and  the  author  holds  that  “ the 
men  who  planned  such  a radical  industrial  pro- 
gramme (as  the  eight-hour  day)  were  possessed  of  a 
profound  wisdom  and  social  vision.”  This  article 
should  be  carefully  read  not  only  by  medical  men 
but  by  employers  and  employed,  for  it  is  not 
unknown  for  the  workmen  to  desire,  tempted  by 
pay,  to  defy  hygienic  laws.  Dr.  Anna  Richardson 
tells  from  her  own  experience  of  the  value 
of  medical  service  among  telephone  operators. 
This  contribution  should  be  of  use  to  factory 
medical  officers  in  indicating  the  work  there  is  to 
do,  and  the  way  in  which  records  can  be  scienti- 
fically analysed.  Dr.  Austen  sets  forth  his  work  in 
examining  factory  employees  before  engagement, 
and  points  out  its  value.  He  places  to  the  credit 
of  efficient  health  service (i.)  diminished  labour 
turnover ; (ii.)  diminished  loss  of  production,  due 
to  absenteeism ; (iii.)  increased  efficiency  and 
lessened  cost  of  production,  due  to  higher 
grade  employees  ; (iv.)  diminished  industrial 

liability  to  accidents,  due  to  elimination  of 
physical  and  mental  defectives ; (v.)  diminished 
moral  hazard,  due  to  the  fact  that  venereal-infected 
employees  are  only  conditionally  employed  ; 
(vi.)  diminished  labour  cost,  due  to  the  reduction 
of  the  excessive  overhead  charge  which  results 
from  transferring  employees  who  are  working  at  a 
physical  disadvantage ; (vii.)  a hospital  and 
dispensary  place  emploxees  in  direct  personal 
touch  with  the  entire  organisation,  and  show  such 


employees  that  their  company  recognises  that 
healthy  individuals  are  the  most  vitally  necessary 
part  of  its  success.”  A paper  on  health  by  an 
engineer,  Professor  Whipple,  is  excellent  in  itself, 
and  valuable  as  surveying  hygiene  from  an 
essentially  practical  point  of  view ; the  view 
of  one  who  has  to  accomplish  what  the 
medical  scientist  declares  should  be  done,  whether 
in  mosquito  control,  drainage  systems,  or  factory 
construction.  Other  articles  deal  with  “ Chip 
Fractures  of  Terminal  Phalanges,”  byDr.Hurley;  and 
“ The  Use  of  Army  Gas  Masks  in  Industries.”  Not 
the  least  valuable  part  of  each  number  is  a supple- 
ment giving  abstracts  of  the  current  literature  of 
industrial  hygiene.  Each  notice  is  signed  by  the 
abstractor,  which  is  likely  to  ensure  more  careful 
work  than  anonymity ; and  the  notices  are  for 
the  most  part  of  such  reasonable  length  that 
the  reader  can  obtain  a real  idea  of  the 
work  mentioned — a point  where  many  abstracts 
of  literature  fail  even  to  the  extent  of  being 
little  more  than  bibliographies.  The  standard 
maintained  here  is,  however,  uneven,  and  we 
recommend  the  editors  to  watch  carefully  this 
important  part  of  their  journal.  We  are  so 
confident  this  journal  meets  a need,  and  has  before 
it  an  opportunity  of  doing  great  and  useful  work, 
that  we  intend  keeping  our  readers  informed  from 
time  to  time  of  the  progress  made. 


THE  COMPLEAT  MASSEUR. 

The  programme  of  the  Conference  of  the  Incor- 
porated Society  of  Trained  Masseuses,  announced 
for  Oct.  2nd-4th,  suggests  the  stirring  of  new  life. 
We  may  associate  it  with  the  petition  recently 
addressed  through  the  Board  of  Trade  to  His 
Majesty  in  Council  begging  that  a Charter  may  be 
granted  to  a society  to  be  known  henceforth  as  the 
Chartered  Society  of  Massage  and  Medical  Gym- 
nastics. The  object  of  the  proposed  society  is  to 
unite  together  the  older  Society  of  Trained 
Masseuses,  which  was  founded  in  1894  and  incor- 
porated in  1900,  and  the  more  recent  foundation, 
the  Institute  of  Massage  and  Remedial  Gymnastics, 
which  was  founded  in  1916.  Up  to  the  time  of 
the  foundation  of  the  Incorporated  Society  of 
Trained  Masseuses  25  years  ago,  massage  treat- 
ment in  this  country  was  in  a parlous  state. 
Anyone  who  chose  could  pose  as  a masseur,  and 
training  was  so  limited  as  to  be  almost  non- 
existent. Small  wonder,  then,  that  the  Swedish 
masseur  became  the  traditional  instrument  to 
employ  when  ordering  “ massage.”  Thanks  almost 
solely  to  the  untiring  efforts  of  the  founders  of 
the  Incorporated  Society  and  their  successors — a 
faithful  and  disinterested  band  whose  work  has 
received  all  too  little  recognition — the  art  of  massage 
was  raised  step  by  step  from  the  lowest  depths 
and  placed  upon  a basis  which,  though  still  far 
from  perfect,  can  only  be  considered  as  remark- 
ably good.  The  lamentable  lack  of  interest 
shown  by  the  medical  profession  as  a whole  has 
been  the  main  stumbling-block  in  the  road  of 
progress.  Many  medical  men  have  studied  and 
practised  electro-therapy  in  recent  years ; there 
are  few  who  would  not  be  hard  put  to  it  if  invited 
to  carry  out  themselves  the  simplest  of  massage 
treatments,  and  fewer  still  who  could  write  out  a 
table  of  exercises  applicable  to  a particular  con- 
dition. The  result  is  that  most  medical  men  who 
order  “ massage  ” or  “ exercises  ” are  incapable  of 
discerning  between  good  and  inefficient  work  and, 


The  Lancet,]  THE  COST  OF  HOUSING  THE  PEOPLE.— PUBLIC-HOUSE  REFORM. 


[Sept.  27,  1919  589 


judging  by  results  alone,  are  liable  to  extol  or 
deprecate  without  discrimination. 

In  an  article  in  a recent  number  of  the  Journal 
of  the  I.S.T.M. , Dr.  Carl  Westman  points  to  the 
remedy.  He  advocates  : — 

(I.)  “Compulsory  visits  for  all  medical  students  to  the 
massage  departments  and  opportunity  for  special  training 
of  those  interested,  such  course  to  run  concurrently  with  the 
medical  studies." 

(II.)  “The  adaptation  and  development  of  the  treatment 
along  scientific  and  rational  lines.” 

The  former  suggestion  will  save  the  medical  man 
of  the  future  from  ignoring  one  of  the  most  valu- 
able methods  of  treatment  in  his  armamentarium. 
The  second  will  then  follow  as  a corollary.  Dr. 
Westman  goes  on  to  advocate  a revised  and 
standardised  training  for  masseurs  (including 
“ masseuses  ”),  with  abolition  of  the  present  six 
months’  course  certificate.  It  may  be  it  is  possible 
in  six  months  to  acquire  a smattering  of  what  is 
generally  included  under  the  term  massage,  a poor 
remedy  on  which  to  rely  in  remedial  work.  For 
surgical  or  orthop£edic  cases  a knowledge  of 
Swedish  remedial  exercises  is  essential,  the 
period  of  training  required  for  admission  to 
the  existing  examination  being  six  months.  A 
year’s  training  is  therefore  an  irreducible  mini- 
mum for  the  fully  qualified  masseur.  The 
formation  of  a register  of  persons  qualified  to 
practise  massage,  and  the  penalisation  of  quackery, 
would  then  protect  the  public  from  the  danger  of 
the  uninstructed  dabbler  in  remedial  gymnastics. 
At  present  the  gymnastic  directors  in  this  country 
have  been  trained  in  the  two  or  three  years’ 
course  at  one  or  other  of  our  leading  physical 
training  colleges.  Their  isolation  from  hospital 
work  is  the  one  great  flaw  in  an  otherwise 
magnificent  training.  These  qualified  gymnasts 
require  recognition  and  protection,  as  well  as  the 
others  who  are  more  especially  trained  in  medico- 
physical  treatment.  The  granting  of  a charter 
should  soon  make  it  possible  compulsorily  to 
extend  their  training  so  as  to  embrace  the  full 
course  of  massage,  Swedish  remedial  exercises,  and 
electrotherapy.  

THE  COST  OF  HOUSING  THE  PEOPLE. 

Sir  Kingsley  Wood,  M.P.,  Parliamentary  Secretary 
to  the  Ministry  of  Health,  speaking  at  Brighton, 
urged  his  hearers  to  set  off  against  the  cost  of 
modern  house  building  the  gain  in  health  which 
the  nation  might  expect  as  the  result  of  better 
accommodation  for  its  humbler  members.  This  is 
probably  the  wisest,  if  not  the  only,  way  in  which 
the  matter  should  be  looked  at.  The  community 
has  to  contemplate  a prospect  of  expenditure  which, 
judged  by  the  ordinary  standard  of  probable 
pecuniary  return,  it  would  not  be  justified  in  under- 
taking. There  is,  however,  this  consolation,  that 
the  Ministry  of  Health,  so  Sir  Kingsley  Wood 
declared,  was  not  going  to  be  satisfied  to  emulate 
the  jerry-builder  of  the  past,  and  we  hope 
to  see  new  houses  in  which  the  saving  in 
repairs  will  to  some  extent  compensate  for 
the  initial  expenditure  on  their  production. 
It  is  to  be  regretted  that  when  a man,  or  the 
nation,  comes  forward  with  money  to  spend  and 
an  object  which  has  to  be  attained  by  its  expendi- 
ture, he  and,  more  than  he,  the  nation,  finds  at 
once  every  one’s  hand  against  him.  It  will  not  be 
a hand  raised  in  violence  ; its  energies  will  be  con- 
centrated not  upon  taking  his  life,  but  upon  empty- 
ing his  pockets.  Sir  Kingsley  Wood  referred  to 
claims  provisionally  made  as  to  the  price  of  land 


for  houses,  amounting  in  the  aggregate  to  £587,000, 
reduced  by  efficient  valuation  by  £143,250.  This  is 
a reduction  of  not  much  less  than  25  per  cent.  The 
building  of  houses  by  tender  is  not  on  quite  a similar 
basis  with  the  acquirement  of  the  land  for  them. 
The  cost  of  the  houses  of  the  class  referred  to  was 
quoted  by  Sir  Kingsley  Wood  as  being  about  £700, 
minor  details  and  accessories  giving  a certain 
amount  of  opportunity  for  economy  to  those  desirous 
of  effecting  it.  The  audience  at  Brighton  were 
reminded  of  the  power  of  local  authorities  to  con- 
tract with  builders  for  the  purchase  of  houses 
erected  by  the  builders  themselves. 


PUBLIC-HOUSE  REFORM. 

The  virtues  and  vices  of  the  existing  licensing 
laws  have  been  carefully  considered  by  a sub- 
committee of  the  Brewers’  Society  and  the  National 
Trade  Defence  Association,  who  have  issued  an 
interesting  draft  of  a new  Licensing  Bill  this  week. 
New  licensing  authorities,  reduced  hours  of  sale,  and 
fresh  penalties  for  inebriety — all  involving  some- 
what drastic  changes — are  proposed,  but  the  most 
interesting  part  of  the  Bill  deals  with  an  attempt 
to  make  the  public-house  a place  comparable  with 
a tea-shop  or  cafe.  Too  long  has  the  liquor  trade 
confined  its  business  to  merely  the  sale  of  liquor, 
and  they  realise  now  the  mistake  of  not  making 
the  “ pub.”  a centre  of  real  and  varied  public 
refreshment  and  entertainment.  Supposing  that 
legislation  should  ensue  upon  this  Bill,  there  will 
be  difficulty,  of  course,  just  now  in  adapting 
existing  premises  to  meet  this  much  needed 
reform,  but  the  policy  of  rendering  places  of 
refreshment  airy  and  commodious,  providing  in 
them  wholesome  food  and  non-alcoholic  beverages, 
is  so  sound  that  expense  should  not  stand  in  the 
way.  Moreover,  money  so  spent  would  be  a good 
investment.  That  the  stuffy  and  unwholesome 
gin-palace  and  the  dirty,  offensive  public-house 
must  go,  and  decent  rendezvous  of  refreshment 
substituted,  has  been  for  a long  time  a very  general 
decision.  


The  Home  Secretary  is  about  to  appoint  an 
inspector  under  the  Cruelty  to  Animals  Act.  The 
appointment  will  be  for  a term  of  four  years  in  the 
first  instance  and  the  salary  will  be  £800  a year, 
together  with  war  bonus  on  the  scale  authorised 
for  the  Civil  Service  and  travelling  allowances  at 
the  usual  Civil  Service  rate.  The  inspector  will 
be  required  to  give  his  whole  time  to  his  duties. 
Candidates  for  this  post  who  possess  the  necessary 
scientific  qualifications  required  for  the  work  should 
apply  to  the  Private  Secretary,  Home  Office,  London, 
from  whom  further  particulars  may  be  obtained. 
Applications  should  be  accompanied  by  one  or  two 
testimonials  and  particulars  of  the  candidate’s 
qualifications,  and  should  reach  the  Home  Office 
not  later  than  Oct.  10th,  1919. 


“THE  LANCET”  OF 

Jan.  18th,  Feb.  8th,  15th,  March  1st,  and 
July  5th. 

The  Manager  will  be  obliged  to  readers  who  have 
not  any  further  use  for  their  copies  of  The  Lancet 
of  the  above  dates  if  they  will  kindly  return  them 
to  him  at  1,  Bedford-street,  Strand,  W.C.  2.  The 
postage  on  the  first  four  numbers  is  one  halfpenny 
each,  and  on  July  5th  one  penny.  He  will  be 
pleased  to  pay  for  those  returned. 


590  The  Lancet,] 


SCOTLAND.— IRELAND. 


[Sept.  27,  1919 


SCOTLAND. 

(From  our  own  Correspondent.) 

Death  of  Professor  Trail  of  Aberdeen  University . 

The  death  took  place  at  Aberdeen  on  Sept.  18th  of  Pro- 
fessor J.  W.  H.  Trail,  who  had  occupied  the  chair  of  botany 
at  the  University  of  Aberdeen  for  42  years.  Professor  Trail, 
who  was  68  years  of  age,  was  born  at  Birsay,  Orkney,  and 
was  educated  at  Aberdeen  University,  graduating  M A.  in 
1870,  M B.,  C.M.  (with  honours)  in  1876,  and  M.D.  in  1879. 
From  1873  to  1875  he  acted  as  naturalist  to  an  exploring 
expedition  in  Northern  Brazil.  In  1877,  at  the  early  age  of 
26,  he  was  appointed  regius  professor  of  botany  at  Aberdeen 
University,  which  appointment  he  held  up  to  the  time  of  his 
death,  when  he  was  senior  member  of  the  Senatus.  He  was 
a Fellow  of  the  Royal  Society  and  of  the  Linnsean  Society, 
and  had  made  many  contributions  to  scientific  journals  on 
botanical  and  zoological  subjects.  Outside  the  University  he 
was  also  well  known  for  his  activities  in  public  life  in 
connexion  with  the  subject  of  education. 

St.  Andrews  University  : Chair  of  Natural  History. 

The  University  Court  of  St.  Andrews  unanimously 
appointed  Dr.  James  Fairlie  Gemmill  to  the  chair  of  Natural 
History  in  University  College,  Dundee.  Dr.  Gemmill  is  a 
distinguished  graduate  of  Glasgow  University,  and  held  there 
the  posts  of  lecturer  in  embryology  and  lecturer-assistant  in 
zoology.  He  was  also  first  president  of  the  Scottish  Marine 
Biological  Association,  which  he  was  largely  instrumental  in 
founding. 

Election  of  Direct  Representative  for  Scotland  to  the  General 
Medical  Council. 

Dr.  Michael  Dewar  has  issued  to  the  profession  in  Scotland 
an  address,  in  which  he  offers  himself  as  a candidate  at  the 
election  to  be  held  in  November  next  for  appointing  a Direct 
Representative  for  Scotland  to  the  General  Medical  Council. 
Dr.  Dewar  is  a graduate  of  Edinburgh  University,  and  is  well 
known  locally  for  his  work  in  connexion  with  the  National 
Health  Insurance  Bill,  both  as  regards  its  terms  and  adminis- 
tration, the  British  Medical  Association,  the  Central  Mid- 
wives Board  (Scotland),  and  the  Medical  and  Dental  Defence 
Union.  Dr.  Dewar  stands  as  a general  practitioner  in  active 
practice,  and  is  in  favour  of — 

(1)  A fairly  high  standard  of  proficiency  in  general  education  for 
entrance  to  the  medical  curriculum. 

(2)  The  compulsory  inclusion  in  all  entrance  examinations  of  the 
following  subjects:  English.  Latin,  mathematics  (including  algebra 
and  arithmetic),  and  an  additional  language. 

(3)  The  recent  action  by  the  General  Medical  Council  in  approving 
of  the  various  examinations  as  qualifying  for  registration  of  medical 
students. 

(4)  The  maintenance  and  extension  of  the  supervision  of  the  pro- 
fessional examinations  by  the  Council. 

(5)  The  establishment  of  a one  portal  system  for  admission  to  the 
medical  curriculum  and  to  the  medical  profession. 

(6)  The  total  prohibition  of  unregistered  dental  practice,  due  regard 
being  given  to  those  who  have  been  practising  dentistry  for  some 
years. 

(7)  The  necessity  for  the  inclusion  of  as  many  general  practitioners 
in  the  Council  as  are  allow  ed  by  the  1886  Act  to  assist  in  dealing  with 
penal  cases. 

He  is  to  address  meetings  of  the  profession  throughout 
Scotland  in  various  centres  during  the  month  of  October  for 
the  purpose  of  further  explaining  and  amplifying  his  views. 

Public  Health  ( Notification  of  Infectious  Disease ) Regulations 
(Scotland),  1919. 

A new  Order  amends  the  form  of  certificate  to  be  given  by 
a medical  practitioner  under  Section  3 of  the  Infectious 
Disease  (Notification)  Act,  1889,  especially  in  the  direction 
of  requiring  the  following  additional  particulars  : — 

Measles.— Date  of  first  appearance  of  rash. 

Tuberculosis.— Localisation  of  the  disease.  Occupation.  Usual  place 
of  residence  (if  other  than  that  given  in  the  notification).  Is  patient 
an  insured  person  under  the  National  Insurance  Acts  ? 

Ophthalmia  neonatorum.— Date  of  birth.  Name  and  address  of 
parent  nr  other  person  (if  any)  having  charge  of  child. 

Malaria  and  dysentery.— Is  this  patient’s  first  attack?  Was  patient 
infected  abroad  ? 

Sept.  21st. 


Dr.  Alexander  Morison.  of  Upper  Berkeley-street, 
London,  has  received  official  sanction  for  the  assumption  of 
the  surname  of  Blackhall  before  his  paternal  surname  of 
Morison. 


IRELAND. 

(From  our  own  Correspondents.) 

The  Irish  Public  Health  Counoil. 

The  personnel  of  the  Irish  Public  Health  CounciU'was 
announced  last  week  in  these  columns.  Its  duties  under  the 
Ministry  of  Health  Act  are  “to  give  advice  and  assist- 
ance, and  to  make  proposals  to  the  Chief  Secretary  in  con- 
nexion with  his  powers  and  duties  under  this  Act.”  Your 
readers  ought  to  know  that  the  constitution  of  the  Council  is 
giving  rise  to  severe  criticism  in  Ireland  on  several  grounds. 
Out  of  17  members  constituting  this  Health  Council,  five, 
so  far,  belong  to  the  medical  profession.  The  nominees 
of  the  Irish  Insurance  Commissioners  (to  be  three 
in  number)  and  of  the  Local  Government  Board  for  Ireland 
(also  to  be  three)  have  not  yet  been  made  public,  beyond 
the  official  chairman  of  each  of  these  bodies.  But  it  is 
probable  that  at  least  one  of  each  group  will  be  a doctor, 
and  we  may  take  it  provisionally  that  six  out  of  the  17 
members  of  the  Irish  Public  Health  Council  will  be  medical 
men,  of  whom  at  least  three  will  be  permanent  officials 
not  now  in  actual  practice.  This  conclave  is  to  suggest 
to  the  Minister  of  Health  in  Ireland  (the  Chief  Secretary) 
some  plan  for  improving  the  public  health  of  the  country, 
and  yet  of  17  members  there  will  be  apparently  only  six 
doctors,  three  of  whom  are  not  in  active  practice  and  not 
one  of  whom  has  been  elected  by  the  whole  body  of  the 
medical  profession. 

Every  one  of  the  medical  members  of  this  Irish  Health 
Council  is  a Dublin  resident.  Considering  the  five  towns  in 
Ireland  of  over  30,000  inhabitants,  Dublin,  with  a population 
of  290,638,  has  445  doctors  ; Belfast,  with  a population  of 
349,180,  has  325  doctors  ; Cork,  with  76,122  inhabitants, 
has  140  doctors  ; Londonderry,  with  a population  of 
39,892,  has  32  doctors;  and  Limerick,  with  38,151 
inhabitants,  has  39  doctors.  Why  should  one  Irish 
city,  which,  albeit  the  capital,  comes  second  in  popu- 
lation, have  all  the  medical  representation  on  a Public 
Health  Council  for  the  whole  of  Ireland  ? Not  only 
the  other  large  towns  but  the  countryside  is  ignored. 
Ireland,  as  compared  with  England,  is  largely  rural,  and  a 
total  of  2398  doctors  are  absolutely  unrepresented  medically 
on  this  advisory  Irish  Public  Health  Council.  The  Poor-law 
medical  officers  of  Ireland,  with  their  wretched  pay,  hard 
work,  and  uncertain  position — quite  different  from  the  Dublin 
permanent  officials — have  not  a single  medical  representative 
on  this  Council,  yet  who  know  so  well  as  they  what  an 
inadequate  and  antiquated  public  health  service  there  is  in 
Ireland  1 Irish  doctors,  who  want  the  public  health  of  the 
country  improved,  are  asking  how  could  six  doctors,  three 
not  in  practice  and  all  residing  in  Dublin,  tender  advice — 
based  on  personal  practical  experience — in  reference  to  the 
problems  of  the  great  rural  districts  of  the  centre  and  south 
of  Ireland,  of  the  “ congested  areas  ” of  the  west  (somewhat 
analogous  to  the  sparsely  populated  parts  of  the  highlands 
and  islands  of  Scotland,  and  of  parts  of  Wales),  and  of  the 
industrial  public  health  difficulties  of  the  north  of  Ireland  ? 

Londonderry  Water  Queues. 

The  supply  of  water  to  Derry  is  daily  growing  less.  The 
reservoirs  on  Sept.  18th  had  only  30  million  gallons  of 
water ; one  portion  of  the  city  is  actually  dependent  on  a 
pump,  which  may  break  down  at  any  moment.  In  other 
parts  there  is  a reduced  supply  given  only  twice  a week,  and 
the  inhabitants  there  have  to  rely  on  a spring  at  the  asylum 
in  Strand-road,  where  in  the  1911  water  famine  a pump  was 
erected,  and  to  this  pump,  an  oasis  in  the  desert,  the 
travelling  caravan  of  thousands  of  men,  women,  and  children 
daily  flock  for  water,  which  they  carry  off  in  every  kind  of 
vessel,  from  tins  to  whisky  kegs,  kettles  to  barrels.  The 
corporation,  in  their  efforts  to  keep  some  regulation  of  the 
“ dry  ” crowd,  have  posted  up  the  following  notice  : “ Take 
your  place  in  the  line  and  wait  your  turn.”  There  is  a crowd 
both  by  day  and  night,  and  carts  and  lorries  are  being 
utilised  to  carry  supplies.  As  for  Belfast,  there  is  still 
considerable  shortage  in  the  store  of  water,  the  total 
amount  in  the  reservoirs  being  1133  million  gallons,  as 
against  1609  million  gallons  in  the  same  week  of 
September,  1918.  Until  the  water  authorities  in  towns 
learn  and  act  upon  the  principle  that  it  is  for  dry  and  not 


The  Lancet,] 


PARIS.— AUSTRALIA. 


[Sept.  27,  1919  591 


wet  seasons  they  must  prepare,  such  famines  as  at  present 
prevail  in  the  water-supply  of  their  areas  will  every  now  and 
again  occur. 

Soarlet  lever  Outbreak  in  Belfast. 

There  has  been  in  Belfast  a very  widespread  epidemic  of 
scarlet  fever  since  the  beginning  of  the  present  month,  so 
that  now  Purdysburn  Fever  (Memorial)  Hospital  is  full  up 
(300  cases),  and  there  are  close  on  100  cases  more  in  the 
Union  Fever  Hospital.  The  patients  are  from  all  parts  of 
the  city  and  from  all  grades  of  society.  There  are  17  cases 
of  scarlatina  in  Coleraine  in  the  fever  hospital,  and  the  out- 
break is  prevalent  in  Kilrea,  co.  Derry. 

Sept.  22nd. 

PARIS. 

(From  our  Own  Correspondent.) 

Increase  of  Rabies  in.  France. 

CASES  of  rabies  are  becoming  more  and  more  numerous  in 
France  because  of  the  large  numbers  of  stray  dogs  in  the 
districts  laid  waste  by  the  enemy.  Many  warnings  recom- 
mending the  provision  of  muzzles  for  dogs  and  their  restraint 
on  a leash  have  been  issued.  These  suggestions,  however, 
have  not  been  generally  adopted.  Dr.  Roux,  director  of  the 
Pasteur  Institute,  at  the  last  session  of  the  Council  of 
Hygiene  and  Health  of  the  Seine  Department,  submitted  to 
the  Prefecture  of  Police  an  urgent  note  pointing  out  the 
gravity  of  the  danger.  He  recommends  that  all  people  bitten 
by  any  sort  of  dog  should  come  immediately  to  the  Pasteur 
Institute.  The  few  failures  of  antirabic  treatment  are  due 
only  to  delay  in  treatment.  Rules  as  to  stray  dogs  and 
wearing  of  muzzles  should  also  be  enforced  with  vigour.  If 
the  public  were  not  so  sentimental  about  dogs,  he  says,  and 
if  the  law  were  administered  more  strictly,  rabies  would 
have  disappeared  from  France  by  now  as  it  did  practically 
before  the  war.  M.  Roux  quoted  the  example  of  England, 
where  rabies  was  unknown,  thanks  to  strict  rules,  until  the 
day  when  dogs  were  smuggled  in  by  air. 

A New  Chair  in  the  Faculty  of  Medicine  of  Paris. 

A Chair  of  Laryngology  has  just  been  created  in  the 
University  of  Paris.  Hitherto  the  only  professor  of  this 
subject  in  France  has  been  Professor  Moure,  of  Bordeaux  ; 
elsewhere  the  teaching  of  laryngology  has  been  undertaken 
by  assistants  appointed  by  the  professor  of  general  medicine 
in  the  practical  clinics.  The  new  professor  is  Dr.  Sebileau, 
supernumerary  professor,  member  of  the  Academy  of  Medi- 
cine, and  surgeon  of  the  Lariboisiere  Hospital,  where  he 
conducts  a large  department  of  laryngology. 

The  Raising  of  the  Official  Tariff  for  Doctors'  and  Chemists' 
Fees  for  Industrial  Accidents. 

The  general  rise  in  the  cost  of  living  and  of  all  salaries  has 
necessarily  led  doctors  to  raise  their  fees,  but  not  in  pro- 
portion to  the  increase  in  prosperity  of  workmen,  manu- 
facturers, and  business  men,  because  medical  men  cannot 
form  a professional  union,  nor  can  they  refuse  to  attend 
patients  when  humanity  calls.  The  public  would  not  extend 
to  them  the  tolerance  allowed  to  strikers  who  stop  traffic 
— trams,  trains,  or  taxis — or  cut  off  the  supply  of 
water,  gas,  or  electricity.  Moreover,  in  certain  cases 
medical  men  are  bound  by  a contract  accepted  before 
the  war.  In  this  category  comes  medical  attention 
given  to  workmen’s  injuries,  to  old  people,  and  to 
the  poor — under  the  law  relating  to  gratuitous  medical  aid. 
The  charges  are  regulated  according  to  an  old  tariff,  which  is 
not  remunerative  because  it  is  calculated  by  the  State  in 
accordance  with  the  insurance  companies,  whose  terms  are 
somewhat  lacking  in  generosity.  This  old  tariff,  which 
provided  a fixed  sum  for  each  category  of  accidents  and  for 
every  sort  of  medical  aid,  has  obviously  become  too  low  for 
present  conditions  of  life.  It  has  become  even  more  unjust, 
inasmuch  as  the  companies  have  raised  their  insurance  rates 
considerably.  The  difference  is  thus  entirely  in  their  favour. 
The  Union  of  Medical  Councils  in  France  have  undertaken  a 
vigorous  campaign  to  raise  the  medical  fees  in  this  tariff,  and 
has  succeeded  in  convincing  the  Parliamentary  commission 
charged  with  the  reconsideration  thereof.  Henceforward  all 
fees  are  to  be  doubled.  The  new  tariff  comes  into  force  as 
from  April  1st,  1919,  except  for  bills  actually  paid  before  the 
law  was  passed  (July  30th).  There  is  thus  no  means  of 


raising  the  prices  on  their  bills,  if  they  apply  to  accidents  sus- 
tained before  April  1st  next.  On  the  other  hand,  the  tariff  is 
provisional,  and  is  only  valid  until  Jan.  1st,  1920,  after  which 
it  will  be  subject  to  quarterly  revision  if  one  of  the  parties — - 
the  State  or  the  Medical  Councils — demands  a further 
modification.  Thus  the  result  obtained  by  the  Union  of 
Medical  Councils  is  quite  important,  although  still  insufficient, 
in  the  opinion  of  many  doctors,  as  workpeople’s  wages  are 
not  double  but  three  or  four  times  what  they  were,  and 
the  insurance  companies  have  raised  the  rates  in  exact 
proportion  to  the  increase  in  salary. 

Sept.  29th.  

AUSTRALIA. 

(From  our  own  Correspondent.) 

The  Influenza. 

The  influenza  epidemic  still  continues  to  show  little  altera- 
tion in  Victoria.  A recrudescence  has  been  noticeable  since 
the  very  cold  weather  began,  early  in  June,  and  there  are 
still  upwards  of  1200  to  1500  cases  as  a daily  hospital  average 
in  the  metropolis,  and  an  unknown,  but  very  large,  number 
of  cases  elsewhere.  On  the  whole  the  case-mortality  appears 
to  be  somewhat  small,  but  there  are  from  10  to  12  deaths 
daily  in  Melbourne.  In  Sydney  there  was  a very  severe  out- 
break during  June  and  the  early  part  of  July,  and  the 
mortality  assumed  serious  proportions  during  one  or  two 
weeks.  The  banks  were  so  short-staffed  that  they  only 
opened  for  two  hours  daily.  With  a warm  spell  in  the 
middle  of  July  the  spread  rapidly  subsided,  and  at  present  is 
well  within  the  capacity  of  the  existing  provision.  In  Perth 
there  have  been  a few  cases,  but  the  disease  has  not  assumed 
alarming  features.  All  inter-State  quarantine  has  been 
abandoned  except  by  Tasmania,  but  as  there  is  no  communi- 
cation between  it  and  the  mainland,  owing  to  the  shipping 
strike,  this  is  no  inconvenience.  The  Commonwealth 
Quarantine  Department  has  announced  the  issue  of  a serum 
for  the  treatment  of  the  affection,  but  the  general  attitude  is 
apathetic  towards  such  methods  after  the  failure  of  vaccine 
inoculation  which  may  now  be  taken  as  established,  at  all 
events,  for  those  vaccines  which  were  employed. 

Medical  War  Relief  Fund. 

A movement  has  been  set  on  foot  by  the  Federal 
Medical  Committee  and  the  New  South  Wales  Branch  of 
the  British  Medical  Association  to  establish  a fund  to 
be  applied  to  medical  men,  or  their  dependents,  who 
have  suffered  financial  reverse  while  on  active  service. 
Clauses  4 and  5 of  a draft  agreement  which  has  been 
adopted  by  all  the  State  branches  provide  that  the  fund 
“shall  be  used  in  assisting  medical  officers  who  have  been 
disabled  and  the  dependents  of  those  who  have  died  ; and 
that  the  fund  shall  also  be  used  to  issue  loans,  with  or  with- 
out interest,  to  medical  men  who,  on  account  of  war  service, 
may  require  temporary  financial  assistance.”  It  is  proposed 
to  raise  the  sum  of  £50,000,  if  possible,  by  voluntary  con- 
tribution. The  weak  spot  in  the  proposal  is  that  apparently 
no  attempt  has  been  made  to  ascertain  the  probable  demand 
that  may  be  made,  which  could  have  been  approximately 
arrived  at  without  much  difficulty,  as  the  proposal  has  only 
been  shaped  since  the  armistice  and  practically  all  the 
medical  officers  are  traceable. 

Returned  Medical  Officers. 

The  medical  officers  who  went  from  Victoria  on  overseas 
service  have  formed  a society  for  the  promotion  of  the 
interests  of  its  members.  They  approached  the  Premier 
with  a request  that  their  secretary  should  be  supplied  in 
advance  with  particulars  of  proposed  Government  medical 
appointments,  and  that  all  such  appointments  made  during 
the  war  should  be  reviewed  with  the  prospect  of  giving 
them  to  returned  men.  The  Premier  saw  no  difficulty  in  the 
first  request,  and  promised  to  think  over  the  other. 

Munificent  Requests. 

Sir  Samuel  McCaughey,  who  recently  died  in  New  South 
Wales,  was  a pioneer  of  the  pastoral  industries  in  Australia, 
and  acquired  a large  fortune.  By  his  will  the  cause  of 
medical  education  should  benefit,  for  the  Sydney  University 
receives  a sum  of  £400,000,  while  the  Brisbane  University 
benefits  to  the  extent  of  £250,000.  The  late  Sir  Samuel 
McCaughey  was  a bachelor. 


592  The  Lancet,] 


TUBERCULOSIS.— URBAN  VITAL  STATISTICS. 


[Sept.  27,  1919 


Personal. 

Mr.  G.  A.  Syme,  F.R.C.S.  Eng.,  having  reached  the 
retiring  age,  has  relinquished  his  position  as  surgeon  to  the 
Melbourne  Hospital  and  received  a special  acknowledgment 
from  the  committee  of  his  long  and  faithful  service.  Mr. 
Syme  volunteered  for  overseas  war  duty,  and  worked  on  a 
hospital  ship  during  the  Anzac  landing,  but  contracted  a 
poisoned  hand,  and  after  a dangerous  illness  was  compelled 
to  proceed  to  England,  where  he  acted  as  consulting  surgeon 
to  the  Australian  medical  establishment.  Mr.  Syme  is 
succeeded  by  Mr.  B.  T.  Zwar,  who  also  was  on  active  service 
with  the  Australian  forces. 

Lieutenant-Colonel  N.  F.  Fairley  has  been  appointed 
assistant  director  of  the  Eliza  Hall  Research  Laboratory  at 
the  Melbourne  Hospital.  He  is  a Melbourne  graduate,  and 
has  done  interesting  work  on  cerebro-spinal  fever  and  on 
bilharziasis. 

August  5th. 


TUBERCULOSIS. 


The  Welsh  National  Memorial. 

According  to  the  report  of  the  King  Edward  VII.  Welsh 
National  Memorial  Association,  which  was  presented  at  the 
seventh  annual  meeting  on  July  26th,  the  work  of  the 
association  has  gone  successfully  forward  in  spite  of  the  war. 
At  the  end  of  July,  1914,  the  association  possessed  87 
hospital  beds.  The  number  of  sanatorium  beds  belonging 
to  the  association  in  this  year  was  148.  By  1919  the  number 
of  hospital  beds  had  risen  to  473,  and  that  of  sanatorium 
beds  to  594.  In  the  year  ending  March  31st,  1914,  the 
patients  examined  numbered  8763.  In  the  year  ending 
March  31st,  1919,  they  numbered  12,260.  During  the  war, 
up  to  this  date,  no  less  than  11,402  had  received  treatment 
in  hospitals,  and  6373  in  sanatoriums.  More  than  50,000 
patients  were  examined  at  dispensaries  and  visiting  stations 
by  tuberculosis  physicians.  Since  1915  there  had  been  no 
delay  in  making  provision  for  discharged  Service  men 
suffering  from  tuberculosis  ; more  than  2500  passed  through 
the  hands  of  the  association’s  medical  staff,  and  more  than 
1600  received  treatment  in  hospitals  and  sanatoriums.  As 
many  as  350  patients  took  their  discharge  against  medical 
advice,  and  53  were  discharged  for  breaches  of  discipline.  The 
two  large  sanatoriums,  Talgarth  and  Llangwyfan,  have  been 
almost  completed,  and  the  work  of  the  building  committees 
has  come  to  an  end.  The  medical  policy  of  the  association 
is  discussed  in  a special  section  of  the  report,  and  many 
recommendations  are  made  as  to  the  organisation  of  the 
campaign  against  tuberculosis.  This  section  deals  with 
principles  and  ideals  rather  than  with  actual  achievements. 
In  presenting  the  report  the  president,  Major  David  Davies, 
said  that  it  had  been  decided  that  the  appointment  of  chief 
medical  officer  to  the  association,  in  succession  to  Dr.  Marcus 
Paterson,  who  resigned  two  years  ago,  had  been  held  in 
abeyance  during  the  war  on  account  of  the  difficulty  of 
securing  the  best  man.  He  added  that  the  suggestion  had 
been  made  that  a chair  of  Tuberculosis  should  be  established 
in  the  Medical  School  of  Wales,  and  that  the  professor  of 
tuberculosis  should  become  the  chief  medical  officer  of  the 
association.  In  this  way  the  close  cooperation  of  the  school 
and  the  association  would  be  secured,  and  the  information 
gathered  by  the  association  would  be  at  the  disposal  of  the 
hundreds  of  medical  students  passing  through  the  medical 
school. 

Sanatoria  in  Reports. 

The  thirty-fourth  annual  medical  report  of  the  Trudeau 
Sanatorium,  published  by  itself,  not  with  the  general  report 
already  reviewed  in  The  Lancet  for  July  26th,  consists 
largely  of  reprints  of  articles  published  by  members  of  the 
Trudeau  School  in  the  American  Review  of  Tuberculosis.  It 
contains,  however,  a previously  unpublished  account  of 
investigations  made  into  the  subsequent  fate  of  patients 
who  had  been  discharged  from  the  sanatorium  20  years  or 
more  earlier.  Of  the  814  patients  traced,  148,  or  18  2 per 
cent.,  were  alive;  666,  or  81-8  per  cent.,  were  dead.  An 
attempt  is  also  made  to  show  how  the  severity  and  extent 
of  the  disease  at  the  time  of  treatment  affects  the  ultimate 
fate  of  the  patient. 

The  report  of  the  Vejlefjord  Sanatorium  for  1918  includes 
a paper  by  its  medical  superintendent.  Professor  Saugman, 
on  thoracoplasty.  This  operation,  he  has  found,  greatly 


improves  the  prognosis  for  patients  in  the  later  stages  of 
pulmonary  tuberculosis,  the  results  of  treatment  for  these 
patients  being  far  better  than  in  earlier  years  when  com- 
pression therapy  was  not  practised.  The  majority  (64  9 per 
cent.)  of  all  the  patients  were  in  the  third  stage,  and  only 
10  5 per  cent,  were  in  the  first  stage  of  the  disease. 
The  proportion  of  patients  discharged  fit  for  work  was 
49  7 per  cent.,  as  compared  with  44  -7  per  cent,  representing 
the  average  for  the  years  1900-1918.  This  improvement 
was  chiefly  due  to  the  better  results  among  the  patients  in 
the  third  stage,  as  great  a proportion  as  33  3 per  cent,  being 
discharged  fit  for  work  instead  of  25  4 per  cent,  in  earlier 
years.  Of  the  patients  in  the  third  stage  45  underwent 
treatment  by  artificial  pneumothorax  (11  failures  on  account 
of  pleural  adhesions)  and  16  underwent  thoracoplastic 
operations.  The  results  in  some  of  these  cases  were 
strikingly  successful. 

The  American  Review  of  Tuberculosis. 

The  May  number  begins  with  a paper  by  Dr.  Paul  A. 
Lewis  on  the  Complement-fixation  Test  in  Tuberculosis.  He 
finds  that  the  numerical  relations  are  such  as  to  make  it 
unsafe  to  apply  this  test  to  the  diagnosis  of  tuberculosis 
except  as  a matter  of  the  most  limited  confirmatory  interest. 
In  a paper  on  the  Influence  of  Protein  Intoxication  on 
Tuberculosis  in  Guinea-pigs  Dr.  Allen  K.  Krause  and  Dr. 
H.  S.  Willis  show  that  repeated  daily  injections  of  (homo- 
logous) t.uberculo-protein  and  (heterologous)  egg  albumin, 
before  experimental  infection  with  tubercle  bacilli,  probably 
render  guinea-pigs  less  resistant  to  tuberculous  infection. 
Dr.  A.  L.  Bloomfield  and  Dr.  J.  G.  Mateer  give  an 
account  of  cutaneous  tuberculin  tests  carried  out  in 
19  consecutive  cases  of  influenza.  They  found  that  during 
the  febrile  stage  of  the  influenza  the  skin  sensitiveness 
to  tuberculin  was  absent  in  every  case  but  one.  During 
convalescence  reactivity  returned  to  89  4 per  cent.,  which 
corresponds  with  the  proportion  of  positive  reactions  among 
otherwise  healthy  individuals.  The  authors  note  that,  in  its 
influence  on  the  cutaneous  tuberculin  test,  influenza  bears  a 
striking  resemblance  to  measles.  In  a paper  on  the  Pneumo- 
thorax treatment  of  Acute  Lung  Abscess  Dr.  B.  Goldberg  and 
Dr.  M.  Biesenthal  publish  three  cases  successfully  treated. 
Their  analysis  of  16  cases  thus  treated,  including  their  three 
cases,  shows  that  recovery  was  effected  in  75  per  cent., 
improvement  in  12  per  cent.,  while  two  patients  (12  per 
cent.)  were  dead.  Their  comparison  of  this  operation  with 
other  methods  suggests  that  artificial  pneumothorax  is  the 
best  procedure.  A somewhat  discursive  paper  on  the  Treat- 
ment of  Tuberculous  Cervical  Adenitis,  by  Dr.  W.  R. 
Abbott,  is  a plea  for  tuberculin  treatment. 


URBAN  VITAL  STATISTICS. 

(Week  ended  Sept.  20th,  1919.) 

English  and  Welsh  Towns.— In  the  96  English  and  Welsh  towns, 
with  an  aggregate  civil  population  estimated  at  16.500,000  persons, 
the  annual  rate  of  mortality,  which  had  been  10’0,  10'7,  and  10’4  in  the 
three  preceding  weeks,  rose  to  10  9 per  1000.  In  London,  with 
a population  slightly  exceeding  4,000,000  persons,  the  annual  death-rate 
was  114,  or  0'5  per  1000  above  that  recorded  in  the  previous  week, 
while  among  the  remaining  towns  the  rates  ranged  from  18  in 
Enfield,  4'9  in  Oxford,  and  5'7  in  Northampton,  to  18'4  in  Middles- 
brough, 190  in  Tynemouth,  and  20  6 in  Great  Yarmouth. 
The  principal  epidemic  diseases  caused  434  deaths,  which 
corresponded  to  a rate  of  1'4  per  1000,  and  Included  322  from 
infantile  diarrhcea,  38  from  diphtheria,  31  from  whooping-cough, 
25  from  measles,  14  from  scarlet  fever,  and  4 from  enteric  fever. 
Measles  caused  a death-rate  of  36  per  1000  in  Tynemouth.  The 
322  deaths  from  Infantile  diarrhma  were  81  in  excess  of  the  number 
in  the  previous  week,  and  included  103  in  London,  25  in  Liverpool, 
12  each  in  West  Ham  and  Middlesbrough,  11  in  Birmingham,  and  9 in 
South  Shields.  There  were  1524  cases  of  scarlet  fever  and  1118  of 
diphtheria  under  treatment  in  the  MetroDolitan  Asvlums  Hospitals 
and  the  London  Fever  Hospital,  against  1504  and  1057  respectively  at 
the  end  of  the  previous  week.  The  causes  of  26  deaths  in  the 
96  towns  were  uncertified,  of  which  3 were  registered  in  Birmingham 
and  3 in  Liverpool. 

Scotch  Towns. — In  the  16  largest  Scotch  towns,  with  an  aggregate 
population  estimated  at  nearly  2.500,000  persons,  the  annual  rate  of 
mortality,  which  had  been  10'9,  10  8,  and  10'2  in  the  three  preceding 
weeks,  rose  to  10’5  per  1000.  The  224  deaths  in  Glasgow  corresponded 
to  an  annual  rate  of  10  4 per  1CO0,  and  included  15  from  infantile 
diarrhcea,  3 from  diphtheria,  2 from  whooping-cough,  and  1 each  from 
enteric  fever,  measles,  and  scarlet  fever.  The  66  deaths  in  Edinburgh 
were  equal  to  an  annual  rate  of  10  2 per  1000,  and  included  2 from 
infantile  diarrhoea, and  leach  from  scarlet  fever  and  whooping-cough. 

Irish  Towns.— The  97  deaths  in  Dublin  corresponded  to  an  annual 
rate  of  12'5,  or  4 8 per  1000  below  that  recorded  in  the  previous  week, 
and  included  9 from  infantile  diarrhoea,  and  1 each  from  enteric 
fever,  scarlet  fever,  and  diphtheria.  The  111  deaths  in  Belfast  were 
equal  to  a rate  of  14'4  per  1020,  and  included  8 from  infantile 
, diarrhcea,  6 from  scarlet  fever,  and  1 from  diphtheria. 


The  Lancet,] 


CONTROL  OF  VENEREAL  DISEASES. 


[Sept.  27,  1919  593 


CONTROL  OF  VENEREAL  DISEASES. 


Prophylaxis  against  Venereal  Disease. 

In  January  last  an  Inter-Departmental  Committee  was 
appointed  by  Dr.  Addison  to  consider  the  risks  of  demobilisa- 
tion to  the  health  of  the  civilian  population  of  the  country 
and  the  measures  to  avoid  them.  A Note  (Cmd.  322. 
H.M.  Stationery  Office.  Price  3rA)  has  now  been  presented 
to  the  Minister  of  Health  reporting  on  one  small  part  of  the 
venereal  problem— namely,  the  advisability  of  encouraging 
the  sale  of  “ packets  ” — i.e. , the  provision  before  exposure 
to  infection  of  means  of  prophylaxis  for  use  either  before  or 
after  exposure.  The  Committee  heard  the  experience  of 
distinguished  medical  representatives  of  various  sections  of 
troops— namely  : for  Canada,  Colonel  J.  G.  Adami  and 
Colonel  J.  A.  Amyot  ; for  Australia,  Lieutenant-Colonel 
G.  Raffan  and  Sir  James  Barrett ; for  New  Zealand,  Major 
J.  Falconer  Brown  ; for  the  United  States,  Colonel  A.  M. 
Whaley,  Colonel  H.  Young,  and  Colonel  W.  T.  Snow  ; for 
the  B.E.F.,  Major  C.  T.  White.  In  addition  evidence  was 
given  by  Lady  Barrett,  Sir  Bertrand  Dawson,  Sir  H.  Bryan 
Donkin,  Sir  William  Osier,  Dr.  Morna  Rawlins,  Sir  G. 
Archdall  Reid,  and  Dr.  Agnes  Savill.  Memoranda  sub- 
mitted by  these  experts  are  given  in  the  appendix  to  the 
Note,  while  in  the  text  are  set  out  the  figures  of  incidence 
of  venereal  disease  among  the  different  troops.  The  general 
conclusion  reached  by  the  Committee  is  short  and  crisp  : — 
The  official  application  of  a packet  system  to  the  civil  com- 
munity is  neither  desirable  nor  practicable.  Paragraph  8 
of  the  Note,  which  is  the  chief  justification  of  this  con- 
clusion, runs  : — 

“ while  certain  drugs  and  preparations  maybe  relied 

upon  to  remove  or  destroy  the  infection  of  venereal  disease  if 
applied  by  skilled  attendants  very  shortly  after  exposure, 
such  satisfactory  results  cannot  be  secured  if  those  drugs 
and  preparations  are  used  unskilfully  or  too  long  a time  after 

exposure experience  indicates  that,  however  careful  the 

instruction,  and  however  scientifically  effective  the  prophy- 
lactic in  itself  might  be  if  used  under  proper  conditions,  it 
frequently  fails  to  protect  when  applied  by  the  individual, 
even  when  this  self-application  is  supported  later  by  addi- 
tional skilled  treatment.  The  consumption  of  alcoholic 
liquors,  carelessness,  natural  excitement,  forgetfulness,  or 
ignorance  has  been  the  cause  of  numerous  failures,  even 
amongst  those  troops  where  the  use  of  such  prophylactic 
measures  has  been  most  efficiently  organised  and  taught.” 
The  Committee,  it  is  added,  set  out  to  examine  the 
evidence  placed  before  them  from  the  scientific  and  the 
medical  point  of  view,  and  it  is  strictly  in  this  spirit  that 
they  desire  to  record  it  as  their  opinion  that  the  irreplaceable 
effect  of  the  moral  factor  has  been  too  frequently  neglected 
or  forgotten. 

The  Note  is  of  value  if  only  for  the  definition  of  certain 
terms  adopted  (“for  the  purpose  of  the  Committee”)  to 
avoid  ambiguity. 

Prophylactic  treatment  to  connote  the  issue  of  drugs  and 
appliances  made  available  before  exposure  to  infection,  for 
use  by  the  individual. 

Early  preventive  treatment  to  connote  treatment  applied 
immediately  after  exposure  to  infection. 

Abortive  treatment  to  connote  treatment  applied  imme- 
diately on  the  appearance  of  symptoms  with  a view  to 
cutting  short  the  duration  of  the  disease. 

The  adoption  of  this  nomenclature  will  clarify  future 
discussion  of  the  subject. 

Legislation  against  Venereal  Disease  in  Sweden. 

We  published  in  1915  and  1916  a series  of  annotations 
dealing  with  reforms  which  were  then  being  advocated  in 
connexion  with  venereal  disease  in  Sweden.  Some  of  these 
have  now  materialised,  and  in  the  Swedish  journal,  Dagens 
Ny Utter,  Bureauchef  Sigurd  Ribbing  has  given  an  account  of 
the  new  law  dealing  with  venereal  disease  which  came  into 
force  on  Jan.  1st  of  this  year.  The  system  of  registration 
and  regulation  of  prostitutes  is  definitely  abolished,  and 
principles  are  adopted  corresponding  more  closely  with 
modern  western  sociological  views.  Every  patient  suffering 
from  venereal  disease  is  now  entitled  to  free  medical 
treatment,  including  drugs  and,  when  necessary,  free 
hospital  treatment.  The  special  wards  hitherto  set  apart  for 
venereal  disease  are  abolished,  so  that  no  invidious  dis- 
tinction is  made  between  venereal  and  other  diseases.  Pro- 
vision is  made  in  the  large  towns  for  polyclinics,  each  town 
of  over  20,000  inhabitants  being  obliged  to  provide  adequate 


polyclinical  accommodation.  To  help  towns  to  meet  this 
obligation,  the  State  undertakes  to  defray  the  cost  of  doctors, 
drugs,  and  other  medical  requirements,  while  the  cost  of 
premises,  of  fuel,  lighting,  nursing,  &c,  must  be  borne  by 
the  local  authorities.  In  return  for  its  substantial 
subsidy  the  State  looks  to  the  local  authorities  to 
provide  good  accommodation  and  to  keep  up  the  standard 
of  efficiency,  so  as  to  meet  modern  requirements.  In 
districts  where  the  establishment  of  polyclinics  is  not 
feasible,  free  medical  treatment  is  undertaken  by  the 
local  medical  authorities,  represented  by  the  State  medical 
practitioners  or  medical  officers  of  health.  It  is  admitted 
that  these  medical  officers  do  not  invariably  possess  the  skill 
and  experience  of  a specialist  in  venereal  diseases,  but  in 
thinly  populated  districts  there  has  been  no  satisfactory 
alternative,  and  several  medical  officers  of  health,  recog- 
nising their  limitations,  have  already  brought  their  know- 
ledge of  venereal  diseases  up  to  date  by  getting  into  touch 
with  special  hospitals  for  these  diseases.  It  is  also  antici- 
pated that  in  the  near  future  special  post-graduate  courses 
in  venereal  diseases  will  be  provided  in  conjunction  with 
grants  of  money  to  practitioners  attending  such  courses. 

The  new  law  makes  it  compulsory  for  every  patient  suffer- 
ing  from  venereal  disease  to  submit  to  medical  treatment  as 
long  as  the  disease  is  in  an  infectious  stage.  If  the  medical 
officer’s  instructions  regarding  treatment  and  prevention  of 
infection  are  not  followed  out,  the  patient  is  liable  to  com- 
pulsory treatment  in  a public  hospital  and  to  detention 
there  until  the  infectious  stage  of  the  disease  is  passed. 
Any  man  or  woman  who  suffers  from  venereal  disease  and 
who  exposes  others  to  this  infection  is  liable  to  imprisonment 
and  hard  labour.  And  it  is  the  duty  of  the  authorities  to 
prosecute  without  the  instigation  of  anyone  who  has  been 
exposed  to  infection  by  the  accused.  New  powers  are 
also  given  the  police  for  dealing  with  brothels  masquerading 
as  hotels. 

The  promoters  of  this  new  law  do  not  flatter  themselves 
that  they  have  even  approximately  solved  the  problems  of 
prostitution  and  venereal  diseases  by  putting  the  above 
reforms  on  the  Statute  books.  Indeed,  they  regard  these 
reforms  merely  as  one  step  to  an  end  that  can  be  attained  only 
by  the  greatest  vigilance  and  by  untiring  supervision  of  the 
working  of  the  innovation.  It  is  also  admitted  that  prostitu- 
tion is  an  expression  of  certain  social  economic  factors  which 
are  hardly  touched  by  the  new  law.  The  war  has  undoubtedly 
swelled  the  ranks  of  the  prostitute  to  an  enormous  extent 
by  inducing  poverty  on  the  one  side,  opulence  on  the  other. 
And,  above  all,  the  housing  problem  is  responsible  for  the 
conditions  which  foster  prostitution.  By  more  efficient 
inspection  of  houses  throughout  the  country,  and  by  local 
authorities  undertaking  the  provision  of  new  houses,  it  is 
hoped  that  a partial  solution,  at  any  rate,  of  this  problem 
may  be  found ; and  in  the  meantime  it  is  considered 
urgently  necessary  by  Hr.  Ribbing  and  his  colleagues 
that  the  present  legislation  dealing  with  child  welfare 
should  be  extended  so  as  to  give  the  authorities  certain 
powers  over  young  adults  of  15  to  18.  Compulsory 
education  and  detention  of  the  incipient  prostitute  of  this 
age  would,  it  is  urged,  do  much  to  convert  the  potential 
vagabond  to  an  industrious  and  virtuous  worker. 

Travelling  Consultants  for  Venereal  Clinics.  ' 

Referring  to  a proposal  made  in  this  column  on  Sept.  6th 
(p.  451)  to  appoint  travelling  consultants  for  venereal  clinics, 

“ Fair  Play  ” writes  : — 

“Your  suggestion  is  excellent,  but  I should  like  to  add 
that  it  does  not  go  far  enough,  and  that  what  is  wanted  is  a 
complete  overhaul  of  the  present  personnel.  The  majority 
of  these  clinics  were  started  during  the  war,  and  appoint- 
ments of  medical  officers  were  made  from  those  available  at 
the  time.  In  some  cases  these  appointments  have  been 
dealt  with  in  the  spirit  of  a closed  corporation,  and  are 
reserved  for  members  of  the  hospital  concerned,  irrespective 
of  their  knowledge  of  venereal  disease.  There  are  now 
many  medical  men  demobilised  who  have  had  experience  in 
Military  Y.D.  Hospitals,  to  say  nothing  of  pre-war  expe- 
rience, and  who  have  returned  to  find  the  doors  to  these  new 
appointments  bolted  and  barred.  As  the  Ministry  of  Health 
is  spending  public  money  on  these  clinics,  it  is  ‘up  to  ’ the 
Ministry  to  see  that  the  money  is  spent  to  the  best  advantage, 
and  that  these  appointments  are  made  by  a system  of  open 
competition.  I have  recently  been  consulted  by  a patient 
who  has  been  woefully  mistreated  at  one  of  these  new 
clinics,  owing  apparently  to  ignorance  on  the  part  of  the 
medical  staff.” 


594  The  Lancet,] 


CONTROL  OF  VENEREAL  DISEASE. 


[Sept.  27,  1919 


(Komspnknn. 


“ Audi  alteram  partem.” 


CONTROL  OF  VENEREAL  DISEASE. 

To  the  Editor  of  The  Lancet. 

Sir, — The  letter  in  your  last  issue  under  this  title  from 
Sir  Bryan  Donkin  with  regard  to  the  deputation  from  the 
National  Council  for  Combating  Venereal  Diseases  to  the 
Public  Health  Committee  of  the  London  County  Council, 
hardly  does  justice  either  to  the  London  County  Council 
or  the  National  Council.  The  London  County  Council  has 
no  “ policy  of  passivity.”  I know  that  it  is  prepared  to  go 
as  far  as  it  possibly  can  in  providing  facilities  for  treatment 
of  venereal  disease  ; but  it  declines  to  assist  in  establishing 
centres  for  “ early  preventive  treatment,”  holding  that  the 
establishment  and  public  advertisement  of  such  centres 
would  be  a direct  incitement  to  vice.  Administrative  and 
financial  difficulties  also  influenced  it. 

It  is  obvious  from  its  answer  to  the  deputation  that  the 
County  Council  did  not  then  realise  that  the  main  request  of 
the  National  Council  was  for  greatly  increased  facilities  for 
effectual  and  continuous  treatment,  and  that  the  “preven- 
tive ” side  was  an  adjunct. 

The  policy  of  the  National  Council  for  Combating  Venereal 
Diseases  is  simple — “ Personal  cleanliness  directly  after  risk 
of  infection,  and  prompt  resort  to  a medical  man.”  No 
question  of  “ 6 hours  ” arises  with  regard  to  it. 

I am  Sir,  yours  faithfully, 

E.  B.  Turner,  F.R.C.S., 

Chairman  of  the  Medical  Committee,  N.C.C.V.D. 

81,  Avenue  Chambers,  Southampton-row,  London,  W.C.I., 

Sept.  24th,  1919. 

THE  BRITISH  FEDERATION  OF  MEDICAL 
AND  ALLIED  SOCIETIES. 

To  the  Editor  of  The  Lancet. 

Sir, — In  your  issue  for  Sept.  20th  appears  an  attempt 
made  by  the  officers  of  this  body  to  reply  to  a corrected  proof 
of  my  letter  to  you  of  Sept.  6fch,  headed  “The  Cult  of 
Individualism,”  the  receipt  of  which  you  acknowledge  in 
your  issue  for  Sept.  13th,  but  which,  however,  you  have  not 
seen  your  way  to  publish. 

As  you  have  deprived  your  readers  of  the  benefit  of  seeing 
this  letter  and  thus  of  forming  an  unbiased  opinion  with 
regard  to  the  many  points  at  issue,  it  is  quite  impossible  to 
deal  satisfactorily  with  the  question  when  treated  with  such 
want  of  fair  play.  Your  heading  to  the  Correspondence 
column — “ Audi  alteram  partem  ” would  seem  to  support 
this  contention.  I am.  Sir,  yours  faithfully, 

Hove,  Sept.  19th,  1919.  E.  ROWLAND  FOTHERGILL. 

*„.*  Before  we  were  able  to  publish  Major  Fothergill’s 
letter — and  the  delay  was  entirely  due  to  his  own  wish — 
it  appeared  in  the  British  Medical  Journal.  As  the  exact 
reference  to  this  publication  was  given  by  Sir  Malcolm 
Morris  and  his  co-signatories,  there  could  be  no  conceivable 
reason  for  using  space  in  reprinting  the  letter.  Major 
Fothergill  knows  perfectly  well  why  his  letter  was  not 
printed,  so  that  his  accusation  of  unfairness  on  our  part  is 
not  a candid  one. — Ed.  L. 


POST  OFFICE  CONTRACT  PRACTICE. 

To  the  Editor  of  The  Lancet. 

Sir, — The  principle  of  contract  practice  is  that  small 
annual  payments  should  be  made  regularly  by  a number  of 
patients  during  periods  of  health,  the  amount  being  calculated 
to  cover  the  expense  of  attendance  on  those  patients  who 
incur  illness.  In  the  case  of  the  Post  Office,  whose  medical 
officers  are  paid  on  this  system,  the  principle  has,  in  my 
opinion,  been  entirely  lost  sight  of  and  destroyed. 

Early  in  the  war  when  postal  employees  joined  the  Army, 
the  Post  Office  medical  officers  were  notified  that  each  man’s 
name,  as  he  joined,  wTould  be  removed  for  the  time  being 
from  the  doctor’s  capitation  list,  but  that  when  the  man 
returned,  even  if  invalided,  he  would  then  be  restored  to  the 
list.  I protested  vigorously  at  the  time,  pointing  out  that 
if  the  men  were  to  be  restored  to  the  list,  whatever  their 


state  of  health,  on  returning  from  military  service,  their 
capitation  fee  should  continue  to  be  paid  during  the  interval 
of  absence,  especially  as  military  service  was  likely  to 
injure  health  in  many  ways.  My  protest  was,  of  course, 
useless.  Names  were  removed  regularly  from  my  list,  with 
the  result  that  my  salary  declined  as  follows : 1915, 
£16  16s.  9 d.  ; 1916,  £10  19s.  1 \d.  ; 1917,  £9  17s.  5 d.  ; 1918. 
£9  Os  9 d.  ; and  doubtless  every  other  Post  Office  medical 
officer  has  experienced  a like  decline  of  salary. 

The  men  are  now  returning,  and  I have  just  received 
a letter  from  the  surveyor  of  the  district  apprising  me  of  the 
restoration  to  my  capitation  list  of  a man  invalided  from 
the  Army  after  months  of  illness  from  Mesopotamian 
malaria  and  who  is  only  a fortnight  out  of  hospital  in 
England.  His  spleen  is  still  palpable  and  he  cannot 
walk  a mile  without  breathlessness.  He  is  now  restored  to 
my  list  for  treatment  at  the  rate  of  8 s.  4 d.  a year,  although 
I have  not  received  a penny  for  him  for  the  last  three  or 
four  years. 

If  these  returning  men  are  to  be  attended  by  us  as  before 
I maintain  that  at  the  very  least  their  capitation  fees  for 
the  period  of  their  absence  in  the  Army  should  be  paid  to 
us,  and  I have  replied  to  this  effect  to  the  surveyor. 

I am,  Sir,  yours  faithfully, 

Bromsgrove.  H.  CAMERON  KlDD. 


THE  IRISH  PUBLIC  HEALTH  COUNCIL. 

To  the  Editor  of  The  Lancet. 

Sir, — You  announced  last  week  in  The  Lancet  the  names 
of  the  Irish  Public  Health  Council,  but  without  comment 
on  them. 

This  Irish  Public  Health  Council,  whose  duty  is  to  advise  , 
the  Chief  Secretary,  as  Health  Minister,  as  to  what  changes 
Ireland  needs  from  a public  health  point  of  view,  was  indeed  i 
wrongly'  constituted  at  the  outset.  It  is  believed  in 
Ireland  that  the  situation  has  been  largely  due  to  the  advice  ; 
of  the  Irish  Branch  of  the  General  Medical  Council,  where 
of  seven  members  only  one  is  elected  by  the  whole  profession. 
The  Irish  medical  profession  was  never  consulted  as  to  the 
Public  Health  Council,  on  whom,  however,  the  burden  will ! 
fall  of  attempting  to  carry  out  any  new  health  scheme.  ' 
The  Chief  Secretary  was  early  advised  that  the  new  Council 
was  going  to  be  wrongly  constituted,  that  the  medical 
members  were  too  few  in  number,  and  that  the  pro- 
fession as  a whole  should  help  in  the  selection  of  their 
own  representatives.  He  knew  our  views  even  before  the 
Bill  went  to  the  House  of  Lords,  but  he  allowed  himself  to' 
be  guided  by  his  permanent  officials  in  Dublin.  As  a result . 
he  has — and  it  is  his  first  attempt  at  a constructive, 
measure  in  Ireland — as  a Council  to  advise  him  as  to  the 
future  public  health  measures  necessary  for  the  whole  of 
Ireland,  a body  of  17  members,  which  has  a medical; 
representation  which  is  too  small  and  which  is  unrepresenta- 
tive in  knowledge  of  the  general  practice  of  this  country, 
being  wTholly  comprised  of  Dublin  persons. 

I am,  Sir,  yours  faithfully, 

Sept.  20th,  1919.  IRISH  MEDICAL  PRACTITIONER. 

***  One  of  our  Irish  Correspondents  deals  with  the  matter 
this  week.— Ed.  L. 


Death  of  Sir  Peter  Wyatt  Squire.— The 
death  of  Sir  Peter  Wyatt  Squire,  which  took  place 
suddenly  on  Sept.  17th,  removes  a prominent  and  dis- 
tinguished figure  from  the  pharmaceutical  world.  His 
services  to  pharmacy,  and  to  the  Royal  Household  in 
his  official  capacity  of  pharmacist,  were  recognised  by 
the  King  a little  over  a year  ago,  when  His  Majesty 
conferred  upon  him  the  honour  of  knighthood.  His 
name  will  alwavs  be  associated  with  “ Squire’s  Com- 
panion to  the  Pliarmacopceia,”  a valuable  compilation1 
initiated  bv  his  father,  the  late  Peter  Squire,  who  was 
President  ‘of  the  Pharmaceutical  Society,  1861-63.  Peter 
Squire’s  work  laid  the  foundations  of  the  British  Pharma- 
copoeia. Sir  Peter  Wyatt  Squire  devoted  much  time  and 
attention  to  keeping  the  “Companion''  up  to  date,  and 
carried  out  considerable  experimental  work  directed  to  4 
verifying  and  revising  the  official  tests.  He  did  also  some 
original  work  on  methods  of  preparing  tissues  for  micro- 
scopic work.  His  advice  on  pharmaceutical  preparations 
and'  compounding  was  eagerly  sought  by  the  medical  pro- 
fession, and  his  prescience  in  regard  to  approved  and  valuable 
formulae  is  well  known. 


The  Lancet,] 


OBITUARY.— MEDICAL  NEWS. 


[Sept.  27,  1919  595 


WILFRID  OMBLER  MEEK,  M.B.,  B.S.Lond., 

MEDICAL  SUPERINTENDENT  OF  BROMPTON  HOSPITAL  SANATORIUM, 
l'RIMLEY. 

Dr.  W.  O.  Meek,  whose  joint  contribution  with  Dr.  J.  J. 
Perkins  and  Dr.  R.  A.  Young  appears  in  our  present  issue, 
died  in  his  sleep  on  Sept.  14th  at  the  sanatorium  which  he 
so  ably  superintended.  He  received  his  medical  education 
at  St.  Thomas’s  Hospital,  London,  where  he  held  a Louis 
Jenner  research  scholarship,  and  after  graduating  in  medicine 
at  London  University  in  1905  he  was  first  house  physician 
and  then  assistant  director  of  the  clinical  and  pathological 
laboratories.  A house  appointment  at  the  Brompton  Hospital 
for  Consumption  turned  his  interests  in  that  direction,  and 
when  Dr.  Marcus  Paterson  left  Frimley  Sanatorium  to  direct 
the  Welsh  National  Memorial  it  naturally  fell  on  Dr.  Meek 
to  succeed  him  in  the  important  post  at  Frimley.  Of  his 
work  there  a friend  (J.  J.  P.),  who  was  staying  with  him  at 
the  time  of  his  death,  writes  : — 

As  the  superintendent  of  a sanatorium  for  tuberculosis 
Meek  was  ideal,  and  if  ever  a man  found  his  proper  work  in 
life  it  was  he.  He  seemed  to  have  all  the  gifts  necessary  for 
success  in  such  a post  and  all  departments  of  his  work 
appealed  to  him  equally.  Nature  and  training  had  combined 
to  fit  him  in  this  peculiar  degree.  His  love  of  outdoor  life 
and  outdoor  things  gave  him  the  interest  in  and  grasp  of 
the  management  of  the  estate  and  the  patients’  work  which 
was  so  noticeable  and  made  this  side  of  his  life  an  unfailing 
delight  to  him. 

As  a physician  he  started  with  a sound  training  in  clinical 
work  gained  in  resident  posts  to  which  his  years  as  assistant 
in  the  clinical  laboratory  at  St.  Thomas’s  Hospital  added 
a thorough  insight  into  modern  pathology  and  modern 
methods  of  research  and  their  application  to  the  problems 
of  tuberculosis.  In  this  he  had  the  advantage  over  the 
ordinary  physician.  The  writer  has  often  admired  the 
happy  suggestions  and  explanations  his  scientific  knowledge 
enabled  him  to  give  of  puzzling  clinical  symptoms.  Even 
after  he  went  to  Frimley,  side  by  side  with  his  administra- 
tive duties,  he  continued  his  research  work,  and  in  addition 
to  what  has  been  published  he  has  left  a large  mass  of 
valuable  experimental  results  on  which  he  was  still  at 
work. 

Based  on  this  thorough  grasp  of  the  pathology  of  tubercu- 
losis, he  had  an  equally  thorough  grasp  of  the  principles  of 
treatment,  on  which  he  held  strong  views.  One  can  sum  up 
his  treatment  by  saying  he  was  patient  and  wonderfully  per- 
sistent and,  it  is  not  too  much  to  say,  profound.  Add  to  these 
qualities  a marked  capacity  for  organisation  and  a firm, 
though  sympathetic,  character,  and  one  need  look  no  further 
for  the  secret  of  the  respect  and  affection  he  won  from  all 
and  of  the  contented,  cheerful,  though  active,  atmosphere 
one  felt  throughout  the  institution.  Everything  went  like 
clockwork  and  went  well. 

It  is  almost  unnecessary  to  add  that  he  was  quite 
unconscious  of  his  many  gifts,  and  day  by  day  seemed  just 
intent  on  the  day’s  work  being  well  done.  Towards  his 
friends  he  was  thoughtful  kindness  itself  and  a very  genial, 
hospitable  companion.  As  one  went  about  with  him  one 
realised  after  a time  that  he  had  a deep  sense  of  sympathy 
with  the  patients,  which  made  him  leave  nothing  untried  for 
their  benefit.  He  was  slow  to  give  up  hope  for  them,  and 
everyone  had  a good  chance  to  improve.  He  knew  every 
case  thoroughly,  the  details  of  their  lives  and  work  as  well 
as  of  their  illness. 

In  late  years  he  had  become  much  impressed  with  the 
necessity  of  making  in  many  instances  some  alteration  in 
their  after-life  at  home  to  enable  them  to  maintain  their 
health.  He  gave  a good  deal  of  attention  to  this  side  of  his 
work,  with  excellent  results,  entering  into  each  case  indi- 
vidually and  giving  really  practical  advice  and  help.  It  was 
from  this  point  of  view  that  he  threw  himself  enthusiastically 
into  the  farm  colony  scheme  of  the  National  Association  for 
the  Prevention  of  Tuberculosis  and  gave  almost  daily 
supervision  to  the  preparations  for  the  colony  which  lies 
almost  close  to  the  Frimley  Sanatorium.  He  had  very  large 
ideas  and  plans  as  to  the  instruction  which  could  be  given 
there.  His  death  is  a severe  blow  to  every  phase  of  tuber- 
culosis work. 

Dr.  Meek’s  critical  attitude  of  mind  was  well  shown  in 
his  contribution  to  a discussion  at  the  Medical  Society  of 
London  on  the  Value  and  Limitations  of  Sanatorium  Treat- 
ment as  regards  the  Working  Classes,  a report  of  which 
appeared  in  The  Lancet  of  Nov.  24th,  1917.  He  carried 
out  the  principles  of  sanatorium  treatment  rationally  and 


scientifically,  adapting  them  to  the  new  developments  of  the 
times.  It  was  his  happy  lot  to  find  himself  able  to  modify 
the  prognosis  in  the  case  of  his  more  resourcefnl  and 
intelligent  patients  by  attention  to  after-care.  And  where 
he  showed  the  way  others  may  follow. 


The  Opening  of  the  Medical  Schools. — At 

the  opening  of  the  October  Session  in  the  Metropolitan 
Medical  Schools  the  following  arrangements  have  been 
made  : — 

St.  Bartholomew's  Hospital. — The  annual  dinner  will  be 
held  on  Sept.  30th,  at  7 for  7.30  P.M.,  at  Princes  Restaurant, 
Dr.  W.  S.  A.  Griffith  presiding. 

Charing  Cross  Hospital. — The  annual  Students’  Dinner 
will  be  held  at  the  Adelaide  Gallery,  Strand,  on  Oct.  1st,  at 

7.30  P.M.,  Colonel  William  Hunter  presiding.  The  prizes 
will  be  distributed  at  the  hospital  on  the  same  date  by 
Sir  Auckland  Geddes,  President  of  the  Board  of  Trade. 

St.  George's  Hospital. — The  opening  address  will  bedelivered 
by  Dr.  Squire  Sprigge,  at  3 p.m.,  on  Oct.  1st.  The  annual 
dinner  will  take  place  at  Princes  Restaurant,  Piccadilly,  on 
the  same  day,  at  6.30  for  7 p.m.,  when  the  chair  will  be 
taken  by  Dr.  J.  H.  P.  Fraser,  D.S.O.,  M.C. 

Guy's  Hospital. — The  biennial  dinner  will  take  place  at 
the  Connaught  Rooms,  at  7 P.M.,  on  Oct.  28th,  Dr.  Lauriston 
Shaw  in  the  chair. 

King's  College  Hospital. — The  introductory  address  will  be 
given  by  Dr.  T.  J.  Macnamara,  LL.D.,  on  Oct.  1st,  at  3 p.m. 
The  annual  dinner  will  be  held  on  the  same  day  at  7 p.m.,  at 
Pagani’s  Restaurant,  Sir  StClair  Thomson  presiding. 

London  Hospital. — Sir  Bertrand  Dawson  will  preside  at  the 
dinner  of  the  Old  Students,  which  will  be  held  at  Princes 
Restaurant  on  Oct.  2nd,  at  7.30  for  8 p.m. 

St.  Mary's  Hospital. — The  prizes  will  be  distributed  on 
Oct.  1st,  at  3 o’clock,  by  Lieutenant-General  Sir  John 
Goodwin,  Director-General  of  the  Army  Medical  Service. 
The  annual  dinner  of  Past  and  Present  Students  will  be  held 
on  the  same  evening  at  the  Connaught  Rooms,  Sir  Almroth 
Wright  in  the  chair. 

Middlesex  Hospital.— The  introductory  address  will  be 
delivered  by  Sir  John  Bland-Sutton,  at  3 p.m.,  on  Oct.  1st, 
and  Surgeon  Rear-Admiral  Sir  Robert  Hill  will  distribute 
the  prizes.  The  Annual  Dinner  will  be  held  on  Oct.  1st,  at 

6.30  for  7 o’clock,  at  the  Holborn  Restaurant,  and  the  Earl  of 
Athlone,  chairman  of  the  Hospital,  will  preside. 

St.  Thomas’s  Hospital. — The  Old  Students’  Dinner  will  be 
held  on  Oct.  1st,  at  7.30  p.m.,  in  the  Connaught  Rooms, 
Great  Queen-street,  London,  Sir  George  Makins,  P.R.C.S., 
presiding. 

University  College  Hospital. — The  annual  dinner  of  Old 
Students  will  be  held  at  the  Imperial  Restaurant,  Regent- 
street,  on  Oct.  3rd,  at  7 for  7.30  p.m.  Sir  John  Rose  Bradford 
in  the  chair. 

Westminster  Hospital. — The  annual  dinner  will  be  held  on 
Oct.  2nd  at  the  Imperial  (Oddenino’s)  Restaurant,  at  7 for 

7.30  p.m.  Mr.  Walter  George  Spencer  in  the  chair. 

London  School  of  Medicine  for  Women. — The  introductory 

address  will  be  given  by  Dr.  Christopher  Addison,  Minister 
of  Health,  at  3 p.m.,  on  Oct.  1st. 

The  Gresham  Lectures. — On  Oct.  14th,  15th, 
16th,  and  17th,  at  6 p.m.,  Sir  Robert  Armstrong-Jones  will 
deliverjour  lectures  at  Gresham  College,  Basinghall-street, 
London,  E.C.,  on  the  Evolution  of  Military  Medicine  and 
Surgery  from  Ancient  Times  and  the  Medical  Lessons 
Derived  from  the  Great  War.  The  lectures  will  be  free  to 
the  public. 

The  Incorporated  Society  of  Trained 
Masseuses.— The  members’  conference  takes  place  in 
London  from  Oct.  2nd^4th.  On  Thursday,  Oct.  2nd,  at  11a.m., 
Captain  F.  Wood  Jones,  R.A.M.C.,  lectures  on  “What  We 
Know  of  Ourselves,”  at  the  Royal  Society  of  Arts,  18,  John- 
street,  London,  W.C. ; at  2.30  p.m.,  Major  R.  C.  Elmslie, 
R.A.M.C.,  deals  with  “Deformities  of  the  Spine,”  at  St. 
Bartholomew’s  Hospital,  after  which  members  are  free  to 
visit  various  departments  of  the  hospital.  On  Friday, 
Oct.  3rd,  at  11a.m.,  Dr.  Justina  Wilson  lectures  on  “ Diseases 
of  the  Respiratory  Tract,”  at  the  Royal  Society  of  Arts  ; at 

2.15  p.m.,  visits  to  various  departments  at  St.  Thomas’s 
Hospital,  by  kind  permission  of  the  authorities ; at 

3.15  p.m. , a demonstration  of  gymnastic  work  will  be  given 
by  Miss  Randell,  sister-in-charge  of  the  massage  and  exer- 
cises department  of  St.  Thomas’s  Hospital ; and  at  6 p.m.,  a 
lecture  will  be  delivered  by  Colonel  A.  H.  Tubby  on  “ Stiff- 
ness of  Joints,”  at  the  Royal  Society  of  Arts. 


596  The  Lancet,] 


THE  SERVICES. 


[Sept.  27,  1919 


The  Rontgen  Society.  — The  officers  and 
members  of  council  for  the  ensuing  year  have  been  elected 
as  follows: — President:  Dr.  Sidney  Russ.  (Past  Presidents 
for  last  three  years : Major  C.  Thurston  Holland,  Major 
G.  W.  C.  Kaye,  Dr.  G.  B.  Batten.)  Vice-Presidents:  Mr. 
.1.  Hall  Edwards,  Professor  A.  W.  Porter,  Professor  J.  W. 
Nicholson.  Honorary  Secretaries:  Dr.  Robert  Knox,  Dr. 
It.  W.  A.  Salmond.  Honorary  Treasurer:  Mr.  Geoffrey 
Pearce.  Honorary  Editor:  Major  G.  W.  C.  Kaye.  Council  : 
Mr.  W.  E.  Schall,  Dr.  G.  H.  Rodman,  Mr.  C.  Howard  Head, 
Mr.  C.  K.  C.  Lyster,  Dr.  J.  Metcalfe,  Dr.  E.  P.  Cumber- 
batch,  Dr.  A.  E.  Barclay,  Mr.  F.  J.  Harlow,  Dr.  W. 
Makower,  Dr.  E.  A.  Owen,  Dr.  J.  Russell  Reynolds,  Mr. 
R.  S.  Wright. 

British  Orthopaedic  Association. — The  annual 
meeting  will  be  held  at  the  rooms  of  the  Medical  Society  of 
London,  11,  Chandos-street,  W.,  on  Nov.  14th,  when  the 
President,  Mr.  Muirhead  Little,  will  deliver  an  address. 
At  10.30  a.m.  there  will  be  a discussion  on  Kineplastic 
Amputations,  in  which  Mr.  T.  H.  Openshaw,  Mr.  S.  Alwyn- 
Smith,  Sir  J.  Lynn-Thoraas,  and  Major  M.  Fitzmaurice- 
Kelly  will  take  part,  and  in  the  afternoon  a discussion  on 
Birth  Paralysis  will  be  opened  by  Mr.  H.  A.  T.  Fairbank 
and  Mr.  Harry  Platt.  Mr.  A.  S.  B.  Bankart  will  discuss  the 
Operative  Treatment  of  Spastic  Paralyses.  The  annual 
dinner  will  be  held  during  the  evening  of  the  same  day, 
and  on  Nov.  15th  hospital  demonstrations  will  be  arranged, 
as  well  as  a visit  to  the  Country  Hospital  for  Cripples  at 
Pinner. 

Death  of  Mr.  W.  M.  Hope. — Mr.  William  More 
Hope,  M.R.C.S.,  L.S.A.,  D.P.H.,  medical  officer  of  health 
for  the  city  of  Gloucester,  was  found  dead  in  bed  at 
his  residence  in  Denmark-road  last  Monday  morning. 
He  had  not  been  in  good  health  for  some  little  time,  but 
discharged  his  official  duties  up  to  the  last.  He  was 
64  years  of  age,  and  took  the  diplomas  of  Member  of  the 
Royal  College  of  Surgeons  and  Licentiate  of  the  Society  of 
Apothecaries  in  1878,  after  which  he  was  for  over  10  years 
secretary  and  bouse  surgeon  to  the  Stamford  and  Rutland 
General  Infirmary.  While  there  his  attention  was  directed 
more  especially  to  preventive  medicine  and  public  health, 
and  having  passed  the  examinations  of  the  Conjoint  Board 
for  the  diploma  in  Public  Health  he  went  to  Gloucester  to 
practise  in  April,  1905,  and  was  appointed  medical  officer  of 
health  of  the  city  and  port  of  Gloucester  in  succession  to  the 
late  Dr.  John  Campbell.  He  was  also  appointed  school 
medical  officer  to  the  city  education  committee  under  the 
medical  inspection  scheme.  Dr.  Hope  was  a bachelor. 

Society  for  the  Study  of  Inebriety. — An 
autumn  conference  of  the  Society  for  the  Study  of  Inebriety 
will  be  held  in  the  rooms  of  the  Medical  Society  of  London, 
11,  Chandos-street,  Cavendish-square,  W.,  on  Tuesday, 
Oct.  14th.  The  conference  is  open  to  all  members  and 
associates  without  fee,  who  may  also  introduce  visitors  on 
forwarding  their  names  and  addresses  to  the  honorary 
secretary.  The  proceedings  will  include  a breakfast, 
which  will  be  held  at  the  Polytechnic,  309,  Regent- 
street,  W.,  at  8.30  A.M.,  when  the  chairman  of  the 
National  Temperance  League,  Mr.  Robert  Whyte,  jun., 
will  preside,  supported  by  Sir  Alfred  Pearce  Gould, 
Lord  D’Abernon,  Sir  Thomas  Whittaker,  M.P.,  and  Dr. 
Mary  Scharlieb.  Mr.  Theodore  Neild,  chairman  of  the 
League’s  Science  and  Education  Committee,  will  present  an 
address.  Those  desiring  to  be  present  should  communicate 
with  Mr.  John  Turner  Rae,  secretary,  at  the  offices  of  the 
League,  34,  Paternoster-row,  E.C.4.  The  sessions  of  the 
conference  will  be  held  in  the  Hall  of  the  Medical  Society  of 
London,  11,  Chandos-street,  Cavendish-square,  W.  At  the 
morning  session,  at  10.30,  the  President  of  the  Society, 
Sir  Alfred  Pearce  Gould,  will  deliver  an  introductory 
address,  after  which  Lord  D’Abernon  will  open  a 
discussion  on  “The  Scientific  Basis  of  Drink  Control.” 
At  the  afternoon  session,  at  2 P.M.,  Sir  Thomas  Whittaker 
will  open  a discussion  on  “ Alcohol  in  Relation  to  Recrea- 
tion and  Refreshment  and  the  Public  House.”  Special 
papers  will  be  presented  and  discussed  at  the  morning  and 
afternoon  sessions,  and  among  communications  promised 
are  the  following  : “ Alcohol  and  Alcoholism  in  Relation  to 
Venereal  Disease,”  by  Mr.  Arthur  Evans;  “Analytical 
Psychology  in  Alcoholism,”  by  Dr.  Maurice  Nicoll ; 
“Special  Clinics  for  Inebriates,”  by  Dr.  J.  A.  Davidson; 
“ The  Influence  of  Dilution  on  the  Toxic  Action  of  Alcoholic 
Liquids,”  by  Dr.  H.  M Vernon.  Tea  will  be  served  in  the 
Library  to  members  and  associates  attending  the  conference 
at  4.30* r. m.  At  5.30  the  eighth  Norman  Kerr  Memorial 
Lecture  will  be  delivered  by  Dr.  Mary  Scharlieb.  C.B.E., 
M.D.,  M.S.,  in  The  Robert  Barnes  Hall  of  the  House  of  the 
Royal  Society  of  Medicine,  1,  Wimpole-street,  the  subject 
being  “ The  Relation  of  Alcohol  and  Alcoholism  to  Maternity 
and  Child  Welfare.” 


®{ )t  §erbices. 


ROYAL  NAVAL  MEDICAL  SERVICE. 

Surg.  Rear-Admiral  H.  W.  G.  Doyne  is  placed  on  the  Retired  List  at 
own  request. 

Surg.-Capt.  G.  A.  Dreaper  is  promoted  to  Surgeon  Rear-Admiral. 


ARMY  MEDICAL  SERVICE. 

Col.  C.  A.  Young,  C.B..  C.M.G.,  retires  on  retired  pay. 

Col.  G.  T.  Rawnsley.  C.B.,  C.M.G  . is  placed  on  the  Half-pay  List 
under  the  provisions  of  Article  351,  Roval  Warrant,  for  pay  and 
promotion. 

Cols.  A.  J.  Luther,  C.B.,  H.  L.  Knaggs,  C.B.,  C.M.G.,  and  B.  H.  Scott. 
C.M.G. , retire  on  retired  pay. 

Temp.  Col.  C.  J.  Symonds,  C.B.  (Major,  R.A.M.C.,  T.F.),  relinquishes 
his  temporary  commission  on  re-posting. 

ROYAL  ARMY  MEDICAL  CORPS. 

Lieut. -Col.  E.  McDonnell  relinquishes  the  temporary  rank  of  Colonel 
on  re-posting. 

The  undermentioned  relinquish  the  acting  rank  of  Lieutenant- 
Colonel  : Major  O.  L.  Otway,  Capt.  R.  G.  S.  Gregg,  Temp.  Capt.  G.  W. 
Milne. 

Major  and  Bt.  Lieut.-Cols.  G.  Ormrod  and  A.  W.  Samper  relinquish 
the  acting  rank  of  Lieutenant-Colonel. 

Major  H.  F.  Shea  relinquishes  the  acting  rank  of  Colonel  on  re-pos‘ing. 
R.  H.  Nicholson,  Fleet  Surgeon,  R.N.,  ret.,  to  be  temporary  Major. 
Capt.  J.  J.  D.  Roche  relinquishes  the  acting  rank  of  Lieutenant- 
Colonel  on  ceasing  to  command  a Medical  Unit. 

Major  T.  B.  Moriarty  to  be  acting  Lieutenant-Colonel  whilst  specially 
employed. 

Capts.  J.  J.  Molvneaux  and  R.  G.  S.  Gregg  to  be  acting  Majors  whilst 
specially  employed. 

The  undermentioned  relinquish  the  acting  rank  of  Major  : Capts.  J. 
Biggam,  A.  L.  Foster,  T.  L.  Fraser ; Temp.  Capts.  E.  McCulloch,  A.  C. 
Hancock,  J.  C.  D.  Allan,  E.  S.  Sowerby,  C.  Y.  Ford  (on  ceasing  to  be 
specially  employed). 

Temp.  Capt.  (acting  Major)  R.  H.  Lucas  to  be  Captain,  and  to  retain 
his  acting  rank  whilst  specially  employed. 

Capt.  J.  C.  Sproule  to  be  acting  Major. 

The  undermentioned  temporary  Captains  to  be  acting  Majors  : J.  M. 
Macfie,  H.  G.  Hobson,  and  J.  Graham  and  E.  K.  Campbell  (whilst 
specially  employed). 

Late  temporary  Captains  to  be  temporary  Captains  : P.  Kitchin, 
G.  L.  Neil,  R.  W.  D.  Hewson,  W.  B.  Honey.  G.  B.  Proctor. 

To  be  temporary  Captains  : J.  A.  Jardine  and  F.  J.  R.  Cowie. 

Officers  relinquishing  their  commissions  Temporary  Lieutenant- 
Colonels  retaining  the  rank  of  Lieutenant-Colonel:  J.  V.  G.  B.  Tighe. 
W.  Harding,  M.  A.  Collins.  Temp.  Majors  H.  T.  Jenkins,  G.  D.  Gray 
(granted  the  rank  of  Lieutenant-Colonel),  R.  T.  Smith  (retains  the  rank 
of  Major),  Temp.  Capt.  (Bt.  Major)  W.  E.  P.  Phillips  (retains  the  brevet 
rank  of  Major).  Temp.  Capt.  G.  Robertson. 

Temporary  Captains  granted  the  rank  of  Major:  A.  G.  Anderson, 
R.  W.  P.  Jackson,  A.  W.  G.  Woodforde,  E.  F.  G.  Ward,  A.  K.  Cosgrave, 
C.  D.  Faulkner,  R.  J.  B.  Madden,  R.  S.  Barker.  A.  Dick.  G.  Muir, 

E.  Tawse,  A.  E.  Quine,  J.  Donald,  W.  J.  Johnson,  R.  S.  Miller. 
Temporary  Captains  retaining  the  rank  of  Captain : G.  N.  Kirkwood, 

E.  R.  Stone,  R.  L.  Sinclair,  A.  L McGrury,  J.  Dulberg,  D.  W.  Smith, 
B.  C.  Ewens,  J.  J.  Armistead.  J.  E.  Barnes,  L.  H.  Skene,  A.  Cleland, 

F.  G.  Gibbs,  J.  P.  P.  Inglis,  R.  H.  Maingot,  J.  R.  Davies,  R.  M.  Lang, 
L.  D.  Cohen,  L.  Gray.  J.  Allan.  M.  Culpin,  R.  H.  Fleming,  J.  C. 
Pad  wick,  A.  W.  T.  Whitworth,  A.  F.  Wright,  R W.  Telford,  A.  R. 
Wightman.  A.  B.  Cooke,  F.  J.  Whitelaw,  J.  H.  Fryer,  B.  B.  Noble, 
R.  T.  Grant,  W.  F.  O'Regan.  S.  Rodin,  C.  F.  Dillon-Kelly.  A.  Graydon. 
J.  T.  Titterton,  H P.  Shackleton,  G.  Riidoch,  D.  Young,  C.  B. 
Tudehope,  J.  B.  Fisher,  A.  D.  Blakely,  W.  Simpson,  C.  H.  L.  Rixon, 
E.  Gofton,  E.  W.  N.  Hobhouse,  G.  F.  May,  A.  E.  Hardy,  C.  Gordon, 
T.  J.  Lydon,  H.  O.  West.  W.  H.  Trethowan.  H.  Spurway,  A.  Robertson, 
R.  C.  McQueen.  C.Salkeld,  P.  L.  L.  Craig,  A.  B.  Lindsay,  P.  Ashe,  F.  O. 
Stedman,  E.  M.  Condy,  F.  Penny.  W.  P.  Miles.  Temp.  Hon.  Capt.  J.  M. 
Bremner  (retains  the  honorary  rank  of  Captaini.  Temporary  Lieutenants 
retaining  the  rank  of  Lieutenant:  H.  T.  O'Neill,  S.  F.  Breakey,  A.  I. 
Girdwood. 

Canadian  Army  Medical  Corps. 

Temp.  Major  J.  A.  Lussier  and  Temp.  Capt.  E.  E.  Locke  retire  in  the 
British  Isles. 

Temp.  Capt.  A.  J.  Fisher  relinquishes  the  acting  rank  of  Major. 

The  British  West  Indies  Regiment. 

The  undermentioned  relinquish  their  commissions:  Temp.  Surg.- 
Capt.  A.  G.  McKenley  and  retains  the  rank  of  Surgeon-Captaiu.  Temp. 
Surg.-Lieut.  F.  A.  Norton  and  retains  the  rank  of  Surgeon-Lieutenant. 

South  African  Medical  Corps. 

Temp.  Major  R.  N.  Pringle  relinquishes  his  commission  on  ceasing 
to  be  employed  and  retains  the  rauk  of  Major. 

Temp.  Capt.  E.  A.  Leviseur  relinquishes  his  commission  on  ceasing 
to  be  employed,  and  retains  the  rank  of  Captain. 

SPECIAL  RESERVE  OF  OFFICERS. 

Capt.  A.  W.  Russell  relinquishes  his  commission  and  is  granted  the 
rank  of  Major. 

Captains  relinquishing  their  commissions  and  retaining  the  rank  of 
Captain  : J.  F Lyons,  A.  B.  Austin. 

Capt.  J.  H.  Neill  relinquishes  his  commission. 

Capt.  W.  G.  H.  Cable  to  be  Major. 

Capt.  D.  M.  Marr  relinquishes  the  acting  rank  of  Major. 

Capt.  W.  Donald  to  be  acting  Major. 

Lieutenants  to  be  Captains  : J.  W.  W.  Newsome,  B.  L.  Slater,  \ . D. 
Wyborn,  W.  Buchan.  A.  C.  Hill,  J.  A.  Ross.  D.  C.  Bowie.  A.  J. 
Macartney,  D.  Ferguson,  J.  A.  Dawson.  A.  I.  Meek,  J.  Morrison, 

G.  W.  C.  Dunlop.  R.  B.  MacGregor.  H.  J.  Parish. 


The  Lancet,] 


APPOINTMENTS.— VACANCIES. 


[Sept.  27,  1919  597 


TERRITORIAL  FORCE. 

Major  (acting  Col.)  T.  Kay  relinquishes  the  acting  rank  of  Colonel 
on  vacating  the  appointment  of  Assistant  Diroctor  of  Modlcal  Services. 

The  undermentioned  relinquish  the  acting  rank  of  Lieutenant- 
Colonel  on  ceasing  to  be  specially  employed:  Majors  (acting  Lieut.  - 
Cols.)  A.  C.  Goodwin,  T.  Frankish  ; Capls.  (acting  Lieut.-Cols.)  A.  C. 
Pearson,  F.  Darlow,  and  T 0.  Clarke. 

Capts.  (acting  Majors)  J.  Taylor,  T.  S.  Worboys,  II.  Pinto-Leito, 
Fi.  L.  D.  Dewdney,  A.  Cl.  Hendley,  A.  II.  P.  Smith,  C.  W.  T. 
Baldwin,  and  G.  B.  Buchanan  relinquish  the  acting  rank  of  Major  on 
ceasing  to  be  specially  employed. 

Capts.  (acting  Majors)  relinquishing  the  acting  rank  of  Major  : G. 
Stevenson,  W.  T.  P.  Meade-King,  F.  Ellis. 

Capts.  R.  W.  Swayne  and  B.  J.  Alcock  to  be  acting  Majors  whilst 
specially  employed. 

Capt.  T.  J.  Faulder  to  be  Major. 

Capt.  C.  Nyhan  relinquishes  his  commission  and  is  granted  the  rank 
of  Major. 

Capt.  S.  Shephcard  relinquishes  his  commission  and  retains  the  rank 
of  Captain. 

1st  Eastern  General  Hospital : Major  (acting  Lieut.-Col.)  L.  Humphry 
relinquishes  the  acting  rank  of  Lieutenant-Colonel  on  ceasing  to  be 
specially  employed. 

3rd  Southern  General  Hospital:  Capt.  J.  F.  Robinson  is  restored  to 
the  establishment.  Capt.  (acting  Major)  R.  E.  Humphry  relinquishes 
the  acting  rank  of  Major. 

5th  Southern  General  Hospital : Capt.  (acting  Lieut.-Col.)  J. Blackwood 
relinquishes  the  acting  rank  of  Lieutenant-Colonel  on  ceasing  to  be 
specially  employed  and  to  remain  seconded. 

2nd  London  General  Hospital:  Major  (Bt.  Lieut.-Col.)  T.  D.  Acland 
is  restored  to  the  establishment. 

4tli  London  General  Hospital  : Capt.  (acting  Major)  W.  Turner 
relinquishes  the  acting  rank  of  Major  on  ceasing  to  be  specially 
employed. 

2nd  London  Sanitary  Company:  Lieuts.  I.  Walker  and  F.  Evans  to 
be  Captains. 

Attached  to  Units  other  than  Medical  Units.— Major  T.  Frankish  to  be 
acting  Lieutenant-Colonel  whilst  specially  employed. 


Midaille  des  Epidemics  (d'Or)  — Lt.-Col.  A.  R.  Aldridge,  C.B.,  C.S.I. 
C.M.G..  If. A M. C.  (R.O.)  i Maj.-Gen.  Sir  H.  R.  Whitehead,  K.C.B. 

Medaille  des  EpiOArniex  ten  Ament).— Temp  Capt.  G.  II.  Eccles,  M.C.. 
R.A.M.C.  (T.F.);  Temp.  Capt.  1).  L.  Williams,  M.C.,  lt.A.M.C. 

Hellenic. 

Order  of  the  Redeemer.— Officer : Col.  E.  T.  F.  Birrell,  C.B.,  C.M.G., 

A.  M.S.  (late  lt.A.M.C.). 

Order  of  George  J.— Officer  : Surg.-Cmdr.  T.  W.  Myles,  R.N. 

Military  Cross.— 2nd  Class:  Temp.  Capt.  W.  K McIntyre,  M.C., 
R.A.M.C.  3rd  Class : Temp.  Capt.  G.  P.  B.  Huddy,  lt.A.M.C.;  Capt. 

B.  E.  Potter,  R.A.M.C.(T.F.). 

Medal  for  Military  Merit.— 3rd  Class  . Col.  E.  T.  F.  Birrell,  C.B., 

C. M.G.,  A. M.S.  (late  R.A.M.C.). 


Italian. 

Croce  di  Guerra.— Capt.  (acting  Maj.)  M.  Coplans,  D.S.O.,  O.B.E., 
R.A.M.C.lT.F.). 


Portuguese 

Military  Order  of  Avis.— Grand  Officer  : Maj.-Gen.  Sir  W.  W.  Pike, 

K.C.M.G!,  D.S.O.  Commander:  Maj.  and  Bt.  Lt.-Col.  P.  Davidson, 
C.M.G.,  D.S.O.,  R.A.M.C.  ; Temp.  Maj.  (acting  Lt.-Col  ) T.  B.  Unwin, 
O.B.E.,  R.A.M.C.  ; Surg.-Cmdr.  P.  H.  Broyden.  R.N.  Chevalier  : Capt. 


(acting  Lt.-Col.)  G.  S.  Parkinson,  D.S.O.,  R.A.M.C. 


Roumanian. 

Order  of  the  Star  of  Roumania  (Grand  Cross).— Chevalier : Temp. 
Capt.  F.  C.  Robbs,  M.C.,  R.A.M.C. 

Order  of  the  Crown  of  Roumania.  —Officer  : Capt.  A.  C.  H.  McCullagh, 
D.S.O.,  R.A.M.C.  (T.F.).  Chevalier:  Capt.  H.  L Garson,  O.B.E., 
M.C.,  R.A.M.C.  (S.R.);  Capt.  F.  Jefferson,  R.A.M.C.  (S.R.);  Capt 
J.  N.  L.  Thoseby,  R.A.M.C. 

Serbian. 

Order  oj  St.  Sava. — 3rd  Class:  Maj.  J.  Ward.  C.M.G..  D.S.O.. 
R.A.M.C.  (T.F.).  Uth  Class  : Temp.  Capt.  R.  A.  Wilson,  R A.M.C. 


ROYAL  AIR  FORCE. 

Medical  Branch.— Wing  Cmdr.  (acting  Group  Capt.)  T.  D.  C.  Barry 
is  transferred  to  unemployed  list. 

Flying  Officers  to  be  Flight  Lieutenants  :— J.  Ferguson,  T.  M.  Davies. 
Capt.  W.  H.  H.  H.  Bennett  (Captain,  R.A.M.C.,  T.F.)  relinquishes 
his  commission  on  ceasing  to  be  employed. 

Squadron  Leader  (acting  Wing  Commander)  F.  F.  Muecke,  Capts. 
W.  fl.  Payne,  J.  Duffin,  G.  W.  Clark,  Lieut.  O.  P.  Turner,  Flying 
Officers  P.  A.  Dormer  and  C.  Lambrinudi,  Flight  Lieuts.  P.  T.  J. 
O’Farrell,  I.  de  B.  Daly,  and  J.  E.  Cox  are  transferred  to  the 
unemployed  list. 

Dental  Branch.— Flying  Officers  to  be  Flight  Lieutenants  : S.  C. 
Turner  and  A.  Williams. 


THE  HONOURS  LIST. 

The  following  awards  to  medical  officers  are  announced  : — 

M.B.E.— Surg.-Cmdrs.  G ,E.  Duncan,  A.  Gaskell,  C.B.,  and  H.  W. 
Gordon-Green,  R.N. ; and  Surg.-Lieut.  A.  G.  L.  Reade,  R.N.V.R. 

In  a despatch  describing  events  In  Syria  and  Palestine,  subsequent 
to  the  conclusion  of  the  armistice  with  Turkey  on  Oct.  31st,  1918, 
received  from  Field-Marshal  Sir  E.  Allenby,  Commander-in-Chief .’ of 
the  Egyptian  Expeditionary  Force,  the  following  reference  to  the 
Medical  Services  appears  : — 

The  Medical  Services  have  dealt  successfully  with  the  difficulties  of 
evacuation  over  long  distances  in  a country  of  undeveloped  communi- 
cations ; and  have  combated  with  excellent  results  the  chief  scourge  of 
Syria  and  Palestine— malaria.  I desire  to  mention  the  good  work  of 
Major-General  A.  E.  C.  Keble  and  Major-General  Sir  R.  H.  Luce,  as 
Directors  of  Medical  Services  at  various  periods. 

FOREIGN  DECORATIONS. 

American. 

Distinguished  Service  Medal.— Surg.-Vice-Adml.  Sir  W.  H.  Norman, 

K. C.B. 

Belgian. 

Ordre  de  la  Couronne.— Chevalier : Temp.  Capt.  J.  R.  Rees,  R.A.M.C. 
Croix  de  Guerre.— Temp.  Capt.  (acting  Maj.)  W.  S.  S Berry, 
O.B.E.,  M.C.,  R.A.M.C.  ; Capt.  lading  Lt.-Col.)  J.  M.  A.  Costello, 
R.A.M.C.  (T.F.)  ; Temp.  Capt.  (acting  Maj.)  W.  S.  Dank9, 
97th  Fd.  Amb.,  R.A.M.C.  ; Capt.  L.  A.  Dinglev,  R.A.M.C. 
(T.F.)  ; Lt.-Col.  (temp.  Col.)  O.  W.  A.  Eisner,  O.B.E.,  D.S.O., 
R.A.M.C.  ; Temp.  Capt.  (acting  Maj.)  T.  Ferguson,  42nd  Fd. 
Amb.,  R.A.M  C. ; Capt.  (acting  Maj.)  J.  D.  Fiddes,  M.C.,  89th  Fd. 
Amb.,  R.A.M.C.  (T.F.) ; Lt.-Col.  G.  J.  Houghton,  D.S.O.,  R.A.M.C.; 
Maj.  and  Bt.  Lt.-Col.  (temp.  Lt.-Col.)  F.  D.  G.  Howell,  D.S.O.,  M.C., 
R.A.M.C.  ; Capt.  I.  R.  Hudleston,  D.S.O.,  136th  Fd.  Amb.,  R.A.M.C. ; 
Temp.  Capt.  (acting  Maj.)  J.  Jack.  M.C.,  28th  Fd.  Amb.,  R.A.M.C.  ; 
Capt.  and  Bt.  Maj.  (acting  Lt.-Col.)  F.  R.  Laing,  R.A.M.C.  ; Temp. 
Capt.  G.  E.  Lindsay,  M.C.,  R A.M.C. ; Temp.  Capt.  C.  W.  B.  Little- 
john, 140th  Fd.  Amb.,  R.A.M.C.  ; Lt.-Col.  (temp.  Col.)  L.  N.  Lloyd. 

C. M.G.,  D.S.O.,  R.A.M.C.;  Temp.  Capt.  J.  B.  Mason,  R.A.M.C.; 
Temp.  Capt.  J.  C.  Robb,  108th  Fd.  Amb.,  R.A.M.C.  ; Lt.  (acting  Maj.) 

L.  S.  C.  Roche,  M.C.,  138th  Fd.  Amb.,  R.A.M.C. ; Capt.  (acting  Lt.-Col.) 
J.  Rowe,  M.C.,  103rd  Fd.  Amb.,  R.A.M.C.;  Capt.  (acting  Maj.)  H.  A. 
Rowell,  M.C.,  R.A.M.C. ; Capt.  H.  Seddon,  R.A.M.C.(T.F.),  attd.  87th 
Fd.  Amb.,  R.A.M.C.  ; Temp.  Capt.  (acting  Maj.)  H.  C.  Watson,  M.C., 
102nd  Fd.  Amb.,  R.A.M.C. 

French. 

Ltgion  d'Honneur.— Chevalier : Maj.  G.  W.  W.  Ware,  D.S.O., 
R.A.M.C. 

Croix  de  Guerre  avec  Etoile  fen  Argent). — Capt.  R.  Burgess,  D.S.O., 
R.A.M.C.  (T.F.) ; Temp.  Capt.  (acting  Maj.)  T.  A.  Lawder,  24th  Fd. 
Amb.,  R A.M.C.;  Capt.  P.  J.  Ryan,  M.C.,  24th  Fd.  Amb.,  R.A.M.C. 

Croix  de  Guerre.— Temp.  Capt.  F.  P.  Montgomery,  M.C.,  R.A.M.C.  ; 
Capt.  J.  A.  A.  Pare,  M.U.,  11th  Canad.  Fd.  Amb.,  C. A.M.C.;  Temp. 
Capt.  (acting  Maj.)  F.  B.  Winfield,  R.A.M.C. 

MMaille  d'Honneur  avec  Glaives  {.en  Vermeil).— Maj.  W.  D.  C.  Kelly, 

D. S.O.,  R.A.M.C.  ; Temp.  Capt.  H.  T.  Retallack-Moloney,  R.A.M.C.  ; 
Maj.  T.  C.  Ritchie,  R.A.M.C. 


Hort,  Violet  G.,  has  been  appointed  Government  Bacteriologist  in 
the  Isle  of  Man. 

MacMillan,  J.,  M.B.,  Ch.B.  Glasg.,  D.P.H.,  Medical  Officer  of  Health 
for  Woolwich. 

Ryland,  A.,  F.R.C.S.  Edin.,  Assistant  Surgeon  to  the  Central  London 
Ear,  Nose,  and  Throat  Hospital. 

Shera,  A.  G.,  M.D.,  B.Ch.,  B. A.  Cantab.,  M.R.C  S.  Eng.,  L.R.C.P. 
Lond.,  Honorary  Clinical  Pathologist,  Princess  Alice  Memorial 
Hospital,  Eastbourne. 

Salford  Royal  Hospital : Stone,  F.  W.,  M.B..  B.S.,  Resident  Surgical 
Officer;'  Fort,  C.  W.,  M.B.,  Ch.B.Manch.,  House  Physician; 
Ellis,  O.  J.,  M.B.,  Ch.M.,  House  Surgeon;  Sparrow,  L.  W., 
M B.,  Ch.B.  Manch.,  Junior  House  Surgeon. 

Certifying  Surgeons  under  the  Factory  and  Workshop  Acts  : Wormald, 
T.  L.,  M.D.,  D.P.H.  Durh.  (Darlington);  Taylor,  J.  M.,  M.D. 
Glasg.,  D.P.H.  (Thorne);  Smith.  T.  B.,  M.B.,  Ch.B.  Glasg. 
(Abertillery) ; Power,  V.  A.,  L.R.C.  P.  & L.R.C.S.Irel.  (Borrisoleigh). 


©rantb. 


For  further  information  refer  to  the  advertisement  columns 
Battersea  General  Hospital,  Battersea  Pari:,  S.  W—  Res.  M.O.  £200. 
Bedford  County  Hospital.— Res.  M.O.  £150. 

Belgrave  Hospital  for  Children,  Clapham-road,  S.  W.—  Two  Asst.  S .’s. 
Also  H P.  and  H.S.  £100  and  £75. 

Bethlem  Royal  Hospital , Lambeth-road,  S.E.— Hon.  Neurologist.  Also 
Jun.  Asst.  P.  £350. 

Birkenhead  Borough  Hospital.  - Jun.  H.S.  £170. 

Birmingham  Municipal  Anti-Tuberculosis  Centre.— Sen.  Asst.  Tuberc. 
O.  £650. 

Bradford  Royal  Infirmary. — Two  H.S's.  £200. 

Brighton,  Royal  Sussex  County  Hospital.— Asst.  Path.  £200. 
Brookwood,  near  Woking,  Surrey  Lunatic  Asylums  Visiting  Com- 
mittee.— First  Asst.  M.O.  £600. 

Cheltenham  Eye,  Ear,  and  Throat  Free  Hospital. — Asst.  S.  £400. 
Cumberland  Education  Committee.—  Two  School  Dentists.  £350. 

Derby,  Derbyshire  County  Council.— Maternity  and  Child  Welfare 

M. O.  £450 

Derby,  Derbyshire  Education  Committee. — Sch.  M.O.  £450. 

Dorchester,  Dorset  County  Council  Education  Committee. — Schoo 
Dentists.  £400. 

Dunfermline,  Carnegie  Dunfermline  Trust.— Sch.  M.O.  £400. 

Durham  County  Council.— Five  Asst.  School  M.O.'s.  £600. 

Eastbourne,  Princess  Alice  Hospital.— R.M.O.  £175. 

East  Riding  Education  Authority. — Sch.  Dent.  £350. 

Frimley,  Bronipton  Hospital  Sanatorium.— Med . Supt.  £600. 

German  East  Afiica  Occupied  Territory.— M.O.'s.  £400-£20-£500. 
Glasgow  Eye  Infirmary.— Res.  H.S.  and  Res.  Asst.  H.S.  £100  and  £75. 
Glasgow,  Scottish  Western  Asylums’  Research  Institute. — Director.  £600. 
Gloucester,  Gloucestershire  Royal  Infirmary  and  Eye  Institution.— 
Asst.  S. 

Grimsby  and  District  Hospital.— H.S.  £300. 

Hampstead  General  and  North-West  London  Hospital,  Haverstock-hill, 

N. W. — Two  P.’s  to  Out-Patients.  P.  for  Dis.  of  Skin,  S.  to  Out- 
patients, and  Clin.  Asst,  in  the  Nose,  Ear,  and  Throat  Department. 

Hereford  County  and  City  Mental  Hospital.— Senior  Asst.  M.O.  £350. 
Hospital  for  Consumption  and  Diseases  of  the  Chest,  Brampton,  S.  W. — 
S.  H.P.  for  six  months.  30  gs.  Asst.  Res.  M.O.  £150.  Asst.  P. 
£250.  Asst,  in  Dept,  of  Path.  £250.  Part-time  Asst,  in  Dept,  of 
Path.  £250. 

Hospital  for  Diseases  of  the  Throat,  Golden -square,  IF.— Hon.  Asst.  S.'s. 
Hospital  for  Epilepsy  and  Paralysis,  Moida  T ale,  W. — Hon.  Psycho- 
logist, Hon.  Ophth.  S.,  and  Hon.  Asst.  P. 

Hospital  for  Sick  Children,  Great  Ormond-street,  W.C.— Res.  Med.  Supt. 

£200.  Also  Asst.  Cas.  M.O. , H.S. , and  H.P.  All  £50. 

Hospital  for  Women,  Soho-square,  W.— Phys.  Con.  Also^on.  M.O. 
Huddersfield  Royal  Infirmary.— Asst.  H.S.  £100. 

Hull  Royal  Infirmary. — Sen.  H.S.  £200. 


598  The  Lancet,] 


BIRTHS,  MARRIAGES,  AND  DEATHS.— MEDICAL  DIARY. 


[Sept.  27,  1919 


Ilford  Urban  District  Council.— Female  Asst.  M.O.H.  £400. 

Italian  Hospital,  Queen-square,  W.C.— Hon.  Ophth.  Surg. 

Leamington,  Warneford,  Leamington,  and  South  Warwickshire 
General  Hospital.— lies.  H.S.  £200. 

Leeds  General  Infirmary. — Res.  M.O.  £150.  Res.  Obstet.  O.  £50. 
Also  Res.  M.O.  at.  Ida  and  Robert  Arthington  Hospitals.  £E0. 
Two  H P.’s  and  Two  U.S.’s. 

Leicester  Royal  Infirmary. — H .P.  £250. 

Liverpool,  Hospital  for  Consumption  and  Diseases  of  the  Chest,  Mount 
Pleasant.— Asst.  M.O.  and  Pathologist.  £175. 

London,  County  of.— Coroner  for  S.E.  District.  £1186  4s. 

London  Hospital,  Whitechapel,  E.,  Genito-Urinary  Department.— 
Clin.  Asst.  One  guinea  per  session. 

London  Lock  Hospital  and  Rescue  Home,  283,  Harrow-road,  IP.,  and 
01.  Dean-street,  IP.— Hon.  S.  to  Out-patients. 

Manchester  Royal  Infirmary  .—Ian.  Antest.  £200. 

Manchester  Royal  Infirmary,  Central  Branch,  Roby-street,  Manchester.— 
Res.  Surg.  O.  £200. 

Manor  House  Orthopxdic  Hospital,  North  End-road,  Hampstead,  N.  IP. 
— Res.  S.O.  £500. 

Middlesex  Hospital,  IP.— Asst.  Ansest. 

Middleton-in-Wharfedale  Sanatorium,  near  Ilkley.—  Asst.  Res.  M.O. 
£325. 

Mothers’  Hospital,  153-16:3,  Lower  Clapton-road,  E.—Bes.  M.O. 

Mount  Vernon  Hospital  for  Consumption  and  Diseases  of  the  Chest, 
N orthwood,  Middlesex, — Asst,  Res.  M O.  £200. 

National  Hospital  for  the  Paralysed  and  Epileptic,  Queen- square, 
W.C. — Radiologist. 

Newcastle-upon-Tyne,  Hospital  for  Sick  Children.—  Jun.  Res.  M.O. 
£200. 

New  South  Wales,  Department  of  Public  Instruction.— Prinpl.  M.O. 
£900. 

Nottingham  General  Hospital. — Asst.  Secretary.  £250. 

Oldham  Royal  Infirmary  —Third  H.S.  £200. 

Paddington  Green  Children's  Hospital,  London,  IP.— H P.  and  H.S. 
£150  each. 

Preston,  Lancashire  County  Council.— Asst.  Disp.  Tuberc.  O.  £550. 
Prince  of  Wales's  General  Hospital,  Tottenham,  N.— H.P.  and  H.S. 

£200.  Also  Jun.  H.S.  and  Jun.  H.P.  £120. 

Queen  Mary’s  Hospital  for  the  East  End,  Stratford,  E.— II.S.  £150. 
Reading,  Berks  Education  Committee. — Sch.  Dent.  £400. 

Reading,  Royal  Berkshire  Hospital.— Hon.  Asst.  P. 

Royal  Tree  Hospital,  Gray's  Inn-road.  W.C.— Hon.  Aneest.  AlsoCas.  O. 
(£100)  and  Registrar. 

Royal  National  Orthopxdic  Hospital,  23U,  Great  Portland-street,  IP.— 
Surg.  Registrars.  100  gs.  Also  Hon.  P. 

St.  Bartholomew’s  Hospital. — Asst.  Administrator  of  Anaesthetics. 

St.  Marylebone  Infirmary.— Asst.  M.O.  £200. 

St.  Marylebone  General  Dispensary,  77,  Welbeck-slreet,  Cavendish- 
square,  IP.— Res.  M.O.  £150. 

Sheffield  City  Education  Committee.— Sch.  Dent.  S's.  £400. 

Sheffield  City,  Winter-street  Tuberculosis  Hospital.— Asst.  Tuberc.  O. 
£300. 

Sheffield  Royal  Infirmary.— H.S.  for  Ear,  Nose,  and  Throat.  £150. 
South  London  Hospital  for  Women,  South  Side,  Clapham  Common,  S.  W. 

Female  Asst.  S.  and  Temp.  Asst.  S. 

Stroud  General  Hospital. — H.S.  £200. 

Sunderland  Royal  Infirmary.— Sen.  H.S..  Two  Jun.  H.S.'s.  and  H.P. 

£250  and  £200  respectively. 

Sut'on  Coldfield  Borough. — M.O.H.  and  Sch.  M.O. 

Taunton  and  Somerset  Hospital,  Taunton.— Res.  Asst.  H.S.  £150. 
Victoria  Hospital  for  Children,  Tite-street,  Chelsea,  S.  IP.— In-patient  P. 
aDd  Two  Out  patient  P.'s. 

Weston-super-Mare,  Somerset  County  Education  Committee.—  School 
Oculist  and  Med.  Inspec.  £450. 

Whitehaven  and  West  Cumberland  Infirmary.— Res.  H.S.  £180. 
Willesden  Urban  District  Council.— Two  Dentists.  £400. 

Worcestershire  Asylum,  Barnsley  Hatl,  Bromsgrove.—  Asst.  M.O. 
8 gs.  per  week. 

The  Chief  Inspector  of  Factories,  Home  Office,  S.W.,  gives  notice  of 
vacancies  for  Certifying  Surgeons  under  the  Factory  and  Workshop 
Acts  at  Almondsbury,  Leven,  and  Maldon. 


Hirijis,  Carriages,  anb  gratis . 


Hlebiral  giarj  far  Ijie  ensuing  8®eek. 


LECTURES,  ADDRESSES,  DEMONSTRATIONS,  &c. 

LONDON  HOSPITAL  MEDICAL  COLLEGE,  in  the  Clinical  Theatre 

of  the  Hospital. 

A Special  Course  of  Instruction  in  the  Surgical  Dyspepsias  will  be 
given  by  Mr.  A.  J.  Walton  : — 

Monday,  Sept.  29th.— 4.30  p.m.,  Lecture  XVII.:— Technique  and 
Complications  of  Gastric  Operations. 

Friday. — 4.30  p.m..  Lecture  XVIII.: — Surgical  Anatomy  of  the 
Liver  and  Gall  Bladder.  (In  the  Dissecting  Room.  ) 


Communications,  Letters,  &c.,  to  tiie  Editor  have 
been  received  from— 


A. — Mr.  E.  A.  Armstrong,  Lond.; 
Major  A.  Abrahams,  R.A.M.C.; 
Sir  R.  Armstrong-Jones,  Lond.; 
Rt.  Hon.  C.  Addison,  M.D., 
M P.;  Mr.  R.  J Albery,  Loud.; 
Dr.  F.  P.  Atkinson,  Be.xhill-on- 
Sea. 

B.  — Birmingham,  Medical  Officer 
of  Health  of ; Mr.  A.  Blackhall- 
Morison,  Lond.;  Board  of  Agri- 
culture and  Fisheries,  Lond  ; 
British  Orthopaedic  Association, 
Lond.;  Mr.  C.  A.  Bang,  Lond.; 
Messrs.  Butterworth  and  Co. 
(India),  Ltd.,  Calcutta ; Dr.  R. 
Blair,  Lond.;  Dr.  J.  Blomfield, 
Lond.;  Prof.  F.  A.  Bainbridge, 
Lond. 

C. — Dr.  A.  V.  Clarke,  Leicester; 
Major  O.  Cliallis.  R.A.M.C.;  Dr. 

H.  P.  Cholmeley,  Forest  Row; 
Dr.  J.  Catton,  San  Francisco; 
Dr.  H.  W.  Crowe,  Harrogate; 
Messrs.  W.  Collins,  Son,  and  Co., 
Lond.;  Dr.  F.  J.  Cutler, 
Hastings. 

D.  — Dr.  J.  L.  Dick.  Lond.;  Dr. 
Prof.  L.  Durante.  Genoa. 

E.  — Dr.  R.  Eager,  Exminster. 

F.  — Dr.  E.  C.  Fernoulhet.  Herne 
Bay;  Col.  N.  Faichnie,  A.D.M.S.; 
Major  E.  R.  Fothergill,  R.A.M.C.; 
Dr.  D.  Forsyth,  Lond.;  Capt. 
N.  B.  B.  Fleming,  R.A.M.U.; 
Factories,  Chief  Inspector  of, 
Lond. 

G —Prof.  Galli,  Bellano  ; Dr.  H.  M. 
Gerson,  Lond.;  Guy’s  War 
Memorial  Fund,  Lond.,  Hon. 
Sec.  of ; Dr.  A.  D.  Gardner, 
Broxbouine  ; Lieut. -Gen.  Sir 
John  Goodwin,  K.C.B.,  C.M.G., 
D.S.O.;  Capt.  E.  W.  Gregory, 
R.A.M.C.(T.F  ) 

H.  — Mr.  C.  E.  Hecht,  Lond.;  Dr. 
F.  H.  Humphris,  Lond.;  Major 
C.  A.  F.  Hingston,  O.B.E., 

I.  M S.;  Home  Office,  Lond  , 
Private  Secretary  of ; Dr.  A.  K. 
Henry,  Lond. 

I. — Insurance  Committee  for  the 
County  of  London. 

J.  — Dr.  R.  Johnson,  Lond. 

K. — King’s  College  Hospital  Medi- 
cal School,  Lond.,  Sec.  of ; Miss 


M.  Knightley,  Lond.;  Dr.  H.  C. 
Kidd,  Bromsgrove. 

L.  — London  Hospital  Medical  Col- 
lege, Sec.  of;  London  (Royal 
Free  Hospital)  School  of  Medi- 
cine for  Women,  Warden  and 
Sec.  of : Dr.  D.  D.  Lee.  Ketter- 
ing ; Mr.  C.  Litchfield,  Lond.; 
Mr.  W.  Leavis,  Lond.;  Dr.  R.  B. 
Low,  C.B.,  Lond.;  Dr.  C.  E. 
Lakin,  Lond. 

M.  — Dr.  J.  A.  Murray,  Lond.;  Mrs. 
C.  M.  McCausland.  Dublin ; 
Ministry  of  Health,  Lond.;  Dr. 
I.  Moore,  Lond.;  Middlesex  Hos- 
pital, Lond.,  Sec.  Supt.  of;  Dr. 
a.  C.  Magian,  Manchester;  Mid- 
dlesex Hospital  Meiical  School, 
Lond.,  Chairman  and  Council  of  ; 
Messrs.  A.  Maloine  et  fils,  Paris ; 
Dr.  C.  S.  Myers,  Lond. 

P. — Dr.  J.  J.  Perkins,  Lond.;  Panel 
Committee  for  the  County  of 
London  ; Dr.  M.  J.  Petty,  Buenos 
Aires ; Dr.  R.  H.  Paramore, 
Rugby;  Dr.  A.  S.  Percival,  New- 
castle on-Tyne ; Mr.  F.  Pam- 
philon,  Gloucester ; Dr.  F.  W. 
Pilkington,  Kencott. 

R. — Rontgen  Society,  Lond.,  Hon. 
Treasurer  of. 

S.  — St.  George’s  Hospital  Medical 
School,  Lond.,  Actg.  Dean  of  ; 
St.  Mary's  Hospital  Medical 
School,  See.  of ; Prof.  W.  Stirling, 
Manchester:  Dr.  N.  I.  Spriggs, 
Leicester  ; Prof.  C.  S.  Sherring- 
ton, Oxford;  Dr.  A.  G.  Shera, 
Eastbourne  ; Dr.  Ch.  Sauvjneau, 
Paris ; Dr.  W.  C.  Sullivan, 
Lond.;  Mr.  R.  V.  Slattery, 
Dublin  ; Society  for  the  Study 
of  Inebriety,  Lond.;  Save  the 
Children  Fund,  Lond. 

T.  — Dr.  J.  Tatham,  Oxted;  Dr.  D. 
Turner,  Edinburgh  ; Miss  F.  M. 
Templeton,  Lond. 

U.  — University  College  Hospital 
Medical  School,  Lond.,  Acting 
Sec.  of. 

V.  — Dr.  P.  N.Yellacott,  Gorleston. 

W. — Westminster  Hospital  Medical 
School,  Sec.  of ; Dr.  H.  William- 
son, Lond.;  Dr.  E.  M.  Wyche, 
Nottingham. 


Communications  relating  to  editorial  business  should  be 
addressed  exclusively  to  the  Editor  of  The  Lancet, 
423,  Strand,  London,  W.C.  2. 


BIRTHS. 

Evans. — On  Sept.  21st,  at  Devonshire-plaee,  W.,  to  Dorothy,  wife  of 
Arthur  Evans,  O B.K.,  M.S.,  F.R.C.S. — a son. 

Fenton.— On  Sept.  Ilth,  at  Croxley  Green,  the  wife  of  W.  J.  Fenton, 
M.D.,  F.R.C.P.,  of  a daughter. 

Minnitt.— On  Sept.  19tli,  at  Kremlin-drive,  Stoneyeroft,  Liverpool, 
the  wife  of  R.  J.  Minnitt,  M.B.,  Ch.B.,  of  a son. 


MARRIAGES. 

Elgke — Hunt. — On  Sept.  18th,  at  the  Parish  Church,  West  Bridgford, 
Nottingham,  Lieutenant-Colonel  (temporary)  Samuel  Charles 
Elgee.  R.A.M.C.,  to  Dorothy  Elizabeth,  eldest  daughter  of  Mr.  and 
Mrs.  Geo.  Hunt,  of  West  Bridgford. 

Whitksipk — Douay.— On  Sept.  15tb,  at  W.  Eperlecques,  France,  James 
Whiteside,  M.B.,  Ch.B.,  Captain,  R.A.M.C.,  to  Helene,  only 
daughter  of  M.  et  Mme.  Charles  Douay,  Ecole  de  Qaryons,  Nord, 
France.  


DEATHS. 

Clarke.— On  Sept.  19th,  at  Newham  House,  Truro,  Huntley  Clarke, 
M.R.C.S.  ' 

Dobson.— On  Sept.  17th,  at  Pendyffryn  Hall,  Penmaenmawr,  Major 
George  Magill  Dobson,  R.A.M.C  , in  his  50th  year. 

Vasky.— On  Sept.  19th,  at  Twyford  Abbey,  Park  Royal,  Fleet-Surgeon 
C.  Lyon  Vasey,  R.N.  (ret.),  aged  70. 

H.B.—A  fee  of  5s.  is  charged  for  the  insertion  ol  Notices  of  Births 
Marriages,  and  Deaths. 


BOOKS,  ETC.,  RECEIVED. 

Lewis.  H.  K.,  London. 

Mind  and  its  Disorders.  A Text-book  for  Students  and  Practitioners 
of  Medicine.  By  W.  H.  B.  Stoddart.  M D.  3rd  ed.  18s. 

Field  Ambulance  Organisation  and  Administration.  By  Lieut. -Col 

J.  H Neil,  N.Z.M.C.  l’p.  viii.  + 125.  4 s.  6 d. 

Macmillan  and  Co.,  London  and  Canada. 

Tne  Whole  Truth  about  Alcohol.  By  George  E.  Flint.  With  intro- 
duction by  Dr.  A.  Jacobi.  Pp.  294.  $1.50. 

Milford,  Humphrey,  London. 

The  Style  and  Literary  Method  of  Luke.  By  H.  J.  Cadbury.  Pp.  72. 

5s.  6cf. 

Palestine  Exploration  Fund.  Hinde-street,  London,  W.  1. 

Hygiene  and  Disease  in  Palestine  in  Modern  and  Biblical  Times.  By 
E.  W.  G.  Masterman,  M.D.  With  preface  by  A.  Macilister. 
Pp.  70.  2s  6 <f. 

Putnam's  (G.  P.)  Sons,  London. 

Married  Love.  By  Marie  C.  Stopes,  D Sc.  With  Preface  by  Dr. 
Jessie  Murray  and  a Letter  from  Prof.  E.  H.  Starling,  F.R.S 
7th  ed.,  revised  and  enlarged.  Pp.  190.  6s. 

Sampson  Low,  Marston,  and  Co.,  London. 

Tne  Natural  History  of  the  Child.  By  Dr.  C.  Dunn.  Pp.  320.  7s.  6d. 
Shaw  and  Sons,  London. 

Surgery  of  the  Lung  and  Pleura.  By  Hon.  Capt.  H.  M.  Davies 
R.A.M.C.  (T.)  260  + xxiv.  pp.  £1  6s. 

1S05,  Spruce  Street,  Philadelphia,  Pa.,  U.S.A. 

Transactions  of  the  American  Pediatric  Society,  May,  1918.  Edited 
by  O.  M.  Schloss,  M.D.  Vol.  XXX.  Pp.  332. 


Thb  Lancet,] 


NOTES,  SHORT  COMMENTS,  AND  ANSWERS  TO  CORRESI’ON DENTS.  [Sept.  27,  1919  599 


JUtes,  Stmt  (ftmmettis,  anb  ^.nskrs 
U Curresponbents. 

THE  AERIAL  COMBATANT  :* 

HIS  PSYCHOLOGY  AND  NERVOUS  PHYSIOLOGY  CONSIDERED 
IN  THE  LIGHT  OP  ATHLETIC  ANALOGIES. 

By  the  late  H.  G.  F.  SpurreLl,  M.A., 
M.B.,  B.Ch.  Oxf., 

CAPTAIN,  It.A.M.C. 


Part  I. 

When  early  in  the  war  it  was  recognised  that  a powerful 
aerial  army  was  required,  the  training  of  a large  number  of 
men  began.  It  was  suspected  that  the  number  of  men  who 
proved  disappointing  under  training  could  be  reduced  if  a 
scientific  method  of  selection  could  be  evolved.  This 
expectation  has  been  to  a great  extent  justified ; but 
failures  under  training  still  occur,  and  a very  large  pro- 
portion of  these  failures  can  be  traced  to  nervous  and 
psychological  causes.  This  may  be  partly  due  to  the  practical 
difficulty  of  detecting  nervous  weakness  when  selecting 
a flying  officer,  but  his  duties  make  such  unusual  demands 
upon  his  nervous  system  that  chance  may  easily  subject 
even  the  soundest  material  to  a breaking  strain.  Much  has 
yet  to  be  learned  regarding  the  selection  of  the  right  nervous 
organism,  how  to  train  it  when  selected,  and  how  to  estimate 
its  recuperative  powers  when  damaged.  In  the  light  of  some 
small  experience  gained  on  the  selection  and  invaliding 
boards  of  the  Royal  Air  Force,  and  in  no  less  instructive 
daily  intercourse  with  members  of  a great,  school  of  military 
aeronautics,  I have  attempted  to  sketch  out  the  nervous 
physiology  of  training  for  aerial  combat,  and  to  trace  to 
underlying  physiological  bases  some  of  the  factors  which 
make  for  success  or  failure  in  the  flying  combatant.  Such 
an  attempt  may  be  profitable,  though  the  risk  must  be  faced 
of  saying  much  that  is  already  tediously  obvious. 

Training  of  the  Flying  Fighter. 

A flying  fighter  must  undergo  three  distinct  stages  in  his 
education.  Firstly,  he  must  be  taught  to  fly.  He  must 
learn  to  fly  instinctively  with  no  more  conscious  mental 
effort  in  handling  his  machine  than  a cavalryman  of  the  old 
school  exerted  in  keeping  his  seat  and  managing  his  horse. 
Secondly,  he  must  learn  to  fight,  to  drop  his  bombs  with 
calculation  aud  precision,  but  making  many  of  the  incidental 
movements  subconsciously,  and  to  manipulate  his  machine- 
gun  with  a trained  hand  but  a free  mind.  Thirdly,  having 
learned  both  to  fly  and  to  fight  in  the  air,  he  must  learn  to 
use  military  intelligence.  He  must  be  able  to  watch  what 
is  going  on  in  a melde,  decide  quickly  whether  to  single 
out  an  opponent  or  go  to  the  help  of  a friend,  to  use  judg- 
ment when  bombing  in  choosing  objectives,  and  he  requires 
special  knowledge  for  gaining,  interpreting,  and  using  infor- 
mation which  may  come  in  his  way.  The  old-time  trooper 
with  a firm  seat  and  a fine  wrist  was  a long  way  from  being 
the  complete  cavalryman,  and  the  skilful  aeronaut  who  is 
dextrous  with  weapons  has  yet  to  become  a flying  soldier. 
With  all  this  to  learn  the  tyro’s  nerve  centres  need  extensive 
and  progressive  development,  and  it  may  clarify  one’s  ideas  to 
translate  the  process  into  physiological  terms. 

Learning  to  fly  may  be  compared  with  learning  any  other 
motor  accomplishment.  The  required  movements  have  to 
be  worked  out  in  consciousness  by  the  highest  cerebral 
mechanism.  The  muscles  which  are  to  perform  them  have 
to  be  developed  to  the  strength  requisite  for  acting  har- 
moniously in  the  new  combinations.  When  the  movements 
have  become  clear  conceptions  which  can  be  consciously 
carried  out  by  trained  muscles,  these  conceptions  have  to  be 
passed  down  the  scale  of  nervous  controlling  centres  until 
they  become  the  property  of  reflex  oentres  and  can  be  per- 
formed automatically,  not  merely  without  requiring  thought, 
but  without  interrupting  thought.  Learning  to  fly  is  closely 
analogous  to  learning  to  bicycle  : the  stages  of  the  nervous 
education  are  the  same.  It  is  also  analogous  to  learning  to 
walk,  but  here  the  analogy  cannot  be  pressed  so  far. 
Evolution  has  not,  either  by  structural  adaptation  or  by 
nervous  tendencies,  given  man  an  hereditary  predisposition 
to  fly  analogous  to  the  predisposition  to  walk.  In  flying  and 
in  bicycling  the  brain  acts  consciously  by  selecting, 
inhibiting,  and  adapting  the  established  reflexes  to  new 
purposes ; but  the  process  is  not  shortened  by  any  of  those 
instincts  which  urge  a child,  in  whom  intelligence  is  only 


* This  paper  was  received  hy  us  after  the  author's  death.  Reference 
to  the  obituary  notice  in  The  Lancet  of  Jan.  4th  (p.  42)  will  show  the 
high  qualifications  which  Captain  Spurrell  brought  to  his  task. 


dawning,  to  make  persistent  efforts  to  walk  when  its  mother 
thinks  it  would  still  be  much  better  employed  crawling. 

Man’s  capacity  for  education  is,  however,  conditioned 
by  his  evolutionary  history.  While  most  animals  have 
specialised  for  a particular  place  in  nature,  in  man  we  see 
an  animal  capable,  by  means  of  tools  and  education,  of 
specialising  himself  for  many  diverse  requirements.  One 
of  his  most  recent  attempts  at  self-education  is  for  the  air. 
He  has  not  the  exclusive  specialisation  for  flight  which 
evolution  has  produced  in  the  bat,  so  if  he  is  to  fly  he  must 
attain  his  end  by  devising  mechanical  means  and  training 
his  nervous  system,  and  this  he  has  proved  himself  capable 
of  doing.  But,  together  with  the  intelligence  and  versatility 
which  enable  him  to  elaborate  movements,  man  must  have 
a very  complete  power  of  delegating  the  controls  elaborated 
by  his  brain  to  lower  automatic  centres.  Only  so  can  he 
prevent  his  brain  from  becoming  overloaded  and  keep  it  free 
to  deal  with  present  needs.  Only  so,  moreover,  can  he 
shorten  his  reaction  times  and  so  gain  the  necessary  rapidity 
for  meeting  the  emergencies  of  daily  life. 

The  Education  of  the  Nervous  System. 

In  actually  learning  to  fly  one  may  trace  three  distinct 
stages  in  the  education  of  the  nervous  system.  First  there 
comes  the  cerebral  stage.  The  way  in  which  the  machinery 
of  the  aeroplane  works  i3  constantly  before  the  mind  and 
the  muscular  movements  to  produce  the  right  effects  in  it 
have  to  be  thought  out  and  performed  consciously,  with 
mental  effort.  Errors  become  slighter  as  time  goes  on, 
because  adaptations  are  taking  place  in  the  receptive  side 
of  the  nervous  system,  which  is  learning  to  deal  with  a multi- 
tude of  unfamiliar  afferent  stimuli.  The  first  stage  passes 
gradually  into  the  second,  or  the  stage  of  transition.  During 
this  stage  automatic  action  is  becoming  perfected  and 
conscious  direction  more  and  more  restricted.  The  pupil 
learns,  by  flying  with  an  instructor  in  a machine,  under 
what  is  known  as  “ dual  control.”  Now  the  relations 
of  the  instructor  to  his  pupil  are  very  closely  parallel 
to  the  relation  of  the  higher  centres  of  the  brain  to 
the  automatic  centres  lower  down  the  scale  in  the  central 
nervous  system.  The  progressive  education  of  the  pupil  and 
the  reflex  centres,  and  the  continually  lessening  intervention 
on  the  part  of  the  instructor  and  cerebral  cortex  present  no 
very  strained  analogy.  But  during  the  stage  of  transition 
there  is  a period  when  the  aeroplane,  though  described 
officially  as  under  dual  control,  is,  physiologically  speaking, 
under  treble  control.  The  nervous  system  of  the  instructor 
works  harmoniously  and  may  be  regarded  as  a unit ; but  the 
pupil,  whose  conscious  and  automatic  nervous  centres  have 
not  yet  arrived  at  a satisfactory  division  of  labour,  is  more 
accurately  to  be  described  as  two  individuals  than  one.  The 
conscious  and  subconscious  nervous  centres  competing  for 
the  control  of  the  muscles  resemble  a fussy,  over-anxious 
instructor  continually  trying  to  help  a wayward  and  awkward 
pupil.  From  what  instructors  tell  me  I gather  that  this  is 
the  least  safe  period  in  the  pupil’s  career,  and  one  can  well 
understand  that  between  the  three  controls  the  machine 
may  come  to  the  ground. 

With  the  arrival  of  the  third  stage  flying  becomes 
instinctive.  The  pupils  thinks  of  what  he  will  do,  not  how 
he  will  do  it,  and  he  learns  by  observation  and  experiment 
how  all  manner  of  various  conditions  affect  his  doing  what 
he  wants  to  do.  Even  now,  of  course,  the  pupil  is  not 
immune  from  mishap.  The  venturesome  type  may  come  to 
grief  by  attempting  things  which  are  beyond  his  powers  or 
the  structural  capacity  of  his  machine ; the  careless  type 
may  have  an  accident  because  he  “ lets  his  wits  go  wool- 
gathering.” The  weakness  of  this  type  lies  in  a deficient 
power  of  inhibition.  It  cannot  repress  irrelevant  stimuli 
which  interfere  with  the  essential  action.  Both  these  types 
prove  unsafe  flyers  in  spite  of  a successful  education,  but 
they  are  essentially  deviations  from  the  normal.  In  the 
normal  man  the  most  dangerous  source  of  accident  is  a 
mental  disturbance  in  which  the  cerebral  hemispheres 
endeavour  once  again  to  take  charge  of  actions  which  have 
for  some  time  past  been  performed  automatically. 

The  extreme  difficulty  of  attempting  and  the  disastrous 
results  which  often  follow  an  attempt  to  perform  consciously 
actions  which  have  become  reflex  are  matters  of  common 
knowledge,  and  it  is  only  when  we  attempt  to  perform 
actions  with  especial  care  that  we  learn  how  many  are  really 
automatic.  We  have  all  seen  the  well-educated  man,  who 
can  speak  fluently  in  ordinary  life,  splutter,  become  inco- 
herent, and  break  down  when  called  upon  to  make  a speech 
or  to  interview  someone  of  importance.  This  is  because  he 
is  making  conscious  efforts  to  speak  clearly  and  gram- 
matically, and  we  have  all  seen  him  recover  miraculously 
when  the  impudence  of  a heckler  distracts  his  attention 
from  the  cares  of  elocution,  or  the  urbanity  of  a great  man 
“ sets  him  at  his  ease  ” by  diverting  his  mind  in  the  direc- 
tion of  the  subject  of  his  interview.  When  a pilot  can  fly 
by  established  reflexes  which  only  need  general  orders  from 
the  presiding  intelligence  it  is  very  perilous  for  the  volitional 
centres  to  attempt  suddenly  to  resume  control.  They  can 


600  The  Lancet,]  NOTES,  SHORT  COMMENTS,  AND  ANSWERS  TO  CORRESPONDENTS.  [Sept.  27,  1919 


resume  control  cautiously  and  deliberately  in  efforts  to 
improve  by  practice  movements  which  are  not  yet  perfect,  but 
that  is  another  thing.  Self-consciousness  is  the  disturbing 
element.  For  instance,  a man  unused  to  Hying  in  Egypt 
knows  that  the  shimmering  sand  and  blinding  glare  will  make 
the  conditions  of  his  landing  unlike  those  of  grass  in  a 
grey  light,  and  he  may  easily  worry  about  this,  and  as 
he  approaches  the  ground  allow  his  conscious  volition  to 
hamper  his  reflexes  with  disastrous  results.  On  the  other 
hand,  a man  suddenly  perceiving  an  obstacle  when  on 
the  point  of  landing,  will  make  the  complex  movements 
necessary  to  avoid  it  quite  subconsciously  and  automatic- 
ally. Whether  he  comes  off  safely  depends  on  extraneous 
circumstances.  In  himself  he  has  every  chance. 

This  return  of  conscious  control  after  reflex  control  has 
been  established  is  like  an  old  instructor,  long  retired  from 
flying,  going  up  with  one  who  was  formerly  his  pupil,  but  is 
fully  proficient  and  in  much  better  trim  than  himself.  If 
the  older  man  nervously  insists  on  flying  in  dual  control 
and  in  interfering  whenever  a difficulty  confronts  them  the 
pair  will  probably  crash.  If  the  veteran  is  there  solely  as 
a passenger  to  use  his  experience  for  strategic  purposes  and 
occasionally  offer  advice  on  major  tactics  they  will  probably 
do  excellent  work.  When  the  pilot’s  nervous  system  has 
been  so  trained  that  the  reflex  mechanism  can  carry  out  the 
requirements  of  intelligent  volition,  yet  the  higher  centres 
which  act  consciously  can  be  relied  on  never  to  embarrass 
the  highly  educated  reflexes  by  untimely  interference,  then 
the  third  stage  in  his  education  is  completed  and  he  can  be 
said  to  have  learned  how  to  fly. 


THE  METROPOLITAN  WATER-SUPPLY  DURING 
APRIL,  MAY,  AND  JUNE,  1919. 

On  the  whole,  the  month  of  April  this  year  maintained 
its  tradition  in  regard  to  rain,  and,  in  fact,  the  rainfall  in  the 
Thames  basin  was  2-76  inches,  being  P02  inches  above  the 
average  mean  rainfall  for  that  month  during  the  previous  36 
years.  The  Thames  water  was  at  times  more  or  less  coloured 
and  turbid.  Nevertheless,  the  results  of  the  chemical  exa- 
mination showed  that,  generally  speaking,  all  three  raw 
waters  (Thames,  New  River,  and  Lee)  showed  an  improve- 
ment in  quality  as  indicated  by  the  albuminoid  nitrogen, 
permanganate,  turbidity,  and  colour  tests.  The  filtered  waters 
also  showed  an  improved  chemical  quality  compared  with  the 
previous  month,  and  the  samples  collected  at  the  different 
works  were  clear  and  bright  and  free  from  suspended  matter. 
The  results  compared  favourably  also  with  the  averages  of  the 
previous  year.  Bacteriologically  the  Thames  and  New  River 
raw  waters  contained  fewer  and  the  River  Lee  raw  water 
more  bacteria  than  their  respective  averages  for  1918.  The 
filtered  waters  were  satisfactory  from  this  point  of  view. 
May  was  a dry  month,  the  rainfall  being  0 64  of  an  inch, 
being  l-34  inches  below  the  average  mean  rainfall  for  this 
month  during  the  previous  36  years.  The  Thames  and  New 
River  raw  waters  showed  a deterioration  in  quality  by 
chemical  tests.  The  raw  waters  of  the  Thames  and  Lee  con- 
tained fewer  and  the  New  River  more  bacteria  than  their 
respective  averages  in  1918.  The  filtered  waters  were  again 
satisfactory.  June  was  also  a relatively  dry  month,  with  the 
rainfall  standing  at  1-06  inches,  being  1T3  inches  below  the 
average  mean  rainfall  for  that  month  during  the  previous  36 
years.  All  three  raw  river  waters  showed,  generally  speak- 
ing, improved  quality  judged  by  chemical  and  physical  tests. 
All  three  proved  to  contain  fewer  bacteria  than  their 
respective  averages  for  the  year  1918.  There  were  no  typical 
B.  coli  in  100  c.cm.  of  the  water  in  72'4  per  cent,  of  the 
filtered  samples  derived  from  the  Thames,  36  8 per  cent, 
from  the  Lee,  and  77-9  per  cent,  from  the  New  River.  Judged 
on  this  high  standard  the  Lee  filtered  water  was  inferior  to 
the  others.  It  is  interesting  to  note  that  the  April  report  is 
stamped  “Local  Government  Board,”  while  those  for  May 
and  June  are  marked  “ Ministry  of  Health.” 

THE  MISCEGENATION  OF  SHAKESPEARE. 

To  the  physical  anthropologist  miscegenation  must  mainly 
be  of  interest  as  it  affects  human  anatomy.  As  the  school  of 
Professor  Keith  points  out,  the  races  of  the  British  Isles  are 
“much  of  a muchness  ” from  the  point  of  view  of  cranio- 
logy — they  are  practically  all  dolichocephalic ; where  long- 
headed races  become  intermixed  that  school  does  not  regard 
the  resultant  types  as  it  would  half-breeds  or  mulattos.  In 
more  historic  times  than  those  of  physical  anthropology  the 
question  of  miscegenation  becomes  important  from  the  point 
of  view  of  brain-differentiation  and  culture-drift.  For  the 
long  heads  are  not  all  alike  either  in  mental  heredity 
or  civilisation. 

Shakespeare  is  the  fine  flower  of  English  genius.  That 
“ Shakespear  ” was  a pseudonym,  chosen  by  Bacon  to 
express  the  fact  that  the  Author  of  the  Plays’  brandished 
the  spear  of  Pallas  in  the  great  age  of  Elizabeth  is 
a suggestion  combated  by  the  history  of  surnames.  Shake- 
speare, a commbn  name  in  Warwickshire,  is  Shalk’s 
Byre,  “the  farm  of  the  villein,"  who,  in  that  part  of 


England,  was  descended  from  a Romanised  Briton.  That 
Shakespeare,  the  man,  was  a very  pronounced  instance 
of  miscegenation  is  an  attractive  supposition.  His  genius 
has  been  described  as  both  Teutonic,  or  Northern — i.e., 
Anglo-Saxon — and  as  British,  Celtic,  or  rather  Cymric, 
for  he  combines  virility  with  mystery  in  a degree  unknown 
to  the  German  Goethe  on  the  one  hand  or  the  old  Welsh 
bards  on  the  other.  We  may  grant,  at  least,  that  Shakespeare 
was  a combination  of  Saxon  and  Briton,  and  that  this  is 
reflected  in  his  masterpieces.  What,  however,  were  the 
ancient  Britons,  from  whom  the  shalks  of  the  byre 
descended  ? According  to  the  late  Sir  Jonathan  Hutchinson, 
who  bases  himself  on  Dr.  Baynes,  the  Shakespeares,  as  well 
as  Mary  Arden,  the  poet’s  mother,  came  of  Roman  stock. 
In  a very  acute  shdrt  paper,  published  in  “ The  Home 
University”  (October,  1898)  Sir  Jonathan  Hutchinson  points 
out  a number  of  considerations  in  favour  of  this  position 
“ During  the  Roman  occupation,’’  he  says,  quoting  Baynes, 
“ Warwickshire  was  the  site  of  several  central  Roman 
stations,  of  which  the  fortified  camps  of  Tripontium  and 
Praeeidium,  on  the  line  of  the  Avon,  were  the  most  impor- 
tant. A Roman  road  crossed  the  Avon  at  Stratford,  and 
radiating  north  and  south,  soon  reached  some  of  the  larger 
Roman  towns  of  the  west,  such  as  Uriconium  and  Corinium. 
Between  these  towns  were  country  villas  or  mansions,  many 
of  them  being,  like  those  at  Woodchester,  magnificent  palaces 
covering  as  much  ground  as  a whole  town.  The  entire 
district  must  in  this  way  have  been  powerfully  affected  by 
the  higher  forms  of  social  life  and  material  splendour  which 
the  wealthier  provincials  had  introduced.”  Nay,  more, 
according  to  Coote  (“  Romans  of  Britain,”  published  in  1878), 
the  whole  of  Britain,  but  especially  the  West,  remained 
essentially  Roman  to  a late  date,  the  country  having  been 
everywhere  measured  out  and  allotted  by  agrimensores  to 
scions  of  good  Roman  stocks  (Julii,  Cornelii,  &c.)> 
whose  descendants  founded  our  western  squirearchy  in 
preference  to  the  rude  Saxon  invaders  of  the  fifth  and 
succeeding  centuries.  Is  it  too  extravagant  to  suppose  that 
through  the  Arden  family,  at  any  rate,  Shakespeare  derived 
the  fissures  of  his  brain  and  the  aquiline  cast  of  his  features  ? 
The  Iberian  or  Mediterranean  type  lingers  everywhere  in 
rural  western  England.  Often  it’  startles  us  by  its  Roman 
nobility  of  contour.  Who  has  not  come  upon  a face 
suggestive  of  Julius  Csesar  in  the  lonely  fields  along  the 
remote  Upper  Thames  at  Bampton  or  in  any  remote  region 
of  Wessex? 

Sir  Jonathan  Hutchinson  closes  his  article  with  the  remark : 
“Of  Shakespeare’s  symmetrical  and  noble  face  we  will  only 
say  that  it  is  not  one  which  could  be  easily  matched  in 
Denmark,  and  still  less  so  in  Germany.  The  resemblance  of 
George  Eliot’s  face  to  that  of  Savonarola  has  often  been 
remarked,  and  as  regards  character  a close  parallel  might  be 
drawn  between  Savonarola  and  Fox.”  George  Fox,  a man 
of  profound  and  original  spiritual  genius,  was  born  at  Fenny 
Drayton,  George  Eliot  (Miss  Evans — a Welsh  name)  at 
Nuneaton,  Samuel  Butler,  author  of  “ Hudibras,”  in  the 
same  neighbourhood,  the  Shakespeares  were  a Snitter- 
field  stock,  the  Ardens  came  from  the  Forest  of  that 
name.  These  places  were  within  15  miles  of  Coventry.  They 
represent  a pocket  of  exceptional  genius,  due  to  a mixture 
of  culture-drifts  and  the  survival  of  a higher  mental  type. 
A similar  pocket  has  been  discovered  by  Professor  Keith  in 
the  countryside  of  the  Hunters,  which  produced  in  its  day 
a remarkable  group  of  medical  men  of  genius. 

EDUCATED  HOME  HELPS  FOR  THE  MIDDLE 
CLASSES. 

The  attention  of  practitioners  is  called  to  a newly  estab- 
lished bureau  for  the  provision  of  educated  middle-aged 
women,  experienced  in  housekeeping  and  holding  certificates 
in  first  aid,  home  nursing,  and  invalid  cookery,  to  help  in 
private  houses  in  cases  of  illness.  No  actual  nursing  will 
be  undertaken,  but  such  work  as  looking  after  the  house 
and  children,  invalid’s  food,  shopping,  and  mending.  It  is 
anticipated  that  the  scheme  will  be  doubly  useful  to  women 
of  slender  means  who  desire  part-time  employment,  and,  on 
the  other  hand,  to  professional  women  living  alone  in  a 
flat  attended  by  a charwoman  only,  or  to  mothers  with  large 
households  whose  convalescence  is  too  often  retarded  by 
worry  about  the  servants,  the  shopping,  aud  the  children’s 
meals.  In  the  modern  servantless  middle-class  homes, 
where  at  most  the  services  of  a daily  maid  are  available,  an 
illness  of  the  mistress  which  confines  her  to  bed  is  likely 
enough  to  bring  household  affairs  to  a full  stop,  as  well 
as  to  create  a period  of  added  strain  to  the  invalid.  We 
take  it  that  the  new  help  is  intended  to  replace  the 
former  ubiquitous  unmarried  sister  or  sister-in  law,  who 
is  nowadays  usually  a busy  bachelor  woman  and  seldom 
available  in  emergency.  The  payment  will  be  not  less  than 
10J.  an  hour  or  5s.  a day  with  food,  or  25s.  a week  with  all 
meals.  All  applications  for  educated  home  helps  or  from 
suitable  candidates  for  employment  should  be  made  to  the 
Women's  Industrial  Council,  6,  York  Buildings,  Adelphi, 
W.C.  2. 


THE  LANCET 

8 Souraal  of  Sritfefy  anti  Jforrtgn  ii^tnrine,  ^urgerp,  (^bsftrtruS,  ^fjp^tologp, 
Cbnnts:trp>  Pjarmacotogp,  IJubltr  health,  anti 

Telegraphic  Address-LANCET  WESTRAND  LONDON  Telephone  Number-GERRARD  6366 


NoioH^CXCVIL  LONDON,  SATURDAY, 


SEPTEMBER  27,  1919.  Pp.  112-Price  lOd. 


Now  Ready.  New  (3rd)  Edition.  With  22  Illustrations.  15s.  net  ; 
postage  6d. 

VICIOUS  CIRCLES  IN  DISEASE. 

By  J.  B.  HURRY,  M.A.,  M.D.  (Cantab.). 

Sir  Clifford  Allbutt  says  “ This  aspect  of  medicine  is  one  which 
no  practitioner  of  the  ars  medendi  can  afford  to  neglect.” 

London  : J.  & A.  Churchill,  7,  Great  Marlborough-street,  W.  1. 

NERVE  INJURIES  and  their  TREATMENT. 

By  Sir  JAMBS  PURVKS  STEWART,  K.C.M.G.,  C.B., 
Senior  Physician  to  the  Westminster  Hospital ; and 
ARTHUR  EVANS,  M S.,  P.R.C.S., 

Surgeon  and  Lecturer  on  Surgery  to  the  Westminster  Hospital. 
Second  Edition.  Revised  and  Enlarged.  The  most  recent  work  on  the 
subject.  Demy  8vo.  Cloth.  Pages  262.  With  137  Illustrations. 
Price  12s.  6d. 

Henry  Prowde,  Hodder  & Stoughton, 

17,  Warwick-8quare,  Newgate-street,  London.  E.C.  4. 

Price  2s.  6d.  net  (postage  3d.). 

OTITIS  MEDIA 

(MASTOID  DISEASE). 

Saving  the  Hearing  of  the  Discharging  Ear  With  Perforated 
Drumhead. 

By  CHARLES  J.  HEATH,  F.R.C.S.  Eng., 

Consulting  Aurist,  Metropolitan  Asylums  Board  ; late  Surgeon, 
Throat  Hospital,  Golden  Square,  London. 

“ the  efforts  which  for  some  years  Mr.  Charles  J.  Heath  has  made 

to  convince  otologists  that  the  radical  mastoid  operation  is  out  of  date. 
As  long  ago  as  1906  he  expounded  his  views  upon  the  cure  of  chronic 
suppuration  of  the  middle  ear  without  the  removal  of  the  drum  or 
ossicles,  or  loss  of  hea-ing.  Since  then  he  has  made  the  matter  his 
constant  study  and  observation,  proving  conclusively  the  value  of  the 
conservative  mastoid  operation  which  he  has  introduced.” 

—Medical  Press. 

Bailliftre,  Tindall  & Cox,  8,  Henrietta  Street,  Covent  Garden, 
London,  W.C.2. 

Demy  8vo.  412  pages,  12  Plates,  and  122  Ulus.  Cloth.  Pricel0s.6d.net. 

Eye,  nose,  throat,  and  ear. 

A Manual  for  Students  and  Practitioners. 

By  JAMBS  FORREST.  M.B.,  Ch  B.Edin. 

Henry  Kimpton,  Medical  Publisher,  263,  High  H »lb>rn,  London,  W.C. 

Y W.  SOLTAU  FEN  WICK,  M.D. 

DYSPEPSIA:  Its  Varieties  and  Treatment. 

Octavo,  455  pages.  13s.  net. 

W.  B.  Saunders  Co.,  9,  Henrietta-street,  W.C.  2. 


B 


• CANCER  OP  THE  STOMACH. 

362  pages.  10s.  6d. 

ULCER  OP  THE  STOMACH  AND  DUODENUM. 

392  pages.  10s.  6d. 

J.  & A.  Churchill,  7,  Great  Marlborough-street,  W.  1. 

8vo,  Cloth.  27  Plates  and  Illustrations.  8s.6d.net.  ( Postage  4d.  exti a. 

WAR  WOUNDS  OF  THE  LUNG. 

Notes  on  their  Surgical  Treatment  at  the  Front. 

By  PIERRE  DUVAL. 

Authorized  English  Translation. 

“An  admirable  monograph.” — Lancet.  “ Will  repay  study. 

Suggestive  of  methods  applicable  to  civil  practice.”— Brit.  Med.  Jour. 
Bristol : John  Wright  & Sons  Ltd.  London  : Simpkin  & Co.  Ltd. 


By  H.  J.  WARING,  M.S.,  M.B.,  B.Sc.Lond.,  F.R.C.S., 

Surgeon  to,  and  Joint  Lecturer  in  Surgery  at,  St.  Bartholomew’s 
Hospital ; Consulting  Surgeon  to  the  Metropolitan  Hospital ; Member 
of  Court  of  Examiners,  Royal  College  of  Surgeons;  late  Examiner 
in  Surgery,  University  of  London. 

New  Edition  Shortly.  8vo,  extra  cloth.  Pp.xvi.-385,  with  58  Engravings. 
Price  12s.  6d.  net. 

QURGICAL  DISEASES  OF  THE  GALL- 
IC BLADDER,  BILE  DUCTS,  AND  LIVER. 
Their  Pathology,  Diagnosis,  and  Treatment, 

(Including  Jacksonian  Prize  Essay.) 

Henry  Prowde  & Hodder  & Stoughton, 

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London  : BailliSre,  Tindall  & Cox,  8,  Henrietta-st.,  Covent  Garden,  W.C. 2 


s 


Second  Edition.  15s.  net. 

BY  HERBERT  J.  PATERSON, 

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THE  SURGERY  OF  THE  STOMACH 
A Handbook  of  Diagnosis  and  Treatment. 

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THE  FUTURE  OF  MEDICINE. 

BY 

SIR  JAMES  MACKENZIE, 

F.R.S.,  M.D.,  F.K.C.P.,  LL.D.  Ab.  k Edin.,  F.R.C.P.I.  (Hon.), 
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Demy  8vo.  Cloth.  Illustrated.  Price  8s.  6d.  net. 

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• — British  Medical  Journal. 


MANUAL  OF  PHYSICS. 

BY 

J.  A.  CROWTHER,  Sc.D., 

Sometime  Fellow  of  St.  John’s  College,  Cambridge ; Demonstrator  in 
Physics  in  the  Cavendish  Laboratory,  Cambridge. 

Crown  8vo.  Cloth.  564  pp.,  with  250  Illustrations.  16s.net. 


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MIND  AND  ITS  DISORDERS. 


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A TEXT-BOOK  FOR  STUDENTS  AND  PRACTITIONERS. 

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THE  DIAGNOSIS  AND  TREATMENT  OF 
HEART  DISEASE. 

By  E.  M.  BROCKBANK,  M.D.Vict.,  F.R.C.P., 

Hon.  Physician,  Rayal  Infirmary,  Manchester,  &c. 

“As  practicable  ani  reliable  as  ever."  — The  Lancet. 


Diseases, 

[Louis’s  Practical  Series. 

Just  Published.  Second  Edition.  With  67  Illus.  Crown  8vo. 

6s.  net ; post  free,  6s.  5d. 

NOTES  ON  GALVANISM  AND  FARADISM. 

By  ETHEL  MARY  MAG1LL,  M.B.,  B.S.  Lond.,  &c. 

“ Well  designed  for  the  purpose  for  which  it  is  intended.” — British 
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[Founded  1823: 


The  Lancet,] 


THE  LANCET  GENERAL  ADVERTISER 


[Sept.  27,  1919 


LESLIES’  ZOPLA 

(ZINC  OXIDE  PLASTER)  Formerly  Zincoplast. 

THE  PERFECTED  SURGICAL  PLASTER. 

Instantly  Self-adhesive.  Will  not  slip  wherever  put.  THE  ONE  REAL 
NON-IRRITATING  PLASTER,  Will  keep  without  drying  up, 

Supplied  on  White  and  Flesh-colour  Cloths,  also  on  Holland  on  Spools  i"  to  4* 
wide  in  5 or  10  yard  lengths  in  rolls  7"  and  12"  wide.  Also  on  moleskin, 
chamois  leather,  felt,  and  waterproof  cloth.  SAMPLES  ON  REQUEST. 

ZOPLA  is  made  by  the  firm  with  the  reputation  for  BROWN  HOLLAND 
STRAPPING  ( Original  make ). 

LESLIES,  Btci.  (British  firm  throughout),  62,  London  Wall,  B.C.  2. 

OXYCEN  PROPERLY  ADMINISTERED  BYoKr  EFFICIENTLY  DESICNEO  APPARATUS 

might  have  saved 

THOUSANDS  OF  LIVES  during  the  recent  epidemic. 

We  make  such  an  apparatus  embodying  the  latest  designs  and 
recommendations  of  Professor  J.  S.  Haldane,  F.R.S. , M.D. 

IT  IS  EXTREMELY  SIMPLE,  EFFECTIYE,  & ECONOMICAL  in  use  of  OXYGEN. 

(In  mp8t  apparatus  of  the  kind  hitherto  employed,  more  Oxygen  haa  been  wasted  than 
used  by  the  patient.) 

WITH  OUR  APPARATUS  THERE  IS  NO  WASTE  OF  OXYGEN. 

S0Lmakers-  SIEBE,  GORMAN  & CO.,  LTD., 

Specialists  in  Breathing  Apparatus  for  Diving,  FlyiDg,  Mountaineer- 
ing, Mining  Work  in  Poison  Gas,  and  for  Medical  purposes. 

187.  WESTMINSTER  BRIDGE  ROAD,  LONDON,  S.  E. 

Telegrams:  “Siebe,  Lamb,  London.”  Telephone  No.:  Hop  3401  (2  lines 


PAPAIN  DEGA 


A specially  selected  Papaw  juice,  unbleached,  carefully  prepared 
and  powdered,  free  from  all  particles  of  inert  resinous  matter. 


PAPAIN  DEGA  retains  full  therapeutic  activity  in  the  presence  of  marked 
alkaline  reaction.  It  may  therefore  be  prescribed  with  Sod.  Bicarb.,  Mag.  Carb.  Pond, 
&c.,  in  cases  of  Chronic  Gastric  Fermentation. 

(We  would  respectfully  aslc  Physicians  to  write  PAPAIN  DEGA  in  full  when  prescribing , in 

order  to  protect  their  patients.) 

1-oz.  bottles,  3/6.  Special  quotations  for  Hospitals.  i-oz.  bottles,  12  6. 


CH  AS.  ZIMMERMANN  & CO.  (Chem.),  Ltd., 

Medical  Dept.  2,  9/10,  ST.  MARY-AT-HILL,  LONDON,  E.C.  3. 

British  Firm,  British  Interests. 

• • 

u 


THE  LANC  F/,T. 

No.  5013.  LONDON,  SATURDAY,  SEPTEMBER  27,  1919.  Vol.  CXCVII. 


CON  T ENTS. 

7 he  whole  of  the  literary  matter  in  The  LANCET  is  copyriyht. 


PRESIDENTIAL  ADDRESS 

on  the  Differentiation  of 
Mankind  into  Racial  Types. 
Delivered  before  the  Anthro- 
pological Section  of  the 
British  Association  for  the 
Advancement  of  Science  by 
Prof.  Arthur  Keith,  M.D. 
Aberd.,  LL.D.,  P.  R.  S„ 
Hunterian  Professor  and 
Conservator  of  the  Museum, 
Royal  College  of  Surgeons 
of  England 553 

ORIGINAL  ARTICLES. 

“ Heteroeerotherapy  ” in  Pul- 
monary Tuberculosis.  By 
J.  J.  Perkins,  M.B., 
F.R.C.P.,  Physician  to  St. 
Thomas’s  and  the  Brompton 
Hospitals ; R.  A.  Young, 
M.D.,  F.R.C.P.,  Physician 
to  the  Middlesex  and 
Brompton  Hospitals : and 

W.  O.  Meek,  M.B.,  Medical 
Superintendent,  the  Primley 
Sanatorium.  (From  the 
Brompton  Hospital  Sanato- 
rium, Frimley,  Surrey) 566 

The  Early  Treatment  of  Mental 
Disorders.  By  R Eager, 
M.D.  Aberd.,  Senior  Assistant 
Medical  Officer  and  Dahuty 
Medical  Superintendent, 
Devon  Mental  Hospital,  Bx- 
minBter:  Major,  R.A.M.C. 

(T.) ; late  O.I/C.,  Mental 
Division,  the  Lord  Derby 
War  Hospital,  Warrington  — 


( illustrated ) 558 

Twilight  Sleep”  in  General 
Practice.  By  G.  Hamilton 
Winch,  M.B.,  Ch.B.  Edin 663 


Hyperkeratosis  of  the  Hair 
Follicles  in  Scurvy.  By 
Harold  Wiltshire,  O.B.E., 
D.S.O.,  M.D.,;  F.R.C.P., 

Physician  to  King’s  College 
Hospital ; late  Assistant 
Consulting  Physician,  B.S.F.  664 
Foreign  Bodies  in  the 
(Esophagus  and  Respiratory 
Passages.  Remarks  on  the 
Dangers  Arising  from  their 
Impaction  and  some  Diffi- 
culties which  may  be  met 
with  in  their  Removal : A 
Plea  for  the  Abolition  of  the 
Coin-catcher,  the  Blind  U6e 
of  the  Bougie  and  Probang, 
and  their  Replacement  by  the 
. Direct  Endoscopic  Methods 
of  Extraction.  By  Irwin 
Moore,  M.B.,  C.M.  Edin., 
Surgeon  to  the  Throat  Hos- 
pital, Golden  square,  W.— 

( Illustrated ) 566 


Wheat  Culture  Media.  By 
Shozaburo  Otabe,  M.D. 
Bale,  Medical  Superinten- 
dent (Temporary)  National 
Sanatorium,  Benenden,  Kent ; 
formerly  Assistant  Medical 
Officer,  Kensington  Infir- 
mary, London ; Assistant, 
Bacteiological  Institution, 

T o k i o Charity  Hospital 
Medical  College.  — ( Illus- 
trated) 576 

REVIEWS  AND  NOTICES  OF 

BOOKS. 

Trench  Fever : a Louse-borne 
Disease.  By  W.  Byam,  J H. 
Carroll,  J.  H.  Churchill,  Lyn 
Dimond,  V.  E.  Sorapure, 

B.  M.  Wilson,  and  LI. 

Lloyd 576 

Massage  and  ttie  Original 
Swedish  Movements.  By  the 
lata  Kurre  W.  Ostrom. 

Eighth  edition 577 

Essentials  of  Surgery.  By 
Archibald  L.  MoDonald, 

M.D 577 

A Manual  of  Gynecology. 

Bv  John  Cooke  Hirst, 

M.D ..bll 

The  Exact  Diagnosis  of  Latent* 
Cancer.  By  O.  C.  Gruner, 
M.D 577 


FRENCH  SUPPLEMENT  TO 
THE  LANCET. 

Under  the  Editorial  Direction 
of  Professor  Charles  Aoh  ard. 
Professor  of  Pathology  and 
Therapeutics  in  the  Univer- 
sity of  Paris  ; and  Dr.  Charles 
Flandin,  D.S.O.,  Chef  de 
Clinique  a la  Faculte  de 
Paris. 

Dysidrosis : its  Parasitic  Nature. 

By  J.  Darier,  Physician  at 
the  Hospital  of  St.  Louis ; 
Member  of  the  Academy  of 
Medicine.— (Illustrated) 578 

The  Contagiousness  of  Flavus 
in  Man.  By  R.  Sabouraud.  681 


LEADING  ARTICLES. 

Temporary  Officers  in  the 
R A.M.C.  : The  New  Con- 
tract....  683 

A Defence  of  Urbanisa- 
tion  583 

Nurse  Anesthetists 584 


ANNOTATIONS. 

Malasia  in  the  United  Sta'es  ...  585 
Industrial  Fatigue  and  Acci- 
dents  585 

The  Printed  Lie 586 

Gangrene  Due  to  Carbon 

Monoxide  Poisoning 686 

The  Centenary  of  the  Hunterian 

Society 687 

Toe  Opening  of  the  Winter 

Session 587 

A New  Medical  Journal 587 

' he  Compleat  Masseur 588, 

The  Cost  of  Housing  the 

People 689 

Public-house  Reform 689 


SPECIAL  ARTICLES. 

Scotland  : Death  of  Professor 
Trail,  of  Aberdeen  Univer- 
sity.—St.  Andrews  Univer- 
sity : Chair  of  Natural 

History.— Election  of  Direct 
Representative  for  Scotland 
to  the  General  Medical 


Council.  — Public  Health 
(Notification  of  Infectious 
Disease)  Regulations  (Scot- 
land), 1919 530 

Ireland : The  Irish  Public 

Health  Council.  — London- 
derry Water  Queues.— Scarlet 
Fever  Outbreak  in  Belfast ....  590 
Paris:  Increase  of  Rabies  in 
Prance — A New  Chair  in 
the  Faculty  of  Medicine  of 

Paris  591 

Australia:  The  Influenza- 

Medical  War  Relief  Fund 591 

Tuberculosis:  The  Welsh 
National  Memorial.  — Sana- 
torium Reports.  — The 
American  Review  of  Tuber- 
culosis   592 

Control  of  Venereal  Diseases : 
Prophylaxis  against  Venereal 
Disease.  - Legislation  against 
Venereal  Disease  in  Sweden. 

— Travelling  Consultants  for 
Venereal  Clinics 693 

Urban  Vital  Statistics: 

English  and  Welsh  Towns 592 

Scotoh  Towns 592 

Irish  Towns 592 

CORRESPONDENCE. 

Control  of  Venereal  Disease 

(Mr.  E.  B.  Turner) 594 

The  British  Federation  of 
Medical  and  Allied  Societies 
(Dr.  E.  Rowland  Fothergill)  594 
Post  Office  Contract  Practice 

(Dr.  H.  Cameron  Kidd) 594 

The  Irish  Public  Health 
Council 594 


OBITUARY, 

Wilfrid  Ombler  Meek,  M.B., 

B.S,  Lend.,  Medical  Super- 
intendent of  Brompton 
Hospital  Sanatorium, 

Frimley 595 

Sir  Peter  Wyatt  Squire 694 

William  More  Hope,  M.R.O.S., 

L S.A.,  D.P.H 696 

MEDICAL  ^NEWS. 

Centenarians 565 

Guy’s  Hospital  War  Memorial..  666 
Freemasons'  Hospital  for  Paying 

Patients  677 

The  Opening  of  the  Medical 

Schools 595 

The  Gresham  Lectures 595 

The  Incorporated  Society  of 

Trained  Masseuses 595 

The  Rontgen  Society 596 

British  Orthopaedic  Associa- 
tion  596 

Society  for  the  Study  of 
Inebriety 596 


THE  SERVICES. 

Royal  Naval  Medical  Service....  696 


Army  Medical  Service 596 

Royal  Army  Medical  Corps 596 

Royal  Air  Force 597 

The  Honours  List 597 

Foreign  Decorations 597 


NOTES.  SHORT  COMMENTS,  &C. 

The  Aerial  Combatant:  His 
Psychology  and  Nervous 
Physiology  Considered  in  the 
Light  of  Athletic  Analogies. 

By  the  late  H.  G.  F.  Spurrell, 
M.A.,  M.B  , B.Ch.  Oxf., 
Captain,  R.A.M.C. — Part  I ..  699 
The  Metropolitan  Water-supply 
During  April,  May,  and  J nne, 

1919 60C 

The  Miscegenation  of  Shakes- 
peare  600 

Educated  Home  Helps  for  the 
Middle  Classes 600 


Appointments 597 

Vacancies 597 

Births,  Marriages,  and  Deaths.,  598 

Medical  Diary 598 

Acknowledgments  of  Commu- 
nications received 598 

Books,  &o.,  received 598 


JOHN  BALE,  SONS  & DANIELSSON,  LTD. 

N E W BOOKS. 

ON  FACIAL  NEURALGIA  AND  ITS  TREATMENT.  By  J.  HUTCHINSON, 

F.R.C.S.  Demy  8vo.  240  pp.  37  Illustrations.  15s.  net,  post  6d. 

WAR  SURGERY  OF  THE  FACE.  By  JOHN  B.  ROBERTS,  A.M  , M.D.  Roy.  8vo.  442  pp. 
256  Illustrations.  20s.  net,  post  6d. 

TEXT=BOOK  OF  CHEMISTRY,  INORGANIC  AND  ORGANIC,  WITH 

TOXICOLOGY,  FOR  STUDENTS  OF  MEDICINE,  PHARMACY,  DENTISTRY,  AND  BIOLOGY. 

By  R.  A.  WITTHAUS,  A M.,  M.D  Seventh  Edition.  Revised  by  R.  J.  E.  SCOTT,  M.  A.,  M.D,  20s.  net,  post  6d. 

THE  URETHROSCOPE  IN  THE  DIAGNOSIS  & TREATMENT  OF 

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1 


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[Sept.  27,  1919 


CHARLES  GRIFFIN  & Co.,  Ltd.,  Publishers. 

V*  All  prices  are  net,  postage  extra. 

Human  Anatomy  (Applied) 

E.  H.  Taylor,  M.D 

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CABINET  FOR  INSTRUMENTS,  &c. 

W7122. — White  enamelled  steel,  with  plate  glass 
door  and  sides,  lock  and  key,  on  stand  with 
drawer  and  plate  glass  shelf  underneath,  and 
rubber-tyred  casters,  as  illustrated. 

No.  1. 

Size  of  cabinet  18x14x8  (2  plate  glass  shelves) 

£7  5 0 

No.  2. 

Size  of  cabinet  24  X 18  X 11  (3  plate  glass  shelves) 

£9  0 0 


6 


Thk  Lanobt,] 


THE  LANCET  GENERAL  ADVERTISER 


[Shpt.  27,  1919 


Bailliere,  Tindall  & Cox 


NOW  READY.  THIRD  EDITION. 

Pp.  xxviii.  + 660.  With  392  Illustrations  and 
6 Coloured  Plates.  PRICE  38s.  net. 

Principles  of  Gynaecology 

“Dr.  Blair  Bell  has  brought  to  the  preparation  of  this  book  a well-ordered  scientific  mind  as  well  as  an 
extensive  knowledge  of  modern  gynacology  and  its  literature.  The  result  is  the  production  of  a volume  of  which 
he  may  justly  be  proud , as  it  is  one  of  the  best  books  on  gynceoology  in  the  English  language , and  will  well  pay 
perusal  by  all  those  interested  in  this  subject." — Practitioner. 


Blair  Bell’s 


Buchanan’s 


IN  THE  OLD  NOMENCLATURE 

( the  only  one  recognised  at  most  Examinations ) 


Manual  of  Anatomy 

SYSTEMATIC  AND  PRACTICAL,  INCLUDING  EMBRYOLOGY.  In  One  Volume. 
FOURTH  EDITION.  Revised  by  a Committee  of  Demonstrators  in  Anatomy. 

(->1  “ The  special  point  about  this  book  is  that  it  claims  to  be  the  only  English  text-book  of  anatomy  retaining  the 

old  nomenclature , which  is  still  official,  and  speaking  generally,  seems  to  be  much  preferred  by  s‘ud>  nts  as 
being  more  simple  and  quite  correct  enough  for  all  practical  purposes.  A large  number  of  terms  of  the  Basle 
nomenclature  is  given  for  reference,  however,  in  an  appendix." — Lancet. 

Pp.  xii.  + 1743.  With  677  Illustrations,  mostly  Original  and  in  Colours.  PRICE30s.net. 


Castellani  & Chalmers 
Manual  of  Tropical  Medicine 

>-v  “ This  book  has  no  rival — it  is  certainly  one  of  the  must  important  contributions  that  has  been  made  to  tropical 

medioine  in  recent  years." — Journal  op  Tropical  Medicine. 

“ The  most  comprehensive  and  up-to-date  manual  on  the  subject." — Medical  Press. 

Pp.  xvii.+  2300.  With  16  Coloured  Plates  and  650  other  Illustrations.  PRICE45s.net. 


SIXTH  EDITION 
(Almost  Ready) 


Whitla’s 

Dictionary  of  Treatment 

“ One  of  the  qualities  of  a practical  work  like  this  is  to  tell  what  to  do  in  emergencies,  and  with  this 
dictionary  handy  for  reference  one  is  sure  never  to  be  caught  napping." — Medical  Press  and  Circular. 


Enlarged  to  Demy  8vo. 


Pp.  x.  + 1080. 


PRICE  25s.  net. 


BAILLIERE,  TINDALL  & COX,  8,  Henrietta  Street,  Covent  Garden,  London,  W.C.  2. 


7 


The  Lanobt,] 


THE  LANCET  GENERAL  ADVERTISER 


[Sept.  27, 1919 


Repairs  by  New  Process 

Damaged  Surgical  Gloves  may  be  restored 
as  good  as  new  by  the  new  process  for 
which  Bates  have  sole  rights  in  the  U.K. 

Slits  or  tears  are  mended  and  new  fingers 
or  wrists  fitted  so  neatly  by  the  process 
that  the  surgeon  cannot  feel  the  mends. 
Repeated  sterilisation  does  not  affect  them  ; 
the  cost  is  trifling. 

Used  regularly  by  many  General 
and  Naval  and  Military  Hospitals. 

Write  for  /toiler  particulars  and  prioes  to — 

W.  & A.  BATES  LTD., 

St.  Mary’s  Mills,  LEICESTER. 

Makers  of  Bates  Cynle  and  Motor  Cycle  Tyres 
and  Motor  Tubes. 

Tyre  repairs  of  all  description?. 


W EVANS  & GO., 

287,  REGENT  ST., 

LONDON, 
W.  X. 


Established 

1886. 

WINTER 
OVERCOATS 

from  sb  Guineas. 

LOUNGE 

SUITS, 

of  Good  Wearing 
Materials, 
from  7 5 Guinea?, 

TO  MEASURE. 

BEST  VALUE  IN  THE  WEST  END. 

Gentlemen  who  have  found  it  difficult  to  obtain  a 
good  fit  are  invited  to  call  and  give  this  old-established 
Firm  a trial. 

Customers  unable  to  visit  can  rely  on  having  a perfect 
fit  guaranteed  by  sending  an  old  suit  as  a guide  for  size . 


THE  BEST  TH1  WORLD  PRODUCES 


There  are  Wol-ey  garments  in  great  variety  for 
men,  women,  and  children,  and  every  garment 
carries  the  well-known  Wolsey 
guarantee  against  shrinkage  in  i 
wash  or  wear.  Any  failure  in  this  | 
respect  means  a new  garment  free,  t 

All  goof  Hosiers,  Drapers,  Out-  j 
filters,  and  S ores  can  supply  j| 

Wolsey,  and  the  Wolsey  Head  ‘ 
trade  mark  proves  its  genuineness. 

WOLSEY  UNDERWEAR  CO. 


LEICESTER 


IP  only  the  public  more  "widely 
realised  the  service  of  Wolsey’s 
Pure  Wool  in  preventing  many  of  those 
ills  which  threaten  us  so  constantly 
in  this  incorrigible  climate  it  would  be 
“all  to  the  good”  for  everyone. 


Medical  Men  and  Nurses  may  com- 
mend Wolsey  Underwear  with  full 
confi  lence  not  only  in  its  hygienic 
excellence  and  economic  value,  but  also 
in  the  assurance  that  it  will  deli  ii‘ely 
assist  in  the  encouragement  and  main- 
tenance of  health. 


Wolsey’s  record  will  endorse  this. 


8 


The  Lancet,] 


THE  LANCET  GENERAL  ADVERTISER 


[Sept.  27,jID19 


uni 


Our  prices  of 
October  15th,  1918, 
are  still  in  force. 


SIZE 

COVERS 

TUBES 

SQUARE 

TREAD 

UNIVERSAL 

NON-SKID 

30  x 3^ 

£ s.  d. 

5.  1.9 

£ s.  d. 

5.17.0 

£ s.  d. 

7.  0.6 

£ s.  d. 

1.  1.6 

810  x 90 

4.15.6 

5.  9.9 

6.16.3 

1.  0.9 

815  x 105 

6.14.0 

7.14.0 

9.  4.0 

1.  9.0 

880  x 120 

8.14.3 

10.  0.  6 

11.  3. 6 

1.16.6 

Ask  your  Dealer  regarding  their 
quality  and  the  price  of  other  sizes. 


= BI.  Ha. 


The  Lanoet,] 


THE  LANCET  GENERAL  ADVERTISER 


[Sept.  27,  1919 


BELDAM 

All-British  Tyres 

For  Long  Mileage  & No  Skids 

THE  narrow  tread  of  the  Beldam  All- 
Rubber  de  Luxe  (see  illustration)  assures 
speed  and  resiliency.  The  “V”  shaped 
projections  at  either  side  of 
the  tread  effectively  prevent 
skidding.  They  also  serve 
to  brush  to  one  side  such 
puncture  makers  as 
nails,  flints,  See. , in- 
stead of  turning  them 
up  (as  the  tyres  of 
round  tread  are  apt 
to  do)  for  the  back 
wheels  to  pick  up. 


IT 


Booklet  “ Teiti- 
mony  " give t the 
opinions  of  uteri 
of  Beldam  Tyre* 
on  their  wearing 
and  non-skidding 
qualities.  May  we 
send  you  a copy  t 


The  Beldam 
Tyre  Co.  Ltd. 

Brentford,  Middlesex 


system  of  your  rbst^War  (Jar. 


gVERY  Motorist  will  demand  perfection  and 
efficiency  in  every  detail  of  his  post-war  Oar. 
He  will  want  a Starting  and  Lighting  8yste»i  o' 
undeniably  good  qualities,  and  in  the  Smith 
Starting  and  Lighting  System  he  will  find 
everything  he  requires. 

The  Smith  8ystem  is  paramount  among  electrical 
apparatus  for  motor-cars,  combining  a powerfnl,  positive, 
automatic  starter  device,  worked  oonjolntly  wttk 
a proved  never-failing  lighting  system.  An  unusually 
high  standard  of  etticieuiy  and  serviceability  Is  embodied 
In  the  Smith  System  because  of  the  many  dlstlnot  aad 
Improved  features  It  possesses. 

The  Smith  Starting  and  Lighting  System  worthily 
upholds  toe  Kr  at  reputation  of  the  greatest  Motor 
Accessories  House  in  the  world,  aud  will  form  an  Integral 
cart  of  the  equipment  of  most  of  the  post-war  oar*. 

Write  io-dav  to  Messrs.  S.  SMITH  4 SONS 
(M.A.),  Ld.,  179-185,  Gt.  Portland  St.,  London, 

W.l,  for  a copy  of  their  little  booklet,  '•  A New 
Era  In  Motoring,”  which  describes  In  detail 
the  Smith  Starting  and  Lighting  System. 

iSmith’s 

Starting  & Lighting 

System 


Godbolds 


A Doctor  cannot  take  risks 

therefore  specify  the 

EHITHi 

arburetter 

on  3roxir  car* 

] ZENITH  CARBURETTER  CO.,  Ltd.,  40-42,  Newman  Street,  W.  1.  [ 


Send  for 
Booklet. 


Telephone : 
Reeent  4812-4831 


Mr.  S.  F.  EDGE  writes  in  “THE  MOTOR” 

“ During  this  winter  I have  been  running  with  a set 
of  Duco  Spring  Gaiters  supplied  by  Broum  Brothers , 
Ltd.,  and  it  is  perfectly  amazing  how  such  a simple  device 
does  add  to  the  comfort  of  a car.  The  springs  work  quite 
differently  when  kept  under  tirst-class'ilubrication  conditions. 

I am  quite  sure  it  will  not.be  long  before  the  springs  will 

be  as  perfectly  lubricated  and  sufficiently  protected  from  dirt 
and  water,  as  the  gears  in  the  gear  box  are,  and  any  manu- 
facturer who  turns  out  a car  with  all  the  leaves  of  the  springs 
open  fo  the  weather  udll  be  looked  upon  as  just  as 
foolish  [as  would  be  the  case  if  he  had 
no  gear  l<  x round  his  geers." 

' ’ -•  > . . 


DUCO 

PATENT 


“Duco”  Spring  Gaiters  are 
supplied  by  all  Garages  and 
Motor  Dealers.  Price  from 
10/6  each.  Special  set  for 
Ford  Cars,  price  2 Gnc. 
per  set  complete. 


SPRING 

GAITERS 


A PERPETUAL 
FiLM  OF  GREASE 
BETWEEN  EACH  LEAF 

i- 


May  we  send  you  our  “DUCO  ' Booklet  t It  is 
sent  post  free  on  request. 

BROWN  BROTHERS,  Limited, 

Great  Eastern  Street,  London,  E.C. 
Deansgate.  Manchester. 

Showrooms  - - 16.  Newmax  Strkkt.',W.  1. 


10 


Thh  Lancet,] 


THE  LANCET  GENERAL  ADVERTISER 


[Sept.  27,  1919 


THE  IDEAL  DOCTOR’S  CAR 

Early  delivery  of  the  famous 

METEORITE  CAR 

fitted  with  11-9  h.p  Coventry 
Simplex  Engine,  66  m/m. 

Bore,  110  m/m.  Stroke. 

Complete  models  at  reason- 
able prices.  All  applica- 
. . tions  to 

A.  E.  MULHOLLAND  & CO., 

Automobile  Agents, 

Tottenham  Chambers,  4-,  Ox-ford  St.,  W.  1. 


HUMBER  CAR, 
£525. 

COR  SALE,  new  Feb.,  1914,  5-SEATER  TOURING 
CAR,  5 Detachable  Wire  Wheels,  all  tyres  and 
tubes  practically  new,  with  Hood,  Side  Curtains, 
Electric  Side  and  Tail  Lamps. 

The  Car  has  one  of  the  best  engines,  made  by 
Humber,  Ltd.,  and  has  just  been  stripped  and 
thoroughly  overhauled,  and  is  in  perfect  condition 
and  open  to  any  expert  examination. 

Dr.  Gandhi,  Cambridge  House,  Bucknall,  Stoke- 
on-Trent. 


iniiiiiiiiiiiniHiuiifp 


Light 
LjfilT  <UL  Cars 

Specially  designed,  for  the  Owner-Driver 

His  Standard  of  Comfort, 
Easy  Control,  Stability, 
Economy  & Ample  Power. 


Send  your  name  and  address 
for  full  details. 

The  Standard  Motor  Co.,  Ltd., 
Coventry. 

2JII£ 

— I* — London  Showrooms,  49,  Pall  Mall,  S’. TV.  1.  — lr 

sillrH  sillrH 


Godbolds. 


CENTRIFUGES 


DELIVERY 
SUBJECT  TO 
WAR  CONDITIONS. 


PRECISION- 

SOLIDITY— 

EFFICIENCY 


BAUSCH  &L0MB 
NEW  MODELS. 

Made  in  their  own 
Factory  at 
Rochester,  U.S.A. 
The  Best  for  Milk 
and  Blood  Analysis. 

DOUBLE-SPEED, 

complete  with  Hsema- 
tokrit,  Automatic 
Blood  Pipette,  two 
Sputum  Tubes,  in 
addition  to  two-arm 
Sedimentation  Attach- 
ment,  with  one 
Graduated  and  one 
Ungraduated  Tube, 

£2:10:0 

SINGLE-SPEED,  with 

Sedimentation  Attach- 
ment and  two  Tubes, 

£1  : 17  : 6 

Plus  5%  war  advance. 


Descriptive  List  “ Zh.S ” 
on  application. 


BAUSCH  & LOMB  OPTICAL  CO., Ltd. 

Contractors  to  British,  Indian,  Colonial  and  Foreign  Governments, 

Agents  lor  Bausch  & torn h Optical  Company,  of  Rochester,  N.Y.,  U.S.A., 

37-38,  HATTON  GARDEN,  LONDON,  E.C.  1. 

OUR  INSTRUMENTS  MAY  BE  OBTAINED  THROUGH  ALL  DEALER8. 


THE  SINGER  “10.” 


AN  IDEAL  DOCTOR  S CAR. 

The  neat  and  handsome  design  of  the  SINGER  “10  ” 
will  always  impress  the  observer  at  a glance.  Bnilt 
throughout  by  highly  skilled  workmen  from  the  finest 
materials  procurable,  we  have  no  hesitation  in  recom- 
mending it  to  stand  the  hard  wear  and  tear  to  which 
a Medical  Practitioner’s  car  is  subject. 

We  are  now  booking  orders,  which  will  be  placed  on 
our  waiting  list,  deliveries  of  which  will  be  made 
strictly  in  rotation. 


Write  to-day  for  full  particulars — 

SINGER  & CO.,  LTD., 

And  17,  HOLBOKN  VIADUCT,  finUCilTDV  EkID 

London,  e.c.  IfUVCNInT,  Enu, 


11 


The  Lancet,] 


THE  LANCET  GENERAL  ADVERTISER 


[Sept.  27,  1919 


Metatarsalgia  and  Callouses 
Caused  by  Weakened  Anterior  Arch 

This  condition  is  recognised  by  depression  of  the  Transverse  Arch  anteriorly  or  at 
the  base  of  the  Metatarsal  bones.  The  dome  like  arching  is  obliterated  and  painful 
callosities  or  corns  form  over  the  depressed  Metatarsal  heads.  The  foot  broadens,  the 
toes  become  dorsal  flexed.  Bunions  appear  at  the  First  and  Fifth  Metatarso-Phalangeal 
articulations.  Digital  nerves  become  impinged  and  severe  cramp-like  pains  are 
experienced  through  the  toes.  This  is  described  by  Whitman  as  Morton’s  Toe. 

These  conditions  are  quickly  relieved  and  permanently  corrected  by  the  use  of 


Scholl’s  Corrective  Foot  Appliances. 


These  appliances  are  especially  designed 
and  constructed  to  restore  the  Anterior 
Arch,  remove  abnormal  pressure  and  permit 
full  freedom  of  motion  to  the  entire  foot. 
Different  types  to  meet  all  emergencies. 


Sold  and  fitted  by  leading  shoe  dealers 
in  every  community,  who  have  been 
instructed  in  Anatomy  of  the  foot  and 
how  to  properly  apply  correctives  to 
the  foot  and  shoe. 


SCHOLL'S  . 1 PPLIA  XCES  can  be  if  great  valve  to  the  medical  man  in 
prescribing  for  Foot  Ailments.  May  me  send  you  descriptive  circular  ? 


THE  SCHOLL  MFC.  CO  , Ltd.,  1-4,  Giltspur  St.,  London,  E.C.  1. 

PARIS-47,  Rue  d Enghien.  DUNEDIN,  N.Z.-13.  Dowling  Street.  MELBOURNE- 332,  Lonsdale  Street. 


SCHOLL'S  BUNION  REDUCER 

protects  the  sensitive  inflamed 
area  from  pressure.  Reduces 
the  enlargement  by  absorption, 
and  stops  shoe  bulging.  Rights 
and  Lefts  in  men's  and  women's 
sizes.  Each  2 * 


SCHOLL'S  TOE-FLEX 

straightens  distorted,  crooked 
toes,  restores  normal  muscular 
action,  and,  by  closing  the  big 
toe  joint,  corrects  bunions. 
Worn  comfortably  in  ordinary 
size  shoes.  Each  1 6 


SCHOLL'S  FOOT-EAZER 

afToros  comfort  and  relief  in  a 
moment  to  Hred  aching  feet.  ; 
weak  arches,  flat  feet.  Ac.  Worn 
comfortably  in  ordinary  size  i 
shoes.  Price  per  pair  9 6 


The  Lancet,] 


THE  LANCET  GENERAL  ADVERTISER 


[Sept.  27,  1919 


THE  FRENCH 


NATURAL  MINERAL 
WATER 


^TTT?I 


The  attention  of  Members  of  the  Medical  Pro- 
fession is  drawn  to  the  fact  that  VICHY=CELESTINS 
and  the  other  State  Springs  of  the  Vichy  Waters, 
are  being  regularly  imported  and  ample  supplies 
are  always  on  hand. 

These  Waters  are  continually  being  prescribed 
by  the  leading  Physicians  and  are  largely  used  in 
the  Hospitals. 


CA  VTION.-  Each  bottle  from  tbe  STATE  SPRINGS  bears  a neck  label 
with  the  word  “VICHY-ETAT”  and  the  name  of  the  SOLE  AGENTS 

ROY  EE,  EixnitedL, 

Bangor  Wharf,  45,  Belvedere  Road,  London,  S.E.  1. 

And  at  LIVERPOOL  and  BRISTOL. 


CATALOGUE  of  SECONDHAND  SURGICAL  INSTRUMENTS,  OSTEOLOGY, 

MICROSCOPES,  POST  FREE. 

Students’  Half  Sets  of  Osteology.  Articulated  Skeletons  and  Disarticulated  Skulls. 

Sec  ondhand  Surgical  Instruments,  Osteology  and  Microscopes  bought,  sold  and  exchanged. 

MILLIKIN  & LAWLEY,  16S,  STRAND,  LONDON.  W.C.  2.  It-??™ 


v FOOT  APPLIANCES 

> RENO  W NED  FOR 

EFFICIENCY  & ELASTICI* 


T HOLLAND  ft  SON.  46  SOUTH  AUDLEY  STREET.  LONDON.^ 


The  Tonic  Food  richest 
in  YITAMINES,  and 
therefore  of  great 
value  in  all  Wasting 
diseases.  Delicate 
children  thrive 


it 


V* 


be°u 


Samples  aid  Literature  on  application. 


OPPENHEIMER,  SON  & CO.,  LTD.,. 

179,  Queen  Victoria  Street- 
London,  E.C.  4. 


13 


The  Lancet,] 


THE  LANCET  GENERAL  ADVERTISER 


[Sept.  27,  1919 


Osmos 

The  Great  British  Aperient  Water. 

The  osmotic  properties  of  this  Water  have  been  found  by  Practitioners  most 
useful  in  the  treatment  of  Habitual  Constipation,  Hepatic  Congestion  and 
Bilious  Attacks,  Obesity,  Haemorrhoids,  Gouty  Affections,  Complications  of 
Pregnancy,  and  Diseases  peculiar  to  Women,  and  Indiscretions  of  Diet. 

Possibly  you  have  not  tested  “ Osmos.”  May  we,  therefore,  have  the 
pleasure  of  sending  you  a bottle,  post  free?  We  will  gladly  do  so  on  receipt 
of  your  card. 

Osmos,  Crown  Wharf,  Hayes,  Middlesex,  England. 


TRADE  MARK 


THE  MARK 
THAT 
DISTINGUISHES 


E.F1AJV  n> 


British  Lysol. 

The  only  genuine  Lysol  bears  this  mark  of  the 
cros9  with  " L ' in  cfentre  This  brand  of  Lysol 
is  a pure  cresol  preparation  and  guaranteed  to 
contain  the  requisite  amount  of  free  cresole 
to  ensure  thorough  disinfection 


LYSOL  IP,  Warfon  RISfraf  f ord.London 


Brand 


= IMPORTANT  NOTICE. — In  order  that  Medical  Men  should  readily  be  able  = 


to  recognise  our  genuine  British  Made  Lysol  we  now  afiix  a small  GREEN  coloured  label, 
as  above  illustrated,  on  the  back  of  each  package.  “ L,”  Brand  Lysol  costs  no  more  than 
inferior  preparations  and  is  guaranteed  in  every  respect.  AsAr  for  “ L”  Brand. 

In  bottles  1/-,  1/9,  3/-,  and  5/-,  and  £ and  1 gallon  drums. 

Samples  Free  on  Request. 

LYSOL  LTD.,  Warton  Rd.,  Stratford,  London,  E.15. 


ii 


The  Lancet,] 


THE  LANCET  GENERAL  ADVERTISER 


[Sept.  27,  1919 


Extract  from  the  Report  to  the  Local 
Government  Board  on  Dried  Milks 

/ Food  Reports  No.  24). 

“In  his  report  for  1911,  Dr.  Robinson  speaks 
especially  of  the  good  results  during  the  diarrhoea 
epidemic  in  September  of  that  year.  Of  240  babies 
under  one  year  fed  on  Glaxo,  only  1 died;  of  160 
others,  37  died.  In  the  report  for  1915,  it  was  stated 
that  almost  without  exception  infants  correctly  fed 
on  Glaxo  thrive  and  are  up  to  the  normal  standard. 
In  a recent  communication  Dr.  Robinson  informs  me 
that  they  now  distribute  30,000  lbs.  yearly  of  dried 
milk  at  no  cost  to  the  ratepayers.  He  considers 
its  excellence  as  a food  proved  beyond  all  doubt.” 
(Page  69.) 


The  Answer  to  the 
“Pure  Milk  Question” 


STANDARDISED  DRIED  MILK 


“ Builds  Bonnie  Babies  ’’ 


Proprietors  : 

J.  Nathan  & Co.  Ltd., 
London  and  N.Z. 


The  Milk  Problem,  and  Infant  Feeding. 

i 

Copyright  Booklet — “ The  Milk  Problem  and  Infant 
Feeding  ” — a Review  of  recent  Clinical  and  Bacterio- 
logical Investigations  on  Dried  Milks  as  applied  to 
Infant  Feeding,  together  with  a Resume  of  the 
Report  to  the  Local  Government  Board  quoted 
above,  and  Bacteriological  Report  and  Analyses 
will  be  sent  you  post  free  on  request  by 

GLAXO  (. Medical  Dept.),  155=157,  Gt.  Portland  St., 
London,  W.  1. 


N 


15 


Thb  Lancet,] 


THE  LANCET  GENERAL  ADVERTISER 


[8kpt.  27,  1919 


$3 


$oweVreParati°/,s 

Southall  BrosandBarclayK 

GV  ^yftanufacturing  Chemists 

J^rmingha^ 


PHENOQUIN 

(Southall) 

is  specific  in  the  elimination  of  uric  acid  from  the  system.  It  is 
the  one  British  product  replacing  the  pre-War  German  Atophan. 

Phenoquin  has  proved  exceptionally  efficacious  in  acute  Gout,  chronic 
Gout,  and  other  forms  of  Arthritis,  promptly  causing  a remarkably  rapid 
increase  in  uric  acid  excretion.  9 

Phenoquin  has  also  proved  its  value  in  acute  articular  Rheumatism  and 
Sciatica.  Dosage— 5-15  tablets  daily.  Descriptive  circular  for  Medical  men; 
post  free  on  application. 

Packed  in  bottles  of  50  and  ICO  tablets . Price  6 - & 11/- 


lP' 


Composition:  Lactose  & Formaldehyde 

ALDEMINT 

Antiseptic  Throat  Tablets 

Effectively  replace  treatment  by 
‘gargles’  in  relaxed  throats  and 
laryngeal  ailments  generally. 

Invaluable  both  as  a prophylactic  against 
Influenza,  Diphtheria, Tonsilitis,  etc.,  and  for 
public  speakers,  actors,  etc. 

In  bothies  containing  50  tablets 
2/-,  of  all  Chemists. 


(LYSOL  BRITISH) 

LYCRESOL 


A Standardised  Disinfectant 

A well  tried  antiseptic  in  concentrated 
form  for  the  use  of  doctors  and  nurses. 
It  contains  a high  percentage  of  cresol,  and 
is  superior  as  a general  disinfectant  and 
deodoriser  to  carbolic  acid. 

A s Lycresol  forms  a saponaceous  solution 
it  easily  removes  mucous  secretions,  etc., 
with  adherent  germs. 

A Measuring  Cup  with  each  bottle. 

Price 4 oz.  9(L  ; 8 oz.  1/3,  16  oz.  2/3  ; 32  oz.  3/6  ; 

1 galL  tins  14/- 


A powerful  urinary  antiseptic. 

Cystoformin 

III  III  Hill  ill  in  II  J FAds  Mirk 
Its  range  of  usefulness  is  very 
wide,  embracing  practically  every 
infected  condition  of  the  bladder  or 
urinary  tract. 

Composition:  - Hexamine  with  Sodium  Acetate 
representing  40  per  cent,  of  its  weight  of  the  former. 
In  17  gr.  tablets.  Taken  dissolved  in  water. 

Sold  in  Tubes  containing  about  20  tablets,  1 '6  each. 


Vitafer 

ffhe'AU-Briiisfr  Tonic  FohTTf 

Awarded  Gold  Medal  at  the  last 

International  Congress  of  Medicine. 

VITAFER.  introduced  before  the  outbreak 
of  war,  now  holds  the  foremost  place  amongst 
tonic  foods. 

It  is  distinguished  in  containing  the  entire 
protein  of  milk.  (Lactalbumen  and  Casein)  in 
being  the  richest  in  assimilable  pho^pho  ls 
and  in  being  non-constipatinr. 

A doctor's  sample  will  be  rent  free  and  post 
paid  to  any  Medical  Practitioner  on  request. 

In  sealed  tins,  price  2/“  & 3/”  of  all  Chem  sts: 
larger  sizes  5/6  & 10/- 


HIPPURATES 


SODIUM,  AMMONIUM  and  LITHIUM, 

indicated  in  cases  of  hypertension  and  in  arterial  pressure, 
and  as  a preventative  treatment  in  Gout  and  Arterio  Sclerosis, 
In  Powder  and  Tablets.  Prices  and  particulars  an  application 


Southall  Bros  & Barclay  mBirminqham 


TnE  Lancet,] 


THE  LANCET  GENERAL  ADVERTISER 


[Sept.  27,  1919 


Prescribe!  by  the  Medical  Profession  for  35  years. 

The  LANCE'I  {London,  Eng.)  describes  it  as— “ Mr.  Benger’s  admirable  preparation.” 

Benge r s Food. 

11  Cause  and  Effect  ” explained. 


BENGER’S  FOOD  is  a cereal  flour  free 
from  indigestible  and  irritant  particles  and 
scientifically  combined  with  natural  digestive 
principles,  which  cause  it  to  become,  after 
preparation,  one  of  the  most  easily  assimilated 
and  highly  nutritive  foods  extant,  and  one  which 
leaves  very  little  insoluble  or  irritant  residue. 

The  digestive  process  is  easily  and  simply  regulated 
by  allowing  the  food  to  stand,  after  the  mixing  with  warm 
milk,  for  5 to  45  minutes. 

The  effect  is  that  the  casein  in  the  milk, 
which  otherwise  would  form  tough  indigestible 
casein  curd  in  the  stomach,  can  only  separate 
into  minute  flocculae ; in  addition  both  the 
protein  and  carbohydrate  material  in  the  food 
itself  are  partially  converted,  so  as  to  be  easily 
assimilated  by  weakened  digestive  systems. 

This  explains  why  Bengers  is  frequently 
retained  when  all  other  foods  are  rejected — 
why  it  can  be  taken  by  the  most  delicate  infant , 
and  by  persons  prostrate  with  illness. 


fi 


(or  Infants,  Invalids  and  the  Aged, 

is  sold  throughout  the  World  by  Chemists,  &c.,  in  sealed  tins. 

Full  particulars  will  be  sent  post  free  to  Members  of  the  Medical  Profession 
on  application  to  Sole  Manufacturers  : 


BENGER’S  FOOD  Ltd.,- 


- Otter  Works,  MANCHESTER,  Eng. 


Branch  Offices 

NEW  YORK  (U.S.A.)  92,  William  Street. 

Canadian  Agents — National  Dru 


depots  throughout  Canada. 


SYDNEY  (N.S.W.)  117,  Pitt  Street. 
& Chemical  Co.,  Ltd.,  34,  St.  Gabriel  Street,  MONTREAL  an4 


N.B.—  BENGE R’S  FOOD  is  the  direct  outcome  of  the  pioneer  work  on  digestive  ferments,  by 
the  late  Sir  William  Roberts,  M.D..F.R.S,  and  the  late  Mr.  F Baden  Benger  FiC  .F.C.S.  in  1880, 
since  when  it  has  been  the  premier  dietetic  preparation  of  its  kind  in  the  British  Empire. 


M74a 


17 


The  Lancet,] 


THE  LANCET  GENERAL  ADVERTISER 


[Sept.  27,  1919 


IN  acute  disease,  where  the  digestive  functions 
are  impaired  and  excessive  nitrogenous  meta- 


bolism necessitate  easily  assimilated  nourish- 
ment, “ OVALTINE  ” will  be  found  of  great  value. 

“ OVALT1NE  ” is  composed  of  a highly  con- 
centrated extract  of  the  vitalizing  and  building- 
up  properties  contained  in  Malt,  Milk,  and  Eggs, 
and  presents  the  essential  elements  of  diet  in 
well-balanced  proportions.  It  forms  a natural 
anabiotic  for  administration  in  debilitated  con- 
ditions where  tissue  waste  has  to  be  restored 
with  a minimum  of  digestive  strain. 

Supplied  by  all  Pharmacists. 

Special  low  prices  are  quoted  to 
Hospitals  and  Kindred  Institutions 
on  direct  application  to  the  makers. 

A liberal  trial  supply  will  be  sent  to  members  of  the  Medical 
Profession  in  private  or  hospital  practice. 


18 


The  Lancet,] 


THE  LANCET  GENERAL  ADVERTISER 


[Sept.  27,  1919 


■ana— 


NOVARSENOBILLON 

For  intravenous  or  intramuscular  injection  in  the  treatment  of 

SYPHILIS 

and  other  spirochsetal  infections. 

In  ampoules  containing  - - 0.15,  0.3,  0.45,  0.6,  0.75,  or  0.9  gram. 


SOME  PUBLISHED  OPINIONS: 


“ For  many  months  now  I have  exclusively  used  Novarsenobillon 
with  the  happiest  results  on  the  patients.” 

The  Lancet,  Oct.  20th,  1917,  p.  618. 

“ Novarsenobillon  in  my  hands  has  proved  a safe  and  most 
efficient  remedy  against  the  Spirochceta  pallida .” 

The  Lancet,  Feb.  16th,  1918,  pp.  243/50. 

“From  this  wide  range  (ol  Arsenical  preparations)  selection  will 
probably  be  a matter  of  personal  preference,  and  perhaps  in  the 
end,  Novarsenobillon  and  Disodo-Luargol  will  be  shown  to  answer 
all  requirements.”  The  Lancet,  June  21st,  1919,  p.  1056. 


ARSENOBILLON 


In  ampoules  containing 


o.  1,  0.2,  0.3,  0.4,  0.5,  0.6  gram. 


Literature  and  all  particulars  may  be  obtained  from 

MAY  8c  BAKER,  LTD.,  Manufacturing  Chemists 
BATTERSEA,  LONDON,  S.W.  11. 


19 


The  Lancet,] 


THE  LANCET  GENERAL  ADVERTISER 


[Sept.  27,  1919 


Armour’s  Organotherapeutic  Series 


| PITUITARY  LIQUID  (Armour) 


is  physiologically  standardised  and  is  entirely  free  from  chemical 
preservatives. 

We  offer  : c.c.  ampoules  for  Obstetrical  Use. 

1 c.c.  ampoules  for  Surgical  Use. 


I OVARIAN  TISSUE  (Armour) 


is  made  from  the  fresh  ovary  of  the  pig,  and  is  especially  concerned  in 
menstruation,  uterus  action,  and  nutrition  generally. 


is  a palatable  combination  of  fresh’raw  marrow  from  the  rib  (AmiOUV) 
bones  of  calves  and  chemically  pure  glycerine — containing  ■ ■ 


I THYROIDS  (Armour) 


The  Physician  who  insists  on  Thyroids  (Armour)  being  used  in  his 
prescriptions  is  assured  of  completely  satisfactory  results. 


1 CORPUS  LUTEUM  (Armour) 


is  dependable,  being  made  from  the  true  substance  taken  from  the  ovaries 
of  only  pregnant  animals.  This  is  a point  of  vital  importance,  and 
our  vast  resources  guarantee  that  only  such  ovaries  are  used. 


I BEEF  JUICE  (Armour) 


is  very  rich  in  albuminoid  principles,  and  nitrogenous  matter,  contain- 
ing unaltered  albumen  of  fresh  uncooked  beef,  easily  assimilable 
peptones,  and  stimulating  meat  extractives.  It  is  free  from  glycerine, 
and  has  a very  pleasant  taste. 


Write  to  us  for  Literature  on  the  above. 


Queen’s  House,  Kingsway, 

LONDON,  2.  Phone  :Holborn  5900 


IH 


1 CLYCERINE  EXTRACT  OF  RED  BONE  MARROW  1 


haemoglobin,  marrow  cells,  nucleins,  and  other  blood-forming  substances.  = 


ARMOUR  & COMPANY,  LTD.,  1 


20 


The  Lancet,] 


THE  LANCET  GENERAL  ADVERTISER 


[Sept.  27,  1919 


ALL  REACTIONS  ,Z  Body  Fluids  & Tissues  are  COLLOIDAL. 

COLLOSOLS  are  pure  and  CROOKES’  COLLOSOLS  are  tested  by 

stable  colloidal  solutions,  ultramlcroscoplc  bacterio- 

Isotonlc  and  isomorphic  with  ^ ^ I I Q O j logical  and  clinical 

the  elements  of  the  body.  UULLUOULO  experiment. 

COLLOSOL  SULPHUR. 

This  Collosol  is  of  proved  therapeutic  value  in  Fibrositis, 
Arthritis  Deformans,  Neuritis,  and  in  diseases  of  the  skin  such  as 
Generalised  Dermatitis,  Acute  Psoriasis,  Acne  and  Seborrhoea. 

Collosol  Sulphur  is  not  presented  as  a substitute  for  the  Spa 
treatment  of  such  affections  where  Spa  treatment  is  available,  but  as 
a supplement  to  it.  A course  of  treatment  at  a Spa  can  be  followed 
up  by  the  exhibition  of  Collosol  should  relapses  occur. 

For  1 patients  who  are  unable  to  take  a course  of  Spa  treatment, 
practitioners  will  find  Collosol  Sulphur  invaluable. 

It  is  prepared  in  five  different  forms — for  external  use  and  bath 
medication,  for  internal  administration,  for  injection,  and  as  a cream, 
with  which  the  affected  part  is  gently  massaged.  Also  as  an  oil  for 
the  scalp. 

For  evidence  of  the  therapeutic  efficacy  of  Collosol  Sulphur,  the 
medical  profession  is  referred  to  the  Second  Report  of  a Committee 
of  the  British  Association  for  the  Advancement  of  Science,  recently 
published  on  behalf  of  the  Department  of  Scientific  and  Industrial 
Research,  pp.  168-9. 

COLLOSOL  MANGANESE 

for  the  treatment  of  Boils,  Carbuncles,  and  other  Coccic  Infections. 
Also  for  the  treatment  of  Anaemia  (see  British  Medical  Journal , 

August  2nd,  1919,  pp.  185-6). 

COLLOSOL  ARGENTUM. 

This  Collosol  has  an  extensive  field  of  usefulness  as  a general 
non-toxic  antiseptic,  and,  unlike  the  salts  of  silver,  it  causes  no  pain  or 
discoloration. 

For  testimony  to  its  great  efficacy  in  gonorrhaeal  ophthalmia — See 
British  Medical  Journal , April  5th,  1919,  pp.  404-5. 

COLLOSOL  IODINE. 

This  Collosol  consists  of  Iodine  in  its  most  active  form,  and  yet  non- 
toxic and  non-staining.  It  never  causes  nausea  and  never  sets  up  iodism. 

For  its  efficacy  in  parasitic  affections— See  British  Medical  Journal , 
May  12th,  1917,  p.  617.  

Particulars,  Literature,  and  Reports  from — 

THE  CROOKES  LABORATORIES 

22,  CHENIES  STREET,  TOTTENHAM  COURT  ROAD,  W.C.1. 

Telephones  : MUSEUM  3663  & 3697. 

BRITISH  COLLOIDS,  LIMITED. 


21 


The  Lancet,] 


THE  LANCET  GENERAL  ADVERTISER 


[Sept.  27. 1919 


.A.  great  advance 
in  the  Treatment 
of  Gonorrhoea. 


Dr.  H.  E.  G in 

The  Lancet,  page  741, 
May  3rd,  1919. 


The 

Best  Antiseptic 
(for  Gonorrhoea) 
on  the  Market 
appears  to  be 
Flavine. 

Dr.  H.  E.  G in 

The  Lancet,  page  741, 
May  3rd,  1919, 


FLAVINE 

TREATMENT  OF 

GONORRHOEA. 


'A1 


a 


CRIFLAVINE  has  proved  a distinct 
advance  on  any  antiseptic  previously 
used  for  the  treatment  of  Gonorrhoea, 
lavation  with  1 in  4,000  acriflavine  being  the 
most  satisfactory  routine  treatment  for  acute 
gonorrhoea  at  present  available. 

“There  are  no  contraindications  to  the  use  of 
acriflavine. 

“196  cases  of  uncomplicated  acute  gonorrhoea 
were  treated  by  acriflavine  lavation.  These 
cases  showed  an  average  of  19‘8  days  in  hospital, 
the  actual  treatment  being  completed  in  15‘4 
days,  and  the  patients  being  retained  for  other 
4'4  days  for  observation  before  being  dismissed 
as  cured.” — May,  1919  (p.  571). 


PRICES : [ 

ACBIFLAVINE  - 5-grm.  bot.,  3/6  10-grm.  bot.,  6/6  20-grm.  bot.,  12/6  g 
PROFLAVINE  • 5 ..  2/6  10  ..  „ 4/6  20  „ „ 8/6 


Sole  Distributing  Agents  (for  the  Flavine*)  in  U.S.A. : — 

HYNSON,  WESTCOTT  & DUNNING,  Pharmaceutical  Chemiete,  Baltimore. 

Supplies  are  available  for  Post  Prescription  Service  on  application  through  any  of  the 
555  Branches  of  BOOTS  THE  CHEMISTS. 


-ACRIFLAVINE  AND  PROFLAVINE  ARE  MANUFACTURED  BY 


MANUFACTURING  CHEMISTS  & MAKERS  OF  FINE  CHEMICALS, 

THE  LABORATORIES, NOTTINGHAM. 


Sir  JESSB  BOOT.  Managing  Director. 


BOOTS  PURE  DRUG  CO.  LIMITED,  1 


The  Lancet,] 


THE  LANCET  GENERAL  ADVERTISER 


[Sept.  27,  1919 


AN  ADVANCE  IN  TREATMENT 


“Byno”  Lecithin 


II 


Lecithin  preparations  are  recognised 
as  possessing  valuable  therapeutic 
properties  in  the  treatment  of  Nervous 
Debility,  whether  of  primary  origin  or 
secondary  to  acute  or  chronic  disorder. 
“ Byno  ” Lecithin  exerts  stimulating 
action  on  both  the  nervous  and  diges- 
tive systems.  The  preparation  is 
readily  assimilable,  the  combination 
with  malt  ensuring  easy  digestion. 


Allen  & H anbury s Ltd. 

LONDON  SHANGHAI 

SYDNEY  BUENOS  AIRES 

DURBAN  PARIS 

TORONTO  NIA  GAR  A FALLS,  N.  Y. 


23 


The  Lancet,] 


THE  LANCET  GENERAL  ADVERTISER 


| -[Sept.  27,  1919 


IN  TUBERCULOSIS 


maintain  body  weight 
geineirsilly 
nutrition  in 


o o 


incipient 
isease 


“Bynol”  is  a combination  of  Cod-Liver 
Oil  and  Malt  Extract,  having  exceptional 
nutritive  power.  The  Oil  used  in  its  manu- 
facture is  a pure  product,  in  the  preparation 
of  which  Messrs.  Allen  & Hanburys  have 
been  directly  engaged  for  over  half  a 
century  at  Lofoten  and  Sondmor,  Norway. 
Medical  reports  show  that  it  is  one  of  the 
best  weapons  for  arresting  loss  of  weight 
and  increasing  capacity  for  assimilation. 


LLEN  9 HANBUTO5  1? 


LONDON 

PARIS- 

DURBAN 


TORONTO 
SYD  NE Y 
SHANGHAI 


The  Lancet,] 


THE  LANCET  GENERAL  ADVERTISER 


[Sept,  27,  1919 


CONTAINS  THE 
ACTIVE  PRINCIPLES 
OF  THE  THYROID, 
PARATHYROID, 
OVARY,  TESTIS  & 
PITUITARY  GLAND 
SUBSTANCES  ::  :: 


Indicated  in  Hysteria  & Uterine 
Disorders.  Also  in  Neurasthenia , 
Melancholia  & Sexual  Neuroses 


TREATMENT  by  pluriglandular  extracts 
favours  general  secretory  activity,  and  many 
cases  of  apparently  monoglandular  deficiency 
benefit  more  by  mixed  Hormone  treatment  than 
by  the  administration  of  the  extract  from  a single 
isolated  unit  of  the  endocrinous  gland  system.  It 
is  now  recognised  that  normal  metabolism  depends 
upon  the  hormone  balance  being  maintained,  and 
that  the  functions  of  the  endocrinic  organs  are  plural 
rather  than  singular.  The  administration  of  gland 
substances  must  not  be  regarded  from  the  narrow 
standpoint  of  replacing  a deficient  secretion,  but 
rather  as  stimulating  particular  organs  to  greater 
activity  for  a longer  or  shorter  time.  “ Polyglandin  ” 
enhances  muscular,  mental  and  nervous  activity,  and 
is  a general  stimulant  to  the  cardio-vascular  system. 


LLEN  9 (Ian HURTS  13d 


LONDON 
PARI  S • 
DURBAN 


TORONTO 

SYDNEY 

SHANGHAI 


25 


Thb  Lancet,] 


THE  LANCET  GENERAL  ADVERTISER 


[Sept.  27, 1919 


Glykeron  and  Glyco-Heroin 

ARE  SYNONYMOUS  APPELLATIONS  AND  ARE  NOW 
KNOWN  AS  SUCH  TO  ALL  DISPENSING  PHARMACISTS 


THESE  designations  may  now  be  used  inter- 
changeably by  the  physician  when  prescribing 
the  preparation  originally  known  only  as  Glyco- 
Heroin  (Smith). 

As  a safeguard  against  having  worthless  imitations 
of  the  preparation  dispensed,  it  is  suggested  that 
the  physician  use  the  name 

GLYKERON 

which  is  non-descriptive  and  more  distinctive,  when 
prescribing  GLYCO-HEROIN  (SMITH)  for  Cough, 

Asthma,  Phthisis,  Pneumonia,  Bronchitis, 
Laryngitis,  Whooping-Cough,  and  kindred 
affections  of  the  respiratory  system. 

DOSE — The  adult  dose  is  one  teaspoonful 
every  two  hours  or  at  longer  intervals 
as  the  individual  case  requires. 

For  children  of  ten  years  or  more,  the 
dose  is  from  one-quarter  to  one-half 
teaspoonful ; for  children  of  three  years 
or  more,  five  to  ten  drops. 

MARTIN  H.  SMITH  COMPANY 

New  York,  U.S.A. 

Sole  British  Agents  : 

T.  CHRISTY  & CO.,  OLD  SWAN  LANE,  LONDON,  E.C.4. 


The  composition  of  GLYCO-HEROIN 
(SMITH)  has  not  been  modified  in 
the  slightest  degree. 


26 


fHS  Lancet, J 


THE  LANCET  GENERAL  ADVERTISER 


[Sept.  27,  1919 


MALTINE 


“MALTINE”  PLAIN  should  not  be  confounded  with  ordinary  so  called 


malt  extracts. 

“ Maltine  ” differs  from  ordinary  preparations  ot 
malt  in  that : — 

(1)  “Maltine  ” contains  the  concentrated  nutritive  elements 
and  organic  phosphates  of  the  choicest  malted  grain. 

(2)  “ Maltine  ” is  absolutely  pure  and  free  from  pre- 
servatives. 

(3)  “Maltine”  is  standardised  in  Diastase,  so  that 
one  part  of  “Maltine”  converts  ten  parts  of  starch  into 
sugar  at  the  body  temperature. 

(4)  “Maltine”  is  more  economical.  Only  one  half 

of  the  ordinary  dose  need  be  prescribed  in  the  case  of 
“ Maltine.” 


The  chief  indications  , of  “Maltine”  are: — 


(1)  “ Maltine  ” is  a powerful  starch  digestant,  and  is  very  successful  in  cases 
of  ptyalytic  and  pancreatic  insufficiency,  and  all  conditions  showing  amylaceous 
indigestion. 

(2)  “ Maltine”  is  a reconstructive  nutrient  of  proved  merit. 

(3)  “ Maltine  ” is  a good  supplementary  nutrient  for  nursing  mothers.  It 
invariably  improves  the  character  of  the  milk  and  maintains  an  adequate  flow. 

(4)  “ Maltine  ” forms  an  ideal  vehicle  and  emulsifying  agent  for  cod  liver  oil, 
cascara,  creosote,  hypophosphites,  phosphates,  iron,  and  pepsin. 

(5)  “ Maltine  ” is  now  largely  used  in  fever  dietary  as  a supplement  to  milk. 

(6)  “Maltine”  when  added  to  milk  pre  ents  coarse  curdling,  and  is  now 
generally  used  in  invalid  and  infant  feeding  for  that  purpose. 

It  is  also  a preventive  of  constipation  in  infants  fed  on  cow’s  milk. 


In  prescribing,  kindly  specify  “ MALTINE  COMPANY.” 

Specimens  and  Literature  sent  Free  of  Charge  to  Medical,  Men  on  request. 

THE  MALTINE  MANUFACTURING  COMPANY,  Limited, 

183,  ACTON  VALE,  LONDON,  W.  3. 


27 


The  lancet,]  the  LANCET  GENERAL  ADVERTISER  [Sept.  27,  1919 


A dainty  and  attractive  form 
of  tonic  - food  medication. 


I SANATOGEN  1 

I CHOCOLATE  | 

= (Genuine  Sanatogen  skilfully  mixed  with  Pascall’s  pure  Chocolate.) 

s It  is  now  generally  admitted  that  pure  chocolate  is  a most  nourishing  ^ . 

s fat  food  and  a delightful  stimulant — particularly  valuable  for  growing 
H children,  who  need  relatively  more  sugar  than  adults  ; for  invalids  whose  s 
= palates  require  tempting ; and  for  those  who  dislike  eating  fat  or  have 
[e  difficulty  in  digesting  starchy  foods. 

= Its  nutritive  and  sustaining  properties — so  much  appreciated  during  the 

H war  by  soldiers  subject  to  extreme  fatigue  and  exposure — are  greatly 
H reinforced  by  the  addition  of  the  well-known  tonic-food  Sanatogen  which, 
s being  an  exceptionally  fine  powder  with  no  strong  taste  or  odour,  does  not  s 
= render  the  chocolate  “ muddy  ” or  unpalatable.  S 

= Sanatogen  Chocolate  must  not,  however,  be  regarded  as  therapeutically  Is 

H equivalent  to  Sanatogen,  since  the  former  cannot  be  administered  in 
M sufficiently  large  doses  to  produce  the  same  effect  as  the  latter ; but  the 
M presence  of  this  tonic-food  does  undoubtedly  increase  the  dietetic  value  of  s 
= the  chocolate.  = 

SANATOGEN  CHOCOLATE  is  obtainable  of  all  Chemists. 

| GENATOSAN,  LTD.  | 

I (Makers  of  Sanatogen,  Formamint,  Genasprin,  &c.), 

1 12,  CHENIES  STREET,  LONDON,  W.C.  1.  (Chairman  : The  Viscountess  Rhondda.) 


28 


The  Lancet,] 


THE  LANCET  GENERAL  ADVERTISER 


[Sept.  27,  1919 


‘Hypoloid 


CAPITULATIONS  SERIES  — No.  7 


BRAND 


(Trade  Mark) 


‘INFUNDIN 


"(Trade  Marh)m 


(PITUITARY  [INFUNDIBULAR]  EXTRACT) 


Pituitary 
Extract  in 
Perfection 


In 

Obstetrics 

rp,0  overcome  uterine  inertia,  make 
a practice  of  using  ‘Infundin’: 
it  will  help  to  maintain  your  reputation 
in -difficult  obstetrical  cases. 

‘JNFUNDIN’  presents  a physiologi- 
cally-standardised pituitary  extract 
of  constant  high  activity.  The 
‘Hypoloid’  product  is  ideal  for  hypo- 
dermic use. 


Reduced 

facsimile 


' Hypoloid ' ‘Infundin,'  0-5  c.c.  and  7 c.c.,  supplied  to  the  Medical  Profession 
in  boxes  of  6,  at  3/0  and  4/6  each,  respectively 


3^=.  BURROUGHS  WELLCOME  & CO.,  London 
Ju£l  new  York  Montreal  Sydney  Cape  Town  Milan 
Shanghai  Buenos  Aires  Bombay 

All  communications  intended  for  the  Head  Office  should  be  addressed  to  Snow  Hill  Buildings,  London.  E.C.  1 

London  Exhibition  Room:  54,  Wigmore  Street,  W. 


quarters. 

Moslems- 


SURRENDER  OF  THE  CITY  OF 
PTOLEMAIS,  OR  ACRE,  TO  THE 
CRUSADERS 

Every  country  of  Europe  had  poured  forth  its 
soldiers  to  take  part  in  the  siege  of  Acre  which  had 
already  lasted  twenty-two  months  when  Richard 
Cceur  de  Lion  and  Philippe-Auguste  of  France 
reached  the  Holy  Land  to  meet  the  armies  of 
Saladin.  Together  they  carried  on  the  siege.  At 
length,  after  nearly  three  years,  during  which 
armies  had  been  almost  annihilated  and  then 
reconstructed  with  fresh  recruits,  the  Saracens 
were  reduced,  by  famine,  pestilence  and  exhaus- 
tion to  the  necessity  of  the  surrender.  In  the 
scene  here  reproduced  from  a French  painting,  the 
besieged  are  laying  down  their  arms  and  delivering 
up  the  keys  of  the  city  to  the  kings  surrounded  by 
their  armies.  The  terms  agreed  to  were  that  the 
true  cross  should  be  given  up  to  the  allies,  rooo 
men  and  200  knights  in  captivity  were  to  be 
surrendered,  the  sum  of  200,000  pieces  of  gold  was 
to  be  paid  within  forty  days,  failing  which  the 
inhabitants  of  the  city  were  to  be  considered  at  the 
mercy  of  the  conquerors.  The  English  and  French 
armies  were  then  instructed  not  to  harm  any  who 
should  leave  the  city.  On  entering  Acre  each 
nation  represented  took  possession  of  one  of  the 
Under  one  pretext  or  another  Saladin  delayed,  and  did  not  carry  out  the  terms.  Richard,  irritated,  massacred  5000 
an  act  which  was  regretted  by  his  whole  army.  Date,  A.D.  1191. 

CO  p y rig  H T 

29 


The  Lancet,] 


THE  LANCET  GENERAL  ADVERTISER 


[Sept.  27,  1919 


OPOLAXYL 

Rational  Treatment  of  CONSTIPATION. 

By  the  double  action  of  secretion  and  peristalsis. 


Dose  : For  obstinate  constipation  2 or3  tablets,  afterwards 
1 tablet  every  3 or  4 days  for  a month. 

In  Bottles  of  50  Tablets. 


IN 


TRICANDLE. 

1 Treatment  of  BURNS,  YARICOSE  ULCERS,  &c. 


The  valuable  physical  properties  of  Ambrine  are  almost  ideal.’’ 

Vide  “ Surgery,  Gynaecology,  and  Obstetrics."  April.  1918. 


LITERATURE , CLINICAL  REPORTS  and  PRICE  LISTS  to  the  Profession  on  REQUEST. 


The  ANGLO-FRENCH  DRUG  Co.,  Ltd.,  238a,  Gray’s  Inn  Road,  London,  W.C.  1. 

Telephone;  Holborn  1311.  Telegrams;  " Ampsalvas,  London." 

Glasgow:  Mr.  W.  B.  RODGER,  69,  St.  George’s  Mansions.  Charing  Cross. 

Ireland  : Mr,  D.  L.  KIRKPATRICK,  95,  The  Mount  Belfast. 

New  York:  1270  BROADWAY.  Montreal:  DANDURAND  BUILDING.  Paris:  5,  RUE  CLAUZEL. 

Bombay  : P.O.  BOX  4S0.  Calcutta  : P.O.  BOX  86.  Jamaica  : Mr.  A.  NOEL  CROSSWELL,  52,  King  Street,  Kingston. 


N O V A R S E N O B E N ZO  L,  914 

SIMPLICITY.  supplied  in  EFFICIENCY 


INTRAMUSCULAR 

INJECTION 


AMP  SYR  I N G 


GLUCARSENOL 


PREPARED  BY 

ROBERT  &CARRIERE 
PARIS. 


(GLUCOSE  SOLUTION  OP  NOVAR SEN OBEN Z OL  IN  AMPOULE- SYRINGE  ) 


MODERN  PH  AR  MACALS.  4 8,  MORTIMER  STREET,  LONDON,  W.  I. 


IMPORTED  UNDER  LICENCE  OF,  AND  TESTED  BY,  THE  BOARD  OF  TRADE. 

NO  PREPARATION.  NO  CONTAMINATION. 


Formula,  of  GLUCARSENOL — 


Novarsenobenzol 

0-20 

Guaiacol 

010 

Stovaine  

0 01 

Solution  of  chemically  pure 

crystallized  Glucose  to  1 

•00  c.c. 

Supplied  in  “ Ampsyring  ” only. 


Doses  : 10, 15,  20,  25  and  30  centigrammes. 


The  AMPSYRING  is  a combined 
AMPOULE  and  SYRINGE. 


INJECTIONS  are  PAINLESS. 


ABSORPTION  is  quicker  and  more 
complete  than  oily  solutions. 


No  Danger  of  Embolism. 


Solution  does  not  change  or 
deteriorate. 


MODERN  PHARMACALS,  48,  Mortimer  Street,  LONDON,  W.  I. 

Telephone:  Museum  564.  Telegrams:  •’ Pharkacals,  Wesdo,  London. " 


30 


Thb  Lanobt,] 


THE  LANCET  GENERAL  ADVERTISER 


[Sept.  27,  1919 


Cadbury’s 

Cocoa  & Chocolate 

The  recognised  standard 
x of  British  manufacture 

MADE  AT  BOURNVILLE. 

• Cadbury,  Hournv; Itc . 


.SCIENTIFIC  BABY  FEEDING 

CHELTINE  MILK  and  MALTED  FOOD 

No.  1.  From  earliest  Infancy  to  5 months.  No.  2.  From  5 months  onwards. 


Regarding  these  CHELTINE  FOODS,  a well-known  dietetic  authority  writes  : — 

“They  contain  all  the  elements  necessary  -for  a complete  Food 
for  Infants.  Being  a Malted  Food,  it  may  be  given  in  early  infancy 
without  producing  constipation.  It  is  beautifully  prepared,  so  as 
to  be  readily  assimilable  by  the  digestive  organs.” 

The  great  importance  of  the  choice  of  Food  for  the  growing,  healthy  Infant  is  fully 
appreciated  by  the  Manufacturers  of  Cheltine  Milk  and  Malted  Food,  its  composition  being 
based  on  the  physical  and  physiological  requirements  of  infant  life.  Experience  has  proved, 
and  medical  men  have  testified  to,  the  value  of  this  Food,  used  as  directed,  in  the 
rearing  of  healthy  babies.  It  is  a safe  and  reliable  tissue-builder,  manufactured  by 
food-specialists  of  long  standing. 

Packed  in  air-tight  tins  in  three  sizes: — oz.  l/7i;  13  oz.  3/-;  26  oz.  5/9. 

No.  3 CHELTINE  MILK  & MALTED  FOOD  ^I^S^m3SSrSt 

enfeebled  digestions,  prices  as  above,  is  being  increasingly  prescribed  by  the  Medical  Profession. 

Should  any  difficulty  be  experienced  in  obtaining  these  Foods  locally,  please  write , 
giving  name  and  address  of  usual  Chemist  or  Store , to  the  Manufacturers — 

THE  CHELTINE  FOODS  CO.,  CHELTINE  WORKS,  CHELTENHAM,  ENGLAND. 

31 


Tbe  Lancet,] 


THE  LANCET  GENERAL  ADVERTISER 


[Sept.  27, 1919 


LEWIS’S  PUBLICATIONS. 

NEARLY  READY.  FOURTH  Edition.  Thoroughly  Revised  and  greatly  Enlarged.  With  74  Plates  and  many  other 

new  Illustrations.  Demy  8vo. 

DISEASES  OF  THE  NOSE  AND  THROAT. 

By  HERBERT  TILLEY,  B.S.  (Lond.),  F.R.O.S.  (Eng.), 

Surgeon  to  the  Ear  and  Throat  Department,  University  College  Hospital  : 

Teacher  of  Laryngology  and  Otology,  University  of  London,  &c. 


With  99  Original  Illustrations,  including  16  Plates.  Demy  8vo.  12s.  6d.  net ; postage  6d. 

THE  ACTION  OF  MUSCLES, 

INCLUDING  MUSCLE  REST  AND  MUSCLE  RE-EDUCATION. 

By  WILLIAM  COLIN  MACKENZIE,  M.D.,  E.R.C.S.,  F.R.S.(Edin.),  Member  of  the  Council  of  the  Anatomical 
Society  of  Great  Britain  and  Ireland  ; formerly  Lecturer  on  Applied  Anatomy  to  the  University  of  Melbourne,  See. 

“The  truth  is  that  the  want  this  book  is  designed  and  fitted  to  supply,  is  one  that  we  never  felt  until  we  were  suddenly  called  on  to 
mend  the  crippling  and  maiming  which  result  from  war.” — British  Medical  Journal. 


JUST  PUBLISHED.  SECOND  Edition.  With  new  Illustrations  (Plates  and  in  the  Text).  Demy  8vo.  9s.net; 

postage  6d.,  abroad  8d. 

THE  THEORY  AND  PRACTICE  OF  MASSAGE. 

By  BEATRICE  M.  G.-COPESTAKE,  Instructress  of  Massage  and  Swedish  Remedial  Exercises  to  the  Nursing 
Staff  of  the  London  Hospital  ; Examiner  to  the  Incorporated  Society  of  Trained  Masseuses,  &c. 

***  This  Revised  Edition  contains  a New  Chapter  on  the  After  Treatment  of  War  Injuries. 


NOW  READY.  SEVENTH  Edition.  With  14  Plates  and  197  other  Illustrations.  Demy  8vo.  Pricel5s.net; 

post  free,  15s.  6d.,  abroad,  15s.  9d. 

LEWIS  JONES’  MEDICAL  ELECTRICITY: 

A Practical  Handbook  for  Students  and  Practitioners. 

Revised  and  Edited  by  LULLUM  WOOD  BATHURST,  M.D.  Lond.,  Physician  in  Charge  of  the  Electro-Therapeutic 
Department,  Royal  Free  Hospital  (Officers’  Section) ; late  Chief  Assistant,  Electrical  Department,  St.  Bartholomew's 
Hospital,  &c.  [Lewis's  Practical  Series. 

“ It  should  bo  in  the  hands  of  all  medical  electricians.  ’— British  Medical  Journal. 

"No  other  volume  dealing  with  this  subject  covers  so  wide  a ground.”— Medical  Press. 


SIXTH  Edition.  With  6 Plates  and  87  Illustrations.  Demy  8vo.  10s.  6d.  net ; post  free,  11s.,  abroad,  Us.  3d. 

PUBLIC  HEALTH  LABORATORY  WORK. 

By  HENRY  R.  KENWOOD,  M.B.,  D.P.H.,  F.O.S.,  Chalwick  Professor  of  Hygiene  in  the  University  of  London; 
Examiner  in  Public  Health  to  the  Royal  Colleges  of  Physicians  and  Surgeons,  London,  &c.  [Lewis's  Practical  Series. 

11  An  admirable  text-hook,  well  suited  to  meet  the  requirements  of  candidates  for  the  Diploma  in  Public  Health,  and  all  who  are  interested 
In  Preventive  Medicine.”— Dublin  Journal  of  Medical  Science. 


TENTH  Edition.  Thoroughly  Revised.  Crown  8vo.  9s.net; 
post  free,  9s.  5d.,  abroad,  9s.  8d. 

ELEMENTS  OF  PRACTICAL  MEDICINE. 

By  ALFRED  H.  CARTER,  M.D.,  M.Sc.,  F.R.C.P.  Lond.,  formerly 
Professor  of  Medicine,  University  of  Birmingham ; Emeritus  Pro- 
fessor of  Physiology,  Queen’s  College,  Birmingham  ; Consulting 
Physician  to  the  Queen’s  Hospital,  Birmingham,  &c. 

“ The  favourable  criticisms  that  have  been  expressed  concerning 
previous  editions  may  be  confidently  reiterated  concerning  this  tenth 
issue.  The  book  has  been  carefully  revised  and  many  chapters 
rewritten.”— British  Medical  Journal. 


NOW  READY.  SECOND  Edition.  With  22  Illustrations. 
Demy  8vo.  8s.  6d.  net;  post  free,  9s.,  abroad,  9s.  2d. 

THE  CAUSATION  OF  SEX  IN  MAN. 

A’.NEW  THEORY  OF  SEX  BASED  ON  CLINICAL  MATERIALS. 

Together  with  Chapters  on  Poreeasting’or  Predicting  the  Sex  of  the 
Unborn  Child,  and  on  the  Determination  or  Production  of  either 
Sex  at  Will. 

By  B.  RUMLEY  DAWSON,  L.K.C.P.  Lond.,  M.K.C.S.  Eng.,  formerly 
Member  of  Council  of  the  Obstetrical  Society  of  London, 
and  Fellow  of  the  Royal  Society  of  Medicine. 

"This  illuminating  work.”— The  Medical  Officer. 


FIFTH  Edition  (Reprinted).  With  29  Plates  (mostly  in  colour) 
comprising  33  Figures.  Demy  8vo.  6s.  net ; post  free,  6e.  6d. 

LANDMARKS  & SURFACE  MARKINGS 
OF  THE  HUMAN  BODY. 

By  L.  BATHE  RAWLING,  M.B.,  B.C.  Cantab.,  F.B.C.S.  Bng., 
Surgeon  with  charge  of  Out  patients,  and  Demonstrator  of  Practical 
and  Operative  Surgery,  St.  Bartholomew’s  Hospital,  Ac. 

“ We  can  confidently  recommend  it  to  everyone  as  a handbook  both 
for  study  and  for  reference.” — Edinburgh  Medical  Journal. 


NOW  READY.  Crown  8vo.  4s.  6d.  net;  postage  3d. 

THE  SYSTEMATIC  TREATMENT  OF 
GONORRHOEA. 

By  N.  P.  L.  LUMB,  Temp.  Capt.,  R.A.M.C.,  Ac. 

" This  excellent  little  volume It  is  a thoroughly  reliable, 

practical  handbook.”— The  Medical  Officer. 

••  For  the  way  in  which  the  author  deals  with  this  aspect  of  the 
disease  we  have  nothing  but  praise."— Dublin  Journal  of  Medical 
Science. 


%*  Complete  CATALOGUE  post,  free  on  apvlication. 

London : H.  K.  LEWIS  & CO.  LTD,  136  Gower  Street  & 24  Gower  Place,  W.C.  1. 

PUBLISHING  AND  WHOLESALE  OFFICE,  28  GOWER  PLACE.  W.C  1. 


32 


38,  OXFORD  ST.,  & 2,  RATHBONE  PLACE,  W.l. 

Telephone  No. : Museim  1484.  Telegram:  “Eayleaf,  Ox.,  London.” 


Thb  Lanoht,]  the  LANCET  GENERAL  ADVERTISER  [Sbpt.  27, 1919 


BAILEY  S GYNAECOLOGICAL  AND  UROLOGICAL  EXAMINATION  CHAIR 

White  enamelled  steel  with  tubular  frame,  all  joints  welded,  adjustable 
head  and  leg-rest.  Pull-out  douching  trough  and  folding  step. 

AN  IDEAL  EXAMINATION  CHAIR. 

Complete  with  combined  Foot  Rests  and  Leg  Crutches. 


No.  H 3353. 


W.  H.  BAILEY  & SON’S 

CYNffCOLOCICAL  AND  UROLOGICAL 
EXAMINATION  CHAIR 


33 


The  Lancet,] 


THE  LANCET  GENERAL  ADVERTISER 


[sept.  27,  1919 


GOLD  MEDAL,  INTERNATIONAL  CONGRESS  OF  MEDICINE,  LONDON,  1913. 

MIST.  DAMIAN^^a  (HEWLETT’S). 

MIST.  DAMIAN.®  CO.  (Hewlett’s)  will  be  found  to  possess  all  the  properties  of  Damians,  viz  : — Its 
alterative  effects  on  the  alimentary  canal  and  tonic  action  upon  the  brain  and  nervous  system  generally. 
It  is  a well-known  fact  that  exhaustion  of  the  organs  and  tissues,  neurasthenia,  and  premature  decay,  are  far 
more  prevalent  at  the  present  day  than  ever  before.  The  causes  are  numerous  and  complex,  but,  perhaps, 
the  principal  reason  is  that  multitudes  have  to  toil  harder  with  their  brains  than  any  previous  race.  The 
resulting  cerebral  anaemia  is,  therefore,  one  of  the  most  general  complaints  in  modern  life.  Not  only 
is  it  found  amongst  the  professional  literary  men,  but  busy  merchants  and  overworked  scholars  are  equally 
the  subjects  of  enfeebled  nerve  power  and  deficient  vitality. 

In  all  these  various  forms  of  loss  of  nerve  power  Mist.  Damian.®  Co.  (Hewlett’s)  is  a powerful  remedy, 
relieving  the  exhaustion  and  confeiring  renewed  capacitv  for  mental  and  physical  endurance. 

As  a nerve  tonic  and  brain  stimulant  it  is  unequalled,  and  its  invigorating  properties  will  be  found 
invaluable  in  many  diseases  where  there  is  great  depression  and  exhaustion.  In  paraplegia,  hemiplegia, 
and  partial  paralysis,  it  is  particularly  indicated,  and  may  be  suitably  and  satisfactorily  employed  wherever 
a powerful  nerve  stimulant  and  restorative  are  required. 

Dose — One  or  Two  Draohms  in  Water. 

MEDICAL  OPINIONS. 

“ I have  tried  your  Mist.  Damian*  Co.  considerably  in  the  dyspepsia  of  commencing  phthisis,  and  can  very  strongly  recommend  Its  use  In 
those  cases.  It  soothes  the  stomach  wonderfully,  and  enables  the  patient  to  take  more  food  whilst  acting  as  a powerful 

stimulant  in  relieving  exhaustion.”— Yours  faithfully,  w.  H.  B , b.a.  (Cantab.),  M.R.C.S.,  L.S.A. 

THE  MEDICAL  ANNUAL.—"  Damian*  is  not  nsed  so  frequently  In  this  country  as  in  America,  where  Its  value  as  a tonic  for  Neurasthenia 
Is  well  known.  Messrs.  Hewlett  & Son  put  up  a very  excellent  preparation  of  this  drug,  combined  with  Nux  Vomica  and  simple  aromatics  and 
bitters,  which  Is  valuable  for  dispensing,  and  yields  very  satisfactory  results  in  treatment.” — 1898. 

Dr.  M , E.N.,  writes  : — “ Famham  (Hants.),  Sept.  1903. 

“ I have  frequently  prescribed  your  Mist.  Damian*  Co.  and  proved  it  efficient  in  treating  Neurasthenia.” 

Packed  in  10-oz.,  22-oz.,  40-oz.,  and  90-oz.  Bottles. 

Introduced  and  Prepared  only  by— 

C.  J.  HEWLETT  & SON,  Ltd..  35  to  42,  Charlotte  St.,  LONDON,  E.C. 



It  was  impossible  during  the  war  to  obtain 

full  supplies  of 

HORLICK’S 
MALTED  MILK 

because  of  the  demands  ot  our  fighting  men  on  Land,  Sea,  and  in  the  Air, 
and  thousands  of  letters  testify  to  their  appreciation  of  its  value.  Supplied 
extensively  to  the  War  Office,  Admiralty,  R.A.F.,  Indian  Soldiers’  Fund, 
Prisoners  of  War,  and  many  Red  Cross  Organisations. 

HORLICK’S  MALTED  MILK  Co.  have  pleasure  in 
announcing  that  full  supplies  are  now  available  for  the 
public  through  the  usual  channels — Chemists  and  Stores. 

Specify  HORLICK’S,  the  product  that  has  stood  the  test  of  time. 
HORLICK’S  MALTED  MILK  Co.,  SLOUGH,  BUCKS,  ENGLAND. 


34 


The  Lancet,] 


THE  LANCET  GENERAL  ADVERTISER 


[Sept.  27,  1919 


“ The  low  temperature  maintained  throughout  the  manufacture 
of  Vitamogen  ensures  a very  high  co  efficient  of  enzymic  activity. 
The  Vitamines  can  almost  be  called  the  ‘soul’  of  ■food.” 

Free  Samples  to  Medical  Men. 

VITAMOGEN  is  in  two  sizes— 2/9  and  5/9 —or  in  bulk. 

Literatu/re  on  the  Vitamines  mill  he  sent  with  Samples  upon  application. 

VITAMOGEN,  Ltd.,  Manufacturers,  24,  Holborn,  London,  E.C.  1. 


V I T A M 0 G EN 

represents  a highly 
Concentrated  Food  and 
contains  free  Vitamine 
in  its  natural  and  un- 
changed condition  — in 
combination  with  Fats, 
Proteids,  and  Carbo- 
hydrates— the  whole 
constituting  a Complete 
Food  in  a palatable  and 
easily  assimilable  form. 


THE  BRITISH  OXYGEN  COMPANY,  JL,TI>6 


IN  CYLINDERS  OF  ANY 
SIZE  FOR  MEDICAL  AND 
OTHER  PURPOSES. 


LONDON : Elverton  Street,  Westminster,  S.W. 

„ Tunnel  Avenue,  East  Greenwich. 

„ North  Wembley,  Middlesex. 

BIRMINGHAM : Saltley  Works. 

COVENTRY : Terry  Road. 

WOLVERHAMPTON : Lower  Walsall  Street. 
MANCHESTER:  Great  Marlborough  Street. 
BIRKENHEAD:  Bromborougb  Port. 
NEWCASTLE-ON-TYNE : Shields  Road,  Walker 
GLASGOW : Rosehill  Works,  Polmadie. 

CARDIFF:  East  Moors. 

SHEFFIELD : Celtic  Works,  Saville  Street. 


Teleph.  4706,  4707,  6717,  & 6718 

Victoria  (4  lines). 
Teleph.  No.  674  Greenwich. 
Teleph.  209  Wembley. 

Teleph.  87  East  Birmingham. 
Teleph.  836  Coventry. 

Teleph.  801  (2  lines),  W’hton. 
Teleph.  2538  Manchester. 

Teleph.  138  Bromborough. 

Gate.  Teleph.  3239  Central. 

Teleph.  No.  840,  841,  & 842 

Queen’s  Park. 
Teleph.  786  Cardiff. 

Teleph.  2801  Central. 

And  SYDNEY.  N.S.W. 


Tel.  Ad. : “ Brin’s  Oxygen,” 

“Sowest  ” London. 


Tel.  Ad. : “ Baryta,"  Birmingham. 
Tel.  Ad. : “ Oxygen,”  Coventry. 

Tel.  Ad. : “Oxygen,”  W’hampton. 
Tel.  Ad. : "Oxygen,”  Manchester. 
Tel.  Ad. : “ Oxygen  ” Bromborougb, 
Tel.  Ad. : “ Oxygen,”  Newcastle. 

Tel.  Ad. : “Oxygen,”  Glasgow. 

Tel.  Ad. : “Oxygen,”  Cardiff. 

TeL  Ad. : “ Oxygen,”  Sheffield. 


DIABETES 


Blatohley's  Celebrated  Bread  and  Biscuits 
supplied  to  nearly  all  the  London  and 
County  Hospitals  & Infirmaries.  Blatohley  's 
Gluten  and  Bran  Biscuits,  a speciality  In 
treatment  of  Obesity,  made  from  a recipe  of 
Dr.  Yorke-Davies.  Price  Lists  free. 


OBESITY 


E BLATCHLEY  35,  GREAT  PORTLAND  STREET,  OXFORD  CIRCUS,  LONDON,  W.  (Late  167,  Oxford  Street ) Established  1838. 


BOILS 

Also  many  forms  of  Skin  disorders  can  be  successfully  treated  with 

ZYMOL 

a specially  prepared  form  of  fresh  brewer’s  yeast  in  which  the  active 
ferment  is  retained  intact. 

SUPPLIED  IN  TABLET  FORM  IN  BOTTLES  OF  50  TABLETS  AT  2 - EACH. 

SOLE  MAKERS: 

WILLOWS,  FRANCIS,  BUTLER  & THOMPSON,  Limited, 

Telegrams-  Wholesale  Manufacturing  Druggists,  Telephone- 

FORTY, LONDON.”  40,  ALDERSGATE  STREET,  LONDON,  E.C.1.  m^CITY- 


The  Lancet,] 


THE  LANCET  GENERAL  ADVERTISER 


[Sept.  27,  1919 


I Faulty  Protein  Digestion 

I and  imperfect  Fat  Digestion 


= are  the  most  common  errors  of  diet  that  produce  the  = 

= symptoms  readily  recognised  as  = 

| Constipation  in  Infants.  1 

= A thorough  understanding  of  the  undeniable  usefulness  of 

| JHUllin's  Ibod  | 

= as  a modifier  of  fresh  cow’s  milk  for  the  correction  of  these  = 

EE  errors  will  save  the  medical  practitioner  much  annoyance.  EE 

— A well-known  doctor  writes : = 

EE  “In  the  case  of  my  own  child,  it  was  much  troubled  at  an  early  age  with  = 

“ constipation,  but  Mellin’s  Food  was  recommended  by  a medical  friend  whose  = 

~ own  baby  took  it  with  excellent  results.  It  proved  to  be  just  what  was  needed,  == 

— and  the  child  is  now  sturdy  and  vigorous.”  L.R.C.P.,  L.M.,  M.R.C.S.  EE 

— Write  to  its  for  Sample  and  result  of  our  observations.  = 

= Mellin’s  Food,  Ltd.,  Peckham,  London,  S.E.  = 


■iiiiiiiieiiiiiniaiiiiMiiBi;!Ni:iiBiiiiiiiiB)iinniBiiiiiiiiBiiiiiniBinuiiiBiiiniiiHiii!iiiiBiiiiiiiiBiiiiiiiiBi)iiiiiia 


FOR 


Ltd..  * 

M*ha/«cturini  ChemipU. 

Oraham  Strut, 
itv  Road.  Lonocn  N 


TRATvll 


A non-toxic  organic  amino  compound  of  sulphur  which  is  injected  in 
the  form  of  a colloidal  emulsion  in  the  treatment  of 

SYPHILIS,  PROTOZOAL  and  CHRONIC  BACTERIAL 
DISEASES  and  ACID  INTOXICATIONS 
(Metallic  Poisoning,  &c.) 

In  syphilis  and  protozoal  diseases  1 INTRAMINE  ’ is  used  as  an 
alterative  to  pave  the  way  for  the  administration  of  the  metallic 
drugs,  and  to  prevent  intoxication  following  their  use. 

Among  chronic  bacterial  diseases,  ‘ INTRAMINE  ’ is  most  efficacious 
in  gonorrhoeal  rheumatism,  urethritis,  acne  rosacea  and  seborrhceic 
eczema. 

In  metallic  poisoning,  such  as  mercurial  stomatitis,  and  arsenical 
dermatitis,  ‘ INTRAMINE  ’ is  of  great  value,  also  in  jaundice  and 
albuminuria. 

‘ INTRAMINE  ’ for  intramuscular  injection  is  supplied  in  two 
solutions  which  must  be  mixed  immediately  before  use. 

‘ INTRAMINE’  for  intravenous  injection  is  supplied  ready  for  use  in 
50  c.c.  AMPOULES. 

‘ INTRAMINE  ’ for  internal  administration  is  supplied  in 
KERAT1NISED  GELATINE  CAPSULES. 


■ Literature  arid  all  Particulars  may  be  obtained  fromtheSole  Manufacturers.  i 

\m  BRITISH  DRUG  HOUSES  Ltd , 22/30, Graham  St,, CityRoad, London ,N.l  / 

36 


The  Lanoht,] 


THE  LANCET  GENERAL  ADVERTISER 


[Sept.  27,  1919 


By 

Appointment 

BABY’S 

It  is  not  what  is  eaten  that  nourishes,  but  what  is  digested. 
“Condensed  milk,”  says  a medical  authority,  “is  almost  as  digestible  as 
peptonised  milk.”  And  a Hospital  Secretary  writes : “ We  often  find 
that  a baby  can  digest  Nestle’s  Milk  when  no  other  form  suits  it.” 

This  explains  what  a Scottish  mother  recently  wrote:  — 

“ During  my  first  little  boy’s  illness  the  doctor  ordered  him  to  be  put  on  a certain  food,  which 
I did  for  seven  weeks,  to  my  great  sorrow,  with  the  result— a hopeless  case  ! But  having  heard 
of  Nestle’s  Milk  I decided  to  try  it,  and  in  three  days  the  baby  was  smiling  at  the  doctor.  He 
was'so  amazed  at  the  remarkable  improvement  that  he  asked  me  what  had  done  it,  so  I told  him 
of  Nestle’s  Milk,  and  he  named  him  ‘the  little  wonder,’  and  said  he  was  very  proud  of  him. 
He  is  now  two  years  and  seven  months  old,  and  has  never  ailed  one  single  day  since  Nestle’s 
introduced  itself.  My  two  children  are  really  a credit  to  your  milk,  and  I cannot  speak  too 
highly  of  the  way  they  have  thriven.” 

For  particulars  of  many  similar  cases,  see 

NESTLES  BABY  BOOK  for  1919 

Free  on  application  to 

NESTLE’S,  6 & 8,  EASTCHEAP,  LONDON,  E.C.  3. 


DIGESTION 


37  Times  More  Powerful  than  Lithia. 


Dissolves  and  eliminates  URIC  ACID.  Purifies  the  Kidneys  and  Frees 
the  Articulations.  Preserves  from  Arterio-Sclerosis  and  Obesity. 


RHEUMATISM. 

GOUT. 

LIT  H I A S I S. 


3 teaspoonfuls  .per  day,  each  teaspoonful  in  a glass  of 
water,  taken  between  meals.  Acute  conditions : 
3 tablespoonfuls  per  day.  No  Contra-indication. 


DERMATOSIS. 

NEURALGIA. 

OXALURIA. 


Price  5/-  and  12 /•  per  Bottle. 

COMMUNICATIONS—  Academy  of  Medicine,  Paris,  Nov.  10th,  1903.  Academy  of  Sciences,  Paris,  Dec.  14th,  1908. 


GOLD  MEDAL,  FRANCO-BRITISH  EXHIBITION,  1908. 

Highest  Awards:  Nancy,  1909.  Qnito,  1909.  Hors  Concours  San  Francisco  Exhibition,  1915. 
Adopted  by  the  FRENCH  ADMIRALTY  (Minist&re  de  Marine)  with  the  approval  of  the  BOARD  OF  HEALTH. 


URODONAL  is  prepared  exclusively  at  CHATELAIN’S  LABORATORIES,  2 is  2 bis  rue  de  Valenciennes.  Paris. 
Can  be  obtained  from  all  Chemists  and  Stores,  or  direct  from  the  Sole  British  and  Colonial  Agents — 

H E P P E LLS,  FOREIGN^HEM ISTsJ  164,  Piccadilly,  LONDON,  W. 

Trial  Supplies  and  Full  Descriptive  Literature  sent  on  application  to  HEPPELL3  at  the  above  Address. 


87 


The  Lancet,] 


THE  LANCET  GENERAL  ADVERTISER 


[Sept.  27,  1919 


EAL  YORKSHIRE 

I PORK  PIES 


Possessing  Character  and  individuality. 

5 lbs.  each.  Price  15/- 
Ginger  Fruit  Cakes.  Very  delicious.  8/6  each. 

Real  Almond  Pound  Cakes. 

A Delightful  eating  Cake.  1 0/6  each. 

Yorkshire  Gingerbread. 

Crisp  from  the  oven.  TO/-  large  box. 

wedd/ng  cake  / rrr\  r 
SPEC/AU5T.  LLlUj.  . 


As  supplied  to  several 
Medical  Men  in  various 
parts  of  the  country  and  to 
well-known  Practitioners 
in  Harley  Street  and 
Wimpole  Street, London, W. 


These  articles  of  food  are 
the  best  of  their  kind 
and  obtainable  from  no 
other  House. 

i 


MILK  FOR  DIABETICS. 


SO  LAC  r».“TIC) 

Double  Cream.  SUGAR  FREE 

— - — ■ 

This  milk  is  a new  product,  prepared  especially  for  Diabetics-  under  the  directions  of  a physician,  and  is  guaranteed 

not  to  produce  sugar  in  the  system. 

It  is  extremely  palatable,  and  being  in  powder  form  will  keep  indefinitely. 

It  can  be  used  for  all  the  purposes  of  ordinary  milk  and  cream,  in  tea,  cofEee,  &c.,  and  for  making  custards, 
blanc  mange,  pastry,  biscuits,  ices,  &c.  It  is  much  more  nourishing  than  cow’s  milk. 

Sample  tin  sent  post  free  Price  3s. 

SOIL  AC,  Limited,  Department  “A,”  221.  Tottenham  Court  Road,  W.  1. 


For  Infant  Feeding 

and  Household  Use. 

HOOKER’S  1 

DRIED  MILK 

(FULL 

CREAM) 

Manufactured  in  Buckinghamshire,  under  the  most  hygienic 

conditions.  Containing  all  the  ingredients  of  rich  cows’  milk 
in  powder  form.  Well  preserved  and  easily  reconstituted. 

HIGHEST  QUALITY  OBTAIN  ABLE.  Good  profit  to  Retailer. 

PRICES  AMD 

TERMS  FROM— 

THEW,  HOOKER 

& GILBE  Y,  LTD., 

Manufacturers  of  Milk  Products 

BUCKINGHAM 

38 


The  Lancet,  ] THE  LANCET  GENERAL  ADVERTISER  [Sept.  27, 1919 


X95g 


The  Government 
could  save  £15,000,000 

in  their  housing  schemes  by  substituting 
in  all  but  the  living  room  gaseous  for  solid 
fuel  fires. 

Full  particulars  as  to  how  this  building  economy 
may  be  effected  can  be  obtained  on  application 
to  the  Secretary — 

THE  BRITISH  COMMERCIAL  GAS  ASSOCIATION 

47  Victoria  Street , Westminster , S.W.\ 


THE  BURBERRY 


The  Super-Weatherproof 

REPRESENTS  the  most  economical  and  distinguished 
form  of  protection  in  out-door  Dress. 

THE  BURBERRY,  by  its  efficient  resistance  to  rain  and 
cold  winds,  ensures  comfort  and  security  under  conditions 
entailing  prolonged  exposure  to  chill  and  damp. 

THE  BURBERRY,  by  faultless  natural  ventilation,  entirely 
avoids  the  vitiated  heat  of  macintosh  or  rubber-lined  coats. 
THE  BURBERRY  is  airylight  and  gives  a splendid  sense 
of  freedom,  whilst  its  hygienic  warmth  in  chilly  weather 
proves  invaluable  for  maintaining  health  and  comfort. 

^ Patterns,  Prices,  and  Catalogue  sent  on  application. 


Every  Burberry 
Garment  bears  a 
Burberry  Label 


BURBERRYS’  CLEANING  WORKS. 

Men’s  and  Women's  Dress  Cleaned  by  the  most 
up-to-date  processes.  Weatherproof  garments 
reproofed.  Moderate  charges.  Prices  sent  on 
request. 


BURBERRYS’  BASINGSTOKE  HOUSE  treats  direct 
commissions  from  Doctors  as  approval  orders — i.e., 
replaces  with  Its  own  cheque  returned  non-approved 
garment. 


BUR  BERRYS 


BASINGSTOKE 


/LONDON  \ 

VHAYMAEKET,  S.W.lJ 


39 


jti|IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIHIIlliiiiiillll||l 


The  Lancet,] 


THE  LANCET  GENERAL  ADVERTISER 


[Sept.  27,  1919 


^iiiiiiiiiiiiiiiiiiiiiiiiiiiin 


RIODINE 


(C18H3303IH)3C3H8. 

An  ORGANIC  DERIVATIVE  Of  IODINE, 

Efficacious  and  Prolonged 
Action , even  in  small  doses. 

1 Never  gives  rise  to  Iodism- 


CALLARD’S 

DIABETIC 

FOODS 

ARE 

RELI  ABLE 


Send  for  Samples  and  Analyses. 

Patients  receive  every  attention. 


CALLARD  & CO.  (Food  Specialists) 

(Callard,  Stewart  & Watt  Ltd.), 

74,  Regent  Street,  LONDON,  S.W.  1. 


KOLA  RED  OIL. 

The  New  Treatment  for  PNEUMONIA,  especially  the  deadly 
form  following  Influenza. 

Of  all  Chemists  or  Manufactory,  18,  LENNOX  AVENUE.  GRAVESEND. 


GALE’S 


“ Ideal  preparation  for  the 
Mouth  Hygiene.  ” 


THERAPEUTICAL 
INDICATIONS : 

Cardio- Vascular  and 
Chronic  Respiratory 
Diseases,  Scrofula, 
Lymphatism,  Obesity, 
and  in  all  cases  re- 
quiring the  use  of 
either  iodine  or 
iodides,  especially 
when  these  disagree 
with  the  patient. 


ASTIER  LABORATORIES.  =: 
45,  Rue  du  Docteur  ~ 
Blanche,  PARIS. 

For  Samples  and  Literature  — 
address : 

WILCOX,  JOZEAU  & CO.,  49,  Haymarket,  = 
London,  S.W. 

Australasia —Messrs.  Joubert  & Joubert,  552,  Flinders  SS 
St.,  Melbourne.  Canada— Rougier  Bros.,  63,  Notre 
Dame  St.  East.  Montreal.  India— Eugene  Meiffre,  SS 
PO.  Box  130,  Bombay;  and  11,  Ezra  St.,  Calcutta.  SS 

lllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllll^ 

40 


An  agreeable  Concentrated  Antiseptic,  with 
pleasant  aroma,  for  Mouth-wash,  Gargle,  &c. 


Price  List  and  Pill  Catalogue  on  application. 

GALE  & COMPY.,  Ltd., 

Wholesale  Chemists  and  Druggists.  (Estab.  1786.) 
16.  BOUVERIE  ST.,  FLEET  ST.,  LONDON,  E.C. 
Tel.  Ad.:  “ Dreadnought,  London.”  'Phone  : 898  Holborn. 


0RTH0-0XYQUIN0LINE  SULPHATE 

“SUPEROL” 

(Registered  Sales  Name). 

IN  POWDER,  GRANULATED  & TABLETS. 

A MOST  EFFECTIVE  NON-POISONOUS 
ANTISEPTIC  & DISINFECTANT. 


SOLE  MAKERS : 

AMSTERDAM  SUPERPHOSPHATE  WORKS, 
Pharmaceutical  Dept.,  UTRECHT,  HOLLAND. 

For  Particulars  apply  to 

K.  RAYMENT,  Sole  Agent  for  Superol  in  the  United  Kingdom, 
2.  BROAD  ST.  PLACE.  LONDON,  E.C.  2.  Phone : London  Wall  4688. 


The  Lancet,] 


[Sept.  27,  1919 


THE  LANCET  GENERAL  ADVERTISER 


from  m 


Heart 


q/°the 


alVern 


^IIIIIIIIIl%2^IHHIIfRL2S!UllllllinT!SSSSUIIIllillin^JUlHH| 


BURROWS 


- TABLE 

WATERS 


(STILL  and  SPARKLING) 

Nature’s  purest  waters— bubbling  up  out  of 
a rook  midst  the  sweet  pure  air  of  the 
Malvern  Hills.  These  celebrated  Waters 
are  bottled  only  at  the  historic  St.  Ann's 
Spring,  Malvern,  and  none  better  can 
be  obtained  for  use  in  the  sick  room. 

SOLD  EVERYWHERE. 
Enquiries  from  the  Medical  Profession 
invited,  and  particulars  of  special  terms  for 
personal  consumption  will  be  forwarded 
on  application  to : W.  & J.  Burrow  Ltd., 
The  Springs,  Malvern;  or  temporary 
London  Offices,  5,  Norfolk  Mews  West, 
Paddington,  W.  (Tel. : Padd.  1810.) 


Burrow 


A Genuine 
and  Wholesome 
Product. 

Extract  from  the  report  of  the 
British  Analytical  Control  on 
“ Skippers.” 

” The  fish  were  in  good  condi- 
tion and  were  packed  in  pure 

Olive  Oil 

The  results  show  that  the  article 
is  entirely  free  from  preserva- 
tives and  is  to  be  regarded 
as  a genuine  and  wholesome 
product.  ’ ' 

The  addition  of  ‘ ‘ Skippers  ’ ' to 
the  diet  of  patients  who  cannot 
take  oil  by  itself  has  been  found 
to  give  good  results. 


Guaranteed  by 

Angus  Watson  & Co.,Nevvcastle-on-Tyne, 


The  Whisky  for  Connoisseurs. 

TUCKEY’S 

Ten  Years  Old 

PURE  MALT  WHISKY 

Soft,  Mellow,  Old  Pot  Still 
Scotch  Whisky. 

The  Lancet  says  : — 

“ It  Is  well  adapted  for  dietetic  purposes  owing 
to  its  purity  and  quality." 


CHAS.  TUCKEY  & CO.,  Ltd., 

London  Offices  : 

3,  Mincing  Lane,  E.C.  3. 


Virginia  Cigarettes. 

JOHN  PLAYER  & SONS  beg  to  draw  the  atten- 
tiqnof  connoisseurs  to  “PERFECTOS”  No.  2 
Cigarettes.  They  are  distinguished  by  a superb 
delicacy,  the  result  of  a matchless  blend  of  the 
Finest  Virginia  Tobacco. 


The  Imperial  Tobacco  Co.  (of  Great  Britain  and  Ireland),  Ltd, 


SPECTROSCOPES  BOUGHT,  SOLD, or  EXCHANGED. 
JOHN  BROWNING  (Dept. 7),  146,  Strand.  London,  W.C. 2.  Estab.1765. 


INSTANTLY  SOLUBLE 

CONDY’s  CRYSTALS 

(The  Best  of  the  Permanganates) 

HANDY,  SAFE,  CHEAP 

2-oz.  size  Is.  3d— CONDY’S,  65,Goswell  Rd.,  London. 


41 


The  Lancet,] 


[Sept.  27,  1919 


THE  LANCET  GENERAL  ADVERTISER 


ZYMOTIC  DISEASES. 

HOGG’S  IMPROVED  STEAM  VAPORISERS 

The  most  Mmole  and  Effectual  Apparatus  for  the  Diffusion  (Regd.) 
of  Antiseptics.  Price  2/6,  post  free  2/9. 

R.  HOGS  & SON,  1,  Southwick  Street,  Hyde  Park,  W. 


DR.  CHAUMIER’S 

?nlvooes=ed  calf  lymph. 

THE  CHEAPEST  AND  MOST  ACTIYE  LYMPH. 


CHARING  CROSS  HOSPITAL 
MEDICAL  SCHOOL 

(UNIVERSITY  OF  LONDON', 

with  which  is  affiliated  the 

RQYAL  WESTMINSTER  OPHTHALMIC  HOSPITAL 

(adjoining). 

OPEN  to  MEN  and  WOMEN  STUDENTS. 


PREPARED  under  the  MOST  MINUTE  ANTISEPTIC  PRECAUTIONS. 

Supplied  in  Tubes,  sufficient  to  vaccinate  1 or  2 persons,  at  8d. 
each  ; 10  persons  at  Is.  3d.  each,  26  persons  at  2s.  3d.  each.  Col- 
lapsible tubeB  for  40  vacclnatlors  3s.  9d.  each.  Postage  and 
packing  2d.  each  extra. 


ROBERTS  & CO.,76,NewBondSt.,L0ND0N,W 


Prepared  strictly  in  accordance  with  the  methods  a<  vocated 
by  Dr.  S.  Monckton  Copeman,  F.R.S. 


ASEPTIC  CLYCERINATED 


Tubes,  Is.  each,  10s.  per  dozen.  Postage  2d. 
Half  Tubes,  3 for  Is.  6d.  5s.  per  dozen.  ,,  M 

Telegrams  ; “ Silicabon,  London."  Telephone  No.  131,7  Battersea 
Postal  Orders  and  Cheques  to  be  made  payable  to  James  Douglas. 

JENNER  INSTITUTE  FOR  CALF  LYMPH, 

73,  Church  Rd.,  Battersea,  London,  S.  W.  ltd 


For  your  next 

GASTROENTEROSTOMY 

use 

LUKENS 

STERILE  CATGUT 

with 

DULOX  NEEDLE 

Tanned  extra  hard  to  resist  digestion. 

Sizes  0 and  1. 


Price  14/-  per  dozen  tubes. 

Sample  sent  on  application  to — 

THE  UNITED  KINGDOM  DENTAL 
MANUFACTURING  CO.,  Ltd., 

POLAND  HOUSE, 

Oxford  Street,  London,  W.  1. 


The  WINTER  SESSION  commences  on  WEDNESDAY,  OCT.  I. 


The  most  central  of  all  the  University 
Schools.  Immediately  accessible  by  train, 
tram,  tube,  and  ’bus,  enabling  students  to  lire 
anywhere  within  a twenty- mile  radius. 

The  Courses  of  Study  are  arranged  to  meet  the 
requirements  of  all  the  Examining  Bodies. 

All  appointments  are  open  equally  to  Men 
and  Women  Students. 


The  COURSE  in  OPHTHALMOLOGY  is  given 
in  the  ROYAL  WESTMINSTER  OPHTHALMIC 
HOSPITAL.  Special  Lectures  and  Demonstra- 
tions are  arranged  for  Post-Graduates. 


An  INSTITUTE  OF  PATHOLOGY,  with  a 
whole-time  Staff  of  scientific  workers  and  fully 
equipped  laboratories,  has  been  established  in 
the  School.  Students  receive  their  training  in 
Preventive  Medicine,  Pathology,  & Bacteriology 
here  and  are  encouraged  to  undertake  Research. 
Special  Facilities  for  Post-Graduate  Research 

and  Study.  

Fees  low  and  inclusive,  no  extras. 


For  Prospectus  and  lull  information  apply  personally  or  by  letter,  to 
the  Dean,  W.  •).  Fenton,  M D..  F.R.C.P., 

Tel.  No  : City  801o.  Charing  Cross  Hospital  Medical  School,  W.C.2. 

GUY’S  HOSPITAL  WAR  MEMORIALr 


A representative  Committee,  composed  of  Governors  of  the  Hospital, 
Members  of  the  Staffs  of  the  Medical  and  Dental  Schools,  and  Past  and 
Present  Students,  has  been  formed  to  collect  funds  and  carry  -out  the 
wishes  of  the  subscribers  as  to  the  character  of  the  Memorial. 

Treasurers H.  Cosmo  O.  Bonsor,  W.  A.  Maggs,  Lauriston  E.  Shaw, 
and  Alfred  D.  Fripp. 

Subscriptions  should  be  forwarded  to  the  Honorary  Secretary, 
“Guv’s  Hospital  War  Memorial  Fund,”  Guy’s  Hospital,  S.E.l,  who 
will  be  pleased  to  give  particulars  of  the  schemes  oroposed. 

POST*G  RADUATE  STUDY. 

LONDON  SCHOOL  OF  CLINICAL  MEDICINE 

At  the  Dreadnought  Hospital,  Greenwich, 
and  its  Affiliated  Hospitals. 

OPERATIVE  SURGERY  only  at  present. 

Apply  to  H.  Ridley  Prentice,  M.D.,  Acting  Dean,  or  to  the 
Secretary,  Seamen’s  Hospital.  Greenwich,  S.E. 

Queen  Charlotte's  Lying  in  Hospital  and 

MIDWIFERY  TRAINING  SCHOOL,  Marylebone,  N.W.  I. 


MEDICAL  STUDENTS  and  QUALIFIED  PRACTITIONERS 
idmitted  to  the  Practice  of  this  Hospital.  Unusual  opportunities  are 
afforded  of  seeing  Obstetrical  Complications  and  Operative  Midwifery, 
about  one-half  of  the  total  admissions  being  primiparous  cases. 

PUPILS  TRAINED  FOR  MIDWIVES  AND  MONTHLY  NUESES. 
On  being  found  competent  each  pupil  Is  awarded  a certificate  of  efficiency. 

Special  Preparation  for  Examination  of  Central 
Midwives  Board. 

CERTIFICATES  AWARDED  as  required  by  the  various  Examining 
Bodies. 

For  rules,  fees,  Ac.,  apply  Arthur  Watts.  Secretary. 


CITY  OF  LONDON  MATERNITY  HOSPITAL 

(formerly  City  of  London  Lying-in  Hospital) 
MIDWIFERY  SCHOOL,  City  Road.  E.C.  1. 

MEDICAL  STUDENTS  admitted  to  HOSPITAL  PRACTICB, 
with  Operative  Midwifery  and  Obstetrical  Complications. 
PUPILS  TRAINED  as  MIDWIVES  and  MONTHLY  NURSES, 
in  accordance  with  Central  Midwires  Board  regulations. 
CERTIFICATES  awarded  as  required  by  Examining  Bodies. 
PRIVATE  WARDS  for  PAVING  PATIENTS. 

For  Prospectus  spply  to  Ralph  B.  Cannings,  Secretary. 


42 


The  Lancet,] 


THE  LANCET  GENERAL  ADVERTISER 


[Sept.  27,  1919 


Royal 


College  of  Physicians 

LONDON. 


of 


The  next  PROFESSIONAL  EXAMINATION  for  the  MEMBER- 
SHIP will  commence  on  Tuesday,  October  21st. 

Candidates  are  required  to  give  fourteen  days'  notice  In  writing  to 
the  Registrar  of  the  College,  with  whom  all  certificates  and  testi- 
monials required  by  the  By-laws  are  to  be  left  at  the  same  time. 

Pall  Mall  East..  S.W. .T.  A.  Ormkrod.  M.D.,  Registrar, 


XTospital  for  Diseases  of  the  Throat, 

_l L Golden-square,  London,  W. 


CLINICAL  INSTRUCTION. 

Clinical  instruction  in  the  Diagnosis  and  Treatment  of  Disease  is 
given  dally  in  the  Out-patient  Department.  Minor  operations  are 
performed  at  10  a. m.  on  four  days  a week. 


HONORARY  MEDICAL  STAFF. 


, Surgeons. 

Mr.  J.  Faulder. 

Mr.  G.  W.  Badgerow. 

Mr.  N.  Patterson. 
Mr.  L.  Coixepgk. 

Mr.  G.  W.  Dawson. 


Out-patients. 
Wednesday,  2 p.m. 
Monday,  2 p.m. 
Tuesday.  6.30  P.M. 
Friday,  2 p.m. 
Tuesday,  2 p.m. 
Thursday,  2 p.m. 
Saturday, 10  a.m. 


Operations. 
Thursday,  10  a.m. 
Wednesday,  9 a.m. 

Friday,  10  a.m. 
Thursday  2 p.m. 
Tuesday,  10  a.m. 


Friday,  2 p.m. 

G.  W.  Dawson.  Dean. 


Asst.  Surgeon. 

Mr.  Gilbert  Chubb.  Friday,  6.30  p.m. 
For  further  information  apply  to 


DIPLOMA  IN  PUBLIC  HEALTH.  &c. 


e Royal  Institute  of  Public  Health. 


Patron  : His  Majesty  The  King. 

Chairman  of  Council : Prof.  Sir  Thomas  Oliver,  M.D..LL.D.,  F.R.C.P.. 
F.  R.S.  Bdin. 

Principal  : Prof.  Sir  William  Smith,  M.D.,  D.Sc.,  LL.D.,  F.R.S.Ediu. 


The  Course  of  Instruction  for  the  Degrees  and  Diplomas  In  Public 
Health,  with  the  necessary  Laboratory  Work,  can  commence  at  any 
time,  and  special  arrangements  are  made  to  suit  the  convenience  of 
those  (Men  and  Women)  holding  Appointments,  &c. 

TUBERCULOSIS. 

A Course  of  Lectures  for  Tuberculosis  Officers,  General  Practitioners, 
and  others  will  commence  on  Thursday,  October  9th,  at  6 p.m. 

Further  particulars  can  be  obtained  from  the  Secretary,  37,  Russell- 
square,  W.0. 1. 


ST.  MARY’S  HOSPITAL  MEDICAL  SCHOOL 

PADDINGTON,  W.  2. 

(University  of  London.) 

The  WINTER  SESSION  will  begin  on  Octeber  1st,  1919. 
LECTURES  and  CLASSES  in  Preliminary,  Intermediate,  and  Final 
subjects  of  the  Curriculum  will  begin  on  this  date. 

For  illustrated  prospectus,  apply  to  the  Dean,  Sir  John  Broadbent, 
Bt„  M.D.,  or  to  the  School  Secretary. 


LONDON  SCHOOL  OF  TROPICAL 
MEDICINE. 

The  next  Session  of  the  School  will  commence  on  1st  October,  1919. 
In  1920  Sessions  will  be  held  commencing  January  19th,  May  3rd, 
and  October  4th  respectively. 

For  prospectus  and  further  particulars  apply  to  : The  Director 
Dr.  H.  B.  Newham,  C.M.G.),  London  School  of  Tropical  Medicine, 
Connaught  Road,  Albert  Docks,  London,  E.  16 ; or  to  the  Secretary 
Seamen’s  Hospital,  Greenwich,  London,  S.E. 

KING’S  COLLEGE  HOSPITAL 
MEDICAL  SCHOOL 

(UNIVERSITY  OF  LONDON). 

OPENING  OF  WINTER  SESSION,  OCT.  1st,  1919. 


Introductory  Address  at  3 p.m.  by 
The  Right  Hon.  T.  J.  MACNAMARA,  LL.D.,  M.A.,  Parliamentary 
Secretary  to  the  Admiralty,  Member  of  Parliament  for 
North-West  Camberwell. 

The  Right  Hon.  the  Viscount  HAMBLEDEN  will  Preside. 

The  Past  and  Present  STUDENTS’  DINNER  will  be  held 
the  same  evening  at  Pagani’s  Restaurant,  Great  Portland- 
street,  W.,  at  7.0  for  7.30  p.m.  Sir  StClair  Thomson  in 
the  Chair. 


The  Prospectus  of  the  School,  giving  information  as  to  Prizes, 
Entrance  and  other  Scholarships,  &c.,  may  be  obtained  poBt  free  on 
application  to  the  Dean,  H.  Willoughby  Lyle,  M.D.,  B.S.Lond., 
F.R.C.S. ; ortoS.  C.Ranner,  M.A.Cantab.,  the  Secretary  of  the  School. 

DIPLOMA  IN  PUBLIC  HEALTH. 

UNIVERSITY  OF  CAMBRIDGE. 

LECTURES  and  PRACTICAL  INSTRUCTION  in  the  subjects 
of  the  Examination  will  begin  10th  October,  1919,  and  16th  January, 
1920,  at  the 

UNIVERSITY  LABORATORIES,  PEMBROKE  ST.,  CAMBRIDGE. 
Hygiene,  Chemistry,  and  Physics — Mr.  J.  E.  Purvis. 

Special  Lectures  on  Water  Purification  by  Professor  Sir  G.  Sims 
Woodhead. 

Bacteriology  and  Preventive  Medicine — Dr.  Graham-Smith. 

Special  Lectures  by  Professor  Nuttall  on  Protozoal  Diseases,  and 
by  Dr.  Shipley  on  Animal  Parasites. 

Practical  Sanitary  Administration,  Hospital  Administration,  School 
Hygiene,  Sanitary  Law,  &c. — Dr.  Laird,  M.O.H.  for  Cambridge,  and 
Dr.  Robinson,  M.O.H.  for  the  Cambridgeshire  County  Council. 
Further  particulars  may  be  obtained  from  Mr.  J.  E.  PURVIS, 
Chemical  Laboratory,  Pembroke-street,  Cambridge. 


DIPLOMA  IN  PUBLIC  HEALTH. 

UN  IVERSITYs  LONDON,  U NIVERSITY  COLLEGE 

Professor — HENRY  R.  KENWOOD,  C.M.G.,  M.B.,  D.P.H.,  F.R.S.E.,  Medical  Officer  and  Public  Analyst  for  the  Borough 
of  Stoke  Newington  ; Medical  Officer  of  Health  and  Education,  Bedfordshire  County  Council,  &c. 

Lecturer  on  Diseases  Common  to  Man  and  the  Lower  Animals — A.  G.  R.  FOULERTON,  F.R.C.S.,  D.P.H. 
Assistant  and  Lecturer— WILSON  JAMESON,  M.A.,  M.D.,  M.R.C.P.,  D.P.H. 

The  Laboratories  are  open  daily  from  10  to  5 (Saturdays  10  to  1)  for  Practical  Instruction  and  Research. 

The  next  Course  begins  early  in  October. 

Demonstrations  of  Sanitary  Appliances  and  Excursions  to  places  of  Public  Health  interest  are  undertaken. 

Arrangements  are  made  to  suit  the  convenience  of  those  engaged  In  practice. 

A Special  Course  of  Bacteriological  Instruction  is  arranged  for  D.P.H.  Candidates. 

Particulars  may  be  obtained  on  application  to 

WALTER  W.  SETON,  M.A..  D.Lit..  Secretarv.  University  College,  London  (Gower-street),  W.C.  1. 


EDINBURGH 


POST-GRADUATE  COURSES  in  MEDICINE 

(In  connexion  with  the  University  and  Royal  Colleges). 

POST-GRADUATE  COURSES  in  CLINICAL’  MEDICINE  and  in  CLINICAL  SURGERY,  designed  to  meet  the  requirements  of 
uraauates  returning  from  Active  Service  on  Demobilisation,  will  be  conducted  during  the  Autumn  Term,  1919,  commencing  14th  October,  and 
oprmg  ie^m*  commencing  7th  January,  and  during  each  subsequent  academic  term. 

AnriTToeir6  throughout  the  term,  and  the  work,  which  will  be  essentially  practical,  will  occupy  the  whole  time  of  members. 

September  1920°  0BSTETRICS*  GYNAECOLOGY,  and  CHILD  WELFARE,  on  similar  lines,  will  be  held  during  the  months  of  August  and 


The  Courses  are  open  to  Women  Graduates. 

Particulars  may  be  had  on  application  to  The  Secretary,  Edinburgh  Post-Graduate  Courses,  University  New  Buildings,  Edutburgh. 

43 


Thb  Lancet,] 


THE  LANCET  GENERAL  ADVERTISER 


[Sept.  27,  1919 


POST-GRADUATE  COLLEGE,  WEST  LONDON  HOSPITAL 

Hammersmith-road,  W.— For  Prospectus  apply  the  Dean. 


J^iverpool  School  of  Tropical  Medicine. 

The  next  Course  of  Instruction  will  be  conducted  in  the  new  labora- 
tories of  the  School,  and  will  commence  on  Monday,  22nd  September, 
1919.  The  date  of  the  D.T.M.  Examination  is  15th  December,  1919.  For 
further  particulars  apply  to  the  Secretary,  School  of  Tropical  Medicine, 
University  of  Liverpool. 


rphe  Hospital  for  Sick  Children 

_L  Great  Ormond-street,  W.C.  1.— TRAINED  NURSES  can  be  had 
on  application  to  the  Matron.  Telegraphic  address  : “ Great  Westcent. 
London.”  Telephone  Nos.:  Museum  1805 and  1806. 

t.  John’s  and  St.  Thomas’s  House. — 

Trained  and  experienced  MEDICAL,  SURGICAL,  MATERNITY 
NURSES  and  MASSEUSES  can  be  obtained  by  application,  personally 
or  by  letter,  to  the  Sister  in  Charge,  12,  Queen’s  square,  W.C.  1 (Tel. 
No.  5099  Central),  or  to  Matron,  St.  Thomas’s  Hospital  (Tel.  4191  Hop.). 
Telegraphic  address  : “ Private  Nurses,  London.” 


s 


J>oyal  Eye  Hospital,  Manchester. 


POST-GRADUATE  CLASS. 


GENERAL 


5,  Mandeville  Place, 

Manchester  Square,  W. 


A Series  of  Eight  Practical  Demonstrations  on  EXTERNAL  DIS' 
EASES  of  the  EYE  will  be  given  by  the  Honorary  Staff  of  this 
Hospital,  at  the  Out-patient  Department  (Nelson-street),  on  Thursdays, 
at  4.30  p.m.,  commencing  October  16th. 

Gentlemen  desirous  of  joining  kindly  send  their  names  to  the 
Secretary,  Dr.  T.  Milnes  Bride,  26,  St.  John-street,  Manchester,  as 
soon  as  possible.  Fee  for  the  Course — One  guinea. 


THE  ANDERSON  COLLEGE  OF  MEDICINE, 

GLASGOW,  W. 


Established  1862  at  Henrietta  Street,  Covent  Garden. 
Thoroughly  experienced  Hospital  - Trained  NUESBS 

NURSINH 

notice,  II  U II  U 111  U the  Homd. 

Also  specially  trained  NURSES  for  Mental  Cases  worked 
under  the  system  of  Co-operation. 

. ASSOCIATION. 

Telephone  : Mayfair  115.  Teleg.  Address  : “ Nutrix,  Wesdo,  London/ 


WINTER  SESSION  opens  13th  October,  1919. 

The  Courses  comprise  MEDICINE,  DENTISTRY,  and  PUBLIC 
HEALTH.  Prospectus  sent  on  application  to  the  Secretary. 

N.B. — Enrolment  begins  on  Wednesday,  1st  October,  but  those 
desirous  of  commencing  the  Study  of  Medicine  or  of  Dentistry  should 
send  their  names  to  the  Secretary  at  once,  and  state  what  classes  they 
propose  to  enter,  so  that  the  requisite  accommodation  may  be  provided . 

TV/Tedical  Hypnotism  and  Curative 

_LY_L  SUGGESTION. — Instruction  given  to  Medical  Men  by  experi- 
enced operator. — Address,  No.  514,  The  Lancet  Office,  423,  Strand, 
W.C, 2. 

UNIVERSITY  EXAMINATION 
POSTAL  INSTITUTION. 

Postal  or  Oral  Preparation  for  all  Medical  Examinations. 

Telephone  6313  Central 

SOME  SUCCESSES 

M.D.(LOnd.),  1901-19  <6  Gold Medallists  1913-19).  238 
M.B.,  B.S.(Lond.)  , Final  1906-19  (completed  exam.)  96 

F.R.C.S.  (Eng.),  1906-19,  Primary  53  ; Final  30 


M.R.C.P.  (Lond.),  1914-19  27 

D.P.H.  (various),  1906-19  147 


AM.  R.C.S.,  L.  R.C.  P.  (Final),  ’06-19  (completed  exam.)  119 
R.A.M.C.  and  R.N.,  Top  Candidates  Jan.  & March,  ’14. 

I.M.S.,  July,  1915.  Second  place. 

M.D.  (Durham)  (Practitioners),  1906-19.  25 
M.D.  (various),  by  Thesis.  Many  Successes. 
Preliminary  (Arts  or  Science). — Many  Successes. 

For  Prospectuses,  List  of  Tutors,  List  of  recent  Successes,  Ac.,  apply  to 
the  Principal,  Mr.  E.  S.  WEYMOUTH,  M.A.,  17,  Red  Lion  Square 
London,  W.C.  1. 

Reversions  and  Life  Interests  in 

Landed  or  Funded  Property  or  other  Securities  and  Annultie. 
PURCHASED  or  LOANS  granted  thereon  by  the 

EQUITABLE  REVERSIONARY  INTEREST  SOCIETY, 
Limited, 

10,  Lancaster-place,  Waterloo  Bridge,  Strand. 

Established  1835. Capital  (paid  up),  £600,000, 


A PEACE  RISK. 

Who  is  carrying  your  death  Risk? 

Is  it  your  Family,  or 
a Life  Assurance  Office  ? 

WHY  NOT  LET  THE  PRUDENTIAL  CARRY  IT? 


ST.  LUKE’S  HOSPITAL. 

Established  1751. 

PRIVATE  NURSING  STAFF  DEPARTMENT. 


TRAINED  NURSES  for  Mental  and  Nervous 

Cases  can  be  had  immediately.  Apply  to  Lady 
Superintendent,  19,  Nottingham  Place,  London,  W.  1. 
Telephone  : Mayfair  5420. 

NORTHERN  BRANCH. — Apply,  Lady  Superintendent, 

57. Clarendon  Road,  Leeds.  Telephone:  Leeds  261B5 


THE  NURSES’  GO-OPERATION 


22,  Langham  St.,  Portland  Place,  W. 


THE  LONDON  TEMPERANCE 

NURSES  CO-OPERATION 

18,  Adam  St.,  Portman  Square,  LONDON,  W.  1. 

Telephone — Telegrams— 

Mayfair  2302.  | Nurslontem,  Phone,  London. 

Supplies  Fully  Trained  HOSPITAL  NURSES. 

Also  MENTAL  and  MALE  NURSES. 

Terms  from  £3:3:0  to  £3  13:6. 

NURSES  INSURED  AGAINST  ACCIDENT.  Apply,  Secretaby. 


MENTAL  NURSES 


ASSOCIATION,  Ltd.  (MALE  and  FEMALE) 

54,  George  Street,  Manchester  Sq.,  London,  W.1 


Superior  Certificated  Mental  Nurses  (Male  and  Female)  supplied  at  a moment’s  notice,  day  or  night. 

Ladies'  Travelling  Companions.  For  a11  MENTAL  and  NERVE  Cases.  All  Eurscs  fully  insured  against  Accident. 

Telegrams:  “ Isolation,  London " Terms:  £2  4 6 to  £ 3 3 O Apply SFCRETARY.  Telephone:  Mayfair  2287 


THE)  1.1*1“  CUT,] 


THE  LANCET  GENERAL  ADVERTISER 


[Sept.  27  1919 

a 


TEMPERANCE 


LONDON : 43,  NEW  CAVENDISH  STREET. 
MANCHESTER  : 176,  OXFORD  ROAD. 
GLASGOW  : 28.  WINDSOR  TERRACE. 

DUBLIN  : 47,  MESPIL  ROAD 


MALE  NURSES  ltd 


TELEGRAMS: 
Tactear,  London. 
Tactear.  Manchester. 
Surgical.  Glasgow. 
Tactear.  Dublin.  - 


TELEPHONES 
London.  1277  Mayfair. 
Manchester,  5219  Central. 
Glasgow,  477  Central. 
Dnblin,  531  Balisbrldge. 


CO-OPERATION 


Superior  trained  Male  Nurses  for  Medical,  Surgical,  Mental,  Dipsomania,  Travelling  and  all  cases.  Nurses  reside  on 
the  premises,  and  are  always  ready  for  urgent  calls  Day  or  Night*  Skilled  Masseurs  & good  Yalet  attendants  supplied. 
Terms  from  £1  16  6.  Nurses  insured  against  accident  Apply  to  the  Secretary. 


TEMPERANCE  ASSOCIATION 

* MALE  NURSES  ltd. 


FEMALE  NURSES 

ASSOCIATION. 


24,  NOTTINGHAM  STREET*  Nottingham  Place,  LONDON,  W. 

Telegrams:  “GENTLEST,  LONDON.”  [ALL  NURSES  INSURED  AGAINST  ACCIDENTS.']  Telephone:  5969  MAYFAIR 
Superior  Trained  Nurses  (Male  and  Female)  for  Medical,  Surgical,  Mental,  Travelling,  and  all  cases. 

Nurses  reside  on  the  premises,  and  are  always  ready  for  urgent  calls,  Day  or  Night. 

Terms  £2  2 O to  £3  3 O.  M.  J.  QUINLAN,  Secretary. 


Telephone  : PADDINGTON  2437 
Telegi  ams : “ ASSISTIAMO,  LONDON  ” 

MALE  NURSES’ 
ASSOCIATION 

29,  YORK  ST.,  BAKER  ST.,  LONDON,  W.l. 

Established  19  years. 


Permanent  Staff  of  Resident  Male  Nurses. 

We  supply  fully-trained  Male  Nurses  for  all  cases. 
Thoroughly  experienced  men  with  special  training 
for  mental  work. 

Masseurs  supplied  for  town  or  country. 


V 


W.  J.  HICKS,  Secretary 


J 


Telephone  : PADDINGTON  2437 
Telegrams:  “ASSISTIAMO,  LONDON” 

For  MEDICAL,  SURGICAL,  and 

MENTAL  NURSES 

Male  or  Female. 


To  those  who  have  employed  our  men,  it  Is  sufficient 
to  say  that  we  now  have  a thoroughly  efficient  Female 
staff,  ohosen  with  the  same  care  as  are  our  Male 
Nurses,  both  In  reference  to  their  knowledge  of 
nursing,  and  their  suitability  for  private  work. 

(Mrs.)  MILLICENT  HICKS,  Superintendent. 
W.  J.  HICKS,  Secretary. 

The  NURSES’  ASSOCIATION 

(In  conjunction  with  the  MALE  NURSES  ASSN.), 

y 29,  YORK  ST.,  BAKER  ST„  LONDON,  W.l,  A 


Co-operation  of  Temperance 


MALE  & FEMALE  NURSES 

60  WEYMOUTH  STREET,  PORTLAND  PLACE,  LONDON,  W.l. 
Reliable  and  Experienced  Nurses  for  all  Cases  at  all  Hours. 
8pecial  Staff  for  Mental  “ Borderline,”  Neurasthenia,  and  Nerve  Cases. 

Telephone:  MAYFAIR  2253  Telegrams:  “NURSINGDOM,  LONDON." 

Terms  £2  : 2 : O to  £3  : 3 :0  per  week.  Apply  M.  SULLIVAN,  Secretary, 


MALE  NURSES 


TEMPERANCE  CO-OPERATION,  LTD. 

TRAINED  MALE  NURSES  AND  VALET  ATTENDANTS  for  MENTAL. 

MEDICAL.  TRAVELLING  AND  ALL  CASES. 


iondon — 1 0,  Thayer  St.,  Manchester  So.,  W.l. 

BIRMINGHAM— 75.  HAGLEY  ROAD. 

MANCHESTER— 237,  BRUNSWICK  STREET  (Facing  Owems 
EDINBURGH  — 7,  TORPHICHEN  STREET.  College) 

Terms  from  £ 2 2 O to  £3  3 O 

ALL  NURSES  ARE  FULLY  INSURED  AGAINST  ACCIDENT 


Telephones ; 

London : 538  Paddington 

Birmingham : 2106  Midland 
Manchester:  4699  Central 
Edinburgh : 2715  Central 


Telegrams : 
Assuaged,  London 
Assuaged,  Birmingham 
Assuaged,  Manchester 
Assuaged.  Edinburgh 


Please  address  all  communica.ions,  W.  WALSHE,  Secretary. 


45 


The  Lancet,] 


THE  LANCET  GENERAL  ADVERTISER 


[Sept.  27,  1919 


MALLING  PLACE,  KENT 

For  LADIES  and  GENTLEMEN  of  Unsound  Mind. 

Terms  moderate.  Apply  to  Resident  Medical  Superintendent. 
Telegrams:  Adam,  West  Mallino.  Telephone:  No.  2 Mallino 

THE  COPPICE,  NOTTINGHAM. 

HOSPITAL  FOR  MENTAL  DISEASES. 

President : The  Bight  Hon.  the  Earl  Manvers. 

This  Institution  is  exclusively  for  the  reception  of  a limited  number 
of  PBIVATE  PATIENTS  of  both  sexes,  of  the  UPPEB  and  MIDDLE 
GLASSES,  at  moderate  rates  of  payment.  It  is  beautifully  situated  in 
Its  own  grounds,  on  an  eminence  a short  distance  from  Nottingham, 
and  commands  an  extensive  view  of  the  surrounding  country  ; and  from 
its  singularly  healthy  position  and  comfortable  arrangements  affords 
every  facility  for  the  relief  and  cure  of  those  mentally  afflicted. 

For  terms,  Ac.,  apply  to  the  Medical  Superintendent. 


ST.  ANDREWS  HOSPITAL 

FOR  MENTAL  DISEASES* 
NORTHAMPTON, 

President  — The  Eight  Hon.  the  Earl  Spencer,  K.G. 

This  Eegistered  Hospital  receives  for  treatment  PBIVATB 
PATIENTS  of  the  UPPEB  and  MIDDLE  CLASSES  of  both  Sexes. 
The  Hospital,  its  branches  (including  a Seaside  Home  at  Llanfairfechan, 
North  Wales),  and  its  numerous  Villas  are  Burrounded  by  nearly  a 
thousand  acres  of  Park  and  Farm. 

Voluntary  Boarders  without  certificates  received. 

For  particulars  apply  to  Daniel  F.  Kambaut,  M.A.,  M.D.,  the 
Medical  Superintendent.  Telefhone  No.  66. 


Home 

FOR  THE  CARE  AND  TREATMENT  OF 

Mentally  Afflicted  Ladies 


OTTO  HOUSE, 

47,  North  End  Road,  West  Kensington,  W.i* 

The  Home  stands  in  large  grounds  close  to 
West  Kensington  Stition. 

For  terms,  apply  to  Miss  BRODIE, 
Resident  Lady  Superintendent. 

Telephone  : Hammersmith  1004. 

Mrs.  SUTHERLAND  (Licensed  Proprietress). 

ASH  WOOD  HOUSE 

KINCSWINFORD,  STAFFORDSHIRE. 

An  old-established  home  like  Institution  for  the 
treatment  of  MENTAL  AFFECTIONS  in  BOTH 
SEXES. 

Full  particulars  as  to  reception,  terms,  &c.,  may 
be  obtained  from  the  Resident  Medical  Officer. 


SPRINGFIELD  HOUSE 

Near  BEDFORD  (TeJf0pli07ne 

A PRIVATE  HOME  for  MENTAL  CASES. 
Terms  from  4 guineas  per  week. 

Apply  to  DAVID  BOWEB,  M.D 

46 


ABELE  GROVE,  EPSOM. 

Telephone  : 203  Epsom. 

A PBIVATE  HOME  for  the  Care  and  Treatment  of  NEBVOUS 
AFFECTIONS  (Neurasthenia,  &c.)  and  INVALIDS. 

Country  House  and  good  grounds.  Healthy  and  Bracing. 
Apply  to  Dr.  Pearse  Chipperfield. 


PORTSMOUTH  CORPORATION  MENTAL  HOSPITAL 

Provision  for  PRIVATE  PATIENT8  has  just  been 
provided  in  two  detached  Villas. 

Inclusive  charges  from  £1  11s.  6d.  per  week. 

Apply  to  the  Medical  Superintendent. 

ST.  GEORGE’S  RETREAT 

BURGESS  HILL,  SUSSEX. 

An  old-established  Licensed  House,  under  the  management  of  the 
Augustinian  Sisters,  for  the  treatment  of  Ladies  mentally  afflicted. 
Grounds  nearly  300  acres.  Carriage  drives  and  motoring.  Marine 
Brighton  Residence  for  change.  Voluntary  Boarders  taken. 

Besident  and  Visiting  Medical  Officers.  London  li  hours. 

For  terms,  &c.,  apply  to  the  Superioress. 

Telephone : Telegrams : 

Post  Office  90.  “ Wivelsfield  Green.”  • 


PLYMPT0N  HOUSE 

ThiB  old-established  Licensed  House  offers  every  advantage  that 
experience  can  suggest  for  the  care  and  treatment  of  Mental  Cases. 

For  terms,  Ac.,  apply  to  the  Besident  Physicians. 

Telephone:  No.  2 Plympton.  Dr.  Alfred  Turner,  Dr.  J.  C.  Nixon. 

BISHOPSTONE  HOUSE,  BEDFORD. 

Telephone  708. 

Private  Home  for  Mentally  afflicted  Ladles  ; ten  only  received. 

Terms  from  6 gns.  weekly. 

Apply,  Medical  Officer,  or  Mrs.  Peele. 

THE  MOAT  HOUSE,  statfafm0^&. 

Stations  : L.  & N.  West,  and  Mid.  Bailways. 

The  House  is  devoted  to  the  care  and  treatment  of  a few  Ladies  suffer- 
ing from  Nervous  and  Mental  Affections,  who  enjoy  the  comfort,  privacy, 
and  occupations  of  home  life.  For  terms,  &c.,  apply  to  the  Besident 
Licensees,  Edward  Hollins,  M.A.Cantab.,  or  (Mrs.)  S.  A.  Michaux. 


THE  GRANGE,  E0TSI¥ham. 

A HOUSE  licensed  for  the  reception  of  a limited  number  of  ladles  ol 
unsound  mind.  Both  certified  and  voluntary  patients  received.  This 
Is  a large  country  house  with  beautiful  grounds  and  park,  five 
miles  from  Sheffield.  Station,  Grange  Lane,  G.C.  Ballway,  Sheffield. 
Telephone  No.  34  Eotherham. 

Besident  Physician— Gilbert  B.  Mould,  L.E.C.P.,  M.B.C.S.  Con- 
mlting  Physician— Orochley  Clapham,  M.D.,  F.B.C.P.B. 

CITY  OF  LONDON  MENTAL  HOSPITAL, 

DARTFORD,  KENT. 

Under  the  Management  of  a Committee  of  the  Corporation  of 
the  City  of  London. 

PBIVATE  PATIENTS  are  received  at  the  rate  of  28s.  and 
upwards  per  week. 

Apply  to  the  Medical  Superintendent. 


BARNWOOD  HOUSE  HOSPITAL  FOR 

MENTAL  DISEASES  near  GLOUCESTER 

Exclusively  for  private  Patients  of  the  Upper  and  Middle  Classes. 
This  institution  is  devoted  to  the  Care  and  Treatment  of  persons  of  both 
sexes  at  moderate  rates  of  payment.  Under  special  circumstances  the 
rates  of  payment  may  be  reduced  by  the  Committee.  For  further  lnfor- 
matlon  apply  to  Arthur  Townsend,  M.D.,  the  Med.  Supt  [Tel.  No.  7. 

ST R ETTON  HOUSE, 

Church-Stretton,  Shropshire. 


A Private  HOME  for  the  treatment  of  Gentlemen  suffering  from 
Mental  Diseases.  Bracing  hill  country.  See  " Medical  Directory,”  p.  2119. 
Apply  to  Medical  Superintendent.  Telephone:  10  P.O.  Church-Stretton 

WYE  HOUSE,  BUXTON. 

FOR  LADIES  AND  GENTLEMEN  MENTALLY 
AFFLICTED. 

Situated  1200  feet  above  sea  level.  Facing  south. 

For  terms,  &c.,  apply  to  the  Res.  Med.  Superintendent, 
W.  W.  Horton,  M.D. 

[Nat.  Tel.  130. 


The  Lancet,] 


THE  LANCET  GENERAL  ADVERTISER 


[Sept.  27,  1919 


NEW  SAUGHTON  HALL 

THE  ONLY  PRIVATE  HOSPITAL  for  the  TREATMENT  of  MENTAL  CASES  in  SCOTLAND 

POLTON,  MIDLOTHIAN. 

New  Sacghton  Hall,  which  takes  the  place  of  Saughton  Hall,  established  in  1798,  is  situated  seven  miles  south  of 
Edinburgh,  in  the  beautiful  neighbourhood  of  Hawthornden  and  Rosslyn,  and  is  surrounded  by  picturesque  and  well- 
timbered  pleasure  grounds  extending  to  125  acres.  There  is  also  a Seaside  House  at  Gullane,  East  Lothian. 

Railway  Stations — Polton,  five  minutes  ; and  Loanhead,  ten  minutes’  walk  from,  the  Institution — reached  in  half-an- 
hour  from  the  Waverley  Station,  Edinburgh.  Telephone — 4 Loanhead. 

Form,  of  admission  for  voluntary  or  certified  cases,  full  instructions,  &c. , can  be  obtained  on  application  to  the  Resident 
Medical  Superintendent,  J.  Batty  Tuke,  M.D.,  F.R.C.P.  Edin.  Inclusive  terms  from  £156  to  £500  per  annum,  according 
to  requirements. 


CAMBERWELL  HOUSE,  33,  PECKHAM  ROAD,  S.E. 

Telegrams:  “ Psycholia,  London.”  Telephone:  New  Cross  1067. 

For  tho  Treatment  of  Mental  Disorders. 

Completely  detached  Villas  for  Mild  Cases.  Voluntary  Boarders  received.  20  acres  of  grounds.  Cricket,  tennis,  croquet,  squash  racquet* , 
bowls,  and  all  ln-door  amusements.  An  Illustrated  Prospectus,  giving  full  Particulars  and  Terms,  may  be  obtained  on  application  to  the  Secretary. 
Senior  Physician:  Francis  H.  Edwards,  M.D.,  M.K.C.P. 

HOVE  VILLA,  BRIGHTON — A Convalescent  Branch  of  the  Above. 


PECKHAM  HOUSE  (“SST) 

112,  PECKHAM  ROAD,  LONDON,  S.E. 

Telegrams  “Alleviated,  London.”  Telephone : New  Cross  676 

An  Institution  licensed  for  the  CARE  and  TREATMENT  of  the  MENTALLY  AFFLICTED  of  Both  Sexes.  Conveniently  situated.  Electric 
trams  and  omnibuses  from  the  Bridges  and  West-End  pass  the  House.  Private  houses  with  electric  light  for  suitable  cases  adjoining  the 
Institution.  Holiday  parties  sent  to  the  Seaside  branch  at  Worthing  during  the  Summer  months.  Moderate  terms. — Apply  to  Medical 
Superintendent  for  further  particulars. 


N0RTHW00DS  HOUSE 

WINTERBOURNE,  near  BRISTOL, 


FOR  PRIVATE  TREATMENT  OF  MENTAL  DISEASES. 

Situated  In  a large  park  In  a healthy  and  plotnresqne  locality, 
easily  accessible  by  rail  via  Bristol,  Winterbourne,  Patohway,  or  Yate 
Stations.  Uncertified  Boarders  received.  For  further  information 
see  Medical  Directory,  page  2069.  Terms  moderate. 

Apply  to  Dr.  J.  D.  THOMAS,  Resident  Physician  and  Licensee,  for 
full  particulars. 


HAYDOCK  LODGE,  Newton  - le  - Willows,  LANCASHIRE. 

A PRIVATE  MENTAL  HOSPITAL  FOR  THE  CARE  AND  TREATMENT  OF  MENTAL  AND  NERVOUS  CASES  OF  BOTH  SEXES 
EITHER  VOLUNTARY  OR  UNDER  CERTIFICATES,  preference  being  given  to  Recoverable  Cases. 

Terms  from  £2  2s.  per  week  upwards.  Private  Apartments  on  special  terms. 

Situated  mid-way  between  Manchester  and  Liverpool.  Two  miles  from  Newton-le-Willows  Station  on  the  L.&N.W.Rly.,  and  close  to  Aahton-ln 
Makerfleld  Station  on  the  G.C.Rly.  In  direct  communication  with  Manchester. 

CONSULTING  ROOMS  (Dr.  Street),  47,  Rodney  Street,  Liverpool,  from  2 to  4 p.m.,  or  by  appointment.  Telephone:  2458  Royal  Liverpool.  Manchester 
(Dr.  Mould),  Winter’s  Buildings,  St.  Ann  Street,  on  Tuesdays  and  Thursdays,  from  12  to  1.30  p.m.,  or  by  appointment. 

Visiting  and  Consulting  Physicians.— 8Ir  JAMES  BARR,  LL.D.,  M.D.,  F.R.C.P.,  72,  Rodney  Street,  Liverpool;  W.  B.  WARRINGTON,  M.D, 
7.R.C  P , 83,  Rodney  Street,  Liverpool;  G.  E.  MOULD,  Physician  for  Mental  Diseases  to  the  Sheffield  Royal  Hospital,  The  Grange,  Rotherham. 

For  further  particulars  and  forms  of  admission  apply  Resident  Medical  Proprietor,  Haydock  Lodge,  Newton-le-Willows,  Lancs. 

Telegraphic  Address : “ Street,  Ashton-in-Makerfleld.”  Telephone:  11  Ashton-ln-Makerfleld. 


BRISLI  NGTON  HOUSE,  near  BRISTOL. 

Telegrams  : Fox,  Brislington.  ESTABLISHED  1S0U.  Telephone  : No.  2 Brisling  ton. 

A PRIVATE  MENTAL  HOSPITAL  for  the  Care  and  Treatment  of  Persons  of  the  UPPER  and  MIDDLE  CLASSES  of  BOTH  SEXES. 

The  House  is  situated  on  an  estate  of  200  acres,  and  has  extensive  Pleasure  Grounds  and  a Farm  connected  with  it.  It  lies  between  Bristol 
and  Bath,  three  miles  from  Bristol  Station  and  within  two-and-a  half  hours’  journey  from  London. 

In  addition  to  the  main  building  there  are  several  villas  completely  detached  and  pleasantly  situated  in  their  own  grounds,  where  there  is 
accommodation  for  suitable  cases.  Patients  can  be  received  without  certificates  as  Voluntary  Boarders. 

For  terms  and  further  particulars  apply  to  the  Medical  Superintendent. 


THE  ROYAL  EARLSWOOD  INSTITUTION  FOR  MENTAL  DEFECTIVES 

( Formerly  the  EARLSWOOD  ASYLUM.) 

REDHILL,  SURREY.  E.  C.  P.  HULL,  Esq.,  J.P.,  Treasurer. 

FOR  THOSE  REQUIRING  CONTROL  with  EXPERT  SUPERVISION  I SELECTED  CASES  admitted  on  reduced  Inclusive  fees.  THOSE 
and  needing  SPECIAL  TRAINING  In  useful  occupations.  UNABLE  TO  PAY  admitted  by  votes  of  Subscribers,  with  part- 

SCHOOLS,  FARMING,  and  various  TRADE  WORKSHOPS.  I payment  towards  cost. 

RECREATIONS  : ALL  outdoor  games,  EXCELLENT  BAND  by  Male  Staff,  for  Concerts,  Danelng,  &c. 

Apply  : The  Medical  Superintendent,  Earlswood,  Bedhlll,  Surrey,  or  to  the  Secretary,  Mr.  Harry  Howard,  14-167Ludgate  Hill,  B.G.  ♦. 
Telephone : Redhtll  344.  Telephone : City  6297. 


47 


The  Lancet,] 


THE  LANCET  GENERAL  ADVERTISER 


[Sept.  27,  191© 


NORTHUMBERLAND  HOUSE, 

Telegrams  GREEN  LANES,  FINSBURY  PARK,  N,  Telephone : 

" spbhldlakv,  Lownos."  (Established  1814.)  Ho.  888,  north. 

A PRIVATE  HOME  for  the  Treatment  of  Ladles  and  Gentlemen  suffering  from  Nervous  and  Mental  Affections.  Pour  miles  from  Char-tog 
Cross  ; eaBy  of  access  from  all  parts. 

Six  acres  of  ground,  highly  situated,  facing  Finsbury  Park. 

Voluntary  Boarders  received  without  certificate.  Seaside  Branch  at  Worthing. 

For  particulars,  apply  to  the  Resident  Physician. 


ST.  ANDREW’S  HOSPITAL 

DOLLIS  HILL,  LONDON,  N.W.  3. 

Telegrams  : Andrews  Hospital,  Cricklewood.  ’Phone  : Willesden  898. 

Rooms  for  PRIVATE  PATIENTS.  Wards  and  Cubicles  (at  inclusive  fees)  for  Gentlepeople  of  limited  means.  Medical 
and  Surgical,  but  not  mental,  contagious,  consumptive,  nor  chronic  cases.  Resident  Doctor. 

For  terms  apply  to  Matron. 


INEBRIETY.  [Telephone : 16  Rlckmansworth. 

DALRYMPLE  HOUSE,  RICKMANSWORTH,  HERTS. 

For  the  treatment  of  Gentlemen  nnder  the  Act  and  privately.  Established  1883  by  an  association  of  prominent  medical  men  and  others  fee 
the  study  of  Inebriety  ; profits,  If  any,  are  expended  on  the  Institution.  Large  secluded  grounds  on  the  banks  of  the  river  Colne  All  kinds  o4 
out-door  and  In-door  recreations  and  pursuits.— For  particulars,  apply  to  F.  S.  D.  Hogg,  M.R.C.S.,  Ac.,  Resident  Medical  Superintendent. 


MENDIP  HILLS  SANATORIUM,  for  the  open-air  treatment. 

Old-established,  beautifully  situated.  300  acres  of  Sanatorium  grounds.  Plnewoods  and  sheltered  avenues.  Altitude  860  feet.  Porou* 
subsoil.  Separate  chalets,  with  verandahs,  hot-water  radiators,  and  electric  light.  Special  features— breathing  an  graduated  exercises,  and 
continuous  inhalation.  Individual  attention.  Resident  Physician — 0.  uthu,  M.D.,  M.R.O.S.,  L.R.C.P. 

Terms  4 guineas  weekly.  For  particulars,  apply  SECRETARY,  Hillgrove,  Wells,  Somerset. 


M A T L OCK  SANATO R I U M 

Situated  on  the  edge  of  the  mountain  limestone  area  of  Derbyshire,  over  700  feet  above  sea-level.  The  buildings  face  south  and  command 
beautiful  views,  while  on  the  north  and  east  they  are  sheltered  by  lofty  hills.  The  surrounding  country  Is  well  known  for  Its  great  beauty  and 
Interest.  The  climate  Is  dry  and  bracing.  The  buildings  are  lighted  by  electricity  and  heated  by  radiators. 

Treatment  is  carried  out  on  modern  lines,  all  special  methods  being  available  In  suitable  cases.  A new  X-ray  apparatus  has  been  installed, 
and  there  Is  a complete  equipment  for  the  carrying  out  of  up-to-date  methods  in  all  Tubercular  and  other  Pulmonary  cases. 

For  particulars  apply  to  Frederick  Kincaid,  M.R.C.S.,  L.R.C.P.,  Medical  Superintendent,  Matlock  Sanatorium,  Matlock,  Derbyshire. 
Telephone  and  Telegraph  : Sanatorium,  Matlock  22. 


PENDYFFRYN  HALL  SANATORIUM 

(NORDRAOH-IN-W  ALES. ) 

Physicians : Dr.  G.  M.  DOBSON  and  Dr.  GERATY. 

FOR  THE  OPEN-AIR  AND  INOCULATION  TREATMENT  OF  ALL  FORMS  OF  TUBERCULOSIS. 

One  of  the  first  Sanatoria  opened  In  the  United  Kingdom  to  carry  out  the  treatment  as  practised  at  Nordrach.  Carefully  graduated 
w ilkB  rise  through  pine,  gorse,  and  heather  to  a height  of  over  1000  feet  above  sea  level,  commanding  extensive  views  of  both  sea  and 
mountains.  Sheltered  from  E.  and  N.E.  winds.  Climate  mild  and  bracing.  Small  rainfall.  Large  average  of  sunshine.  There  are  over  five 
miles  of  walks  in  the  private  grounds.  Rooms  heated  by  hot-water  radiators  and  lit  by  electric  light. 

Sister  and  full  Nursing  Staff.  Trained  Nurse  on  duty  all  night. 

Tileerams  : Perdyffrvn  ; and  Telephone  : 20  Penmaenmawr.  Apply,  Secretary,  Pendyffryn  Hall.  Penmaenmawr,  North  Wales 


DROITWICH  BRINE  BATHS  WARNING. 

The  Public  are  warned  that  the  full  benefits  of  tho  treatment  for  Rheumatism  and  kindred  complaints  CAN  ONLY  BE  OBTAINED  IN  TH  fa 
NATURAL  BRINE  BATHS  AT  DROITWICH,  FOR  WHICH  THERE  IS  NO  SUBSTITUTE.  LOVELY  HOLIDAY  DISTRICT.  GOOD 
H 3TBLS,  &c.  Illustrated  Booklet  Post-free  from  Baths  Manager,  J.  H.  Hodlyer,  46,  Spa  Enquiry  Offices,  Droitwieh  (Wares.).  SPECIAL 
FACILITIES  TO  MEDICAL  MEN, 


MONTANA 

Accommodation  for  150  patients. 
SUR  SIERRE, 
SWITZERLAND. 

TUBERCULOSIS  CURE 
STATION  (Opening  JUNE  1st) 

THE  FINEST  IN  EUROPE. 
5000  feet  high. 


Principal  Resident  Medical  Officer  : 
Bernard  Hudson,  M.D  Cantab., M.R.C.P., 
Late  Physician  to  the  Queen  Alexandra 
Sanatorium,  Davos  Platz. 


FULL  PARTICULARS  FROM  THE  SECRETARY,  5,  ENDSLEIGH  GARDENS,  LONDON,  N.W.  1. 


PALACE  HOTEL, 


48 


The  Lancet,] 


THE  LANCET  GENERAL  ADVERTISER 


[Sept.  27,  1919 


For  COMFORT  and  HEALTH  Visit 

The  CATERHAM  SANITARIUM 

“Battle Creek  System." 


Telephone : 88. 

Telegrams  : “ Hydro,  Caterham.” 


Medical  Superintendent : 
Dr.  F.  C.  Shone. 


SMEDLEY’S  HYDRO. 

- MATLOCK.  Established  1853. 

Physicians:  G.  C.  R.  Harblnson,  M.B.,  B.Ch. 

R.  MacLelland,  M.D.,  C.M.  (Rdln.) 
Prospeotus  and  full  Information  on  application  to  Managing  Director. 


INEBRIETY 


MELBOURNE  HOUSE,  LEICESTER 
PRIVATE  HOME  FOR  LADIES. 
Medical  Attendant:  Robert  Seyestre,  M.A.,  M.D.  Cantab. 
Principal:  Henry  M.  Riley,  Assoc.  Soc.  Study  of  Inebriety. 

Thirty  years’  Experience.  Excellent  Medical  References. 

For  Terms  and  Particulars,  apply  Miss  Rlley  or  Principal. 
Telegrams:  “Medical,  Leicester. Nat.  Telephone  : 769 

EPILEPSY.  THE  DAYID  LEWIS  COLONY. 

Stands  in  its  own  grounds  of  180  acres  and  is  situated  in  a beautiful 
part  of  Cheshire,  2i  miles  from  Alderley  Edge  Station,  and  14  miles 
from  Manchester.  Electric  light  throughout.  The  Colony  system 
ensures  the  social  life  and  employment  most  suitable  for  those  who 
suffer  from  Epilepsy.  Patients  certifiable  under  the  Lunacy  or  Mental 
Defective  Acts  are  not  eligible  for  admission.  Two  Resident 
Physicians.  Terms  for  Middle-  and  Upper-class  Patients,  from  38s. 
a week  upwards,  according  to  accommodation  and  requirements. 
Private  rooms  can  be  provided. 

For  further  Information  apply  to  the  Director,  Dr.  Alan  McDougall, 
Warford,  near  Alderlev  Edge.  Cheshire. 

EPILEPSY. 

olt  hurst  House  School, 

Warford,  Alderley  Edge 
Under  the  Management  of  the  Committee  of  the  David  Lewis  Colony.) 

Home  Life,  Medical  Care,  School  Education,  most  suitable  for  boys 
subject  to  Epilepsy.  Terms  38s.  weekly. 

Further  particulars  may  be  obtained  from  Dr.  Alan  McDougall, 
The  Colonv,  Warford.  Alderley  Edge. 


Telegraphic  Address : 

‘Relief,  Old  Oatton.” 


Telephone : 

‘ 290  Norwich." 


NERVOUS  & MENTAL  AFFECTIONS 

Ladies  only  received. 

^The  Grove,  Old  Catton,  Norwich. — 

JL  A High-class  Home  for  the  Curative  Treatment  of  Nervour 
Affections.  Voluntary  Boarders  are  also  received  without  certificates 
Nurses  supplied  to  take  charge  of  patients  under  the  care  of  their  owe 
medical  attendants.  For  full  particulars  apply  to  the  Misses  MoLlntook 
or  to  Cecil  A.  P.  Osburne,  F.R.C.S.E..  Medical  Superintendent. 

CLARENCE  LODGE 

CLARENCE  ROAD,  CLAPHAM  PARK. 

Stations  : Clapham  Road  and  Clapham  Common. 

A Licensed  Home  for  Mental  and  Nervous  Patients. 
Twelve  Ladies  only  received  for  treatment  under  eminent  Specialist 
and  given  individual  care  and  the  comforts  of  their  own  homes. 
Suitable  cases  received  as  voluntary  boarders.  The  house  is  surrounded 
by  well-wooded  grounds  ; shady  lawns  for  tennis,  croquet,  Ac. 

Associated  Rooms,  Private  Rooms,  or  Suites.  Very  moderate  terms. 
Illustrated  Prospectus  from  Resident  Licensee,  Mrs.  Thwaites. 
Telephone  : 494  Brixton. 

HOME  FOR  FEEBLE-MINDED, 

BRUNTON  HOUSE,  LANCASTER. 

There  are  now  a few  vacancies  in  this  well-appointed  private  estab- 
Jishment.  It  is  easily  accessible  from  Lancaster,  overlooks  Morecambe 
Bay,  and  possesses  extensive  gardens  and  grounds,  with  tennis  and 
croquet  lawns.  Varied  scholastic  and  manual  instruction.  Individual 
attention  is  given  to  pupils  by  experienced  staff  under  a Resident  Phy- 
sician and  Lady  Matron,  Terms  on  application  to  Dr.  W.  H.  Coupland. 

THE  WARNEFORD,  OXFORD. 

HOSPITAL  FOR  MENTAL  DISORDERS.- 

President : The  Right  Hon.  the  Earl  of  Jersey. 

This  Registered  Hospital,  for  the  Treatment  and  Care,  at  moderate 
charges,  of  Mental  Patients  belonging  to  the  educated  classes,  stands 
in  a healthy  and  pleasant  situation  on  Headington  Hill,  near  Oxford 
Voluntary  boarders  are  also  received  for  treatment.— For  further 
particulars  apply  to  the  Medical  Superintendent. 


CHEADLE  ROYAL. 


A HOSPITAL  FOR  MENTAL  DISEASES, 

C.H  E A I)  L B,  CHESHIRE. 

AND  ITS  SEASIDE  BRANCH, 

GLAN-Y-DON,  COLWYN  BAY, 

NORTH  WALES. 

The  object  of  the  above  is  to  provide  the  most  efficient  means  for 
the  oure  of  mental  diseases  in  those  who  belong  to  the  upper  and 
middle  classes. 

Voluntary  boarders  as  well  as  certified  patients  are  received  for 
treatment. 

For  terms  and  further  information  apply  to  the  Medical  Superin- 
tendent, W.  Scoworoft,  M.R.C.S.,  Ac. , at  Cheadle,  or  he  may  be  seen 
at  72,  Bridge-street,  Manchester,  on  Tuesdays  and  Fridays  from  2 to  3. 
Telephone  : 208  “Cheadle  Hulme."  3594  “ Manchester.” 

Grove  House,  AH  Stretton,  Church 

STRETTON,  SHROPSHIRE. 

A PRIVATE  HOME  for  the  Care  and  Treatment  of  a limited  numbor 
of  Ladies  Mentally  Afflicted. 

Climate  healthy  and  bracing. 

Apply  to  Dr.  McOlintock,  Proprietor  and  Resident  Medical  Super- 
intendent. 

Home 

(Certified',  Female,  in  house  of  Medical  Man  in  West  of 
England.  Terms  about  £8  8s.  a week. — Apply,  Mr.  Percival  Turner, 
4,  Adam-street,  Adeiphl,  Strand.  W.C.  2. 

Doctor  (young),  experienced,  has 

VACANCY,  Mental,  Nerve  Convalescent.  Charming  residence 
near  sea ; 4 acres  shady  lawns,  tennis,  croquet,  bowls,  golf,  billiards, 
bridge,  music.— Address.  No.  966.  The  Lancet  Office.  423,  St  land,  W.C.  2. 

Home  for  Chronics  and  Maternity 

CASES.  From  £5  5s.  per  week  upwards.  Nurses  supplied  at 
short  notice  to  any  part.  Tel  : Otley  67.— Apply,  Matron,  Wharfedale 
Nursing  and  Nurses'  Home,  Leeds-road,  Otley,  Yorks. 

TJesident  Patients. — Descriptive  List 

-A-lJ  (Illustrated)  of  Medical  Men  in  all  parts  willing  to  receive 
Resident  Patients  sent  without  charge.  Or  selection  will  be  made  on 
statement  of  nature  of  case  and  terms  to  the  General  Manager,  Scholastic, 
Clerical  & Medical  A^-sn., Ltd. ,22,  Craven-street,  Trafalgar  square,  W.C.  2. 

would  be  glad  to  hear  of 


wanted  for  Mental  Case 


Medical  Man  willing  to  take  RESIDENT  PATIENT— gentleman 
suffering  from  Neurasthenia.  No  other  patients  preferred.  Fees  must 
not  exceed  guineas  per  week,  but  comfortable  home  suitable  to 
gentleman  of  refined  tastes  essential.  London  or  near  London  preferred. 
— Apply.  Mrs.  W.,  138,  Lexham-gardens.  W.8. 


L)sycho-Therapy. — Medical  Man,  now 

JL  demobilised,  with  nearly  twenty  years’  experience,  is  prepared 
to  take  NBURAaTHBNIC  or  PSYCHASTHENIC  ADULTS  and 
CHILDREN  in  his  own  home  in  a cathedral  town  near  the  South 
Coast.  — For  terms  aud  full  particulars,  apply  to  the  sole  agent, 
Mr.  Percival  Turner,  4,  Adam-street.  Adelphi,  Strand,  W.C.  2. 

IN  BEAUTIFUL  COUNTRY.  18  MILES  FROM  LONDON. 

Littleton  Hall,  Brentwood,  Essex 

(400  feet  above  sea-level).  A HOME  for  a few  LADIES 
Mentally  Afflicted.  Large  grounds.  Liverpool  street  half  an  hour. 
Stations : Brentwood  one  mile ; Shentield  one  mile.  Voluntary 

Boarders  received.  Vacancy.— For  terms,  &e.,  apply  Dr.  Haynes. 
Telephone  and  Telegrams  : Haynes.  Brentwood  45. 

A Medical  Man,  married  with  no 

children,  residing  in  an  exceptionally  pretty  and  healthy  country 
town  in  the  West  Midlands,  700  feet  above  sea  level,  is  willing  to  take  as 
a RESIDENT  PATIENT  a lady  or  gentleman  requiring  trealment  for 
any  condition.  Mental  or  Physical.  Convenience  for  various  forms  of 
electric  treatment  or  massage  in  the  house.  Gravel  soil,  perfect 
drainage,  pure  soft  water.  Motor-oar  kept.  Advertiser  is  a Cambridge 
graduate  between  fifty  and  sixty  years  of  age  who  has  had  special 
experience  of  mental  and  nervous  complaints. — Address,  No.  524, 
The  Lancet  Office.  423,  Strand.  W.C.  2. 

Surgical  Registrars. — The  Committee 

of  the  ROYAL  NATIONAL  ORTHOPAEDIC  HOSPITAL  invite 
applications  for  the  post  of  Surgical  Registrar.  Two  appointments  will 
b«  made.  Applications,  with  copies  of  testimonials,  should  reach  the 
Secretary,  234,  Great  Portland-9treet,  W.  1,  not  later  than  October  4th. 
Honorarium  100  guineas  per  annum.  Further  particulars  may  be 
obtained  on  application  to  the  Secretary.  

W/Tllesden  Urban  District  Council. — 

I Y Appointment  of  Two  DENTISTS.— The  Willesden  Urban 
District  Council  require  the  services  of  Two  Dentists  for  work  in 
connection  with  Maternity  and  Child  Welfare  and  School  Children. 
Both  appointments  are  whole-time. 

The  salary  is  £400- £500  by  £25  annual  increments. 

Forms  of  application  may  be  obtained  from  the  undersigned,  to  whom 
they  must  be  returned  not  later  than  the  14th  October.  1919. 

George  F.  Buchan,  Medical  Officer  of  Health. 
Municipal  Offices,  Dyne-road,  Kilburu,  N.W.6. 

49 


Thb  Lancet,] 


THE  LANCET  GENERAL  ADVERTISER 


[Sept.  27, 1919 


Hospital  for  Epilepsy  and  Paralysis, 

Maida  Vale,  W.-HONORARY  PSYCHOLOGIST  required. 
Applications  are  invited  for  the  post  of  Honorary  Psychologist  to  the 
above  Hospital. 

Applications,  giving  age  and  full  particulars,  must  be  accompanied 
by  copies  of  three  recent  testimonials  and  reach  the  undersigned  by 
Wednesday,  October  8th. 

H.  W.  Burlkigh,  Secretary  and  General  Superintendent. 

Hospital  for  Epilepsy  and  Paralysis, 

Maida  Vale,  W.— HONORARY  OPHTHALMIC  SUKGBON 
required. 

Applications  are  invited  for  the  post  of  Honorarv  Ophthalmic 
Surgeon  to  the  above  Hospital.  Candidates  must  be  Fellows  of  the 
Royal  College  of  Surgeons,  England,  and  will  be  required  to  attend  the 
Hospital  on  one  morning  a week. 

Applications,  giving  age  and  full  particulars,  must  be  accompanied 
by  copies  of  three  recent  testimonials  and  reach  the  undersigned  by 
Wednesday,  October  8th. 

H.  W.  Burleigh,  Secretary  and  General  Superintendent. 

TTospital  for  Epilepsy  and  Paralysis, 

_LJ_  Maida  Vale,  W.-HONOIURY  ASSISTANT  PHYSICIAN 
required. 

Applications  are  invited  for  the  post  of  Honorary  Assistant  Physician. 
Candidates  must  be  Fellows  or  Members  of  the  Hoyal  College  of 
Physicians  and  Graduates  of  a University. 

Applications,  giving  age  and  full  particulars,  must  be  accompanied 
by  copies  of  three  recent  testimonials  and  reach  the  undersigned  by 
Wednesday,  October  8th. 

H.  W.  Burleigh,  Secretary  and  General  Superintendent. 

"NTational  Hospital  for  tlie  Paralysed 

A.  1 and  EPILEPTIC.— RADIOLOGIST. — The  Board  of  Manage- 
ment will  proceed  shortly  to  appoint  a Radiologist,  and  are  inviting 
applications  from  duly  qualified  gentlemen,  which,  accompanied  by 
recent  testimonials,  should  be  addressed  to  the  Secretary,  National 
Hospital  for  the  Paralysed  and  Epileptic,  Queen-square,  W.C.  1,  from 
whom  all  particulars  may  be  obtained,  on  or  before  October  6th,  1919. 
Godfrey  H.  Hamilton,  Secretary. 

ondon  Hospital,  Whitechapel,  E.  1. 

.1  J GENITO  URINARY  DEPARTMENT.— A qualified  CLINICAL 
ASSISTANT  is  required  for  the  Women's  Section.  He  or  she  is  to 
attend  two  Sessions  per  week— on  Wednesday  and  Saturday  afternoons 
from  2 P.M.  to  5 p.m. 

Remuneration  is  at  the  rate  of  One  Guinea  per  session,  and  the 
appointment  is  for  six  months. 

Apply,  giving  former  experience,  to  the  House  Governor,  London 
Hospital,  E.  L 

rrhe  Italian  Hospital,  Queen-square, 

1 London,  W.C.  1. — The  Committee  of  Management  invite  appli- 
cations for  the  post  of  HONORARY  OPHTHALMIC  SURGEON. 
Candidates  must  be  Fellows  of  a Surgical  College  the  degrees  of  which 
are  recognised  by  the  British  Medical  Council,  or  possess  equivalent 
degrees  from  a Royal  Italian  University,  and  they  shall  have  their 
names  on  the  British  Medical  Register.  Applications,  with  copies 
(only)  of  testimonials,  should  be  sent  to  the  Secretary  and  Controller 
on  or  before  Saturday,  the  4th  October. 

rrhe  Belgrave  Hospital  for  Children 

(Incorporated),  Clapham-road,  S.W.9.  — The  Committee  of 
Management  invite  applications  for  Two  ASSISTANT  PHYSICIANS. 

Candidates  must  be  Graduates  in  Medicine  of  an  English  University 
and  Fellows  or  Members  of  the  Royal  College  of  Physicians  of  London. 
Applications,  with  copies  of  testimonials,  must  be  delivered  to  the 
undersigned  by  Monday,  13th  October,  1919,  from  whom  further 
Information  may  be  obtained.  By  order. 

Thomas  Clapham,  Secretary. 

A pplications  are  invited  for  the  office 

XI  of  ASSISTANT  ANESTHETIST  to  the  MIDDLESEX 
HOSPITAL,  W.  1.  Candidates,  who  must  be  fully  qualified  Medical 
Practitioners,  are  requested  to  send  their  applications  and  a copy  of 
their  testimonials  to  the  undersigned  not  later  than  Monday, 
October  6th.  The  appointment  is  an  annual  one  and  the  selected 
candidate  will  be  expected  to  take  up  the  duties  of  the  office  at  once. 

By  order  of  the  Weekly  Board. 

Walter  Kewley, 

Secretary-Superintendent. 

Tffie  Hospital  for  Women,  Solio- 

square,  W.  1.— The  Committee  are  desirous  of  appointing  an 
Honorary  Medical  Officer  as  PHYSICIAN  CONSULTANT  to  the  Hos- 
pital, and  applications  are  hereby  Invited  for  the  post.  Candidates 
must  be  Fellows  or  Members  of  one  of  the  Royal  College  of  Physicians 
of  the  United  Kingdom,  and  on  the  Honorary  Medical  Staff  of  a London 
General  Hospital. 

Applications  and  testimonials  must  be  forwarded  to  the  undersigned 
(from  whom  furtherinformation  may  be  obtained)  on  or  before  Tuesday, 
October  21st.  1919.  ' Alfred  Hayward.  Secretary. 

rphe  Hospital  for  Women,  Soho- 

JL  square,  W.  1.— A vacancy  having  occurred  in  the  office  of 
HONORARY  MEDICAL  OFFICER  in  charge  of  Out-patients,  appli- 
cations are  hereby  invited  for  the  post.  Candidates  must  he  Graduates 
In  Medicine  of  a recognised  University,  and  Fellows  of  one  of  the  Royal 
Colleges  of  Surgeons  of  the  United  Kingdom. 

Applications  and  testimonials  must  be  forwarded  to  the  undersigned 
(from  whom  further  information  may  be  obtained)  on  or  before  Tuesday, 
October  21st,  1919.  Alfred  Hayward,  Secretary. 

50 


Hospital  for  Consumption  and 

DISEASES  of  the  CHEST,  Brompton,  S.W. — A vacancy 
having  occurred  in  the  office  of  SURGEON,  the  Committee  of  Manage- 
ment invite  applications  for  the  post.  Candidates  are  requested  to 
send  in  applications  and  testimonials  on  or  before  Thurpday, 
October  16th,  1919.  They  must  be  Fellows  of  the  Royal  College  of 
Surgeons  of  England,  and  hold  the  appointment  of  Surgeon  or 
Assistant  Surgeon  at  a General  Hospital  in  London. 

Brompton.  September,  1919.  Fredcrick  Wood,  Secretary. 

TT  ospital  for  Consumption  and 

J L DISEASES  of  the  CHEST,  Brompton,  S.W.—  The  Committee 

of  Management  invite  applications  for  the  post  of  HOUSE  PHY- 
SICIAN (for  which  there  are  three  vacancies).  The  duties  include 
work  in  the  Out-patient  Department  as  well  as  in  the  wards.  Further 
particulars  may  be  obtained  from  the  undersigned,  to  whom  applica- 
tions, with  testimonials,  should  be  addressed.  The  appointment  la 
for  six  months,  with  an  honorarium  of  30  guineas. 

Applications  received  from  qualified  Women. 

September.  1919. Frederick  Wood,  Secretary. 


TT  ospital  for  Consumption  and 

_l L DISEASES  of  the  CHEST,  Brompton,  S.W. —The  Committee 

of  Management  Invite  applications  for  the  post  of  ASSISTANT 
RESIDENT  MEDICAL  OFFICER.  Candidates,  who  will  be  required 
also  to  undertake  the  duties  of  a House  Poysician,  must  be  Registered 
Practitioners,  and  must  have  held  a resident  Hospital  appointment  for 
six  months.  Salary  £150  per  annum,  with  board  and  residence. 
Applications,  with  testimonials,  to  be  sent  in  on  or  before  October  I6th, 
1919. 

Brompton,  September,  1919.  Frederick  Wood,  Secretary. 

Hospital  for  Consumption  and 

DISEASES  of  the  CHEST,  Brompton,  S.W.— Vacancies  haring 
occurred  in  the  office  of  ASSISTANT  PHYSICIAN,  the  Committee  of 
Management  Invite  applications  for  the  post.  Candidates  are  requested 
to  send  in  applications  and  testimonials  not  later  than  Thursday, 
October  16th,  1919.  They  must  be  Doctors  or  Bachelors  of  Medicine, 
and  Fellows  or  Members  of  the  Hoyal  College  of  Physicians  of  London. 
A successful  candidate  is  also  eligible  for  appointment  as  Assistant  in 
the  Clinical  Laboratories  at  a remuneration  of  £250  per  annum. 
Brompton,  September,  1919 Frederick  Wood,  Secretary. 

TT  ospital  for  Consumption  and 

_l L DISEASES  of  the  CHEST,  Brompton,  S.W. —The  Committee 

of  Management  invite  applications  for  the  post  of  Whole-time 
ASSISTANT  in  the  Department  of  Pathology.  Candidates  must  be 
duly  qualified.  Preference  will  be  given  to  aoplicants  who  have  had 
previous  experience  in  Bacteriological  and  Pathological  technique. 
Further  particulars  may  be  obtained  at  the  Hospital.  Salary  £250  per 
annum.  Applications,  with  testimonials,  to  be  sent  in  on  or  before 
October  16th,  1919. 

Brompton,  September,  1919. Frederick  Wood,  Secretary. 

TT  ospital  for  Consumption  and 

J L DISEASES  of  the  CHEST.  B-orapton.  S.W. —The  Committee 

of  Management  invite  applications  for  the  postof  Part-time  ASSISTANT 
in  the  Department  of  Pathology.  Candidates  will  be  required  to  have 
had  special  training  in  Bio  chemical  methods.  The  appointment  is 
being  made  with  a view  to  encouraging  research  into  chemical  problems 
in  connexion  with  Tuberculosis.  Further  particulars  may  be  obtained 
at  the  Hospital.  Salary  £250  per  annum.  Applications,  with  testi- 
monials, to  be  sent  in  on  or  before  October  16th,  1919. 

Brompton,  September,  1919. Frederick  Wood.  Secretary. 

Brompton  Hospital  Sanatorium, 

Frimley.— The  Committee  of  Management  of  the  Hospital  for 
Consumption  and  Diseases  of  the  Chest,  Brompton,  S.W.,  invite 
applications  for  the  post  of  MEDICAL  SUPERINTENDENT  at  the 
Sanatorium.  Salary  £600  per  annum,  with  board  and  residence. 
Candidates  must  be  qualified  to  practise  medicine  and  surgery  and  be 
duly  registered.  Applications,  with  testimonials,  to  be  sent  in  not 
later  than  Thursday,  16th  October,  1919.  Further  particulars  may  be 
obtained  upon  application  to  the  Secretary  at  the  Hospital. 

Brompton,  September,  1919. Frederick  Wood,  Secretary. 

Q1 

LD  shortly,  an  ASSISTANT  MEDICAL  OFF'ICEE  (Male),  whose 
main  duties  would  be  concerned  with  Tuberculosis.  The  Ward  con- 
sists of  some  90  beds  (average  occupied  about  70-80),  and  are  under  the 
medical  supervision  of  Dr.  Halliday  Sutherland,  Visiting  Physician  to 
the  Tuberculosis  Wards. 

The  cases  include  every  phase  of  Tuberculosis,  and  the  appointment 
provides  a wide  experience  which  would  qualify  for  other  posts  tn  the 
Tuberculosis  Service.  Salary  £200  a year,  all  found.  Garden.  Quiet 
quarters.  Good  off-duty  time.  Apply,  Medical  Superintendent,. 
St,  Marylebone  Infirmary,  Rackham-street,  Ladbroke-grove,  W.  10. 

t.  Marylebone  General  Dispensary, 

77,  Welbeck-street,  Cavendish-square,  W.  1.— A vacancy  having 
occurred  in  the  office  of  RESIDENT  MEDICAL  OFFICER  to  this 
Institution,  the  Directors  are  prepared  to  receive  applications  for  the- 
vacant  office.  Candidates  must  be  registered,  and  hold  a Medical  and 
Surgical  qualification.  Salary  £150  per  annum,  with  furnished  apart- 
ments, attendance,  coals,  and  light.  The  appointment  is  for  one  year, 
the  occupant  being  eligible  to  become  a candidate  lor  re-election  on  the 
vacancy  being  advertised.  Written  applications  and  testimonials  to  be 
forwarded  not  later  than  Monday,  October  6th,  and  candidates  must 
attend  the  Medical  Committee  at  the  Dispensary  on  Wednesday, 
8th  October,  at  4.30  p.m.  precieely.  This  appointment  is  suitable  lor  a 
gentleman  reading  for  a higher  examination.  :— - 

22nd  September,  1919.  Hugh  Stokes,  Secretary. 


[t.  Marylebone  Infirmary. — Wanted 


S 


Thk  Lancet,] 


THE  LANCET  GENERAL  ADVERTISER 


[Sept.  27,  1919 


"Doyal  Free  Hospital,  Gray’s  Inn-road, 

H W.C.  1. — Applications  aie  Invited  for  the  poet  of  HONORARY 
ANAESTHETIST.  Information  with  regard  to  the  times  of  duty  may 
be  obtained  from  the  Secretary,  to  whom  applications  should  be 
addressed  on  or  before  October  4th,  1919.  __ 

Doyal  Free  Hospital, Gray’s  Inn-road, 

1 I)  W.C.I.— Applications  are  invited  from  duly  qualiiied  and  regis- 
tered Practitioners  for  the  post  of  CASUALTY  OFFICER.  Salary  £100 
per  annum,  with  residence.  Duties  to  commence  on  the  iBt  November, 
1919.  Applications,  stating  age,  with  three  copies  of  recent  testimonials, 
should  be  sent  to  the  Secretary  on  or  before  October  4th,  1919. 

Reginald  R.  Garratt,  Secretary. 

"Doyal  Free  Hospital,  Gray’s  Inn-road, 

JLl)  W.C.  1. — Applications  are  invited  for  the  post  of  SURGICAL 
REGISTRAR.  Duties  to  commence  on  the  1st  November,  1919.  Candi- 
dates, who  must  be  fully  qualified,  must  apply,  stating  age,  qualifica- 
tions, and  experience,  accompanied  by  copies  of  three  testimonials  and 
addressed  to  the  Secretary,  on  or  before  October  4th,  1919. 
Reginald  R,  Garratt,  Secretary. 

nphe  Anti-Vivisection  Hospital,  the 

JL  BATTERSEA  GENERAL  HOSPITAL  (Incorporated),  Battersea 
Park,  S.W.  11. -RESIDENT  MEDICAL  OFFICER  wanted  for  Cancer 
Wing,  to  work  under  Honorary  Specialist's  supervision.  Some  know- 
ledge of  Electro-Therapy  essential.  Commencing  salary  £200,  with 
board,  lodging,  laundry,  &c.  Apply  by  letter,  with  copies  of  three 
recent  testimonials,  to  Secretary. 

The  Mothers’  Hospital, 

153-163,  Lower  Clapton-road,  E.  5. 

A RESIDENT  MEDICAL  OFFICER  is  required  at  this  Maternity 
Hospital  and  School  of  Midwifery.  Commissioner  Adelaide  Cox,  The 
Salvation  Army  Women’s  Social  Work  Headquarters,  280,  Mare-street, 
Hackney,  E.  8,  desires  to  meet  with  a Christian  woman  for  this 
important  sphere  of  useful  service. 

Manor  House  Orthopaedic  Hospital. 

The  Committee  of  Management  require  a RESIDENT 
SURGICAL  OFFICER  at  £500  per  annum,  with  board.  The  position 
carries  the  duties  of  Surgical  Registrar,  the  seeing  of  out-patients  and 
admission  of  new  cases.  Applications  must  reach  the  Secretary  on  or 
before  17th  October.  Bernard  Gilbert,  Secretary,  Manor  House 
Orthopaedic  Hospital,  North  End-road,  Hampstead,  N.W.3. 


Paddington  Green  Children’s 

HOSPITAL,  London.  W.2. 

HOUSE  PHYSICIAN.  HOUSE  SURGEON. 

These  appointments  will  become  vacant  on  1st  November,  1919. 
Salary  of  House  Physician  £150,  and  House  Surgeon  £150  a year,  with 
board,  residence,  and  washing. 

Applications,  with  copies  of  three  testimonials,  must  be  sent  in  to 
the  undersigned  not  later  than  the  9th  < letober. 

24th  September,  1919. F.  Stanley  Cheer,  Secretary. 


The  London  Lock  Hospital  and 

RESCUE  HOME, 

283,  Harrow-road,  W.  9,  and  91,  Dean-street,  W.  1. 

HON.  SURGEON  TO  OUT-PATIENTS. 

Candidates  for  this  appointment  are  requested  to  send  in  their 
applications,  with  not  more  than  three  copies  of  testimonials,  to  the 
Secretary,  at  283,  Harrow-road,  W.  9,  not  later  than  October  6th,  1919. 
The  election,  which  is  by  ballot  of  the  Governors,  will  be  duly  announced 
to  the  candidates.  No  personal  canvassing  of  the  Board  or  Medical 
Staff  permitted.  Candidates  must  be  Fellows  of  the  Royal  College  of 
Surgeons  (Eng.)  By  order  of  the  Board. 

Sept.  20th,  1919. Hy.  J.  Eason,  Secretary. 

/bounty  of  London. — Appointment  of 

VV  CORONER  for  the  South-Eastern  District  of  the  County  of 
London.— The  London  County  Council  invites  applications  from  duly 
qualified  persons  for  the  appointment  of  Coroner  for  the  South-Eastern 
District  of  the  County  of  London.  The  salary  attached  to  the  office  is 
£1186  4s.  a year. 

The  Coroner  will  be  required  to  provide  the  necessary  office  accom- 
modation and  clerical  assistance,  and  also  to  defray  all  other  expenses 
of  the  office  (including  the  services  of  an  approved  deputy),  except  the 
actual  disbursements  under  the  Council’s  schedule  of  fees,  allowances, 
and  disbursements  made  at  the  holding  of  an  inquest. 

The  duties  of  Coroners  are  regulated  by  the  Coroners  Act,  1887,  and 
other  Acts.  Section  12  of  the  Coroners  Act,  1887,  provides  that  “ Every 
Coroner  for  a county  shall  be  a fit  person,  having  land  in  fee  sufficient 
in  the  same  county  whereof  he  may  answer  to  all  manner  of  people.” 
Preference  will  be  given  to  persons  who  have  served  or  attempted  to 
serve  with  the  Forces  of  the  Crown. 

Candidates  must  possess  either  a legal  or  a medical  qualification,  and 
the  candidate  appointed  will  be  required  to  give  an  undertaking  that 
he  will  devote  his  whole  time  to  the  duties  of  his  office,  and  that  he  will 
agree  to  any  future  scheme  that  may  be  formulated  by  the  Council 
affecting  the  salaries  and  duties  of  coroners. 

Appliealions  must  be  made  on  the  official  form  which  can  be  obtained 
from  the  Clerk  of  the  London  County  Council,  County  Hall,  Spring 
Gardens,  S.W.  1.  The  latest  time  for  receiving  applications  is  11  a.m. 
on  Monday,  6th  October,  1919. 

Candidates  must  be  British  subjects,  and  it  is  desirable  that  they 
should  not  be  under  tbirty-five  or  over  fifty  years  of  age. 

Canvassing  of  members  of  the  Council,  either  directly  or  indirectly 
will  be  held  to  be  a disqualification  for  the  appointment. 

James  Bird,  Clerk  of  the  London  County  Council, 


St.  Bartholomew’s  Hospital. — 

ASSISTANT  ADMINISTRATOR  OF  ANESTHETICS  (non- 
resident).—The  Committee  invite  applications  for  the  abo>  e office. 
Candidates  must  be  registered  Practitioners.  Applications,  with  testi- 
monials, must  be  left  with  the  undersigned,  from  whom  further  parti- 
culars may  be  obtained,  on  or  before  Monday,  the  6th  October,  1919.  ;r 
September,  1919. Thomas  Haves,  Clerk  to  the  Governors. 

Queen  Mary’s  Hospital  for  the  East 

END.  Stratford,  I?  15.— Applications  are  invited  for  the  post  of 
HOUSE  SURGEON  at  the  above  Institution.  Salary  at  the 
rate  of  £150  per  annum,  with  board,  apartments,  and  washing.  The 
work  of  the  Hospital  includes  Eye,  Ear,  Nose  and  Throat,  and 
Maternity  Departments. 

Applications  to  be  sent  at  once  to  the  undersigned. 

A.  W.  Scrivener,  Secretary. 


rph 


e Prince  of  Wales’s  General  Hos- 
pital, Tottenham,  N.  15.— Applications  are  invited  for  the 
following  posts,  vacant  on  the  15th  October  next : — 

HOUSE  PHYSICIAN.  £200  per  annum. 

HOUSE  SURGEON.  £200  per  annum. 

JUNIOR  HOUSE  SURGEON.  £120  per  annum. 

JUNIOR  HOUSE  PHYSICIAN.  £120  per  annum, 
with  residence,  board,  and  laundry. 

The  appointments  are  from  15th  October  to  15th  April,  1920. 
Candidates  (Male)  must  be  duly  qualified  and  registered,  and  applica- 
tions, together  with  copies  of  three  recent  testimonials,  to  be  sent  to 
me  on  or  before  the  30th  September  next. 

September  16th,  1919.  Fredk.  W.  Drewett,  Director. 

Bethlem  Royal  Hospital. — In  con- 

nexion  with  the  above,  another  Hospital  has  been  established 
(quite  apart  from  the  main  buiiding)  at  52,  Lambeth-road,  S.E.  1,  for 
the  treatment  of  early  cases  of  neurological  and  psychiatrical  interest. 
Applications  are  invited  for  the  post  of  HONORARY  NEUROLOGIST, 
Candidates  must  be  duly  registered  Practitioners  and  either 
Graduates  of  a University  or  Fellows  or  Members  of  the  College  of 
Physicians.  Further  particulars  in  regard  to  the  appointment,  if 
desired,  will  be  furnished  by  the  undersigned,  to  whom  applications, 
accompanied  by  copies  of  testimonials,  must  be  forwarded  on  or  before 
Monday,  October  6th.  John  L Worsfold,  Clerk. 

Bridewell  Roval  Hospital.  New  Bridge-street,  E.C.4. 

Bethlem  Royal  Hospital,  Lambeth- 

road,  S.E.  — Wanted,  JUNIOR  ASSISTANT  PHYSICIAN. 
Candidates  for  this  office  must  be  fully  qualified  Medical  Practitioners, 
possessed  both  of  Medical  and  Surgical  qualifications  as  required  for 
registration  by  the  General  Council  of  Medical  Education,  provided 
they  be  either  Members  of  a British  College  of  Physicians  or  Graduates 
in  Medicine  of  a British  University  recognised  by  the  aforesaid  Council, 
unmarried,  and  not  exceeding  thirty  years  of  age. 

The  salary  will  be  £350  per  annum,  with  annual  increments  of  £30, 
subject  to  the  approval  of  the  Court,  to  £500  per  annum,  apartments  in 
the  hospital,  complete  board,  and  laundry  being  provided. 

All  applications  and  testimonials  must  be  accompanied  by  answers 
to  a printed  form,  which  with  a copy  of  the  duties  may  be  obtained  at 
my  office  here,  and  such  applications,  &c.,  must  be  forwarded  to  me  on 
or  before  October  6th.  Candidates  are  required  to  present  themselves 
before  the  Medical  Committee  at  Bethlem  Hospital  on  Wednesday, 
October  8th,  at  2.15  p.m.  John  L.  Worsfold,  Clerk. 

Personal  canvassing  not  allowed. 

Bridewell  Roval  Hospital,  New  Bridge-street,  E.C.  4. 

The  Hospital  for  Sick  Children* 

Great.  Ormond-street,  W.C.  1.  — A RESIDENT  MEDICAL 
SUPERINTENDENT  is  required  on  the  13th  October,  1919. 

Candidates  are  invited  to  send  in  their  applications,  addressed  to  the 
Secretary,  before  12  o’clock  on  Monday,  the  6th  October,  accompanied 
by  copies  of  not  more  than  three  testimonials  given  specially  for  the 
purpose. 

The  appointment  is  made  for  one  year,  but  may  be  held  subject  to 
re-election  for  a period  of  three  years.  Salary  £200  per  annum,  with 
board  and  residence  in  the  Hospital,  and  £5  washing  allowance. 

Candidates  must  be  registered  Medical  Practitioners,  and  must  have 
held  a responsible  Hospital  appointment. 

All  candidates  must  appear  before  the  Joint  Committees  at  their 
meeting  on  Wednesday,  8th  October,  at  5 p.m.  precisely. 

Forms  of  application  and  copies  of  the  rules  may  be  obtained  from 
the  Secretary  at  the  Hospital. 

By  order  of  the  Committee  of  Management. 

September,  1919.  James  McKay,  Acting  Secretary. 


nphe  Hospital  for  Sick  Children, 

_I_  Great  Ormond-street,  W.C.  1.— The  following  Resident  appoint- 
ments will  shortly  be  vacant  :— 

ASSISTANT  CASUALTY  MEDICAL  OFFICER,  13th  October,  1919, 

HOUSE  SURGEON,  1st  November,  1919 

HOUSE  PHYSICIAN,  1st  November.  1919. 

Candidates  are  invited  to  send  in  their  applications,  addressed  to  the 
Secretary,  belore  12  o'clock  on  Monday,  6th  October,  1919,  with  copies 
of  not  more  than  three  testimonials  given  specially  for  the  purpose, 
and  also  evidence  of  their  having  held  a responsible  Hospital 
appointment. 

The  appointment  is  made  for  six  months.  Salary  £50,  washing 
allowance  £2  10s.,  and  board  and  residence  in  the  Hospital. 

Candidates  must  be  unmarried  and  possess  a legal  qualification  to 
practise. 

All  candidates  must  appear  before  the  Joint  Committees  at  their 
meeting  on  Wednesday,  8th  October,  at  5 p.m.  precisely. 

Forms  of  application  and  copies  of  the  rules  may  be  obtained  from 
the  Secretary. 

By  order  of  the  Committee  of  Management. 

September,  1919.  James  McKay,  Acting  Secretary, 

51 


The  Lanoet,] 


THE  LANCET  GENERAL  ADVERTISER 


[Sept.  27.  1919 


onorary  Physician.  — The  Com- 

raitteeof  tae  ROYAL  NATION  AL  O RTHOPAiDIC  HOSPITAL 
invite  applications  for  the  appointment  of  Honorary  Physician. 
Applications,  with  copies  of  testimonials,  should  reach  the  Secretary, 
234,  Great  Portland-street,  W.  1,  not  later  than  Saturday,  October  4th. 


TTospital  for  Diseases  of  the  Throat, 

J L Golden-square,  W.  I. — Applications  are  invited  for  the  appoint- 

ment of  HONORARY  ASSISTANT  SURGEONS. 

Candidates  must  be  registered  Medical  Practitioners. 

Applications,  accompanied  by  copies  of  three  recent  testimonials, 
■should  be  sent  to  me  not  later  than  Saturday,  October  25th. 

By  order.  Wm.  Holt,  Seey.-Supt. 


TTampstead  General  and  North-West 

J_JL  LONDON  HOSPITAL,  Haverstock-hill,  N.W.  3. — The  Council 
Invite  applications  : — Two  PHYSICIANS  TO  OUT-PATIENTS, 
PHYSICIAN  FOR  DISEASES  OF  THE  SKIN.  Candidates  must  be 
Members  or  Fellows  of  the  Royal  College  of  Physicians,  London. 

Applications,  Ac.,  should  reach  the  Secretary  not  later  than  Friday, 
October  10th. 


T/fount  Vernon  Hospital  for  Con- 

-LyI  SUMPTION  and  DISEASES  of  the  CHEST,  Northwood, 
Middlesex.— An  ASSISTANT  RESIDENT  MEDICAL  OFFICER  is 
required.  Applicants  must  be  fully  qualified  and  registered.  Salary 
£200,  with  board,  lodging,  washing,  Ac. 

Applications,  with  copies  of  testimonials,  to  W.  J.  Morton,  Secretary 
Offices,  7,  Fit zroj -square,  W.  1. 


orcestersliire  Asylum,  Barnsley 

Hall,  Bromsgrove.— ASSISTANT  MEDICAL  OFFICER 
(Locum  Tenens)  required  for  three  weeks  from  October  3th  or  9th. 
Salary  8 guineas  per  week,  with  board  and  lodging. — Apply  to  the 
Medical  Superintendent  (giving  particulars  and  references'. 

radford  Royal  Infirmary  (215  beds, 

5 Resident  Officers). — Two  HOUSE  SURGEONS  wanted  for 
beginning  of  November.  Candidates  must  be  single  and  legally  qualified. 
Salary  £200  per  annum,  with  board  and  rooms. 

Applications,  stating  age,  qualifications,  and  previous  experience 
(if  any),  with  copies  of  recent  testimonials,  to  be  received  by 
7th  October.  J.  J.  Barron,  Secretary-Superintendent. 


TTampstead  General  and  North-West 

J JL  LONDON  HOSPITAL,  Haverstock-hill,  N.W.  3. — The  Council 

invite  applications  for  the  post  of  SURGEON  TO  OUT-PATIENTS. 
Candidates  must  be  Fellows  of  the  Royal  College  of  Surgeons,  England. 

Applications,  &c.,  should  reach  the  Secretary  not  later  than  .Friday, 
October  10th. 


Hampstead  General  and  North-West 

LONDON  HOSPITAL,  Haverstock-hill,  N.W.  3. — There  is  a 
vacancy  for  a CLINICAL  ASSISTANT  in  the  EAR,  NOSE,  & THROAT 
DEPARTMENT.  The  position  offers  a suitable  opportunity  for  anyone 
who  intends  to  specialise  in  this  work. 

Applications,  &c.,  should  reach  the  Secretary  not  later  than  Oct.  10th. 


Qouth  London  Hospital  for  Women 

South  Side,  Clapham  Common,  S.W.  4. 

The  Board  of  Management  invite  applications  from  fully  qualified 
Medical  Women  tor  the  poets  of  ASSISTANT  SURGEON  and 
TEMPORARY  ASSISTANT  SURGEON — the  latter  appointment  to  be 
for  a period  of  twelve  months.  Full  particulars  may  be  obtained  from 
the  Secretary.  Canvassing  Members  of  the  Board  is  not  allowed. 

Applications,  with  copies  of  testimonials,  to  reach  the  Secretary  at 
the  Hospital  not  later  than  the  first  post  on  October  31st. 

Belgrave  Hospital  for  Children 

(Incorporated),  Clapham-road,  S.W.  9.  — The  Committee  of 
Management  invite  applications  for  the  posts  of  HOUSE  PHYSICIAN 
and  HOUSE  SURGEON,  which  will  shortly  become  vacant.  Applicants 
must  be  fully  qualified  and  registered.  The  appointments  are  for  six 
months,  with  board,  residence,  and  washing  provided.  Salary  at  the 
rate  of  £100  per  annum  In  the  case  of  House  Physician,  and  £75  per 
annum  in  the  case  of  House  Surgeon. 

Applications,  with  copies  of  testimonials,  to  be  forwarded  on  or 
before  October  13th,  to  the  undersigned,  from  whom  further  particulars 
may  be  obtained.  By  order. 

Thomas  Clapham,  Secretary. 

ria  Hospital  for  Children, 

Tite-street,  Chelsea,  S.W.  3.— The  Committee  of  Management 
invite  appllcatl  ms  for  the  following  vacancies  on  the  Honorary  Staff  : 
(a)  IN-PATIENT  PHYSICIAN  (the  Senior  Out-patient 
Physician  is  a candidate); 

<b)  Two  OUT-PATIENT  PHYSICIANS. 

Candidates  for  these  posts  must  be  Fellows  of  the  Royal  College  of 
Physicians  of  Loudon  and  Graduates  in  Medicine  of  a University 
recognised  by  the  Medical  Council. 

Candidates  are  expected  to  call  on  the  Medical  Staff,  and  should  send 
in  their  applications,  with  testimonials,  to  the  Secretary  of  the 
Hospital  on  or  before  Saturday,  11th  October,  1919. 

By  order. 

H.  G.  Eveked,  Secretary. 


I 


lford  Urban  District  Council 


Appointment  of  WOMAN  ASSISTANT  MEDICAL  OFFICER 
OF  HEALTH.— The  Urban  District  Council  of  Ilford  invites  applica- 
tions from  properly  qualified  Medical  Women  for  the  office  of  Woman 
Assistant  Medical  Officer  of  Health,  for  duties  in  connexion  with 
General  Public  Health  Work,  Maternity  and  Child  Welfare  Work,  and 
School  Medical  Inspection.  Candidates  must  possess  the  Diploma  of 
Public  Health  or  similar  qualification,  and  have  definite  experience  in 
Children’s  Diseases. 

The  aggregate  salary  of  the  officer  will  be  £400  per  annum,  rising 
by  annual  increments  of  £25  to  a maximum  of  £450. 

The  person  appointed  will  be  required  to  devote  her  whole  time  to  the 
duties  of  the  office,  to  reside,  in  any  case,  within  the  Urban  District  of 
Ilford,  and  to  enter  into  a contract  with  the  Council  for  the  due  per- 
formance and  fulfilment  of  all  the  duties  and  conditions  governing  the 
appointment. 

Candidates  must  not  be  more  than  forty-five  years  of  age. 

Applications,  which  must  be  made  on  forra3  obtainable  (with  list  of 
duties)  from  the  undersigned,  accompanied  by  copies  of  three  recent 
testimonials  (which  will  not  be  returned),  endorsed  “ Woman  Assistant 
Medical  Officer  of  Health,”  must  be  received  at  my  office,  at  the  Town 
Hall,  Ilford,  not  later  than  12  o clock  noon  on  Tuesday,  the  14th  day  of 
October,  1919. 

Canvassing  members  of  the  Council,  directly  or  indirectly,  is  pro- 
hibited and  will  disqualify.  By  order. 

Ai>am  Partington,  Clerk  and  Solicitor  to  the  Council. 

Town  Hall,  Ilford,  September,  1919. 

52 


Dorset  County  Council  Education 

COMMITTEE  — Appointment  of  SCHOOL  DENTISTS.— Three 
School  Dentists  required.  Duties:  To  examine  the  teeth  of  schorl 
children  and  treat  those  with  dental  defects.  Salary  £400  per  annum, 
with  travelling  expenses. 

Application  form  and  terms  of  appointment  may  be  obtained  from 
Secretary  for  Education,  County  Offices,  Dorchester. 

Taunton  and  Somerset  Hospital, 

Taunton  (106  beds).  — A qualified  RBSIDENT  ASSISTANT 
HOUSE  SURGEON  required  at,  once.  Salarv  at  the  rate  of  £159  rer 
annum,  with  board,  lodging,  and  laundry.  The  appointment,  which 
is  for  six  months,  is  not  open  to  Medical  Women. 

Apply,  with  copies  of  not  more  than  three  testimonials,  to 

Reginald  A.  Goodman,  Secretary. 

Thie  Royal  Sussex  County  Hospital, 

JL  Brighton. — An  AS3ISTANT  PATHOLOGIST  to  the  Pathological, 
Bacteriological,  and  Clinical  Research  Department  of  the  above  Institu- 
tion is  required.  Salary  £200  per  annum,  with  an  additional  payment 
of  £100  per  annum  in  lieu  of  board,  residence,  and  laundry. 

Applications,  with  copies  of  testimonials,  to  be  sent  to  the  under- 
signed at  the  Hospital  immediately. 

J.  Harold  Penfold,  Acting  Secretary. 

CAldham  Royal  Infirmary. — Wanted 

at  once,  a THIRD  HOUSE  SURGEON.  ^Salary  at  the  rate  of 
£200  per  annum,  with  board,  residence,  and  laundry.  The  appoint- 
ment will  be  for  six  months,  then  eligible  for  promotion  to  Second 
House  Surgeon’s  post. 

Duties  in  Ophthalmic,  Casualty,  Out-patients,  and  V.D.  Departments. 
Applications,  with  testimonials,  to  be  sent  not  later  than  October  7th, 
to  E.  Lionel  Blake,  Supt.  and  Secy. 

Leicester  Royal  Infirmary. — House 

PHl'SICIAN— A vacancy  has  arisen  for  the  post  of  House 
Physician. 

Salary  at  the  rate  of  £250  per  ahnum,  with  board,  apartments,  and 
washing. 

Applications  to  be  forwarded  at  once  to  the  undersigned. 

Harry  Johnson,  House  Governor  & Secretary. 
22nd  September,  1919. 

Qtroud  General  Hospital. — House 

k_y  SURGEON.— The  Committee  are  prepared  to  consider  the  appli- 
cation of  candidates  (women  eligible)  for  the  post  of  HOUSE  SURGEi  N 
at  the  Stroud  General  Hospital.  Candidates  must  be  duly  qualified  ar  d 
registered.  Salary  £200  per  annum,  with  board,  lodging,  and  washing. 
The  Hospital  is  well  equipped  and  serves  a population  of  40,000  in  a 
manufacturing  and  agricultural  district.  Applications  should  be  sent, 
with  testimonials,  to  the  Honorary  Secretary,  the  Hospital,  Stroud, 
Glos.,  not  later  than  Tuesday,  October  14th,  1919. 

Manchester  Royal  Infirmary. — 

Central  Branch,  R )by-streer,  Manchester.  52  beds.  Pensioners. 
New  casualties  ab-'ut  30  daily. — RESIDENT  SURGICAL  OFFICER. 
The  Board  of  Management  of  the  Manchester  Ri.yal  Infirmary  invite 
applications  for  the  above  appointment.  The  appointment  is  for  six 
months.  Remuneration  i9  at  the  rate  of  £200  per  annum,  with  board 
and  residence.  Applications,  accompanied  by  copies  of  three  testi- 
monials, to  be  sent  to  the  undersigued  on  or  before  Monday, 
6th  October,  1919.  By  order. 

Frank  G.  Hazell,  General  Superintendent  and  Secretary. 
20th  September,  1919. 

General  Hospital,  Nottingham. — An 

ASSISTANT  SECRETARY  (Male)  is  required  at  the  above 
Institution.  Candidates  must  have  organising  ability,  a thorough 
knowledge  of  Hospital  Bookkeeping  and  Accounts,  and  be  experienced 
in  Committee  work.  Commencing  salary  £250  per  annum.  Applica- 
tions, stating  age  and  experience,  together  with  copies  of  three  recent 
testimonials,  and  endorsed  “ Assistant  Secretary,”  to  be  delivered  to  me 
not  later  than  Saturday,  October  18th,  1919.  Previous  Hospital  experi- 
ence and  a knowledge  of  Shorthand  and  Typewriting  will  be  a recom- 
mendation. P.  M.  MacColl,  House  Governor  A Secretary. 


Thk  Lancet,] 


THE  LANCET  GENERAL  ADVERTISER 


[8ept.  27,  1929 


"Perk  shire  Education  Committee. — 

I ) Applications  are  invited  from  registered  Dental  Surgeons  for 
the  aopointment  of  SCHOOL  DENTIST  under  the  Berkshire  Educa- 
tion Committee. 

The  officer  appointed  will  be  required  to  devote  his  whole  time  to  the 
services  of  the  Committee  and  to  act  under  the  direction  of  the  School 
Medical  Officer. 

The  salary  will  be  at  the  rate  of  £100  per  annum.  Out-of-pocket 
travelling  expenses  actually  incurred  will  be  paid  according  to  scale. 

The  appointment  will  be  terminable  by  three  months’  notice  on  either 
side. 

Further  particulars  and  forms  of  application  may  be  obtained  from 
the  undersigned. 

All  applications  must  be  sent  In  before  27th  October,  1919. 

Canvassing  members  of  the  Committee  will  disqualify. 

W.  C.  F.  Anderson,  Education  Secretary. 
Shire  Hall,  Heading.  Sa»t.  lfiih,  1919 

Somerset  County  Education  Com- 

MITTEE.— SCHOOL  OCULIST  and  MEDICAL  INSPECTOR 
(Male  or  Female). -The  Committee  invite  applications  for  the  above 
appointment.  Special  experience  in  Eye  diseases  and  Refraction  work 
is  essential,  while  experience  in  dealing  with  children  is  desirable. 

Commencing  salary  £450  p“r  annum,  increasing  to  £550  by  yearly 
increments  of  £25,  with  necessary  travelling  and  out-of-pocket 
expenses. 

Applications,  stating  age,  qualifications,  and  previous  experience, 
accompanied  by  copies  of  not  more  than  three  recent  testimonials, 
must  be  forwarded  not  later  than  Monday,  Oct.  13th,  to  the  under- 
signed, from  whom  all  further  particulars  can  be  obtained. 

Canvassing  will  disqualify. 

W.°  G.  Savage,  County  School  Medical  Officer. 
Boulevard,  Weston-s-Mare. 

rpke  Royal  Infirmary,  Sunderland. — 

1 Wanted,  SENIOR  HOUSE  SURGEON  (with  previous  Hospital 
experience),  Two  JUNIOR  HOUSE  SURGEONS,  and  HOU4E 
PHYSICIAN.  Candidates  must  possess  double  qualifications  (regis- 
tered). Tbe  appointments  will  be  for  six  months,  or  for  such  longer 
period  as  may  be  mutually  agreed  upon.  Salary  for  Senior  appoint- 
ment £250  per  annum,  other  appointments  £200  per  annum,  with 
board,  residence,  and  laundry. 

There  are  236  beds  for  patients  and  four  resident  medical  officers. 
Applications,  stating  age,  with  certificate  of  registration  and  copies 
of  three  recent  testimonials,  to  be  sent  to  the  Secretary  on  or  before 
Wednesday,  October  1st,  endorsed  “ Application  for  Resident  Appoint- 
ment.’' 

The  election  will  t*ake  place  on  October  9th,  and  the  successful  candi- 
dates will  be  required  to  enter  upon  their  duties  on  November  1st. 
Further  information  may  be  obtained  from  the  undersigned. 
September  13th,  1919. S.  C.  Fryers,  Secretary. 

Lancashire  County  Council. — 

Appointment  of  ASSISTANT  DISPENSARY  TUBERCULOSIS 
OFFICER. — The  Lancashire  County  Council  are  preparer!  to  receive 
applications  for  the  post  of  one  Assistant  Dispensary  Tuberculosis 
Officer  at  a salary  of  £550  per  annum,  rising  by  annual  increments  of 
£25  to  £625  per  annum. 

Applicants  must  be  registered  Medical  Practitioners  between  twenty- 
five  and  forty  years  of  age,  and  mu6t  devote  the  whole  of  their  time  to 
the  duties  as  defined  by  the  Council.  Candidates  must  have  held 
bouse  appointments  for  at  least  six  months  in  a General  Hospital,  and 
have  had  special  experience  in  the  diagnosis  and  treatment  of 
Tuberculosis. 

The  possession  of  a Diploma  in  Public  Health  and  practical  experience 
in  Bacteriological  work  will  be  deemed  additional  qualifications  for  the 
post. 

Applications,  accompanied  by  copies  of  three  recent  testimonials,  to 
be  delivered  to  the  undersigned  not  later  than  the  first  post  on 
10th  October,  1919. 

Forms  of  application,  terms  of  appointment,  and  list  of  duties,  can  be 
obtained  from  the  undersigned. 

AU  letters  must  be  marked  on  the  outside,  “ Appointment  of 
Dispensary  Tuberculosis  Officer."  Harcourt  E.  Clare, 

County  Offices,  Preston. Clerk  of  the  County  Council. 

Durham  Comity  Council.  — The 

County  Education  Committee  invite  app'ieations  for  five 
vacancies  for  ASSISTANT  SCHOOL  MEDICAL  OFFICERS,  to  act 
under  the  County  Medical  Officer  in  connexion  with  the  inspection  of 
children  attending  elementary  schools,  and  such  other  duties  as  may 
from  time  to  time  be  required  by  the  Education  Committee. 

The  commencing  salary  will  be  £500  per  annum,  rising  by  annual 
increments  of  £25,  to  £700  per  annum,  together  with  reasonable 
travelling  and  out-of-pocket  expenses.  Tbe  successful  candidates  will 
be  required  to  devote  their  whole  time  to  the  duties  of  the  office,  and 
to  reside  in  or  near  the  districts  to  which  they  may  be  attached,  at  a 
place  to  be  approved  by  the  County  Education  Committee 
In  making  the  appointments  preference  will  be  given  to  candidates 
who  have — 

(1)  Enjoyed  special  opportunities  for  tbe  study  of  the  diseases 
children ; 

(2)  Had  some  definite  experience  in  school  hygiene ,-  and 

(3)  Had  adequate  training  in  State  Medicine,  or  held  a diploma  in 
public  health. 

The  appointments  will  be  subject  to  three  calendar  months’  notice  on 
either  side,  to  expire  on  the  last  day  of  any  calendar  month.  Applica- 
tions, endorsed  “ School  Medical  Inspector,”  accompanied  by  copies  of 
not  more  than  three  testimonials,  must  be  sent  not  later  than  Wednes- 
day, the  1st  October,  1919,  to  the  undersigned,  from  whom  forms  of 
application  (to  be  completed  in  candidate’s  own  handwriting)  can  be 
obtained. 

Canvassing,  directly  or  indirectly,  is  prohibited  and  will  disqualify. 

A.  J.  Dawson,  Director  of  Education. 
Shire  Hall,  Durham,  12th  September,  1919.  (No.  54,  1919.) 


Princess  Alice  Hospital,  Eastbourne. 

Applications  are  invited  for  tbe  post  of  Male  RESIDENT’ 
MEDICAL  OFFICER.  Candidates  must  be  unmarried,  fully  qualified 
and  able  to  commence  duties  on  the  1st  November.  The  appointment 
Is  for  six  months  and  may  be  extended.  Salary  at  the  rate  of  £175  per 
annum.  There  will  be  ample  time  for  reading.  Applications,  stating 
age,  qualifications,  and  accompanied  by  not  more  than  four  reeen! 
testimonials,  should  be  sent  to  the  Hon.  Secretary  (from  whom  further 
particulars  may  be  obtained)  not  later  than  Saturday,  4th  October. 

Hospital  for  Consumption  and 

DISEASES  of  the  CHEST,  Mount  Pleasant,  Liverpool.— The- 
Committee  of  the  Hospital  invite  applications  for  the  post  of 
ASSISTANT  MEDICAL  OFFICER  and  PATHOLOGIST.  Salary  £175 
per  annum  (non-resident),  with  liberty  to  private  practice. 

Candidates  must  be  Graduates  of  a British  or  Irish  Uuiversity  or- 
Members  of  the  Royal  College  of  Physicians. 

Applications,  with  copies  of  three  recent  testimonials,  to  be  sent  in,- 
endorsed  “ Assistant  Medical  Officer,’’  not  later  tban  tbe  5th  prox,  to 
the  Secretary,  70,  Mount  Pleasant,  Liverpool.  


Birmingham  Municipal  Anti-Tuber- 

CULOsis  CENTRE.— Applications  are  invited  from  registered 
Medical  Practitioners,  between  the  ages  of  twenty-five  and  forty  years 
who  are  experienced  in  the  Diagnosis  and  Treatment  of  Tuberculosis,, 
for  the  post  of  SENIOR  ASSISTANT  TUBERCULOSIS  OFFICER,  at 
a salary  of  £650  per  annum.  Candidates  must  have  held  a resident 
appointment  in  a General  Hospital  for  six  months,  and  must  also  have 
held  a recognised  Tuberculosis  appointment  for  at  least  one  year. 

Applications,  on  a form  to  be  obtained  from  the  Chief  Tuberculosis 
Officer.  44a,  Broad-street,  Birmingham,  with  copies  of  three  recent 
testimonials,  should  be  received  not  later  than  Sept.  30th,  1919. 

East  Riding  Education  Authority. — - 

SCHOOL  DENTIST — The  Authority  invite  applications  for  the* 
appointment  of  a School  Dentist  at  a salary  of  £350  per  annum  ; at 
present  there  is  a bonus  of  £65  per  annum.  Necessary  out-of  pocket 
and  travelling  expenses  will  be  paid. 

The  officer  appointed  will  be  required  to  devote  the  whole  of  his  time- 
to  the  service  of  the  Committee,  and  to  act  under  the  directions  of  the- 
Chief  School  Medical  Officer. 

Applications,  stating  age,  qualifications,  and  experience,  together  witfc. 
copies  of  recent  testimonials,  to  be  sent  to  me  not  later  than  30lh  Sept  . 

John  Bickersteth, 

Clerk  of  the  East  Riding  Education  Authority. 


West  Riding  County  Council. — 

ASSISTANT  RESIDENT  MEDICAL  OFFICER.  — The- 
County  Council  of  the  West  Riding  of  Yorkshire  invite  applications  for- 
the  appointment  of  an  Assistant  Resident  Medical  Officer  for  the: 
Middleton-in-Wharfedale  Sanatorium,  nearllkley. 

Salary  £325  per  annum. 

Further  particulars  and  form  of  application  may  be  had  from  the- 
undersigned,  by  whom  all  applications,  together  wii  b copies  of  not  more- 
t.han  three  recent  testimonials,  must  be  received  not  later  than  the- 
6th  October,  1919. 

Francis  Alvey  Darwin,  Clerk  of  the  County  Council. 
County  Hail,  Wakefield,  September,  1919. 

rphe  Royal  Infirmary,  Sheffield 

JL  (377  beds). 

OPEN  ELECTION. 

Wanted, an  Ear,  Nose,  and  Throat  HOUSE  SURGEON.  Salary  £150 
per  annum,  with  board  and  residence. 

The  duties  of  the  officer  to  be  elected  will  include  work  in  the 
In-  and  Out-patient  Departments,  under  the  supervision  of  tbe- 
Honorary  Medical  Staff. 

Applications,  which  are  invited  from  persons  who  must  be  fully 
qualified,  should  be  sent  to  the  Secretary  immediately,  stating  age. 
qualifications,  and  any  previous  experience. 

By  order. 

Board  Room.  August.  1919.  .Tno.  W.  Barnes,  Secretary. 

/general  Infirmary  at  Leeds. — 

VJ  Wanted:— RESIDENT  MEDICAL  OFFICER.  Salary  £150  per 
annum,  with  board,  residence,  and  laundry. 

RESIDENT  OBSTETRIC  OFFICER.  Salary  £50  per  annum,  witb 
board,  residence,  and  laundry. 

RESIDENT  MEDICAL  OFFICER  at  the  Ida  and  Robert  Arthington 
Hospitals.  Salary  £60  per  annum,  with  board,  residence,  and  laundry 
Two  HOUSE  PHYSICIANS.  1 Without  salary,  but  with  board,  resi- 
Two  HOUSE  SURGEONS.  / dence,  and  laundry. 

Candidates  must  be  legally  qualified  and  registered,  and  applications  , 
with  testimonials,  should  be  addressed  to  the  Secretary  to  the  Faculty 
at  the  Infirmary.  By  order. 

9th  September.  1919.  Fred  J.  Bray,  General  Manager,. 

(Cumberland  Education  Committee. — 

\_J  SCHOOL  DENTISTS. — The  Committee  propose  to  appoint  Two 
Whole-time  Dentists,  and  applications  are  invited  from  qualified  and 
registered  Dentists  (men  and  women). 

The  duties  will  primarily  consist  in  examining  the  teeth  of  the- 
school  children  in  the  county  and  in  remedying  dental  defects. 

Some  work  may  also  be  necessary  under  the  County's  Maternity  and 
Child  Welfare  Scheme. 

Salary  £350  per  annum,  rising  to  £400  by  £25  annually,  with  reason- 
able travelling  expenses. 

Applications,  which  must  be  on  the  form  provided,  must  reach  the 
School  Medical  Offi 'er,  48.  War wick-ro  d , Carlisle,  on  or  before  the- 
11th  November,  and  forms  of  applieat  ei  may  be  obtained  from  hkr:  . 
togetberwith  further  particulars  of  the  appointment. 

Canvassing,  directly  or  indirectly,  will  disqualify. 

C.  Courtenay  Hodgson,  Secretary  to  the  Committee. 
The  Courts,  Carlisle,  September,  1919. 

53 


Thk  Lancet,] 


THE  LANCET  GENERAL  ADVERTISER 


[Sept.  27,  1919 


/Cheltenham  Eye,  Ear,  and  Throat 

\J  FREE  HOSPITAL.— Post  of  ASSISTANT  SURGEON  vacant. 
Salary  £400,  Apply.  Hon,  Sec. 

'VUhitehaven  and  West  Cumberland 

T T INFIRMARY.— Wanted,  a RESIDENT  HOUSE  SURGEON. 


Salary  £180  a year,  with  board,  Ac. 
Infirmary,  Whitehaven. 


Applications  to  the  Secretary, 


Borough  Hospital,  Birkenhead. — 

Wanted  JUNIOR  HOUSE  SURGEON,  qualified.  Duties 
include  anaesthetics  and  casualties.  Salary  £170  per  annum,  with  board 
and  laundry,  Ac.  Applications,  with  testimonials,  to  be  sent  to  the 
Secretary  at  the  Hospital. 

Huddersfield  Royal  Infirmary.  — 

Wanted  immediately,  a fully  qualified  Male  ASSISTANT 
HOUSE  SURGEON.  Salary  £100  per  annum,  with  board,  residence, 
and  washing.  Applications,  stating  age,  with  copies  of  testimonials, 
to  be  sent  to  Mr.  J.  Bate,  Secretary,  Royal  Infirmary,  Huddersfield. 

Bedford  County  Hospital. — Wanted, 

a RESIDENT  MEDICAL  OFFICER,  duly  qualified  in  Medicine 
and  Surgery,  to  act  as  House  Physician  for  a term  of  six  months 
Salary  £150  per  annum.  Board,  lodging,  and  laundry.  Apply,  stating 
particulars  and  three  testimonials,  to 
September  15th,  1919. The  Secbetary. 

/Irimsby  and  District  Hospital 

VJ  (50  beds). — Wanted  immediately,  a duly  qualified  HOUSE 
SURGEON.  Salary  £300  per  annum,  payable  monthly,  with  board, 
residence,  and  laundry. 

Apply  to  E.  Ben.  Chapman,  Prudential  Chambers,  Victoria-street, 
•Grimsby. , 

The  Hospital  for  Sick  Children, 

Newcastle- upm-Tyne.  (74  beds.)— Applications  are  invited  for 
the  post  of  JUNIOR  RESIDENT  MEDICAL  OFFICER.  Salary  £200 
per  annum,  with  board,  residence,  and  laundry.  Duties  to  commence 
at  once.  Applications,  stating  age  and  copies  of  testimonials,  to  be 
sent  to  the  Secretary,  Mr.  Neil  Brodie,  Star  Buildings,  26,  Northum- 
berland-street,  Newcastle-upon-Tyne. 

Y\7arneford,  Leamington,  and  South 

YY  WARWICKSHIRE  GENERAL  HOSPITAL,  Leamington 
Spa.— Wanted,  a RESIDENT  HOUSE  SURGEON,  fully  qualified  and 
registered.  Salary  per  annum  £200,  with  board,  residence,  and  laundry. 

Applications,  accompanied  by  not  more  than  three  recent  testi- 
monials, must  reach  the  undersigned  not  later  than  the  1st  October 
next.  C.  R.  W.  Offhn, 

House  Governor  and  Secretary. 

Hereford  County  and  ’City  Mental 

HOSPITAL.— Wanted,  a SENIOR  ASSISTANT  MEDICAL 
OFFICER  (Male),  age  under  thirty-five,  single,  doubly  qualified,  to 
live  In.  Experienced  in  treatment  of  Mental  Diseases.  Salary  £350  per 
annum,  increasing  by  annual  increments  of  £25  to  £400,  with  board, 
lodging,  washing,  and  attendance.  Laboratory  facilities  are  available. 
The  appointment  is  under  the  Asylum  Officers’  Superannuation  Act. 
1909. 

Applications,  Btating  availability,  with  copies  of  not  more  than  three 
recent  testimonials,  to  he  sent  to  the  Medical  Superintendent,  The 
Mental  Hospital,  Burghill,  nr.  Hereford. 



Derbyshire  County  Council. — 

MATERNITY  and  CHILD  WELFARE  MEDICAL  OFFICER. 
Applications  are  Invited  for  the  above  position  at  a commencing 
salary  of  £450  per  annum,  together  with  travelling  and  reasonable 
out-of-pocket  expenses. 

Particulars  of  duties  and  forms  of  application  may  be  obtained  from 
the  undersigned,  to  whom  they  must  be  returned,  filled  in,  together 
with  copies  of  not  more  than  three  recent  testimonials,  on  or  before 
Friday,  October  10th,  1919. 

Sidney  Barwise,  M.D.,  County  Medical  Officer  of  Health. 
New  County  Offices,  Derby,  September  23rd,  1919. 

"PYerby  shire  Education  Committee. — 

I / SCHOOL  MEDICAL  OFFICER. — Applications  are  invited  for 
the  above  position  at  a salary  of  £450  per  annum,  rising  by  annual 
increments  of  £25  to  £600  per  annum,  together  with  £100  per  annum 
for  travelling  expenses. 

Particulars  of  duties  and  forms  of  application  may  be  obtained  from 
the  undersigned,  to  whom  they  should  be  returned,  filled  up,  together 
with  copies  of  not  more  than  three  recent  testimonials,  on  or  before 
Friday,  October  10th,  1919. 

Sidney  Barwise,  M.D.,  School  Medical  Officer. 
New  County  Offices,  St.  Mary’s  Gate,  Derby, 

September  23rd,  19lS. 

HThe  Royal  Infirmary,  Hull. — Senior 

_L  HOUSE  SURGEON  wanted.  The  Hospital  contains  125  surgical 
beds.  Theie  are  in  addition  a Resident  House  Physician,  Assistant 
House  Surgeon,  and  two  Casualty  House  Surgeons.  Candidates  must 
ba  fully  qualified,  registered,  and  unmarried,  and  preference  will  he 
given  to  such  as  have  previously  held  a similar  appointment.  The 
salary  is  £200  per  annum,  with  boird  and  furnished  apartments.  The 
selected  candidate  will  be  required  to  enter  into  an  agreement  to  remain 
not  less  than  ore  year  and  to  give  or  receive  three  months'  notice  to 
terminate  his  engagement.  Applications,  stating  age,  qualifications, 
and  previous  experience,  with  copies  of  testimonials,  to  be  sent 
addressed  " Chairman,  House  Committee." 

Benjamin  Brooks,  Secretary. 

51 


HThe  Gloucestershire  Royal  Infirmary 

_J_  and  BYE  I NSTITUTION.— There  1b  a vacancy  for  an  ASSISTANT 
SURGE  )N  on  the  acting  Medical  Staff  of  this  Institution. 

By  the  rules  of  the  Hospital  “ the  Assistant  Surgeon  shall  be  a Fellow 
or  Member  of  the  Royal  College  of  Surgeons  of  England,  or  a Fellow  or 
Licentiate  of  the  Royal  Colleges  of  Surgeons  of  Ireland  or  Edinburgh, 
or  a Graduate  in  Surgery  of  one  of  the  Universities  recognised  by  the 
Medical  Council  of  the  United  Kingdom.” 

Candidates  should  send  in  their  applications,  diplomas,  and  testi- 
monials, under  cover  to  the  Secretary,  on  or  before  Wednesday,  the 
29th  day  of  October  next. 

Members  of  the  acting  Medical  Staff  are  appointed  by  the  Election 
Committee. 

Gloucester,  September  25th,  1919.  G.  Hurford,  Secretary. 


/Mty  of  Sheffield  — Wanted,  Assistant 

TUBERCULOSIS  OFFICER,  to  live  at  Winter  Street  Tuber- 
culosis Hospital,  and  to  devote  his  whole  time  to  the  Municipal  Tuber- 
culosis Scheme. 

Salary  £300  per  annum,  rising  to  £400  per  annum  by  annual 
increments  of  £50,  with  board,  residence,  and  laundry. 

Applications,  stating  age,  qualifications,  and  experience,  with  codes 
of  testimonials,  to  be  rent  on  or  before  October  8th,  to  the  Medical 
Officer  of  Health,  Town  Hall,  Sheffield. 

/Vty  of  Sheffield. — Education  Com- 

\J  MITTEE.— Appointment  of  SCHOOL  DENTAL  SURGEONS.- 
Applicatlons  are  invited  from  duly  qualified  Dental  Surgeons  for 
appointment  as  School  Dental  Surgeons  to  the  Education  Committee. 
Salary  to  commence  at  £400  per  annum,  rising  to  £450  by  annual 
increments  of  £25,  with  opportunity  of  increasing  the  amount  by 
evening  work  at  the  Clinic. 

The  persons  appointed  will  be  required  to  devote  the  whole  of  their 
time  to  the  services  of  the  Committee,  and  to  act  under  the  super- 
intendence of  the  Chief  School  Medical  Officer. 

Forms  of  application  may  be  obtained  from  the  Secretary,  to  whom 
they  should  be  returned  not  later  than  13th  October,  1919. 

Personal  canvassing  will  disqualify. 

Percival  Sharp,  Director  of  Edncation. 
123,  Hawley-street,  Sheffield,  22nd  September,  1919. 

"D  oyal  Berkshire  Hospital. — The 

JLt  Board  of  Management  invite  applications  lor  the  appointment 
of  HONORARY  ASSISTANT  PHYSICIAN. 

Candidates  must  be  Fellows  or  Members  of  the  Royal  College  of 
Physicians,  London,  or  Medical  Graduates  of  one  of  the  Universities  of 
Great  Britain  or  Ireland,  and  must  be  registered. 

The  elected  candidate  will  be  appointed  for  the  period  ending  on  the 
third  Tuesday  in  January,  1920,  but  will  be  eligible  for  re-election. 

Candidates  are  required  to  provide  65  copies  of  their  application,  and 
of  not  more  than  four  recent  testimonials. 

The  applications  and  testimonials  must  be  addressed  to  the  Secretary, 
and  reach  him  not  later  than  October  11th,  1919. 

The  election  will  take  place  on  October  2Ut,  1919. 

Canvassing  by  or  on  behalf  of  the  candidate  will  disqualify  him. 
Reading,  27th  September.  1919.  Herman  Burney.  Secretary 


Surrey  Lunatic  Asylums  Visiting 

COMMITTEE,  Brookwood,  near  Woking.— Appointment  of 
FIRST  ASSISTANT  MEDICAL  OFFICER.— Applications  are  invited 
for  the  post  of  First  Assistant  Medical  Officer  under  the  Sutrey  County 
Asylums  Committee  from  duly  registered  Medical  Practitioners  who 
have  had  previous  experience  in  Asylum  work. 

Salary,  if  married  man  is  appointed,  £600  per  annum,  rising  by 
annual  increments  of  £25  to  a maximum  of  £700  per  annum,  together 
with  a house  free  of  rent,  rates  and  faxes ; if  a single  man,  £480,  rising 
by  annual  increments  of  £25  to  £580,  with  board,  lodging,  attendance, 
aud  laundry. 

The  appointment  will  be  subject  to  the  rules  and  regulations  affecting 
the  Asylum  and  will  be  determinable  by  three  months'  notice  on 
either  side. 

Applications  upon  the  prescribed  form,  which  can  be  obtained  from 
the  undersigned,  may  be  accompanied  by  copies  of  not  more  than  three 
recent  testimonials  which  will  not  be  returned),  must  be  sent  not  later 
than  the  8th  October,  1919. 

R.  A.  Hodges,  Clerk  to  the  Committee. 
County  Hall,  Kingston-on-Thames,  22nd  September.  1919. 

Borough  of  Sutton  Coldfield. — 

Applications  are  invited  for  the  appointment  of  MEDICAL 
OFFICER  OF  HEALTH  and  SCHOOL  MEDICAL  OFFICER. 

Area  of  Borough  13.030  acres. 

Estimated  Population 22,000. 

Rateable  Value  £143,565. 

Schools— 10  in  number.  School  population  about  2,400. 

An  office  is  provided  in  the  Council  House  in  connexion  with  the 
work  of  the  Medical  Officer  of  Health,  to  be  used  jointly  by  him  and 
the  Sanitary  Inspector. 

Office  accommodation  will  also  be  provided  at  the  Children’s  Welfare 
Centre  in  Holland-street,  where  the  work  of  the  School  Medical 
Service,  Infants  Welfare,  Dental  Clinic.  Ac.,  will  be  carried  on. 

It  is  distinctly  understood  that  the  office  of  Medical  Officer  of  Health 
and  School  Medical  Officer  will  be  a first  charge  on  the  time  of  the 
person  appointed.  He  will  be  responsible  for  the  organisation  and 
supervision  of  the  work  of  both  services  (including  Infant  Welfare,  Jtc.), 
and  have  control  of  the  Sanitary  Inspector  and  his  assistants,  and  the 
School  Nurses  and  Health  Visitors,  with  a view  to  the  proper  coordina- 
tion of  these  services,  to  be  carried  out  so  as  to  comply  with  the 
Statutes  and  the  Regulations  of  the  Government  Departments  con- 
cerned. He  will  attend  and  report  to  appropriate  Committees  of  the 
Council,  and  prepare  such  Statistics.  Reports,  Ac.,  as  may  be  required 
by  them  or  the  various  Government  Departments.  Salary  according  to 
experience  and  qualifications. 

Applications,  with  copies  of  three  recent  testimonials,  to  be  addressed 
on  or  before  the  18th  October,  1919,  to 
Sutton  Coldfield.  R.  A.  Reay  Xadix,  Town  Clerk. 


The  Lancet,] 


THE  LANCET  GENERAL  ADVERTISER 


[Sept.  27,  1919 


M! 


anchester  Royal  Infirmary. — 

JUNIOR  ANESTHETIST.— The  Board  of  Management  of  the 

Manchester  Royal  Infirmary  Invite  applications  for  the  above  office. 
Applicants  must  be  fully  qualilied  and  reglstere  1.  The  appointment  is 
for  twelve  months,  but  the  holder  of  the  office  is  eligible  for  re-election. 
Salary  £200  per  annum.  Atten lances  five  mornings  each  week. 

Candidates  must  state  age,  and  send  applications  and  three  testi- 
monials to  the  undersigned  not  later  than  9 a.m.  on  Saturday, 
4th  October,  1919.  By  ord°r. 

Frank  G.  Hazell.  Gen.  Supt.  & Secretary. 
Manchester  Royal  Infirmary,  23rd  September,  1919. 


Qcottish  Western  Asylums’  Research 

k_y  INSTITUrfa. — Applications  are  invited  for  the  post  of 
DIRECTOR.  Salary  commences  £600.  Candidates  must  be  skilled  in 
modern  clinical  and  laboratory  methods  and  technique,  and  be  capable 
of  undertaking  and  directing  Research  Work  in  Mental  and  Nervous 
Affections. 

Applications,  stating  qualifications  and  experience,  to  be  sent 
to  the  Secretary,  Dr.  J.  H.  MacDonald,  Hawkhead  Asylum, 
Cardonald,  Glasgow,  from  whom  all  further  particulars  may  be 
obtained. 


The  Glasgow  Eye  Infirmary. — The 

Directors  invite  applications  for  the  appointments  of  RESIDENT 
HOUSE  SURGEON  and  RESIDENT  ASSISTANT  HOUSE  SURGEON. 
Salary  for  House  Surgeon  £100  per  annum,  and  Assistant  House 
Surgeon  £75  per  annum,  both  with  apartments  and  board.  The 
gentlemen  appointed  will  enter  upon  duty  on  30th  October  next  or  as 
may  be  arranged.  Applications,  in  writing,  with  copy  testimonials, 
should  be  lodged  with  the  undersigned. 

Harold  J.  Black,  Secretary. 
88,  West  Regent-street,  Glasgow,  18th  September,  1919. 


Th 


e Carnegie 

SCHOOL  MEDICAL 


Dunfermline  Trust. — 

OFFICER. — Applications  are  invited  for 


appointment  as  Assistant  School  Medical  Officer  (Man)  at  a salary  of 
£400  per  annum,  rising  by  annual  increments  of  £25  to  £500.  The 
duties  will  include  the  examination  and  treatment  of  school  children 
and  the  giving  of  a course  of  lectures  in  the  Dunfermline  College  of 
Hygiene  and  Physical  Education.  Candidates  should  state  any  special 
experience  they  may  have  of  work  bearing  upon  the  treatment  of 
children,  such  as  Eye,  Ear,  or  X-Ray  work,  and  should  give  particulars 
of  their  military  service  (if  any)  and  of  any  disability  from  which  they 
suffer  as  a result  of  such  service. 

The  Officer  appointed  will  be  required  to  devote  the  whole  of  his 
time  to  the  work,  and  to  act  under  the  direction  of  the  Chief  Medical 
Officer. 

Applications,  stating  age.  qualifications,  and  experience,  together  with 
one  copy  of  not  more  than  three  recent  testimonials,  should  be  sent  not 
later  than  30th  September,  to  the  Secretary,  Carnegie  Dunfermline 
Trust,  Abbot-street,  Dunfermline. 

Sept.  10th.  1919. 


IX/Tatron,  Assistant,  wanted  for  Glasgow 

JLYX  DISTRICT  MENTAL  HOSPITAL,  Gartloch,  Gartcosh.  Candi- 


dates should  hold  the  Certificate  of  the  Medico-Psychological  Associa- 
tion for  training  in  Mental  Diseases,  and  preference  will  be  given  to 
one  with  General  Training.  Salary  to  commence  £113,  with  board, 
lodging,  laundry,  and  uniform.  Apply,  stating  age,  experience,  and 
where  trained,  to  M-dical  Superintendent. 


"Principal  Medical  Officer. — Depart- 

_L  MENT  OF  PUBLIC  INSTRUCTION,  NEW  SOUTH  WALES.— 
Salary  £900  per  annum.  Professional  Division.  Duties  to  conduct 
and  supervise  medical  examination  of  schools  and  school  pupils 
throughout  the  State,  organise  and  direct  school  travelling,  hospital 
and  school  dental  clinics,  and  generally  act  as  Medical  Adviser  to  the 
Department.  Applicants  must  be  duly  qualified  Medical  Practitioners. 
Preference  will  be  given  to  a suitable  applicant  who  is  registered  in 
New  South  Wales  and  has  served  with  the  A.I.F. 

Applications,  stating  age,  qualifications,  experience,  Ac.,  should 
reach  the  Secretary,  Public  Service  Board,  Sydney,  not  later  than 
10th  No\  ember,  3919. 

Agent-General  for  New  South  Wales. 
Sydney  House,  26,  Cockspur-street.  London,  S.W.  1, 

8th  September,  1919. 


pile  Secretary  of  State  for  the  Colonies 

_I_  announces  vacancies  for  pensionable  posts  of  MEDICAL 
OFFICERS  in  the  Occupied  Territ.orv  of  GERMAN  EAST  AFRICA. 

The  salary  is  on  the  scale  of  £400-£20-£500  a year,  with  duty  allow- 
ance of  £40  a year,  and  after  six  years’  service  £525-£25-£600  a year, 
with  duty  allowance  of  £50.  War  bonus  is  granted  at  present  at  the 
rate  of  £55  per  annum  to  unmarried  officers  and  £105  per  annum  to 
married  officers. 

The  Senior  appointments  in  the  Medical  Department  are  those  of 
Senior  Medical  Officer  on  the  scale  of  £600-£25-£750,  with  duty  allow- 
ance of  £60,  and  of  Deputy  Principal  Medical  Officer,  Senior  Sanitary 
Officer,  and  Principal  Medical  Officer,  the  scales  for  which  are  not  yet 
determined. 

Particulars  as  to  leave  and  pension  may  be  had  on  application. 

Free  quarters  are  provided  or  an  allowance  is  given  in  lieu,  and  free 
first-class  passages  to  and  from  East  Africa  are  provided  on  first 
appointment  and  on  leave. 

Medical  Officers  are  permitted  to  take  private  practice  on  the  under- 
standing that  they  give  precedence  to  their  official  duties. 

Intending  candidates  should  write  to  the  Private  Secretary  for 
Appointments.  Colonial  Office,  Downing-street,  S.W.l. 

No  testimonials,  &c.,  should  be  sent  in  until  the  candidate  has  received 
a form  of  application  from  the  Colonial  Office. 

Downing-street,  Sept.  9th,  1919. 


TVTanted,  a Medical  Office r for  an 

Y Y Expedition  proceeding  to  Gold  Coast  (West  Africa).  Must  be 
fully  qualified  and  experienced.  Age  twenty-five  to  thirty.  Salary  on 
a twelve  months’  agreement,  £500  per  annum,  with  free  quarters, 
travelling  out  and  home.  Medical  certificate  of  fitness  to  serve  in 
Tropics  required. — Write  to  G.  Alexander,  Capei  House,  62,  New  Broad- 
street,  London,  E.C. 


Surgeon.  — Messrs.  Elder 


Qhip’s 

K-/  Dempster  and  Co. limited,  have  a few  vacancies  for  Surgeons  in 
their  West  African  Service.  Pay  £20  per  month.  Fees  allowed  for 
attendance  on  passengers.  Length  of  voyage  varies  from  six  to  ten 
weeks,  according  to  particular  route.— Apply,  Medical  Superintendent, 
Messrs.  Elder  Dempster  and  Co.,  Limited.  Colonial  House,  Liverpool. 


TVTanted,  Locum  Tenen.  Good 

I T General  Practitioner  for  Doctor  in  Pietermaritzburg  February 
to  October  1920  —Particulars,  apply,  “ Natal,"  Post  Office,  Droitwich. 


, Assistant  Medical  Officer  in 

Private  Asylum.  Salary  £300  per  annum.  Mental 
experience  required. — Address,  No,  555,  The  Lancet  Office,  423,  Strand. 
W.C.2. 

A ssistant  required  immediately  in 

1A.  good-class  Practice,  Thames  Valley.  £460,  all  found,  and  half 
Midwifery  fees.— Address,  No.  542,  The  Lancet  Office,  423,  Strand, 
W.C.2. 


ocum  Tenens  Provided 

at  short  notice. 

Apply  to  Mr.  PERCIVAL  TURNER, 
the  oldest  and  only  Agent  who  for  forty  years,  without  agency  fee  to 
Principals,  has  supplied  Practitioners  with  reliable  substitutes, 

4 & 5,  ADAM  STREET,  ADELPHI,  STRAND,  W.C.2. 
Telegrams : Epsomlan,  London.  Telephone : Gerrard  399. 

After  5 P.M.— Tel.  Epsom  695. 


ocums  can  be  had  for  Holidays  if 

booked  at  once.— Lee  & Martin,  Ltd.,  93,  Hall-road.  Handsworth. 
Birmingham.  Telegrams:  “Locum,  Birmingham.”  Telephone:  191 
Northern.  

| ^o  cum  Tenens  Provided 

at  SHORT  notice. 

Apply  to 

ARNOLD  & SONS 
(J.  E.  Arnold,  E.  R.  Arnold), 

Surgloal  Instrument  Manufacturers, 
ESTBD.  100  YEARS, 

MEDICAL  TRANSFER  DEPARTMENT, 

6,  GILTSPUR  STREET,  LONDON,  B.O.l. 
Telegrams : “ Instruments,  London.”  Telephone  : 5240  City  (3  lines). 

B.,  B.C.  (Camb.)  requires  Part- 

• time  Work  in  London,  while  working  for  D.P. H.— Address, 
No.  523,  The  Lancet  Office,  423,  Strand,  W.C.  2. 

B.  requires  Part  time  Work  in 

• Liverpool  or  district  while  working  for  D.P. H.— Address, 
No.  541,  The  Lancet  Office,  423,  Strand,  W.C.  2. 


Partly  qualified  Gentleman  wants  a 

post  a9  a MEDICAL  ASSISTANT  anywhere. — Address,  No.  544, 
The  Lancet  Office,  423,  Strand,  W.C.  2. 

F B.C. S.,  having  recently  relinquished 

• General  and  Surgical  Practice,  desires  Full  time  Work  till  end 
of  year.  Would  consider  institution  work,  assisting  Surgeon,  taking 
over  General  Practice,  or  looking  after  Death  Vacancy. — Address,. 
No.  546,  The  Lancet  Office,  423,  Strand,  W.C.  2. 

MD.,  aged  35,  desires  Assistantship 

• with  view  to  Partnership  or  Succession,  in  good-class  or 
mixed  Practice.  Highest  social  and  professional  references.— Address, 
No.  547.  The  Lancet  Office,  423,  Strand,  W.C.  2. 

T ate  H.P.  (B.art.’s),  passed  M.B., 

I A B.C.  (Cambridge),  married,  requires  As  3I3TANT3HIP,  prefer 
ably  with  view,  in  Country  Practice.  Within  80  miles  London 
preferred. — Address,  No.  553,  The  Lancet  Office,  423,  Strand,  W.C.  2. 


Eye  Specialist,  M.B.,  4 years  assistant 

1 in  Paris  ophthalmic  hospital,  desires  situati  n as  ASSISTANT 
in  Private  Practice.— Address,  No  554,  The  Lancet  Office,  423,  Strand, 
W.C.  2. 

F5 


'The  Lanoht,] 


THE  LANCET  GENERAL  ADVERTISER 


[Sbpt.  27,  1619 


VAischarged  N.C.O.  seeks  post  as  Lab. 

1 / ASSISTANT.  Good  working  knowledge  of  Bacteriology. 
Excellent,  medium  maker.  Six  years'  experience — civil  and  mi.itary.— 
Address, 'No.  540,  The  Lancht  Office,  423,  Strand,  W.C.  2. 

T^x-Chief  Sick  Berth  Steward,  R.N. 

1 a (Pensioner)  requires  situation  as  DISPENSER,  or  any  position 
of  trust. — J.  Y.,  62,  Bentbam-ioad,  South  Hackney,  E.  9. 

Lady  Dispenser  (Hall)  requires  post 

with  Doctor  or  Hospital.  London  preferred.  Two  and  a half 
years’  various  experience.  Free  end  of  September.— Testimonials  on 
^application  to  Miss  Warren,  17.  Mildred-avenue,  Watford. 

' ady,  Graduate  and  experienced 

J a driver,  seeks  Dost  to  Drive  Doctor's  or  private  C*r,  and  do  some 

Secretarial  Work.  North  London.  Neighbourhood  of  Highgate  pre- 
ferred.— Apply,  T.t  3,  North-grove,  Highgate,  N.  6. 

/"Ihautfeuse  with  Car. — Lady  resident 

V_/  in  London,  with  own  Car,  would  be  glad  to  act  as  ChauffeuBe 
•whole  or  part  time.  Medical  or  Professional  man  preferred.  Careful 
and  experienced  driver.— Write,  giving  particulars,  to  '•  Car"  372,  care 
Deacons.  Leadenhall-street,  E.C.3. 

T^Tanted  immediately,  a Third  Partner 

▼ f in  an  old-established  Practice  near  Liverpool.  Share  of  over 
i£450  for  sale,  with  ample  scope  for  increase.  No  clubs.  No  panel. 
Early  prospect  of  increased  share.  Premium  £900. — Address,  No.  543, 
The  Lancet  Office,  423,  Strand,  W.C.  2. 

Norfolk. — A Partner  required  in  an 

_L  x old-estah.ished  General  Practice,  situaied  in  a small  county 
^.own,  producing  over  £1650  pgr  annum.  Panel  list  1400.  Fees  2s.  6d. 
to  12s.  6d  ; Midwifery  30s.  to  5 guineas.  Population  5000.  Excellent 
(house,  containing  live  bedrooms,  Ac.,  one  acre  of  garden,  and  garage  ; 
•rent  £60  per  annum.  Premium  one  and  a half  years’  purchase  for  Half 
tShare.—  Quote  Folio  898,  Arnold  A Sons,  Transfer  Dept.,  6,  Giltspur- 
street,  London,  E.C.  1 (opposite  St.  Bartholomew's  Hospital). 

AVAnted,  in  Suffolk  or  adjacent 

T f county,  on  or  near  Coast  preferred,  a PARTNERSHIP 
returning  £800  and  upwards  bv  experienced  Practitioner  with  means. 
—Details  to  4081,  Mr.  Percival  Turner,  4,  Adam-street,  Strand,  W.C.  2. 

Private  Asylum  or  Borderland  House. 

PARTNERSHIP  required  by  M.D.,  aged  thirty  live,  with  nine 
years’  experience  in  treatment  of  Nervous  and  Mental  Diseases.  Neces- 
sary capital  available  now.  Highest  social  and  professional  references. 
— Address,  No.  548,  The  Lancet  Office,  423,  Strand,  W.C.  2. 

T^equired,  a Country  Town  or  S.  Coast 

PRACTICE  producing  not  less  than  £1000  per  annum.  A good 
fciOKse  and  garden  essential.  Advertiser  can  negotiate  at  ouce.— Send 
■details  In  confidence  to  M.B.,  eare  of  Arnold  A Sons,  Transfer  Dept., 
iS,  Giltspur-street,  London,  E.C.  1 (opposite  St.  Bartholomew's  Hospital). 


Wanted,  North  London,  a large  Cash 

and  Panel  PRACTICE.  Receipts  not  Ies9  than  £1CL0  peranuum. 
^Purchaser  can  settle  at  once.— Send  full  particulars  in  confidence  to 
C.,  care  of  Arnold  & Sons,  Transfer  Dept.,  6,  Giltspur-street,  London, 
E.C.  1 (opposite  St.  Bartholomew's  Hospital). 


W 


TATanted  in  London  or  near,  General 

T ? PRACTICE  of  £1C00  a year  or  more.  Applicant  is  prepared  to 
buy  at  once,  and  has  ample  means.— Apply,  No.  3931,  Mr.  Percival 
Turner,  4,  Adam-street,  Adelphi,  Strand,  W.C.  2. 

anted  by  M.D.,  F.R.C.S.,  a 

PRACTICE  in  nice  part  of  Devon,  with  good  house  and 
garden.  Small  piece  with  Cottage  Hospital  preferred.  Income  £6C0  to 
£900.  — Apply,  Blundell  & Rigby,  Walter  House,  418-422,  Strand,  W.C. 2 

Wanted,  Middle-class  Practice,  with 

or  without  panel,  £800  to  £1500  a year.  In  or  near  London 
preferred  ; other  districts  considered.  Partnership  would  be  enter- 
tained. Client  can  purchase  at  once.— Apply,  Peacock  and  Hadley, 
29,  Craven-street,  Strand,  W.C.  2.  (No  charge  unless  sale  effected.) 

"Wanted  bv  M.B.,  F.R.C.S.,  aged  34, 

T T a PRACTICE  or  PARTNERSHIP  in  the  South  of  England, 
•with  scope  for  Surgery.  Income  shout  £800.  Now  free. — Apply, 
Blundell  A Rigby,  Walter  House.  418-422,  Strand,  W.C.  2. 


AAAnted,  Practices  and  Partnerships. 

Y Y Messrs.  ARNOLD  Jt  SONS,  Surgical  Instrument  Manu- 
facturers l Eslbd.  100  years),  are  in  urgent  need  of  Practices  and 
Partnerships  for  several  of  their  Clients  who  are  anxious  to  settle 
^lown  at  once.— Send  full  particulars,  in  confidence,  Arnold  A Sons. 
Transfer  Dept.,  6,  Giltspur-street,  London,  E.C.l  (opposite  St.  Bartholo- 
mew's Hospital). 

56 


To  Purchasers.  — Do  not  buy  any 

Practice  or  Partnership  without  an  investigation  Into  bocks 
and  other  inquiries  by  an  expert  specially  competent  to  conduct  the 
Bame.  Forty  years’  personal  attention  to  such  inquiries  has  given  Mr. 
PERCIVAL  TURNBR  an  unique  ability  to  advise  in  all  cases.  — Terms 
and  full  particulars  free  on  application  to  4,  A lam-street,  Adelphi 
Strand,  W.C.2.  Telephone : 399  Gerrard.  Telegram:  Kpsomian,  London, 


For  Disposal,  Practices  or  Partner- 

SHIPS.  — Messrs.  ARNOLD  A SONS,  Surgical  Instrument 
Manufacturers  (Estbd.  100  years),  have  been  Instructed  to  privately 
dispose  of  a large  number  of  really  good  Practices  and  Partnerships. 
Gentlemen  are  requested  to  state  their  requirements  and  amount  of 
capital  available.  No  charge  to  purchasers.— Address,  Arnold  A SonB, 
Transfer  Dept.,  6,  Giltspur-street,  London,  E.C.l  (opposite  St.  Bartholo- 
mew’s Hospital) 

For  Disposal. — A really  good  Practice 

Is  not  always  to  be  had  directly,  but  Mr.  PERCIVAL  TURNER 
(with  forty  years’  personal  experience)  can  generally  offer  applicants 
something  suitable  on  being  furnished  with  details  of  their  require- 
ments. Nearly  all  the  best  Practices  are  Sold  by  him  without  being 
advertised. — Full  information  free  of  charge  on  application,  personally 
or  by  letter,  to  4,  Adam-street,  Adelphi,  Strand,  W.C.  2. 


Partnership  introduction  of  6 to  18 

months  to  good-class  Suburban  PRACTICE  doing  at  present  over 
£1600  a year.  Very  desirable  investment  and  personally  known. — For 
details,  apply  to  Mr.  Herbert  Needes,  199,  Piccadilly,  W.  1. 

Partnership. — Share  for  Disposal  in 

good-class,  old-established,  Non-Panel  PRACTICE  In  Military- 
Naval  centre  in  South  of  England.  Good  schools,  Hospital,  Ac.  Income 
of  Share  about  £1200  per  annum.  Premium  two  years'  purchase. 
Incoming  partner  preferably  Surgeon,  married,  experienced,  and  with 
necessary  capital.— Apply,  with  personal  particulars,  to  No.  489, 
Tkk  LakCkt  Office,  423,  Strand,  W.C.  2.  No  agents. 


TAeath  Vacancy.  — Midland  Spa. — 

1 / Large  Panel  and  Private  PRACTICE. — Full  particulars,  apply 
Lee  and  Martin,  Ltd.,  Medical  Agents,  93,  Hall-road,  Hands  worth, 
Birmingham. 


Qtaffordshire 

PRACTICE.  Rece 


Partnership. — Seaside  Resort,  South 

WALES.  — Old-established  Mixed  PRACTICE.  Average  net 
receipts  £1953  One-third  or  Half  for  disposal.  Transferable  appoint- 
ments about  £160.  Panel  2000.  Fees  3s.  6d.  to  12s.  6d.  Ample  scope 
for  surgery.  One  year’s  purchase,  part  down,  remainder  by  easy  instal- 
ments.—Lee  & Martin,  Ltd.,  Medical  Agents,  93,  Hall-road,  Hands- 
worth,  Birmingham. 

Country  Practice.  — Staffordshire. — 

V_/  Average  receipts  £1275 per  annum.  Panel  about 600.  Goodfees. 
Rent  £32;  am  ole  accommodation,  including  seven  bedrooms  and 
excellent  surgeries.  Good  gardeu.  Oue  year's  purchase.— Lee  A Martin, 
Ltd. 

. — Industrial  and  General 

_ Receipts  £1178.  Panel  1600,  increasing.  Trans- 

ferable appointments.  Introduction.  One  or  two  years' Partnership. 
Good  fees.  Rent  £60,  or  house  for  sale.  £1500.  Ample  accommodation. 
£1500  to  sell  outright,  or  £750  for  Half  Share. — Lee  & Marlin,  Ltd. 

/Country  Practice.  — Unopposed.  — 

LINCOLNSHIRE.  — Receipts  £698.  Panel  450.  Good  scope. 
Good  fees.  Rent  £30.  Lease.  Garden.  Sport  and  educational  facilities. 
£600  down,  or  £800  in  three  instalments — Lee  A Martin,  Ltd. 

iverside  Town.  — Old-established 

PRACTICE  in  Worcestershire.  £1C66.  Panel  475.  Fees 
28. 6d.  to  £1  Is.  House  for  sale.  Ample  accommodation.  £1200. — 
Lee  A Martin,  Ltd. 

Shropshire.  — Country  Practice.  — 

IxJ  £473.  Panel  300,  increasing.  Reasonable  offer.— Lee  A Martin 
Ltd. 

Cheshire.— T750.— Panel  600.  Good 

V_y  fees.  Oue  opponent.  Rent  £21.  Good  accommodation.  Small 
garden.  £500,  half  down,  bilance  by  arrangement. — Lee  & Martin,  Ltd., 
Medical  Agents,  93,  Hall-road,  Handsworth,  Birmingham. 

orth  of  England. — Nearly  T1000  a 

„ year  in  a prosperous  business  Town  on  Coast.  Panel  over  800. 

Good  house  and  garden  ; rent  £80.  Good  schools.— Apply,  No.  6629, 
Mr.  Percival  Turner,  4,  Adam-street,  Adelphi,  Strand,  W.C.  2. 

Lancs. — An  old-established  General 

PRACTICE  situated  in  a thickly  populated  industrial  district. 
Receipts  £1000  Panel  list  1200.  Fees  2s.  6d.  upwards  plus  medicine. 
Midwifery  30s.  6d.  to  42s.  Nice  house,  containing  four  bedrooms,  Ac., 
large  garden  and  garage;  rent  £55  per  annum.  Premium  one  years 
purchase. — Quote  Folio  1119,  Arnold  A Sons,  Transfer  Dept.,  6,  Giltspur- 
street,  London,  B.C.  1 (opposite  St.  Bartholomew's  Hospital). 


R 


N 


The  Lancet,] 


THE  LANCET  GENERAL  ADVERTISER 


[Sept.  27,  1929 


on  don,  W. — For  Disposal  in  resi- 

dent.t&l  district.  £480  a year.  Panel  300.  Opposition  below 
average.  Easily  worked.  Good  house;  rent  £85.  Good  scope  for  a 
younger  man.  Price  £600. — Apply,  No.  6618,  care  of  Mr.  Percivaj 
Turner,  4,  Adam- street.  Adelphi,  Strand,  W.C.  2. 


Vorks. — Old-established  Practice  for 

I Sale  in  lovely  district,  owner  retiring.  Detached  house,  large 
garden,  tennis  court,  &c.  ; rent  £100.  Receipts  nearly  £1200.  Great 
scope.  Price  £2000,  part  deferred.— Apply,  Manchester  Medical  and 
Scholastic  Association,  8,  King-street. 


outh  Wales. — £1500  a year. — Resi- 
dential neighbourhood  of  large  town.  Panel  1000.  Appoint- 
ments worth  £80-£90.  Good  corner  house  with  garage  to  be  sold, 
£1000.  Premium  for  goodwill,  one  and  a half  years'  purchase. — Apply, 
No.  6617,  care  of  Mr.  Percival  Turner,  4,  Adam-street,  Adelphi,  Strand, 
W.C.  2. 


ent. — A General  Practice  situated  in 

a thickly  populated  industrial  district.  Receipts  over  £770. 
Panel  list  1170.  Fees  2s.  6d.  upwards.  Midwifery  31s.  6d.  to  £5  5s. 
Villa  residence  containing  8 rooms,  &c.,  three-quarters  of  an  acre 
garden,  garage,  Ac.  ; rent  £60  per  annum  Premium  £750. — Quote 
Folio  1090,  Arnold  & Sons,  Transfer  Dept.,  6,  Giltspar-street,  London, 
E.0. 1 (opposite  St.  Bartholomew’s  Hospital). 


rTnusual  Opportunity. — Wales.  — 

V_y  Excellent  chance  lor  Welshman.  Unopposed  for  many  miles. 
Good  doctor’s  house  available.  Panel  600,  and  otuer  appointments  to 
be  had.  Prospect  of  about  £1000  a year.  Premium  only  £150. — Apply, 
No.  6624,  Mr.  Percival  Turner,  4,  Adam-street,  Adelphi,  Strand,  W.C.  2. 


o Let  (in  Seymour- street),  Front 

Ground-floor  CONSULTING  ROOM.  with  attendance,  £150.-^ 
Address,  No,  549,  The  Lancet  Oflice,  423,  Strand,  W.O.  2.  __ 

UNIQUE  AND  GENUINE  OPPORTUNITY. 

ursing  Home  for  Sale,  30  miles 

from  London.  Fine  old  roomy  house,  containing  large  dining 
room  ; private  sitting-room  ; eight  private  patient’s  rooms  ; splendidly 
fitted  operating  theatre  and  anscsthetic  room  ; bathroom  ; two  nurses’ 
bedrooms ; ample  domestic  offices.  Stabling  ; garage.  Beautiful  situa- 
tion ; good  garden  ; tennis  lawn  ; productive  kitchen  garden  ; low  rent. 
Price  for  goodwill,  lease,  and  appointments  as  a going  concern,  £1500. 
Books  can  be  inspected. — Apply,  Edwin  Fear  Walker,  Winchester.  , 

Exceptional  Opportunity  for  Acquiring  a Charming  Littlk 
Property  on  S.E  Coast  Suitable  for  RESIDENT  PATIENTS. 

uaint  Elizabethan  style  House  in 

one  and  a quarter  acres  beautifully  laid  out  grounds— tennis, 
croquet  lawns— billiard  room,  motor  shed,  gas,  water,  kown 
electric  light,  main  drainage,  latest  sanitation.  Excellent  shcwer. 
needle,  plunge,  and  swimming  bath.  Close  to  sea  and  town.  C 00$ 
income  can  be  made  with  Resident  Patients.  Freehold  £3300. 

Dr.  V.,  White  Lodge,  Beltinge,  Herne  Bay,  Kent. 

asement  to  Let,  18  ft.  by  .14  ft.,  with 

private  door,  suitable  for  Surgery.  Electric  light  installed. 
£35  per  annum. — May  and  Philpots,  140,  Brixton  Hill,  London,  S.W. 

ey  Clark,  ILouse  and  Consulting 

Room  Agent,  3a,  Wirapole-street,  W.  A quarter  of  a century’s 
experience  with  the  medical  specialist. 

List  of  Houses,  Consulting  Rooms,  and  Nursing  Homes  iree  on 
application.  Tel.  : 396  Mayfair.  


Qouth  Midlands.  — - An  unopposed 

[ T Country  PRACTICE  about  fifty  miles  from  London  In  good 
agricultural  and  pleasant  residential  district.  Receipts  £1000  a year. 
Small  house;  rent  about  £40.  Station  in  village.  Efficient  introduc- 
tion given.  Premium  £1100.— Apply,  Peacock  and  Hadley,  19,  Craven- 
street,  Strand,  W.C.  2. 


London  Suburbs. — £800  a year.— 

Very  old-established  PRACTICE  in  favourite  residential  suburb. 
Vendor  retiring  through  illness.  Great  scope.  Easily  worked.  Panel 
1600.  Good  house  and  garden  available.— Apply,  No.  6628,  Mr.  Percival 
Turner,  4,  Adam-street,  Adelphi,  Strand,  W.C.  2. 


TTrgent. — £1500  a year,  increasing.— 

VJ  Unopposed  PRACTICE  in  Agricultural  and  Residential  district 
in  Berkshire.  Panel  950.  Fees  5s.  to  21s.  Large  house  available. 
Otving  to  ill-health  only  short  introduction  can  be  gi*en.  Vendor  will 
accept  £1200  from  immediate  purchaser.— Apply,  No.  6591,  Mr.  Percival 
Turner,  4,  Adam-street,  Adelphi,  Strand,  W.C.  2. 


AJorfolk. — An  old-established  General 

X PRACTICE  In  a large  coast  town.  Receipts  £2000.  No  panel. 
Fees  3s.  upwards  ; Midwifery  3 guineas  upwards.  Ample  scope.  Excellent 
house,  situated  in  the  main  road,  containing  three  bedrooms,  two 
attics,  Ac.,  Bmall  garden.  Premium  £1600,  payable  half  down  and  the 
balance  by  arrangement.— Quote  Folio  1108,  Arnold  & Sons,  Transfer 
Dept.,  6,  Giltspur  street,  London,  E.C.l  (opposite  St.  Bartholomew's 
Hospital). 

TTrgent  Sale.  — £1000  a year. — 

V_/  Increasing  PRACTICE  in  thriving  and  increasing  business 
Town  in  Midlands  with  good  hospital  for  immediate  sale.  Appoint- 
ments and  panel  over  £500.  Convenient  house  and  garden.  Easily 
worked.  Furniture  and  small  car  can  be  bought  if  desired.  Premium 
£1000. — Apply,  6586,  Mr.  Percival  Turner,  4,  Adam-street,  Adeiphl, 
Strand,  W.C.  2. 


TJampshire.  — A General  Practice 

J L situated  in  a charming  country  district.  Receipts  over  £1100. 

Panel  list  850.  Fees  2s.  6d.  to  21s. ; Midwifery  63s.  upwards.  Popula 
tion  4000.  A detached  house,  containing  two  reception-rooms,  five 
bedrooms,  Ac.,  one  acre  of  garden;  rent  £55  ner  annum.  Rent  of 
Branch  Surgery  £20  per  annum.  Premium  £1800.— Quote  Folio  1092, 
Arnold  A Sons,  Transfer  Dept,,  6.  Giltspur  street,  London,  E.C.  1 
(opposite  St.  Bartholomew’s  Hospital). 


[Argent  Sale. — S.  Africa.—  For  Dis- 

vj  posal,  APPOINTMENT  and  PRIVATE  PRACTICE  (unopposed) 
worth  at  least  £800  a year,  with  ample  scope  and  prospects,  together 
with  brick  built  modern  freehold  family  house,  detached,  with  stables, 
out-buildings,  garage,  and  5 acres  of  land  well  stocked  with  the  choicest 
fruit  trees — oranges,  lemons,  plums,  peaches,  grapes,  Ac.  Premium  for 
everything  as  it  stands,  including  furniture  md  goodwill,  only  £1200. 
House  and  land  alone  valued  at  ±.1400.  Must  he  taken  up  by  December  1st. 
Vendor  can  be  Seen  in  London  by  appointment. — Apply  to  Mr.  Percival 
Turner,  4,  Adam-street,  Adelphi,  Strand,  W.C.  2. 


For  Sale,  Industrial  Practice  in 

Midlands.  Panel  £300.  Receipts  £800.  Scope  unlimited. 
Large  Panel  Practice  wanted  in  London.— Address,  No.  550, 
The  Lancet  Office,  423,  Strand,  W.C.  2. 


ESTABLISHED  1860. 

MESSRS.  BEDFORD  & CO. 

(C.  E.  Bedford,  F.S.I.,  F.A.I.), 

SURVEYORS,  AUCTIONEERS,  AND  ESTATE  AGENTS, 

10.  Wigmore  Street,  Cavendish  Square,  W. 
SPECIALISTS  IN  PROFESSIONAL  HOUSES  AND  CONSULTING 
ROOMS  in  Harley-street  and  leading  medical  positions. 
Telephone  : 2412  Paddington. 

ELLIOTT,  SON  & BOYTON 

(J.  BOYTON,  P.  H.  WINTER,  H.  H.  HOLT,  A H.  E.  ALLPRESS.) 

6,  VERE  STREET,  Cavendish  Square,  W. 

AUCTIONEERS , ESTATE  AGENTS  & SURVEYORS. 
Messrs.  Elliott,  Son  A Boyton  are  the  beet  local  Agents  for 
HOUSES  and  CONSULTING  ROOMS  in  the  Harley,  Wimpole. 
Queen  Anne,  and  other  streets  off  Cavendish  and  Portman  Squares. 
Established  73  years.  Telephone  Nos.  2L03  and  2L03  Mayfair. 


Pure  China  Tea.  As  imported  direct 

from  China,  without  auy  admixture  whatever.  In  6 lb.  parcels,, 
carriage  paid,  £1  2s.  6d.  each.— J.  B.  Thomson  & Co.,  5,  Rumford- 
place,  Liverpool. 

( guaranteed  Pure  Olive  Oil  in  about 

V_J  forty  gallon  casks  in  stock.— Naylors  A Davies,  34,  Moorfields„ 


Fair  Cartoons  for  Sale. — 


Liverpool. 

Vanity 

T Doctors,  Surgeons,  Scientists  from  Is.  6d.  each.  Any  Carter 
puoiished  by  Vanity  Fair  supplied.  Lists  free.— R.  Weir  & Co.,  High- 
road, Woodford.  E.  18. 

For  Sale,  Crocker’s  Atlas  of  Skin 

DISEASES.  8 vols.  What  offers:-  M.R.C.S.  GOWN,  good  con- 
dition, 35s.  Durham  Undergrads.  GOWN,  20s.— Addiess,  No.  545, 
The  Lancet  Office,  423,  Strand,  W.C.  2. 

Wanted  to  purchase  immediately, 

Y Y HEARSON  VACUUM  PARAFFIN  BATH,  COOL I NCUBATUR 
ELECTRIC  220  D.C.,  also  IIOT  AIR  STERILISER  WASSERMANK 
BATH. — Letters  to  No.  551.  The  Lancet  Office,  423,  Strand,  W.C.  2. 

For  Sale. — 1.  Electric  Transformer 

with  light  and  cautery.  2.  ELECTROLYSIS  APPARATUS. 
3.  CONSULTING  ROOM  WEIGHING  MACHINE.-Can.be  seen^by 
appointment  at  6.  Upper  Wimpole-street,  W.  1. 


AN  IDEAL  PROTECTION  FOR  MEDICAL  MEN. 


or  A.ocldent  with  PERMANENT  BENEFITS  to  the  65th  year  of  age. 
No  confinement  to  the  house  when  disabled. 

For  full  details  apply,  stating  date  of  birth  and  amount  of  weekly 
compensation  required,  to : 

Messrs.  ARNOLD  A SONS, 

Transfer  Dept.,  6,  Giltspur-street,  London,  E.C.  1. 
(Opposite  St.  Bartholomew’s  Hospital.) 


57 


The  Lancet,] 


THE  LANCET  GENERAL  ADVERTISER 


[Sept.  27,  1919 


STEVENS’  AUCTION  ROOMS  (Eatab.  1760). 

A Sale  by  Auction  is  held  every 

Friday,  at  12.30,  which  affords  first-class  opportunities  for  tne 
disposal  or  purchase  of  SCIENTIFIC,  OPTICAL,  and  ELECTRICAL 
APPARATUS.  Microscopes  and  Accessories,  Telescopes,  Surveying 
Instruments,  Photographic  Cameras  and  Lenses,  Cinematographs  and 
Films,  Lanterns  and  Slides,  Lathes  and  Tools.  Books  and  Miscellaneous 
Property.  Frequent  Sales  of  Natural  History  and  Ethnological 
Specimens,  Curiosities,  Ac.,  are  also  held. 

Catalogues  and  terms  for  selling  will  be  forwarded  on  application  to 
Mr.  J.  C.  STEVENS,  38,  King  street.  Covent  Garden,  London,  W.C.2. 

MEDICAL  MEN  & DEMOBILISATION. 

RA.M.C.  Officers  & Medical  Men 

« generally  now  requiring  MUFTI  DRESS  can  be  assured  of 
obtaining  perfect  fitting  garments,  ready  for  wear  or  to  measure  In 
twenty-four  hours,  made  from  finest  materials,  at  lowest  possible 
remunerative  prices. 

Patterns  and  simple  Self-Measurement  Form  Post  Free. 
The  recognised  House  for  Perfect  Fitting  Clothes. 

HADDV  HAII  207,  OXFORD  STREET  W.  1. 

1 Irt  I\  K I llrVLL.,  149,  CHEAPSIDE.  E.C.  2. 


The  Colonies  and  Abroad. 

One  Year  £2  0 0 

Six  Months  10  0 

Three  Months  ...  0 10  0 


Received  too  Late  for  Classification. 

A doption. — Good  Home  wanted  for 

i \ healthy  boy,  twelve  months,  of  good-clafs  English  parentage. 
No  premium. — Address,  No.  556.  The  Lancet  Office.  423,  St  rand.  W C.  2, 

THE  LANCET 

SUBSCRIPTIONS. 

THE  LANCET  is  published  on  Friday  morning  each  week,  price  1 Od. 
The  postage,  inland,  is  one  halfpenny  for  each  six  ounces;  abroad, 
one  halfpenny  for  each  two  ounces. 

The  rates  of  subscriptions  are  as  follows  : — 

Inland. 

One  Year  £1  16  0 

• Six  Months  0 18  0 

Three  Months  ...  0 9 0 

Subscriptions  (which  may  commence  at  any  time)  are  payable  In 
advance.  Cheques  and  Post  Office  Orders  (crossed  “London  County 
Westminster  and  Parr’s  Bank,  Covent  Garden  B-anch”)  should  be 
made  payable  to  the  Manager,  Mr.  Charles  Good,  The  Lancet  Offices, 
423,  Strand,  London,  W.C.2. 

ADVERTISING. 

Books  and  Publications -> 

Official  and  General  Announcements  I Four  Lines  and  under  £0  4 0 
Trade  and  Miscellaneous  Advertise-  f Every  additional  Line  0 0 9 

Quarter  Page,  £2.  Half  a Page,  £4.  An  Entire  Page,  £3. 
Special  terms  for  Position  Pages. 

Advertisements  (to  ensure  insertion  the  same  week)  should  be 
delivered  at  the  Office  not  later  than  Wednesday,  accompanied  by  a 
remittance. 

Answers  are  now  received  at  this  Office,  by  speolal  arrangement,  to 
Advertisements  appearing  in  The  Lancet. 

Offices  : 423  and  424,  Strand,  London,  W.C.2  : and  1,  2.  and  3,  Bedford  st 


HERBERT 

Mayfair  2299. 


NEEDES  (!!£■: 

199,  PICCADILLY,  W.  1. 


EVERY  DESCRIPTION  OF  BUSINESS  transacted  by  this,  the 
OLDEST  MEDICAL  AGENCY  IN  THE  KINGDOM. 


Mr.  ,J.  C.  NEEDES 

(P.  W.  NEEDES  F.  B.  NEEDES) 

MEDICAL  PARTNERSHIP  AND  CONVEYANCING 
AGENCY, 

8,  DUKE  STREET,  ADELPHI,  W.C.  2. 

(Late  1,  Adam  Street,  Adelphi.) 

Telegrams:  “ Acquirement , Westrand,  London."  Telephone:  OerrardSShS 

Tlhis  Agency  (which  has  been  estab- 

I lished  since  1875)  undertakes  the  Sale  of  Practices,  the  Intro 
duotlon  of  Partners,  Valuations,  Investigations  on  behalf  of  Purchasers 
the  supply  of  trustworthy  Locum  Tenens  and  Assistants,  and  every 
other  description  of  Medical  Agency  Business. 

N.B. — No  charge  made  to  Purchasers. 


DS  J.  FIELD  HALL 

(FIELDHALL,  LIMITED), 

MEDICAL  TRANSFER  AGENT, 

12,  CRAVEN  STREET,  STRAND,  W.C.  2 


Telephone  : 
4667  Ghrrard. 


Telegram*  : 

“Fieldhall,  Westrand-London. 


ALL  BRANCHES  of  AGENCY  WORK  undertaken. 

Purchasers  stating  their  requirements  in  full  will  be  sent  partlouiai 
of  ruitable  PRACTICES  and  PARTNERSHIPS  for  Sale  free  of  charge 

58 


BLUNDELL  & RIGBY, 

Walter  House,  418-422,  STRAND,  W.C.  2. 

(Entrance  Bedford  Street.)  Telephone:  7148  Gerhard. 

Cable  Address  : (via  Eastern)  “ Recallable,  London.” 

LOCUMS  SUPPLIED. 

"Partnership. —Half  Share  of  £1600, 

1 increasing,  in  be-iutiful  Country  Town  in  Home  County. 
Appointments,  &c  , £700.  Large  or  small  house. 

"Presidential  Suburb. — Half  Share  of 

_1_V  £1550  in  N.W.  district.  Great  scope. 

Couth  Devon. — Unopposed  Practice 

of  £9(0  in  beautiful  district.  Usual  appointments,  Ac.  Small 
house;  rent  £30. 

T\7est  London. — Lock-up  Surgery 

Y Y doing  about  £500.  Low  rent.  Small  panel.  Premium  £4C0. 

Isle  of  Man.  — Unopposed  Seaside 

PRACTICE  of  £600.  Choice  of  houses.  Premium  £300. 

/Cheshire. — ProsperousManufacturing 

vj  Town.  Receipts  £1250.  Panel  £650.  Little  Midwifery,  3 guineas 
up.  Opposition  slight.  Good  house  ; rent  £60. 

T/UestRiding. — Receipts  about£  1100. 

V Y Panel  1900.  Rent  £55.  Population  50.0CO.  Fifteen  opponents. 

TUGthin  20  miles. — Old-established 

V V PRACTICE  of  £1500.  No  resident  opponent.  Appointments 
and  panel  £600.  Good  house  and  large  garden  ; rent  £70. 

Yorks. — Partnership. — Third  Share 

of  £3000  in  Country  Town  in  nice  agricultural  district.  Cottage 
hospital  and  good  scope  for  a surgeon. 

Herts. — Middle-  and  Working-class 

PRACTICE  of  £1000  in  good  Town.  Panel  700.  Rent  £60. 
Premium  £850,  £600  down. 

T ondon,  S.W.  — Old-established, 

I 1 Middle-class  non-Panel  PRACTICE  of  £1300.  Good  house  and 
garden  ; rent  £60.  Premium  £1350,  part  down.  Vendor  retiring. 

Norfolk.—  Old-established  Practice  in 

1 l email  Country  Town.  Receipts  over  £1100.  Panel  and  appoint- 
ments £600.  Good  modern  house  with  garage ; rent  £50. 

Northumberland.  — Partnership. — 

Half  Share  of  £2000  in  nice  Country  Town.  Half  premium  down, 
balance  by  instalments. 

Derbyshire . — P artner  ship . — Third 

Share  of  £2200.  Unopposed  Practice  in  lovely  district.  Small 

hoU86. 

Practice  of 

Photos  of  the  place  here.  Premium 

£9.0,  £350  down. 

Liverpool  Surburb. — Old-established 

PRACTICE  of  £1000.  No  panel  but  plenty  of  scope  for  this. 
Low  rent.  Piemium  £1000. 

Couth  Devon. — Old-established  good- 

O class  non-panel  PRACTICE  in  large  Town.  Receipts  £1180. 
Suitable  house.  Premium  only  £750  for  quick  sale  owing  to  illness. 

XUest  London.  — Old  - established 

f Y PRACTICE  of  £550,  small  panel.  Scope  for  active  man.  Good 
house  can  be  bought  cheaply. 

Leicestershire. — Half  Share  of  £1500 

with  scope  up  to  £1800.  Unopposed  Practice  with  good  pantl 
and  appointments.  Excellent  house  with  large  garden. 

Northumberland. — Practice  of  £13  < 5 

_Lr  in  suburb  of  large  Town.  Good  house;  rent  £60.  Panel  600. 
Premium  £1150. 

Devon.  — Assistant  and  Partner 

wanted  In  nice  Country  district.  Third  or  Half  of  £1800. 
Cottage  hospital. 

T ondon,  S.W. — Half  Share  of  £1240 

I J with  plenty  of  scope.  Nice  Residential  district.  Panel  1100. 

Qoutli  Coast. — Old-established,  good- 

O class  non  panel  PRACTICE  of  £700,  let  down  owing  to  illness. 
Fashionable  place,  with  good  schools.  Ac. 

Home  County. — Unopposed  Practice 

of  £1000.  Good  society  and  all  kmas  of  sport.  Large  bouse 
and  grounds. 

Purchasers  stating  their  requirements  can  have  Particulars  of  other 
Prac.ices  not  advertised. 


uuuoo. 

A ustralia.  — Seaside 

£1750.  Splendid  climate.  Photos 


Thh  Lanobt,] 


THE  LANCET  GENERAL  ADVERTISER 


[.Sept.  27,  1919 


THE  SCHOLASTIC,  CLERICAL,  & MEDICAL  ASSOCIATION, 


■1 

(Established  in  1880  by  Mr.  G.  B.  Stocker ) , 


LIMITED. 


22,  CRAVEN  STREET,  TRAFALGAR  SQUARE,  W.C.  2. 

Telegraphic  Address  : " TRIFORM,  WEST  11 A ND,  LONDON."  Telephone  No.  185/,  (Gerrard). 

ASSISTANTS  AND  LOCUM  TENENS  SUPPLIED.  RESIDENT  PATIENTS  INTRODUCED. 


NO  CHARGE  TO 

<1)  LONDON,  N.W.— PRACTICE  £75C-£800  In  residential  Suburb. 

. No  Panel.  No  dispensing.  Not  much  Midwifery.  Suitable 
house  could  be  purchased.  Premium  one  and  a half  year’s 
purchase.  Ample  scope. 

(2)  EASTERN  COUNTIES— PARTNERSHIP  in  unopposed  Country 
Practice  £1800  p a.  Panel  over  1500.  Premium  Five-twelfths 
Share,  two  years'  purchase. 

<3)  MIDLANDS.  — PARTNERSHIP  in  Country  Practice  about  £2400 
In  beautiful  part.  Panel  1100.  Very  good  house  and  garden. 

Share  worth  £950  p.a.  Premium  £1000. 

<4)  SHROPSHIRE.— PARTNER  required  in  Country  Town  Practice 
about  £1500.  Good  house.  Premium  One-half  Share  one  and 
a half  years'  purchase.  Cottage  Hospital. 

(5)  WEST  MIDLANDS.— Increasing  unopposed  Country  PRACTICE 

about  £500  p a.,  including  appointments  worth  about  £140  and 
panel  396.  Rent  £50.  Premium  £700  by  arrangement.. 

(6)  LANCS. — Town  PRACTICE  about  £900  p.a.,  including  appoint- 

ments £300  and  panel  700.  About  twelve  Midwiferies.  Good 
bouse  and  garden.  Moderate  premium. 

<7)  MIDLANDS. — Old  established  Country  PRACTICE,  doing  about 
£1500,  in  residential  and  hunting  district.  Pretty  semi- 
detached house  (4  bedrooms,  Ac),  nice  garden;  rent  £36. 

Premium  £1575.  Cottage  Hospital. 

<8)  PARTNERSHIP  in  unopposed  Country  Practice  about  £1500  p.a. 

Midlands.  Panel  1400-1500.  Little  Midwifery.  House  contains 
5 bedrooms.  Garden,  &c.,  3 acres.  Premium  One-half  Share, 
one  and  a half  years'  purchase. 

<9)  LONDON,  N.E.— Middle-class  PRACTICE  £800-£900  p.a.  Small 
panel.  Good  house  (6  bedrooms,  Ac.),  large  garden.  Premium 
£500.  Ample  scope. 

<10)  PARTNER  required.— Practice  £1600-£1700  in  clean  Manufacturing 
Town  in  Cheshire.  Panel  nearly  2000.  One-balf  Share  for 
disposal  Young,  unmarried  man  preferred.  Scope  for  Surgery. 

(11)  STAFFS.— PRACTICE  about  £1200  p.a.  Industrial  Town.  Good 
appointments  and  panel  1700.  No  Midwifery.  Good  house 
(5  bedrooms,  electric  light).  Premium  one  year's  purchase. 

NUMEROUS  OTHER  PRACTICES  AND  PARTNERSHIPS  NOT  ADVERTISED. 
Medical  Partnerships,  Transfers  Sf  Assistantships  (Barnard  & Stocker) 


PURCHASERS. 

(12)  NORTH  WEST  OF  ENGLAND.-PARTNERSHIP  fwith  Suc- 

cession) in  Practice  about  £16C0,  in  Town  of  52,000.  Panel 
2177.  Premium  One-half  Share,  £850;  £500  down. 

(13)  WORCS. — Country  PRACTICE  over  £1000  in  beautifully  situated 

Village.  Small  panel.  Midwifery  discouraged.  Good  house. 
Premium  £1200. 

(14)  LONDON,  N.— Outlying  Suburb.  Increasing  PRACTICE  £1400 

p.a.  Panel  800.  Rent  £60.  Premium  one  and  a quarter 
years’  purchase. 

(15)  GLAMORGAN.— PARTNERSHIP  in  Country  Town  Practice, 

doing  about  £1200,  including  appointments  worth  £360  and 
panel  £400  p.a.  Premium  One-half  Share  one  year's  purchase. 

(16)  NORTH  OF  ENGLAND.— University  City.  PARTNERSHIP  in 

Middle  and  Working-class  Practice  over  £2300  p a.  Premium 
for  One-third  Share  one  year’s  purchase,  payable  £300  down. 

(17)  MIDLANDS.— Increasing  Town  PRACTICE.  Receipts,  1918, 

£640.  Panel  639.  Specially  built  house,  with  good  garden. 
Price  £2200  (part  mortgage).  Premium  one  year's  purchase. 

(18)  YORKSHIRE,  WEST  RIDING.-Country  PRACTICE  averaging 

nearly  £16(0  p.a.  Panel  1400.  Good  house  and  garden  and 
paddock.  Pjemium  one  year's  purchase. 

(19)  STAFFS.— Country  PRACTICE  £1270  p a.  Panel  600.  Fees  5s. 

to  £1  Is.  Large  old-fashioned  house,  garden,  and  paddock. 
Premium  one  year’s  purchase. 

(20)  UNDER  20  MILES  FROM  LONDON.  — Very  old-established 

PRACTICE,  £2346  p.a.,  in  residential  district.  Panel  500.  Fees 
upto£lls.  Rent  £60.  Premium  one  and  a half  years’ purchase. 

(21)  LANCS.— Manufacturing  Town.  PRACTICE  nearly  £900  p.a. 

Panel  1351.  Premium  £670. 

(22)  NORFOLK.— Country  Town.  Middle-class  PRACTICE.  Receipts 

past  year  £1100,  including  appointments  £250.  Panel  500. 
Premium  one  year’s  purchase. 

(23)  NORTH-EAST  OF  ENGLAND.— Colliery  district.  Increasing 

PRACTICE  over  £1850.  Panel  2000.  Rent  £32.  Premium  £1600. 

(24)  PARTNERSHIP  in  Town  Practice  about  £1800  p.a.  Under  fifteen 

miles  from  London.  One-third  Share  at  first  at  two  years’ 
purchase. 

FULL  DETAILS  ON  APPLICATION. 

Published  by  the  Association.  Price  12s.  6d. 
Mr.  A.  V.  Storey,  General  Manager. 


MEDICAL  AGENCY.  Established  over  40  Tears. 

Mr.  PERCIVAL  TURNER,  4 & 5,  Adam  Street,  Strand,  W.C.  2. 

Telegrams  : “ Epsomian,  London."  Telephone  : Gerrard  399.  After  Office  Hours— Epsom  695. 

LOCUM  TENENTS  provided— no  charge  to  Principals.  Every  description  of  AGENCY  and  ACCOUNTANCY  work  undertaken. 


PARTNERSHIPS  FOR  DISPOSAL. 


No.  6625.  YORKSHIRE.  — £2690  a year.  Small  Country  Town. 

Cottage  Hospital.  Panel  950.  1/3  Share  for  Sale  at 

first. 

„ 6619.  EASTERN  COUNTY.  — £1700  a year.  Old  established. 
Large  Town.  1/2  Share  for  Sale. 

„ 6615.  MIDLANDS.— £1500  a year.  Unopposed.  Panel  1500. 
1/2  Share  for  Sale. 

PRACTICES  OVER 


No.  6605.  MIDLANDS.— £180.0  a year.  Large  Town.  Scope  fcr 
Surgery.  Panel  1600.  1/2  Share  for  £1000.  Urgent. 

,,  6529.  SOMERSET.  — £2000  a year.  Good  Country  Town, 
with  great  scope.  Hospital  and  fair  amount  of 
surgery.  Residential  locality.  1/3  Share  and  more  later. 

„ 6506.  BEDFORDSHIRE.— £2100  a year.  Good  old  established 
family  Practice  in  Hospital  Town.  Senior  retiring. 
1/2  Share.  Large  house  and  gat  den. 

£800  A YEAR. 


No.  6595.  DURHAM. — £1900  a year.  Non-panel.  Old-established. 

Held  twenty-seven  years.  Busy  Town. 

,,  6588.  YORKSHIRE.— £2050  a year.  Old-established.  Suburb  of 
large  Town.  Very  nice  house  and  garden.  Panel  3000. 
Suit  two  friends.  One  year's  purchase. 

,,  6586.  DERBYSHIRE. — £950  a year.  Midland  Town.  Easily 
worked.  Appointments  and  panel.  £530.  Small  house. 
,,  6547.  YORKSHIRE.- £1160a year.  Panel  1200.  Increasing.  Town 
of  20,000,  only  three  opponents.  No  car.  Price  £1000. 

„ 6541.  LANCASHIRE.— £2200  a year.  Panel  1600.  Old-established. 

Large  Town.  Scope  for  two  men.  Price  £1600,  half  by 
instalments. 


No.  6537.  YORKS  HIRE. -£1000  a year.  Panel  800.  Old-established. 

Pleasant  Town.  Hospital.  Opposition  light.  Price  £1100. 

„ 6533.  DERBYSHIRE.— £720  a year.  Old  established.  Good  house 
and  garden,  lawn.  Ac.  Panel  400.  No  conveyance  needed. 

,,  6532.  YORKSHIRE. — £1600  a year.  Increasing.  Suburb  of  large 
City.  Easily  worked.  Panel  1100.  Good  house,  large 
garden.  Long  introduction. 

„ 6522.  NORTHUMBERLAND.  — £1900  a year.  Old-established. 

Unopposed.  On  rail.  Good  house  and  garden.  Panel 
2000.  Price  £2000.  part  down. 

„ 6514.  NORTHUMBERLAND.— £800  a year.  Very  old,  unopposed, 
safe  PRACTICE.  Rail  close.  All  sport.  Small  house 
and  two  acres,  £30.  Price  only  £400. 


Note.— Pract ices  marled  with  an  asterisk  have  been  personally  investigated  or  visited  by  Mr.  Turner. 


Full  details  of  any  of  the  above  and  of  many  others  for  disposal  not  advertised  will  he  sent  free  on 
application  to  Mr.  PEKCIVAL  TURNER  as  above. 


- PEACOCK  & HADLEY  <Z) 

(Mr.  A.  HADIEY), 

MEDICAL  TRANSFER  AGENCY, 

19,  Craven  Street,  Strand,  W.C.  2. 

Wires  : Herbaria,  Westrand—  London.  Telephone  : Central  1112 


THE  MANCHESTER  CLERICAL,  MEDICAL, 
AND  SCHOLASTIC  ASSOCIATION,  LTD. 

The  oldest  MEDICAL  Agency  in  Manchester,  8,  KING  STREET 

Telegraphic  Address:  “Student,  Manchester." 

TRANSFERS  and  PARTNERSHIPS  arranged,  and  Investigations. 
Valuations,  Ac.,  undertaken.  ASSISTANTS  and  LOCUM  TENENS 
3UPPLIED  PRACTICES  for  Sale  Particulars  on  application. 

59 


Thb  Lancet,] 


THE  LANCET  GENERAL  ADVERTISER 


[Sept.  27,  1919 


Alcresta  Tablets  of  Ipecac  in  Amebic  Dysentery 

and  in  Endamebic  Pyorrhea 


The  oral  administration  of  the  ipecac  alkaloids  is  proving  more  advantageous  than  the  hypodermatic  in* 
jection  of  emetine,  especially  in  the  treatment  of  endamebic  carriers  and  in  the  prevention  of  relapses. 

UNCOATED  AND  DISINTEGRATING— CAUSE  NO  NAUSEA 


Each  tablet  contains  the  alkaloids  (emetine  and  cephaeline)  from  ten  grains 
of  Ipecac,  U.  S.  P.(  held  in  an  adsorption  compound  with  hydrated  aluminum 
silicate.  The  tablets  disintegrate  but  this  adsorption  compound  passes  through 
the  acid  contents  of  the  stomach  and  releases  the  alkaloids  only  in  the  alkaline 
intestinal  secretions — thus  preventing  gastric  disturbances. 

Ten  or  twenty  tablets,  representing  one  hundred  or  two  hundred  grains 
of  ipecac,  may  be  given  in  a day  without  vomiting  or  nausea. 

Distributed  through  the  Drug  and  Dental  Trades  in  bottles  containing  40 
and  500  tablets.  Further  information  on  request. 

Agents  for  Great  Britain 

JOHN  MORGAN  RICHARDS  & SONS,  LIMITED 

46  Holborn  Viaduct,  London,  E.  C. 

Made  only  by 

• ELI  LILLY  & COMPANY 

INDIANAPOLIS,  U.  S.  A. 


Valentino’s  Meat-Juice 

For  Quieting  the  Irritable  Stomach  in 
Pregnancy,  for  Rapidly  Restoring  the 
Vital  Forces  in  Hemorrhage,  for  Sus- 
taining and  Strengthening  in  Long  and 
Exhausting  Labor,  Valentine’s  Meat- 
Juice  is  Extensively  employed  in 

Obstetrical  Practice 

Dr.  M.  DeCristoforis,  Prof.  Lecturer  on  Mid- 
wifery and  Gyneecdogy , Milan,  Italy : 4 4 The  preparation, 
Valentine's  Meat- Juice,  has  been  successfully  used  by 
me  in  a serious  case  of  acute  puerperal  hemorrhage.  The 
patient  could  take  no  food  or  drink.  Valentine's  Meat- 
Juicb  was  completely  retained  and  restored  very  promptly 
the  strength  and  the  cardiac  impulsion.” 

Dr.  E.  Duloroy,  Physician  Accoucheur  to  the  Inter- 
national Hospital,  Paris,  I ranee:  4,A  young  accouch£e, 
in  a very  weak  condition  and  suffering  from  stomach 
trouble,  could  retain  no  food,  but  was  able  to  assimilate 
Valentine's  Meat-Juice  given  at  first  in  small  doses.  An 
improvement  was  quickly  visible,  the  patient  reqovered 
her  strength  and  is  today  in  good  health.” 

For  Sale  by  European  and  American  Chemists  and  Druggists. 

VALENTINE’S  MEAT-JUICE  COMPANY, 


D 135 


RICHMOND.  VIRGINIA,  U.  S.  A. 


Printed  and  Published  bv  the  Proprietors,  W ablet  and  Son  (1912),  Ltd.,  at  No.  423,  St  rani,  and  Nos.  1 and  2,  Bedford  street. 
60  adjoining,  In  the  County  of  London.— Saturday,  September  27th,  1919 


2 ,.,  !',  Mental  Bankruptcy  y'- 

and  nervous  insolvency  are  the 
results  of  the  present  day  tendency  to  go 
through  life  constantly  on  “high  gear” 

Brain,  nerves,  and  body  cells  in  general,  need  what  have  been  called 
“chemical  foods,”  such  as  calcium,  sodium,  potassium,  phosphorus, 
manganese,  and  iron.  The  effect  of  these  is  favored  by  the  ‘ ‘dynamic’  ’ 
action  of  small  doses  of  quinine  and  strychnine,  continued  for  a con- 
siderable period. 

Syr.  Hypophosphites  Comp.  Fellows 

presenting  these  important  elements  in  a uniform, 
stable,  and  easily  assimilable  form,  is  clinically  efficient, 
as  over  fifty  years  of  increasing  use  have  testified 


Sanities  and  Literature  on  request 


FELLOWS  MEDICAL  MFG.  CO.,  Inc.,  26  Christopher  St.,  New  York 


thb Lanoht,]  the  LANCET  GENERAL  ADVERTISER [Skpt.  27, 1919 


= Makers  of  Howards’ Quinine.Aspirin  Tablets, Calomel,  Pare  Epsom  Salts, Sodii  Bicarb., &c.  = 


I 

1 HOWARDS’  Standard  ETHER  j 

3 for  producing 

I ANESTHESIA  I 

I AS  USED  BY  THE  LEADING  HOSPITALS. 

HOWARDS  & SONS  have  supplied  the  London 
Hospital  for  many  years  past  with  all  the  Anaesthetic  Ether 
j§  which  has  been  required,  and  it  has  given  entire  satisfaction 

during  the  whole  of  the  period.  H It  was  from  Howards  that 
the  Army  Medical  Department  drew  a very  large  proportion  H 

of  their  supplies  of  Anaesthetic  Ether  throughout  the  War. 

ORDER  THROUGH  YOUR  WHOLESALER 
1 1-lb.  i-lb.  d-lb.  patent  grip  bottles 

MANUFACTURED  BY  HOWARDS  & SONS  LTD 
! ILFORD  (Estab.  1797)  LONDON 


Thb  lancbt,] THE  LANCET  GENERAL  ADVERTISER  [8kpt.  27, 1919 


Keeping  Faith— 

The  scientific  principles  on  which  Antiphlogistine  was 
originally  compounded,  have  always  been  the  common 
property  of  the  medical  profession. 

The  faithfulness  with  which  the  original  product  has,  for 
more  than  tiventy-five  years,  been  maintained,  remains  the 
proud  stewardship  of  the  original  makers. 

The  unbiased  reports  of  thousands  of  physicians,  basing 
their  opinion  upon  their  experience  with  Antiphlogistine  in 
both  hospital  and  private  practice,  conclusively  prove 
its  dependable  value  in  all  inflammatory  and  con- 
gestive conditions. 


IS  THE  SAME  TO-DAY  AS  IT 
WAS  TWENTY-FIVE  YEARS  AGO. 


The  Denver  Chemical  Manufacturing  Company, 

LONDON,  E.  8. 


IV